Informed Consent in Speech-Language Pathology Documentation When Recommending Diet Changes.

The Dysphagia Outcome and Severity Scale is used both clinically and within dysphagia research, internationally. Although it was developed using videofluoroscopic swallowing studies, it is frequently used to rate Flexible Endoscopic Evaluations of Swallowing. The validity and reliability of DOSS-use with FEES, however, has not previously been evaluated. This study investigated the validity and rater reliability of clinicians using DOSS to rate FEES. Eleven Speech-Language Pathologists (SLPs) with varied dysphagia experience were recruited to review and DOSS-rate 17 soundless FEES (198 bolus swallows) recorded from 11 heterogenic dysphagic patients (2 cases with repeat FEES) and 4 healthy adults. The SLPs DOSS-ratings were compared against the initial comprehensive dysphagia evaluation (including patient diagnosis, interview, cranial nerve and complete FEES assessment) with Functional Oral Intake Scale (FOIS) and DOSS outcome measures. The SLPs were blinded to patient details and comprehensive dysphagia examination. Re-randomised rating of FEES cases occurred two weeks later (intra rater reliability). Criterion validity for DOSS-ratings (compared against comprehensive dysphagia evaluation with FOIS and DOSS) were strong–very strong (rs = 0.858 and 0.936 respectively; p < 0.001). Inter rater reliability demonstrated high agreement (α = 0.891), also intra rater reliability demonstrated almost perfect agreement (Kw = 0.945). This study’s results, with strong–very strong criterion validity and high rater reliability by SLPs, adds to the evidence for DOSS-use with FEES. Future validity research comparing DOSS with both FEES and VFSS simultaneously is recommended.

To investigate the influence of early dysphagia on quality of life in patients with partial laryngectomy, and to investigate the application value of Flexible Endoscopic Evaluation of Swallowing (FEES). This study included 30 inpatients who underwent partial laryngectomy due to laryngeal cancer. In the early postoperative period, a comprehensive assessment was conducted on each patient, encompassing Videofluoroscopic Swallowing Study (VFSS), Flexible Endoscopic Evaluation of Swallowing (FEES), and MD Anderson Dysphagia Inventory (MDADI). Each patient underwent two evaluations at different time points following the surgical procedure, all conducted on the same day. The patients’ first MDADI assement score after surgery was 45.4 ± 3.6 points, and the second score was 54.7 ± 13.4 points. VFSS as the gold standard, FEES showed good sensitivity (84%) and specificity (94%) for detecting aspiration, as well as good sensitivity (78%) and moderate specificity (86%) for detecting penetration. The Kappa consistency test results showed high consistency between FEES and VFSS swallowing function evaluations (Kappa value = 0.669); evaluations of thin liquid, thick liquid, and solid bolus had high consistency (Kappa value = 0.631, 0.675, and 0.678, respectively), while evaluations of semi-liquid bolus had poor consistency (Kappa value = 0.598); evaluations of four bolus sizes all had high consistency (Kappa value = 0.658, 0.647, 0.705, 0.670). The Kappa values for evaluating patients undergoing horizontal partial laryngectomy, vertical partial laryngectomy, and supraglottic laryngectomy were 0.572, 0.604, and 0.680, respectively. This study shows that dysphagia is an important problem affecting the early quality of life of patients after partial laryngectomy, and early instrumental evaluation is also extremely important. This study also emphasizes the reliability problems in the identification of false invasion and aspiration. FEES can be used to evaluate the early swallowing function of patients after partial laryngectomy, thus guiding the timing and type of eating, and evaluating the rehabilitation effect. In addition, compared with VFSS, FEES have more advantages for the identification of penetration.

Many adults in residential aged care homes (RACHs) live with oropharyngeal dysphagia (OD) and its physiological, psychosocial, and economic sequalae. Timely, evidence-based assessment of OD can help healthcare teams to create OD management plans that optimize consumer health and minimize healthcare costs. Instrumental swallowing assessment (ISA), specifically flexible endoscopic evaluation of swallowing (FEES) and videofluoroscopic swallowing studies (VFSS), is generally accepted to be an important component of dysphagia assessment and management in older adults. However, its role in RACHs has not been empirically examined. This study aimed to explore the role and use of ISA in adults in RACHs from the perspective of speech-language-pathologists (SLPs) experienced in a RACH setting and/or FEES and VFSS. A three-round electronic Delphi study was conducted to guide 58 SLPs in Australia towards consensus using a combination of multiple-choice questions, statements with five-point Likert scale agreement options, and open-ended questions. Participants' responses were analyzed using descriptive statistics and content analysis after each survey round. Feedback about group responses was provided before subsequent surveys. Consensus was defined as 70% or greater agreement. Participants reached consensus about obstacles and facilitators to the use of ISA in RACHs. Participants agreed that FEES was a valuable tool in RACHs and that a mobile service model may have advantages over standard off-site assessment. SLPs believed that appropriate governance processes, infrastructure and education were necessary to develop a safe, high-quality service. These views support equitable access to ISA across settings, aligning with person-centered care, re-ablement, and care-in-place.

The purpose of this study is to determine if speech-language pathologists' (SLP) ratings of palpated hyolaryngeal excursion (pHLE) during a clinical swallow evaluation (CSE) are predictive of spatial measures of hyolaryngeal excursion determined by instrumentation (iHLE). Adults between the ages of 18-99 were recruited with a physician referral to complete a CSE and videofluoroscopy swallow study. Four SLP investigators completed ratings of pHLE palpation during a CSE. Spatial measures of hyoid peak elevation were taken from videofluoroscopy swallow studies. Statistical analyses included multiple linear regression to determine the best-fitting model to predict iHLE from palpated ratings. Data from 77 volunteers (44 female, mean age 71.6) were used for statistical analyses. The linear regression model indicated three significant predictors of superior (upward) hyoid peak position, including palpation, bolus consistency, and the number of swallows. There were no significant predictors of anterior (forward) hyoid peak position from the tested factors. The emergence of these significant predictors suggests that palpation may provide insight into superior HLE movements during a CSE. Next steps will be to determine if palpation improves SLPs' diagnostic accuracy and clinical decision-making during swallow assessment without instrumentation.

This study investigated rater confidence when rating airway invasion with the penetration-aspiration scale (PAS) on flexible endoscopic evaluations of swallowing (FEES), raters' accuracy against a referent-standard, inter-rater reliability, and potential associations between clinician confidence, experience, and accuracy. Thirty-one clinicians who use FEES in their daily practice were asked to judge airway invasion with the PAS and to rate their confidence that their score was correct (0-100) for 40 video clips, five in each of the 8 PAS categories. We found that raters were most confident in rating PAS 1, 7, and 8. The average confidence score across all videos was 76/100. Confidence did not have a significant relationship with accuracy against the referent-standard. Accuracy was highest for PAS 1 (92%), followed by PAS 8 (80%), PAS 7 (77%), and PAS 4 (72%). Accuracy was below 60% for PAS 2, 3, 5, and 6, the lowest being for PAS 3 (49%). Mean accuracy for all ratings, compared to referent-standard ratings, was highest for the intermediate group (71%), followed by expert (68%) and novice (65%). In general, we found that certain PAS scores tend to be rated more accurately, and that participating SLPs had varied confidence in PAS ratings on FEES. Potential reasons for these findings as well as suggested next steps are discussed.

An increased prevalence of mood and anxiety disorders in patients with dysphagia has been noted previously, but whether dysphagia severity may be exacerbated by anxiety and depression has never been studied before. The purpose of this study is to identify the effect of pre-existing diagnosis of anxiety and/or depression (anxiety/depression) on the Eating Assessment Tool (EAT-10), a validated patient-reported outcome measure for dysphagia. We hypothesized that patients with dysphagia and normal instrumental evaluation have higher EAT-10 score in the presence of pre-existing anxiety and depression. A retrospective chart review was conducted of patients seen at the multi-disciplinary dysphagia clinic of an urban academic institution. EAT-10 scores and pre-existing diagnoses of anxiety/depression were collected at the first visit with laryngologists. The two-sample t-test was used to compare mean EAT-10 scores between the anxiety/depression and no anxiety/depression groups, stratified by swallowing dysfunction etiology. The study included 290 consecutive patients seen starting in January 2018. In this cohort, 60 (21%) had pre-existing anxiety, 49 (17%) depression, and 36 (12%) both. Overall, 59 patients had normal swallowing based on instrumental swallowing testing (flexible endoscopic evaluation of swallowing, videofluoroscopic swallow study, esophagram, or esophagoscopy). Among those, mean EAT-10 score was significantly higher in patients with anxiety and/or depression (n = 30) (14.63, SD = 11.42) compared to those with no anxiety and/or depression (n = 29) (8.93, SD = 6.59) (p = 0.023). While anxiety/depression may aggravate dysphagia in patients with normal swallowing function, this correlation may not hold in those with objective swallowing dysfunction. 4 Laryngoscope, 134:2115-2120, 2024.

Background: Acute cerebral stroke is a common problem that is frequently associated with dysphagia resulting in an increased risk of aspiration pneumonia, complication, and mortality. Methods: A literature review was carried out using the search terms ‘stroke unit and endoscopy', ‘stroke unit and dysphagia', and ‘stroke unit and gastroenterology'. Results: Only few papers focus on the role of endoscopy in stroke units. One major role is the early detection of dysphagia by flexible endoscopic evaluation of swallowing (FEES). FEES appears to have a higher sensitivity and specificity compared to bedside tests and challenges videofluoroscopy. In contrast, other stroke-associated gastrointestinal complications requiring endoscopic diagnostic or therapeutic intervention, such as gastrointestinal bleeding, abdominal pain, or stasis, and the need to provide fluid and food via gastrostomy or jejunostomy are rarely seen in stroke units and become relevant during and after the rehabilitation phase. Conclusion: FEES should involve an interdisciplinary team comprising neurologists, speech and language pathologists and/or therapists, as well as gastroenterologic endoscopists.

Lung Disease in Children With Laryngotracheoesophageal Clefts.

Understanding differences in practices and preferences during videofluoroscopic swallow studies: A survey of radiologists and speech language pathologists in the United States

Purpose Speech-language pathologists are specialists in communication, swallowing, and weaning as core members of the multidisciplinary tracheostomy team. Inconsistent tracheostomy care is known to result in staff and patient frustration, delayed intervention, and patient harm. Little is known about international speech-language pathology tracheostomy practices. Method This global survey explored training, clinical practices, perceived knowledge, skills and roles, as well as barriers to change and successes. Questions consisted of likert scale and open-ended questions. 1 458 Speech-language pathologists completed the survey representing six continents and 52 countries. Result Overall, speech-language pathologists were confident in their knowledge and skills. Tracheostomy teams were viewed as a key facilitator of best care. Access to Flexible Endoscopic Evaluation of Swallowing was variable and considered valuable by all. Four key themes emerged: Knowledge and skills, roles and multidisciplinary tracheostomy team relationships, written documentation and protocols, and access to resources. Multidisciplinary tracheostomy team relationships and being valued as a professional were the most common concerns. Speech-language pathologists had a plethora of successes to share that had changed their workplace. Conclusion This survey shows speech-language pathologists are aligned internationally with common purpose and values. Speech-language pathologists voiced challenges in multidisciplinary tracheostomy team relationships, standardising practice, and resourcing. Benchmarking is the first step to targeted change and we hope this will support and empowerclinicians to continue to innovate tracheostomy practice.

The purpose of this prospective, double-blinded, multirater, systematic replication study was to investigate agreement for aspiration risk, in the same individual, between videofluoroscopic swallow studies (VFSS) and the Yale Swallow Protocol. Participants were 25 consecutive adults referred for dysphagia testing who met the inclusion criteria of completion of a brief cognitive assessment, oral mechanism examination, and no tracheotomy tube. First, all participants were administered the Yale Swallow Protocol by two experienced speech-language pathologists trained in protocol administration. Failure criteria were inability to drink the entire amount, interrupted drinking, or coughing during or immediately after drinking. Second, all participants completed a VFSS within 5-10min of protocol administration. A speech-language pathologist, blinded to protocol results, reviewed the VFSS to determine aspiration status in a binary (yes/no) manner. Inter-rater agreement between two speech-language pathologists was 100% for identification of aspiration risk with the Yale Swallow Protocol. Inter-rater agreement between the speech-language pathologist and the radiologist for identification of aspiration status with VFSS was 100%. Twenty percent of VFSS recordings were viewed again 3-6months after initial data collection, and intrarater agreement for identification of thin liquid aspiration was 100%. Sensitivity for the Yale Swallow Protocol=100%, specificity=64%, positive predictive value=78%, and negative predictive value=100%. Importantly, all participants who passed the protocol did not aspirate during VFSS. Multiple, double-blinded raters and VFSS as the reference standard agreed with previous research with a single, nonblinded rater and FEES as the reference standard for identification of aspiration risk. The clinical usefulness and validity of the Yale Swallow Protocol for determining aspiration risk in a small sample size of male participants has been confirmed. Future research is needed with a larger and more heterogeneous population sample.

The American Speech-Language Hearing Association (ASHA) added fiberoptic endoscopic evaluation of swallowing (FEES) to the scope of practice for speech-language pathologists (SLPs) in 2001. In January 2021, ASHA created a revisional tutorial on clinical competency training for FEES. However, a national training protocol for FEES practice still does not yet exist. There is limited literature about SLPs and their attitudes regarding any specific training for FEES or learning opportunities for FEES, particularly any conducted with mentorship in communities of practice, often used by physicians in endoscopic training. SLPs may benefit from reviewing the training models in place within physician learning communities to transfer to SLP practice, just as the SLP profession has borrowed the direct and hands-on endoscopic skills for FEES from physician practices.

Transoral robotic surgery (TORS) yields excellent oncologic outcomes in patients with oropharyngeal squamous cell carcinoma (OPSCC). The outcomes of early swallow rehabilitation with speech-language pathologists (SLP) in this population have not been fully investigated. To evaluate swallow physiology and patient perception of swallow function in the perioperative period after TORS. This retrospective cohort study reviewed medical records of adult patients with OPSCC who underwent TORS from 2017 to 2024 at a single tertiary care center. Patients were included if they had a histologic diagnosis of SCC and a videofluoroscopic swallow study (VFSS) prior to undergoing treatment with TORS. TORS. At various perioperative time points, SLP performed a VFSS that generated a Dynamic Image Grade of Swallowing Toxicity (DIGEST) score and patients completed the MD Anderson Symptom Inventory (MDADI) questionnaire for subjective assessment of swallow function. For most patients, on postoperative day (POD) 1, SLP performed a bedside swallow evaluation and recommended compensatory swallow maneuvers, if necessary. Oral diet was initiated using the International Dysphagia Diet Standardization Initiative (IDDSI) for pureed solids and thin or mildly liquids for 2 weeks. Data on hospital stay and enteral tube placement were collected. Primary outcomes included swallowing at 6 weeks postoperatively assessed before potential adjuvant therapy by VFSS and MDADI. Secondary outcomes included complications and enteral tube feeding requirements. Among the 212 patients included, median age was 61 (IQR, 55-68) years and 31 patients (14.6%) were female. At baseline, 207 patients (97.6%) had normal VFSS scores. A total of 203 patients (95.8%) were evaluated by SLP on POD 1, and the remainder of the patients were evaluated by the surgical team. Median hospital length of stay was 2 days (IQR 1-2 days), and by the time of discharge, 207 patients (97.6%) were tolerating an oral diet. Fourteen patients (6.6%) required enteral feeding tube placement in the immediate postoperative period. At 6 weeks, 21 of the 33 patients (63.6%) with paired baseline and 6-week postoperative MDADI data reported a significant worsened swallowing perception. Six of the 66 patients (9.1%) with a postoperative VFSS at 6 weeks showed an objective decrease in swallowing compared with baseline. Of the 169 patients with diet documented at 6 weeks postoperatively, 95.3% (n = 161) were consuming a soft to regular diet. In this cohort study, patients with OPSCC treated with primary TORS had excellent short-term swallowing outcomes. Only a small proportion required a nasogastric tube at discharge, and at 6 weeks although most reported a worsening in swallow perception, they did not have an objective decrease in swallow function as measured by VFSS and most were tolerating a soft to regular diet.

ObjectiveTo identify the prevalence, pattern, and nature of swallowing dysfunction (SwD) in a consecutive cohort of patients with laryngomalacia (LM), and to determine factors associated with a higher burden of SwD.Study DesignThis was a retrospective review of consecutive patients diagnosed with LM by 2 pediatric otolaryngologists between 2013 and 2022 and a minimum of 3‐month follow‐up.SettingTertiary care pediatric otolaryngology referral center.MethodsConsecutive cohort of patients less than 3 years old with LM diagnosed on flexible laryngoscopy were reviewed. Patients with incomplete follow‐up, lack of swallowing assessment, and genetic conditions or syndromes were excluded. All patients underwent at minimum a systematic clinical swallowing evaluation by a speech‐language pathologist specialized in pediatric dysphagia. Patients with concerning clinical exams underwent instrumental swallow evaluation (Videofluoroscopic Swallow Study [VFSS] or Flexible Endoscopic Evaluation of Swallowing [FEES]). The prevalence of abnormalities of clinical swallowing evaluation, instrumental swallow evaluation data, and details of management were collected.ResultsTwo hundred and twelve patients met criteria and were included in the final analysis. One hundred and fifteen patients (54%) had an instrumental assessment (VFSS or FEES). Of the instrumental assessments performed, 96 (69%) were abnormal. Of the total patient cohort, 55 (26%) had laryngeal penetration and/or aspiration. One hundred and seventeen (55%) had clinical or instrumental indications for intervention, with 18 (8%) requiring tube feeding. Patients with severe LM and those treated surgically had a statistically significant higher rate of penetration and aspiration.ConclusionPatients with LM have a high burden of dysphagia requiring medical intervention. The authors advocate for routine and systematic assessment of all patients with LM for swallowing dysfunction.

The purpose of this study was to cross-culturally validate the Swedish version of the Gugging Swallowing Screen (GUSS-S) for use in the acute phase of stroke. Further, to evaluate the inter-rater reliability between different healthcare professionals. GUSS was translated into Swedish using a forward-backward method followed by expert rating to obtain content validity. For criterion validity, the GUSS-S score was compared with Flexible Endoscopic Evaluation of Swallowing (FEES) assessed with the Penetration-Aspiration Scale (PAS) in acute stroke patients (≤ 96 h after stroke onset). Convergent validity was calculated by comparison with the Functional Oral Intake Scale (FOIS) as per the comprehensive FEES assessment, the Standardized Swallowing Assessment (SSA), and the National Institutes of Health Stroke Scale (NIHSS). To evaluate inter-rater reliability, a nurse and a speech-language pathologist (SLP) independently assessed 30 patients. In total, 80 patients (32 women, median age 77 years (range 29–93) were included, mean 1.7 ± 0.9 days after admission. With a cut-off value of 14 points, the GUSS-S identified aspiration with a sensitivity of 100% and a specificity of 73% (area under the curve: 0.87, 95% CI 0.78–0.95). Spearman rank correlation showed very strong correlation between the GUSS-S and PAS (rs=-0.718, P = < 0.001) and FOIS (rs=0.720, P = 0.001) and strong correlation between the GUSS-S and SSA (rs=0.545, P = < 0.001) and NIHSS (rs=-0.447, P = 0.001). The inter-rater agreement for GUSS-S was substantial (Kw=0.67, P = < 0.001). The results indicate that the GUSS-S is a valid and reliable tool for the assessment of dysphagia in acute stroke patients by different healthcare professionals.