Anatomy, Ear / Nose / Throat, Head and neck, Fluoroscopy, Dynamic swallowing studies, Swallowing disorders
C. Newman, F. Newman, C. Thompson; Melbourne, VIC/AU
Imaging findings OR Procedure details
- Define physiological cause of swallow symptoms
- Determine aspiration risk
- Prescribe safe diet and fluid consistencies including compensatory strategies
- Determine rehabilitation practices
- Evaluate change in swallow function as an objective outcome measure
Frame rates (pulses/sec):
Enhanced VFSS images improves accuracy and practitioner reliability in detecting the degree of aspiration or penetration[5,6].
- Fluids = 30 frames per second ·Solids = 15 frames per second ·AP plane = 4 frames per second*
*note - standard protocol may vary between departments.
- Mean effective dose = 0.44 mSv ·Mean fluoroscopic time = 2.9 minutes
A well-designed protocol provides a systematic framework to define the limits of the swallow system by testing a range of diet and fluid consistencies, bolus volumes and compensatory strategies.
- Speech pathologists always perform a clinical examination prior to undergoing VFSS.
- Licenced radiographer present assisting with fluoroscopic image acquisition and optimisation.
- Barium contrast is used as it is relatively benign if aspirated.
- Patient in a seated position.
- Subsequent trials of various consistencies mixed with barium pending safe and effective trial management considering factors such as airway protection / penetration / aspiration / oral and pharyngeal residue.
- Swallow is assessed in the lateral plane by default.
- AP trial(s) are performed only if indicated such as when suspected pathology is asymmetric (e.g. CVA, H&N surgery).
See Figure 1
Figure 2 - Anterior cervical osteophytes:
- Impingement of the posterior pharyngeal wall.
- Reduced base of tongue to posterior pharyngeal wall contact leading to reduced pharyngeal drive and disruption of pharyngeal clearance.
- Impaired epiglottic deflection and airway protection.
Figure 3 - Cricopharyngeal Bar / Spasm
- Causes stasis at the level of the pyriform fossae or impaired transit through the upper oesophagealsphincter.
- Regurgitation from upper oesophagus to pharynx and/or airway.
Figure 4a and 4b - Pharyngeal Pouches
- Both impede pharyngeal transit, pharyngeal stasis and regurgitation.
- Symptoms of food sticking, coughing/choking, halitosis.
Figure 5 - Aspiration
- Can result in aspiration pneumonitis / aspiration pneumonia.
- Aspiration is considered anything that passes below the level of the vocal folds whereas penetration is anything that enters the airway above the level of the vocal folds.
- Aspiration and penetration can be intermittent and can only be confidently assessed at ≥ 30 frames per second.
Figure 2 image ©️ "Gupta P et al (2018) Cricoid and cervical osteophytes causing dysphagia: an extremely rare and interesting case. Radiol Bras 51(1): 67-68".
Figures 3-5 images ©️Radiopaedia.org
DOCUMENTATION OF RESULTS
The VFSS report is a written medical record of the procedure with a number of standardised scoring systems assisting to rate the swallow assessment [9,10].
The report provides:
- A summary of the swallowing deficits and management recommendations for safe oral intake.
- Details regarding appropriate consistencies of diet and fluids, therapeutic strategies and postural modifications including rehabilitation exercises.
- Referrals are made to other agencies (if required).
The report takes on average 1 hour to complete and is sent to the referring medical practitioner and relevant healthcare providers.