Pharyngeal and esophageal swallow technique

Where possible, the barium swallow should be performed with the fluoroscopy table in the erect position and ideally using a carbonated barium solution. Timing of the swallow for imaging is all important and it is of value when explaining the requirements to give the patient a trigger word such as telling them to swallow when they hear the word ‘now’ as in ‘swallow now’.

Before commencement of formal imaging, the patient is given an initial swallow of barium, and its passage to the stomach is screened to check there is no mechanical obstruction. The patient is placed in the right anterior oblique or lateral position as this projects the esophagus away from the spine and trachea. In this position, there is a better chance of differentiating barium in the trachea originating from a tracheo-esophageal fistula from that which has been aspirated. Regardless of the cause of the barium in the trachea, the patient will cough if that reflex is present. Coughing will result in the barium coating the trachea which might subsequently make it difficult to determine the cause for the barium being present.

Imaging

As an optimal minimum, imaging patients with high dysphagia should include videofluoroscopy or rapid imaging sequences of the pharynx (e.g. at least 3–4 frames per second). Videofluoroscopic assessment of swallowing disorders is expored further in Chapter 7.

The pharynx is examined in the lateral, the left or right anterior oblique, and the anteroposterior projection. The alternate oblique need only be considered if an abnormality is suggested. If pharyngeal imaging options are limited, the lateral projection provides the greatest breadth of information and can demonstrate aspiration and pharyngeal abnormalities such as pharyngeal pouch, webs, pharyngeal neoplasm, prominence of the cricopharyngeus (Figures 8.1, 8.2, 8.3, 8.4 and 8.5) and osteophyte impression.

Figure 8.1 Lateral pharynx – pharyngeal pouch.

Figure 8.2 Lateral pharynx – web demonstrated.

Figure 8.3 Lateral pharynx – carcinoma.

Figure 8.4 Anteroposterior pharynx.

Figure 8.5 Right anterior oblique pharynx – carcinoma.

Imaging of the esophagus, esophago-gastric junction and gastric fundus must always be included whether symptoms suggest high or low dysphagia. Turning the patient towards the right anterior oblique position will demonstrate the esophagus away from the spine (Figures 8.6 and 8.7).

Figure 8.6 Upper esophagus.

Figure 8.7 Mid esophagus.

Demonstration of the esophagus can be achieved by asking the patient to drink the barium and keep swallowing as quickly as possible. Esophageal distension is maintained by the second swallow inhibiting the first and the third inhibiting the second etc. If the patient cannot cope with continuous swallowing, the alternative is to take a number of separate swallows, overlapping imaging of the distended esophagus.

The importance of obtaining full distenson of the esophagus cannot be emphasized enough as plaque lesions can be missed (Figure 8.8). If full distension is not considered to have been achieved the swallow must be repeated.

Figure 8.8 Plaque tumor above hiatus hernia.

Subtle esophageal strictures may not demonstrate convincingly on a liquid barium swallow; in these instances asking the patient to swallow a small barium sulfate coated marshmallow can be effective in demonstrating the point of hold-up.

Separate images should be taken of the esophago-gastric junction (Figures 8.9, 8.10 and 8.11); the optimal degree of obliquity can be identified from the initial screened swallow. Additional images should be considered as appropriate if an abnormality is suggested.

Figure 8.9 Lower esophagus and gastro-esophageal junction.