PERSPECTIVES SIG 13

Clinical Focus

The Modified Barium Swallow Study

for Oropharyngeal Dysphagia:
Recommendations From an
Interdisciplinary Expert Panel
Bonnie Martin-Harris,a Heather Shaw Bonilha,b Martin B. Brodsky,c
David O. Francis,d Margaret M. Fynes,e Rosemary Martino,f Ashli Karin O’Rourke,g
Nicole M. Rogus-Pulia,h Noemi Alice Spinazzi,i and Jessica Zarzourj

Purpose: Dysphagia occurs as a component of a wide up-to-date, comprehensive, evidence-based information

variety of diseases and conditions. When unrecognized on the diagnosis and evaluation of oropharyngeal dysphagia.
or poorly managed, dysphagia can result in malnutrition, Specifically, a lack of quality guidance on the ordering,
volume depletion, and reduced quality of life, as well as performance, and reporting of the MBSS has hindered
aspiration, pneumonia, and death. This document focuses efforts to improve standardization and ensure quality
specifically on oropharyngeal dysphagia. The modified continuity of care.
barium swallow study (MBSS) is a fluoroscopic motion Method: In 2019, a group with expertise in oropharyngeal
study used to evaluate oropharyngeal anatomy and dysphagia (speech-language pathologists, radiologists, and
swallowing physiology in real time. It is typically performed referring physicians) convened with the goal of specifying
by a speech-language pathologist together with a radiologist a core set of expert recommendations/best practices to
and often assisted by a radiologic technologist. Because achieve a high-quality MBSS.
oropharyngeal dysphagia has such a varied presentation, Results: Here, we present the results of the participants’
the guidance to diagnose and treat oropharyngeal dysphagia discussions and provide consensus recommendations
in the United States falls under the purview of several regarding ordering, performing, and reporting an MBSS.
professional societies and organizations. However, a Conclusion: The overarching goal of this summary is to
thorough review of available practice guidelines and emphasize the need for and encourage the development of
appropriateness criteria issued to date reveals a deficit of MBSS practice guidelines to support clinicians and patients.

D
ysphagia represents a physiologic impairment
a
Roxelyn and Richard Pepper Department of Communication that occurs along the continuum of swallowing
Sciences and Disorders, School of Communication, Departments of from mouth to stomach. Dysphagia has been re-
Otolaryngology-Head and Neck Surgery and Radiation Oncology, ported in up to 8% of the world’s population, or almost
Feinberg School of Medicine, Northwestern University, Evanston, IL;
Edward Hines, Jr. VA Hospital, Hines, IL h
b UCSF Benioff Children’s Hospital Oakland, UCSF School of
Department of Rehabilitation Sciences; Department of Health Sciences
Medicine, CA
and Research, Medical University of South Carolina, Charleston i
c Abdominal Imaging Section, Department of Radiology, University of
Department of Physical Medicine & Rehabilitation; Department of
Alabama School of Medicine, Birmingham
Medicine, Division of Pulmonary and Critical Care Medicine; and j
Department of Speech-Language Pathology, Rehabilitation Sciences
Outcomes After Critical Illness and Surgery (OACIS) Research
Institute, Department of Otolaryngology-Head & Neck Surgery,
Group, Johns Hopkins University, Baltimore, MD
d Faculty of Medicine, University of Toronto, Krembil Research
Division of Otolaryngology, Wisconsin Surgical Outcomes Research
Institute University Health Network, Toronto, Ontario, Canada
(WiSOR), Department of Surgery, University of Wisconsin, Madison
e
Susquehanna Imaging Associates, University of Pittsburgh Medical Correspondence to Bonnie Martin-Harris:
Center, PA [email protected]
f Editor-in-Chief: Kendrea L. (Focht) Garand
Department of Otolaryngology - Head and Neck Surgery, Medical
University of South Carolina, Charleston Editor: Mary J. Sandage
g
Department of Medicine, Division of Geriatrics and Gerontology, Received December 31, 2020
University of Wisconsin-Madison School of Medicine and Public Revision received February 12, 2021
Health; Geriatric Research Education and Clinical Center (GRECC), Accepted February 15, 2021
William S. Middleton Memorial Veterans Hospital https://doi.org/10.1044/2021_PERSP-20-00303

610 Perspectives of the ASHA Special Interest Groups • Vol. 6 • 610–619 • June 2021 • Copyright © 2021 The Authors
This work is licensed under a Creative Commons Attribution 4.0 International License.
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 SIG 13 Swallowing and Swallowing Disorders (Dysphagia)

600 million people (Cichero et al., 2017). In 2012, it was • identify and distinguish the presence, type, and esti-
estimated that over 9 million adults experienced difficulty mated severity of physiologic swallowing impairment;
swallowing in the preceding 12 months (Bhattacharyya, • determine the safety of oral intake (airway protection);
2014). Advancing age is a major risk factor for dysphagia.
The prevalence is 15%–22% in community-dwelling older • determine the efficiency of oral intake (clearance);
adults over 50 years of age (Aslam & Vaezi, 2013; Barczi • detail the effects of selected frontline interventions
et al., 2000; Cook & Kahrilas, 1999; Jardine et al., 2018; (postures, maneuvers, bolus variables) on swallowing
Lindgren & Janzon, 1991) and up to 40% for those in physiology, airway protection, and efficiency;
long-term care settings, where disorders most associated • identify indications for specific interventions that are
with dysphagia—head and neck cancer, stroke, and certain appropriate for the clinical condition of the patient; and
neurological conditions—occur more often (Barczi et al.,
2000; Jardine et al., 2018; Siebens et al., 1986). Importantly, • develop intake (oral, tube, etc.) and diet texture/
these incidence and prevalence rates are likely underesti- nutritional management plans in collaboration with the
mates given that dysphagia often goes unrecognized or physician and other interdisciplinary team members.
underreported (González-Fernández et al., 2009). Studying Because oropharyngeal dysphagia presents in such a
and estimating the burden of dysphagia is difficult using wide variety of clinical circumstances, the issuance of guid-
claims databases (e.g., Medicare) as most often the disease ance to diagnose and treat oropharyngeal dysphagia in
leading to dysphagia is coded (e.g., stroke) rather than the the United States falls under the purview of a number of
coincident dysphagia diagnosis. Furthermore, dysphagia different professional societies and organizations. These in-
signs or symptoms can be subtle or even silent, which re- clude the American Speech-Language-Hearing Association
sults in many undiagnosed cases. (ASHA), the American College of Radiology (ACR), the
The morbidity, mortality, quality of life, and cost bur- American Academy of Otolaryngology—Head and Neck
dens of dysphagia are significant. Unrecognized or poorly Surgery, the American Gastroenterological Association,
managed dysphagia can lead to malnutrition, volume deple- and the Dysphagia Research Society. Several of these
tion, reduced quality of life, aspiration, pneumonia, and even organizations have published guidelines/practice parame-
death (Altman et al., 2010; Brodsky et al., 2017; Ekberg ters/appropriateness criteria in the past 2 decades to assist
& Feinberg, 1992; Gelperin, 1974; Macht et al., 2013, 2011; clinicians in the diagnosis and treatment of dysphagia (see
Martino et al., 2005; Palmer et al., 2000; Patel et al., Table 1). Careful review of these practice guidelines and
2017; Popa Nita et al., 2013). A recent study assessing the appropriateness criteria (ACR, 2017, 2018, 2020a; ASHA,
degree to which a diagnosis of dysphagia affects in-hospital 2020a; Boaden et al., 2020; Collins, 2013; Cook & Kahrilas,
mortality, length of stay, discharge disposition, and costs 1999) reveals that there is a lack of up-to-date, comprehen-
among adult U.S. inpatients found that (a) adult patients sive, evidence-based information on the diagnosis of oropha-
with dysphagia were 1.7 times more likely to die in the hos- ryngeal dysphagia, and on the performance and reporting of
pital compared to those without dysphagia; (b) patients
with dysphagia had mean hospital length of stay that were
twice those without dysphagia (9 vs. 5 days); (c) patients Disclosures
with dysphagia were 33% more likely to be transferred to a Financial: Bonnie Martin-Harris receives MBSImP Royalty from the Medical University
postacute care facility; and (d) total inpatient costs were of South Carolina owner and license guarantor to Northern Speech Services (NSS) as
well as compensation for contributions to development and review of article content
approximately $6,000 higher among those with a diagno-
by Bracco Diagnostics, Inc. Heather Shaw Bonilha receives compensation for
sis of dysphagia (Patel et al., 2018). Dysphagia is also as- contributions to development and review of article content by Bracco Diagnostics,
sociated with a significant increase in psychosocial burden, Inc. Martin B. Brodsky receives royalties from MedBridge, Inc., as well as
with approximately 41% of dysphagia patients reporting compensation for contributions to development and review of article content by
Bracco Diagnostics, Inc. David O. Francis receives compensation for contributions to
anxiety during mealtimes (Martino et al., 2010) and 36%
development and review of article content by Bracco Diagnostics, Inc. Margaret M.
avoiding eating with others (Ekberg et al., 2002). Fynes receives compensation for contributions to development and review of article
Oropharyngeal dysphagia refers to physiologic swal- content by Bracco Diagnostics, Inc. Rosemary Martino receives compensation for
lowing impairment(s) that impact airway protection and contributions to development and review of article content by Bracco Diagnostics,
bolus clearance through the upper aerodigestive tract. The Inc. Ashli Karin O’Rourke has no relevant financial interests to disclose. Nicole M.
Rogus-Pulia receives compensation for contributions to development and review
reference standard for the assessment of oropharyngeal of article content by Bracco Diagnostics, Inc. Noemi Alice Spinazzi receives
dysphagia is the modified barium swallow study (MBSS), compensation for contributions to development and review of article content by
also known as a videofluoroscopic swallow study. The MBSS Bracco Diagnostics, Inc. Jessica Zarzour receives compensation for contributions
is a real-time fluoroscopic motion study used to assess swal- to development and review of article content by Bracco Diagnostics, Inc.
Nonfinancial: Bonnie Martin-Harris has no relevant nonfinancial interests to
lowing physiology and airway protection. Optimally, the disclose. Heather Shaw Bonilha has no relevant nonfinancial interests to disclose.
exam is performed by a speech-language pathologist (SLP) Martin B. Brodsky has no relevant nonfinancial interests to disclose. David O. Francis
together with a radiologist, assisted by a radiologic technol- has no relevant nonfinancial interests to disclose. Margaret M. Fynes has no relevant
ogist, to evaluate anatomy and swallowing physiology simul- nonfinancial interests to disclose. Rosemary Martino has no relevant nonfinancial
interests to disclose. Ashli Karin O’Rourke has no relevant nonfinancial interests to
taneously in real time (Martin-Harris, Canon, et al., 2020). disclose. Nicole M. Rogus-Pulia has no relevant nonfinancial interests to disclose.
The objectives of the MBSS are to (Martin-Harris, Canon, Noemi Alice Spinazzi has no relevant nonfinancial interests to disclose. Jessica Zarzour
et al., 2020; Martin-Harris, Steele, & Peterson, 2020) has no relevant nonfinancial interests to disclose.

Martin-Harris et al.: MBSS for Assessment of Oropharyngeal Dysphagia 611

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SIG 13 Swallowing and Swallowing Disorders (Dysphagia)

the MBSS. The availability of high-quality guidance would established that pediatric patients may also require assess-
serve to improve standardization, permit reliable intrapatient ment of swallowing; however, since assessment of pediatric
evaluation of repeat examinations, and allow for interpatient dysphagia has its own specific and complex considerations,
examination comparisons within and between institutions. it was deemed by this expert panel to be outside of the
Moreover, dissemination of and adherence to such guid- scope of this clinical focus article (Arvedson et al., 2020;
ance would reduce repeat testing and positively impact Martin-Harris, Carson, et al., 2020).
patient care.
In 2019, a group of health care providers with exper-
tise in dysphagia convened with the goal of specifying a Background: the MBSS
core set of evidence-based, expert recommendations/best The MBSS is a real-time, fluoroscopic motion study
practices on ordering, performing, and reporting a quality, performed to assess swallowing physiology, airway protection,
high-yield MBSS. The group included three SLPs (B. M.-H., and efficiency (clearance) during administration of barium
M. B. B., and R. M.), two radiologists (M. M. F. and J. Z.), sulfate–containing liquid and solid boluses. These boluses
and two physicians who typically refer patients for an MBSS are of various consistencies (i.e., thicknesses, viscosities)
(one adult otolaryngologist [D. O. F.] and one pediatrician and administered at different volumes, given that consis-
[N. A. S.]). Here, we present a distillation of the discussions tency and volume are known to impact swallowing physi-
among participants, with the key points highlighted as ology and airway protection (Hazelwood et al., 2017). If
specific “consensus recommendations” at the conclusion the MBSS is conducted using evidence-based practice, the
of each section. Agreement regarding these “consensus rec- outcomes have high likelihood to improve the safety, health,
ommendations” among all meeting participants, as well as and quality of life of dysphagic patients and care providers
additional authors (H. S. B., A. K. O., N. M. R.-P.), was (Melnyk, 2015). As such, this essential assessment requires
achieved via several rounds of review until the content was intensive and specific training combined with the judgment
acceptable to all. Appropriate literature was cited to provide and experience of both the SLP and the radiologist.
context and to ensure that the recommendations were evi- Early in the study of oropharyngeal dysphagia, items
dence based. Note that the focus herein will be on adults containing barium sulfate were prepared by an SLP or
with oropharyngeal dysphagia, since the majority of metrics other clinician by mixing different gastrointestinal barium
and tools have been evaluated in this population. It is well sulfate products with a variety of actual foods, liquids, or

Table 1. Currently available guidelines, practice parameters, and appropriateness criteria for dysphagia (ACR, 2017, 2018, 2020a; ASHA,
2020a; Collins, 2013; Cook & Kahrilas, 1999).

Guidelines/practice
Society/ parameters/
organization appropriateness criteria Details Link

ASHA Dysphagia practice parameters; • Articles on adult and pediatric https://www.asha.org/Practice-Portal/Clinical-

MBSS appropriateness dysphagia, including section on Topics/
criteria instrumental assessment of dysphagia
• Guidance on which adult and pediatric
patients should receive an MBSS
ACR Practice parameters for • Details on performance of the MBSS, Performing MBSS: https://www.acr.org/-/
performing and reporting including indications, technical specifications, media/ACR/Files/Practice-Parameters/
an MBSS; dysphagia and safety Modified-Ba-Swallow.pdf
appropriateness criteria • Links to reporting practice parameter General reporting: https://www.acr.org/-/
and appropriateness criteria media/ACR/Files/Practice-Parameters/
CommunicationDiag.pdf
Dysphagia appropriateness criteria:
https://acsearch.acr.org/docs/69471/Narrative/
AAO No formal practice guidelines • Article in ENT Today on diagnosis and https://www.enttoday.org/article/diagnosis-
or appropriateness criteria treatment of swallowing disorders (Collins, treatment-of-swallowing-disorders-requires-
for dysphagia 2013) featuring 3 cases and discussion of focused-evaluation-by-otolaryngologists/
when to use MBSS vs. FEES
AGA No formal practice guidelines • Technical Review in Gastroenterology on —
or appropriateness criteria management of oropharyngeal dysphagia
for dysphagia (Cook & Kahrilas, 1999)
DRS No formal practice guidelines — —
or appropriateness criteria
for dysphagia

Note. ACR = American College of Radiology; ASHA = American Speech-Language-Hearing Association; AAO = American Academy of
Otolaryngology; MBSS = modified barium swallow study; FEES = fiberoptic endoscopic evaluation of swallowing; AGA = American Gastroenterological
Association; DRS = Dysphagia Research Society.

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 SIG 13 Swallowing and Swallowing Disorders (Dysphagia)

Table 2. Common diseases/conditions and signs and symptoms

thickeners. These clinician- or institution-specific prepara-
associated with adult oropharyngeal dysphagia (ASHA, 2020b;
tions resulted not only in a high degree of variability in Bhattacharyya, 2014; Eslick & Talley, 2008; Jaffer et al., 2015;
consistency but also the potential for such products to Liu et al., 2018; Spieker, 2000).
adhere to the mucosal lining, leading to suboptimal or er-
roneous diagnoses (Steele et al., 2013). In addition, the pre- Diseases/conditions
cise aspects of swallowing anatomy and function evaluated
were based largely on the individual radiologist’s and/or • Head and neck cancer
• Neurologic diseases/disorders
SLP’s protocol and/or experience. Lack of valid and reliable, ○ Stroke
standardized methods for the assessment of oropharyngeal ○ Dementia
swallowing precludes the ability to compare swallowing ○ Parkinson’s disease
performance of patients over time and between clinicians. ○ Neuropathy
• Cardiovascular diseases/disorders
Nonstandardized practices persist in many institutions in the • Nononcologic extrinsic pathologies that create a mass effect
United States today. The consensus recommendations pre- (e.g., enlarged thyroid or cervical osteophytes)
sented below attempt to address specific contrast-, technical/ • Pulmonary disorders
procedural-, interpretation-, and reporting-related practices, • Psychological conditions
○ Anxiety
with the intention of improving MBSS standardization. ○ Depression
It is important to also note what the MBSS is not.
The MBSS is not a “pass/fail” test. The clinical picture Signs and symptoms
that results from the MBSS is often complex and nuanced, • Drooling and poor oral management
not binary. In addition, the MBSS is not a “food test,” but • Food or liquid remaining in the oral cavity after the swallow
rather a study that allows clinicians to identify and distin- • Inability to maintain lip closure, leading to food and/or liquids
leaking from the oral cavity
guish the presence and severity of swallowing impairment. • Food and/or liquids leaking from the nasal cavity
Actual food items often do not correlate perfectly with the • Complaints of food “sticking”
various volumes/consistencies used to assess swallowing in • Globus sensation or complaints of a “fullness” in the neck
the fluoroscopy suite; however, an astute and well-trained • Complaints of pain when swallowing
• Wet or gurgly sounding voice during or after eating or drinking
clinician will be able to determine appropriate diet and • Coughing during or right after eating or drinking
therapy recommendations from a thorough examination. • Difficulty coordinating breathing and swallowing
Finally, the MBSS is not the appropriate exam for evalua- • Recurring aspiration pneumonia/respiratory infection and/or fever
tion of esophagus; a complete esophageal assessment re- • Extra effort or time needed to chew or swallow
• Changes in eating habits—specifically, avoidance of certain
quires specific protocols that go beyond the extent of this foods/drinks
summary. • Weight loss or dehydration from not being able to eat enough

Screening and Evaluation for Oropharyngeal

Dysphagia and Ordering an MBSS be evaluated. When a patient fails a basic screening for dys-
phagia (i.e., results indicate the patient is positive for dyspha-
Oropharyngeal dysphagia can occur as a component
gia), they should be kept nil per os (nothing by mouth) and
of many different clinical conditions (see Table 2; ASHA,
referred for a clinical assessment by an SLP to determine if
2020b; Bhattacharyya, 2014; Eslick & Talley, 2008; Jaffer
an MBSS is appropriate.
et al., 2015; Liu et al., 2018; Spieker, 2000). Because of the
significant risk of morbidity (e.g., pneumonia), it is impor- Contraindications for an MBSS are few and include
tant to screen patients at risk for oropharyngeal dysphagia reduced alertness, noncooperativity, inability to be safely
using a tool validated for dysphagia and/or aspiration transported and positioned, and inability to follow simple
(Sherman et al., 2018). The goal of screening is to identify directions. An allergy to a component of the contrast ma-
those at risk, but not to direct any intervention beyond re- terial is also a contraindication, but such allergies are rare
ferral for an expert to evaluate using clinical assessment (ACR, 2020b).
(Martino et al., 2000; McCullough & Martino, 2013). Consensus recommendation no. 1: Because dysphagia
Dysphagia screening can be performed by nurses, physicians, is associated with significant morbidity and mortality, pa-
or other health care professionals. Several clinical evaluation tients at risk of dysphagia (see Table 2) should be screened
tools exist, and they vary (Martino et al., 2013) but typically by a qualified and properly trained health care provider using
include patient-reported symptoms and physical exami- a tool that has proven sufficiently reliable and valid.
nation, including an examination of oromotor function Consensus recommendation no. 2: An order for a
(Anderson et al., 2016; Brodsky et al., 2016; Joundi et al., “swallowing evaluation” following a positive screening result
2017; Leder & Suiter, 2014; Liu et al., 2018; Martino et al., should trigger a referral to an SLP to perform a clinical as-
2009; O’Horo et al., 2015). In addition, the presence of any sessment (at bedside or in the clinic) to determine whether
clinical signs that indicate whether the patient is safe for oral an instrumental assessment is appropriate for the patient.
intake or if an instrumental examination (MBSS or fiberop- Consensus recommendation no. 3: An MBSS should
tic endoscopic evaluation of swallowing) is warranted should be considered when:

Martin-Harris et al.: MBSS for Assessment of Oropharyngeal Dysphagia 613

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SIG 13 Swallowing and Swallowing Disorders (Dysphagia)

• A patient fails a validated screening test and has had a Consistent with all radiologic examinations, the video
clinical assessment suggestive of swallow inefficiency images should be digitized in native or in a converted for-
or poor airway safety mat that does not disturb image quality. The full fluoros-
• The risks of not identifying and managing swallowing copy video images with appropriate labeling of boluses
impairment(s) outweigh the minimal risks associated administered ideally should become a part of the electronic
with the MBSS (e.g., aspiration of barium; risk of ra- medical record and accessible to providers and patients.
diation exposure in adults) Radiation safety is a consideration with any exami-
nation that utilizes ionizing radiation; however, the MBSS
• The medical status of the patient has changed (e.g., post- in adults is considered a low-dose radiation study (total
surgical procedure, acute illness associated with dyspha- median effective dose = 0.27 mSv), roughly equivalent to
gia, neurodegenerative diagnosis)
1 month of natural background radiation and less than
• A pretreatment baseline of the patient’s swallowing phys- that of a mammogram (Bonilha, Huda, et al., 2019). Also,
iology is necessary to determine prognosis and underlying the excess cancer risk per unit effective dose (%/Sv) from
issues related to recovery prior to medical treatments an MBSS exam in adults has been found to be lower than
(e.g., radiation therapy, surgery, chemotherapy) the risk estimates for uniform whole-body irradiation, with
• There are known or possible anatomical departures an extremely low increased cancer risk of 0.0097% for the
from normal anatomy (e.g., surgical removal/resection; highest risk adult population, that is, young females (Bonilha,
genetic syndromes; congenital malformations of the Wilmskoetter, et al., 2019). The major source of occupational
head, neck, and aortic arch) that may affect swallowing radiation exposure during the MBSS is due to scattered radi-
physiology ation (Peladeau-Pigeon & Steele, 2013). Use of typical lead
shielding for both clinicians and patients has been shown
• Clinical findings are suggestive of physiologic impairment
to reduce radiation exposure by 95% (Christodoulou et al.,
and/or aspiration
2003). Thus, radiation exposure to a clinician wearing lead
• Findings of the MBSS are likely to change patient shielding is extremely minimal (Bonilha, Huda, et al., 2019;
management Bonilha, Wilmskoetter, et al., 2019; Hayes et al., 2009).
Nevertheless, clinicians should adhere to the “As Low As
Reasonably Achievable” principle, including routinely using
Performing an MBSS personal protective equipment, increasing the distance from
To obtain a quality MBSS, it is important to ensure, the radiation source, and limiting unnecessary exposure
at a minimum, adequate fluoroscopic technical specifications, (Bonilha, Huda, et al., 2019; Bonilha, Wilmskoetter, et al.,
the use of barium sulfate contrast consistencies and volumes 2019; Galgano et al., 2019; Martin-Harris, Canon, et al.,
that will most likely reveal the presence of and explanation 2020; Peladeau-Pigeon & Steele, 2013). Due to the low ra-
for any dysphagia, and assessment of any compensatory pos- diation exposure to and related cancer risks for adult patients,
tures or maneuvers. A summary of the technical consider- and the extremely low radiation exposure to and related
ations required to obtain an accurate MBSS are summarized cancer risks for clinicians, clinicians should not shorten
in Table 3 (Peladeau-Pigeon & Steele, 2013). Because the MBSSs of adults in a manner that would impact the acquisi-
swallowing mechanism is physiologically complex and oc- tion of information that would be of value to patient care
curs relatively rapidly, the MBSS must be conducted with due to radiation exposure concerns (Bonilha, Huda, et al.,
adequate spatial and temporal resolution. A high-quality 2019).
video capture system should be used to permit frame by The most common contrast agent used for oropharyn-
frame and slow motion viewing necessary for optimizing geal swallowing assessment (i.e., the material that provides
the accuracy and reliability of physiologic swallowing as- radiographic opacification) contains the active ingredient
sessment and aspiration detection. Specifically, the fluoros- barium sulfate. Barium atoms are highly radiodense at the
copy setting should be continuous (or 30 pulses per second) energies used for medical X-rays, and barium sulfate–coated
and the video capture rate at 30 frames per second, be- or impregnated fluids or foods show up on fluoroscopy
cause it has been shown that identification of swallowing images as dark objects, allowing the tracking of the bolus
impairment and aspiration events are missed with lower through the upper digestive tract (Peladeau-Pigeon & Steele,
video capture rates and temporal resolution (Bonilha et al., 2013). Currently, Varibar (Bracco Diagnostics Inc.) is the
2013; Peladeau-Pigeon & Steele, 2013; Mulheren et al., only Food and Drug Administration–approved contrast agent
2019). Furthermore, high-resolution digital image record- available in the United States that is specifically indicated
ing should be used to optimize the clarity of structures and for the MBSS (VARIBAR HONEY, 2018; VARIBAR
diagnostic accuracy. In addition, for most patients, both NECTAR, 2018; VARIBAR PUDDING, 2016; VARIBAR
lateral and anterior–posterior projections should be obtained THIN HONEY, 2018; VARIBAR THIN LIQUID, 2019).
to evaluate symmetry of oropharyngeal function, the impact Varibar was designed with the most suitable radiodensity
of applied compensatory strategies, and gravity-assisted for fluoroscopic evaluation of the oropharyngeal region and
esophageal clearance in the upright position (Hazelwood formulated such that it does not coat the mucosal lining of
et al., 2017; Martin-Harris et al., 2008; Martin-Harris, the pharynx (Robbins et al., 2002). Varibar is available in
Canon, et al., 2020). five standardized formulations of varying thickness (thin

614 Perspectives of the ASHA Special Interest Groups • Vol. 6 • 610–619 • June 2021

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 SIG 13 Swallowing and Swallowing Disorders (Dysphagia)

Table 3. Summary of technical aspects influencing a quality MBSS (Peladeau-Pigeon & Steele, 2013).

Parameter Minimum adequacy for quality MBSS

Spatial resolution A minimum of 400 raster lines (for both vertical and horizontal spatial resolution)
Imaging temporal resolution Can use continuous or pulsed (at 30 pps), provided that image quality obtained is sufficient and radiation
exposure is minimized
Recording temporal resolution Video recording frame rate of 30 frames per second (image registration rate irrelevant for continuous
fluoroscopy)
Video capture Radiology staff and information management systems should be consulted to ensure appropriate computer
processing speed, RAM, graphics cards, and monitor quality are achieved, and the need for any file
conversion or compression are addressed. There should also be a process for appropriately labeling
each swallow with information about the type of bolus administered (i.e., audio recording, text label)
to allow for accurate review of images.
Contrast agent Standardized barium-sulfate concentration and consistencies from thin to pudding “on-label” using FDA-
approved Varibar products
Radiation safety Use shielding and minimize time and distance; adhere to ALARA principle

Note. MBSS = modified barium swallow study; pps = pulse per second; FDA = Food and Drug Administration; ALARA = as low as reasonably
achievable.

liquid, nectar, thin honey, honey, and pudding), all con- these standardization methods permit contributions to big
taining the same 40% w/v concentration of barium sulfate data initiatives (Garand et al., 2018; MBSImP, 2020).
(VARIBAR HONEY, 2018; VARIBAR NECTAR, 2018; Depending on the institution, staffing priorities may
VARIBAR PUDDING, 2016; VARIBAR THIN HONEY, preclude the presence of a radiologist together with a ra-
2018; VARIBAR THIN LIQUID, 2019). In standardized diologic technologist and an SLP in the fluoroscopy suite
MBSS methodology, swallowing of a full range of volumes for every MBSS (Martin-Harris, Canon, et al., 2020). Nev-
and consistencies of barium are tested, typically from lower ertheless, the presence of all three professionals in some
volume to higher volume, and from thin to thick, using a manner is considered best practice by the expert panel, as
standardized assessment tool (Martin-Harris & Jones, 2008; each would ideally possess a unique role (see below). Pro-
Martin-Harris et al., 2017). Although data support that tocols may be instituted that preferentially use remote
each swallowing task has sufficiently high probability to cap- methods to safely achieve appropriate and adequate in-
ture the most severe physiologic swallowing impairment, volvement of the required staff.
the clinical condition of the patient may dictate an exception Consensus recommendation no. 4: Minimum technical
to a standard protocol. “Standardized” is not meant to requirements for an optimal MBSS should include adminis-
equate to “rigid” or “inflexible,” but rather an understand- tration of standardized barium sulfate contrast agent vol-
ing that a minimum, validated standard should be achieved umes and consistencies, utilization of standardized protocols
to consider the exam comprehensive (Hazelwood et al., 2017;
Martin-Harris, Canon, et al., 2020).
The Modified Barium Swallow Impairment Profile Table 4. Modified Barium Swallow Impairment Profile components
(MBSImP) is a well-validated tool for assessment of 17 com- (MBSImP, 2020).
ponents of swallowing physiology and bolus clearance for
each consistency of barium sulfate contrast (see Table 4; Oral impairment domain:
Hazelwood et al., 2017; Martin-Harris et al., 2008; MBSImP, 1. Lip closure
2. Tongue control during bolus hold
2020). The MBSImP is the only available assessment tool 3. Bolus preparation/mastication
that has been rigorously tested and validated for the spe- 4. Bolus transport/lingual motion
cific purpose of scoring oropharyngeal swallow physiology 5. Oral residue
(Martin-Harris et al., 2017) and has been implemented 6. Initiation of the pharyngeal swallow
Pharyngeal impairment domain:
widely in both research and clinical settings (MBSImP, 7. Soft palate elevation
2020). Importantly, validation of the MBSImP has been 8. Laryngeal elevation
conducted with the use of Varibar, allowing for consistent 9. Anterior hyoid excursion
information to be obtained in the same manner both within 10. Epiglottic movement
11. Laryngeal vestibular closure
and between patients, clinicians, and settings. Measures of
12. Pharyngeal stripping wave
penetration/aspiration (penetration–aspiration scale), swallow 13. Pharyngeal contraction
efficiency combined with airway invasion (Dynamic Imaging 14. Pharyngoesophageal segment opening
Grade of Swallowing Toxicity), and kinematic and temporal 15. Tongue base retraction
measures may also be included (Brewer et al., 2000; Hutcheson 16. Pharyngeal residue
Esophageal impairment domain:
et al., 2017; Martin-Harris & Jones, 2008; Molfenter & Steele, 17. Esophageal clearance (upright position)
2014; Rosenbek et al., 1996; Steele et al., 2019). Importantly,

Martin-Harris et al.: MBSS for Assessment of Oropharyngeal Dysphagia 615

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SIG 13 Swallowing and Swallowing Disorders (Dysphagia)

that specify continuous fluoroscopy settings and adequate Consensus recommendation no. 6: Minimal compo-
digital video capture rates to obtain high-resolution images, nents of MBSS radiologist’s report should include relevant
implementation of As Low As Reasonably Achievable, use clinical information; bolus volumes and sequence; assessment
of standardized scoring interpretation metrics, and the abil- of oral and pharyngeal anatomy; findings in the oral, pha-
ity to store and retrieve the resulting high-definition MBSS ryngeal, and esophageal phases (including swallow initia-
images. tion, epiglottic inversion, laryngeal elevation, pharyngeal
Consensus recommendation no. 5: In an ideal setting, stripping, distention and opening of the pharyngoesophageal
a radiologist, a radiologic technologist, and an SLP should segment, retrograde flow into the nasopharynx, laryngeal
be present for every MBSS to perform the following: penetration, tracheal aspiration, esophageal clearance); and
overall impression.
• Radiologist to operate the fluoroscopy equipment, ob-
serve anatomic and physiologic components of swallow- Consensus recommendation no. 7: Minimal compo-
ing during fluoroscopy, confer with the SLP regarding nents of the MBSS SLP’s report should include history of
the fluoroscopy images as they appear on the screen, pre- present complaint (including date of onset, symptoms); medical
pare a radiology report (see Reporting section below) and social history; type of barium/contrast used, bolus (i.e.,
consistency and volume), manner of presentation (e.g., tea-
• SLP to administer the series of contrast agent consis- spoon, cup, straw), number of presentations per bolus type;
tencies, observe anatomic and physiologic components identification of presence, type, and severity of oropharyn-
of swallowing during fluoroscopy, confer with the radi- geal physiologic components of swallowing impairment and
ologist regarding the interpretation of fluoroscopy images esophageal body clearance, and presence and timing of laryn-
as they appear on the screen, attempt any compensatory geal penetration and aspiration; and implementation and im-
strategies to assist the patient with a maximally efficient pact of rehabilitative strategies.
and safe swallow, review the video capture of the MBSS
as appropriate, perform off-line analysis of videofluoro- • All of the aforementioned information presented as re-
scopic images, prepare an SLP report (see Reporting sults should then be synthesized with clinical reasoning
section below) and patient overall condition to provide a summary of
the primary swallowing impairments, consequential
• Radiologic technologist to set up contrast materials in
physiological deficits (i.e., aspiration and oropharyngeal
the fluoroscopy suite; assist in positioning of the patient;
residue) and nutritional risks, and recommendations for
in the absence of a radiologist, operate the fluoroscopy
oral intake and liquid/food texture modifications.
equipment
• Swallowing therapy recommendations should include
measurable goals, frequency and projected duration of
Reporting an MBSS treatment, and a prognostic recovery statement. Refer-
As is the case when performing the MBSS, the report- rals to specialists should be made with specific atten-
ing of the results of the MBSS benefits from standardization tion and description as to why there is need for further
(Brodsky, 2012). It is the opinion of this panel that ideally, testing/treatment.
to avoid any confusion or conflict, there would be a single • Patient education should be documented (e.g., review
report encompassing the findings of both the radiologist and of the MBSS, written guidelines provided) and the
the SLP. However, this is precluded by the current reim- patient’s/caregiver’s response to this education.
bursement system. Therefore, until that is possible, the pri-
ority is to ensure that a single picture of the clinical findings
is what is documented and that both reports are easily ac-
Future Directions
cessible to members of the patient’s health care team. A main objective of providing consensus recommen-
In general, the focus of the two reports differs, with dations is to promote the implementation of a valid, reli-
structural/anatomic and diagnostic information on the pa- able, and standardized MBSS, not only in performing the
tient’s swallowing adequately described by the radiologist, exam but also in interpreting it, storing the information,
and structural physiologic and airway protection information and reporting the findings. The authors hope to use these
on the patient’s swallowing adequately described in the SLP’s consensus recommendations to develop multidisciplinary
report. Additionally, the SLP’s report would review the use guidelines that can be used by all health care providers that
and success of any compensatory strategies evaluated during interact with patients with oropharyngeal dysphagia.
the MBSS, along with any findings that would guide the
health care team in making recommendations to address
future rehabilitation, food/liquid consistency, and mode of Conclusions
intake. The ideal way to achieve this goal routinely is for Development of multidisciplinary guidelines for the
the two parties to collaborate regarding the MBSS findings assessment of oropharyngeal dysphagia will undoubtedly
and to use a similar assessment template, although with contribute to improvements in outcomes for millions of
differing emphasis, to ensure overall agreement. This is affected patients. Consensus around a simple core set of
best facilitated by real-time collaboration during the MBSS recommendations is a first step. Uniformity in screening
and by each party sharing reports via electronic linkage. patients for dysphagia and conducting comprehensive

616 Perspectives of the ASHA Special Interest Groups • Vol. 6 • 610–619 • June 2021

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 SIG 13 Swallowing and Swallowing Disorders (Dysphagia)

clinical swallowing assessments will ensure that dysphagia stroke: Part 2: Initial and sustained nurse accuracy and reli-
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Aslam, M., & Vaezi, M. F. (2013). Dysphagia in the elderly. Gas-
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and standardized practices facilitate interpatient comparisons Barczi, S. R., Sullivan, P. A., & Robbins, J. (2000). How should
by minimizing issues with heterogeneity and strengthening dysphagia care of older adults differ? Establishing optimal
studies focused on comparing dysphagia causes and inter- practice patterns. Seminars in Speech and Language, 21(4),
ventions. Inclusion of standardized nomenclature by both 347–361. https://doi.org/10.1055/s-2000-8387
SLPs and radiologists in reporting the MBSS will facilitate Bhattacharyya, N. (2014). The prevalence of dysphagia among adults
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Bonilha, H. S., Blair, J., Carnes, B., Huda, W., Humphries, K.,
McGrattan, K., Michel, Y., & Martin-Harris, B. (2013). Prelimi-
Acknowledgments nary investigation of the effect of pulse rate on judgments of
The initial meeting of health care experts was supported by swallowing impairment and treatment recommendations. Dyspha-
Bracco Diagnostics, Inc. The authors thank Maya Therattil, for gia, 28(4), 528–538. https://doi.org/10.1007/s00455-013-9463-z
participation in the MBSS Consensus Panel Meeting, and Cindy Bonilha, H. S., Huda, W., Wilmskoetter, J., Martin-Harris, B., &
Schultz, for assistance with medical writing. Therattil and Schultz Tipnis, S. V. (2019). Radiation risks to adult patients under-
were compensated by Bracco Diagnostics, Inc. for their participa- going modified barium swallow studies. Dysphagia, 34(6),
tion and for their services, respectively. This clinical focus article 922–929. https://doi.org/10.1007/s00455-019-09993-w
was partially prepared at the William S. Middleton Veteran Af- Bonilha, H. S., Wilmskoetter, J., Tipnis, S., Horn, J., Martin-
fairs Hospital in Madison, WI; GRECC manuscript no. 003-2021. Harris, B., & Huda, W. (2019). Relationships between radia-
The views and content expressed in this clinical focus article are tion exposure dose, time, and projection in videofluoroscopic
solely the responsibility of the authors and do not necessarily re- swallowing studies. American Journal of Speech-Language
flect the position, policy, or official views of the Department of Pathology, 28(3), 1053–1059. https://doi.org/10.1044/2019_AJSLP-
Veteran Affairs, the U.S. government, or the National Institutes 18-0271
of Health. Brewer, K., Leonard, R., & Kendall, K. (2000). Dysphagia assess-
ment and treatment planning—A team approach. SIG 13 Per-
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