Swallowing Disorders – Interpretation of

Radiolographic Studies
Robin Smithius
Radiology department of the Rijnland Hospital in Leiderdorp, Netherland

Publication date January 3, 2007

In this overview a simple method of interpreting swallowing disorders is presented.
We will concentrate on four basic findings:
 Asymmetric swallowing
 Stasis of contrast
 Cricopharyngeal dysfunction
 Aspiration

Normal Swallowing
Swallowing is a complex movement.
It requires the coordination of nerves and muscles in the buccolabial area, the tongue, the
palate, the pharynx, the larynx and finally the esophagus.

Oral Phase
In the oral phase food is prepared for swallowing and then transported to the pharynx.
This is a preparatory phase in which the food is held within the mouth while the base of the
tongue and the soft palate close the oral cavity posteriorly to prevent food spilling into the
open larynx and trachea.
A bolus is formed in the central portion of the tongue and then pushed posteriorly toward
the pharynx with an anterior-to-posterior tongue elevation.
As the bolus enters the pharynx the actual swallow or pharyngeal reflex is triggered.
Pharyngeal Phase
This phase is a reflex action. The bolus passes through the pharynx quickly and then enters
the esophagus.
This takes place in less than a second.
The initiation of this process starts when the bolus passes the anterior faucial arch and
reaches the posterior pharyngeal wall.
Elevation of the soft palate prevents material from entering the nasal cavity.
This stage is followed by the pharyngeal constrictor muscles pushing the bolus further into
the pharynx, toward the cricopharyngeal sphincter.
The larynx prevents material from entering the trachea by respectively closing the true
vocal cords, false vocal folds, and aryepiglottic folds.
Contraction of the lower pharyngeal constrictor is followed by relaxation of the
cricopharyngeal muscle, allowing the bolus to pass into the esophagus.
Fluoroscopic imaging
The most important images of the swallowing study are those taken of the lateral view.
Click through the images 1-8 on the left.
1. The base of the tongue and the soft palate close the oral cavity posteriorly (arrow) to
prevent spill of food into the open larynx.
2. Hyoid bone and base of the tongue move in a cranial direction and lift the larynx
(arrow).
3. Soft palate elevates to prevent spill into the nasopharynx (thin arrow) and the larynx
closes by contraction of the aryepiglottic folds (broad arrow)
4. Contraction of the upper pharyngeal constrictor (arrow)
5. Contraction of the middle pharyngeal constrictor (arrow)
6. Contraction of the lower pharyngeal constrictor and relaxation of the
cricopharyngeal muscle (arrow)
7. Epiglottis elevates to regain its resting position and the larynx opens.
8. Epiglottis in resting position and larynx is open (arrow).
The AP-view is less important than the lateral view in the analysis of patients with
dysphagia.
It is especially important to look for asymmetry.
Once a good series of the pharyngeal phase has been acquired, follow the contrast bolus all
the way down to the gastroesophageal junction.
1. Contrast enters the pharynx.
2. The lateral food chanels fill symmetrically as the epiglottis divides the bolus into a
left and right portion (blue arrows).
3. Contrast reaches the hypopharynx.
4. Cricopharyngeus opens and contrast enters the esophagus.
5. Pharyngeal constrictors squeeze all the contrast into the esophagus.
6. No stasis.

Indication For a Radiographic Swallowing Study

Indications for a swallowing study are dysphagia, globus sensation and aspiration.
Dysphagia is a general term used to describe the inability to move food properly from the
mouth to the stomach.
Globus sensationis a term to describe the feeling, that there is something in the throat, that
is in the way or needs to be swallowed.
Aspiration is the most severe form of a swallowing disorder and can result in aspiration
pneumonia, chronic lung disease or choking.
In some patients with chronic lung disease a swallowing study can be performed to look for
'silent aspiration'.

Study of Swallowing
When starting a study, try to find out exactly what the patients problem is, so you can
customize the series.
Is there a risk of aspiration (i.e. wet voice, recurrent pneumonia, aspiration).
If so, do not start the examination with barium contrast, but instead use non-ionic water-
soluble contrast.
If, during the first few swallows no aspiration takes place, you can switch back to barium,
as this gives better quality images.
When solid food is the problem, you may want to add a solid substance to the barium (for
instance biscuits or bread).
The examination of patients with a possible swallowing disorder consists of:
1. Fluorographic study of the actual swallowing.
2. Double-contrast images of the pharynx.
3. Examination of the esophagus.
We start with one or two lateral swallows followed by a lateral double-contrast view of the
pharynx (see later).
Then an AP-swallow is recorded followed by an AP double-contrast view of the pharynx.
Next the passage through the esophagus is recorded, followed by double-contrast views of
the gastroesophageal junction.
Before we start the examination, the procedure is explained to the patient and we practise
certain manoeuvres (i.e. modified Valsalva).
Use only a small amount of barium for the first swallow and if the patient is doing fine,
coninue with larger portions.
Aspiration of a small amount of barium is usually not a big problem, but you don't want a
lot of barium filling the bronchi.
Double contrast images of the pharynx
For the lateral view, ask the patient to sing an aaa, as this will move the tongue in an
anterior position and give a better view on the oro- and hypopharynx.
In Dutch this will be the letter eee, as it is pronounced the same as the english aaa.
For the AP-view the modified Valsalva manoeuvre is performed.
The patients has to blow air through the tightened lips as in trumpet-playing, while relaxing
the neck region.
Always practise this manoeuvre prior to the examination, so the patient knows what to do.
On the left DC views of the pharynx. Outpounching of the lateral wall of the pharynx is
normal and can be quite severe (Dizzy Gillespie).These are called 'lateral pharyngeal ears'.
Examination of the esophagus
Always follow the passage of barium through the esophagus until it enters the stomach.
Disorders of the gastroesophageal junction are often experienced as a problem within the
throat.
The rationale for this is that in patients with a distal obstruction, gastroesophageal reflux or
a motility disorder, the cricopharyngeal muscle has to work very hard to prevent
foodspillage back into the pharynx - along with its risk of aspiration.
This increased muscle tone gives the patient the sensation that there is a problem in the
throat.
The patient on the left complained of globus sensation.
This was due to severe reflux and subsequent increased tone of the cricopharyngeal muscle.
A complex paraesophageal hernia is seen.
Excellent views of the gastroesophageal junction can be achieved by doing the following:
1. Ask the patient to swallow zoru-granules for optimal gas filling of the stomach.
2. Tell the patient not to belch, but to keep the air in the stomach until the moment of
swallowing.
3. Place the patient in the left anterior oblique position.
4. Lift the table top 45 degrees.
5. Swallow high density barium for optimal esophageal coating.
6. Images are taken when air regurgitates from the stomach into the barium-coated
esophagus.

How to Analyze Swallowing Disorders

A simple way to analyze a swallowing study is to concentrate on four easily detectable
findings.
These are:
 Asymmetry
 Stasis
 Cricopharyngeal dysfunction
 Aspiration
These findings are mostly already apparent during the examination, but analysis of all the
images will clarify the mechanisms that cause these abnormal findings.
These imaging findings may be isolated findings or may be related to each other.
For instance, premature closure of the cricopharyngeal muscle may lead to stasis of contrast
in the pharynx, which may result in aspiration as the larynx opens at the end of swallowing.

Asymmetry
Asymmetric swallowing on an AP-view is usually the result of an asymmetric tilting of the
epiglottis.
Sometimes it is caused by rotation of the head, but in many cases no real explanation is
found.
Even when the head is not rotated, the epiglottis can tilt asymmetrically when it hits the
posterior pharyngeal wall.
This is more likely to occur when only a small bolus is given,as the pharynx will not fully
distend.
An asymmetric swallow may be followed by a symmetric swallow in the same patient
when a larger bolus is given.
In the case on the left rotation of the head closes the side to which the head is turned
(Figure).
If a patient has a unilateral pharyngeal paresis, turning of the head towards the affected side
will help the patient in preventing aspiration.
By turning the head towards the affected side, this side will be closed preventing stasis on
this side and possible secondary aspiration.
On the far left asymmetry is seen on the fluorographic study (green arrow).
A tumour in the right pyriform sinus has to be excluded.
On the DC view on the right the piryform sinus is normal (green arrow), but at the level of
the vallecula on the right a lobulated proces is seen (yellow arrow) and at a higher level a
smooth indentation of the oropharynx is seen (blue arrow).
The lobulated tumor at the level of the valleculae proved to be remnants of the tongue
tonsil, which is a common finding and sometimes difficult to differentiate from cancer of
the tongue base.
In some cases endoscopy is needed to differentiate the two.

Stasis
Stasis is the result of insufficient cleansing of the pharynx, either due to an obstruction (i.e.
dysfunction of the cricopharyngeus) or due to insufficient contraction of the pharyngeal
constrictors.
Insufficient contraction is the result of pharyngeal paresis resulting from a neuromuscular
disorder.
Excessive movements of the tongue base and larynx are sometimes seen on lateral
fluorographic studies to compensate for the loss of function of the pharyngeal constrictors.
When the patient resumes breathing, aspiration can occur .
Cricopharyngeal Dysfunction
Insufficient opening and premature closure are the most common problems of the
cricopharyngeal muscle.
Normally you should not see an impression of the cricopharyngeus during passage of the
bolus, but a small non-obstructive indentation is sometimes seen and is not clinically
significant (Figure).
It can however sometimes explain the symptoms of the patient.
It is assumed that the passage of food irritates the mucosa that covers the cricopharyngeal
muscle resulting in a globus sensation.

Premature closure of the cricopharyngeus results in an increased pressure in the

hypopharynx, just above the cricopharyngeus, as the pressurewave of the
pharyngeal constrictors pushes the bolus downwards.
This increased pressure can result in an outpouching at a weak spot in the posterior
pharyngeal wall (Killian's dehiscence).
First this will result in a small pouch, that in time can increase and form a true
Zenker's diverticulum (Figure).
A Zenker's diverticulum is always the result of cricopharyngeal dysfunction.
Aspiration
There are three instances when aspiration can occur: before, during or after the actual
swallow.
 Aspiration before swallowing is either the result of insufficient closure of the oral
cavity during the preparatory phase or inability to start the swallow reflex when
contrast enters the pharynx.
 Aspiration during swallowing is due to insufficient closure of the larynx.
 Aspiration after swallowing is the result of stasis of contrast in the pharynx - when
the larynx opens the contrast leaks into the trachea.

Aspiration before swallowing

When tongue or soft palate are unable to prevent spillage of food into the pharynx,
aspiration may occur since the larynx is still open.
Weakness of these muscles in the mouth and the throat is due to paralysis or myopathy.
Aspiration during swallowing
This is due to an insufficient closure of the larynx when it should be closed.
Closure of the larynx is a result of anterosuperior lifting of the larynx which allows the true
cords, false cords and finally, the aryepiglottic folds to contract, followed by a backwards
folding of the epiglottis over the closed larynx.
The aryepiglottic folds are the main gatekeepers, while the epiglottis plays only a minor
role in preventing aspiration.
Both failure of these intrinsic muscles of the larynx as well as failure of the extrinsic
muscles (i.e. muscles that lift the larynx) may lead to aspiration during swallowing.
Weakness of the extrinsic muscles is seen after radiotherapy, in neurologic disorders and in
recurrens nerve paralysis (i.e. neuromuscular dysfunction).

Aspiration after swallowing

This is the result of stasis of contrast in the pharynx due to insufficient contraction of the
pharyngeal constrictors or insufficient opening of the cricopharyngeal muscle.
When the larynx opens the contrast may leak into the trachea.
Diagnosis and Rehabilitation Swallowing Disorder
Diagnosis
The results of the swallowing examination help in establishing a final diagnosis.
Based on this examination alone however, a specific diagnosis usually cannot be made,
since most severe swallowing disorders are the result of a complex neuromuscular
dysfunction.
Hence the swallowing study should be regarded as part of the total evaluation of the patient
by gastroenterologist, neurologist and speech therapist.
The strength of the fluoroscopic examination is, that it is the only examination that can
show us, what is really going on during swallowing and can therefore lead to a
rehabilitation plan.
Swallowing Rehabilitation
Swallowing rehabilitation is a specialty on its own.
Here we will make some brief comments on rehabilitation as it may help you to better
understand the dynamics of swallowing.
In unilateral pharyngeal paralysis stasis can be prevented by closing down one of the
lateral food channels by turning the head towards the affected side or by manually
compressing it.
Patients with aspiration before swallowing due to insufficient closure of the mouth, can be
helped by flexing their head during chewing and thus holding the food in the anterior part
of the oral cavity.
In patients with aspiration during or after swallowing the 'supraglottic swallow' may help.
Before swallowing a deep breath is taken.
Air is prevented to leak out of the airways by compressing the vocal cords.
Immediately after swallowing the patient has to cough forcefully in order to clear the
airways and the throat from any residual food.
Some patients only aspirate when they ingest fluids.
These patients can be helped by changing their fluid intake into jelly-like liquids.