The Effect of Voluntary Pharyngeal Swallowing Maneuvers on Esophageal Swallowing Physiology

Oesophageal fluoroscopy in adults-when and why?

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.

Effect of Visual Biofeedback Obtained Using the Iowa Oral Performance Instrument on the Suprahyoid Muscle Activation Level During Effortful Swallowing Maneuver

Effortful swallowing (ES) is a maneuver prescribed for patients who experience pharyngeal residues after swallowing owing to weakness of the tongue and pharyngeal constrictor muscles. ES can increase the pharyngeal contraction force by intentionally increasing the degree of effort during swallowing. However, the effect is limited as the nature of swallowing makes it difficult to maintain a constant high-effort level. The aim of this study was to assess the effect of visual feedback, delivered by the Iowa Oral Performance Instrument (IOPI), a tongue pressure measurement device on ES maneuver effort. Overall, 34 healthy adults performed five sets of ten ES, once every 10 s. The ES maneuver was conducted under two conditions, ES with and without IOPI biofeedback in a crossover design. IOPI biofeedback was provided at 80% of the maximum posterior oral tongue pressure. The suprahyoid muscle activation level was assessed using surface electromyography during the ES maneuver. The mean suprahyoid muscle activation levels in all sets for which IOPI biofeedback was provided were significantly higher than those during ES maneuver without biofeedback (p < 0.05). IOPI biofeedback can help maintain the ES maneuver target effort, utilizing a constantly high swallowing pressure potentially promoting better pharyngeal pressures and muscle strength.

Implementation of Esophageal Screening in an Outpatient Hospital-Based Setting: A Quality Improvement Project

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.

The Modified Barium Swallow Study and Esophageal Screening: A Survey of Clinical Practice Patterns

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.

Abnormal Esophageal Clearance Identified During Modified Barium Swallow Study in an Acute Poststroke Cohort

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.

Effect of effortful swallow on pharyngeal pressures during swallowing in adults with dysphagia: A pharyngeal high-resolution manometry study

Purpose: Evidence base to support the use of the effortful swallow in clinical populations with dysphagia is currently lacking. This study aims to quantify the effects of effortful swallowing on pharyngeal swallowing biomechanics in adults with dysphagia using pharyngeal high-resolution manometry (PHRM).Method: ManoScan HRM equipment with a 4.2 mm pressure catheter was used. Participants completed duplicate 10ml baseline and 10ml effortful liquid (IDDSI Level 0) swallows in randomised order. PHRM data were analysed using a semi-automated online platform (www.swallowgateway.com).Result: Fifteen adults (8 males; range 45-86 years) with mixed aetiology dysphagia (Functional Oral Intake Scale Level 2-5) were included. Median pharyngeal contractile (156.81 mmHg cm s; IQR 80.62) increased significantly (213.50 mmHg cm s; IQR 117.2) during effortful swallowing. Significant increases were also observed in velopharyngeal pressure, mesopharyngeal pressure, hypopharyngeal pressure and upper oesophageal sphincter (UOS) relaxation duration. UOS integrated relaxation pressure (IRP) was not significantly altered with effortful swallowing.Conclusion: Effortful swallowing induced significant biomechanical changes to swallow in adults with dysphagia. Increases in global pharyngeal rigour, tongue base pressure and UOS opening duration were captured by PHRM during effortful swallowing. Further investigation in larger homogeneous clinical populations is needed to verify the physiological effects of this frequently employed intervention.

Effect of Topical Nasal Anesthetic on Comfort and Swallowing in High-Resolution Impedance Manometry

OBJECTIVES/HYPOTHESIS

Use of topical nasal anesthetic (TNA) is common in high-resolution impedance manometry (HRIM). This study investigated the effect of TNA on swallowing and procedure tolerability during HRIM with a 4.2-mm catheter, a more commonly used catheter size with impedance capabilities.

STUDY DESIGN

Randomised experimental study with blinding of participants.

METHODS

Twenty healthy participants (mean age = 33 years, 16 female) were randomized to undergo HRIM using the ManoScan™ ESO Z 4.2-mm catheter twice, 1 week apart, under two conditions: with TNA (viscous lidocaine) and with placebo. Analyses included esophageal data of three saliva, three saline (5 mL), and three bread swallows (2 cm × 2 cm) performed while reclined 45°, and pharyngeal data under the same conditions while seated upright. Pharyngeal and upper esophageal sphincter (UES) HRIM parameters were analyzed using the Swallow Gateway analysis platform. Visual analogue scale (VAS) scores rating procedural comfort were analyzed.

RESULTS

There were no significant physiological differences in pharyngeal and UES parameters between conditions. There were also no significant differences in VAS scores under placebo (mean = 54.8, standard deviation (SD) = 19.3) and TNA (mean = 60.0, SD = 21.9) (t[19] = -0.9, P = .4) conditions; however, there was a significant difference in the first versus second session (t[19]) = 5.1, P < .05).

CONCLUSIONS

TNA did not improve comfort, but it also did not significantly affect swallowing behavior. There was, however, a practice effect regardless of TNA use with improved tolerance of the 4.2-mm catheter and likely more natural swallowing behavior during the second session of HRIM.

LEVEL OF EVIDENCE

3 Laryngoscope, 2022.

Visualizing the Esophagus During Modified Barium Swallow Studies: A Systematic Review

Purpose Despite the emphasis on using evidence-based practice for patient care, as clinicians, we sometimes find that there is insufficient evidence to support our clinical practices. One example of this is the "contentious" inclusion of routine, standardized visualization of the esophagus during modified barium swallow studies (MBSSs). This review sought to investigate the evidence for inclusion of routine esophageal visualization during the MBSS, a practice that is supported by the long-established interrelationship between all aspects of the oral, pharyngeal, and esophageal swallowing continuum. Method Searches were conducted in PubMed, Scopus, and CINAHL databases. Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines were followed to identify articles that met prespecified inclusion and exclusion terms. Results Five articles were included in this review, which identified that esophageal findings were present in 48.67% of those participants whose MBSS included esophageal visualization. Conclusion This review supports a standardized, validated, reliable visualization protocol of the esophagus during the MBSS as a critical component to the accurate diagnosis and formulation of treatment recommendations for patients with swallowing disorders.

Diagnostic Accuracy of an Esophageal Screening Protocol Interpreted by the Speech-Language Pathologist

Oropharyngeal and esophageal dysphagia may occur simultaneously. However, symptoms are often evaluated separately. Few standardized, multi-texture esophageal screening protocols exist as an addition to the modified barium swallow study (MBSS). Given the gap in MBSS evaluation standards, providers may be lacking information needed to fully assess the swallowing process and create appropriate dysphagia management plans. The aim was to assess the diagnostic accuracy of a standardized esophageal screening protocol performed by an SLP compared to formal reference esophageal examinations. A cross-sectional analytic study was performed. Consecutively referred patients who underwent same-day consultation with the SLP and a gastroenterologist were included. MBSS with a standardized esophageal screen was performed. Same-day formal esophageal testing was completed and included timed barium emptying study or high-resolution manometry. Summary diagnostic accuracy measures were calculated. Seventy-three patients matched the inclusion criteria. Median age was 62.5 years (25-87), 55% were female. Sensitivity of the esophageal screen for the detection of esophageal abnormality was 83.7% (95% CI 70-91.9%); specificity was 73.7% (95% CI 55.6-85.8%). The positive likelihood ratio was 3.14 (95% CI 1.71-5.77), whereas the negative likelihood ratio was 0.22 (95% CI 0.11-0.45). Positive and negative predictive values were 82% and 76%, respectively. Use of a systematic, multi-texture esophageal screen protocol interpreted by SLPs accurately identifies multiphase dysphagia and should be considered in addition to standard MBSS testing. Inclusion of a cursory esophageal view may more adequately assess dysphagia symptoms and help to promote multidisciplinary care.

Characterization of Esophageal and Sphincter Reflexes across Maturation in Dysphagic Infants with Oral Feeding Success vs Infants requiring Gastrostomy

To test the hypothesis that esophageal and sphincteric sensory-motor reflexes are distinct across maturation in infants with dysphagia receiving gastrostomy-tube (G-tube). This is a retrospective review of 29 dysphagic infants (N = 15 study requiring gastrostomy, N = 14 age matched control achieving oral feeds) that underwent longitudinal pharyngeal-esophageal manometry at 42.3 (37-50.2) weeks postmenstrual age (PMA) and 48.9 (43.3-57.9) weeks PMA. Graded stimuli (0.1-5 mL) of varying media (air, water, and apple juice) tested esophageal peristaltic reflex, upper esophageal sphincter contractile reflex (UESCR), and lower esophageal sphincter relaxation reflex (LESRR). Comparisons were performed between study and controls and across maturation (time-1 vs time-2). Data represented as mean ± SE or OR (95% CI). Across maturation (time-1 vs time-2): Study infants did not exhibit significant differences across in peristaltic, UES, or LES reflexes (all p > 0.05). In contrast, controls exhibited increased UES resting pressure (13 ± 3 vs 17 ± 3 mmHg, p = 0.001), LES resting pressure (22 ± 3 vs 25 ± 3 mmHg, p < 0.009), LES nadir pressure (0.5 ± 1 vs 4.3 ± 1 mmHg, p = 0.001), and esophago-deglutition responses [2.5 (1.23-4.88), p = 0.04], and decreased secondary peristalsis [0.44 (0.31-0.61), p = 0.001], UESCR [0.4 (0.25-0.65), p = 0.001], LESRR [0.4 (0.24-0.75), p = 0.01], and symptoms [0.6 (0.45-0.83), p = 0.005]. Among infants with dysphagia, esophageal provocation induced peristaltic reflex, UESCR, and LESRR advance with longitudinal maturation when infants are oral-fed successfully, but not in those who received gastrostomy. Underlying mechanisms may be related to esophageal sensitivity, afferent or efferent transmission, and coordination of upstream excitation and downstream inhibition, which can be potential therapeutic targets for improving feeding capabilities after gastrostomy placement in infants with dysphagia.

Oesophageal screening during videofluoroscopy: International practices and perspectives of speech-language pathologists

Purpose: The aim of this study was to investigate international oesophageal screening (OS) practices during videofluoroscopy (VFS) amongst speech-language pathologists (SLPs) and to establish SLP perspectives regarding OS during VFS.Method: A 25-item online survey was developed and disseminated internationally. Respondents were SLPs with dysphagia and VFS experience. Information was sought on OS practices and perspectives. Descriptive statistics were used to analyse results.Result: A total of 202 SLPs completed the survey from USA, UK, Ireland, New Zealand, Australia and Austria. Fifty-eight per cent (n = 117/202) of SLPs internationally include an OS during VFS. This rate varies across USA (81%; 91/113), UK (69%; 18/26) and Ireland (60%; 18/30). Only 25% (29/117) of SLPs use a validated OS protocol. Most SLPs perform an OS in an anterior-posterior view (55%; 64/117) with patients seated (54%; 64/117). Bolus consistencies administered vary greatly. SLPs evaluate oesophageal bolus clearance (81% (95/117), bolus redirection (64%; 75/117), oesophageal transit time (49%; 57/117) and oesophageal pathology (11%; 13/117). Perceived challenges include scope of practice, patient positioning, protocol uncertainty and multidisciplinary support.Conclusion: Over half of SLPs internationally responding to the survey include an OS during VFS. Few follow validated protocols and analysis practices vary. OS guidelines and training opportunities are needed to ensure validated OS protocols are adopted into clinical practice.

How Closely do Machine Ratings of Duration of UES Opening During Videofluoroscopy Approximate Clinician Ratings Using Temporal Kinematic Analyses and the MBSImP?

Clinicians evaluate swallow kinematic events by analyzing videofluoroscopy (VF) images for dysphagia management. The duration of upper esophageal sphincter opening (DUESO) is one important temporal swallow event, because reduced DUESO can result in pharyngeal residue and penetration/aspiration. VF is frequently used for evaluating swallowing but exposes patients to radiation and is not always feasible/readily available. High resolution cervical auscultation (HRCA) is a non-invasive, sensor-based dysphagia screening method that uses signal processing and machine learning to characterize swallowing. We investigated HRCA's ability to annotate DUESO and predict Modified Barium Swallow Impairment Profile (MBSImP) scores (component #14). We hypothesized that HRCA and machine learning techniques would detect DUESO with similar accuracy as human judges. Trained judges completed temporal kinematic measurements of DUESO on 719 swallows (116 patients) and 50 swallows (15 age-matched healthy adults). An MBSImP certified clinician completed MBSImP ratings on 100 swallows. A multi-layer convolutional recurrent neural network (CRNN) using HRCA signal features for input was used to detect DUESO. Generalized estimating equations models were used to determine statistically significant HRCA signal features for predicting DUESO MBSImP scores. A support vector machine (SVM) classifier and a leave-one-out procedure was used to predict DUESO MBSImP scores. The CRNN detected UES opening within a 3-frame tolerance for 82.6% of patient and 86% of healthy swallows and UES closure for 72.3% of patient and 64% of healthy swallows. The SVM classifier predicted DUESO MBSImP scores with 85.7% accuracy. This study provides evidence of HRCA's feasibility in detecting DUESO without VF images.

A Systematic Review of the Physiological Effects of the Effortful Swallow Maneuver in Adults With Normal and Disordered Swallowing

Purpose This systematic review summarizes the biomechanical and functional effects of the effortful swallow in adults with and without dysphagia, highlighting clinical implications and future research needs. Specifically, the effects of the effortful swallow on swallowing physiology, safety, and efficiency were identified, as well as the strengths and limitations of current research. Method Recommendations specified by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses were followed. A literature search of three databases and relevant articles cited in the searched studies was performed. Two evaluators independently analyzed the studies for eligibility criteria, and final inclusion of studies was decided by consensus. Evaluators also assessed each study for quality of evidence. Results Twenty-three studies were included in this systematic review. Main findings indicated that the effortful swallow generated greater pressures in the tongue-to-palate, pharynx, upper esophageal sphincter, and esophageal regions. Inconsistent results for hyolaryngeal excursion were reported, as well as for swallowing function. Instructions of the effortful swallow varied greatly across studies. Two of the 23 studies were judged to be of high quality, and the remaining studies were of medium quality based on the quality indicators of this review. Conclusions Biomechanical effects of the effortful swallow included increased pressures in the oral, pharyngeal, and esophageal regions. Future investigations should address the effects of the effortful swallow in individuals with dysphagia and its potential role as a rehabilitative maneuver. Moreover, standardization of the effortful swallow instructions based on its physiological and functional effects is essential.

The Emerging Importance of High-Resolution Manometry in the Evaluation and Treatment of Deglutition in Infants, Children, and Adults: New Opportunities for Speech-Language Pathologists

Purpose Diagnostic precision and prolonged testing before, during, and after deglutition is lacking across the age spectrum. Conventional clinical evaluation and radiologic methods are widely used but are reliant on human perception, carrying the risk of subjectivity. High-resolution manometry (HRM) is an emerging clinical and research tool and has the capability to objectively measure the dynamics, kinetics, regulatory, and correlation aspects of deglutition. Method We review the basics of manometry and the methods, metrics, and applications of this technology across the age spectrum. The goal is to aid in the translation of HRM from research tool to clinical use by the speech-language pathologist in the development of better global plans to understand normal and abnormal deglutition. Results HRM is an easily adaptable precise diagnostic tool that can be used to examine deglutition phases and abnormalities across the age spectrum from neonates to nonagenarians and can be a valuable adjunct to specialty evaluation of persistent deglutition disorders. Conclusion New opportunities will emerge upon further research for larger-scale translation once normative data and recognition of biomarkers of abnormality are ascertained.

Esophageal Transit Times Vary with Underlying Comorbid Disease

Objectives

Little is known about esophageal transit times (ETT) in relation to underlying comorbid disease or aspiration risk. Our study evaluated liquid ETT in patients relative to underlying comorbid disease and compared this with ETT in healthy adults. We examined whether prolonged ETT was associated with swallow risk.

Study Design

Prospective observational study.

Setting

Radiology department.

Subjects

Patients included those referred to speech pathology for a videofluoroscopic study of swallowing (VFSS) within a tertiary hospital.

Methods

A total of 617 patients (49% female; mean ± SD age, 77 ± 15 years) and 139 healthy adults (56% female; age, 59 ± 22 years) were included. All patients underwent a standardized VFSS with esophageal screening. Patients were categorized by chief underlying disorder: previous stroke (n = 207), other neurologic condition (n = 188), respiratory conditions (n = 91), or gastroenterology conditions (n = 131). All VFSSs were analyzed with objective measures. ETT and penetration-aspiration scores were compared between groups.

Results

Advancing age was significantly associated with increased ETT ( P < .05). When controlling for age, mean 20-mL ETT remained significantly different across groups: healthy adults, 11 seconds; stroke, 17 seconds; other neurologic condition, 15 seconds; gastroenterology, 14 seconds; and respiratory, 9 seconds ( P < .001). One-third of patients aspirated; no healthy adults aspirated. Increasing ETT was associated with aspiration events ( P < .001).

Conclusions

Liquid ETTs differ among patients with different underlying primary diagnoses. Patients following stroke show significantly prolonged ETT and increased risk of aspiration. Prolonged ETT may influence symptom complaint and warrants consideration.

Respiratory-Swallow Pattern Following Total Laryngectomy

The goal of this study was to further characterize respiratory patterns in total laryngectomees with attention to respiratory-swallow pattern as it relates to presence/absence of tracheoesophageal puncture (TEP) and bolus consistency. It was hypothesized that participants with TEP would exhibit respiratory-swallow patterns that were significantly different than those without TEP and that bolus consistency (thin or solid) would modulate respiratory-swallow pattern. Data were collected from 12 adults (8 male), aged 46-67 years (mean 57) status post total laryngectomy (1-30 years; average 6 years). Those actively receiving chemoradiation, with history of esophageal cancer, with neurologic disease, with history of lung cancer, with known or suspected recurrence of head and neck cancer (HNC), or with severe cognitive deficits were excluded. Laryngectomy participants were asked to swallow three sips of water and three bites of graham cracker. Submental surface EMG activity was used to detect swallows and a custom stoma mask in line with a pneumotachograph measured airflow during the swallows. Non-parametric Mann-Whitney test for differences was used to detect significance for our dependent variables, TEP or bolus consistency and independent variables, respiratory-swallow pattern. Laryngectomee's showed preference for swallow during inspiration which is inconsistent with the expiratory pattern preference found in healthy adults with intact larynges by McFarland et al. (Respir Physiol Neurobiol 234:89-96, 2016) but consistent with the pattern preference for inspiration (or non-dominant respiratory-swallow phase pattern) found in the HNC population at-large by Brodsky et al. (J Appl Physiol 112(10):1698-1705, 2012). No significant difference was found in swallow pattern with regards to presence/absence of TEP or bolus consistency.

SLP-Perceived Technical and Patient-Centered Factors Associated with Pharyngeal High-Resolution Manometry

High-resolution manometry (HRM) objectively measures swallowing-related pressures in the pharynx and esophagus. It has been used in many research applications, but it is unclear how HRM is perceived amongst speech-language pathologists (SLP) as it enters into clinical practice. The purpose of this study was to explore SLP perceptions of clinical HRM use. Based on qualitative data collected at four focus groups held at two national conferences and a survey based on open-ended questions, we found broad consensus among those queried regarding how HRM's objective and targeted data could enhance diagnosis and drive treatments. However, we found less consensus among SLPs regarding which patients may and may not benefit, as well as when in the clinical process HRM would best supplement existing technologies, showing a need for further research. These findings highlight how SLPs can be motivated to adopt new clinical technologies if they see a patient-centered benefit and underscore the need for continued SLP education on pharyngeal HRM.

Correlates of Early Pharyngeal High-Resolution Manometry Adoption in Expert Speech-Language Pathologists

Pharyngeal high-resolution manometry (HRM) is at a point of entry into speech-language pathologist (SLP) clinical practice. However, the demographic characteristics of SLPs who are early adopters of HRM are unclear; perspectives of early adopters may shape how the technology is received by the field at large. We hypothesized that younger SLPs, those working in outpatient settings, those with a strong knowledge base in HRM, and those with experience in other types of instrumentation are more likely to have interest in adopting HRM. We surveyed the population of board-certified SLPs (BCS-S; n = 262) with a 33% response rate (n = 78). Firth logistic regression was used to determine differences in those expressing interest in adopting HRM into future practice (n = 28) and those who did not (n = 45) from the analytic sample of 73 respondents. The best fitting model predicted that SLPs: (1) with training in more types of instrumentation; and (2) believing they could explain the HRM procedure to a patient were more likely to plan to adopt pharyngeal HRM into regular clinical practice. Experience with a variety of instrumentation techniques may encourage SLPs to use new forms of technology. Knowledge of early adopter demographics will allow for development of targeted trainings and determination of HRM implementation barriers. Identification of a clinician sub-group more likely to adopt other new technologies in the future may also be possible.

Effect of topical nasal anesthetic on swallowing in healthy adults: A double-blind, high-resolution manometry study

OBJECTIVE

Topical nasal anesthetic (TNA) is used when evaluating pharyngeal swallowing with high-resolution manometry (HRM). It is unclear if desensitizing the nasal mucosa improves procedure tolerability or affects pharyngeal pressure. This study evaluated the effects of TNA on comfort and pharyngeal pressure using HRM.

METHODS

A double-blinded study was conducted with 20 healthy participants ( x¯ = 27 years). Participants performed five saliva and five 10-mL swallows during two exams with ManoScan HRM ESO catheter (Medtronic, Minneapolis, MN) randomized under placebo (nonanesthetic lubricant) and anesthetized (0.4 mL of 2% viscous lidocaine hydrochloride) conditions. Comfort was rated using a 100-mm visual analog scale (VAS). Pharyngeal HRM amplitude and timing were analyzed.

RESULTS

VAS ratings were similar under placebo (mean = 38.4, standard deviation [SD] = 19.92) and TNA conditions (mean = 33.78, SD = 18.9), with no significant differences between placebo and anesthetized conditions (t[19] = 1.23, P = 0.23) or tolerability at first and second procedure (t[19] = 1.38, P = 0.18). Lower maximum and mean pharyngeal pressure were found for the TNA condition when compared to placebo (dry: maximum [-15.45 mmHg, standard error (SE) = 5.06 mmHg, P = 0.021]; mean [-5.22 mmHg, SE = 1.58 mmHg, P = 0.005]), and (liquid: maximum [-14.79 mmHg, SE = 5.01 mmHg, P = 0.010]; mean [-2.79 mmHg, SE = 1.99 mmHg, P = 0.008]).

CONCLUSION

This double-blind, randomized study is the first to investigate effects of TNA on tolerability and pharyngeal pressure using HRM. Results indicate TNA offered no significant difference in procedure comfort while affecting the magnitude of pharyngeal swallowing.

LEVEL OF EVIDENCE

4. Laryngoscope, 128:1335-1339, 2018.

Biomechanical Quantification of Mendelsohn Maneuver and Effortful Swallowing on Pharyngoesophageal Function

Objective

To quantify the effects of 2 swallowing maneuvers used in dysphagia rehabilitation—the Mendelsohn maneuver and effortful swallowing—on pharyngoesophageal function with novel, objective pressure-flow analysis.

Study Design

Evaluation of intervention effects in a healthy control cohort.

Setting

A pharyngoesophageal motility research laboratory in a tertiary education facility.

Subjects

Twelve young healthy subjects (9 women, 28.6 ± 7.9 years) from the general public, without swallowing impairment, volunteered to participate in this study.

Methods

Surface electromyography from the floor-of-mouth musculature and high-resolution impedance manometry–based pressure flow analysis were used to assess floor-of-mouth activation and pharyngoesophageal motility, respectively. Subjects each performed 10 noneffortful control swallows, Mendelsohn maneuver swallows, and effortful swallows, with a 5-mL viscous bolus. Repeated measures analyses of variance was used to compare outcome measures across conditions.

Results

Effortful and Mendelsohn swallows generated greater floor-of-mouth contraction ( P = .001) and pharyngeal pressure ( P < .0001) when compared with control swallows. There were no changes at the level of the upper esophageal sphincter, except for a faster opening to maximal diameter during maneuver swallows ( P = .01). The proximal esophageal contractile integral was reduced during Mendelsohn swallows ( P = .001).

Conclusion

Effortful and Mendelsohn maneuver swallows significantly alter the pharyngoesophageal pressure profile. Faster opening of the upper esophageal sphincter may facilitate bolus transfer during maneuver swallows; however, reduced proximal esophageal contractility during Mendelsohn maneuver swallows may impair bolus flow and aggravate dysphagic symptoms.

Esophageal Swallowing Timing Measures in Healthy Adults During Videofluoroscopy

Objectives:

Establishing the range of normal esophageal bolus transit times (ETT) is valuable when distinguishing pathology from normal variance, especially in elderly patients, and has not been documented for paste or pill. The aim of this study was to measure esophageal transit of liquid, paste, and pill during upright videofluoroscopy.

Methods:

One hundred eighteen healthy adults (mean age 54; range 20-98 years; SD = 21.40) with no complaints of dysphagia completed a videofluoroscopy with esophageal visualization including 20 ml liquid barium, 5 ml paste, and pill.

Results:

Mean ETTs were: 20 ml fluid, 10.7 seconds (SD = 13.6, median = 5.76, IQR = 4.33, range, 2.0-60.0); pill, 25.3 seconds (SD = 24.0, median = 12.70, IQR = 49.81, range, 1.0-60.0); paste, 28.6 seconds (SD = 23.31, median = 17.47, IQR = 53, range, 4.0-60.0). Age was significantly associated with increasing 20 ml fluid ETT ( P < .001) but not pill ( P = .58) or paste ETT ( P = .12). Fluid ETT over 10 seconds occurred in 10% of participants between 20 and 59 years, in comparison to 35% over 60 years ( P < .001).

Conclusions:

These normative values provide a standardized protocol and guidance in interpretation when completing esophageal visualization as part of videofluoroscopy. While measuring fluid ETT may support referral for further specialist investigations, slower paste and pill ETT may be normal findings. Age-related slowing in fluid ETT was seen in healthy adults. Further investigation of ETT is needed in both normal and dysphagic subjects.

Expanding Instrumental Options for Dysphagia Diagnosis and Research: Ultrasound and Manometry

Diagnostic assessment of swallowing in routine clinical practice relies heavily on the long-standing techniques of videofluoroscopic swallowing study (VFSS) and videoendoscopic evaluation of swallowing (VEES). These complementary and sophisticated techniques provide a real-time visualization of biomechanical movements of the structures involved in swallowing and consequent effects on bolus flow. Despite the sophistication of this instrumentation, interpretation relies heavily on subjective clinical judgement and temporal resolution is limited, limitations that may influence patient management. Adjunctive diagnostic assessments may be utilized to compensate for the limitations posed by VFSS and VEES. Ultrasound and pharyngeal manometry do not represent the latest in technological advances, with both emerging in swallowing research over 20 years ago. However, both have resisted integration into routine clinical practice, despite the fact that they offer quantitative metrics of swallowing that are not available using standard techniques. The aim of this review is to present recent research on these two less frequently used modalities in clinical swallowing assessment, discuss potential applications in clinical practice and review supportive data on test-retest reliability, rater reliability and validity. The paper will conclude with a case report that exemplifies the unique contribution of these modalities in executing and revising therapeutic approaches for a patient with neurogenic dysphagia.

Pressure topography metrics for high-resolution pharyngeal-esophageal manofluorography-a normative study of younger and older adults

BACKGROUND

We aimed to define normative values for novel pressure topography metrics for high-resolution pharyngeal-esophageal manofluorography. The effects of age, gender, and bolus properties were examined.

METHODS

Concurrent high-resolution manometry (HRM) and videofluoroscopy data were collected from 22 younger (aged 21-40) and 22 older (aged 60-80) healthy subjects. Pressure topography was analyzed by correlating pressure domains with videofluoroscopic events. Nine pressure topography metrics of the pharyngeal and proximal esophageal swallow were extracted; four of these were also compared with previously obtained esophageal HRM studies to assess the effects of catheter diameter.

KEY RESULTS

Older individuals exhibited more vigorous contractility in the pharynx than did younger subjects with all bolus types, but the greatest values for both groups were with effortful swallow and on that measure the age groups were similar. Upper esophageal sphincter (UES) intrabolus pressure during sphincter opening was also greater in the older subjects. Some gender differences were observed, particularly related to proximal esophageal contractile vigor. Bolus consistency had no consistent effect. Studies using the larger catheter diameter resulted in significantly greater contractile vigor in the UES and proximal esophagus.

CONCLUSIONS & INFERENCES

Older adults exhibited more vigorous pharyngeal contractions than young adults, albeit within a similar range of capacity, perhaps reflecting a compensatory response to other age-related physiological changes. Greater UES intrabolus pressures observed during bolus transit in the older group likely reflect reduced UES compliance with age. Normative data on novel HRM metrics collected in this study can serve as a reference for future clinical studies.

Esophageal Visualization as an Adjunct to the Videofluoroscopic Study of Swallowing

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 oropharyngeal dysphagia. Fluoroscopic screening involving the oropharynx 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 swallowing (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 otorhinolaryngology (ORL) (59) or by a speech-language pathologist (52) were recruited. A VFSS was performed according to protocol, 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 recordings were analyzed using objective digital measures of timing and displacement.

Results

Sixty-eight percent of patients had an abnormal esophageal 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 maximum 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 visualization allows timely referral for further investigation by appropriate medical specialties, avoiding incomplete management of patients with dysphagia.

A framework for understanding shared substrates of airway protection

Deficits of airway protection can have deleterious effects to health and quality of life. Effective airway protection requires a continuum of behaviors including swallowing and cough. Swallowing prevents material from entering the airway and coughing ejects endogenous material from the airway. There is significant overlap between the control mechanisms for swallowing and cough. In this review we will present the existing literature to support a novel framework for understanding shared substrates of airway protection. This framework was originally adapted from Eccles' model of cough²⁸ (2009) by Hegland, et al.⁴² (2012). It will serve to provide a basis from which to develop future studies and test specific hypotheses that advance our field and ultimately improve outcomes for people with airway protective deficits.