INSTRUMENTAL ASSESSMENT OF

DYSPHAGIA

Dr Mari Viviers 2017

Instrumental techniques for the study of

swallowing
Criteria
Pt requirements:
Suspected aspiration during beside
evaluation/clinical assessment
Patients experiencing pain during
swallowing
Patients experiencing choking/gagging
during clinical assessment
Patient should be alert enough to
tolerate an instrumental assessment in
the radiography department
Instrumental techniques for the
study of swallowing not only VFSS
Various imaging and non-imaging
procedures to study various aspects of
normal and/or abnormal swallowing
physiology
Imaging studies
Ultrasound (used primarily for research
studies)
Tongue function
Oral transit time
Hyoid motion
Not visualize pharynx-mix of tissue
(cartilage, bone, muscle)
Only oral stage
Imaging studies
Videoendoscopy (FEES)
Flexible fiberoptic examination of swallowing
Anatomy of oral cavity and pharynx from above before and after
swallow
Flexible scope in nose to level of soft palate/below
Topical anesthetic
Cannot visualize oral phase
Above soft palate: velopharyngeal closure and inward movement of
lateral and/or posterior pharyngeal walls
Tip behind the uvula: can observe before and after swallow
Difficult to define the exact nature of physiologic disorder and the
effectiveness of treatment strategies
Observations from residual food
Rigid scope
Children 6-8 years do not cooperate well, also adults with cognitive
disorders
Imaging studies FEES
(contd)
Video/digitally recorded
Excellent superior view of the pharyngeal anatomy and
Relationship between epiglottis, airway entrance,
valleculae, aryepiglottic folds and pyriform sinuses
No radiation
Sensory awareness: touching pharyngeal and laryngeal
structures
Uncomfortable
Observe vocal folds: placement at/below tip of epiglottis
Observe airway closure maneuvers, e.g. supraglottic and
super-supraglottic swallow (only prior to swallow)
Biofeedback during practising of ariway closure
maneuvers.
Positioning of the
endoscope

Source: Evaluation and Treatment of Swallowing Disorders, Logemann, J.A., 1998

 Modified Barium Swallow MBS/
Videofluoroscopic swallow study VFSS

Purpose is not only to determine

whether a person is aspirating but WHY
they are aspirating
Designed to study anatomy & physiology
of the different phases of swallowing
Enables assessment of variety of food
consistencies
Designed to define management &
treatment strategies
MBS
Quantitative assessment
Permits frame-by-frame analysis of swallow by
means of digital/video-recorder (see picture)
Recording of swallow can be repeatedly
examined in slow motion
MBS

Allows slow motion analysis in order to define movement

disorders
Info on bolus transit times, motility problems and etiology of
aspiration
Low dose radiation
Enables visualization of (see picture)
Oral activity during chewing and the oral stage of
swallowing
Triggering of pharyngeal swallow in relation to position of
the bolus
Motor aspects of pharyngeal swallow-mov of larynx, hyoid,
tongue base, pharyngeal walls and CP region
Not measurement of pressure
MBS
Variety of food types: Measured amounts
of liquid (1-10ml), liquid from cup, pureed
food and cookie (chewing).
Lateral observation vs Anterior-Posterior
view
Reason for aspiration and define optimal
eating strategies
Treatment strategies: postural changes,
sensory input, swallowing therapy
techniques (Swallowing maneuvers), bolus
viscosity changes
How to begin?
Positioning
Position pt in his usual eating position
Shoulders as low as possible
Preferably seated (provide support if
necessary)(adult & child)
Initial radiographic observations
Lips anteriorly, hard palate superiorly,
posterior pharyngeal wall posteriorly
and the bifucation of the airway and
esophagus inferiorly.
If suspected to aspirate: magnify area
around the bifurcation of the airway and
esophagus to determine amount of
aspiration on 1st swallow or two.
Then reduce image to include entire
vocal tract on remaining swallow to id.
reason for aspiration.
Lateral view during MBS
Initial radiographic observations
Pts arms should hand at sides (no shoulder elevation
Following structures should be visible when patient is upright in the
lateral plane:
-Tongue
-Floor of the mouth
-Mandible
-Valleculae
-Epiglottis
-Hyoid bone
-Aryepiglottic folds
-Thyroid cartilage
-False vocal fold
-True vocal fold
-Cricoid cartilage
Food presentation during MBS
LATERAL VIEW: Thin liquid: 1 ml &
It is very important to 3ml (spoon), 5 ml &
start of with small 10 ml (syringe), cup
amounts drinking
Begin with LIQUIDS 1/3 teaspoon of paste
Present at least 3 of cookie coated
consistencies (thin with barium
liquid, paste, material Volume can be
requiring chewing)
increased until/unless
At least 2 swallows of
pt aspirates
each consistency
Food presentation
(contd)
Posterior-Anterior view
To keep radiation exposure to a
minimum, only administer food
consistencies found to be most difficult
in lateral view
Measures & Observations
on MBSS
Lateral view:
Oral transit time
Pharyngeal transit times
Pharyngeal delay time
Movement patterns of the bolus
Lingual movement
Oral, pharyngeal and cervical esophageal phases of
swallowing
Timing of aspiration relative to triggering of pharyngeal
swallow
The approximate amount and cause
(anatomic/physiologic) of aspiration.
Effect of treatment strategies for elimination of aspiration.
Measures &
Observations
Oral transit time: Time from the initiation
of the tongue movement to beginning of the
voluntary oral stage until the bolus head
reaches the point where the lower edge of
the mandible crosses the tongue base
(Logemann, 1998, p. 77). 1-1.5 seconds.
Pharyngeal delay time (PDT): Begins
when the bolus head reaches the point
where the lower edge of the mandible
crosses the tongue base and ends when
the laryngeal elevation begins.
Measures obtained from MBS
Pharyngeal transit time (PTT): The time
elapsed from the triggering of the pharyngeal
swallow until the bolus tail passes through
the cricopharyngeal region. Maximum 1 sec.

It also allows observation if aspiration occurs

and the approximate amount of aspiration as
well as the cause. If aspiration occurs
before, during or after the pharyngeal
swallow.
Observations in planes
Lateral plane observation
Observe if food or liquid enters the airway
Observe if there is pooling the valleculae
or pyriform sinuses
Observe swallowing with different foods
(textures)
Effect of postural changes on the swallow
Effect of compensatory techniques
Observations in planes
Anterior-posterior plane:
Symmetry of structures and function
Larynx during phonation
ORAL PREPARATORY PHASE
Ability of tongue to lateralize food
Pattern of jaw motion in crushing food
during chewing
Shape of tongue for holding bolus (sides
in contact with central groove)
Anterior-Posterior
(cont):
Movement of the vocal folds
If barium moves through the areas
symmetrically
If pooling in valleculae and pyriform
sinuses is symmetrical
Anterior-Posterior (A-P)
view during MBS
A-P view: Pooling in valleculae &
pyriform sinuses
Contraindications for
MBS
Patient not alert enough to eat
Only oral phase problems
Patient refuses to eat
Patient does not want to open mouth for food or
liquid: dementia, apraxia, orally defensive
Order of interventions introduced
during MBS
1. Postural techniques
2. Techniques to increase oral sensation
3. Swallow manuevres (not feasible in pts who
have cognitive problems/language
impairments)
4. Volume changes
5. Food consistency modifications
Once an effective set of interventions have been
identified give larger volumes of the same
food
Summary:
Imaging techniques:
Ultrasound
Non-imaging
techniques:
Video-endoscopy
Electromyography
Videofluoroscopy
Electroglottography
Scintigraphy
Cervical auscultation
(sounds of
swallowing &
respiration)
Pharyngeal
manometry