Videofluoroscopic assessment of patients with dysphagia: pharyngeal retention is a predictive factor for aspiration

Objective dysphagia is very common after radiotherapy in oropharyngeal cancer patients

OBJECTIVE

Dysphagia is one of the most serious adverse events in the treatment of head and neck cancer. This cross-sectional study aimed to assess pharyngeal residue, and penetration/aspiration in oropharyngeal cancer patients (OPC) after radiotherapy using flexible endoscopic evaluation of swallowing (FEES).

METHODS

A total of 35 OPC patients who had received radio-(chemo) therapy (R(C)T), including 8 patients with primary R(C)T), were included and examined by FEES to determine the swallowing status and were asked to indicate their swallowing ability on a visual scale to reflect the problem perceived by the patient. During FEES the patients were given three standardized bolus consistencies and four test pills. Penetration, aspiration, and residue were evaluated and classified.

RESULT

Relevant dysphagia was present in 23/35 (66%) patients. Almost half of all patients (15/35) showed aspiration (53% (8/15) silent). Residue occurred in 91% but without correlation to aspiration. A significant association between dysphagia and impaired pill swallowing was found (P = .003) occurring in 20 of 35 patients. Even in patients with small tumors and without prior surgery severe dysphagia was found.

CONCLUSIONS

Severe dysphagia is frequent after R(C)T affecting more than half of the patients with OPC. The frequent impaired pill swallowing ability should be considered Therefore, regular dysphagia diagnostics in the follow-up setting are advisable to initiate appropriate treatment and raise patients' quality of life, prevent aspiration pneumonia, and improve overall outcomes after tumor therapy.

Reliability and Confidence of Dynamic Imaging Grade of Swallowing Toxicity (DIGEST) Rating Among Research and Clinical Speech Pathologists Before and After Implementation of a Training Manual: A Multi-site Study

DIGEST is a validated, open-source method to grade the severity of pharyngeal dysphagia from the modified barium swallow (MBS) study. Dissemination and implementation of DIGEST is rising, making it critical to understand reliability and facilitators of accurate implementation among users. The aim was to assess reliability of the tool among speech-language pathology (SLP) raters practicing at multiple sites before and after review of a DIGEST training manual and evaluate confidence of DIGEST use pre-and post-training. Thirty-two SLPs from 5 sites participated in a blinded longitudinal DIGEST rating study. Raters were provided a standardized training set of MBS (n = 19). Initial SLP ratings (round 1, R1) were followed by a 2-4 week break before raters rated a re-keyed MBS set (round 2, R2). A minimum 4-8 week wash-out period then preceded self-study of the DIGEST training manual which was followed by a final rating (round 3, R3) and a post-manual survey afterwards. Baseline reliability (R1) of overall DIGEST was on average k = 0.70, reflecting agreement in the substantial range. Seventy-five percent of raters (24/32) demonstrated reliability ≥ 0.61 in the substantial to almost perfect range prior to training. Inter-rater reliability significantly improved from R1 to R3 after review of the DIGEST manual, with the largest change in DIGEST-Efficiency (mean change: DIGEST k = .04, p = .009, DIGEST-Safety k = .07, p = 0.03, and DIGEST-Efficiency k = .14, p = 0.009). Although DIGEST reliability at baseline was adequate in the majority of raters, self-study of the DIGEST training manual significantly improved inter-rater reliability and rater confidence using the DIGEST method, particularly when assigning DIGEST-Efficiency grade. These early data show promise that provider training may be useful to aid in fidelity of DIGEST implementation among SLP clinical users with varying DIGEST experience.

The Influence of Perspective on Perception: Assessing Residue Across Planes of Videofluoroscopy

OBJECTIVES

(1) To determine whether perception of pharyngeal residue severity differs by view plane on videofluoroscopy. (2) To explore whether the Bolus Clearance Ratio (BCR) can be reliably applied in the anterior-posterior (AP) plane. (3) To investigate the relationship between perception of residue severity and BCR measures across view planes.

METHODS

Images of the same bolus condition in lateral and AP were rated using a simple 5-point ordinal descriptive scale (none, trace, mild, moderate, severe) by 225 speech-language pathologists via electronic survey. BCR measures were obtained for the same set of images from four trained raters. Wilcoxon signed-rank tests and cumulative mixed modeling were used to compare ratings by plane. BCR reliability was calculated using intraclass correlation coefficients. Perceptual ratings were compared with BCR measures using Spearman correlations.

RESULT

(1) Perception of residue severity was not consistent across plane in 9/10 image pairs (p < 0.05), with a significant fixed effect of plane on severity rating (β = 0.41; z = 7.27; p < 0.001). The directionality of differences varied by case. (2) Inter-rater reliability for BCR measures was good across lateral (intraclass correlation coefficient [ICC] = 0.82) and AP (ICC = 0.87) planes, with superior intra-rater reliability in AP (lateral ICC = 0.85; AP ICC = 0.98). (3) There was a strong positive correlation between perceptual ratings and BCR measures in both planes.

CONCLUSIONS

Perception of pharyngeal residue severity differs between lateral and AP planes with inconsistent directionality raising important questions about the clinical implications of single plane studies. The BCR shows good-excellent reliability and strong correlation with perception across planes, offering a promising method for cross-plane quantification.

LEVEL OF EVIDENCE

3, diagnostic study with a gold standard Laryngoscope, 135:1352-1358, 2025.

A Tool for the Assessment of Swallowing Safety and Efficiency in Adults: Turkish Adaptation of Boston Residue and Clearance Scale

The objective of this study was to create a Turkish language adaptation of the Boston Residue and Clearance Scale (BRACS), a validated and reliable tool. The BRACS scale was first translated into Turkish and a Turkish version was subsequently developed. Fiberoptic endoscopic examination of swallowing (FEES) was administered to collect data from 25 dysphagic patients who were hospitalized after a stroke. The recorded films were subjected to editing procedures to ensure their appropriateness for the assessment of swallowing disorders and were then dispatched to a panel of five speech and language therapists for evaluation using the adaptation of the BRACS instrument. The scoring by the experts was evaluated using both explanatory factor analysis (EFA) and confirmatory factor analysis (CFA). Convergent validity, item reliability, and construct (composite) reliability were measured by calculating the average variance extracted (AVE) values. For the 12 location items, EFA revealed 3 main latent factors: the laryngeal vestibule and the oropharynx and hypopharynx. The Turkish BRACS had excellent inter-rater reliability (Krippendorff's alpha coefficient values ranged from 0.93 to 0.95) and high internal consistency (Cronbach's alpha values ranged from 0.88 to 0.93). Inter-rater ICCs for the first and second sessions were 0.83 and 0.85, respectively. CFA showed that all fitted criteria reached acceptable or perfect fit levels. The findings indicated that the proposed factor structure was validated. The AVE values are between 0.61 and 0.73 which was taken as evidence of convergent validity. The Turkish adaptation of the BRACS tool demonstrates both reliablity and validity, rendering it a useful and credible tool for assessing residual severity, particularly in clinical settings.

Investigation of Pharyngeal Swallow Function of Healthy Older Adults Using Visual Analysis of Swallowing Efficiency and Safety Scale

To assess the pharyngeal swallow function of older adults in terms of safety and efficiency using the VASES scale. Twenty healthy individuals aged 60-80 years were included. They were evaluated using the EAT-10 K and VVST, followed by the FEES assessment. VASES was used to assess the residue in the oropharynx, hypopharynx, Epiglottis, Laryngeal vestibule, Vocal folds, and Sub glottis, and the aspiration and penetration during swallowing. Residue was present in the oropharynx, hypopharynx, epiglottis, and laryngeal vestibule for 95%, 85%, 45%, and 15% of the swallowing trials. The median residue amount was found to be 2% in the oropharynx and 1% in the hypopharynx. 70% of swallows yielded a score of PAS score of 1, followed by PAS 3 for 20% and PAS 2 for 10%. VASES facilitated the quantification of the residue across anatomical sites. Older adults did have compromised swallow safety and efficiency.

Predicting Swallowing Recovery in Subacute Stroke Patients via Temporal and Spatial Parameters of Videofluoroscopy

PURPOSE

The purpose of this study was to identify the temporal and spatial parameters of videofluoroscopic swallowing study (VFSS) that could predict the recovery of swallowing function in subacute stroke patients.

METHODS

We included 102 patients who were admitted to the Department of Rehabilitation Medicine between 2019 and 2022. Patients were classified into good and poor prognosis groups according to whether they had restored prestroke swallowing function or were able to consume sufficient nutrition via oral feeding to meet their body's needs. Univariate and multivariate regression analyses were used to identify the predictors. Calibration and discrimination were tested using the Hosmer-Lemeshow test and area under the curve (AUC), respectively.

RESULTS

Of the 102 included patients, 51 had a good prognosis for swallowing function within 6 months of onset. The final multivariate regression model included three significant factors: laryngeal closure duration (LCD) (OR: 0.998; 95% CI: 0.996-0.999; p < 0.05), maximum width of the upper esophageal sphincter opening (MWUESO) (OR: 1.251; 95% CI: 1.073-1.458; p < 0.05), and pharyngeal residual grade (PRG) (p < 0.05). The shorter LCD and larger MWUESO were positive predictors of good swallowing function outcomes, while higher PRG was a negative predictor of good outcomes. The AUC for PRG, MWUESO, and LCD were 0.767 (p < 0.05), 0.738 (p < 0.05), and 0.681 (p < 0.05), respectively.

CONCLUSION

Identifying prognostic factors for the recovery of swallowing function in patients with poststroke dysphagia is essential for developing treatment strategies. The findings of this study may provide an important reference for developing appropriate therapeutic interventions to promote the recovery of swallowing function in stroke patients.

Pharyngeal Residue Scoring in Fiberoptic Endoscopic Evaluation of Swallowing: Reliability Comparison and Applicability Among Different Scales

Several scales to assess pharyngeal residue in Fiberoptic Endoscopic Evaluation of Swallowing (FEES) are currently available. The study aimed to compare the reliability and the applicability in real clinical practice among four rating scales: the Pooling Score (P-SCORE), the Boston Residue and Clearance Scale (BRACS), the Yale Pharyngeal Residue Severity Rating Scale (YPRSRS), and the Residue Ordinal Rating Scale (RORS). Twenty-five FEES videos were evaluated four times, once for each scale, by four speech and language pathologists. To test intra-rater reliability, the same raters re-assessed the videos two weeks apart. To test the applicability, raters recorded the time required to complete each assessment and the perceived difficulty/ease on a visual-analog scale (VAS). The intra-rater and the inter-rater reliability were calculated with Cohen's weighted Kappa and the Fleiss weighted Kappa, respectively. Time and perceived difficulty/ease scores were compared. The intra-rater reliability analysis showed almost perfect agreement for YPRSRS (k = 0.91) and RORS (k = 0.83) and substantial agreement for P-SCORE (k = 0.76) and BRACS (k = 0.74). Pairwise comparison showed no significant differences among the scales. The inter-rater reliability for the YPRSRS (k = 0.78) was significantly higher than P-SCORE (k = 0.52, p < 0.001), BRACS (k = 0.56, p < 0.001), and RORS (k = 0.65, p = 0.005). The BRACS required the longest time (p < 0.001) and was perceived as the most difficult scale (p < 0.001). The RORS was perceived as the easiest scale (p < 0.05). In conclusion, the YPRSRS showed the highest reliability, while raters perceived the RORS as the easiest to score. These results will allow clinicians to consciously choose which scale to use in clinical practice.

Videofluoroscopic Swallowing Studies: A Proposed Checklist

PURPOSE

The videofluoroscopic swallowing study (VFSS) is used widely in dysphagia research. However, variations exist in the conduct and interpretation of VFSS, including differences in contrast agents, food and fluid consistencies tested, patient positioning, intervention strategies trialed, fluoroscopy settings, resolution, and image storage solutions. It cannot be assumed that VFSS exams yield directly comparable results across different studies. It is essential that relevant elements of VFSS be clearly reported in research. The goal of this article is to outline optimal VFSS reporting as part of the Framework for RigOr aNd Transparency In REseaRch on Swallowing (FRONTIERS), a critical appraisal tool intended to promote rigor and transparency in dysphagia research.

METHOD

We developed a set of 27 questions regarding the rigor and transparency of VFSS reporting, based on review of previous research articles. These were reviewed by all members of the FRONTIERS Framework collaborative, to determine which questions were mandatory, unnecessary, or needed revision, prior to inclusion in the final critical appraisal tool.

RESULTS

The final FRONTIERS Framework tool contains 20 questions and seven subquestions regarding VFSS. These are grouped into four themes: patient/participant positioning, equipment and recording settings, contrast agents, and rating methods, including operational definitions and reliability.

CONCLUSIONS

The VFSS section of the FRONTIERS Framework tool is intended to facilitate and promote rigorous and transparent reporting of all elements that may influence the interpretation of VFSS in research. This critical appraisal tool can also be used to guide research design and the evaluation of study outcomes contributing to best practices in the field of dysphagia research.

Pharyngeal phase of swallowing in post-stroke dysphagia: videoendoscopy and speech-language-hearing assessment

PURPOSE

To investigate the outcomes of fiberoptic endoscopic evaluation of pharyngeal swallowing phase and clinical evaluation of swallowing among dysphagic individuals with and without chronic stroke in different food consistencies.

METHODS

This is a cross-sectional and retrospective study based on data collection from medical records. 134 swallowing video endoscopy exams of dysphagic patients were analyzed, in which they were divided into two groups according to the diagnosis of stroke, in which data were collected regarding mobility and strength of the tongue, phonation and cough efficiency, and the pharyngeal signs of dysphagia with four food consistencies from the International Dysphagia Diet Standardization Initiative (IDDSI), for comparison between groups. To analyze and classify the severity of pharyngeal residues, the Yale Pharyngeal Residue Severity Rating Scale (YPRSRS) was used by two independent professionals.

RESULTS

There was a significant difference in the presence of pharyngeal residue, laryngeal penetration and laryngotracheal aspiration in all consistencies evaluated (level 0, 2, 4 and 7) (p= <0.001), in addition to the association with multiple swallowing in thin liquid, slightly thickened liquid and solid (level 0, 2 and 7) (p= 0.026).

CONCLUSION

Dysphagic individuals diagnosed with stroke showed differences in videoendoscope signs of pharyngeal residue, laryngeal penetration and laryngotracheal aspiration, regardless of the food consistency assessed, compared to dysphagic individuals without the diagnosis. Just as there was a difference in the finding of multiple swallowing only in the consistencies of thin liquid, extremely thickened liquid and solid.

Oropharyngeal swallowing hydrodynamics of thin and mildly thick liquids in an anatomically accurate throat-epiglottis model

Understanding the mechanisms underlying dysphagia is crucial in devising effective, etiology-centered interventions. However, current clinical assessment and treatment of dysphagia are still more symptom-focused due to our limited understanding of the sophisticated symptom-etiology associations causing swallowing disorders. This study aimed to elucidate the mechanisms giving rise to penetration flows into the laryngeal vestibule that results in aspirations with varying symptoms. Methods: Anatomically accurate, transparent throat models were prepared with a 45° down flapped epiglottis to simulate the instant of laryngeal closure during swallowing. Fluid bolus dynamics were visualized with fluorescent dye from lateral, rear, front, and endoscopic directions to capture key hydrodynamic features leading to aspiration. Three influencing factors, fluid consistency, liquid dispensing site, and dispensing speed, were systemically evaluated on their roles in liquid aspirations. Results: Three aspiration mechanisms were identified, with liquid bolus entering the airway through (a) the interarytenoid notch (notch overflow), (b) cuneiform tubercle recesses (recess overflow), and (c) off-edge flow underneath the epiglottis (off-edge capillary flow). Of the three factors considered, liquid viscosity has the most significant impact on aspiration rate, followed by the liquid dispensing site and the dispensing speed. Water had one order of magnitude higher aspiration risks than 1% w/v methyl cellulose solution, a mildly thick liquid. Anterior dispensing had higher chances for aspiration than posterior oropharyngeal dispensing for both liquids and dispensing speeds considered. The effects of dispending speed varied. A lower speed increased aspiration for anterior-dispensed liquids due to increased off-edge capillary flows, while it significantly reduced aspiration for posterior-dispensed liquids due to reduced notch overflows. Visualizing swallowing hydrodynamics from multiple orientations facilitates detailed site-specific inspections of aspiration mechanisms.

A shocking intraoperatively diagnosis of ochronotic knee arthropathy: a case report

Introduction

Alkaptonuria is an autosomal extremely rare recessive metabolic disorder with incidence reported to occur as 1:100 000-1:250 000 live births worldwide. This rare metabolic disorder is characterized by the accumulation of homogentisic acid due to a deficiency in homogentisic acid 1,2 dioxygenase. Homogentisic acid subsequently oxidizes and accumulates in the connective tissue. The knee is the most significant peripheral joint to be affected by the disorder. The authors present the first case of ochronotic arthropathy in Syria.

Case presentation

A 46-year-old male presented with bilateral pain in the knees. the pain was affecting his day-to-day activities, and not responding to conservative management. Anteroposterior standing radiographs demonstrated extensive degenerative disease. Intraoperatively, the diagnosis was done after noticing that the quadriceps tendon and the articular cartilage of the femur, tibia, and patella were blackened during cemented total knee replacement of the knee.

Conclusion

Ochronotic arthropathy should be kept in mind in middle age patients with severe osteoarthritis to not be surprised by the rare alkaptonuria diagnosis if arthroplasty was indicated.

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.

Critical swallowing functions contributing to dysphagia in patients with recurrent laryngeal nerve paralysis after esophagectomy

BACKGROUND

Recurrent laryngeal nerve paralysis (RLNP) after esophagectomy can cause aspiration because of incomplete glottis closure, leading to pneumonia. However, patients with RLNP often have preserved swallowing function. This study investigated factors that determine swallowing function in patients with RLNP.

METHODS

Patients with esophageal cancer who underwent esophagectomy and cervical esophagogastric anastomosis were enrolled between 2017 and 2020. Videofluoroscopic examination of swallowing study (VFSS) and acoustic voice analysis were performed on patients with suspected dysphagia including RLNP. Dysphagia in VFSS was defined as score ≥ 3 of the 8-point penetration-aspiration scale VFSS and acoustic analysis results related to dysphagia were compared between patients with and without RLNP.

RESULTS

Among 312 patients who underwent esophagectomy, 74 developed RLNP. The incidence of late-onset pneumonia was significantly higher in the RLNP group than in the non-RLNP (18.9 vs. 8.0%, P = .008). Detailed swallowing function was assessed by VFSS in 84 patients, and patients with RLNP and dysphagia showed significantly shorter maximum diagonal hyoid bone elevation (10.62 vs. 16.75 mm; P = .003), which was a specific finding not seen in patients without RLNP. For acoustic voice analysis, the degree of hoarseness was not closely related to dysphagia. The length of oral intake rehabilitation for patients with and without RLNP was comparable if they did not present with dysphagia (8.5 vs. 9.0 days).

CONCLUSIONS

Impaired hyoid bone elevation is a specific dysphagia factor in patients with RLNP, suggesting compensatory epiglottis inversion by hyoid bone elevation is important for incomplete glottis closure caused by RLNP.

Comparison of swallowing disorder in patients with tongue cancer undergoing reconstruction with either a radial forearm free flap or a submental island flap

PURPOSE

In this study, the swallowing status of patients with tongue cancer undergone tongue reconstruction using radial forearm free flaps (RFFF) and submental flaps were compared.

METHODS

A total of 26 patients with tongue cancer undergone tongue resection were randomly treated by tongue reconstruction with either submental flap or RFFF approach. Swallowing status of the patients was investigated using fiberoptic endoscopic evaluation of swallowing (FEES) by measurement of pharyngeal residue and penetration scales.

RESULTS

The pharyngeal residue scale in vallecula and pyriform sinus and the average of vallecula and pyriform sinus on days 10 and 30 post-operation as well as penetration scale at the same time showed no significant difference between two groups. However, the time to start oral feeding was significantly reduced in the submental group compared to the free flap group (P = 0.031). A positive Pearson correlation was found between the size of oral tongue and base of tongue resection and some of swallowing parameters.

CONCLUSION

Since there was no significant difference between submental and free flap respected to swallowing disorder, the submental flap is prior to free flap due to lower cost and hospitalization and less complication after tongue reconstruction.

Treatment of Post-stroke Dysphagia With Interferential Current: Three Case Reports and a Review of the Literature

Stroke is damage to the central nervous system due to vascular pathology. Stroke causes many complications. One of the most important of these complications is dysphagia. Dysphagia is a major cause of morbidity and mortality. In recent years, the benefits of using interferential current (IFC) stimulation in the treatment of dysphagia due to various etiologies have been demonstrated. However, there are significant gaps in the literature regarding patient populations, treatment procedures, and evaluation of treatment response. Here, we report the treatment of three cases of dysphagia after ischemic stroke with IFC stimulation and review the current literature. The patients had no previous treatment for dysphagia and were using only compensatory methods. This case report highlights the benefit of IFC stimulation in the treatment of post-stroke dysphagia both clinically and videofluoroscopically. It should be kept in mind that IFC stimulation may be an important alternative in the treatment of post-stroke dysphagia.

The Role of Bolus Residue and Its Relation with Respiratory Problems in Children with Esophageal Atresia

Bolus residue is significant risk factor for postswallow aspiration. A retrospective study was performed to evaluate the role of bolus residue and its relation with respiratory problems in children with esophageal atresia. Children were evaluated for demographic features, type of esophageal atresia, associated anomalies, and respiratory problems. The videofluoroscopic swallowing evaluation (VFSE) was performed, and scored by using the penetration aspiration scale (PAS), bolus residual score (BRS) and normalized residual ratio scale (NRRS). Children with and without respiratory problems were also compared in terms of aspiration and bolus residue. Forty-one children with a median age of 15 months (1-138 months), male:female ratio of 26:15 was included. 65.9% (n = 27) of children were type-C and 24.4% (n = 10) were type-A EA. In 61% (n = 25) of children had liquid aspiration (PAS ≥ 6) and 9.8% (n = 4) had aspiration in pudding consistencies. Children with aspiration in liquids had significantly higher NRRS and BRS scores in vallecular residue for pudding consistencies when compared to children without aspiration (p < 0.05). No difference was detected in terms of PAS scores and bolus residual parameters between children with and without respiratory problems (p > 0.05). Children with aspiration in liquids have higher scores of BRS and NRRS at the level of vallecular especially in pudding consistencies. VFSE findings for bolus residue did not show significant relation with respiratory problems. Respiratory morbidity in children with EA is multifactorial and may not only explained by bolus residuals and aspiration.

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.

Efficacy of High-Intensity Training in Patients with Moderate to Severe Dysphagia after Glossectomy

Dysphagia is the main impairment arising from glossectomy for tongue cancer treatment. The study aimed to determine if an eight-week training protocol paired with accuracy tasks and swallowing exercises is effective and can improve tongue strength and swallowing in patients after tongue resection. Maximum isometric pressures, tongue endurance, swallowing pressures, mealtime duration, and oropharyngeal swallow function were studied in patients with moderate to severe dysphagia after glossectomy. Twenty-five (25) patients and thirty-one (31) healthy participants were enrolled in the study. The therapy group (TG) consisted of seventeen (17) patients who followed an 8-week treatment protocol and had multiple measurements. The follow-up control group (FUG) consisted of eight non-treated patients who had a baseline and an 8-week follow-up examination. Healthy participants served as the reference group (RF). Maximum isometric pressures, endurance, and swallowing pressures increased significantly in the TG versus the FUG. Significant improvement was documented in the TG regarding the EAT-10 questionnaire, the Penetration-Aspiration Scale scores at thickened and solid boluses, and post-swallow residues at thickened and solid boluses. The treatment protocol with tongue strength exercises combined with accuracy tasks and swallowing exercises improves the post-operative swallowing function in patients after glossectomy. Patients in the TG had more significant and quicker improvement in pressures and endurance compared to FUG.

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.

Quantifying Pharyngeal Residue Across the Adult Life Span: Normative Values by Age, Gender, and Swallow Task

PURPOSE

We quantified pharyngeal residue using pixel-based methods in a normative data set, while examining influences of age, gender, and swallow task.

METHOD

One hundred ninety-five healthy participants underwent a videofluoroscopic swallow study following the Modified Barium Swallow Impairment Profile (MBSImP) protocol. ImageJ was used to compute Normalized Residue Ratio Scale and the Analysis of Swallowing Physiology: Events, Kinematics and Timing (ASPEKT) pharyngeal residue measures. Reliability was established. Descriptive statistics were performed for all residue measures. Inferential statistics were performed using ASPEKT total scores (i.e., %C2-42). Logistic regression models explored predictors of residue versus no residue. Generalized linear mixed models explored predictors of nonzero residue. Spearman rho explored relationships between ASPEKT total residue scores and MBSImP Component 16 (Pharyngeal Residue) scores.

RESULTS

Majority of swallows (1,165/1,528; 76.2%) had residue scores of zero. Residue presence (%C2-42 > 0) was influenced by age (more in older [F = 9.908, p = .002]), gender (more in males [F = 18.70, p < .001]), viscosity (more in pudding, nectar, and honey [F = 25.30, p < .001]), and volume (more for cup sip [F = 37.430, p < .001]). When residue was present (363/1,528 = 23.8%), amounts were low (M = 1% of C2-42, SD = 2.4), and only increasing age was associated with increased residue (F = 9.008, p = .007) when controlling for gender and swallow task. Increasing residue was incremental (0.01% of C2-42 per year). As ASPEKT total residue values increased, MBSImP Component 16 scores also increased.

CONCLUSIONS

Pharyngeal residue amounts were very low in healthy adults. Residue presence can be influenced by age, gender, and swallow task. However, when present, the amount of pharyngeal residue was only associated with increasing age.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.21957221.

Temporal Sequence of Laryngeal Vestibule Closure and Reopening is Associated With Airway Protection

BACKGROUND

Upper esophageal sphincter opening (UESO), and laryngeal vestibule closure (LVC) are two essential kinematic events whose timings are crucial for adequate bolus clearance and airway protection during swallowing. Their temporal characteristics can be quantified through time-consuming analysis of videofluoroscopic swallow studies (VFSS).

OBJECTIVES

We sought to establish a model to predict the odds of penetration or aspiration during swallowing based on 15 temporal factors of UES and laryngeal vestibule kinematics.

METHODS

Manual temporal measurements and ratings of penetration and aspiration were conducted on a videofluoroscopic dataset of 408 swallows from 99 patients. A generalized estimating equation model was deployed to analyze association between individual factors and the risk of penetration or aspiration.

RESULTS

The results indicated that the latencies of laryngeal vestibular events and the time lapse between UESO onset and LVC were highly related to penetration or aspiration. The predictive model incorporating patient demographics and bolus presentation showed that delayed LVC by 0.1 s or delayed LVO by 1% of the swallow duration (average 0.018 s) was associated with a 17.19% and 2.68% increase in odds of airway invasion, respectively.

CONCLUSION

This predictive model provides insight into kinematic factors that underscore the interaction between the intricate timing of laryngeal kinematics and airway protection. Recent investigation in automatic noninvasive or videofluoroscopic detection of laryngeal kinematics would provide clinicians access to objective measurements not commonly quantified in VFSS. Consequently, the temporal and sequential understanding of these kinematics may interpret such measurements to an estimation of the risk of aspiration or penetration which would give rise to rapid computer-assisted dysphagia diagnosis.

LEVEL OF EVIDENCE

2 Laryngoscope, 133:521-527, 2023.

Application of Ultrasonography in Neurogenic Dysphagia: A Systematic Review

Swallowing disorders are common in neurological diseases, with dysphagia representing one of the most prevalent complications that may cause poor quality of life, reduce independence, and increase mortality. Rapid identification of dysphagia is necessary to reduce the risk of penetration and aspiration, and to early start rehabilitation protocols. Among the methods that can be used to evaluate dysphagia and its components, ultrasound imaging has been suggested to support the evaluation of dysphagia by providing measures of both static and dynamic anatomical components. The aim of this systematic review is to evaluate the usefulness of ultrasonography in neurogenic dysphagia according to current literature. From 2000 to 2020, 633 studies with the appropriate search terms for ultrasound and dysphagia were identified. After screening them, 10 studies were included in the qualitative analysis. Patients with the following neurologic conditions were studied with ultrasonography for dysphagia: Parkinson's disease, muscle dystrophy, amyotrophic lateral sclerosis, and stroke. The main outcomes of ultrasonography were swallowing muscles thickness (e.g., tongue), and dynamic measures such as hyoid displacement. The different protocols used in the studies, as well as their outcomes, did not allow to provide standard procedures and normative or cut-off values in the presented diseases. Because there are a variety of tools, methods, and techniques that have been used in the studies that were reviewed, it is difficult to evaluate them using established standards. However, ultrasonography correlates well with clinical evaluation of dysphagia and therefore has prognostic and rehabilitation potential. Future studies should aim to develop and utilize a common interdisciplinary protocol that includes standard procedures and outcomes to define normative values applicable in the different conditions.

Bolus Clearance Ratio Elevated in Patients With Neurogenic Dysphagia Compared With Healthy Adults: A Measure of Pharyngeal Efficiency

PURPOSE

Postswallow pharyngeal residue is a risk factor for aspiration, implies swallowing inefficiency, and increases the work of eating. The Bolus Clearance Ratio (BCR) is a derived metric that relates quantities of bolus material observed in the pharynx at two different points: before and after a swallow. The ratio provides a percentage estimate of bolus clearance. In healthy adults, mean BCR is < .05; that is, less than 5% of an ingested bolus is retained in the pharynx. The aim of this study was to compare BCR measures from patients referred for videofluoroscopic swallow studies with concerns related to stroke (n = 100) or other neurological conditions (n = 131, including Parkinson's disease and dementia) with BCRs for 139 healthy adults across the age range.

METHOD

BCR for a 20 ml of thin liquid barium bolus was measured. Additional metrics included age, penetration-aspiration scale (PAS) score, and quantitative measures of timing and displacement. Correlations were explored between BCR and pharyngeal constriction ratio (PCR), pharyngoesophageal segment opening (PESmax), maximum hyoid displacement (HMax), and total pharyngeal transit time (TPT).

RESULTS

BCR values for patients with stroke (Mdn = 9%, interquartile range [IQR]: 19%, range: 0%-73%) and other neurological conditions (Mdn = 9%, IQR: 16%, range: 0%-96%) were significantly higher than in healthy norms (Mdn = 2%, IQR: 4%, range: 0%-16%, p < .001). BCR was significantly correlated with age (R _s = .23, p < .01), TPT (R _s = .20, p < .01), PCR (R _s = .55, p < .01), PESmax (R _s = -.17, p < .01), HMax (R _s = -.16, p < .01), and PAS (R _s = .38, p < .01).

CONCLUSIONS

BCR was elevated in patients with neurogenic dysphagia in comparison with healthy norms and was significantly associated with increased aspiration severity (i.e., PAS). BCR was also correlated with pharyngeal timing and displacement parameters, with the strongest correlation with pharyngeal constriction-a measure of pharyngeal strength. The BCR offers clinicians a simple, quantitative measure of bolus residue and, therefore, pharyngeal efficiency and may be used to assess change in patients over time and with treatment.

Incidence, clinical signs, and videofluoroscopic swallow study abnormalities associated with airway penetration and aspiration in 100 dogs

BACKGROUND

Videofluoroscopic swallow studies (VFSS) utilizing penetration-aspiration (P-A) scoring assesses airway protection in people. On VFSS, penetration (ingesta or secretions immediately cranial to the vocal folds) and aspiration (material caudal to the vocal folds) are associated with increased risk of lung injury in people. Penetration-aspiration (P-A) scoring has been validated in animal models, but the incidence of P-A, clinical signs (CS), and dysphagic disorders associated with P-A in dogs are unknown.

OBJECTIVES

Using VFSS, identify the incidence of P-A, compare CS between dogs with and without P-A, and identify predisposing dysphagic abnormalities for P-A.

ANIMALS

One hundred client-owned dogs.

METHODS

Sequential VFSS and associated medical records from dogs presenting to the veterinary teaching hospitals at Auburn University (n = 53) and the University of Missouri (n = 47) were retrospectively reviewed. Statistical comparisons were made using Mann-Whitney tests, one-way analysis of variance (ANOVA) on ranks, multiple linear regression, and Spearman rank order correlation (P < .05).

RESULTS

On VFSS, the incidence of pathologic P-A was 39%. No significant differences in CS were found between dogs with or without P-A (P > .05), with 14/39 dogs with P-A presenting without respiratory CS. Pharyngeal (P < .001) and esophageal (P = .009), but not oral-preparatory (P = .2) dysphagia was more common with P-A. Pharyngeal weakness (P < .001) and esophago-oropharyngeal reflux (EOR; P = .05) were independent predictors of P-A and were moderately and weakly positively correlated with P-A score respectively (P < .001, r = 0.489; P = .04, r = 0.201).

CONCLUSIONS

Penetration-aspiration occurs in dogs in the absence of respiratory CS (i.e., occult P-A). Dogs with pharyngeal weakness and EOR should be considered at risk for P-A.

Quantification of the Swallowing Mechanism Through Muscle Synergy Analysis

Decreased swallowing function increases the risk of choking and aspiration pneumonia. Videofluoroscopy and computed tomography allow for detailed observation of the swallowing movements but have radiation risks. Therefore, we developed a method using surface electromyography (sEMG) to noninvasively assess swallowing function without radiation exposure. A 44-channel flexible sEMG sensor was used to measure the sEMG signals of the hyoid muscles during swallowing in 14 healthy young adult and 14 elderly subjects. Muscle synergy analysis was performed to extract the muscle synergies from the sEMG signals, and the three synergies were extracted from the hyoid muscle activities during the swallowing experiments. The experimental results showed that the three synergies represent the oral, early pharyngeal, and late pharyngeal swallowing phases and that swallowing strength is tuned by the strength of the muscle activities, whereas swallowing volume is controlled by adjusting muscle activation timing. In addition, the timing of the swallowing reflex is slower in elderly individuals. The results confirm that the proposed approach successfully quantifies swallowing function from sEMG signals, mapping the signals to the swallowing phases.

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.

Pharyngeal electrical stimulation in amyotrophic lateral sclerosis: a pilot study

Background:

Patients with amyotrophic lateral sclerosis (ALS) suffer from dysphagia that increases the risk for aspiration, pneumonia and weight loss. Pharyngeal electrical stimulation (PES) is a therapeutic technique that applies electric stimuli to the patient’s pharynx in order to improve swallowing based on the principle of cortical plasticity and reorganization. Previous studies have demonstrated positive effects in patients with various neurological diseases.

Objective:

This study was initiated to investigate the effect of PES on swallowing function in patients with ALS.

Methods:

In all, 20 ALS patients with severe dysphagia [characterized by a Penetration Aspiration Scale (PAS) of at least 4 in thin liquid] were randomized to receive either PES for 10 min at 3 consecutive days in addition to Standard Logopaedic Therapy (SLT) or SLT alone. Swallowing function was evaluated by Fiberoptic Endoscopic Evaluation of Swallowing (FEES) at five timepoints: at baseline, 1 day, 4 days, 3 weeks and 3 months after treatment. Primary endpoint was the severity of penetrations or aspirations as classified by PAS. Secondary endpoints were adverse events, dysphagia-related quality of life, Swallowing Quality of Life (SWAL-QOL), Dysphagia Severity Rating Scale (DSRS), residues, leaking, ALS Functional Rating Scale Revised (ALSFRS-R), and the performance in Clinical Evaluation of Swallowing (CES). The trial is registered under the name of ‘Pharyngeal Electrical Stimulation in Amyotrophic Lateral Sclerosis’ with ClinialTrials.gov, number NCT03481348 (https://clinicaltrials.gov/ct2/show/NCT03481348).

Results:

Both groups combined showed a significant improvement (p = 0.003) of median Total-PAS from 3.6 [interquartile range (IQR) = 2.9–5.0] at baseline to 2.3 (IQR = 1.8–4.0) 1 day after treatment. During subsequent study visits, PAS increased again but remained below baseline. PES and control group did not differ significantly 1 day after intervention (p = 0.32). Similar effects were found in the majority of secondary endpoints.

Interpretation:

The findings suggest that PES may not provide an additional positive effect on swallowing function in ALS. SLT seems to yield at least short-term positive effects on swallowing function and swallowing-specific life quality in ALS.

Registration: ClinialTrials.gov: NCT03481348

Modifying Puree Meals in Residential Aged Care Facilities: A Multi-Centre Feasibility and Acceptability Study

Purees are often recommended for older adults in residential aged care facilities (RACFs) to target swallowing difficulties and nutrition. However, they lack appeal and may have negative impacts on nutritional intake. This study investigated the subjective experiences and objective swallowing function and safety of older adults in response to a modified puree. Twenty-eight residents from three RACFs whose regular diets consisted of purees were recruited. Purees were modified to improve visual appeal by adding a commercial enzyme gellant. Each participant was observed during three puree and three modified puree meals, and completed a brief questionnaire after each meal. A videofluoroscopic swallowing study (VFSS) was performed with 16 of the participants. Compared to purees, modified purees were observed to be easier for oral processing and intake amount was higher, but participants required assistance more often and mealtimes were longer. Participants did not show preference for either type of puree. VFSS showed similar swallowing responses between the two puree types; however, a distinction was observed for modified pureed meat compared to other ingredients. Modifying puree meals in RACFs is a feasible approach to improve nutritional intake while maintaining swallowing safety, but their appeal to consumers is not definitive.

Jaw-retraction exercise increases anterior hyoid excursion during swallowing in older adults with mild dysphagia

OBJECTIVES

The present study aimed to evaluate the effectiveness of a newly designed jaw-retraction exercise for strengthening the geniohyoid muscle and thus improving the anterior movement of the hyoid bone during swallowing.

BACKGROUND

Although previous studies suggest a relationship between anterior hyoid excursion and upper esophageal sphincter (UES) opening, there are currently no reports of physical exercises without the use of special equipment that can effectively improve this movement of the hyoid bone during swallowing.

MATERIALS AND METHODS

This before-after study included patients presenting to the authors' hospital with mild dysphagia (Level 5 on the Dysphagia Outcome and Severity Scale). The participants were instructed to perform a jaw-retraction exercise designed to strengthen the geniohyoid muscle. Each participant was instructed to perform two sets of the exercise daily for four weeks, with each set consisting of five repetitions. Before and after the four-week training period, videofluoroscopic swallowing studies were performed and later analysed.

RESULTS

Twenty-five patients with a median age of 77 were included. The median peak anterior hyoid position before and after exercise were 129.82 and 132.74 (%C2-C4 length), respectively, and this increase was found to be significant (P = .007). The median extent of UES opening before and after exercise were 8.6 and 9.3 (mm), respectively, and this increase was also found to be significant (P = .040).

CONCLUSION

Our findings demonstrate that the jaw-retraction exercise can effectively improve the anterior movement of the hyoid bone. This exercise may be effective in individuals with oral frailty when signs of swallowing disorders are observed.

Mechanisms and management considerations of parent-chosen feeding approaches to infants with swallowing difficulties: an observational study

Videofluoroscopy swallow studies (VFSS) and high-resolution manometry (HRM) methods complement to ascertain mechanisms of infant feeding difficulties. We hypothesized that: (a) an integrated approach (study: parent-preferred feeding therapy based on VFSS and HRM) is superior to the standard-of-care (control: provider-prescribed feeding therapy based on VFSS), and (b) motility characteristics are distinct in infants with penetration or aspiration defined as penetration-aspiration scale (PAS) score ≥ 2. Feeding therapies were nipple flow, fluid thickness, or no modification. Clinical outcomes were oral-feeding success (primary), length of hospital stay and growth velocity. Basal and adaptive HRM motility characteristics were analyzed for study infants. Oral feeding success was 85% [76-94%] in study (N = 60) vs. 63% [50-77%] in control (N = 49), p = 0.008. Hospital-stay and growth velocity did not differ between approaches or PAS ≥ 2 (all P > 0.05). In study infants with PAS ≥ 2, motility metrics differed for increased deglutition apnea during interphase (p = 0.02), symptoms with pharyngeal stimulation (p = 0.02) and decreased distal esophageal contractility (p = 0.004) with barium. In conclusion, an integrated approach with parent-preferred therapy based on mechanistic understanding of VFSS and HRM metrics improves oral feeding outcomes despite the evidence of penetration or aspiration. Implementation of new knowledge of physiology of swallowing and airway protection may be contributory to our findings.

An Exploration of Lung Volume Effects on Swallowing in Chronic Obstructive Pulmonary Disease

Purpose Chronic obstructive pulmonary disease (COPD) limits respiration, which may negatively impact airway safety during swallowing. It is unknown how differences in lung volume in COPD may alter swallowing physiology. This exploratory study aimed to determine how changes in lung volume impact swallow duration and coordination in persons with stable state COPD compared with older healthy volunteers (OHVs). Method Volunteers ≥ 45 years with COPD (VwCOPDs; n = 9) and OHVs (n = 10) were prospectively recruited. Group and within-participant differences were examined when swallowing at different respiratory volumes: resting expiratory level (REL), tidal volume (TV), and total lung capacity (TLC). Participants swallowed self-administered 20-ml water boluses by medicine cup. Noncued (NC) water swallows were followed by randomly ordered block swallowing trials at three lung volumes. Estimated lung volume (ELV) and respiratory-swallow patterning were quantified using spirometry and respiratory inductive plethysmography. Manometry measured pharyngeal swallow duration from onset of base of tongue pressure increase to offset of negative pressure in the pharyngoesophageal segment. Results During NC swallows, the VwCOPDs swallowed at lower lung volumes than OHVs (p = .011) and VwCOPDs tended to inspire after swallows more often than OHVs. Pharyngeal swallow duration did not differ between groups; however, swallow duration significantly decreased as the ELV increased in VwCOPDs (p = .003). During ELV manipulation, the COPD group inspired after swallowing more frequently at REL than at TLC (p = .001) and at TV (p = .002). In conclusion, increasing respiratory lung volume in COPD should improve safety by reducing the frequency of inspiration after a swallow.

Compensatory Effects of Sequential 4-Channel Neuromuscular Electrical Stimulation for the Treatment of Acute, Subacute, and Chronic Dysphagia in a Prospective, Double-Blinded Randomized Clinical Trial

Background. The precise mechanism of 2-channel neuromuscular electrical stimulation (NMES) treatment is unknown, and controversy remains over its efficacy. The sequential 4-channel NMES was newly developed based on normal contractile sequences of swallowing-related muscles. Objective. To assess the clinical efficacy of sequential 4-channel NMES during swallowing. Methods. In this prospective RCT, 52 inpatients with dysphagia (acute, subacute, and chronic state) after stroke, brain tumor, or encephalitis were enrolled. Participants who underwent a videofluoroscopic swallowing study (VFSS) and clinical evaluation were enrolled and were randomly assigned to the 4-channel NMES or sham group. The 4-channel NMES and sham groups swallowed thin and honey-like fluids under NMES (sequential stimulation on suprahyoid and infrahyoid) and sham stimulation, respectively. The procedures were evaluated with the VFSS. Pre- and post-treatment evaluations were performed with the videofluoroscopic dysphagia scale (VDS), penetration-aspiration scale (PAS), Likert scale, and kinematic analysis. Results. The 4-channel NMES group showed significantly greater improvements than the sham group with respect to oral VDS, pharyngeal VDS, total VDS, and PAS (P < .05). Furthermore, the Likert scale for satisfaction, easiness, and discomfort for swallowing showed favorable results for the 4-channel NMES group (P < .05). In the kinematic analysis, the peak speed point, distance, and velocity of hyoid movement were significantly greater in the 4-channel NMES group (P < .05). Conclusions. Sequential 4-channel NMES activating the suprahyoid, thyrohyoid, and other infrahyoid muscles during swallowing showed significant clinical improvement with respect to VDS, PAS, and kinematic analysis. Therefore, sequential 4-channel NMES is a potential new functional electrical stimulation system for the treatment of dysphagia.

Quantifying Bolus Residue and Its Risks in Children: A Videofluoroscopic Study

Purpose Postswallow residue is a clinical sign of swallow impairment and has shown a strong association with aspiration. Videofluoroscopy (videofluoroscopic study of swallowing [VFSS]) is commonly used to visualize oropharyngeal swallowing and to identify pharyngeal residue. However, subjective binary observation (present or absent) fails to provide important information on volume or location and lacks objectivity and reproducibility. Reliable judgment of changes in residue over time and with treatment is therefore challenging. We aimed to (a) determine the reliability of quantifying pharyngeal residue in children using the bolus clearance ratio (BCR), (b) determine associations between BCR and other timing and displacement measures of oropharyngeal swallowing, and (c) explore the association between BCR and penetration-aspiration in children. Method In this single-center retrospective observational study, we obtained a set of quantitative and descriptive VFSS measures from 553 children (0-21 years old) using a standard protocol. VFSS data were recorded at 30 frames per second for quantitative analysis using specialized software. Results Good interrater (ICC = .86, 95% CI [.74, .961], p < .001) and excellent intrarater reliability was achieved for BCR (ICC = .97, 95% CI [.91, 1.000], p = 001). Significant correlations between BCR and pharyngeal constriction ratio and total pharyngeal transit time were reported (p < .05). Using binomial logistic regression modeling, we found BCR was predictive of penetration-aspiration in children, χ²(13) = 58.093, p < .001, 64.9%. Children with BCR of ≥ 0.1 were 4 times more likely to aspirate. Conclusion BCR is a reliable, clinically useful measure to quantify postswallow residue in children, which can be used to identify and treat children with swallow impairments, as well as to measure outcomes of intervention.

Swallowing dysfunction following radiation to the rat mylohyoid muscle is associated with sensory neuron injury

Radiation-based treatments for oropharyngeal and hypopharyngeal cancers result in impairments in swallowing mobility, but the mechanisms behind the dysfunction are not clear. The purpose of this study was to determine if we could establish an animal model of radiation-induced dysphagia in which mechanisms could be examined. We hypothesized that 1) radiation focused at the depth of the mylohyoid muscle would alter normal bolus transport and bolus size and 2) radiation to the mylohyoid muscle will induce an injury/stress-like response in trigeminal sensory neurons whose input might modulate swallow. Rats were exposed to 48 or 64 Gy of radiation to the mylohyoid given 8 Gy in 6 or 8 fractions. Swallowing function was evaluated by videofluoroscopy 2 and 4 wk following treatment. Neuronal injury/stress was analyzed in trigeminal ganglion by assessing activating transcription factor (ATF)3 and GAP-43 mRNAs at 2, 4, and 8 wk post treatment. Irradiated rats exhibited decreases in bolus movement through the pharynx and alterations in bolus clearance. In addition, ATF3 and GAP-43 mRNAs were upregulated in trigeminal ganglion in irradiated rats, suggesting that radiation to mylohyoid muscle induced an injury/stress response in neurons with cell bodies that are remote from the irradiated tissue. These results suggest that radiation-induced dysphagia can be assessed in the rat and radiation induces injury/stress-like responses in sensory neurons.NEW & NOTEWORTHY Radiation-based treatments for head and neck cancer can cause significant impairments in swallowing mobility. This study provides new evidence supporting the possibility of a neural contribution to the mechanisms of swallowing dysfunction in postradiation dysphagia. Our data demonstrated that radiation to the mylohyoid muscle, which induces functional deficits in swallowing, also provokes an injury/stress-like response in the ganglion, innervating the irradiated muscle.

Predicting penetration-aspiration through quantitative swallow measures of children: a videofluoroscopic study

PURPOSE

Quantitative measures have improved the reliability and accuracy in interpretation and reporting of videofluoroscopy (VFSS). Associations between quantitative VFSS measures and swallow safety in children are not widely reported. The ability to predict aspiration in children, even if not observed during brief VFSS, will improve diagnostic reporting and potentially reduce the need for extended radiation time. The aims of this study were to determine associations between quantitative fluoroscopic swallow measures and penetration-aspiration and to predict likelihood of penetration-aspiration.

METHODS

We selected videofluoroscopic data of 553 children from a pediatric hospital database for this single-center retrospective observational study. A standard protocol of VFSS administration was used and data were recorded at 30 frames-per-second. A set of quantitative and descriptive swallow measures was obtained using a specialized software with satisfactory inter-rater and intra-rater reliability. Binomial logistic regression with backward likelihood ratio was conducted, while controlling for age, gender, and etiology.

RESULTS

We found bolus clearance ratio (BCR), pharyngeal constriction ratio (PCR), duration to hyoid maximal elevation (Hdur), and total pharyngeal transit time (TPT) to be predictive of penetration-aspiration in children. PCR was the most predictive of penetration-aspiration in children (61.5%). Risk of aspiration was more than 100 times, when BCR =  ≥ 0.1, TPT =  ≥ 2 s, Hdur =  > 1 s or PCR =  ≥ 0.2 (p < 0.05 for all measures).

CONCLUSION

The results confirm the potential of objective quantitative swallow measures in predicting the risk of aspiration in children with dysphagia. These parameters provide predictive measures of aspiration risk that are clinically useful in identifying children of concern, even if no aspiration is observed during VFSS.

Prevalence and Severity of Dysphagia Using Videofluoroscopic Swallowing Study in Patients with Aspiration Pneumonia

INTRODUCTION

The purpose of this study was to identify the prevalence and severity of dysphagia in patients diagnosed with aspiration pneumonia, with and without neurologic disorders.

METHODS

We retrospectively reviewed the medical records of inpatients with aspiration pneumonia who underwent a videofluoroscopic swallowing study (VFSS) for evaluation of dysphagia. Patients were divided into two groups based on the presence or absence of neurologic disorders. The prevalence and severity of aspiration and pharyngeal residue due to dysphagia were assessed using the penetration-aspiration scale (PAS) and pharyngeal residue grade (PRG).

RESULTS

A total of 784 patients were enrolled; of these, 58.7% were males and the mean age was 76.12 ± 6.69. Penetration-aspiration-related dysphagia (PAS scores 3-8) was seen in 56.5% of all subjects, and 32.5% showed silent aspiration (PAS 8). Pharyngeal residue-related dysphagia (PRG scores 2-3) was seen in 65.2% of all patients, and the PAS and PRG were positively correlated. On dividing the subjects into two groups based on the presence of neurologic disorders, there was no significant difference in prevalence of the dysphagia between groups (PAS: p = 0.641; PRG: p = 0.872) with the proportion of silent aspiration (p = 0.720).

CONCLUSION

In patients hospitalized for aspiration pneumonia, there was a high prevalence of dysphagia. There were no differences in the prevalence and severity of dysphagia in patients with aspiration pneumonia based on the presence or absence of a neurologic disorder. Therefore, diagnostic evaluation of dysphagia is necessary regardless of the presence of neurologic disorders.

Mansoura Fiberoptic Endoscopic Evaluation of Swallowing Residue Rating Scale (MFRRS): An Anatomically Based Tool - A Preliminary Study

OBJECTIVE

The aim of this work was to design an anatomically based scale for judging post-swallow residue in the pharyngeal cavities, for use during the fiberoptic endoscopic evaluation of swallowing (FEES) in patients with dysphagia, and to assess its feasibility.

METHODS

Two 7-point ordinal scales (one for vallecular residue and one for pyriform sinus residue), were developed using detailed anatomic landmarks to denote residue levels. Hard copy color images of a specified frame, from 210 videos of 30 adult FEES evaluations demonstrating the range of all possible residue patterns, were selected (n = 56 valleculae, 62 pyriform sinuses). Half of these images were used to train 4 raters. The remaining half of the images were randomly ordered and rated by the trained raters. Two weeks later the same images were randomized again, and each rater re-analyzed them. The inter- and intra-rater reliability and criterion validity were determined using the kappa statistics and their standard errors. The internal consistency of the items in MFRRS was examined.

RESULTS

MFRRS showed strong inter-rater reliability (valleculae, κ = 0.832 ± 0.038; pyriform sinus, κ = 0.855 ± 0.034), almost perfect intra-rater reliability (valleculae, κ = 0.964 ± 0.018; pyriform sinus, κ = 0.962 ± 0.02), almost perfect concurrent validity (valleculae, κ = 0.968 ± 0.020; pyriform sinus, κ = 0.0971 ± 0.017), and excellent internal consistency (valleculae, Cronbach's α = 0.990; pyriform sinus, Cronbach's α = 0.985).

CONCLUSION

MFRRS is a feasible and reliable, anatomically based tool that can provide more accurate pharyngeal residue judgments. The optimized description of residue accumulation patterns can contribute to a better overall description of the functional problem and future description of dysphagia phenotypes.

Immediate effect of neuromuscular electrical stimulation on swallowing function in individuals after oral and oropharyngeal cancer therapy

Objective

To analyze the immediate effect of sensory and motor neuromuscular electrical stimulation, in oral and pharyngeal stages of swallowing, in individuals after oral and oropharyngeal cancer therapy.

Methods

The study was conducted on 10 individuals (mean age of 58 years) submitted to oral and oropharyngeal cancer therapy. The individuals were submitted to videofluoroscopy, during which they were randomly asked to swallow 5 mL of liquid, honey, and pudding, in three conditions: without stimulation, with sensory neuromuscular electrical stimulation, and with motor neuromuscular electrical stimulation. The degree of swallowing dysfunction was scored (Dysphagia Outcome and Severity Scale), as well as the presence of food stasis (Eisenhuber scale), and measurement of the oral and pharyngeal transit time. The results were statistically analyzed by the Friedman test or analysis of variance for repeated measures.

Results

The Dysphagia Outcome and Severity Scale revealed improvement for one individual with both sensory and motor stimuli, and worsening in two individuals, being one with motor and one with sensory stimulus. In the Eisenhuber scale, the neuromuscular electrical stimulation changed the presence of residues to variable extents. Concerning the oral and pharyngeal transit time, no difference was observed between the different stimulation levels for the consistencies tested (p > 0.05).

Conclusion

Both sensory and motor neuromuscular electrical stimulations presented a varied immediate impact on the oral and pharyngeal stages of swallowing in individuals after oral and oropharyngeal cancer therapy. Thus, the results of the immediate effect suggest that the technique is not indicated, evidencing the need of caution in the use of neuromuscular electrical stimulation for the rehabilitation of dysphagia, after HNC treatment.

The Effect of Lingual Resistance Training Interventions on Adult Swallow Function: A Systematic Review

Lingual resistance training has been proposed as an intervention to improve decreased tongue pressure strength and endurance in patients with dysphagia. However, little is known about the impact of lingual resistance training on swallow physiology. This systematic review scrutinizes the available evidence regarding the effects of lingual resistance training on swallowing function in studies using Videofluoroscopic Swallowing Studies (VFSS) with adults. Seven articles met the inclusion criteria and underwent detailed review for study quality, data extraction, and planned meta-analysis. Included studies applied this intervention to a stroke and brain injury patient populations or to healthy participants, applied different training protocols, and used a number of outcome measures, making it difficult to generalize results. Lingual resistance training protocols included anterior and posterior tongue strengthening, accuracy training, and effortful press against hard palate with varying treatment durations. VFSS protocols typically included a thin barium stimulus along with one other consistency to evaluate the effects of the intervention. Swallowing measures included swallow safety, efficiency, and temporal measures. Temporal measures significantly improved in one study, while safety improvements showed mixed results across studies. Reported improvements in swallowing efficiency were limited to reductions in thin liquid barium residue in two studies. Overall, the evidence regarding the impact of lingual resistance training for dysphagia is mixed. Meta-analysis was not possible due to differences in methods and outcome measurements across studies. Reporting all aspects of training and details regarding VFSS protocols is crucial for the reproducibility of these interventions. Future investigations should focus on completing robust analyses of swallowing kinematics and function following tongue pressure training to determine efficacy for swallowing function.

Visuoperceptual Analysis of the Videofluoroscopic Study of Swallowing: An International Delphi Study

INTRODUCTION

The Videofluoroscopic Swallow Study (VFSS) is a commonly used dysphagia assessment that is routinely analysed visuoperceptually. However, no consensus exists regarding which visuoperceptual measures should be used to analyse VFSSs. Current visuoperceptual measures for VFSSs are limited by poor quality and incomplete or indeterminate psychometric properties.

OBJECTIVE

This study aimed to establish the content validity for a new visuoperceptual VFSS measure for oropharyngeal dysphagia in adults, by identifying relevant domains of the construct and generating items and corresponding response scales.

METHODS

Consensus among experts in dysphagia and VFSS from over 20 countries was achieved across three rounds of anonymous online surveys, using the Delphi technique. Participants judged relevance and comprehensiveness of definitions of visuoperceptual domains of VFSS and the relevance of various domains to the overall construct. After reaching consensus on definitions of relevant domains, consensus on items were established using the same process.

RESULTS

Participants achieved consensus on definitions of 32 domains recommended for analysis, and at least one item per domain (range 1-4). Domains selected by participants included both those which occur in existing measures and domains which have not been included in any measures to date. This study will form the basis for content validity of a new measure for VFSS.

CONCLUSIONS

This first phase of developing a visuoperceptual measure of VFSS resulted in the identification of 32 domains and 60 items for oropharyngeal dysphagia. Developers can now advance to the next phase of measure construction; prototype development and psychometric testing.

Interventions Involving Biofeedback to Improve Swallowing in People With Parkinson Disease and Dysphagia: A Systematic Review

OBJECTIVES

To examine the effectiveness of biofeedback used in the treatment of adults with Parkinson disease (PD) and dysphagia, define the factors associated with biofeedback treatment outcomes, and inform a theory to guide the implementation of biofeedback in future dysphagia interventions.

DATA SOURCES

A systematic review using a narrative synthesis approach of all published and unpublished studies were sought with no date or language restrictions. Ten electronic databases (EMBASE, PubMed, CINAHL, Web of Science, Scopus, Science Direct, AMED, The Cochrane Database of Systematic Reviews, ProQuest Dissertations and Theses A & I, Google Scholar) were searched from inception to April 2019. This search was updated in January 2020. The methodological quality of included studies was assessed using Downs and Black checklist.

STUDY SELECTION

Four studies were included. The methodological quality of the included studies was low with a high risk of bias. Data were analyzed narratively and descriptively. Despite the heterogeneity of the included studies, the findings suggest that interventions incorporating visual biofeedback may have positive effects on swallowing-related quality of life.

CONCLUSIONS

Based on these preliminary findings, we provide directions for further research and clinical interventions that incorporate an augmentative biofeedback component of swallowing interventions in people with PD. Future studies should be rigorously designed and set appropriate biofeedback treatment in terms of types, schedules, and timing.

The relationship between posterior pharyngeal wall thickness and swallowing function after radiation therapy

Background: Dysphagia is a complication following radiation therapy (RT) for head and neck cancers (HNC). Radiologic findings of posterior pharyngeal wall thickening (PPWT) after RT has not been quantified and correlated to swallowing outcomes.Aims/objective: To evaluate PPWT and its impact on swallowing function following RT.Material and methods: Retrospective analysis of pre- and three-month post-RT PPWT, demographics, oncologic history, and swallowing parameters of patients undergoing RT for HNC. Multivariate analysis of variance was performed to evaluate the effect of PPWT on swallowing outcomes.Results: The mean age of the cohort (n = 207) was 61.8 (± 11.29) years. The mean PPWT increased by 0.28 (± 0.19) cm (p = .00) three-months after RT. A significant difference in PPWT score between tumor subsites, χ²(2) = 45.883, p = .00, with the highest mean rank score of 135.97 for nasopharynx and 103.46 for oropharynx. PPWT was significantly associated with increased pyriform sinus retention, higher Penetration-Aspiration Scale (PAS) scores and post-deglutitive aspiration (p < .05).Conclusions and significance: PPWT increase significantly after RT for HNC. Increased PPWT was associated with mean radiation dose to the nasopharynx and oropharynx and was an independent risk factor for increased pharyngeal residue, higher PAS scores, and timing of aspiration (p < .05).

Swallowing Patterns in the HNC Population: Timing of Penetration-Aspiration Events and Residue

Objective

This study described swallowing patterns in a large head/neck cancer (HNC) cohort.

Study Design

In a retrospective review of data from a randomized controlled trial, we studied timing of penetration events as they related to aspiration and oral/pharyngeal residue.

Setting

Retrospective review of a multicenter randomized controlled trial.

Subjects and Methods

In total, 168 patients who were >3 months postradiation received baseline modified barium swallow evaluations. Retrospective analyses of data from these exams were studied, including Penetration-Aspiration Scale (PAS) scores and timing of these events (before, during, or after the swallow), as well as percentage of oral and pharyngeal residue.

Results

Aspiration occurred more frequently after than before or during the swallow ( P < .05). There were significantly more events of penetration that led to aspiration after the swallow (n = 260) when compared to events before (n = 6) or after (n = 81) the swallow. There was more pharyngeal (16%-25%) than oral residue (5%-20%). Weak correlations were found between thin liquid, nectar-thick liquid, pudding residue, and PAS scores, with varying significance (pharyngeal residue/PAS rs: .26*, .35*, .07*; oral residue/PAS rs: .21*, .16, .3; * P < .05).

Conclusion

The predominant pattern for this sample of postradiation patients with HNC with dysphagia was aspiration that occurred after the swallow, rather than before or during the swallow. The aspiration was directly caused by penetration events that occurred during the swallow, resulting in aspiration as the airway reopened. Patients demonstrated more pharyngeal residue than oral residue, but a weak relationship was found between residue and penetration/aspiration events. These results guide clinicians in targeting appropriate swallowing interventions.

Interventions for oropharyngeal dysphagia in acute and critical care: a systematic review and meta-analysis

PURPOSE

To determine the effectiveness of dysphagia interventions compared to standard care in improving oral intake and reducing aspiration for adults in acute and critical care.

METHODS

We searched electronic literature for randomised and quasi-randomised trials and bibliography lists of included studies to March 2020. Study screening, data extraction, risk of bias and quality assessments were conducted independently by two reviewers. Meta-analysis used fixed effects modelling. The systematic review protocol is registered and published.

RESULTS

We identified 22 studies (19 stroke, 2 intensive care stroke and 1 general intensive care) testing 9 interventions and representing 1700 patients. Swallowing treatment showed no evidence of a difference in the time to return to oral intake (n = 33, MD (days) - 4.5, 95% CI - 10.6 to 1.6, 1 study, P = 0.15) (very low certainty) or in aspiration following treatment (n = 113, RR 0.79, 95% CI 0.44 to 1.45, 4 studies, I2 = 0%, P = 0.45) (low certainty). Swallowing treatment showed evidence of a reduced risk of pneumonia (n = 719, RR 0.71, 95% CI 0.56 to 0.89, 8 studies, I2 = 15%, P = 0.004) (low certainty) but no evidence of a difference in swallowing quality of life scores (n = 239, MD - 11.38, 95% CI - 23.83 to 1.08, I 2 = 78%, P = 0.07) (very low certainty).

CONCLUSION

There is limited evidence for the effectiveness of swallowing treatments in the acute and critical care setting. Clinical trials consistently measuring patient-centred outcomes are needed.

Changes in Pharyngeal Width Over Time as an Indicator of Dysphagia in Stroke Patients

Objective

To verify the pharyngeal width at rest as a measurement that could be used to assess changes in the degree of dysphagia over time in stroke patients.

Methods

In a cohort of stroke patients, we performed serial measurements of the pharyngeal width at the midpoints of the second (C2) and third (C3) cervical vertebral bodies using lateral neck X-rays while the patients were at rest. The JOSCYL width, a parameter named after the first initial of each developers’ surname and defined as the average value of the upper and lower pharyngeal widths, was used to formulate the JOSCYL scale, which was calculated as the JOSCYL width × 100/neck circumference. All patients also underwent serial videofluoroscopic swallowing studies (VFSSs). The Spearman correlation analysis was used to detect correlations between the serial VFSS results, JOSCYL widths, and JOSCYL scale values.

Results

Over time, we observed significant positive and negative correlations of change in the JOSCYL width and scale with changes in the Penetration-Aspiration Scale and the Dysphagia Outcome and Severity Scale scores, respectively.

Conclusion

The JOSCYL width and JOSCYL scale clearly reflected changes in dysphagia in stroke patients over time. These parameters may provide an easier method for evaluating whether post-stroke dysphagia has been alleviated.

Measurement of Pharyngeal Residue From Lateral View Videofluoroscopic Images

Purpose The field lacks consensus about preferred metrics for capturing pharyngeal residue on videofluoroscopy. We explored four different methods, namely, the visuoperceptual Eisenhuber scale and three pixel-based methods: (a) residue area divided by vallecular or pyriform sinus spatial housing ("%-Full"), (b) the Normalized Residue Ratio Scale, and (c) residue area divided by a cervical spine scalar (%(C2-4)2). Method This study involved retrospective analysis of an existing data set of videofluoroscopies performed in 305 adults referred on the basis of suspected dysphagia, who swallowed 15 boluses each (six thin and three each of mildly, moderately, and extremely thick 20% w/v barium). The rest frame at the end of the initial swallow of each bolus was identified. Duplicate measures of pharyngeal residue were made independently by trained raters; interrater reliability was calculated prior to discrepancy resolution. Frequency distributions and descriptive statistics were calculated for all measures. Kendall's τb tests explored associations between Eisenhuber scale scores and pixel-based measures, that is, %-Full and %(C2-4)2. Cross-tabulations compared Eisenhuber scale scores to 25% increments of the %-Full measure. Spearman rank correlations evaluated relationships between the %-Full and %(C2-4)2 measures. Results Complete data were available for 3,545 boluses: 37% displayed pharyngeal residue (thin, 36%; mildly thick, 41%; moderately thick, 35%; extremely thick, 34%). Eisenhuber scale scores showed modest positive associations with pixel-based measures but inaccurately estimated residue severity when compared to %-Full measures with errors in 20.6% of vallecular ratings and 14.2% of pyriform sinus ratings. Strong correlations (p < .001) were seen between the %-Full and %(C2-4)2 measures, but the %-Full measures showed inflation when spatial housing area was small. Conclusions Generally good correspondence was seen across different methods of measuring pharyngeal residue. Pixel-based measurement using an anatomical reference scalar, for example, (C2-4)2 is recommended for valid, reliable, and precise measurement.

Factors associated with signs of aspiration in older adults: A prospective study

This was a prospective cohort design study that followed a group of older adults for up to 12 months. Two hundred and ninety-one participants with a mean age of 81.4 ± 9.1 years were recruited. Signs of aspiration were screened by the Yale Swallow Protocol. Variables investigated for risk were oromotor functions, self-perception of swallowing function, cognitive function, and medical history. Seventy participants were revisited for a follow-up aspiration screening 8 to 9 months later. Multivariate logistic regression found that male sex, need for assistance for feeding and mobility, reduced cognitive function, subjective judgement of swallowing function, and oromotor function were major variables that can be used to screen for older adults who may require referrals for swallowing assessment. Those who continue to show signs of aspiration across time exhibit a more frail profile than their counterparts who do not.

Efficacy of an education program for nurses that concerns the use of point-of-care ultrasound to monitor for aspiration and pharyngeal post-swallow residue: A prospective, descriptive study

BACKGROUND

For nurses to provide swallowing care that is appropriate to individual patients' swallowing functions, techniques for using ultrasound to monitor for aspiration and pharyngeal post-swallow residue would be helpful.

OBJECTIVES

This study seeks to clarify the effectiveness of an education program concerning the use of ultrasound to assess swallowing function (the "Swallowing Point-of-Care Ultrasound Education Program"). This assessment is based on a comparison of the observation skills of general nurses' and certified nurses in dysphagia nursing in this regard; both groups underwent the education program, but dysphagia nurses have greater knowledge of swallowing functions as a result of their training.

METHODS

This prospective descriptive study was conducted as a post-graduate education program in two locations in Japan. The swallowing point-of-care ultrasound education program comprised four elements: e-learning, practical seminar, self-learning, and objective structured clinical examination. The objective structured clinical examination was used after the program to assess whether the participants had obtained the necessary skills. The general nurses were then asked to report the ease-of-use of the education materials.

RESULTS

Of the 32 participants enrolled in the program, 22 general nurses and nine dysphagia nurses completed the program. In the objective structured clinical examination concerning monitoring for aspiration, the dysphagia-nurses group had a higher proportion of participants evaluated as "excellent" (p = 0.007); this group had a significantly higher ability to maintain adequate images during the swallowing process than did the general-nurse group (p = 0.034). However, there was no difference between the two groups regarding monitoring for post-swallowing residue. Further, over 70% of the nurses gave a positive evaluation of the user-friendliness of the e-learning and practical seminar.

CONCLUSIONS

Our results suggest that the swallowing point-of-care ultrasound education program provides both general nurses and dysphagia nurses with sufficient knowledge and skill to monitor for aspiration and post-swallowing residue.

Effects of Expiratory Muscle Strength Training on Videofluoroscopic Measures of Swallowing: A Systematic Review

Purpose Expiratory muscle strength training (EMST) is increasingly utilized in dysphagia rehabilitation; however, little is known about the effects of this approach on swallowing function or physiology. We conducted a systematic review to appraise and synthesize evidence regarding the effects of EMST on videofluoroscopic measures of swallowing in individuals with medical diagnoses, in which dysphagia is a concern. Method A literature search was conducted according to Cochrane guidelines. Of 292 nonduplicate articles, 11 were judged to be relevant for review. These underwent detailed review for study quality, risk of bias evaluation, and synthesis of swallowing outcomes. Results The selected articles described EMST in a variety of patient populations using either the EMST150 or the Phillips Threshold positive expiratory pressure device. The typical protocol involved five sets of five breaths through the device (25 breaths/day), 5 days per week for 4 weeks. Exercise loads were set between 50% and 75% depending on the population, and treatment was typically supervised by a clinician weekly. The Penetration-Aspiration Scale was the most commonly reported videofluoroscopic outcome measure. Conclusions differed as to whether or not swallowing improved following a course of EMST. Differences in videofluoroscopy protocols, methods of summarizing participant performance, and statistical approaches across studies meant that meta-analysis of swallowing outcomes could not be completed. Conclusion This review failed to find clear evidence regarding the effects of EMST on videofluoroscopic measures of swallowing. Heterogeneity in the etiologies and baseline severity of dysphagia across studies and in the methods used to measure swallowing outcomes was a particular barrier to data synthesis.