TIPS FOR THE RADIOLOGIST

Why
videofluoroscopy?

A R Lloyd-Jones
MCommPath

Department of Speech Therapy and Audiology
Pretoria Academic Hospital

Swallowing may be defined as a
highly complex and co-ordinated
sequence of neuromuscular events
designed to transport food and liquids
from the oral cavity, through the
pharynx and oesophagus, to the
stomach. During this process, the res-
piratory function ceases briefly to
allow the digestive function to take
place and resumes once the swallow-
ing sequence has been completed.'
When this complex sequence of
events becomes disordered and the
transportation of material is no longer
efficient or effective,then dysphagia is
present.

Dysphagia may manifest in vary-
ing degrees, from mild symptoms
such as the sensation of food sticking
in the throat, to severe dysphagia
where the oral intake of food or liq-
uids is impossible. Dysphagia can also
occur at any stage of life,from the pre-
mature infant who cannot suck and
swallow, to the geriatric patient, and
can have a profound effect on the
quality oflife experienced. Symptoms
such as coughing and choking, drool-
ing, nasal regurgitation and
oesophageal reflux may cause the suf-
ferer to withdraw from society and
experience feelings of isolation and
depression.' In addition, dysphagia
carries the sequelae of malnutrition,

dehydration and aspiration if left
undiagnosed and untreated.'

In view of the serious mortality
and morbidity associated with dys-
phagia it is important to differentiate
between the symptoms of dysphagia
and the causes of dysphagia, as the
causative factor may be an underlying
disease or disorder that may be debil-
itating or life threatening.' This
process of differentiation involves a
comprehensive evaluation of the
patient and the expertise of a number
of medical and allied medical disci-
plines in order to provide the detailed
information that is crucial to diagno-
sis and management of this condi-
tion.' The speech pathologist and the
radiologist are essential members of
this multidisciplinary dysphagia team.

Evaluation of
dysphagia

As with any patient the evaluation
commences with a case history fol-
lowed by a clinical evaluation but 'the
literature clearly indicates that clinical,
bedside evaluation is an inadequate
and poor predictor of pharyngeal dys-
phagia" Consequently other more
objective means of evaluating swal-
lowing, and especially the pharyngeal
phase of swallowing, have been
sought. As the ability to visualise the
phases of swallowing aids in evalua-
tion, radiographic techniques have
been used since the early 1900s. The
development of fluorography during
the 1930s allowed the examination of
the movement patterns of the oral

42 SA JOURNAL OF RADIOLOGY • March 2002

cavity, pharynx and oesophagus/
With the development of technology
the fluorographic technique has been
refined and now fluorographic studies
are recorded on videotape, reducing
the exposure to radiation by making
the examination time shorter, and by
offering the opportunity for immedi-
ate review of the examination.

Another imaging technique that
can be used is ultrasonography.
Ultrasound clearly visualises muscles,
and depicts the surfaces between mus-
cles, organs and blood vessels, and a
variety of other tissues as well as the
motion of these structures. However,
the ultrasound does not visualise
bone.' There is a further limitation to
ultrasound as not all the phases of
swallowing can be visualised, the
ultrasound cannot demarcate the
bolus after it has passed into the
hypopharynx and cannot track the
bolus during the oesophageal phase,"
Ultrasound does not hold any danger
from radiation and can be used over
and over again with impunity.

Many other methods of objective
evaluation of the swallowing mecha-
nism exist. Of these methods fibreop-
tic endoscopy coupled with video-
recording facilities appear to be the
most popular. Manometry, scintigra-
phy, electromyography and cervical
auscultation are also utilised but no
other method matches the advantages
of video fluoroscopy. Video-fluo-
roscopy has become known as the
gold standard for swallowing evalua-
tion.

Rationale for this
choice

In order to choose the most eco-
nomical and efficacious method of
evaluating swallowing some impor-
tant factors must be taken into con-



TIPS FOR THE RADIOLOGIST

sideration. The examination should
offer the means to track the bolus as
well as the motions of the swallowing
mechanism, while allowing the ability
to observe if any bolus enters the air-
way and at what time during the swal-
lowing event the aspiration takes
place. Another factor to be considered
is whether the examination allows for
the use of real food bolusses that cor-
respond to a natural diet which would
facilitate the management of the dys-
phagia. If a procedure can be utilised
in treatment and follow-up of the dys-
phagic patient it is an added benefit."

With videofluoroscopy, the proce-
dure produces a clear pictorial image
of all the phases of swallowing, name-
ly oral preparatory, oral prepulsive,
pharyngeal as well as oesophageal.
This procedure provides a complete
image of the bony structures of the
oropharynx, airway and digestive
tract, while the use of high-density
barium contrast material outlines the
surface and the soft tissue of the
tongue, velum, pharynx, larynx and
the oesophagus. This means that
videofluoroscopy is easy to interpret
as it gives a clear likeness of the
anatomical structures in their actual
form and proportion. In addition, the
procedure is dynamic and allows a
clear image of the bolus flow through
the aerodigestive tract while providing
valuable information regarding the
patterns of movement as well as the
timing of events during swallowing.
This makes diagnosing the physiolog-
ic and temporospatial components of
dysphagia much more accurate and
efficient.S

With regard to the other factors
such .as the bolus type and manage-
ment of dysphagia, video fluoroscopy
also offers the most information. The

protocol used during videofluo-
roscopy can utilise food from the nor-
mal diet in different textures and con-
sistency in order to examine the effects
of the various bolus characteristics on
the mechanism of swallowing.
Information gained from using differ-
ent bolus textures will clearly indicate
if, for example, a patient aspirates on
thin fluids or on a solid particulate
bolus. This will aid in managing the
dysphagia as the diet of the patient
may be manipulated to provide all
foods in a texture and consistency
compatible with aspiration-free oral
feeding,"

Further management of swallow-
ing disorders is facilitated by using
videofluoroscopy as airway protection
manoeuvres and various postural
techniques can be used during the
examination and the efficacy of the
strategy evaluated immediately. The
video recording can be used later as an
instructional aid for the patient
demonstrating that the techniques
work in providing him or her with a
safe oral swallow.'

In summary, 'Video fluoroscopy is
not designed to determine whether
someone aspirates, but rather to
understand why they aspirate.
Further, the study is designed to
define optimal eating strategies to
enable the patient to continue at least
partial intake,"

Who to refer
Any patient who complains of a

swallowing disorder should at the very
least be referred to a speech therapist
who can utilise screening instruments
to identify the extent of the problem/
This will avoid doing a videofluo-
roscopy on patients who have mild
oral phase dysphagia. However, 'if the

43 SA JOURNAL OF RADIOLOGY • March 2002

main complaint is indicative of respi-
ratory difficulty or suggests the likeli-
hood of aspiration or laryngeal pene-
tration, videofluoroscopy is indicated.'

As a result of the varied aetiology
of dysphagia which encompasses neu-
rogenic causes, as well as neoplastic
and structural causes, the symptoms
presented by the patient also indicate
whether a video fluoroscopic exami-
nation should be performed. A
patient who complains of a gradual
onset, difficulty in swallowing pills
and fluids as well as an increase in eat-
ing time probably has a neurogenic
disorder as the underlying cause and
the complaint should be investigated
using videofluoroscopy. A patient
who complains of a more sudden
onset, painful swallowing, food stick-
ing in the throat and weight loss may
have a tumour or a mass and should
undergo a videofluoroscopy"

It is important to remember that
video fluoroscopy is not an exclusive
procedure but that the result obtained
from videofluoroscopy will indicate
the selection of further tests and pro-
cedures to confirm or dispute the
findings. It appears to be a common
misperception that the videofluo-
roscopy means that no other tests
need to be performed. However,
should a tumour or mass be identified
further examinations such as a CT
scan or MRI will be needed to investi-
gate further. If an oesophageal com-
ponent is identified during the video-
fluoroscopy then clear-tests such as
manometry, ph monitoring, Ba swal-
low, etc. are the next investigations
required. The videofluoroscopy can
aid in diagnosing the swallowing dis-
order but also saves time and money
by indicating which other procedures
will be necessary.



TIPS FOR THE RADIOLOGIST

Who should do
the videofluo-

roscopy?
As the purpose of a videofluo-

roscopy is to determine the deficits in
the swallowing mechanism that pro-
duce the symptoms as well as the ther-
apeutic strategies necessary to com-
pensate for the deficits, it is logical that
both a radiologist and a speech thera-
pist should be involved in this proce-
dure.

The radiologist contributes exper-
tise from many fields such as neurora-
diology as well the knowledge to iden-
tify structural abnormalities. The
radiologist is able to help tie together
the information from various studies
in order to arrive at a diagnosis.
Furthermore, the radiologist is
responsible for the technical aspects of
the procedure such as exposure and
the identification and reduction of
image artifacts ensuring the quality of
the imaging."

The speech therapist has specialist
knowledge of the movement patterns
of the oral structures, pharynx and

larynx during deglution and comple-
ments the radiologist's knowledge of
structural deficits. The speech thera-
pist also has knowledge of the effects
of bolus characteristics on swallowing
as well as the various postural changes
and airway protection manoeuvres.
Therefore, she can determine which
techniques would facilitate safe oral
feeding. In this way the combination
of the skills of both these professionals
leads to effective and efficient deci-
sion-making regarding diagnosis and
management of the patient's prob-
lem.'

In conclusion, videofluoroscopy is
a short, relatively cheap, easy-to-inter-
pret test that provides comprehensive
information regarding all the phases
of swallowing, the deficits and struc-
tural defects of the swallowing mech-
anism and lends itself to the evalua-
tion of the therapeutic techniques
employed to overcome the swallowing
problem. This procedure involves the
combination of the radiologist's skills
and the speech therapist's skills to
diagnose and manage dysphagia suc-
cessfully. For in the words of Virginia

Woolf: 'One cannot think well, love
well, sleep well, if one has not dined
well:

References
1. Bradley PJ, Evaluation of the normal swallow-

ing mechanism. CME Bulletin Otorhino-
laryngology, Head and Neck Surgery 1998; 2 (1):
4-8.

2. Mathog RH, Fleming SM. A clinical approach
to dysphagia. Am ] Otolaryngol 1992; 13: 133-
138.

3. Veldee MS, Peth LD. Can protein-calorie mal-
nutrition cause dysphagia. Dysphagia 1992; 7:
86-101.

4. Fleming SM. Treatment of mechanical swallow-
ing disorders, In: Groher ME, ed. Dysphagia
Diagnosis and Management. 2nd ed. Boston:
Butterworth-Heineman, 1992: 237-253.

5. Miller RM. Clinical examination for dysphagia.
In: Grober ME, ed. Dysphagia. Diagnosis and
Management. 2nd ed. Boston: Butterworth-
Heineman, 1992: 143-163.

6. Leder SB, Sasaki CT, Burrel MI. Fibreoptic
endoscopic evaluation of dysphagia to identify
silent aspiration. Dysphagia 1988; 13: 19-21.

7. Logeman JA. Evaluation and Treatment of
Swallowing Disorders. 2nd ed. Austin, Texas:
Pro-Ed,1998.

8. Sonies Be. Dysphagia: A model for differential
diagnosis for adults and children. In: Cherney
LR, ed. Clinical Management of Dysphagia in
Adults and Children. 2nd ed. Chicago, illinois:
Aspen Publications, 1994.

9. Ekberg O. Evaluation of swallowing. In: Groher
ME, ed. Dysphagia Diagnosis and Management.
2nd ed, Boston: Butterworth-Heineman, 1994:
163-196.

44 SA JOURNAL OF RADIOLOGY. March 2002