Application of ultrasonography in assessing oropharyngeal dysphagia in stroke patients

Assessing the oral and suprahyoid muscles in healthy adults using muscle ultrasound to inform the swallowing process: a proof-of-concept study

The oral and suprahyoid muscles are responsible for movements of swallowing. Our study aimed to determine the reproducibility of static and dynamic measurements of these muscles using bedside ultrasound equipment. Forty healthy participants were recruited prospectively. Primary outcomes were evaluation of mass measurements of the anterior bellies of the digastric, mylohyoid, geniohyoid and tongue in B-mode ultrasound. Secondary outcomes were evaluation of geniohyoid muscle layer thickness and function using M-mode. Muscle mass measurements demonstrated little within-participant variability. Coefficient of Variance (CoV) across muscles were: anterior belly digastric (5.0%), mylohyoid (8.7%), geniohyoid (5.0%) and tongue (3.2%). A relationship between sex (r2 = 0.131 p = 0.022) was demonstrated for the geniohyoid muscle, with males having higher transverse Cross Sectional Area (CSA) (14.3 ± 3.6 mm vs. 11.9 ± 2.5 mm, p = 0.002). Tongue size was correlated with weight (r2 = 0.356, p = 0.001), height (r2 = 0.156, p = 0.012) and sex (r2 = 0.196, p = 0.004). Resting thickness of the geniohyoid muscle layer changed with increasing bolus sizes (f = 3.898, p = 0.026). Velocity increased with bolus size (p =  < 0.001, F = 8.974). However swallow time and slope distance did not, potentially influenced by higher coefficients of variation. Oral and suprahyoid muscle mass are easily assessed using bedside ultrasound. Ultrasound may provide new information about muscle mass and function during swallowing.

Ultrasonographic analysis of the hyoid bone distance in individuals with neurogenic oropharyngeal dysphagia

To compare the ultrasound measurement of distance from the approximation of the hyoid bone during of the maximum deglutition peak between healthy individuals and neurogenic dysphagic individuals and to verify the effect of food consistencies on the displacement of the hyoid bone. Prospective, controlled clinical study. Ultrasound recordings of the oropharyngeal deglutition were conducted in 10 adults diagnosed with oropharyngeal dysphagia and in 10 healthy adults, matched by sex and age group. A portable ultrasound model Micro ultrasound system with a microconvex transducer 5-10 MHz, coupled to a computer as well as the head stabilizer were used. The ultrasound images were recorded using the AAA software (Articulate Assistant Advanced) at a rate of 120 frames/second. Food consistencies level 0 (free volume and 5 mL) and level 4 (5 mL) were used, based on the International Dysphagia Diet Standardisation Initiative (IDSSI). The calculation of the mean and standard deviation was used for the descriptive analysis, while the repeated measures ANOVA test was used for the inferential analysis. Results showed dysphagic individuals had lower elevation of the hyoid bone marked by a longer distance from the approximation of the hyoid bone during of the maximum deglutition peak when compared to healthy individuals, regardless of the food consistency offered. It was concluded that the ultrasound measurement of distance from the approximation of the hyoid bone during of the maximum deglutition peak showed less laryngeal elevation in individuals with neurogenic oropharyngeal dysphagia when compared to healthy individuals for all food consistencies offered.

Methodological Procedures to Acquire and Analyze Ultrasound Images of Swallowing: A Scoping Review

This scoping review aimed to identify methodological procedures for acquiring and analyzing ultrasound images related to swallowing in adults and older adults. The inclusion criteria were based on the PCC strategy (participants, concept, and context), as follows: population (adults and older adults), concept (ultrasound assessment), and context (swallowing assessment). The review included observational, experimental, descriptive, and analytical studies and excluded those that were not available in full, animal studies, in vitro studies, letters to the editor, errata, study protocols, and those that used ultrasound for purposes other than swallowing. There were no language and time restrictions. Two independent blinded professionals selected 81 articles that met the inclusion criteria from different databases. The most evaluated parameters included tongue morphology and movements, hyoid bone displacement, swallowing muscle area, and pharyngeal residue detection, such as pharyngeal wall mobility. They used convex and linear transducers (3 MHz to 8 MHz) positioned in the submental, laryngeal, and lateral regions of the neck. The subjects were seated and instructed to eat different food volumes and consistencies. The literature mapping showed that ultrasound is a promising diagnostic tool, helping clinicians understand swallowing disorders, as it provides static and dynamic images in different modes and positions. Also, patients receive real-time biofeedback of changes related to dysphagia.

Dynamic suprahyoid muscle ultrasound in assessing oropharyngeal dysphagia in neurological disorders

BACKGROUND

Appropriate evaluation and management of dysphagia are essential in neurological disorders. However, there is currently a lack of a simple yet reliable method for dysphagia evaluation.

AIM

This study aimed to investigate the usefulness of new dynamic M-mode ultrasonography (US) parameters of suprahyoid muscle (SHM) to evaluate dysphagia.

DESIGN

Prospective observational, cross-sectional study.

SETTING

Inpatient setting at neurology department of tertiary medical center.

POPULATION

A total of 89 patients with dysphagia and 175 healthy volunteers were enrolled in the study. Patients were subdivided into mild and severe dysphagia groups depending on the need for dietary changes and disease classification, which included amyotrophic lateral sclerosis, peripheral neuromuscular diseases, and stroke.

METHODS

Dynamic M-mode US was performed during swallowing to obtain the SHM thickness (the baseline thickness of the SHM), SHM displacement (peak-to-peak amplitude of SHM movement), SHM difference (SHM displacement - SHM thickness), SHM ratio (SHM displacement/SHM thickness), peak-to-peak time, and total duration. A videofluoroscopic swallowing study (VFSS) was performed.

RESULTS

Significant differences were found in SHM displacement and SHM difference according to dysphagia severity (P<0.001). The SHM ratio, total duration (P<0.001), and peak-to-peak time (P=0.001) differed significantly according to the patients' underlying diseases. The pharyngeal delay time and penetration-aspiration scale from the VFSS demonstrated significant negative correlations with SHM displacement and difference (P<0.001). By combining SHM difference and total duration, patients with dysphagia could be distinguished from healthy controls, with the highest negative predictive value of 95.6%.

CONCLUSIONS

Dynamic M-mode US of the SHM provided added value in evaluating the severity of dysphagia and differentiating swallowing mechanics of dysphagia related to underlying neurological disorders.

CLINICAL REHABILITATION IMPACT

Dynamic M-mode US of the SHM can serve as a supportive tool for rapid screening and repetitive follow-up of patients with dysphagia, which would contribute to dysphagia rehabilitation in patients with various neurological disorders.

Assessing Swallowing Dysfunction Aggravation in Chronic Obstructive Pulmonary Disease Patients Using Ultrasonic Measurements With Swallowing Movement Parameters

OBJECTIVE

To investigate the correlation between ultrasonic measurements of swallowing movement parameters and aggravation of swallowing dysfunction in patients with chronic obstructive pulmonary disease (COPD).

METHODS

COPD patients with swallowing dysfunction (n = 120) and COPD patients with normal swallowing function (n = 100) treated in our hospital between January 2020 and January 2023 were included in observation and control groups, respectively. The correlation between ultrasonic measurements of swallowing movement parameters and COPD with swallowing dysfunction was analyzed. The observation group was divided into mild and severe groups according to their Gugging Swallowing Screen (GUSS) scores. The correlation between ultrasonic measurements of swallowing movement parameters and COPD exacerbation combined with swallowing dysfunction was analyzed.

RESULTS

In the observation group, Hyoid muscle thickness, hyoid bone displacement, geniohyoid muscle movement distance, HLAS, and CSR were lower compared to the control group, negatively associated with COPD-related swallowing issues. Conversely, geniohyoid muscle movement time and minimum hyohyoid distance (NHLA) were higher in the observation group, positively correlated with COPD-related swallowing dysfunction. In COPD patients with swallowing problems, the severe group exhibited lower values for lingual muscle thickness, hyoid bone displacement, geniohyoid muscle movement distance, HLAS, and CSR compared to the mild group, while geniohyoid muscle movement time and NHLA were higher in the severe group. Receiver operating characteristic (ROC) curves were created, indicating the promising diagnostic utility of these parameters for assessing the presence and severity of swallowing dysfunction in COPD patients.

CONCLUSION

The ultrasonic measurement of swallowing motion parameters can effectively assess swallowing dysfunction in COPD patients.

Impact of sarcopenia and malnutrition on swallowing function utilizing ultrasonography in patients with acute heart failure: A retrospective cohort study

BACKGROUND & AIMS

This study aimed to determine the impact of sarcopenia and nutritional risk on swallowing-related muscles by ultrasonography and dysphagia occurrence in older patients with acute heart failure (AHF) during hospitalization.

METHODS

Patients with AHF aged ≥65 years without dysphagia (Food Intake LEVEL Scale [FILS] score ≥9) before admission were classified into four groups at admission: robust group, sarcopenia group (Asian Working Group for Sarcopenia 2019), nutritional risk group (geriatric nutritional risk index <92), and complicated group (with both sarcopenia and nutritional risk). Swallowing function (maximal hyoid displacement, geniohyoid muscle area and brightness, and maximal tongue pressure) and FILS were investigated from the medical records.

RESULTS

In total, 131 patients with AHF (mean age 82.8 ± 7.1 years, 71 males) were enrolled during the study period; 33, 58, 5, and 35 were classified into the robust, sarcopenia, nutritional risk, and complicated groups, respectively. In the covariance analysis adjusted for age, sex, comorbidities, and cardiac function, the complicated group had significantly worse swallowing function than the sarcopenia and robust groups (P < 0.05). In the Cox proportional hazards model, in which event occurrence was defined as the first-time FILS score of ≥9 obtained during hospitalization, the sarcopenia group (hazard ratio [HR]: 0.83, 95 % confidence interval [CI]: 0.51-1.34, P = 0.438) and nutritional risk group (HR: 0.77, 95 % CI:0.25-2.32, P = 0.637) were not significantly different, but the complicated group (HR: 0.54, 95 % CI: 0.31-0.95, P = 0.033) had significantly lower cumulative event rates with the robust group as the reference.

CONCLUSION

Sarcopenia and nutritional risk in older patients with AHF are risk factors for decreased swallowing function.

Bedside Ultrasound to Identify and Predict Severity of Dysphagia Following Ischemic Stroke: Human Versus Artificial Intelligence

OBJECTIVE

Dysphagia is a significant ischemic stroke complication that can lead to aspiration. Identification of at-risk patients can be logistically difficult and costly. Researchers investigated whether quantitative ultrasound assessment of hyoid bone movement during induced swallowing would predict failure of videofluoroscopy (VFS) or fiberoptic endoscopic evaluation of swallowing (FEES), as determined by a penetration-aspiration scale (PAS) score. Additionally, ability of a machine learning (ML) algorithm to predict PAS success or failure from real-time ultrasound video recordings was assessed.

METHODS

A prospective, single-blinded, observational pilot study was conducted from June 2019 through March 2020 at a comprehensive stroke center on a convenience sample of patients admitted with diagnosis of acute ischemic stroke undergoing VFS or FEES as part of dysphagia assessment. Researchers performed a midsagittal airway ultrasound during swallowing in patients receiving an objective swallowing assessment by speech language pathologists who were blinded to ultrasound results. Sonologists measured hyoid bone movement, and researchers then constructed an ML algorithm designed for real-time video analysis using a long short-term memory network with an embedded VGG16 convolutional neural network.

RESULTS

Videos from 69 patients were obtained with their respective PAS results. In total, 90% of available videos were used for algorithm training. After training, the ML algorithm was challenged with the 10% previously unseen videos and then compared with PAS outcomes. Statistical analysis included logistic regression and correlation matrix testing on human ultrasound measurements. Cohen's κ was calculated to compare deep learning algorithm prediction with PAS results. Measurement of hyoid bone elevation, forward displacement, total displacement and mandible length was unable to predict PAS assessment outcome (p values = 0.36, 0.13, 0.11 and 0.32, respectively). The ML algorithm showed substantial agreement with PAS testing results for predicting test outcome (κ = 0.79; 95% confidence interval: 0.52-1.0) CONCLUSION: Manual ultrasound measurement of hyoid movement during swallowing in stroke patients failed to predict PAS swallowing results. However, an ML algorithm showed substantial agreement with PAS results despite a small data set, which could greatly improve access to dysphagia assessment in the future.

The Hyoid Bone Kinematics in Dysphagic Stroke Patients: Instantaneous Velocity, Acceleration and Temporal Sequence Matters

Hyoid bone excursion (HBE) is one of the most critical events in the pharyngeal phase of swallowing. Most previous studies focused on the total displacement and average velocity of HBE. However, HBE during swallowing is not one-dimensional, and the change of velocity and acceleration is not linear. This study aims to elucidate the relationship between the instantaneous kinematics parameters of HBE and the severity of penetration/aspiration and pharyngeal residue in patients with stroke. A total of 132 sets of video-fluoroscopic swallowing study images collected from 72 dysphagic stroke patients were analyzed. The maximal instantaneous velocity, acceleration, displacement, and the time required to reach these values in the horizontal and vertical axes were measured. Patients were grouped according to the severity of the Penetration-Aspiration Scale and the Modified Barium Swallow Impairment Profile- Pharyngeal Residue. The outcome was then stratified according to the consistencies of swallowing materials. Stroke patients with aspiration were associated with a lower maximal horizontal instantaneous velocity and acceleration of HBE, a shorter horizontal displacement, and prolonged time to maximal vertical instantaneous velocity compared to the non-aspirators. In patients with pharyngeal residue, the maximal horizontal displacement of HBE was decreased. After stratification according to bolus consistencies, the temporal parameters of HBE were more significantly associated with aspiration severity when swallowing thin bolus. Meanwhile spatial parameters such as displacement had a bigger influence on aspiration severity when swallowing viscous bolus. These novel kinematic parameters of HBE could provide important reference for estimating swallowing function and outcomes in dysphagic stroke patients.

Hyolaryngeal Movement During Normal and Effortful Swallows Determined During Ultrasonography

PURPOSE

This study investigated (a) the effects of the effortful swallow under two different instructions (tongue emphasis vs. pharyngeal squeezing) on hyoid displacement and hyoid-larynx approximation, (b) the association between tongue pressure and hyolaryngeal movement during normal swallowing and the effortful swallow produced with tongue emphasis, and (c) age-related differences in hyolaryngeal movement during normal and effortful swallows (tongue emphasis vs. pharyngeal squeezing) in healthy individuals.

METHOD

Forty healthy adults (20 younger and 20 older) swallowed their saliva as they normally do (normal swallow) and performed the effortful swallow with tongue emphasis and pharyngeal squeezing. Tongue-to-palate pressure during swallowing was measured using the Iowa Oral Performance Instrument, hyolaryngeal movement was measured using ultrasonography, and submental surface electromyography was used to track swallows.

RESULTS

Results revealed differences in hyolaryngeal movement across swallowing types. Both types of effortful swallows showed greater hyolaryngeal movement than normal swallows. Additionally, hyolaryngeal movement was greater during the effortful swallow with tongue emphasis than the effortful swallow with pharyngeal squeezing. Age-related differences were found only in hyoid-larynx approximation during the effortful swallow with tongue emphasis (younger > older adults). Furthermore, moderate positive correlations were identified between tongue pressure and hyolaryngeal movement during normal swallows and the effortful swallow with tongue emphasis.

CONCLUSIONS

The findings show that varying instructions of the effortful swallow affect hyolaryngeal movement differently, suggesting that clinicians may need to individualize the effortful swallow instruction according to the physiological impairments of each patient. Additionally, natural age-related changes in swallowing physiology do not seem to affect an individual's ability to perform the effortful swallow or to impact hyolaryngeal movement. Finally, the association between tongue pressure and hyolaryngeal movement during normal swallows and the effortful swallow with tongue emphasis suggests that the tongue plays a critical role in swallowing, priming subsequent swallowing events.

Application of Real-time Submental Ultrasonography to Assess Swallowing

Background

Speech and swallowing dysfunction are common problems in head-and-neck cancer (HNC) survivors. Ultrasound (US) is a good method to assess suprahyoid muscles and hyoid bone movement, and it can provide valuable information on swallowing. The aims of this study were to measure the biometry of the supraglottic muscles and hyoid bone movement during swallowing and elucidate the application of real-time US for assessing swallowing dysfunction.

Methods

We collected data from HNC and thyroid cancer patients with dysphagia symptoms and healthy controls without a history of cancer or dysphagia symptoms for comparison. Real-time submental US was used to check the anterior belly of the digastric muscle, geniohyoid (GH) muscles, and hyoid bone movement during swallowing. Logistic regression analysis was used to explore significant US predictors of dysphagia. Based on the regression coefficients of independent variables, we established the nomogram prediction model for dysphagia.

Results

There were significant differences in GH size at contraction, GH size increase percentage, GH length at rest, GH length increase percentage, anterior displacement of the hyoid bone and superior displacement of the hyoid bone between the cancer survivors with dysphagia and volunteers without dysphagia. In multivariate logistic analysis, after adjusting for sex and age, the proportion of GH length contraction <22% (odds ratio [OR]: 6.8 95% confidence interval [CI]: 1.1-42.6) and hyoid bone superior displacement <3.3 mm (OR: 10.7, 1.8-64.1) were associated with a higher risk of dysphagia (P < 0.05).

Conclusion

We confirmed that GH muscle and hyoid bone movement are important for normal swallowing function. US is a good method to assess the suprahyoid muscles and hyoid bone movement, which could provide valuable information on swallowing.

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.

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.

Non-Contact Assessment of Swallowing Dysfunction Using Smartphone Captured Skin Displacements

Early and accurate dysphagia diagnosis is essential for reducing the risk of associated co-morbidities and mortalities. Barriers to current evaluation methods may alter the effectiveness of identifying at-risk patients. This preliminary study evaluates the feasibility of using iPhone X-captured videos of swallowing as a non-contact dysphagia screening tool. Video recordings of the anterior and lateral necks were captured simultaneously with videofluoroscopy in dysphagic patients. Videos were analyzed using an image registration algorithm (phase-based Savitzky-Golay gradient correlation (P-SG-GC)) to determine skin displacements over hyolaryngeal regions. Biomechanical swallowing parameters of hyolaryngeal displacement and velocity were also measured. Swallowing safety and efficiency were assessed by the Penetration Aspiration Scale (PAS), Residue Severity Ratings (RSR), and the Normalized Residue Ratio Scale (NRRS). Anterior hyoid excursion and horizontal skin displacements were strongly correlated with swallows of a 20 mL bolus (r_s = 0.67). Skin displacements of the neck were moderately to very strongly correlated with scores on the PAS (r_s = 0.80), NRRS (r_s = 0.41-0.62), and RSR (r_s = 0.33). This is the first study to utilize smartphone technology and image registration methods to produce skin displacements indicating post-swallow residual and penetration-aspiration. Enhancing screening methods provides a greater chance of detecting dysphagia, reducing the risk of negative health impacts.

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.

Application of Ultrasonography in Neurogenic Dysphagia: A Systematic Review

Swallowing disorders are common in neurological diseases, with dysphagia representing one of the most prevalent complications that may cause poor quality of life, reduce independence, and increase mortality. Rapid identification of dysphagia is necessary to reduce the risk of penetration and aspiration, and to early start rehabilitation protocols. Among the methods that can be used to evaluate dysphagia and its components, ultrasound imaging has been suggested to support the evaluation of dysphagia by providing measures of both static and dynamic anatomical components. The aim of this systematic review is to evaluate the usefulness of ultrasonography in neurogenic dysphagia according to current literature. From 2000 to 2020, 633 studies with the appropriate search terms for ultrasound and dysphagia were identified. After screening them, 10 studies were included in the qualitative analysis. Patients with the following neurologic conditions were studied with ultrasonography for dysphagia: Parkinson's disease, muscle dystrophy, amyotrophic lateral sclerosis, and stroke. The main outcomes of ultrasonography were swallowing muscles thickness (e.g., tongue), and dynamic measures such as hyoid displacement. The different protocols used in the studies, as well as their outcomes, did not allow to provide standard procedures and normative or cut-off values in the presented diseases. Because there are a variety of tools, methods, and techniques that have been used in the studies that were reviewed, it is difficult to evaluate them using established standards. However, ultrasonography correlates well with clinical evaluation of dysphagia and therefore has prognostic and rehabilitation potential. Future studies should aim to develop and utilize a common interdisciplinary protocol that includes standard procedures and outcomes to define normative values applicable in the different conditions.

Assessment and treatment of neurogenic dysphagia in stroke and Parkinson's disease

PURPOSE OF REVIEW

Neurogenic dysphagia worsens quality of life and prognosis of patients with different neurological disorders. Management of neurogenic dysphagia can be challenging. This review provides a comprehensive overview of current evidence on screening, diagnosis, and treatment of neurogenic dysphagia in stroke and Parkinson's disease, suggesting clues for clinical practice.

RECENT FINDINGS

The pros and cons of diagnostic techniques are discussed in the light of updated evidence. Findings from recent meta-analyses of different treatment approaches, including traditional dysphagia therapy, peripheral and central neurostimulation techniques, and treatment with botulinum toxin, are critically discussed, emphasizing inconsistencies and controversial issues.

SUMMARY

Screening tests and clinical swallow examination should be routinely performed in neurological patients at risk for dysphagia. In patients testing positive for dysphagia, first-line instrumental investigations, represented by fiberoptic endoscopic evaluation of swallowing or videofluoroscopic swallow study, should be performed to confirm the presence of dysphagia, to assess its severity, and to inform the treatment. Second-line and third-line instrumental methods can be used in selected patients to clarify specific pathophysiological aspects of oropharyngeal dysphagia. Treatment strategies should be personalized, and combination of traditional dysphagia therapy with innovative treatment approaches may increase the chance of restoring effective and safe swallowing.

Reliability of Ultrasound Examination of Hyoid Bone Displacement Amplitude: A Systematic Review and Meta-Analysis

In swallowing, the hyoid bone moves up and forward in response to the activation of suprahyoid muscles, opening the upper esophageal sphincter and aiding the airway protection mechanism. This displacement measure has been analyzed with ultrasound images because this method does not expose the patient to radiation, has a good cost-benefit ratio, and is safe for the patient. However, there is no consensus on the reliability of this ultrasound measure. The objective of this study was to analyze the reliability of measuring hyoid bone displacement amplitude in swallowing with ultrasound. The systematic review encompassed five databases (MEDLINE, Scopus, EMBASE, Web of Science, Cochrane Library) and gray literature. There was no limitation of language or year of publication. The search/selection/extraction methodology was conducted by two authors blindly and independently, and differences were solved by a third rater. Three studies met the eligibility criteria: two of them analyzed the reliability in non-dysphagic populations and the other, in dysphagic patients. The transducer was positioned in the submandibular region in all studies. The authors were not clear about the training time to acquire and analyze ultrasound images. The meta-analysis had an interrater reliability of 0.858 (95% CI: 0.744-0.924) and intrarater reliability of 0.968 (95% CI: 0.903-0.990). There was, however, heterogeneity of p = 0.005 for intrarater reliability. Despite good reliability, the heterogeneity reinforces the importance of training and protocol standardization for image acquisition and analysis.

Temporal measures of oropharyngeal swallowing events identified using ultrasound imaging in healthy young adults

Swallowing is a complex process that involves precise coordination among oral and pharyngeal structures, which is essential to smooth transition of bolus and adequate airway protection. Tongue base retraction and hyolaryngeal excursion are two significant swallowing movements, and their related events can be examined using ultrasound imaging, which is physically and radioactively non-invasive. The present study aimed to 1) establish the temporal sequences and timing of swallowing events identified using ultrasound imaging, and 2) investigate the variability of the above temporal sequences and 3) investigate the effect of bolus type on the variability of temporal sequences in non-dysphagic individuals. Forty-one non-dysphagic young adults of both genders (19 males and 22 females) participated in the study. Ultrasound images were acquired mid-saggitally at their submental region during swallowing of boluses with different volume (i.e. 5mL or 10mL) and consistencies (i.e. IDDSI Levels 0 and 4). Timing and sequence of six events 1) displacement onset (TBOn), 2) maximum displacement (TBMax) and 3) displacement offset of tongue base retraction (TBOff); and, 4) displacement onset (HBOn), 5) maximum displacement (HBMax) and 6) displacement offset of the hyoid bone excursion (HBOff) were extracted from the ultrasound images. Out of the 161 swallows, 85.7% follow a general sequence of HBOn < TBOn < HBMax < TBMax < HBOff < TBOff. Percentage adherence to six anticipated paired-event sequences was studied. Results suggested the presence of individual variability as adherence ranged from 75.8% to 98.1% in four of the anticipated sequences, leaving only two sequences (HBOn < TBMax and TBMax < HBOff) obligatory (i.e. 100% adherence). For non-obligatory sequences, it was found that bolus type may have an effect on the level of adherence. Findings of the present study lay the groundwork for future studies on swallowing using ultrasound imaging and also the clinical application of ultrasonography.

Automated assessment of hyoid movement during normal swallow using ultrasound

BACKGROUND

The potential for using ultrasound by speech and language therapists (SLTs) as an adjunct clinical tool to assess swallowing function has received increased attention during the COVID-19 pandemic, with a recent review highlighting the need for further research on normative data, objective measurement, elicitation protocol and training. The dynamic movement of the hyoid, visible in ultrasound, is crucial in facilitating bolus transition and protection of the airway during a swallow and has shown promise as a biomarker of swallowing function.

AIMS

To examine the kinematics of the hyoid during a swallow using ultrasound imaging and to relate the patterns to the different stages of a normal swallow. To evaluate the accuracy and robustness of two different automatic hyoid tracking methods relative to manual hyoid position estimation.

METHODS & PROCEDURES

Ultrasound data recorded from 15 healthy participants swallowing a 10 ml water bolus delivered by cup or spoon were analysed. The movement of the hyoid was tracked using manually marked frame-to-frame positions, automated hyoid shadow tracking and deep neural net (DNN) tracking. Hyoid displacement along the horizontal image axis (HxD) was charted throughout a swallow, and the maximum horizontal displacement (HxD max) and maximum hyoid velocity (HxV max) along the same axis were automatically calculated.

OUTCOMES & RESULTS

The HxD and HxV of 10 ml swallows are similar to values reported in the literature. The trajectory of the hyoid movement and its location at significant swallow event time points showed increased hyoid displacement towards the peak of the swallow. Using an interclass correlation coefficient, HxD max and HxV max values derived from the DNN tracker and shadow tracker are shown to be in high agreement and moderate agreement, respectively, when compared with values derived from manual tracking.

CONCLUSIONS & IMPLICATIONS

The similarity of the hyoid tracking results using ultrasound to previous reports based on different instrumental tools supports the possibility of using hyoid movement as a measure of swallowing function in ultrasound. The use of machine learning to automatically track the hyoid movement potentially provides a reliable and efficient way to quantify swallowing function. These findings contribute towards improving the clinical utility of ultrasound as a swallowing assessment tool. Further research on both normative and clinical populations is needed to validate hyoid movement metrics as a means of differentiating normal and abnormal swallows and to verify the reliability of automatic tracking.

WHAT THIS PAPER ADDS

What is already known on this subject There is growing interest in the use of ultrasound as an adjunct tool for assessing swallowing function. However, there is currently insufficient knowledge about the patterning and timing of lingual and hyoid movement in a typical swallow. We know that movement of the hyoid plays an essential role in bolus transition and airway protection. However, manual tracking of hyoid movement is time-consuming and restricts the extent of large-scale normative studies. What this study adds We show that hyoid movement can be tracked automatically, providing measurable continuous positional data. Measurements derived from this objective data are comparable with similar measures previously reported using videofluoroscopy and of the two automatic trackers assessed, the DNN approach demonstrates better robustness and higher agreement with manually derived measures. Using this kinematic data, hyoid movement can be related to different stages of swallowing. Clinical implications of this study This study contributes towards our understanding of the kinematics of a typical swallow by evaluating an automated hyoid tracking method, paving the way for future studies of typical and disordered swallow. The challenges of image acquisition highlight issues to be considered when establishing clinical protocols. The application of machine learning enhances the utility of ultrasound swallowing assessment by reducing the labour required and permitting a wider range of hyoid measurements. Further research in normative and clinical populations is facilitated by automatic data extraction allowing the validity of prospective hyoid measures in differentiating different types of swallows to be rigorously assessed.

Swallowing assessment in patients with dysphagia: Validity and reliability of a pocket-sized ultrasound system

BACKGROUND

The use of ultrasound as an adjunct to clinical swallowing evaluation provides quantitative physiological and morphological data. As a low-risk procedure, ultrasound imaging can be performed outside of a medical setting. This is particularly important for patients living in rural areas with restricted access to a hospital. Technical advances have produced pocket-sized ultrasound technology that is more affordable, and therefore within the fiscal reach of most allied health services.

AIMS

To explore the validity and reliability of pocket-sized ultrasound technology in dysphagia assessment.

METHODS & PROCEDURES

Data were acquired from 43 patients with dysphagia using the Clarius ultrasound device. Ultrasound and videofluoroscopic measures of hyoid and laryngeal displacement during liquid and puree swallowing were collected concurrently to quantify correlation and agreement between identical measures derived from the two instruments. Reliability of ultrasound was assessed for measures of hyoid and laryngeal displacement, tongue thickness, and size of the submental muscles in eight patients. Reliability was evaluated for the entire process of data acquisition including scanning and online measurement using an iPad in a clinical setting and for offline measurement on a computer screen to explore environmental influences on reliability.

OUTCOMES & RESULTS

Results revealed poor correlation between the measures of interest across instruments. Reliability of the entire process of data acquisition in a clinical setting was insufficient while reliability was more promising for offline measurements.

CONCLUSIONS & IMPLICATIONS

The clinical use of pocket-sized ultrasound devices, such as the Clarius system, for swallowing evaluation is not indicated at this time. Enhanced validity and reliability of the entire process of data acquisition are needed prior to clinical translation of such technology.

WHAT THIS PAPER ADDS

What is already known on the subject The use of ultrasound allows for radiation-free, non-invasive swallowing assessment. Some data suggest that ultrasound is valid and reliable in the evaluation of swallowing using standard-sized equipment. Insufficient validity and reliability have been reported for pocket-sized ultrasound technology in the assessment of healthy swallowing. What this paper adds to existing knowledge This research is the first to provide validity and reliability data of the pocket-sized Clarius technology in the evaluation of swallowing in patients with dysphagia. Insufficient validity and reliability of online data acquisition in a clinical environment were found. Reliability for offline measurement was more promising. What are the potential or actual clinical implications of this work? The clinical use of pocket-sized ultrasound devices, such as the Clarius system, for swallowing assessment is not indicated at this time.

Swallowing kinematic analysis might be helpful in predicting aspiration and pyriform sinus stasis

Aspiration due to dysphagia can lead to aspiration, which negatively impacts a patient’s overall prognosis. Clinically, videofluoroscopic swallow study (VFSS) is considered the gold-standard instrument to determine physiological impairments of swallowing. According to previously published literature, kinematic analyses of VFSS might provide further information regarding aspiration detection. In this study, 449 files of VFSS studies from 232 patients were divided into three groups: normal, aspiration, and pyriform sinus stasis. Kinematic analyses and between-group comparison were conducted. Significant between-group differences were noted among parameters of anterior hyoid displacement, maximal hyoid displacement, and average velocity of hyoid movement. No significant difference was detected in superior hyoid displacement. Furthermore, receiver-operating characteristic (ROC) analyses of anterior hyoid displacement, velocity of anterior hyoid displacement, and average velocity of maximal hyoid displacement showed acceptable predictability for detecting aspiration. Using 33.0 mm/s as a cutoff value of average velocity of maximal hyoid displacement, the sensitivity of detecting the presence of aspiration was near 90%. The investigators therefore propose that the average velocity of maximal hyoid displacement may serve as a potential screening tool to detect aspiration.

Complications during Fiberoptic Endoscopic Evaluation of Swallowing (FEES) in 5680 examinations

OBJECTIVE

To evaluate retrospectively the incidence of complications during Fiberoptic Endoscopic Evaluation of Swallowing (FEES) in 5680 examinations.

PATIENTS AND METHODS

5680 patients were evaluated at the Department of Otorhinolaryngology, Audiology and Phoniatrics of Pisa University Hospital between January 2014 and December 2018, involving both inpatients and outpatients. Most common comorbidities included neurological pathologies such as stroke (11.8%), neurodegenerative diseases (28.9%) and a history of previous head and neck surgery (24.6%). The evaluation was conducted by clinicians with experience in swallowing for a minimum of 10 years with the assistance of one or more speech language pathologists.

RESULTS

In all patients studied the endoscope insertion was tolerated and it was possible to visualize the pharyngo-laryngeal structures. Most patients reported discomfort In a minority of patients, complications were recorded, such as anterior epistaxis, posterior epistaxis, vasovagal crises and laryngospasm. Laryngospasm was recorded in patients affected by Amyotrophic Lateral Sclerosis (ALS). Multivariate binary logistic regression showed that discomfort, chronic gastrointestinal diseases, neurodegenerative diseases and brain tumors were risk factors associated with minor complications.

CONCLUSIONS

FEES proved to be easy to perform, well tolerated by the patients and cost-effective. It can be performed at the patient's bedside and it is characterized by low rate of complications. As a matter of fact, normally only discomfort, gagging and/or vomit are reported. Only rarely complications occur, such as anterior or posterior epistaxis episodes or vasovagal crises, but these are still easily managed. Exceptionally, more severe complications are reported: adverse drug reactions to substances such as blue dye (methylene blue) and local anesthetics (not used in our protocol), and laryngospasm.

Translating Ultrasound into Clinical Practice for the Assessment of Swallowing and Laryngeal Function: A Speech and Language Pathology-Led Consensus Study

Ultrasound (US) has an emerging evidence base for the assessment of swallowing and laryngeal function. Accessibility and technological advances support the use of US as a clinical assessment tool; however, there is insufficient evidence to support its translation into clinical practice. This study aimed to establish consensus on the priorities for translation of US into clinical practice for the assessment of swallowing and laryngeal function. Nominal Group Technique (NGT) was used as a formal method of consensus development. Clinicians and academics, all members of an international US working group, were invited to participate in the study. Two NGT meetings were held, where participants silently generated and then shared ideas. Participants anonymously ranked items. Rankings were aggregated before participants re-ranked items in order of priority. Discussions regarding rankings were recorded and transcribed to inform analysis. Member-checking with participants informed the final analysis. Participants (n = 15) were speech and language pathologists, physiotherapists and sonographers representing six countries. Fifteen items were identified and prioritised 1-13 (including two equally ranked items). Reliability, validity and normative data emerged as key areas for research while development of training protocols and engagement with stakeholders were considered vital to progressing US into practice. Analysis revealed common themes that might be addressed together in research, in addition to the ranked priority. A measured approach to the translation of US into clinical practice will enable effective implementation of this tool. Priorities may evolve as clinical and professional contexts shift, but this study provides a framework to advance research and clinical practice in this field.

Emerging Role of Ultrasound in Dysphagia Assessment and Intervention: A Narrative Review

Ultrasonography has gained increasing attention as a non-invasive and radiation-free instrument for the assessment of swallowing function. In the past decades, an extensive repertoire of ultrasonographic techniques, such as, B-mode dynamic scanning, pixel analysis, M-mode, Doppler, 3D reconstruction, and sonoelastography, has been applied in the evaluation of oropharyngeal structures and movement. Yet, a universal consensus on the examination protocols and clinical implications remains to be established. This review aimed to provide a brief introduction of the application of ultrasound in dysphagia assessment and intervention, encompassing the ultrasonography of swallowing-related muscles, tongue movement, and hyolaryngeal excursion, as well as ultrasound-guided interventions in the management of dysphagia. In addition to non-invasiveness, ultrasonography, a portable, easy to use, and low-cost technique, could compliment videofluoroscopic swallowing study as a first-line screening and follow-up tool for the evaluation of swallowing function, although further study is warranted to provide quantitative diagnostic and prognostic values. Finally, ultrasonography aids in the precisely targeted injection of botulinum toxin in patients exhibiting oropharyngeal muscle spasticity.

Ultrasound: Reliability of a Pocket-Sized System in the Assessment of Swallowing

Purpose Ultrasound imaging offers a noninvasive adjunct to clinical swallowing assessment. Published reliability of sophisticated ultrasound systems is promising; however, no data exist for reliability using more affordable, pocket-sized devices. This study explored intrarater, interrater, and test-retest reliability of swallowing measures acquired with pocket-sized ultrasound technology. Method Five participants collected measures of swallowing from 20 healthy individuals using the Clarius ultrasound. Hyoid excursion and thyrohyoid approximation were derived during saliva, liquid, and puree swallowing. The cross-sectional area of the floor of mouth muscles and tongue thickness were obtained at rest. Measures were collected at two occasions minimum 11 days apart. Reliability was assessed for the entire process of data acquisition including scanning and online measurement, and for offline measurement of saved images. Results For most measures, reliability was poor (ICC [intraclass correlation coefficient] < .50) to moderate (ICC = .50-.75) for the entire process of data acquisition and poor to good (ICC > .75) when measuring saved images. Conclusion Further work is needed to elucidate whether our study findings apply to the Clarius system only or the data suggest a general limitation of pocket-sized ultrasound technology.

Ultrasound: an emerging modality for the dysphagia assessment toolkit?

PURPOSE OF REVIEW

Videofluoroscopy (VFSS) and fibreoptic endoscopic evaluation of swallowing (FEES) are established instrumental techniques to support differential diagnosis and treatment of oropharyngeal dysphagia. Whilst their value is undisputed, each tool is not without limitations. The COVID-19 pandemic has restricted access to VFSS and FEES leading clinicians to explore alternative or augmentative tools to support swallowing assessment.Ultrasound (US) is an established tool for visualisation of head and neck anatomy, including structures implicated in swallowing. Although US has been utilised in swallowing research for many years, its application has not translated into common clinical practice. This review presents and debates the evidence for and against use of US for clinical swallowing assessment.

RECENT FINDINGS

Evaluation of swallowing muscle morphometry and measurement of isolated swallowing kinematics are two primary uses of US in swallowing assessment that have been identified in the literature. Use of US to detect bolus flow, aspiration and residues is in its early stages and needs further research.

SUMMARY

US shows promise as an adjunctive modality to support assessment of swallowing. With standardisation, these measurements may have potential for transition into clinical care. Reliability and validity testing and development of normative data are imperative to ensure its use as an evidence-based instrumentation.

Automatic Hyoid Bone Tracking in Real-Time Ultrasound Swallowing Videos Using Deep Learning Based and Correlation Filter Based Trackers

(1) Background: Ultrasound provides a radiation-free and portable method for assessing swallowing. Hyoid bone locations and displacements are often used as important indicators for the evaluation of swallowing disorders. However, this requires clinicians to spend a great deal of time reviewing the ultrasound images. (2) Methods: In this study, we applied tracking algorithms based on deep learning and correlation filters to detect hyoid locations in ultrasound videos collected during swallowing. Fifty videos were collected from 10 young, healthy subjects for training, evaluation, and testing of the trackers. (3) Results: The best performing deep learning algorithm, Fully-Convolutional Siamese Networks (SiamFC), proved to have reliable performance in getting accurate hyoid bone locations from each frame of the swallowing ultrasound videos. While having a real-time frame rate (175 fps) when running on an RTX 2060, SiamFC also achieved a precision of 98.9% at the threshold of 10 pixels (3.25 mm) and 80.5% at the threshold of 5 pixels (1.63 mm). The tracker's root-mean-square error and average error were 3.9 pixels (1.27 mm) and 3.3 pixels (1.07 mm), respectively. (4) Conclusions: Our results pave the way for real-time automatic tracking of the hyoid bone in ultrasound videos for swallowing assessment.

Best Practice Recommendations for Stroke Patients with Dysphagia: A Delphi-Based Consensus Study of Experts in Turkey-Part I: Management, Diagnosis, and Follow-up

Dysphagia is one of the most common and important complications of stroke. It is an independent marker of poor outcome after acute stroke and may become chronic after the acute period and continues to affect all aspects of the patient's life. Patients with stroke may encounter any of the medical branches in the emergency room or outpatient clinic, and as in our country, there may not be specialists specific for dysphagia, such as speech-language pathologists (SLP), in every hospital. This study aimed to raise awareness and create a common opinion of medical specialists for stroke patients with dysphagia. This recommendation paper has been written by a multidisciplinary team and offers 45 recommendations for stroke patients with dysphagia. It was created using the eight-step Delphi round via e-mail. This study is mostly specific to Turkey. However, since it contains detailed recommendations from the perspective of various disciplines associated with stroke, this consensus-based recommendation paper is not only a useful guide to address clinical questions in practice for the clinical management of dysphagia in terms of management, diagnosis, and follow-up, but also includes detailed comments for these topics.

Recovery of early postoperative muscle strength after deep neuromuscular block by means of ultrasonography with comparison of neostigmine versus sugammadex as reversal drugs: study protocol for a randomised controlled trial

INTRODUCTION

Despite the use of quantitative neuromuscular monitoring together with the administration of reversal drugs (neostigmine or sugammadex), the incidence of residual neuromuscular blockade defined as a train-of-four ratio (TOFr) <0.9 remains high. Even TOFr >0.9 cannot ensure adequate recovery of neuromuscular function when T1 height is not recovered completely. Thus, a mathematical correction of TOFr needs to be applied because the return of a normal TOFr can precede the return of a normal T1 twitch height. On the other hand, different muscles have different sensitivities to neuromuscular blockade agents; thus, complete recovery of one specific muscle group does not represent complete recovery of all other muscles. Therefore, our study aims to assess the muscle strength recovery of respiratory-related muscle groups by ultrasound and evaluate global strength using handgrip dynamometry in the early postoperative period when TOFr=0.9 and corrected TOFr (cTOFr)=0.9 with comparison of neostigmine versus sugammadex as reversal drugs.

METHODS AND ANALYSIS

This study will be a prospective, single-blinded, randomised controlled trial involving 60 patients with American Society of Anesthesiologists physical status I-II and aged between 18 and 65 years, who will undergo microlaryngeal surgery. We will assess geniohyoid muscle, parasternal intercostal muscle, diaphragm, abdominal wall muscle and handgrip strength at four time points: before anaesthesia, TOFr=0.9, cTOFr=0.9 and 30 min after admission to the post anaesthesia care unit. Our primary objective will be to compare the effects of neostigmine and sugammadex on the recovery of muscle strength of different muscle groups in the early postoperative period when TOFr=0.9 and cTOFr=0.9. The secondary objective will be to observe the difference of muscle strength between the time points of TOFr=0.9 and cTOFr=0.9 to find out the clinical significance of cTOFr >0.9.

ETHICS AND DISSEMINATION

The protocol was reviewed and approved by the Ethics Committee of The First Affiliated Hospital, Sun Yat-sen University. The findings will be disseminated to the public through peer-reviewed scientific journals.

TRIAL REGISTRATION NUMBER

ChiCTR2000033832.

Ultrasound: Validity of a Pocket-Sized System in the Assessment of Swallowing

Adequate hyoid and laryngeal displacement facilitate safe and efficient swallowing. Although videofluoroscopy is commonly used for assessment of this biomechanical event, ultrasound provides benefits as a radiation-free modality for this purpose. This study investigated validity of a pocket-sized ultrasound system (Clarius™) in the assessment of hyoid and laryngeal excursion. Hyoid excursion and thyrohyoid approximation were concurrently assessed in 20 healthy adults using ultrasound and videofluoroscopy during saliva, liquid, and puree swallowing. Correlation analyses were performed to evaluate validity. There was a strong and moderate positive association between ultrasound and videofluoroscopic measurements of hyoid excursion during dry and liquid swallowing, respectively. No evidence for a significant association was found for ultrasound and videofluoroscopic measurements of hyoid excursion for puree swallowing and of thyrohyoid approximation for any bolus type. Further work towards improved validity is necessary prior to clinical transfer of the pocket-sized Clarius™ system in clinical swallowing assessment.

Detecting Oropharyngeal and Esophageal Emptying by Submental Ultrasonography and High-Resolution Impedance Manometry: Intubated vs. Non-Intubated Video-Assisted Thoracoscopic Surgery

Postoperative swallowing, affected by general anesthesia and intubation, plays an important part in airway and oral intake safety regarding effective oropharyngeal and esophageal emptying. However, objective evidence is limited. This study aimed to determine the time required from emergence to effective oropharyngeal and esophageal emptying in patients undergoing non-intubated (N) or tracheal-intubated (I) video-assisted thoracoscopic surgery (VATS). Hyoid bone displacement (HBD) by submental ultrasonography and high-resolution impedance manometry (HRIM) measurements were used to assess oropharyngeal and esophageal emptying. HRIM was performed every 10 min after emergence, up to 10 times. The primary outcome was to determine whether intubation affects the time required from effective oropharyngeal to esophageal emptying. The secondary outcome was to verify if HBD is comparable to preoperative data indicating effective oropharyngeal emptying. Thirty-two patients suitable for non-intubated VATS were recruited. Our results showed that comparable HBDs were achieved in all patients after emergence. Effective esophageal emptying was achieved at the first HRIM measurement in 11 N group patients and 2 I group patients (p = 0.002) and was achieved in all N (100%) and 13 I group patients (81%) within 100 min (p = 0.23). HBD and HRIM are warranted for detecting postoperative oropharyngeal and esophageal emptying.

Application of Ultrasound Biofeedback to the Learning of the Mendelsohn Maneuver in Non-dysphagic Adults: A Pilot Study

This study aimed to investigate the application of ultrasound to the learning of swallowing maneuver. Forty non-dysphagic adults of both genders who were naïve to the Mendelsohn maneuver participated in the study. They were randomly assigned to receive ultrasound or surface electromyography (sEMG) as biofeedback when acquiring the Mendelsohn maneuver. Thirty-eight subjects (n = 19) completed the Learning phase. Accuracy of executing the Mendelsohn maneuver was measured immediately (Post-training percentage accuracy) and one week post-training (Retention percentage accuracy). Whereas comparable numbers of training blocks were completed by the two groups (t(31.51) = 3.68, p = 0.330), the Ultrasound group attained significantly higher percentage accuracies than the sEMG group at both Post-training (t(28.88) = 4.04, p < 0.001, d = 1.309) and Retention (t(30.78) = 2.13, p = 0.042, d = 0.690). Ultrasound is a more effective biofeedback than sEMG in the acquisition of the Mendelsohn maneuver and may be adopted to the rehabilitative treatment for dysphagic individuals. Non-specificity of sEMG as biofeedback should be emphasized when it is employed in the training and learning of swallowing maneuvers. Findings from the present study suggest that ultrasound is preferable to sEMG as biofeedback in the learning of the Mendelsohn maneuver.

Impact and Management of Dysphagia in Inflammatory Myopathies

PURPOSE OF REVIEW

Dysphagia is a common symptom in inflammatory myopathies. This review provides an overview on the epidemiology, clinical impact, and management of dysphagia in myositis. Relevant diagnostic tools and treatment strategies are discussed.

RECENT FINDINGS

Dysphagia can occur in any inflammatory myopathy, particularly in inclusion body myositis (IBM). It can lead to malnutrition or aspiration with subsequent pneumonia or even death. Dysphagia can be explored and monitored by patient-reported outcome scales for swallowing. New diagnostic tools such as real-time MRI and oro-pharyngo-esophageal scintigraphy have been studied for assessing dysphagia. Botulinum toxin injection can alleviate dysphagia in IBM. High-dose glucocorticosteroids are considered a first-line treatment for dysphagia in all other myositis subforms. Evaluation of dysphagia in myositis requires thorough clinical workup and appropriate instrumental procedures. Treatment options are available for dysphagia, but controlled trials and consensus on best patient care are required for this important symptom.

Correlation of Temporal Parameters of Laryngeal Excursion by Using Force-Sensing Resistor Sensors with Hyoid Motion in Videofluoroscopic Swallowing Study

Small flexible force-sensing resistor (FSR) sensors can detect laryngeal excursion during swallowing, but the detected laryngeal excursion has not been correlated with videofluoroscopic swallowing study (VFSS) results. Here, we tested the correlation of temporal parameters between the laryngeal excursion recording by FSR sensor and the hyoid motion recording by VFSS under simultaneously swallowing test recordings. Swallowing measurements were recorded in a radiological suite by simultaneously using VFSS and FSR sensors to detect hyoid motion and laryngeal excursion, respectively. Volunteers sat with their head vertical to the Frankfort plane. Two FSR sensors, each for detecting thyroid cartilage excursion and thumb pressing, were placed. VFSS images and FSR sensor signals during single 5-mL barium liquid (30% wt/volume %) bolus swallowing were collected and analyzed for four swallows per participant. In total, 15 men (28.0 ± 4.1 years old); 14 women (28.4 ± 4.2 years old) were recruited. Temporal parameters between VFSS and noninvasive system demonstrated a strong correlation by Pearson's correlation analysis: in men (R = 0.953-0.999) and in women (R = 0.813-0.982), except for VT1-V1 compared with FT1-F1, which demonstrated a moderate correlation in women (R = 0.648; all p < 0.001). Only VT1-V1 and FT1-F1 in women displayed a significant difference (p = 0.001). Therefore, this is the first study to simultaneous record VFSS and noninvasive signals by FSR sensor. The correlation of temporal parameters between these two tests was strong. This finding is valuable for future applications of this noninvasive swallowing study tool.

May ultrasonography be considered a useful tool for bedside screening of dysphagia in patients with acute stroke? A cohort study

BACKGROUND

Dysphagia is a primary risk factor for pneumonia and affects around 50% of acute stroke patients. Systematic bedside swallowing screening of acute stroke patients is recommended before oral intake. Currently there is lack of comprehensive dysphagia assessment tools with robust good accuracy, clinical utility and cost-effectiveness. An altered hyoid bone movement may represent a major risk factor for aspiration. Ultrasonography quantitatively measures hyoid-larynx approximation, which was found reduced in stroke patients with dysphagia. Although ultrasonography was suggested for assessing stroke patients with dysphagia, there is lack of evidence about the acute phase of stroke. Thus, our aim was to investigate the use of ultrasonography for bedside screening of dysphagia in acute stroke patients.

METHODS

Nineteen acute stroke patients were included. Each patient performed clinical bedside screening for dysphagia by means of the Gugging Swallow Screen and the Functional Oral Intake Scale. Furthermore, all patients underwent ultrasonography in order to measure the distance between the thyroid cartilage and hyoid bone during swallowing (water bolus of 3 mL). The hyoid-larynx approximation distance (obtained by subtracting [a-b] the shortest distance between the hyoid bone and thyroid cartilage during swallowing (b) from the initial resting distance (a) and degree {[(a-b)/a]×100} were calculated).

RESULTS

The Functional Oral Intake Scale showed a significant direct association with the hyoid-larynx approximation distance (P=0.011) and degree (P=0.005). Also, the Gugging Swallow Screen showed a significant direct association with the hyoid-larynx approximation distance (P=0.008) and degree (P=0.004). The hyoid-larynx approximation distance and degree were significantly reduced in dysphagic patients.

CONCLUSIONS

Our findings support the use of ultrasonography in aid of swallowing clinical (non-instrumental) evaluation for the bedside screening of dysphagia in acute stroke patients.

Using ultrasound to characterize the tongue-food interface: An in vitro study examining the impact of surface roughness and lubrication

We measured the apparent reflection coefficient of a 1-MHz ultrasound compressional wave at the interface between rough and lubricated tongue mimicking surfaces and various food gels, composed of agar or gelatin. For the smoothest mimicking surface, when a lubricating layer was present, the apparent reflection coefficient was fairly similar for the different food gels (33.6% on average). The apparent reflection coefficient was significantly larger in the following situations: (i) tongue asperities were high and dense; (ii) lubrication levels were low; and (iii) gels were less rigid (range for the different gels-45.9-84.3%). The apparent reflection coefficient conveys the ability of food gels to mold themselves to surface asperities or to form a coupling film of liquid at the interface. This study demonstrates that ultrasound methods can and should be used to explore the physical phenomena that underlie the texture perceptions resulting from tongue-palate interactions.

Evaluation of swallowing movement using ultrasonography

The aim of this study is to develop an index to assess swallowing function by ultrasonography to evaluate the relationship between movements of the hyoid bone and the larynx while swallowing water. Forty-two younger participants (mean age, 20.3 ± 3.4 years) and 42 older participants (mean age, 75.1 ± 10.6 years) with normal swallowing function were included in the study. Movements of the hyoid bone and the larynx while swallowing 5 mL of water were observed using ultrasonography. Two-dimensional distances from the starting points of the hyoid bone and the larynx to their points of maximum movement were measured as displacements. The hyoid bone-laryngeal motion ratio was defined as the hyoid bone displacement divided by the laryngeal displacement. Parameters were compared among four groups: younger male, younger female, older male, and older female. The hyoid bone displacement differed significantly between the younger and older groups, and the laryngeal displacement differed significantly between age groups and sexes. The hyoid bone-laryngeal motion ratio was not significantly correlated with age, height, or body weight, and did not show a significant difference between the four groups. Thus, the hyoid bone-laryngeal motion ratio is an index that evaluates swallowing movement and is independent of physique and physiological changes associated with aging.

Does the M.D. Anderson Dysphagia Inventory correlate with dysphagia-limit and the Unified Parkinson Disease Rating Scale in early-stage Parkinson's disease?

BACKGROUND

Dysphagia is a common and critical condition that occurs in Parkinson's disease (PD), and it may appear in early stages. However, few reliable swallowing-related questionnaires are currently available. Therefore, finding efficient questionnaires for surveying dysphagia during the early stages of PD is necessary.

PURPOSE

This prospective study aimed to identify the correlations between the M.D. Anderson Dysphagia Inventory (MDADI) with dysphagia limit (DL) and the Unified Parkinson Disease Rating Scale (UPDRS) in early-stage PD.

METHODS

Forty-two patients with early-stage PD were recruited from a medical center. Data were collected for analysis of swallowing-related quality of life using the MDADI, symptom severity using the UPDRS, and DL using a noninvasive swallowing-respiration assessment system.

RESULTS

Our results showed that the MDADI, including its composite and subscales, was not correlated with DL. The composite scores of the MDADI were moderately correlated with the total score of the UPDRS (r = -0.504; p < 0.05) as well as with the second and third sections of the UPDRS scores (r = -0.453 to -0.478; p < 0.05). These results indicated that the impaired MDADI score can predict symptom severity (UPDRS), especially in activities of daily life and motor function.

CONCLUSION

The impaired MDADI for early-stage PD was determined, and decreased DL as a presentation of dysphagia could not be reflected by the MDADI. The MDADI may be used as a quick and convenient questionnaire for predicting the severity of early-stage PD, but not for the screening of early or subclinical dysphagia.

Influence of Nasogastric Tubes on Swallowing in Stroke Patients: Measuring Hyoid Bone Movement With Ultrasonography

OBJECTIVE

To investigate the influence of a nasogastric tube (NGT) on swallowing simulated saliva in stroke patients.

METHODS

Three groups of participants were enrolled into the study: group A (20 stroke patients with a NGT), a control group B (25 stroke patients without a NGT), and group C (25 healthy adults with no brain lesions or dysphagia). Participants swallowed 1 mL of water to simulate saliva. Patients in group A were tested twice: once with a NGT (group A1) and once after the NGT was removed (group A2). The distance of hyoid bone movement was measured by subtracting the shortest distance between the mandible and hyoid bone (S) from the distance at resting state (R) measured with ultrasonography. The degree of the movement was calculated by (R-S)/R. The trajectory area of hyoid bone movement (Area) and the interval between the beginning of hyoid bone movement and the moment of the shortest hyoid-mandible approximation (Interval) was calculated by a computer program.

RESULTS

From group A: R-S and (R-S)/R of group A2 at 1.14±0.36 cm and 0.30±0.09 cm and were significantly greater than those of group A1 at 0.81±0.36 cm and 0.22±0.08 cm (p=0.009 and p=0.005). After removing the NGT as seen in group A2, R-S and (R-S)/R were improved to the level of those of group B at 1.20±0.32 cm and 0.30±0.09 cm (p=0.909 and p=0.997). The Area of group A2 was larger and the Interval of group A2 was shorter than those of group A1 though a comparison of these factors between A2 and A1 did not show a statistically significant difference.

CONCLUSION

A NGT interferes with the movement of the hyoid bone when swallowing 1 mL of water in stroke patients though the movement is restored to normal after removing the NGT.

Sonographic assessment of swallowing in irradiated nasopharyngeal carcinoma patients

Objectives/Hypothesis

Ultrasonography is an emerging clinical tool to study the dysfunction of swallowing muscles. This was the first sonographic study to assess the relationship between suprahyoid muscle contraction, hyoid bone displacement, and penetration‐aspiration status (PAS) during swallowing in nasopharyngeal carcinoma (NPC) patients treated with radiotherapy (RT). The study also aimed to establish reliability data for the sonographic technique described.

Study Design

Cross‐sectional study.

Methods

Geniohyoid muscle contraction was quantified using brightness‐mode ultrasonography in this study of 40 post‐RT NPC patients. A series of physiological parameters and PAS were measured using videofluoroscopy.

Results

Intra‐ and inter‐rater agreement values ranged from 0.75 to 0.96 across various sonographic measurements. Percentage increase in the cross‐sectional area of the geniohyoid muscle correlated with anterior (r = 0.42, P < .05) but not superior (r = 0.27, P = .09) hyoid displacement. Anterior hyoid displacement and pharyngeal constriction ratio were significantly associated with PAS score.

Conclusions

Sonographic measurement of suprahyoid muscles provides valuable information on muscle function and is potentially a useful clinical tool in swallowing assessment. Further research is needed to refine the role of this examination in dysphagia.

Level of Evidence

2b. Laryngoscope, 2552–2559, 2018

Reliability of Ultrasonography in Evaluating Hyoid Bone Movement

Background

Timely and adequate laryngeal elevation along with hyoid bone movement is an essential component of the swallowing movement under normal physiological conditions. The purpose of this study was to verify the reproducibility of using ultrasonography to evaluate hyoid bone displacement during swallowing through the assessment of inter- and intrarater reliability and examine its accuracy by comparing the results with videofluoroscopic swallowing study (VFSS).

Methods

A self-designed water balloon was fixed to the transducer, which provided good contact between the transducer and the submental skin. Ten participants with dysphagia were recruited. The measurements of hyoid bone displacement using ultrasonography were performed by two of the authors. All the participants underwent ultrasonographic examinations and VFSS within 24 hours.

Results

The intrarater intraclass correlation coefficient (ICC) of the two examiners was 0.996 and 0.959, respectively (p < 0.01); the interrater ICC between the two examiners was 0.892 (p < 0.05). ICCs between VFSS and ultrasonography for two researchers were 0.815 and 0.916 (p < 0.01).

Conclusion

Submental ultrasonography is a reliable and accurate method for assessing the hyoid bone movement.

Dynamic muscle ultrasound identifies upper motor neuron involvement in amyotrophic lateral sclerosis

OBJECTIVE

The aim of the present study was to elucidate the pattern of change in bulbar muscles using ultrasound in patients diagnosed with amyotrophic lateral sclerosis (ALS).

METHODS

Changes in the mylohyoid and geniohyoid muscle complex (mylohyoid-geniohyoid-muscle-complex) thickness were recorded while swallowing 5 ml of water using M-mode ultrasound in 30 ALS patients compared to 20 healthy controls. The ratio of mylohyoid-geniohyoid-muscle-complex thickness as determined by the maximum thickness of mylohyoid-geniohyoid-muscle-complex during swallowing divided by thickness at rest, was compared between ALS patients and controls, with the correlation between thickness ratio, echogenicity and clinical parameters assessed.

RESULTS

Overall, the thickness ratio in ALS patients was 1.39 ± 0.23 (mean ± SD) compared to 1.55 ± 0.17 in controls (p < 0.05). In sub-analysis, the thickness ratio was significantly decreased in ALS patients with bulbar-onset disease compared to those with limb-onset disease (p < 0.01) and controls (p < 0.01). Thickness ratio negatively correlated with the severity of upper motor neuron involvement in the bulbar region (p < 0.05).

CONCLUSIONS

Bulbar muscle ultrasound represents a novel method to detect impaired mobility and thereby provides an objective assessment of upper motor neuron involvement in the bulbar region of ALS patients.