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Scharitzer M, Pokieser P, Ekberg O. Oesophageal fluoroscopy in adults-when and why? Br J Radiol 2024; 97:1222-1233. [PMID: 38547408 PMCID: PMC11186568 DOI: 10.1093/bjr/tqae062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2023] [Revised: 01/15/2024] [Accepted: 03/18/2024] [Indexed: 06/21/2024] Open
Abstract
Oesophageal fluoroscopy is a radiological procedure that uses dynamic recording of the swallowing process to evaluate morphology and function simultaneously, a characteristic not found in other clinical tests. It enables a comprehensive evaluation of the entire upper gastrointestinal tract, from the oropharynx to oesophagogastric bolus transport. The number of fluoroscopies of the oesophagus and the oropharynx has increased in recent decades, while the overall use of gastrointestinal fluoroscopic examinations has declined. Radiologists performing fluoroscopies need a good understanding of the appropriate clinical questions and the methodological advantages and limitations to adjust the examination to the patient's symptoms and clinical situation. This review provides an overview of the indications for oesophageal fluoroscopy and the various pathologies it can identify, ranging from motility disorders to structural abnormalities and assessment in the pre- and postoperative care. The strengths and weaknesses of this modality and its future role within different clinical scenarios in the adult population are discussed. We conclude that oesophageal fluoroscopy remains a valuable tool in diagnostic radiology for the evaluation of oesophageal disorders.
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Affiliation(s)
- Martina Scharitzer
- Department of Biomedical Imaging and Image-Guided Therapy, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria
| | - Peter Pokieser
- Teaching Center, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria
| | - Olle Ekberg
- Department of Translational Medicine, Diagnostic Radiology, Lund University, Skåne University Hospital, Inga Marie Nilssons gata 49, 205 02 Malmö, Sweden
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Gregor JW, Watts SA. Implementation of Esophageal Screening in an Outpatient Hospital-Based Setting: A Quality Improvement Project. AMERICAN JOURNAL OF SPEECH-LANGUAGE PATHOLOGY 2023; 32:2603-2614. [PMID: 37722389 DOI: 10.1044/2023_ajslp-23-00069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/20/2023]
Abstract
PURPOSE Despite evidence supporting interconnectivity of oropharyngeal and esophageal swallowing, evaluation and treatment are dichotomized. When the videofluoroscopic swallowing study (VFSS) only considers oropharyngeal swallowing, the full scope of swallowing impairment may be missed. A lower rate of esophageal screening in an outpatient hospital setting may result from lack of speech-language pathologist (SLP) training and understanding of screening feasibility. This project was an internal quality improvement project (QIP) at Mayo Clinic in Arizona to (a) educate and train SLPs on conducting the Robust Esophageal Screening Test (REST) and (b) determine the feasibility of REST protocol implementation in a multidisciplinary swallow clinic. METHOD Fishbone analysis was used to identify potential causes of the gap in quality. Six Sigma methodology was used to outline the QIP. SLPs were trained in the REST protocol. To ensure adequate training, reliability ratings were assessed with the Cohen's kappa statistic. Esophageal screening via REST was implemented as an adjunct to the standard protocol during VFSS over a 3-month period for referred patients with dysphagia. Clinical findings were recorded. RESULTS All clinical rater SLPs reached the threshold of κ = .8 to ensure adequate rater reliability. Among 136 outpatients who underwent esophageal screening via REST, 100 patients completed the full REST screening and 36 completed a partial REST screening. Of the 100 full screenings, 80 patients had a failed screening, which indicated a potential esophageal swallowing impairment. Findings were discussed by members of the multidisciplinary dysphagia care team. CONCLUSIONS The results of this QIP show that focusing on assessment of dysfunction and interplay across the swallowing continuum can substantially improve patient care by expediting and specifying next steps of the multidisciplinary dysphagia care team.
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Affiliation(s)
- Jessica W Gregor
- Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic Phoenix, AZ
| | - Stephanie A Watts
- Department of Otolaryngology-Head and Neck Surgery, Morsani College of Medicine, Tampa, FL
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Randall DR, Young-Speirs M, Walker K. Association of the "Jet Phenomenon" with Positive Symptom Outcome Following Surgical Treatment of Cricopharyngeus Muscle Dysfunction. Dysphagia 2023; 38:1440-1446. [PMID: 37093277 DOI: 10.1007/s00455-023-10573-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Accepted: 03/31/2023] [Indexed: 04/25/2023]
Abstract
OBJECTIVES Cricopharyngeus muscle dysfunction (CPMD) is a common cause for progressive dysphagia and can lead to dietary restriction, reduced nutrition, weight loss, and pneumonia. Controversy exists whether CPMD is best managed with primary surgical treatment of the cricopharyngeus muscle and who represents a good surgical candidate. METHODS Retrospective review of patients diagnosed with CPMD who underwent surgical treatment were evaluated through prospectively collected pre- and postoperative Eating Assessment Tool-10 (EAT-10) and Functional Oral Intake Scale (FOIS). Videofluoroscopic swallowing studies (VFSS) were reviewed for presence or absence of a high-pressure barium stream through the upper esophageal sphincter, termed the jet phenomenon (JP). RESULTS We identified 42 patients with CPMD who underwent surgical treatment and had serial Eating Assessment Tool (EAT-10) measures obtained pre- and postoperatively. Mean EAT-10 scores improved by 12.1 points (95%CI = 8.6-15.6), p < 0.0001. There was a significantly greater improvement among patients with JP (|∆EAT-10|= 17.0, 95%CI = 12.5-21.4) compared to those without (|∆EAT-10|= 6.2, 95%CI = 1.6-10.8), p = 0.0013. Patients with JP also showed improved FOIS score (p = 0.0023) while those without JP did not. CONCLUSION This study provides the initial report on the utility of JP as a VFSS feature that is strongly associated with improved outcomes following surgical treatment of CPMD. Further work determining the physiologic correlates responsible for JP will help clarify its predictive capabilities. LEVEL OF EVIDENCE Level 3.
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Affiliation(s)
- Derrick R Randall
- Section of Otolaryngology-Head & Neck Surgery, Department of Surgery, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.
- Peter Lougheed Centre, Outpatient Dysphagia Clinic, Calgary, AB, Canada.
| | | | - Kim Walker
- Peter Lougheed Centre, Outpatient Dysphagia Clinic, Calgary, AB, Canada
- Speech Language Pathology, Department of Allied Health, South Health Campus, Calgary, AB, Canada
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McCarthy K, Finch E, Miles A. The Introduction of a Protocol for Esophageal Screening in Videofluoroscopic Swallowing Studies: Exploring Clinical Impacts and Barriers. AMERICAN JOURNAL OF SPEECH-LANGUAGE PATHOLOGY 2023; 32:2267-2281. [PMID: 37668538 DOI: 10.1044/2023_ajslp-23-00022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/06/2023]
Abstract
PURPOSE Esophageal screening is a valuable inclusion in videofluoroscopic swallowing studies (VFSSs). However, routine standardized esophageal screening does not always occur in clinical practice. This study introduced and evaluated an esophageal screening protocol at one Australian hospital. METHOD Radiology, gastroenterology, and speech-language pathology endorsed an esophageal screening protocol, which followed a timed 20-ml International Dysphagia Diet Standardisation Initiative Level 0 bolus from mouth to stomach in an upright anterior-posterior position. Measures exploring clinical impacts and barriers were recorded. Participants were compared with 100 consecutive VFSS patients prior to the introduction of the esophageal screening protocol. RESULTS During the esophageal screening protocol trial, 163 VFSSs were conducted with recruited patients. Aspiration risk (29%, n = 47/163) and positioning limitation (3%, n = 5/163) were barriers to esophageal screening. Rates of esophageal screening significantly increased with the esophageal screening protocol (χ2 = 63.462, p < .001). There was no difference in radiation dose for patients who had esophageal screening and those who did not in the esophageal screening protocol group (U = 1689.000, p = .237). The VFSS team breached the esophageal screening protocol for some patients, when evaluating esophageal transit time (n = 28) and recommending gastroenterology referral (n = 6). There was no difference between groups for rates of gastroenterology consults (χ2 = 1.805, p = .188) or dysphagia procedures (χ2 = 1.951, p = .209). CONCLUSIONS This study confirms that routine esophageal screening provides additional clinical information to assist holistic dysphagia management without adverse operational impacts. Further research with the multidisciplinary dysphagia team has commenced to continue to optimize and refine esophageal screening practice.
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Affiliation(s)
- Kellie McCarthy
- Princess Alexandra Hospital, Brisbane, Queensland, Australia
- School of Health and Rehabilitation Sciences, The University of Queensland, Brisbane, Australia
| | - Emma Finch
- Princess Alexandra Hospital, Brisbane, Queensland, Australia
- School of Health and Rehabilitation Sciences, The University of Queensland, Brisbane, Australia
- Research and Innovation, West Moreton Health, Ipswich, Queensland, Australia
| | - Anna Miles
- Department of Speech Science, School of Psychology, The University of Auckland, New Zealand
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Watts S, Gaziano J, Kumar A, Richter J. The Modified Barium Swallow Study and Esophageal Screening: A Survey of Clinical Practice Patterns. AMERICAN JOURNAL OF SPEECH-LANGUAGE PATHOLOGY 2023; 32:1065-1082. [PMID: 36917803 DOI: 10.1044/2022_ajslp-22-00022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/06/2023]
Abstract
PURPOSE Modified barium swallow study (MBSS) is a videofluoroscopic evaluation of oropharyngeal swallowing. Views of esophageal bolus flow during MBSS are permitted under speech-language pathology practice guidelines. However, controversy exists over its implementation. Poor consensus and limited practice guidance may lead to clinical practice variations. Aims of the investigation were to (a) describe current practice patterns of speech-language pathologist visualizing bolus flow through the esophagus during the MBSS, (b) understand areas of variation when incorporating esophageal visualization during the MBSS, and (c) determine clinicians' willingness to modify MBSS procedures to include esophageal imaging. METHOD A web-based survey (Qualtrics XM) consisting of 26 questions was distributed via web posting and e-mail to members of the American Speech-Language-Hearing Association Special Interest Group 13 and Dysphagia Café. The survey was open for 3 months. Descriptive and associative statistics were completed. Field-testing was performed prior to dissemination of the survey to address content validity. RESULTS A total of 321 individuals participated; 265 responses were used for analysis. Ninety-three percent of respondents viewed the esophagus during the MBSS. Twelve percent followed to the proximal esophagus, 15% to the mid esophagus, 66% to the lower esophagus, and 6% to varied levels. Variability was also reported in contrast type, volume administered, and nomenclature used. Interestingly, few people (3.61%) disagreed that esophageal visualization should be performed during MBSS. CONCLUSIONS Speech-language pathology respondents in this study visualize contrast flow through the esophagus and are enthusiastic about expanding the standard MBSS. However, results of the survey demonstrate a lack of uniformity in assessment practices. Unfortunately, this may impact the diagnostic accuracy and clinical utility when adding esophageal visualization to the MBSS. This study highlights the need for a standardized protocol and identifies current barriers and controversies that may prevent expanding the MBSS to more comprehensively evaluate individuals with dysphagia.
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Affiliation(s)
- Stephanie Watts
- Department of Internal Medicine, University of South Florida, Tampa
| | - Joy Gaziano
- Department of Internal Medicine, University of South Florida, Tampa
| | - Ambuj Kumar
- Department of Internal Medicine, University of South Florida, Tampa
| | - Joel Richter
- Department of Internal Medicine, University of South Florida, Tampa
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Reedy EL, Simpson AN, O'Rourke AK, Bonilha HS. Abnormal Esophageal Clearance Identified During Modified Barium Swallow Study in an Acute Poststroke Cohort. AMERICAN JOURNAL OF SPEECH-LANGUAGE PATHOLOGY 2022; 31:2643-2662. [PMID: 36179218 DOI: 10.1044/2022_ajslp-22-00029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
PURPOSE Dysphagia impacts many poststroke survivors with wide-ranging prevalence in the acute and chronic phases. One relatively unexplored manifestation of poststroke swallowing impairment is that of primary or co-occurring esophageal dysphagia. The incidence of esophageal dysphagia in this population is unknown despite the shared neuroanatomy and physiology with the oropharynx. We aimed to determine the presence of abnormal esophageal clearance in an acute poststroke sample using the Modified Barium Swallow Impairment Profile (MBSImP) Component 17 (esophageal clearance) as our outcome measure. METHOD We performed a retrospective, cross-sectional, cohort study of 57 poststroke patients with acute, first-ever, ischemic strokes. All participants received a modified barium swallow study (MBSS) using the MBSImP protocol and scoring metrics. Swallowing impairment was determined using a combination of MBSImP scores and Penetration-Aspiration Scale scores. Swallowing outcome measures were collected including Functional Oral Intake Scale and International Dysphagia Diet Standardization Initiative (IDDSI) scores. We performed tests of association and logistic regression analysis to determine if statistically significant associations exist between judgments of esophageal clearance and other swallowing impairments and/or swallowing outcome measures. RESULTS In our study of poststroke patients who received an MBSS as part of their care, 57.9% had abnormal esophageal clearance. Statistically significant associations were also identified in measures of pharyngeal physiology (MBSImP scores) and swallowing outcome measures (IDDSI scores and alternate means of nutrition). CONCLUSIONS Abnormal esophageal clearance was identified in greater than half of our poststroke patients. There is a dearth of scientific research regarding esophageal function poststroke. While esophageal visualization during the MBSS is not diagnostic of esophageal impairment, it may serve as an indicator for those poststroke patients who require dedicated esophageal testing to best determine the full nature of their swallowing pathophysiology and make the most effective treatment recommendations.
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Affiliation(s)
- Erin L Reedy
- Health Sciences and Research, Medical University of South Carolina, Charleston
| | - Annie N Simpson
- Health Sciences and Research, Medical University of South Carolina, Charleston
- Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston
| | - Ashli K O'Rourke
- Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston
| | - Heather Shaw Bonilha
- Health Sciences and Research, Medical University of South Carolina, Charleston
- Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston
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Wilson H, Mocanu V, Wong C, Karmali S. The Utility of the Marshmallow Barium Swallow Esophagogram for Investigation of Ineffective Esophageal Motility: A Systematic and Narrative Review. JOURNAL OF GASTROINTESTINAL AND ABDOMINAL RADIOLOGY 2022. [DOI: 10.1055/s-0042-1751256] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/15/2022] Open
Abstract
Abstract
Objectives Current gold standard investigations to determine the pathology of ineffective esophageal motility (IEM) are invasive and resource-intensive. Marshmallow barium swallow esophagogram (MBSE) is emerging as a more feasible modality; however, our understanding of its role in the clinical setting is limited. Our aim was to appraise the current literature and describe the effectiveness and limitations of MBSE as a potential diagnostic tool when investigating the pathological cause of IEM.
Methods A search in PubMed was conducted on May 23, 2021. Search terms included “marshmallow” AND “barium.” We included all studies which examined MBSE in the context of esophageal disease. The primary outcome of interest was to characterize the use of MBSE in current literature.
Results A total of 12 studies were retrieved after initial search with 9 studies meeting final inclusion criteria. A total of 375 patients were included, with 296 patients (79%) having a relevant diagnosis or symptom prompting investigation with MBSE. The most common diagnoses included referral to a gastroenterology clinic for a barium swallow (44%), post-Angelchik insertion (23%), and dysphagia (13%). Esophageal disease was identified in both the MBSE and other screening tests in 63% participants, whereas in 27% participants abnormalities were only seen using the MBSE.
Conclusion There is currently limited high-quality evidence on the use of MBSE to diagnose IEM. Further large-scale studies comparing its use in patients with different pathologic causes of IEM and of older age are required to further delineate the optimal delivery of this emerging diagnostic modality.
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Affiliation(s)
- H. Wilson
- Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - V. Mocanu
- Department of Surgery, University of Alberta, Edmonton, Alberta, Canada
| | - C. Wong
- Division of Gastroenterology, University of Alberta, Edmonton, Alberta, Canada
| | - S. Karmali
- Department of Surgery, University of Alberta, Edmonton, Alberta, Canada
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