CH 32

32
Videofluoroscopic Evaluation of
Oropharyngeal Swallowing
Tessa Goldsmith
INTRODUCTION Normal and Abnormal Biomechanical

MULTIDISCIPLINARY NATURE OF THE Movements
VFSS Lips and Cheeks
THE DIFFERENCE BETWEEN THE VFSS Tongue
AND THE BARIUM SWALLOW Soft Palate or Velum
INDICATIONS FOR THE VFSS Epiglottis
CLINICAL EXAMINATION Hyoid and Larynx
PROCEDURE FOR THE VFSS Pharyngeal Wall
Positioning Glottic Closure
Contrast Agents Cricopharyngeus/Pharyngoesophageal
Recording Segment
Reporting the Findings Esophagus
NORMAL SWALLOWING Temporal Coordination of Biomechanical
Oral Preparatory Stage Events in Relation to Bolus Flow
Oral Transport Stage Timeliness of Onset of Pharyngeal Swallow
Pharyngeal Stage Duration of Oral and Pharyngeal Transit
Esophageal Stage Laryngeal Penetration and Transglottic
EFFECTS OF AGING ON OROPHARYNGEAL Aspiration
SWALLOWING Evaluation of Therapeutic Strategies
INTERPRETATION OF FINDINGS OVERVIEW OF A NORMAL VFSS
Normal and Abnormal Anatomy CONCLUSION
INTRODUCTION and about 60% of residents in long-term care facilities have

dysphagia.1
The process of transferring food or liquids from the Stroke is the leading cause of oropharyngeal dysphagia.
oral cavity to the esophagus consists of a series of Approximately 30% to 90% of patients with acute stroke
intricately connected and exquisitely timed biomechanical have signs of dysphagia, and of those, 38% to 50% have
events. When abnormalities of oropharyngeal swallowing aspiration on the videofluoroscopic swallowing study
occur, they can lead to potentially life-threatening health (VFSS).2–4 Other progressive neurologic disorders such as
outcomes such as aspiration pneumonia, dehydration, amyotrophic lateral sclerosis, dementia, and Parkinson’s
and/or malnutrition, not to mention the devastating so- disease also affect swallowing function. Moreover, oropha-
cial consequences of the problem. While epidemiologic ryngeal swallowing disorders can be manifestations of any
data are sparse, current estimates on the incidence and of a multitude of systemic diseases such as those illustrated
prevalence of dysphagia indicate that 16% to 22% of in Table 32-1.1
adults over 50 years of age experience swallowing Oropharyngeal dysphagia is usually the result of a
difficulties; 12% to 13% of acute care hospitalized patients physiologic disorder of the swallowing process rather than a
1727
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1728 UPPER AERODIGESTIVE TRACT
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)
MULTIDISCIPLINARY NATURE OF THE VFSS

mucosal or structural aberration. Therefore, diagnosis Optimally, the radiologist in collaboration with a speech
demands an understanding of the complexity of the pathologist trained in dysphagia evaluation and management
multifaceted temporal, spatial, and pressure-related compo- perform the VFSS together, with each professional bringing
nents of the swallowing process. While several instrumental his or her individual expertise. The radiologist is trained to
diagnostic procedures are available for diagnosing oropha- identify structural abnormalities and disease processes,
ryngeal swallowing disorders, such as endoscopy, scintigra- while the speech language pathologist possesses an in-depth
phy, and ultrasonography, each provides only limited understanding of the dynamics of oral and pharyngeal
information. The dynamic VFSS provides the most com- movements during normal and disordered swallowing and is
plete appreciation of the individual elements of the oral, familiar with the therapeutic strategies that can improve
pharyngeal, and laryngeal events that drive the bolus swallowing safety and efficiency. The speech language

Chapter 32 Videofluoroscopic Evaluation of Oropharyngeal Swallowing 1729
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.

Table 32-2 Positioning

PARAMETERS THAT GUIDE THE PROGRESS OF THE VFSS
The patient is seated upright in a comfortable posture in a
From To
chair. Chairs designed specifically for the VFSS are
Lateral projection → AP projection available. These chairs fit into the fluoroscopic unit and
Liquids → Semisolids, solids, and tablets permit easy transfer of patients from stretchers or wheel-
Small boluses → Large boluses chairs, as well as easy position changes from lateral to AP
Clinician-delivered bolus → Patient-controlled bolus delivery views. The VFSS always commences with the patient in the
delivery lateral view. The field of view includes the lips anteriorly,
Uncompensated swallows → Compensatory maneuvers the posterior pharyngeal wall and cervical spine posteriorly,
the nasopharynx superiorly, and the upper esophageal
Adapted from Mills RH. Increasing the precision of the videofluoroscopic segment and C7 inferiorly (Fig. 32-1A). This wide view
swallowing evaluation. In: Mills RH, ed. Evaluation of Dysphagia in Adults:
Expanding the Diagnostic Options. Austin, TX: Pro-Ed, 2000;103-144.
enables assessment of the various stages of swallowing at
one time. After contrast with the various consistencies is
administered and any necessary maneuvers are performed,
the patient is turned to the AP projection for observation of
PROCEDURE FOR THE VFSS the symmetry of muscular contraction. For the AP views, the
fluoroscopic unit is focused on the oral cavity so that the
The VFSS aims to simulate habitual swallowing behavior palate forms the superior border of the image and the vocal
as much as possible, taking into account that barium contrast folds and tracheal column form the inferior border. To
does not closely resemble typical solid or liquid substances. improve the quality of the image, the field is collimated so
Although several standard protocols have been de- that the lateral borders of the mandible are at the outer aspect
scribed,6, 18, 19 there is no real consensus about the most of the field of view (Fig. 32-1B).
appropriate protocol, probably because no one protocol is
suitable for all patients. The VFSS is tailored to the patient’s
complaints, medical profile, cognitive status, results of the
clinical swallowing evaluation, and the patient’s risk of Contrast Agents
aspiration. In all instances, efforts are made to limit
aspiration of the contrast material. In some cases, the study Patients are given small amounts of barium sulfate in
is terminated when the patient aspirates. However, in most various forms such as liquid, paste mixed with pudding or
instances, controlled volumes of different barium consisten- applesauce to create a semisolid consistency, and a portion
cies coupled with swallowing maneuvers allow for evalua- of a cookie coated with barium paste. Since the study is not
tion of their effectiveness. The general sequence of the designed to identify mucosal pathology, it is not necessary to
procedure is illustrated in Table 32-2 and is adapted from use a contrast agent with a very high weight/volume
Mills.20 concentration. Some clinicians attempt to replicate the
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

FIGURE 32-2 Phases of normal swallowing.

account for the frequently observed phenomenon in normal Esophageal Stage

adults of trace and transient liquid penetration high in the
laryngeal vestibule, which is extruded out as the swallow In contrast to the oral and pharyngeal stages of
progresses.28 swallowing, the esophageal stage is the longest, lasting
The upright suprahyoid portion of the epiglottis forms for 8 to 20 seconds in normal adults. The transfer of
the posterior border of the vallecula at the base of the food from the mouth to the stomach via the esophagus
tongue, and acts to divide the advancing bolus and direct it results from the coordinated relaxation of the upper and
down the lateral channels of the hypopharynx (pyriform lower esophageal sphincters and the peristaltic contraction
sinuses) and into the cervical esophagus. As the pharyngeal waves that sweep the length of the conduit after the
stage of the swallow progresses the epiglottis inverts, pharyngeal swallow. Primary and secondary peristaltic
contributing to the closure of the laryngeal inlet. The waves are the result of contraction of the striated and
epiglottis moves passively, and its inversion is dependent on smooth esophageal regions, which shortens the esophagus
the contraction of its muscular attachments in a two-stage in rostrocaudal sequences. The mass of the bolus entering
process. Contraction of the suprahyoid muscles pulls the the esophagus initiates primary and secondary esophageal
hyolaryngeal complex anteriorly, and with it the epiglottis contractions. If the cricopharyngeus does not close in an
to the horizontal plane. Thereafter, contraction of the appropriately rapid manner, esophagopharyngeal reflux
thyroepiglottic muscle inverts the epiglottis to a completely can occur. Thus, the timing of both the opening and
downfolded position assisted by pressure from the bolus closing of the cricopharyngeus is critical to a normal
above.29–31 Of note, epiglottic downfolding may be incon- swallow. In addition, this region must remain open long
sistent in occurrence. Ekberg and Nylander32 noted that the enough to allow the entire bolus to enter the esophagus.
epiglottis can remain upright in normal adults when a small These factors illustrate the delicate and precise timing of
bolus is swallowed. Appreciation of the passive nature of events during a normal swallow, and they are discussed
epiglottic movement per se is important in interpreting later in the chapter.
abnormal deflection on a radiographic examination be-
cause the function of the surrounding structures must be
examined.
Respiration ceases for approximately 0.75 second during EFFECTS OF AGING ON OROPHARYNGEAL
an obligatory apneic period. This period of apnea varies with SWALLOWING
bolus consistency and volume; the larger the bolus volume
and/or the more viscous its consistency, the longer the The features of normal swallowing described above
duration of apnea.25 Respiration resumes after the swallow undergo changes with aging, even in the elderly normal.
on the expiratory phase of the respiratory cycle, which is These changes must be recognized when evaluating the
thought to have a role in clearing material possibly swallowing of older patients in order to avoid overdiagno-
penetrating the laryngeal vestibule. sis and overtreatment of normally occurring phenom-
Opening of the cervical esophagus occurs as the ena. There is a natural progressive change in the sensory
suprahyoid muscles contract, pulling the larynx upward, and motor components of oropharyngeal swallowing that
forward, and away from the posterior pharyngeal wall. may make older normal persons vulnerable to dyspha-
Conventional wisdom suggests that opening of the upper gia. Physiologic features of swallowing in older individu-
esophagus is achieved through relaxation of the toni- als include slower manipulation of solids and a delay in
cally contracted cricopharyngeus muscle. While intrin- initiating the pharyngeal stage of swallowing, which
sic relaxation of the pharyngoesophageal segment must results in an unprotected airway for an increased length of
occur, research has shown that the movement of the time. The range of opening of the upper esophageal
entire larynx upward and forward approximately 2 to 2.5 segment is reduced as a result of tissue fibrosis and
cm under the tongue base affects the major opening degeneration, which in turn results in more pharyngeal
force, assisted by intrinsic relaxation of the pharyngo- retention than in a younger patient. High laryngeal
esophageal segment and by the bolus pressure from penetration of the laryngeal vestibule may be observed in
above.33, 34 Opening of the upper esophageal segment is older individuals before completion of the swallow. How-
modulated by bolus variables such that larger or more ever, persistent laryngeal penetration and aspiration is never
viscous boluses result in earlier onset, greater magnitude, normal, and the material is usually ejected from the
and longer duration of opening than smaller, less viscous laryngeal inlet as the swallow progresses. Aging can bring
boluses.25, 34 with it loss of skeletal muscle mass, as well as changes in
Contraction of the obliquely arranged pharyngeal con- muscle strength and muscle contraction, all of which may
strictor muscles generates additional pressures on the tail of contribute to a weaker bolus drive and increased stasis in the
the bolus, especially at the area between the valleculae and oral cavity and pharynx. Furthermore, aging individuals are
the arytenoid cartilages. These sequential contractions more susceptible to disease, which in turn restricts the
contact the tongue base, acting as a clearing force to remove functional reserve capacity in dealing with the normal
boluses from the pharyngeal recesses and propel them into structural and physiologic changes that accompany normal
the cervical esophagus.35 Pharyngeal bolus transit is very aging.
rapid, occurring in less than 1 second, and is consistent in In elderly patients, dysphagia is frequently the result of
duration regardless of the viscosity or volume of the bolus or combinations of several conditions such as diabetes, chronic
the age of the patient. obstructive pulmonary disease, congestive heart failure,

renal failure, immunocompromised status, and/or cachexia. Table 32-3

Some conditions that are not sufficient to cause dysphagia in SCHEMA FOR INTERPRETATION OF VFSS
younger adults can challenge the naturally declining
Normal and abnormal anatomy
physiology of older adults. Such conditions include the
Normal and abnormal biomechanical movements of structures of the
presence of a nasogastric feeding tube, medication side oral pharyngeal swallowing mechanism
effects, and chronic illness.36–38
Temporal coordination of biomechanical events in relation to bolus
flow
Penetration/aspiration
Swallowing efficiency
INTERPRETATION OF FINDINGS
Evaluation of therapeutic strategies
Interpretation of the dynamic images of the VFSS must Changes in bolus volume, viscosity, rate of delivery
accomplish two goals. The first is to identify the presence of Changes in posture
an oropharyngeal swallowing disorder and to describe the Rehabilitative swallowing maneuvers
physiologic underpinnings of its component parts. The
Adapted from Murray J. Manual of Dysphagia Assessment in Adults. San Diego,
second but equally important goal is to determine which CA: Singular Publishing, 1999;113-151.
therapeutic maneuvers are likely to facilitate improved
swallowing safety and efficiency. A declaration of the
presence or absence of aspiration or bolus obstruction or
hesitation is insufficient. In order to exploit the therapeutic Normal and Abnormal Anatomy
value of the VFSS, it is necessary to consider the reason for
symptoms of aspiration or residue. Logemann,12 a pioneer Lateral and AP scout films taken prior to fluoroscopy can
of the VFSS, takes a very strong position on this point: highlight variations in anatomy that may contribute to the
‘‘Aspiration and residue are symptoms of swallowing swallowing problem and that may require closer scrutiny. If
disorders, not swallowing disorders themselves . . . the this is not possible, it is advisable to scan the oral cavity and
anatomic and/or neurologic muscular dysfunctions are pharynx fluoroscopically from the lips to the posterior
the actual disorders leading to the symptom for which the pharyngeal wall, as well as the proximal trachea and
treatment is designed’’ (p. 71). In contrast, an exhaustive esophagus, prior to the administration of contrast. The
interpretation of any of the many components of the swallow anatomic configuration of the mandible is observed for
may not yield useful clinical information and may be too evidence of surgical resection and possible plated recon-
time-consuming. Clinicians should resist the urge to struction (Fig. 32-3). In addition, gross deviations of
comment exclusively on bolus location in the oral cavity, mandibular–maxillary relationships are observed. The
pharynx, airway, or cervical esophagus and should consider
the aberrant forces that caused the bolus to flow in the
observed directions.
Therefore, the challenge is to develop a schema that
permits identification of the salient abnormal events in order
to arrive at an integrated understanding of the biomechanical
basis of impairment. These data form a foundation for
assessing therapeutic maneuvers. Assessment of the video-
fluoroscopic images involves description of abnormal
anatomy, analysis of the timing and coordination of the
biomechanical events of the swallow, and determination of
laryngeal penetration. Finally, the effectiveness of swallow-
ing strategies attempted during the VFSS is evaluated in
order to make recommendations for oral nutrition. This
schema, outlined in Table 32-3, follows the outline
suggested by Murray.39
Dodds et al.22 make the important point that the goal of
interpretation is not to diagnose disease. There are very few
typical presentations of diseases on the VFSS, and
symptoms of a variety of diseases or conditions can appear
similarly on the study. For example, a severely decondi-
tioned patient with significant loss of muscle mass and
pharyngeal weakness may closely resemble a patient with
polymyositis with respect to solid bolus swallowing. Thus, it
would not be possible to offer a differential diagnosis of
polymyositis when viewing the results of a VFSS alone. The
clinical history is very important and assists in generating
hypotheses and recommendations for further diagnostic
evaluation. FIGURE 32-3 Mandibular reconstruction.

FIGURE 32-4 A, Patient with total

glossectomy with free flap reconstruction.
B, Patient with a glossectomy (arrows)
where reconstruction of the tongue has
failed.
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.

muscles. However, the flap is bulkier than the normal

pharyngeal muscles, and there is no observed contraction of
the flap during swallowing.
The contour of the cervical spine is well appreciated in
the lateral projection, and note is taken of the location and
size of cervical osteophytes (Fig. 32-7A). Approximately
20% to 30% of the elderly population present with diffuse
skeletal hyperostosis (DISH) manifesting as cervical osteo-
phytes at C5-C6 and of these, 28% complain of symptoms of
dysphagia.40, 41 Osteophytes, if sufficiently large, may
impinge directly on the cervical esophagus and hypophar-
ynx, allowing only squirts of the bolus to pass. Periosteo-
phytic edema or inflammation may increase the dysphagia.
Osteophytes can coexist with reduced laryngeal closure and
may additively cause more severe dysphagia than if either is
present alone (Fig. 32-7B). It is important to resist the
temptation to implicate the osteophyte solely as the
predominant etiology of the swallowing difficulty, particu-
larly in acute-onset dysphagia. Osteophytes develop over
time, and most patients adapt unconsciously to their
presence. In patients who have had surgery or radiation
therapy that restricts the motion of the hyoid bone (and thus
of the larynx), the coexistence of pronounced osteophytes
can be a cause of dysphagia. Other causative biomechanical
factors should be considered in these cases, such as weak
FIGURE 32-6 Radiation effects on structures of the hypopharynx, laryngeal excursion or impaired tongue base retraction,
epiglottis, and arytenoid cartilages. The posterior pharyngeal wall is particularly since surgical reduction of osteophytes is a risky
thickened (arrow).
and complex procedure. Valadka et al.41 illustrate this point
very clearly in a report on a patient who underwent resection
tongue base mass, as occurs in patients with tongue base of an anterior cervical osteophyte for relief of dysphagia
resections from carcinoma. In patients who have had after two separate diagnostic evaluations by two different
pharyngeal resections with flap reconstructions, a soft-tissue otolaryngologists failed to detect base of tongue cancer.
fullness is seen, often simulating the pharyngeal constrictor Some patients have undergone cervical fusion procedures
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.

with autologous grafts or rod placements. These patients

may present with hematoma formation, edema, infection,
and denervation with injury to the recurrent laryngeal nerve
as a result of the surgical necessity of shifting structures
across the midline to reach the cervical spine. Usually the
pharyngeal edema subsides within a few days of surgery;
however, if severe, the pharyngeal contraction waves and
bolus clearance, particularly during swallowing of solid
foods, may be temporarily compromised. If fibrosis affects
the pharyngeal constrictor muscles, poor pharyngeal con-
traction can be permanent. Increased prevertebral space soft
tissue that is observed in patients treated with radiation
therapy and/or chemotherapy for hypopharyngeal tumors
subsides more slowly but has the same impact on the
swallow. It is not uncommon to observe pharyngeal wall
edema in these patients months after radiation therapy is
completed, as seen in Figure 32-8.
The pharyngeal recesses form the conduit for bolus flow,
and their capaciousness or lack thereof can assist in
compensating for disordered pharyngeal contractions. For
example, patients with recent pharyngeal wall resections
may display edema such that the pyriform sinuses are unable
to contain even a small amount of residue after the swallow,
and this may lead to prompt aspiration. On the other hand,
patients with generalized deconditioning and muscle wast-
ing in the pharynx may present with generous pyriform FIGURE 32-9 Stricture (arrow) of the cervical esophagus after
sinuses that can contain considerable residue that does not laryngectomy.
empty into the laryngeal vestibule.
Calcifications of the laryngeal cartilages, carotid arteries,
and various ligaments appear as areas of radiodensity at misinterpretation of these sites of calcification as droplets of
fluoroscopy and on x-ray films. Taking note of these areas barium. This can decrease the overdiagnosis of laryngeal
prior to the administration of contrast will eliminate the aspiration.
The presence of a laryngectomy must be noted. These
patients are generally not at risk for aspiration of contrast;
however, they may present with bolus hesitation as a result
of strictures at the surgical site, scarring or resection of the
hyoid-related musculature, or as a result of radiation therapy
(Fig. 32-9).
Vocal fold adduction is best observed in the AP
projection. Glottic closure, as discussed previously, is
critical for swallowing, and even cursory evaluation of vocal
fold movements during phonation is helpful in determining
the risk of aspiration and the presence of vocal fold
asymmetry. However, the diagnosis of vocal fold paralysis
should be made with caution, as image clarity can be
obscured by the vocal folds superimposed on the dense bony
structure of the cervical spine. Videofluoroscopy does not
provide a detailed view of the laryngeal structure because of
the poor resolution of the cartilaginous structures. Some-
times contrast present in the airway outlines the laryngeal
structures more clearly and provides information about
arytenoid cartilage edema, surgical resection, the contour of
the aryepiglottic folds, and the amount of tracheal aspiration.
Patency of the airway should be appreciated and the
presence of a tracheostomy tube noted. Tracheal or
supraglottic stents may be present, and their location in the
trachea should be noted, as at times the superior edge of the
upper limb of a T-tube stents open the glottis, affecting
airway protection. In most cases, however, sufficient
FIGURE 32-8 Severe edema of the posterior pharyngeal wall ( ppw) superior and hyolaryngeal excursion prevents aspiration of
and blunting of the epiglottis (e) in a patient 3 months after receiving contrast of certain consistencies. Unless the patient is
radiation therapy for a pharyngeal tumor. mechanically ventilated, it is advisable to have the patient

swallow with the tracheostomy tube cuff deflated. Ideally,

the tracheostomy tube should have a diameter that permits
airflow around the tube in the trachea such that finger
occlusion of the hub of the tube or capping is possible. A
one-way speaking valve may also be used, allowing
inhalation through the tracheostomy tube and exhalation
through the oral cavity as the one-way valve closes. Closure
of the vocal folds at the glottis permits a strong clearing
cough if the patient aspirates. A cursory appreciation of the
underlying anatomic variations allows the clinician to
develop hypotheses about the potential swallowing problem
and to speculate, at least in part, about the possible risks of
performing the swallowing study.
Normal and Abnormal Biomechanical

Movements
Lips and Cheeks
The lips must close around the spoon or cup in order to
contain the bolus in the oral cavity. Lip protrusion is
necessary for straw drinking. While lip seal functionality
can readily be observed during the clinical swallowing
evaluation, the ease with which the bolus is accepted can FIGURE 32-10 Normal hold position of a liquid bolus in the lateral
affect tongue posturing. Contraction of the buccinator view.
muscles together with lip closure and tongue tip contact
against the alveolar ridge facilitates cohesive bolus forma-
tion in the oral cavity. Weak lip closure may result in loss of liquid boluses are identified radiographically in the lateral
the bolus anteriorly from the oral cavity, as in drooling. projection as elliptically shaped entities contained on the
Absent lip and jaw closure occurs in patients with bulbar tongue dorsum, prevented from spilling into the pharynx by
ALS and affects containment of saliva as well as food and depression of the soft palate against the back of the tongue
contrast. Sometimes drooling occurs because of reduced (contraction of the palatoglossus muscle). In the AP
sensation of the lips as well as reduced motor output. projection, the bolus is seen enclosed in a central groove on
Resection of mandibular tumors or even lingual cancers the tongue dorsum, with the buccinators contracted against
necessitates mandibulotomy, severing the labial branch of the dental ridges and the lateral borders of the tongue in
the alveolar nerve and affecting awareness of lip closure, contact with the alveolar ridge (Fig. 32-11).
and resulting in lack of awareness of saliva or contrast on the During mastication, the material is placed on the tongue
lips or chin. In patients with facial droop, for example as a and the midline and lateral borders of the oral tongue move
result of unilateral middle cerebral artery distribution the bolus toward the dental arches. In the AP view, opening
cerebrovascular accident or acoustic neuroma resection and closing of the jaw enables rotary tongue movements to
affecting facial nerve function, the bolus may fall immedi- the left and right. Frequently, some of the bolus spills into
ately into the lateral buccal sulcus of the affected side, where the lateral sulci but most normal individuals can sweep the
it pools. sulci clean with the tongue tip and lateral borders and
reassemble the bolus ready for swallowing. The palatoglos-
Tongue sal seal observed in liquid and semisolid bolus manipulation
Movement of the tongue plays a central role in is broken in mastication by the constant movements of the
swallowing. Its function is to manipulate the bolus, position posterior tongue. Therefore, it is not unusual for the head of
it carefully, and propel it from the oral cavity into the the bolus to be seen moving toward the vallecular space
pharynx. There is a great deal of normal variability in bolus while mastication and bolus formation are in progress. If
formation and propulsion. Dodds et al.42 identified two types leakage of the bolus is observed during formation of
of oral swallowing events. In the first type, tipper swallows, semisolids or liquids, it is referred to as premature spillage
the bolus is positioned on the dorsum of the tongue and the and is an indication of muscle weakness either in the tongue
swallow is initiated with the tip of the tongue against the or in the palatoglossus muscle. The risk is that the material
incisors (Fig. 32-10). In the second type, dipper swallows, will spill into the open airway and be aspirated prior to the
the bolus is held under the tongue in the anterior sulcus of onset of the pharyngeal swallow response. Once the bolus is
the floor of the mouth, and the tongue tip must scoop up the formed, a series of wave-like movements of the tongue
bolus and elevate it onto the tongue before swallowing. dorsum creates pressure on the bolus and propels it with a
Dodds et al.42 observed dipper swallows more commonly in piston-like motion21, 22 from anterior to posterior against the
older individuals. Furthermore, some normal individuals hard and soft palates toward the oropharynx. The tongue
take large sips and bites and swallow large mouthfuls at base depresses and moves anteriorly, forming a ramp or
once; others segment the bolus into distinct portions and chute down which the bolus flows. The posterior tongue
swallow small amounts. In normal individuals, formed movement continues with the tongue base contacting the

posterior pharyngeal wall, helping to direct the bolus toward

the vallecular space (Fig. 32-12). In the AP view, bolus
propulsion is observed as cohesive midline bolus flow.
Abnormalities in swallowing resulting from impaired
tongue function can affect the passage of the bolus to a
minor or major degree. The most extreme impairment in
tongue function is observed in patients with total reduction
in tongue bulk and hence movement, as in total glossectomy,
or marked lingual atrophy, as in advanced ALS. These
patients present with difficulty positioning the bolus on the
tongue, manipulating it, or controlling it for propulsion. In
the case of semisolid boluses, videofluoroscopic images
reveal stasis of material on the tongue or reconstructed
tongue or in the valleculae. Less viscous consistencies fall
into the lateral or anterior sulci or spill in an uncontrolled
fashion into the pharynx. Mashing of the tongue against the
palate or vertical movements of chewing lacking rotary
actions are inefficient, as the tongue does not draw the bolus
together in a cohesive manner. In compensation, the patient
may extend the head to enlist the assistance of gravity for
bolus propulsion. Sometimes opening and closing the jaw,
especially in cases of total glossectomy, where the tongue
has been reconstructed with a regional or free myocutaneous
flap, helps to compress the bolus against the palate and FIGURE 32-12 Contraction of the posterior pharyngeal wall seen as a
slowly move it posteriorly to the pharynx. However, in these bulge (arrow). The hyoid bone is elevated superiorly and anteriorly and the
patients, it is not unusual to observe contrast adhering to the pharyngoesophageal segment is distended to receive the advancing bolus
hard palate or coating the dorsum of the tongue. Improved from above.
efficiency in bolus propulsion may be observed by following
bites of semisolid material with sips of liquids, provided that
airway protection is intact. One of the compensatory what has been referred to as a dump swallow maneuver, in
strategies developed by patients with total glossectomy is which the bolus is swallowed as a result of suprahyoid
activity, laryngeal closure, and pharyngeal shortening.
Mastication of solid boluses is unrealistic in these patients,
as deforming the solid, mixing it with saliva, and reforming
it are not possible. These patients are in danger of aspirating
large, unmasticated boluses.
Partial glossectomy can have a profound effect on bolus
control, manipulation, and deformation. The location of the
resection and nature of reconstruction will dictate the nature
and severity of the impairment and the location of the
residue. The effects of structural changes can be variable and
wide-ranging even among patients with similar operative
procedures and radiation treatments. Patients with anterior
oral tongue glossectomy crossing the midline or with floor
of mouth resection have the greatest challenge in holding the
bolus cohesively for propulsion. These patients display a
marked amount of residue in the oral cavity and require head
extension or careful placement of the bolus in the posterior
pharynx. During VFSS it may be helpful to bypass
assessment of the oral stage in order to determine
pharyngeal swallow impairment by controlled injection of
boluses into the pharynx via a catheter or syringe. Once the
integrity of the pharyngeal swallow has been established,
compensatory strategies increasing bolus volume may be
attempted.
Tongue base resections affect tongue base retraction and
bolus propulsion through the pharynx and hypopharynx.
Disturbance of the suprahyoid musculature that sometimes
accompanies these resections affects laryngeal excursion,
FIGURE 32-11 Right lateral floor of mouth resection and lateral and therefore epiglottic downfolding and airway protection.
hemiglossectomy resulting in stasis of contrast in the lateral buccal sulcus The outcome of bilateral tongue base resection may present
(arrow). radiographically as significant residue along the pharyngeal

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 32-13 Nasopharyngeal regurgitation (arrow).
FIGURE 32-15 Laryngeal penetration (arrow) during the swallow to

the level of the true vocal folds in a patient with a supraglottic
that the epiglottis is a cartilage with attachments to the hyoid laryngectomy. In this procedure the hyoid bone, epiglottis, and supraglottis
bone, tongue base, and larynx. Since the epiglottis is a are resected. Aspiration is prevented by forceful adduction of the true vocal
‘‘passive performer,’’24 its inversion depends on adequate folds during the swallow.
function of these attached structures, which are most often
implicated in impaired epiglottic movement. Biomechanical
movements of structures attached to the epiglottis should
receive attention when therapeutic maneuvers are selected Inversion of the epiglottis can also be visualized in the AP
for evaluation during the VFSS. projection, appearing as a slit-like opacity within the column
Prior to the onset of the pharyngeal swallow, the of barium (Fig. 32-14).
epiglottis deflects advancing secretions or boluses around In the standard supraglottic laryngectomy procedure, the
the laryngeal inlet.39 The laryngeal vestibule is shielded by entire epiglottis is resected together with the carcinoma of
the movement of the epiglottis from the upright to the the supraglottis, making the laryngeal vestibule vulnerable
horizontal position by thyrohyoid shortening and is clearly to penetration or aspiration of oral secretions, liquid
visualized on fluoroscopy, particularly in the lateral view. materials, and solid materials (Fig. 32-15). Patients are
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

esophagus once the outpouching occurs, the patient is

asymptomatic.
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).

sections of the larynx. Vocal fold paralysis can result from

disease processes such as brainstem stroke, progressive
motor neuron disease, skull base tumors, or infection. In
addition, iatrogenic vocal fold paralysis is a well-
documented risk in patients who have undergone thyroidec-
tomy, cardiac surgery, carotid endarterectomy, or various
thoracic surgical procedures. Some patients with injury to
the recurrent laryngeal nerve resulting in unilateral vocal
fold paralysis may, but do not always, demonstrate
penetration of the airway during swallowing of liquids.
Similarly, wide surgical resection of the larynx, as seen in
supraglottic laryngectomy or hemilaryngectomy, affects
closure of the airway in the horizontal or vertical plane.
Since many of these patients also undergo pre- or
postoperative radiation therapy, fibrosis of the laryngeal
structures further compromises airway closure. Patients who
have recently required endotracheal intubation may exhibit
impaired laryngeal adduction as a result of trauma to the
vocal folds. Patients who demonstrate aspiration during the
swallow as a result of impaired airway closure are excellent
candidates for using postural strategies such as rotation of
the head to the affected side or compensatory maneuvers
such as the supraglottic swallow technique described in a
later section.
When glottic closure is impaired during the swallow, it
is likely that the protective or reflexive cough in response FIGURE 32-18 Lateral view of a cricopharyngeal prominence
to aspiration will also be involved. This increases the (arrow).
patient’s risk of developing pulmonary compromise since
they will be unable to clear material from the airway either
reflexively or upon instruction. referred to as a cricopharyngeal bar, cricopharyngeal
achalasia, or cricopharyngeal hypertrophy) is a controversial
Cricopharyngeus/Pharyngoesophageal Segment entity in terms of its role in dysphagia (see Fig. 32-20). It
The pharyngoesophageal region is located ‘‘beneath the appears as a shelf in the posterior barium column at the level
pharyngeal air column and posterior to the arytenoid of the cricoid cartilage and can be reproducible or
cartilages’’ (Murray,39 p. 126) and is approximately 3 to 4 inconsistent. Its location can be variable in relation to the
cm in length, with the cricopharyngeus muscle comprising 1 cervical vertebrae because of the superior excursion of the
cm of this length.51 It is difficult to identify precisely the larynx during the swallow. The presence of a cricopharyn-
high-pressure zone of the pharyngoesophageal segment geal bar increases with age, with 6.3% to 22% of elderly
because of the tight contact of the mucosal walls. Cook52 normal persons displaying this phenomenon.32, 54, 55
suggested that its location corresponds to the middle and Abnormal contraction (or lack of relaxation) of the
lower third of the cricoid cartilage. cricopharyngeus muscle is visible only during swallowing.
Opening of the pharyngoesophageal segment occurs as a It may occur as a function of uncoordinated timing or may
function of three factors: intrinsic relaxation of the be the result of intrinsic muscle fibrosis, for example in
cricopharyngeus muscle, intrabolus pressure, and, most postradiation stricture. In either case, the muscle contraction
importantly, anterosuperior distraction of the hyolaryngeal appears as an indentation in the barium column, which, if
complex away from the posterior pharyngeal wall, as severe, can obstruct the lumen, and is particularly trouble-
discussed above. Only the last can be reliably observed on some during swallows of solid food and pills. It is
VFSS, but all factors may be involved in failure of opening. sometimes seen in primary muscle disease such as polymyo-
In the normal condition, the cricopharyngeus muscle sitis, peripheral or central cranial nerve palsy, brainstem
complex does not indent the barium column, and increased stroke, or pharyngeal paresis.15 Radiographic imaging of the
bolus volume increases the duration and diameter of opening cricopharyngeal prominence is best visualized during
of the pharyngoesophageal segment25, 52 (Fig. 32-12). swallowing of large mouthfuls of barium (Fig. 32-18). It is
Functional failure of opening of the pharyngoesophageal important to remember that fluoroscopic imaging only
segment may be the result of failure of or incoordinated provides information about the degree of opening or
cricopharyngeal relaxation, as occurs in patients with obstruction of the bolus flow. It does not document the
oculopharyngeal muscular dystrophy, lateral medullary extent of spasm or pressure, which is measured by
syndrome, and Parkinson’s disease.53 Impaired hyolaryn- manometric recordings. If cricopharyngeal achalasia is
geal elevation may also affect opening of the pharyngo- suspected, manometric investigation may be necessary.
esophageal segment, as has been described, resulting in The functional significance of a cricopharyngeal promi-
postswallow retention in the pyriform sinuses. nence increases in the context of coexisting pharyngeal
Structural pharyngoesophageal abnormalities are numer- problems such as reduced pharyngeal contractions. In fact,
ous. The most common, cricopharyngeal prominence (also there are instances when the pharyngoesophageal segment

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
FIGURE 32-19 Lateral (A) and AP (B) views

of a Zenker’s diverticulum (arrows).

Table 32-4 Timeliness of Onset of Pharyngeal Swallow

COMMON OROPHARYNGEAL BIOMECHANICAL
IMPAIRMENTS AND THEIR RELATED Timing of onset of the pharyngeal swallow is important
RADIOGRAPHIC FINDINGS in determining the interaction between bolus flow in relation
Biomechanical Impairment Radiographic Findings to airway protection. Delayed onset of the pharyngeal
swallow response is also referred to as pharyngeal delay,62
Reduced lip closure Barium spills out from the lips duration of stage transition,63, 64 stage transition duration,39
Reduced range of coordination of Bolus coats tongue diffusely delayed swallow reflex,65 or delayed pharyngeal swallow12
tongue movement (Fig. 32-20). It is affected by a number of conditions
Reduced tongue lateralization Bolus is not deformed promptly including stroke, Parkinson’s disease, ALS, prior radiation
during chewing therapy, postendotracheal intubation/tracheostomy, or oral
Impaired cognitive function, neu- Hesitancy initiating swallowing cavity resection affecting laryngopharyngeal sensation. The
ral function, or oral sensation longer the delay in initiating the pharyngeal swallow
Reduced labial or buccal tension Stasis in buccal sulci response after the bolus is in the pharynx, the greater the risk
Reduced tongue shaping Stasis in floor of mouth of latent material spilling into the airway.45 Thin liquids
Impaired tongue motion Abnormal AP lingual movements travel rapidly through the oral cavity and pharynx, and an
Reduced tongue elevation Poor tongue-to-palate contact unprotected airway is vulnerable to an advancing bolus if the
Parkinson’s disease Repetitive tongue rolling pharyngeal response is not elicited promptly. More viscous
Reduced tongue or palatal Premature spillage of bolus substances such as solids and semisolids travel more slowly
control Penetration and/or aspiration and cohesively and allow the sensory system more time to
before the swallow respond with respect to initiating the motor responses for
Dry oral cavity Diffuse coating of barium over airway protection and opening of the pharyngoesophageal
tongue and pharynx segment.
Impaired tongue movement Slow oral transit time In the most extreme case, the pharyngeal response, with
Delayed onset of pharyngeal Bolus fills valleculae and/or pyri- its sequence of events for driving the bolus through the oral
swallow form sinuses before swallow is pharynx and hypopharynx, can be absent. Fortunately, this is
activated a relatively uncommon occurrence, but it can be seen in
Velopharyngeal insufficiency Nasal regurgitation patients with lateral medullary syndrome where there is
Impaired tongue base retraction Residue in valleculae and on injury to the central swallowing pattern generator. In
pharyngeal wall moderate brainstem dysfunction it may be possible to
Reduced hyolaryngeal excursion Residue in pyriform sinuses observe the onset of components of the pharyngeal swallow
Incomplete epiglottic deflection response, but these may be uncoordinated and may lack the
Aspiration during and after the correct sequence. For example, in the lateral projection, it
swallow may be possible to observe aspiration before the swallow
Hypertonic cricopharyngeus Reduced opening of the pharyn-
muscle goesophageal segment
Increased pyriform sinus residue
Large cervical osteophyte Incomplete epiglottic deflection
Diminished pharyngeal wall con- Stasis along pharyngeal wall
tractions (unilateral or bilateral) Residue in valleculae and/or pyr-
iform sinus
Laryngeal penetration and/or
aspiration after the swallow
Reduced hyolaryngeal excursion Impaired epiglottic downfolding
Impaired tongue base retraction
Laryngeal penetration and/or
aspiration
Incomplete laryngeal closure Laryngeal penetration/aspiration
during the swallow
Zenker’s diverticulum Regurgitation after swallow from
pouch in cervical esophagus
Impaired vocal fold adduction Laryngeal penetration and/or
aspiration during the swallow
movements of the structures of the oral cavity, larynx,

pharynx, and pharyngoesophageal segment as isolated
events. It is the sequenced coordination of these events,
many of which overlap temporally, that affects the direction
or misdirection of the bolus through the upper aerodigestive FIGURE 32-20 Pharyngeal delay with coating of the valleculae
tract. (arrows).

response is elicited, and/or mistimed tongue propulsion and

pharyngeal clearance with failure of the bolus to enter the
esophagus.66, 67
Bolus characteristics of volume and viscosity modulate
the timing of the onset of the pharyngeal swallow with the
beginning of vocal cord adduction and airway closure.
Research in normal adults has shown that vocal cord
adduction and the onset of hyolaryngeal elevation begins
when large liquid boluses are placed in the oral cav-
ity.25, 26, 28 Radiographically, this is most easily observed in
the lateral plane. The laryngeal vestibule narrows as the
arytenoid cartilages rock and tilt toward the base of the
epiglottis and the glottis closes. This results in a negative
onset time in that the liquid bolus has not exited the oral
cavity and yet the pharyngeal swallow response has begun.
For example, Lazarus et al.68 found that an average normal
pharyngeal delay time for a 5 ml liquid bolus was -0.6
second in adults aged 18 to 80 years.
Different anatomic landmarks are used by different
researchers in calculating pharyngeal delay in relation to
bolus flow. In the most commonly used definition, the onset
of the pharyngeal swallow occurs as the head of the bolus
crosses the intersection of the ramus of the mandible and the
tongue base.13, 39 Pharyngeal delay time has been observed
to increase with age,28 in which a large portion of the bolus FIGURE 32-21 High laryngeal penetration (arrow) without aspira-
reaches the vallecular space before the onset of airway tion.
closure and hyolaryngeal elevation. This is thought to be the
result of reduced sensory awareness of the bolus but is also
oropharynx, taking aspiration into account. The numerical
considered a normal variant in older individuals (>70 years
value provided by this measure may be particularly helpful
of age).
when determining change in function after treatment.
Purees and solid boluses have increased viscosity and
therefore travel more slowly, presenting less of a threat to an
open airway. During normal mastication, boluses move in
small amounts over the tongue base and into the valleculae Laryngeal Penetration and Transglottic
in the presence of an open airway, and the pharyngeal Aspiration
swallow response may not be triggered until the material
reaches the pyriform sinuses or touches the aryepiglottic Identification of material in the airway has traditionally
folds. This phenomenon is not considered abnormal in the been the key abnormal finding on a VFSS and is often the
case of solid bolus swallowing and does not necessarily catalyst for terminating the study for fear of airway
increase the relative risk of laryngeal penetration or compromise. Aspiration or laryngeal penetration is not a
aspiration. Perlman et al.69 suggested that only when the binary event, and the physiologic circumstances surrounding
boluses remain in the pharynx longer than 1 second but less its occurrence must be described to determine the full
than 2 seconds before the beginning of laryngeal closure is implications. The first challenge is definition. The literature
the pharyngeal swallow onset considered mildly delayed. A is replete with ambiguous terminology to describe the
delay of 5 seconds or more is considered severe. entrance of barium contrast into the laryngeal vestibule,
larynx or trachea. For purposes of this chapter the following
definitions are used: Laryngeal penetration refers to the
Duration of Oral and Pharyngeal Transit presence of barium contrast in the laryngeal vestibule that
does not pass below the level of the true vocal folds into the
Swallowing efficiency is estimated by determining the trachea (Fig. 32-21). Aspiration refers to the presence of
duration of transit of the bolus through the oral cavity and barium contrast below the level of the true vocal folds in the
pharynx. Counting the number of swallows required to clear subglottis or trachea.
a liquid or solid bolus provides a rough guide of swallow The most clinically useful way of resolving the confusion
efficiency. Usually a 5 to 30 ml bolus is cleared in a single is to describe the amount and viscosity of barium in the
swallow and may be followed by a second clearing swallow. airway, its lowest location, the timing of its occurrence in the
There is greater variability in solid boluses, particularly airway, and the patient’s response to its presence. Detection
those that require longer mastication. Several swallows are of silent aspiration, defined as aspiration in the absence of a
required to clear boluses with hard textures.70 reflexive patient response, is a distinct advantage pro-
A more precise assessment of oropharyngeal swallow vided by the VFSS and assists in prognostication. Rosenbek
efficiency is described by Rademaker et al.71 This measure et al.64 describe an 8-point penetration-aspiration scale
depicts the interaction between the speed of bolus flow and based on videofluoroscopic data that fulfils this purpose
the efficiency with which the material is cleared from the (Table 32-5).

Table 32-5
EIGHT-POINT PENETRATION-ASPIRATION SCALE
Score Description of Events
1 Material does not enter the airway

2 Material enters the airway, remains above the vocal folds,
and is ejected from the airway
3 Material enters the airway, remains above the vocal folds,
and is not ejected from the airway
4 Material enters the airway, contacts the vocal folds, and is
ejected from the airway
5 Material enters the airway, contacts the vocal folds, and is
not ejected from the airway
6 Material enters the airway, passes below the vocal folds,
and is ejected from the airway
and is not ejected from the airway
and no effort is made to eject
From Rosenbek JC, Robbins J, Roecker EV, Coyle JL, Woods JL. A
penetration-aspiration scale. Dysphagia 1996;11:93-98.
FIGURE 32-22 Aspiration during the swallow.

It is instructive to note that laryngeal penetration is not
uncommon in normal healthy adults. Robbins et al.28 found commonly in the pyriform sinuses, it is referred to as
that 20% of their adult subjects showed high laryngeal secondary penetration or secondary aspiration.
penetration during the swallow and received a score of 2 on
the penetration-aspiration scale, indicating that the material
was ejected from the larynx before the swallow was Evaluation of Therapeutic Strategies
completed. Given its occurrence in normal patients, it would
be unnecessary to terminate the VFSS on the basis of One of the major advantages of the VFSS is that it
laryngeal penetration alone, particularly if the patient senses provides an opportunity to assess the value of therapeutic
the material in the airway.
In addition to defining the nature of the penetration or
aspiration, it is necessary to understand the physiologic basis
for its occurrence, particularly when therapeutic strategies
are to be evaluated. Laryngeal penetration or aspiration can
occur before, during, or after the pharyngeal swallow
response is activated. Aspiration before the swallow usually
is due to impaired tongue movement for bolus control,
resulting in premature spillage into the pharynx and/or
delayed onset of the pharyngeal swallow. Aspiration during
the swallow implies that the swallow response has been
initiated but laryngeal closure is incomplete, resulting in
penetration or aspiration (Fig. 32-22). Any of the multiple
airway protective forces such as true and vestibular vocal
fold closure or hyolaryngeal elevation with epiglottic
inversion may be impaired, resulting in an exposed
laryngeal inlet. Aspiration after the swallow is usually the
result of retention in the pharyngeal recesses from an
impaired pharyngeal contraction clearing force, reduced
hyolaryngeal elevation with a reduction in opening of the
pharyngoesophageal segment, or hypertonicity of the
cricopharyngeal region (Fig. 32-23). Residue may also
appear in the pyriform sinuses after the swallow as a result
of emptying of a Zenker’s diverticulum or cervical
esophageal dysmotility.
Commonly, if the penetration or aspiration occurs during
the initial descent of the bolus during the swallow, it is
referred to as primary penetration or aspiration. If the FIGURE 32-23 Aspiration after the swallow in a patient who has
penetration or aspiration occurs after the initial descent of undergone radiation therapy for a hypopharyngeal tumor. ac, Arytenoid
the bolus, from residual bolus in the valleculae or more cartilages; e, epiglottis; h, hyoid bone.

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
Functional Impairment Physiologic Impact
Changes in Bolus Viscosity

Increase bolus viscosity Impaired tongue control Reduces rate of liquid bolus flow
Aspiration before the swallow Allows improved lingual control
Impaired laryngeal closure Bolus remains cohesive
No response to bolus placement Increased sensory stimulation activates bolus
manipulation (e.g., chewing of solids)
Decrease bolus viscosity Impaired anterior posterior bolus propulsion Reduced resistance to bolus flow
Weak pharyngeal contraction
Changes in Bolus Volume
Increase bolus size Delayed onset of pharyngeal swallow Increases stimulation of sensory receptors to activate
swallow response
Decrease bolus volume Severe tongue weakness Increased control
Postural Changes
Chin down Delayed onset of pharyngeal swallow Widens vallecular space
Reduced tongue drive on bolus Displaces tongue posteriorly
Aspiration before the swallow Narrows angle of laryngeal vestibule
Head rotation to affected side Unilateral pharyngeal weakness Isolates damaged side from bolus flow
Reduced laryngeal excursion and opening of Reduces pressure of pharyngoesophageal segment
pharyngoesophageal segment Increases vocal fold adduction
Unilateral vocal fold paralysis
Head tilt to unaffected side Unilateral oral or pharyngeal weakness Redirects bolus flow down unaffected side
Head extended Reduced tongue propulsion Gravitational forces assist bolus flow
Velopharyngeal incompetence Reduces nasal regurgitation
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
Indication Physiologic Effect
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,
Foundas AL. Aspiration in patients with acute stroke. Arch Phys Med
nasopharynx. The posterior tongue may be seen to first Rehabil 1998;79:14–19.
descend slightly and then the tongue base should move 4. Horner J, Massey EW, Brazer SR. Aspiration in bilateral stroke
dorsally, touching the posterior pharyngeal wall. The patients. Neurology 1990;40:1686–1688.
pharyngeal phase should normally initiate as the bolus 5. Wu CH, Hsiao TY, Chen JC, Chang YC, Lee SY. Evaluation of
reaches the upper posterior aspect of the tongue. The hyoid, swallowing safety with fiberoptic endoscope: comparison with
videofluoroscopic technique. Laryngoscope 1997;107:396–401.
and thus the larynx, should then move forward and upward, 6. O’Donoghue S, Bagnall A. Videofluoroscopic evaluation in the
while the epiglottis should be seen to tilt passively assessment of swallowing disorders in paediatric and adult popula-
downward, resting upon the arytenoid cartilages and tions. Folia Phoniatr Logop 1999;51:158.
muscles. Forward movement of the posterior pharyngeal 7. Martin-Harris B, Logemann JA, McMahon S, Schleicher M, Sandidge
J. Clinical utility of the modified barium swallow. Dysphagia
wall should occur, signaling pharyngeal contraction, and as 2000;15:136–141.
the bolus reaches the lower hypopharynx, the cricopharyn- 8. Palmer JB, DuChane AS, Donner MW. Role of radiology in
geus should open, with no posterior cricopharyngeal rehabilitation of swallowing. In: Jones B, Donner MW, eds. Normal
indentation being seen on the barium column. The cricopha- and Abnormal Swallowing: Imaging in Diagnosis and Therapy. Berlin:
ryngeus should then close as cervical esophageal primary Springer-Verlag, 1991; 215–225.
9. Logemann JA. Evaluation and Treatment of Swallowing Disorders.
and secondary contractions are initiated. There should be no San Diego, CA: College-Hill Press, 1983.
residual contrast in the vallecula or pyriform sinuses with 10. Stenson KM, MacCracken E, List M, Haraf DJ, Brockstein B,
liquids. Some residua may be seen with purees and solids; Weichselbaum R, Vokes EE. Swallowing function in patients with
however, this should be cleared on subsequent swallows of head and neck cancer prior to treatment. Arch Otolaryngol Head Neck
Surg 2000;126:371–377.
saliva. Similarly, tongue or pharyngeal coating should be 11. Kendall K, McKenzie S, Leonard R. Dynamic swallow study:
rapidly cleared on the next swallow of saliva. objective measures and normative data. In: Leonard R, Kendall K, eds.
In the AP or frontal projection, the lateral pharyngeal Dysphagia Assessment and Treatment Planning: A Team Approach.
walls should be filled symmetrically by the bolus, bulging San Diego, CA: Singular Publishing, 1998;101–160.
outward without any ‘‘dog ears’’ (pharyngoceles). The 12. Logemann JA. Evaluation and Treatment of Swallowing Disorders,
2nd ed. Austin, TX: Pro-Ed, 1998.
vocal folds may be seen to adduct fully, and the barium 13. Logemann JA. Manual for the Videofluoroscopic Study of Swallow-
column should smoothly enter the cervical esophagus. ing. Austin, TX: Pro-Ed, 1993.
14. Beck TJ, Gayler BW. Image quality and radiation levels in
videofluoroscopy for swallowing studies: a review. Dysphagia
1990;5:118–128.
CONCLUSION 15. Perlman AL, Lu C, Jones B. Radiographic contrast examination of the
mouth, pharynx and esophagus. In: Perlman AL, Schulze-Delrieu K,
Diagnosis of oropharyngeal swallowing disorders de- eds. Deglutition and Its Disorders. San Diego, CA: Singular
Publishing, 1997;153–199.
mands an understanding of the complex normal and 16. Jones B, Ravich WJ, Donner MW, Kramer SS. Pharyngoesophageal
abnormal biomechanical events that drive boluses from the interrelationships: observations and working concepts. Gastrointest
oral cavity through the hypopharynx and into the esophagus. Radiol 1985;10:225–233.
The VFSS provides information about the physiologic 17. Splaingard ML, Hutchins B, Sulton LD, Chaudhuri G. Aspiration in
rehabilitation patients: videofluoroscopy vs. bedside clinical assess-
substrates underlying the swallowing process that extends ment. Arch Phys Med Rehabil 1988;69:637–640.
beyond the simple detection of aspiration. Thoughtfully 18. Robbins JA, Sufit R, Rosenbek J, Levine R, Hyland J. A modification
executed studies that draw on the expertise of the radiologist of the modified barium swallow. Dysphagia 1987;2:83–96.
and speech pathologist in understanding the problem permit 19. McKenzie S. Swallow evaluation with videofluoroscopy. In: Leonard
evaluation of therapeutic strategies aimed at improving the R, Kendall K, eds. Dysphagia Assessment and Treatment Planning: A
Team Approach. San Diego, CA: Singular Publishing, 1997;83–99.
chance that the patient can eat safely and efficiently by 20. Mills RH. Increasing the precision of the videofluoroscopic swallow-
mouth. ing examination. In: Mills RH, ed. Evaluation of Dysphagia in Adults:
Expanding the Diagnostic Options. Austin, TX: Pro-Ed, 2000;103–
144.
21. McConnel FM, Cerenko D, Jackson RT, Guffin TN. Timing of major
ACKNOWLEDGMENTS events of pharyngeal swallowing. Arch Otolaryngol Head Neck Surg
1988;114:1413–1418.
The author wishes to thank the following individ- 22. Dodds WJ, Logemann JA, Stewart ET. Radiologic assessment of
abnormal oral and pharyngeal phases of swallowing. Am J Roentgenol
uals:Cary Crehan, R.T., M.B.A., for his assistance in 1990;154:965–974.
printing the images used in this chapter; Sandy Martin, 23. Miller AJ. The Neuroscientific Principles of Swallowing and
M.S., C.C.C., Joanne Gutek, M.A., C.C.C., and Suzanne Dysphagia. San Diego, CA: Singular Publishing, 1999;107–134.
Danforth, M.S., C.C.C., for their invaluable editorial 24. Perlman AL, Christensen J: Topography and functional anatomy of the
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.
25. Dantas RO, Kern MK, Massey BT, Dodds WJ, Kahrilas PJ, Brasseur
JG, Cook IJ, Lang M. Effect of swallowed bolus variables on oral and
pharyngeal phases of swallowing. Am J Physiol 1990;258:G675–
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32

INTRODUCTION Normal and Abnormal Biomechanical

INTRODUCTION and about 60% of residents in long-term care facilities have

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MULTIDISCIPLINARY NATURE OF THE VFSS

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Table 32-2 Positioning

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FIGURE 32-2 Phases of normal swallowing.

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account for the frequently observed phenomenon in normal Esophageal Stage

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renal failure, immunocompromised status, and/or cachexia. Table 32-3

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FIGURE 32-4 A, Patient with total

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muscles. However, the flap is bulkier than the normal

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with autologous grafts or rod placements. These patients

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swallow with the tracheostomy tube cuff deflated. Ideally,

Normal and Abnormal Biomechanical

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posterior pharyngeal wall, helping to direct the bolus toward

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FIGURE 32-13 Nasopharyngeal regurgitation (arrow).

FIGURE 32-15 Laryngeal penetration (arrow) during the swallow to

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esophagus once the outpouching occurs, the patient is

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sections of the larynx. Vocal fold paralysis can result from

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FIGURE 32-19 Lateral (A) and AP (B) views

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Table 32-4 Timeliness of Onset of Pharyngeal Swallow

movements of the structures of the oral cavity, larynx,

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