A Multidisciplinary Approach to Esophageal Dysphagia:

Role of the SLP

Darlene Graner, M.A., CCC-SLP, BRS-S

Sharon Burton, M.D.

What is the role of the SLP?

• Historically– SLPs the preferred providers for

evaluation and treatment of oral and pharyngeal stage dysphagia

– Assessment of the esophagus was not always included in the evaluation

ASHA Guidelines

• Guidelines for Speech-Language Pathologists Performing Videofluoroscopic Swallowing Studies (2004)

Issue: Pharyngoesophageal considerationsWhile it is the responsibility of appropriately trained physicians to

evaluate and diagnosis esophageal stage dysphagia…. Clinicians should be aware that oropharyngeal swallowing function is often altered in patients with esophageal motility disorders and dysphagia. …SLP have knowledge and skills to recognize patient signs and symptoms..associated with esophageal phase dysphagia.

ASHA Policy Statement

• Knowledge and Skills Needed by Speech-Language Pathologists Performing Videofluoroscopic Swallowing Studies (2004)

B. Skills required

7. If esophageal screening is completed, describe any suspected anatomic and/or physiologic abnormalities of the esophagus which might impact the pharyngeal swallow, deferring to radiology for diagnostic statements

ASHA Position Statement

Instrumental Diagnostic Procedures for Swallowing (1991)

The results of the VFSS may suggest that referral to a radiologist/gastroenterologist for an upper GI series or air contrast esophagram may be needed to view the esophagus. SLPs should have sufficient knowledge to make an appropriate referral and plan cooperative management.

ACR Appropriateness Criteria

• Abnormalities of the mid or distal esophagus or gastric cardia can cause referred dysphagia to the upper chest or pharynx

• Therefore, a combined radiographic evaluation of the pharynx, esophagus and gastric cardia is recommended in patients with unexplained pharyngeal dysphagia

Goals

• Review normal esophageal anatomy and physiology and how we evaluate them

• Demonstrate anatomic and/or physiologic abnormalities of the esophagus which might impact the pharyngeal swallow and produce dysphagia symptoms

• Present unknown case examples

Normal Esophagram

• Double Contrast– High density barium– “thick”– Fizzies

• Goal: Mucosal detail– Esophagitis– Neoplasm

Single Contrast Phase

• Low density barium– “thin”– Single swallows for

peristalsis– Multiple swallows for

detection of• Rings• Strictures• Hernia

Esophageal Dysphagia

Structural Causes

– Diverticula– Web – Ring– Stricture– Hernia– Neoplasm

Motility Disorders

– Achalasia– Scleroderma– Diffuse spasm– Non-specific

esophageal dysmotility (NEMD)

Cervical Web

• 1 - 2 mm, anterior wall

• Hemispheric and circumferential webs (rings) cause solid food dysphagia

• Associations: – GE reflux, Plummer-

Vinson syndrome

GE Reflux

• Fluoroscopic evaluation is limited for detection of GER

• 24-hour ambulatory pH testing is the most accurate way to document reflux

• Evaluate patient for complications of GERD

Peptic Esophagitis

• Abnormal Motility• Granular mucosa• Thickened folds > 3mm• Nodularity• Ulceration• Better detected with

endoscopy

Peptic Strictures

• Distal esophagus• Hiatal hernia in > 90%• Fluoroscopy better than EGD for

ring and stricture detection– 95% sensitivity

• EGD for biopsy and dilatation

Barrett Esophagus

• Columnar metaplasia

• Occurs in 10-15% of patients with reflux esophagitis

• Premalignant

• High stricture or ulcer, reticular pattern

Eosinophilic Esophagitis

• Esophageal biopsies: – Many intraepithelial eosinophils

(80/high power field)

• Associated with food allergies

• Treatment:– Oral steroid (Fluticasone) therapy– 220 mcg two puffs a day

Hiatal Hernias

• Sliding

• Paraesophageal

• Mixed

• Intrathoracic stomach

Esophageal Cancer

Risk factors for squamous cell

carcinoma:

Smoking

ETOH

Achalasia

Chronic GERD

Barrett esophagus

Adenocarcinoma

Achalasia

• Primary – Idiopathic– Progressive dysphagia– Dilated esophagus – Birdbeak

• Secondary– Neoplasm of distal esophagus

or gastric cardia– Chagas disease

Achalasia

– Aperistaltic esophagus– Failure of relaxation of lower

esophageal sphincter

Treatment options– Dilatation– Heller myotomy and

fundoplication– Botox injection

Scleroderma

• Motility pattern– Proximal 1/3 striated muscle

• normal peristalsis

– Distal 2/3 smooth muscle• impaired motility

• Patulous GE junction– GE reflux can cause distal stricture

• Chest pain• Intermittent dysphagia• Segmental nonperistaltic contractions• Corkscrew esophagus• Muscular hypertrophy

Diffuse Esophageal Spasm (DES)

References

• Adler, D. G., Romero, Y., Primary esophageal motility disorders. Mayo Clin Proc. 2001;76:195-200.

• Crescenzo, D. G., Trastek, V. F., Allen, M. S., Deschamps, C., Pairolero, P. C. Ann Thorac Surg. 1998; 66:347-350.

• Martin, R. E., Letsos, P., Taves, D. H., Inculet, R. I., Johnston, H., Preikasaitis, H. G., Oropharygeal dysphagia in esophageal cancer before and after transhiatal esophagectomy, Dysphagia. 2001; 16:23-31.

• Philippsen, L. P., Weisberger, E. C., Whiteman, T. S., Schmidt, J. L., Endoscopic stapled diverticulotomy: Treatment of choice in Zenker’s diverticulum. The Laryngoscope. 2000; 110:1283-1286.

• Sofer, E., Murray, J. A., Schulze-Delrieu, K., Esophagoscopy and tests of esophageal function. In Perlman, A. L. and Schulze-Delrieu, K. (eds) Deglutition and its Disorders. Singular Publishing Group: San Diego. 1998.

Reference Links

– Levine M.S., Rubesin S.E. Diseases of the Esophagus: Diagnosis with Esophagography. Radiology 2005; 237:414-427.

– http://radiology.rsnajnls.org/cgi/content/full/237/2/414?maxtoshow=&HITS=10&hits=10&RESULTFORMAT=&author1=levine&fulltext=esophagus&searchid=1&FIRSTINDEX=0&sortspec=relevance&resourcetype=HWCIT

– ACR Appropriateness Criteria: Dysphagia http://www.acr.org/s_acr/bin.asp?CID=1207&DID=11772&DOC=FILE.PDF