The Procedure

Optimally, the examination is performed with the patient in an upright position, either sitting or standing.

The patient is first viewed in the lateral plane.
1. The fluoroscopic image should be manually collimated to include the lips anteriorly, the cervical spine posteriorly, the hard palate superiorly, and the cricopharyngeus muscle (upper esophageal sphincter) inferiorly.
2. The speech pathologist attempts to feed the patient small amounts of "foods" of different consistencies, such as thin liquid (barium), thick liquid (barium), and applesauce, mashed potatoes, or pudding marked with barium. Progression to larger-sized boluses depends on the patient's ability to handle the material without airway penetration or aspiration. The patient may be given bites of barium-coated cracker, chopped fruit, or bread to examine his/her ability to masticate foods.
3. The variety of food consistencies and volumes enables the speech pathologist to determine which foods best match the patient's swallowing capabilities and to plan individualized treatment strategies.
After the swallowing assessment in the lateral plane is completed, the patient may be turned 90 degrees and viewed anteriorly to evaluate the symmetry of oral and pharyngeal function during swallowing.
1. The fluoroscopic field of view (FOV) is manually collimated to exclude unfiltered x-rays at the sides of the neck which would degrade the image.
2. The cephalocaudad extent of the image should be from the hard palate to the sterno-clavicular joints.
3. During this part of the examination, the patient performs several swallows of thick barium while videofluoroscopy is done in the anteroposterior (AP) projection.
An important part of the modified barium swallow exam is the assessment of rehabilitation strategies.
1. Once the patient's oral and pharyngeal abnormalities are defined, compensatory and therapeutic techniques can be tried, and their effects can be assessed under fluoroscopy.
2. With the application of these techniques, the modified barium swallow is both an evaluative and a rehabilitative procedure.
If the patient is capable of swallowing barium and food without significant airway penetration or aspiration, the examination should not be concluded without evaluation of the esophageal phase of swallowing. For outpatients, however, this must be performed on a different day because of insurance billing issues.
1. It should be noted that referred symptoms are common and that esophageal disease is often manifested by pharyngeal or even oropharyngeal symptoms.
2. One of the most frequent reasons for failure to make a diagnosis in patients with swallowing disorders is failure to fully assess the esophagus for inflammatory, neoplastic, reflux, or motility disorders. (Refer to the Barium Swallow section for the technique of examining the esophagus).