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DYSPHAGIA ASSESSMENT AND TREATMENT PLANNING: A TEAM APPROACH
rotation may be to clear hypopharyngeal residue, avoid it in the first place,
or both.
The compensatory tasks or strategies
available to a given patient depend on
cognition; upper aerodigestive tract
sensory integrity; head/neck oral,
pharyngeal, and laryngeal anatomy
and range of motion, control, and
strength; respiratory health/resilience;
and upper body postural stability and
control. Again, as progression through
both the standard protocol and exploration of strategies involves constant risk
assessment, this information must be
compiled prior to the DSS.
Valves and Chambers
With respect to swallowing, the aerodigestive tract can, simplistically, be represented as a series of chambers and
valves. Chambers expand to accommodate bolus material and then compress/
constrict in peristaltic fashion to direct
material to the next chamber. Valves are
those structures that open and close,
alternately preventing and then permitting bolus entrance from one chamber
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to the other (Video 1–1, Straw Drinking). The lips, comprising the initial
“valve,” and oral cavity “chamber” (at
least anteriorly) comprise the first of
these structures and are typically available for visual assessment. Valves and
chambers, and their assessment during
the fluoroscopic swallow study, are discussed here.
Compensations of Oral
Chambers and Valves
As many observations of the anterior
oral cavity can be made without fluo-
roscopy, the DSS is most valuable in
assessing the competence of the posterior oral cavity (OC). Nevertheless,
inadequate oral bolus management has
implications for airway safety. Consequently, all observations, combined
with clinical findings, are valuable. In
the OC, a bolus is prepared, created,
and maintained as it is transferred
toward the pharynx. These competencies are dependent on lingual shaping
and agility of a muscular floor within a
hard-walled chamber of bone and, usually, teeth. Successful oral transit also
requires sensation for judgment (bolus
readiness in consistency and size) and
mucosal wetness.
When ability to control and propel
the bolus in the oral cavity is poor, compensatory tasks or “tools” available to
the clinician include bolus consistency,
bolus placement, and gravity. Site of placement of the bolus on the tongue and/
or head/neck flexion and/or extension
may be used to manipulate bolus position and flow. If necessary, the OC can
be bypassed by using a syringe with a
short catheter to deliver the bolus to the
posterior tongue (an example of this
strategy is included on the companion
website for Chapter 10). If oral transit
must be bypassed in this manner, competent bolus control is less likely and
the patient should be instructed for preswallow breath holding to prevent the
uncontrolled bolus from entering the
airway before glottic closure for swallow. Very lateral bolus placement and
side-lying or leaning may also reduce
the likelihood of aspiration during this
maneuver. It should be remembered
that the decision to undertake manipulation of OC events that facilitate oral
transit is dependent on the competence of events in the pharynx. That
is, oral transit impairments cannot be
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fully assessed if pharyngeal transit and
laryngeal airway protection are intractably incompetent.
Observation of Nonswallow Tasks
As noted, when the amount of contrast
must be very limited because of serious
airway threat, speech and other oral
nonswallow tasks may provide valuable insights. Speech tasks require different but perhaps no more demanding
range of motion and agility than oral
deglutitive tasks, especially mastication
of hard solids. Observations of speech
tasks can be helpful in clarifying subtle
limitation in the lingual and palatal
range for movement. When indicated,
our protocol includes repetition of
vowel extremes (/i/ as in “heat,” /a/
as in “hot,” and /u/ as in “hoot”) as
well as consonants whose production
requires lingual tip (/t/, /d/) or posterior palatal contact and palatal closure
(/k/, /g/). If historical or clinical findings leave questions regarding posterior
lingual or palatal competence, additional tasks can be added to the DSS
without adding significant time to the
study. Techniques to measure palatal
anatomy and competence using multiview fluoroscopy have long been available and aid in differentiating between
anatomic and movement failures when
valving for swallow is incompetent.
The Linguapalatal Valve
The anatomy and physiology of the oral
and pharyngeal chambers are linked by
the linguapalatal valve (or retro-oral
portal [Bosma, 1956]), which is created
by posterior tongue elevation against
the bony palate or against the tensed
and lowered soft palate. This valve acts
alternately to contain the bolus within
the oral cavity and then release it into
the pharynx.
The linguapalatal valve differs from
other pharyngeal valves in the complexity of its role in both oral preparatory and oral transit components of
deglutition, and because it is central in
the relationship between the initiation
of both swallow gestures (movements of
swallow structures) and bolus transit.
During swallow of liquids, especially
boluses >1 mL, failure to coordinate
onset of bolus transit with swallow
gestures is likely to result in nasal
reflux, aspiration, or regurgitation. In
swallows of other consistencies, and
perhaps very small liquid boluses, particularly those associated with mastication, the linguapalatal valve may open
repeatedly to allow small amounts of
the bolus into the pharynx before swallow gestures are initiated. Because of
this normal variability, interpretation
of linguapalatal valving failure can
only be made if instructions are clearly
understood and the patient is able (and
trying) to comply. Failure of linguapalatal valving may result in absent pharyn-
geal transit or in discoordination of the
onset of pharyngeal bolus transit with the
initiation of sequential swallow gestures.
If linguapalatal valving failure results in bolus entry into the pharynx
prior to initiation of swallow gestures,
strategies that can delay or prolong
bolus flow or that employ pharyngeal
anatomy and gravity to deflect the bolus
from the airway are useful. Such strategies include head/neck flexion and/or rota-
tion, upper body reclining on one side or the
other (the degree depending on the impact
desired), increasing bolus viscosity (the
degree depending on the need), and limiting
bolus size to the capacity of the valleculae
and piriform sinus. Alternatively, or additionally, voluntary preswallow laryngeal
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DYSPHAGIA ASSESSMENT AND TREATMENT PLANNING: A TEAM APPROACH
closure may protect the airway until pharyngeal transit is complete. Strategies
believed to facilitate timely initiation
of pharyngeal gestures by enhancing
sensory information are widely used
and involve manipulation of the charac-
teristics of the bolus (size, temperature, texture, taste) or presenting other stimulation
(e.g., cold touch to the faucial pillars) just
before offering the bolus (see Chapter 10
for additional discussion of the effects
of various stimuli on swallow).
When failure of linguapalatal valving results in initiation of bolus transit
after initiation of swallow gestures, the
bolus will fall into the pharynx partway through the sequence of swallow gestures or after they have been
completed. Depending on the specific
impairment, strategies may be aimed
at slowing or deflecting the bolus or
at facilitating bolus flow. Strategies to
slow or deflect the bolus include lim-
iting the amount of the bolus falling into
the piriform sinuses (side-leaning and head
rotation) until repeated swallow gestures
can complete pharyngeal transit. Strate-
gies to facilitate bolus flow include head/
neck extension with voluntary preswallow
airway closure followed by flexion and head
(not upper body) tilting or rotation.
Compensations of Pharyngeal
Chambers and Valves
The pharynx switches from respiratory
to deglutitive physiology by altering the
shape of its chamber and the configuration of its valves. Most of the time, the
pharynx is an airway: The linguapalatal
valve may be open or closed, the velopharyngeal valve is open, the laryngeal
valve is open, and the pharyngoesophageal valve is closed. Failure of any of
these valves and/or failure to maintain
pharyngeal patency for breathing can,
at least, disturb respiration and negatively impact deglutition.
During normal swallow, the switch
from respiratory to deglutitive valving
begins immediately, or even before,
the bolus is delivered to the oropharynx (see Chapter 1). During pharyngeal transit, the pharyngeal airspace
first expands and then is obliterated
(completely in young normal swallowers). In the oropharynx, expansion
to accommodate the bolus is achieved
by forward movement of the tongue
base and flexibility of the lateral walls;
obliteration of the cavity is achieved
by medial movements of these structures. In the hypopharynx, expansion
is accomplished by forward movement
of the hyolaryngeal complex and lateral
walls, as well as the relaxed PES. At the
same time, elevation/foreshortening
of these structures helps to engulf the
bolus and draw it into the esophagus
(Kennedy & Kent, 1985).
Pharyngeal Valves
The Velopharyngeal Valve. Failure
of velopharyngeal valve timing or extent of closure results in leakage of the
bolus (or of air) into the nasopharynx
and diminished ability to generate
oropharyngeal pressures for propelling the bolus through the oropharynx
for swallow (or to divert air through
the mouth for speech). Observation of
velopharyngeal function during speech
(plosives and fricatives) may yield
insights into velopharyngeal function
for swallow. Strategies to compensate
for, or improve, velopharyngeal valve
closure include head/neck rotation and
manipulation of bolus size and/or viscos-
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ity. When compensatory strategies fail,
other therapies, possibly prosthetic or
behavioral, can be guided by findings
of the dynamic swallow study.
Failure of timing or extent of velopharyngeal valve opening results in
competition between respiration and
deglutition, particularly during mastication. This can slow meals and decrease the comfort and ease of eating or
drinking. Strategies to compensate for
an impaired velopharyngeal airway
include increasing the time allowed for
respiration between swallows. Techniques
that accomplish this objective include
limiting the size and viscosity of the bolus,
the rate of bolus presentation, and the total
number of boluses given.
The Laryngeal Valves. Dysphagia due
to either structural or sensory-motor
laryngeal valve dysfunction may compromise the last line of defense against
aspiration. If the patient’s history or
clinical evaluation suggests laryngeal
dysfunction contributing to dysphagia
or breathing problems, the dysphagia
evaluation should include a laryngological exam.
Failure of timing or extent of supraglottic and glottic laryngeal valve closure results in leakage into the trachea.
This failure may also impact hypopharyngeal pressure generation necessary
to propel the bolus through the PES and
into the esophagus. Strategies available
to compensate for ineffective laryngeal
closure will depend on the etiology,
that is, impaired sensation, reduced
movement, and altered structure. These
strategies generally aim to deflect bolus
flow around the larynx and/or to optimize laryngeal elevation and closure.
These potentially include head/neck flex-
ion and/or rotation, upper body side-lying
(or reclining), and increased effort resulting in prolongation of laryngeal closure
and/or elevation.
Failure of timing or extent of supraglottic and glottic laryngeal valve opening may or may not be obvious during
quiet breathing and swallowing small
boluses. In other cases, stridor may be
present even in these situations. However, even subtle laryngeal airway
obstruction, like other conditions that
result in air hunger, can result in intolerance for the obligatory respiratory
pause during swallow. Such impairment may affect subtle relationships
between deglutition and respiration
(Hiss et al., 2003).
The Pharyngoesophageal Valve (or
PES). Failure of extent or timing of PES
opening (expansion) due to changes
in the PES valve structure itself may
be due to neuromuscular impairment
or decreased tissue compliance (fibrosis). Inadequate opening limits the
amount of food or liquid entering the
esophagus per swallow. Strategies to
compensate for decreased PES patency
aim at prolonging maximum opening,
or increasing the number of swallows
per bolus, and protecting the laryngeal
airway from residue between or after
swallows. Strategies include repeated
swallows per bolus on a single respiration,
increased and prolonged maximum hyoidlaryngeal elevation and laryngeal closure,
head/neck rotation, flexion or extension,
or upper body reclining. Shaker and
colleagues (1997) and Kahrilas et al.
(1991) have reported increases in opening extent or duration associated with
exercises designed to increase hyoid
displacement. Restricting bolus size
may also be a useful strategy, since PES
opening is volume dependent.
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DYSPHAGIA ASSESSMENT AND TREATMENT PLANNING: A TEAM APPROACH
When the PES never closes completely, the pharynx and larynx are
vulnerable to reflux of just-swallowed
material in the esophagus, as well as
chronic gastroesophageal reflux (GER).
Compensatory strategies are aimed at
maximizing the effects of gravity on the
bolus to keep it in the esophagus. These
include slowing the rate of bolus presen-
tation and adhering to behavioral precautions, that is, postprandial maintenance
of upright posture and caution in the
ingestion of substances that may reduce
LES pressures or otherwise increase
the likelihood of GER. The identification and appropriate treatment of PES
valve dysfunction requires teaming
with ENT and gastrointestinal medicine physicians.
Pharyngeal Chamber
Failure of pharyngeal chamber obliteration results in contrast residue that
falls into the available distal pocket
(valleculae or piriform sinuses) after/
between swallows. Selection of strategies depends on identification of site of
incompetence. Strategies to compensate for incomplete pharyngeal clearing
can be aimed at diversion of the bolus
away from the failure site, increased
effort (extent or duration) of pharyngeal constriction or of PES opening, and
prevention of aspiration when clearing
takes longer to achieve. These strategies may include head/neck rotation or
flexion, prolonged and increased laryngeal
elevation, repeated swallows, postswallow
voluntary laryngeal clearing, and upper
body reclining.
Failure of pharyngeal expansion due
to pharyngeal wall stiffness reduces the
size of the bolus that can be accommodated. If wall stiffness affects the size or
presence of essential pharyngeal spaces
(the “gutters” lateral to the epiglottis
and the piriform sinuses), the bolus is
diverted into rather than around the larynx. Compensation for these structural
changes includes effort strategies aimed
at early, prolonged, and vigorous laryngeal
closure. Observation of the pharynx dur-
ing vocal pitch change and other speech
and nonspeech aerodynamic tasks may
offer insight into pharyngeal tone and
movement range.
TEAMWORK
The upper aerodigestive tract is remarkable for the number of professionals
whose patients can be profoundly affected by dysphagia and who have their
own particular and nuanced insights
into diagnosis and management of
dysphagia (dysphagia therapists, radiologists, laryngologists, physiatrists,
neurologists, gastroenterologists, pulmonologists, dieticians, nurses, and physical and occupational therapists). We
believe that the fluoroscopic swallow
study should contribute to diagnosis
and management of dysphagia beyond
the bailiwick of the behavioral therapist.
STUDY QUESTIONS
1. What aspects of the DSS make it
“standardized”?
2. Can you name three benefits of
using a protocol when conducting
a DSS?
3. Ideally, what structures would you
like to visualize in lateral view
fluoroscopy?
4. What strategies might you try with
a patient who has difficulty get-
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119
ting bolus material out of the oral
cavity? What concerns would you
have about using these?
5. Can speech tasks be helpful in understanding swallowing deficits?
6. What strategies might you use to
facilitate initiation of pharyngeal
gestures?
7. Why would poor velopharyngeal
opening interfere with swallowing?
8. What strategies may be helpful in
deflecting bolus flow around the
larynx? In optimizing laryngeal
elevation and closure?
9. What techniques might facilitate
poor PES opening?
What behavioral strategies might
10.
benefit a patient with poor pharyngeal clearing?
(More information about strategies, and
their rationale, is presented in Chap ter 10.)
REFERENCES
Bosma, J. F. (1956). Myology of the pharynx
of cat, dog, and monkey with interpretation of the mechanism of swallowing.
Annals of Otology, Rhinology, and Laryngology, 65, 981–992.
Bosma, J. (1957a). Studies of the pharynx.
I. Poliomyelitic disabilities of the upper
pharynx. Pediatrics, 19, 881–907.
Bosma, J. (1957b). Deglutition: Pharyngeal
stage. Physiological Reviews, 37, 276–299.
Castell, J. A., Castell, D. O., Schultz, A. R.,
& Georgeson, S. (1993). Effect of head
position on the dynamics of the upper
esophageal sphincter and pharynx. Dys-
phagia, 8, 1–6.
Fant, G. (1970). Acoustic theory of speech pro-
duction. Mouton.
Hiss, S. G., Strauss, M., Treole, K., Stuart, A.,
& Boutilier, S. (2003). Swallowing apnea
as a function of airway closure. Dyspha-
gia, 18, 293–300.
Kahrilas, P. J., Logemann, J. A., Krugler, C.,
& Flanagan, E. (1991). Volitional augmentation of upper esophageal opening
during swallowing. American Journal of
Physiology, 260, 450–456.
Kendall, K. A., & Leonard, R. J. (2002). Video-
fluoroscopic upper esophageal sphincter
function in elderly dysphagic patients.
Laryngoscope, 112, 332–337.
Kendall, K. A., Leonard, R. J., & McKenzie,
S. (2004). Airway protection: Evaluation
with videofluoroscopy. Dysphagia, 19,
65–70.
Kennedy, J., & Kent, R. D. (1985). Anat-
omy and physiology of deglutition and
related functions. Seminars in Speech and
Language, 6, 257–272.
Lamvik, K., Jones, R., Sauer, S., Erfmann, K.,
& Huckabee, M. L. (2015). The capacity
for volitional control of pharyngeal swallowing in healthy adults. Physiology and
Behavior, 152(Pt. A), 257–263.
Leonard, R., Belafsky, P. C., & Rees, C. J.
(2006). Relationship between fluoroscopic
and manometric measures of pharyngeal
constriction: The pharyngeal constriction
ratio. Annals of Otology, Rhinology, and
Laryngology, 115, 897–901.
Leonard, R., Kendall, K., & McKenzie, S.
(2004a). Structural displacements affecting pharyngeal constriction in nondysphagic elderly and nonelderly adults.
Dysphagia, 19, 133–141.
Leonard, R., Kendall, K., & McKenzie, S.
(2004b). UES opening and cricopharyngeal bar in nondysphagic elderly
and nonelderly adults. Dysphagia, 19,
182–191.
Logemann, J. (1983). Evaluation and treat-
ment of swallowing disorders. College-Hill
Press.
Logemann, J. A., Boshes, B., Blonsky, E.
R., & Fisher, H. B. (1977). Speech and
swallowing evaluation in the differential diagnosis of neurologic disease.
Neurologia, Neurocirugia, and Psiquiatria,
18(Suppl. 2–3), 71–78.
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DYSPHAGIA ASSESSMENT AND TREATMENT PLANNING: A TEAM APPROACH
Maeda, K., Ono, T., Otsuka, R., Ishiwata, Y.,
Kuroda, T., & Ohyama, K. (2004). Modulation of voluntary swallowing by visual
inputs in humans. Dysphagia, 19, 1–6.
Ohmae, Y., Ogura, M., Kitahara, S., Karaho,
T., & Inouye, T. (1993). Effects of head
rotation on pharyngeal function during
normal swallow. Annals of Otology, Rhi-
nology, and Laryngology, 107, 344–348.
Shaker, R., Kern, M., Bardan, E., Taylor, A.,
Stewart, E. T., Hofmann, R. G., . . . Bonn-
evier, J. (1997). Augmentation of deglutitive upper esophageal sphincter opening
in the elderly by exercise. American Jour-
nal of Physiology, 272, 1518–1522.
Triadafilopoulos, G., Hallstone, A., Nelson-
Abbott, H., & Bedinger, K. (1992). Oropharyngeal and esophageal interrelationships in patients with nonobstructive
dysphagia. Digestive Diseases and Sci-
ences, 37, 51–57.
DSS: A Systematic
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Approach to Analysis
and Interpretation
Rebecca Leonard and Susan McKenzie
The normal oral-pharyngeal-laryngeal
swallow is a smoothly coordinated,
highly skilled event (Martin-Harris et
al., 2005). Assessment of the dysphagic
patient involves analysis to determine
(a) whether one or more of the many
oral, pharyngeal, or laryngeal events
required to accomplish a swallow are
abnormal and (b) the implications of
that abnormality for a patient with a
unique medical and social history. The
more narrowly and accurately abnormalities can be described and interpreted, the more likely any subsequent
treatment will be successful.
The number of swallow events and
their requisite speed, normal variability, and adaptability are obstacles to
specifying and interpreting abnormalities on dynamic fluoroscopic swallow
studies (DSSs). For this reason, and as
described previously, we have adopted
a standard approach to DSS direction,
analysis, and interpretation. The intent
of this approach is to control many of
the conditions that affect swallow performance, thus facilitating analysis and
interpretation.
Assessment of the swallow observed
fluoroscopically includes, in our practice, both subjective description and
objective analyses of critical aspects of
swallow. Observations are organized
by timing and movements of critical
structures, the competence of chambers
and valves, and the collective effects of
these on bolus transit. Events that are
measured (described in Chapter 8) can
be compared with the performance of
normal swallowers on the same task,
making determinations of normal versus abnormal possible even for less
experienced clinicians. If objective
comparisons between swallows by the
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DYSPHAGIA ASSESSMENT AND TREATMENT PLANNING: A TEAM APPROACH
same patient over time or treatment are
desired, measurements are informative
even without normative data.
Interpretation of fluoroscopic observations, whether an abnormality is
detected or not, involves correlation of
the observed performance to a complex
array of contexts. The first correlation
might be with other swallows observed
(clinically or fluoroscopically) or with
the patient’s complaint; for example,
does the patient complaint predict
performance on fluoroscopy? Or, does
performance change with the swallow
task? Correlation of different swallowing tasks within the same fluoroscopy
session can reveal conditions that provoke decompensation. Correlation
with broader contexts (e.g., nutritional,
medical, surgical, and neurological
histories) may have implications for
prognosis and medical/surgical management. Thus, interpretation of fluoroscopic swallow studies determines
consistency or “fit”—
observed behavior predictable based
on what is known about the patient?
If fluoroscopy reveals nasopharyngeal
incompetence, for example, what evidence in the complaint (e.g., clinical
observation, behavioral history, surgical history) would predict that finding? If the observation is not explained
by what is known about the patient,
further investigation (fluoroscopic,
clinical, or historical probing) may be
warranted.
that is, is the
(e.g., kinetics [force] and friction) can be
inferred to some extent. Such inferences
can be strengthened by studies that
assess these elements directly, such as
manometry (Leonard et al., 2006).
CHAMBERS DIVIDED BY
VALVES
— A CONCEPTUAL
PERSPECTIVE FOR ANALYSIS
As introduced in Chapter 6, we have
found that conceptualizing the upper
aerodigestive tract as a series of valves
and chambers is helpful in performing and observing the DSS, as well as
in assessing the study. Analysis of the
oral, pharyngeal, and laryngeal spaces
as a series of mutable chambers (tubes
or cavities) and valves is an accepted
tool for the analysis of speech or voice
(Fant, 1970, 1980; Flanagan, 1972).
Kennedy and Kent (1985) proposed a
similar model of tubes and valves for
description of swallow. The authors
divided the oral and pharyngeal chambers based on spatial orientation (horizontal and vertical), differences in their
function, and the presence of a functional valve between them (i.e., the posterior linguapalatal or retro-oral valve)
(Bosma, 1957a, 1957b).
During analysis of fluoroscopic studies, we have also found it insightful to
further subdivide the pharynx into the
oropharynx and the hypopharynx. This
division has become apparent to us in
the following ways:
BIOMECHANICAL
INTERRELATIONSHIPS
Although only kinematic (movement)
observations can be made from fluoroscopy, other biomechanical elements
n
Airway threat escalates signifi-
cantly as the bolus passes from
one chamber to another. Contrast
retained in the oral cavity is least
likely to be aspirated and most
easily expelled. Contrast retained
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in the oropharynx is more threatening but can be expelled by
hawk-spit or suctioning. Contrast
retained in the hypopharynx, on
the other hand, cannot be voluntarily expelled unless it is at
the entry to or in the larynx (and
cough is effective), and it is very
difficult to suction. Awareness of
this progression of risk is helpful
when directing the swallow study.
n
The oropharynx and hypophar-
ynx differ in their actions for
swallow. Bolus flow through the
oropharynx is normally midline
propelled by the retracting tongue
and the medializing constrictors.
In the hypopharynx, bolus flow
is deflected around the larynx by
the epiglottis, primarily laterally,
as the pharynx foreshortens to
engulf and draw the bolus distally.
In our setting, we have typically
described pharyngeal peristalsis,
subjectively, as “normal,” “incomplete,” “absent,” or “excessive.”
“Excessive” refers to either pharyngeal or tongue base behavior
that appears greater than usual.
We have observed this in situations where one structure or the
other, that is, tongue or pharynx,
is impaired, while the other seemingly attempts to compensate by
overacting. (See videos illustrating
normal and impaired pharyngeal
peristalsis on the companion website: Video 7–1, NrmPhPeristalsis;
Video 7–2, AbsInc-PhPeristalsis;
and Video 7–3, ExcPhPeristalsis.
Videos 7–1 to 7–3 have been reduced in speed in order to focus
on pharyngeal peristalsis. In Video
7–3, it is apparent that peristalsis is contributed to largely [and
to a greater extent than usual]
by the pharyngeal walls, with
the impaired tongue minimally
involved. The observed activity is
thus described as “excessive.”)
n
Finally, in our experience, patients
appear to use the mid-pharyngeal
deflecting structures, the valleculae/epiglottis, as a functional
valve, the opening and closing of
which can be controlled if need
be. Certainly, patients lacking the
means to control or even stop the
bolus at this point are severely
impaired. We have typically
described epiglottic behavior as
“normal,” “reduced,” or “absent.”
(See Video 7–4, AbsIncEpigInv on
the companion website illustrating the effect of absent or incomplete epiglottic inversion.)
As noted, we have found the perspective of the oral, pharyngeal, and laryngeal spaces as a series of chambers
and valves to be a useful model in the
assessment of fluoroscopic swallow
studies. What follows is a discussion of
our approach to analysis and interpretation using this model.
DSS Analysis: Bolus Transit Time
Versus Swallow Gesture Times
The goal of swallow gestures (movements of chamber and valve structures) is to move the bolus quickly and
completely from the mouth, through
the pharynx, and into the esophagus,
without leaks into the trachea or nasopharynx and without backflow into
the mouth from the pharynx or into
the pharynx from the esophagus. DSS
analysis in our setting considers timing
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