Videofluoroscopic predictors of aspiration in patients with oropharyngeal dysphagia

Bedside Clinical Swallow Test and the Fiberoptic Endoscopic Evaluation of Swallow - Level of Agreement

Introduction

Bedside test are important tool for evaluating aspiration during swallowing. FEES that is functional endoscopic evaluation of swallowing is a gold standard method used in evaluation of dysphagia patients. Through this study we aim to assess the sensitivity and specificity of Bedside Clinical swallow evaluation in comparison with Fiberoptic Endoscopic Evaluation of Swallowing.

Objective

To analyze which physiological examination amongst oro motor labial examination, lingual examination, gag reflex, coughs during or post swallow, change in voice quality and hyo-laryngeal excursion during swallow with semisolid and thin liquid consistency in the Bedside Clinical swallow evaluation is better indicator for presence or absence of aspiration.

Methodology

38 patients with different diagnostic entities were presented& included in the study for the assessment of swallowing difficulties as presence or absence of aspiration and possibility of weaning from nasogastric or Nasojejunal tube between March 2016 to October 2016. They were 32 (86%) males and 6 (14%) females. Aspiration correlates were assessed using bedside test (labial movement, lingual movement, gag reflex, strength of productive cough, hyo-laryngeal excursion, And post swallow changes in the quality of voice). FEES was then performed and sensitivity and specificity was compared.

Result

Bedside test showed 84.62% sensitivity and 100% specificity in comparison to FEES. Gag and voice quality were noted to have significant difference with value of 0.009 and 0.033 respectively.

Conclusion

Bedside tests can be considered as an important, easy, sensitive, and specific for the detection of aspiration. Combination of gag reflex and change of voice as parameters of aspiration compared with FEES showed high sensitivity and specificity.

Conceptualizing Adult Dysphagia in the United States Within the International Classification of Functioning, Disability and Health (ICF)

Despite the well-documented safety concerns and effect on quality of life, there does not yet exist a wide-reaching framework that links the etiologies of swallowing disorders to the potential short- and long-term outcomes in the context of International Classification of Functioning, Disability and Health (ICF). This paper introduces an expert-reviewed conceptual framework to highlight common etiologies of dysphagia as well as integrate immediate outcomes of dysphagia with long-term outcomes of dysphagia in terms of medical problems, health-related quality of life, functional effect, and psychosocial features. It also outlines the potential cyclical nature of long-term dysphagia outcomes perpetuating the original dysphagia. This framework serves to inform clinicians of important dysphagic outcomes and to bring awareness to long-term outcomes that should be monitored by health care professionals, caregivers, or people with dysphagia.

Effects of Head and Neck Alignment and Pharyngeal Anatomy on Epiglottic Inversion During Swallowing in Dysphagic Patients

The effects of head and neck alignment and pharyngeal anatomy on epiglottic inversion remain unclear. This study investigated the factors involved in epiglottic inversion, including head and neck alignment and pharyngeal anatomy, in patients with dysphagia. Patients with a chief complaint of dysphagia and who underwent videofluoroscopic swallowing study at our hospital from January to July 2022 were enrolled. They were divided into three groups based on the degree of epiglottic inversion as the complete-inversion (CI), partial-inversion (PI), and non-inversion group (NI) groups. Data were compared among the three groups; a total of 113 patients were analyzed. The median age was 72.0 (IQR: 62.0-76.0) years; 41 (36.3%) and 72 (63.7%) were women and men, respectively. There were in 45 (39.8%) patients in the CI, 39 (34.5%) in the PI, and 29 (25.7%) in the NI groups, respectively. Single-variable analysis revealed significant relation to epiglottic inversion of Food Intake LEVEL Scale score, penetration-aspiration score with 3-mL thin liquid bolus, epiglottic vallecula and pyriform sinus residue, hyoid position and displacement during swallowing, pharyngeal inlet angle (PIA), epiglottis to posterior pharyngeal wall distance, and body mass index. Logistic regression analysis with complete epiglottic inversion as the dependent variable revealed the X coordinate at maximum hyoid elevation position during swallowing and PIA as significant explanatory variables. These results suggest that epiglottic inversion is constrained in patients with dysphagia who have poor head and neck alignment or posture and a narrow pharyngeal cavity just before swallowing.

Quantitative Analysis of Temporal Parameters Correlated with Aspiration and Lesion Location in Stroke Patients

The purpose of this study was to identify differences in temporal parameters correlating to the presence of aspiration and the severity of penetration-aspiration scale (PAS) in patients with dysphagia after stroke. We also investigated whether there was a significant difference in temporal parameters based on the location of the stroke lesion. A total of 91 patient videofluoroscopic swallowing study (VFSS) videos of stroke patients with dysphagia were retrospectively analyzed. Various temporal parameters including oral phase duration, pharyngeal delay time, pharyngeal response time, pharyngeal transit time, laryngeal vestibule closure reaction time, laryngeal vestibule closure duration, upper esophageal sphincter opening duration and upper esophageal sphincter reaction time were measured. Subjects were grouped by the presence of aspiration, PAS score, and location of the stroke lesion. Pharyngeal response time, laryngeal vestibule closure duration, and upper esophageal sphincter opening duration were significantly prolonged in the aspiration group. These three factors showed positive correlation with PAS. In terms of stroke lesion, oral phase duration was significantly prolonged in the supratentorial lesion group, while upper esophageal sphincter opening duration was significantly prolonged in the infratentorial lesion group. We have demonstrated that quantitative temporal analysis of VFSS can be a clinically valuable tool identifying dysphagia pattern associated with stroke lesion or aspiration risk.

The Hyoid Bone Kinematics in Dysphagic Stroke Patients: Instantaneous Velocity, Acceleration and Temporal Sequence Matters

Hyoid bone excursion (HBE) is one of the most critical events in the pharyngeal phase of swallowing. Most previous studies focused on the total displacement and average velocity of HBE. However, HBE during swallowing is not one-dimensional, and the change of velocity and acceleration is not linear. This study aims to elucidate the relationship between the instantaneous kinematics parameters of HBE and the severity of penetration/aspiration and pharyngeal residue in patients with stroke. A total of 132 sets of video-fluoroscopic swallowing study images collected from 72 dysphagic stroke patients were analyzed. The maximal instantaneous velocity, acceleration, displacement, and the time required to reach these values in the horizontal and vertical axes were measured. Patients were grouped according to the severity of the Penetration-Aspiration Scale and the Modified Barium Swallow Impairment Profile- Pharyngeal Residue. The outcome was then stratified according to the consistencies of swallowing materials. Stroke patients with aspiration were associated with a lower maximal horizontal instantaneous velocity and acceleration of HBE, a shorter horizontal displacement, and prolonged time to maximal vertical instantaneous velocity compared to the non-aspirators. In patients with pharyngeal residue, the maximal horizontal displacement of HBE was decreased. After stratification according to bolus consistencies, the temporal parameters of HBE were more significantly associated with aspiration severity when swallowing thin bolus. Meanwhile spatial parameters such as displacement had a bigger influence on aspiration severity when swallowing viscous bolus. These novel kinematic parameters of HBE could provide important reference for estimating swallowing function and outcomes in dysphagic stroke patients.

Quantitative approach to analyze hyoid bone movement during swallowing by ultrasound: an integrative review

PURPOSE

To synthesize the scientific knowledge on which measurements of hyoid bone movement during swallowing are obtained by ultrasonography and how to extract these measures.

RESEARCH STRATEGIES

The PECO question and combinations of descriptors and keywords were formulated in the electronic databases Medline/PubMed, EMBASE, Web of Science, Scopus and Lilacs.

SELECTION CRITERIA

Articles that used ultrasonography to analyze measurements of hyoid bone movement during swallowing were included, regardless of language, year of publication, or presence of deglutition disorders.

DATA ANALYSIS

The included articles were analyzed for: year, study site, study design, population, sample size, equipment used, transducer positioning, measurements obtained, method of extraction, and reliability of measurements.

RESULTS

Twenty-six articles met the eligibility criteria. The most frequent measurement was hyoid movement maximum amplitude, followed by time and velocity. There was great variability in the study population, equipment used, positioning of the transducer and method of extraction of the measurements. Thus, it was not possible to find a standard model to extract the measures. The level of reliability was investigated in only eight articles.

CONCLUSION

Amplitude, time and velocity are the measures of hyoid bone movement during swallowing that can be obtained by ultrasonography. There is no standardization on how to extract these measurements.

Non-Contact Assessment of Swallowing Dysfunction Using Smartphone Captured Skin Displacements

Early and accurate dysphagia diagnosis is essential for reducing the risk of associated co-morbidities and mortalities. Barriers to current evaluation methods may alter the effectiveness of identifying at-risk patients. This preliminary study evaluates the feasibility of using iPhone X-captured videos of swallowing as a non-contact dysphagia screening tool. Video recordings of the anterior and lateral necks were captured simultaneously with videofluoroscopy in dysphagic patients. Videos were analyzed using an image registration algorithm (phase-based Savitzky-Golay gradient correlation (P-SG-GC)) to determine skin displacements over hyolaryngeal regions. Biomechanical swallowing parameters of hyolaryngeal displacement and velocity were also measured. Swallowing safety and efficiency were assessed by the Penetration Aspiration Scale (PAS), Residue Severity Ratings (RSR), and the Normalized Residue Ratio Scale (NRRS). Anterior hyoid excursion and horizontal skin displacements were strongly correlated with swallows of a 20 mL bolus (r_s = 0.67). Skin displacements of the neck were moderately to very strongly correlated with scores on the PAS (r_s = 0.80), NRRS (r_s = 0.41-0.62), and RSR (r_s = 0.33). This is the first study to utilize smartphone technology and image registration methods to produce skin displacements indicating post-swallow residual and penetration-aspiration. Enhancing screening methods provides a greater chance of detecting dysphagia, reducing the risk of negative health impacts.

The Association Between Smokeless Tobacco and a Lung Mass in a Healthy Young Male

Smokeless tobacco is widely used in the United States. Many commonly used forms of smokeless tobacco may contain microorganisms that can change the oral flora of tobacco users. Here we present a case of a previously healthy 21-year-old male who presented with six weeks of worsening cough productive of yellow sputum as well as pleuritic left-sided chest and back pain. Computed tomography (CT) of the chest showed a large 3.9 x 5.5 x 6.3 cm mass-like lesion. He was extensively worked up for potential causes of this mass, including autoimmune, HIV testing, sputum staining for acid-fast bacilli, and fungal serologies. He was empirically treated with antibiotics and antifungals. He ultimately underwent a CT-guided biopsy which was negative for malignancy and tuberculosis. The culture from the biopsy revealed 5,000 colony forming units of Streptococcus intermedius. Based on the sensitivities of the culture, he was switched to intravenous ceftriaxone and discharged to complete a course of intravenous antibiotics.  This case showcases a healthy 21-year-old male with no prior history who had an extensive workup for the possible causes and risk factors predisposing to a lung abscess. This workup was negative, and his only risk factor was the use of smokeless chewing tobacco. Smokeless tobacco may be associated with increased risk of lower respiratory tract infections and can increase the risk of lung abscess in an immunocompetent adult. More research is required to understand this association.

Non-Invasive Sensor-Based Estimation of Anterior-Posterior Upper Esophageal Sphincter Opening Maximal Distension

OBJECTIVE

Dysphagia management relies on the evaluation of the temporospatial kinematic events of swallowing performed in videofluoroscopy (VF) by trained clinicians. The upper esophageal sphincter (UES) opening distension represents one of the important kinematic events that contribute to healthy swallowing. Insufficient distension of UES opening can lead to an accumulation of pharyngeal residue and subsequent aspiration which in turn can lead to adverse outcomes such as pneumonia. VF is usually used for the temporal and spatial evaluation of the UES opening; however, VF is not available in all clinical settings and may be inappropriate or undesirable for some patients. High resolution cervical auscultation (HRCA) is a noninvasive technology that uses neck-attached sensors and machine learning to characterize swallowing physiology by analyzing the swallow-induced vibrations/sounds in the anterior neck region. We investigated the ability of HRCA to noninvasively estimate the maximal distension of anterior-posterior (A-P) UES opening as accurately as the measurements performed by human judges from VF images.

METHODS AND PROCEDURES

Trained judges performed the kinematic measurement of UES opening duration and A-P UES opening maximal distension on 434 swallows collected from 133 patients. We used a hybrid convolutional recurrent neural network supported by attention mechanisms which takes HRCA raw signals as input and estimates the value of the A-P UES opening maximal distension as output.

RESULTS

The proposed network estimated the A-P UES opening maximal distension with an absolute percentage error of 30% or less for more than 64.14% of the swallows in the dataset.

CONCLUSION

This study provides substantial evidence for the feasibility of using HRCA to estimate one of the key spatial kinematic measurements used for dysphagia characterization and management. Clinical and Translational Impact Statement: The findings in this study have a direct impact on dysphagia diagnosis and management through providing a non-invasive and cheap way to estimate one of the most important swallowing kinematics, the UES opening distension, that contributes to safe swallowing. This study, along with other studies that utilize HRCA for swallowing kinematic analysis, paves the way for developing a widely available and easy-to-use tool for dysphagia diagnosis and management.

Deep Learning for Automatic Hyoid Tracking in Videofluoroscopic Swallow Studies

The hyoid bone excursion is one of the most important gauges of larynx elevation in swallowing, contributing to airway protection and bolus passage into the esophagus. However, the implications of various parameters of hyoid bone excursion, such as the horizontal or vertical displacement and velocity, remain elusive and raise the need for a tool providing automatic kinematics analysis. Several conventional and deep learning-based models have been applied automatically to track the hyoid bone, but previous methods either require partial manual localization or do not transform the trajectory by anatomic axis. This work describes a convolutional neural network-based algorithm featuring fully automatic hyoid bone localization and tracking and spine axis determination. The algorithm automatically estimates the hyoid bone trajectory and calculates several physical quantities, including the average velocity and displacement in horizontal or vertical anatomic axis. The model was trained in a dataset of 365 videos of videofluoroscopic swallowing from 189 patients in a tertiary medical center and tested using 44 videos from 44 patients with different dysphagia etiologies. The algorithm showed high detection rates for the hyoid bone. The results showed excellent inter-rater reliability for hyoid bone detection, good-to-excellent inter-rater reliability for calculating the maximal displacement and the average velocity of the hyoid bone in horizontal or vertical directions, and moderate-to-good reliability in calculating the average velocity in horizontal direction. The proposed algorithm allows for complete automatic kinematic analysis of hyoid bone excursion, providing a versatile tool with high potential for clinical applications.

Longitudinal Analysis of Swallowing Displacement Kinematics After Oropharyngeal Cancer Treatment

BACKGROUND/OBJECTIVE

Quantitative swallowing displacement kinematics evolve in patients treated for oropharyngeal squamous cell carcinoma (OPSCC). We aimed to longitudinally assess these measurements and correlate them with functional swallowing outcomes.

METHOD

A retrospective review was conducted on patients with OPSCC treated with definitive (chemo)radiation ([C]RT) or surgery with adjuvant (chemo)radiation (S-[C]RT) who completed at least two videofluoroscopic swallow studies (VFSS). Longitudinal analysis was accomplished via mixed-effects logistic regression for the Functional Oral Intake Scale (FOIS), and Penetration Aspiration Scale (PAS), and mixed-effects linear regression for kinematic measures. Spearman's correlation was conducted between changes in FOIS/PAS and kinematic measures.

RESULTS

Ninety-seven patients (76 males; mean age 61) completed 245 VFSS studies. A total of 94% had human papillomavirus (HPV)/p16 positive OPSCC and 74% were T0-T2. Sixty-four patients underwent [C]RT while 33 patients underwent S-[C]RT. After treatment, posterior pharyngeal wall at hold (PPWhold) increased 3.2 standard deviation (SD) between 0 and 6 months (p < 0.001), then decreased 2.2 SD between 6 and 12 months (p < 0.001) and did not return to baseline. Hyoid-to-larynx (HL) (p = 0.046) and maximal hyoid displacement (Hmax) + HL (p = 0.042) increased between 6 and 12 months. Hmax (p = 0.020) and Hmax + HL (p < 0.001) decreased between 12-24 months beyond baseline values. The decrease in HL and increase in PPWhold (p < 0.05) correlated with an increase in PAS. From baseline, increased pharyngeal constriction ratio correlated with decreased FOIS and PPWhold (p < 0.05).

CONCLUSIONS

Quantitative swallowing kinematic measures can effectively track changes in swallowing physiology. Increased PPWhold and restricted hyolaryngeal movement were seen in patients with OPSCC after treatment and correlated with a change in swallowing outcome, emphasizing the need for serial VFSS monitoring and targeted intervention.

LEVEL OF EVIDENCE

3 Laryngoscope, 2022.

Comparison of Validated Videofluoroscopic Outcomes of Pharyngeal Residue: Concordance Between a Perceptual, Ordinal, and Bolus-Based Rating Scale and a Normalized Pixel-Based Quantitative Outcome

PURPOSE

This study compared the concordance between two validated videofluoroscopic pharyngeal residue outcome scales used in clinical and research settings: the Dynamic Imaging Grade of Swallowing Toxicity (DIGEST) and the Analysis of Swallowing Physiology: Events, Kinematics and Timing (ASPEKT) percent residue metric.

METHOD

Two trained raters completed independent and blinded videofluoroscopic ratings of both DIGEST efficiency and ASPEKT percent pharyngeal residue outcomes for bolus trials of 5 cc Varibar thin liquid (n = 223), thin liquid comfortable cup sips (n = 223), and 5 cc Varibar thin honey (n = 223). Spearman's rho and Kruskal-Wallis analyses were performed for each bolus type.

RESULTS

Significant associations between DIGEST and ASPEKT pharyngeal residue outcomes were noted for 5 cc thin (r = .54, p < .001), cup sip thin (r = .41, p < .001), and 5 cc thin honey (r = .60, p < .001) bolus trials. ASPEKT percent residue increased across worsening DIGEST efficiency ordinal scale levels, with a main effect for each bolus type. Post hoc analysis revealed significant differences in the ASPEKT percent residue values between each DIGEST pairwise comparison for the thin cup sip bolus trial and for each pairwise comparison except between the moderate-to-severe (less than half vs. majority) ordinal levels for the 5 cc thin and 5 cc honey bolus trials, p < .05.

CONCLUSIONS

Perceptual, ordinal (DIGEST) and quantitative, pixel-based (ASPEKT) videofluoroscopic pharyngeal residue outcomes were associated in this data set of 669 bolus trials. Future research is warranted to confirm these results.

A Basic Study for Predicting Dysphagia in Panoramic X-ray Images Using Artificial Intelligence (AI)—Part 1: Determining Evaluation Factors and Cutoff Levels

Background: Dysphagia relates to quality of life; this disorder is related to the difficulties of dental treatment. Purpose: To detect radiographic signs of dysphagia by using panoramic radiograph with an AI system. Methods: Seventy-seven patients who underwent a panoramic radiograph and a videofluorographic swallowing study were analyzed. Age, gender, the number of remaining teeth, the distance between the tongue and the palate, the vertical and horizontal hyoid bone position, and the width of the tongue were analyzed. Logistic regression analysis was used. For the statistically significant factors, the cutoff level was determined. The cutoff level was determined by using analysis of the receiver operations characteristic (ROC) curve and the Youden Index. Results: A significant relationship with presence of dysphagia was only observed for the vertical hyoid bone position. The area under the curve (AUC) was 0.72. The cutoff level decided for the hyoid bone was observed to be lower than the mandibular border line. Conclusions: In cases where the hyoid bone is lower than the mandibular border line on a panoramic radiograph, it suggests the risk of dysphagia would be high. We will create an AI model for the detection of the risk of dysphagia by using the assessment of vertical hyoid bone position.

Swallowing kinematic analysis might be helpful in predicting aspiration and pyriform sinus stasis

Aspiration due to dysphagia can lead to aspiration, which negatively impacts a patient’s overall prognosis. Clinically, videofluoroscopic swallow study (VFSS) is considered the gold-standard instrument to determine physiological impairments of swallowing. According to previously published literature, kinematic analyses of VFSS might provide further information regarding aspiration detection. In this study, 449 files of VFSS studies from 232 patients were divided into three groups: normal, aspiration, and pyriform sinus stasis. Kinematic analyses and between-group comparison were conducted. Significant between-group differences were noted among parameters of anterior hyoid displacement, maximal hyoid displacement, and average velocity of hyoid movement. No significant difference was detected in superior hyoid displacement. Furthermore, receiver-operating characteristic (ROC) analyses of anterior hyoid displacement, velocity of anterior hyoid displacement, and average velocity of maximal hyoid displacement showed acceptable predictability for detecting aspiration. Using 33.0 mm/s as a cutoff value of average velocity of maximal hyoid displacement, the sensitivity of detecting the presence of aspiration was near 90%. The investigators therefore propose that the average velocity of maximal hyoid displacement may serve as a potential screening tool to detect aspiration.

Validation and psychometric properties of the Turkish version of Neuromuscular disease Swallowing Status Scale (NdSSS) in patients with oro-pharygo-esophageal dysphagia in neuromuscular disorders

Objective

Dysphagia is one of the most disabling conditions arising from neuromuscular disorders(NMD). There is no specific methods to use in the evaluation of dysphagia in NMD patients. We aimed both to evaluate the applicability of the Neuromuscular Disease Swallowing Status Scale (NdSSS) for dysphagia in all phases of swallowing in various NMD patients and to investigate psychometric properties of this scale.

Methods

Patients with NMD were enrolled. Functional Oral Intake Scale (FOIS), Fiberoptic Endoscopic Evaluation of Swallowing (FEES), NdSSS and High-Resolution Esophageal Manometry (HRM) were performed on all subjects within 72 hours. While the convergent and concurrent validities were used as validation method, Cohen's kappa and Cronbach's alpha coefficient were calculated for inter-rater reliability. The correlation between FOIS, PAS and HRM diagnosis according to Chicago version 3.0 (CCv3) were analyzed.

Results

115 NMD patients were included. There was good correlation between NdSSS and FOIS and PAS scores (Spearman's rank correlation coefficient (r):0.927, r:0.927 and r:-0.836, r:0.841, respectively). Also, there was a positive good correlation between NdSSS and CCv3 evaluating disorders of esophageal peristalsis (r:0.677-0.679, p=0.001). When evaluated separately, there were good correlation between NdSSS levels; and PAS (r:-0.648-0.656); and CCv3 (r:0.514-0.573) levels for ALS. For Myasthenia gravis there was a good correlation between NdSSS levels; and CCv3 (r:0.577-0.622); FOIS (r:0.508-0.521); and PAS (r:-0.504-0.519) scores. Also, for myopathy; a very good(CCv3(0.976-0.982)) and good(FOIS (0.511-0.581) and (PAS (-0.516-0.550)) correlations were defined for myopathy.

Conclusion

The NdSSS was found applicable to detect both oropharyngeal and esophageal dysphagia risk in patients with NMD and is a valid and reliable swallowing screening tool that can evaluate oro-pharyngo-esophageal dysphagia in NMD patients.

Effects of dual-task interference on swallowing in healthy aging adults

A wide body of literature has demonstrated that the neural representation of healthy swallowing is mostly bilateral, with one hemisphere dominant over the other. While several studies have demonstrated the presence of laterality for swallowing related functions among young adults, the data on older adults are still growing. The purpose of this paper is to investigate potential changes in hemispheric dominance in healthy aging adults for swallowing related tasks using a behavioral dual-task paradigm. A modified dual-task paradigm was designed to investigate the potential reduction in hemispherical specialization for swallowing function. Eighty healthy right-handed participants in the study were divided into two groups [Group 1: young adults (18–40 years) and Group 2: older adults (65 and above)]. All the participants performed a timed water swallow test at baseline and with two interference conditions (silent word repetition, and facial recognition). The results of the study revealed the following 1) a statistically significant effect of age on swallow performance; 2) statistically significant effect of each of the interference tasks on two of the swallow measures (VPS and VPT) in younger adults; and 3) no significant effect of the interference tasks on the swallowing performance of older adults. These findings suggest that aging substantially affects swallowing in older individuals, and this potentially accompanies a reduction in the hemispheric specialization for swallowing related tasks.

Automatic Hyoid Bone Tracking in Real-Time Ultrasound Swallowing Videos Using Deep Learning Based and Correlation Filter Based Trackers

(1) Background: Ultrasound provides a radiation-free and portable method for assessing swallowing. Hyoid bone locations and displacements are often used as important indicators for the evaluation of swallowing disorders. However, this requires clinicians to spend a great deal of time reviewing the ultrasound images. (2) Methods: In this study, we applied tracking algorithms based on deep learning and correlation filters to detect hyoid locations in ultrasound videos collected during swallowing. Fifty videos were collected from 10 young, healthy subjects for training, evaluation, and testing of the trackers. (3) Results: The best performing deep learning algorithm, Fully-Convolutional Siamese Networks (SiamFC), proved to have reliable performance in getting accurate hyoid bone locations from each frame of the swallowing ultrasound videos. While having a real-time frame rate (175 fps) when running on an RTX 2060, SiamFC also achieved a precision of 98.9% at the threshold of 10 pixels (3.25 mm) and 80.5% at the threshold of 5 pixels (1.63 mm). The tracker's root-mean-square error and average error were 3.9 pixels (1.27 mm) and 3.3 pixels (1.07 mm), respectively. (4) Conclusions: Our results pave the way for real-time automatic tracking of the hyoid bone in ultrasound videos for swallowing assessment.

Influence of Thermal and Gustatory Stimulus in the Initiation of the Pharyngeal Swallow and Bolus Location Instroke

INTRODUCTION/OBJECTIVE

The aim of this study is to analyze the influence of sour taste and cold temperature in the initiation of the pharyngeal swallow (IPS) and bolus location at pharyngeal swallow onset in individuals after stroke.

METHODS

Cross-sectional prospective study. The study included 52 individuals with unilateral ischemic stroke. Each individual was assessed by videofluoroscopic swallowing study with 5ml of paste bolus offering four different stimuli (natural, cold, sour, and sour-cold). The individuals were divided into two groups according to the offer sequence. Group 1 (G1) - received a randomized sequence of stimuli (24 individuals), and Group 2 (G2) -the stimuli were offered in the following order: natural, cold, sour, and sour-cold(28 individuals). The IPS time and bolus location at pharyngeal swallow onset were analyzed. The bolus location at pharyngeal swallow onset was defined using six different levels.

RESULTS

Individuals in G1 did not show a significant difference in IPS time between stimuli. However, individuals in G2 presented a significantly shorter IPS time with the sour and sour-cold stimuli than with natural or cold stimuli. The bolus location at pharyngeal swallow onset did not show significant difference between stimuli in both groups. On the other hand, in the G2 it was observed higher frequency of swallowing with sour-cold stimulus at level 1 (the bolus head was located in any region between the fauces pillar and the point where the tongue crosses the inferior border of the mandible).

CONCLUSION

The sour and sour-cold stimuli influenced the IPS time when they were offered in a sequential order. Moreover, both the IPS time and bolus location at pharyngeal swallow onset were not influenced by the sour and sour cold-bolus when offered in a random sequence.

Variations in Hyoid Kinematics Across Liquid Consistencies in Healthy Swallowing

Purpose Judgments regarding hyoid movement are frequently included in evaluations of swallowing. However, the literature lacks reference values for measures of hyoid kinematics in healthy swallowing. This study explores hyoid movement across the continuum from thin to extremely thick liquids. Method Participants were 39 healthy adults under the age of 60 years (19 men) who underwent videofluoroscopy involving three sips each of 20% w/v thin barium and six sips each of slightly, mildly, moderately, and extremely thick barium. Half of the thickened stimuli were prepared using xanthan gum; and half, with a starch-based thickener. Sip volume was derived from pre- and post-sip cup weights. Hyoid position was tracked frame-by-frame relative to the anterior-inferior corner of C4. Measures of peak hyoid position (along the XY axis) were normalized to a C2-C4 scalar, and measures of time-to-peak position, speed, and time-to-peak speed were derived. As a first step, Spearman's correlations confirmed the influence of sip volume on these hyoid measures. Linear mixed-effects models then explored the effects of stimulus, sip volume, and task repetition on the dependent variables. Results The data set comprised 975 swallows with available hyoid tracking data. Sip volume was correlated with peak hyoid XY position (rs = .15, p < .01), time-to-peak position (rs = -.15, p < .05), and speed (rs = .13, p < .01). No significant differences in hyoid kinematics were found across stimuli. Conclusion Measures of hyoid movement in healthy swallowing remain stable across the range from thin to extremely thick liquids with no systematic alterations in hyoid position or kinematics.

The Influence of Airflow Via High-Flow Nasal Cannula on Duration of Laryngeal Vestibule Closure

The purpose of this experimental study was to investigate the influence of airflow via high-flow nasal cannula (HFNC) on the duration of laryngeal vestibule closure (dLVC) and Penetration-Aspiration Scale (PAS) scores. Twenty-nine healthy adults participated in a repeated-measures design. Each participant completed a videofluoroscopic swallow study while receiving airflow via HFNC across a control condition of zero flow and conditions of 10, 20, 30, 40, 50, and 60 L/min. Five raters rated dLVC and PAS scores. Laryngeal vestibule closure was complete on all swallows. Linear regression revealed that the amount of airflow via HFNC significantly influenced dLVC, F(1, 810) = 19.056, p < .001. The mode of airway invasion for each airflow condition was PAS 2, with > 80% frequency compared to other PAS scores. Aspiration (PAS 7 or 8) did not occur. A Fisher's Exact test determined there was no association between normal/abnormal PAS score and no airflow/HFNC (p = .610). Findings indicate that for healthy adults, airflow via HFNC influenced dLVC in a dose-dependent manner with no change in airway invasion. The influence of HFNC on dLVC was a positive relationship, meaning when airflow increased, dLVC increased, and when airflow decreased, dLVC decreased. Modulation of dLVC in response to the amount of airflow highlights the ability of healthy adults to adapt to swallow conditions as needed to protect the airway.

How Closely do Machine Ratings of Duration of UES Opening During Videofluoroscopy Approximate Clinician Ratings Using Temporal Kinematic Analyses and the MBSImP?

Clinicians evaluate swallow kinematic events by analyzing videofluoroscopy (VF) images for dysphagia management. The duration of upper esophageal sphincter opening (DUESO) is one important temporal swallow event, because reduced DUESO can result in pharyngeal residue and penetration/aspiration. VF is frequently used for evaluating swallowing but exposes patients to radiation and is not always feasible/readily available. High resolution cervical auscultation (HRCA) is a non-invasive, sensor-based dysphagia screening method that uses signal processing and machine learning to characterize swallowing. We investigated HRCA's ability to annotate DUESO and predict Modified Barium Swallow Impairment Profile (MBSImP) scores (component #14). We hypothesized that HRCA and machine learning techniques would detect DUESO with similar accuracy as human judges. Trained judges completed temporal kinematic measurements of DUESO on 719 swallows (116 patients) and 50 swallows (15 age-matched healthy adults). An MBSImP certified clinician completed MBSImP ratings on 100 swallows. A multi-layer convolutional recurrent neural network (CRNN) using HRCA signal features for input was used to detect DUESO. Generalized estimating equations models were used to determine statistically significant HRCA signal features for predicting DUESO MBSImP scores. A support vector machine (SVM) classifier and a leave-one-out procedure was used to predict DUESO MBSImP scores. The CRNN detected UES opening within a 3-frame tolerance for 82.6% of patient and 86% of healthy swallows and UES closure for 72.3% of patient and 64% of healthy swallows. The SVM classifier predicted DUESO MBSImP scores with 85.7% accuracy. This study provides evidence of HRCA's feasibility in detecting DUESO without VF images.

Therapeutic Effect, Rheological Properties and α-Amylase Resistance of a New Mixed Starch and Xanthan Gum Thickener on Four Different Phenotypes of Patients with Oropharyngeal Dysphagia

Thickened fluids are a therapeutic strategy for oropharyngeal dysphagia (OD). However, its therapeutic effect among different phenotypes of OD patients has not yet been compared. We aimed to assess the therapeutic effect and α-amylase resistance of a mixed gum/starch thickener [Fresubin Clear Thickener^® (FCT)] on four phenotypes of OD patients: G1) 36 older; G2) 31 head/neck cancer (HNC); G3) 30 Parkinson’s disease; and G4) 31 chronic post-stroke. Therapeutic effect of FCT was assessed during videofluoroscopy using the Penetration-Aspiration Scale (PAS), for 5/20 mL boluses, at four levels of shear-viscosity (<50, 250, 1000 and 2000 mPa·s). The effect of α-amylase was assessed after 30 s of oral incubation. Patients had high prevalence of VFS signs of impaired efficacy (98.44%) and safety (70.31%) of swallow with a severe PAS score (4.44 ± 0.20). Most severe OD was in HNC (80.6% unsafe swallows). FCT showed a strong therapeutic effect on the safety of swallow at a range between 250–1000 mPa·s (74.19–96.67%, safe swallows in G1, G3, G4, and 58.06% in G2), without increasing pharyngeal residue. Viscosity was unaffected by α-amylase. Increasing shear-viscosity with FCT causes a strong viscosity-dependent therapeutic effect on the safety of swallow. This effect depends on the phenotype and is similar among older, Parkinson’s and post-stroke patients.

Hyoid position as a novel predictive marker for postoperative dysphagia and dysphonia after anterior cervical discectomy and fusion

PURPOSE

The purpose of this study is to investigate the predictive value of the hyoid horizontal positional change on the severity of dysphagia and dysphonia (PDD) after anterior cervical discectomy and fusion (ACDF) comparing pre-vertebral soft-tissue thickness (PVST).

METHODS

This is a retrospective observational study with prospectively collected data at a single academic institution. ACDF patients between 2015 to 2018 who had complete self-reported PDD surveys and pre- and postoperative lateral cervical radiographs were included in the analysis. PDD was assessed utilizing the Hospital for Special Surgery Dysphagia and Dysphonia Inventory (HSS-DDI). The hyoid-vertebral distance (HVD) and PVST (the averages of C2 to C7 levels (PVSTC2-7) and all operating levels (PVSTOP)) were assessed preoperatively and upon discharge. The associations among postoperative changes of HVD, PVSTs, and the 4-week HSS-DDI score were evaluated.

RESULTS

Of the 268 patients with a HSS-DDI score assessment, 209 patients had complete data. In univariate analyses, HVD and PVSTC2-7 changes demonstrated significant correlations with HSS-DDI, whereas PVSTOP showed no significant association. After adjusting with sex and operating level, the changes in HVD (p = 0.019) and PVSTC2-7 (p = 0.009) showed significant associations with the HSS-DDI score and PVSTOP showed no significant association. PVSTC2-7 could not be evaluated in 12% of patients due to measurement difficulties of PVST at lower levels.

CONCLUSION

We introduce a novel potential predictive marker for PDD after ACDF. Our results suggest that HVD can be utilized for the risk assessment of PDD, especially in PVST unmeasurable cases, which accounts for over 10% of ACDF patients.

Tracking Hyoid Bone Displacement During Swallowing Without Videofluoroscopy Using Machine Learning of Vibratory Signals

Identifying physiological impairments of swallowing is essential for determining accurate diagnosis and appropriate treatment for patients with dysphagia. The hyoid bone is an anatomical landmark commonly monitored during analysis of videofluoroscopic swallow studies (VFSSs). Its displacement is predictive of penetration/aspiration and is associated with other swallow kinematic events. However, VFSSs are not always readily available/feasible and expose patients to radiation. High-resolution cervical auscultation (HRCA), which uses acoustic and vibratory signals from a microphone and tri-axial accelerometer, is under investigation as a non-invasive dysphagia screening method and potential adjunct to VFSS when it is unavailable or not feasible. We investigated the ability of HRCA to independently track hyoid bone displacement during swallowing with similar accuracy to VFSS, by analyzing vibratory signals from a tri-axial accelerometer using machine learning techniques. We hypothesized HRCA would track hyoid bone displacement with a high degree of accuracy compared to humans. Trained judges completed frame-by-frame analysis of hyoid bone displacement on 400 swallows from 114 patients and 48 swallows from 16 age-matched healthy adults. Extracted features from vibratory signals were used to train the predictive algorithm to generate a bounding box surrounding the hyoid body on each frame. A metric of relative overlapped percentage (ROP) compared human and machine ratings. The mean ROP for all swallows analyzed was 50.75%, indicating > 50% of the bounding box containing the hyoid bone was accurately predicted in every frame. This provides evidence of the feasibility of accurate, automated hyoid bone displacement tracking using HRCA signals without use of VFSS images.

Effect of a gum-based thickener on the safety of swallowing in patients with poststroke oropharyngeal dysphagia

BACKGROUND

Increasing viscosity with thickening agents is a valid therapeutic strategy for oropharyngeal dysphagia (OD). To assess the therapeutic effect of a xanthan gum-based thickener (Nutilis Clear^® ) at six viscosities compared with thin liquid in poststroke OD (PSOD) patients.

METHODS

A total of 120 patients with PSOD were studied in this controlled, multiple-dose, fixed-order, and single-blind study using videofluoroscopy (VFSS). A series of boluses of 10 mL thin liquid and 2000, 1400, 800, 450, 250, and 150 mPa s viscosities were given in duplicate, interrupted in case of aspiration. We assessed the safety and efficacy of swallow and the kinematics of the swallow response.

KEY RESULTS

A total of 41.2% patients had safe swallow at thin liquid which significantly increased for all viscosities from 71.9% at 150 mPa s to 95.6% at 1400 mPa s (P < .001). PAS score (3.7 ± 2.3) at thin liquid was also reduced by increasing bolus viscosity (P < .001). The prevalence of patients with aspiration at thin liquid was 17.5% and decreased at all viscosities (P < .01), except at 150 mPa s. Increasing viscosity shortened time to laryngeal vestibule closure (LVC) at all viscosities (P < .01) and reduced bolus velocity at ≥450 mPa s (P < .05). The prevalence of patients with pharyngeal residue at each viscosity 37.7%-44.7% was similar to that at thin liquid (41.2%).

CONCLUSIONS AND INFERENCES

The prevalence of unsafe swallow with thin liquids is very high in PSOD. Increasing shear bolus viscosity with this xanthan gum-based thickener significantly increased the safety of swallow in patients with PSOD in a viscosity-dependent manner without increasing the prevalence of pharyngeal residue.

Validation of the Normalized Laryngeal Constriction Ratio in Normal and Disordered Swallowing

PURPOSE

The timing of laryngeal vestibule closure (LVC) is important for airway protection during swallowing. However, it is unknown whether the extent of LVC contributes to airway protection. The goal of this study is to validate the extent of LVC via a measure called laryngeal constriction ratio (LCR).

METHODS

A retrospective analysis of videofluoroscopic swallows was conducted on 38 stroke participants and 40 healthy controls. The LCR was calculated by deriving a size-normalized area of airspace from a 1) maximum closed laryngeal vestibule and a 2) maximum open laryngeal airspace (at rest). Airway invasion severity was derived via the Penetration-Aspiration Scale score.

RESULTS

Six hundred forty-nine videofluoroscopic swallows were analyzed. A mixed model analysis revealed a statistically significant mean difference between the normalized laryngeal constriction ratios of healthy individuals (mean (m) = 0.003) versus older dysphagic patients (m = .026) (P = 0.001), quantifying less closure in older patients with dysphagia. Additionally, swallows with airway compromise had a statistically worse LCR when compared to swallows without airway compromise (P = 0.001).

CONCLUSION

The normalized LCR might be a valid fluoroscopic surrogate measure for LVC and, furthermore, airway compromise during swallowing. By investigating spatial measurements in the laryngeal vestibule during safe and unsafe swallows, the LCR provides a direction for further research to allow for critical examination of the physiology relating to closure degree in order to precisely detect and treat abnormalities during swallowing.

LEVEL OF EVIDENCE

4 Laryngoscope, 130:E190-E198, 2020.

Development, intra- and inter-rater reliability of the New Zealand Secretion Scale (NZSS)

Purpose: The New Zealand Secretion Scale (NZSS) has been developed for comprehensive assessment of accumulated secretions during endoscopy. The scale rates secretion severity under the subcategories location, amount and response. This study describes the scale's development and reliability when used by experts and untrained raters. Method: One expert scored 254 endoscopy videos using the NZSS and performed repeat measures on 100 randomly selected videos one month later. These 100 videos were scored by a second expert in a randomised order. In a second arm of the study, 28 raters scored 10 endoscopy videos, without training on the NZSS. Seventeen had experience in endoscopy (mean 1.8 years, SD = 1.0). Reliability was calculated across the entire cohort and as a function of experience interpreting endoscopy. Result: Strong internal consistency (Cronbach's α = 0.88), and high inter-item (>0.60) and corrected item-total correlations (>0.70) were established. Inter-rater (ICC = 0.99) and intra-rater reliability (ICC = 0.95) of the experts was excellent. Inter-rater reliability of the untrained raters ranged from ICC = 0.65-0.79, with no significant influence of experience on reliability. Conclusion: The NZSS is a reliable assessment of secretion severity during endoscopy and can be used without training. This comprehensive scale will support research evaluating the predictive value of accumulated secretions.

Swallow Screen Associated With Airway Protection and Dysphagia After Acute Stroke

OBJECTIVE

The goal was to examine the outcomes of an existing swallow screen protocol in comparison to results from a formal videofluoroscopic protocol.

DESIGN

Prospective cohort study.

SETTING

Acute hospital.

PARTICIPANTS

Patients after acute stroke (N=48).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

The Johns Hopkins Hospital Brain Rescue Unit 3 oz Swallow Screen was implemented by nursing staff upon admission. Videofluoroscopy was conducted within 72 hours of diagnostic neuroimaging and initial swallow screen. Predictive values of the bedside swallow screen (pass/fail) for clinical judgment of dysphagia on videofluoroscopy (presence/absence) were calculated. Overall impairment scores from the Modified Barium Swallowing Impairment Profile were analyzed with respect to swallow screen results.

RESULTS

Thirteen participants failed the swallow screen, and 35 passed. Of the 35 patients who passed the swallow screen, 15 were clinically diagnosed with dysphagia on videofluoroscopy. Although pass/fail of the swallow screen was not a significant predictor of presence/absence of dysphagia, a logistic regression model including components of Laryngeal Elevation, Laryngeal Vestibule Closure, and Anterior Hyoid Excursion, and sex was statistically significant for swallow screen outcome.

CONCLUSION

The results of this study suggest that a swallow screen of aspiration risk can identify patients with the most need for videofluoroscopic evaluation and dysphagia management. Additionally, patients who fail a swallow screen are more likely to present with physiologic impairments related to airway protection on videofluoroscopy.

Relationship between pharyngeal response time and lateralized brain lesion in stroke

Objectives: To analyze the relationship between pharyngeal response time (PRT) and lateralization of brain lesions. Methods: A Cross-sectional study. 73 videofluoroscopic swallow studies (VFSS)were conducted on patients after stroke The study subjects were divided into : group 1 (G1) consisting of 39 individuals with left cortical lesion and group 2 (G2) consisting of 34 individuals with right cortical lesions. The VFSS of G1 and G2 subjects were analyzed using puree (A) and liquid (B) consistencies, and  were also subdivided into young adults and older persons. . The mean PRT was divided into times shorter and longer than 250 ms. Results: No statistically significant difference was observed between G1 and G2 for the A and B consistencies, being obtained : G1 (A mean: 56.6 ms; B mean: 99.5 ms; A mean: 3627 ms; B mean: 1712 ms) and G2 (A mean: 79.6 ms; B mean: 110.7 ms; A mean: 2040 ms, B mean: 1529 ms), for PRT shorter (A:p = .673; B: p = 1.000) and longer (A: p = .435; B: p = .847) than 250 ms, respectively. No statistically significant difference was found regarding the variable age in the comparison between young and old adults for mean PRT according to the A and B consistencies in G1 (A: p = .260; B: p = .732) and G2 (A: p = .586; B: p = .104). Conclusion: No relationship between PRT and lateralization of brain lesion was observed with respect to subject age and to the swallowing of different food consistencies.

Predictors of Penetration-Aspiration in Parkinson’s Disease Patients With Dysphagia: A Retrospective Analysis

Objective:

Penetration-aspiration is considered the most severe sign of dysphagia, with aspiration pneumonia as one of its consequences. More than half of Parkinson’s disease (PD) patients suffer from dysphagia, and aspiration pneumonia is among the primary causes of mortality in PD patients. However, the identification of predictors of penetration-aspiration in PD patients remains an understudied topic. The purpose of this study was to identify predictors of penetration-aspiration in patients with PD.

Methods:

The data of 89 PD patients with dysphagia who underwent routinely conducted videofluoroscopic studies of swallowing (VFSS) were included in this retrospective study. The occurrence of penetration-aspiration was defined as scores ≥3 on the Penetration-Aspiration Scale (PAS). Four commonly reported signs of dysphagia in PD patients were evaluated as possible predictors. Furthermore, the relationships between the occurrence of penetration-aspiration and liquid bolus volume as well as clinical severity of PD (modified Hoehn and Yahr scale) were examined.

Results:

Logistic regression showed that a delayed initiation of the pharyngeal swallow (odds ratio [OR] = 7.47, P = .008) and a reduced hyolaryngeal excursion (OR = 5.13, P = .012) were predictors of penetration-aspiration. Moreover, there was a strong, positive correlation between increasing liquid bolus volume and penetration-aspiration (γ = 0.71, P < .001). No correlation was found between severity of PD and penetration-aspiration (γ = 0.077, P = .783).

Conclusion:

Results of the present study allow for a better understanding of penetration-aspiration risk in PD patients. They are useful for treatment planning in order to improve safe oral intake and adequate nutrition.

The Prediction of Risk of Penetration-Aspiration Via Hyoid Bone Displacement Features

Videofluoroscopic swallow studies are widely used in clinical and research settings to assess swallow function and to determine physiological impairments, diet recommendations, and treatment goals for people with dysphagia. Videofluoroscopy can be used to analyze biomechanical events of swallowing, including hyoid bone displacement, to differentiate between normal and disordered swallow functions. Previous research has found significant associations between hyoid bone displacement and penetration/aspiration during swallowing, but the predictive value of hyoid bone displacement during swallowing has not been explored. The primary objective of this study was to build a model based on aspects of hyoid bone displacement during swallowing to predict the extent of airway penetration or aspiration during swallowing. Aspects of hyoid bone displacement from 1433 swallows from patients referred for videofluoroscopy were analyzed to determine which aspects predicted risk of penetration and aspiration according to the Penetration-Aspiration Scale. A generalized estimating equation incorporating components of hyoid bone displacement and variables shown to impact penetration and aspiration (such as age, bolus volume, and viscosity) was used to evaluate penetration and aspiration risk. Results indicated that anterior-horizontal hyoid bone displacement was the only aspect of hyoid bone displacement predictive of penetration and aspiration risk. Further research should focus on improving the model performance by identifying additional physiological swallowing events that predict penetration and aspiration risk. The model built for this study, and future modified models, will be beneficial for clinicians to use in the assessment and treatment of people with dysphagia, and for potentially tracking improvement in hyolaryngeal excursion resulting from dysphagia treatment, thus mitigating adverse outcomes that can occur secondary to dysphagia.

Association Between Pharyngeal Pooling and Aspiration Using Fiberoptic Endoscopic Evaluation of Swallowing in Head and Neck Cancer Patients with Dysphagia

Postswallow pharyngeal pooling may be a risk factor for tracheal aspiration. However, limited literature shows the potential association between pharyngeal pooling and aspiration in head and neck cancer (HNC) patients. This study investigates the relationship between postswallow pharyngeal pooling and aspiration in HNC patients with oropharyngeal dysphagia. Furthermore, the effects of tumor stage, tumor location, and cancer treatment on aspiration were examined. Ninety dysphagic HNC patients underwent a standardized fiberoptic endoscopic evaluation of swallowing (FEES) using thin and thick liquid boluses. For each swallow, three visuoperceptual ordinal variables were scored: postswallow vallecular pooling, postswallow pyriform sinus pooling, and aspiration. Logistic regression analyses with correction for the location of pooling, tumor stage, tumor location, and cancer treatment were performed to explore the association between pooling and aspiration. No significant association was found between postswallow vallecular pooling and aspiration for thin liquid. However, severe versus mild-to-moderate postswallow vallecular pooling of thick liquid was significantly associated to aspiration. Similar results were seen after correction for the presence of pyriform sinus pooling, tumor stage, tumor location, or type of cancer treatment. This study showed a significant association between severe postswallow pyriform sinus pooling of thick liquid and aspiration, independent of the presence of vallecular pooling, tumor stage, tumor location, or cancer treatment. Concluding, location (valleculae versus pyriform sinuses), liquid bolus consistency (thin versus thick liquid), and amount of postswallow pharyngeal pooling (no pooling, mild/moderate pooling, severe pooling) have an influence on the probability of aspiration in dysphagic HNC patients, and they should be carefully considered during FEES, even in the absence of aspiration during the examination.

Presentation of oropharyngeal dysphagia and rehabilitative intervention following esophagectomy: a systematic review

No study has systematically reviewed the evidence on presentation of oropharyngeal dysphagia and swallowing rehabilitation following esophagectomy. The purposes of this systematic review are to 1) qualitatively synthesize the current findings on oropharyngeal swallowing abnormalities identified by instrumental swallowing evaluations, 2) describe the reported health-related outcomes in relation to swallowing abnormality following esophagectomy, and 3) examine the efficacy of reported rehabilitative interventions for oropharyngeal dysphagia in patients who underwent esophagectomy. Publications were searched using five electronic databases. No language or publication date restrictions were imposed. Two authors performed a blind review for published or unpublished studies that reported swallowing biomechanics and dysphagic symptoms using instrumental evaluation of swallowing, specifically the videofluoroscopic swallowing study and fiberoptic endoscopic evaluation of swallowing, and/or health-related outcomes in relation to swallowing abnormalities, and/or therapeutic interventions for oropharyngeal dysphagia following esophagectomy. Twelve studies out of 2,193 studies including 458 patients met the inclusion criteria. Reported abnormal swallowing biomechanics included vocal fold immobility, delayed onset of swallowing, reduced hyolaryngeal elevation, and reduced opening of the upper esophageal sphincter. Aspiration (0-81%) and pharyngeal residue (22-100%) were prevalent. Those abnormal swallowing biomechanics and swallowing symptoms were commonly reported following both transhiatal and transthoracic esophagectomy. Pneumonia presented in 5-25% of the study patients. One quasi-experimental study examined the effectiveness of swallowing exercises for postoperative oropharyngeal dysphagia; three case series reported a benefit of the chin-tuck maneuver in reducing aspiration and residue. This review revealed distinct swallowing impairments and increased pneumonia risks following esophagectomy. This review also found that evidence on the efficacy of therapeutic interventions was limited. Future studies are warranted to develop effective rehabilitative interventions for postesophagectomy patients with oropharyngeal dysphagia.

Correlation Between Pharyngeal Residue and Aspiration in Fiber-Optic Endoscopic Evaluation of Swallowing: An Observational Study

OBJECTIVES

To examine the correlation between pharyngeal residue severity and clearance to penetration/aspiration on fiber-optic endoscopic examination of swallowing (FEES).

DESIGN

Retrospective cohort.

SETTING

Kaplan Medical Center dysphagia clinic.

PARTICIPANTS

Patients (N=110) visiting a dysphagia clinic between 2014 and 2016 undergoing FEES.

INTERVENTIONS

FEES were scored for penetration/aspiration with the Penetration Aspiration Scale (PAS), for residue severity using the Yale Pharyngeal Residue Severity Rating Scale (YPR-SRS). The numbers of swallows required to clear the pharynx were recorded. The first and the worst bolus challenges for each consistency (liquid, purée, solid) were analyzed.

MAIN OUTCOME MEASURES

YPR-SRS and number of clearing swallows were correlated with the PAS of the same bolus challenge.

RESULTS

The study population's mean age was 67±13.4 years; 54% were men (n=58). A significant correlation was found between the YPR-SRS and the PAS for all consistencies tested, in each anatomical site (vallecula or pyriform sinus) and for both the first and worst bolus challenges (P<.001 for all). The correlation of residue with aspiration was stronger when vallecula and pyriform sinuses scores were summated (Pearson product-moment correlation coefficient=0.573/0.631/0.446 for liquid/purée/solid for worst bolus challenge). Incorporating the number of clearing swallows to the YPR-SRS strengthened the correlation with PAS.

CONCLUSIONS

Residue severity and clearance correlate with penetration/aspiration on FEES. The YPR-SRS can be applied to standardize description of residue in FEES and to aid in dysphagia evaluation.

Swallowing outcomes in patients with subcortical stroke associated with lesions of the caudate nucleus and insula

Objective The present study was performed to investigate the relationships between swallowing outcomes and lesion location, bolus characteristics, and age in patients with subcortical stroke.

PATIENTS

Patients with subcortical and insular stroke (mean age, 57.38 ± 12.71 years) were investigated. All patients (n = 21) completed both brain magnetic resonance imaging studies and videofluoroscopic swallowing studies. Main Outcome Measures The oral transit duration, pharyngeal transit duration (PTD), laryngeal response duration, and Penetration-Aspiration Scale (PAS) score were applied to examine the efficiency of propulsion and airway protection in three swallowing tasks. Path analyses were performed to assess the relationships between swallowing outcomes and lesion location, age, bolus viscosity, and bolus volume. Results Caudate nucleus (CN) lesions were associated with higher PAS scores. Insular lesions were associated with a longer PTD. Advanced age was associated with a longer PTD. Bolus viscosity significantly moderated the association between CN lesions and higher PAS scores. Conclusions In the present cohort, CN lesions impacted airway protection and insular lesions impacted pharyngeal transit. An increased bolus viscosity reduced the aspiration severity. These results suggest that lesion location is an important indicator to predict subsequent dysphagia in patients with subcortical stroke.

Coordination of Pharyngeal and Laryngeal Swallowing Events During Single Liquid Swallows After Oral Endotracheal Intubation for Patients with Acute Respiratory Distress Syndrome

To evaluate timing and duration differences in airway protection and esophageal opening after oral intubation and mechanical ventilation for acute respiratory distress syndrome (ARDS) survivors versus age-matched healthy volunteers. Orally intubated adult (≥ 18 years old) patients receiving mechanical ventilation for ARDS were evaluated for swallowing impairments via a videofluoroscopic swallow study (VFSS) during usual care. Exclusion criteria were tracheostomy, neurological impairment, and head and neck cancer. Previously recruited healthy volunteers (n = 56) served as age-matched controls. All subjects were evaluated using 5-ml thin liquid barium boluses. VFSS recordings were reviewed frame-by-frame for the onsets of 9 pharyngeal and laryngeal events during swallowing. Eleven patients met inclusion criteria, with a median (interquartile range [IQR]) intubation duration of 14 (9, 16) days, and VFSSs completed a median of 5 (4, 13) days post-extubation. After arrival of the bolus in the pharynx, ARDS patients achieved maximum laryngeal closure a median (IQR) of 184 (158, 351) ms later than age-matched, healthy volunteers (p < 0.001) and it took longer to achieve laryngeal closure with a median (IQR) difference of 151 (103, 217) ms (p < 0.001), although there was no significant difference in duration of laryngeal closure. Pharyngoesophageal segment opening was a median (IQR) of - 116 (- 183, 1) ms (p = 0.004) shorter than in age-matched, healthy controls. Evaluation of swallowing physiology after oral endotracheal intubation in ARDS patients demonstrates slowed pharyngeal and laryngeal swallowing timing, suggesting swallow-related muscle weakness. These findings may highlight specific areas for further evaluation and potential therapeutic intervention to reduce post-extubation aspiration.

Sonographic assessment of swallowing in irradiated nasopharyngeal carcinoma patients

Objectives/Hypothesis

Ultrasonography is an emerging clinical tool to study the dysfunction of swallowing muscles. This was the first sonographic study to assess the relationship between suprahyoid muscle contraction, hyoid bone displacement, and penetration‐aspiration status (PAS) during swallowing in nasopharyngeal carcinoma (NPC) patients treated with radiotherapy (RT). The study also aimed to establish reliability data for the sonographic technique described.

Study Design

Cross‐sectional study.

Methods

Geniohyoid muscle contraction was quantified using brightness‐mode ultrasonography in this study of 40 post‐RT NPC patients. A series of physiological parameters and PAS were measured using videofluoroscopy.

Results

Intra‐ and inter‐rater agreement values ranged from 0.75 to 0.96 across various sonographic measurements. Percentage increase in the cross‐sectional area of the geniohyoid muscle correlated with anterior (r = 0.42, P < .05) but not superior (r = 0.27, P = .09) hyoid displacement. Anterior hyoid displacement and pharyngeal constriction ratio were significantly associated with PAS score.

Conclusions

Sonographic measurement of suprahyoid muscles provides valuable information on muscle function and is potentially a useful clinical tool in swallowing assessment. Further research is needed to refine the role of this examination in dysphagia.

Level of Evidence

2b. Laryngoscope, 2552–2559, 2018

Effects of remifentanil on pharyngeal swallowing: A double blind randomised cross-over study in healthy volunteers

BACKGROUND

Exposure to remifentanil increases the incidence of pulmonary aspiration in healthy volunteers. This effect may be explained by impairment of airway defence mechanisms and/or altered swallowing function. Pressure-flow analysis is a technique that allows objective assessment of swallowing based on pressure-impedance patterns recorded during bolus swallowing.

OBJECTIVES

The aim of this study was to use pressure-flow analysis to quantify the effect of remifentanil on healthy pharyngeal swallowing and to compare these effects with morphine.

DESIGN

A double-blind, randomised, cross-over study.

SETTING

A tertiary care teaching hospital.

VOLUNTEERS

Eleven young volunteers (mean age, 23 years) and seven older volunteers (mean age, 73 years).

INTERVENTIONS

Volunteers were studied twice and received either a target-controlled remifentanil infusion (target concentrations: young, 3 ng ml; old, 2 ng ml) or a bolus injection of morphine (dose: young, 0.1 mg kg; old, 0.07 mg kg). Pharyngeal pressure and impedance were recorded with an indwelling catheter while swallowing 10 boluses of liquid during each measuring phase. Variables defining swallowing function were calculated and compared to determine drug effects.

MAIN OUTCOME MEASURES

Pharyngeal pressure-flow variables following remifentanil exposure.

RESULTS

Changes produced by remifentanil in the measured variables were consistent with greater dysfunction of swallowing. Both the strength of the pharyngeal contractions and pharyngeal bolus propulsion were reduced, whereas flow resistance was increased. The swallow risk index, a global index of swallowing dysfunction, increased overall. At the experimental doses tested, morphine produced similar, but less extensive effects on swallowing.

CONCLUSION

Remifentanil induced dysfunction of the pharyngeal swallowing mechanism. This may contribute to an increased risk of aspiration.

TRIAL REGISTRATION

NCT01924234 (www.clinicaltrials.gov).

Architecture of the Suprahyoid Muscles: A Volumetric Musculoaponeurotic Analysis

PURPOSE

Suprahyoid muscles play a critical role in swallowing. The arrangement of the fiber bundles and aponeuroses has not been investigated volumetrically, even though muscle architecture is an important determinant of function. Thus, the purpose was to digitize, model in three dimensions, and quantify the architectural parameters of the suprahyoid muscles to determine and compare their relative functional capabilities.

METHOD

Fiber bundles and aponeuroses from 11 formalin-embalmed specimens were serially dissected and digitized in situ. Data were reconstructed in three dimensions using Autodesk Maya. Architectural parameters were quantified, and data were compared using independent samples t-tests and analyses of variance.

RESULTS

Based on architecture and attachment sites, suprahyoid muscles were divided into 3 groups: anteromedial, superolateral, and superoposterior. Architectural parameters differed significantly (p < .05) across muscles and across the 3 groups, suggesting differential roles in hyoid movement during swallowing. When activated simultaneously, anteromedial and superoposterior muscle groups could work together to elevate the hyoid.

CONCLUSIONS

The results suggest that the suprahyoid muscles can have individualized roles in hyoid excursion during swallowing. Muscle balance may be important for identifying and treating hyolaryngeal dysfunction in patients with dysphagia.

Alterations in hyolaryngeal elevation after esophageal anastomosis: A possible mechanism for airway aspiration

AIM

A prospective study was performed to evaluate anatomical alterations and hyolaryngeal elevation (HE) by videofluoroscopic swallowing study (VFSS) in patients with esophageal atresia-tracheoesophageal fistula (EA-TEF).

METHODS

Patients operated for EA-TEF were evaluated for age, sex, type of atresia and time to esophageal anastomosis. All patients were evaluated by videofluoroscopic swallowing study (VFSS). Penetration-Aspiration scale (PAS≥7 is considered as aspiration), distance between upper esophageal sphincter and 2nd cervical vertebrae (UES-C2) and hyolaryngeal elevation (HE) were evaluated by the same deglutitionist who was blind to the study. The results of EA-TEF patients were compared with healthy children.

RESULTS

Eighteen patients with EA-TEF and 10 healthy controls were included. The median age was 16months (12-36m) in EA-TEF and 18months (13-51m) in controls. Male-to-female ratio was 5:4 and 4:1 respectively. 12 of cases were isolated-EA, 1 of them was EA-proximal TEF and 5 of the cases were EA-distal TEF. Half of the cases had primary EAN and others underwent delayed esophageal repair. Early oral feeding was also started in 9 patients (50%) whereas others had delayed oral feeding. VFSS showed aspiration in 27.7 (n=5) of cases (PAS≥7) in EA group. The median distance between UES-C2 was 3.04cm (min: 2.17-max: 3.94) in EA and 4.17cm (min: 3.45-max: 6.24cm) in controls. Median distance for HE was 0.37cm (min: 0.18-max: 1.1cm) in EA and 1.15 (min: 0.61-max: 1.06cm) in controls. The distance between UES-C2 was significantly lower than controls (p<0.05) and HE was decreased in EA-TEF without any statistical significance.

CONCLUSION

Children with EA-TEF had shortened distance between airway and upper esophagus. HE may be inefficient to protect airway during deglutition. Anatomical alterations after EAN suggest that airway problems may be related with decreased HE in children with EATEF.

LEVEL OF EVIDENCE

Level II (Development of diagnostic criteria in a consecutive series of patients and a universally applied "gold standard").

Effect of an impaired oral stage on swallowing in patients with Parkinson's disease

We investigated the swallowing function in patients with Parkinson's disease (PD) using deteriorated tongue control because patients with PD frequently exhibit an impaired oral stage of swallowing and the tongue movement affects oral and pharyngeal stage. In total, 201 patients with PD (106 men, 95 women; mean age 70·6 ± 8·0 years; median Hoehn-Yahr Stage III) were studied. The patients swallowed 10 mL of liquid barium under videofluorography, and their oral transit time (OTT) was measured. Based on 20 healthy controls (mean age 70·3 ± 7·8 years) with an OTT + 2 standard deviation (0·89 + 2 × 0·46) of 1·81 s, the patients with PD were divided into 167 patients with an OTT < 1·81 s and 34 patients with an OTT ≥ 1·81 s. Swallowing function was compared between the groups and assessed using logistic regression analysis. The following factors were significantly associated with oral stage impairment in both groups: tongue-to-palate contact, tongue root-to-posterior pharyngeal wall contact, premature spillage into the pharynx, aspiration and onset of swallowing reflex. Logistic regression analysis showed that tongue root-to-posterior pharyngeal wall contact, onset of swallowing reflex and aspiration were independent factors. PD patients with prolonged OTT displayed poor lingual control and decreased range of motion of the tongue due to bradykinesia and rigidity. Such problems in the oral stage affected the subsequent pharyngeal stage of swallowing with aspiration. Lingual movement in the oral stage thus appears to play an important role in the sequential movement of swallowing in PD.

Laryngeal Closure during Swallowing in Stroke Survivors with Cortical or Subcortical Lesion

BACKGROUND

One of the major, and most harmful, symptoms of dysphagia in stroke survivors is aspiration. Survivors of unilateral cortical strokes with dysphagia and resulting aspiration have been reported to have greater initiation delays in laryngeal closure than those who did not aspirate. Few studies have reported such data in survivors of subcortical stroke.

METHODS

This study measured initiation of laryngeal closure (ILC) and laryngeal closure duration (LCD) in 2 groups of subjects: 15 stroke survivors with cortical lesions and 15 stroke survivors with subcortical lesions. Means and standard deviations of ILC and LCD were analyzed on 5-mL thin liquid and 5-mL puree boluses using a 100-ms timer during subsequent analysis of videofluoroscopic swallowing examinations. Statistical comparisons were used by repeated measures analysis of variance. Significance level was set at P < .05.

RESULTS

ILC was significantly longer in stroke survivors with a subcortical lesion than in those with a cortical lesion for both bolus consistencies. However, there were no significant differences between the 2 groups in LCD. Stroke survivors with a subcortical lesion had a greater incidence of penetration or aspiration and silent aspiration than those with a cortical lesion and a longer delay in the ILC.

CONCLUSIONS

Subcortical lesions may put these survivors at greater risk of aspiration due to delayed initial laryngeal closure and reduced oral and laryngeal sensation. The subcortical damage, which occurs at the basal ganglia, may interrupt the ILC.

Relationship between jaw opening force and hyoid bone dynamics in healthy elderly subjects

PURPOSE

This study aimed to examine the relationship between jaw opening force and hyoid bone dynamics and resting position in elderly individuals based on gender.

SUBJECTS AND METHODS

Subjects were 36 healthy elderly individuals aged ≥65 years without dysphagia (16 men and 20 women; mean age 75.5 years, range 65-88 years). Videofluorographic images during the swallowing of 10 mL of 40% (w/v) barium sulfate were obtained and the degrees of anterior, superior, and hypotenuse displacements of the hyoid bone and maximum/resting hyoid position were evaluated. Jaw opening force was measured three times using a jaw opening force sthenometer; the mean of these three measurements was used for analysis.

RESULTS

In men, there was a positive correlation between jaw opening force and resting hyoid position and negative correlations among all the degrees of anterior, superior, and hypotenuse displacements of the hyoid bone. In women, there was no statistically significant correlation between jaw opening force and any of the measurement items. There was no statistically significant correlation between jaw opening force and maximum hyoid position in either men or women.

CONCLUSION

Our findings suggest that low jaw opening force leads to low resting hyoid position only in elderly men, and a lower hyoid position in healthy elderly men results in a larger total amount of hyoid displacement during swallowing. Moreover, a maximum hyoid position in healthy individuals of either gender does not differ depending on their jaw opening force.

Subjective Assessment of Videofluoroscopic Swallow Studies

Objective

The videofluoroscopic swallow study (VFSS) is the gold standard diagnostic tool to evaluate oropharyngeal dysphagia. Although objective measurements on VFSS have been described, there is no universal method of analysis, and the majority of clinicians use subjective interpretation alone. The purpose of this investigation was to evaluate the accuracy of subjective VFSS analysis.

Study Design

Double-blinded experiment.

Setting

Tertiary care laryngology center.

Subjects and Methods

Seventy-six de-identified videos from VFSS evaluations of patients with dysphagia were presented to blinded, experienced speech-language pathologists and laryngologists individually. Evaluators rated each video as normal or abnormal for hyoid elevation (HE), pharyngeal area (PA), pharyngeal constriction ratio (PCR), and pharyngoesophageal segment opening (PESo). A blinded investigator assessed evaluators’ inter- and intrarater agreement and compared their responses to objectively measured results for these parameters to examine accuracy.

Results

Evaluators correctly classified only 61.5% of VFSS videos as normal or abnormal, with moderate interrater agreement (κ = 0.48, P < .0001). Intrarater agreement was highly variable (κ = 0.43-0.83). Accuracy was greatest for PCR (71.6%), with poorer performance for HE (61.3%), PESo (59.2%), and PA (45.3%). Interrater agreement was moderate for all parameters, with greater concordance for PCR (κ = 0.59) and PESo (κ = 0.54) and less for HE (κ = 0.40) and PA (κ = 0.44). Evaluators unanimously agreed on a correct interpretation of a VFSS only 28% of the time.

Conclusion

Subjective assessment of VFSS parameters is inconsistently accurate when compared with objective measurements, with accuracy ratings ranging from 45.3% to 71.6% for specific parameters. Inter- and intrarater reliability for subjective assessment was moderate and highly variable.

Increased Bolus Volume Effect on Delayed Pharyngeal Swallowing Response in Post-stroke Oropharyngeal Dysphagia: A Pilot Study

Objective

To confirm a relationship between the pharyngeal response and bolus volume, and examine whether increasing the fluid bolus volume can improve penetration and aspiration for stroke dysphagic patients.

Methods

Ten stroke patients with a delayed pharyngeal response problem confirmed by a videofluoroscopic swallowing study (VFSS) were enrolled. Each subject completed two swallows each of 2 mL, 5 mL, and 10 mL of barium liquid thinned with water. The pharyngeal delay time (PDT) and penetration-aspiration scale (PAS) were measured and the changes among the different volumes were analyzed.

Results

PDTs were shortened significantly when 5 mL and 10 mL of thin barium were swallowed compared to 2 mL. However, there was no significant difference in PAS as the bolus volume increased.

Conclusion

The increased fluid bolus volume reduced the pharyngeal delay time, but did not affect the penetration and aspiration status.

The effectiveness of the head-turn-plus-chin-down maneuver for eliminating vallecular residue

Purpose When swallowing efficiency is impaired, residue accumulates in the pharynx. Cued or spontaneous swallows in the head neutral position do not always successfully clear residue. We investigated the impact of a novel maneuver on residue clearance by combining a head turn with the chin down posture. Methods Data were collected from 26 participants who demonstrated persistent vallecular residue after an initial head neutral clearance swallow in videofluoroscopy. Participants were cued to perform a head-turn-plus-chin-down swallow, with the direction of head turn randomized. Pixel-based measures of residue in the vallecular space before and after the maneuver were made on still frame lateral images using ImageJ software. Measures of % full and the Normalized Residue Ratio Scale (NRRS) were extracted. Univariate analyses of variance were used to detect significant reductions in residue. Results On average, pre-maneuver measures showed residue filling 56-73% of the valleculae, depending on stimulus consistency (NRRS scores: 0.2-0.4). More than 80% of pre-swallow measures displayed NRRS ratios > 0.06, a threshold previously linked to increased risk of post-swallow aspiration. Conclusion The head-turn-plus-chin-down maneuver achieved significant reductions in residue for thin and nectar-thick fluids, suggesting that this maneuver can be effective in reducing persistent vallecular residue with these consistencies.