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Purpose: Spinal pathology is very common with advancing age and can cause dysphagia; however, it is unclear how frequently these pathologies affect swallowing function. This study evaluates how cervical spinal pathology may impact swallowing function in dysphagic individuals observed during videofluoroscopic swallowing studies (VFSSs). Method: A retrospective case–control study was performed on 100 individuals with dysphagia as well as age-/gender-matched healthy controls (HCs) with available VFSS. Spinal anatomy of patients was classified into two predetermined categories, and a consensus decision of whether spinal pathology influenced swallowing physiology was made. Validated swallow metrics, including Modified Barium Swallow Impairment Profile (MBSImP) component scores, Penetration–Aspiration Scale (PAS) maximum scores, and 10-item Eating Assessment Tool (EAT-10) scores, were compared between the spine-associated dysphagia (SAD), non-SAD (NSAD), and HC groups using Kruskal–Wallis one-way analysis of variance. Results: Most patients with dysphagia had spinal pathology. Spinal pathology was judged to be the primary etiology of dysphagia in 16.9% of patients with abnormal spine pathology. Median EAT-10 scores were statistically different among the three groups, with the NSAD group scoring the highest and the HC group scoring the lowest. Similarly, median PAS scores were significantly different between dysphagic groups and HCs. Median MBSImP Oral Total scores were significantly different only between the NSAD group and HCs, whereas Pharyngeal Total score was not significantly different among the groups. Conclusions: Spinal pathology is commonly observed during VFSS and can contribute to dysphagia, resulting in worse swallowing-related outcomes when compared with HCs. Patients judged to have SAD tended to have better outcomes than patients with dysphagia from other etiologies, perhaps due to the progressive nature of spinal disease that allows for compensatory swallowing physiology over time.

Purpose: This retrospective study investigated the impact of age, sex, and swallow task on bolus hold location during cued liquid swallows in healthy, community-dwelling adults. Furthermore, we investigated the association between bolus hold location and Modified Barium Swallow Impairment Profile (MBSImP) Components 2 (bolus hold) and 4 (lingual transport) scores. Method: Cued swallows of standardized barium liquids (thin, nectar-thickened, honey-thickened) observed during videofluoroscopy in 195 participants were judged as either tipper or dipper bolus hold type. Logistic regression was used to determine relationships between bolus hold location and age, sex, and swallow task. Fisher's exact test was used to determine associations between MBSImP scores and bolus hold type. Results: The majority of swallow tasks (95%) were of tipper bolus hold type. A significant relationship was observed between age and bolus hold type for swallows of 5-ml thin liquid and 5-ml honey-thickened liquid, with older individuals more likely to demonstrate a tipper bolus hold type. Sex was observed to be a significant factor for two swallow tasks (cup sip of thin liquid and 5 ml of nectar-thickened liquid), with males being more likely to be dippers. No significant relationships were observed between bolus hold type and MBSImP Component 2 or 4 scores. Conclusions: A tipper bolus hold type was the most common type observed in healthy adults, although the dipper bolus hold type was also observed (albeit at a lower frequency). These study findings further contribute to defining typical swallowing behaviors.

BACKGROUND: Post-operative dysphagia is one of the most common complications of anterior cervical spine surgery (ACSS). OBJECTIVE: Examine post-operative structural and physiologic swallowing changes in patients with dysphagia following ACSS as compared with healthy age and gender matched controls. METHODS: Videofluoroscopic swallow studies of adults with dysphagia after ACSS were retrospectively reviewed. Seventy-five patients were divided into early (≤2 months) and late (> 2 months) post-surgical groups. Modified Barium Swallow Impairment Profile (MBSImP), Penetration-Aspiration Scale (PAS) scores, and pharyngeal wall thickness (PWT) metrics were compared. RESULTS: Significant differences were identified for all parameters between the control and early post-operative group. MBSImP Pharyngeal Total (PT) scores were greater in the early group (Interquartile Range (IQR) = 9–14, median = 12) versus controls (4–7, 5, P

Purpose Dysphagia is a common symptom experienced by patients with motor neuron disease (MND). The Yale Swallow Protocol (YSP) is a validated screening instrument for identifying patients at risk for aspiration. The purpose of this exploratory cross-sectional, multicenter study was to investigate how the YSP results in identifying aspiration risk in patients with MND in comparison with aspiration observed during a videofluoroscopic swallow study (VFSS). Method Participants referred for VFSS as part of clinical management were recruited from four specialized MND clinics. All participants were administered the YSP immediately prior to the VFSS by a speech-language pathologist, with results recorded as pass or fail. Aspiration on VFSS was determined using the Penetration–Aspiration Scale (scores 6–8). A 2 × 2 contingency table was constructed to compare results of YSP with those on VFSS. Results Thirty-one patients with MND (13 males, 18 females; M age = 64 ± 12 years) referred for VFSS participated in this study. Of the 22 patients who failed the YSP, interrupted drinking was the most frequent reason (65%). Compared to the VFSS, the YSP yielded a sensitivity of 80%, a specificity of 33%, positive predictive value of 36%, and negative predictive value of 78%. Conclusions The YSP is a simple tool and easy to utilize and has a high sensitivity in identifying aspiration risk in amyotrophic lateral sclerosis. A future investigation with a larger sample size is needed to better investigate the utility of YSP as a screening tool for this population.

Obstructive sleep apnea (OSA) is a common sleep-related breathing disorder characterised by repeated narrowing and closure of the upper airway during sleep. Despite growing evidence that dysphagia is a frequent sequela of OSA, the role of speech-language pathologists (SLPs) in managing OSA remains unclear. The aim of this international study was to evaluate SLPs knowledge, attitudes, and experience of OSA. A validated questionnaire, OSA Knowledge and Attitudes (OSAKA), was distributed to SLPs internationally via an online survey. Additional information on demographics, educational history, and clinical practices was ascertained. From a total of 1647 respondents, 822 clinicians from twenty-four countries were included in the final analysis. Knowledge of OSA among SLPs was limited; the mean (SD) rate of correct answers was 55% (22%). Over half of SLPs reported patients with OSA on their caseload, with the majority of patients referred for dysphagia services. Yet, only half of SLPs reported confidence in their ability to assess or manage dysphagia in patients with OSA. SLPs’ experience of OSA had an effect on their knowledge and attitudes [F (2, 817) = 17.279, p

PurposeThis tutorial will provide speech-language pathologists with foundational knowledge about systematic reviews and their importance in everyday practice. It will also assist clinicians in developing critical appraisal skills so that current research can be translated judiciously to clinical environments for patient care. Systematic reviews are often regarded as the highest level of research evidence for implementing best evidence-based practice, because they synthesize research findings from multiple high-quality research studies, identify methodological weaknesses and biases from the studies included, and assist in illuminating areas for future research work based on current gaps in the literature. While systematic reviews can provide comprehensive knowledge to inform clinical practice, few speech-language pathologists receive training on appraising and applying the findings from systematic reviews appropriately within clinical settings.ConclusionClinicians within the field of speech-language pathology can use the framework provided in this tutorial to evaluate systematic reviews as a preliminary step for determining appropriate assessment and treatment methods for implementing evidence-based practice within clinical settings.

Purpose The purpose of this study was to investigate factors influencing the initiation of pharyngeal swallow (IPS) in healthy, nondysphagic adults. Method A total of 195 healthy participants ranging in age from 21 to 89 years participated in a modified barium swallow study. IPS was quantified using the Modified Barium Swallow Impairment Profile standardized scoring system across nine swallowing tasks observed in the lateral viewing plane for each participant. Results Large variability for bolus head location at time of hyoid burst (IPS) was observed within this healthy cohort, ranging from the ramus of the mandible to the pyriform sinuses. Significant effects of bolus volume, viscosity, sex, and race were also observed. Conclusion Study findings indicate that IPS is variable in healthy adults and influenced by volume, viscosity, sex, and race. Thus, variability in IPS may be considered typical in otherwise nondysphagic adults. The clinical significance of high Modified Barium Swallow Impairment Profile IPS scores in dysphagic patients, therefore, must be considered within the context of other swallowing impairments. Supplemental Material https://doi.org/10.23641/asha.12735935

Purpose Our objectives were to (a) identify oral and pharyngeal physiologic swallowing impairment severity classes based on latent class analyses (LCAs) of the Modified Barium Swallow Impairment Profile (MBSImP) swallow task scores and (b) quantify the probability of severity class membership given composite MBSImP oral total (OT) and pharyngeal total (PT) scores. Method MBSImP scores were collected from a patient database of 319 consecutive modified barium swallow studies. Because of missing swallow task scores, LCA was performed using 25 multiply imputed data sets. Results LCA revealed a three-class structure for both oral and pharyngeal models. We identified OT and PT score intervals to assign subjects to oral and pharyngeal impairment latent severity classes, respectively, with high probability (probability of class membership ≥ 0.9 given OT or PT scores within specified ranges) and high confidence (95% credible interval [CI] widths ≤ 0.24 for all total scores within specified ranges). OT scores ranging from 0 to 10 and from 14 to 18 yielded assignments in Oral Latent Classes 1 and 2, respectively, while OT = 22 was assigned to Oral Latent Class 3. PT scores ranging from 0 to 13 and from 18 to 24 yielded assignments in Pharyngeal Latent Classes 1 and 2, respectively, while PT = 26 was assigned to Pharyngeal Latent Class 3. Conclusions LCA of MBSImP task-level data revealed significant underlying oral and pharyngeal ordinal class structures representing increasingly severe gradations of physiologic swallow impairment. Clinically meaningful OT and PT score ranges were derived facilitating latent class assignment. Supplemental Material https://doi.org/10.23641/asha.12315677

Purpose This clinical focus article considers the roles of the clinical swallow examination (CSE) as a clinically meaningful assessment method used in both adult and pediatric populations. Method This clinical focus article explores the utility of the CSE across the life span. Specifically, components, reliability, standardized assessments, and limitations of the CSE within the adult and pediatric populations are highlighted. Conclusions The CSE remains a crucial assessment tool for the speech-language pathologist. The experienced clinician can make important judgments regarding patient safety and function. If the CSE is conducted mindfully and methodically, findings can help chart the course of care for individuals needing additional assessment and possibly intervention.

At the time of writing this paper, there are over 11 million reported cases of COVID-19 worldwide. Health professionals involved in dysphagia care are impacted by the COVID-19 pandemic in their day-to-day practices. Otolaryngologists, gastroenterologists, rehabilitation specialists, and speech-language pathologists are subject to virus exposure due to their proximity to the aerodigestive tract and reliance on aerosol-generating procedures in swallow assessments and interventions. Across the globe, professional societies and specialty associations are issuing recommendations about which procedures to use, when to use them, and how to reduce the risk of COVID-19 transmission during their use. Balancing safety for self, patients, and the public while maintaining adequate evidence-based dysphagia practices has become a significant challenge. This paper provides current evidence on COVID-19 transmission during commonly used dysphagia practices and provides recommendations for protection while conducting these procedures. The paper summarizes current understanding of dysphagia in patients with COVID-19 and draws on evidence for dysphagia interventions that can be provided without in-person consults and close proximity procedures including dysphagia screening and telehealth.

Objectives Half of patients with amyotrophic lateral sclerosis experience sialorrhea due to facial weakness. Although anticholinergic medications are first-line therapy, they often lead to unacceptable side effects. Radiation therapy and botulinum toxin may be considered when medical management fails. In this systematic review, we investigated the effectiveness of these interventions. Methods Eligible studies were retrieved from PubMed and Scopus databases up to March 2017 along with hand-searching of references from primary articles. Results Fourteen studies (N = 138) examined the benefits of botulinum toxin. Studies varied in salivary glands treated, dosages used, and the use of botulinum toxin subtype A or B. A majority of studies showed benefit after treatment. Although most studies reported only mild adverse effects, 2 case studies revealed severe complications including recurrent TMJ dislocations and rapid deterioration in bulbar function. Ten studies (N = 171) examined the benefits of radiation. Most studies reported improvement with only mild adverse events reported. Conclusions Both radiation and botulinum toxin are effective treatments for sialorrhea in patients with amyotrophic lateral sclerosis and should be considered when medical management fails. Radiation may offer longer duration of symptom improvement with fewer complications.

Quantitative analysis of modified barium swallow (MBS) imaging is useful to determine the impact of various disease states on pharyngeal swallowing mechanics. In this retrospective proof of concept study, kinematic analysis and computational analysis of swallowing mechanics (CASM) were used to demonstrate how these methods differentiate swallowing dysfunction by dysphagia etiology. Ten subjects were randomly selected from four cohorts of dysphagic patients including COPD, head and neck cancer (HNC), motor neuron disease, and stroke. Each subject was age- and gender-matched with healthy, non-dysphagic controls. MBS videos of 5 ml thin and 5 ml thick bolus trials from each subject were used. A MATLAB tracker tool was adapted and updated to collect and compile data for each video (n = 160). For kinematic measurements, a MANOVA was performed with post-hoc analyses to determine group differences. For CASM measurements, a morphometric canonical variate analysis with post hoc analysis was performed to determine group differences. Kinematic analyses indicated statistically significant differences between HNC cohort and controls in distance measurements for hyolaryngeal approximation (p = .001), laryngeal elevation (p = 0.0001), pharyngeal shortening (p = 0.0002), and stage transition duration timing (p = 0.002). Timing differences were noted between the stroke cohort and controls for pharyngeal transit time (p = 0.007). Multivariate morphometric canonical variate analysis showed significant differences between etiology groups (p < 0.0001) with eigenvectors indicating differing patterns of swallowing mechanics. This study demonstrated that swallowing mechanics among cohorts of dysphagic patients can be differentiated using kinematics and CASM, providing different but complementary quantitative methods for investigating the impact of various disease states on swallowing function.

Purpose This study investigated the impact of age and sex on mastication performance in healthy, nondysphagic, community-dwelling adults as observed during videofluoroscopy. Method Videofluoroscopic swallowing study imaging and mastication performance metrics (cycles, duration) were used to evaluate 185 healthy individuals (102 women, 83 men) aged 21–89 years. Results A significant effect of age on mastication cycles was not observed; however, a significant but weak effect of age on mastication duration was found. Female participants were observed to have significantly more mastication cycles and longer mastication durations compared to male participants. Three behavioral patterns of mastication performance emerged. Conclusions The results of this study contribute to normative data of mastication performance. An individual's sex was found to have a significant effect on mastication performance, although, in contrast to previous studies, age was not observed to significantly alter mastication performance. Differences in study methodologies likely explain the latter finding.

Purpose The aim of this study was to identify factors influencing pharyngeal laterality of bolus clearance through the pharyngoesophageal segment. Method Two swallowing trials (5-ml nectar-thickened liquid and 5-ml pudding) administered in the anteroposterior viewing plane during videofluoroscopy were extracted from a normative database of 195 healthy adult participants. Each swallow was determined as either having no laterality, right dominance/right side only, or left dominance/left side only. Descriptive measures were performed on all data variables. Chi-square tests were performed to determine the relationship between laterality and several factors, including age category, sex, race, and swallow task. Results The majority of swallows demonstrated no laterality. No significant associations were observed between laterality and the following factors: age category, race, or swallow task. Significant differences in laterality were observed between males and females, with females more likely to demonstrate no laterality. Conclusions Majority of swallows in the current healthy sample demonstrated no laterality preference. If present, males were more likely to demonstrate laterality compared to females. Laterality observed during videofluoroscopy does not imply impairment if there are no other factors present influencing bolus flow into the esophagus (e.g., mass). Study findings further define typical swallowing behaviors, allowing clinicians to better delineate normal variations from true impairment. Further research should include a larger sample of individuals aged 80 years and older, as well as additional swallowing tasks, to further investigate patient- and bolus-related factors on laterality.

Objectives: The purpose of this study was to examine age-related effects on esophageal transit times (ETT) among healthy adult participants. Methods: A total of 175 healthy, non-dysphagic participants underwent a modified barium swallow study (MBSS), and ETT was recorded for two standardized swallowing tasks. Differences across age groups were determined using Kruskal–Wallis test. Relationships between an Esophageal Clearance (Modified Barium Swallow Impairment Profile Component 17) score and ETT were also explored. Results: No significant differences were observed in ETT across age groups for nectar-thickened liquid ( P = .335) or pudding ( P = .231) consistencies. No significant differences were observed between males and females in ETT for either the nectar ( P = .112) or pudding trial ( P = .817). For nectar, the mean ETT for patients with Component 17 scores of 2 or greater were significantly higher than that of participants with a score of 0 ( P 0 demonstrated significantly higher mean ETT compared to participants with a score of 0 (with P = .0008 and P Conclusion: Study findings failed to support age-related or sex-related differences in ETT for two standardized swallowing tasks administered during a MBSS in healthy individuals. The normative values following a standardized protocol in this study provide guidance in clinical interpretation of esophageal function.

The purpose of this systematic review was to examine the application of event-related potentials (ERPs) to investigate neural processes of swallowing functions in adults with and without dysphagia. Computerized literature searches were performed from three search engines. Studies were screened using Covidence (Cochrane tool) and followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement standards (PRISMA-2009). A total of 759 studies were initially retrieved, of which 12 studies met inclusion criteria. Electrophysiological measures assessing swallowing functions were identified in two major ERP categories: (1) sensory potentials and (2) pre-motor potentials. Approximately 80% of eligible studies demonstrated strong methodological quality, although most employed a case series or case-control study design. Pharyngeal sensory-evoked potentials (PSEPs) were used to assess pharyngeal afferent cortical processing. The temporal sequence of the PSEP waveforms varied based on the sensory stimuli. PSEPs were delayed with localized scalp maps in patients with dysphagia as compared to healthy controls. The pre-motor ERPs assessed the cortical substrates involved in motor planning for swallowing, with the following major neural substrates identified: pre-motor cortex, supplementary motor area, and primary sensorimotor cortex. The pre-motor ERPs differed in amplitude for the swallow task (saliva versus liquid swallow), and the neural networks differed for cued versus non-cued task of swallowing suggesting differences in cognitive processes. This systematic review describes the application of electrophysiological measures to assess swallowing function and the promising application for furthering understanding of the neural substrates of swallowing. Standardization of protocols for use of electrophysiological measures to examine swallowing would allow for aggregation of study data to inform clinical practice for dysphagia rehabilitation.

Objectives: Typical aging may result in subclinical swallowing alterations (presbyphagia), which can place an individual at risk for dysphagia-related conditions, such as aspiration pneumonia, secondary to loss of functional reserve and rising incidence of age-related diseases associated with dysphagia. The purpose of this study was to investigate occurrence of airway invasion among healthy, nondysphagic community-dwelling adults. Further, we tested for differences of airway invasion across age categories and between sexes. Methods: Each eligible participant underwent a videofluoroscopic swallow study using a standardized approach of various volumes and viscosities. Ten swallows observed in the lateral viewing plane was assessed for observation of bolus airway invasion using the Penetration-Aspiration Scale (PAS) scoring system. Eligible participants (N = 195) were categorized according to 1 of 3 age categories (21-39 years, 40-59 years, 60 years and older) and sex (male, female) for analyses. Results: Out of 1936 swallows analyzed, we observed penetration in 113 swallows (5.8%) and aspiration in 6 swallows (0.3%). Majority (98%) of bolus airway invasion events occurred during the swallow. Mean or worst PAS scores did not significantly differ across age categories or between sexes. The odds ratios of PAS impairment between age categories did not reveal any significant differences. Males were more likely to have impaired PAS scores relative to females (odds ratio [OR] = 3.5; P = .01). Conclusions: Entrance of ingested material into the airway observed during videofluoroscopy is uncommon in healthy adults, which helps support the notion that aging may not directly correlate with increased risk of aspiration. Rather, the increased risk of aspiration observed in the aging population may result from the increased incidence of neurological and other diseases with dysphagia as common sequelae with advancing age. Future investigations should compare age-matched healthy controls with a diseased population (eg, cerebral vascular accident) to further explore the relationship between aspiration risk as a function of age compared to consequence of disease/injury.

Introduction: Universally established comprehensive clinical bulbar scales objectively assessing disease progression in amyotrophic lateral sclerosis (ALS) are currently lacking. The goal of this working group project is to design a best practice set of provisional bulbar ALS guidelines, available for immediate implementation within all ALS clinics. Methods: ALS specialists across multiple related disciplines participated in a series of clinical bulbar symposia, intending to identify and summarize the currently accepted best practices for the assessment and management of bulbar dysfunction in ALS Results: Summary group recommendations for individual speech, Augmentative and Alternative Communication (AAC), and swallowing sections were achieved, focusing on the optimal proposed level of care within each domain. Discussion: We have identified specific clinical recommendations for each of the 3 domains of bulbar functioning, available for incorporation within all ALS clinics. Future directions will be to establish a formal set of bulbar guidelines through a methodological and evidence-based approach. Muscle Nerve 59:531–531, 2019. Fil: Pattee, Gary L.. No especifíca; Fil: Plowman, Emily K.. University of Florida; Estados Unidos Fil: Garand, Kendrea L.. University of Alabama at Birmingahm; Estados Unidos Fil: Costello, John. No especifíca; Fil: Brooks, Benjamin Rix. No especifíca; Fil: Berry, James D.. No especifíca; Fil: Smith, Richard A.. No especifíca; Fil: Atassi, Nazem. No especifíca; Fil: Chapin, Jennifer L.. University of Florida; Estados Unidos Fil: Yunusova, Yana. University of Toronto; Canadá Fil: McIlduff, Courtney E.. No especifíca; Fil: Young, Eufrosina. No especifíca; Fil: Macklin, Eric A.. No especifíca; Fil: Locatelli, Eduardo R.. No especifíca; Fil: Silani, Vincenzo. Università degli Studi di Milano; Italia Fil: Heitzman, Daragh. No especifíca; Fil: Wymer, James. University of Florida; Estados Unidos Fil: Goutman, Stephen A.. No especifíca; Fil: Gelinas, Deborah F.. No especifíca; Fil: Perry, Bridget. No especifíca; Fil: Nalipinski, Paige. No especifíca; Fil: Stipancic, Kaila. Children's Hospital Boston; Estados Unidos Fil: O'Brien, Meghan. Children's Hospital Boston; Estados Unidos Fil: Sullivan, Stacey L.. No especifíca; Fil: Pioro, Erik P.. No especifíca; Fil: Gargiulo Monachelli, Gisella Mariana. Consejo Nacional de Investigaciones Científicas y Técnicas; Argentina. Consejo Nacional de Investigaciones Científicas y Técnicas. Oficina de Coordinación Administrativa Parque Centenario. CEMIC-CONICET. Centro de Educaciones Médicas e Investigaciones Clínicas "Norberto Quirno". CEMIC-CONICET; Argentina Fil: Green, Jordan R.. No especifíca

This pilot study explored agreement on swallowing-related quality-of-life scores reported by individuals with Parkinson’s disease (PD) and their caregivers. Thirty-six patient–caregiver pairs completed the Swallowing Quality of Life Questionnaire (SWAL-QOL) using an online survey format. Additional background and clinical information was ascertained. A Wilcoxon signed-rank test was completed to compare the means of scores between individuals with PD and caregivers. Factors potentially influencing SWAL-QOL scores (age, employment status, sex, ethnicity, race, previous history of swallowing evaluation or treatment, caregiver concern about patient cognition, caregiver burden, and time since onset of disease) were explored using Spearman Coefficient Correlation tests. The Holm–Bonferroni method was used to adjust for multiple comparisons. Results did not reveal significant differences in SWAL-QOL scores between individuals with PD and caregiver pairs. There was a moderate degree of reliability and agreement between paired patient and caregiver scores, with the average ICC measures being 0.598 (95% CI [358, 0.748]) (F(71, 72) = 2.451, p

Purpose The purpose of the current project was to explore the feasibility for subtyping dysphagia traits or patterns of scores in a subset of data from the Modified Barium Swallow Impairment Profile global registry in patients referred to videofluoroscopic swallowing studies across 5 common medical categories: (a) cardiothoracic, (b) gastroenterology, (c) head and neck cancer, (d) neurology, and (e) pulmonary. Method Videofluoroscopic swallowing study imaging and Modified Barium Swallow Impairment Profile metrics were used to evaluate 235 patients with dysphagia grouped into 1 of the 5 categories. Two summative domain scores (oral total [OT] and pharyngeal total [PT]) and 17 component scores were tested for differences among the categories. Results When compared with the gastroenterology category, significantly higher OT/PT scores were observed in neurology and pulmonary categories (all p values < .05). Four oral and 6 pharyngeal domain components significantly differed across medical categories: tongue control during bolus hold (all p values < .04). Conclusions The results of this feasibility study demonstrate that summative scores of swallowing physiology alone are not sufficiently robust to distinguish subtypes of dysphagia in broad, heterogeneous medical categories. Using OT/PT as subtypes only separated gastroenterology from the other categories, suggesting overlap in OT/PT scores between the latter categories.

Kendrea L Garand,1 Charlie Strange,2 Luca Paoletti,2 Theresa Hopkins-Rossabi,3 Bonnie Martin-Harris3 1Department of Speech Pathology and Audiology, College of Allied Health Professions, University of South Alabama, Mobile, AL 36688, USA; 2Division of Pulmonary, Critical Care, and Sleep Medicine, College of Medicine, Medical University of South Carolina, Charleston, SC 29425, USA; 3Department of Communication Sciences and Disorders, School of Communication, Northwestern University, Evanston, IL 60208, USA Background: Swallowing impairment (dysphagia) has been associated with COPD and may contribute to exacerbations of this chronic and progressive disease. Further, risk of mortality increases with concomitant presence of cachexia in the COPD population. The purpose of this prospective study was to depict oropharyngeal swallowing physiology in underweight patients with stable but advanced-stage COPD. Patients and methods: Ten underweight patients with stable but advanced COPD underwent a modified barium swallow study. Analysis of oropharyngeal swallowing function was completed using the standardized Modified Barium Swallow Impairment Profile and the Penetration–Aspiration Scale. Scores from the Dysphagia Handicap Index and 10-item Eating Assessment Tool were collected to assess patient perception of swallowing difficulty. Findings were compared to age- and sex-matched healthy controls. Results: Significantly higher MBSImP oral total scores (P=0.007) were observed in COPD patients compared to matched controls, but no difference was observed in pharyngeal total scores (P=0.105). Patients with COPD had significantly higher maximum PAS scores compared with controls (P=0.030). There was no significant difference in EAT-10 or DHI scores between patients with COPD and controls (P=0.41 and P=0.08, respectively). Conclusion: Underweight patients with severe but stable COPD present with dysphagia that may not be recognized by the patient. Further investigation is needed to elucidate the interaction between the respiratory–swallowing systems, how muscular weakness may contribute to swallowing impairment, and responsiveness to swallowing treatment. Keywords: COPD, swallowing impairment, MBSImP, dysphagia, underweight

Swallowing impairment (dysphagia) is a common sequela in patients with motor neuron disease (MND). The purpose of this retrospective, observational pilot investigation was to characterize how pharyngeal swallowing mechanics are impacted in patients with MND using a comparison with healthy, non-dysphagic control group. Computational analysis of swallowing mechanics (CASM) was used to determine covariate biomechanics of pharyngeal swallowing from videofluoroscopic assessment in 15 patients with MND and 15 age- and sex-matched healthy controls. Canonical variant analysis with post hoc discriminate function analysis (DFA) was performed on coordinate data mapping functional muscle groups underlying pharyngeal swallowing. Differences in swallowing mechanics associated with group (MND; control), motor neuron predominance (upper; lower), onset (bulbar; spinal), and swallow task (thin, pudding) were evaluated and visualized. Pharyngeal swallowing mechanics differed significantly in patients with MND compared with healthy controls (D = 2.01, p < 0.0001). Post hoc DFA pairwise comparisons suggest differences in pharyngeal swallow mechanics by motor neuron predominance (D = 5.03, p < 0.0001), onset (D = 2.03, p < 0.0001), and swallow task (D = 1.04, p < 0.0001). Pharyngeal swallowing mechanics of patients with MND differ from and are more heterogeneous than healthy controls. These findings suggest patients with MND may compensate reductions in pharyngeal shortening and tongue base retraction by extending the head and neck and increasing hyolaryngeal excursion. This work and further CASM investigations will lead to further insights into development and evaluation of targeted clinical treatments designed to prolong safe and efficient swallowing function in patients with MND.

Study designs have numerous advantages and disadvantages that must be considered when addressing a research question, hypothesis, and objective. These include but are not limited to cost, feasibility, and ethical concerns. This review describes common study designs from the dysphagia literature with corresponding relevant examples for each design type. Further, discussion of the main differences between descriptive and analytical, qualitative and quantitative, observational and experimental, and retrospective and prospective study designs is provided. Specific aspects of various study designs, including matching, randomization, and blinding are also discussed. Finally, the importance of working closely with experts, such as epidemiologists and biostatisticians, in the early stages of research to assist with selection of the most appropriate study design and development of the research protocol is strongly recommended.

Swallowing impairment (dysphagia) represents the highest functional morbidity in oropharyngeal (OP) head and neck (HNC) treated either with surgical approaches followed by radiation or with more recent organ preservation protocols, including combined chemotherapy and radiation. Despite the promising overall increasing survival rates, swallowing impairments remain chronic, are often resistant to traditional swallowing therapy, and have devastating consequences on health and well-being. The respiratory-swallow cross-system approach presented here extends beyond traditional swallowing interventions that commonly targets muscles and structures alone, and is instead, directed toward the re-establishment of optimal respiratory-swallowing coordination. Results from our work investigating a respiratory-swallow treatment (RST) paradigm is presented, including results from an RST clinical trial in HNC patients, primarily with OP cancers, with chronic and with intractable dysphagia post-cancer and post-traditional swallowing treatment. Future work will investigate the impact of RST on the degree and durability of clinical outcomes, including oral intake and quality of life, while also examining the potential added benefits of a home practice program that uses a commercially available and easy to use recording and analysis hardware and software.

The Modified Barium Swallow Impairment Profile (MBSImP™©) is a standardized method for the assessment of swallowing physiology from videofluoroscopic imaging used by teams of speech-language pathologists (SLPs) and radiologists during modified barium swallowing studies (MBSS). The approach is grounded in research and motivated by patient need toward minimizing wide variation in clinical practice and equivocal swallowing assessment findings when attempting to compare assessment results across the continuum of care and between clinical settings. Various methods of scoring are used, which are dependent upon the nature and purpose of the clinical or research question. The MBSImP™© initiated with an National Institute of Health [NIH] supported study has been field tested for 13 years. The standardized method aims to enhance the validity and reliability of swallowing metrics, improve transparency and reproducibility of clinical and research MBSS practices, as well as to optimize patient safety, comfort, expectations, and outcomes. The physiologic study of swallowing impairment using the MBSImP™© has become a program of research that strategically includes a data science initiative using a global registry of quality, safety and outcome metrics.

The purpose of this systematic review was to summarize and qualitatively analyze published evidence elucidating the prevalence of dysphagia and detail alterations in swallowing function in patients with OSAS. Computerized literature searches were performed from four search engines. The studies were selected based on the inclusion and exclusion criteria. The studies were screened using Covidence (Cochrane tool) and followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement standards (PRISMA-2009). A total 2645 studies were initially retrieved, of which a total of 17 studies met inclusion criteria. Two reviewers, blinded to each other, evaluated level and strength of evidence using the Oxford Centre for Evidence-based Medicine Levels of Evidence and QualSyst, respectively. Dysphagia prevalence ranged from 16 to 78% among the eligible studies. Studies varied in operational definitions defining swallowing dysfunction (dysphagia) and method used to assess swallowing function. Approximately 70% of eligible studies demonstrated strong methodological quality. The majority of studies (n = 11; 65%) reported pharyngeal swallowing impairments in patients with OSAS, including delayed initiation of pharyngeal swallow and penetration/aspiration. This systematic review describes swallowing function in patients with OSAS. However, due to the variability in defining OSAS and dysphagia, in the assessment method used to determine dysphagia, and heterogeneity of study designs, true prevalence is difficult to determine. Clinicians involved in the management of OSAS patients should employ validated assessment measures to determine if swallow dysfunction is present.

Summary Objective Laryngeal endoscopy with stroboscopy, a critical component of the assessment of voice disorders, is rarely used as a treatment outcome measure in the scientific literature. We hypothesized that this is because of the lack of a widely used standardized, validated, and reliable method to assess and report laryngeal anatomy and physiology, and undertook a systematic literature review to determine the extent of the inconsistencies of the parameters and scales used in voice treatment outcome studies. Study Design Systematic literature review. Methods We searched PubMed, Ovid, and Cochrane for studies where laryngeal endoscopy with stroboscopy was used as a treatment outcome measure with search terms representing “stroboscopy” and “treatment” guided by Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement standards. Results In the 62 included articles, we identified 141 terms representing 49 different parameters, which were further classified into 20 broad categories. The six most common parameters were magnitude of glottal gap, mucosal wave amplitude, location or shape of glottal gap, regularity of vibration, phase symmetry, and presence and size of specific lesions. Parameters were assessed on scales ranging from binary to 100 points. The number of scales used for each parameter varied from 1 to 24, with an average of four different scales per parameter. Conclusions There is a lack of agreement in the scientific literature regarding which parameters should be assessed to measure voice treatment outcomes and which terms and scales should be used for each parameter. This greatly diminishes comparison and clinical implementation of the results of treatment outcomes research in voice disorders. We highlight a previously published tool and recommend it for future use in research and clinical settings.

Videofluoroscopic imaging of swallowing known as the Modified Barium Study (MBS) is the standard of care for assessing swallowing difficulty. While the clinical purpose of this radiographic imaging is to primarily assess aspiration risk, valuable biomechanical data is embedded in these studies. Computational analysis of swallowing mechanics (CASM) is an established research methodology for assessing multiple interactions of swallowing mechanics based on coordinates mapping muscle function including hyolaryngeal movement, pharyngeal shortening, tongue base retraction, and extension of the head and neck, however coordinates characterizing pharyngeal constriction is undeveloped. The aim of this study was to establish a method for locating the superior and middle pharyngeal constrictors using hard landmarks as guides on MBS videofluoroscopic imaging, and to test the reliability of this new method. Twenty de-identified, normal, MBS videos were randomly selected from a database. Two raters annotated landmarks for the superior and middle pharyngeal constrictors frame-by-frame using a semi-automated MATLAB tracker tool at two time points. Intraclass correlation coefficients were used to assess test-retest reliability between two raters with an ICC = 0.99 or greater for all coordinates for the retest measurement. MorphoJ integrated software was used to perform a discriminate function analysis to visualize how all 12 coordinates interact with each other in normal swallowing. The addition of the superior and middle pharyngeal constrictor coordinates to CASM allows for a robust analysis of the multiple components of swallowing mechanics interacting with a wide range of variables in both patient specific and cohort studies derived from common use imaging data.

The aim of this Symposium was to develop a consensus based, bulbar assessment protocol for implementation within NEALS clinics.A one-day symposium, held in April 2017, was organized into Speech and Swallowing sections to establish summary recommendations for the assessment of bulbar dysfunction within each group.Summary recommendations included speech referrals and AAC evaluations at initial visit, CNS-BFS, maximum sustained phonation, and speaking rate. Dysarthria evaluation included the speech subsystem involvement of respiration, phonation, resonance, and articulation. Specific recommendations for swallowing were established for each of the following domains: dietary/oral intake, airway defense physiologic capacity, swallow safety screen, patient-reported swallow-related outcomes, oral sensorimotor exam, and pulmonary function. Practice parameters focused upon patient education and unresolved questions included the use of videofluoscopy, monitoring diet progression, and swallow safety screening.The working goal is to establish a clinical bulbar protocol, designed to be incorporated within ALS clinics and ultimately to formulate a best practice set of bulbar ALS guidelines, available for implementation throughout the international ALS community.