HSC Section 6 Nov2016 Green Book

Otolaryngology–Head and Neck Surgery 152(3)

finding. Normative data in older adults are required to clar- ify this and are currently under way. As one would expect, differences in the primary etiology causing dysphagia were noted between referral sources. However, it is clinically significant that there was no signif- icant difference in the prevalence of esophageal abnormal- ities between referral sources. These results advocate for esophageal visualization irrespective of the referral source. Esophageal abnormalities appear difficult to predict by etiology. Yet, as has been previously reported, patients with impaired PESmax were more likely to have both pharyn- geal 17 and esophageal abnormalities. 1 The association of reduced PESmax and prolonged ETT is hypothesized to rep- resent a compensatory strategy. To limit retrograde flow and minimize the ‘‘threat’’ that a retained bolus presents in the esophagus, the upper esophageal sphincter hypertrophies and becomes less compliant. 1,17 This is measured as a reduction in absolute PES opening. Identification of reduc- tion in PES opening therefore should prompt esophageal evaluation. This study demonstrates that inclusion of esophageal visualization as part of a VFSS protocol can help identify and categorize patients’ problems when referred with a symptom of dysphagia. This may allow further investiga- tions to be requested (including formal esophagram) or referral to appropriate medical services to quantitate and characterize the esophageal disorder more thoroughly. Therapeutic recommendations can be refined and targeted to the appropriate service, and the patient receives the most complete information and holistic management. A short visualization that adds only 2 further swallows (each screened for a maximum of 15 seconds) does not sig- nificantly increase radiation exposure or the overall study time. The additional radiation exposure incurred by per- forming esophageal visualization was recorded as less than 0.1 mSv. Background radiation dose annually exceeds 3 mSv, and therefore the incremental increase in exposure related to esophageal views is very low. 18-21 Compared with formal esophagram, which incorporates several additional views and longer screening time, the simple esophageal visualization may direct referral or management of the patient without exposing him or her to the higher radiation dose of a full esophagram. 11 Concerns regarding scope of practice with regard to eso- phageal diagnosis have been raised. Speech-language pathologists are not expected to be esophageal diagnosti- cians. The visualization provides simple parameters for onward referral, as transit times longer than normal (15 sec- onds) can be easily measured by automated timer and indi- cate the need for further review. The referrer, who will decide whether further investigation is warranted and who should perform this, usually directs this. The onus will not fall on the speech-language pathologist performing the test to interpret the clinical significance of any findings. In fact, identification of an esophageal discrepancy likely to pro- duce symptoms, particularly in the absence of other likely causes, may assist the speech-language pathologist in

deciding what advice and guidance to give regarding eating strategies, rehabilitative exercises, and body positioning.

Limitations A proportion of patients (17%) were difficult to screen due to positioning issues, limiting the view of the LES. However, these patients were generally more disabled and often wheel- chair bound and may not have tolerated a full esophagram (requiring the ingestion of large quantities of barium in the prone position) either. The barium capsule was used in only 40 procedures, despite evidence that it increases the sensitiv- ity of the screen. 11 This was thought to be due to hesitancy from speech-language pathologist to give patients with dys- phagia a capsule. It is likely that capsule use is not safe for all dysphagic patients and that SLP clinical decision making is necessary in evaluating risk in each individual patient. There are no comparative normative data for pill transit times, and this is currently being investigated. PESmax was measured solely in the lateral view. The addition of an anterior-posterior measure would have provided more infor- mation regarding the extent of PES opening impairment. A measure of hyoid displacement and/or hyoid-larynx approxi- mation would have added to the study by allowing further analysis of the cause of PES opening impairment. This was not a validation study, and no formal esophagram was per- formed routinely for comparison. Accuracy of esophageal abnormality detection therefore cannot be confirmed. Conclusion Esophageal abnormalities are highly prevalent in patients referred to a VFSS clinic with a symptom of dysphagia. One- third of patients present only with esophageal phase abnorm- alities. Traditional fluoroscopic screening of the oropharynx alone fails to identify these patients. Esophageal visualization is a useful adjunct to VFSS as it provides preliminary infor- mation regarding the esophageal phase of swallowing. It enables appropriate referrals to radiology, ORL, and/or gas- troenterology to be made and avoids patients being falsely reassured, misdiagnosed, and mismanaged. Acknowledgments The authors thank the Waitemata District Health Board–Speech- Language Therapy Department for access to their clinical database. Author Contributions Anna Miles , study design, data collection, analysis and manuscript preparation and final approval; Jessica McMillan , study design, data collection, analysis and manuscript preparation and final approval; Katie Ward , data collection and analysis and final approval; Jacqui Allen , study design, analysis and manuscript preparation and final approval.

Disclosures Competing interests: None. Sponsorships: None. Funding source: None.

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