9/14/15 Esophageal Dysphagia
KSHA 2015
JUST THE BASICS PLEASE!
JOANNA WYCKOFF, MA/CCC, L-SLP
Referrals
—  Providers often refer for a MBS because of lack of
knowledge about the symptoms associated with oral
pharyngeal dysphagia versus esophageal dysphagia.
—  Often the location of difficulty as presented by the
patient is incorrect.
—  Also as a process of elimination towards a diagnosis.
Symptoms of dysphagia
Oral/Pharyngeal/Esophageal?
— 
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— 
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— 
— 
— 
— 
— 
— 
— 
Coughing and choking
Throat clearing
Pain in throat or chest during or after swallow
Difficulty swallowing liquid
Difficulty swallowing solid food or certain types of foods
Feeling of something “stuck in the throat” (globus)
Regurgitation or vomiting after swallowing
Feel like can’t breathe after swallow
Abnormal gag
Wetness/wheezing/strider is heard after eating
Unable to eat at a normal rate
Loosing weight without trying
Early satiation
1 9/14/15 Why screen the esophagus
Why screen the esophagus?
—  Avoid misdiagnosing & mistreating
¡  Treating pharyngeal dysphagia when esophageal dysphagia is
primary
¡  Incidental findings
¡  Creditability of the SLP as part of the health care team
—  Missing opportunity to assist with the plan of care
¡  To MD and patient
—  Education
Normal Esophageal Peristalsis
2 9/14/15 Why screen the esophagus?
8
—  Doesn’t make sense to
MBS stops
here
make an arbitrary stop at
the UES. Swallowing is a
continuous
neuromuscular event
that starts at the mouth
and ends at the stomach.
Esophageal
screen to
here.
Misdiagnosis
—  Two types:
¡  Patient has pharyngeal dysphagia but also has esophageal
dysphagia. The latter would have been missed if screen not
done.
¡ 
Patient has esophageal dysphagia but does not show any oral
pharyngeal dysphagia. The former would be missed is a
screening not done.
3 9/14/15 The Esophagus, To Screen or Not To Screen . . . That
Is the Question, the Responsibility, and Liability
—  “Our professional American Speech-Language-Hearing
Association (ASHA) guidelines state, if a speechlanguage pathologist suspects on the basis of the clinical
history that there may be an esophageal disorder
contributing to the patient’s dysphagia, then “An
esophageal screening can be incorporated into most
[videofluoroscopic swallowing studies, or]
VFSS” (ASHA, 2004). However, the esophageal screen
has not been defined by ASHA or by the American
College of Radiology.”
¡ 
Caryn Easterling, SIG 13 The Esophagus, To Screen or Not To Screen . . . That Is
the Question, the Responsibility, and Liability, Perspectives on Swallowing and
Swallowing Disorders (Dysphagia), June 2012, Vol. 21:68-72.
ASHA Guideline for SLP performing VSS
—  “Clinicians should be aware that oropharyngeal
swallowing function is often altered in patients with
esophageal motility disorders and dysphagia.
Speech-language pathologists [SLPs] have
knowledge and skills to recognize patient signs and
symptoms associated with esophageal phase
dysphagia.”
¡ 
The American Speech-Language-Hearing Association (ASHA) “Guidelines for SpeechLanguage Pathologists Performing Videofluoroscopic Swallowing Studies” (ASHA, 2004)
Blair, J., & Martin-Harris, B (2010)
—  Blair and Martin-Harris (2010) reported a
significant correlation between findings of delayed
pharyngeal swallow response time and abnormal
esophageal clearance noted on an esophageal screen
and confirmed by combined multichannel
intraluminal impedance (MII) and esophageal
manometry.
—  Blair, J., & Martin-Harris, B. (2010, November). MBSImp and combined MII/
esophageal manometry. Paper presented at Annual Convention of the American
Speech-Language-Hearing Association, Philadelphia, PA.
4 9/14/15 Mendell, D. A., & Logemann, J. A. (2002)
—  A retrospective study was designed to (a) determine whether differences in
the pharyngeal swallow were noted in 9 patients diagnosed by a
gastroenterologist with gastroesophageal reflux disease (GERD) compared
to 9 age-matched normal controls and (b) identify and describe those
swallow events.
—  The GERD group had significantly longer pharyngeal response and
pharyngeal transit time, changes in base of tongue to posterior pharyngeal
wall approximation, as well as decreased hyoid excursion and UES
deglutitive anteroposterior opening.
—  Interesting, the symptoms of the 9 GERD patients were consistent: food
sticking (n = 6), regurgitation of food (n = 3), coughing (n = 2), noisy
swallow (n = 2), and pressure in the throat when swallowing (n = 1).
¡ 
Mendell, D. A., & Logemann, J. A. (2002) A retrospective analysis of the pharyngeal swallow in patients
with a clinical diagnosis of GERD compared with normal controls: A pilot study. Dysphagia, 17, 220–226.
Oropharyngeal and Esophageal Interrelationships in
Patients with Nonobstructive Dysphagia (1992)
¡ 
“Normal swallowing requires the close functional coordination
of the mouth, pharynx and esophagus. If one becomes
impaired, it is likely the others may be affected. “
¡ 
The group that had esophageal dysphagia had disturbed
lingual peristalsis, slowed pharyngeal transit time, poor
pharyngeal constriction, laryngeal vestibular and tracheal
bolus penetration.
Triadafilopoulus, G. et al. 1992 Digestive Diseases and Sciences, Vol.
37, No. 4; April 1992
SLP role with esophageal dysphagia
15
•  Educate the patient on the stages of swallow and
the role of the esophagus
•  Reduce anxiety. Empower the patient to self
advocate as a natural result of education.
•  Educate on reflux (lifestyle, medications, food
choices, risks)
•  Educate on things that might reduce or ease the
symptoms of esophageal dysphagia.
•  Make recommendations to the referring physician
for the patient and help with the plan of care.
5 9/14/15 Primary or secondary dysphagia
16
•  If there are oropharyngeal disorders and esophageal
disorders, have to determine which is causing the
primary dysphagia. This is usually easy to do.
•  Talk with the radiologist. Radiologists can diagnose
esophageal disorders; SLP’s cannot. Reference your
observations and clinical judgment in your report.
•  If you quote a diagnosis, reference it back to your
discussion with the Radiologist in your report. Could
also just reference the Radiologists report for
esophageal exam findings.
General information about the esophagus
1.  Striated and smooth muscle
2.  Circular and longitudinal muscle
3.  Primary and secondary peristalsis
4.  Layers of the esophageal body
5.  Divisions of the esophagus
1. Striated muscle and Smooth muscle
—  Striated muscle of the pharynx and cervical esophagus
¡ 
¡ 
¡ 
Striated muscle - 5% of esophagus
Voluntary control
Primary peristalsis
—  Mixed
¡ 
35% to 40%
—  Smooth muscle
¡ 
¡ 
¡ 
50% to 60%
Involuntary control
Secondary peristalsis triggered by distention
6 9/14/15 2. Longitudinal and Circular muscle
—  Longitudinal muscle:
¡  When contracts during swallowing, it shortens the esophagus
by 10% contributing to the movement of the bolus distally
—  Circular muscle
¡  When the muscle contracts, it causes a squeezing motion
pushing a bolus distally.
—  The force of the contraction and speech of flow is
dependent upon age of the patient, bolus volume,
temperature and intra abdominal pressure.
Z Line and Circular and Longitudinal Muscle
3. Primary peristalsis
1. 
2. 
3. 
4. 
5. 
Primary esophageal peristaltic wave is a continuation of the
peristaltic wave that originates in the pharynx shortly
following the initiation of a swallow.
This wave passes from the pharynx through the upper
esophageal sphincter (UES) to the striated muscle portion of
the esophagus.
There is progressive sequential contraction of the circular
muscle and longitudinal muscle of the esophagus which
causes contraction above and relaxation below the bolus.
The bolus travels rapidly down the length of the esophagus;
2-4 cm per second through the smooth muscle portion of the
esophagus and through the lower esophageal sphincter into
the stomach.
Takes about 6 to 10 seconds
7 9/14/15 Secondary peristalsis
—  Secondary peristalsis is caused by smooth muscle
contraction (involuntary) triggered by esophageal
distension of residual bolus contents after the
primary peristalsis.
—  Secondary peristalsis helps move the residual
bolus to the stomach and starts above the
distended area.
—  UES relaxation does not occur with secondary
peristalsis.
Tertiary Contractions
•  Multiple simultaneous contractions
•  Non-peristaltic so do not move the bolus
4. Layers of the esophagus
From the lumen moving out:
—  Mucosa
¡ 
¡ 
¡ 
Epithelium
Lamina propria
Muscularis mucosa
—  Submucosa¡  Submucosal nerve plexus
—  Muscularis externa
¡  Circular muscle
¡  Myenteric nerve plexus
¡  Longitudinal muscle
—  Serosa
¡  Connective tissue
¡  Epithelium
8 9/14/15 Myenteric Plexus
•  It is a nerve network that is between the circular and
longitudinal muscle layers
•  It serves as a relay between the vagus nerve and smooth
muscle of the distal esophagus and LES.
•  Excitatory neurons mediate contraction of both
longitudinal and circular muscle
•  Inhibitory neurons affect only the circular muscle
Layers of the esophagus
5. Divisions of the esophagus
1.  Upper Esophageal Sphincter (UES)
2.  Cervical esophagus 2-3 cm in length
3.  Thoraxic esophagus 21 cm
4.  Abdominal esophagus 1 – 1.5 cm
5.  Lower Esophageal Sphincter (LES)
9 9/14/15 Upper Esophageal Sphincter (UES)
—  Combination of inferior pharyngeal constrictor and
cricopharyngeal muscle (lateral and posterior)
—  High pressure area-80 to 100 mmHg; tonic contraction at
rest
—  Diameter of UES opening increases with larger bolus
volume
—  Open duration for about 1 second
—  Relaxes with sleep, swallow, anesthesia, belching
Figure 1 Anatomy of the closing and some opening muscles of the upper
esophageal sphincter (UES).
GI Motility online (May 2006) | doi:10.1038/gimo12
Cervical Esophagus
—  2 to 3 cm long
—  First 1 cm is the UES
—  Striated muscle
—  The cervical esophagus extends from the
pharyngoesophageal junction (C5-6) to the
suprasternal notch.
10 9/14/15 Thoracic esophagus (mid-distal)
•  The thoracic esophagus extends from the suprasternal
notch to the diaphragmatic hiatus, passing posterior to
the trachea, the tracheal bifurcation, and the left main
stem bronchus. The esophagus lies posterior and to the
right of the aortic arch at the T4 vertebral level.
•  Mixed of striated/smooth muscle
•  Bronchoaortic constriction; around the left main
bronchus and aortic arch, 15 – 17 mm in diameter; this is
also a low pressure area.
Abdominal esophagus (distal)
•  The abdominal esophagus extends from the
diaphragmatic hiatus to the orifice of the cardia
of the stomach.
•  1 – 1.5 cm
•  Smooth muscle
•  Natural area of narrowing where the LES goes
through the diaphragm 16 to 19 mm diameter
Lower Esophageal Sphincter (LES)
—  Constant contraction but relaxes 2 to 3 seconds after the
onset of the swallow; followed by transient contraction
which may be twice the pressure of the resting tone.
—  Relaxes with distention of the esophagus, belching or
vomiting
—  Narrow – relaxing only to 16-19 mm in diameter
—  High pressure zone; resting pressure is 10 to 30 mmHg
above intragastric pressure
—  Extends 2 cm intra-abdominally
—  LES pressure is greatest at night and lowest after a meal.
11 9/14/15 Areas of constriction
34
—  Superiorly: level of
cricoid cartilage,
juncture with pharynx
—  Middle: crossed by
aorta and left main
bronchus (15-17 mm)
—  Inferiorly:
diaphragmatic
sphincter (16-19mm)
Pay attention to the symptom complaints of the
patient
35
•  Dysphagia with heartburn
•  Pain with swallowing (odynophagia)
•  Sensation of it “stopping” a few seconds after
swallow
•  Regurgitation
•  When- Occurs immediately after swallow or much later, even
days later?
•  What- Ask about taste and consistency
•  Slow or rapid onset of dysphagia
Symptom complaints
36
•  Food &/or liquids that are difficult
• 
How has it changed since symptoms first started
•  Consistent or intermittent?
•  Chest pain/retrosternal pain
•  Bleeding
•  Constipation
•  Early satiety
•  Halitosis
12 9/14/15 Symptom complaints
37
•  Weight loss (rapid or slow)
•  Waterbrash
•  Xerostomia
•  Respiration difficulty
•  Laryngeal/Voice difficulty
•  Globus sensation
•  Ask where and have patient point to it
Observable symptoms with esophageal disorders
38
•  Piecemeal deglutition
•  Excessive mastication
•  Repetitive swallowing dry swallowing
•  Oral disorganization
•  Regurgitation
•  Difficulty with bread, meat, larger pills
Esophageal screening
39
Dime’s
diameter 18mm
•  Give one bolus and ask the patient to swallow it all on
one swallow. Wait until primary peristalsis finished.
•  Use a large enough bolus to distend the esophagus. (At
least 15 ml)
•  = or > 13 mm (Barium tablet is 13 mm)
•  Screen even if the oral pharyngeal swallow is abnormal to
r/o esophageal dysphagia as primary.
•  Screen even if the oral pharyngeal swallow is normal
especially if the patient is having symptoms.
•  Remember it is a screening, not diagnostic.
•  Also remember the patient is upright, so have the
advantage of gravity. This does not rule out esophageal
problems.
13 9/14/15 Esophageal disorder classification
Motor (smooth muscle)
1. 
a. 
b. 
Primary
Secondary (caused by another condition)
2.  Disorders of the cervical esophagus (striated muscle)
3.  Structural Disorders:
¡ 
¡ 
¡ 
¡ 
¡ 
Inflammatory
Neoplastic
Iatrogenic
Congenital
Acquired
1.a Motor - Primary
—  Generally get worse
—  Need diagnostic exam for movement such as
esophagram or manometry
—  Often have noncardiac chest pain
—  Examples of primary motor disorders:
¡  Achalasia
¡  Diffuse esophageal spasm
¡  Nutcracker esophagus
Achalasia
42
14 9/14/15 Diffuse esophageal spasm
43
1.b Examples of Motor - Secondary
—  Schleroderma
¡  Causes thickening and hardening of connective tissue/smooth
muscle
÷  Decreased
peristalsis and weak LES
—  Diabetes
¡  Neuropathy
÷  Esophageal
dysmotility
—  Reflux
¡  Esophageal mucosal changes such as esophagitis
÷  Esophageal
dysmotility
Structural Esophageal Disorders
45
—  Inflammatory esophagitis –
¡ 
infections, reflux, corrosive (chemical or pill induced), radiation,
eosinophlic
—  Neoplastic –
¡ 
Barrett’s esophagus, adenocarcinoma
—  Iatrogenic –
¡ 
lacerations, tears, ruptures
—  Congenital –
¡ 
esophageal atresia, tracheoesophageal fistula, strictures, cysts,
diverticula
—  Acquired –
¡ 
hiatal hernia, strictures, webs, rings, diverticula
15 9/14/15 Solid food dysphagia- Dr. Peter Belafsky
Strictures
47
—  Narrowing of the esophagus
—  If <12 mm have symptoms
—  Schatzki ring (dilate before gets too small)
—  GERD management
Barrett’s
48
Barrett’s Esophagus
Barrett’s Adenocarcinoma
16 9/14/15 Esophageal cancer
49
Disorders of the cervical esophagus
50
—  Cricopharyngeal hypertension
—  Cricopharyngeal bar
—  Cervical osteophytes
—  Anterior cervical webs
—  Zenker’s diverticulum
Cricopharyngeal Bar
51
17 9/14/15 Cervical Osteophyte
52
Anterior Cervical Web
53
—  Web on anterior wall of esophagus
—  Associated with iron deficiency
—  Called Plummer Vinson
—  Balloon dilation
Zenker’s Diverticulum
54
18 9/14/15 Frequent recommendations
for Motility & Stricture Disorders
55
— 
— 
— 
— 
— 
— 
— 
— 
— 
— 
— 
— 
— 
— 
Avoid thickened liquids
Avoid fiberous food and tough meat
Avoid bread unless toasted
Chew food well
Eat slowly
Alternate solids with liquids
Drink warm liquids with meal
Avoid cold liquids
Repeated dry swallows
Modify pill form if needed
GER education
Avoid NSAIDS
Multiple swallows/hard swallows
Stay upright after eating for several hours
Non obstructive CP Bar
—  Mendelsohn
—  Tongue base exercises
—  Hyolaryngeal excursion exercise
—  Reflux education
—  Shaker exercises
GER education
— 
— 
— 
— 
— 
— 
— 
— 
— 
— 
— 
— 
— 
— 
Avoid NSAIDS
Avoid caffeine
Decrease red meat
Avoid chocolate, peppermint, spicy, acidic, fried fatty foods, carbonated
beverages.
Avoid alcohol
Eliminate smoking
Increase exercise, weight management
Elevate head of bed 6 to 8 inches
Avoid tight fitting clothing around the waist
Don’t bend over after meals
Smaller meals more frequently
Avoid eating 2-3 hours before bed
Gum chewing to increase saliva production
Educate patient on types of acid control in medications (PPI, H2 blocker,
antiacids)
19 9/14/15 Wording for report showing primary esophageal
dysphagia
58
“The patient is showing a primary esophageal dysphagia
with secondary pharyngeal dysphagia. The Radiologist
noted severe esophageal spasms and retroflow of the bolus
was observed during a esophageal screening. The retroflow
bolus passed through the UES and pooled in the pyriform
sinuses. The patient attempted to swallow again however
aspiration occurred from the overflow during this secondary
swallow. There was already moderate residue in the
pyriforms secondary to weak hyolaryneal excursion prior to
the additional bolus from the retroflow bolus.
Ø 
Wording for report for pharyngeal dysphagia
—  The patient is showing primary
pharyngeal stage dysphagia secondary to
limited hyolaryngeal excursion which
limited UES sustained opening and caused
residue to collect in the pyriform sinuses.
Aspiration was noted secondary to the
overflow from the pyriform sinuses. The
esophagus was scanned showing no gross
abnormalities.
Example
60
Ø  “Refer to the Radiologist’s report regarding his clinical
impressions during the esophageal screen.”
Ø  “The Radiologist noted ___________ during the exam.”
Ø  “Although the radiologist did not feel the episodes of tertiary
contractions were abnormal; the patient became quite anxious
during this time and did not want to continue.” The patient
stated “this is what happens at home only worse at times.”
Ø  “The patients pharyngeal symptoms were reproduced
simultaneously with bolus transfer through the narrowed area
in the esophagus.”
20 9/14/15 Example
61
Ø 
“May want to consider……May benefit from…….”
Ø 
“Patient was instructed to follow up with the referring physician to
determine if further workup is recommended.”
Ø 
“The patients history and symptoms are consistent with …may
suggest…might be better assessed with other diagnostic exams such
as ……to help with the diagnosis and treatment plan. “
Example
62
Interpretation:
The patient had a normal oral and pharyngeal swallow. An
esophageal screening was completed. The 13 mm barium tablet
lodged for 30 seconds when traveling through the esophagus
around the aeorta. The Radiologist did not feel this was a
“significant clinical finding for stricture.”
Recommendations:
The patient was instructed to follow up with his physician to discuss
if further workup is recommended. The patient may benefit from
diagnostic esophageal exams such as EGD or esophagram;
particularly if the patient’s symptoms worsen or progress to
difficulty with bread and meat.
References
American Speech-Language-Hearing Association. (2004). Guidelines for
—  speech-language
pathologists performing videofluoroscopic swallowing
studies.
—  Blair, J., & Martin-Harris, B. (2010, November). MBSImp and combined
MII/esophageal manometry. Paper presented at Annual Convention of the
American Speech-Language-Hearing Association, Philadelphia, PA.
—  Chaudhuri, C., Rao, N., Aliga, N., Quill, A., & Brady, S. (2010, November).
Incidence of esophageal dysphagia in rehabilitation patients. Poster
presented at the Annual Convention of the American Speech- LanguageHearing Association, Philadelphia, PA.
—  Cook, I. J. (2008). Diagnostic evaluation of dysphagia. Nature Clinical
Practice: Gastroenterology & Hepatology, 5, 393–403.
Mendell, D. A., & Logemann, J. A. (2002). A retrospective analysis of the
—  pharyngeal
swallow in patients with a clinical diagnosis of GERD compared
with normal controls: A pilot study. Dysphagia, 17, 220–226.
21 9/14/15 References
—  Allen, J. E., White, C., Leonard R., & Belafsky, P. C. (2012). Comparison of
esophageal screen findings on videofluoroscopy with full esophagram
results. Head & Neck, 34, 264–269.
—  American College of Radiology. (2011). ACR practice guideline for the
performance of the modified barium swallow. Retrieved February 1, 2012,
from www.acr.org/SecondaryMainMenuCategories/quality_safety/
guidelines/dx/gastro/modified_barium_swal low.aspx
—  American College of Radiology. (2008). ACR practice guideline for the
performance of esophagrams and upper gastrointestinal examinations in
adults. Retrieved February 1, 2012, from
—  Caryn Easterling, SIG 13 The
Esophagus, To Screen or Not To Screen . . . That Is
the Question, the Responsibility, and Liability, Perspectives on Swallowing and
Swallowing Disorders (Dysphagia), June 2012, Vol. 21:68-72.
—  Triadafilopoulus, G. et al. 1992 Digestive Diseases and Sciences, Vol. 37, No. 4;
April 1992
References
—  http://emedicine.medscape.com/article/1948973-
overview#a1 (EGD videos)
—  http://www.nature.com/gimo/contents/pt1/full/
gimo6.html (GI Motility on line)
22