The barium swallow test, also known as a modified barium swallow study, is an X-ray imaging procedure used to evaluate swallowing function. During the test, the patient ingests barium sulfate, a contrast material that shows up on X-rays. The radiologist then takes X-ray images and videos to observe the movement of the barium through the mouth, throat, and esophagus to detect abnormalities in the swallowing mechanism.
The barium swallow test has been used for decades to diagnose swallowing disorders, known as dysphagia. However, some medical professionals argue that this decades-old test may be outdated in the era of more advanced medical imaging techniques. This article will examine the pros and cons of the barium swallow test and whether it still has value in swallowing assessment today.
What is the barium swallow test?
As mentioned, the barium swallow test involves having the patient drink liquid barium and eat barium-coated foods while X-ray videos are taken. The barium shows up brightly on X-rays and allows the radiologist to clearly see the anatomy and function of the mouth, throat, and esophagus during swallowing.
Some key components of the barium swallow examination include:
– Observing the timing, coordination, and safety of the swallow
– Assessing the ability to keep food/liquid in the mouth and propel it backwards
– Watching the movement of the tongue and contractions of throat muscles
– Checking for food/liquid entering the airway
– Looking for pooling or retention of barium after swallowing
– Evaluating the effectiveness of strategies to improve swallowing
This test aims to determine if there are any abnormalities in the swallowing mechanism that need treatment or rehabilitation. It can detect issues like aspiration (food/liquid entering the airway), pharyngeal retention (pooling in the throat), impaired laryngeal elevation, and more.
What conditions can it help diagnose?
The barium swallow test can help identify many swallowing disorders, including:
– Dysphagia – Difficulty swallowing
– Oropharyngeal dysphagia – Swallowing problems in the mouth and throat
– Esophageal dysphagia – Impaired swallowing due to esophageal abnormalities
– Aspiration – Food/liquid entering the airway
– Pharyngeal retention – Pooling of food/liquid in the throat
– Cricopharyngeal dysfunction – Improper opening of the upper esophageal sphincter
– Esophageal web or rings – Abnormal tissue growth in the esophagus
– Esophageal stricture – Narrowing of the esophagus
– Achalasia – Failure of the lower esophageal sphincter to relax
– Esophageal carcinoma – Esophageal cancer
It can also help distinguish between an oral versus pharyngeal phase dysfunction. The barium swallow test is often used alongside endoscopy of the esophagus, stomach, and small intestine (EGD) for a comprehensive evaluation.
What are the potential benefits of the barium swallow test?
There are several potential benefits associated with the barium swallow examination:
Direct visualization of swallowing anatomy and physiology
The key advantage of this test is that it allows direct visualization of the swallowing structures and function. The coating of barium sulfate makes abnormalities in the esophagus and pharynx clearly visible on X-ray. The radiologist can pinpoint the exact location and nature of any dysfunction.
Ability to detect certain swallowing abnormalities
The barium swallow exam is considered the gold standard test for detecting aspiration, where food or liquid enters the airway. It is also superior for finding pharyngeal retention of food, strictures, webs, rings, and other anatomical abnormalities in the esophagus. Functional issues like impaired laryngeal elevation and cricopharyngeal dysfunction are also readily identified.
Observation of swallowing strategies
This test allows the radiologist and speech pathologist to observe the effects of different swallowing strategies on the patient’s ability to swallow safely and efficiently. Various solid foods and liquid consistencies can be trialed. Postural changes, swallow maneuvers, altered bolus size, and other techniques can be visualized to determine the best approach for the individual.
Supporting info for personalized treatment plans
The detailed imaging andvideo footage provides valuable information for developing personalized rehabilitation programs for dysphagia. Targeted exercises and swallowing techniques can be implemented based on the specific swallowing impairments identified.
Noninvasive and radiation exposure is limited
The barium swallow study is considered relatively noninvasive, especially compared to endoscopy exams. It does not require sedation or scope insertion through the mouth or nose. While it does use ionizing radiation, the amount is generally less than a CT scan or barium X-rays of the upper gastrointestinal tract. Radiation is limited by taking short video clips focused only on swallowing.
What are the main criticisms and limitations?
While the modified barium swallow study offers several benefits, it also has some notable drawbacks and limitations:
Doesn’t reflect typical eating conditions
A main criticism of this test is that having patients swallow barium in an unfamiliar radiology setting does not necessarily reflect their normal eating behavior. It lacks the social experience, distractions, variety of food textures, etc. found during regular meals. Any issues swallowing barium may not manifest during a typical meal.
Risk of aspiration
Having patients intentionally swallow barium does carry a small risk of aspiration, especially in those with dysphagia. While generally harmless, aspirated barium is difficult to clear naturally and increases infection risk. However, the test is done in a controlled setting with suctioning available if needed.
Radiation exposure
While less than many studies, there is still exposure to ionizing radiation from the X-ray imaging. This may limit how often the test can be performed, especially in more vulnerable populations like children and pregnant women.
Operator dependent
The accuracy of the test depends greatly on the skills of the radiologist and speech pathologist administering it. Their analysis of the swallowing footage is subject to human error and bias. Standardized protocols and proper training help increase consistency.
Doesn’t assess effects of strategies/treatments
The barium swallow test alone does not show the longer-term effects of rehabilitation strategies and treatments for dysphagia. Follow up exams would be needed to determine if swallow function improves with therapy over time. It provides a one-time snapshot.
Can only detect structural/functional abnormalities
While good for anatomical and mechanical issues, the barium swallow exam cannot identify neurological and muscular disorders impairing swallow function. It does not reveal the root neuromuscular causes of dysphagia on its own.
Possibility of false positive results
There is a chance for false positive results where the images suggest an abnormality that does not actually exist. Barium coating in normal structures could be mistaken for pooling, retention, or penetration into the airway.
Are there any modern alternatives or adjuncts?
The barium swallow study remains the gold standard imaging exam for dysphagia, but there are some advanced alternatives and adjunct tests that can provide additional information:
Fiberoptic endoscopic evaluation of swallowing (FEES)
This involves passing a fiberoptic endoscope through the nasal cavity to visualize the pharynx before, during, and after swallowing. Can be combined with barium swallow for complete view.
High-resolution manometry (HRM)
Precisely measures pressure activity in the esophagus. Useful for identifying causes of dysphagia like achalasia, although limited view.
Electromyography (EMG)
Records electrical activity of swallowing muscles. Can help pinpoint neuromuscular disorders not seen on barium swallow.
Videofluoroscopic swallow study (VFSS)
Alternative technique using video rather than still images. Allows for more detailed temporal analysis of swallowing.
Functional MRI (fMRI)
Maps brain activity during swallowing tasks. Research tool for investigating neurological swallowing disorders.
Who should get a barium swallow test?
The following patients are appropriate candidates for a modified barium swallow examination:
– Those reporting symptoms of dysphagia such as difficulty/pain swallowing, choking on food, regurgitation, aspiration pneumonia.
– Individuals with conditions that increase dysphagia risk like stroke, neurological disorders, head and neck cancers.
– Patients undergoing intubation/mechanical ventilation who are at higher risk for impaired swallow function.
– As a screening test for elderly patients or others with frailty and malnutrition.
– To assess swallow function before and/or after surgery for disorders like Zenker’s diverticulum.
– Anyone needing more detailed swallow evaluation after abnormal clinical bedside tests.
– Those who have not improved with standard dysphagia treatment approaches.
– Children with unexplained feeding/swallowing difficulties or recurrent aspiration pneumonia.
The test is often ordered by physicians including gastroenterologists, otolaryngologists, neurologists, pulmonologists, and primary care providers.
Does insurance cover the barium swallow test?
Most major insurance plans cover a modified barium swallow study when medically necessary. Coverage details can vary by plan and location, but in general:
– Medicare covers it under Part B when ordered by a doctor for diagnosis of dysphagia or other swallowing disorders. Patient responsible for 20% coinsurance after deductible met.
– Medicaid programs in most states cover it with prior authorization. Little to no cost sharing.
– Most private insurers cover it but with varied cost sharing. Copays average $100-200, coinsurance 10-50% of allowable charges.
– Preauthorization may be required, especially for repeat exams. Clinical dysphagia symptoms usually need to be present.
Out-of-pocket costs for uninsured patients average $500-1500. Low-cost testing may be available from hospital charity care programs based on income.
Overall, the barium swallow study is considered medically necessary by most plans when used appropriately for dysphagia diagnosis. Checking details with the insurer can avoid surprise bills.
What does the preparation involve?
Some key steps for patients undergoing a barium swallow examination include:
– No eating or drinking for 4-6 hours prior to allow for adequate fasting. Crucial for limiting aspiration risk.
– Inform medical team of all medications, swallowing issues, food allergies. Contrast allergy is rare but increases risk.
– Arrive early to registration to complete intake forms and change into hospital gown.
– An IV line may be placed for hydration, medication administration.
– Dental appliances including dentures are removed prior to decrease chances of dislodgement/aspiration.
– Scan is done in radiology room, either upright or lying down. Takes 15-30 minutes total.
– Thick barium paste is given first, then thin liquid barium during scans. Multiple swallows are imaged.
– Test is monitored by radiologist and speech pathologist. Suctioning available if needed for safety.
– Patient may be asked to swallow in different positions, use certain maneuvers during test.
– Barium may cause temporary constipation. Laxatives, increased fluids can help relieve it.
Proper preparation helps ensure the barium swallow examination goes smoothly and provides the most useful diagnostic images. Patients should seek specific instructions from the ordering physician.
What does the barium taste like and is it safe if aspirated?
The barium used for modified barium swallow studies has a thick, chalky, unpleasant taste that can be unpalatable, especially for those with dysphagia. However, it is designed specifically to be as safe as possible if any amount is aspirated into the airway.
Key facts about barium swallow mixture taste and safety:
Taste
– Thick, chalky texture described as unpleasant, foul, or sickening
– Bland flavor, may be hint of added mint or fruit flavoring
– More palatable preparations available but less ideal for imaging
– Can coat mouth, teeth, and throat leading to lingering taste
Safety if aspirated
– Classified as nontoxic and nonirritating to lung tissue
– High density shows up readily on X-rays
– Does not dissolve but can be coughed up or suctioned out
– May be constipating but passes through gastrointestinal tract
– Small residual amounts can remain in lungs long-term with no issues
– Much safer alternative to older oil-based contrast mixtures
So while not pleasant tasting, barium is designed to be very low risk for aspiration. This allows visualization of swallowing function with minimal safety concerns. Patients should follow radiology guidelines to limit ingestion.
What do the results indicate and how are they used?
The barium swallow examination produces X-ray images and video that provide detailed anatomical and functional information about a patient’s swallowing abilities. Some key results that may be reported:
Normal vs abnormal swallow function
Whether swallowing appears normal or shows abnormalities in safety, efficiency, timing, strength, coordination, etc.
Location/grade of dysfunction
Where swallowing breakdown occurs – oral phase, pharyngeal phase, esophageal phase. Severity rating may be assigned.
Penetration/aspiration presence
Evidence and amount of food/liquid entering the larynx or trachea before, during, or after swallowing.
Effectiveness of compensation strategies
How use of posture changes, swallow maneuvers, bolus modifications, etc. impacts swallowing function.
Specific diagnoses
Medical conditions like dysphagia, aspiration, strictures, cancers, etc. causing observed swallowing impairments.
Results guide treatment such as diet modifications, swallowing therapy, medications, or surgery. Follow up testing may be warranted after treatment to reevaluate function.
What is the role of the speech-language pathologist?
Speech-language pathologists (SLPs) play a key role alongside radiologists in conducting and interpreting barium swallow studies. Specific responsibilities include:
– Preparing barium mixtures of different consistencies
– Conducting clinical swallow evaluations before and after test
– Tracking trial specifics like volumes, flow rates, swallow strategies utilized
– Observing patient fatigue, respiratory status, and safety throughout
– Helping position patients, administer trials, provide cues as needed
– Identifying signs of penetration/aspiration events
– Collaborating with radiologists to reach consensus on results and diagnoses
– Integrating findings into personalized dysphagia management plans
– Educating patients and caregivers on safe swallowing techniques
– Following up on therapy progress and repeat testing needs
In many cases, the SLP serves as the dysphagia expert guiding interpretation of the barium swallow results to make appropriate recommendations. Their involvement enhances the value of the test.
Conclusion
While the modified barium swallow study has some limitations, it remains the gold standard diagnostic imaging examination for dysphagia. The ability to visualize swallowing anatomy and physiology in real-time makes it a valuable tool for identifying abnormalities and guiding treatment. With proper training and protocols, it can provide useful functional information to improve swallowing function and safety.
Modern techniques like FEES are useful adjuncts but do not replace the detailed structural images possible with barium swallow exams. Combined with clinical swallow evaluations by speech pathologists, the barium swallow test will likely continue providing unique benefits in the diagnosis of complex dysphagia cases into the foreseeable future. However, further research is still needed comparing this test to emerging technologies.