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DYSPHAGIA ASSESSMENT AND TREATMENT PLANNING: A TEAM APPROACH
endoscopic evaluation of swallowing.
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Barium Radiographic
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Evaluation of the Pharynx
and Esophagus
Jacqui Allen
Radiographic examination of the pharynx has typically been referred to as
a barium swallow, modified barium
swallow, or dynamic swallowing study
(DSS) and is accomplished by videofluoroscopy or video radiography.
These studies have been considered
the gold standard in imaging the pharyngoesophagus and have been refined
over decades (Carbo et al., 2021; Levine
& Rubesin, 2017). Other radiographic
methods that can be used for examination of the pharynx include cineradiography and rapid sequence digital radiography, ultrasound (USS), computed
tomography (CT), magnetic resonance
imaging (MRI), and fluoromanometry.
Dynamic MRI techniques (cine-MRI,
turboFLASH MRI, high-speed MRI),
which are free of ionizing radiation,
have been described to assess swallow
(Amin et al., 2012; Hartl et al., 2006;
Kitano, 2002; Kreeft et al., 2012; Olthoff
et al., 2016). However, technical limitations (i.e., poor temporal resolution,
supine positioning, and expense) have
limited their wide application.
Radiographic examination of the
esophagus is termed a barium meal or
swallow, or esophagram. This study
is often combined with examination
of the stomach and duodenum if performed by a radiologist but may focus
solely on the esophagus and transit into
the stomach when performed as part of
a dynamic swallowing study led by a
speech pathologist. The pharynx and
esophagus may be examined together
in one sitting or may be examined separately. To obtain optimal information
from the examination and minimize
radiation exposure, it is important to
understand the indications and technique for each of these examinations.
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DYSPHAGIA ASSESSMENT AND TREATMENT PLANNING: A TEAM APPROACH
DESCRIPTION OF EQUIPMENT
Examination of the pharynx and esophagus is generally performed in a fluoroscopy suite that is equipped with a system for rapid sequence filming. Rapid
sequence recording is necessary because the process of swallowing occurs
quickly (pharyngeal phase is typically
less than 1 second), and in order to analyze the swallowing process, this capability must be available. Frame rates of
30 fps are recommended for videofluoroscopic swallowing studies, to ensure
capture of bolus and structural movements in the pharynx, when the airway
is at greatest risk (Bonilha et al., 2013).
Previously, cineradiography was
utilized to evaluate the pharynx and
esophagus, but with the advent of digital processing, cineradiography has
largely become obsolete and has been
replaced by videofluoroscopy, which is
a recording of the fluoroscopic image
by a videorecorder and magnetic tape,
or frequently now onto digital media.
Although spatial resolution is less with
videofluoroscopy than with cineradiography, it is generally adequate for
most studies. It has the advantages of
less radiation exposure, easier manipulation of the images, and the ability to
record sound.
More recently, rapid sequence digital
radiography, which is capable of rapid
sequence filming of up to 6 frames per
second (fps), has become available. Advantages of this system include excellent spatial resolution; easy manipulation of the images, including brightness
and contrast changes; and relatively
low radiation exposures. The chief
disadvantages are too few frames per
second for some studies and its lack of
availability in many departments.
Newly developed cine-MRI and turboFLASH MRI sequences can acquire
up to 24 frames per second (Olthoff
et al., 2016; Zhang et al., 2012). This
technology may offer the opportunity to examine deglutition with less
(or no) ionizing radiation. However, a
large magnet (3 tesla) MRI machine is
required, which is (as yet) not commonplace in most radiology departments.
High-speed, continuous T2-weighted
MR sequences at 10 fps have also
been examined for swallow evaluation (Tanaka et al., 2014). The exciting
aspect of using MRI to evaluate swallowing is that to track the swallow,
only saline is administered rather than
a contrast agent, which is potentially
safer for dysphagic individuals. Further research is needed to evaluate MRI
imaging in a swallow-disordered population (Tanaka et al., 2014).
Videofluoromanometry is gaining
acceptance as a study that can provide
dynamic as well as functional structural information about deglutition
and includes insights regarding bolus
flow, pressure signatures, and pressure
voids that may help direct interventions (Reginelli et al., 2016).
RADIATION EXPOSURE
AND SAFETY
Exposure to radiation occurs with examination of both the pharynx and the
esophagus. For this reason, patients
should be carefully evaluated before
these studies are done to determine with
certainty that the examination is indicated. This is of particular concern with
younger patients and female patients.
Younger patients are up to 10 times
more susceptible to injury from radia-
5. BARIUM RADIOGRAPHIC EVALUATION OF THE PHARYNX AND ESOPHAGUS
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89
tion exposure than are older patients.
Lifetime risks of cancer depend on age
at exposure and gender. There may be
twice the risk of cancer for equivalent
studies in the 0- to 9-year age range
compared to 30- to 39-year age bracket.
In patients over 70 years of age, the risk
is around 1/3 of the risk for those in
their 30s, and if older than 80 years, the
estimated risk drops to 1/10 of that of a
30-year-old (Vano et al., 2021).
Radiation dose is cumulative, and
the National Council for Radiation
Protection (NCRP) and International
Atomic Energy Association (IAEA)
support the linear nonthreshold theory
(LNT). This states that there is no “safe”
dose of medical radiation and that all
medical radiation should conform
to the ALARA principle: As Low As
Reasonably Achievable (http://www
.imagegently.org; http://www.acr.org).
It is now estimated that 1% to 2% of cancers are induced by medical radiation
(Berrington de González et al., 2009;
Smith-Bindman et al., 2009) and that
the lifetime relative risk of cancer from
screening radiological procedures may
range from 4 to 7/1,000 for men and 6
to 13/1,000 for women (Berrington de
González, 2011). However, recently the
IAEA discouraged an additive strategy
for individuals undergoing repeated
or recurrent medical radiation imaging
studies given that the effect of multiple
studies depends upon the age at exposure, gender, and time frame over which
the studies were completed. There is
substantial variability in the possible
effective dose and cumulative dose for
an individual. Population-based estimates of cancer risk may be up to three
times higher or lower than that quoted
for a “reference patient” (age-averaged,
gender-averaged, and region-averaged
reference models; Vano et al., 2021). All
clinicians ordering tests involving ionizing radiation must be cognizant of the
risks and benefits of the procedure for
each individual.
The referring physician, radiologist,
and speech-language pathologist (SLP)
should all be involved in the decision
to perform a study. In addition, individuals conducting the examination
should have knowledge of radiation
exposure and use appropriate protection from radiation, for both the patient
and the individuals conducting the
examination. Radiation exposure to
the patient can be measured in several
ways, including skin exposure, gonadal
dose, and total body exposure. Radiation exposure is also expressed in different units, including grays, rads, or
seiverts. The seivert is preferred, as it
is a unit that has been normalized for
the tissue effects of radiation. Different
tissues have different levels of susceptibility to radiation, and this is normalized by the seivert measurement allowing comparison of the effect of the dose
received depending on the susceptibility of the site of radiation. An alternative method is to use the dose area
product (DAP), which is a measure of
effective radiation dose. When combined with a standardized multiplier
determined by the tissue characteristics of the exposed tissue, the DAP can
yield information regarding the true
tissue exposure. Other measures may
be more appropriate depending upon
the mode of imaging, for example, dose
length product (DLP), for CT imaging
(Vano et al., 2021).
Of particular concern in examination
of the pharynx and upper esophagus
is radiation exposure to the thyroid.
Radiation exposure of the lens of the
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DYSPHAGIA ASSESSMENT AND TREATMENT PLANNING: A TEAM APPROACH
eye and spinal cord is also an important
consideration when the head and neck
are exposed to radiation. A comparison
of skin/thyroid radiation exposure for
the techniques used for radiographic
swallowing studies is seen in Table 5–1.
Factors affecting radiation dose include the following: kilovolt peak (kVp),
which is the peak voltage across the
x-ray tube; milliampere seconds (mAs),
which is the tube current multiplied by
exposure time; image field size; source
to skin distance; source to detector distance; and use of a grid. Most modern
fluoroscopic machines incorporate safety
features to minimize radiation such as
beam coning, last frame hold, auto-
Table 5 –1. Radiation Dose Rate During
Videofluoroscopy Swallowing Study
(mGy/min)*
Projection Skin Thyroid
Posterior-anterior 9.5 .27
Lateral 7.7 .99
* Exposure factors include: Automatic brightness
control with 65 kVp, 1.1 mA, 8:1 grid, source
to skin distance — 46 cm, source to detector
distance — 86 cm, 9” field of view.
matic kVp adjustment, grid removal,
and adjustable frame rates. Operators
should employ appropriate shielding,
reduce screening time to the minimum
needed to achieve the required information, and avoid backscatter by removing objects within the beam path. The
patient should always be positioned
closest to the detector, and staff should
stand a minimum of 5 feet from the
beam emitter whenever possible.
During a normal year, most people
are exposed to approximately 3 mSv of
background radiation. One chest x-ray
imparts an additional 0.01 mSv of radiation, while traveling on an international
transatlantic flight would expose passengers to 0.04 mSv of additional radiation. Most fluoroscopic swallowing
studies are estimated to deliver doses
in the range of 0.04 to 1 mSv depending
on total fluoroscopy time (Table 5–2).
Chau and Kung (2009) measured
videofluoroscopic swallow study doses
using the DAP in patients undergoing
studies for neurological abnormalities
or after radiation to the head and neck.
They demonstrated a mean DAP of
2.42 ± 2.04 Gy cm
2
for an effective dose
of 0.31 ± 0.26 mSv for all studies, well
Table 5–2. Radiation Dose Comparison
Radiation
Test Situation
Chest x-ray 0.01
Annual background radiation 3
Trans-Atlantic aircraft flight 0.04
Videofluoroscopic swallowing study 0.04–1
CT scan (head) 2
CT scan (abdominal) 5
Dose (mSv)
5. BARIUM RADIOGRAPHIC EVALUATION OF THE PHARYNX AND ESOPHAGUS
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91
within the quoted range (Chau & Kung,
2009). Mean fluoroscopy time was 4.23
± 2.56 minutes. When they compared
the dose and screening time for stroke
patients versus patients treated with
radiation for nasopharyngeal cancer,
the mean dose and screening time
were significantly greater in the stroke
patients: 2.61 versus 1.80 Gy cm
2
and
4.26 versus 3.65 minutes, respectively.
Younger patients are at greater risk of
radiation impacts. Henderson et al.
(2016) conducted videofluoroscopic
swallowing studies in children, average
age 38 months, using 25-fps swallowing
loops. Measured DAP and total fluoroscopy times were equivalent to studies
undertaken in the same radiology suite
but conducted at slower frame rates
(0.048 mSv at 25 fps vs. 0.043 mSv at
6fps; Henderson et al., 2016).
Despite care being needed to optimize fluoroscopic swallows, it is imperative to get all the information needed
from the study. Therefore, reducing
frame rates to minimize radiation dose
may not be helpful given that important swallow information may be lost
or go undetected. There must be a balance between an effective study and
minimizing long-term radiation risk.
In the elderly (those >65 years), there is
very little added cumulative risk from
low-dose radiation such as that utilized
in the DSS. There is far greater risk to
health in missing aspiration or swallow
impairment in this age group, and the
clinician should be aware of all factors
involved. Bonhila et al. (2013) demonstrated that slower frame rates (15 fps
vs. 30 fps) during videofluoroscopic
swallow studies results in less accurate
identification of impairment and alterations of treatment recommendations
based on the study.
INDICATIONS
History and clinical examination provide invaluable information in assessing the dysphagic patient. However,
silent aspiration may occur without
significant symptoms and therefore it
may be undetected by the patient history. It is critical to determine if silent
aspiration is present in a given patient
as it is one of the leading causes of disability and death in patients with neurological conditions, head and neck
cancer, or head and neck trauma or
following surgery (Carbo et al., 2021;
Garon et al., 2009; Ramsey et al., 2003,
2005). An instrumental examination is
required to fully assess the pharyngeal
and esophageal phases of swallowing
and to definitively evaluate for silent
aspiration. This may be accomplished
endoscopically or radiographically.
The optimal radiographic procedure
is the dynamic swallowing study or
DSS. DSS provides critical information regarding the transit and pathway
of the bolus through the oropharynx,
hypopharynx, pharyngoesophageal
segment, and esophagus. This examination is indicated in patients presenting
with persistent dysphagia, odynophagia, aspiration, pulmonary pathology,
chronic cough, regurgitation, weight
loss, or, in some cases, symptoms of
reflux or esophageal pathology (chest
pain or pressure) or in patients after
surgery or radiotherapy to the head
and neck.
The study should only be requested
after assessment by either a physician
or SLP (or preferably both). Because
radiation exposure is involved, careful consideration must be given to performing the optimal study in the shortest possible time. Although a protocol is
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DYSPHAGIA ASSESSMENT AND TREATMENT PLANNING: A TEAM APPROACH
essential, the clinician performing the
procedure must be familiar with the
patient’s symptoms, signs, and indications for the examination. In this way,
the DSS can be tailored to answer the
clinical question and minimize screening time. Specific maneuvers or strategies can be tested during the study to
enable safe treatment recommendations.
Contraindications to esophageal examination with standard barium swallow
and esophagram include inability of the
patient to swallow, obstruction of the
pharynx or esophagus, and inability to
tolerate aspiration. These problems are
minimized with the DSS.
EXAMINATION TECHNIQUE
Because of its general availability and
ability to demonstrate motion, videofluoroscopy is the method most often
used for swallowing studies and other
examinations of the pharynx. Preparation of contrast should use a standardized formulation to allow comparison
across time and across individuals. The
International Dysphagia Diet Standardization Initiative (IDDSI) structure provides comparison of the texture of contrast agent to food textures and detailed
instructions on preparation of each
thickness level (levels 0–7; © The International Dysphagia Diet Standardization Initiative 2019, https://iddsi.org/
framework). The examination is performed in the standing or sitting position using a standard fluoroscopy table
in the upright position. For patients
who are unable to support themselves,
chairs have been developed that provide support for the patient’s head
and neck. The examination is usually
performed first in the lateral position.
The patient takes a bolus of barium
(about 60% weight/volume) into the
mouth and is instructed to swallow
while a recording is made from the
oral cavity to the cervical esophagus.
Structures that are visualized include
the oral cavity, base of the tongue, valleculae, epiglottis, piriform sinuses,
pharyngoesophageal segment, and
cervical esophagus (Figure 5–1) (Carbo
et al., 2021; Dodds, 1989; Dodds et al.,
1990). In the normal person, the passage of a bolus of barium from the
mouth to the cervical esophagus takes
approximately 1 second. During the lateral evaluation of swallowing, several
bolus sizes and consistencies may be
evaluated.
A similar recording of a swallow
is then done in the frontal (anteroposterior, AP) projection (Figures 5–2
and 5–3). The valleculae and piriform
sinuses are usually better seen in this
projection, whereas the epiglottis and
cricopharyngeus muscle are less well
visualized. Some pathologies, such as
Zenker’s diverticulum, may be bet-
Figure 5–1. Lateral view of the pharynx.
The base of the tongue and uvula are
indicated by arrows.
5. BARIUM RADIOGRAPHIC EVALUATION OF THE PHARYNX AND ESOPHAGUS
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Figure 5–3. Slight narrowing in anterior-
posterior view reflects location of cricopharyngeus muscle.
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Figure 5–2. Anterior posterior view of the
pharynx. Residue is noted in the valleculae.
ter viewed from this position as well
(Figure 5–4). Asymmetries reflecting
unilateral weakness, for example, of
the pharynx, are also likely to be better appreciated in the frontal view. In
both projections, recordings are made
while the patient swallows several different quantities and consistencies of
barium, and in some cases, swallowing
is evaluated with a bolus of food mixed
with barium.
Findings of particular interest that
may be observed during DSS in the oro-
Figure 5–4. Zenker’s diverticulum (at arrow )
is filled with barium in anterior-posterior
view.
pharynx include inadvertent passage
of barium into the airway, termed penetration (when material remains above
the vocal folds) or aspiration (when
material passes through the vocal
folds). DSS is an extremely sensitive
tool in identifying airway violation, in
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