Component

17: Esophageal Clearance

Esophageal clearance is the only component in the esophageal domain and represents bolus clearance through
the esophagus in the upright position assisted by gravity. This component is optimally scored from the AP view
but can also be assessed in the lateral and slightly oblique planes, if necessary. The bolus is followed from the
oral cavity through the lower esophageal sphincter. The component is scored only using nectar and pudding
consistencies (similar to Component 13, Pharyngeal Contraction). You do not score esophageal clearance based
on residue that exists prior to giving the consistencies in the AP view. The goal is to observe esophageal
clearance in the position in which the patient eats and drinks. It must be clear to the attending radiologist that
the clinician is not attempting to “diagnosis motility or structural anomalies.” Rather, clearance affects
treatment strategies and the process of eating and drinking. Our studies and others have shown that problems
with esophageal clearance may negatively influence oropharyngeal swallowing dynamics.

SCORING EXAMPLES
The following images are intended to help you differentiate between impaired Esophageal Clearance scores 0-4.

(0) Complete clearance, esophageal coating:
There should be complete clearance of contrast after primary or secondary peristalsis. This may appear as
esophageal coating resembling a trace outline of the esophageal walls. In the image below, there is complete
clearance of the bolus through the distal esophagus. The bolus can be seen passing through the LES and into
the stomach.

(1) Represented by esophageal retention:
Characterized by esophageal retention after primary or secondary peristalsis resembling a “collection” of
contrast material anywhere along the esophagus. At least some of the bolus passes through the UES and into
the stomach.

(2) Represented by esophageal retention with retrograde flow BELOW the PES:

(3) Represented by esophageal retention with retrograde flow THROUGH the PES:

1 1


(4) Represented by minimal to no esophageal clearance:

*Images captured 14 seconds apart. Contrast never passes through the LES.


LIMITED ESOPHAGEAL VIEW
Certain clinical circumstances can prevent capture of complete bolus transit through the lower esophageal
sphincter. However, there are instances in which a score can be given appropriately and with relative certainty.
Follow these general guidelines to determine if a score can be given and what that score should be:

1. If you cannot see the entire esophagus (e.g. limited view of the PES or portion of the thoracic
esophagus) and there is not residual barium that you can see, score: (0) Complete clearance;
esophageal coating and note in your report the finding during a limited examination.
2. If you see part of the esophagus and there is clearly residual remaining, score: (1) Esophageal retention,
and note in your report the finding during a limited examination.
3. If you see part of the esophagus with retrograde flow below the PES, score: (2) Esophageal retention
with retrograde flow below the PES and note in your report the finding during a limited examination.
4. If you see part of the esophagus with retrograde flow through the PES, score: (3) Esophageal retention
with retrograde flow above the PES and note in your report the finding during a limited examination.

It is always best to obtain complete esophageal visualization whenever possible, but when not possible, the
guidelines above allow for the existing impairment to be documented.



SCORING THE LATERAL VIEW
The MBSImP™© Guide explains that Component 17, Esophageal Clearance, is “optimally scored from the AP
view but can also be assessed in the lateral and slightly oblique planes, if necessary. The bolus is followed from
the oral cavity through the LES. The component is scored only using nectar and pudding consistencies.”

Do not score esophageal clearance based on observations in the lateral or oblique plane unless observations
occur with consistencies used in the AP position (nectar and pudding). In the rare situation that an adequate
AP view cannot be obtained AND you are unable to capture complete bolus transit through the LES in the
lateral or oblique planes, score esophageal clearance in the limited lateral or oblique view according to the
guidelines listed under Limited Esophageal View.

The following sequence was selected from a videofluorographic record lacking an AP view secondary to
positioning constraints unique to the patient. The same positioning constraints did not allow for complete
esophageal follow through to the LES in the lateral plane. Given the limitations, one would score Esophageal
Clearance in the lateral view according to the guidelines listed under Limited Esophageal View.

1 1 2 2 3 3

The sequence clearly demonstrates retrograde flow of the bolus back through the PES and into the pharynx
after the initial swallow of a nectar consistency. This patient would receive a score of (3), Esophageal retention
with retrograde flow above the PES.


COMMON SCORING ERRORS

Chin Elevation and Retrograde Flow
When scoring esophageal clearance in the AP view, it is standard to have the patient slightly elevate the chin to
allow for visualization of the pharynx. In some cases, chin elevation can cause the thoracic esophagus to rise. If
this occurs concurrently with esophageal retention, the bolus may appear to “retrograde flow”. The graphic
below illustrates an observable change in chin elevation that parallels a level change in the column of barium.
You would NOT score this as (2), Esophageal retention with retrograde flow below the PES, as movement of the
barium column is clearly a direct result of chin elevation. Complete follow through would be necessary before
assigning a score.

1 2
1


Esophageal Clearance vs. PES Opening
The following graphic is obtained in lateral view with nectar consistency. The sequence captures the bolus
passing through the pharynx and in to the cervical esophagus. The bolus appears to retrograde flow back into
the pharynx. What you are actually observing is impaired PES opening. Contrast does not completely pass
through the PES (outlined in transparent blue marking) during the first swallow secondary to partial distension
and partial duration of the PES with partial obstruction of bolus flow.

1 2 3

4 5