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Videofluoroscopic Evaluation of
Oropharyngeal Swallowing
Tessa Goldsmith
1727
Table 32-1 through the oral cavity into the cervical esophagus. Its
CAUSES OF OROPHARYNGEAL DYSPHAGIA comprehensiveness has earned it the status of the gold
standard.5, 6
Iatrogenic
VFSS provides immediate information on bolus transit in
Medication side effects (neuroleptics, chemotherapy) relation to structural movements of the oral cavity and
Postsurgical muscular or neurogenic hypopharynx. The purpose of the examination is not simply
Radiation to determine whether the patient is aspirating. The study is
Corrosive (pill injury, intentional) important because it helps define the underlying physiology
Infectious of the swallowing disorder for rehabilitation planning. By
Botulism careful analysis of the sequence of events during oropharyn-
Lyme disease geal swallowing, therapeutic strategies can be introduced
Syphilis systematically and their effectiveness evaluated. A critical
Mucositis (herpes virus, cytomegalovirus, Candida)
objective is to determine a prescription for safe and effective
feeding and swallowing.7, 8
Metabolic
Unlike the barium swallow, which has been the mainstay
Amyloidosis
of fluoroscopic imaging of the upper aerodigestive tract for
Thyrotoxicosis about 50 years, the VFSS is a relatively new examination in
Myopathic the armamentarium of speech language pathologists for
Connective tissue disease examination of oropharyngeal swallowing. The VFSS is
Dermatomyositis and polymyositis widely used in hospital and rehabilitation settings and has
Myasthenia gravis recently been adapted for mobile use with a C-arm
Myotonic dystrophy fluoroscope in long-term care and school facilities. The
Oculopharyngeal muscular dystrophy study is alternatively known as a cine-swallow study after
Paraneoplastic syndromes the cinefluorographic technology that preceded video
Sarcopenia
recordings of dynamic radiographic events. It has also been
called the cookie swallow, a term coined by Logemann9 to
Neurologic
emphasize the assessment of the oral stages of swallowing
Stroke (hemispheric, subcortical, brainstem)
using cookies and barium as the contrast medium. The term
Head trauma most widely used today is modified barium swallow, which
Brain tumors is frequently confused with barium swallow. Others have
Cerebral palsy referred to the study as the oropharyngeal motility swallow-
Guillain-Barré syndrome ing study,10 dynamic swallow study,11 and videofluoroscopic
Huntington’s disease oropharyngeal swallowing study.12, 13 For the purposes of
Parkinson’s disease this chapter, the term videofluoroscopic swallowing study
Multiple sclerosis (VFSS) will be used.
Amyotrophic lateral sclerosis The VFSS has high clinical utility. In a recent study by
Postpolio syndrome
Martin-Harris et al.,7 83% of their 608 consecutive
heterogeneous subjects displayed abnormal swallowing on
Tardive dyskinesia
VFSS and 48.4% of those patients benefited from compen-
Metabolic encephalopathies
satory swallowing strategies that improved their swallowing
Dementia safety and efficiency. However, the clinical utility of the
Structural disorders examination depends on comprehensive evaluation of
Cricopharyngeal prominence muscular movements in relation to bolus flow, not simply on
Zenker’s diverticulum evaluation of the bolus flow itself. Focus on the bolus flow
Cervical web alone, which is common among novice clinicians, provides
Pharyngoceles information about symptomatology but not etiology. Suc-
Tumors of the oral cavity, oropharynx, hypopharynx, and larynx cessful therapeutic compensations or maneuvers are based
Osteophytes and skeletal abnormalities on an understanding of the etiology of the disorder.
Congenital disorders (cleft palate)
pathologists should be acutely aware of his or her diagnostic food or liquid becoming ‘‘caught in the throat.’’ While
range and should rely heavily on the radiologist for aspiration may be obvious, it may also present silently in
identification of disease. The radiologist provides input the form of a weak volitional cough or a wet or
about radiation safety procedures and positions the fluoro- ‘‘gurgly’’ vocal quality after eating or drinking. Symptoms
scope to provide the clearest image of the area under of silent aspiration are strongly related to transglottic
consideration.14 Together, both professionals estimate the aspiration on videofluoroscopic evaluation.2 Splaingard et
risk of continuing to administer contrast to the patient and al.17 observed that 40% of their subjects who aspirated on
make recommendations for oral intake based on the results VFSS were not identified as having aspirated on the bedside
of the study. examination.
Patients should be alert and be able to accept food by
mouth in a reasonable length of time. If therapeutic
THE DIFFERENCE BETWEEN THE VFSS AND strategies are to be evaluated, patient cooperation is
necessary. Hemodynamically unstable patients or those
THE BARIUM SWALLOW with severe deconditioning who have not had practice
sitting upright should be transported to the radiology suite
The traditional barium swallow study differs from the only with extreme caution, as the effect of positioning
VFSS in several ways. The routine procedure for the barium the patient may overwhelm and fatigue the patient,
swallow includes a full-column, single-contrast or mucosal affecting the outcome of the examination. In such cases, it
relief double-contrast study and a motility assessment of may be prudent to defer the examination until the patient’s
the esophagus.15 The fluoroscopy unit is focused on the health improves. Patients should be able to sit upright or
hypopharynx and follows the bolus as it traverses the close to upright comfortably for the procedure for several
esophagus into the stomach. The focus of this study is on minutes.
the thoracic esophagus, and the oral manipulation of the
bolus is not primarily evaluated. Aspiration is noted if it
occurs, but the mechanism of aspiration cannot be deter-
mined unless the oral and pharyngeal stages of swallowing CLINICAL EXAMINATION
are carefully examined. Gas-producing granules and high-
density barium may be administered for assessment of In most instances, the patient is known to the speech
possible mucosal irregularities, and high-density liquid language pathologist prior to the VFSS. Previous clinical
barium is used to assess esophageal motility. If a stricture or encounters permit the clinician to obtain a comprehensive
esophageal narrowing is suspected, a 13 mm barium tablet medical and swallowing history and to perform an assess-
may be given. In the barium swallow, the patient is exam- ment of oral motor and sensory function. In addition, it is
ined in upright and recumbent positions and in anterior- likely that the speech language pathologist has observed the
posterior (AP), lateral, and oblique projections. Usually patient swallowing liquids and solids. The clinical swallow-
single or sequential plane films taken during the swallow are ing evaluation allows the clinician to hypothesize about the
generally adequate to capture the bolus as it moves through nature of the underlying pathophysiology of the swallow and
the esophagus.15 to attempt therapeutic strategies at the bedside. In addition,
By comparison, the VFSS focuses on the oral cavity, the patient may be taught compensatory swallowing
oropharynx, nasopharynx, hypopharynx, larynx, and cervi- strategies in preparation for the VFSS.
cal esophagus. In an attempt to simulate the habitual In certain settings, however, the VFSS may be the first
swallowing function, patients are required to swallow encounter, and thus a detailed history is required to plan the
controlled and uncontrolled volumes of barium contrast with study. Relevant history information details the onset and
a variety of consistencies while seated upright and imaged in progression of the patient’s dysphagia symptomatology as
the lateral and AP projections. Typically, esophageal well as current diet, food consistency preferences and
function is not examined in detail during the VFSS. avoidances, duration of mealtimes, strategies the patient has
However, a survey scanning the esophagus to determine found helpful to alleviate the problem, unintended weight
whether the contrast material has passed through the loss, and medical consequences of the dysphagia. If the
gastroesophageal junction provides some screening infor- patient is fed nonorally via a gastrostomy or nasogastric
mation about esophageal function and may suggest that tube, the circumstances surrounding its placement must be
further evaluation is needed. This is especially important understood. The patient’s medical and surgical history and
since 35% of patients have combined pharyngeal and current medications are examined for their etiologic
esophageal components to their dysphagia and the site of the contribution to the dysphagia, including recent hospitaliza-
lesion does not correspond accurately with the patient’s tions for pneumonia, radiation therapy to the head and neck,
complaint.16 and/or gradual changes in speech intelligibility.
Prior to the radiographic examination, an assessment of
the motor and sensory function of the oral mechanism is
INDICATIONS FOR THE VFSS performed. Note is made of asymmetries of labial, lingual,
and palatal movements, reduction in range of motion,
Patients who present with signs of pharyngeal dysphagia strength or coordination, and restricted sensation to light
on xclinical examination are most appropriate for a VFSS touch. An absent gag reflex is noted, as well as impairment
study. Problems may include overt complaints of coughing of volitional coughing and laryngeal excursion during dry
and choking when eating or drinking as well as signs of swallowing.
FIGURE 32-1 Ideal view for imaging oropharyngeal swallowing in the (A) lateral and (B) AP projections.
thinnest liquids, such as water or juice, by diluting through the study before proceeding with the remainder of
the barium liquid. While this more closely resembles the the examination.
viscosity of thin liquids, its reduced radiodensity reduces the Traditionally, the radiologist terminates the barium
reliability with which small amounts of aspiration can be swallow examination when aspiration is detected. However,
accurately detected. sometimes aspiration is observed early in the examination
The boluses are measured and are given in increments to and terminating the study will not allow evaluation of the
determine performance with a variety of volumes. Contrary efficacy of therapeutic strategies that may indeed eliminate
to expectation, some patients have greater difficulty initiat- aspiration. Compensatory or rehabilitative maneuvers are
ing a swallow with smaller liquid boluses than with larger introduced if the patient aspirates or demonstrates inefficient
ones. Sometimes it is necessary to evaluate the patient while swallowing behaviors. Such maneuvers are assessed for
swallowing thickened liquids or specially prepared food- their effectiveness in both the lateral and AP projections.
stuffs such as bread and hard meats coated with barium. In Ideally, more than one trial per bolus is needed to improve
some settings, patients are encouraged to bring foods with the reliability of the findings.
which they have difficulty, the goal being to simulate the Termination of the study will depend on patient-specific
scenario that causes the dysphagia. If the patient has parameters such as the amount of aspiration, the patient’s
difficulty taking pills, a 13 mm barium tablet may be given, sensitivity to the aspiration, effectiveness of clearance from
although extreme caution should be exercised if the patient the trachea, and the underlying medical history. For
is seen to experience moderate to severe oropharyngeal example, an ambulatory patient, who has no history of
dysphagia. Aspiration of a barium tablet can lead to aspiration pneumonia, is cognitively intact, and whose
significant complications, particularly in a compromised airway is effectively cleared with a cough is more likely to
patient. tolerate aspiration than a patient who is bed bound and has
recently been mechanically ventilated, with a weak cough.
Recording
Fluoroscopic images are recorded in real time by
Reporting the Findings
high-definition video recording equipment for later analysis
In many facilities, the speech pathologist and radiologist
and review. Image data can be stored on videotape or, with
generate separate reports on the results of the VFSS. Ideally,
new technology, in digital form on a hard drive or digital
a report that details observations of the structural compo-
video disk. Because of the complexity of the events of the
nents of the oropharyngeal mechanism, as well as a
swallow occurring in a short period of time, video recorders
description of the biomechanical events of the swallow and
should be capable of slow-motion review and frame-by-
the results of therapeutic procedures, would reflect the
frame analysis. A microphone is needed to record the
collaborative nature of this radiographic procedure.
instructions to the patient and to record audible responses
such as coughing and the patient’s vocal quality. Static or
spot films can be taken during the fluoroscopic procedure if
suspected pathology is identified. NORMAL SWALLOWING
In an effort to reduce radiation exposure, some clinicians
use pulse fluoroscopy, particularly during mastication of Traditionally, the description of swallowing is divided
solid boluses. Since swallow onset after mastication is into four stages: the oral preparatory stage, the stage of oral
variable, it is possible to miss the important biomechanical transit, the pharyngeal stage of swallowing, and the
events if the fluoroscope is turned off. Rapid-sequence esophageal stage. This description is artificial in that it fails
digital radiography has become available in many hospitals. to capture the fluidity of the normal swallow and it ignores
Among the advantages of this system are the excellent the impact one stage has on the progress of the next. In this
image resolution quality (1024 lines per inch), the relatively section, an attempt is made to outline the features of the
low-dose radiation, and the ability to enhance the image on a normal oropharyngeal swallow from a physiologic stand-
frame-by-frame basis.20 However, one disadvantage is that point using the pressure generation model as the basis for the
its capture rate of six frames per second may be too slow to discussion. In the section on Interpretation of Findings, the
ensure visualization of the intricacies of the pharyngeal radiologic manifestations of the normal and abnormal
swallow, which in normal instances can be completed in less physiology of swallowing are discussed. However, in order
than 1 second. to make clinical sense of radiographic findings, it is
While clinicians should be mindful of the cumulative necessary to understand the complexity and fluidity of
recording time, the examination should be long enough to normal swallowing physiology.
obtain the answers to the critical questions. Fluoroscopy The process of safe and efficient swallowing demands
time can be controlled by thorough preparation for the exquisite timing and coordination of more than 30 pairs of
examination based on the history and the findings of the muscles and 6 cranial nerves that are under voluntary and
clinical swallowing assessment. Clinicians should take care involuntary nervous control. Boluses are prepared and
to administer only that contrast necessary to answer propelled through the oral cavity, pharynx, and esophagus
particular questions reliably, expecting to extrapolate some and enter the stomach in an extremely complex process that
information to slightly larger boluses or to consistencies that lasts for less than 20 seconds, with the longest phase
differ minimally in viscosity. For the beginning clinician, it occurring in the esophagus. A dynamic pressure gradient,
may be necessary to review the video recording partway generated by the opening and closing of a series of ‘‘valves’’
in the tube-like structure of the oral cavity and hypopharynx, Pharyngeal Stage
is responsible for propagation of the bolus into the
esophagus. The events of the pharyngeal stage of swallowing occur
concomitantly with the oral transport stage and can be
described as a single pressure-driven event in which the oral
Oral Preparatory Stage cavity, pharynx, and cervical esophagus form a single tube.
The ‘‘valves’’ of the system (lip closure, contraction of the
In the first preparatory stage, the food or liquid is buccinators, closure of the velopharyngeal port, adduction
manipulated until it is ready for swallowing. This stage of the vocal folds, and contraction of the pharyngeal
involves mastication of solid boluses and positioning of musculature) act to close the cavity and, in conjunction with
semisolid or liquid boluses for transfer into the hypophar- the ‘‘piston-like movement’’21 of the tongue and contraction
ynx. Bolus preparation is under voluntary control and can be of the pharyngeal constrictor muscles, generate pressure
halted at any point. It is during this stage that pleasure is within this continuous tube. A pressure differential occurs as
taken from the food by stimulation of the multiple the hyolaryngeal complex elevates superiorly and anteriorly,
chemoreceptors and sensory receptors located on the tongue opening the upper esophageal segment and propelling the
dorsum and to a lesser degree in the pharynx. The length bolus into the cervical esophagus.22
of this stage varies, depending on the consistency of The pharyngeal stage is the most complex stage of the
the material being manipulated, the presence of saliva, the swallow in terms of muscular coordination and timing. It is
individual preference of bolus size for swallowing, and the during this stage that airway protection must occur
style of chewing. Liquids, including saliva, and semisolid simultaneously with opening of the upper esophagus to
materials such as pudding require minimal manipulation. prevent aspiration into the trachea and to facilitate transfer
The bolus is formed by pressure generated by contraction of of the bolus into the esophagus.
the buccinator and labial musculature, and elevation of the Stimulation of the sensory impulses of cranial nerves IX,
edges of the tongue aids in shaping the bolus and positioning X, and XI (glossopharyngeal, vagus, and accessory,
it on the tongue dorsum in preparation for propulsion of the respectively) marks the onset of the pharyngeal stage of
bolus to the pharynx. Simultaneously, the soft palate is swallowing. The glossopharyngeal nerve transmits visceral
depressed against the tongue base, creating a palatoglossal sensation from the pharynx, taste sensation from the
seal, which prevents leakage of liquids or semisolids into the posterior one third of the tongue, and touch, pain, and
pharynx before they are ready to be swallowed. thermal sensation from the mucous membranes of the
During mastication of solid foods, finely coordinated oropharynx and posterior tongue.23 The superior laryngeal
movements of intrinsic and extrinsic lingual muscles move branch of the vagus nerve supplies sensation to the mucosa
the bolus to the dental arches. Opening of the jaw and lateral covering the epiglottis and the posterior tongue and
and rotary movements of the mandible against the maxilla endolarynx, while the recurrent laryngeal nerve supplies
grind food into smaller pieces. Cohesive bolus formation of sensation to the subglottis and the mucosa of the cervical
solids and liquids depends on the presence of sufficient esophagus.24 These sensory impulses travel to the nucleus
saliva that binds the material together, tongue movement tractus solitarius (NTS) in the medullary reticular formation
that sweeps the crevices of the oral cavity, and lip closure located within the brainstem, which integrates multiple
that prevents spillage of food from the mouth. It is important functions related among others to respiration and swallow-
to note that during mastication, unlike manipulation of ing24 (p. 70). Neurons from the NTS project to other
liquids and semisolids, the bolus is not completely contained brainstem regions including the nucleus ambiguus (NA).
in the oral cavity. Here the rotary and lateral mandibular The motor neurons of the NA innervate the palatal,
movements release the palatoglossal seal, and some material pharyngeal, laryngeal, and esophageal muscles critical to the
falls into the valleculae prior to the onset of the pharyngeal pharyngeal stage of swallowing. Together with input from
phase. higher cortical and subcortical structures, the coordinated
and precisely timed actions occurring in the pharyngeal
stages of swallowing are possible.
Oral Transport Stage Airway protection, opening of the upper esophagus, and
pharyngeal clearance transform the aerodigestive tract from
During the second stage of swallowing, the oral transit or its function as a respiratory system to a deglutitional system.
oral transport phase, the prepared bolus is propelled into the Airway protection takes place in the horizontal and vertical
pharynx by a series of anterior-to-posterior wave-like planes, begins simultaneously with bolus entry into the
contractions of the tongue in contact with the incisors and pharynx, and can occur even when the bolus is first placed in
the lateral borders of the palate. The soft palate elevates, the mouth.25 Intrinsic laryngeal closure begins with adduc-
permitting the bolus to enter the pharynx and preventing tion of the vocal folds (contraction of the thyroarytenoid,
nasal regurgitation. Simultaneously, the floor of mouth vocalis, interarytenoid, and lateral cricoarytenoid muscles)
muscle complex, including the suprahyoid muscles, con- toward the midline. 26, 27 The vestibular vocal folds and the
tracts and the base of the tongue depresses and moves supraglottis also adduct to close the laryngeal airway. Vocal
anteriorly, forming a chute down which the bolus can flow. fold adduction is the first event to occur during the swallow
This, in turn, causes pressure on the bolus and drives it and continues throughout the swallow sequence. Shaker et
cleanly into the pharynx. This stage of swallowing, al.27 noted that in one third of their normal subjects, true
illustrated in Figure 32-2, lasts for less than 1 second and is vocal fold approximation was incomplete prior to laryngeal
under voluntary neural control. elevation and during the pharyngeal swallow. This may
tongue posture is observed at rest and in both lateral and AP nasogastric feeding tube and replace it if necessary after the
projections. Observations can be made about tongue bulk, study.
particularly in the area of the base of the tongue. Asymmetry The epiglottis is observed for signs of surgical resection
of the tongue following surgical resection can be appreci- and evidence of edema or fibrosis as a result of radiation
ated, although accurately differentiating the left from the therapy (Fig. 32-6). The relationship of the tongue base to
right side is not possible in the lateral view. Sometimes the posterior pharyngeal wall is noted with respect to the
surgical reconstruction of the tongue has the appearance of area that must be approximated to drive the bolus into the
normal tongue bulk when in fact a myocutaneous flap is in hypopharynx. However, it cannot automatically be assumed
place and anchors surrounding tissue (Fig. 32-4). In other that reduced tongue base muscle mass or pharyngeal soft
situations, the tongue bulk may be atrophied, as in the tissue at rest, that is, a vacuous pharyngeal lumen, will not
patient with ALS or in a patient who is deconditioned. This adduct completely during swallowing. Sometimes compen-
may signal impaired bolus formation, control, and pro- satory pharyngeal wall adduction is observed with a reduced
pulsion.
The structure of the soft palate at rest is observed for its
completeness and bulk. The posture of the soft palate at rest
and during speech tasks can provide information about bolus
containment before the swallow as well as velopharyngeal
sufficiency during swallowing. Palatal appliances should be
examined for their purpose. For example, palatal obturators
occlude fistulae of the hard palate or the nasopharynx; a
palatal lift promotes improved velopharyngeal closure by
elevating the soft palate during swallowing; and a palatal
reshaping device may augment the contour of the hard and
soft palates to form a surface against which the tongue can
contact for bolus propulsion. Assessment of swallowing
function with and without palatal appliances in position
during swallowing may be indicated.
Nasogastric feeding tubes do not need to be removed
during the fluoroscopic study, as they usually do not
interfere directly with swallowing function. There are three
exceptions: firstly, if the nasogastric tube is coiled in the
pharynx, it may affect swallowing efficiency (Fig. 32-5);
secondly, increased pharyngeal retention may be observed if
the bore of the feeding tube is large and the tube itself is rigid
in the context of a weakened swallow; and thirdly, if the
feeding tube is located in the midline postcricoid region such
that the arytenoid cartilages are stented open, and complete
rotation of the cartilages and adduction of the vocal folds are
restricted. This last scenario can best be appreciated in
the AP view. In these cases, it may be wise to remove the FIGURE 32-5 Nasogastric tube coiled in the hypopharynx.
FIGURE 32-7 A, Cervical osteophyte (arrow) and its effect on swallowing, with inhibited epiglottic deflection
and laryngeal closure resulting in aspiration. B, Osteophyte (arrow) aspiration is observed during the swallow as a
result of restricted epiglottic deflection and hyolaryngeal excursion.
wall and in the vallecular space, and aspiration may occur thrusting is a reverse swallow pattern, usually of neurologic
before the swallow because of uncontrolled spillage or after origin such as in patients with cerebral palsy, in which the
the swallow from the residue. Piecemeal swallowing may be tongue thrusts forward between the incisors, pushing the
observed in which the boluses are purposefully segmented food out of the mouth. Usually mastication as well as
and swallowed in small portions. Multiple swallows of the swallowing is affected in these patients.
same bolus is a hallmark behavior of reduced tongue base Radiation therapy for oral cavity, pharyngeal, and
function. laryngeal tumors carry the side effect of xerostomia, or dry
Patients with hemiglossectomy in which the tongue is mouth, and tongue function during swallowing can be
resected only on one side may be able to compensate for disturbed as a result of radiation therapy alone. Reduced
their defects by containing the bolus on the unaffected side. volume and consistency of saliva affect the ease of bolus
Functionality, however, will depend on preservation of formation, particularly with more solid textures, and can
mobility of the tongue on the unaffected side. If the tongue is result in residue on the tongue or palate. In addition, the
tethered in reconstruction by a regional or free flap, or is speed of tongue movement can be reduced in these patients
fibrosed as a consequence of radiation therapy, compensa- as a result of tissue fibrosis, a condition that can occur
tory behaviors may be restricted. In these cases, residue will immediately after radiation therapy or even a year after
be observed along the oral cavity and pharynx in the area of radiation treatments are completed.9
the defect. AP views reveal asymmetric bolus flow very
clearly. Soft Palate or Velum
The posterior tongue contributes to the glossopalatal seal, The soft palate has two distinct purposes during the
which is particularly important during liquid swallows. swallow. In the oral stage, contraction of the palatoglossus
Compromise of this valve as a result of weakness or contains the bolus in the oral cavity. Once the pharyngeal
resection can result in loss of bolus control, and liquids may swallow response is initiated, the soft palate elevates against
be presented prematurely to the pharynx prior to initiation of the lateral and posterior pharyngeal walls, creating a seal of
the pharyngeal swallow response, potentially resulting in the velopharyngeal port.
aspiration. Premature spillage into the pharynx and hypopharynx can
Lingual tremors at rest may not result in oral stage occur due to weakness of the palatoglossal seal, increasing
swallowing disorders. However, patients with Parkinson’s the risk of aspiration. As was mentioned earlier, premature
disease or Parkinson-like symptoms may have difficulty spillage can only be considered such during liquid and
initiating bolus propulsion. Overall lingual weakness may semisolid bolus preparation, where mastication is not
co-occur and can manifest in searching movements of the required. There is normal loss of the palatoglossal seal
tongue and repetitive small-amplitude AP movements during mastication of solid boluses due to lingual and
slowly shuffling the bolus toward the pharynx in an action mandibular movements. Cranial nerve dysfunction or palatal
referred to as tongue pumping. This behavior mimics the resection can cause premature spillage. Careful inspection of
festinating behaviors common in ambulation patterns of soft palate elevation is required, as sometimes it appears that
patients with Parkinson’s disease. These patients may lack the soft palate is elevating when in fact the tongue is moving
the range of motion for coordinated rotary lingual move- posteriorly, propping up the soft palate.
ments and uncontrolled boluses may spill prematurely into Nasal regurgitation of liquids or solids is the result of an
the pharynx, resulting in aspiration particularly with liquid incompetent velopharyngeal mechanism and can be ob-
contrast. Oral dyskinesia with lingual chorea may be served in patients with palatal or tonsillar fossa resection, or
observed in patients with Huntington’s disease. In these cranial nerve or muscular dysfunction. Cranial nerve
cases, tongue movements are dyssynchronous, resulting in dysfunction can be the result of, for example, ALS, skull
large bites, poor mastication, and rapid swallowing.43, 44 base tumor, or cerebral or brainstem stroke (Fig. 32-13). The
Bilateral tongue weakness can be observed in a variety of increased pressure by the tongue to propel the bolus into the
conditions, the most common of which is cerebrovascular pharynx causes the bolus to take the path of least resistance,
accident, in which dysarthria and dysphagia are sympto- resulting in nasal regurgitation when there is reduced
matic. Thin liquids and textured solids present the greatest nasopharyngeal closure during swallowing. Nasal regurgita-
challenge to these patients, who are unable to cradle the tion is usually more pronounced with liquid boluses or when
boluses on the tongue or coordinate movements for the patient’s chin is tucked in. Patients may control their
mastication and run the risk of uncontrolled bolus loss. nasopharyngeal incompetence by adopting a head upright
Limited tongue-driving force results in vallecular retention posture or by swallowing consistencies of higher viscosity
and weak bolus flow through the hypopharynx, and where than liquids.
sensation is preserved, multiple swallows represent the Palatal obturators or palatal lifts are dental appliances
patient’s attempt to clear the residue. Patients with unilateral constructed to reduce nasal regurgitation, increasing the
tongue weakness, as in unilateral stroke or skull base tumors integrity of the velopharyngeal port. In cases of severe
affecting the hypoglossal nerve, may be able to compensate incompetence when an appliance is not available, these
for the weakness by chewing on the contralateral side, albeit patients can be instructed to hold the nose closed with their
in an awkward and protracted fashion. Retrieving boluses fingers in an attempt to improve the seal and increase
from the buccal sulci is complicated and may require digital pressure on the bolus without leakage into the nasopharynx.
removal.
Efficiency of swallowing can be affected by the habitual Epiglottis
tongue posture. Normally, the tongue moves posteriorly Downfolding of the epiglottis is frequently a focus in
along the palate, driving boluses into the pharynx. Tongue VFSS interpretation. It is important to bear in mind, though,
FIGURE 32-14 Normal epiglottic (arrow) deflection during swallowing in the lateral (A) and AP (B) views.
taught voluntary airway protection techniques, enabling In most cases, anterior and superior movement coexist;
them to swallow in most cases. however, it is possible to observe increased impact in one or
Thickening and fibrosis of the epiglottic mucosa and the other movement plane. For example, it is possible for
attached supporting structures occur after radiation therapy, patients to present with reduced anterior excursion while
affecting the extent of downfolding even if hyolaryngeal superior movement is preserved. In reality, safe and efficient
excursion is spared. An edematous epiglottis may attach to swallowing demands sufficient superior and anterior excur-
the tongue base and appear blunted in the lateral radio- sion.
graphic view, restricting the guarding function of the
epiglottis and obliterating the valleculae.39 Pharyngeal Wall
Impaired laryngeal excursion or tongue base retraction The pharyngeal constrictors move the pharyngeal wall
has the effect of maintaining vallecular continence, in anteriorly during the pharyngeal swallow to function as a
contrast to the ‘‘flattening out’’ of the valleculae that occurs surface that the tongue base can contact to drive the bolus
in normal epiglottic deflection, and stasis is observed in the into the hypopharynx. In addition, contraction of the
valleculae after the swallow. Furthermore, transient penetra- constrictors and the longitudinal pharyngeal musculature
tion can occur along the laryngeal surface of the epiglottis (salpingopharyngeus, palatopharyngeus, and stylopharyn-
during the pharyngeal swallow, which may or may not be geus) shortens the pharynx, clearing the bolus from the
extruded from the laryngeal vestibule, depending on the pharyngeal recesses and propelling it into the cervical
competence of hyolaryngeal excursion. esophagus. In the lateral projection, pharyngeal contraction
The danger of impaired epiglottic downfolding lies in the is seen as a progressive anterior bulge from superior to
amount of residue remaining in the valleculae after the inferior along the posterior wall. Propagation in the pharynx
swallow. The greater the stasis, the greater the risk that is very rapid, 12 to 25 cm/sec, compared with 1 to 4 cm/sec
material (liquid or solid) will spill over the tip of the in the esophageal phase.26, 27 In the AP projection, medial
epiglottis or over the aryepiglottic folds and penetrate the excursion of the lateral pharyngeal walls is seen bilaterally
airway.45 in the normal individual, but in up to 20% of normal
subjects, swallowing can occur down only one side.47 The
Hyoid and Larynx term pharyngeal contraction wave is preferable to pharyn-
The radiodensity of the hyoid bone makes its movement geal peristalsis, as peristalsis applies to a circumferential
trajectory quite easy to track during swallowing on VFSS. muscular tube such as exists in the esophagus and does not
The hyoid bone is suspended by muscular attachments pertain to the pharynx, as the anterior pharyngeal wall is
extending from the tongue and mandible to the larynx. composed of the tongue base, laryngeal vestibule, and
Contractions of the geniohyoid, mylohyoid, and anterior larynx12 (Fig. 32-12).
belly of the digastric muscles are primarily responsible for The effect of impaired pharyngeal wall motion is residue
superior and anterior movement of the hyoid bone.15 The along its length or in the pharyngeal recesses. In unilateral
hyoid bone is attached along its inferior border to the thyroid impairment, the residue is located along the weak side and is
cartilage by the thyrohyoid ligament, which is shortened best viewed in the AP projection. Usually the stronger side
during hyolaryngeal excursion. These movements are pushes the bolus over to the weaker side, which has
clearly viewed in the lateral radiographic projection. In the increased flaccidity; hence the unilateral retention. How-
normal individual, the hyolaryngeal complex moves an ever, in the AP plane, unilateral pharyngeal wall weakness is
average of 2 cm anteriorly and 2 to 2.5 cm superiorly from visualized as residue in one of the pyriform sinuses or in one
rest to maximal excursion (Fig. 32-12).25, 34, 46 Increased side of the vallecula (Fig. 32-16). Double or multiple
bolus volume affects the duration and extent of maximal swallows per bolus may indicate pharyngeal weakness. The
hyolaryngeal excursion. patient may also report the failure of bolus clearance.
The primary function of hyolaryngeal excursion is to pull Bilateral pharyngeal weakness can be seen in patients
the entire larynx away from the posterior pharyngeal wall, suffering from progressive neurologic disease, decondition-
thus creating a continuous conduit for the advancing bolus ing, sarcopenia of the oropharyngeal musculature, and
from the hypopharynx through the cervical esophagus. This radiation fibrosis. Patients with pharyngectomy extending
has the dual effect of opening the upper esophageal segment across the midline experience severe stasis even when
while simultaneously protecting the laryngeal vestibule as tongue base retraction is relatively spared. Postural thera-
the epiglottis deflects. As the larynx elevates, the arytenoid peutic maneuvers to be discussed later, which alter the
cartilages rock and tilt anteriorly to contact the base of the dimensions of the pharynx, are sometimes helpful.
epiglottis, closing the entrance to the airway.12 Weak pharyngeal contraction is difficult to separate from
Impairment of hyolaryngeal excursion results therefore weak tongue base retraction. Each biomechanical movement
in stasis in the pyriform sinuses after the swallow or in must be inspected for its contribution in the event that
penetration of the laryngeal vestibule during the swallow pharyngeal residue is observed. Furthermore, impaired
resulting from incomplete closure of the supraglottic laryngeal elevation can affect epiglottic deflection and may
entrance. While transglottic aspiration may not occur erroneously implicate the pharyngeal constrictors.
immediately, the presence of material in the larynx may Transient pharyngeal outpouchings may be observed
make it more likely. Since pyriform sinus stasis can also during swallows of liquid boluses larger than 7 to 12 cc.48
result from impaired pharyngeal clearance or inadequate These outpouchings are the result of pharyngeal mucosa
intrinsic relaxation of the cricopharyngeus muscles, all herniating through focal weakness in the thyrohyoid
possibilities must be probed before reduced laryngeal membrane anterior to the thyrohyoid ligament and are
excursion is held primarily responsible. believed to occur due to dyssynchronous contraction of the
Glottic Closure
Protection of the airway involves numerous biomechani-
cal movements that change the aerodigestive tract from a
respiratory to an alimentary system.49 Epiglottic inversion
and hyolaryngeal excursion close the airway in a vertical
plane. Closure of the laryngeal vestibule in the horizontal
plane is made possible by adduction of the true and
vestibular vocal folds and can be first detected during the
oral stage of swallowing. Respiration ceases at this point,
increasing the subglottic pressure and helping to keep
boluses from entering the airway. The airway remains
closed for 0.6 to 0.7 second and opens again once the larynx
descends and the epiglottis is in the resting position.22, 50
Glottic closure is not clearly observed with videofluoros-
copy, and inferences about its integrity are based on the
presence or absence of barium flow. In the lateral view,
closure of the laryngeal vestibule is inferred when the air
column disappears. Through frame-by-frame analysis of
the video recording, it is possible to visualize rocking of the
arytenoid cartilages anteriorly to appose the base of the
epiglottis. In the AP projection, normal glottic closure is
FIGURE 32-16 Unilateral weakness of the right pharyngeal wall usually superimposed on the bony spine, compromising
resulting in stasis on that side. Contraction of the left lateral pharyngeal
wall, indicated by the arrow, moves the bolus over to the weaker right side.
detection of midline vocal fold adduction. However, when
aspiration occurs, an outline of the true and vestibular vocal
folds and the laryngeal ventricle is clearly visible.
oblique and longitudinally oriented pharyngeal muscles48 in Laryngeal penetration and/or aspiration are the primary
the context of increased intrapharyngeal pressures (Fig. consequences of impaired closure of the glottis. Incoordi-
32-17). While these outpouchings have been considered a nated timing of laryngeal closure is one of the major culprits
normal variant, Curtis et al.48 observed that they become and is discussed in a later section. Neuromuscular or
symptomatic when the bolus arrival coincides with the structural defects can impair laryngeal closure, can occur
appearance of the pharyngocele. When the bolus is in the unilaterally or bilaterally, and can involve small or large
FIGURE 32-17 Lateral (A) and AP (B) views of a patient with pharyngoceles (arrows).
only appears to be prominent in relation to absent or weak resection of the pouch and concurrent cricopharyngeal
pharyngeal contraction forces. Careful evaluation of pharyn- myotomy necessary to avoid formation of recurrent diver-
geal contractility independent of the cricopharyngeus ticula.60
muscle complex is necessary to determine the underlying Occasionally, a small irregularity is noted on the anterior
etiology of reduced bolus flow through the pharyngoesoph- wall of the hypopharynx that corresponds to the postcricoid
ageal segment. Dynamic fluoroscopic imaging is necessary region. This indentation has been attributed to a submucous
to make this distinction. Cricopharyngeal myotomy may be venous plexus and/or redundant mucosa.61 This irregularity
recommended as the treatment of impaired opening of the is often pliable and not fixed, as in the case of a tumor, which
cricopharyngeal muscle complex. Recent studies have can be confirmed if necessary with a CT scan or endoscopic
shown that this procedure has limited value in patients with evaluation. Table 32-4 provides a summary of impaired
abnormal laryngeal excursion. Without the mechanical biomechanical movements in oropharyngeal swallowing
traction of the larynx away from the posterior pharyngeal and their related radiographic findings.
wall, bolus flow through the segment is markedly restricted
even after myotomy.56, 57 Ergun and Kahrilas58 state that Esophagus
cricopharyngeal myotomy is indicated only when there is Propagation of boluses through the esophagus is the
complete obstruction of bolus flow, with increased intrabo- result of primary and secondary peristalsis lasting for
lus pressure and a decreased transsphincteric flow rate, as approximately 8 seconds.1 While a discussion of esophageal
seen on manometric study as well as fluoroscopic imaging. motility is beyond the scope of this chapter, it is important to
Zenker’s diverticulum represents an abnormality of the emphasize the need to observe contrast moving through the
opening of the pharyngoesophageal segment and, if large, entire lumen of the esophagus in patients who complain of
can affect swallowing of solids and liquids. A Zenker’s solid food dysphagia and who present with normal
diverticulum is defined as ‘‘a mucosal outpouching of the oropharyngeal swallowing of semisolid and even textured
hypopharyngeal wall located in Killian’s triangle between boluses. Obstruction of the lower esophageal segment by a
the upper border of the cricopharyngeus and inferior 13 mm barium tablet or failure to pass the tablet in these
pharyngeal constrictor muscles’’59 (p. 1229). Figure 32-19 cases may support the need for further radiographic or
presents images of a Zenker’s diverticulum in the lateral and endoscopic evaluation.
AP projections. The cricopharyngeus is described as fibrotic
and stiff and reduces the opening of the lumen in the context
of normal laryngeal excursion. During VFSS, contrast fills Temporal Coordination of Biomechanical
the pouch, and as the larynx descends and pressure is placed Events in Relation to Bolus Flow
on the pouch, its contents are emptied and some of the
regurgitated material may fall into the airway. Surgical Up to this point, the focus of interpretation of VFSS
correction is the appropriate treatment, with pexy or has been on displacement of the bolus as a result of
Table 32-5
EIGHT-POINT PENETRATION-ASPIRATION SCALE
From Rosenbek JC, Robbins J, Roecker EV, Coyle JL, Woods JL. A
penetration-aspiration scale. Dysphagia 1996;11:93-98.
FIGURE 32-24 Aspiration (A) (arrow) eliminated by the chin-down posture (B), indicating increased
narrowing of the laryngeal vestibule and greater tongue base retraction.
strategies. Appropriate selection of these strategies as Rehabilitative therapy procedures place aspects of the
isolated maneuvers or in combination depends on the precise patient’s swallow under voluntary control and alter the
characterization of the biomechanical and temporal events physiology of the swallow12; they are listed in Table 32-7.
of the swallow resulting in impairment. Therapeutic These maneuvers require sophisticated cooperation by the
procedures are either compensatory or rehabilitative in patient, with the ability to understand, learn, and apply the
nature.12 Compensatory strategies are designed to alter the treatment strategy. For example, the super-supraglottic
bolus flow in an attempt to eliminate the patient’s disordered swallow requires the patient to perform a Valsalva maneuver
symptoms. Postural changes involve changing the position while swallowing a bolus and to cough after the swallow in
of the head in order to alter the geometry of the oral, an effort to invoke voluntary airway protection.76 Since
pharyngeal, and laryngeal systems. Individual techniques these therapeutic maneuvers take some time for the patient
can reduce the angle of opening of the upper airway, as to learn, it is fitting for the speech pathologist to anticipate
occurs in the chin-down (chin tuck) posture72, 73 (Fig.
32-24), or can improve hyolaryngeal excursion and increase
the propulsive force on the bolus by obstructing paretic
pharyngeal musculature, as in head rotation74, 75 (Fig.
32-25). Correct performance of these postural changes
requires minimal cooperation from the patient since the
instructions are single step and simple, for example, ‘‘Put
your chin on your chest.’’ Matching the physiologic
outcome of the postural change with the patient’s swallow-
ing problem increases the likelihood of the effectiveness of
the technique. The frequently employed chin-down posture
does not assist all patients. In fact, if contrast fills the
pyriform sinus prior to the onset of the pharyngeal swallow,
there is an increased risk of aspiration as the larynx elevates
and the pyriform sinuses empty.
Other compensatory techniques involve manipulating
bolus viscosity and volume and increasing sensory input.
Changing bolus viscosity is a powerful tool in assisting
patients with dysphagia, and a wide range of options is
available, from thin liquids to textured solids.13, 68 Increas-
ing the bolus volume for liquids may be helpful in patients
with incomplete oral or pharyngeal contraction, such as
those with total glossectomy.12, 25, 75 Smaller volumes of
liquids may be indicated in patients with reduced laryngeal
closure. The effectiveness of these trials can be evaluated by FIGURE 32-25 Head rotation to the right in this patient with
videofluoroscopy. Table 32-6 lists the most common right-sided pharyngeal weakness obstructs bolus flow on the affected side,
compensations and their physiologic indications. causing the bolus to flow down the left side of the pharynx.
Table 32-6
COMPENSATORY SWALLOWING STRATEGIES AND THEIR IMPACT ON SWALLOWING PHYSIOLOGY
which therapeutic maneuvers may require assessment and to bolus). Assessment of therapeutic maneuvers is conducted
teach them to the patient before the study. The VFSS can be in the lateral and anterior projections, using several trials to
used to determine how accurately the patient has performed ensure the reliability of the findings.
the maneuver and can be shown to the patient after
completion of the study to assist with treatment recommen-
dations. OVERVIEW OF A NORMAL VFSS
Compensatory and rehabilitative procedures can be used
in isolation or in combination. For example, a patient who Although much detail regarding the normal swallow has
presents with unilateral impaired pharyngeal weakness and been presented, it is useful to summarize the main points to
weak tongue base retraction, resulting in pharyngeal observe on a normal VFSS. On the lateral view, there should
retention and aspiration of residue after the swallow, may be coordinated tongue movements and, in general, the bolus
benefit from head rotation to the impaired side (to close off should remain on the upper surface of the tongue. The
the weaker pharynx) together with a chin tuck (reducing the soft palate should be caudal, against the tongue base prior
laryngeal opening size and increasing drive on the bolus) to initiation of the pharyngeal phase of the swallow. As
and an effortful swallow maneuver (to increase force on the the tongue thrusts dorsally, the soft palate should touch the
Table 32-7
REHABILITATIVE MANEUVERS THAT ALTER THE PHYSIOLOGY OF THE SWALLOW
Super supraglottic swallow instruction: Aspiration before, during, and after the Improved airway protection with decreased
″Bear down, swallow, cough, and swallow swallow amount of laryngeal penetration or aspira-
again″ tion
Effortful swallow instruction: ″Swallow as Weak tongue base and pharyngeal wall con- Improved clearance of pharyngeal recesses
hard as you can″ tractions
Mendelsohn maneuver instruction: ″Swal- Poor coordination of tongue base movement Sustains laryngeal elevation during swallow
low and keep your larynx elevated until you to the posterior pharyngeal wall
have completed the swallow″ Increased pharyngeal retention in the pyri- Sustains opening of pharyngoesophageal
form sinuses segment
posterior pharyngeal wall, effectively closing off the 3. Daniels SK, Brailey K, Priestly DH, Herrington LR, Wiesberg LA,
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The author wishes to thank the following individ- 22. Dodds WJ, Logemann JA, Stewart ET. Radiologic assessment of
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printing the images used in this chapter; Sandy Martin, 23. Miller AJ. The Neuroscientific Principles of Swallowing and
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swallowing structures. In: Perlman AL, Schulze-Delrieu K, eds.
comments; and Hugh Curtin, M.D., for his generosity of Deglutition and Its Disorders. San Diego, CA: Singular Publishing,
spirit and knowledge. 1997;15–42.
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