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214 P. Pokieser and M. Scharitzer
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Fig. 28 a This 86-year-old man after a stroke has markedly
delayed triggering. After the contrast medium enters the pharynx,
the piriformsinuses (arrow)arefilledbeforetheinvoluntaryactof
Fig. 29 a This 66-year-old woman with dermatomyositis has a
high-grade pharyngealweakness. Before the swallow, the bolus is
controlled on the back of the tongue. b In the late intradeglutitive
phase, a bolus of 15 ml is separated in two parts (arrows). The
weak stripping wave is not ableto propel the whole bolus into the
transport for liquids and solid food as well, complementary to manometry—the gold standard for diagnosing esophageal motility disorders. Manometry can be
combined with VF as videomanometry. This method
synchronizes the videofluoroscopic record of the bolus
transportandthemeasurementofpressure.Evaluation of
esophagealtransportand gastricemptying is obtained by
scintigraphy. Delayed gastric emptying, well known in
diabetes, may interfere with esophageal transport and
contribute to symptoms such as dyspepsia, epigastric
fullness, or heartburn. pH probe studies can detect pathologic gastroesophageal reflux, while VF can describe
the dynamic appearance of the esophagogastric junction
during and after passage of a bolus. Intraluminal
impedance monitoring is a relatively new technique
offering the possibility of measuring bolus movement in
swallowing begins. b Intradeglutitive phase of the same patient.
c Retentions in the valleculae and in the hypopharynx after the
swallow indicate pharyngeal weakness; no aspiration occurred
esophagus, often also combined with a weak tongue movement.
Meanwhile, apart of the bolus has entered the cervicalesophagus.
Drops of contrast medium have penetrated into the laryngeal
vestibule. c Also note the aspiration from retentions after the
involuntary swallow—postdeglutitive aspiration (arrow)
the esophagus without radiation. Combined with
manometry or pH, pressure changes and bolus transit as
well as detection of all types of reflux episodes independent of the pH, can be evaluated. Therefore, these
investigations offer additional new methods for patients
with persisting GERD symptoms after acid suppressive
therapy or with non-acid reflux. Comparisons of
impedance and VF have shown almost identical volume
clearance of the swallowed contrast media (Simren et al.
2003). Impedance measurements are also used for a new
technique called ‘‘impedance planimetry,’’ which measures cross-sectional areas in the esophagus in order to
gradate esophageal stenosis. Hiatus hernia, cardiac
insufficiency, the esophagogastric junction after surgery,
such as fundoplication, myotomy, dilatation, gastric
banding, and other operations, are studied
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Fig. 30 a Same patient as in (Fig. 29) in the frontal projection.
Symmetric retentions in the piriform sinuses are present, a fluid
level at the laryngeal entrance indicates the potential of postdeglutitive aspiration, and contrast material has already entered the
videofluoroscopically to rule out early and late postoperative complications such as stenosis, leakage, or
perforation. VF is the diagnostic test of choice to obtain a
general overviewof thewhole swallowing tract, to detect
macropathologic changes and disordered function as
well. Pertinent to the clinical problem, a tailored VF
examination can be designed to be the basis for other
diagnostic tests or to complete their results in a complementary way.
4 Imaging of Swallowing Disorders
4.1 Technical Considerations
Videofluoroscopy is performed with a fluoroscopy unit
connected to a video recorder. This dynamic examination studies motility of the oral, pharyngeal and
esophageal phases, whereas the spot film examinations
demonstrate morphology. Any fluoroscopic unit that
offers remote control equipment is appropriate. By
larynx (arrows). b Smaller retentions after a second swallow,
whichwasperformed by the patienttoclear the hypopharynx from
retention. c A third swallow succeeded, only slight retention
remained, and no more material had penetrated into the larynx
using the jog-wheel function, the videofluoroscopic
study can be analyzed frame by frame, several times.
Computer-based dynamic recording on hard disk,
DVD, or CD is still under development and offers have
to be evaluated carefully in case of interest. Continuously recording for 20 s seems to be the minimum,
while inexpensive and easy storage of the examinations
is mandatory.
The introduction of digital fluoroscopy and computer-based workstations offers a higher spatial resolution and new possibilities for the interpretation by
lower radiation exposure at the same time. Digital
images obtained during a dynamic study can be postprocessed and transmitted more easily.
4.2 Examination Technique
The approach as described by Ekberg and Pokieser
(1997) is based on the patient’s history, planning the
investigation in detail. The radiographic examination
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Fig. 31 a Ten years before the examination, this 62-year-old
woman was operated onand underwentradiation onthe right side
for a floor-of-the-mouth carcinoma. Delayed triggering of the
swallowing reflex is present. Contrast material runs over the
valleculae into the discrete dilated right piriform sinus (arrow).
has to include all structures involved in swallowing,
from the lips to the stomach. Nevertheless, it is
important to focus the examination on specific areas.
In any patient with a high suspicion of laryngeal or
pharyngeal disease, the laryngeal vestibule should be
included in the image from the beginning. It is very
common that the first swallow is the worst swallow
and that only the first swallow will reveal dysfunction.
It is certainly very important to realize that there are
two fundamentally different examinations of swallow.
One is customized for the diagnosis, i.e., the search for
why the patient has a specific symptom (diagnostic
study). It is basically concerned with finding that particular patient’s worst swallow and therefore might
include maneuvers for decompensation of a compensated swallow (Buchholzet al. 1985).This is in contrast
to the diagnostic examination that is done when the
dysfunction in a specific patient has been revealed; this
test basically tries to reveal the patient’s best swallow
and therefore always includes maneuvers for compensation of adecompensated swallow (therapeuticstudy).
b Duringswallowing, the bolus passes over the right side, causing
the weak lateral pharyngeal wall to bulge (arrow) Ipsilateral, the
pharyngoesophageal sphincter is visible as a lateral cricopharyngealbar(arrowhead).c Afterswallowing,oneseesthe asymmetric
or unilateral retention on the right—on the operated side
It is always important to observe as many swallows as
possible, as dysfunction may be intermittent. Moreover, the benefits of therapeutic maneuvers are notoriously difficult to assess. The performance of dynamic
studies turns the investigator from a photographer into
both a film director and camera operator. Since FEES
has gained raising availability and importance in the
assessment of aspiration and the value of swallowing
maneuvers, indications for a therapeutic videofluoroscopic swallow have decreased. In patients with suspicion of aspiration, FEES is increasingly the primary
investigation method, and a radiological diagnosis of
aspiration is mainly needed in the absence of videoendoscopic assessment.
No special preparation is needed for theradiological
examination of the upper gastrointestinal tract. The
patient is examined with his dentures or other oral
appliances in place so that the patient’s swallow is as
normal as possible. Nasogastric feeding tubes should
be removed prior to the investigation, but due to the
discomfort during reinsertion of tubes, this has to be
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The radiological substrate of this analysis is the
movements of anatomical structures that cause the formation andcontinuouspropulsionofthebolusofcontrast
medium. Physiologically, the act of swallowing is divided into three phases: the oral, the pharyngeal and the
esophageal phase. The duration of theoral phase may be
determined arbitrarily. The pharyngeal phase takes less
than1 s. The esophagealphasetakesapproximately10 s.
The esophageal phase is about 10 times as long as
the pharyngeal phase.
For radiographic analysis of theact of swallowing,it
is useful to summarize the involved anatomical structures into seven functional units (Pokieser et al. 1995).
The description of normal and pathological functional findings of the seven functional units of the act
of deglutition is a simplification of the subject, but
does include the most important clinical findings
needed by those embarking on routine diagnosis of
the act of swallowing (Fig. 1).
4.2.2 Design of Videofluoroscopic Scripts
A standard examination of these seven functional
units is performed by lining up various film sequences
of the video recording of the act of swallowing and
fluoroscopy. During the pharyngeal phase of swallowing, the functional units should be filmed in a
stationary position, as the recording will be blurred
and rendered unusable for study if the central beam is
moved. During the esophageal phase, the central
Fig. 32 A small pharyngocele on the left side, in an asymp-
tomatic patient. On the left side, the pharyngocele has
evaginated (arrow)
beam may follow the bolus, because the esophageal
propulsion is relatively slow (*4 cm/s).
4.2.2.1 Swallowing Disorders without Suspicion
of Aspiration
decided withregard to theclinical problem. The patient
should stand or sit on the footboard of the fluoroscopic
table. Esophageal motility can be depicted best in the
horizontal position, when the contrast material is
pushed mainly by esophageal motility (Fig. 1).
Debilitated patients can be examined on a specially
designed chair. Patients should not experience stress
during swallowing, and the investigator has to take
care to provide a quiet, comfortable environment
during the study.
Patients suffering from dysphagia, globus, chest pain,
or other clinical conditions related to swallowing may
have no clinical symptoms of aspiration. These
patients should swallow boluses of normal size and
should be investigated in all standard positions as
mentioned below. The examination begins with films
of the erect standard positions, followed by tests of
esophageal motility in the horizontal, supine and
prone positions. Plain films in double-contrast technique should be added, according to the clinical
problem. Effervescent powder disturbs the standard-
4.2.1 The Seven Functional Units
The systematic analysis procedure known from X-ray
reporting proved to be useful for reporting film
sequences as well.
ized examination of the esophageal tube and should
be given after studying the esophageal motility in the
horizontal position. The passage of contrast material
should be followed to the duodenojejunal junction.
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Fig. 33 a This 63-year-old man has pronounced ventral spond-
ylophytes that narrow the pharynx at the level of the laryngeal
entrance (arrows). b During the swallow, the epiglottic tilt is
Fig. 34 a A further example of a pharyngeal space-occupying
mass—here we see a recurring tumor of the hypopharynx in a
48-year-old man. The first photo shows broadening of the
dorsal pharyngeal soft tissues in a lateral view (arrows). b In
the frontal view, we see the tumor as a structure with irregular
margins, in the right portion of the hypopharynx. The passage
4.2.2.2 Swallowing Disorders with Suspicion of
Aspiration
The investigation is restricted to erect standard projections, if aspiration occurs. With increasing
amounts of contrast material, severe aspiration can be
avoided by stopping any increase when the patient
aspirates. Different consistencies are applied in diagnostic studies pertinent to the symptom, and in therapeutic studies to find out the best consistency
without aspirating. This is best done in collaboration
with a speech and language pathologist, who has
complementary clinical information and interest in
the therapeutic approach.
From a systematic point of view, every film scene
may be defined by three characteristics: First, the
selected section for imaging and the patient’s standard
hindered (arrow).cAfter swallowing, somedropswere aspirated
from moderate retentions (arrow)
of the bolus is directed over the left side (arrows). c Retentions
in the pharynx and a moderate postdeglutitive aspiration are
present in lateral projection. The epiglottis is thickened (arrow)
by tumor infiltration. The same appearance of a swollen
epiglottis is found in epiglottitis, for example, postradiation in
adults or of infectious origin in children
position; second, the selected type of contrast medium;
and third, the amount of contrast medium.
4.2.3 Standard Positions
for Videofluoroscopy
Refer Figs. 2, 3, 4, 5, 6, 7.
4.2.4 Type of Contrast Medium
We use high-density barium suspension to visualize
the morphology and function from the oral cavity to
the esophagus.
Non-ionic iodinated low-osmolar or iso-osmolar
water-soluble contrast material is necessary for
patients with clinical suspicion of aspiration or perforation. Hyperosmolar iodinated contrast medium is
contraindicated in patients with suspicion of
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Fig. 35 a When the contrast bolus reaches the level of the PE
segment, the dorsal pharyngeal wall should have smooth margins
because the sphincter relaxes. A slight wave-like margin is
normal–itis causedbytheintervertebraldisks(arrows).bAfterthe
passage of a normal-sized bolus, no residuals should be left in the
Fig. 36 a A 45-year-old woman with globus sensation and mild
reflux disease for 3 years. The functional appearance of the
sphincterisabnormal. Thereis a dorsal,rounded impressionofthe
column of contrast medium at the level of the PE segment,
representing a moderate cricopharyngeal bar with a narrowing of
30 % (arrow). b A 63-year-old man with dysphagia. Marked
pharynx, only coating of the pharyngeal and pharyngoesophageal
wall is seen. Radiographically, a posterior indentation at the
pharyngoesophageal junction during bolus passage indicates the
levelofthecricopharyngealmuscle,butmaybeseenalsowhenthe
PE segment is closed (arrow)
dysfunction of the PE segment,a cricopharyngealbar shows60 %
narrowing. c Extreme incomplete opening. We find two indentations(arrow)in terms of a double sphincter, which can be found in
various neuromuscular disorders.This78-year-old woman suffers
from muscular dystrophy
aspiration. In addition, solids are indicated to show a
stricture, a solid-induced spasm or dysphagia, as well
as for postoperative control studies. Therefore, a piece
of bread with barium or placebo tablets with a 14 mm
diameter can help in the evaluation of solid-induced
abnormalities. The use of different consistencies is
extremely helpful in patients with aspiration of only
liquid boluses in order to assess the further therapeutic and dietetic management.
4.2.5 Amount of Contrast Medium
The normal amount of a single swallow of an adult
patient is about 15 ml. However, a healthy adult can
manage liquid boluses up to 50 ml and more. The
amount of contrast material should be varied
according to the individual capabilities. The examination includes up to 10 swallows of 15–30 ml of
liquid barium sulfate. In the beginning, the amount of
contrast media is 15 ml. In cases of suspected
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seven units may be analyzed for malfunction. The
movements of the visible anatomical structures are
the basis of the analysis, the passage of the bolus
displays, and whether the function of the swallowing
tract is adequate for the given amount and material.
Each unit represents an area where the investigator
can focus the analysis easily. Videofluoroscopy shows
just a part of the complex structures below the barium
coating. The strength of the method is the ability to
see the entire swallowing action with its effect on
bolus transport simultaneously.
4.3.1 Tongue—Oral Cavity
4.3.1.1 Normal Function of the Tongue
Incompetent Bolus Manipulation. An incompetence in
manipulating the bolus summarizes many different
dynamic findings (Fig. 9). The inability of the tongue
to hold the bolus on its upper surface, fragmentation
Fig. 37 In this 55-year-old woman with mixed connective
tissue disease, the PE segment remains open during all three
phases of swallowing. In addition, one always finds a weakness
of the pharynx and retentions (arrows) in such patients
of the bolus, and uncoordinated movements such as
tremor or undulations may be visible. When lip closure is insufficient and material runs out over the lips,
this is called ‘‘drooling.’’ (Fig. 10).
Weakness of the Tongue. Weakness of the tongue
is often combined with pharyngeal weakness; reten-
aspiration, it is reduced to 3 ml for the first swallow.
If this bolus volume is tolerated, the bolus size should
be increased to 5 ml, and then up to 15 ml.
The contrast medium can be applied in many different ways, according to the abilities of the patient.
Cups, drinking bottles, spoons or straws may suite.
The best way to administer contrast material orally
can be designed according to the feeding history and
clinical presentation of the patient.
tion in the valleculae can be caused by both, and
overlaps cannot be differentiated (Fig. 11).
When weakness of the tongue is present, a high
consistency of the contrast material proves to be more
sensitive, such as barium paste or bread with barium.
Water-soluble contrast material can be propelled
more easily, thus masking a weakness of the tongue.
Incompetent Tongue-Palate Seal. Incompetence of
the apposition of the soft palate, and the tongue leads
to leakage of the bolus into the oropharynx (Fig. 12).
Weakness or postoperative defects of the tongue, the
4.3 Reporting on the Seven Functional
Units of Swallowing
soft palate or both, can cause this functional deficit.
The differentiation between leakage and late trigger-
ing of the involuntary swallow can be difficult, when
The basic principles of the functional physiology and
pathology of swallowing constitute the actual radiological basis for reporting VF.
the oral transit time is short. This might be the case
when the patient reclines the head to compensate for
difficulties in oral transport.
The seven functional units are a radiological
approach based on the dynamic radiological infor-
4.3.2 Soft Palate
mation (Fig. 8).
Often, there are several functional disorders of the
4.3.2.1 Normal Function of the Soft Palate
same functional unit in a single patient. Countless
combinations of findings occur, but typical ‘‘patterns
of findings’’ are to be observed. Step by step, the
(a) Incomplete Elevation (Figs. 13, 14).
(b) Insufficient Velopharyngeal Closure (Fig. 15).
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Fig. 38 a This38-year-oldmansuffersfroma globussensation.A
smallweblocatedventrally inthelower PEsegment (arrow)isonly
visible for parts of a second. The small membrane flap will hardly
hinder the passage, yet is an indirect indication of other accompanying functional disorders. b Typical venous plexus at the
postcricoidlevel. Thisnormaldynamicappearanceof aninconstant
irregularity must not be misdiagnosedas a web (arrows). Websare
Fig. 39 a A 77-year-old woman with high-grade dysphagia
for solid and liquid foods. Here we see a constant Zenker’s
diverticulum, a little more than 2 cm in size. Even without
contrast medium, it can be detected by a small air bubble in the
always thin and sharply delineated. This differentiates them from
the retrocricoid venous plexus, which shows normal, movable,
round mucosal folds. c This 81-year-old man with dysphagia for
solids has a circular web with a marked jet phenomenon. The
obstruction by a web may accelerate the flow after the narrowing.
This functional finding is known as the ‘‘jet phenomenon’’
dorsal soft tissues of the pharynx (arrow). b Despite its small
size of 12 mm, this diverticulum (arrow) causes a compression
of the gastrointestinal pathway and hinders the bolus passage.
c After swallowing, a constant 12 mm diverticulum is left
4.3.3 Epiglottis
4.3.3.1 Normal Function of the Epiglottis
Incomplete Epiglottic Tilt. An incomplete epiglottic
tilt is almost always combined with retentions in the
valleculae, and often with hypopharyngeal retentions
and numerous other disturbances of the pharyngeal
phase (Fig. 16). Tumors, swelling after radiation, or
inflammatory diseases such as epiglottitis, and postoperative structural deficits up to total resection
should be considered (Fig. 17).
4.3.4 Hyoid and Larynx
4.3.4.1 Normal Function of the Hyoid and the
Larynx
Poor Elevation. Tracheostomy, pharyngealor laryngeal
resections, radiation therapy or muscular weakness are
commoncausesof poor movementsof the epiglottisand
the larynx (Fig. 18). Over time, this condition contributes to pharyngeal retention and aspiration (Fig. 19).
The next four functional disorders are related to
insufficient protection of the respiratory tract, namely,
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Severity of Aspiration. An important aspect of the
evaluation of aspiration is its severity. Video cinematography can be quite valuable here. However, it
should be mentioned that any decision with regard to
prognosis and therapy can only be made by taking all
clinical data into account.
The simple gradation described in Fig. 25 is
helpful for reporting the severity of aspiration. Several examples of intra-deglutitive aspiration of various grades of severity are also given in Fig. 25.
When the coughing attack has subsided or is entirely
absent,italways signifiesahighgradeofaspirationanda
great likelihood of broncho-pulmonary complications.
At the end of the examination, the bronchial tree
should be documented with chest films or fluoroscopy. This facilitates an estimate of the depth of
Fig. 40 This 73-year-old woman with massive dysphagia has
a Zenker’s diverticulum approximately 4 cm in size, seen on
lateral view. Very large Zenker’s diverticula are usually
visualized as obstructions of passage even on ordinary static
images. On dynamic images, we see here an incorrect
esophageal pathway—displayed by the characteristic ridge
between the diverticulum and the esophagus. The point of entry
into the diverticulum (white arrow) is markedly wider than the
esophageal pathway (black arrow). Besides, the latter is
compressed by filling of the diverticulum
aspiration and the amount of aspirated material.
4.3.5 Pharyngeal Constrictors
Normal Function. The fifth functional unit includes
the activity of the pharyngeal constrictors.
The pharyngealwave ofcontraction starts atthe levelof
C1 in lateral projection (Fig. 26). Here it has advanced up
to C2–C3. The rapid upward movements of the hyoid and
larynx also take place at the beginning of the involuntary
penetration of contrast medium into the larynx and
the three basic forms of aspiration into the trachea:
pre-deglutitive, intra-deglutitive and post-deglutitive
aspiration.
Penetration. After penetration, we will look at the
basicformsofaspiration.The termspre-,intra-andpostdeglutitive refer to the involuntary act of swallowing,
and the rapid, automatic motion of the larynx, hyoid and
pharynx. Thus, aspiration may occur before, during or
after the rapid swallowing movement (Fig. 20).
Pre-deglutitive Aspiration. The first type of aspiration occursduring preparation of the swallow and leads
to an entryof bolus intothe airway beforetriggering the
pharyngeal phase of swallowing (Figs. 21, 22).
Intra-deglutitive Aspiration. The second important
timingofaspirationisintra-deglutitiveaspiration,which
occurs during the rapid involuntary act of swallowing
(Fig. 23).
Post-deglutitive Aspiration. The third basic form
of aspiration is post-deglutitive aspiration after the
involuntary act of swallowing. This form of aspiration
occurs during incomplete swallowing, which causes
retention in the pharynx (Fig. 24). Frequently, it is
due to weak pharyngeal muscles.
act of swallowing. As the voluntary act smoothly passes
into the involuntary one, the physiological beginning may
be difficult to determine. In the normal act of swallowing,
there should always be a rapid and continuous passage
through the pharynx as soon as the angle of the jaw has
been passed or the valleculae have been reached(Fig. 27).
Delayed Swallowing Reflex. Delayed triggering of
the involuntary act of swallowing is an important and
common finding (Fig. 28). Delay occurs when the
contrast mediumhas reachedthe levelof the valleculae
before the involuntary act of swallowing is triggered.
Pre-deglutitive aspiration may be present, when the
closure of the laryngeal vestibule is also delayed.
Several swallows can show a different length of the
delay. Often, the delay is worst in the first swallow and
may improve during the examination. An approximated simple measurement can be obtained with the
time code of thevideorecorder or software,bycounting
the frames from the moment the contrast material
passes the angle of the jaw until involuntary swallowing has begun. It is clinically useful to count in steps of
0.5 s. Delays from 0.5 s up to 3 s are frequent in neuromuscular disorders. The swallowing reflex is absent
if the reflex does not trigger for 30 s.
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