A Quick Start Guide to Dysphagia: Diagnosis, Treatment & The Role of Stress

[Ashley Agan MD]
So let's get into talking about dysphagia, and Gopi and I, when we were talking about it, we were thinking, well, first we probably need to just set the stage with some terminology because even Gopi and I use different terms when talking about barium swallow, modified barium swallow, video fluoroscopy, FEES, there's all these different terms. These are all technically swallow studies, different ways to look at the swallow, but if you can call them different things depending on who you are or where you are, tell us about that.

[Theresa Richard SLP]
Interesting. The modified barium swallow study has been around a while. Gosh, I think maybe in the seventies I believe is when Dr. Jeri Logemann, basically, I don't want to say invented it, but pretty much is the one that came up with that procedure. And that sort of was the gold standard for the longest time. And that is an x-ray, it's done from the side. So you're able to see the swallow on an x-ray. Dr. Susan Langmore in the nineties, basically invented FEES, which is fiberoptic endoscopic evaluation of swallowing. It's a top-down view obviously with the endoscope. So each has their pros and cons. What I like to say is which test is best. And to me, it's the one you can actually get. And I think we all know limitations of working in hospitals, working in doctor's offices. Are you rural? Where are you located? Sometimes the logistics of getting the ideal test just do not happen, especially if you're in the NICU or working in skilled nursing. For me, ideally, I just always say the test you can get is the best. We can obviously get into the pros and cons of some.

What I do want to talk about also is the difference between the modified barium swallow study and a barium swallow that GI does, because so many times this is something that I just want to educate every intake coordinator and her schedule or at a hospital. I even went through it with my own son. We were trying to get one scheduled. And she's like, are you sure you don't want the barium swallow? And I was like, no, I know what test I need. And so that's just so frustrating and I hate that they're coined so similarly, but video fluoroscopy is sort of the new name now or a video swallow basically because it's done with fluoro. So, a lot of people still do call it the modified barium swallow study, but video fluoroscopy is now sort of the new term to use.

[Ashley Agan MD]
Okay. And, that's probably better because then it takes the barium name out of it. So you're less likely to confuse barium swallow and modified barium swallow. Okay. Good to know.

[Gopi Shah MD]
And when you're thinking, let's say you, I think you make a great point. It's which one can you get? But let's say you have a patient that will tolerate both. Which one do you like for what problems or which one tells you what?

[Theresa Richard SLP]
So in my perfect world, I would always do a FEES first. And I say that because I think there's so much information that it can give us right off the bat. It's a real live picture. So you're viewing the larynx, you're viewing the vocal folds, you can see the esophageal inlet. So there's things that you can see right off the bat that we might be able to say, “Ooh, this is something that just needs to go right to ENT, or this just needs to go right to GI.” I think sometimes we get ahead of ourselves and try to intervene and try to fix things therapeutically that might need surgical or medical intervention. With the FEES specifically, a lot of times, I mean, we just see so much, effects of reflux or even allergies, things like that. So that's when we got to send them off to you guys to just get them medically or surgically stable first.

So that's why I'm such a big believer in FEES as sort of the primary tool, especially because it is so easy for us to use all the time and doesn't involve all the logistics of radiology, but things that you see on FEES, we assess, especially a lot of secretions, a lot of these patients that are trachs and vents, secretions are a huge thing. So we can sort of tell if they have secretion management or not. We are able to view different foods and liquids and textures that we can actually see them on the FEES. We assess for different laryngeal, pharyngeal anatomy, and sensory deficits. You can view if there's vocal fold paralysis or paresis, you can check out why there might be different voice changes. And especially, it can be really beneficial for things like pre or post head and neck cancer surgery as well. So those are sort of the top things that you would really want to go to FEES first. But like I said, I'm really biased. And I admit that, and I always say that FEES is the best tool to use first, but a lot of people that don't have experience with FEES and still believe that video fluoroscopy is the gold standard, I'll absolutely take the information we can get from that any day, but video fluoroscopy is superior when looking at esophageal issues, because we're able to see basically from the nose down to the stomach, if the radiologist allows us to scan down that far and get a view of the lower esophagus as well, you do get a much better image of the oral phase of the swallow on video fluoroscopy, because it's on the side. So you can tell if there's chewing, rotary chew, if they're able to, basically bolus transit. You're able to tell if the tongue is moving in the right direction, all that stuff. So, Yeah. Those are pretty much the biggest differences about when you would use one or the other, but a lot of it comes down to logistics if I'm being honest.

[Ashley Agan MD]
There's a patient group that I always struggle with. The patient comes in and their chief complaint is dysphasia. They're having some trouble swallowing. They have a normal, flexible scope exam. They are not losing weight, seem perfectly healthy and normal otherwise. Get a modified barium swallow, it's also normal. And they're like, well, doc, why can't I swallow? I really am having trouble swallowing. I'm really not gonna let this go. Because you tell them, okay, the good thing is everything looks normal, normal, normal, but they're like, no, I'm not normal. What's going on? How do you take care of those patients or what do you usually find?

[Theresa Richard SLP]
A majority of the time it's muscle tension dysphasia, I'm not sure if you guys are familiar with that.

[Ashley Agan MD]
Yeah. Yeah. Let's talk about that. As I feel like I learned that term in the last, maybe couple of years from our speech therapists.

[Theresa Richard SLP]
Yup. Yup. And that's really sort of what we're finding. And, I believe there's even more work that came out this year. Even spelling it out even more. And a lot of it is just stress. They're seeing it a lot more now after COVID. It's really interesting because it's a lot of just where people are holding their stress and their tension, but it's so bad that the muscles are so inflamed that it's really impairing the swallow. So a lot of it is these vocal exercises, these vocal relaxation techniques. So, speech pathologists work with swallowing and voice. I only do swallowing, but a lot do both or some just do voice, but that's sort of where I rely on my SLP colleagues that specialize in voice to do these vocal relaxation techniques, which can help to relax the swallow. Something else that I don't know that it's controversial now, but I did write about it in my book because it comes up enough is sort of the psychological component too. And patients going for hypnotherapy or therapy, or they may have been through trauma subconsciously long, long, long ago. And so there actually is research and there are studies that have shown that, sometimes these patients need this subconscious change in order to be able to swallow if there is nothing that we can see on an actual swallow study.

[Gopi Shah MD]
I mean it makes sense when you think about, in our GI clinic, there's a GI psychologist, you know what I mean? So your swallow, it's all together. It's part of that theme. So it makes sense for sure.

[Theresa Richard SLP]
Yeah, I think as a medical professional, you want to just be able to see the problem and diagnose it and fix it. And it's not that easy sometimes. And I know some people think that's woo woo and isn't the truth, but there is some truth to it. And so I do want patients to know that is something. If they're desperate and want to research that a little bit further.

[Gopi Shah MD]
I think in ENT, especially because so much of it is quality of life, right? Some of the problems that we have, or see in our patients, whether it's vertigo, feeling dizzy, the migraine, the sinus headache patient, or, dysphasia. Any little bit that can help the patient move forward, whether you've identified something or not. And many times there's not necessarily a pathologic reason, or a surgery or medicine, but if there's some things, some tool, that's always helpful.

[Ashley Agan MD]
Yeah. And I've had patients who bring up stress to me. So, I may be talking to him and say, well, good thing is everything looks normal. We're not finding anything. And like, sometimes they'll say, do you think it could be stress? You know? And I'll be like, well, yes. Tell them are you stressed? Like, yeah, actually let's talk about that. So I think, patients are, kind of, cluing in, on how that mind-body connection works and how if you are stressed out, sometimes your body doesn't work right.

[Gopi Shah MD]
Sometimes as physicians, especially, I don't think we're always clued into that.

[Ashley Agan MD]
Right. That's not part of our training. Yeah.

[Gopi Shah MD]
We’re supposed to find that pathologic problem.

[Ashley Agan MD]
See the problem. Yeah. And fix the problem.

[Theresa Richard SLP]
I've definitely gotten into some arguments with other professionals just in our field about it, because I'm just like, there's nothing else to explain. Like you said, and then you send a patient off to a psychologist or to further explore it and they come back and they're like, that worked. I had to do these exercises or do these different guided meditation exercises and it helped. So, I think it's one thing I know from being a mother and dealing with my son's issues, you have to listen to the patient, we know what we know, but we only know what we learned.