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DYSPHAGIA ASSESSMENT AND TREATMENT PLANNING: A TEAM APPROACH
Hypopharynx: Valving.
The epiglottic, laryngeal, and pharyngoesophageal valves of the hypopharynx divert
the bolus away from the airway and
draw it into the esophagus. Failure of
adequate opening of the pharynx at the
epiglottis and PES will slow bolus flow
and may prevent complete bolus clearing. Inadequate PES closure increases
potential for backflow of material in
the esophagus (either a just-swallowed
bolus or material refluxed from the
stomach). Inadequate supraglottic closure is associated with supraglottic residue. Of course, inadequate glottic or
supraglottic valving increases the likelihood of aspiration. (As discussed previously, the epiglottis with its surrounding pharyngeal walls diverts, controls,
and at times prevents transfer of the
bolus into the hypopharynx. Please see
that discussion.)
Hypopharynx: Laryngeal Valve:
Supraglottic and glottic laryngeal valving
provide primary defense for the trachea
and lungs. Compared with other valves
involved in swallow, this valve differs
markedly in complexity and behavioral capabilities. Competence of the
laryngeal valve for swallow requires,
in addition to range, agility, and coordination of movement, intact sensation
and ability to respond to stimulation
protectively, even proactively, to anticipate a threatening situation. Laryngeal
closure adequate to withstand bolus
pressures during swallow depends on
sensory as well as motor competence.
Laryngeal reopening and maintenance
of a sufficient laryngeal airway are
required for oral nutrition/hydration.
Analysis: Supraglottic penetration (contrast material that stays above the glot-
tis) is judged to be abnormal when it is
frequent and/or is not ejected during
the swallow.
Aspiration during fluoroscopy is
defined as contrast material that passes
into and through the glottis. By far the
most helpful construct for describing
aspiration timing is that developed by
Logemann (1983, p. 65). In our experience, however, rather than referencing
aspiration timing relative to “the swallow” or triggering of the swallow reflex,
we have found it more useful to specify
aspiration timing relative to achievement of laryngeal closure, as observed
fluoroscopically (in lateral view, laryngeal closure is inferred from contact
between the downfolding epiglottis
and rising, anterior movements of the
arytenoids), once the bolus has entered
the pharynx (regardless of other swallow gestures). Logemann’s description,
with this modification, is as follows:
n
Aspiration before laryngeal clo-
sure for swallow, that is, after
the bolus has entered the pharynx and before approximation of
the epiglottis and arytenoids (as
observed on lateral view fluoroscopy) is complete (see example in
Video 7–7, ASPBefore on the companion website).
n
Aspiration during maximum (but
inadequate) laryngeal closure for
swallow, that is, epiglottis and
arytenoids may approximate, but
closure is not sufficient to prevent
aspiration (see example in Video
7–8, ASPDuring on the companion website).
n
Aspiration after or between swallows,
following reopening for respiration
(see example in Video7–9, ASPAfter
on the companion website).
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Interpretation: Aspiration prior to laryngeal closure for swallow is considered
a failure of timing most often associated with abnormalities of other swallow events, among them (a) inadequate
control of the bolus, (b) inability to
coordinate onset of pharyngeal gestures with onset of pharyngeal transit
due to movement or sensory deficits, or
(c) structural deficits that direct bolus
flow toward, instead of away from, the
larynx (such as poor epiglottic protection). Cognitive deficits (poor attention,
distractibility, difficulty suppressing
other behaviors) and unstable head/
neck posture make aspiration prior to
laryngeal closure more likely as well.
The longer the bolus takes to traverse
the pharynx, the more likely it will be
aspirated. In patients after cerebrovascular accident, prolonged pharyngeal
transit has been shown to increase the
risk of developing aspiration pneumonia, even if aspiration is not detected dur-
ing the fluoroscopy (Johnson et al., 1993).
Risk of aspiration during the DSS,
as noted earlier, also increases when
closure is not coordinated with bolus
arrival in the PES.
Aspiration during laryngeal closure
for swallow is due to incompetent
laryngeal valving and may only become
apparent when the maximally closed
valve is exposed to pressure from the
bolus as it passes the aditus. Thus, if
it is judged unsafe to swallow a large
liquid contrast bolus during fluoroscopy, this valve cannot be completely
evaluated. Aspiration during laryngeal
closure is, of course, more likely when
both supraglottic and glottic closure is
incompetent. The observation of aspiration during the swallow should be consistent with the findings of voice evaluation, patient complaint, and feeding,
especially drinking history. Management of patients with laryngeal dysfunction is directed by the ENT physician. If incompetent laryngeal valving
is suspected, referral should be made
immediately.
Aspiration after the swallow is
always of oropharyngeal or hypopharyngeal residue, that is, a consequence
of inadequate pharyngeal clearing (discussed in previous sections). Table 7–1
provides subjective impressions routinely recorded in our setting.
Hypopharynx: PES Valve:
The PES valve
opens to draw the bolus into the esophagus, expands depending on bolus size,
and then closes, preventing backflow of
bolus material into the pharynx from
the esophagus. Between swallows, the
PES remains closed to prevent any gastroesophageal reflux (GER) from reaching the airway. During DSS, questions
most often arise regarding timing and
extent of PES opening. Occasionally,
PES closure is inadequate.
Analysis:
Determination of PES opening abnormality is not always clear.
Prominence of the PES on fluoroscopy
(cricopharyngeal bar) does not necessarily mean opening is restricted.
Atrophy of the pharyngeal wall just
above the PES complicates interpretation by making the PES appear more
prominent. In addition, PES opening
is volume dependent, that is, increases
with size of the bolus (see Chapter 8).
Consequently, if concerns about swallow safety do not permit swallow of a
large liquid bolus, the PES may not be
thoroughly evaluated. In addition, the
standard deviation for normal opening
extent is large. Thus, measurement of
the PES in both AP and lateral views
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DYSPHAGIA ASSESSMENT AND TREATMENT PLANNING: A TEAM APPROACH
Table 7–1. Subjective Impressions From Fluoroscopy
Site of Aspiration
Relative to
Airway Closure
Epiglottic
Inversion
Pharyngeal
Peristalsis
Before — Aspiration that occurs prior to maximum closure of
the airway (may be indicative of poor oral control, reduced
sensation, or delayed response to material entering the
pharyngeal airway).
During — Aspiration that occurs during the time when the
airway appears to be maximally closed for swallow (reflects a
problem with airway protection, e.g., vocal fold paralysis).
After
— Aspiration that occurs after the airway has relaxed after
a swallow (typically related to residue that fails to clear).
Normal
bolus transfer to pharynx.
Incomplete — Inversion occurs but is incomplete, often with
contrast material retained in the vallecula.
Absent — No evidence of epiglottic inversion during swallow.
Normal
superior to inferior pharynx.
Incomplete — Lacks either contact between tongue and
pharynx, or achieves contact at some point but without
normal peristaltic action.
Absent
of tongue–pharynx contact and peristalsis.
Excessive — reflects peristalsis with excessive pharyngeal or
tongue movement, typically in response to weakness in the
other structure.
— Epiglottis inverts completely, without interrupting
— Is within normal limits in extent and is sequential from
— Minimally apparent or completely absent evidence
Evidence of
Caution/
Compensation
increases confidence in identifying
restriction. Consequences of obstruction (proximal dilation and backflow)
may help to confirm poor PES opening in the absence of other obstruction.
Abnormal timing of PES opening cannot be determined without measurement and comparison to other timing
measures. For example, PES opening
that appears delayed relative to bolus
arrival in the hypopharynx may be normally timed relative to other swallow
gestures. In this case, then, arrival of
Early hyoid elevation, tongue retraction, airway closure
behaviors that suggest patient may be fearful or attempting
to compensate for difficulty (chin tuck, for example).
—
the bolus may be early (due perhaps to
poor control) rather than PES opening
being late.
Determination of PES closure abnormality is clear: Contrast should be
entirely cleared from the walls of the
PES once the swallow is complete.
Interpretation: Abnormal PES opening
extent may not be due to failure to relax
or structural abnormalities of the PES
but to inadequate movement of structures that pull the relaxed PES open
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137
(hyoid and laryngeal displacements)
or propel the bolus through the PES
(tongue and pharyngeal walls). (Please
see previous discussions of these components.) If these components are
normal, structural or neuromuscular
aspects of PES function are implicated.
If the PES is indeed obstructive, consistencies should be found in detailed
patient complaint and dietary history
(e.g., smaller amounts easier to swallow, extreme caution and careful chewing required for solid materials). Unexplained PES obstruction in patients is
frequently attributed to chronic GER.
Often, this will present as a “cricopharyngeal bar” on fluoroscopy (see Chapter 5).
The finding of abnormal PES closure
should correlate with neurological, surgical, or radiation therapy history.
Esophagus: AP Screen. For those
who can manage a large bolus volume and who are not scheduled for
an esophagram, we would typically
conclude the DSS with an AP screen of
the esophagus. For this portion of the
DSS, the patient, standing upright, is
given a large liquid bolus, 20 to 30 mL,
followed by a tablet or capsule. If the
patient describes difficulty with one or
the other, tablet or capsule, this information would determine which is used.
Movement of each bolus is tracked
from the upper esophageal sphincter
to the lower esophageal sphincter and
clearance into the stomach.
Involving only two additional swallows, the large liquid bolus and a tablet or pill, the AP screen (see Chapter5)
can prove quite useful in identifying
either motility or structural abnormalities. Though it certainly does not
simulate or replace an esophagram,
findings may generate information
that can be used by the observing or
referring physician to generate appropriate additional referrals for the
patient, including an esophagram. In
our clinical setting, evidence of a motility abnormality may generate a referral for manometry, while evidence of
a structural abnormality would likely
result in a referral for a transnasal
esophagoscopy (described in Chapter9). The advantage of both manometry and transnasal esophagoscopy is
that, unlike an esophagram, they do not
require exposure to radiation. In addition, both are powerful diagnostic tests
and may be recommended following
a full esophagram for further elaboration of a motility or structural abnormality. Examples of both motility and
structural abnormalities observed in an
AP view are presented in videos on the
companion website for this chapter, as
well as in media accompanying Chapter 15. Included here are examples of:
n
diffuse esophageal spasm (Video
7–10, DiffuseEsophSpasm)
— dyscoordination in esophageal contractions;
n
esophageal stricture (Figure 7–2)
— narrowing of esophageal lumen;
and
n
stasis (Video 7–11, Stasis) — mate-
rial that adheres to esophageal tissue and is generally visible after
the bulk of material has been transported through the esophagus.
REPRISE
Accurate analysis of swallow function
during fluoroscopic studies like DSS
is dependent on detailed knowledge
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www
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DYSPHAGIA ASSESSMENT AND TREATMENT PLANNING: A TEAM APPROACH
Figure 7–2. Esophageal stricture, narrowing of esophageal lumen apparent in antero-
posterior esophageal screen.
of the biomechanical relationships
between normal swallow events, as
well as the ability to distinguish normal from abnormal behaviors despite
the variability associated with different
swallow tasks and multiple additional
influences on swallow performance. As
noted repeatedly, accurate assessment
is also best guided by prior knowledge
of performance on speech, feeding, and
voice evaluations; detailed patient complaint; and a complex array of histories
(neurological, developmental, dietary,
medical, and surgical among them) that
are particular to an individual patient.
This requires the clinician to have a
working knowledge of what the potential impacts of various diagnoses and
conditions might be on swallow and
on the appropriate direction of the fluoroscopic study. Other differences that
may appear to reflect impairment may
actually reflect differences associated
with normal aging. Reduced PES opening and pharyngeal constriction during swallowing, as well as prolonged
swallow times, have been reported by
us and other investigators and require
additional understanding by clinicians
involved in fluoroscopic evaluations
(Kendall et al., 2004; Kendall & Leonard, 2002; Leonard et al., 2004a, 2004b;
see Chapter 8).
Interpretation, or derivation of
meaning and implications from analysis, is the process of correlating fluoroscopic observations with what is known
about the individual patient from historical review, interview, and clinical
performances and then ferreting out
consistencies and inconsistencies, both
of which will guide recommendations
and interventions. If consistencies are
not identified, analysis may suggest
additional investigation. Accurate
interpretation of fluoroscopic swallow
studies like the DSS cannot be achieved
in isolation but lean heavily on awareness of the roles and interests of a variety of medical specialties and interaction with those professionals.
Most important for the patient,
accurate analysis and interpretation of
fluoroscopic swallow studies improve
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139
efficacy of dysphagia management by
improving specificity of intervention.
We would encourage readers to go back
to review Chapters 6 and 7 following
reading of Chapter 8 and investigation
of measurement strategies. Hopefully,
the combination of materials will provide a more complete understanding
of both normal swallow and how it can
best be assessed fluoroscopically.
STUDY QUESTIONS
1. Which “chamber” represents the
greatest airway threat? Why?
2. What “valves” are critical to swallow function? How?
3. Can you characterize differences in
aspiration depending on where it
occurs relative to maximum airway
closure?
4. How is pharyngeal “peristalsis” different from pharyngeal “constriction”? Or, are they the same?
5. What might be an advantage of
an AP screen of the esophagus, as
opposed to a complete diagnostic
6. What is the role of the epiglottis
during swallowing? What are possible consequences of impaired epiglottic function?
7. Describe three ways that pharyngeal abnormalities may contribute
to dysphagia.
8. Is there an advantage to tracking
bolus transit separately from swallow gestures? Explain.
9. In assessing PES function, what
other structural variables are important to consider?
10. How is “airway closure” assessed
in lateral-view fluoroscopy?
REFERENCES
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.
Fant, G. (1970). Acoustic theory of speech pro-
duction. Mouton.
Fant, G. (1980). The relations between area
functions and the acoustic signal. Pho-
netica, 37, 55–86.
Fink, B. R., & Demarest, R. J. (1978). Laryngeal
biomechanics. Harvard University Press.
Flanagan, J. (1972). Speech analysis, synthesis,
and perception. Springer-Verlag.
Johnson, E. R., McKenzie, S. W., & Siev-
ers, A. (1993). Aspiration pneumonia in
stroke. Archives of Physical Medicine and
Rehabilitation, 74, 665.
Kendall, K. A., & Leonard, R. J. (2002).
Videofluoroscopic 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. G., & Kent, R. D. (1985). Anat-
omy and physiology of deglutition and
related functions. Seminars in Speech and
Language, 6, 257–272.
Leonard, R. (2017). Two methods for quanti-
fying pharyngeal residue on fluoroscopic
swallow studies: Reliability assessment.
Annals of Otolaryngology and Rhinology,
4(3), 1158–1163.
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.
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DYSPHAGIA ASSESSMENT AND TREATMENT PLANNING: A TEAM APPROACH
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). The evaluation and treat-
ment of swallowing disorders. College-Hill
Press.
Martin-Harris, B., Michel, Y., & Castell,
D. O. (2005). Physiologic model of oropharyngeal swallowing revisited. Oto-
laryngology-Head and Neck Surgery, 133,
234–240.
Dynamic Swallow Study:
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Objective Measures and
Normative Data in Adults
Rebecca Leonard
THE PATH TO OBJECTIVE
MEASURES
Our interest in making objective measures started at about the same time our
team began meeting weekly to discuss
patients. In reviewing their dynamic
swallow studies, it became apparent that
we sometimes disagreed about what
we were seeing, even when we watched
a recording repeatedly and in slow
motion. In general, and consistent with
many subsequent literature reports
(Ekberg et al., 1988; Gibson & Phyland,
1995; Karnell & Rogus, 2005; Kuhlemeier et al., 1998; McCullough et al.,
2001; Perlman et al., 1994; Scott et al.,
1998), we were usually in agreement
for binary observations — for example,
whether or not there was aspiration,
penetration, velopharyngeal reflux, or
significant postswallow residue. Swallows that appeared greatly prolonged
typically produced consensus as well.
Times that were possibly prolonged, on
the other hand, were problematic. For
other observations
hyoid moved, the pharynx constricted, or
the pharyngoesophageal segment (PES)
opened — our judgments frequently differed. Beyond our problems with subjective reliability, and in fact even when
we did agree, there was a strong feeling
within our team that without objective
information, our impressions and recommendations lacked credibility.
In the interest of harmony, improved
objectivity, and enhanced credibility, we
searched available resources for information that would lead to improved
assessments. We had been performing
fluoroscopy studies in our craniofacial
— how normally the
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DYSPHAGIA ASSESSMENT AND TREATMENT PLANNING: A TEAM APPROACH
anomaly patients and had referred frequently to the cephalometric literature
for help in evaluating velopharyngeal
function in a quantitative manner. With
the fluoroscopic evaluation of swallow
introduced by Logemann and her colleagues (Blonsky et al., 1975; Logemann,
1983; Logemann et al., 1977), we recognized that it also lent itself to quantitative analysis. We adopted Logemann’s
recommended protocol with its emphasis on standardization and have been
employing it, with a few additions
and alterations, ever since. Apart from
some work on timing, however, which
began to emerge in the 1980s, quantitative guidelines pertinent to swallowing
were slow to emerge. Although limited,
the data available were quite useful;
very quickly, we added timing information to our studies.
Initially, we used conventions described by Logemann (1983) for measuring transit times, but the parameters she
was using were not always present or
identifiable in our studies. For example,
the faucial pillars were not easily visualized, and neither the angle of the mandible nor the faucial pillars were always
present in patients who had undergone
head and neck resections. In time, we
modified our scheme to facilitate measurement, in particular, in our large head
and neck population. Our first effort to
collect normative timing data was in a
group of 16 adults who were undergoing
upper gastrointestinal (GI) studies for
distal esophageal GI complaints (unpublished data, 1988; Johnson & McKenzie,
1993). The resulting data were consistent with those reported by other investigators (Cook et al., 1989; Curtis et al.,
1984; McConnel, 1988a, 1988b), and our
standard deviations were small, which
encouraged us to move forward.
Soon after adding timing information
to our studies, we explored possibilities for displacement measures. When
several members of our own team, as
well as outsiders recruited for the task,
made measurements that demonstrated
good inter- and intrarater reliability, we
again felt we were moving in the right
direction. As always, we incorporated
measurements into routine patient
assessments, and our measurement
techniques reflect this perspective. Our
confidence improved further when our
data appeared comparable to values
reported by other investigators using
different techniques (Dantas et al., 1990;
Dejaeger et al.,1997; Dodds et al., 1988;
Ekberg, 1988; Jacob et al., 1989; Kahrilas
et al., 1988; Scott et al., 1998).
Normative Data
Ultimately, we collected additional normative data, using the same equipment
and measurement strategies we used for
patients. In time, we performed fluoroscopy studies on large groups of younger
and more elderly normal subjects,
respectively (Kendall, 2002; Kendall &
Leonard, 2001; Kendall et al., 2000, 2001,
2003, 2004a, 2004b; Leonard et al., 2000).
As a team, we were now able to use our
measurement scheme to compare patient
data to nondysphagic subjects according
to age and gender. Observations from
these studies also provided us with a
much better idea about normal variability and the range of behaviors, both
times and displacements, which characterize normal swallow. Normative data
are presented in Table 8–1 for the measures we obtained for adults younger
than 65 years of age and a more elderly
population of adults over 65 years.
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>5 sec = 90%
2–3 sec = 33%
±1.9 12.6±2.1
(M)(F)
± I5.1 mm ± I3.6 mm
3–5 sec = 48%
<65>65 >65+bar
<65 >65
Morphometryofthe Cartilaginous
Larynx (mm)
Cric 24.6±1.9 21.6±1.5
(M)3.79(.54) 4.20 (.74)
(F)2.95(.59) 3.36 (.55)
(M)2.67(.8)2.68(.62) 2.63 (.84)
(F)1.86(.53) 2.02 (.68) 2.08 (.53)
Aryt 16.6
Total=41.2mm 34.2mm
Sprinzl GM,et al. Head &Neck, December (1999).
Increasedaspirationpneumonia risk
post CVA
Hyoidtomandible @baseline(cm)
Hyoidtolarynx@baseline (cm)
NORMAL DISPLACEMENT mean with 2SD
Table 8 –1. Normative Values for Timing, Duration, and Displacement Measures for Subjects Under and Over Age 65 Years
<AGE 65 yrs>AGE65yrs
Hmax+HL(M) 3.33 1.86 3.72 1.82 Hmax+HL(M) 4.06 .98
Pam/Pah (F) .02.03 .02.04 .03.06 Pam/Pah (F) .02.06 .07.15 .14.28
Pam/Pah (M) .02.04 .04.05 .06.12 Pam/Pah (M) .02.04 .03.04 .13.28
Pamax (F) .10.18 .12.23 .17.33 Pamax (F) .25.46 .521.041.383.33
Pamax (M) .13.22 .24.36 .2838 Pamax (M) .24.49 .35.46 .901.06
PESmax .39.38 .51.30 .90.55 PESmax .37.34 .50.37 .80.40
HL (F) 1.10 1.48 1.08 1.17 1.07 1.10 HL (F) 1.27 .871.241.2 1.23 1.30
HL (M) 1.33 .921.301.081.25.83 HL (M) 1.50 .681.711.431.581.35
Hmax (F) 1.39 1.00 1.62 1.12 1.81 1.46 Hmax (F) 1.63 1.06 1.79 1.54 2.07 .45
Hmax (M) 2.00 1.42 2.12 1.38 2.41.36 Hmax (M) 1.98 1.41 2.08 1.62 2.48 2.04
MEASURE (cm) 1CC3CC 20 CC MEASURE(cm)1CC 3CC20CC
PA HOLD(M) 7.9 (4.2) (F) 6.5(3.4) PA HOLD(M) 11.4(6.0) (F) 8.09 (4.0)
Hmax+HL(F) 2.49 1.72.88.86 Hmax+HL(F) 3.30 .55
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