The Association Between Dysphagia Symptoms, DIGEST Scores, and Severity Ratings in Individuals with Parkinson's Disease

The Swallow Disturbance Questionnaire (SDQ) is a screening tool developed to identify patients with Parkinson's Disease (PD) in need of objective swallowing evaluation. In a previous investigation, the SDQ did not predict abnormal airway protection on a videofluoroscopic swallowing study (VFSS). This investigation was undertaken to determine whether SDQ scores were more accurate when a global measure was used. The Dynamic Imaging Grade for Swallowing Toxicity (DIGEST) is a validated measure that provides a safety, efficiency, and total severity grade based on VFSS. A secondary analysis was performed using data from 20 patients with PD who had participated in a standardized VFSS protocol. The study sample was predominantly male (80%) with an average age of 71 years, and an average PD duration of 9 years. Using an established cut-off score, participants were subdivided into those with "normal" (n = 10) and "abnormal" SDQ scores (n = 10). Recordings were scored using the DIGEST protocol by two blinded raters who also rated overall dysphagia severity from the VFSS. There was good agreement between the two raters on the DIGEST and strong correlations between DIGEST scores and clinician perceptions of dysphagia severity. Higher SDQ scores were associated with poorer Efficiency on the DIGEST but not Safety or Total scores. Consistent with other PD studies, subjective perceptions of dysphagia were poorly predictive of objective findings on VFSS. There is little information about the validity of the DIGEST for rating neurogenic dysphagia. Our study provides preliminary support for the use of the DIGEST in the PD population.

Endoscopic and observational findings of swallowing of traditional and molded puree in healthy individuals

Puree is commonly prescribed for patients with mastication and bolus formation difficulties, but its appearance might negatively impact appetite and intake. Molded puree is marketed to be an alternative to traditional puree, but the process of molding puree could alter the properties of the food significantly and lead to different swallowing physiology as compared to puree. The current study investigated the differences between traditional and molded puree in terms of swallowing physiology and perception in healthy individuals. Thirty two participants were included. Two outcomes were used to quantify the oral preparatory and oral phase. Fibreoptic endoscopic evaluation of swallowing was used to assess the pharyngeal phase as it could retain the purees in their original form. Six outcomes were collected. Perceptual rating of the purees were provided by participants in six domains. Molded puree required significantly more masticatory cycles (p < 0.001) and longer time for ingestion (p < 0.001). Molded puree had longer swallow reaction time (p = 0.001) and more inferior site of swallow initiation (p = 0.007) compared with traditional puree. Participants' satisfaction with the appearance, texture and overall of molded puree was significantly greater. Molded puree was perceived to be more difficult to chew and swallow. This study established that the two types of puree were different in various aspects. The study also provided important clinical implications regarding the use of molded puree as a form of texture modified diet (TMD) in patients with dysphagia. The results could serve as the foundation of larger cohort studies on the effect of various TMDs on patients with dysphagia.

The Introduction of a Protocol for Esophageal Screening in Videofluoroscopic Swallowing Studies: Exploring Clinical Impacts and Barriers

PURPOSE

Esophageal screening is a valuable inclusion in videofluoroscopic swallowing studies (VFSSs). However, routine standardized esophageal screening does not always occur in clinical practice. This study introduced and evaluated an esophageal screening protocol at one Australian hospital.

METHOD

Radiology, gastroenterology, and speech-language pathology endorsed an esophageal screening protocol, which followed a timed 20-ml International Dysphagia Diet Standardisation Initiative Level 0 bolus from mouth to stomach in an upright anterior-posterior position. Measures exploring clinical impacts and barriers were recorded. Participants were compared with 100 consecutive VFSS patients prior to the introduction of the esophageal screening protocol.

RESULTS

During the esophageal screening protocol trial, 163 VFSSs were conducted with recruited patients. Aspiration risk (29%, n = 47/163) and positioning limitation (3%, n = 5/163) were barriers to esophageal screening. Rates of esophageal screening significantly increased with the esophageal screening protocol (χ2 = 63.462, p < .001). There was no difference in radiation dose for patients who had esophageal screening and those who did not in the esophageal screening protocol group (U = 1689.000, p = .237). The VFSS team breached the esophageal screening protocol for some patients, when evaluating esophageal transit time (n = 28) and recommending gastroenterology referral (n = 6). There was no difference between groups for rates of gastroenterology consults (χ2 = 1.805, p = .188) or dysphagia procedures (χ2 = 1.951, p = .209).

CONCLUSIONS

This study confirms that routine esophageal screening provides additional clinical information to assist holistic dysphagia management without adverse operational impacts. Further research with the multidisciplinary dysphagia team has commenced to continue to optimize and refine esophageal screening practice.

Evaluation of feeding difficulties using videofluoroscopic swallow study and swallowing therapy in infants and children

BACKGROUND

Infants and children with feeding difficulties have swallowing dysfunction and high risk of aspiration, which could be silent without choking, resulting in recurrent pneumonia and long-term respiratory morbidity. Videofluoroscopic swallow study (VFSS) is a useful tool for real-time visualization of the swallowing process and airway aspiration. This study reported a single-institutional 10-year experience of VFSS in pediatric patients with feeding difficulties and the efficacy of swallowing therapy.

METHODS

From 2011 to 2020, 30 infants and children with feeding difficulties received VFSS examinations in a medical center at a median age of 19 months (range 7 days-8 years). The images of the swallowing process (oral phase, triggering of pharyngeal swallowing, and pharyngeal phase) under videofluoroscopy were analyzed by a radiologist and a speech-language pathologist. Aspiration severity was assessed from VFSS observations and rated by an eight-point Penetration-Aspiration-Scale (PAS), with higher scores indicating increased severity. Swallowing therapy was performed by experienced speech-language therapists, and follow-up of oral feeding tolerance and risk of aspiration pneumonia was done.

RESULTS

Of the 30 patients, 24 (80%) had neurological deficits. High PAS scores (6-8) were observed in 25 (83.4%) patients, and 22 had a PAS score of 8, indicating silent aspiration. Of the 25 patients with high PAS scores, 19 (76%) had neurological deficits, and 18 (72%) depended on tube feeding at a median age of 20 months. Swallowing problems occurred most frequently during the pharyngeal phase in the patients with high PAS scores. VFSS-based swallowing therapy improved oral feeding ability and reduced aspiration episodes.

CONCLUSION

Infants and children with swallowing dysfunction and neurological deficits had high risk of severe aspiration. Swallowing problems in the pharyngeal phase were the most common VFSS findings in patients with severe aspiration. VFSS may help guide problem-oriented swallowing therapy to reduce the risk of recurrent aspiration.

Imaging of pharyngeal pathology

The pharynx plays a significant role in swallowing and speech, and this is reflected in both its complex anatomy and degree of physiological motility. Patients who present with pharynx-related symptoms such as sore throat, globus, dysphagia or dysphonia will usually undergo visual and nasal endoscopic examination in the first instance. Imaging is frequently required to supplement clinical assessment and this typically involves MRI and CT. However, fluoroscopy, ultrasound and radionuclide imaging are valuable in certain clinical situations. The aforementioned complexity of the pharynx and the myriad of pathologies which may arise within it often make radiological evaluation challenging. In this pictorial review, we aim to provide a brief overview of cross-sectional pharyngeal anatomy and present the radiological features of a variety of pharyngeal pathologies, both benign and malignant.

Factors that influence development of speech pathology skills required for videofluoroscopic swallowing studies

BACKGROUND

Perceptual, cognitive and previous clinical experience may influence a novice Videofluoroscopic Swallowing Study (VFSS) analyst's trajectory towards competency. Understanding these factors may allow trainees to be better prepared for VFSS training and may allow training to be developed to accommodate differences between trainees.

AIMS

This study explored a range of factors previously suggested in the literature as influencing the development of novice analysts' VFSS skills. We hypothesised that knowledge of swallow anatomy and physiology, visual perceptual skills, self-efficacy and interest, and prior clinical exposure would all influence VFSS novice analysts' skill development.

METHODS & PROCEDURES

Participants were undergraduate speech pathology students recruited from an Australian university, who had completed the required theoretical units in dysphagia. Data assessing the factors of interest were collected-the participants identified anatomical structures on a still radiographic image, completed a physiology questionnaire, completed subsections of the Developmental Test of Visual Processing-Adults, self-reported the number of dysphagia cases they managed on placement, and self-rated their confidence and interest. Data for 64 participants relating to the factors of interest were compared with their ability to accurately identify swallowing impairments following 15 h of VFSS analytical training, using correlation and regression analysis.

OUTCOMES & RESULTS

Success in VFSS analytical training was best predicted by clinical exposure to dysphagia cases and the ability to identify anatomical landmarks on still radiographic images.

CONCLUSIONS & IMPLICATIONS

Novice analysts vary in the acquisition of beginner-level VFSS analytical skill. Our findings suggest that speech pathologists who are new to VFSS may benefit from clinical exposure to dysphagia cases, sound foundational knowledge of anatomy relevant to swallowing and the ability to see the anatomical landmarks on still radiographic images. Further research is required to equip VFSS trainers and trainees for training, to understand differences between learners during skill development.

WHAT THIS PAPER ADDS

What is already known on the subject The existing literature suggests that no vice Video fluoroscopic Swallowing Study (VFSS) analysts training may be influenced by their personal characteristics and experience. What this study adds This study found that student clinicians, clinical exposure to dysphagia cases and their ability to identify anatomical landmarks relevant to swallowing on still radiographic images prior to training best predicted their ability to identify swallowing impairments after training. What are the clinical implications of this work? Given the expense of training health professionals, further research is required into the factors that successfully prepare clinicians for VFSS training, including clinical exposure, foundational knowledge of anatomy relevant to swallowing and the ability to identify the anatomical landmarks on still radiographic images.

Ultrasonography for Eating and Swallowing Assessment: A Narrative Review of Integrated Insights for Noninvasive Clinical Practice

Dysphagia is a syndrome of abnormal eating function resulting from a variety of causative diseases, and is associated with malnutrition. To date, the swallowing function has been difficult to examine without the use of invasive and expensive methods, such as the videofluorographic swallowing study or fiberoptic endoscopic evaluation of swallowing. In recent years, progress has been made in the clinical application of ultrasound equipment for the evaluation of body compositions near the body surface, including the assessment of nutritional status. Ultrasound examination is a noninvasive procedure and relatively inexpensive, and the equipment required is highly portable thanks to innovations such as wireless probes and tablet monitoring devices. The process of using ultrasound to visualize the geniohyoid muscle, digastric muscle, mylohyoid muscle, hyoid bone, tongue, masseter muscle, genioglossus muscle, orbicularis oris muscle, temporalis muscle, pharynx, esophagus, and larynx, and the methods used for evaluating these structures, are provided in this study in detail. This study also aims to propose a protocol for the assessment of swallowing-related muscles that can be applied in real-world clinical practice for the diagnosis of sarcopenic dysphagia, which can occur in elderly patients with sarcopenia, and has received much attention in recent years.

Timeline to dysphagia resolution after endoscopic intervention of an interarytenoid defect based on Video Fluoroscopic Swallow Study dysphagia severity

INTRODUCTION

We previously reported that endoscopic repair of a Type 1 Laryngeal Cleft (LC1) or Deep Interarytenoid Groove (DIG) improves swallowing function postoperatively. However, caregivers often ask about the timeline to resolution of the need for thickening. This study re-examines this cohort to answer this important caregiver-centered question.

METHODS

We reassessed a 3-year retrospective, single-center dataset of children with dysphagia found to have a LC-1 or DIG on endoscopic exam. The primary outcome was rate of complete resolution of dysphagia at 2, 6, and 12 months after endoscopic intervention. A sub-group analysis was made based on severity of dysphagia prior to intervention and by type of endoscopic repair.

RESULTS

Thirty-nine patients with mean age 1.35 years that had a LC-1 or DIG met criteria for inclusion. Rate of complete dysphagia resolution increased over time. Those with mild dysphagia (flow-reducing nipple and/or IDDSI consistency 1 or 2) had brisker resolution than those with moderate dysphagia (IDDSI consistency 3 or 4) at 2 months (67% vs 5%, p < 0.01) and at 6 months (80% vs 18%, p < 0.01) after endoscopic repair. There was no difference in dysphagia resolution between patients grouped by type of endoscopic repair.

CONCLUSION

Addressing an interarytenoid defect in patients will not result in immediate, complete dysphagia resolution in most patients. However, patients that only require a flow-reducing nipple and/or thickening to an IDDSI consistency 1 or 2 have brisker resolution of the need for thickening than those that require an IDSSI consistency 3 or 4 prior to intervention. These results inform pre-operative discussions of the timeline to resolution based upon severity of dysphagia and help manage caregiver expectations.

Oesophageal screening in videofluoroscopic swallow studies: Perceptions and practices of Australian speech-language pathologists

PURPOSE

There is building evidence that oesophageal screening (OS) should be considered a critical component of videofluoroscopic swallow studies (VFSS). This study surveyed Australian speech-language pathologists (SLPs) regarding current practices and perceptions of OS in VFSS.

METHOD

A 16-24 item online survey was distributed to Australian SLPs via relevant email forums. One response per site was requested. Survey questions explored experience and training in VFSS, skill and confidence with OS, OS protocol use, and pathways following OS.

RESULT

One hundred and one SLPs across all Australian states and territories responded, with 70% (n = 69/99) from metropolitan hospitals and 74% (n = 75/101) having more than five years' VFSS experience. While 69% (n = 70/101) of SLPs conducted OS, only half (n = 35/70) conducted OS routinely, and only 4% (n = 3/70) always used published OS protocols. Barriers to OS, for some participants, were concerns about scope of practice and confidence.

CONCLUSION

This study confirms higher levels of OS in Australia compared to similar international surveys and provides rich data on the Australian context. Prescriptive clinical guidelines for OS, consensus regarding a preferred OS protocol, and specific OS training may clarify SLP scope of practice and improve SLP confidence and standardisation in OS.

Temporalis and masseter muscle thickness as predictors of post-stroke dysphagia after endovascular thrombectomy

PURPOSE

Post-stroke dysphagia (PSD) is a common sequela of stroke. Given the association between dysphagia and sarcopenia, we aimed to investigate the association between PSD and temporal muscle thickness (TMT) and masseter muscle thickness (MMT) following endovascular thrombectomy (EVT) in patients with large-vessel occlusion (LVO).

METHODS

This retrospective cohort study included hospitalized patients with LVO stroke who underwent EVT between January 1, 2018, and October 31, 2022. TMT and MMT were measured using brain computed tomography (CT) angiography. The correlation between relevant clinicodemographic factors and both TMT and MMT was examined. The relationship between each of two parameters (TMT and MMT) and PSD, which was defined as the retention of the nasogastric (NG) tube at 4 and 12 weeks, was evaluated in adjusted logistic regression models.

RESULTS

Among the 148 participants, the mean TMT and MMT was 5.9 ± 1.6 and 11.2 ± 2.3 mm, respectively. Lower age, male sex, higher body mass index (BMI), higher albumin levels, and a lower initial National Institute of Health Stroke Scale (NIHSS) score were associated with higher TMT and MMT (p < 0.05). In the logistic regression analysis adjusted for age, sex, BMI, serum albumin, and NIHSS score, lower TMT and MMT significantly correlated with PSD at weeks 4 and 12 (p < 0.001).

CONCLUSION

TMT and MMT are associated with age, sex, BMI, albumin, and the initial NIHSS score. Both TMT and MMT are independent indicators of post-EVT PSD in stroke patients and serve as reliable predictors of NG removal.

Quantitative approach to analyze hyoid bone movement during swallowing by ultrasound: an integrative review

PURPOSE

To synthesize the scientific knowledge on which measurements of hyoid bone movement during swallowing are obtained by ultrasonography and how to extract these measures.

RESEARCH STRATEGIES

The PECO question and combinations of descriptors and keywords were formulated in the electronic databases Medline/PubMed, EMBASE, Web of Science, Scopus and Lilacs.

SELECTION CRITERIA

Articles that used ultrasonography to analyze measurements of hyoid bone movement during swallowing were included, regardless of language, year of publication, or presence of deglutition disorders.

DATA ANALYSIS

The included articles were analyzed for: year, study site, study design, population, sample size, equipment used, transducer positioning, measurements obtained, method of extraction, and reliability of measurements.

RESULTS

Twenty-six articles met the eligibility criteria. The most frequent measurement was hyoid movement maximum amplitude, followed by time and velocity. There was great variability in the study population, equipment used, positioning of the transducer and method of extraction of the measurements. Thus, it was not possible to find a standard model to extract the measures. The level of reliability was investigated in only eight articles.

CONCLUSION

Amplitude, time and velocity are the measures of hyoid bone movement during swallowing that can be obtained by ultrasonography. There is no standardization on how to extract these measurements.

Outcomes of different zero-profile spacers in the treatment of two-level cervical degenerative disk disease

PURPOSE

The purpose of this study was to analyze the clinical and radiological outcomes of two different zero-profile spacers (ROI-C and anchor-C) in contiguous two-level ACDF for CDDD patients.

METHODS

We retrospectively analyzed patients who underwent contiguous two-level ACDF due to CDDD between January 2015 and December 2020 in our hospital. Patients who received ROI-C and anchor-C were included as the study groups, and those who underwent plate-cage construct (PCC) were included as the control group. The primary outcome measures were radiographical parameters, and the secondary outcome measures were dysphagia, JOA scores and VAS scores for these patients.

RESULTS

A total of 91 patients were enrolled in the study; there were 31, 21 and 39 patients in the ROI-C, anchor-C and PCC groups, respectively. The mean follow-up duration was 24.52 months (range, 18-48 months) in the ROI-C group, 24.38 months (range, 16-52 months) in the anchor-C group and 25.18 months (range, 15-54 months) in the PCC group. The loss of the intervertebral space height and cage subsidence rate in the ROI-C group were significantly higher than those in the anchor-C group and PCC group at the final follow-up (P < 0.05). The ROI-C group showed a lower incidence of adjacent segment degeneration than the anchor-C group and PCC group, but the difference was not significant. The fusion rates were not different among these three groups. The early dysphagia rate was significantly lower in the patients with zero-profile spacers than in the PCC group (P < 0.05), but the difference was not significant at the last follow-up. No relevant differences were found in the JOA scores and VAS scores.

CONCLUSIONS

Zero-profile spacers showed promising clinical outcomes in CDDD patients having contiguous two-level ACDF. However, ROI-C resulted in a higher intervertebral space height loss and a higher cage subsidence rate than anchor-C during the follow-up.

Advances for Dysphagia in the Digital Age: Integrative Imaging and Wearable Technologies

BACKGROUND

In the past four to five decades, the field of swallowing science has made significant strides in the evaluation and treatment of swallowing disorders (dysphagia). Despite these strides, several gaps in knowledge remain and optimal approaches for dysphagia management have yet to be established. Part of this hindrance stems from our relatively limited understanding of the complex underlying swallowing mechanisms which further limits our ability to examine how these mechanisms may be altered in patients with dysphagia and how to optimally target them in therapy. To overcome this hindrance, it is critical that we develop sensitive new tools and methods that will allow for the precise and personalized examination of patients' complex swallowing control and neurophysiological changes, and for the direct targeting of this control to improve treatment effectiveness.

SUMMARY

Herein, the advantages and limitations of current approaches in the study of swallowing biomechanics and central and peripheral swallowing control mechanisms are first summarized. Then, two examples of recent technological advances developed by the author's multidisciplinary team are described, including an integrative MRI sequence that allows for the simultaneous examination of oropharyngeal swallow and brain activity (SimulScan), and a novel wearable surface electromyography sensor technology (i-Phagia) designed for swallowing rehabilitation monitoring. The current state, limitations, and future applications of both technologies are discussed. Upon optimization and validation, such technological advancements can offer unprecedented opportunities to gain direct and precise insights on the swallowing mechanism. Information gained from these and similar new technologies can act as a catalyst for the future development of optimized personalized dysphagia care. By leveraging advances in current methods, multidisciplinary collaborations, and new digital age technologies, the field of dysphagia can take the next giant leap forward in improving clinical care and patient lives.

KEY MESSAGES

There is a critical need to develop sensitive new tools and methods that will allow for the precise and personalized examination of the complex swallowing mechanism and lead to the development of physiology-based and more effective interventions. The digital age is the ideal time to begin leveraging the technological advancements of fields such as imaging, electrophysiology, wearables, and machine learning to advance dysphagia research and practice. A new integrative MRI sequence and a novel wearable surface electromyography sensor technology developed by the author's team are presented, as examples of recent technological advances that can play an important role in the future of personalized dysphagia care.

A Tutorial on Diagnostic Benefit and Radiation Risk in Videofluoroscopic Swallowing Studies

The videofluoroscopic swallowing study (VFSS) is a key tool in assessing swallowing function. As with any diagnostic procedure, the probable benefits of the study must be weighed against possible risks. The probable benefit of VFSS is an accurate assessment of swallowing function, enabling patient management decisions potentially leading to improved patient health status and quality of life. A possible (though highly unlikely) risk in VFSS is carcinogenesis, arising from the use of ionizing radiation. Clinicians performing videofluoroscopic swallowing studies should be familiar with both sides of the risk benefit equation in order to determine whether the study is medically justified. The intent of this article is to provide the necessary background for conversations about benefit and risk in videofluoroscopic swallowing studies.

The Influence of Sex, Age, and Repeated Measurement on Pixel-Based Measures of Pharyngeal Area at Rest

PURPOSE

Videofluoroscopic (VFSS) measurements of pharyngeal swallow mechanics can differentiate age- and disease-related changes in swallowing. Pharyngeal area at rest (PhAR) may differ in people with dysphagia, although its impact is not clear. Before the role of PhAR in dysphagia can be explored, it is important to establish whether PhAR remains stable across repeated measures in healthy adults, and varies as a function of sex or age. We hypothesized that healthy adults would show stable PhAR across repeated measures, but that larger PhAR would be seen in men versus women and in older versus younger adults.

METHOD

We collected VFSS data from 87 healthy adults (44 men, M age = 46 years, range: 21-82). Trained raters identified the swallow rest frame after the initial swallow of each bolus and measured unobliterated pharyngeal area on these frames, in %(C2-4)2 units. Repeated-measures analyses of variance with a factor of sex, a covariate of age, and a repeated factor of task repetition were performed across the first 12 available measures per participant (N = 1,044 swallows).

RESULTS

There were no significant variations in PhAR across repeated measures. A significant Sex × Age interaction was seen (p = .04): Males had significantly larger PhAR than females (p = .001), but females showed larger PhAR with advancing age (R = .47).

CONCLUSIONS

These data confirm stability in PhAR across repeated measurements in healthy individuals. However, significant sex and age differences should be taken into consideration in future studies exploring the role of PhAR in people with dysphagia.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.22043543.

Quantifying Pharyngeal Residue Across the Adult Life Span: Normative Values by Age, Gender, and Swallow Task

PURPOSE

We quantified pharyngeal residue using pixel-based methods in a normative data set, while examining influences of age, gender, and swallow task.

METHOD

One hundred ninety-five healthy participants underwent a videofluoroscopic swallow study following the Modified Barium Swallow Impairment Profile (MBSImP) protocol. ImageJ was used to compute Normalized Residue Ratio Scale and the Analysis of Swallowing Physiology: Events, Kinematics and Timing (ASPEKT) pharyngeal residue measures. Reliability was established. Descriptive statistics were performed for all residue measures. Inferential statistics were performed using ASPEKT total scores (i.e., %C2-42). Logistic regression models explored predictors of residue versus no residue. Generalized linear mixed models explored predictors of nonzero residue. Spearman rho explored relationships between ASPEKT total residue scores and MBSImP Component 16 (Pharyngeal Residue) scores.

RESULTS

Majority of swallows (1,165/1,528; 76.2%) had residue scores of zero. Residue presence (%C2-42 > 0) was influenced by age (more in older [F = 9.908, p = .002]), gender (more in males [F = 18.70, p < .001]), viscosity (more in pudding, nectar, and honey [F = 25.30, p < .001]), and volume (more for cup sip [F = 37.430, p < .001]). When residue was present (363/1,528 = 23.8%), amounts were low (M = 1% of C2-42, SD = 2.4), and only increasing age was associated with increased residue (F = 9.008, p = .007) when controlling for gender and swallow task. Increasing residue was incremental (0.01% of C2-42 per year). As ASPEKT total residue values increased, MBSImP Component 16 scores also increased.

CONCLUSIONS

Pharyngeal residue amounts were very low in healthy adults. Residue presence can be influenced by age, gender, and swallow task. However, when present, the amount of pharyngeal residue was only associated with increasing age.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.21957221.

Pixel-Based Swallow Measurements: Correcting Nonsquare Pixels

PURPOSE

This research note illustrates the effects of video data with nonsquare pixels on the pixel-based measures obtained from videofluoroscopic swallow studies (VFSS).

METHOD

Six pixel-based distance and area measures were obtained from two different videoflouroscopic study units; both yielding videos with nonsquare pixels with different pixel aspect ratios (PARs). The swallowing measures were obtained from the original VFSS videos and from the videos after their pixels were squared.

RESULTS

The results demonstrated significant multivariate effects both in video type (original vs. squared) and in the interaction between video type and sample (two video recordings of different patients, different PARs, and opposing tilt angles of the external reference). A wide range of variabilities was observed on the pixel-based measures between original and squared videos with the percent deviation ranging from 0.1% to 9.1% with the maximum effect size of 7.43.

CONCLUSIONS

This research note demonstrates the effect of disregarding PAR to distance and area pixel-based parameters. In addition, we present a multilevel roadmap to prevent possible measurement errors that could occur. At the planning stage, the PAR of video source should be identified, and, at the analyses stage, video data should be prescaled prior to analysis with PAR-unaware software. No methodology in prior absolute or relative pixel-based studies reports adjustment to the PAR prior to measurements nor identify the PAR as a possible source of variation within the literature. Addressing PAR will improve the precision and stability of pixel-based VFSS findings and improve comparability within and across clinical and research settings.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.21957134.

Videofluoroscopy Practice in India: A Survey of Speech-Language Pathologists

Owing to differences in clinical approaches toward videofluoroscopic swallowing studies (VFSS), professional and governing bodies in some countries have implemented guidelines for performing VFSS. However, in India, the establishment of such practice guidelines is in initial stages of acceptance and there are no uniform guidelines. The aim of the current study was to investigate and describe the clinical practice patterns related to VFSS assessments among Speech-Language Pathologists (SLPs) in India. An electronic survey consisting of 34 questions categorized into four main sections (demographic details and education; current practice; instrumental and technical considerations; protocol and assessment methods) was sent to SLPs registered with the Indian Speech and Hearing Association (ISHA) through email and social media from August 2020 to January 2021. A total of 129 eligible responses were received. More than 50% of the participants used a standard assessment and analysis protocol. Barium and water-soluble contrasts were mostly used, and 97% of participants did not know what percent weight to volume (w/v) or volume to volume (v/v) contrast to fluid were used. Considerable amount of variability was observed in the responses of our participants, which was consistent with international surveys of VFSS practice patterns. Lack of adequate radiation safety measures was also observed. Our findings suggest a need to increase awareness and training among Indian SLPs in technical and procedural aspects of VFSS, and more sensitization toward radiation safety. ISHA should consider forming a committee to develop and adopt uniform nationwide practices in VFSS. Future studies exclusively investigating barriers and facilitators to VFSS practice in the Indian scenario are necessary.

Upper Instrumented Vertebrae, Number of Levels Fused, and Plate Morphology Do Not Affect Severity of Chronic Dysphagia After Anterior Cervical Spine Surgery

BACKGROUND

Disordered swallowing, or dysphagia, is the most common complication after anterior cervical spine (ACS) surgery. Many operative factors are associated with development of dysphagia. The aim of this study was to explore how number of levels instrumented, specific levels fused, and plate morphology affect chronic dysphagia after ACS surgery.

METHODS

Consecutive patients referred to a tertiary center for otolaryngology evaluation for chronic dysphagia after ACS surgery between 2012 and 2017 were enrolled. Basic demographic data were obtained. Plain radiographs were reviewed for number of levels fused, upper instrumented vertebrae, and plate morphology. Plate morphology was categorized as a closed, small window, large window, or no profile plate. The 10-item Eating Assessment Tool (EAT-10) was used to assess dysphagia severity.

RESULTS

Of 171 patients referred for dysphagia, 126 met inclusion criteria; 54% were female, with a mean age of 63 years (range, 32-88 years). Mean EAT-10 score was 18.5 ± 10.1. Mean time from spine surgery to videofluoroscopic swallow study for dysphagia was 58.3 months. Mean number of levels fused was 2.2 ± 0.9. There were no significant differences in EAT-10 scores in single-level versus multilevel fusion (19.0 vs. 18.4, P = 0.76) as well as with regard to upper instrumented vertebrae or plate morphology.

CONCLUSIONS

In this series of patients with chronic dysphagia following ACS surgery, the severity of dysphagia as measured by the EAT-10 was not affected by upper instrumented vertebrae, number of levels fused, or plate morphology.

Autonomous Swallow Segment Extraction Using Deep Learning in Neck-Sensor Vibratory Signals From Patients With Dysphagia

Dysphagia occurs secondary to a variety of underlying etiologies and can contribute to increased risk of adverse events such as aspiration pneumonia and premature mortality. Dysphagia is primarily diagnosed and characterized by instrumental swallowing exams such as videofluoroscopic swallowing studies. videofluoroscopic swallowing studies involve the inspection of a series of radiographic images for signs of swallowing dysfunction. Though effective, videofluoroscopic swallowing studies are only available in certain clinical settings and are not always desirable or feasible for certain patients. Because of the limitations of current instrumental swallow exams, research studies have explored the use of acceleration signals collected from neck sensors and demonstrated their potential in providing comparable radiation-free diagnostic value as videofluoroscopic swallowing studies. In this study, we used a hybrid deep convolutional recurrent neural network that can perform multi-level feature extraction (localized and across time) to annotate swallow segments automatically via multi-channel swallowing acceleration signals. In total, we used signals and videofluoroscopic swallowing study images of 3144 swallows from 248 patients with suspected dysphagia. Compared to other deep network variants, our network was superior at detecting swallow segments with an average area under the receiver operating characteristic curve value of 0.82 (95% confidence interval: 0.807-0.841), and was in agreement with up to 90% of the gold standard-labeled segments.

Deep Learning for Automatic Hyoid Tracking in Videofluoroscopic Swallow Studies

The hyoid bone excursion is one of the most important gauges of larynx elevation in swallowing, contributing to airway protection and bolus passage into the esophagus. However, the implications of various parameters of hyoid bone excursion, such as the horizontal or vertical displacement and velocity, remain elusive and raise the need for a tool providing automatic kinematics analysis. Several conventional and deep learning-based models have been applied automatically to track the hyoid bone, but previous methods either require partial manual localization or do not transform the trajectory by anatomic axis. This work describes a convolutional neural network-based algorithm featuring fully automatic hyoid bone localization and tracking and spine axis determination. The algorithm automatically estimates the hyoid bone trajectory and calculates several physical quantities, including the average velocity and displacement in horizontal or vertical anatomic axis. The model was trained in a dataset of 365 videos of videofluoroscopic swallowing from 189 patients in a tertiary medical center and tested using 44 videos from 44 patients with different dysphagia etiologies. The algorithm showed high detection rates for the hyoid bone. The results showed excellent inter-rater reliability for hyoid bone detection, good-to-excellent inter-rater reliability for calculating the maximal displacement and the average velocity of the hyoid bone in horizontal or vertical directions, and moderate-to-good reliability in calculating the average velocity in horizontal direction. The proposed algorithm allows for complete automatic kinematic analysis of hyoid bone excursion, providing a versatile tool with high potential for clinical applications.

Striatal Dopaminergic Loss and Dysphagia in Parkinson Disease

PURPOSE

To better understand the development of dysphagia in patients with Parkinson disease (PD) and to identify possible neuromodulatory target regions of dysphagia, we studied the striatal dopamine transporter (DAT) availability distribution by subtype of dysphagia.

METHODS

In this retrospective cross-sectional study, patients with PD who underwent videofluoroscopic swallowing study and N-(3-[18F]fluoropropyl)-2β-carbon ethoxy-3β-(4-iodophenyl) nortropane (18F-FP-CIT) PET at intervals of less than 1 month were analyzed. The 14 binarized subitem scores of the Videofluoroscopic Dysphagia Scale were analyzed using a voxel-wise Firth's penalized binary logistic regression model, adjusting for age and disease duration at videofluoroscopic swallowing study.

RESULTS

Sixty-five patients with PD were finally included. Striatal mapping showed association of decreased DAT availability with 5 subitems with 1 or more clusters surviving the statistical threshold: 1 oral phase and 4 pharyngeal phase subitems. The overlap maps created by superimposing clusters for all 5 statistically significant subitems revealed associations of dysphagia in PD with decreased DAT availability in the bilateral ventral striatum. Of these, 4 subitems belonging to the pharyngeal phase-specific dysphagia were additionally found to be related to dopaminergic degeneration of the bilateral anterior-to-posterior caudate and ventral striatum.

CONCLUSIONS

These findings suggest that subitem/phase-specific striatal subregional dopaminergic depletion may explain the dysphagia of PD. This dopaminergic degeneration of striatal subregions specific to the phases of dysphagia may serve as a potential target for neuromodulatory brain stimulation through stimulation of cortices functionally connected.