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DYSPHAGIA ASSESSMENT AND TREATMENT PLANNING: A TEAM APPROACH
particular when aspiration occurs without a response from the patient. This is
termed silent aspiration and is common
in patients with neurological deficits
or disorders and sensory impairments
(such as after radiotherapy or surgery
to the head and neck). Silent aspiration can have significant clinical consequences, including pneumonia, lung
abscess, and death (Garon et al., 2009;
Ramsey et al., 2003, 2005). Because
there is no obvious response from the
patient, silent aspiration cannot be
detected during clinical examination.
A change in voice quality after a swallow may indicate presence of bolus
material on the vocal folds, but as noted,
silent aspiration may happen with no
clues. Instrumental evaluation is the
only reliable method of detection.
Other findings that should be observed include hyolaryngeal elevation,
epiglottic retroversion, vallecula and
piriform sinus residue, and posterior
cricoid (PC) region findings. The PC
region may show a variety of indentations in the barium stream (Allen et al.,
2011). Outlining of the posterior cartilaginous lamina of the cricoid gives a
slightly flattened indentation on the
anterior wall of the PC region. This is
a normal anatomical finding. A thin
shelf-like indentation may be seen on
the anterior wall of the PC region just
below the cricoid lamina. This is typically an esophageal web. These are often
small (1–2 mm) and nonobstructive but
can become larger and circumferential
and then narrow the esophageal inlet.
Finally, a small rounded impression
may be seen on the anterior wall of the
PC region, termed the posterior cricoid plication. This is mobile with the
larynx, nonobstructive, and caused by
mucosa overlying prominent muscle
strips and veins beneath the pharyngoesophageal mucosa (Allen et al., 2011).
This is also a normal anatomical variant
and is asymptomatic.
Once the pharyngeal phase has been
assessed in the AP plane, the patient is
asked to swallow a large bolus (20cc)
of barium, and this is followed right
through to the stomach. We term this
the esophageal screen (Allen et al., 2012).
Because it is possible for an abnormality in the esophagus to cause pharyngeal
symptoms, in most cases, this organ
should be evaluated along with the pharynx (Carbo et al., 2021; Smith et al., 1998).
As part of the esophageal screen,
the patient is administered a 13-mm
barium tablet to swallow, and this is
again followed from oral cavity to the
stomach. Holdup of the tablet at any
point is noted. During the esophageal
screen, particular note is made of the
transit time to the stomach (normal ≤
10 seconds for a liquid bolus, but up
to 30 seconds for paste or solid textures), completeness of bolus transfer
(i.e., whether residue remains in the
esophagus), intraesophageal reflux,
intraesophageal stasis, constrictions of
the barium stream, or presence of hiatal
hernia (Miles et al., 2016). Extra screening time required to perform this view
is only 10 to 15 seconds. The esophageal screen has a sensitivity and specificity of greater than 70% for common
esophageal pathologies and may allow
the clinician to direct further investigations more appropriately (Allen et al.,
2012; Miles et al., 2015). For example, if
a constriction is noted, the patient may
be sent for gastrointestinal (GI) upper
endoscopy to delineate the nature of
the mechanical obstruction, or if there
is significant intraesophageal stasis or
reflux, manometry may be warranted.
5. BARIUM RADIOGRAPHIC EVALUATION OF THE PHARYNX AND ESOPHAGUS
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The esophageal screen does not replace
a formal esophagram but may give
valuable information regarding the
cause of patient symptoms and direct
further appropriate investigations (e.g.,
transnasal esophagoscopy, manometry,
pH probe) without the increased radiation exposure associated with formal
esophagram. Examples of findings on
the esophageal screen are presented in
Figures 5–5 and 5–6.
Formal esophageal evaluation (esoph-
agram/barium swallow) is generally
examined by fluoroscopy and spot
films, which can be obtained either by
standard films or digital recording of
individual frames. This examination is
also done by observing a bolus of barium as it passes through the esophagus
from the level of the cricopharyngeus
to the stomach (Carucci & Turner, 2015;
Levine & Rubesin, 2017). The examination is performed in the frontal, lateral,
and oblique projections, and observations are made in both the upright and
recumbent positions.
Figure 5–5. Hiatal hernia is noted on
anteroposterior esophageal screen. Hernia
is indicative of a portion of the stomach
that pushes upward through a small opening called the hiatus into the esophagus.
Figure 5–6. Large bolus swallow on an-
teroposterior screen reveals esophageal
stricture.
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DYSPHAGIA ASSESSMENT AND TREATMENT PLANNING: A TEAM APPROACH
The esophagus is a tubular structure that measures approximately 23 to
25cm in length and 1 to 2 cm in diameter. The upper limit of the esophagus
is at the upper esophageal sphincter
at the level of the cricopharyngeus
muscle, and the lower border is the
cardiac orifice where the esophagus
joins the stomach. The aorta causes an
indentation on the left side of the mid-
Figure 5–7. Barium in esophagus; arrow
indicates indentation of aortic arch on
left.
portion (Figure 5–7), and just below
this level, there is often an indentation
caused by the left mainstem bronchus.
The anatomy of the distal esophagus
is somewhat complex but important
to understand when evaluating clinical problems. In the distal esophagus,
there is an area of increased pressure
known as the lower esophageal sphincter (LES). The increased pressure in this
area can be measured by intraluminal
manometry, and an area of intermittent
narrowing is often seen during barium
studies. Approximately 2 cm above
the LES, a second ring is often visualized, which is typically at the junction
of the esophageal mucosa and the gastric mucosa (squamocolumnar junction, SCJ). This mucosal indentation is
referred to as a Schatzki ring. If this ring
is above the diaphragmatic pinch by
greater than 2 cm, the gastroesophageal
junction is elevated and an esophageal
hiatus hernia is present. The anatomy
of this region is seen in Figure 5–8.
In addition to evaluation of the
esophageal anatomy, peristalsis is observed in the prone position. The types
of peristalsis that are seen include the
primary wave (initiated by swallowing), secondary peristalsis (initiated by
retained barium in the esophagus), and
tertiary contractions (nonpropulsive
contractions of the distal third of the
esophagus) (Mittal, 2016).
An important part of this examination is the evaluation for possible reflux
of barium from the stomach into the
esophagus. Reflux of stomach contents
into the esophagus is a very common
condition that usually causes pain in
the epigastric or substernal regions
but occasionally produces dysphagia
or odynophagia (Miles et al., 2015). In
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the argument against its use is that it
is highly nonphysiologic and no one
would be likely to eat or drink in this
position. This maneuver results in more
false-positive results.
Abnormalities that may be seen during the examination of the esophagus
include hiatal hernia, with or without
reflux; webs, rings, or strictures; benign
or malignant tumors (suggested by
irregular narrowing); and motility disorders of the distal esophagus, including achalasia. When abnormalities are
seen on the esophagram, the findings
must be correlated with the findings
of the DSS and the patient’s clinical
symptoms to determine the clinical
significance. These patients are often
referred for further evaluation (including endoscopy) and treatment.
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Figure 5–8. Anatomy of the distal esoph-
agus demonstrated by barium swallow.
A Schatzki ring is well demonstrated (at
).
arrow
addition, reflux into the hypopharynx
may result in aspiration, hoarseness,
and cough. The examination is done
in the supine position after the patient
has consumed about 300 to 400 mL of
barium solution. While the examiner
observes the gastroesophageal junction
fluoroscopically, the patient is asked to
cough, do a Valsalva maneuver, and
raise both legs above the x-ray table.
All of these techniques increase intraabdominal pressure and thus may produce reflux. Some radiologists advocate
using the “water siphon test,” which
consists of observation for reflux with
the patient in the Trendelenburg position while drinking water. Although
this test is more likely to induce reflux,
STUDY QUESTIONS
1. How is radiation exposure to a
patient measured?
2. What factors affect radiation dose?
3. What are some contraindications
for a barium esophagram?
4. What structures and pathologies
may be better viewed from a frontal (AP) projection than a lateral
projection?
5. What are the findings one might
see on barium screening of the
esophagus?
6. What are the typical dimensions of
the esophagus?
7. Can esophageal dysmotility be ap-
preciated on an esophagram?
8. Can the aorta be appreciated on an
9. If a Schatzki ring is identified, where
is its location?
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DYSPHAGIA ASSESSMENT AND TREATMENT PLANNING: A TEAM APPROACH
10. What is the difference between primary and secondary peristalsis in
the esophagus?
11. What techniques are used during
esophagram to test for reflux?
How much radiation exposure
12.
occurs with a typical DSS?
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sky, P. C. (2011). Posterior cricoid region
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Carbo, A., Brown, M., & Nakrour, N. (2021).
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Garon, B. R., Sierzant, T., & Ormiston, C.
(2009). Silent aspiration: Results of 2000
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das, P., & Sigal, R. (2006). Cine magnetic
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spin echo for evaluation of dysphagia
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Henderson, M., Miles, A., Holgate, V., Pery-
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Levine, M. S., & Rubesin, S. E. (2017). His-
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Miles, A., Clark, S., Jardine, M., & Allen, J.
(2016). Esophageal swallowing timing
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311(3), G431–G443.
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Chen, M. Y. M. (1998). Lower esophageal
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. . . Morimoto, Y. (2014). The use of highspeed, continuous, T2-weighted magnetic resonance sequences and saline for
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Efstathopoulos, E., Granata C., & Andersson J. (2021). Dosimetric quantities
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Dynamic Fluoroscopic
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Swallow Study:
Swallow Evaluation
With Videofluoroscopy
Rebecca Leonard and Susan McKenzie
Known in our center as the dynamic
swallow study and in others as the modified barium swallow, this well-known
procedure was initially described by
Logemann et al. (1977). When we began
doing these studies, we chose the name
dynamic swallow study (DSS) to reduce
confusion with other barium swallow
studies and to indicate our focus on
oral, pharyngeal, and laryngeal movements during the swallow, as well as on
anatomy. Recording and imaging technologies have advanced significantly,
with improvements both in image
quality and ease of analysis. In this
text, three chapters are devoted to various aspects of the fluoroscopic swallow
study. This focus on fluoroscopy is not
just about the study, however. When we
began doing studies and attempting to
101
get as much information from them as
possible, both subjectively and from
objective measures of swallow mechanics, we found that our understanding
of swallow function, and dysphagia,
was significantly enhanced. Fluoroscopy also continues to be the tool that
provides the most information about
mechanical characteristics of swallowing; consequently, its use and the results
that are possible with its careful analysis
are emphasized here.
INDICATIONS
Patients are referred for DSS whose complaints, signs/symptoms, and/or histories suggest oral, pharyngeal, laryngeal, or pharyngoesophageal segment
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DYSPHAGIA ASSESSMENT AND TREATMENT PLANNING: A TEAM APPROACH
(PES) dysfunction. Ideally, all will have
undergone evaluation, at least by their
primary physician and perhaps treatment for underlying diseases. In our
practice, which includes both outpatients and inpatients, the dysphagia may be acute or chronic, obvious
or subtle, severe or mild. The DSS is
undertaken to identify risks to respiratory/pulmonary and nutrition/hydration health and to target potential
behavioral, surgical, or medical interventions more precisely and effectively.
DSS is not indicated in situations where
performance status might fluctuate rapidly due to expected improvement or
deterioration in health condition, when
moving the patient is dangerous, or
when positioning the patient appropriately for the exam is not possible.
LIMITATIONS
Limitations of the use of fluoroscopy
in dysphagia assessment and management include its invasive nature, which
limits the frequency and length of
individual studies (typically less than
3 minutes and rarely more than 4 in
our setting). Also, the image obtained
is only two-dimensional, though additional information may be available by
filming in both lateral and anterior-posterior views. Prior review of patient history, and a thorough clinical evaluation,
will optimize time spent in the fluoro
suite. Review of the recorded DSS after
the study is completed also helps to
maximize information from a limited
period of observation. Frequency of
repetition of the study should also be
carefully considered due to the risks of
radiation exposure.
Another limitation of fluoroscopy
is its dependence on the quality of
images obtained. If critical structures
or events are not visible at all, or are
too dark or too light, valuable information may be lost. In Figure 6–1, optimal
and suboptimal images are illustrated.
In Figure 6–1A, the oral cavity and the
entire pharynx are readily visible. The
onset of bolus transit, and any potential difficulties associated with oral
or oral-pharyngeal transit, should be
clear. In addition, the airway below the
larynx is visible even at rest, allowing
for clear observation of an aspiration
event, or opening of the upper esophageal sphincter (UES). In Figure 6–1B,
the hyoid and larynx, and the separation between larynx and sublaryngeal
airway, are observable even anteriorly,
which is important for assessing hyoidlarynx approximation. In contrast, note
the extremely dark representation of the
oral cavity, nasopharynx, and part of
the oral-pharynx in Figure 6–1C. Ability to define the onset of bolus transit
would be difficult in this case. In Figure
6–1D, it is apparent that the area below
the larynx is not visible. In this case, it
may be difficult to appreciate aspiration
or the opening of the UES, or to determine how well the larynx and hyoid
approximate during the swallow.
In some cases, the difficulty with
image quality is patient related, that is,
positioning of the patient in a manner
that permits good image resolution is
not easily possible. In other instances,
it may be a lack of attention to, or experience with, the fluoroscopic swallow
study that creates difficulty. It is the
responsibility of the clinician conducting the study, however, to try to ensure
the best quality possible. One example
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A B
103
C
Figure 6–1. A. Optimal radiographic view illustrating good definition of oral cavity and
pharynx. B. Radiographic view illustrating good definition of anterior airway structures
and area of trachea below larynx. Material aspirated into the upper trachea should
be readily apparent. C. Portion of oral cavity and upper pharynx shown is so dark that
structures and bolus material are likely to be difficult to differentiate. D. Lack of good
visualization in region of upper esophagus and subglottis will make appreciation of
PES opening and possible aspiration difficult to determine.
of a “trick” that can sometimes be help-
www
ful is illustrated in Video 6–1, ZDtwoviews, included on the companion
website. The patient illustrated in the
clip has a tracheostomy tube solely
because of his severe dysphagia. Dur-
D
ing the study, his struggle to transfer
bolus material through the pharynx and
into the esophagus is apparent. At one
point, a massive amount of bolus material is refluxed. However, the cause of
this difficulty is not clear until, late in
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