Modified Mondays: When there’s more than one main character
My favorite movies and shows are usually ones that center around a group of good characters. Huge fan of “Friends”, “The Office” …and I could talk about the Marvel Universe all day. Multiple main characters may add depth and interest in a show…but in swallowing it adds a layer of complexity that is easy to miss.
Our patient this week is a perfect example. Clinically, he presented with recent onset of coughing with some complaints of solid food sticking. During the MBS, our Illinois SLP Paula soon noted incomplete airway closure with penetration and aspiration. Our patient had an inconsistent response to the aspiration and the chin tuck was found to be fairly effective. Having found this “main character” on the lateral view, it would have been reasonable to ascribe the patient’s symptoms and complaints to the aspiration, as well as the pharyngeal residues noted after the swallow, and end the study. However, because our SLPs are encouraged to complete the esophageal sweep when indicated, Paula turned the patient A-P and… found a second main character-suspected achalasia. The team was then able to not only recommend a course of treatment for the patient’s oropharyngeal dysphagia, but also make the appropriate and much needed referral to the GI.
Sweeping down to the esophagus is resisted in some settings, but we have good evidence that many patients who have oropharyngeal dysphagia also have some type of esophageal diagnosis as well. Furthermore, we have work showing that SLPs are good at noticing anomalies in the esophagus, and also that the MBS study often results in a GI referral. With everything we know about the esophagus/dysphagia relationship (and are continuing to learn), taking the few extra seconds of radiation exposure when indicated is worth it. Failing to do so can result in a missed referral and delayed diagnosis and treatment (as could have happened in this case).
Dysphagia is complex and needs a great deal of critical thinking to assess the whole picture. Identifying all the main characters can be as tricky as… well, catching all the “Easter eggs” in Marvel. (My personal fave was spotting the [fake] Infinity Gauntlet in Thor.) It’s hard to see them all, but once you do, it can give you a more complete understanding of the plot.
See below for some resources on scanning the esophagus:
Improving the Diagnostic Capability of the Modified Barium Swallow Study Through Standardization of an Esophageal Sweep Protocol - PubMed (nih.gov)
Inter-rater reliability for speech-language therapists' judgement of oesophageal abnormality during oesophageal visualization - PubMed (nih.gov)
Esophageal visualization as an adjunct to the videofluoroscopic study of swallowing - PubMed (nih.gov)