When the Tests Are Normal, But Your Patient Still Can’t Swallow

Patients who present with swallowing difficulties or disorders are typically assessed using either a modified barium swallow study (MBSS) or a fiberoptic endoscopic evaluation of swallowing (FEES) by speech-language pathologists (SLPs). Used alongside complimentary imaging (esophagram, CT and MRI), the purpose of MBSS is to directly visualize a patient’s swallowing anatomy and physiology and assess the safety and efficiency of their swallow. However, some patients may have subjective swallowing complaints yet have normal instrumental exams.

A poster presentation at the Combined Otolaryngology Spring Meetings (COSM) by the American Broncho-Esophagological Association (ABEA) May 15-19, 2024, in Chicago, IL looked at the percentage of patients with normal exams to better understand referral patterns and demographic information of those patients to get a better idea of how many patients may still have swallowing issues that are not fully explained by the available work-ups.

“In our study, we wanted to determine the clinical yield of patients who have normal MBSS assessments,” explains Michelle Adessa, BM, MS, CCC-SLP a speech-language pathologist (SLP) in Cleveland Clinic’s Voice Center and lead author on the poster. “We also wanted to understand and identify any referral patterns that could be reevaluated in order to refine the referral process and possibly improve quality for patients. As a speech-language pathologist, patients who have complaints about swallowing, but normal exam results are often referred to me and other SLPs. So, I think this research was really born out of my clinical practice and my desire to better understand the patients who were being sent to me.”

Study design and findings

The retrospective review study included patients who were referred for an MBSS assessment between January 1, 2019, and December 31, 2019. The research group identified which of those patients had a normal exam, and they were stratified by present/absent history of neurological disease (e.g., stroke, TBI) or head and neck cancer (HNC). The group also recorded the referral source, patient age, diagnoses and any diet recommendations.

In total, 615 patients were referred for MBSS, and 285 (46%) of those cases were normal. The group noted that of those 285 patients, 209 (73% of normal MBSS; 34% of total MBSS) had no history of neurological disease or HNC and were predominately female (female 128, 61%, male 81, 39%). The median duration of their complaint prior to their normal MBS was nine and a half months.

Patients were being referred for MBSS for several reasons. These included: dysphagia, unspecified (48, 23.0%); dysphagia, other (6, 2.9%); dysphagia, pharyngeal (8, 3.8%); dysphagia, esophageal (14, 6.7%); dysphagia, oropharyngeal (43, 20.6%); dysphagia, pharyngoesophageal (12, 5.7%); gastroesophageal reflux disease/laryngopharyngeal reflux (7, 3.3%); chronic cough (11, 5.3%); chronic throat clearing (2, 1.0%); and other (including Zenker’s diverticulum 58, 27.8%). None of the patients involved in the study had a diagnosis of dysphagia, oral or dysphagia, cricopharyngeal.

“In order to determine the referral diagnoses of these patients, we had to base everything off their ICD-10 codes,” explains Adessa. “This was somewhat limiting because we can't always fully glean all of the necessary information about the patient's complaint solely by the ICD-10 diagnosis. Swallowing issues can be multifactorial, and the ICD-10 codes don’t always capture all the nuance.”

Patient referrals primarily came from three different specialties: otolaryngology (ENT) (72, 34.4%); gastroenterology (GI) (57, 27.3%); and primary care (PCP) (23, 11.0%).

“Any physician can recommend an MBSS assessment,” says Adessa. “But we found that most of the referrals were coming from ENT, GI and PCP. We also have a small number of patients referred to us from psychology, psychiatry, spine and thoracic, and pulmonology as well. I would say pulmonology has some crossover too with care for the chronic cough population as well as overlap with many of the functional upper airway disorders that we see like inducible laryngeal obstruction and laryngeal hypersensitivity.”

Care at Cleveland Clinic

“At Cleveland Clinic we have a phenomenal team of SLPs who perform MBS studies,” says Adessa. “When we have a patient with normal exam results, we’ll send them back to the referring physician for further evaluation and management. Perhaps they need more testing, a trial of reflux medication or possibly swallow therapy. We’re really looking to collect as much information as we can to give us the best idea of what’s going on. Since there are often several factors at play, strong multidisciplinary communication and collaboration is vital, and our SLP team has been able to develop strong relationships with not just our patients, but with clinicians in other specialties throughout Cleveland Clinic.”

She also mentions that her patients will sometimes present with complex issues, so even after she gets a referral, she still works closely with the referring physician to ensure they are taking a holistic approach to treating a patient’s swallowing disorder. “There’s really a wide range of complexity involved with swallowing disorders,” says Adessa. “For example, I’ll see patients who have a fear of swallowing. In these cases, there’s quite a bit of overlap with GI psychology. My colleagues from that department and I will do co-treatment sessions with these patients to address as many of the issues at play as we can. With other patients, we might also collaborate with our bariatric surgeons, otolaryngologists, physical therapists and even audiologists on occasion. That’s one of the benefits for patients who come to large medical centers like Cleveland Clinic. We can take a multidisciplinary approach to care because we have the resources and the people available to us. We can evaluate what’s going on thoroughly and then develop an individualized treatment plan based on input from all stakeholders.”

Looking ahead

Adessa also expects that the findings from this study could have the potential to really impact care at Cleveland Clinic down the road. There are plans for a follow-up study to determine if there are any unifying characteristics of patients with subjective swallowing issues who have normal evaluations and see if anything could be done better.

“When we treat patients, we want to make sure we’re turning over every stone and taking a holistic approach to care,” says Adessa. “If the tests come back negative and we don't find anything, our care shouldn’t just stop there; we should still treat the patient's complaints. That's where I think we could see an impact in clinical care from this study. We recognize that we have a huge clinical yield and a discrepancy between the number of patients who are complaining about a swallowing problem and returning a clinical finding.”

She continues, “I think this is an area that we should continue to explore, and I think that we need to broaden our conceptual framework for what a swallowing problem is. I think if we can reshape or reverse-engineer our thinking on this issue, we are going to discover more information that can positively direct care and positively impact patients.”