C. Aspiration
Discussion
The modified barium swallow study demonstrates silent aspiration of
thin liquids, nectar thick liquids and puree. Mild tertiary
contractions, slow bolus passage from the esophagus to the
gastroesophageal junction, and contrast entering the right and left
mainstem bronchi is observed. The patient has significant
oral-pharyngeal dysphagia evidenced by decreased tongue base retraction,
absent epiglottic inversion, incomplete laryngeal vestibule closure,
and decreased upper esophageal sphincter opening, all likely
attributable to late effects of radiation therapy.
Deglutition (or swallowing), facilitates the passage of food and
fluids from the mouth, through the pharynx and into the esophagus, while
closing the epiglottis.1 The four phases of swallowing
include the oral preparatory, oral, pharyngeal, and esophageal phases.
Swallowing begins with the voluntary oral phases, after which there is
an involuntary reflex that involves rapid and accurate coordination
between sensory input and motor function.2 This involves cranial nerves V, VII, IX, X and XII.
Patients with neurological deficits may have difficulty with either
the oral phase or the pharyngeal phase or both. Impaired tongue
movement while chewing or swallowing can cause food to fall into the
pharynx and into the open airway before completion of the oral phase. A
delayed pharyngeal swallowing reflex can cause food to fall into the
airway. Decreased peristalsis in the pharynx can leave residue in the
pharynx after swallowing, which can fall into or be inhaled into the
airway. Dysfunction of the larynx or cricopharyngeus muscle can cause
decreased airway protection during swallowing and hence lead to
aspiration causing pneumonitis or aspiration pneumonia.
Long term complications of head and neck cancer treated with
chemo-radiotherapy and surgery may include dysphagia and aspiration.2 Silent
aspiration is the penetration of food below the level of the true vocal
cords, without cough or any outward signs of difficulty.3 Patients
with silent aspiration may not show any signs of aspiration during a
clinical exam but it can be detected by the modified barium swallow
study.2
The modified barium swallow study (MBSS), also known as video
fluoroscopic swallow study (VFSS) uses barium and fluoroscopy to
evaluate the physiologic and anatomic components involved in the
swallowing process, as well as the integrity of airway protection.4,5
It is a non-invasive test with low dose radiation which helps
determine which solid or liquid consistencies are suitable for the
patient to ingest with the aim of preventing aspiration.1
Although the standard bedside swallow exam can identify patients who are
at risk for or who have dysphagia, studies have shown that in
comparison to a modified barium swallow study, the bedside exam is
neither very sensitive nor specific in detecting aspiration.4
A combination of the modified barium swallow study and regular
swallowing therapy can restore oral intake in more than 85% of
dysphagic, neurologically impaired and surgically treated patients who
have had head and neck cancer. In the absence of the MBSS, precise
swallowing therapy cannot be planned and there would be an increase in
time and money spent in attempting to evaluate and treat dysphagia.
(Choice A) Schatzki’s ring is a circumferential submucosal ring at
the gastroesophageal junction. Most frequent presenting symptoms are
progressive dysphagia to solid foods and commonly associated with
improperly chewed meat, described as a sensation of food sticking in the
chest. Barium swallow shows a concentric ring at the gastroesophageal
junction.
(Choice B) Diffuse esophageal spasm is a motility disorder
characterized by intermittent uncoordinated contractions of the
esophagus. It commonly presents with dysphagia to solids and liquids,
and atypical chest pain. Barium swallow shows a typical appearance of
repetitive, non-peristaltic contractions that produce a "corkscrew"
appearance.
(Choice D) Zenker’s diverticulum is a sac-like posterior outpouching
of the mucosa and submucosal layers (false diverticulum), in the
hypopharynx. It typically presents with a history of dysphagia followed
by as sensation of food stuck in the throat and halitosis. Barium
swallow delineates an outpouching lesion in the hypopharynx.
(Choice E) Esophageal achalasia is a motility disorder characterized
absence of esophageal peristalsis and failure of relaxation of the lower
esophageal sphincter. It typically presents with dysphagia for solids
and liquids, regurgitation of undigested food, heart burn and chest
discomfort. Barium swallow typically shows narrowing at the
gastroesophageal junction in a "bird beak" configuration with proximal
dilatation of the esophagus.
References
-
Peterson R. Radiologic Technology 2018: 89(3): 257-275.
-
Lee S-Y, Kim BH, Park YH. Analysis of dysphagia patterns using a
modified barium swallowing test following treatment of head and neck
cancer. Yonsei Medical Journal 2015; 56(5): 1221-6.
-
Teasell RW, McRae M, Heitzner J, et al. Frequency of
videofluoroscopic modified barium swallow studies and pneumonia in
stroke rehabilitation patients: a comparative study. Arch Phys Med
Rehabil 1999; 80: 294–8.
- Martin-Harris B, Logemann JA, McMahon S, et al. Clinical utility of
the modified barium swallow. Dysphagia 2000; 15(3): 136–141.
-
Brady S, Donzelli J. The Modified barium swallow and the functional
endoscopic evaluation of swallowing. Otolaryngologic Clinics of North
America 2013; 46: 1009-1022.