Posted by My choice became the tie-breaker!🫠 How many times have you gotten a referral for someone simply saying, “Something gets stuck when I swallow,” or “There’s something in my throat” ? And how many times have you asked that person to point to where they feel this, only to later find either nothing at all or the oposite direction?! The mismatch can be maddening! This article is amazing for not only more evidence to fight for the esophageal sweeps, but also to think twice about where your patient points to!🤔
Title: Pharyngeal Versus Esophageal Stasis: Accuracy of Symptom Localization
Authors: Marvina & Thibeault
Journal: American Journal of Speech-Language Pathology
Year of Publication: 2020
Design Type: prospective analysis
Purpose: “The purpose of this article was to determine whether patients who complain of bolus stasis are accurate at localizing bolus stasis as measured by a videofluoroscopic swallowing study with an esophagram” “We also sought to determine the most common radiological findings for complaints of stasis at each complaint location”
Population: adults from University of Wisconsin–Madison Voice and Swallow Outcomes Clinic database
Inclusion criteria: participant with complaints of stasis and completed a combined VFSS and esophagram
Exclusion criteria: Those with a preexisting neurological diagnosis, head and neck cancer/surgery, or muscle disease (e.g., muscular dystrophy)
The authors signify that their research builds on prior evidence by looking at areas that were missed such as “reason for referral, stasis complaint, or accuracy of symptom localization of these” nor “include information on accuracy based on the patient’s specific stasis complaint location (e.g., pharynx or esophagus), variations with age, or the most common findings at specific stasis complaint locations.”
A final total of 301 participants with an average age of 57 y/o received a VFSS (by dysphagia-specialist SLP) using Varibar in the following presentations in lateral projection:
- thin (teaspoon, 10 cc, 30cc, sequential swallow)
- pudding/cookie
- 13 mm barium tablet
- 30 cc thin barium and pudding bolus in A-P view
- Additional strategies as deemed appropriate by SLP (e.g. chin tuck, etc.)
The VFSS was immediately followed by a non-standardized esophagram (by radiologist) with Varibar in the following presentations:
- thin barium with or without effervescent granules (upright+prone positions)
- single and sequential swallows (i.e. single- vs double- contrast esophagrams)
- barium-coated marshmellow or additional barium tablet at radiologist/SLP’s discretion
- Any esophagram labeled as incomplete/partial were excluded from analysis
Prior to the evaluations, participants also completed:
- EAT-1O (plus additional analysis for Question 8 “When I swallow food sticks in my throat”)
- Reflux Severity Index (RSI)
- Intake form containing questions like “Do you ever feel that food, liquid, or pills get stuck?”
- prompting further marking on a similar figure where subjects could mark multiple areas which were later analyzed separately and by grouped areas:
- upper region–pharynx, pharynx+cervical esophagus
- lower region–thoracic esophagus
- combo of upper/lower complaints–cervical+thoracic esophagus
- “other” location combinations
- prompting further marking on a similar figure where subjects could mark multiple areas which were later analyzed separately and by grouped areas:
While both the SLP and Radiology reports were coded in a yes/no for presence of stasis, each looked at things a bit differently with SLPs focusing on stasis in valleculae and pyriforms along with additional comments in Impression section (e.g. stasis at Zenker’s diverticulum etc.), but neither were blinded to the patients’ complaints or history (aka bias😉).
The radiology report was also coded into 4 esophageal categories: a) Within functional limits (no abnormalities), b) Structural abnormality (stricture, web, paraesophageal hernia, or hiatal hernia), c) Functional abnormality (esophageal dysmotility, intraesophageal reflux or bolus escape, esophageal stasis, or gastroesophageal reflux), d) Combined abnormality (elements of both structural and functional abnormalities). Additionally, coded into those that “were likely” (e.g. stricture, web, dysmotility) and “not typically” associated with esopahgeal stasis (e.g. hiatal ernia, GERD).
What did they find?
“The most common stasis location complaint was the pharynx (37%), followed by the pharynx and cervical esophagus (18%), the cervical esophagus (18%), the thoracic esophagus (9%), and the cervical and thoracic esophagus (6%).” p.3
In terms of ACCURACY:
- Only 34% of total patients were accurate in localizing stasis
- Thoracic esophagus accuracy: 68%
- Cervical esophagus: 48%
- Cervical+thoracic: 41%
- Pharynx+cervical esophagus: 24%
- Pharynx: 15%
- “Other” combinations: 11%
“When the results of the oropharyngeal exam and the esophagram were combined, esophageal stasis in isolation was the most common finding at all complaint locations, with the exception of patients who complained of stasis in the cervical and thoracic esophagus where the most common finding was no stasis.”
“Pharyngeal stasis in isolation was the least common finding, regardless of complaint location.”
p.5
The above was also still true even when grouping for the more basic “upper/lower” region categories!
“esophageal abnormalities likely to cause esophageal stasis (stricture, web, dysmotility, intraesophageal reflux or bolus escape, and esophageal stasis) were found in 60% of the patients, suggesting that many patients with esophageal stasis localize their stasis in the pharynx.“ p.7
The findings were the same when grouped by “upper region” (pharynx+cervical esophagus) for “complaints of food sticking in the throat,” with only 28% actually having pharyngeal stasis vs 58% having esophageal stasis from esophagram findings. In other words, “58% of the patients would have undergone an insufficient exam for diagnosing their dysphagia” if the exam was limited to only the oropharynx!!😲🤯
In terms of EAT-10 and RSI:
“Scores (0–4) on the individual EAT-10 item “When I swallow food sticks in my throat” were associated with pharyngeal stasis but not with esophageal stasis…suggesting that patients with higher scores on this particular question were more likely to have pharyngeal stasis and less likely to have esophageal stasis.” p.7
Total scores for EAT-10 didn’t matter for pharyngeal stasis (on VFSS) or esophageal stasis (on esophagram).
“RSI score was not associated with pharyngeal stasis on the VFSS or with esophageal stasis on the esophagram…suggesting that the RSI score does not predict pharyngeal or esophageal stasis.” p.7
In terms of AGE:
While age didn’t matter if complaints were in the “upper region” for either pharyngeal or esophageal stasis, it did have an effect for the lower and combined regions:
- Complaints for “Combined” areas:
- older patients = higher likelihood for pharyngeal and/or esophageal stasis
- Complaints for “Lower” areas:
- younger patients = higher likelihood for pharyngeal and/or esophageal stasis
Takeaway:
Overall, patients aren’t accurate at localizing where they “feel something.” When in doubt–esophageal sweep it out–because there’s more than likely “something going on” down below!🧐
“The high percentage of patients with esophageal dysphagia that manifests as a pharyngeal symptom highlights the importance of including an examination of the esophagus during a VFSS in patients with a stasis complaint.” p.7
Article Referenced: FREE ASHA ACCESS
Marvin, S., & Thibeault, S. (2020). Pharyngeal Versus Esophageal Stasis: Accuracy of Symptom Localization. American journal of speech-language pathology, 29(2), 664–672. https://doi.org/10.1044/2019_AJSLP-19-00161
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