Shake, Rattle and Roll: When Swallowing Becomes Complicated

By Mary Jo Cartoni, M.A., CCC-SLP

Before I became a speech-language pathologist (SLP), I never realized how complicated the seemingly simple act of swallowing was for some patients, particularly those with Parkinson’s Disease. These are some answers to frequently asked questions about what to do if you suspect a swallowing problem.

WHAT IS AN MBSS AND HOW DO I GET ONE?

A Modified Barium Swallow Study (MBSS) aka 'videofluoroscopic swallow study' (VFSS) is something your primary care physician can order.

Normal swallowing consists of three phases:

Phase 1: Oral

Phase 2: Pharyngeal

Phase 3: Esophageal

The MBSS is a very simple diagnostic test that looks at the first two phases of swallowing: the oral and the pharyngeal phases. It is sometimes confused with a "Barium Swallow Study" (aka an 'esophagram') which examines the third (final) phase of the swallow, the esophageal phase.

Be sure a Barium Swallow Study isn't inadvertently ordered if an MBSS is, in fact, the desired test. It happens more often than one might expect (even though the MD knows which is which, sometimes the person entering the order into a computer makes the wrong menu selection, since the names of these tests are so similar).

HOW CAN I TELL IF MY SWALLOWING PROBLEM IS LIKELY TO BE OROPHARYNGEAL OR ESOPHAGEAL?

A general rule of thumb is that when someone has difficulty swallowing liquids, the trouble is often an oropharyngeal issue. Conversely, when someone has trouble swallowing solid foods, this is often an esophageal problem. Of course, there are always exceptions. For example someone with poor dental health or someone who has weakened oral muscles due to a stroke, might have a problem with solid foods resulting in an oral phase problem. Conversely, some people with certain types of esophageal phase dysphagia have difficulty with liquids as well as with solids. Your ordering physician will be able to make the best recommendation in re: to this.

WHO WILL BE PERFORMING THE MBSS?

Speech-language pathologists do MBSS and gastroenterology (GI) physicians do the esophagrams. People are sometimes surprised that SLPs evaluate and treat dysphagia (swallowing disorders), but when you think of it, the structures used for speech and voice are very much those used in the oral and pharyngeal phases of the swallow. Currently in hospital settings, I'd estimate that 80-90% of the patients SLPs see daily are those with dysphagia. In my experience as an SLP, swallowing has really taken precedence over communication and cognition in the acute care setting in the past 20 years.

WHAT IS IT LIKE TO HAVE A MODIFIED BARIUM SWALLOW STUDY?

There's no preparation for the MBSS. You can eat before the test but don't be too full to eat/drink more when you get there. Those who need dentures or partials to eat just need to have to have them handy. Patients must be able to follow directions (e.g., if someone isn't a fluent English speaker, we'd need to line up a translator in advance of the study; or if they have a hearing problem, they need to have their hearing aids, or the instructions can be written as needed). Patients have to be able to swallow well enough to participate in such an exam. For example, if dysphagia is very severe, (i.e., the patient is not able to reliably produce a swallow) this test is not appropriate, because swallowing has to be possible in order to obtain useful information from this test.

Typically during the MBSS, the person is asked to eat various consistencies of solid foods (for example, something mushy like apple sauce; something soft but that requires chewing like fruit cocktail; and something hard and dry like graham crackers). They are also asked to swallow liquid textures such as water and/or soda--and if needed, thickened liquids (often thickened apple juice). A little barium is added to each of the textures of foods/liquids that are trialed and the person is observed under fluoro (a type of x-ray) as they chew and swallow each bite/sip. They may be asked to drink from a spoon, cup and/or straw. The person may also be asked to swallow a barium pill to evaluation pill swallowing.

IN GENERAL, WHAT ARE THE OBJECTIVES OF AN MBSS?

1. To determine the presence/absence of "penetration" (when material approaches the airway (wind pipe) but does not go below the level of the vocal cords) and/or "aspiration" (when material enters into the airway below the level of the vocal cords) and whether this is "silent" (no cough response) or if a reflexive cough or throat clear is generated / how effective this was in clearing the material.

2. To determine the specific reasons for penetration/aspiration, if present. That is, what specific aspect(s) of the oropharyngeal swallow is/are not working correctly and thereby resulting in penetration/aspiration?

3. To determine the effectiveness of various compensatory strategies, for example, is it helpful to employ a head turn or tilt, chin tuck, multiple swallows, breath hold techniques, effortful swallow, throat clear, modification of the size of the sip or bite, texture variants, and others. Each technique targets the particular cause of penetration or aspiration, and for this reason, a chin tuck will not be helpful for everyone and in fact, can make aspiration worse in some people. The strategies selected to trial will be dependent upon the findings of the MBSS.

It's important to also realize that even though 3-5 minutes of images are usually obtained during an MBSS, it is in fact, a "snapshot" of a person's swallow. Other factors that can skew the findings can include presence/absence of fatigue; pain; whether a person is "on" of "off" medications, etc.

In a nutshell, the goals of an MBSS are:

1.) To tell if penetration/aspiration is present;

2.) If so, why it occurred (what part of the oropharyngeal swallow sequence wasn't working just right); and

3.) Which, if any, strategies or techniques are effective in preventing or limiting penetration/aspiration.

SHOULD I HAVE AN MBSS DONE FOR BASELINE INFORMATION BEFORE I HAVE SYMPTOMS OF DYSPHAGIA (SWALLOWING PROBLEMS)?

Getting an MBSS before it's really needed, is not necessarily a great idea. Presumably it will just show that you have a normal swallow. There is a substantial amount of fluoro exposure with these tests, so unless there is a specific problem to observe, it doesn't make sense to do one. People can have repeat MBSS when warranted, though. It's not as though you can only have one or two, but you need to be conservative re: their use.

AFTER THE MBSS, WHAT ARE MY OPTIONS?

There are a number of dysphagia therapy options. These are often initiated after the MBSS so that treatment focus may be directed at the problem areas of the swallow as identified by the evaluation. Over time, the effectiveness of such treatment can be impacted by any progressive aspects of the underlying diagnosis, but that shouldn't prevent anyone from initiating therapy, since the progression of such diseases/conditions can vary so much from one individual to another. Most of us would opt for doing whatever we can to maintain maximal swallow status for as long as possible. The SLP who performs the MBSS can make the best recommendations re: follow-up treatment options.

Postscript from Mary Jo Cartoni:

Because my focus was to tell you more about the MBSS, I realize that I neglected to mention that swallowing can also be evaluated clinically. In other words, an SLP can evaluate swallow function without diagnostic imaging, such as an MBSS, in an outpatient office visit, or at the bedside, if the person is a patient in the hospital. In fact, this type of clinical evaluation is often done first, with the MBSS following, as needed.

A clinical/bedside swallow evaluation is very similar to the MBSS in that the person is asked to swallow a variety of textures (but no barium needed) and is observed by the SLP for clinical signs and symptoms of aspiration (coughing, wet/gurgle-like vocal quality, throat clearing, etc.) Various swallowing techniques/strategies can be trialed, as with the MBSS, depending upon the results. The advantage of a clinical swallow evaluation is that there is no fluoro exposure. The disadvantage is that there are no images obtained. However, a clinical swallow evaluation can be very effective when performed by an experienced SLP.

In the hospital where I work, most of our in-patients are treated for swallowing based upon the results of their clinical swallow evaluations. Those patients that are more challenging to evaluate/treat clinically receive MBSS evaluations. With outpatients, often the person's MD has determined that an MBSS is the appropriate first step, and so in that scenario, the MBSS is performed rather than the clinical swallow evaluation.

http://katekelsall.typepad.com/my_weblog/2009/04/when-swallowing-and-breathing-get-out-of-sync.html