Bedside Swallow Evaluation Research Articles

Approach to obtaining a swallow study in a five-year-old with a disability and significant procedural anxiety: A case report.

A five-year-old male with spastic quadriplegia cerebral palsy and an expressive communication disorder presented because the family desired liberalization of diet. The diet consisted of pureed solids and no liquids due to deficits identified on bedside swallow evaluation; further dysphagia assessment had not been obtained due to significant procedural anxiety. Comprehensive approaches were taken involving premedication with buspirone, desensitization, distraction, and positive reinforcement. The fluoroscopic swallow study was successfully completed, and the patient's diet was upgraded to include moderately thickened liquids. Procedural anxiety management in special populations is not well-researched. The lack of definitive recommendations regarding these issues increases the difficulty of managing these patients. This case highlights one successful approach to addressing individual needs using widely-available pharmacologic and environmental techniques. Additionally, this case reinforces the need to identify underlying causes for procedural anxiety and involve an interdisciplinary team. Attempts should be made to identify factors driving procedural anxiety. After discussing with the patient and family, relevant information should be relayed to staff with an open-ended invitation to propose ideas. While not all hospitals have equivalent resources, concerns related to unfamiliarity, underlying anxiety, and locus of control can be addressed with limited resource utilization, as demonstrated in this case.

Acoustic Screening of the "Wet voice": Proof of Concept in an ex vivo Canine Laryngeal Model.

Current protocols for bedside swallow evaluation have high rates of false negative results. Though experts are not consistently able to screen for aspiration risk by assessing vocal quality, there is emerging evidence that vocal acoustic parameters are significantly different in patients at risk of aspiration. Herein, we aimed to determine whether the presence of material on the vocal folds in an excised canine laryngeal model may have an impact on acoustic and aerodynamic measures. Two ex vivo canine larynges were tested. Three liquids of different viscosities (1:100 diluted glycerin, pure glycerin, and honey-thick Varibar) were placed on the vocal folds at a constant volume. Acoustic and aerodynamic measures were obtained in both adducted and abducted vocal fold configurations. Intraglottal high-speed imaging was used to approximate the maximum divergence angle of the larynges in the studied conditions and examine its relationship to vocal efficiency (VE) and acoustic measures. In glottic insufficiency conditions only, we found that several acoustic parameters could predict the presence of material on the vocal folds. Based on the combination of the aerodynamic and acoustic data, we found that decreased spectral energy in the higher harmonics was associated with decreased VE in the presence of material on the vocal folds and/or glottic insufficiency. Decreased spectral energy in the higher harmonics of the voice was found to be a potential biomarker of swallowing dysfunction, as it correlates with decreased vocal efficiency due to material on the vocal folds and/or glottic insufficiency, both of which are known risk factors for aspiration. NA Laryngoscope, 133:2517-2524, 2023.

S2315 Epiglottic Calcification, a Rare a Cause of Dysphagia

Introduction: In consideration of dysphagia, most cases predominate in the oropharyngeal region with the remainder caused primarily by esophageal causes. Lesser known and studied is the development of dysphagia and globus sensation from epiglottic pathology, namely epiglottic calcification. With less than a dozen published cases in literature, very little data exists on identification, diagnosis, and treatment of this known cause of morbidity. Here we present a case of oropharyngeal dysphagia arising from a rare cause, epiglottic calcification. Case Description/Methods: An 81-year-old male with history of aortic stenosis and carotid artery stenosis presented with worsening dysphagia over the course of one month. The patient reported significant dysphagia initially to solids and subsequently to liquids causing a weight loss of over 50 pounds. Physical exam of oropharynx and neck was unremarkable. Bedside swallow evaluation suggested mildly decreased hyolaryngeal movement, but no other significant abnormalities were identified. A Barium swallow study revealed incomplete epiglottic excursion during the pharyngeal phase of swallowing. With gastroenterology consultation, patient underwent evaluation with contrast-enhanced esophagogram that showed severe esophageal dysmotility and reflux. CT of neck demonstrated calcification of epiglottis without epiglottal enlargement, which was ultimately found to be the source of his concern. Via ENT, the patient underwent flexible fiberoptic laryngoscopy, and via gastroenterology, patient underwent EGD with biopsy. Yet, no esophageal or gastric pathology other than epiglottic calcification were identified. As no definitive treatment modality was outlined despite evaluation, patient was changed to a modified diet with ongoing speech and swallow therapy with outpatient follow up (Figure). Discussion: Epiglottic calcification is a rare cause of dysphagia that is poorly understood in its etiology, clinical course and outcomes. With our case, we hope to add to literature a unique presentation and imaging. Furthermore, with our case it is demonstrated that despite consultant recommendations, no clear evaluation process or treatment modality currently exists, lending to further study of this pathology. Currently, diagnosis can be accomplished with radiologic evaluation along with exclusion of other causes; however, no definitive treatments are available for this condition. Although the condition itself is rare, it adds to the differential diagnosis as a cause of significant dysphagia.Figure 1.: Calcification of epiglottis (red arrow) visualized on CT scan.

September 2022 Medical Image of the Month: Epiglottic Calcification

No abstract available. Manuscript truncated after 150 words. In consideration of dysphagia, most cases predominate in the oropharyngeal region with the remainder caused primary by esophageal causes. Lesser known and studied is the development of dysphagia and globus sensation from epiglottic pathology, namely epiglottic calcification. With less than a dozen published cases in literature, very little data exists on identification, diagnosis, and treatment of this known cause of morbidity. Here we present a case of oropharyngeal dysphagia arising from a rare cause, epiglottic calcification. An 81-year-old man with a history of aortic stenosis and carotid artery stenosis presented with worsening dysphagia over the course of one month. The patient reported significant dysphagia, initially to solids and subsequently to liquids causing a weight loss of over 50 pounds. Physical exam of the oropharynx and neck were unremarkable. A bedside swallow evaluation suggested mildly decreased hyolaryngeal movement, but no other significant abnormalities. A barium swallow study revealed incomplete epiglottic excursion …

Dysphagia Profiles Among Inpatients with Dementia Referred for Swallow Evaluation.

Background:Alzheimer’s disease and related dementias (ADRD) patients who are hospitalized often develop oropharyngeal dysphagia, increasing risk for adverse outcomes, such as aspiration pneumonia. However, prevalence estimates of dysphagia are highly variable and often based on patient report or clinical testing rather than visualization of the swallow.Objective:The aims of this study were to determine prevalence and severity of dysphagia among inpatients with ADRD referred for swallowing evaluation.Methods:Electronic health record (EHR) abstraction of ADRD diagnosis and presence and severity of clinically-determined dysphagia on bedside swallow evaluation (BSE) and videofluoroscopic swallow study (VFSS).Results:16% (n = 268) had an ADRD diagnosis or were taking dementia-specific medication based on the EHR. 75% (n = 202) were diagnosed with dysphagia on the BSE. 60% subsequently underwent VFSS (n = 122) with dysphagia confirmation in 92% (n = 112). ADRD inpatients were significantly more likely to be diagnosed with dysphagia based on the BSE (p < 0.0001) than those without ADRD. Additionally, dysphagia on the VFSS was more severe in the ADRD group (p < 0.03).Discussion:ADRD individuals may be vulnerable to developing or worsening dysphagia during hospitalization. Results underscore the importance of evaluating swallowing function in hospitalized patients with ADRD in order to facilitate targeted intervention.

Pharyngeal Dysphagia in Individuals With Cervical Spinal Cord Injury: A Prospective Observational Cohort Study.

Objectives: To identify and describe the types and time course of dysphagia following cervical spinal cord injury (SCI). Methods: This was a prospective cohort study conducted in an SCI inpatient rehabilitation unit. Seventy-six individuals with SCI were enrolled. Inclusion criteria were age 18 years or older, admitted into SCI inpatient rehabilitation unit, and medically stable for participation in bedside swallow evaluation (BSE) and videofluoroscopic swallow study (VFSS). All participants first underwent a BSE, of whom 33 completed a VFSS. A follow-up BSE was conducted on individuals who tested positive on the initial BSE and continued to show signs of dysphagia. Diagnosis and type of dysphagia as well risk factors were collected. Results: Twenty-three out of 76 individuals with cervical SCI were diagnosed with dysphagia using the BSE. All participants with positive BSE and VFSS had pharyngeal dysfunction. For participants with a positive initial BSE and persisting dysphagia (n = 14), a follow-up BSE demonstrated resolution within 34 days. Risk factors associated with dysphagia were older age, nasogastric tube, invasive mechanical ventilation, tracheostomy, and pneumonia. Posterior spinal surgery was associated with a decreased risk of dysphagia. Conclusion: Dysphagia was present in 30% of individuals based on the initial BSE. All individuals with dysphagia demonstrated pharyngeal phase dysfunction on the VFSS. No participants experiencing dysphagia were missed on the BSE as confirmed by VFSS. In the subset of individuals who received a follow-up BSE, the time course of resolution of dysphagia was at most 34 days from initial BSE.

Abstract WP313: Stroke Patient Characteristics Have Minimal Impact on Reliability of Teleswallow Evaluation

Purpose: To evaluate patient characteristics that may lead to inappropriate dietary texture recommendations by Teleswallow evaluation by Speech Language Pathologists (SLPs). Background: Following stroke, screening for dysphagia using a swallow evaluation is essential for patient safety. Liquid and solid diet recommendations are given per our standardized four-level scale, ranging from nothing by mouth (NPO) to regular for solid and thin for liquid. We have previously shown good agreement between tele- and bedside swallow evaluation by SLPs, for both liquid and solid dietary textures. In this study, we sought to determine whether patient characteristics account for slight differences in inter-rater reliability. Methods: Kendall’s tau-b and Wilcoxon Signed Rank test for related samples were used to look for significant differences between teleswallow and bedside swallow recommendations for patients with left and right stroke locations or varying levels of stroke severity measured by NIHSS. Evaluations for robot vs bedside swallow screens were categorized as in “agreement” or “disagreement”. Logistic regressions, with age and gender added as covariates, were then used to test the effects of NIHSS and stroke location on the odds of agreement of teleswallow and bedside swallow recommendations. Results: One hundred stroke patients received both evaluations with median 42.0 minutes between evaluations. The average patient age was 67.7 (±14.4) and 50% were female. Median NIHSS score was 4 (interquartile range (IQR) = 7), and 53% (n = 48) of patients had left-brain strokes and 47% (n = 42) had right-brain strokes. Our analysis showed no significant differences between recommendations for stroke location, for either liquid or solid textures. There was also no significant impact on the odds of agreement based on severity, by NIHSS score, for solid textures. However, the odds of agreement between recommendations for liquid textures were 13% less per NIHSS point (OR = 0.876, 95% CI 0.772 - 0.993, p = 0.04). Conclusion: Stroke severity had a small impact on the agreement between teleswallow and bedside recommendations for liquid, but not solid, diet textures.

The diagnostic test accuracy of clinical swallow assessment for oropharyngeal aspiration: a systematic review

Review question/objective The objective of this systematic review is to synthesise the best available evidence on the diagnostic test accuracy (sensitivity and specificity) of Clinical Swallow Assessment (CSA) compared with Video Fluoroscopic Swallow Study (VFSS) in diagnosing oropharyngeal aspiration in children and adults with dysphagia. In this review, VFSS will be the 'Gold Standard' or, reference test and CSA will be the index test. VFSS is the radiographic assessment of swallow function usually performed by a Speech Pathologist and Radiologist. CSA is defined as a non-invasive, non-instrumental assessment of swallow function. It is usually performed by a Speech Pathologist and includes a thorough case history and assessment of oro-motor function. For example, tongue, jaw movement, cough reflex and review of swallow function with a range of food and fluids. A rating is usually provided to describe the level of function and likely presence or absence of aspiration. Based on the CSA findings the Speech Pathologist recommends specific diet and fluid modifications, feeding techniques and positioning techniques to enable safe oral feeding. Inclusion criteria Types of participants Studies will be considered in this review if they include: infants, children or adults with dysphagia. The following definitions will be used within this review: - infant will be defined as < 36 months; - children will be defined as 36 months – 18 years; - adults will be defined as 18 years and over; - dysphagia will be defined as 'a swallowing disorder' 6. The definition uses 36 months as the cut off between infants and children as this is the stage when the infant transitions from sucking patterns used for bottle feeding and early solids and begins to chew solids, self feed and drink from a range of cups consistent with an older child 4. There will be no exclusion of studies based on age or gender. Studies will be excluded that include the population of head and neck cancer (HNC) patients, patients with a tracheostomy in situ and patients with craniofacial anomalies. The primary treatment for HNC patients includes surgery and radiotherapy . Radiotherapy can have a specific impact on swallowing , not necessarily seen in other populations and surgical resections can result in predictable swallowing difficulties . Patients with a tracheostomy in situ and patients with craniofacial anomalies also have known anatomical changes that have a specific impact on swallow function. The clinician undertaking the clinical swallow assessment has access to any anatomical changes following surgery. This is different to other populations whereby information regarding specific neurological and anatomical information is not necessarily available. Focus of the review The focus of this review will be on diagnostic test accuracy (sensitivity and specificity) of Clinical Swallow Assessment (CSA) compared with Video Fluoroscopic Swallow Study (VFSS) in diagnosing oropharyngeal aspiration in children and adults with dysphagia. In this review, VFSS will be the 'Gold Standard' or, reference test and CSA will be the index test. The terms VFSS and Modified Barium Swallow (MBS) refer to the same study. Although this review will use the term VFSS defined as the radiographic assessment of the oral and pharyngeal swallow, MBS studies will also be included. The terms Clinical Swallow Assessment and Bedside Swallow Evaluation also refer to the same diagnostic tool . Clinical Swallow Assessment (CSA) will be used within this review, defined as the non-instrumental, non-radiologic assessment of swallow function by a Speech Pathologist, however studies of Bedside Swallow Evaluation will also be included. Studies that do not use CSA as the index test or do not use VFSS as the reference test will be excluded. In addition, studies of effectiveness, experience or comparison of treatment interventions will be excluded. The diagnostic test accuracy of CSA and VFSS will be compared using: sensitivity and specificity. Where possible, positive and negative predictive values will also be analysed and reported. Sensitivity of a diagnostic test is defined as 'the ability of the test to identify correctly those who have the disease'34. Specificity of a diagnostic test is defined as 'the ability of the test to identify correctly those who do not have the disease' Positive predictive value is defined as the proportion of patients who test positive and actually have the disease in question . Negative predictive value is defined as the proportion of patients who test negative and actually do not have the disease in question .

Hospital Bound

You have accessThe ASHA LeaderStudent's Say1 Dec 2013Hospital BoundWant to work in acute care after graduation? A newly minted SLP shares some advice. Maryam JelvaniMA, CCC-SLP Maryam Jelvani Google Scholar More articles by this author , MA, CCC-SLP https://doi.org/10.1044/leader.SSAY.18122013.58 SectionsAboutPDF ToolsAdd to favorites ShareFacebookTwitterLinked In New graduates rarely have difficulty finding speech-language pathology jobs in schools. But those interested in acute-care positions face a more difficult job search, as most employers are looking for speech-language pathologists with at least a year of acute-care experience. If your medical clinical experience is limited, what can you do to improve your competency and candidacy for a hospital position? That’s the question I was asking myself last year, when I started looking for a hospital position while finishing my clinical fellowship at a skilled-nursing facility. I was eager to know what to expect and how to prepare. Now, I’m the main SLP in a 300-plus-bed hospital. Here are some tips I picked up that may be useful for SLPs seeking to work with adults in hospitals. Try to do all or part of your clinical fellowship in an acute or subacute medical setting. This experience is the best advantage you can give yourself as a new graduate. If those settings are not an option, start taking medical continuing education courses and attending medical speech-language pathology workshops that will enhance your knowledge base. You can take courses (some that are CEU-eligible) in voice-strengthening techniques, fiberoptic endoscopic evaluation of swallowing, the modified barium swallow study, and working with tracheostomy and ventilator-dependent patients. You can also take CEUs to review indications for different parenteral and enteral feeding options, as hospital SLPs make recommendations for alternative nutrition to physicians. Shadow SLPs who do the kind of work you’re interested in. For example, you can contact the SLP at a local hospital and ask if you can observe an outpatient modified barium swallow study (these are often scheduled in advance). If you’re interested in working with patients with laryngectomies and tracheotomies, find a hospital that provides speech-language services for these populations. First-hand experience with both MBSS and tracheostomy patients is usually a must for hospital settings. Master essential medical knowledge. You’ll need this information to understand the bigger picture of a patient’s medical condition and history: common medical conditions and abbreviations; pertinent findings on chest X-rays and brain scans; the significance of different lab values; norms for vital signs; medications that have an impact on cognition, speech or swallowing; and the scope of practice for various medical specialists. You can find this information in medical speech-language pathology textbooks or even on the Internet. Perfect your bedside swallow evaluation skills. Swallowing evaluations will make up the majority of your consults. Review cranial nerve testing for speech and swallowing. Get to know the various dysphagia protocols used in hospitals (for example, the National Dysphagia Diet) so that you can monitor the accuracy of your patients’ meal consistencies in collaboration with dieticians. Master quick, standardized screens for cognition and language. Because of the priority given to swallowing consults, cognitive and language testing sometimes gets placed on the back burner in hospitals. I’ve found that I can fit these assessments in by using a collection of quick standardized screeners that take 10 to 20 minutes to administer. Take the time to look up and practice administering some of these screens, some of which are available free online. If you are successful in finding and landing a hospital position, you still have work to do. Find out which rehabilitation facilities are nearby and what services each provides. A main goal of your assessment in the hospital setting will be to communicate with the patient, family, case managers, and occupational and physical therapists to plan for the patient’s discharge. If you stay informed about the specific rehabilitation programs in your area—those for stroke or brain injury, for example—and recommend them when appropriate, you can play a huge advocacy role in ensuring successful recovery for your patients. Author Notes Maryam Jelvani, MA, CCC-SLP, works at Shady Grove Adventist Hospital in Rockville, Md. She received her master’s in speech-language pathology from the University of Maryland in 2012 after completing clinical placements in two hospitals. She completed her fellowship at a skilled nursing facility. 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Prospective Quality Initiative to Maximize Dysphagia Screening Reduces Hospital-Acquired Pneumonia Prevalence in Patients With Stroke

Dysphagia can lead to pneumonia and subsequent death after acute stroke. However, no prospective study has demonstrated reduced pneumonia prevalence after implementation of a dysphagia screen. We performed a single-center prospective interrupted time series trial of a quality initiative to improve dysphagia screening. Subjects included all patients with ischemic or hemorrhagic stroke admitted to our institution over 42 months with a 31-month (n=1686) preintervention and an 11-month (n=648) postintervention period. The intervention consisted of a dysphagia protocol with a nurse-administered bedside dysphagia screen and a reflexive rapid clinical swallow evaluation by a speech pathologist. The dysphagia initiative increased the percentage of patients with stroke screened from 39.3% to 74.2% (P<0.001). Furthermore, this initiative coincided with a drop in hospital-acquired pneumonia from 6.5% to 2.8% among patients with stroke (P<0.001). Patients admitted postinitiative had 57% lower odds of pneumonia, after controlling for multiple confounds (odds ratio=0.43; confidence interval, 0.255-0.711; P=0.0011). The best predictors of pneumonia were stroke type (P<0.0001), oral intake status (P<0.0001), dysphagia screening status (P=0.0037), and hospitalization before the beginning of the quality improvement initiative (P=0.0449). A quality improvement initiative using a nurse-administered bedside screen with rapid bedside swallow evaluation by a speech pathologist improves screening compliance and correlates with decreased prevalence of pneumonia among patients with stroke.

Post-extubation dysphagia is associated with longer hospitalization in survivors of critical illness with neurologic impairment

IntroductionCritically ill patients can develop acute respiratory failure requiring endotracheal intubation. Swallowing dysfunction after liberation from mechanical ventilation, also known as post-extubation dysphagia, is common and deleterious among patients without neurologic disease. However, the risk factors associated with the development of post-extubation dysphagia and its effect on hospital lengthofstay in critically ill patients with neurologic disorders remains relatively unexplored.MethodsWe conducted a retrospective, observational cohort study from 2008 to 2010 of patients with neurologic impairment who required mechanical ventilation and subsequently received a bedside swallow evaluation (BSE) by a speech-language pathologist.ResultsA BSE was performed after mechanical ventilation in 25% (630/2,484) of all patients. In the 184 patients with neurologic impairment, post-extubation dysphagia was present in 93% (171/184), and was classified as mild, moderate, or severe in 34% (62/184), 26% (48/184), and 33% (61/184), respectively. In univariate analyses, statistically significant risk factors for moderate/severe dysphagia included longer durations of mechanical ventilation and the presence of a tracheostomy. In multivariate analysis, adjusting for age, tracheostomy, cerebrovascular disease, and severity of illness, mechanical ventilation for >7 days remained independently associated with moderate/severe dysphagia (adjusted odds ratio = 4.48 (95%confidence interval = 2.14 to 9.81), P<0.01). The presence of moderate/severe dysphagia was also significantly associated with prolonged hospital lengthofstay, discharge status, and surgical placement of feeding tubes. When adjusting for age, severity of illness, and tracheostomy, patients with moderate/severe dysphagia stayed in the hospital 4.32 days longer after their initial BSE than patients with none/mild dysphagia (95% confidence interval = 3.04 to 5.60 days, P <0.01).ConclusionIn a cohort of critically ill patients with neurologic impairment, longer duration of mechanical ventilation is independently associated with post-extubation dysphagia, and the development of post-extubation dysphagia is independently associated with a longer hospital length of stay after the initial BSE.

Clinical prognostic indicators of dysphagia following prolonged orotracheal intubation in ICU patients

IntroductionThe development of postextubation swallowing dysfunction is well documented in the literature with high prevalence in most studies. However, there are relatively few studies with specific outcomes that focus on the follow-up of these patients until hospital discharge. The purpose of our study was to determine prognostic indicators of dysphagia in ICU patients submitted to prolonged orotracheal intubation (OTI).MethodsWe conducted a retrospective, observational cohort study from 2010 to 2012 of all patients over 18 years of age admitted to a university hospital ICU who were submitted to prolonged OTI and subsequently received a bedside swallow evaluation (BSE) by a speech pathologist. The prognostic factors analyzed included dysphagia severity rate at the initial swallowing assessment and at hospital discharge, age, time to initiate oral feeding, amount of individual treatment, number of orotracheal intubations, intubation time and length of hospital stay.ResultsAfter we excluded patients with neurologic diseases, tracheostomy, esophageal dysphagia and those who were submitted to surgical procedures involving the head and neck, our study sample size was 148 patients. The logistic regression model was used to examine the relationships between independent variables. In the univariate analyses, we found that statistically significant prognostic indicators of dysphagia included dysphagia severity rate at the initial swallowing assessment, time to initiate oral feeding and amount of individual treatment. In the multivariate analysis, we found that dysphagia severity rate at the initial swallowing assessment remained associated with good treatment outcomes.ConclusionsStudies of prognostic indicators in different populations with dysphagia can contribute to the design of more effective procedures when evaluating, treating, and monitoring individuals with this type of disorder. Additionally, this study stresses the importance of the initial assessment ratings.

The role of direct laryngoscopy in the diagnosis of laryngeal cleft

Objective: To identify the presenting features of a laryngeal cleft in children. To compare rigid and flexible endoscopic methods available for identifying laryngeal cleft and determine their utility. Methods: The charts of all patients diagnosed with laryngeal cleft in a tertiary care institution between 2009 and 2010 were evaluated retrospectively for age, gender, comorbidity, presenting features, and results of bedside swallow evaluation. Findings on flexible and direct laryngoscopy, both performed under general anesthesia, were compared. Results: Eleven patients had a diagnosis of laryngeal cleft, confirmed by direct laryngoscopy. Nine of eleven had signs of aspiration on modified barium swallow study (MBSS). Of the eight subjects who underwent flexible laryngoscopy by a pulmonologist, a deep interarytenoid groove was only reported in four cases. In all eleven cases, the arytenoids could be physically separated during direct laryngoscopy, allowing for definitive diagnosis of the cleft and identification of its type and severity. Conclusion: Video swallow studies and flexible laryngoscopy may raise suspicion or even diagnose a laryngeal cleft, however, a laryngeal cleft must be confirmed by direct laryngscopy in which the interarytenoid space is palpated. Furthermore, a patient in whom symptoms persist but no laryngeal cleft is identified on flexible examination should have a direct laryngoscopy to rule out a cleft.

The Incidence of Oropharyngeal Dysphagia in Infants With GERD‐Like Symptoms

Symptoms of infantile gastroesophageal reflux disease (GERD) may overlap with oropharyngeal dysphagia, but the evaluation and treatment of these conditions vary greatly. In this investigation, the incidence of oropharyngeal dysphagia in infants with GERD-like symptoms is determined. A retrospective chart review was performed on infants referred to a pediatric gastroenterology clinic for GERD-like symptoms. A feeding screen was performed in all infants. Standardized bedside swallow evaluation and modified barium swallow (MBS) studies were then performed when clinically indicated. A similarly aged cohort of normal participants also underwent a standard bedside swallow evaluation for group comparison. Study population included 67 infants. A swallow evaluation was recommended in 39 of 67 infants with abnormalities noted in all. Swallowing abnormalities were more frequent and clustered in infants with GERD-like symptoms vs controls. MBS was abnormal in 16 of 17 qualifying infants. Characteristics of at-risk infants included extreme prematurity, developmental delay, or symptoms refractory to antireflux medications. Oropharyngeal dysphagia is prominent in infants with GERD-like symptoms.

Diagnostic Accuracy of Bedside Swallow Evaluation Versus Videofluoroscopy to Assess Dysphagia in Individuals With Tetraplegia

To assess the accuracy of bedside swallow evaluation (BSE) compared with videofluorosopic swallow study (VFSS) in diagnosing dysphagia in individuals with tetraplegia due to spinal cord injury (SCI). A prospective diagnostic accuracy study according to STAndards for the Reporting of Diagnostic accuracy studies (STARD) criteria. A county hospital with acute inpatient SCI unit. Thirty-nine subjects with SCI and tetraplegia were enrolled. All of the subjects underwent BSE, and 26 subjects completed the VFSS. Individuals with SCI underwent a BSE followed by a VFSS within 72 hours of the BSE. The subjects were diagnosed as having dysphagia if they had positive findings in either BSE or VFSS. Sensitivity, specificity, and positive and negative predictive values were calculated by using VFSS as the criterion standard. Fifteen subjects (38%) were diagnosed as having dysphagia based on the BSE results. Among the subjects who completed the VFSS, 11 were diagnosed with dysphagia (42%) and 4 were diagnosed with aspiration (10%). Of the 26 subjects who completed both BSE and VFSS, only 1 subject was diagnosed differently compared with BSE (3.8%). Different diet recommendations were made in 4 cases after VFSS versus BSE. Different liquid recommendations were made in 8 cases after VFSS versus BSE. Sensitivity of BSE was 100% (95% confidence interval [CI], 71.5%-100%), specificity was 93.3% (95% CI, 68.1%-99.8%). A positive predictive value of BSE was 91.7% (95% CI, 61.5%-100%), and the negative predictive value was 100% (95% CI, 76.8%-100%). Dysphagia is present in approximately 38% of individuals with acute tetraplegia. Because only one of the 21 subjects was diagnosed differently based on VFSS, we believe that BSE is an appropriate screening tool for dysphagia for individuals with cervical SCI. However, VFSS provided additional information on diet and liquid recommendations, so there appears to be an important clinical role for the VFSS.

723 Aspiration after Lung Transplantation: Incidence, Risk Factors, and Accuracy of the Bedside Swallow Evaluation

Aspiration contributes to early and late allograft dysfunction after lung transplantation. The objective of this study was to define the incidence of aspiration after lung transplantation, determine the accuracy of the bed-side swallowing evaluation and identify factors that contribute to its development.

Dysphagia and Respiratory Care in Individuals with Tetraplegia: Incidence, Associated Factors, and Preventable Complications

Dysphagia occurs in a significant number of individuals with spinal cord injury (SCI) presenting to acute care and inpatient rehabilitation. This prospective study has found dysphagia in nearly 40% of individuals with tetraplegia. Tracheostomy, mechanical ventilation, nasogastric tube, and age are significant risk factors. The detrimental complications of dysphagia in SCI can cause significant morbidity and delays in rehabilitation. Thus, early and accurate diagnosis of dysphagia is imperative to reduce the risk of developing life-threatening complications. Incidence and risk factors of dysphagia and the use of the bedside swallow evaluation (BSE) and videofluoroscopy swallow study (VFSS) to diagnose dysphagia are presented. The often underappreciated role of respiratory therapists, including assist cough, high tidal volume ventilation, and the use of Passy-Muir valve, in the care of individuals with SCI who have dysphagia is discussed. Improved secretion management and respiratory stabilization enable the individuals with dysphagia to be evaluated sooner and safely by a speech pathologist. Early evaluation and intervention could improve upon morbidity and delayed rehabilitation, thus improving overall clinical outcomes.

The Diagnostic Test Accuracy of Clinical Swallow Assessment for Oropharyngeal Aspiration: A Systematic Review.

Review question/objective The objective of this systematic review is to synthesise the best available evidence on the diagnostic test accuracy (sensitivity and specificity) of Clinical Swallow Assessment (CSA) compared with Video Fluoroscopic Swallow Study (VFSS) in diagnosing oropharyngeal aspiration in children and adults with dysphagia. In this review, VFSS will be the 'Gold Standard' or, reference test and CSA will be the index test. VFSS is the radiographic assessment of swallow function usually performed by a Speech Pathologist and Radiologist. CSA is defined as a non-invasive, non-instrumental assessment of swallow function. It is usually performed by a Speech Pathologist and includes a thorough case history and assessment of oro-motor function. For example, tongue, jaw movement, cough reflex and review of swallow function with a range of food and fluids. A rating is usually provided to describe the level of function and likely presence or absence of aspiration. Based on the CSA findings the Speech Pathologist recommends specific diet and fluid modifications, feeding techniques and positioning techniques to enable safe oral feeding. Inclusion criteria Types of participants Studies will be considered in this review if they include: infants, children or adults with dysphagia. The following definitions will be used within this review: - infant will be defined as < 36 months; - children will be defined as 36 months – 18 years; - adults will be defined as 18 years and over; - dysphagia will be defined as 'a swallowing disorder' 6. The definition uses 36 months as the cut off between infants and children as this is the stage when the infant transitions from sucking patterns used for bottle feeding and early solids and begins to chew solids, self feed and drink from a range of cups consistent with an older child 4. There will be no exclusion of studies based on age or gender. Studies will be excluded that include the population of head and neck cancer (HNC) patients, patients with a tracheostomy in situ and patients with craniofacial anomalies. The primary treatment for HNC patients includes surgery and radiotherapy . Radiotherapy can have a specific impact on swallowing , not necessarily seen in other populations and surgical resections can result in predictable swallowing difficulties . Patients with a tracheostomy in situ and patients with craniofacial anomalies also have known anatomical changes that have a specific impact on swallow function. The clinician undertaking the clinical swallow assessment has access to any anatomical changes following surgery. This is different to other populations whereby information regarding specific neurological and anatomical information is not necessarily available. Focus of the review The focus of this review will be on diagnostic test accuracy (sensitivity and specificity) of Clinical Swallow Assessment (CSA) compared with Video Fluoroscopic Swallow Study (VFSS) in diagnosing oropharyngeal aspiration in children and adults with dysphagia. In this review, VFSS will be the 'Gold Standard' or, reference test and CSA will be the index test. The terms VFSS and Modified Barium Swallow (MBS) refer to the same study. Although this review will use the term VFSS defined as the radiographic assessment of the oral and pharyngeal swallow, MBS studies will also be included. The terms Clinical Swallow Assessment and Bedside Swallow Evaluation also refer to the same diagnostic tool . Clinical Swallow Assessment (CSA) will be used within this review, defined as the non-instrumental, non-radiologic assessment of swallow function by a Speech Pathologist, however studies of Bedside Swallow Evaluation will also be included. Studies that do not use CSA as the index test or do not use VFSS as the reference test will be excluded. In addition, studies of effectiveness, experience or comparison of treatment interventions will be excluded. The diagnostic test accuracy of CSA and VFSS will be compared using: sensitivity and specificity. Where possible, positive and negative predictive values will also be analysed and reported. Sensitivity of a diagnostic test is defined as 'the ability of the test to identify correctly those who have the disease'34. Specificity of a diagnostic test is defined as 'the ability of the test to identify correctly those who do not have the disease' Positive predictive value is defined as the proportion of patients who test positive and actually have the disease in question . Negative predictive value is defined as the proportion of patients who test negative and actually do not have the disease in question .

Rigid Laryngoscopy Is Necessary to Diagnose Laryngeal Cleft

Objective: 1) Identify the signs and symptoms of a laryngeal cleft in children. 2) Compare diagnostic methods available for identifying laryngeal cleft and determine their utility. Method: The charts of all patients diagnosed with laryngeal cleft in a tertiary care institution between 2009 and 2010 were evaluated retrospectively for age, gender, comorbidity, symptoms, bedside swallow evaluation, and results of imaging studies. Findings on flexible and direct laryngoscopy, both performed under general anesthesia, were compared. Results: Six patients had a diagnosis of laryngeal cleft, confirmed by direct laryngoscopy, performed for cough and signs of aspiration. In 3 cases the pattern on a barium video swallow examination heightened suspicion of laryngeal cleft. Flexible laryngoscopy was performed on all patients by a pulmonologist. Laryngeal cleft was suspected in four cases but could not be confirmed. Direct laryngoscopy was performed by an otolaryngologist. Direct laryngoscopy, in which the arytenoids could be physically separated, allowed for definitive diagnosis of the cleft and identification of its type and severity in all 6 cases. Conclusion: Video swallow and flexible laryngoscopy can raise suspicion of a rare laryngeal cleft in patients with otherwise common symptoms. A laryngeal cleft and its type can be definitively diagnosed by a direct laryngoscopy in which the inter-arytenoid space is palpated.

Dysphagia in individuals with tetraplegia: incidence and risk factors

Background/objective: Dysphagia following cervical spinal cord injury (SCI) can increase risk for pulmonary complications that may delay the rehabilitative process. The objective of this study was to identify risk factors for dysphagia after cervical SCI.Design: Prospective cohort study.Methods: Individuals with cervical SCI within 31 days of injury underwent a bedside swallow evaluation (BSE) followed by a videofluoroscopy swallow study (VFSS) within 72 hours of the BSE. Subjects were diagnosed as having dysphagia if they had positive findings in either BSE or VFSS.Results: Twenty-nine patients (7 female and 22 male) were enrolled. Of these, 21 (72%) had high cervical tetraplegia (C4 or higher) and 8 (38%) had lower cervical tetraplegia. A tracheostomy was present in 18 (62%) patients; 15 (52%) subjects were on ventilators. Dysphagia was diagnosed in 12 (41%) subjects. Dysphagia was noted in 62% of the subjects with tracheostomy and 53% of the subjects on the ventilator, but only tracheostomy resulted in a statistically significant association with dysphagia (P = 0.047). All three subjects who had nasogastric tubes were diagnosed with dysphagia (P = 0.029). The relationships between dysphagia and gender, high versus low tetraplegia, presence of halo or collar, head injury, and ventilator use were not statistically significant, but age was a significant risk factor (P = 0.028).Conclusions: Dysphagia is present in about 41% of individuals with acute tetraplegia. Only age, tracheostomy, and nasogastric tubes were identified as significant risk factors for dysphagia for individuals with tetraplegia. No relationship between dysphagia and level of SCI, spine surgery, collar, and ventilator use was found to exist.