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DYSPHAGIA ASSESSMENT AND TREATMENT PLANNING: A TEAM APPROACH
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(2006). Relationship between fluoroscopic and manometric measures of
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Other Technologies in
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Dysphagia Assessment
Maggie A. Kuhn
Recent advances have produced technology that is increasingly smaller,
faster, and more sophisticated. These
developments have influenced the
field of swallowing disorders and
have greatly enhanced our ability to
efficiently diagnose and appropriately
care for patients with such conditions.
To provide comprehensive treatment
for individuals with dysphagia, a broad
understanding of evolving diagnostic modalities is critical; these include
endoscopic, imaging, motility, and
reflux studies.
ENDOSCOPY
Transnasal Esophagoscopy
Distal chip videoscopes have largely
replaced flexible fiberoptic models and
provide high-resolution images of the
esophagus with ultrathin transnasal
endoscopes. Traditionally, esophagos-
copy has been performed transorally
with a rigid or flexible endoscope
requiring a patient be adequately
sedated. Since its introduction in the
1990s, unsedated transnasal esophagoscopy (TNE) has been widely adopted
and performed reliably and comfortably
in the office. Multiple reports have confirmed its safety and accuracy (Howell
et al., 2016; Postma etal., 2005). In their
series, Postma et al. (2005) report the
most frequent indications for TNE as
esophageal screening in persons with
reflux, globus, and dysphagia. Of 700
procedures, only 17 had to be aborted
because of a tight nasal vault. The most
serious complication was self-limited
epistaxis (<2%).
Comprehensive dysphagia evaluation should include assessment of the
esophagus, as patients are not particularly accurate at localizing the site of
their swallowing symptoms. In fact,
approximately one third of individuals
who localize the site of their dysphagia
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DYSPHAGIA ASSESSMENT AND TREATMENT PLANNING: A TEAM APPROACH
above the clavicle will have an esophageal etiology for their symptom (Castell et al., 1979). Transnasal esophagoscopy is a suitable first-line tool for this
assessment and has greatly enhanced
our ability to diagnose esophageal
pathology in persons with pill or solid
food dysphagia. In their prospective
study of over 300 patients undergoing
TNE, Howell et al. (2016) report that
the most common findings prompting a change in patient management
include squamocolumnar irregularity,
reflux esophagitis, esophageal stricture
(Figure 9–1), and infectious esophagitis.
Furthermore, TNE has proven to be an
instrumental tool in the evaluation of
high-risk populations with dysphagia,
including those treated for head and
neck cancer. In a study of 100 head and
neck cancer survivors undergoing TNE,
only 13% had normal endoscopies, with
esophagitis and stricture representing
the most common findings (Farwell
etal., 2010).
Guided Observation of
Swallowing in the Esophagus
The fiberoptic endoscopic evaluation
of swallowing (FEES) is a useful tool to
assess the pharyngeal phase of deglutition and does not expose patients to
radiation. Owing to the ease of performing TNE in unsedated, upright
individuals, clinicians have the ability to extend the endoscopic evaluation of swallowing into the esophagus.
Guided observation of swallowing in
the esophagus (GOOSE) is the esophageal counterpart to FEES (Video 9–1,
GOOSE on the companion website). In
the clip, a patient is given applesauce,
and its passage through the esophagus
is observed. Later, the scope is inserted
through the lower esophageal sphincter
(LES) and retroflexed to observe a pill
exit the esophagus into the stomach.
To accomplish GOOSE, the ultrathin
endoscope is passed through the nose
and placed just beyond the soft palate,
above the tip of the epiglottis. FEES
is carried out as previously described
(see Chapter 4). If no oral or pharyngeal abnormality responsible for the
patient’s dysphagia is encountered,
or if a comorbid esophageal disorder
is suspected, GOOSE is performed.
The endoscope is passed through the
upper esophageal sphincter (UES) into
the cervical esophagus during a saliva
or water swallow. Normal esophageal
transit is approximately 2 cm per sec-
www
Figure 9–1. Transnasal esophagoscopy findings in peptic esophageal disease. A. Ero-
sive esophagitis (LA Class A) and peptic stricture proximal to the gastroesophageal
junction. B. Long segment of Barrett’s esophagus. C. Advanced adenocarcinoma of
the distal esophagus with food debris.
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177
ond. Any esophageal residue from the
previously performed FEES suggests
delayed esophageal transit. With the
scope in the esophagus, the patient is
first given a 15-cc bolus of thin liquid
impregnated with food coloring, and
esophageal peristalsis is visualized as
the liquid passes. The lumen of the
esophagus should obliterate around
the endoscope as the liquid is transported through. The esophagoscope
is promptly advanced to follow the
liquid bolus as it moves through the
entire length of the esophagus and
passes into the stomach. The patient
may then be fed a puree (applesauce) or
solid (marshmallow, cracker, or bagel)
consistency. Depending on individual
complaints, a pill may be administered
as well (Figure 9–2). At the end of the
examination, a retroflexed view of the
gastric cardia is obtained from within
the stomach. The patient is given a
15-cc bolus of thin liquid, and the timing from the initiation of the swallow
to the entry of the bolus into the stomach is noted. A transit time >15 seconds suggests an esophageal transit
problem.
IMAGING
Although fluoroscopy and endoscopy
remain the mainstays of instrumental
swallowing evaluation tools, the novel
application of existing imaging modalities to deglutition has increasingly been
explored. While some of these techniques remain largely as research tools,
some have found clinical applications
in specific patient populations or as
biofeedback-based therapies.
Ultrasound
Sonography is widely used in neck and
thyroid evaluation; it was first used as
a tool in swallowing assessment many
decades ago. Owing to significant operator variability and limited evaluation
of the swallowing sequence, ultrasound
is less commonly used than other imaging modalities, such as fluoroscopy, by
dysphagia clinicians. However, it offers
the benefits of radiation-free evaluation and an inexpensive, point-of-care
assessment, which have fostered its
application in certain clinical settings.
Ultrasound has been shown to accurately demonstrate muscle morphology
as well as oral, pharyngeal, and laryngeal kinematics (Huckabee et al., 2015).
This functionality holds potential for
the diagnostic role of ultrasound and
establishes it as a useful adjunct to sitespecific, biofeedback-driven therapy.
Figure 9–2. Guided observation of swal-
lowing through the esophagus (GOOSE)
in a patient with dysphagia to pills reveals
a retained pill and liquid stasis above a
distal peptic stricture.
Scintigraphy
Scintigraphy is a nuclear imaging study
that measures the presence and quantity of nuclear radiotracer. During
swallowing scintigraphy, patients are
seated upright and oblique in front
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DYSPHAGIA ASSESSMENT AND TREATMENT PLANNING: A TEAM APPROACH
of a large-field gamma camera. It is
helpful to use radiolabeled markers
to identify patient landmarks, as pharyngeal anatomic resolution is limited
during scintigraphy. Liquid boluses
containing a nuclear tracer, commonly
Technetium99m, are administered and
multiple sequential data displays are
acquired. This readily allows for the
visualization of immediate aspiration
into the lung fields, whereas delayed
presence in the chest is an indicator of
gastroesophageal or esophagopharyngeal reflux and aspiration (Falk etal.,
2015). A composite image of bolus
location is generated after background
counts are subtracted.
Applications of scintigraphy for
swallowing assessment have emerged
in both clinical and research contexts.
Because it allows for objective quantification of nuclear tracer bolus and
avoids radiation exposure, scintigraphy
is a promising adjunct to videofluoroscopy. Comparisons to videofluoroscopy
show that swallowing scintigraphy
has fair to good accuracy in measuring early pharyngeal entry, pharyngeal
transit time, and postswallow pharyngeal residue (Huang et al., 2013). Mainly
reserved for research settings, studies
have demonstrated superb accuracy
with this imaging modality that obviates radiation exposure, which makes it
particularly attractive for pediatric populations. The major limitation of this
modality is lack of anatomic resolution.
Magnetic Resonance Imaging
assessment of task-specific cortical activation, further enhancing our understanding of swallowing neurocircuitry,
and may one day be used beyond the
research domain in assigning diagnoses, prognoses, and therapies to
patients with dysphagia. Recent and
rapid improvements in dynamic MRI
acquisition allow real-time capture of
all phases of deglutition as well as highresolution evaluation of the anatomic
structures participating in swallowing.
Comparison with traditional videofluoroscopy has shown excellent accuracy
and reproducibility of dynamic MRI
swallow studies (Lafer et al., 2013).
While this modality spares patients
from radiation exposure, it is expensive
and time-consuming and is often limited in degrees of patient positioning.
High-Resolution Computed
Tomography
Computed tomography (CT) allows
for the simultaneous acquisition of
structural and functional information
and may be most applicable to those
needing imaging surveillance, such as
head and neck cancer patients. Threedimensional reconstructions yield
useful information about constriction
properties and bolus flow (Fujii et al.,
2011). Significant aspects of high-resolution computed tomography, including cost, acquisition time, and radiation exposure, limit its wide adoption
as a primary modality for swallowing
evaluation.
The application of functional magnetic
resonance imaging (MRI) to swallowing kinematics has greatly advanced
our knowledge of swallowing neurophysiology. This technology allows for
MOTILITY
Efficient deglutitive motility requires
adequate contractile forces to propel
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bolus transit, as well as the anterograde
movement of the physical bolus through
the digestive tract. Tests of manometry
and impedance have become common
tools of the swallowing clinician. Technological advances have made possible
much more detailed motility evaluations of specific pharyngoesophageal
components, including the upper and
lower esophageal sphincters. In addition, expanding device functionality
now allows for simultaneous manometric and impedance acquisition.
Esophageal Manometry
Since its recent introduction, highresolution esophageal manometry
(HRM) has largely replaced conventional manometry. HRM is performed
with a 2.7-mm or 4.2-mm-diameter
catheter containing 36 circumferential,
solid-state pressure sensors spaced 1 cm
apart, whereas conventional manometry catheters contain only 5 sensors
spaced widely apart. Thus, HRM provides a unique high-fidelity measurement of pharyngeal, sphincteric, and
esophageal body physiology displayed
on a dynamic, color-coded spatiotemporal topography plot (Figure 9–3).
Since 2009, HRM findings have guided
the categorization of esophageal motility disorders known as the Chicago
Classification©, most recently updated
to version 4.0 in 2021 (Yadlapati et al.,
2021).
Figure 9–3. Normal HRM pressure topography plot with complete UES relaxation
(asterisk ).
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DYSPHAGIA ASSESSMENT AND TREATMENT PLANNING: A TEAM APPROACH
Pharyngeal Manometry
In cases of severe dysphagia, it is often
difficult to distinguish between pharyngeal weakness, poor pharyngeal/
cricopharyngeal coordination, and
incomplete UES relaxation. Simultaneous pharyngeal and UES manometry
provides valuable information about
pharyngeal strength, UES resting pressure and relaxation, and pharyngoesophageal coordination (Figure 9–4).
Such information is critical in driving
pharyngoesophageal dysphagia management. In 2020, an international
working group published recommendations for the clinical application of
high-resolution pharyngeal manometry
(HRPM) (Omari et al., 2020). This group
has provided important consensus on
HRPM methodology, protocol, and
analysis. In some cases, HRPM may
help predict who might benefit from
surgical cricopharyngeal myotomy,
while in others, it guides swallowing
therapy, which might include manometric biofeedback-driven strategies.
Enhancements to HRM technology
have recently allowed for variable pressure measurement about individual sensors, which appears to more accurately
measure the asymmetric anatomy and
pressure pattern of the pharynx (Rosen
et al., 2017). Broadened clinical applications of pharyngeal HRM and growing
access to training have led to increasing
use by speech-language pathologists in
the assessment and care of dysphagia
(Knigge et al., 2014).
Multichannel Intraluminal
Impedance
Impedance measures resistance to current flow. Intraesophageal content with
high ionic concentrations (food, drink,
or refluxate) has a low resistance (high
conductivity). When food from the
pharynx or refluxate from the stomach
enters the esophagus, impedance drops.
Thus, impedance provides a measure
of anterograde or retrograde transit
within the esophagus (Figure 9–5). The
addition of multichannel intraluminal
impedance to HRM furthers the clinician’s understanding of swallowing
transit by illustrating bolus presence,
postswallow residue, and UES distension during swallowing. Bolus clearance, as indicated by impedance findings, provides additional information
about the clinical significance of motility impairment.
Figure 9–4. Pharyngeal and UES HRM. A. Complete relaxation of the UES (asterisk ) and
normal hypopharyngeal pressure wave (arrow ) . B. Incomplete UES relaxation (asterisk )
with preserved hypopharyngeal pressure wave (arrow ). C. Hypertensive and absent
UES relaxation (asterisk ) with absent pharyngeal contraction (arrow ). B = baseline UES
pressure.
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Figure 9–5. High-resolution manometry without (A) and with (B) impedance tracing
(purple). Depicted is normal esophageal peristalsis and the presence of a sliding hiatal
hernia. The addition of impedance confirms an incompetent LES where stomach and
hernia contents have traveled retrograde into the distal esophagus (white asterisks).
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Nonacid reflux has been implicated
in chronic cough and aspiration, dysphagia, throat clearing, and globus.
Combined multichannel intraluminal
impedance and pH testing quantifies
both acid and nonacid reflux; it is now
the preferred technique for hardwired
pH testing. It has been particularly
helpful in evaluating persons with
persistent reflux symptoms on acidsuppressive therapy. Of individuals on
reflux medication with persistent symptoms, 20% will have symptoms from
persistent acid reflux, 40% will have
symptoms from nonacid reflux, and
40% will have symptoms not related to
reflux (Tutuian & Castell, 2005).
High-Resolution
Impedance Planimetry
Functional lumen imaging probe (FLIP)
is a recent addition to the toolset useful in esophageal evaluation. Generally
performed during sedated endoscopy,
it measures esophageal cross-sectional
area and pressure in the esophagus
using a distensible, fluid-filled bal-
loon containing a catheter covered in
impedance electrodes. FLIP readily
allows measurement of esophagogastric junction distensibility, referred to
as distensibility index (DI), and esophageal body motor response (secondary
peristalsis) to specific balloon target
volumes (Figure 9–6). Contraction patterns are categorized by the presence of
(a) repetitive anterograde contractions
(RACs), a normal finding; (b) repetitive retrograde contractions (RRCs);
(c)absent contractions; or (d) other contraction pattern. The combination of DI
and contractile information assists in
the diagnosis of certain esophageal disease states, including esophagogastric
junction outflow obstruction, achalasia,
scleroderma, and ineffective esophageal motility (Savarino et al., 2020).
Gastric Emptying
Impaired gastric emptying can manifest
as dysphagia and can exacerbate pharyngeal and esophageal phase swallowing impairments. Conventional assessment of gastric emptying is performed
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Figure 9–6. Functional lumen imaging probe (FLIP) tracings. A. Normal DI (asterisk ) and present RACs (arrows) consistent with normal study.
) and present RACs (arrows) consistent with esophagogastric junction outflow obstruction. C. Diminished DI (asterisk )
B. Diminished DI (asterisk
and absent contraction consistent with achalasia.
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with a nuclear medicine study. During
the exam, a subject consumes radiolabeled food, and multiple images are
acquired with a gamma detector at
scheduled time points for 4 hours after
meal consumption. An alternative to
this lengthy and often unreliable evaluation has recently been shown to be as
informative as traditional gastric emptying studies (Kuo et al., 2008). Wireless
capsule monitoring with the SmartPill
®
(Medtronic, Minneapolis, MN) measures whole-gut transit
— stomach,
small bowel, colon. The device contains
pH, temperature, and pressure detectors and is swallowed with a standard
composition meal or SmartBar (Figure9–7A). The capsule transmits data
to a wireless receiver worn or carried
by the subject throughout the study.
Analysis of the receiver data generates
gastric transit time, colonic transit time,
and combined small and large bowel
transit time (Figure 9–7B). Gastric transit time more than 5 hours is considered
delayed. Impaired gastric emptying is
commonly observed in patients with
diabetes but can also result from a number of other neuromuscular conditions.
Although treatments for delayed gastric emptying are limited, knowledge of
transit through the stomach is critical to
evaluate dysphagia symptoms, particularly those arising from the chest and
epigastric regions.
Ambulatory pH Testing
Reflux disease is a major contributor
to pharyngeal and esophageal phase
swallowing disorders. In a review of
patients presenting to a tertiary swallowing center, gastroesophageal reflux
(GER) represented the most common
cause of dysphagia, present in 27% of
the cohort (Hoy et al., 2013). Reflux has
been causally linked to cricopharyngeal
dysfunction and Zenker’s diverticulum
(Sasaki et al., 2003). The ability to accurately diagnose reflux disease is essential
to the care of persons with dysphagia.
Figure 9–7. Wireless motility capsule for whole-gut transit monitoring. A. Smartpill® cap-
sule is 1.3 × 2.6 cm in size and contains pH, pressure, and temperature sensors. B. The
Smartpill
the study. At ingestion (black single arrow ), temperature rises to that in the body and
pH drops. Gastric emptying (gray arrow ) is identified by a marked increase in pH. In
normal subjects, the capsule will spend up to 59 hours in the colon (double black
arrow ) before exiting the body.
®
tracing displays pH, pressure, and temperature values acquired throughout
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