Palpation as a Method To Predict Spatial Instrumental Hyolaryngeal Excursion Measures.

BackgroundUltrasound (US) is not widely used as part of the speech and language therapy (SLT) clinical toolkit. The COVID‐19 pandemic has intensified interest in US as an alternative to SLT instrumental tools such as the videofluoroscopic swallowing study (VFSS), fibreoptic endoscopic evaluation of swallowing (FEES) and endoscopic evaluation of the larynx (EEL) as a non‐invasive, non‐aerosol‐generating procedure that can be delivered at the bedside to assess swallowing and/or laryngeal function. To establish the appropriacy of routine US use, and in response to a national professional body request for a position statement, a group of expert SLTs conducted a rapid review of the literature.AimTo explore critically the clinical utility of US as an assessment tool for swallowing and laryngeal function in adults.Methods & ProceduresA rapid review of four databases was completed to identify articles using US to assess swallowing and/or laryngeal function in adults compared with reference tests (VFSS/FEES/EEL/validated outcome measure). Screening was completed according to predefined inclusion/exclusion criteria and 10% of abstracts were rescreened to assess reliability. Data were extracted from full texts using a predeveloped form. The QUADAS‐2 tool was used for quality ratings. Information from included studies was summarized using narrative synthesis and visual illustration.Outcomes & ResultsTen papers used US to assess swallowing, and 13 to assess laryngeal function. All were peer‐reviewed primary studies across a range of clinical populations and with a wide geographical spread. Four papers had an overall low risk of bias, but the remaining 19 had at least one domain where risk of bias was judged as high or unclear. Applicability concerns were identified in all papers. The papers that used US to assess swallowing varied widely in terms of the anatomical structures assessed and methodology employed. The papers assessing laryngeal function were more homogenous in their methodology. Sensitivity and specificity data were provided for 12 of the laryngeal function papers with ranges of 64.3–100% and 48.5–100%, respectively.Conclusions & ImplicationsThere is burgeoning evidence to support the use of US as an adjunct to SLT clinical assessment of swallowing and laryngeal function. However, the current literature does not support its use as a tool in isolation. Further research is required to establish reliability in US assessment as well as clear SLT‐driven protocols and training.What this paper addsWhat is already known on the subject US has demonstrated potential as an assessment tool for objective parameters of swallowing. Its use for laryngeal assessment (gross vocal fold movement) is also widely recognized within the literature. This review appraised the literature related to US as an alternative or adjunctive tool for the assessment of swallowing and laryngeal function.What this paper adds to existing knowledge This paper identifies that the current evidence base for US as a swallowing or laryngeal assessment tool is heterogenous and of variable quality. No study combined the assessment of swallowing and laryngeal function, and only two studies assessed more than one parameter of swallowing, limiting the clinical application of the results.What are the potential or actual clinical implications of this work? This review shows that US is a non‐invasive accessible tool that can offer a detailed focal assessment of swallowing and laryngeal function, such as hyoid displacement and vocal fold mobility. With the development of protocols, training packages and competency standards, US has the potential to be used as an adjunct to SLT assessment of swallowing and laryngeal function. There is not currently enough evidence to support the use of US as a stand‐alone tool for SLT assessment of swallowing or laryngeal function.

Informed consent is a legal and ethical requirement in health care, yet limited research has examined how speech-language pathologists (SLPs) document the process when recommending diet modifications. The study investigated the presence of the five components of informed consent in SLP documentation. A retrospective review was conducted on 201 clinical swallow evaluations, videofluoroscopic swallowing study (VFSS), and flexible endoscopic evaluations of swallowing reports. Reports were selected from medical records from two health care companies across acute and outpatient settings. Two raters reached consensus on the presence of the five core components of informed consent: understanding, disclosure, treatment, alternatives, and choice. On average, SLPs documented only two of the five components, and no report contained all five. Documentation of "choice" was significantly higher in outpatient settings compared to acute care (p = .006). Clinical swallowing evaluations were less likely to include "understanding" (p = .02) and "choice" (p > .001) compared to instrumental assessments, such as VFSS and flexible endoscopic evaluations of swallowing. The findings reveal a gap between ethical and legal standards and current documentation practices when recommending diet modifications. Incomplete documentation may compromise personal autonomy and increase the risk of professional liability. Enhanced education, targeted training, and systematic implementation of informed consent protocols are essential to promote best practice and safeguard both people with dysphagia and clinicians.

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

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.

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.

The videofluoroscopic swallowing study (VFSS) is used by speech-language pathologists (SLPs) to assess swallowing under fluoroscopy, introducing radiation risk to patients and SLPs. Challenges with routine practice, work-as-prescribed (WAP), are not well-studied among SLPs. We aimed to identify barriers in safe radiation practices among SLPs performing VFSS and suggest methods to reduce radiation exposure. We conducted a single-center study of SLP-led VFSS (January 2024–May 2025). Data collection included surveys, observations, an educational intervention, a focus group, and dosimetry. Assisting patients directly in the fluoroscopy field-of-view (FOV) resulted in increased reliance on personal protective equipment (PPE) and dosimetry. Badge compliance was inconsistent, and ancillary PPE (e.g., lead glasses, gloves) was often ill-fitting or absent. The safety of SLPs was dependent on the availability of better-fitting PPE and administrative and engineered controls: distancing, dosimetry compliance, and appropriate lead shielding. These recommendations should be explored to improve radiation safety among SLPs during VFSS.

The use of percutaneous endoscopic gastrostomy (PEG) tubes in older patients did not show any benefits in terms of survival, improvement in quality of life, or reduction in aspiration pneumonia. Significant gaps exist regarding the evidence for the evaluation and management of dysphagia in older patients. This study aimed to diagnose swallowing disorders and highlight the importance of swallowing therapy in older patients in intensive care units (ICUs). Twenty-five older patients (12 men, 13 women, mean age 67.22 ± 24.03 years) hospitalized in the ICUs with complaints of dysphagia were analyzed prospectively. The 12 weeks (14-16 sessions) of swallowing therapy were administered to patients with dysphagia who signed the (voluntary) consent form. The bedside water swallowing test (BWSS), Functional Oral Intake Scale (FOIS) Score, Clinical Swallowing Evaluation, Mini Nutritional Assessment Test (MNAT), Eating Assessment Tool (EAT-10), the Turkish version of the World Health Organisation Quality of Life Scale Elderly Module, and the Swallowing Therapy Programme Protocol were applied. Pretherapy stage (T1) and post-therapy stage (T2) results were compared with videofluoroscopy swallowing study (VFSS) recordings with thin liquids, moderately thick liquids, extremely thick liquids, and crackers (International Dysphagia Diet Standardization Initiative [IDDSI] Levels 0, 3, 4, and 7, respectively). The World Health Organisation Quality of Life Scale Elderly Module (WHOQOL-OLD) raw scores significantly improved from T1 (38.63 ± 7.05) to T2 (73.07 ± 4.82). The bedside water swallowing test results demonstrated statistically significant differences in therapy timings among older patients (p < 0.001). There were significant improvements in swallowing physiology, as represented by the improved oral and pharyngeal composite scores of the Modified Barium Swallow Impairment Profile (MBSImP) and Penetration-Aspiration Scala (PAS) levels. Before therapy, all patients exhibited high rates of oropharyngeal residue with thin liquids and spoon-thick pudding viscosities (MNA ≤ 17). The results reported in the present study show that malnutrition risk is linked to a poorer QoL in older patients on admission to ICUs. Statistical analyses revealed the dominant effects of functional status and eating-related factors on QoL in this group. Early dysphagia diagnosis of older patients and subsequent application of exercise-based swallowing therapy increase the quality of life of patients. In this study, exercise-based swallowing therapy was developed in Turkey and can be used in older patients as part of a holistic cognitive-communication-swallowing intervention program. Results prove the effectiveness of the developed exercise-based swallowing therapy on the cognitive-communication-swallowing skills of older patients. The present findings reinforce the role of nutrition as a priority for improving patients' perceptions of QoL. Further studies are required to investigate and identify the interventions that improve QoL in older patients. More studies with better research designs are required to establish whether nutritional intervention is effective in enhancing QoL in this vulnerable group.

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.

A Simple Bedside Stroke Dysphagia Screen, Validated against Videofluoroscopy, Detects Dysphagia and Aspiration with High Sensitivity

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.

Clinical practice guidelines for videofluoroscopic swallowing studies: A systematic review

Children with neurodevelopmental disorders can have feeding problems. Malnutrition and recurrent aspiration pneumonia can increase the risk of morbidity and mortality. Video-fluoroscopic study of swallowing (VFSS) is essential in understanding the pathological mechanisms involved during swallowing. The aim of the present study was to assess the role of VFSS in assessment and management of four children with various neurodevelopmental disorders in a multidisciplinary feeding team. We describe the team approach, with the participation of child neurologist, radiologist with the rehabilitation team including the speech therapist, occupational therapist and dietician, in the assessment and plan of management. Video-fluoroscopic study of swallowing had been useful in assessing the type of swallowing problems with treatment goals targeted to the basic underlying pathophysiological mechanism. A child neurologist should be involved in the multidisciplinary oromotor rehabilitation program for neurologically impaired children with feeding problems.

To assess the risk of aspiration associated with post-swallow residue subsites in Fiberoptic Endoscopic Evaluation of Swallowing (FEES) in bottle-fed infants <1 year of age. This is a retrospective matched-pairs cohort study at an academic tertiary children's hospital. FEES and Videofluoroscopic Swallowing Study (VFSS) trials performed within the same infant <5 days apart were paired by matching bolus consistency and bottle flow rate. Positive aspiration was defined by the "or rule" in which aspiration is positive when either FEES or VFSS within a matched pair is positive. Eighty-seven FEES-VFSS matched pairs from 29 patients (16 males; mean [SD] age, 2.9 [2.8] months) were included. The rate of positive aspiration, as defined by the "or rule", was 59% (51/87). In FEES, post-swallow pyriform sinus residue was present in 16% (14/87) and anterior commissure residue 27% (31/87). Risk of positive aspiration was increased by pyriform sinus residue (odds ratio [OR] 5.4, 95% confidence interval [CI] 1.9-19.3, p < 0.01) and anterior commissure residue in FEES (OR 2.5, 95% CI 1.1-6.1, p = 0.03). In the neonate subgroup, <1 month of age, multivariate-adjusted analysis showed that anterior commissure residue had better diagnostic accuracy for aspiration than in older infants (overall 70% vs. 42%, p < 0.01; sensitivity 60% vs. 10%, p < 0.01), whereas pyriform sinus residue had worse accuracy (overall 41% vs. 70%, p = 0.02; sensitivity 13% vs. 43%, p = 0.02). This study demonstrates that pyriform sinus and anterior commissure residue during infant FEES were associated with fivefold and twofold increased risk of aspiration, respectively. Using a retrospective matched-pairs cohort, this study assesses the diagnostic accuracy of post-swallow residue in FEES for predicting aspiration. Laryngoscope, 134:1431-1436, 2024.

Negative impact of computed tomography-based low skeletal muscle mass on swallowing recovery in patients with post-stroke dysphagia

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.