Modified barium swallow

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Videofluoroscopic swallow studies (also often called modified barium swallow studies) are a variation on traditional barium swallow studies. Although typical barium swallow studies / esophagrams evaluate the pharynx, the goal in these studies is to even more closely evaluate the oral cavity, pharynx, and cervical esophagus for oropharyngeal dysphagia through a variety of additional maneuvers.

Indications

A videofluoroscopic swallow study is most often used to evaluate

Evaluations for dysphagia or aspiration are often performed

  • post cerebral infarct
  • in a patient with a history of neuromuscular disease
  • post head and neck surgery
  • after radiation to the head or neck

Contraindications

There are few contraindications. If the patient is grossly aspirating on exam, then the exam can be performed quickly and carefully to gather limited information on why the aspiration is occurring / which structures are involved, but this must always be balanced against the risk of large volume aspiration of barium contrast medium, which can markedly impair respiratory function.

The patient usually must be able to sit or stand, and the exam is only rarely performed in a supine position.

Procedure

Equipment
  • fluoroscopic equipment capable of cinefluoroscopy
    • capability for rapid sequence spot images is also useful
  • barium of different consistencies
    • "thin" barium
    • nectar-thick and/or honey-thick barium
    • barium pudding
    • (optional high density barium)
Technique

There are many ways of performing the study and it is often tailored to the individual patient. For instance if a patient is grossly aspirating you may start with thicker density materials to improve the likelihood of a successful swallow and then work toward thinner materials in order to "stress" the capacity of the swallowing mechanism. If the patient's swallow is more normal, you may go in the reverse direction. These studies are often performed with a speech pathologist who can direct much of the exam since he or she follows the patient clinically and may be interested in one part of the swallowing function more than another.

If the patient grossly aspirates during any part of the study, consider ending the study.

A sample protocol:

  • AP and lateral scout radiographs of the neck
    • try to center around the hyoid bone and hypo pharynx
  • if the patient is relative mobile and you plan on following the pharyngeal exam with an esophagram, then get scouts of the chest as well
  • start in the lateral projection with high density barium to coat the pharynx (rapid sequence or cinefluoroscopy)
    • the taste and density/consistency of this material is not normal for most patients, so a little tolerance is given for a slightly abnormal first swallow
    • size and center the images so that they include the lips, the soft palate, and the upper cervical esophagus (at least to the level of the cricopharyngeus)
  • assuming this is normal, turn the patient into the AP position and repeat
    • after the contrast passes through the pharynx, follow it down to the distal esophagus (if a swallowing chair is not preventing you) to rule out a large distal esophageal lesion/stricture that may be contributing to the swallowing disorder (you also don't want to force and obstructed patient to swallow a large volume of material)
    • return to the pharynx in the AP projection and ask the patient to phonate ("ooooh", "eeeeee", etc.) to evaluate for asymmetric pharyngeal motion
  • if the patient is capable and you are planning an evaluation of the full esophagus (barium swallow), the consider performing it at this point, before administration of low-density barium and potentially cracker materials are administered which may limit your evaluation of the esophageal mucosa
  • return to the lateral projection
    • repeat with "thin barium" which has a consistency more like water
      • save cinefluoroscopy images to evaluate the swallow mechanism in slow motion later
    • depending on how the patient does, follow up with nectar-thick or honey-thick barium materials to see how the pharynx handles these more dense consistencies
      • save cinefluoroscopy images
    • finish with barium pudding-thick materials and/or a cracker dipped in high density barium
      • save cinefluoroscopy images