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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

and esophageal abnormalities.

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.

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.

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.

Otolaryngology–Head and Neck Surgery 152(3)

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