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Online Only: Julia Gates, George G. Hartnell, and Gary D. Gramigna Videofluoroscopy and Swallowing Studies for Neurologic Disease: A Primer Radiographics 2006; 26: e22 [Abstract] [Full text]

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Videofluoroscopy and Swallowing Studies for Neurologic Disease

Siegfried Peer, MD   (10 March 2006)

Videofluoroscopy and Swallowing Studies for Neurologic Disease 10 March 2006
Siegfried Peer, MD, Radiologist Department of Radiology, Innsbruck University Hospital, Innsbruck Austria Send letter to journal: Re: Videofluoroscopy and Swallowing Studies for Neurologic Disease siegfried.peer{at}uibk.ac.at Siegfried Peer, MD	Editor: With great interest I read the article by Gates et al (1) on videofluoroscopy in patients with neurologic disorders. They state that this is a seldom taught procedure, practiced by few radiologists, which is true. Being part of a strong European tradition of videofluoroscopy, I would like to add some comments on their proposed examination protocol. First, I would like to see some advice for the less experienced radiologist on how individual swallows should be analyzed. While the oral and esophageal phases may be analyzed in real time or slow motion, a frame-by-frame analysis is absolutely mandatory for interpretation of the swallows, especially in patients with neurologic disorders of swallowing. The pharyngeal phase lasts only about 1 second but includes a variety of subtle actions triggered by different nerves and involves many small muscles with distinct functions. My second comment concerns the grading of aspiration. From my personal experience—but this is also stressed by experts in the field such as Ekberg (2) and Jones (3)—it is important to define the exact timing of aspiration. Does it occur before, during, or after the swallow? This is especially important in regard to rehabilitative measures and the choice of protective maneuvers the patient can use to avoid aspiration. References 1. Gates J, Hartnell GG, Gramigna GD. Videofluoroscopy and swallowing studies for neurologic disease: a primer. RadioGraphics 2006;26:e22. doi:10.1148/rg.e22. Published November 8, 2005. 2. Ekberg O, Pokieser P. Radiologic evaluation of the dysphagic patient. Eur Radiol 1997; 7:1285–1295. 3. Jones B. Normal and abnormal swallowing. 2nd ed. New York, NY: Springer, 2003. Drs Gates, Hartnell, and Gramigna respond: We thank Dr Peer for his interest in our article (1). Videofluoroscopy is fast becoming a dying art for radiologists in the United States; all too often, speech pathologists work independently or may “benefit” from the company of a technologist who is present only to “stand on the pedal.” Many radiologists are pulled in too many directions to lend detailed input or guidance for swallow studies. Ultimately, radiology residents suffer and are not well trained. To that end, we saw a need to fill a void with a primer rather than a definitive and comprehensive text. Thus, we focused on neurologic disorders, as these are the most commonly encountered causes of swallow abnormalities, and tried to formulate a straightforward, systematic approach. We do not disagree with Dr Peer’s opinion that a frame-by-frame analysis is extremely important. A detailed analysis occurs when the videotape is replayed over (and over). We certainly benefit from image manipulation in every study we analyze. These techniques include freeze-frame, frame-by-frame, and slow motion playback. Both the oral and pharyngeal phases can be studied; the timing and coordination of complex neuromuscular events can be evaluated. Unfortunately, we did not include the more subtle details in our primer because we considered them to be more than introductory (although our original manuscript does include discussion of this). When aspiration is graded, we do use a swallow checklist; the timing of aspiration is noted. This checklist is given in the Appendix of the article. Perhaps this was not strongly expressed, as Dr Peer seems to have some concerns. We completely agree with him; the timing of aspiration relative to swallow (ie, before: reduced lingual control; during: reduced laryngeal closure; after: reduced pharyngeal contraction) certainly affects behavioral swallow treatments. As Logemann (2) has stated, “The modified barium swallow is designed not only to assess whether the patient is aspirating, but also why, so appropriate efficient treatment can be initiated.” References 1. Gates J, Hartnell GG, Gramigna GD. Videofluoroscopy and swallowing studies for neurologic disease: a primer. RadioGraphics 2006;26:e22. doi:10.1148/rg.e22. Published November 8, 2005. 2. Logemann JA. Evaluation and treatment of swallowing disorders. 2nd ed. San Diego, Calif: College Hill Press, 1998.