394 – Pressure, Pumps, and the UES:The Case for Pharyngeal Manometry in Clinical Practice

On this episode, Theresa sits down with Dr. Diane Longnecker, Assistant Professor at Baylor University and clinical researcher at Baylor Scott and White, and Jamie Anderson, medical SLP and clinical instructor at the University of South Florida, to talk about something a lot of clinicians have heard of but aren't quite sure what to do with: pharyngeal manometry. Jamie starts with a confession most of us can probably relate to — she rolled her eyes at it when she first heard about it. Now she can't imagine practicing without it. Dr. Longnecker walks us through why she started using it clinically back in 2019, what her very first case taught her about the limits of visual interpretation, and why she no longer sends a patient for UES management without it. They break down what pharyngeal manometry actually tells you that your modified barium swallow study and FEES simply can't, which patients belong in the referral pool, what the barriers to starting a program actually look like (reimbursement, analysis time, catheter placement), and why someone in this field needs to take ownership of the UES. If you've been curious about this tool but didn't know where to start, this conversation is a genuinely helpful place to begin.

Get the show notes and references: https://syppodcast.com/394

The post 394 – Pressure, Pumps, and the UES:The Case for Pharyngeal Manometry in Clinical Practice appeared first on Swallow Your Pride Podcast.

Episode Transcript

(00:12):
Welcome to the Swallow Your Pride podcast. I'm
your host, Teresa Richard. I'm a board certified
specialist in swallowing and swallowing disorders, a mobile
fees business owner, and founder of the MedSLP
collective.
This podcast is all about delivering the latest
evidence based practice to medical SLPs everywhere.
Whether you're a new clinician seeking tangible tools
for treatment or a seasoned vet stuck in

(00:33):
a rut, my goal is to help ditch
the old school ways of the past that
no longer serve you or your patients, to
reinvigorate your passion for our field, to broaden
your knowledge about our scope of practice, and
to inspire you to practice at the top
of your license. So if you're listening, I
encourage you to swallow your pride, be open
and willing to learn, because let's face it,
your patients deserve that kind of care. With

(00:54):
that, let's dive right in. Just a quick
disclaimer that all statements and opinions expressed in
this episode do not reflect on the organizations
associated with the speakers and are their own
opinions solely.
Alright. Good morning, Jamie. Good morning, doctor Longnecker.
So happy to have you both on with
me this morning.
Good morning. Good morning. You. Alright. So this

(01:15):
is such a last minute podcast recording, which
I love more than anything. Jamie texted me
yesterday and said, hey. Can we get out
and record this podcast episode today or tomorrow?
And I said, yep. We absolutely can. So
here we are. We've all just gotten our
children to school, and now we are off
to the races. So, Jamie, tell the people
a little bit about yourself and why we're
here today.
Yeah. Sure. So I'm Jamie Anderson. I'm a

(01:36):
speech pathologist and clinical instructor at University of
South Florida, Tampa, not too far from you,
Teresa.
I work at a swallowing center, so mostly
with gastroenterology,
speech pathology, do a lot of modified barium
swallow studies, some scoping,
and just newly pharyngeal manometry, which is, you
know, part of what I wanted to come

(01:58):
on and talk about, and I had to
bring doctor Longnecker on because, everything that I
know about it is because of her.
Awesome. Yes. Doctor Longnecker, share a little bit
about yourself? Yeah. That is sweet.
Well, I'm an I'm currently an assistant professor
at Baylor University.
That's in Waco, Texas. I actually live in
Dallas, though, and still hold a clinical appointment
at Baylor Scott and White, which is where

(02:19):
I spent the vast majority of my clinical
career before before I finished my PhD and
went back into academia.
And that Baylor Scott and White out of
Dallas
is where I started the manometry program
back in 2019,
and where I still see manometry cases and,
a lot of my research comes out of
the Baylor Scott and White system. And so
I have this, like, beautiful merge between

(02:43):
a research academic teaching appointment,
at Baylor University, and I still hold a
clinical appointment, which sort of lets Jamie and
I have all of this fun together from
a research and a and a clinical
perspective. So I'm glad to be here. Awesome.
I love that. That seems like the the
dream job for many people that get into
research because they hate to give up clinic

(03:03):
totally. So I love that for you. Yeah.
Alright. Okay. So where where do we wanna
dive in? I think, you know, I I
wanna dive in with I I've loved learning
so much about manometry from researchers. Right? And
I've had a bunch of researchers on. We've
talked about manometry.
We've talked about what it can tell us,
but
I think there's so much more that can
be done with it in our field clinically.

(03:24):
I you know, it's usually the the researchers
or the MDs that are always doing the
manometry, but is there a role for this
for SLP clinicians, and what does that look
like? I I'll jump in just then as
a clinician to then and get,
doctor Longnecker in. I I was just sharing
as we were chatting about doing this today.
And, Diane, you didn't remember this, but I

(03:45):
have a distinct memory of learning about pharyngeal
manometry. It was in 2019
right when you were starting your program, and
you were on the phone. You were getting
your PhD,
and you wanted to study pharyngeal manometry. And
I was very pregnant, putting away all these,
like, clothes in Fort Lauderdale, like, for baby
clothes. And you told me about it, and
I just rolled my eyes. And I said,

(04:07):
like, oh, this is the new shiny tool
for speech pathology. Like, you know, all the
cool kids are doing it, that type of
thing. And I told
doctor Long to greet
that I the audacity of me to, like,
be so against it, you know, with zero
knowledge. So, like, at this point in my
career,
I worked alongside gastroenterology, and I I see

(04:28):
the utility of esophageal manometry. And, you know,
our esophageal or esophageal
disorder experts cannot do what they do without
esophageal manometry. I didn't even know what it
was at that time. So I I I
almost wanted to start there because I think,
as the practicing clinician
without,
you know, the exposure to it or without
the knowledge to it. I at least for

(04:49):
me, my first instinct was just kind of
like, what's the point? And so I know
that, you know and, Diane, you've done research
along this, like, area of, like, where are
we in our acceptance of, like, this concept.
But
now, you know, fast forward,
I have had such cool experiences after being
trained to show, oh, this patient who I

(05:11):
did a modified barium swallow study and maybe
even a fees, I still have questions that
I haven't answered, Infringementometry
has been able to do that. So I
don't know if you wanna take it from
there. Yeah. You actually, like, bled nicely. My
dissertation work was actually in implementation science.
Sort of I'm a PhD in health studies,
which is sort of an offshoot of public
health. And so my dissertation work was actually

(05:33):
using a public health theory
to try to understand the readiness of our
field to adopt manometry.
And then I used,
that same theory and sort of the constructs
of that theory to develop an education module
to try to understand if I could, like,
move clinicians along the readiness scale.
And so, actually, Jamie makes, like, a perfect,
example of, like, the vast majority of our

(05:54):
field is in this
phase of precontemplation
with this tool. And precontemplation,
like, it you can either be unaware of
it, like, you're just naive to the benefit
of it, or you can be resistant to
it. Right? Other or you have, like, been
exposed
in some form of another or somebody that

(06:15):
you tend to look up to is against
it, and so you are precontemplative
of it because
of usually one of those two things. And
so
I think,
it's just interesting that Jane I don't remember
that story.
But it's interesting because once I ran through
my whole dissertation,
that is where the vast majority of our
field is there, where they're like, I don't

(06:35):
get it. Either I don't get it or,
like, no. This is silly kind of thing.
Anyways, where I think you know, I started
using it, though, when I was a clinician,
not a researcher. I got interested in it
because I was attending Dysphasia Research Society as
a clinician, and it was sort of buzzing
a little bit. And I thought, man, I
have those resources to me. Like, I have

(06:56):
those collaborators. I have those GI physicians,
and I see the benefit of it to
them. I wonder if I can figure out
how to do this. And, actually,
I think it sort of speaks to, like,
the development of one of these programs is
really a multidisciplinary
team approach. And I had really, really good
collaborators that were willing to, like, take a
risk on me trying to figure out how

(07:16):
to do it,
outside of, you know, these, like, already developed
programs.
And what was I always use my very
first case
in any modified or in any manometry presentation
I give. I actually use the very first
manometry case that I did because it was
humbling from day one. So I had seen

(07:37):
this patient,
and I I, at this point, am, like,
sixteen,
fifteen years out. I've done 100 I mean,
thousands and thousands of swallow studies. Like, I
feel like I'm a pretty decent clinician at
this point, but I did a swallow study
on her. And I was like, man, I
don't understand why your swallow looks like this.
I was like, I think it's UES dysfunction,
but I can't fully tell. Well, then once

(07:59):
my team bought into doing manometry, I was
like, oh, we should bring that person in
because I can't figure out why she would
have dysphagia.
I said, I think it's UES,
but let's just pull her in and see
what's going on. I pulled her in, and
it was absolutely nothing I had ever guessed
based on my visual interpretation on the modified
barium swallow study,
which then thus changed her treatment plan, which

(08:19):
then thus changed her outcome. And I always
use that case because I think
as good as you get with the tools
that we typically have, there's still something manometry
offers you that our visual interpretation using fees
or MBS
just doesn't offer us.
And so, yeah, it's been a really fun
journey to, like, do clinical work with manometry

(08:40):
and do my research with manometry because I
get to sort of, like,
see the whole spectrum of what that looks
like.
That is awesome. Okay. Doctor Longmecker, I I
wanna just really get back to back to
basics here. So if if clinicians are listening
and they're like, oh, a new tool. Love
this.
What what do the logistics look like? Is
this something we're able to perform autonomously?

(09:02):
Do we need a GI in the room?
What do the logistics look like from that
perspective?
Yeah. I'm only gonna speak to how we
have it structured at our clinic,
and we're in a major hospital system. So
how the how it works, in case no
one knows, is there's a catheter
that, it looks not so dissimilar to, like,
an NG tube or or, you know, something

(09:24):
of that caliber, but it has sensors along
it. And the catheter passed transnasally
through the pharynx into the esophagus.
That takes practice.
That takes skill. That takes now I will
tell you that we have competencies within our
hospital system
that speech pathology can go through to become
sort of internally
determined competent for passing those catheters.

(09:47):
We also though you know, we had a
robust esophageal
manometry program going before and,
manometry
techs that are trained by our GI physicians
and GI lab staff, we're placing these and
still can place them for us.
I will say,
the one thing at least in Texas that
gets it a little tricky is,

(10:09):
numbing.
And, like, administration of a medication like lidocaine
is out of a Texas speech pathology license,
and so we aren't able to numb. I
will say we do them not numbed as
well. Like, I just did one last week
where we didn't numb the patient.
It's a you know, the procedure's a little
uncomfortable. So all that to say is we
don't have a GI physician in room with

(10:30):
us. Every now and again, a tech, like,
a manometry tech that runs all the other
and anal and other manometries will be in
room with us. But we don't have a
physician in room, but we have a lot
of internal competency
based
metrics that have been managed. So, like, the
the institution as a whole feels like we're
competent. Not so dissimilar to, like, at least
in Texas, not so dissimilar to, like, how

(10:51):
we manage fees or how we manage something
like that where, like, you can't just walk
in and do it. But once you're determined
competent by whatever
competency program you have, then And you saying
fees, I just have to say, I actually
just tried for the first time,
to place the catheter myself because like your
clinic,
doctor Mannmeier, the

(11:12):
we have an LPN or we have a
nurse that that places the catheter, and she's
doing esophageal manometries all the time. And just
like, you know, again, I learned, everything from
you that, you know, she's pulling the catheter
up away from the esophagus that she's typically
assessing for us to look at the pharynx.
And I'm thinking, well, you know, sometimes she's
not there, and sometimes I only wanna look

(11:33):
at the pharynx. So I need to learn
how to place this catheter. And, I was
very humbled, and I went over to my
students because, you know, we we teach them
how to, like, rigid scope, how to flex
scope. And sometimes, you know, it's when you've
done something for such a long time, it's
like riding a bicycle. And so you're you
know, I was like, I don't get it.
Why can't you get, you know, placing a
flex scope? And then here I am thinking

(11:53):
that placing a catheter like, the soft geminometry
catheter, I thought
it wouldn't be that hard, and it was
it was, very humbling. So I I'm in
that process. But for me too, our our
nurses,
placed the catheter for us. Jamie, do you
is is it within the the SLP scope
of practice to be able to place it?
So I it's I believe state by state.

(12:14):
I I know a great example, Kate Davidson,
who does beautiful work and has worked with,
like, Ashley O'Rourke and such. She does she's
published and shown the use of it therapeutically,
and I know that she places it herself.
And, like, during, I've gone to I think
did you go to the Wisconsin one, Diane,
or the,
the Charleston one? The MST. Yeah. Yeah. So

(12:35):
at that, she talked about it. And so
I do know I think it's a state
by state, you know,
regulations, but I know Kate Davidson's speech, but
I'll just not, you know, not RN, not
physician, and she's placed it. I,
so far, that's what I'm, like, exploring here.
Yeah. We have, like I said, we
our manometry techs are for all intents and

(12:57):
purposes, MAs, like medical assistants that have been
brought in and trained specifically for this within
our institution. And so our internal competencies
don't mandate that you have to have a
certain type of,
degree or type of, you know, external training
or something. We do a lot of internal
training and internal competencies for that.

(13:19):
And so once we brought that to our
institution's sort of compliance and risk department, they
were like, well, yeah, it doesn't it doesn't
make any sense to us, at least, that
if a if a speech pathologist can pass
this endoscope and a MA can pass the
manometry catheter, as long as you have documented
enough
supervised
successful passes in the manometry catheter, I can

(13:41):
see
why you might be able to pass like,
sign sign off on this internal competency and
do it here at this institution.
So
Awesome. Thank you. Yeah. Love this stuff. So
so cool.
Yeah. So I think, you know, in talks
talking about the ability to do it within
an institution, I think we are both speaking
from a standpoint that we have

(14:02):
already manometry programs that are well established and
that we kinda snuck our way in and
said, hey. While you're looking at the esophagus,
can we pull it up and look at
the pharynx?
And that's very different than
you wanna buy a brand new equipment
and then, you know, start the program from
scratch. And so, you know, we were definitely
a little or very lucky from that standpoint.

(14:24):
But both of us, when she started and
then same for me, I I just
kinda just started doing it. And, unfortunately,
you know, I don't know when the time
is to talk about it, but talking about
barriers. Right? One is the cost, although so
Medtronic is a big company. Labri is another
one that's, you know, created,
the, you know, a a really much more

(14:45):
affordable device to to be or,
system, I should say.
But I think one of the biggest barriers
too, and I can imagine, you know, Teresa,
if you're gonna start doing it, is the
the,
money that you're receiving for it. So there's
no charge code,
to provide, and I don't know if there's
anything moving in that direction.

(15:05):
So we don't get anything extra. Like, I
can charge a clinical swallow, but I typically
charge a clinical swallow when I do my
modified barium swallow study. And so, you know,
what, a swallow treatment and just like that
doesn't really cover what the cost is or
or, you know and there's obviously the research
benefit, the clinical benefit, but I don't know
about the physical benefit. So that's a hard

(15:25):
argument to to to take.
Yeah. I do think that that sort of,
one of the things I think a lot
of programs that are not in these big
research institutes that have a bunch of funding
to try to get equipment for this, which
was me when I started as a clinician
before I was a researcher for it,
is piggybacking on those that already have it.

(15:45):
So befriending your GI colleagues is gonna be
incredibly important because
not only do we not get reimbursed well
for this procedure, but we also then, like,
don't get reimbursed well enough to, like, maintain
the system, maintain the catheters, purchase when they
break, fix when they break. Right? Like, all
the things.
And so if you can sort of piggyback
on another department

(16:07):
that is already doing it,
it it's great. But I
that would be my one word of wisdom
for, like,
people that wanna start it is try try
to do it with some collaborators. I think
it's more sustainable
and and bigger picture, honestly. Right? Like, we
that also bleeds into probably a whole another
conversation on, like, do you only do the
pharynx, or do you do the pharynx and

(16:28):
the esophagus altogether? That was gonna be my
next question. Yeah.
I will tell you at Baylor Scott and
White, like, where we run out of, we
run the system the whole system together when
we're doing assessments for it Only because we're
we truly philosophically believe that the system is
one continuous tubing system. And so
GI was kind enough to let me sort

(16:48):
of tag into their system, and they were
like, but we really want the esophageal
part of this information. I was like, valid.
I think that that's valid. And so, actually,
we drop
the catheter. Our, how we logistically do it
most of the time unless there's a reason,
like, for instance, there's an esophageal manometry that
was done last week and we need pharyngeal,

(17:08):
right,
is we drop the catheter, the manometer the
actually, the manometry tackle, drop the catheter,
do the entire esophageal part of that study,
and then they call. And they're like, hey,
Diane. We're ready for you. And I go
in, do just the pharyngeal part of, like,
pull the catheter back, do the pharyngeal part,
and then decannulate the catheter, like, pull the
catheter out.
And that way we have the entire system

(17:30):
at the same time.
It also logistically,
well, fiscally is more beneficial.
Right? But it's also logistically more beneficial because
they are, like, setting up, getting the pay
prepping the patient, dropping the catheter,
processing the catheter. They're monitoring the pay like,
they're doing all of that. And so I
can truly just, like, fly in and fly

(17:52):
back out because the heart the sort of
the bulk of this procedure is, especially from
an assessment standpoint, not if you're doing using
it for biofeedback. But if you're using it
for an assessment
procedure,
the bulk of your time is on the
analysis on the back end. So the faster
you can get through the, like, protocol and,
like, gather the data,
the,

(18:12):
maybe the less discrepancy you have in your
effort from what we get paid.
That's just a thought. And so we have,
like, logistically set it up as efficiently as
we possibly can in capturing the whole system.
Yeah. And so I think picturing,
again, what does it actually look like if
when
Diane or I

(18:32):
separate clinics are in there for the trials,
then we're following the protocols that started with
the consensus paper from Omar Marie and colleagues
in 2020.
There's now 18 swallows, you know, three five
cc boluses, three ten cc boluses, three twenty
cc boluses,
three and it's all thin liquid saline. There
are some new things on the market for

(18:53):
thickened,
versions, and,
but I don't really I think the norms
are are still to be determined.
And then we do five and ten ml,
of pudding
and then three crackers.
And so it's a full 18. And then
so that's the actual trial. They're sitting up
compared to lying down with the esophageal manometry
you're pulling out. So if you imagine, you

(19:14):
know, giving those trials, you're really only been
there for maybe five minutes.
But what she says for the analysis, now
you take those 18 swallows, and then I
was trying to count it out on the
way here. It's about eight measures that we're
looking at, and there's different ways to analyze
it, but doctor Longnecker and myself manually analyze
it. And so that means that we are
literally with a little

(19:35):
mouse, you know, cursor
across eight measures times 18 swallows,
which is very time consuming.
That's not the only way of doing it.
One is, swallow gateways, a a cloud based
system, but, of course, from an institutional standpoint,
like sending patient information to the cloud, you
just there's a lot of logistics there.

(19:55):
Labry,
is creating or or is is in the
midst. I I don't know if it's fully
out there. If you have the Labry system,
but both of us have the Medtronic system,
they have an internal,
one there, but it still seems like it's
pretty time consuming.
And so,
yeah. Again, the the time, right, which, again,
if you're barely getting any money for this
this we're I feel like all we're talking

(20:16):
about is barriers. We gotta talk about the
good stuff. But if you, you know, if,
you know, the amount you don't really get
much
financially for it. And then the amount of
time that it takes to analyze it, you
know, it takes time. But that's what just,
that was a big project for
doctor Longnecker and myself. We I just, presented
the first time a poster at, Dysphasia Research

(20:37):
Society, and that really came from,
Diane's
retrospective
collection of all of her clinical studies that
she had
done since, you know, 2019
or so.
And I said, you know what? I have
been since 2022, her and I have, like,
gone on Teams message your Teams meetings and
kinda talked about this and and, like, she

(20:59):
showed me how to analyze it. I rewatch
those Teams, you know, meetings,
and then I'd have these very sporadic cases.
Right? And so I'm doing a case once
every three to four months or something, and
then I'm coming back on saying, how do
I do this? How do I do this?
And so I said, you know what? I
I need an excuse
to measure
a lot of them and get really good
at it. Right? We all know that, like,

(21:19):
MBSIMP
is a great training tool because you force
clinicians to sit down and look at hundreds
of swallow studies.
And so the same thing, I said, I
need an excuse that will force me down
and measure, and so that's what I did.
And before that, it would take me hours
to measure something, and then now, you know,
I'm closer to thirty minutes to get it
you know? But that's still a thirty minute,

(21:40):
like, really hyper focused
to analyze something like this. But
once you get all of
you know? So there's a lot of barriers
for this to kinda get out there, but
I think,
we can also talk about the the clinical
utility of it.
Yeah. Yeah. Let let's let's pivot to that
because I would I would love to know
more about how you guys are using it,
what patient population. Yeah. Let's talk about all

(22:02):
the good stuff. How where we started with
this back in 2019 was, like, any swallow
study. We did it where, like, if the
swallow study came through
and I was like, I don't understand, it
would go to manometry.
Like, if I saw the outcome and I
was like, I can't really put my finger
on this
or if I thought there might be UES

(22:22):
dysfunction. I was like, I wonder if this
is UES dysfunction or if this is some
sort of pharyngeal dysphagia that is that looks
like UES dysfunction, but it's like a pharyngeal
pumping system problem.
And so that's where we started.
I will say,
more than anything, I think there are certain
populations where it's not that beneficial.

(22:42):
Right?
I think that we can talk about those
too. But, essentially, anytime there were questions that
I didn't feel like I could confidently answer,
or if I was gonna go ask my
ENT or my GI doc to go medically
or surgically manage something
that wasn't, like, an obvious structural abnormality. So
if it was, like, a functional thing, and

(23:02):
I was like, this is a UES dysfunction.
You should figure that out. I felt like
the due diligence was to go get manometry
to really flush that out. I think that
actually,
in my experience, this ability to understand how
the UES works, how the pharynx is working,
and how they interplay between the two of
them, I think that is where the real
benefit of manometry at this point lies.

(23:24):
That's where I'm using it. I'm actually using
it mostly
as a diagnostic tool.
I very rarely use it for biofeedback.
Mhmm. Can you share maybe oh, go ahead,
Jamie. Yeah. Yeah. I was gonna say just
to I'll piggyback off of that. And I
think,
I I definitely think of two,

(23:45):
concepts of why I would wanna use pharyngeal
manometry, and it's exactly UES dysfunction, questionable UES
dysfunction,
or an idiopathic
dysphagia.
So for UES dysfunction,
you know, I'm sure if, you know, anybody
that works with ENTs or GIs and you're
saying, hey. I think this person has a
UES dysfunction. And the moment that they see
that swallow and if there is

(24:06):
a inkling of weakness that you can see,
oh, that base of tongue is a little
bit, you know, reduced. Oh, that high laryngeal
excursion doesn't really, like, fully elevate or come
forward. Then they go, that's not a UBS
problem. That's a pharynx problem. Right? And so
we could, like, instinctually no. No. No. I
think it's a UBS problem, and I think
that this person could benefit from a dilation
or a Botox or a myotomy.

(24:27):
It has been so helpful, one, to prove
to myself when I'm wrong,
because I've also been wrong. And I've gone,
no. You need to do this to The
US, and then find out that it's actually
just weak,
or I've,
come to it and and
been able to say no based off in
the in another Amari and colleagues,
paper that came out in 2025, and it's

(24:48):
great to speak the same language. They said,
well, did you do 10 ml, you know,
boluses
on the swallow city,
to be able to see how the UES
opens? And then have you done this pharyngeal
manometry? And then if we get consensus using
pharyngeal manometry, then there's not this back and
forth conversation. It's like, oh, no. We we
know that it is. And the other one

(25:08):
is definitely the idiopathic. Right? The patients that
are coming in, and I'm going, okay. You
don't have a neurogenic diagnosis. Your cranial nerve
exam is normal. You have no neuro symptoms,
and yet
I
see this, like, possible weakness, like, versus, you
know, if I have an idiopathic and I'm
like, oh, well, I see your lingual fasciculations
and you've had weakness that's progressed over time,
then I'm like, oh, I I need to

(25:29):
send you to neuro. But if I'm sitting
there going like, I I see weakness,
but it doesn't really make sense, or I
see residue,
and I I guess it must be weakness.
This is really that step forward to, like,
go, okay. Can I this will tell me
more quantitatively,
less subjective,
what is the pressures? What is the contractile

(25:51):
interval? What is the actual strength of it
compared to norms so that it really can
confirm, yes, there's weakness. Let's go send them
to neuro because we don't really know why
we have this weakness.
Or, oh, actually, it's muscle tension, or, actually,
it's UAS dysfunction. And I've I've been surprised
by that too, where I don't I I'm
not looking at the UAS, and I don't
actually think about it, but it is this,
like, backflow situation of, like, this is working

(26:12):
so hard because it's working this, like, obstruction
that we can't really see in a fluoro.
Yeah. Can you guys share maybe some clinical
signs you would see on you know, for
fees? You know, maybe you just suggested, like,
backflow or residue
or video fluoroscopy. What are some what are
some clinical signs you would see on each
of those that would then yield the further
referral to manometry?

(26:33):
I'll start with, I'll start. I'll talk, MBS
because that's where mostly I because because I
truly think this, like, UES and pharyngeal interplay
is where,
manometry is so valuable.
The MBS gives you a lot of that
information. You know what I mean?
So one is, I think, if there is

(26:55):
if there is residual and you're like, man,
I can't really tell, like,
I can't tell you how many times there's
been residual.
And I put manometry in, and it's actually,
the pharynx is not weak. Like, that residual
is not from a reduced motion. That residual
is from an outflow obstruction, which means, like,
it's it's pushing hard and not going through
the UES. And so that's more of, like,

(27:16):
a a compliance issue of the UES, whether
it's
right. There's something going on
with the UES.
I would say so residual that that is
not obviously weakness that could be explained by
some sort of diagnosis, kinda what Jamie was
saying.
I think that's probably one of the keys.
Or if the UES you're like, man, that's
really not opening, and I can't tell if

(27:37):
that's not opening because of this weakness or
if that's not opening because it's some sort
of, like, a true UES dysfunction.
Those are kind of the big two. If
if it's obvious
that
there's, like, some sort of structural
abnormality, manometry can confirm, I guess, in theory,
could confirm, like, look. That's a c that's

(27:59):
a true CP bar that needs to be
managed,
or that's a
truly
be like, I'm confident. This is absolutely this,
x, y, or z, then you don't need
manometry. It's when there's this, like, ambiguity to
it that you're trying to figure out, like,
why do I have this and I don't
fully understand?
That's where I find the value from a
modified standpoint. So it's it's usually component 14

(28:21):
on MBSIMP if you do MBSIMP.
Or it's sort of this, like, why do
I have residual? Why do I have but
the base of tongue doesn't look that weak,
and this, like, I don't understand. Right? It's
usually those. Yeah. I I I'll I can
briefly talk on fees. And right before I
do, I just wanted to say when you're
talking about outflow obstruction, the way
after doing pharyngeal manometry, and this is something

(28:44):
that doctor Longenecker and I are very passionate
about that now that I've spent enough time
in this world, But I
the purpose of us talking about this on
a podcast is not just to say,
oh, you need manometry in your life, then,
like, you're not doing justice to your patients
without it. Absolutely not. I actually think that
even just learning about it and visually
watching studies

(29:05):
in comparison with manometry really, like, shakes your
world. You once you look at a manometry
next to it next to an MBS,
you can't look in a MBS the same
way. And, I mean, a a small plug
and has nothing to do with me, but
Diane did a Tim's lecture,
and she did a beautiful job where you
watch an MBS and you guess, and I

(29:26):
love you always use the pump versus valve.
But you look at an MBS and then
you look at a manometry, and you you
really, like, are are shattering
what your assumptions are. And, again, speaking to
doctor Longnecker that we are always looking at
it mechanically
versus looking at it as this, like, pump
and valve. And so I often then will
look, and this is, like, when you start
seeing Fringo Seals and things, then I'm like,

(29:47):
oh, is this a
this is my
there's probably better analogies, but, like, this is,
like, the the clogged toothpaste. And I have,
like, literally dealt with it this morning. Right?
Is that I can be squeezing as hard
as I possibly want on that toothpaste bottle,
or or tube. But
if the
the cap is is clogged,
then it's just I'm gonna have to, like,

(30:09):
over pressurize it, and it's because of the
clog of that. And so that's when she
meets, like, this outflow obstruction.
And so so often we're you know, we
think about it mechanically, but it's instead, like,
what's going on with the pressure, and is
it this, like, upward
situation?
And same as doctor Longenecker, I do modify
bearing swallow studies primarily, and then I end

(30:29):
up using fees as like, that's usually my
go to, before I had pharyngeal manometry or
I have like, I I have this ability
to kinda triangulate
the swallow at times. And sometimes, like, these,
I've you know, over the years, I've been
humbled to go, oh, yeah. I forgot MBS
is a two d image, and I've done
this, like, cervical hardwares or things like that

(30:49):
that, like, from a two d standpoint, didn't
look like it was obstructed, and then all
of a sudden, it's, like, taking up the
entire left syrinx. And so from
same concept, but I think, in doctor Ashley
O'Rourke, she talks a lot about I think
she uses these much more. She's laryngology, but
works with speech pathology
to assess the swallow and assess UBS dysfunction.

(31:09):
So different camps of thoughts and things, but
you will definitely, I think, see that concept
of, like, when you see that retrograde flow.
Right? They finish the swallow, they relax, and
then, you know, that that bolus is coming
up from the UES backup.
I think that that's
that's where, again, you know, that we're thinking
about where does pharyngeal manometry come in. But
it really isn't. It's not for those ones

(31:30):
that we we have the answers for. It's
the ones that we don't have the answers
for. Yeah. Can I say one more thing
about, one of, like, the red flags that
triggers a manometry for me is,
when there is a lateral pharyngeal diverticulum,
so when I flip my AP and there's
little
transient, like, pseudo diverticulums
that form,

(31:51):
so those typically form those are forming between
the inferior and the middle pharyngeal constrictors,
and those are typically classified as, like, a
Anything that's a is, like, a pressure type
of diverticulum,
and I immediately am like, pressure? We have
a pressure problem, and the only test that's
gonna tell me if if my pressure's wrong
in the pharynx is gonna be manometry. So

(32:11):
if I'm ever alerted
with, like, a a transient pharyngeal diverticulum
in AP, I immediately wanna go dig and
see what the pressure system is looking like,
and manometry is really great at that.
So let's talk about okay. So now we
use this as a diagnostic tool.
Where does our findings take us? So do
you then refer to GI and say, hey,

(32:34):
dude. I found this. Go fix it. Or
does this yield our swallowing treatment plan? What
what do next steps yield?
Yeah. Both. I think both. Right? And, actually,
I, my laryngology team uses this with alongside
be far more than my GI team does.
While my GI team has, like, afforded me
to hop in and, like, use their equipment,
and they use

(32:54):
parental sum.
The ones that it really impacts their workflow
are my laryngologist.
And, actually, I just had one last week.
They called and they were like, hey.
I've the the modified looks like it may
be UES dysfunction, but, like, I don't wanna
go in and, like, do anything for this
UES until I know for sure. Can you
go in and do manometry? Because I'm willing
to go Botox or dilate or and in

(33:16):
hand, but I don't wanna do that if
I think it's a pharyngeal
drive, a pharyngeal pumping system problem. And so,
we dropped the catheter. Sure enough, the UES
actually is not the problem. This is a
pharyngeal propulsion issue. And, no, the UES didn't
open, but, like, not because it's stuck. It's
because the pharynx has essentially no contraction left
in it at the moment. And so what's

(33:36):
really nice about it is not only does
it, yes, like,
tell me, like, oh, this is a for
instance, that case, like, this is a speech's
responsibility
at this point. This has nothing to do
with like, they don't need to take and
do them do anything with that person. It's
speech's responsibility.
And that initially, when I started the program,
was really where it started, where it was,
like, speech was driving the referrals for manometry,

(33:56):
and then it was, like, telling me, like,
yes. I can confidently say this needs to
stay with speech to help manage this. Or
I can say, no. This needs to be
medically or surgically managed by the laryngologist I
send out. And now the beauty of, like,
that reciprocal that relationship that we have formed
is they're asking for it too because they
have learned, like, the value in trying to
figure out because that no surgeon

(34:18):
wants to go in and do something that
Well, right. Right. Can ultimately fix it. You
know what I mean? I mean, I hate
to say this, but I feel like sometimes
we're just dilation happy. Right? Like, it just
seems like that's the way to go, and
then you end up with these patients that
just
need to continuously keep getting that done. And
is that really the root cause? It it
right. And I think that that actually is
a big piece of why I wanted to

(34:40):
bring pharyngeal mammometry to to our center is
that
we've just hired fantastic laryngologists.
But, historically,
it's been really hard for me to get
a patient to get Botox to the UBS.
And I I understand right from dilation to
Botox to myotomy, there's, you know, increased risks,

(35:00):
and more permanency,
you know, in a it ends part of
it. But many of these, you know, we're
saying, hey. This is a UES dysfunction. I
just proved it in a manometry, and it's
a neurogenic
etiology to such. You can dilute it all
day, but it's not gonna do anything.
And so talk about, like, these, you know,
frail patients that have been going under anesthesia

(35:20):
to get a dilation that's not gonna work.
And so that's, like, long term. And, again,
to plug another you know, to to be
to be published,
soon, I think.
You know, systematic review of what she looked
at, like, UES dysfunction
and how is it, you know, treated. And,
I mean, I I'll let you summarize it,
but it's all over the place. Right? Yeah.

(35:41):
It's all over the place. Right? It's like
who
it really depends on,
provider training and comfort, and I think, like,
it's so infrequently
at least in the systematic review we ran,
it's so infrequently driven by actual assessment outcomes.
And I think manometry holds
the ability to help better guide treatment of
the UES.

(36:02):
And, like Jamie said, there's risk involved in
everything. Right? So, like,
they if there's a possibility that this person
does not need to go under any sort
of anesthesia for any sort of medical or
surgical intervention,
and we can still fix the swallow, then
that is
often the the way you wanna go. Right?
Just for, like, patient risk.
And it gets better outcomes. Like this my

(36:23):
physician that last week was like, hey. Can
you tell me if I need, like, which
one it is?
She also wants good outcomes, and she knows,
like, could I take him to the Operating
Room? Sure.
But, like, is it gonna yield me better
patient outcomes than just keeping them in therapy?
Right? And so, like, I think it's always,
like, you just it's a very when used
well, I think it's very good at, like,

(36:44):
making our assessment very patient centric
and our treatment very patient specific
rather than sort of, like, a a broad
swath of, like, well, I just do this
because this is what I've always done kind
of thing. You know? Yep. I love that.
Oh, I love this conversation, you guys. Okay.
Jamie's gotta hop off in a few. Jamie,
I want you to share you guys have

(37:05):
a swallow symposium coming up soon.
Yeah. Those were it. Yeah. Yeah. Thank you
so much. Yes. Yes. So,
June 6, it's a Saturday. It's full day.
We are hosting University of South Florida and
Tampa General Hospital is hosting our third annual
swallowing symposium.
It is free free free f r e
e. Free.
Free.

(37:26):
It it provides,
CUs, ASHA CUs, as well as CME. And
so if there's any of your colleagues, physicians,
nurse practitioners, you know, anybody out else out
there that then not a speech pathologist. Right?
We're all working on this together.
It is a multidisciplinary
lineup. So we have ENT, GI, GI surgery,
speech pathology,
allergy and immunology,

(37:46):
psychology.
I hopefully didn't leave anybody off.
Are all the speakers at four sessions. Everybody
speaks for about twenty minutes. We have a
panel discussion at the end. If you like
pharyngeal manometry as a topic, I'll be speaking
about it, and so you can actually visually
see what's going on.
And soon, if you look up, we'll, I'm
providing the link,
to register, but our website,

(38:07):
hopefully, in the next week, so maybe by
the time this comes out, we'll have all
of our recordings from the past two years,
just for free learning and education. So, yeah,
please come. It's to celebrate gymnastics, Asia Awareness
Month. It it our sponsors are the reason
why it makes it happen, but I feel
strongly just like, of course, Teresa does,

(38:28):
that we should,
get good education. And, we are very lucky
to have doctor Longnecker speak on UES dysfunction
last year, so that should be up on
the recording.
Phew. So please come on online and in
person, I should say too. We will we
will link it as well. Do you have
the the website off the top of your
head, Jamie?
I would look up USF. It's it's a
long website, but USF swallowing symposium, and then

(38:50):
it'll pop right up. Yeah. It's like USF
on health, all the things. Yeah. Awesome. Any
any final thoughts you'd like to share?
I think I I I just was talking,
but, I mean, what I would just say,
the one thing that we didn't talk about,
doctor Longnecker and I met in 2013. She
was my clinical fellow mentor. So, again, full
full clinician. I was a full clinician. I
was a CF.

(39:10):
I was way over my right being over
my head.
I still learned so much from her today.
She is not just a colleague. She's a
really dear friend. Though if you're a student,
if you're a CF, if anywhere you are
in your career,
keep those really great mentors close by because,
you know, at this point, we're now, you
know, clinical research
collaborators despite that she's in Texas and I'm

(39:32):
in Florida. So, you know, keep good friends.
They're they're great.
I think it's reciprocal. Right? It goes both
ways. You know? So you,
I would say thirteen years ago when she
started, clearly, I was a mentor. And then
I think at this point, like, it's truly
this, like, back and forth relationship. I learned
probably as much from her as she learns
from me.
And I I think that it shows that,

(39:53):
like, true clinical and research
collaborations
and and relationships are possible,
because there are things that Jamie can does
can have and access and all the things
that I don't,
and vice versa. And so, like, if you
find a good one, stick with them.
Find find one like Jamie that asks, like,
really good questions and makes you think,

(40:14):
and makes it she makes me grow too.
So
And find one like Diane to, you know,
when you ask the crazy questions, she doesn't
make you feel crazy for this. Absolutely not.
No. I I to be honest, I mean,
I I shared this, I think, in a
in a blog post or something a few
weeks ago. But when I first started doing
fees so much, it was like, I just
had this group text of other fees people
that was just like, what the heck am

(40:36):
I seeing? Like, sometimes, you know, it it's
even to this day, you know, like, you
guys have talked about. I mean, I've done
thousands of fees, but sometimes you just see
something that you're just like,
what is going on here? Like, there's you
know, whether it is something neuro or whether
it's idiopathic or, you know, never be afraid
to reach out and ask a smart friend.
I I love, you know, the phone a
friend thing, and I love having a lot

(40:56):
of really smart friends, you know, that I
can quickly text because it happens to everybody.
And and so I think younger clinicians that
get frustrated not knowing all the answers, it's
a lifelong
phenomenon of not knowing all the answers.
Well said. Well said. When I first started
doing manometry, I,
I was I was twenty nineteen, so, like,

(41:17):
even fewer people were doing it clinically at
that point. And I was like, I have
literally no idea what I'm doing. And I
would, like, I would
stay up hours and hours and hours at
night, and I actually finally got the courage
to reach out to Corinne Jones. And I
was like, hi. I was like, I I
would love some help with this. And she

(41:37):
was the kindest. We would share screen. I
would, like, do a study. I would de
identify it, and I would pull it up.
And I'm like, am I marking this correctly?
Like, tell me if I'm doing this right.
And she gave she was so selfless with
her time
and really and I think that's the thing.
Like, find a find a good
collaborator that is more knowledgeable in whatever area
you wanna grow in, and they will give

(41:59):
you time.
And I I I credit her for, like,
getting in there when I was, like
had no idea what I was doing. And
I'm so grateful to her because then she
taught you. And because she taught you, I
finally met her at DRS last year. And
I'm like, thank you. And she's like, who
are you? I'm like, you taught Diane who
taught me. You know? And so yeah. It
it it keep giving. You know?

(42:21):
Give and receive. Right? Yeah. I I love
this because I I do feel like there
are those core universities that are just doing
monometry. Like, it's as common
as video philanthropy and fees these days. You
know? But then there's other clinicians that just
want to learn it and are hungry to
learn it. So, you know, I'm so grateful
to you guys for getting a lot of
this information out there because I you know,
even for myself, I I kept looking into

(42:43):
it, and I kept trying to reach out
to people. And I'm like, is there really
a role for this
just, for lack of better term, like, just
as a clinical SLP? You know? Because it
always seems to be really research heavy, and
and it's taken me a while to say,
you know, is this something that I should
offer in my clinic? And, you know, thank
you, Jamie, for explaining the the reimbursement stuff
because that is a barrier as well. But,

(43:05):
you know, maybe as we
show the benefit of it some more, then
perhaps there you know, it could be looked
at to possibly have its own code or
whatever that looks like in the future. But
I'm more and more convinced actually now
than I was, like, even a couple of
years ago that I think we're kind of
where
we were at the infancy of fees. Right?

(43:26):
Where
we have enough data, we have enough research
that says there's value, and it's safe, and
it's,
you know, it's effective, and, like, it gives
us information. And I think at this point,
we need clinicians just to go do it.
And, like,
does that make sense? And I'm and but
here's what I always say when I give
these lectures. Like, if you choose to be

(43:46):
an early adopter of this, which I think
even at this point, like, you whoever starts
it would be considered an early adopter. Like,
it's still pretty not new.
You just have to be willing to
keep up with the literature and be flexible
because how you do it today even me,
like, since I started in '19, I've changed
my protocol because the recommendations have changed. And
so you have to just be willing to,

(44:06):
like, be flexible, keep up with it, and
know that, like, what how you do it
today, it might look different in five years.
It might look different in two years. Right?
But I I really do believe that unless
we begin to clinically try to use it,
it will be stuck in the lab. And,
like, well, it will be really hard to
for the average clinician to see how it's

(44:27):
clinically utilized.
Diane, sure if you can, you know okay.
So so we have some really hungry, overachieving
early adopters that wanna go now, you know,
start this program. Where would you have them
start?
I, one, would check into your internal resources.
So see who you have at your institution
or at your disposal, like, if you're not

(44:48):
in a hot big hospital system,
because I think the more feasible, fiscally feasible
way to do it,
is to partner with your GI team.
I also think they're gonna have a bunch
of the infrastructure already set up. Right? They're
gonna know, like, they're if they're running esophageal
manometry, it's very easy to tag pharyngeal manometry
into that. So I think
pull your community and figure out who your

(45:10):
people are because it's definitely not a, like,
single like, it's gonna be very hard to
do it with, like, by yourself, essentially, especially
if in your big hospital system, a lot
of bureaucracy and a lot of policies and
procedures
and productivity
expectations and all these things. Right? So find
your people. I think that's the first thing.
I will say,

(45:32):
the didactic education,
there's a lot of free didactic education. Like,
Tim's has some. I think Jamie mentioned it.
There's also, like, paid courses, like MUSC and
Madison and some other ones put them on.
I would say, at some point, you have
to do that kind of stuff to understand
what that tool is.
But
that that only gets you so far. You're
gonna need somebody that's willing to, like, get

(45:53):
in and, like, really get in with you,
kinda like Corinne did with me, where it's
like, once the logistics and you can get
it down and you kind of cerebrally understand,
you're gonna need someone that a mentor that's
willing to help you,
figure it out. And so I would say
those are the first big three things. Find
your people,
under like, take some courses,

(46:14):
and find a mentor that's willing to give
you some time. And that would be those
are kind of the first three big steps,
I think. Yeah. Yeah. Because it's interesting because
they're we're not at a level that we
have any sort of established competency. Right?
I mean, even there is that you know,
we do have the MBSIMP, which is wonderful,
and a lot of people do use that
as established competency. But for some facilities, there's
just not you know, even for fees. You

(46:34):
know, ASHA used to have guidelines as to
what deemed someone competent, but they don't even
have those anymore. So it's gotta be something
that, you know, either you establish that within
your facility or, you know, we we trust
SLPs to not do things without having proper
adequate training.
Yeah. No. There is no, like, standard competency.
Like I said, I I've always worked in

(46:54):
a major medical institution,
and so I always rely back on our
our compliance and our risk department. Like, let's
talk through the internal pass like, process and
policy for this because then I know that
they support that. But so, yeah, I would
rely on that. I will see there are,
there are some decent, like, paper like, working
group papers, the most recent being in 2025

(47:17):
that will actually give you guidance on the
protocol
and the metrics to analyze and things like
that.
Yeah.
I will say that's probably one of the
more intimidating parts is, like, what is my
norm for this? Right? Like, I don't even
know what like, what is normal for this?
And so, like, making sure that you have
the correct norms and you're using the correct,
like, protocol of swallows and things to help

(47:38):
make sure you get the answers is important
too.
Final thoughts, anything we didn't cover?
I would say at this point in my
practice, I can't imagine
I I don't send for UES management without
manometry,
just because there's so often I'm wrong. I
think that's the other thing is so often
my eyes, even though they are highly trained,

(48:01):
are wrong. Like, my interpretation of what I
visually see in a system that, yes, is
mechanical and, like, I can pick up the
mechanical movements well.
The pressure, I'm I can't pick up. And,
like, I'm so often sort of tricked by
that. Yeah. And I think that's the other
piece is, like,
knowing that, like,
as
objective

(48:21):
as our
instrumental assessments are, there's still limitations
to them that manometry then fills the gap
for. So it's just another.
It's not in every patient kind of study,
but it is definitely,
additional information when you think there might be
a pressure related
problem. Yeah. Yeah. The the reason I love
it and the more you convinced me in

(48:42):
the last hour is Okay. Good.
I I think about and and I even
I think we did about three podcast episodes,
gosh, maybe five, six years ago about, okay.
You're noticing
all of this UES dysfunction or something is
going on with the esophagus, but you don't
know what it is. And so we refer
to GI.
And sometimes that just sends the patient into

(49:02):
this
spiral of a bajillion tests.
And I think, you know, as
you know, and and and just as you
had in your PhD and and I have
in my PhD too is really looking at
public health dollars. And is that the best
use of public health dollars and also a
patient's time?
And so, you know, I know we've gotten
a bad rap with some GIs and just
saying, hey. There's suspected UES dysfunction. You know,

(49:24):
go run a bunch of tests. And then
sometimes they'll call us back and say, okay.
What test do you want me to run?
You know, is it a
is it a upper GI? Is it a
herbarium? Is it what you know, is it
EGD? They go through their,
you know, typical list of of tests to
run. And I think this just gets everybody
more on the same page of narrowing it
down a lot more and not sending the

(49:46):
patient in the GI on a wild goose
hunt.
Yeah. I also think that,
as good of I work with fantastic GIs
and laryngologists,
like, very highly trained. I they would, like,
follow in esophagus, and, like, they're super
great as GI docs. Not just general GI.
They're, like, esophagologists,
like, have spent their entire career
doing esophagus work.

(50:07):
And then I have laryngologists that are great
and, like, very highly trained. I would say
until we,
really started
getting manometry
and, like, focusing on the UES,
they wanted nothing to do with it. GI
wants to get past it, and the laryngologist
wants to look at the voice. Right? And
so until we could, like,
figure out and I actually think there was

(50:28):
a role in, like, my me and and
the speech department taking ownership in the sphincter.
Right? So, like, you can't overstep your scope.
Like, there's still things we can't do, but
it's no man's land. Even when you look
at the esophagus, like, the esophageal manometry,
they'll give you UES reads. They don't they
don't they're like, oh, I did. And you're

(50:49):
like, yeah. The system gave me UES reads.
And they're like, oh, I don't pay any
attention to that.
And so I think,
where it's like, is this speech a scope
of practice? I'm like, it's somebody's gotta own
the UES.
Right? And I think that, like, this is
kind of a prime opportunity for speech
in collaboration with those providers
to really try to say, like, hey. This
sphincter is far more complicated than you think

(51:11):
it is, and someone's gotta own it. And
the reason I think speech probably needs to
be a big lead in that is it
has so much influence from the pharynx,
that the GI and the laryngologist
often don't have as deep of an understanding
as speech does in. Yeah. That's that's awesome.
That's so so interesting. Thank you for sharing
that perspective, Diane.
Doctor Longnecker, thank you so much for your

(51:32):
time today. Jamie had to hop off, but
thank you guys so much, and we'll leave
their contact info in the show notes. And
we'll also leave a link to Jamie's swallow
symposium. It is completely free,
for those of you that wanna check it
out either in person or online. I'm hoping
to go in person if my schedule allows,
but, really grateful for both of your your
time.
Yeah. Thank you.

(51:53):
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