What are the indications for and procedure of videofluoroscopy (video fluoroscopy)?

Videofluoroscopy Indications and Procedure

Videofluoroscopy is the gold standard imaging modality for evaluating swallowing dysfunction and is indicated for patients with suspected oral-pharyngeal dysphagia, particularly when aspiration is a concern. 1

Primary Indications

• Suspected oral-pharyngeal dysphagia - Patients who report swallowing problems, including association of cough while eating or drinking and fear of choking 1
• Persistent cough - Especially when associated with eating or drinking, which may indicate aspiration 1
• Neurological conditions that commonly cause dysphagia:
  • Stroke
  • Dementia
  • Myasthenia gravis
  • Amyotrophic lateral sclerosis
  • Parkinson's disease
  • Multiple sclerosis 1, 2
• Unexplained oropharyngeal dysphagia - When the cause cannot be determined through other evaluations 1
• Persistent wheezing in infants not responding to standard treatments (bronchodilators, corticosteroids) 1
• Silent aspiration - Particularly important as 55% of patients who aspirate demonstrate silent aspiration with absent protective cough reflex 1

Clinical Identifiers Predicting Need for Evaluation

• Need for oral/pharyngeal suctioning
• Malnutrition or unintentional weight loss
• Feeding tube in place
• Abnormal chest x-ray findings (patchy opacity, lower lobe infiltrate, aspiration)
• Dysarthria or dysphonia
• Weak voluntary cough
• Reflexive cough or wet voice after water bolus
• Drooling or nasal regurgitation 1

Contraindications for Videofluoroscopy

• Lethargy
• Absent swallow response on command
• Abnormal upper airway sounds
• Inability to manage oral/pharyngeal secretions
• Respiratory rate > 35 breaths/min 1

Procedure: How Videofluoroscopy is Performed

Basic Setup and Personnel

• Performed by a multidisciplinary team including:
  • Radiologist
  • Speech-language pathologist (SLP)
  • Sometimes a dietitian 3
• Uses fluoroscopic equipment to capture real-time moving X-ray images during swallowing 4

Examination Protocol

1. Patient positioning: Patient is seated upright or in lateral position for optimal visualization of oral cavity, pharynx, and upper esophagus 4

2. Contrast administration:

   • Various consistencies of barium-containing substances are used:
     • Thin liquids
     • Thickened liquids
     • Pureed food
     • Barium-impregnated solid food 1

3. Dynamic assessment: The examination evaluates:

   • Oral preparatory phase (bolus manipulation, tongue motion)
   • Oral propulsive phase (difficulty propelling the bolus)
   • Pharyngeal phase (laryngeal penetration, tracheal aspiration)
   • Esophageal phase (in some protocols) 1

4. Specific parameters evaluated:

   • Bolus manipulation and control
   • Tongue motion
   • Hyoid and laryngeal elevation
   • Pharyngeal constrictor motion
   • Soft-palate elevation
   • Epiglottic tilt
   • Laryngeal penetration
   • Cricopharyngeus muscle function 1

5. Duration: Total videofluoroscopy time typically averages about 1 minute per patient (range 40-90 seconds) to minimize radiation exposure 1

Advanced Techniques

• Combined videofluoroscopy and manometry (videomanometry) can provide simultaneous recording of anatomical alterations and functional data of oropharyngeal pressure 5

• Modified barium swallow is a specific type of videofluoroscopic procedure focused on the oral cavity, pharynx, and cervical esophagus, often performed with an SLP to evaluate rehabilitation strategies 1

Clinical Applications and Benefits

• Identifies patterns of swallowing impairment, allowing targeted treatment changes 4
• Detects silent aspiration that may not be clinically apparent 1, 2
• Guides appropriate feeding modifications that can reduce aspiration by approximately 90% 1
• Helps determine the need for alternative feeding methods (nasojejunal or gastrostomy) 1
• Evaluates the effectiveness of swallowing rehabilitation strategies 1

Important Considerations

• For unexplained oropharyngeal dysphagia, a combined examination of the oral cavity, pharynx, esophagus, and gastric cardia may be appropriate, as distal esophageal or gastric cardia abnormalities can cause referred dysphagia to the upper chest or pharynx 1

• In patients with neurologic impairment, videofluoroscopy can provide crucial information on patterns of swallowing mechanism impairment 4, 6

• For infants with persistent wheezing, finding swallowing dysfunction through videofluoroscopy can lead to feeding modifications that reduce aspiration and improve respiratory symptoms 1

• Judicious use of videofluoroscopy is recommended to limit radiation exposure, particularly in pediatric patients 1