A swallow test, also known as a modified barium swallow study, is a test that evaluates your swallowing ability. It is typically performed by a speech-language pathologist and involves drinking barium while being video fluoroscoped. This allows the speech pathologist to view the anatomy and physiology of swallowing in real time and assess any difficulties or abnormalities. Swallow studies may be conducted at hospitals, outpatient clinics, rehab centers, or speech therapy offices equipped with fluoroscopy.
What is the purpose of a swallow test?
A swallow test serves several important purposes:
- Identify swallowing difficulties (dysphagia)
- Determine the cause of dysphagia
- Assess risk of aspiration (food/liquid entering the airway)
- Evaluate effectiveness of feeding strategies and diet modifications
- Monitor progression of swallowing disorders
- Provide biofeedback during swallow retraining
By observing the swallowing physiology, the speech pathologist can analyze the strength and coordination of the mouth, throat, and esophageal muscles during swallowing. Abnormalities in the timing, strength, or coordination of these structures can increase the risk of choking, aspiration pneumonia, malnutrition, and other complications.
Who needs a swallow evaluation?
A swallow test may be recommended for individuals with symptoms or conditions that put them at high risk for dysphagia, including:
- Stroke
- Parkinson’s disease
- Multiple sclerosis
- ALS
- Muscular dystrophy
- Head and neck cancer
- Head/facial trauma
- Difficulty chewing/swallowing
- Drooling
- Gurgly or wet voice after swallowing
- Frequent throat clearing
- Coughing or choking when eating/drinking
- Recurrent aspiration pneumonia
- Unexplained weight loss
A swallow study may also be warranted before surgical procedures involving the head, neck, or esophagus to identify any pre-existing swallowing impairment that could increase surgical risks.
What happens during the test?
During a modified barium swallow study:
- You sit upright facing the fluoroscopy machine.
- Barium sulfate contrast material is mixed with different food and liquid consistencies.
- Foods may include pudding, applesauce, crackers with barium paste.
- Liquids may range from thin (water) to thick (nectar, honey).
- You are recorded eating and drinking while the radiologist or speech pathologist observes.
- Multiple swallows of each consistency are evaluated.
- You may be asked to swallow in different positions or perform various maneuvers.
- The speech pathologist may provide tips and strategies for safer swallowing during the test.
The test takes about 30 minutes depending on how many consistencies are evaluated. The barium outlines the swallowing anatomy on X-ray, showing the movement of food/liquid through the mouth, throat, and esophagus.
How should you prepare for the test?
To prepare for a modified barium swallow study:
- Fast for 4-6 hours prior to improve visualization.
- Stop eating food and liquids by mouth if aspiration is strongly suspected.
- Inform your doctor about all medications you take.
- Notify your doctor if you are pregnant or suspect pregnancy.
- Wear comfortable clothing with no metal fasteners.
- Do not wear jewelry around the neck.
- Arrive 15 minutes early to fill out forms.
No other special preparation is required. You will be asked to remove any dentures prior to the test.
What happens after the swallow test?
After your swallow evaluation:
- The speech therapist will review initial impressions with you.
- The radiologist will analyze the fluoroscopy results.
- A full report will be compiled with test findings.
- Results are typically available within 1-3 days.
- Your doctor will go over the test report and recommended treatment options.
- Follow-up appointments to initiate swallowing therapy may be scheduled.
- Diet upgrades or downgrades may be suggested based on study findings.
Your doctor may recommend additional tests if the cause of dysphagia remains unclear after the swallow study.
What do the results mean?
Possible swallow study findings include:
- Normally coordinated swallow: No evidence of dysphagia.
- Oral phase dysphagia: Weak lip closure, poor bolus formation/transport, delayed swallow reflex.
- Pharyngeal phase dysphagia: Reduced laryngeal elevation, vallecular residue, pyriform sinus residue, aspiration.
- Esophageal phase dysphagia: Poor UES opening, esophageal dysmotility, reflux.
- Penetration/aspiration: Bolus enters airway but is ejected (penetration) or remains in airway (aspiration).
- Silent aspiration: Aspiration occurs without reflexive cough.
The radiologist and speech pathologist will determine the physiologic reasons for any swallowing impairments observed and recommend appropriate interventions. This may include swallowing therapy, diet modifications, medication changes, compensatory strategies, or further medical evaluation.
What are the limitations of a swallow evaluation?
While swallow studies provide important information, they have some limitations:
- Exposure to radiation, although minimal.
- Primarily assesses anatomy, some neurological issues may be missed.
- Does not directly assess sensation which influences swallowing.
- May not fully represent typical eating if anxiety alters natural pattern.
- Cannot detect all subtle aspiration, particularly silent aspiration.
Findings may need to be correlated with other assessments to fully evaluate dysphagia. Following recommendations from the speech-language pathologist can maximize swallowing safety despite these limitations.
What are the risks of a swallow study?
Risks associated with swallow evaluations are minimal but may include:
- Exposure to low-dose radiation. Lead shielding minimizes exposure.
- Possible allergic reaction to barium. Let your doctor know if you have any food or medication allergies prior to the test.
- Aspiration of small amounts of barium. The speech therapist takes precautions to minimize this risk.
There is no discomfort involved with the test. You may experience a mild chalky taste from the oral contrast. The barium may cause some temporary constipation which generally resolves within a few days. Contact your doctor if you experience barium impaction lasting more than 2-3 days.
What does insurance cover for swallow studies?
Coverage for swallow evaluations may vary depending on your insurance plan. Some key points regarding coverage include:
- Medicare covers swallow studies when medically necessary.
- Medicaid reimbursement depends on state guidelines.
- Most private insurances provide coverage but may require prior authorization.
- Out-of-pocket fees range from $100-500 without insurance.
- Speech therapy following the test may require separate preauthorization.
- Discuss costs with your provider and insurance company ahead of time.
Swallow studies performed in a hospital setting are generally covered while outpatient clinic fees may not be. Contact your insurance provider to learn about your policy’s specific coverage details.
Where can I find a speech pathologist to perform a swallow study?
There are a few ways to find a qualified speech-language pathologist in your area to conduct a swallow evaluation:
- Ask your primary care physician or neurologist for a referral.
- Search the American Speech-Language-Hearing Association’s online directory.
- Check with nearby hospitals – many have speech therapy departments.
- Contact outpatient rehabilitation clinics or skilled nursing facilities.
- Search online directories like Healthgrades or Yelp.
- Ensure the speech pathologist has expertise in dysphagia and VFSS.
It’s best to choose a speech therapist who routinely performs these specialized swallow studies to ensure you receive an accurate assessment. They will conduct the test and make management recommendations based on the results.
What credentials should a speech therapist have to perform swallow evaluations?
To properly conduct a modified barium swallow study, the speech-language pathologist should have:
- Master’s degree in speech-language pathology.
- Active license in your state.
- Certificate of Clinical Competence (CCC-SLP) from ASHA.
- Training and experience in dysphagia assessment.
- Knowledge of neuroanatomy related to swallowing.
- Skills in objective fiberoptic endoscopic evaluation.
- Strong collaboration skills with radiology.
Specialty training and certification in VFSS interpretation is also preferred. Speech therapists with a Swallowing Disorders Certificate from ASHA are optimally qualified. The best clinicians have years of hands-on experience performing these studies alongside radiologists.
Why see a speech therapist instead of a GI doctor?
There are a few key reasons speech therapists take the lead role in swallow evaluations versus GI doctors:
- Swallowing is considered more of a neurological than GI function.
- Speech therapists specialize in the oral, pharyngeal, and esophageal phases of swallowing.
- They receive more focused training in dysphagia diagnosis and management.
- Speech therapy techniques help strengthen muscles for safe swallowing.
- They can provide swallowing strategies and diet recommendations.
- GI issues like reflux are only part of the swallowing picture.
A gastroenterologist can assess for strictures, motility disorders, and GI reasons for dysphagia symptoms. But a speech therapist is best positioned to perform the full pharyngeal swallow analysis as part of a modified barium swallow study.
How do you know if you need a swallow evaluation?
Consider asking your doctor for a swallow study if you experience any of the following:
- Coughing or choking when eating/drinking
- Wet/gurgly sounding voice during/after eating
- Frequent throat clearing during meals
- Unexplained fevers or lung infections
- Difficulty initiating a swallow
- Food sticking in the throat
- Burning sensation in the throat
- Needing to cut up all foods to swallow safely
- Weight loss without trying
A VFSS is also recommended before starting oral intake after prolonged intubation or mechanical ventilation. If you are at risk for dysphagia due to neurological illness or injury, a baseline swallow study can identify issues early.
What is the difference between an endoscopy and a swallow study?
Key differences between endoscopy and a modified barium swallow study include:
- Endoscopy: Inserts scope down esophagus to inspect anatomy and identify lesions.
- Swallow study: Uses fluoroscopy during swallows to examine physiology and function.
- Endoscopy: Performed by a gastroenterologist, often with anesthesia.
- Swallow study: Conducted by a speech pathologist while patient is awake.
- Endoscopy: Primarily assesses esophageal structure.
- Swallow study: Focuses on oral and pharyngeal swallowing function.
The two procedures offer complementary information. While endoscopy is more invasive, it provides detailed visualization of the upper digestive tract. Swallow studies allow dynamic assessment of swallowing function to identify impairments not seen on endoscopy.
Can swallowing problems be fixed?
Many swallowing disorders can be improved and managed with appropriate treatment:
- Swallowing therapy – Exercises and techniques to strengthen weak muscles.
- Diet modifications – Adjusting food/liquid textures to prevent choking.
- Medications – Changing medicines causing dry mouth or reflux.
- Surgery – Removing obstructions interfering with swallowing.
- Minimal oral care – Keeping the mouth clean and moist.
- Changing head position – Tucking chin or turning head for safer swallows.
While some conditions like stroke or Parkinson’s cannot be cured, compensatory strategies can help prevent complications and allow return to safe oral intake. With therapy and practice, even severely impaired individuals can regain functional swallowing ability.
Conclusion
A modified barium swallow study is a key assessment tool for identifying swallowing disorders known as dysphagia. This dynamic imaging exam conducted by a speech-language pathologist provides critical information about the safety and efficiency of the swallowing mechanism. Results guide management to improve swallow function, prevent complications of dysphagia, upgrade diets, and enhance quality of life. With proper diagnosis and therapy, significant improvements in swallowing ability are possible.
