Barium Swallow Research Articles

The long lost denture: a rare case of an acquired, non-malignant tracheo-oesophageal fistula

BackgroundIngested dental prosthesis are susceptible to impaction in the gastrointestinal tract due to their sharp edges, size and contour. Delays in presentation arise from the lack of clear history of ingestion and misdiagnosis occurs due to the radiolucency of denture material on plain radiography. An acquired, non-malignant tracheo-oesophageal fistula (TOF) may develop from a chronically impacted denture. Surgical management of a TOF secondary to denture is a challenging clinical problem that is rarely reported in the literature and no previous case reports have described the two-staged reconstruction approach that we present here.Case presentationWe report a case of a male in his early 60s who presented to an acute general hospital with symptoms ongoing for over one year of dysphagia, recurrent chest infections and weight loss. Barium swallow and computed tomography identified an ingested dental prosthesis (denture) that had caused a TOF. He was transferred to our specialist thoracic surgery unit where an attempt to remove the foreign body endoscopically was abandoned due to firm impaction and risk of further injury. The subsequent multi-disciplinary management of this complex case required a two-staged reconstruction approach. The first procedure involved extracting the foreign body, repairing the underlying defects with tracheal resection and anastomosis, and creating an oesophageal diversion with cervical oesophagostomy. The second procedure achieved continuity of the gastrointestinal tract with gastric pull-up and pharyngo-gastric anastomosis. Following rehabilitation, the patient was discharged on oral intake alongside percutaneous jejunostomy feeding.ConclusionsEarly recognition and removal of impacted dental prosthesis is essential to prevent morbidity and mortality. Delayed diagnosis can lead to acquired TOF with associated consequences such as recurrent pulmonary infection, mediastinitis and nutritional deficit. Challenges we encountered, such as failed attempts at endoscopic retrieval and the difficult dissection of fibrotic tissue, were directly due to the delayed identification of the denture. We highlight the importance of holding a high index of clinical suspicion of foreign body ingestion in dental prosthesis wearers who present with recurrent chest infections and ongoing dysphagia. We also promote the need for a collaborative multi-disciplinary approach in the surgical management of complex cases.

Achalasia: beyond the basics

Achalasia is a rare oesophageal disease characterised by an unrelaxing lower oesophageal sphincter and abnormal peristalsis of the oesophageal body. Achalasia symptoms include dysphagia to solid and liquid, chest pain, regurgitation and weight loss. Achalasia diagnosis might be delayed for many years when atypical symptoms dominate. Significant progress has been made over the last two decades regarding our understanding of pathophysiology, methods of evaluation and management. The development of high-resolution manometry in particular has improved the diagnosis of achalasia, as well as other major motility disorders. Subtyping achalasia into manometric patterns has pathophysiological and therapeutic implications. Furthermore, complementary tests such as timed barium swallow and the functional lumen imaging probe (EndoFLIP; Crospon Medical Devices, Galway, Ireland) have significantly added to achalasia diagnosis algorithm and management decision-making. Progression in management has helped optimise established therapy (pneumatic dilatation and Heller myotomy) and introduced new endoscopic treatments (peroral endoscopic myotomy) and surgical techniques (surgical robotic Heller myotomy). This review will aim to shed light on the most recent advances in achalasia diagnosis, classification and management.

How preoperative upper gastrointestinal investigations affect the management of bariatric patients: results of a cohort study of 897 patients.

Preoperative diagnostic protocols vary worldwide, some prioritizing safety while others question routine procedures. Building on prior research, this study explores the impact of diverse preoperative findings on bariatric management and procedure selection. In a retrospective analysis of prospective data of over 1000 bariatric surgery patients from January 2017 to December 2022 undergoing primary laparoscopic Roux-en-Y gastric bypass (LRYGB) or sleeve gastrectomy (LSG) were analyzed. Preoperative assessment included upper endoscopy, upper GI series, and esophageal manometry. Sonography data were excluded. The primary endpoint examined the influence of preoperative exams on procedure selection, the secondary endpoint evaluated their therapeutic impact. 897 patients (741 RYGB, 156 SG) were included. All underwent upper endoscopy, revealing common findings such as type C gastritis and reflux esophagitis. Upper endoscopy prompted a therapeutic consequence in 216 patients (24.3%), resulting in a number needed to screen (NNS) of 4.1. Upper GI series and manometry were more frequently performed before LSG. Upper GI series detected hiatal hernias and motility disorders but did not result in any change of procedures. Esophageal manometry found pathologies in 37 (25.3%) patients rising to 41.5% if symptoms were present. Overall, 16 (1.8%) patients experienced a change in the planned procedure, with 14 changes prompted by preoperative findings and two by technical difficulties. We advise routine upper endoscopies for all patients undergoing LRYGB or LSG, while reserving upper GI series only for selected cases. Manometry should be exclusively performed on symptomatic patients undergoing LSG, ensuring a balanced and individualized preoperative assessment.

The Role of GERD Diagnosis and Treatment in Preventing Lung Function Decline After Pediatric Lung Transplantation.

Gastroesophageal reflux disease (GERD) after lung transplantation (LuTx) can lead to chronic lung allograft dysfunction. Our aim was to assess the prevalence of GERD in pediatric LuTx recipients and to investigate the impact of medical and surgical GERD treatment on lung function. Ethical approval was obtained. Data of all consecutive patients who underwent LuTx from 2013 to 2023 and aged < 18 years at the time of the study were prospectively collected. A GERD diagnostic algorithm was established, including assessment of symptoms (vomiting, heartburn, regurgitation, cough, recurrent airway infections), bronchoscopy, forced expiratory volume in 1 second, and pH impedance. Further investigations included upper gastrointestinal series and esophagogastroduodenoscopy. Patients with GERD underwent medical treatment or fundoplication. Lung function was monitored. Thirty-six patients (2 months-18 years, 50% male) were included. Twenty-nine (80%) underwent spirometry, 16 (45%) pH impedance study, and 14 (39%) esophagogastroduodenoscopy. Twenty-two (61%) had no GERD symptoms and 12 (33%) showed normal pH impedance study or esophagogastroduodenoscopy. Fourteen (39%) patients had GERD symptoms, all 9 tested symptomatic patients (25%) had pathological GERD-specific diagnostics. Three (8%) patients underwent fundoplication after a median of 1.6 years (range 1.1-5.7 years) post-LuTx without surgical complications. After a median follow-up of 2.3 years (range 1.3-2.8 years) post-fundoplication, all (n = 3) had complete remission of GERD symptoms and lung function improvement. Lung function decline was observed in 6 (67%) of the tested symptomatic patients on proton-pump inhibitors (PPIs) treatment. Over one-third of our patients presented with GERD symptoms after LuTx. Symptoms and lung function may be reliable GERD indicators. Given the high prevalence of GERD, we suggest a routine posttransplant diagnostic algorithm including pH impedance study. Eighty percent of all symptomatic patients had a lung function decline despite PPI. Fundoplication is safe and may improve long-term outcome in pediatric LuTx recipients.

Esophageal tortuosity in achalasia: increased length-to-height ratio predicts inferior symptom relief and esophageal emptying following myotomy.

Current classification of achalasia does not account for variability in esophageal tortuosity. The esophageal length-to-height ratio (LHR) was developed to objectively quantify tortuosity, based on the premise that the esophagus must elongate to become tortuous. Hence, we assess the relationship of esophageal tortuosity, measured by LHR, to preoperative patient characteristics and post-myotomy outcomes, including longitudinal symptom relief and esophageal emptying. From 01/2014 to 01/2020, 420 eligible adult patients underwent myotomy for achalasia at our institution, 216 (51%) Heller myotomy and 204 (49%) per-oral endoscopic myotomy. LHR was measured on pre- and first postoperative timed barium esophagram (TBE), with larger values signifying greater tortuosity. Variable predictiveness and risk-adjusted longitudinal estimates of symptom relief (Eckardt score ≤ 3) and complete emptying, in relation to LHR and manometric subtype, were estimated. Median [15th, 85th percentile] preoperative LHR was 1.04 [1.01, 1.10]. Preoperative esophageal width > 3cm and age > 68years were most predictive of increased LHR. Increased LHR corresponded with decreases in longitudinal postoperative symptom relief and complete esophageal emptying, with a 4% difference in symptom relief and 20% difference in complete emptying, as LHR increased from 1.0 to 1.16. After adjusting for patient factors, including LHR, manometric subtype was less predictive of symptom relief, with estimated symptom relief occurring in 4% fewer patients with Type III achalasia, compared to Types I and II. Overall, LHR decreased following myotomy in patients with an initially tortuous esophagus. Length-to-height ratio was the only variable highly predictive of both longitudinal post-myotomy symptom relief and complete esophageal emptying, whereas manometric subtype was less predictive. These findings highlight the importance of tortuosity in the treatment of patients with achalasia, suggesting that inclusion of esophageal morphology in future iterations of achalasia classification is warranted.

Features of Swallowing Function in Sporadic Inclusion Body Myositis: Preliminary Evidence Using Well-Tested Assessment Frameworks.

Evidence surrounding swallowing impairment in sporadic inclusion body myositis (IBM) is based on nonstandardized and nonvalidated assessment methods. We investigated (a) IBM's impact on swallowing function and oral intake status using well-tested assessment frameworks; (b) changes in swallowing over time; and (c) age, sex, and swallowing impairment severity's influence on oral intake status. We conducted a secondary analysis of Modified Barium Swallow Impairment Profile (MBSImP) and Functional Oral Intake Scale (FOIS) data from 13 patients with IBM (seven females; Mage = 60.2 [±13.6] years) and 13 age- and sex-matched healthy controls. We compared MBSImP Overall Impression (OI), Oral Total (OT), Pharyngeal Total (PT), and FOIS scores between groups. Specific to the IBM cohort, we analyzed repeated OT and PT scores and calculated whether age, sex, and OT and PT scores predicted FOIS scores. The IBM cohort demonstrated poorer OI scores across six swallowing components than healthy controls (each p < .05). Unlike OT scores (p = .84), PT (p = .033) and FOIS (p < .001) scores were worse in the IBM cohort. Repeated OI scores revealed changes in three swallowing components (each p < .05), but repeated OT (p = .16) and PT (p = .30) scores did not significantly change. Age, sex, and OT and PT scores did not influence FOIS scores (each p > .05). Pharyngeal impairments were most prominent in the IBM cohort, and their oral intake status was adversely affected. Our preliminary data showcase the application of robust assessment methods to investigate swallowing function in IBM, enhancing standardization and comparability across studies. https://doi.org/10.23641/asha.27165450.

Effect of Stellate Ganglion Block on Dysphagia and Cognitive Impairment in Cerebral Small Vessel Disease: A Randomized Controlled Study.

Cerebral small vessel disease (CSVD) can potentially and frequently lead to dysphagia and cognitive impairment. Stellate ganglion block (SGB) can alleviate the symptoms by regulating neural pathways and improving cerebral blood circulation. This study aimed to explore the clinical effect of SGB on airway protection, dysphagia, cognitive impairment, and activities of daily living (ADL) in CSVD patients. This was a randomized controlled study conducted from February 2021 to May 2023, including 84 CSVD patients with dysphagia and cognitive impairment. The participants were randomly divided into the SGB group (n = 42) and the untreated group (n = 42). All received standard-of-care rehabilitation for 20 days. The SGB group received SGB once a day additionally. Assessments were conducted on Day 1 and Day 20, respectively. The Penetration-Aspiration Scale (PAS) was primary outcome. Modified Barium Swallow Impairment (MBSImp), Mini-Mental State Examination (MMSE), Modified Barthel Index (MBI) and adverse events were secondary outcomes. This study was registered at ClinicalTrials.gov, Identifier: NCT06176404. There were two dropout cases in the untreated group. Time effect with statistical significance was observed in all assessments (p < .05). Group effect with statistical significance was observed in the PAS (z = -17.283, p < .001), MBSImp-Oral (z = -3.382, p = .001), MBSImp-Pharyngeal (z = -2.639, p = .008), MMSE (F = 7.450, p = .008), and MBI (F = 6.408, p = .013). During the treatment, there were no severe adverse events. SGB can significantly and safely improve airway protection, dysphagia, cognitive function, and ADL in CSVD patients with dysphagia and cognitive impairment who received standard-of-care rehabilitation.

6575 From Tonsils to the Thyroid: A Rare Case of Acute Suppurative Thyroiditis in an Immunocompetent Adult

Abstract Disclosure: F. Sajid: None. A. Mubashir: None. F. Mohsin: None. M. Sattar: None. Introduction: Acute suppurative thyroiditis (AST) is a rare infection of the thyroid gland due to its high vascularity, protective encapsulation, and high iodine content. Most AST cases occur in children with anatomical aberrations or in immunosuppressed adults. Here, we describe a case of AST in an immunocompetent woman. Case: A 54-year-old woman with no medical history presented to the emergency department due to dyspnea, dysphagia, and odynophagia for two days. She reported a four-day history of sore throat, fever, and chills. She was saturating well on room air but was sitting in a tripod position. She had erythema, swelling, tenderness to palpation in the anterior neck with a hoarse voice, and moderate trismus. Nasopharyngoscopy revealed no mass, but the scope could not pass beyond the velum due to edema. The patient’s condition quickly deteriorated, necessitating emergent intubation for acute hypoxic respiratory failure. After intubation, the patient had cardiac arrest with asystole requiring resuscitation and successful ROSC. The initial CT scan showed extensive soft tissue abnormalities in the nasopharynx and parapharyngeal tissues, extending to the thyroid gland and mediastinum with the possibility of developing abscesses. A thyroid ultrasound showed a heterogeneous thyroid gland without nodules or increased vascularity. Treatment commenced with ampicillin-sulbactam. Laboratory results showed Free T4 of 4.74 ng/dL (0.58-1.64), TSH 0.03 MCIU/mL (0.39-4.08), Total T3 1.56 ng/dL (0.72-1.35), WBC 19.3 K/UL (4.8-10.8), and elevated ESR and CRP levels. Thyroid-stimulating Immunoglobulin (TSI), Thyroid Peroxidase (TPO) Antibody, and Thyrotropin Binding Inhibitory Immunoglobulin (TBII) were negative, making AST the top differential. Methimazole was initiated due to concerns of thyroid storm, but it was quickly tapered due to a significant decrease in Free T4 levels and suspicion of AST. A repeat CT scan revealed more defined abscesses along the bilateral pharyngeal walls extending to the thyroid bed. The patient underwent bilateral tonsillectomy and drainage of the abscesses. She was extubated the following day. Cultures from the abscesses grew rare Klebsiella pneumoniae, susceptible to Ampicillin-sulbactam. A barium swallow on day 14 showed no evidence of a pyriform sinus fistula. She was discharged on day 15 with Augmentin for 7 days. On discharge, free T4 decreased to half (2.39 ng/dL), and Total T3 normalized (1.08ng/dL). Conclusion: This case presents a rare instance of AST in an immunocompetent patient without anatomical anomalies, stemming from the spread of peritonsillar and parapharyngeal abscesses into the thyroid bed. AST should be considered in cases of deep neck infections, as it is a potentially life-threatening disease. It is crucial to identify and treat AST early to prevent complications. The primary treatment involves antibiotics, incision, and drainage. Presentation: 6/1/2024

Esophageal Function Testing Patterns in the Evaluation and Management of Lung Transplantation: Results of a National Survey.

We surveyed esophageal motility laboratories affiliated with adult pulmonary transplant centers to determine esophageal function testing (EFT) practices. Gastroesophageal reflux and esophageal dysmotility are associated with worse lung transplant outcomes, yet no consensus guidelines for EFT exist in this population. A deidentified online survey was sent to gastrointestinal motility laboratory directors of 49 academic and community-affiliated medical centers that perform lung transplants. Practice characteristics, including annual lung transplant volume and institutional EFT practices pre-lung transplantation and post-lung transplantation were queried. Respondents were categorized by transplant volume into small and large programs based on median annual volume. Among 35 respondents (71% response rate), the median annual transplant volume was 37, and there were 18 large programs. Institutional EFT protocols were used pretransplant by 24 programs (68.6%) and post-transplant by 12 programs (34.2%). Among small and large programs, 52.9% and 72.2% always obtained high-resolution manometry before transplant, respectively. Endoscopy before transplant was performed more often in small programs (n=17, 100%) compared with large programs (n=15,83.3%). Pretransplant endoscopy ( P =0.04), barium esophagram ( P <0.01), and high-resolution manometry ( P =0.04) were more common than post-transplant. In contrast, post-transplant reflux monitoring off-therapy was more common than pretransplant ( P =0.01). In general, pulmonologists direct referrals for EFT and gastroenterology consultation (n=28, 80.0%), with symptoms primarily prompting testing. In the absence of established guidelines, substantial variability exists in pretransplant and post-transplant EFT, directed by pulmonologists. Standardized EFT protocols and gastroenterologist-directed management of esophageal dysfunction has potential to improve lung transplant outcomes.

Prospective Evaluation of Abelchia/RCPD Patients: Abnormalities in High-Resolution Esophageal Manometry.

The purpose of this study was to prospectively evaluate patients with abelchia using standardized investigations to explore possible underlying mechanisms. Patients presenting with clinical scenario consistent with RCPD were recruited into the study after informed consent. All patients underwent standardized investigations: Self reporting questionnaires EAT-10, VHI-10, and RSI scores, as well as esophagogastroscopy, barium swallow, and high-resolution esophageal manometry (HRM), were performed. RCPD patients demonstrated a minor increase in the mean EAT-10 (5.2 ± 1.2) and normal RSI/VHI-10 scores. Barium swallow revealed 53% (CI 38%-64%) were abnormal with reflux with hiatus hernia (37%) and dysmotility (16%) as most common findings. HRM showed that 67% (CI 54%-78%) were abnormal. Ineffective motility was found in 41%, a further 23% showed a complete absence of peristalsis, whereas 33% were normal. RCPD is a clinical condition of lifelong inability to belch and associated symptoms. The underlying pathophysiology is poorly understood. This study demonstrates that a significant number of RCPD patients have abnormal esophageal neural network with high proportion of abnormal or absent esophageal peristalsis. 3 Laryngoscope, 2024.

Case report : lemmel syndrome-aggravated by consumption of fatty food

Introduction and Importance: One of the very rare causes of obstructive jaundice, Lemmel’s syndrome is caused due to biliary mechanical compression by a juxtapapillary diverticulum. It is defined as obstructive jaundice due to juxtapapillary diverticulum in the absence of cholelithiasis, periampullary tumours or other detectable obstacles. It is extremely rare syndrome therefore studies need to be done for proper diagnosis and management. Case Presentation: Our patient, a 73-year-old woman, gave a history of recent acute right hypochondriac pain that had subsided the day before. Lab investigations were performed and liver enzymes were found to be significantly raised. An endoscopy followed by an endoscopic ultrasound was performed for further diagnosis which showed the diverticulum outpouching from the duodenum. MRCP was then performed which revealed a dilated common bile duct and common hepatic duct, with tapering at the distal end, most likely to be a stricture. Lemmel syndrome was identified based on the clinical presentation and imaging results. A dilated common bile duct, and two large duodenal diverticula with interdiverticular papilla was discovered during the patient’s endoscopic ultrasound which was performed by the gastrointestinal team. Clinical Discussion: Duodenal diverticula are the second most common site of diverticula after colon with an incidence of 1-5% in radiological series3. Lemmel’s syndrome is a rare cause of obstructive jaundice associated with juxtapapillary diverticulum. With a low incidence rate, only a few cases of Lemmel’s syndrome are reported with the first case reported in 1934 by Lemmel.4 Imaging techniques such as barium meal, EUS, ERCP, or magnetic resonance cholangiopancreatography are used to confirm the diagnosis. Our observations demonstrate that the diverticulum which is often found on the medial wall of the second half of the duodenum and contains bezoar, compresses the distal common bile duct laterally. Nowadays, ERCP and EUS are used to confirm the diagnosis.5 Only symptomatic periampullary duodenal diverticulum(PDD) requires conservative or surgical therapy. The first line of treatment for biliopancreatic PDD problems is endoscopic sphincterotomy, which is 95% effective.6 Conclusion: Lemmel syndrome occurs due to the compression of the common bile duct by a duodenal diverticulum. Imaging including CT scan and MRCP are important for the diagnosis of this syndrome. Treatment modalities are not the same for each patient, however.

Pharyngostoma reconstruction after laryngectomy and radiotherapy: A retrospective study and literature review

BackgroundThe occurrence of pharyngocutaneous fistula or pharyngostoma after oncologic head and neck surgery is a serious complication. It is the most common complication after major hypopharyngeal and laryngeal ablative surgery. AimThe purpose of this study is to review the surgical approach and evaluate the results regarding reconstruction methods of pharyngostoma, caused after laryngectomy and radiotherapy. Patients & MethodsThe total patient number is 15. Pharyngostoma caused swallowing difficulties, as well as frequent aspiration pneumonia. The intervention interval from laryngectomy to pharyngeal reconstruction varied between one to three years, depending on the symptoms’ severity and after the complete failure of conservative rehabilitation methods. Pharyngostoma reconstruction was performed mainly with pectoralis major myocutaneous flap in eleven cases. The radial forearm free flap (RFF) and the anterolateral thigh free flap (ALT) were also used in the rest four cases. ResultsThe postoperative course was uncomplicated and in most cases the feeding with soft food started after a barium meal between 15-20 days postoperatively. Complications include wound dehiscence and leak treated conservatively and one case of carotid rupture. ConclusionsThe gold standard for pharyngostoma reconstruction, after laryngectomy and cervical radiotherapy, remains the use of pectoralis major myocutaneous flap. In cases of extensive neck radionecrosis free flaps are preferable. Reliable and stable cover of the large vessels of the neck beside with the reconstruction of the digestive tract and the function of swallowing are issues, which are analysed in corelation with the avoidance of stenosis and swallowing difficulties.

S676 A Comparison of the 3 Subtypes of Achalasia Using High Resolution Manometry, Timed Barium Esophagram, and EndoFLIP

S676 A Comparison of the 3 Subtypes of Achalasia Using High Resolution Manometry, Timed Barium Esophagram, and EndoFLIP

S608 An Evaluation and Comparison of Timed Barium Esophagram and EndoFLIP in Patients With Clinically Relevant EGJOO vs Normal Manometric Controls

S608 An Evaluation and Comparison of Timed Barium Esophagram and EndoFLIP in Patients With Clinically Relevant EGJOO vs Normal Manometric Controls

The history and use of the timed barium esophagram in achalasia, esophagogastric junction outflow obstruction, and esophageal strictures.

Dysphagia is one of the most common complaints that gastroenterologists encounter in the outpatient setting. To evaluate this common complaint, patients are often sent for a barium esophagram, a test that is widely available, inexpensive, and easy to perform. This simple test provides a reliable method to evaluate esophageal anatomy and structural abnormalities. This narrative reviews the history of the development and validation of the timed-barium esophagram (TBE), along with its strengths and limitations, and discusses its use in the pre- and posttreatment assessment of patients with achalasia, esophagogastric junction outflow obstruction (EGJOO), and esophageal strictures. Providing excellent anatomic detail of the esophagus and an accurate assessment of esophageal emptying, over time, the TBE has become part of the standard workup in our Swallowing Center for patients with dysphagia.

Efficacy of Posterior Pharyngeal Wall Injection for Velopharyngeal Dysfunction in Adults.

Posterior pharyngeal wall (PPW) injection is often employed to treat velopharyngeal deficiency (VPD). We sought to analyze the impact of PPW injection on severity of dysphagia and dysphonia. Retrospective chart review was conducted of patients undergoing PPW injection from 2018 to 2023 at a tertiary laryngology center. Effects on Voice Handicap Index-10 (VHI-10), Eating Assessment Tool-10 (EAT-10), soft palate closure on modified barium swallow, and auditory-perceptual measures of hypernasality and audible nasal air emission were analyzed. 67 PPW injections were performed in 29 patients (11 female). Mean age was 59.4 ± 17.0 years. Etiologies were head and neck cancer (n = 23) and neurologic conditions (n = 6). 30 PPW injections were performed concurrent with intervention on the upper esophageal sphincter (25 dilations, 3 myotomies, 2 botulinum toxin injections), and 8 with a glottic procedure (6 vocal fold injections, 2 thyroplasties). Change scores were 3.87 (-6.85 to -0.89, p = .012) for VHI-10 and -3.00 (-4.75 to -1.25, p = 0.001) for EAT-10. These were statistically different from 0 for the whole cohort but not in the subset of patients undergoing concurrent voice and/or swallow surgery. Soft palate closure scores tended to be better (but not statistically significant) on MBS after PPW injection. Hypernasality and audible nasal air emission both improved after injection. PPW injection appears to have a therapeutic effect on dysphagia/dysphonia in patients with VPD; however, many patients have multifactorial impairment. Additional study is needed to determine benefit of PPW when performed in conjunction with other procedures in this complex patient population. Level 4 (Case series) Laryngoscope, 2024.

Beyond visualizing the bird beak: esophagram, timed barium esophagram and manometry in achalasia and its 3 subtypes.

Achalasia is a rare esophageal motility disorder characterized by lack of primary peristalsis and a poorly relaxing lower esophageal sphincter. This disease process can be examined several ways and these evaluations can offer complementary information. There are three manometric subtypes of achalasia, with differing appearances on esophagram. Differentiating them is clinically important, because treatment for the subtypes varies. Timed barium esophagram (TBE) is a simple test to quantitatively evaluate esophageal emptying. TBE can be used to diagnose achalasia and assess treatment response. Considerable variation in the TBE protocol exist in the literature. We propose a standardized approach for TBE to allow for comparison across institutions.

Modified Barium Swallow Study for Children: Technique and Utility

Modified Barium Swallow Study for Children: Technique and Utility

Modified Barium Swallow Study for Children: Technique and Utility

Modified Barium Swallow Study for Children: Technique and Utility

Respiratory-swallow patterning and oropharyngeal swallowing impairment in patients undergoing evaluation for lung transplant.

Although swallowing impairment is prevalent following lung transplantation, baseline respiratory and swallowing characteristics are often overlooked. Respiratory disease processes may predispose lung transplant candidates to altered respiratory-swallow patterning and swallowing impairment. This cross-sectional study included patients referred for a Modified Barium Swallow Study during lung transplant evaluation. Swallowing impairment was measured using the Modified Barium Swallow Impairment Profile and Penetration-Aspiration Scale. Respiratory plethysmographic signals synchronized with videofluoroscopy were analyzed to determine phase patterning, pause duration, and rate. Mixed-effects logistic regression was used to identify linkages between respiratory and swallowing measures. Fifty patients were included and demonstrated delayed swallow initiation (49/50), oral residue (37/50), incomplete pharyngoesophageal segment opening (35/50), and esophageal retention (43/50). Airway invasion occurred infrequently (10/50). Atypical respiratory patterning was significantly associated with impairment in pharyngeal swallow initiation (OR [95% CI] = 1.76 [1.16, 2.68], p = 0.009), laryngeal elevation (OR [95% CI] = 1.45 [1.01, 2.07], p = 0.044), and laryngeal vestibular closure (OR [95% CI] = 2.57 [1.48, 4.46], p < 0.001). Increased pause duration was associated with impaired initiation (OR [95% CI] = 2.24 [1.20, 4.16], p = 0.011), laryngeal elevation (OR [95% CI] = 1.18 [1.03, 1.36], p = 0.018), laryngeal closure (OR [95% CI] = 1.28 [1.9, 1.50], p = 0.003), and tongue base retraction (OR [95% CI] = 1.33 [1.13, 1.56], p < 0.001). Patients undergoing evaluation for lung transplant demonstrated impaired swallowing and phase patterning. Preliminary findings implicate the need for further evaluation of respiratory-swallow coordination and its potential role in swallowing impairment before and after lung transplantation.