What are the next steps after an RF (Radiofrequency) video fluoroscopy swallowing study?

Next Steps After Video Fluoroscopy Swallowing Study

The immediate next step is to review the study results with a speech-language pathologist to determine specific dietary modifications, swallowing strategies, and need for further evaluation based on the findings. 1

Immediate Post-Study Actions

Results Review and Interpretation

• The study results must be analyzed by a speech-language pathologist (ideally in collaboration with the radiologist who performed the study) to identify specific swallowing abnormalities including aspiration, penetration, pharyngeal residue, delayed swallow initiation, or structural abnormalities 1, 2
• The interpretation should include assessment of the Penetration-Aspiration Scale (PAS) score, which guides treatment decisions 1
• Note that subjective interpretation alone has only 61.5% accuracy compared to objective measurements, so detailed analysis is critical 3

Dietary and Swallowing Recommendations

If aspiration or penetration is identified, immediate dietary modifications are required 1:

• For patients with aspiration on thin liquids (PAS ≥3), thickened liquids reduce aspiration risk by more than 90% 1
• Specific texture modifications should be prescribed based on which consistencies were safely swallowed during the study 1, 4
• Patients with severe aspiration may require nothing-by-mouth status with alternative feeding routes (nasogastric or gastrostomy tube) 1

Compensatory Strategies Testing

The videofluoroscopy should have tested therapeutic maneuvers during the study itself 5, 4:

• Postural changes (chin tuck, head rotation)
• Swallowing techniques (supraglottic swallow, effortful swallow)
• Bolus modifications (volume, consistency)
• These successful strategies should be incorporated into the treatment plan 1

Further Evaluation Based on Findings

If Structural Abnormalities Are Identified

Complete esophageal evaluation is mandatory if pharyngeal abnormalities are found or if symptoms persist 1:

• A biphasic esophagram should be performed to evaluate the entire esophagus and gastroesophageal junction, as 68% of patients with dysphagia have esophageal transit abnormalities, and one-third have esophageal findings as the only abnormality 1, 6
• The biphasic technique has 96% sensitivity for esophageal cancer and can detect both structural lesions (strictures, rings, tumors) and functional abnormalities (motility disorders, reflux) 1, 6
• Patients with pharyngeal carcinomas have significantly increased risk of synchronous esophageal carcinomas, requiring complete esophageal examination 1

If Motility Disorders Are Suspected

• Consider videofluoromanometry if standard videofluoroscopy shows normal structure but abnormal function 1
• Esophageal manometry may reveal low pharyngeal pressures or upper esophageal sphincter dysfunction not visible on standard imaging 1

If Initial Study Is Non-Diagnostic

• Fiberoptic endoscopic evaluation of swallowing (FEES) can be performed as a complementary study, with 90% agreement with videofluoroscopy for aspiration detection and 88% sensitivity 7
• FEES is particularly useful for bedside evaluation and can assess laryngeal sensation, secretion management, and pharyngeal residue 1
• CT neck and chest is generally not indicated unless structural abnormalities require further characterization 1

Ongoing Management

Speech-Language Pathology Follow-Up

Regular follow-up with speech-language pathology is required until the patient achieves stable baseline function 1:

• Patients with ongoing abnormal function need regular reassessment 1
• For chronic swallowing challenges, indefinite follow-up may be necessary 1
• Repeat videofluoroscopy may be needed to assess progression or response to therapy 1

Nutritional Monitoring

Close nutritional monitoring is essential, particularly for patients with feeding modifications 1:

• Follow-up with a registered dietitian should continue until nutritionally stable baseline is achieved 1
• Monitor for weight loss (>5% in 1 month or >10% in 6 months), dehydration, or inadequate caloric intake 1
• Consider prophylactic feeding tube placement for severe weight loss, ongoing dehydration, severe aspiration, or anticipated long-term swallowing disorders 1

Risk Stratification for Pneumonia

Certain findings predict higher pneumonia risk even with proper liquid-thickening guidance 1:

• PAS score ≥3 increases pneumonia risk 4-fold (OR 4.03) 1
• History of prior aspiration pneumonia increases risk 7-fold (OR 7.00) 1
• Poor performance status increases risk nearly 2-fold (OR 1.85) 1
• Impaired laryngeal sensation increases risk 2.3-fold (OR 2.32) 1
• These patients require more aggressive monitoring and intervention 1

Critical Pitfalls to Avoid

• Do not assume a normal gag reflex indicates safe swallowing—it does not predict aspiration risk 1
• Silent aspiration (PAS score 8) occurs in 55% of patients with aspiration and requires the same aggressive management despite absence of cough 1, 6
• Do not limit evaluation to the pharynx alone—always evaluate the complete esophagus and gastric cardia, as distal lesions can cause referred pharyngeal symptoms 1, 6
• Subjective interpretation of videofluoroscopy has only 45-72% accuracy for specific parameters, so objective measurements should be used when possible 3
• Early NG tube feeding (within 7 days) substantially decreases death risk compared to delayed feeding or early PEG placement in acute stroke patients 1