Dr Rania Habib (Host): The Dysphagia Research Society estimates that dysphagia affects between 300,000 and 700,000 individuals in the United States each year. The USF Health Voice Center is the only multidisciplinary academic voice center in the Tampa Bay area, and they offer a unique and comprehensive treatment approach to dysphagia.

Welcome to MD Cast by Tampa General Hospital, a go-to listening location for specialized physician-to-physician content and a valuable learning tool for world-class healthcare.

I'm your host, Dr. Rania Habib. Joining me today is Dr. Yassmeen Abdel-Aty, Assistant Professor at the University of South Florida Department of Otolaryngology, Head and Neck Surgery, and Dr. Stephanie Watts, a researcher and speech-language pathologist, who is also an Assistant Professor in the Department of Otolaryngology Head and Neck Surgery at the University of South Florida. They are here to discuss the Multidisciplinary Dysphagia Clinic at USF Health Voice Center. Welcome, doctors, and thank you so much for joining me today.

Dr Yassmeen Abdel-Aty: Thank you for having us.

Dr Stephanie Watts: Thank you so much. I'm excited.

Host: To begin, I'd love to understand the role that each of you have at the Voice Center. Dr. Abdel-Aty, let's start with you.

Dr Yassmeen Abdel-Aty: My role is to evaluate patients in a more medical perspective as well as a surgical perspective if there are any surgical interventions that can be done, I offer those to patients. So, my role is the medical role.

Host: Wonderful. And Dr. Watts, what about you?

Dr Stephanie Watts: I am a speech-language pathologist by training. And I did additional training during my PhD, and I focused on dysphagia, so assessment and management of dysphagia and then additional clinical training during my course of study in fellowship, specifically in dysphagia. So, my role is to be a partner to Dr. Abdel-Aty, and manage behavioral aspects of dysphagia care.

Host: That's wonderful. I love that you're both really focused on these complex situations that really need this multidisciplinary approach. So, Dr. Abdel-Aty, what is the USF Health Voice Center's Multidisciplinary Dysphagia Clinic, and what conditions are treated by the team?

Dr Yassmeen Abdel-Aty: The dysphagia clinic is a multidisciplinary clinic, meaning that Dr. Watts and I see patients together at the same time and evaluate them together. We do interventions together, procedural interventions together, and also any testing that's required we do within our clinic as well.

So, any condition that causes a swallowing disorder, we treat, whether it's post stroke, problems with swallowing, vocal fold paralysis if it impacts swallowing, head and neck cancer patients who have had radiation can have swallowing difficulties. So, we have a big range of patients with swallowing issues from multiple different causes and backgrounds. And being together is very helpful to kind of tease out the cause, so that we can properly treat the patient.

Host: What age groups do you guys primarily treat at the center?

Dr Yassmeen Abdel-Aty: Right now, we're seeing 13 and above.

Host: That's fantastic. So, you see a wider range of patients. What symptoms should prompt a physician to refer a patient to the Multidisciplinary Dysphagia Clinic, Dr. Watts?

Dr Stephanie Watts: So like Dr. Abdel-Aty noted, we see patients with a span of health conditions which lead to dysphagia, which is a symptom of a disease. So, neurogenic, congenital, head and neck cancer. So really, across age and etiology, any difficulty swallowing, food getting stuck, feeling of a lump in the throat, throat pain or discomfort when swallowing, coughing and choking when eating or drinking, heartburn, regurgitation, and really food stuck at any level, high in the throat, low in the throat, and/or in the chest.

Host: I love that you guys treat such a wide array of patients in those different age groups. So when a patient is actually referred to the clinic, what should they expect from a visit, Dr. Abdel-Aty?

Dr Yassmeen Abdel-Aty: So, they'll expect to see both myself and Dr. Watts. We start off getting a history of the patient together, and discussing that. And then, we do some testing. So, one of the things we do is a stroboscopy exam, which is mainly looking at the function of the vocal cords. Oftentimes, we will get an endoscopic swallow study where we put the flexible fiberoptic scope and have them swallow different consistencies. And then, we discuss whether more testing is needed and come up with a treatment plan at that point.

Host: I know you mentioned a few of the tests that you do, but what other diagnostic procedures or tests might be ordered, Dr. Watts?

Dr Stephanie Watts: So, we are very excited to announce that we perform modified barium swallow studies for our practice. This is a test conducted in the radiology suite in front of a video x-ray, and so food and liquid, different consistencies of barium are given in order to visualize the oral, esophageal, and pharyngeal phases of swallowing. We may also order things like an esophagram called a barium swallow. This is similar to an MBS as in it's a fluoroscopy exam. This will focus on the esophagus or the swallowing tube, and the patient will be given different contrast media as a double contrast study and be placed in different positions such as reverse trendelenburg to look for things like reflux.

We may also order high-resolution manometry, and this test measures the pressure at different levels in the throat and the esophagus. So, a small cannula is placed through the nose, down through the esophagus into the stomach, past the LES, and use all of these assessments to understand the reason for the patient's dysphagia and how to care for them.

Host: That's fantastic. And how do you guys make that decision about which of those tests you order on each patient?

Dr Yassmeen Abdel-Aty: It really depends on the patient's history. It points us in the direction of what information we need. With swallowing, the swallowing mechanism goes from the lips all the way down to the stomach. So oftentimes, we need to be able to evaluate that whole system. And so in the clinic, obviously, we do a very good head and neck exam, cranial nerve exam, oral cavity exam. And then, we do some of our scopes in the clinic, looking at the throat and the inside of the throat and the functioning. We don't oftentimes see the esophagus unless we order a test. So, I perform transnasal esophagoscopy, which is when the patient actually swallows the camera, and I look at their entire esophagus. I can take biopsies if necessary. So, Dr. Watts can also look at the esophagus radiographically, and I'll have her chime in on that.

Dr Stephanie Watts: Sure. So during the modified barium swallow study, it's standardized for the mouth and the throat. So, it's historically an oropharyngeal examination. But these kind of phases and pieces of dysphagia are historically dichotomized incorrectly. So, we add a standardized and validated screening tool of the esophagus called the REST, the robust esophageal screening test. And so with information about the head and neck, cranial nerve exam, oral and pharyngeal function, and a screening of the esophagus, we usually have a really good idea of what tests to order next and what additional imaging is needed.

Host: That's wonderful. And I love that you guys are in the room with the patient, you know, to evaluate them together, because you really have an understanding of both the surgical side and the behavioral side. So, what treatment options are offered at the Multidisciplinary Dysphagia Clinic? And I'd love for you guys to break it down into the behavioral versus the surgical options. Dr. Watts, would you like to start?

Dr Stephanie Watts: I think this is one of the key elements that makes our intricate collaboration and partnership so special. Because historically when you have a patient sent, for a swallowing evaluation, perhaps an MBS to start, that patient is often taken right to swallowing therapy and has a distant relationship with a surgeon or a physician. And so at our practice in our center, we work hand in hand with treatment. And if I am starting off with treatment and find, "Hey, I do need the medical and surgical aspect of this." Or if Dr. Abdel-Aty starts off with something surgical in nature, such as a dilation or a myotomy, then I can also assist with the behavioral aspect and exercise and following the patient.

In terms of behavioral management, we offer several things, we treat the patient with traditional therapy, exercises, but in addition to that, offer sEMG biofeedback program. We have one of the largest biofeedback home loaner programs in the state. And so, we provide patients with a small device that they can take home, and they can visualize their swallowing as they're doing their exercises. We currently have a grant-funded study to look at that application a little bit further. And we also provide things like expiratory muscle strength training for individuals who need to improve their cough efficiency and airway clearance. And those are some of the unique aspects that we offer behaviorally.

Host: That's fantastic. Now, Dr. Abdel-Aty, when do you decide that surgical intervention is needed and what are some of the options they have from the surgical standpoint?

Dr Yassmeen Abdel-Aty: So, the fact that we're seeing patients together oftentimes helps decide whether or not it's time to do a procedure. So when Dr. Watts is seeing a patient, she's thinking of how would this patient do in therapy? Would that be a benefit to them? And just discusses that with me and the patient. So, oftentimes she can be like, "This patient doesn't seem like they cognitively could benefit from therapy. So, maybe let's more quickly do something surgical versus another patient." She might say, "Well, let's try some therapy and see how they do. And if their symptoms are improved, maybe we don't need to do a procedure at that point." So, it's a discussion between the two of us. Obviously, I'm a surgeon and I like to operate, but it's not always indicated or the best for the patient. And being able to discuss both medical and behavioral treatment at the same time helps me make my surgical decision.

The other part of it is that medical treatment is often necessary. So, oftentimes people will have severe dysphagia, and it will be a symptom of undiagnosed or untreated GERD. So, I can do an upper endoscopy or a transnasal esophagoscopy, take biopsies, or see if there's any damage from chronic GERD. We also have EsoGuard, which is a screening tool where you swallow a little capsule in the clinic attached to a cannula. It's a two-minute procedure and samples the cells at the LES. It's a pap smear, essentially. It Just gives you a yes or no if cells are abnormal, which can help us make a decision if an upper endoscopy is indicated. But some of those patients, you know, do very well on PPIs or different reflux medicines which can improve their dysphagia.

Other patients might have, EOE. So, on upper endoscopy, we take some biopsies and find that that's their cause of dysphagia, and we can involve our GI colleagues in treating that. And we help with the surveillance for that, since we can do awake surveillance of the esophagus. Other medicines could be, if they have a candidiasis of the esophagus, and we find that, that they be treated with antifungals and their swallowing goes away. So, it's not just surgical. Medical treatment is also a big role, depending on the cause of the patient's dysphagia. Surgically, dilation and superdilation are one of the most common things I'll do, but also that depends on the particular patient and what their problems are.

So, CP hypertrophy can respond to superdilation, which is essentially two balloons next to each other to give an infinity shape. There's actually a balloon called the infinity balloon. And that dilates the esophagus in the kidney bean shape, which is what the upper esophageal inlet looks more like a kidney bean than a circle. So, that's one thing. We oftentimes on MBS will find Zenker's diverticulum and need to do a CP myotomy or diverticulectomy, which is another surgical option. And these patients sometimes do great right after surgery. Sometimes they have pharyngeal weakness, secondary to their disease, and then they get more of a behavioral treatment postoperatively.

The other interesting thing that outside of the operating room, since I do do transnasal esophagoscopy, I can also do those balloon dilations, biopsies, and exams in the clinic, which is helpful. It's really great for patients, especially older patients who should not be undergoing anesthesia. Also if patients don't have a ride, they're not getting anesthesia so they can drive themselves. Turn around is easier because they just come for their visit and go home. And it gives the patients that option. Often times, patients do prefer to be asleep and I don't blame them for that. But it's nice for them to have some options of how they want to get their treatment. Because often times the cost too of going to an operating room, just stepping foot in a hospital, facility fee, anesthesia fee, and all that is sometimes cost-prohibitive.

Host: Yeah, I love that you guys are giving them so many different options and really honing in together as a team as to what options are going to be the best for them. What are the future directions of the Multidisciplinary Dysphagia Clinic?

Dr Stephanie Watts: I'm excited for the years to come. It's been excellent growth since Dr. Abdel-Aty and I have formed this clinic, and we have some really exciting research projects in the pipeline for the next couple years. We'll have to jump back on here and share that data when it's ready for distribution. We also have some fantastic growth within our clinical operations over the next couple of years to better serve our patients.

I think that Dr. Abdel-Aty touched so nicely in her explanation of when we make the care decisions. It's not a delayed time frame. Those decisions are made with respective thought of each other's profession. So, I'm always thinking about how can medical and surgical care help this person. And Dr. Abdel-Aty is always thinking about how can behavioral care help this person. And so, with the growth of our department and our center, we're adding research component which we're excited about, and we're adding some really exciting clinical components as well, which further will expedite patient care.

Host: That is fantastic. So if someone wants to refer a patient to your clinic, Dr. Abdel-Aty, how would they do that?

Dr Yassmeen Abdel-Aty: So, I can give you our office number. It's 813-821-8012. But also if anyone in the community wants to run a patient by me, you can always reach out to me on social media. It's just my first and last name dot MD. That's something that I like doing, just talking about cases with people in the community. Our center also has laryngology rounds that we do with both MDs and SLPs in the community to discuss cases. So even if someone is farther away and maybe the patient can't come see me or maybe they can see me via telehealth, I'm still okay discussing the case and giving my thoughts and Dr. Watt's thoughts on strategies for the patient.

Host: That is fantastic. Well, thank you both for your time today. Are there any last minute little tidbits of information that you'd like to share with our audience?

Dr Yassmeen Abdel-Aty: I would just like to reiterate the benefit of being able to evaluate patients medically, surgically, and behaviorally at the same time, because a lot of these patients get lost in the shuffle. They get discharged from the hospital, they don't know where to go. And it's a lot of testing and a lot of things you have to think about. So when you can have a one-stop shop, and be able to do all those things at the same time, it's really helpful for patients. It's hard enough making doctor's appointments and going back and forth. And we try to make it as easy as we can for our patients.

Dr Stephanie Watts: Absolutely. I may add that when it comes to dysphagia, which is a symptom of disease, that this can affect anywhere along the track from the mouth to the gut, so the mouth, the throat, and the esophagus. These issues may occur simultaneously. So, a full comprehensive examination of each component is necessary. And so, combining the multidisciplinary and the multi-phase aspect of dysphagia management is essential and beneficial to the patient.

Host: It was so fascinating learning about your very special Multidisciplinary Dysphagia Clinic at the Voice Center at USF. So, thank you both for joining us today.

Dr Yassmeen Abdel-Aty: Thank you so much for having us. This was very fun.

Dr Stephanie Watts: Thank you so much.

Dr Rania Habib (Host): Thank you for listening to MD Cast by Tampa General Hospital, which is available on all major streaming services for free. I'm your host, Dr. Rania Habib, wishing you well.

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