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192 M. Bu¨low
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few reports could be found describing this condition.
However, there are reports suggestingthat persons with
psychological conflicts in an attempt to reduce unacceptable emotional responses may convert them into
more acceptable physical manifestations (Finkenbine
and Miele 2004; Lehtinenand Puhakka 1976. Ithasalso
been suggested that patients with this condition may
sufferfromanxiety and depression (DeLucas-Taracena
and Montanes-Rada 2006).
Several different terms are used to describe the
condition of dysphagia with psychiatric origin, where
‘‘psychogenic dysphagia’’ is the most well known.
Sometimes the term ‘‘sitophobia,’’ from the Greek
words sito (‘‘food’’) and phobia (‘‘fear,’’ ‘‘aversion’’),
may be used to describe a condition with pathologic
fear of swallowing. Other terms which may be used are
‘‘choking phobia or swallowing phobia’’ (Seems et al.
2009; De Lucas-Taracena and Montanes-Rada 2006;
McNally 1994), ‘‘globus hystericus’’ (Finkenbine
and Miele 2004; Ravich et al. 1989; Stacher 1983,
1986), ‘‘hysterical dysphagia’’ (Ciyiltepe and
Türkbay 2006; Nicasso et al. 1981), ‘‘phagophobia’’
(Ciyiltepe and Türkbay 2006; Shapiro et al. 1997), and
‘‘pseudodysphagia’’ (Bradley and Narula 1987).
2 Symptoms in Psychogenic
Dysphagia
Psychological factorswhich inhibit normalswallowing
and result ininefficient and/or disorganizedswallowing
are thought to be related to signs of psychogenic dysphagia. Nicholson et al. (2010) think that psychogenic
dysphagia is a problematic diagnosis.The psychological mechanism and how it differs from conscious
simulation still remains unclear.
The most common complaint of patients with
psychogenic swallowing problems is fear of swallowing manifested as difficulties initiating the
swallowing and thereby sometimes avoidance of
eating. Certain foods, fluids, and pills may cause
huge problems for patients to swallow (Barofsky
and Fontaine 1998; Ciyiltepe and Türkbay 2006;
Leopold and Kagel 1997; Ravich et al. 1989;
Shapiro et al. 1997). Also, abnormal oral behaviors,
with repeated deviant tongue movements, a feeling
of throat pressure, and complaint of globus were
found in this patient group. Complaints reported by
Bradley and Narula (1987) and Shapiro et al.
(1997) are a globus sensation, general difficulties in
swallowing, breathing problems, and fear of choking.
Also, malnutrition and weight loss may be associated with a swallowing condition with psychiatric
origin (Barofsky and Fontaine 1998; Ciyiltepe and
Türkbay 2006; Finkenbine and Miele 2004; Shapiro
et al. 1997).
In some literature, psychogenic dysphagia has
been described as a conversion disorder. Psychological conflicts and anxiety are transformed into
somatic symptoms and are regarded as an unconscious process. Kanner (1935) described dysphagia
as a primary conversion disorder. A case was presented of a 12-year-old boy who had developed
dysphagia to solid foods owing to physical abuse by
his father for eating improperly. In our swallowing
clinic we have encountered similar cases. A young
single mother, with a 5-year-old daughter, worked
as a cashier in a grocer’s shop. She was unable to
take a normal lunch break because of customer
demands, which was a high stress factor in her
working conditions. After a period of time she was
unable to eat and swallow in a normal way. Her
complaints were primarily oral in nature, along with
difficulties in initiating the swallow. Videofluoroscopic swallow evaluation (VFSE) showed signs of
oral dysphagia with intact pharyngeal function.
Another example is a middle-aged woman with an
abnormal oral phase of swallowing and fear of
initiating the swallowing. She told us during one of
her therapeutic sessions that during her childhood
she had been forced by a strict grandmother to
always empty her plate. She experienced great fear
when she visited her grandmother, especially when
forced to eat with her. When exposed to stress later
in life, she reacted with an inability to eat and
swallow normally.
Another form of conversion disorder described as a
manifestation of both a physiological disorder and
psychiatric illness is the sensation of globus
(Finkenbine and Miele 2004). Bradley and Narula
(1987) described the sensation of a ‘‘lump’’ or ‘‘fullness’’ localized to the throat in association with
globus hystericus, hysterical dysphagia, or pseudodysphagia. Their conclusion was that when no
evident cause is found, the condition may be a
‘‘‘primary globus pharyngeus’, or a ‘secondary globus
pharyngeus’ when the etiology was detectable’’
(p. 689). Okada et al. (2007) analyzed in a case study
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six children with phagophobia according to psychopathology and current treatment. Their results indicated that evaluation of premorbid personality is
crucial to the prognosis.
Psychological factors have also been found to be
associated with esophageal dysphagia. Esophageal
contractions can result from psychological stress.
Kronecker and Meltzer(1883) reported that esophageal
contractions, not onlydueto emotional tension, butalso
in some cases due to cold or hot food could react with
nonpropulsive contractions. Other interesting observations have shown that stimuli not relatedto ingestion
such as intense short sounds may influence esophageal
contraction and are likely to form part of the defense
reaction of a healthy organism (Stacher 1983).
Abnormal oral swallowing behaviors in the presence of intact pharyngeal stage function may be
revealed on radiological swallowing evaluations. In
some cases, such oral abnormalities may be associated
with psychogenic dysphagia. Diffuse esophageal
symptoms mayalso be related to psychological factors.
According to Jones (2003), patients with psychogenic
dysphagia may demonstrate a variety of swallowing
signs during VFSE, including the presentation of small
boluses, multiple tongue movements, and ‘‘complex
oral motions such as rocking, swirling, bunching and
pumping’’ (p. 97). Also, the presence of a pharyngeal
swallow delay without oral propulsion of bolus has
been described by Jones (2003).
Even ifreports regarding communicative symptoms
associated with psychogenicdysphagia are notfound in
the literature, an interesting case study describes a
63-year-old male ‘‘deglutition stutterer.’’ The man
developed myoclonusof the tongue and contractionsof
the hypopharyngeal muscles in the moment of deglutition. The history was remarkable for pharyngeal
spasms in his youth, which reemerged as described
above in stressful situations (Escher 1983).
At our swallowing clinic, from 2002 to 2010 we
completed 2,084 VFSE studies, and psychogenic
dysphagia was diagnosed in 25 cases (0.01%). The
most frequent complaints regarding swallowing signs
and symptoms are listed in Table 1. The patients
often presented with more than one symptom. Those
patients with complaints of globus without pharyngeal dysfunction or with suspected esophageal
dysfunction were referred to either an otolaryngologist or a gastroenterologist for further clinical or
instrumental evaluation.
Table 1 The most frequent complaints in psychogenic
dysphagia regarding swallowing signs and symptoms in our
videofluoroscopic swallow evaluation (VFSE) studies
Complaint No. of
Fear of swallowing 13 of 25
Experienced difficulties in swallowing specific
consistencies
Problems in initiating the pharyngeal swallow.
(The patient experienced a feeling of being
unable to swallow. On VFSE we could
document a normal pharyngeal swallow.)
Oral abnormalities (such as multiple tongue
movements with difficulties in propelling the
bolus posteriorly to pass the base of the tongue
and initiating the pharyngeal swallow)
Globus complaints 6 of 25
Normal pharyngeal swallow 25 of 25
patients
13 of 25
10 of 25
8of25
3 Epidemiology
From different swallowing clinics it has been reported
that a minor group of the patients complaining of
swallowing problems have psychogenic dysphagia.
Among patients referred to the Johns Hopkins Swallowing Center, 13% had been diagnosed with psychogenic dysphagia or globus hystericus. However,
when this group was later reevaluated, more than half
of the group were found to have an organic cause of
the dysphagia (Ravich et al. 1989). From a large
sample of patients seen in a swallowing center and
complaining of swallowing difficulties, a normal
pharyngeal swallow revealed on VFSE (with additional abnormal oral behaviors in some cases)
accounted for approximately only 3% of the group
(Barofsky et al. 1993). Malcolmson (1966) diagnosed
231 patients with globus hystericus, and negative
clinical and radiological evaluations were found in
20% of the patients. Patients with different psychosomatic disorders of gastrointestinal tract were studied (612 patients) by Korkina and Marilov (1995). In
70% of the 612 patients studied, relatives of the
patient also had psychosomatic diseases, suggesting
the possible influence of genetic and environmental
factors in this condition. Choking phobia was found to
be more frequent in females (two thirds of cases) and
had a high comorbidity with anxiety disorders. Life
events such as divorce, disease in the family, or
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unemployment, as well astraumatic eating antecedents,
were also frequently present (De Lucas-Taracena and
Montanes-Rada 2006). Prevalence studies have
shown that 45% of young and middle-aged people are
estimated to suffer from symptoms of globus, often in
combination with strong emotion (Thompson and
Heaton 1982).
4 Swallowing Evaluation
A diagnosis of psychogenic origin must be used with
caution and only after a thorough evaluation. At the
Johns Hopkins Swallowing Center, Ravich et al.
(1989) performed a reevaluation of 23 patients with
the diagnosis of psychogenic dysphagia or globus
hystericus. They subsequently found that more than
half of these patients had an underlying physical
explanation for their difficulty swallowing. In 65% of
the patients (15 of 23), pharyngeal dysfunction,
structural obstruction, or esophageal dysmotility was
found. Owing to those findings, they suggested that
when any changes or progression of symptoms was
reported, a careful reevaluation should be performed.
Stacher (1986) also recommended caution when
attributing symptoms of dysphagia to psychogenic
origins and emphasized the importance of performing
instrumental examinations:
in the throat, fear of choking, and/or the inability to
swallow solids. A complete and careful medical history is crucial and should therefore be the first part of
the swallowing evaluation (Castell and Donner 1987).
Important considerations in the medical history
include the patient’s symptoms, when they occur, and
under what circumstances; the duration of swallowing
difficulty; and determination regarding a history of
eating disorders, weight loss, and family history of
dysphagia. Following the medical history, a physical
examination should be performed to rule out any
organic causes of the symptoms. A multidisciplinary
approach may be required, involving professionals
from the fields of neurology, otolaryngology, speech–
language pathology, radiology, and gastroenterology.
The next step, often indicated for a complete evaluation, is an instrumental assessment of swallowing
(i.e., VFSE to evaluate oropharyngeal swallowing,
barium swallow/esophogram to assess esophageal
function). Esophagoscopy, manometry, pH monitoring, and endoscopy may also be of value. Laboratory
tests to rule out disturbances as hypoglycemia or
hyperglycemia, systemic infections, or toxins may
also be of importance in establishing the diagnosis of
psychogenic dysphagia. Another technique discussed
by Vaiman et al. (2008) is to use surface electromyography (sEMG) of deglutition to investigate suspected psychogenic dysphagia (Table 2).
It is not justifiable to label dysphagic symptoms, for
which no organic etiology can be detected, as psycho-
genic or psychosomatic. Patients with such symptoms
should be studied by means of esophageal manometry
and/or pH-metry to reveal the nature of their disorder
and to enable adequate therapy (p. 502).
A careful and thorough evaluation must be completed, and may also include psychological assessment when a psychogenic dysphagia is suspected.
Okada et al. (2007) studied psychopathology and
treatment in children with phagophobia, and they
found that an evaluation of premorbid personality was
crucial to the prognosis. The diagnosis of psychogenic
dysphagia should, to avoid misdiagnosis, be reserved
for patients with strong psychological symptoms and/
or fear of swallowing. (Jones 2003). A positive
dysphagia history consisting of different complaints
associated with the moment of swallowing is often
found in patients with psychogenic dysphagia. The
patients may report the feeling of a lump or pressure
5 Treatment of Psychogenic
Dysphagia
A multidisciplinary approach including professionals
from the fields of psychiatry, psychology, otolaryngology, neurology, speech–language pathology,
radiology, and gastroenterology may be required in
the treatment of psychogenic dysphagia. A combination of psychological treatment and dysphagia
therapy seems to be the most effective treatment
of psychogenic dysphagia (Ball and Otto 1994;De
Lucas-Taracena and Montanes-Rada 2006). In a case
report by Ciyiltepe and Türkbay (2006), a 13-yearold boy suffering from psychogenic dysphagia
treated with such an approach is described. A psychological behavior management program has to
consist of behavior modification, insight-oriented
therapy, and family therapy. The dysphagia therapy
sessions should include therapeutic eating trials with
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Table 2 Treatment of psychogenic dysphagia
Evaluation of psychogenic dysphagia Professionals commonly
History
A thorough history is often obtained in a multidisciplinary fashion emphasizing Otolaryngologist
Patient complaints Psychiatrist
Symptoms and when they occur and under what circumstances Psychologist
Duration of swallowing difficulty Speech–language
Determination regarding a history of eating disorders Radiologist
Weight loss Laboratory staff
Family history of dysphagia
Clinical examinations
Physical examinations may be performed by a multidisciplinary team of professionals including;
Otolaryngologist
Speech–language pathologist
Gastroenterologist
Psychiatrist
Psychologist
Instrumental examinations
Radiology;
VFSE
Hypopharynx esophagus examination (a morpholgic swallowing examination)
Videomanometry (examination for analysis of quantitative intraluminal pressure changes in the
pharynx and the esophagus)
Gastroenterology;
pH-metry (24-h pH recording)
Gastroscopy (assessment of the morphology in the esophagus and stomach
Surface electromyography
Different laboratory tests (to eliminate electrolyte disturbances, sideropenic anemia, or iron deficiency)
involved
Gastroenterologist
pathologist
various consistencies, as well as oral motor exercise
programs. Also relaxation exercises, breathing support, and functional coughing could be of benefit for
the patient. In a report by Shapiro et al. (1997), the
benefit of behavioral techniques and the use of
hypnosis in a single case were discussed. Also, other
studies have emphasized the positive effect of
behavioral therapy. For example, Nicasso et al.
(1981) described behavioral therapy as a beneficial
and even life-saving approach for hysterical behavior. The importance of explaining normal swallowing mechanisms, the role of emotions, and the use of
a holistic approach was pointed out by Bretan et al.
(1996). A relationship of trust between the patient
and the clinician is essential (Finkenbine and Miele
2004). In some cases, family therapy may be of
benefit (Oberfield 1981).
To treat patients with psychogenic dysphagia may
be a challenge. However, in our swallowing clinic we
have also experienced that a combination of psychological treatment and dysphagia therapy may be a
successful treatment for some patients with psychogenic dysphagia. We have found that it may be of
benefit for patients if the dysphagia therapy sessions
involve education regarding normal swallowing physiology combined with breathing exercises. Such training involving the coordination of breathing and
swallowing necessary for safe swallowing could help
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the patient to understand the physiological process of
the swallowing and thereby hopefully decrease the fear
References
of swallowing. Therapeutic eating sessions starting
with the consistency easiest to swallow may also be of
benefit. Close collaboration between the dysphagia
clinician and psychologists and psychiatrists is, in our
experience, necessary for optimal management.
Pharmalogical treatment with antianxiety medications has been reported to be an effective treatment in
some casesof psychogenicdysphagia (McNally 1994).
De Lucas-Taracena and Montanes-Rada (2006) found
that antipanic drugs (alprazolam, lorazepam, bromazepan, imipramine, clomipramine, fluoxefine, paroxetine) were of proven efficacy, with a remission rate
of 58.5%.
Surgical treatment is not appropriate in the management of swallowing disorders of psychogenic origin,
although psychogenic dysphagia has been reported to
result from surgical intervention. Nicasso et al. (1981)
described a 60-year-old man with postoperative hysterical dysphagia following esophagectomy and cervical
esophagogastrostomy secondary to esophageal cancer.
Postoperatively, the patient complained of globus,
although instrumental evaluations revealed the patient
was able to swallow safely and adequately.
6 Conclusion
Psychogenic dysphagia is an uncommon swallowing
condition, most often characterized by fear of swallowing. On VFSE abnormal oral behaviors such as
repeated deviant tongue movements may be present,
but the pharyngeal stage swallowing is revealed to be
normal. Also, esophageal dysfunction may at times be
associated with psychogenic symptoms. To establish
a diagnosis of psychogenic dysphagia, a thorough
evaluation must be performed. The evaluation should
involve careful taking of the medical history, clinical
and instrumental examinations, and, if necessary,
laboratory tests. The best therapeutic management
approach appears to be a combination of a dysphagia
therapy and psychological treatment. It has also been
reported that patients, in some cases, have benefited
from antianxiety medications. For best management
of a patient with psychogenic dysphagia, evaluation
and treatment should be performed with a multidisciplinary approach
Ball SG, Otto MW (1994) Cognitive-behavioral treatment of
choking phobia: 3 case studies. Psychother Psychosom
62:207–211
Barofsky I, Fontaine KR (1998) Do psychogenic dysphagia
patients have an eating disorder? Dysphagia 13:24–27
Barofsky I, Buchholz D, Edwin D, Jones B, Ravich W (1993)
Characteristics of patients who have difficulties initiating
swallowing [abstract]. In: Annual meeting of the Dysphagia
Research Society, Lake Geneva, September 1993
Bradley PJ, Narula A (1987) Clinical aspects of pseudody-
sphagia. J Laryngol Otol 101:689–694
Bretan O, Henry MA, Kerr-Correa F (1996) Dysphagia and
emotional distress. Arq Gastroenterol 3:60–65
Castell DO, Donner MW (1987) Evaluation of dysphagia: a
careful history is crucial. Dysphagia 2:65–71
Ciyiltepe M, Türkbay T (2006) Phagophobia: a case report.
Turk J Pediatr 48:80–84
De Lucas-Taracena MT, Montanes-Rada F (2006) Swallowing
phobia: symptoms, diagnosis and treatment. Actas Esp
Psiquiatr 34:309–316
Escher F (1983) A deglutition stutterer. Contribution on
psychogenic inability to swallow. HNO 31:104–106
Finkenbine R, Miele VJ (2004) Globus hystericus: a brief
review. Gen Hosp Psychiatry 26:78–82
Jones B (2003) Pharyngoesophageal interrelationship and
reflexes involved in airway protection. In: Jones B (ed)
Normal and abnormal swallowing: imaging in diagnosis and
therapy, 2nd edn. Springer, New York, pp 91–96
Kanner L (1935) Child psychiatry. Thomas, Springfield
Korkina MV, Marilov VV (1995) Variants of psychosomatic
personality development in disease of the gastrointestinal
tract. Nevropatol Psikhiatr Im S S Korsakova 95:43–47
Kronecker H, Meltzer SJ (1883) Der Schluckmekanismus,
seine Erregungen und seine Henimung. Arch Anat Physiol
Physiol Abt 7:328–362
Lehtinen V, Puhakka A (1976) A psychosomatic approach to
the globus hystericus syndrome. Acta Psychiatr Scand
53:21–28
Leopold NA, Kagel MC (1997) Dysphagia—ingestion or
deglutition?: a proposed paradigm. Dysphagia 12:
202–206
Malcolmson KG (1966) Radiological findings in globus
hystericus. Br J Radiol 39:583–586
McNally RJ (1994) Choking phobia: a review of the literature.
Compr Psychiatry 35:83–89
Nicasso PM, Arnold ES, Prager RL, Bryant PR (1981)
Behavioral treatment of hysterical dysphagia in a hospital
setting. Gen Hosp Psychiatry 3:213–217
Nicholson TR, Stone J, Kanaan RA (2010) Convensiondisorder:
a problematic diagnosis. J Neurol Neurosurg Psychiatry.
[Epub ahead of print: 29Oct] doi:10.1136/jnnp.2008.171306
Oberfield RA (1981) Family therapy with adolescents: treat-
ment of a teenage girl with globus hystericus and weight
loss. J Am Acad Child Psychiatry 20:822–833
Okada A, Tsukamoto C, Hosogi M, Yamanaka E, Watanabe K,
Ootyou K, Morishima T (2007)A study of psycho-pathology
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and treatment of children with phagophobia. Acta Med
Okayama 61:261–269
Ravich WJ, Wilson RS, Jones B, Donner MW (1989)
Psychogenic dysphagia and globus: reevaluation of 23
patients. Dysphagia 4:35–38
Seems S, Wielenska RC, Savoia MG, Bernik M (2009)
Choking phobia: full remission following behavior therapy.
Rev Bras Psiquiatr 31:257–260
Shapiro J, Franko DL, Gagne A (1997) Phagophobia: a form of
psychogenic dysphagia. A new entity. Ann Otol Rhinol
Laryngol 106:286–290
Stacher G (1983) Swallowing the psyche. Wien Klin
Wochenschr 8:502–511
Stacher G (1986) Differential diagnosis of psychosomatic
deglutition disorders. Wien Klin Wochenschr 98:
658–663
Thompson WG, Heaton KW (1982) Heartburn and globus in
apparently healthy people. Can Med Assoc J 126:46–48
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Otorhinolaryngol 265:663–668
Part III
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Imaging and Other Examination Techniques
The Clinical and Radiological Approach
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to Dysphagia
Peter Pokieser and Martina Scharitzer
Contents
1 Introduction.............................................................. 201
2 Symptoms of Swallowing Disorders ...................... 203
2.1 Dysphagia .................................................................. 204
2.2 Aspiration................................................................... 207
3 Multidisciplinary Evaluation of Swallowing
Disorders................................................................... 207
4 Imaging of Swallowing Disorders .......................... 215
4.1 Technical Considerations .......................................... 215
4.2 Examination Technique............................................. 215
4.3 Reporting on the Seven Functional Units
of Swallowing............................................................ 220
References.......................................................................... 235
Abstract
The intention of this chapter is to introduce a
multi-disciplinary diagnostic work-up and, in particular, to present a practical and structured
radiological approach. Swallowing disorders are
common. U.S. statistics indicate that more than 5
% of the population has swallowing difficulties,
and in hospitals up to 50% (Logemann 1995). The
swallowing tract crosses many anatomic regions.
Liquid and solid foods have to be transported
properly from the oral cavity into the pharynx and
through the esophagus into the stomach. Thus, a
wide variety of diseases may affect deglutition,
resulting in a multidisciplinary work-up of dysphagic patients. Videofluoroscopy (VF) of deglutition is the method of choice to investigate the
whole swallowing tract in a ‘‘one-stop-shopping’’
fashion. VF can depict patho- logic findings of
morphology and function as a basis to decide on a
further specialized work-up.
1 Introduction
P. Pokieser (&) M. Scharitzer
Department of Radiology, University of Vienna,
Währinger Gürtel 18-20, 1090 Vienna, Austria
e-mail: peter.pokieser@meduniwien.ac.at
O. Ekberg (ed.), Dysphagia, Medical Radiology. Diagnostic Imaging, DOI: 10.1007/174_2012_617,
Ó Springer-Verlag Berlin Heidelberg 2012
The intention of this chapter is to introduce a multidisciplinarydiagnosticwork-upand,inparticular,topresent
a practical and structured radiological approach. Swallowing disorders arecommon. U.S. statisticsindicate that
more than 5 % of the population has swallowing difficulties, and in hospitals up to 50 % (Logemann 1995).
The swallowingtract crossesmanyanatomicregions.
Liquid and solid foods have to be transported properly
from the oral cavity into the pharynx and through the
esophagus into the stomach. Thus, a wide variety of
201
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Table 1 Suggested protocol for the evaluation of symptoms
D Difficulty swallowing?
Y Yesterday compared with 2 years ago?
S Solid, liquid or both?
P Pattern of swallowing events?
H Heartburn history?
A Area of symptoms?
G Gradual or sudden onset?
I Interventions?
A Auxiliary clues, such as weight loss?
Fig. 1 Prone oblique position: Contrast material is given by a
straw. Abnormal structural movements may be diagnosed.
Further misdirection or retention of a bolus can be documented.
The seven functional units may serve as a basis for the
structured radiological report on deglutition
Fig. 2 First standard position. Overview of the lateral oral
cavity and pharynx. In this position, the pharynx is shown in the
largest possible section of the image in a way that the oral cavity
and, in the caudal aspect, also the upper esophageal sphincter is
included (arrow).Thepatientis examined in theuprightposition,
either standingor sitting.Usually the patient is turnedto the right
side, slightlyoblique. It is useful torepeat this sceneafter turning
the patient to the left, if stenoses need to be ruled out
Fig. 3 Second standard position. This setting shows the upper
esophageal sphincterinthelateral view, slightly oblique(arrow).
The upper esophageal sphincter can be evaluated particularly
well in this targeted image of the cervicothoracic junction
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Fig. 4 Third standard position. Sometimes it is useful to view
the oral cavity separately. In doing so, the movement of the soft
palate during speech can be visualized. However, the pharyngeal phase is largely eliminated in this setting. While speaking,
the soft palate rises up to the posterior wall of the nasopharynx,
while the patient says ‘‘Kathy’’ (arrow)
diseases may affect deglutition, resulting in a multidisciplinary work-up of dysphagic patients. Videofluoroscopy (VF) of deglutition is the method of choice to
investigate the whole swallowing tract in a ‘‘onestop-shopping’’ fashion. VF can depict pathologic findingsof morphologyandfunction as a basisto decideon a
further specialized work-up.
2 Symptoms of Swallowing Disorders
Establishing medical history is the first step in the
investigation of patients with swallowing disorders, in
order to individually tailor the examination and to cor-
symptoms. A questionnaire helps structure the patient’s
history and should include the onset and duration of
swallowing disorders, the pattern of swallowing events,
the location of symptoms,the consistencies offoods that
lead to swallowing difficulties, as well as history of
aspiration, regurgitation, coughing, pneumonia and
Fig. 5 Fourth standard position. Frontal view of the oral
cavity, the pharynx and the cervical esophagus. The symmetry
of the passage has to be documented
previous operations affecting the upper gastrointestinal
tract and neurological diseases.
For an adequate work-flow of diagnostic tests and
therapeutic concepts, the patient’s history has to be
differentiated into practical categories. With increasing experience with this patient group the investigator
may step further into the ‘‘art and science of historytaking in the patient with swallowing difficulties’’
(Table 1) (Hendrix 1993).
For the imaging specialist, the patient’s history
guides the design of the VF examination and has to be
integrated critically into the interpretation of the study.
Do the VF findings or other test results explain the
patient’s symptoms?(EkbergandPokieser1997). When
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