Radiologic Evaluation of Swallowing: The Esophagram

Basic questions I: Dysphagia

Does food get stuck in your throat while you eat?

Where do you feel food sticking throat/thorax/stomach?

Does food come back into your throat/mouth after you swallowed?

Do you have to cut your food into small pieces?

Do you need to take a drink after swallowing solids?

Do you have to vomit occasionally? If so, when?

Do you suffer from too much saliva?

Do you have problems swallowing your saliva?

Do you suffer from hoarseness?

Do you suffer from a gargling voice?

Is there saliva on your pillow when you wake up in the morning?

Do you have hearing impairments?

Do you suffer from any neurological impairment?

Basic questions II: Suspicion of aspiration

Do you have to cough while drinking?

Do you have to cough while eating? Before drink/after swallowing?

Do you have to choke while eating/drinking?

Do you have to cough while choking?

Are you able to cough?

Do or did you suffer from pulmonary complications?

How do you drink? Out of a bottle/from a spoon/by a straw?

Is the symptom connected with respiratory problems?

Basic questions III: Globus sensation

Do you suffer from globus sensation or other related symptoms?

Are your symptoms present while you eat/without eating/both?

Do you suffer from a problem in your throat?

Do you feel a lump in your throat?

Do you feel an urge to clear your throat?

Do you suffer from too much phlegm in your throat?

Basic questions IV: Noncardiac chest pain

Do you feel pain behind the sternum after a swallow?

Do you suffer from noncardiac chest pain or related symptoms?

Do you suffer from heartburning sensations?

Do you suffer from reflux?

Auxiliary questions:

Did you lose weight?

What is your body mass index?

Do you suffer from any mood changes?

Did other changes occur, e.g., in speech, walking, writing, cognition, affection?

For how long do the symptoms impair your quality of life?

How much is your quality of life impaired by your symptoms?

Do you go out to eat and drink with other persons?

Can you eat by yourself or need someone’s help?

How long does it take for you to finish a meal?

What treatment did you have so far? (medications, previous diagnostic studies, functional swallowing therapy)

What do you eat for breakfast/lunch/dinner?

Do you use compensatory strategies?

Do you suffer from nasal regurgitation?

Do you have a dry mouth?

Do you feel the food going down when you swallow? Do you feel an obstruction for solid food and/or liquids?

This will enable the radiologist to custom-tailor the radiologic examination. If the patient is oriented in time and space and gives a reliable impression he/she is questioned directly. Otherwise an accompanying person is questioned according to the below scheme. Adapted from [5]

Radiologic Equipment

A fluoroscopic unit that includes remote control is mandatory. Spot-film imaging is also important for documentation of anatomy. Videorecording is important for functional evaluation. Modern image intensifiers have a high spatial and contrast resolution. This equipment enables high-quality videorecording which actually makes interpretation easy. Moreover, with a high-quality digital system it is not necessary to use conventional cassette films anymore. Flat-panel detectors (FPD) are solid-state X-ray digital radiography devices similar in principle to the image sensors used in digital photography and video. Amorphous selenium FPDs are X-ray photons converted directly into charge. Flat-panel detectors are sensitive and fast. Their sensitivity allows a lower dose of radiation [6, 7]. They are lighter, smaller in volume, and more accurate. FPD has replaced videofluoroscopy. Therefore the radiologic evaluation should be integrated in the RIS/PACS system of the radiologic department. Recording should be obtained continuously. It is important to monitor all swallows, particularly the first swallow as this often appears to be the worst swallow.

Radiologic Examination Technique: A Practical Approach

The radiologic examination has to include all structures involved in swallowing from the lips to the stomach. But according to the above clinical history the examination is usually focused on one or two specific areas. If there is a high suspicion of misdirected swallowing, the laryngeal vestibule should be included from the beginning in lateral projection. It is very common that the first swallow is the worst swallow, and that only the first swallow will reveal misdirected swallowing. On the other hand, in a patient with suspected misdirected swallowing, it is important that at the end of the examination when the esophagus has been examined and the patient has swallowed several boluses the status in the laryngeal vestibule should be documented, because sometimes the misdirected swallowing is revealed only at the end. In patients with a suspicion of esophageal abnormalities it is important to start the examination with evaluation of the esophagus. That could even mean starting with a solid bolus before the esophagus is extended by air or too much barium is retained.

It is important to distinguish between two types of radiologic examinations. One is custom-tailored for revealing the cause of the patient’s symptoms, which means the worst swallow. The other examination is the therapeutic swallowing study which is custom-tailored by either introducing maneuvers or different viscosities or other boluses for compensation of abnormalities [8]. This therefore can be described as how to achieve the best swallow. Different modes of decompensating a compensated swallow are also important [9]. It is always important to observe many swallows because dysfunction may be intermittent.

Radiology of swallowing relies on a systematic approach. One has to look specifically at certain areas of the swallowing apparatus. These can be divided into seven functional units, namely [1] tongue, [2] soft palate, [3] epiglottis, [4] hyoid and larynx, [5] pharyngeal constrictor, [6] pharyngoesophageal (PE) segment, and [7] esophagus.

Fluoroscopy has to begin before the ingestion of the bolus. Fluoroscopy of the pharynx should also include a few seconds after the passage of the bolus into the esophagus. It is important not to change the position of the central beam during fluoroscopy because otherwise the anatomic details will be unsharp. The bolus should enter and leave the film sequence. The central beam should not follow the bolus. However, in the esophagus in the prone position, the bolus moves slowly at a speed of 1–4 cm/s and should be followed by the central beam from the pharynx to the stomach.

Contrast Medium

  1. (a)



High-density barium (HD) is used for evaluation of the morphology and function of the tongue, soft palate, epiglottis, hyoid and larynx, pharyngoesophageal sphincter, and esophagus. Low-density barium (LD) is used for evaluation of the contracting wave in the pharynx and peristaltic wave in the tubular esophagus. The esophagus should be evaluated in the prone right anterior oblique position. It should also be evaluated, if possible, in an erect position.

  1. (b)

    Water-soluble contrast agents


Low-osmolar iodinated (WL) contrast agents are used if aspiration or a tracheoesophageal fistula is suspected. Iso-osmolar iodinated (WI) contrast agents should be used if the patient has restricted pulmonary function and aspiration is suspected. It should also be used in children under 3 years of age. Hyperosmolar iodinated contrast medium should not be used.

  1. (c)



A solid bolus (S) should always be given if a stricture or solid-bolus-induced spasm is suspected. This means that if there are symptoms of solid-bolus dysphagia, the solid bolus should be used. The solid bolus can be in the form of a bread sphere coated with barium. Another option is a tablet with approximately 13 mm diameter, for example an antacidum. The test is positive if the solid bolus stays in the esophagus for longer than 30 s in spite of oral intake of fluid. The obstruction can be due to spasm or hypomotility which can be difficult to reveal. It can also be due to a stricture. In patients with strictures this small solid bolus usually does not give any symptoms while spasm or hypomotility or in fact hypersensitivity usually is symptomatic.

A semisolid bolus (SS) , i.e., paste or pudding (with barium) or other consistencies, may also be used. Typically patients can safely swallow boluses of a specific consistency whereas aspiration occurs with less viscous consistencies.

Amount of Contrast Medium

The normal bolus in an adult is about 15 ml. However, a much larger bolus can be swallowed. Sometimes a small bolus like 5 ml can be harder to swallow than a bigger bolus. Also the chemical constituency is of importance.

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Jan 31, 2018 | Posted by in ABDOMINAL MEDICINE | Comments Off on Radiologic Evaluation of Swallowing: The Esophagram

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