Indications, Contraindications, and Patient Preparation

Indications

Evaluation of swallowing function in patients with:

• Stroke or neurological disorders (e.g., Parkinson’s disease, ALS, MS)
• Head/neck cancers or surgery
• Dysphagia (difficulty swallowing)
• Recurrent aspiration pneumonia
• Developmental or congenital swallowing problems (pediatrics)

Contraindications

• Severe aspiration risk (determined by physician/Speech-Language Pathologist [SLP])
• Inability to sit upright for study (unless modifications possible)
• Barium contraindicated if suspected perforation — water-soluble contrast may be used

Patient Preparation

• No specific dietary restrictions (unlike UGI or esophagram)
• Patient may need to bring dentures if normally worn for eating
• Explain the exam: patient will swallow small amounts of barium-coated food/liquids while imaging is recorded
• Performed in collaboration with a Speech-Language Pathologist (SLP), who prepares consistencies and directs swallowing tasks

Projections / Imaging Procedure

Lateral Projection (Primary)

CR Location & Positioning

• SID: 40–48 inches
• Patient position: Upright, seated in lateral position relative to IR or fluoroscopic unit
• Adjustments: Chin slightly elevated, MSP parallel to IR, arms relaxed at sides
• CR: Perpendicular, directed to oropharynx region at level of C4–C6
• Pt. Instructions: Swallow on command when given food/liquid bolus
• Exposure: Fluoroscopic recording during swallowing

Evaluation Criteria

• Visualization of oral cavity, pharynx, larynx, cervical esophagus
• Movement of barium bolus from mouth → pharynx → esophagus
• Detection of penetration into larynx or aspiration into trachea
• Documentation of effectiveness of swallowing maneuvers

AP Projection (Supplemental)

CR Location & Positioning

• SID: 40 inches
• Patient position: Upright, facing tube, back against upright detector
• Adjustments: MSP centered, chin slightly elevated
• CR: Perpendicular at C4–C6
• Pt. Instructions: Swallow on command
• Exposure: Fluoroscopy during swallowing

Evaluation Criteria

• Demonstrates symmetry of bolus passage
• Assesses lateral pharyngeal wall motion and aspiration

Procedure Adaptation

• Pediatrics: Smaller bolus amounts, thickened liquids or soft solids; high cooperation needed.
• Geriatrics: Consider fatigue — study may need to be shortened.
• Tracheostomy patients: May require suction and modified bolus preparation.
• Non-ambulatory patients: Study can be performed in wheelchair or stretcher with lateral orientation.

Exposure Factors & Technical Considerations

• SID: 40–48 inches
• kVp: 80–100 (lower than UGI to enhance soft tissue and airway visualization)
• mAs: Very low — fluoroscopic recording captures motion
• Contrast:
  • Thin liquid barium
  • Thickened barium (nectar, honey consistency)
  • Barium-coated foods (applesauce, cookie, cracker)
• Collimation: Include oral cavity through cervical esophagus
• Recording: Digital video capture is standard for SLP review

⚠️ Safety Note:
Barium is non-toxic to the respiratory system. If aspirated, it is less likely to cause pneumonia than water-soluble iodinated contrast. For this reason, barium is preferred for swallowing studies, except in cases where perforation is suspected, in which case iodinated contrast must be used.