Videofluoroscopy: Are Your Exam Protocols “Giving” Your Patients Dysphagia?
In 1999, I decided to leave my clinical position as a speech-language pathologist and pursue my Ph.D. in dysphagia. When returning to the university setting, I knew there would be opportunities to teach students and other clinicians alike, so I thought it would be a good idea to tape a normal videofluoroscopy. And who better to serve as the “normal example” than me?
With the cooperation of my radiologist colleague, I set out to perform the perfect normal videofluoroscopy examination, which consisted of swallowing different consistencies and demonstrating various maneuvers.
Residue Present in Videofluoroscopy Exam
Imagine my horror when I discovered a small, but not insignificant, amount of residue in my pyriform sinuses – just above my UES – after single sips of liquid barium! I was not aware that I might have dysphagia, could not feel this residue, and had no explanation for finding abnormalities in my own swallowing (other than seasonal allergies and a stuffy nose).
During several teaching engagements, I used this video to explore clinician reactions to my swallowing. Pairing the video with a generic story about a middle-aged woman with a feeling of food sticking in the throat, I confirmed that clinicians considered my swallowing to be abnormal. It was amusing to hear the variety of proposed interventions before revealing the truth!
A Second Test Shows Conflicting Results
In 2012, I once again had an opportunity to undergo a videofluoroscopy as part of a colleague’s research study on nominally healthy individuals. Imagine my delight to discover I was “cured” and presented with a completely healthy swallow with no residue! What had changed over the 13 years between these examinations?
What Changed Between the Two Exams?
A critical difference in the way these two videofluoroscopy exams were performed can explain the difference in the residue, or lack there of, seen in my pharynx.
- In 1999, we prepared barium by taking a jug of liquid barium suspension off the shelf in the radiology suite and adding water until we felt it “looked like a thin liquid.”
- By 2012, barium preparations specifically designed for imaging of the oropharynx were commercially available, and in my own practice we had developed very strict standard operating procedures and recipes for preparing low-density barium that wasn’t supposed to coat the pharyngeal mucosa.
I concluded that the historic practice of eyeballing barium recipes led to situations where we confused barium coating for residue. That is, we created false positive impressions of swallowing impairment!
Standardizing Videofluoroscopy Protocols and Procedures
Today, we understand that standardization in videofluoroscopy protocols and procedures is essential for accurate detection of impairment in our patients. Making sure the barium is appropriately prepared is only one of the aspects of videofluoroscopy that needs to be standardized.
