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DYSPHAGIA ASSESSMENT AND TREATMENT PLANNING: A TEAM APPROACH
or narrowing of the pharynx during the
swallow. The critical role of the contractile chamber walls against which the
piston must work should not escape
appreciation. When the role of lingual
retraction is limited because of anatomic or neurologic impairment, the
compensation provided by the pharyngeal constrictors can still result
in complete pharyngeal constriction.
From the fluoroscopic study, evidence
pertinent to both pharyngeal constriction and tongue movement is available. Measurement of pharyngeal area
represents a possibility for objectively
assessing this information in a manner
that considers all forces accomplishing
pharyngeal transit, not just the tongue.
The lateral view of the pharynx on
the swallow study is a two-dimensional
representation of a three-dimensional
space, and we often rely on the amount
of residual barium seen in the hypopharynx to define the size of the space
at maximum constriction. Despite these
limitations, we feel that the measures
provide a useful way to evaluate the
“piston” action of the tongue working
against the descending, peristaltic constriction of the pharyngeal walls. Pharyngeal area measures have the added
advantage of being relatively easy to
obtain in most subjects.
When poor pharyngeal constriction
is identified on the swallow study, a
loss of tongue mobility or bulk may be
the primary etiology. If tongue activity
appears normal, weakness of the pharyngeal constrictors (as is often seen in
stroke victims) may be the reason. The
result is usually persistent pharyngeal
residue. Patients will be at an increased
risk for aspiration of the residue when
the glottis reopens for respiration. Strategies such as the “double swallow” or
“effortful swallow,” directed at clearing
the residue before resuming respiration, may be recommended.
PES Distension
PESmax. The maximum opening of
the PES during a swallow, PESmax,
is measured (see Video 8–7, PESmax).
As discussed earlier for Pop–Pcl, PES
is defined as the narrowest point in
the opening between C3 and C6 (most
often, between C4 and C6) during the
swallow. Because efficient transfer of
the bolus into the esophagus is dependent on adequate PES opening, some
measure of PES opening is an obvious
choice for inclusion in any measurement battery. As discussed previously,
however, the actual location of the point
designated PES is arguable. By defining
the PES as the narrowest point between
C3 and C6, we were able to achieve an
r of 0.95 on this measure for normal
subjects.
A plot showing a complete set of timing, duration, and displacement data
for an individual patient matched in age
to normal subjects is presented in Figure 8–4. As noted, we do not routinely
extract all measures for all swallows on
our standardized assessment but rather
from the largest bolus swallowed and
from any bolus volume/consistency
that appears to differ from others in
terms of safety, effort, or efficiency.
Two Measures for Quantifying
Pharyngeal Residue
One of our ongoing goals is to develop
new objective measures that are relevant to describing impaired swallow
www
Figure 8–4. Plot displays
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objective data for patient
matched to normal
controls.
1.36
2.1
0.83
1.2
0.46
0.9
0.64
(mean+/-1s.d.)
0.93
NORMAL PATIENT
DURATION(secs)
PATIENT
NORMAL
(mean+/-1s.d.)
2
2.5
1.5
0.67
1
0.13
0.32
1
0
0.5
0.11
0.52
0.90
0.32
1.17
0.99
BOLUSTRANSIT/SWALLOWGESTURETIMES
NORMAL PATIENT
1.91
1.64
DISPLACEMENT(cm)
2.82
PATIENT:___________________
B1 AEstart H1 BV1BV2 AEclosePop BP1H2PES mHLH3PAmax PclBP2 EM
>65YRSFEMALES
2
2.5
1
1.5
SECS
0
0.5
-0.5
(mean+/-1s.d.)
4
3.5
1.8
0
1
2
3
2.5
0.5
1.5
165
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DYSPHAGIA ASSESSMENT AND TREATMENT PLANNING: A TEAM APPROACH
function in dysphagic patients. In some
cases, these have come about as a consequence of technology advances that
have made new measures not only
possible but also “doable” in an affordable, expedient manner. Two measures
that we have recently developed, and
for which preliminary reliability data
have been collected, are designed to
quantify bolus residue in the pharynx.
Residue, as noted often in this text and
by many other authors (Dejaeger et al.,
1997; Eisenhuber et al., 2002; Kelly et
al., 2008), represents a clear threat to
airway safety, yet our attempts to classify it have generally been subjective.
Newer methods that use quantitative
techniques have been described, primarily for bolus material in one location, and may require resources not
readily available in many clinical situations (Dyer et al., 2008; Molfenter &
Steele, 2013; Pearson et al., 2013).
One of the measures described here,
the bolus clearance ratio (BCR), can
quantify residue in a semiautomatic
fashion and is applicable for bolus
located in one site or multiple sites or
spread diffusely over pharyngeal structures. It can also be calculated for any
bolus volume or consistency. Bolus
material is first assessed for the frame
immediately prior to opening of the
PES, or upper esophageal sphincter.
Any residual bolus, or contrast material, is then remeasured immediately
after the swallow (frame just after PES
closure). Alternatively, the “postswallow” measure can be determined after
clearing swallows, collectively, or after
each clearing attempt. Measurement
of BCR is demonstrated on the com-
www
panion website (Video 8–8, BCR on the
companion website). In a recent study,
investigators determined BCR values in
553 children 0 to 21 years of age referred
for fluoroscopic swallow studies. Based
on binomial logistic regression analyses, the authors found that subjects
with a BCR greater than or equal to .01
were four times more likely to aspirate
(Dharmarathna et al., 2021). Such evidence suggests the measure may be
of particular value in a population for
whom limited radiation exposure is a
critical issue and in whom a uniform
protocol for conducting fluoroscopy
studies can be problematic.
In another investigation (Jardine
et al., 2020), BCR was calculated for
275 healthy individuals ranging in age
from 18 to 99 years. Though BCRs for
the group were generally low (<
.05, or
< 5% of the bolus), values were found
to be significantly elevated in older, as
compared to younger, subjects, suggesting changes in swallow structures
and function associated with normal
aging.
A second measure, the pharyngeal
residue ratio (PRR), is a ratio of bolus
postswallow to the area of the pharynx
with a 1-mL bolus held in the oral cavity
(i.e., PAhold), as previously described
for the calculation of the PCR. The PRR
measure (Figure 8–5) may be particularly useful when comparisons to anatomic variables, according to age or
gender, are desired. Though these measures are relatively new and their utility in studies of dysphagic patients still
under investigation, preliminary data
for their reliability have been reported
and are quite good (Leonard, 2017).
We are optimistic that future work will
improve and facilitate residue assessments for both clinical and research
purposes.
8. DYNAMIC SWALLOW STUDY: OBJECTIVE MEASURES AND NORMATIVE DATA IN ADULTS
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of the pharynx from the oropharynx to
the esophagus. A significant component
of this behavior, but one that is perhaps
not as apparent as the alternating constriction and relaxation of structures, is
the extent to which the pharynx actually shortens during the swallow. This
is illustrated in Video 8–9, BulletPharynx on the companion website. In the
video, a patient with a bullet fragment
lodged in the pharyngeal wall attempts
several swallows. The presence of the
bullet allows the viewer to appreciate the marked symmetry in elevation
A
and relaxation that occurs between
the bullet (and, thus, pharyngeal wall)
and both the hyoid and larynx. The
technique for measuring pharyngeal
shortening is illustrated in Video 8–10,
Pharyngeal Shortening Measure on the
companion website. We are currently
collecting normative data for this measure and believe they will contribute
significantly to our understanding of
the biomechanical characteristics of
normal and disordered swallow.
167
www
www
B
Figure 8–5. A. Denominator in pharyngeal
residue ratio (PRR) is the two-dimensional
area of the pharynx with a 1- mL bolus
held in the oral cavity. B. Numerator in PRR
is the area of contrast material remaining
in pharynx after swallow/closure of the
upper esophageal sphincter.
Pharyngeal Shortening
Another component of normal swallow for which normative data are currently being collected is the pharyngeal
shortening measure. Constriction of
the pharynx during swallow involves
the sequential opening and closing
Age, Gender, and Bolus Size/
Consistency Differences
for Spatial Measures
Several differences in variables for
which normative data are available
were identified for spatial measures.
Age differences were found for PESmax
and PCR; PESmax is reduced in the
elderly, and PCR is increased compared
with younger subjects (see Table8–1).
Hmax was reduced in elderly females
compared with younger females, but this
difference was not found for younger
and elderly males (see Table8–1). Gender differences were also identified as
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DYSPHAGIA ASSESSMENT AND TREATMENT PLANNING: A TEAM APPROACH
significant for all displacement measures, on all bolus sizes and consistencies
investigated, except for PESmax, which
did not differ significantly according
to gender on any bolus considered (see
Table 8–1).
Bolus size differences were noted
for all displacement measures except
maximum approximation of the larynx and hyoid during swallow (true
for all bolus sizes). One interpretation
of this finding is that hyoid-to-larynx
approximation (HL) may have more to
do with airway protection and maintaining a constant level of such during
swallow, as opposed to adjusting PES
opening size. PESmax did increase
with increasing bolus size, presumably
to accommodate the larger bolus size
or in response to changes in intrabolus
pressures. Increased PES opening with
increasing bolus size corresponds to an
increase in Hmax with increasing bolus
sizes (in both age groups and for both
males and females) and may reflect the
anterior traction on the PES by the forward movement of the hyoid, as well
as increased intrabolus pressures (see
Table 8–1).
CLINICAL IMPLICATIONS
OF IMPAIRED SPATIAL
DISPLACEMENTS
Impairments in spatial displacements
are an important reason for aspiration
and dysphagia in many patient populations. Their calculation can provide
excellent insights into causes of impairment, as well as therapeutic objectives
that might be considered. Our own
research, for example, has demonstrated the following:
n
In a study comparing normal sub-
jects, patients with nonobstructive
cricopharyngeal bars, patients
with obstructive cricopharyngeal
bars, and patients with Zenker’s
diverticuli, data suggested an
association between cricopharyngeus muscle dysfunction and progressive dilation and weakness of
the pharynx (Belafsky et al., 2010).
That is, PAhold increased with
increasing obstruction at the level
of the upper esophageal sphincter
(decreased PESmax). Our interpretation of this finding is that in
response to prolonged obstruction
at the upper esophageal sphincter,
the pharynx may dilate. If so, pharyngeal constriction and clearing
during swallow may be affected.
n
In a subsequent study, effects
of cricopharyngeal myotomy, a
surgical approach to modifying
obstruction at the PES, were considered for PES opening size, PCR,
and PAhold. PES max was improved (increased) and PCR was
reduced (also improved). PAhold,
however, did not change, suggesting that dilation of the pharynx associated with long-term
obstruction at the PES may be
permanent (Allen et al., 2010).
n
Domer et al. (2014) reported both
a significant decrease in PESmax and a significant increase in
PCR in patients with unilateral
vocal fold paralysis compared
with age- and gender-matched
normal control subjects. Patients
had experienced either idiopathic
or iatrogenic unilateral paralysis with accompanying dysphagia; 38% (of 25 patients) demon-
8. DYNAMIC SWALLOW STUDY: OBJECTIVE MEASURES AND NORMATIVE DATA IN ADULTS
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169
strated aspiration. Results suggest
that aspiration and dysphagia
in this population are not just a
consequence of impaired airway
protection.
n
Leonard and Belafsky (2011) re-
ported changes in various spatial
measures associated with cervical spine surgery and anterior
instrumentation. Measures in two
groups of patients, one <2 months
from surgery and one >2 months
from surgery, were compared
with those of normal control subjects (age and gender matched to
patients). PESmax was decreased
significantly in the early postsurgical group but was improved in
the late group. Other measures,
including thickness of the posterior pharyngeal wall that interfered with epiglottic inversion
and pharyngeal clearing, may
persist and contribute to patients’
continued complaints.
n
Increases in PCR appear to be a
near-hallmark feature of swallowing in patients with myotonic
muscular dystrophy (Leonard et
al., 2001). In some patients investigated, in fact, the pharyngeal
area when maximally constricted
(for a 20-mL bolus) was actually
larger than in the Hold position.
This suggests that pharyngeal
weakness associated with this disease may become so pronounced
that the presence of a large bolus
causes the pharynx to distend or
expand rather than constrict to
propel the bolus into the esophagus. In monitoring our myotonic
muscular dystrophy patients (and
others who demonstrate simi-
lar weakness), we pay particular
attention to this measure in counseling patients regarding a possible transition from oral to partial
or nonoral feeding.
n
PCR has been further shown to
be associated with aspiration in
a variety of patient populations
(Yip et al., 2006). Data from 260
sequential patients undergoing
DSSs were examined for those
who aspirated and those who did
not aspirate. Those patients who
did aspirate (on the largest bolus
swallowed) demonstrated a mean
PCR of 0.32 cm
2
, while those who
didn’t had a mean PCR of 0.20 cm
(both values were elevated compared with normal). Furthermore,
individuals with a PCR greater
than 0.25 cm
2
were three times
more likely to aspirate compared
with other patients. In evaluating
patients, we are seriously concerned about safe swallowing in
patients with PCRs of this value,
even when we do not observe
aspiration on the DSS.
n
In a later study, stroke patients
(CVA) who did and did not aspirate on the largest bolus swallowed on the DSS were considered
(Leonard, unpublished data). The
group consisted of 300 patients.
Patients with a PCR of 0.25 cm
were six times more likely to aspirate than those with values below
0.25 cm
n
PCR may be a useful surrogate
2
.
measure of pharyngeal strength.
In a comparison of maximum
pharyngeal pressures obtained
on manometry (PCP) and PCR
from a separate DSS in the same
2
2
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DYSPHAGIA ASSESSMENT AND TREATMENT PLANNING: A TEAM APPROACH
patients, a negative correlation of
−0.7 was found for the two measures (Leonard et al., 2006). Furthermore, only two patients with
a PCR significantly elevated from
normal (for age and gender) were
found to have maximum pharyngeal clearing pressures within the
normal range on manometry, and
pressures for these two patients
were very low: 60 and 61 mm
Hg, respectively. In a subsequent
study (Leonard et al., 2011), PCP
and PCR were investigated in
patients undergoing simultaneous fluoroscopy and manometry
studies. The correlation between
the two measures, for 25 patients,
was −0.72. Of particular interest,
no patient who had a normal PCR
had an abnormal PCP; further, no
patient with an abnormal PCR
(>.25 cm
2
) had normal PCPs (>60
mm Hg). These results support
our previous findings suggesting
the potential of an objective fluoroscopic measure to predict manometric measures when manometry is not available.
n
In an investigation of elderly
patients with no obvious medical
or surgical cause of their dysphagia (Kendall & Leonard, 2001),
74% of patients had an elevated
PCR. Elevated PCR was also
found to be a factor in 75% of
cases of aspiration identified in
this population. Interestingly, the
timing of maximum pharyngeal
constriction remained appropriately coordinated with the position of the bolus in the pharynx in
these same patients.
n
As noted previously, our com-
parison of younger and more
elderly nondysphagic individuals
revealed a substantial number of
elderly subjects with at least small
cricopharyngeal bars (31%) (Leonard et al., 2004b). Interestingly, no
bars were noted in our younger
group of subjects. Not surprisingly, PESmax was also reduced in
the elderly group compared with
the younger group. Evaluation of
elderly individuals should consider
the increased likelihood of asymptomatic cricopharyngeal bars.
n
In an investigation of factors af-
fecting pharyngeal constriction
in nonelderly and elderly normal
subjects, several findings were of
interest (Leonard et al., 2004a).
As described, PCR was elevated
in the elderly, compared with
younger subjects, suggesting a
reduced ability to constrict and
possibly clear the pharynx during swallow. In addition, the
two-dimensional pharyngeal area
measured in the Hold position
was larger in the elderly subjects,
as was the distance between the
larynx and the hyoid at Hold.
The distance from the hyoid to the
mandible did not differ between
groups; however, the distance
between the hyoid and larynx at
Hold was significantly greater in
the elderly subjects. A measure of
the anterior-posterior view of the
pharynx at Hold was also wider
in the elderly subjects. These data,
as well as additional information
we have obtained, suggest that the
pharynx in elderly subjects may
be larger, or longer, than that in
younger individuals. In addition,
the pharynx did not constrict as
completely, and the larynx did
8. DYNAMIC SWALLOW STUDY: OBJECTIVE MEASURES AND NORMATIVE DATA IN ADULTS
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171
not elevate to the same extent in
elderly subjects. These data comprise an important reference in
assessing swallow in elderly dysphagic patients and in differentiating normal from abnormal in
this group.
n
In an investigation of elderly nor-
mal and dysphagic subjects (Kendall & Leonard, 2001), hyoid dis-
placement was greater on smaller
bolus sizes in the elderly patient
group as compared to individuals without dysphagia. This was
interpreted as a possible compensation for the decreased hyoid
duration at maximum displacement noted in the patient group
and may represent a strategy that
can be used with other patients.
The observations reviewed here represent just a few that can be made when
large amounts of objective data become
available for patients representing different disorders. In short, the use of a
standardized DSS protocol and objective
measures enhance the power of fluoroscopy as a diagnostic tool, because it
n
permits us to compare our patients
to normal subjects according to
age and gender;
n
provides an objective means of
tracking changes in patients across
time and treatments;
n
supplies us with a basis for char-
acterizing dysphagia in unique
patient populations;
n
allows us to go beyond the deter-
mination of aspiration versus no
aspiration, or appropriate dietary
recommendations; to understand
the biomechanical deviations
from normal deglutition that con-
tribute to the dysphagia and how
these present a risk to patients
outside the environment of the
DSS evaluation;
n
reveals information that, increas-
ingly, we are finding can be related
to other instrumental measures of
swallow function; and
n
is now, in our practice, a part of
the repertoire of diagnostic tests
routinely ordered by many physician specialists charged with
evaluating and treating dysphagic
patients.
STUDY QUESTIONS
1. Which structural displacements
during swallowing differ in younger
and older individuals? According
to gender?
2. Describe at least one relationship
between bolus transit and swallow
gesture times that may be of particular value in evaluating some
patients.
3. Do pharyngeal transit times differ
according to age and/or gender?
4. What subjective impressions from
fluoroscopy studies have demonstrated reasonable interjudge
reliability?
5. Define bolus transit at B1, BV1,
BV2, BP1, and BP2.
6. Why was the “hold” position selected as a referent for measures
of structural displacements (compared with a “rest” position)?
7. What are some problems in using the
angle of the mandible as a marker
for the onset of bolus transit?
8. What is the advantage of tracking
bolus transit times separately from
swallow gesture times?
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DYSPHAGIA ASSESSMENT AND TREATMENT PLANNING: A TEAM APPROACH
9. What relationships between swallow gestures, or between swallow
gestures and bolus transit, appear
to be invariant in both younger and
older normal individuals?
10. The measure of pharyngeal constriction, PCR, may be a reasonable
surrogate for what other instrumental measure?
11.
What was unique about PES open-
ing in the normal elderly population described?
What evidence from fluoroscopy
12.
indicates differences in swallowing
mechanics according to age?
13. Is there evidence to suggest that
understanding swallow mechanics
may help us predict aspiration?
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