What is the difference between a bedside swallow exam and a videofluoroscopic swallow study?

bedside swallow exam is a quick clinical screening performed by a speech-language pathologist or doctor to check for obvious signs of trouble, such as coughing or wet voice, but it cannot see inside the throat. A videofluoroscopic swallow study (VFSS), also known as a barium swallow, uses real-time X-rays to visualize exactly how food and liquid move through the mouth, throat, and esophagus, allowing clinicians to see if material is entering the airway (aspiration) and identifying the specific phase of swallowing where the problem occurs.

How should I prepare for a barium swallow or videofluoroscopic swallow study?

You will typically be asked to fast for 4 to 6 hours before the test to ensure your stomach is empty, which improves the visibility of the esophagus. You should wear comfortable clothing and remove any metal objects, such as necklaces or dentures, that could interfere with the X-ray images. If you have difficulty swallowing pills, inform the medical team beforehand, as they may need to adjust the consistency of the barium mixture or the timing of the procedure.

Can a dysphagia test diagnose the underlying cause of my swallowing difficulty, or does it only show that a problem exists?

Dysphagia tests primarily identify the location and mechanism of the swallowing dysfunction, such as whether the issue is in the oral phase, pharyngeal phase, or esophageal phase. While they can reveal structural abnormalities like strictures or masses that cause the problem, they often do not diagnose the root neurological or systemic disease on their own. For example, a test might show delayed swallowing reflexes, which suggests a neurological cause, but further evaluation by a neurologist or additional imaging may be required to determine if the cause is a stroke, Parkinson’s disease, or another condition.

What are the risks associated with undergoing a fiberoptic endoscopic evaluation of swallow (FEES)?

FEES involves passing a thin, flexible camera through the nose to view the throat, which can cause temporary discomfort, a gag reflex, or a runny nose. The main risk is that the procedure can trigger a coughing fit or temporary irritation of the throat. It is generally considered safe and does not involve radiation, unlike a barium swallow. However, patients with severe nasal congestion or a deviated septum may find the insertion difficult, and the test should be postponed if you have an active upper respiratory infection to avoid spreading germs or causing excessive irritation.

Dysphagia Tests

Dysphagia tests identify the cause of swallowing difficulty and help prevent serious complications such as choking, dehydration, malnutrition, and aspiration pneumonia.

Overview

Dysphagia is a term that means difficulty swallowing. Usually, when you swallow, food moves easily from your mouth, down your throat, and into your stomach. During this process, the food travels through a muscular tube called the esophagus.

It’s normal to occasionally have trouble swallowing, such as if you don’t chew some food well enough or if you eat too fast. But if you have dysphagia, trouble swallowing is an ongoing problem. It can take more time and effort to move food from your mouth to your stomach. When you try to swallow liquids, food, or even your saliva, you may cough or choke. Swallowing may be uncomfortable or painful, and these issues may even stop you from swallowing.

Dysphagia can happen at any age, but it’s more common in older adults or in people with certain neurologic diseases. Many different conditions can cause dysphagia, and some of them can be very serious.

Dysphagia tests can diagnose different types of dysphagia and may help screen for or diagnose various conditions that can cause it. It’s important to get a diagnosis, because if you have dysphagia and don’t treat it, you might be at risk for:

Choking
Dehydration (a loss of too much fluid)
Malnutrition (not getting enough food for your body to work properly)
Aspiration (food or liquids getting into your airway), which can lead to pneumonia

Other names: bedside swallow, clinical swallow, dysphagia screening tool, fiberoptic endoscopic evaluation of swallow (FEES), barium swallow, esophagram, videofluoroscopic swallow study (VFSS), upper endoscopy

Why a Dysphagia Test May Be Needed

You may need this test if you have symptoms of dysphagia. These can include:

Coughing or gagging when swallowing
Feeling of food being stuck in your throat
Pain when swallowing
Being unable to swallow
Food or liquids coming back up through your throat or mouth, including from GERD (gastroesophageal reflux disease)
Frequent heartburn
A hoarse or weaker voice
Weight loss
Drooling

If food has gotten stuck in your airway and you’re having trouble breathing, call 911 for help right away.

What Happens During a Dysphagia Test?

There are several different types of dysphagia tests. A radiologist or a radiology technician most often does these tests. Depending on your symptoms, you may have one or more of the following:

Bedside Swallow Screen

You will sit upright in a bed or chair.
A health‑care provider may ask you questions about your symptoms and how long you’ve had trouble swallowing.
You may be asked to do certain movements, such as smacking your lips together or sticking out your jaw.
You will be given different foods and drinks to swallow. These may include water, other liquids, soft foods, and solid foods.
The provider will check your teeth, lips, jaw, cheeks, and neck while you swallow.

A bedside swallow test is a common type of dysphagia screening tool. Other tools include a questionnaire or discussion about past or current swallowing difficulties and a water swallow test. During a water swallow test, your provider will observe how easily you can drink water from a cup.

Fiberoptic Endoscopic Evaluation of Swallow (FEES)

You will sit upright in a bed or chair.
A provider will slide an endoscope (a thin, flexible tube with a light and camera) into your nose and to the back of your throat.
You will eat bits of food and/or drink liquids that may be colored with a dye.
The endoscope allows your provider to watch food travel down your throat as you swallow.

Upper Endoscopy

You will lie on your side on an exam table.
An IV (intravenous) line will be placed in your arm or hand.
Medicine to relax you will be injected intravenously (by IV).
Your provider may spray a numbing medicine on the back of your throat.
Once the relaxing and numbing medicines have taken effect, your provider will insert an endoscope into your mouth and throat.
The endoscope will take pictures of your esophagus, stomach, and part of your small intestine.
The tube may also have a tool attached that can be used to take a biopsy (removal of a small sample of tissue) to examine after the procedure.

Videofluoroscopic Swallow Study (VFSS) – Modified Barium Swallow

You will stand or sit on an x‑ray table.
You will be given different foods and liquids covered with barium. Barium coats internal organs and tissues so they can be seen more clearly on an x‑ray, allowing your provider to see how you swallow.
While you swallow, a special x‑ray called fluoroscopy tracks the barium‑coated food in real‑time as a live video as it moves through your mouth, throat, and esophagus.

Preparation

Your provider will let you know if there are any special instructions to follow. You may need to fast (not eat or drink) for several hours or more before your test. You may be asked to avoid doing anything that will coat your throat, such as smoking, chewing gum, or sucking on hard candy.

You may need to stop taking certain medicines before the test, so tell your provider about everything you take. But don’t stop taking any medicines unless your provider tells you to.

You may also want to make a list of your swallowing problems ahead of time so you can share them with your provider during the test.

If you are having an upper endoscopy, you will be given a medicine that can make you drowsy, so you should arrange for someone to take you home.

Risks

There is very little risk to having a bedside swallow, but there is a small chance that fluid might get into your lungs during the procedure.

During a FEES or upper endoscopy, you may feel some discomfort when the endoscope is inserted, but serious complications are rare. There is a very small risk of getting a tear in your intestine. If you had a biopsy, there is a small risk of bleeding at the site. Bleeding usually stops without treatment.

You should not have a VFSS, which is a type of x‑ray, if you are pregnant or think you may be pregnant. The radiation from these x‑rays can be harmful to a developing baby. For others, there is little risk to having these tests. The radiation dose is very low and not considered harmful for most people, but talk to your provider about all the x‑rays you’ve had in the past. The risks from radiation exposure may be linked to the number of x‑ray treatments you’ve had over time.

Tell your provider if you have any known allergies to the barium used in the test. Your stool may look white for several days after the test as you pass the barium. You may have constipation if all the barium doesn’t pass out of your body.

Understanding the Results

Your results may show your provider where the problem is or what type of dysphagia you might have. These can include:

Oral cavity dysphagia

A disorder of the mouth in which you have difficulty chewing or breaking down food. Causes may include:

Weakness after a stroke
Muscular or nerve problems

Oropharyngeal dysphagia

A disorder of the throat in which you have difficulty starting to swallow. Causes may include:

Certain types of cancer
Neurologic diseases such as multiple sclerosis or Parkinson’s disease
Pharyngoesophageal diverticulum, a small pouch that forms and collects food particles in your throat

Esophageal dysphagia

A disorder of the esophagus in which you have difficulty moving food down your esophagus. Causes may include:

Esophageal stricture (narrowing of your esophagus)
Esophageal cancer
GERD (gastroesophageal reflux disease), a condition in which the contents of your stomach leak backward into your esophagus

A bedside swallow screen or other type of dysphagia screening tool will only show if you are at risk for one of the above disorders. If your results show you are at risk, your provider will probably order follow‑up testing.

If you have questions about your results, talk to your provider. They may also consider your symptoms and medical history to understand your test results.

Next Steps & Specialist Referral

If you are having trouble swallowing, your provider may refer you to one of the following specialists:

A speech and language pathologist, a provider that specializes in diagnosing and treating speech, language, and communication disorders.
An otolaryngologist, a doctor who specializes in diagnosing and treating disorders of the ear, nose, and throat.
A gastroenterologist, a doctor who specializes in diagnosing and treating disorders of the digestive system.
A neurologist, a doctor who specializes in diagnosing and treating disorders of the brain, spinal cord, and nervous system.

References

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