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9 Approach to Image Interpretation
9.1 INTRODUCTION
Swallowing, or deglutition, is one of the most intricate neuromuscular processes in the human
body, involving the precisely timed coordination of over 30 pairs of muscles and multiple cranial
nerves across the oral, pharyngeal, and esophageal regions. When any part of this system becomes
impaired—due to stroke, neurological disorders, structural anomalies, or aging—the result is dysphagia, and this can lead to serious medical complications such as aspiration pneumonia, malnutrition, and dehydration. To assess and diagnose dysphagia effectively, the videouoroscopic swallow
study (VFSS), also known as the modied barium swallow study (MBSS), is widely recognized as
the gold standard. This dynamic, real-time X-ray procedure allows clinicians to visualize bolus
transit and evaluate the physiological mechanisms of swallowing in detail. However, interpretation
of the VFSS has historically varied across clinicians and institutions, often lacking standardization
and consistency. A transformative advancement in the eld came with the work of Bonnie MartinHarris, a leading voice in swallowing science and a pioneer in instrumental dysphagia assessment.
Recognizing the need for a structured, reproducible, and objective approach to VFSS interpretation,
Martin-Harris led the development of the modied barium swallow impairment prole (MBSImP).
This protocol revolutionized the eld by deconstructing the complex swallow into 17 discrete,
observable physiological components—each systematically scored based on validated criteria.
Under her leadership, the MBSImP became not only a diagnostic tool, but a clinical framework for
standardization, interdisciplinary communication, and evidence-based treatment planning [1,2].
9.2 OBJECTIVES AND SIGNIFICANCE OF THE MBSImP
As already mentioned, the MBSImP was established in order to accomplish many goals, its primary
objectives being to [3–43]:
◾
Standardize VFSS interpretation: By providing a uniform framework, the MBSImP reduces variability and subjectivity in VFSS assessments, ensuring consistency across clinicians and institutions, making it easier for less experienced readers to achieve consistency and condence in
diagnosing.
◾
Enhance diagnostic precision: Detailed analysis of specic swallowing components allows for precise identication of dysfunctions, aiding in targeted therapeutic interventions, leaving little to
no space for personal considerations that might derail from the right path.
◾
Facilitate effective communication: A common terminology and scoring system might improve
interdisciplinary communication among healthcare providers, including speech-language
pathologists, radiologists, and physicians, both in the same institution and around the world.
◾
Support evidence-based practice: The protocol is grounded in empirical research, promoting interventions that are scientically validated and tailored to individual patient needs.
9.3 THE MBSImP PROTOCOL OVERVIEW
The MBSImP protocol is a standardized checklist that evaluates the act of swallowing, breaking it
down into 17 physiological components, categorized into 3 domains:
1. Oral Phase (6 components).
2. Pharyngeal Phase (9 components).
3. Esophageal Phase (2 components).
Each swallow is analyzed based on 17 components divided across 3 phases as follows.
ORAL PHASE (6 COMPONENTS)
1. Lip closure.
2. Tongue control during bolus hold.
3. Bolus preparation/mastication.
4. Bolus transport/lingual motion.
5. Oral residue.
6. Initiation of pharyngeal swallow.
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DOI: 10.1201/9781003508113-9
aPProaCh to Image InterPretatIon
PHARYNGEAL PHASE (9 COMPONENTS)
7. Soft palate elevation.
8. Laryngeal elevation.
9. Anterior hyoid excursion.
10. Epiglottic movement.
11. Laryngeal vestibular closure.
12. Pharyngeal stripping wave.
13. Pharyngeal contraction.
14. Pharyngoesophageal segment opening (PESO).
15. Tongue base retraction.
ESOPHAGEAL PHASE (2 COMPONENTS)
16. Pharyngeal residue.
17. Esophageal clearance.
Each component is assessed using an ordinal scale, with scores reecting the severity of impairment.
The worst observed performance across trials is documented to guide clinical decision-making.
This systematic scoring method enhances reliability and facilitates comparison over time, in each
component and in the same patient, making it easier to monitor and assess if and how therapeutic
approaches are working.
9.4 PATIENT PREPARATION AND POSITIONING
Of course, proper preparation and positioning are crucial for the accuracy of the MBSImP:
◾
Patient history: As we have already extensively discussed in a previous chapter, a thorough history intake is needed on conditions affecting swallowing, such as stroke, neurological diseases,
head and neck cancers, or reux.
◾
Positioning: The patient is seated upright at a 90-degree angle, typically in a lateral view to visualize oral, pharyngeal, and cervical esophageal phases. Anteroposterior (AP) views may be
added to assess symmetry and pharyngeal contraction. For the esophageal evaluation, please
see Chapter 7 on imaging technique.
◾
Safety measures: Use of protective shielding is essential to minimize radiation exposure. Clinical
staff should monitor patients for fatigue or distress during the study.
9.5 STANDARDIZED BOLUS ADMINISTRATION
The MBSImP employs a standardized sequence of bolus types and volumes to ensure consistency
and reproducibility across patients and facilities. The typical sequence includes:
◾
Thin liquids: 5 mL via teaspoon, 10 mL via teaspoon, cup sip, and sequential swallows
◾
Nectar-thick liquids: 5 mL via teaspoon
◾
Honey-thick liquids: 5 mL via teaspoon
◾
Puree (pudding-thick): 5 mL via teaspoon
◾
Solid: 1/4 of a Lorna Doone cookie coated with barium
Each bolus is mixed with a standardized barium sulfate contrast agent to enhance visibility under
uoroscopy. The order of administration is designed to progress from least to most challenging,
enabling the identication of fatigue or consistency-specic decits.
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ImagI ng of the Pharynx and t he esoP hagus
9.6 DETAILED ANALYSIS OF THE 17 PHYSIOLOGICAL COMPONENTS
9.6.1 Lip Closure
Lip closure assesses the ability to maintain an anterior seal during bolus intake and transport.
Adequate lip closure is essential to prevent anterior spillage and maintain intraoral pressure necessary for effective bolus manipulation and transport. Impaired lip closure may result in drooling,
reduced oral intake, and a heightened risk of aspiration. Score, at any point during the swallow,
the presence and location of contrast material seen between or outside the lips on the lateral view.
If lips are not completely in frame, score what can be seen and note that the exam was limited
(Figure9.1a–f).
Figure 9.1 Component 1: Lip Closure. 0 = No labial escape. Contrast is contained within the oral
cavity; there is no evidence of escape beyond the oral mucosa. 1 = Interlabial escape; no progression to anterior lip. Trace amounts of contrast outline the interlabial space. No progression to the
anterior lip. 2 = Escape from interlabial space or lateral juncture; no extension to vermilion border.
Progression of contrast onto but not beyond the vermilion border of the lower lip. 3 = Escape progressing to mid-chin. Contrast progresses beyond the vermilion border to the mid-chin but not
beyond. 4 = Escape through open lips. Profuse escape between open lips progresses beyond the chin
regardless of bolus consistency or swallow task.
◾
0: No labial escape.
◾
1: Interlabial escape; no progression to anterior lip.
◾
2: Escape from interlabial space or lateral juncture; no extension beyond vermilion border.
◾
3: Escape progressing to mid-chin.
◾
4: Escape beyond mid-chin.
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9.6.2 Tongue Control during Bolus Hold
This component evaluates the ability to hold a cohesive bolus in the oral cavity before initiating
the swallow. Impaired control can result in premature spillage into the pharynx, increasing the
risk of penetration or aspiration before protective reexes are triggered. Score during swallowing
tasks that require the patient to perform a bolus hold, so essentially with 5 mL thin, cup sip thin,
5 mL nectar, cup sip nectar, 5 mL honey, prior to the initiation of productive tongue movement to
propel the bolus. Score even if the patient is unable to follow instructions or there is neuromuscular impairment. “Dippers,” described by Jeri Dodds in the 1980s, hold the bolus on the anterior
oor of the mouth prior to swallowing. If this is a customary manner of holding the bolus, score 0
(Figure9.2a–f).
Figure 9.2 Component 2: Tongue Control. 0 = Cohesive bolus between tongue and palatal seal.
Contrast is contained between the tongue and palatal seal, anteriorly, posteriorly, and laterally. No
escape to the lateral sulci, oor of mouth, or pharynx “dippers/tippers.” The bolus is held on the
anterior oor of the mouth prior to swallowing; if the customary manner of holding is not impaired,
score 0. 1 = Escape to lateral buccal cavity/oor of mouth (FOM). Bolus escapes to either or both
of the lateral sulci or the oor of the mouth or is spread diffusely throughout the oral cavity. 2 =
Posterior escape of less than half of the bolus. Less than half of the bolus (relative to the amount
given) passes through the tongue to the palatal seal posteriorly. 3 = Posterior escape of greater than
half of the bolus. Greater than half of the bolus (relative to the amount given) enters the pharynx.
◾
0: Bolus held cohesively with no escape, between tongue and palate.
◾
1: Escape to lateral sulci or oor of the mouth.
◾
2: Posterior escape of less than half the bolus.
◾
3: Posterior escape of more than half the bolus.
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ImagI ng of the Pharynx and t he esoP hagus
9.6.3 Bolus Preparation/Mastication
This component assesses the ability to manipulate and chew solid textures, forming a cohesive
bolus ready for swallowing. Effective mastication is critical for reducing food to a safe-to-swallow
consistency. Inadequate preparation may result in unchewed food entering the pharynx, leading to
increased aspiration and choking risks (Fig ure 9.3a–e).
Figure 9.3 Component 3: Bolus Preparation/Mastication. 0 = Timely and efcient chewing and
mashing. Smooth and continuous process without hesitation. 1 = Slow, prolonged chewing/mashing with complete recollection. Complete recollection prior to bolus transport. 2 = Disorganized
chewing/mashing with solid pieces of bolus unchewed. Unchewed pieces of food are swallowed/
remaining in the oral cavity, continuing to chew after the initial swallow. Many times depicted as
vertical munching-type behavior. 3 = Minimal chewing/mashing with the majority of the bolus
unchewed. Many times the bolus warrants expectoration.
◾
0: Timely and efcient chewing with appropriate bolus formation.
◾
1: Slow or prolonged chewing with complete recollection.
◾
2: Disorganized chewing/mashing with solid pieces of bolus unchewed.
◾
3: Minimal chewing with incomplete bolus formation.
9.6.4 Bolus Transport/Lingual Motion
This component assesses the effectiveness of the tongue in transporting the bolus from the oral
cavity to the oropharynx. Inadequate lingual motion can result in oral residue, delayed swallow
initiation, and compromised bolus clearance. It has to be scored after the initial gesture toward a
productive tongue movement for oral bolus transport. Take care not to base your score on oral residue (Figure 9.4 a–f).
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Figure 9.4 Component 4: Bolus Transport/Lingual Motion. 0 = Brisk tongue motion. Quick and
efcient anteroposterior transition of the bolus through the oral cavity. 1 = Delayed initiation of
tongue motion. Patient who experiences difculty in planning and initiating any goal-directed
motor task. Patients usually require multiple cues to initiate bolus transport. Once initiated, though,
tongue movement and bolus transport progress normally. 2 = Slowed tongue motion. Tongue movement progresses slowly in an anterior-to-posterior direction. Bolus is slowly manipulated but progresses through the oral cavity in a posterior direction toward the oropharynx. 3 = Repetitive/
disorganized tongue motion. The tongue rocks the bolus anteriorly and posteriorly prior to productively moving the bolus through the oral cavity. Do not confuse bolus accommodating movement;
you must observe at least 3 repetitions of tongue rocking. 4 = Minimal to no tongue motion. No
apparent movement of the tongue despite cueing.
◾
0: Complete and coordinated lingual movement with full bolus transport.
◾
1: Delayed initiation of tongue motion.
◾
2: Slowed tongue motion.
◾
3: Repetitive/disorganized tongue motion.
◾
4: Minimal to no tongue motion.
9.6.5 Oral Residue
Oral residue refers to any material remaining in the oral cavity after the swallow is completed.
Residue in the oral cavity may indicate impaired bolus clearance, increasing the risk of aspiration
on subsequent swallows. This can also contribute to inefcient oral intake and extended mealtimes.
This has to be scored after completion of the rst swallow, or following the last swallow of the
sequential swallowing task. Compensatory swallows should not be considered when formulating
OR score (Fig u r e 9.5a–f).
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ImagI ng of the Pharynx and t he esoP hagus
Figure 9.5 Component 5: Oral Residue. 0 = Complete oral clearance. Complete oral clearance
with no contrast remaining. 1 = Trace residue lining oral structures. Trace residue that resembles an
outline or coating of the structures. 2 = Residue collection on oral structures. A collection of bolus
remaining on the oral structures, an amount sufcient to extract or “scoop” from the oral cavity.
3 = Majority of bolus remaining. The majority (> half) of the bolus remains in the oral cavity, relative
to the bolus size. 4 = Minimal to no clearance. Generally requires expectoration; anterior escape is
not considered clearance.
◾
0: No residue present.
◾
1: Trace residue on tongue or in sulci.
◾
2: Residue collection on tongue, hard palate, or oor of the mouth.
◾
3: Majority of bolus remains in the oral cavity.
◾
4: Minimal to no bolus clearance.
9.6.6 Initiation of Pharyngeal Swallow
This component evaluates the location of the bolus head at the moment the pharyngeal swallow is
triggered. The rst initiation of the pharyngeal swallow is represented by the rst movement of the
brisk superior-anterior hyoid trajectory. Delayed initiation of the swallow can allow bolus material
to spill into the unprotected airway before laryngeal closure, signicantly increasing the risk of
penetration or aspiration (Figure 9.6a–f).
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aPProaCh to Image InterPretatIon
Figure 9.6 Component 6: Initiation of Pharyngeal Swallow. 0 = Bolus head at posterior angle of
ramus. Bolus head at the posterior angle of the ramus of the mandible and the back of the tongue
at the time of the rst hyoid excursion. Do not consider residue from a previous swallow. 1 = Bolus
head in valleculae. Bolus head in the region of the valleculae at the time of rst hyoid excursion. 2 =
Bolus head at the posterior laryngeal surface of the epiglottis, the space between the base of the valleculae and the superior surface of the pyriform sinuses. If the bolus head has exited the valleculae
and has not reached the superior limit of the pyriform sinuses, score (2). 3 = Bolus head in pyriforms,
at the time of rst hyoid excursion. 4 = No visible initiation at any location.
◾
0: Swallow initiated with bolus at posterior angle of ramus of mandible.
◾
1: Bolus reaches valleculae before swallow initiates.
◾
2: Bolus reaches laryngeal surface of epiglottis.
◾
3: Bolus enters pyriform sinuses before swallow.
◾
4: No observable initiation.
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ImagI ng of the Pharynx and t he esoP hagus
9.6.7 Soft Palate Elevation
Soft palate elevation assesses the ability of the velum to elevate and retract to make contact with
the posterior pharyngeal wall during swallowing. Adequate soft palate elevation is essential for
preventing nasal regurgitation and maintaining oropharyngeal pressure during bolus propulsion.
Soft palate to pharyngeal wall contact is based on the presence of contrast or air between the two
structures, best seen on the lateral viewing planes at the height or maximum displacement of the
soft palate. Impairment can lead to nasal leakage, reduced swallow efciency, and residue in the
nasopharynx (Figure 9.7a–f).
Figure 9.7 Component 7: Soft Palate Elevation. 0 = No bolus between soft palate/pharyngeal
wall. 1 = Trace column of contrast or air between SP and PW, at maximum displacement of the soft
palate. 2 = Escape to nasopharynx. 3 = Escape to nasal cavity, or presence of contrast material progressing to the level of the nasal cavity at the time of maximum soft palate displacement. 4 = Escape
to nostril with/without emission. Escape or presence of contrast material progressing to the level of
the nostril with or without nasal emission.
◾
0: Complete elevation and contact with the posterior pharyngeal wall; no nasal penetration.
◾
1: Trace column of contrast or air between soft palate and pharyngeal wall.
◾
2: Escape of contrast into nasopharynx.
◾
3: Escape of contrast into the nasal cavity.
◾
4: Escape to nostril with/without emission.
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9.6.8 Laryngeal Elevation
This component assesses the vertical movement of the larynx during swallowing, which is critical
for airway protection and upper esophageal sphincter (UES) opening. The elevation of the larynx
is accomplished by contraction of the thyrohyoid muscle and pharyngeal shortening. We evaluate
the approximation of the forwardly displaced arytenoid cartilages to the posteriorly displaced epiglottic petiole, at the time the epiglottis reaches its most horizontal position. Inadequate elevation
compromises airway closure and can lead to aspiration. It also impairs the mechanical opening of
the UES, causing residue in the pharynx or pyriform sinuses (Figure 9.8a–e).
Figure 9.8 Component 8: Laryngeal Elevation. 0 = Complete superior movement of thyroid cartilage with complete approximation of arytenoids to epiglottic petiole. No visible air or contrast in
the laryngeal vestibule. The arytenoids are rmly pressed into the base of the epiglottis. 1 = Partial
superior movement of thyroid cartilage with partial approximation of arytenoids to epiglottic petiole. Partial approximation of the arytenoids to the epiglottic petiole with a trace or narrow column
of air or contrast between the arytenoids and the epiglottic petiole. 2 = Minimal superior movement
of thyroid cartilage with minimal approximation of arytenoids to epiglottic petiole, with a wide
column of air or contrast between the arytenoids and epiglottic petiole. 3 = No superior movement
of thyroid cartilage. No approximation of the arytenoids to the epiglottic petiole.
◾
0: Complete superior movement with full approximation of arytenoids to the epiglottic base.
◾
1: Partial superior movement with partial approximation.
◾
2: Minimal movement with minimal approximation.
◾
3: No movement or approximation.
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