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Purpose: Thickened liquids are frequently used as an intervention for dysphagia, but gaps persist in our understanding of variations in swallowing behavior based on incremental thickening of liquids. The goal of this study was to establish reference values for measures of bolus flow and swallowing physiology in healthy adults across the continuum from thin to extremely thick liquids. Method: A sex-balanced sample of 38 healthy adults underwent videofluoroscopy and swallowed 20% weight-to-volume concentration barium prepared in thin and slightly, mildly, moderately, and extremely thick consistencies using a xanthan gum thickener. Participants took comfortable sips and swallowed without a cue; sip volume was measured based on presip and postsip cup weights. A standard operating procedure (the ASPEKT method: Analysis of Swallowing Physiology: Events, Kinematics and Timing) was used to analyze videofluoroscopy recordings. Results: The results clarify that, for thin liquid sips (10-14 ml), a single swallow without clearing swallows is typical and is characterized by complete laryngeal vestibule closure, complete pharyngeal constriction, and minimal postswallow residue. Aspiration was not seen, and penetration was extremely rare. Bolus position at swallow onset was variable, extending as low as the pyriform sinuses in 37% of cases. With thicker liquids, no changes in event sequencing, laryngeal vestibule closure, pharyngeal constriction, or postswallow residue were seen. The odds of penetration were significantly reduced. A longer timing interval until onset of the hyoid burst movement was seen, with an associated higher bolus position at swallow onset. Other timing measures remained unaffected by changes in bolus consistency. Conclusion: The results include new reference data for swallowing in healthy adults across the range from thin to extremely thick liquids.

The 8-point Penetration-Aspiration Scale (PAS) was introduced to the field of dysphagia in 1996 and has become the standard method used by both clinicians and researchers to describe and measure the severity of airway invasion during swallowing. In this article, we review the properties of the scale and explore what has been learned over 20 years of use regarding the construct validity, ordinality, intervality, score distribution, and sensitivity of the PAS to change. We propose that a categorical revision of the PAS into four levels of increasing physiological severity would be appropriate. The article concludes with a discussion of common errors made in the statistical analysis of the PAS, proposing that frequency distributions and ordinal logistic regression approaches are most appropriate given the properties of the scale. A hypothetical dataset is included to illustrate both the problems and strengths of different statistical approaches.

Fibreoptic Endoscopic Evaluation of Swallowing (FEES) and Videofluoroscopic Swallow Studies (VFSS) are instrumental assessments of dysphagia which provide videos of the internal structures of swallowing. They are commonly regarded as ‘gold-standard’ assessments; however, there is no consensus regarding a gold-standard measure to analyse the video recordings that they produce. Measures require sound psychometric properties to be suitable for clinical or research purposes. To date, no review of psychometric properties of FEES and VFSS measures has been undertaken or formally reported. This review assessed the quality of the psychometric properties of visuoperceptual measures of FEES and VFSS. Electronic databases were searched for studies reporting on psychometric qualities of visuoperceptual measures which are used to analyse recordings from FEES and VFSS. All dates until February 2017 were included. The Consensus-based Standards for the selection of health Measurement Instruments (COSMIN) checklist was used to evaluate the methodical quality of studies. The measures’ overall quality was then assessed by combining COSMIN ratings with quality criteria. Forty-five studies, reporting on 39 measures, met the inclusion criteria for this review. Data about the measures’ psychometric properties were very limited. Twenty-one measures had information available about reliability only, while 18 had information on up to five of the possible nine psychometric properties categorised within the COSMIN framework. The majority of the FEES and VFSS measures’ psychometric properties were rated as ‘indeterminate’ overall, due to the small number of studies, issues with design, statistical analyses, and reporting practices of extant studies. There is insufficient evidence to recommend any individual measure included in this review as valid and reliable to interpret VFSS and FEES recordings. Further research, which utilises robust methodological design and reporting, is needed to examine the psychometric properties of measures for FEES and VFSS.

Purpose The tracheoesophageal puncture for the voice prosthesis (VP) placement is the recognized gold standard in post-laryngectomy voice rehabilitation. Despite the development of specific intraoperative techniques, a subset of patients will suffer from poor functional outcomes due to pharyngoesophageal spasms (PES). This paper evaluates the functional outcomes after transcutaneous botulinum toxin type A (BTX-A) infiltration for PES with a videofluoroscopy-guided technique. Methods Since 2022, eight consecutive patients with VP and affected by PES were treated with BTX-A injection by a standard videofluoroscopic guided technique at the European Institute of Oncology, IRCCS (IEO) in Milan. A lidocaine test was performed pre-operatively to evaluate the potential effect of chemical neurectomy. All patients with positive lidocaine tests were injected with 50 IU of BTX-A (Allergan, Irvine, CA) according to the sites marked during the videofluoroscopy. Reported symptoms (VHI, SECEL), perceptual (INFVo), aerodynamic (MPT) and manometric parameters were collected before and after treatment. Results In all cases, BTX-A was performed as an outpatient procedure without complications. For seven patients, only one BTX-A injection was needed, while one patient required a re-injection. Subjective and perceptive improvement after BTX-A was significant for VHI, SECEL and INFVo. MPT showed significant improvement after a chemical neurectomy. After a mean follow-up of 6 months, all patients maintained a good TES quality. Conclusion The videofluoroscopic guided BTX-A injection of the pharyngoesophageal tract showed to be a feasible and reproducible technique in all cases. The pharyngoesophageal videofluoroscopy allows defining of patients’ anatomical landmarks that help the surgeon to perform a homogeneous injection, empowered by post-injection massage.

Purpose Post-stroke dysphagia (PSD) is the most common type of dysphagia. Stroke patients with sustained dysphagia have poorer outcomes. The severity of PSD is assessed using miscellaneous scales with unknown consistencies. We aim to investigate the consistencies among miscellaneous scales, which could aid in the assessment of PSD. Methods A total of 49 PSD patients were enrolled. Functional Oral Intake Scale (FOIS), Dysphagia Severity Scale (DSS), Ohkuma Questionnaire, Eating Assessment Tool-10, and Repetitive Saliva Swallowing Test were performed. FOIS was performed by physicians, and DSS was conducted by both the physicians and nurses; the physicians used either videofluoroscopy (VF) or videoendoscopy (VE) for evaluation; while, the nurses assessed PSD by observation and subjective judgment. Results When using VF (VF-DSS and VF-FOIS) as the gold standard for the evaluation, VE-FOIS ( κ  = 0.625, 95% CI 0.300–0.950, p  < 0.001) has a substantial agreement with VF-FOIS, and VE-DSS ( κ  = 0.381, 95% CI 0.127–0.636, p  = 0.007) has a fair agreement with VF-DSS. The weighted kappa of FOIS to DSS in VE (weighted κ  = 0.577, 95% CI 0.414–0.740, p  < 0.001) is not lower than that in VF (weighted kappa = 0.249, 95% CI 0.136–0.362, p  < 0.001). Conclusion For both DSS and FOIS, only VE has a statistically significant agreement with VF. Though VF has been viewed as the traditional gold standard of dysphagia screening, it has the limitations of being invasive and equipment dependent. For PSD, VE could be considered as a substitution when VF is not available or suitable.

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.

The aim of this study was to test reliability, content, construct, and external validity of a new modified barium swallowing study (MBSS) tool (MBSImp) that is used to quantify swallowing impairment. Multiple regression, confirmatory factor, and correlation analyses were used to analyze 300 in- and outpatients with heterogeneous medical and surgical diagnoses who were sequentially referred for MBS exams at a university medical center and private tertiary care community hospital. Main outcome measures were the MBSImp and index scores of aspiration, health status, and quality of life. Inter- and intrarater concordance were 80% or greater for blinded scoring of MBSSs. Regression analysis revealed contributions of eight of nine swallow types to impressions of overall swallowing impairment ( p  ≤ 0.05). Factor analysis revealed 13 significant components (loadings ≥ 0.5) that formed two impairment groupings (oral and pharyngeal). Significant correlations were found between Oral and Pharyngeal Impairment scores and Penetration-Aspiration Scale scores, and indexes of intake status, nutrition, health status, and quality of life. The MBSImp demonstrated clinical practicality, favorable inter- and intrarater reliability following standardized training, content, and external validity. This study reflects potential for establishment of a new standard for quantification and comparison of oropharyngeal swallowing impairment across patient diagnoses as measured on MBSS.

Purpose Reference data from healthy adults under the age of 60 years suggest that the 75th and 95th percentiles for pharyngeal residue on swallows of thin liquids are 1% and 3%(C2-4) , respectively. We explored how pharyngeal residue below versus above these values prior to a swallow predicts penetration-aspiration. Method The study involved retrospective analysis of a previous research data set from 305 adults at risk for dysphagia. Participants swallowed six thin boluses and three each of mildly, moderately, and extremely thick barium in videofluoroscopy. Raters measured preswallow residue in %(C2-4) units and Penetration-Aspiration Scale (PAS) scores for each swallow. Swallows were classified as (a) \"clean baseline\" (with no preswallow residue), (b) \"clearing\" swallows of residue with no new material added, or (c) swallows of \"additional material\" plus preswallow residue. Frequencies of PAS scores of ≥ 3 were compared across swallow type by consistency according to residue severity (i.e., ≤ vs. > 1%(C2-4) and ≤ vs. > 3%(C2-4) . Results The data set comprised 2,541 clean baseline, 209 clearing, and 1,722 swallows of additional material. On clean baseline swallows, frequencies of PAS scores of ≥ 3 were 5% for thin and mildly thick liquids and 1% for moderately/extremely thick liquids. Compared to clean baseline swallows, the odds of penetration-aspiration on thin liquids increased 4.60-fold above the 1% threshold and 4.20-fold above the 3% threshold (mildly thick: 2.11-fold > 1%(C2-4) , 2.26-fold > 3%(C2-4) ). PAS scores of ≥ 3 did not occur with clearing swallows of moderately/extremely thick liquids. Lower frequencies of above-threshold preswallow residue were seen for swallows of additional material than for clearing swallows. Compared to clean baseline swallows, the odds of PAS scores of ≥ 3 on swallows of additional material increased ≥ 1.86-fold above the 1% threshold and ≥ 2.15-fold above the 3% threshold, depending on consistency. Conclusion The data suggest that a pharyngeal residue threshold of 1%(C2-4) is a meaningful cut-point for delineating increased risk of penetration-aspiration on a subsequent swallow.

Objetivo: Analizar la evidencia teórica y de experiencia que existe acerca del uso de la videofluoroscopia en el diagnóstico de la disfagia en pacientes adultos. Materiales y métodos: Esta revisión se realizó siguiendo los parámetros propuestos por la Declaración PRISMA, se identificaron bases de datos y se definieron los términos claves en la búsqueda de información. Se utilizó el modelo PIO para construir la pregunta de investigación. Resultados: La búsqueda permitió obtener un total de 3999 artículos. Posteriormente, se aplicaron filtros establecidos, con una muestra final de 12 artículos que permitían dar respuesta a la pregunta de investigación. La videofluoroscopia actualmente se considera el Gold Standard y la prueba más recomendada para la evaluación objetiva de la función de la deglución, que posibilita la medición cuantitativa de las disfagias. Conclusiones: Es importante su implementación y aplicación para la evaluación de disfagia en el paciente adulto.

High-resolution cervical auscultation (HRCA) is an emerging method for non-invasively assessing swallowing by using acoustic signals from a contact microphone, vibratory signals from an accelerometer, and advanced signal processing and machine learning techniques. HRCA has differentiated between safe and unsafe swallows, predicted components of the Modified Barium Swallow Impairment Profile, and predicted kinematic events of swallowing such as hyoid bone displacement, laryngeal vestibular closure, and upper esophageal sphincter opening with a high degree of accuracy. However, HRCA has not been used to characterize swallow function in specific patient populations. This study investigated the ability of HRCA to differentiate between swallows from healthy people and people with neurodegenerative diseases. We hypothesized that HRCA would differentiate between swallows from healthy people and people with neurodegenerative diseases with a high degree of accuracy. We analyzed 170 swallows from 20 patients with neurodegenerative diseases and 170 swallows from 51 healthy age-matched adults who underwent concurrent video fluoroscopy with non-invasive neck sensors. We used a linear mixed model and several supervised machine learning classifiers that use HRCA signal features and a leave-one-out procedure to differentiate between swallows. Twenty-two HRCA signal features were statistically significant (p < 0.05) for predicting whether swallows were from healthy people or from patients with neurodegenerative diseases. Using the HRCA signal features alone, logistic regression and decision trees classified swallows between the two groups with 99% accuracy, 100% sensitivity, and 99% specificity. This provides preliminary research evidence that HRCA can differentiate swallow function between healthy and patient populations.