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Original Research—Laryngology and Neurolaryngology

Esophageal Visualization as an Adjunct

to the Videofluoroscopic Study of

Swallowing

Otolaryngology–

Head and Neck Surgery

2015, Vol. 152(3) 488–493

American Academy of

Otolaryngology—Head and Neck

Surgery Foundation 2015

Reprints and permission:

sagepub.com/journalsPermissions.nav

DOI: 10.1177/0194599814565599

http://otojournal.org

Anna Miles, PhD

, Jessica McMillan, MSc

, Katie Ward, MSc

, and

Jacqui Allen, MBChB, FRACS

1,2

No sponsorships or competing interests have been disclosed for this article.

Abstract

Objective

. Complaints of dysphagia for solids lead to speech-

language pathology (SLP) referral. Yet many of these patients

are later diagnosed with esophageal rather than oropharyn-

geal dysphagia. Fluoroscopic screening involving the oro-

pharynx alone fails to identify these patients. The aim of this

study was to investigate the prevalence of esophageal

abnormalities in an SLP-led videofluoroscopic study of swal-

lowing (VFSS) clinic.

Study Design

. Prospective, observational study.

Setting

. Radiology suite, public hospital.

Subjects and Methods

. In total, 111 consecutive mixed-

etiology patients referred to the clinic by otorhinolaryngol-

ogy (ORL) (59) or by a speech-language pathologist (52)

were recruited. A VFSS was performed according to proto-

col, and at completion, esophageal visualization (in anterior-

posterior plane) was performed by administration of a large

liquid barium bolus and a barium capsule. All VFSS record-

ings were analyzed using objective digital measures of timing

and displacement.

Results

. Sixty-eight percent of patients had an abnormal eso-

phageal transit. One-third of those referred presented

exclusively with esophageal abnormalities, while one-third

had both oropharyngeal and esophageal abnormalities. Oral

abnormalities, reduced pharyngoesophageal segment maxi-

mum opening (PESmax), and increasing age were significantly

associated with esophageal abnormalities.

Conclusion

. Fluoroscopic evaluation of the pharynx alone,

without esophageal review, risks incomplete diagnosis of

patients with esophageal disorders. Using esophageal visuali-

zation allows timely referral for further investigation by

appropriate medical specialties, avoiding incomplete manage-

ment of patients with dysphagia.

Keywords

deglutition, deglutition disorders, dysphagia, esophageal visua-

lization, speech-language pathology, otorhinolaryngology

Received August 13, 2014; revised October 23, 2014; accepted

December 4, 2014.

ssociations between oropharyngeal abnormalities

and esophageal abnormalities are poorly understood

but well documented.

1-3

Oropharyngeal alterations

have been reported in patients with gastroesophageal reflux

disease.

Neurologic diseases such as Parkinson disease

5,6

and systemic conditions such as scleroderma

lead to both

oropharyngeal and esophageal abnormalities. In a recent

study using high-resolution manometry, O’Rourke and col-

leagues

describe a variety of esophageal alterations during

voluntary pharyngeal maneuvers (effortful swallow and

Mendelsohn), adding to the theory that changing one point

in the swallowing system can lead to positive or negative

changes elsewhere. In addition, patient accuracy in locating

the level of bolus holdup has been shown to be poor, with

patients often indicating the cervical region or levels more

proximal than the true site of bolus stasis, particularly when

this occurs in the esophagus.

1,9,10

Smith and colleagues

reported 57% of respondents located a solid bolus impacted

at a distal esophageal ring to the level of the sternal notch.

Complaints of dysphagia for solids regularly lead to

speech-language pathology (SLP) referral rather than gastroen-

terology or otorhinolaryngology (ORL). Traditionally, SLP-led

videofluoroscopic study of swallowing (VFSS) has assessed

the oropharynx exclusively, even when symptoms might sug-

gest esophageal complaints. This results in failure to identify

patients with esophageal problems. These patients are sent

home with no diagnosis and either continue to manage their

symptoms alone or undergo a variety of other diagnostic tests

over a prolonged period of time before reaching correct diag-

nosis and treatment. An esophageal screen was described and

validated by Allen and colleagues in 2012.

They compared

fluid esophageal screens with full esophagrams in 74 mixed-

The University of Auckland, Auckland, New Zealand

Waitemata District Health Board, Auckland, New Zealand

Corresponding Author:

Anna Miles, PhD, Speech Science, University of Auckland, Private Bag

92019, Auckland 1142, New Zealand.

Email:

a.miles@auckland.ac.nz

Reprinted by permission of Otolaryngol Head Neck Surg. 2015; 152(3):488-493.

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