Modified Barium Swallow Study: Gold Standard or Old News?

The Modified Barium Swallow Study, no matter what name is used, has been considered a gold standard for many years in the assessment of dysphagia.  

Recently there has been a lot of debate about whether the MBSS continues to be the gold standard or if FEES (Flexible Endoscopic Evaluation of Swallowing) has taken the place as the gold standard evaluation.

For some reason, it’s become an either/or world that you only get FEES or you only do MBSS.   This is just absurd!

Both tests can provide valuable information.

The MBSS can give you valuable information (FEES posts coming soon!)  You can visualize the oral cavity as the patient prepares to swallow the bolus.  You can visualize as the bolus passes through the pharynx and hopefully through the esophagus.

You can view the patient laterally, you can use an anterior-posterior view or even an oblique view as needed to gather as much information as possible regarding the swallow.

Communication is key.

As the treating SLP, it is so important to get information to the SLP completing the instrumental assessment regarding patient history, why you are ordering the study and possibly even some information about your tentative treatment plan, current diet level, etc.  Most patients are not able to relay the information the same way an SLP would, if at all.

Are there any strategies you think might be beneficial?

Are there any consistencies you want trialed?  Let the SLP know!!

The SLP completing the MBSS doesn’t quite get off the hook.

As the assessing SLP or the SLP completing the instrumental assessment, it is critical that the treating SLP receive a report they can use to build a treatment plan.  It is impossible to educate a patient on why they are on an altered diet or why they need to use such and such compensation when the SLP is unsure.  The report needs to include compensations trialed and effective or ineffective.  It’s also very difficult to know what consistencies, amounts, etc to use for therapeutic trials if the study was discontinued after one instance of aspiration on a teaspoon of thin.

Remember though, sometimes the report never gets to the treating SLP.   Sometimes they try like crazy to get it, but they are never able to do so.

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You won’t get an instrumental assessment if you don’t request it.

Often instrumental assessments are not recommended for a variety of reasons.  Maybe you have sent multiple patients out for an MBSS and the report is not what you need to create a solid treatment protocol.  Maybe the patient refuses or the doctor refuses or the facility refuses.

It is time that we educate physicians, nurses and other medical professionals on the purpose of the MBSS.  Physicians often know or have a good idea that a patient had a stroke.  They still use the CT scan and/or MRI to determine size of stroke, location of stroke and whether the stroke is acute or an old infarct.

We need the same diligence in our field to assess dysphagia beyond just penetration/aspiration and diet selection.  Whether the physician orders the MBSS or the patient participates should be irrelevant to our recommendation for MBSS.  If we believe the MBSS is an important tool to our patient’s care, document and recommend.

Theresa Richard created a great guide for gaining access to instrumental assessment.   The Step-by-Step Guide to Advocating For Access to Instrumentation for Our Patients



5 thoughts on “Modified Barium Swallow Study: Gold Standard or Old News?

  1. What a great post. It has been nearly 30 years since I first walked into a flouro suite in a large teaching hospital with the goal of educating a radiologist about why a speech-language pathologist should be in radiology performing a procedure.

    Throughout that time span, I have worked with a handful of interested radiologist, and also some who prefaced the study by saying” I hate doing these things.”

    Over the same 30 years, the field of dysphagia has grown tremendously, our knowledge base via research and clinical practice seems to provide new information almost weekly, and yet, as a profession, we seem to still fuss with the same issues, including support for the SLP’s referral for an instrumental exam when warranted.

    I have the opportunity to work with a colleague who performs mobile MBS exams. Following completion of the study, I am able to review the video with my patient/s as often as needed, describe and discuss what the findings represent, and offer a rationale for treatment recommendations. I have found this moment to be crucial to goal setting and patient adherence.

    Hopefully, young clinicians armed with even more of a knowledge base than I had 30 years ago, will follow the advice you put forward in your post, and not yield to the various outside pressures to provide any less than is appropriate to the patient’s under our care.

  2. This is a fantastic article. The MBSS is only as good as the SLP, in terms of knowing all the areas/functions to address during the MBSS (lip closure, lingual involvement, etc)
    Also, FEES has been very difficult for the population I work with (dementia). Its noxious, they do not understand the components of the assessment. The MBSS is stressful enough, but they only have to “eat”, therefore, the MBSS has been my choice for many years.

  3. I appreciated article very much and agree with your viewpoint. Sadly, some large acute care hospitals are so fast-paced that there is pressure to complete the studies quickly. They leave no time to explore compensatory strategies. I really like the idea of mobile MBS. I will look into that!

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