KUNNAMPALLIL GEJO JOHN, MASLP

KUNNAMPALLIL GEJO JOHN, MASLP

 For the evaluation of swallowing, radiology is crucial.

It allows evaluation of both function and structure of the organs involved. During swallowing of a radiopaque bolus (such as barium), movements of anatomic structures as well as bolus transposition can be studied. On dysphagia team the radiologist should act as a consultant to the other team members, selecting from different imaging modalities.

KUNNAMPALLIL GEJO JOHN, MASLP

 videofluroscophy,

cineradiography,
computered tomography (CT), magnet resonance imaging (MRI),

ultra sound and

nuclear medicine

according to the patient needs.

KUNNAMPALLIL GEJO JOHN, MASLP

 The radiologist should contribute knowledge from

other field such as neuroradiology, tying together information from different studies in addition to dynamic and \or static barium swallow. The radiologist also is responsible for technical aspects such as exposure technique and the identification and reduction of imaging artifacts.

KUNNAMPALLIL GEJO JOHN, MASLP

 However, as a swallowing team member a radiologist

must also be aware of the limitations of radiology for assessment of cause and treatment of function and structure

KUNNAMPALLIL GEJO JOHN, MASLP

 The radiogenic examination takes advantage of the

interaction between imaging, radiation and materia. However, such interaction also has a potential effect and may cause damage. Therefore it is important to always perform the examination in such a way that radiation is kept to minimum. Even more important is to avoid an unnecessary examination.

KUNNAMPALLIL GEJO JOHN, MASLP

 However if the indication for the radiologic

examination is correct, the advantage of the study will always exceed the risk to the patient.

KUNNAMPALLIL GEJO JOHN, MASLP

 Feeding can be evaluated radiographycally in most

patients. Only patients who can be immobilize during deglutition need to exclude. The effectiveness and contribution of the radiologic study in the circumstances of the patient who is resistant or has severe impairment depends on the patience and skill of the radiologist.

KUNNAMPALLIL GEJO JOHN, MASLP

 The result of the study may determine whether the

patient will orally fed and, eventually weather the patient go home or to a long term care facility. In patients who are difficult to examine, such as those with psychosis or MR, sedation before the study is contraindicated as the results will be invalid.

KUNNAMPALLIL GEJO JOHN, MASLP

 A videofluoroscopic swallow study may

be ordered after a clinical swallow evaluation is completed if there is concern that a patient may be aspirating on food or liquids, has significant oral dysphagia that can not be seen clearly from the outside, or if patient has significant complaints of food getting stuck in the throat.
KUNNAMPALLIL GEJO JOHN, MASLP

 This procedure is completed in a

radiology suite along with a radiologist and radiology technologist present. The patient is given different consistencies and textures of food and drink laced with barium to swallow while under fluoroscopy. The patients swallow is evaluated by observing the contrast move through the mouth, throat, and esophagus.
KUNNAMPALLIL GEJO JOHN, MASLP

 A Fiberoptic Endoscopic Evaluation

of Swallowing and Sensory Test is a procedure to evaluate a patient swallowing a variety of materials for an extended session. This test is ordered to evaluate the pharyngeal swallowing abilities.
KUNNAMPALLIL GEJO JOHN, MASLP

 The procedure is completed at bedside in the patients

room at the hospital or for an outpatient, in the speech-language pathology suite. A flexible endoscope is passed through a patients nose to allow viewing of the pharyngeal space.

KUNNAMPALLIL GEJO JOHN, MASLP

 The patient is then given a variety of

liquids and textures to eat and drink so that their swallow may be evaluated for effectiveness and safety. Recommendations can be made upon this evaluation for further therapy or compensations needed for safe swallowing.
KUNNAMPALLIL GEJO JOHN, MASLP

 Barium swallow exams help clinicians identify

anatomical and functional abnormalities in the upper digestive tract by allowing them to see the formation of the barium contrast bolus and its movement through the cricopharyngeal, the esophagus and the lower esophageal sphincter into the stomach. Barium sulfate suspensions serve as radio-opaque contrast material in gastrointestinal tract imaging examinations.

KUNNAMPALLIL GEJO JOHN, MASLP

 Double-contrast exams are sometimes used if it is

necessary to examine the pharyngeal or esophageal mucous membrane physiology, such as in suspected cases of Barrett Esophagus. Double-contrast exams employ both liquid barium contrast and gas. Barium swallow and modified barium swallow (MBS) are routinely--but inaccurately--combined in the medical literature.

KUNNAMPALLIL GEJO JOHN, MASLP

 barium swallow and MBS are distinct examinations

and should not be confused. Despite the fact that MBS is widely described as a barium swallow, these terms are not interchangeable.

KUNNAMPALLIL GEJO JOHN, MASLP

 MBS involves a videotaped fluoroscopic imaging exam

of swallowing anatomy and physiology. It is now the gold standard for assessing swallow dysfunction. MBS was originally used to identify aspiration risk, which remains a major function of the exam. MBS is also used to therapeutically train patients in safe swallowing techniques.

KUNNAMPALLIL GEJO JOHN, MASLP

 MBS is conducted jointly by the radiology team and a

speech pathologist to assess aspiration risk (aspiration location and extent) and oral and pharyngeal swallow function as the patient swallows a progressively thicker sequence of barium-impregnated foods. If liquid samples are not aspirated, the patient typically will he given thicker liquid and food samples.

KUNNAMPALLIL GEJO JOHN, MASLP

Contraindications and Limitations : Patient history of allergic reaction to barium sulfate, suspected esophageal perforation and patient inability to cooperate with instructions are contraindications for barium swallow and MBS examination. Non-alert patients should not undergo barium contrast swallow exams.

KUNNAMPALLIL GEJO JOHN, MASLP

 Pediatric patient exams are much more time

limited due to radiation exposure concerns. Pregnancy is usually considered a contraindication tot barium swallow and MBS because of the risk of radiation exposure to the fetus Particularly after barium swallow, which commonly employs large volumes of barium contrast liquid, patients may experience constipation.
KUNNAMPALLIL GEJO JOHN, MASLP

 For barium swallow, patients should be

instructed to completely avoid food and drink 12 hours before the exam and to cease taking anticholinergics and narcotics 24 bouts before the exam. Patients should be informed that although the preliminary barium swallow exam requires up to 30 minutes to complete, additional images may be required tot up to 6 hours. All watches, jewelry and metal should be removed from the patient.
KUNNAMPALLIL GEJO JOHN, MASLP

 MBS is best described to patients as a moving x-ray

that is videotaped for later analysis. Female patients should be asked to verify that they are not pregnant. The patient will he asked to stand or sit upright in a chair fitted to the radiographic table, remaining still, for 10 minutes.

KUNNAMPALLIL GEJO JOHN, MASLP

 Patients should be exposed to the fluoroscopic unit as

quickly as possible and lead skirts should be used to protect reproductive organs. The radiologic technologist should wear a gown, gloves, lead apron and thyroid shield.

KUNNAMPALLIL GEJO JOHN, MASLP

 When bedridden patients are to be examined with

MBS--or when barium swallow patients are suspected or known to have a history of aspiration--it is critically important to keep the head of the bed at an angle greater than 30[degrees] even after the exam is concluded

KUNNAMPALLIL GEJO JOHN, MASLP

 This is necessary to prevent excessive

contrast aspiration during the exam and to prevent secondary, reflux-related aspiration after the exam has been concluded. Prior to preparing the barium mixture, the speech pathologist assesses the consistency of the mixture to achieve diagnostic accuracy. Low-viscosity liquid barium suspensions are typically prepared with a density of 1.0 g/mL.
KUNNAMPALLIL GEJO JOHN, MASLP

 . Liquid barium typically has no marked effects on the

viscosity of all fluids, particularly juices. When juices are included in MBS contrast material series, careful attention should be given to changes in viscosity after barium is added.

KUNNAMPALLIL GEJO JOHN, MASLP

 For barium swallow, the patient is positioned upright

for videotaped lateral and frontal pharynx projections that track the progression of the barium contrast bolus, which the patient is asked to swallow throughout the examination.

KUNNAMPALLIL GEJO JOHN, MASLP

 Lateral projections of regions with suspected pathology

often are taken subsequently. The patient is then securely strapped in the supine position on a tilting table. The patient is rolled with the table to allow for imaging of provoked underlying GERD or evidence of hiatal hernia as the barium progress through the digestive system. (Patients are never placed in a supine position in MBS.) Finally, a spot image of the stomach often is made to detect gastric outlet obstructions or other stomach pathology.

KUNNAMPALLIL GEJO JOHN, MASLP

 During MBS exams, the fluoroscopic tube

should stay focused on the oropharyngeal anatomy after each swallow. Patients are positioned upright and imaged using a tilttable fluoroscopic trait connected to a video recorder and display screen. The precise location and extent of barium contrast residue immediately after the swallow is critically important to correctly identify swallowing disorders.
KUNNAMPALLIL GEJO JOHN, MASLP

 Specific structural or surgical abnormalities that are

known or suspected should be scanned thoroughly. The entire oropharyngeal anatomy should be scanned if probable causes for swallow dysfunction are not known.

KUNNAMPALLIL GEJO JOHN, MASLP

 Anterior-posterior and lateral projections should be

taken with the patient breathing and vocalizing. The lateral swallow series then is videotaped, with special attention paid to the first swallow for evidence of barium aspiration at the epiglottis. During the second swallow, tongue and soft palate function is observed.

KUNNAMPALLIL GEJO JOHN, MASLP

During the third swallow, cricopharyngeal function is observed and the bolus is followed through the esophagus to the stomach to observe peristaltic contraction and lower esophageal sphincter function. Lateral projections allow measurement of contrast bolus transit times, clear visualization of contrast aspiration into the larynx and tracking of the bolus through all phases of the swallowing process. Swallow symmetry can be assessed during anterior-posterior projection; in most normal individuals, the bolus will move through the pharynx and into the esophagus in 2 halves.
KUNNAMPALLIL GEJO JOHN, MASLP

 Normal findings with barium contrast studies revolve

normal size, contour and function of swallowing anatomy. Different pathologies cause distinct types of atypial swallowing and barium contrast exams are an important tool in distinguishing causes.

KUNNAMPALLIL GEJO JOHN, MASLP

 for example, patients whose dysphagia is caused by

neurological pathologies experience more difficulty when swallowing liquids than solids. Therefore, the use of liquids and foods of varying thickness during MBS exams can provide clinically useful clues about the cause and location of underlying pathologies.

KUNNAMPALLIL GEJO JOHN, MASLP

 MBS is a highly sensitive test in the assessment of

physiological causes of dysphagia as welt as anatomical causes. The rest provides clinicians with significantly more information for therapy than other common diagnostic exams, such as traditional manometry.

KUNNAMPALLIL GEJO JOHN, MASLP

 . Some authors believe esophagcal manometry should

be the exam of first resort in the diagnostic assessment of motor dysfunction-related dysphagia (eg, hypomotility); however, normal clearance of barium contrast from the esophagus correlates extremely well with normal manometric findings.

KUNNAMPALLIL GEJO JOHN, MASLP

 Aspiration is not a cause of dysphagia but is a common

side effect. Aspiration can be subtle. Scales haw: been proposed to quantify and categorize the extent of aspiration. ( A light coating of the epiglottis is indicative of barium contrast penetration into the respiratory tract.

KUNNAMPALLIL GEJO JOHN, MASLP

 Presence of barium in the lower tracheobronchial tree

indicates major aspiration. Small amounts of barium contrast will not harm the patient, although this should be avoided in patients with chronic obstructive pulmonary disease (COPD; eg, advanced emphysema). The maximum volume of tolerable patient contrast aspiration is subjective and policies vary between institutions.

KUNNAMPALLIL GEJO JOHN, MASLP

 The oral, pharyngeal, PES, esophageal stages of

swallowing are precisely scheduled and syemetric and are redially appreciated radiographycally (Kurtis etal 1985). Interpretation is done in slow motion by swallowing stage, following a precise scheme of sequenced observation.

KUNNAMPALLIL GEJO JOHN, MASLP

 A normal individual is able to follow the instruction to drink

from a cup and to make a bolus of appropriate signs in a coordinated way. Liquid barium is not masticated or blended in oral cavity. The bolus should be well contained in the oral cavity (Hamlet etal 1988) on instruction too swallow the bolus should immediately be bought on to the posterior tongue. In the anteriopostriour view of tongue dorsum is grooved to cradle the bolus in the swallow preparatory position. Delay in transfer and jerky tongue or jaw movements are abnormal.

KUNNAMPALLIL GEJO JOHN, MASLP

 Pharyngeal swallow is then initiated. During eventual

oral processing of the bolus, there is superior, inferior, and some anteriopostriour movements of the hyoid bone. At the voluntary initiation of the pharyngeal swallow, however, the hyoid bone moves distinct superior and anterior. There is also a distinct opposition of the thyroid cartilage and the hyoid bone. The larynx and the pharynx with the PES moves superiorly (Palmer et al. 1988).

KUNNAMPALLIL GEJO JOHN, MASLP

 Peristaltic pharyngeal swallowing is probably caused by

bolus passage through the facial isthmus, between the tongue and the palate. Radiologically, it is convenient to use the beginning of the anterior hyoid movement as the starting point of the pharyngeal swallow. The tongue thrust propels the bolus posteriourly in to the pharunx and further down in to PES and cervical esophagus, assuming the pharyngeal constractor wall has normal compliance. The palatopharyngeal isthmuses closed by the elevation of the muscular palate and constrictor convergence, which is mostly medialword of the lateral wall. No regurgitation of barium in to the nasopharynx occurs in normal patients.

KUNNAMPALLIL GEJO JOHN, MASLP

 Closure of the airway occurs four anatomically distinct

and functionally separate levels, that are (1) the epiglottis (2) sub-epiglotic portion of the laryngeal vestibule, (3) the supra-glottis portion of the laryngeal vestibule (4) the vocal fold (Ardan & Kemb 1952,1956).

KUNNAMPALLIL GEJO JOHN, MASLP

 The closure is best assessed in the anteriopostriour

view. Closure of the airway starts at the vocal folds and progresses in superior direction in the peristaltic like manner.

KUNNAMPALLIL GEJO JOHN, MASLP

 During resting conditions between swallows, the epiglottis is

kept in an upright position. During swallowing, the epiglottis first attains a horizontal position and then an inverted position. The first movement of the epiglottis is passive and occurs synchronously with the elevation of the larynx. This movement is due to the anterior of the hyoid bone and the approximation of the thyroid cartilage to the hyoid bone.

KUNNAMPALLIL GEJO JOHN, MASLP

 The vestibule can be described as a bent tube, with an

angle of about 45 degrees. This angulations divides the vestibule anatomically in to a cranial and caudal segment. Simultaneous with the initiation of the pharyngeal swallow, there is an elevation of the pharynx and larynx, as well as an apposition of the thyroid cartilage to the hyoid bone by contraction of the thyroid muscle.

KUNNAMPALLIL GEJO JOHN, MASLP

 Normal pharyngeal constrictor activity is reflected in

several ways during swallowing. Normal tone keeps the pharynx as a relatively straight tube without flaccidity and outpunching. Therefore, the force created by the tongues thrust can act on the bolus, propelling it down to the esophagus.

KUNNAMPALLIL GEJO JOHN, MASLP

 . Contraction of the constrictors is then seen as a

peristaltic wave, stripping the barium from the pharynx and leaving only a thin coating on the mucosa. This peristaltic wave always is conspicuous in the frontal view and is regularly seen in the lateral view as a few millimeter deep, smooth indention traversing inferiorly.

KUNNAMPALLIL GEJO JOHN, MASLP

 The PE segment is composed of the most inferior

portion of the inferior constricto, the crycopharyngeous and the most superior portion of the cervical esophagus. Between swallowing, the PES provides a barrier to air reaching the esophagus during inspiration and keep refluxed or regurgitated material from the stomach and esophagus from entering the pharynx.

KUNNAMPALLIL GEJO JOHN, MASLP

 During swallow the PES open by a combined effect of

cessation of muscle tone elevation by the anterior movement of the hyoid bone and larynx, and by the instrumental pressure of the bolus. During normal conditions there should be no indication of crycopharyngeal muscle posteriourly in to the barium column when the PES is well distended.

KUNNAMPALLIL GEJO JOHN, MASLP

 In most persons there is a slight delay before the

peristaltic contraction continue in to cervical esophagus

KUNNAMPALLIL GEJO JOHN, MASLP

 Normal esophagus function is seen as a

peristaltic wave traversing from the cervical esophagus that is elicited by the pharyngeal peristalsis. During liquid barium swallow, normally only a thin coat of barium covers the mucosa. However, loss of peristaltic activity at the level of the aortic arch, were the transition between striated and smooth muscle occurs, is regularly seen and should not be considered abnormally.
KUNNAMPALLIL GEJO JOHN, MASLP

 In terms of what abnormality can be expressed in the

for anatomical levels, a rule of thumb is that dysfunction is by the far principal abnormality in the oral cavity and pharynx. In those with motility dysfunction in the PES, structural abnormalities may coexist. In the esophagus, structural abnormality predominate.

KUNNAMPALLIL GEJO JOHN, MASLP

 In the patients with neurogenic disease,

oral dysfunction regularly predominates over pharyngeal dysfunction. Incoordinated, jerky movements of the tongue and jaw and chewing jesters are abnormal when a liquid bolus is helps in the oral cavity. Delayed transfer of bolus with in the oral cavity in to ready to swallow preparatory position is abnormal.
KUNNAMPALLIL GEJO JOHN, MASLP

 And tongue can not displace the bolus

posteriourly. There is a strong correlation between an abnormal anterior movement of the hyoid bone and overall abnormal oral and pharyngeal function as well as defective opening of the PE segment. Abnormal initiation of the pharyngeal stage of swallow is easily appreciated when the bolus is conveyed in to pharynx with out the pharynx being elevated and without occurrence of conspectus indicator of a serious abnormality.

KUNNAMPALLIL GEJO JOHN, MASLP

 Abnormal hyoid movement is seen

either as lack of anterior displacement, or total absence of movement. Motion is also being delayed in relation to bolus positioning. I.e. the bolus is in the pharynx before the hyoid elevation.

KUNNAMPALLIL GEJO JOHN, MASLP

 This is an indicator of dissociation

between oral and pharyngeal stages and is a frequent cause of misdirected bolus. Absence of thyroid apposition is always abnormal and is often coincident with airway penetration.

KUNNAMPALLIL GEJO JOHN, MASLP

 Abnormal movement of epiglottis is common and

always indicative of pharyngeal dysfunction. Defective secoundary movements of the epiglottis from an horizontal to a inverted position is common. This is seen as the epiglottis remaining in the horizontal position. However there is a variety of abnormalities were epiglottis tilt down incompletely.

KUNNAMPALLIL GEJO JOHN, MASLP

 Defective closure of the supraglottic portion of the

laryngeal vestibule causes the bolus to reach the airway. In the majority of patients with abnormal closure of the supraglottic portion of the laryngeal vestibule, closure is accomplished too late. The barium will reach in to the lumen of the vestibule and either will be expelled superiorly in to pharynx or inferiorly in to trachea beyond the vocal folds.

KUNNAMPALLIL GEJO JOHN, MASLP

 Complete absence of closure of supraglottic vestibules

rare and is only seen in patients with a defective thyroid apposition. The closure of the supraglottic portion of the laryngeal vestibule is crucial to protection of the airway. When the bolus extents beyond the point it is a matter of chance whether it is expelled or reaches the trachea.

KUNNAMPALLIL GEJO JOHN, MASLP

 Pharyngeal constrictors playa a crucial role in

swallowing (Ekberg 1981) if constrictors muscles are paretic, the pharyngeal chamber undergoes an abnormal expansion during the compression phase of swallow. This lack of compliance may result in impaired transits of bolus from the oral cavity in to the esophagus, even if the tongue act as normal. Defective action of the pharyngeal constraction leads to retention of barium in the pharynx.

KUNNAMPALLIL GEJO JOHN, MASLP

 Failure of the PE segment to open may be seen in

neurogenic disease. The failure of the crycopharyngeal muscle to open or elongate may be due to (1) defective relaxation (2) defective distensability (3) hypertrophy, (4) fibrosis. These are commonly associated with abnormal motor function in the segment above and below.

KUNNAMPALLIL GEJO JOHN, MASLP

 Abnormal motor function of the esophagus is

radiologically demonstrated as absent or defective primary peristalsis or as increased or vigorous conditions. The opening of the lower esophageal sphincter may be abnormal, either in close or opening.

KUNNAMPALLIL GEJO JOHN, MASLP

Thank you

KUNNAMPALLIL GEJO JOHN, MASLP