Modified Barium Swallow Study:

Abnormal or Normal Swallowing

Chelsley Tuttle
March 14, 2010
Audience and Scope

The purpose of this article is to inform prospective Speech-Language Pathologists (SLPs)

about a Modified-Barium Swallow Study (MBSS) that is used in studying the swallowing
process. The swallowing process, consisting of four stages, will be discussed in order to
determine what is being seen on the MBSS. A MBSS is essential in determining if there
is an obstruction of some kind in someone’s swallow. This is an extremely vital process
that future SLPs will need to use in order to help prevent possible weight loss from a lack
of nutrition or possible death, due to aspiration (choking) pneumonia. An article such as
this would be found in a Dysphagia (swallowing) Manual or Graduate Level Coursework.

Introduction

The Modified Barium Swallow Study is a procedure used for

assessing dysphagia (difficulty swallowing) in patients of all
ages. The MBSS process is an important tool for
distinguishing normal swallows compared to those that have
abnormal structures and functions occurring throughout the
swallow. This study is done with a Speech Pathologist and a
Radiologist. Figure 1 shows an x-ray of a Modified Barium
Swallow.

Source: Page, 2006

Figure 1 – MBSS x-ray

Process of Swallowing

When watching a MBSS it is necessary to know what to be looking for, which is the
swallow itself. Normal swallowing is usually a very rapid, almost instantaneous activity
which will be broken up into four different stages:
- The Oral Preparatory Stage
- The Oral Phase of Swallowing
- The Pharyngeal Stage of Swallowing
- The Esophageal Phase
These anatomical structures are listed below (see Figure 2).
If the swallow does not follow these stages, it becomes an abnormal swallow which can
lead to drastic scenarios that a Speech Language Pathologist ultimately wants to stay
away from. These stages vary amongst each other according to the characteristics of the
bolus (ball of food).

Oral Preparatory Stage

This stage is characterized by the breaking down of foods to a consistency that is suitable
for swallowing. Saliva is added to this mixture, along with the movement of the teeth
and jaw to break down the food properly, while the lips provide a seal and the tongue
helps control the bolus. If there happens to be poor dentition or lack of dentures it can
alter this process. One can still breathe through their nose during this portion of the
swallowing stage.

Oral Phase of Swallowing

This stage beings the swallow and lasts about 1 second. This allows for the tongue to
move the bolus or liquid to move to backwards towards the pharynx. The tongue tip is
elevated and rolling backwards squeezing the bolus back, where the soft palate closes to
seal the nasal passage.

Source: Purves et al, 4th edition

Figure 2 – Anatomy used in swallowing

Pharyngeal Stage of Swallowing

This portion of the swallow is involuntary and is very important that the series of events
happens accordingly in order to avoid aspiration. The velum is elevated in order to open
the pharynx. Respiration ceases, so the bolus does not go into the lungs and cause
aspiration. The posterior (back) portion of the tongue moves the bolus posteriorly into
the pharynx. Laryngeal framework is pulled up and hyoid is rotated in order to have the
epiglottis invert (close) so foreign objects do not enter, but continues and slides right over
the epiglottis and gets to the super esophageal lumen. The tongue base retracts, as well as
the pharyngeal muscles, to allow the bolus to squeeze cleanly through the pharynx. This
is where the cricopharyngeus muscle relaxes to allow food to pass to the esophagus and
then contracts again.

Esophageal Phase
This is the slowest of all stages and begins as the bolus passes the cricopharyngeus
muscles. The esophagus carries the bolus to the stomach by gravity and peristalsis
(contractions of muscles, causing item *bolus* to continue moving downward).

Why is a MBSS needed?

A Modified-Barium Swallow Study is necessary in order to determine if a patient has an

abnormal swallow or not. An abnormal swallow can result in a patient being
embarrassed of their effortful swallow, causing them to not eat as much as they should,
allowing them to have possible weight loss. It is also possible that these patients will
aspirate on their food, causing serious problems.

Normal, safe swallowing habits are dependent on the following:

- intact oral and pharyngeal structures
- accurate and timely muscular coordination and activity
- intact sensory receptors and feedback

All of these habits can be identified by the MBSS, allowing a Speech Language
Pathologist to try and prevent further difficulty for the patient to swallow.

MBSS Procedure

This procedure is an x-ray study of the swallowing function that is performed by a speech
pathologist and a radiologist. The entire test will last approximately 15 minutes, while
the radiologist takes moving x-ray images of the patient swallowing food or liquid that is
mixed with barium in order to have it show up on the x-ray.

The Speech Language Pathologist (SLP) directs the order of sequence and trials of food
and liquid throughout the exam. It is the SLP’s primary job to read the results, to dictate
them to other care givers, and to follow up with a plan of treatment, usually determining
what type of diet the patient will be on.

Prior to the exam, the Speech Language Pathologist must look at the patients’ history
record and determine what their difficulties may be. Often times, it is here that the SLP
is able to find out if the patient is having trouble with certain foods, causing them to feel
as if something is stuck in their throat, see if they are having difficulty with the amount of
salvia in their mouth, etc. It is also a good idea for the SLP to document if the patient
indicates that they avoid certain foods as well. A quick evaluation of the oral cavity is
done to see if there are any obvious neurological indications that could be causing the
patient to have difficulty swallowing.

The patient is then positioned in the fluoroscopy equipment, which consists of the x-ray
machine and a computer based program that shows the visual swallow. The patient
remains standing and is aligned properly by the Radiologist in order for their profile,
lateral plane, to be examined on the computer screen that the Speech Language
Pathologist is looking at.
An SLP generally is the one who feeds the patient the varying consistencies of liquid and
food that contain barium, so the swallow is visible on the x-ray. The consistencies that
are given to the patient usually include a thin liquid, a nectar thick liquid, a cracker, and a
pureed substance, like pudding. This gives the SLP a variety of consistencies to try and
determine which ones the patient has more difficulty with.

As the patient is fed these items, the SLP and Radiologist are watching the computer
screen to see if the patient can form a bolus properly and is watching as the substance
enters the pharynx and on down through the swallowing process. The MBSS allows the
SLP and Radiologist to see if and where there is a problem occurring. Once this is
determined the SLP generally alters the patients diet if that is what needs to be done, or
even suggests therapy.

To see a modified barium swallow click on the following link (Rossino, 2006).

Conclusion

The Modified Barium Swallow Study is done under the direction of a Speech-Language
Pathologist and a Radiologist operating the equipment. The results gathered from a
MBSS determine appropriate oral diets for those patients who struggle with swallowing.
It also may determine whether or not a patient may need another means of feeding, such
as tube feeding, due to the fact that they are obstructing their airway and even the
slightest change in their diet would not be beneficial. The Modified Barium Swallow
Study is a study that is extremely useful and definitely helps alter and save the lives of
those struggling with dysphagia.
 Works Cited

Figures:
http://images.google.com/imgres?
imgurl=http://www.cartage.org.lb/en/themes/sciences/LifeScience/GeneralBiology/Physi
ology/DigestiveSystem/ComponentsDigestive/swallow_1.gif&imgrefurl=http://www.cart
age.org.lb/en/themes/sciences/LifeScience/GeneralBiology/Physiology/DigestiveSystem/
ComponentsDigestive/ComponentsDigestive.htm&usg=__g6sFCDvINomY1iPUdZ6pKq
La2lk=&h=321&w=534&sz=31&hl=en&start=1&um=1&itbs=1&tbnid=uYntjO_Z0tFo
DM:&tbnh=79&tbnw=132&prev=/images%3Fq%3Dswallowing%26um%3D1%26hl
%3Den%26client%3Dfirefox-a%26sa%3DN%26rls%3Dorg.mozilla:en-US:official
%26tbs%3Disch:1

http://www.radiographicceu.com/article23.html

Link to video:

http://video.google.com/videoplay?
docid=4375530805602416900&ei=QgiQS8CIHJu2qwLpo4WTBQ&q=modified+barium
+swallow&client=firefox-a#

Information:

http://www.dukehealth.org/health_library/care_guides/cancer/treatment_instructions/videofluoro
scopicswallowstudy

http://www.nidcd.nih.gov/health/voice/dysph.htm

Ferrand, C. T. & Bloom, R. L. (1997). Introduction to organic and neurogenic disorders of

communication. Boston: Allyn and Bacon