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

Routine Projections (ARRT Required)

Lateral Projection

CR Location & Positioning

• SID: 40–48 inches
• Patient position: Upright, seated laterally to the IR or fluoroscopic tower
• Adjustments: Chin slightly elevated; midsagittal plane parallel to IR; arms relaxed at sides
• CR: Perpendicular, directed to oropharyngeal region at level of C4–C6
• Patient instructions: Swallow on command when given food or liquid bolus
• Exposure: Continuous fluoroscopic recording during swallowing

Evaluation Criteria

• Coverage (what anatomy must be included and how you verify it’s complete): Oral cavity, pharynx, larynx, trachea, and cervical esophagus included.
• Rotation checks (how symmetry or alignment tells you if positioning is correct): Mandible and vertebral bodies superimposed; shoulders aligned.
• Motion checks (how sharpness confirms patient cooperation/exposure timing): Sharp anatomic detail of epiglottis, tongue, and bolus; minimal blur.
• Technique checks (what contrast, density, soft tissue visibility, and artifacts to look for): Adequate contrast for soft-tissue visualization; bolus clearly outlined.
• Clinical aim (when applicable, e.g., reflux, obstruction, displacement, etc.): Evaluate swallowing sequence, penetration, and aspiration risk in real time.

Supplemental Projections

AP Projection

CR Location & Positioning

• SID: 40 inches
• Patient position: Upright, facing the x-ray tube with back against upright detector
• Adjustments: Midsagittal plane centered; chin slightly elevated; shoulders relaxed
• CR: Perpendicular at C4–C6
• Patient instructions: Swallow on command when directed
• Exposure: Fluoroscopic recording during swallowing

Evaluation Criteria

• Coverage: Pharynx, larynx, and upper esophagus visible.
• Rotation checks: Trachea midline; mandible and hyoid symmetric.
• Motion checks: Bolus path and soft-tissue movement sharply visualized.
• Technique checks: Proper kVp to demonstrate soft tissues and airway; no overexposure.
• Clinical aim: Assess symmetry of bolus passage and pharyngeal wall motion.

Procedure Adaptation

• Pediatrics: Use small bolus volumes and thickened consistencies; maintain child comfort and cooperation.
• Geriatrics: Minimize study length due to fatigue; provide seating support.
• Tracheostomy patients: Use suction precautions and modified bolus as directed by SLP.
• Non-ambulatory patients: Perform in wheelchair or stretcher using 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 semisolids (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.

Memory Aids

• “Lateral for Larynx” – The lateral view shows airway protection and aspiration clearly.
• “SLP Leads” – The Speech-Language Pathologist directs bolus size, texture, and timing.
• “Barium Bright, Airway Light” – Barium shows as bright contrast; airway remains radiolucent.
• “C4–C6 Centering Rule” – CR centered at the pharyngeal level of C4–C6 for all projections.