On the physiology of normal swallowing as revealed by magnetic resonance imaging in real time

An open-source toolbox for measuring vocal tract shape from real-time magnetic resonance images

Real-time magnetic resonance imaging (rtMRI) is a technique that provides high-contrast videographic data of human anatomy in motion. Applied to the vocal tract, it is a powerful method for capturing the dynamics of speech and other vocal behaviours by imaging structures internal to the mouth and throat. These images provide a means of studying the physiological basis for speech, singing, expressions of emotion, and swallowing that are otherwise not accessible for external observation. However, taking quantitative measurements from these images is notoriously difficult. We introduce a signal processing pipeline that produces outlines of the vocal tract from the lips to the larynx as a quantification of the dynamic morphology of the vocal tract. Our approach performs simple tissue classification, but constrained to a researcher-specified region of interest. This combination facilitates feature extraction while retaining the domain-specific expertise of a human analyst. We demonstrate that this pipeline generalises well across datasets covering behaviours such as speech, vocal size exaggeration, laughter, and whistling, as well as producing reliable outcomes across analysts, particularly among users with domain-specific expertise. With this article, we make this pipeline available for immediate use by the research community, and further suggest that it may contribute to the continued development of fully automated methods based on deep learning algorithms.

Visualization of deglutition and gastroesophageal reflux using real-time MRI: a standardized approach to image acquisition and assessment

This study aims to develop a standardized algorithm for gastroesophageal image acquisition and diagnostic assessment using real-time MRI. Patients with GERD symptoms undergoing real-time MRI of the esophagus and esophagogastric junction between 2015 and 2018 were included. A 10 ml bolus of pineapple juice served as an oral contrast agent. Patients performed Valsalva maneuver to provoke reflux and hiatal hernia. Systematic MRI assessment included visual presence of achalasia, fundoplication failure in patients with previous surgical fundoplication, gastroesophageal reflux, and hiatal hernia. A total of 184 patients (n = 92 female [50%], mean age 52.7 ± 15.8 years) completed MRI studies without adverse events at a mean examination time of 15 min. Gastroesophageal reflux was evident in n = 117 (63.6%), hiatal hernia in n = 95 (52.5%), and achalasia in 4 patients (2.2%). Hiatal hernia was observed more frequently in patients with reflux at rest (n = 67 vs. n = 6, p < 0.01) and during Valsalva maneuver (n = 87 vs. n = 8, p < 0.01). Real-time MRI visualized a morphologic correlate for recurring GERD symptoms in 20/22 patients (90%) after fundoplication procedure. In a large-scale single-center cohort of patients with GERD symptoms undergoing real-time MRI, visual correlates for clinical symptoms were evident in most cases. The proposed assessment algorithm could aid in wider-spread utilization of real-time MRI and provides a comprehensive approach to this novel imaging modality.

GERD-related chronic cough: Possible mechanism, diagnosis and treatment

GERD, or gastroesophageal reflux disease, is a prevalent medical condition that affects millions of individuals throughout the world. Chronic cough is often caused by GERD, and chronic cough caused by GER is defined as GERD-related chronic cough (GERC). It is still unclear what the underlying molecular mechanism behind GERC is. Reflux theory, reflex theory, airway allergies, and the novel mechanism of esophageal motility disorders are all assumed to be linked to GERC. Multichannel intraluminal impedance combined with pH monitoring remains the gold standard for the diagnosis of GERC, but is not well tolerated by patients due to its invasive nature. Recent discoveries of new impedance markers and new techniques (mucosal impedance testing, salivary pepsin, real-time MRI and narrow band imaging) show promises in the diagnosis of GERD, but the role in GERC needs further investigation. Advances in pharmacological treatment include potassium-competitive acid blockers and neuromodulators (such as Baclofen and Gabapentin), prokinetics and herbal medicines, as well as non-pharmacological treatments (such as lifestyle changes and respiratory exercises). More options have been provided for the treatment of GERC other than acid suppression therapy and anti-reflux surgery. In this review, we attempt to review recent advances in GERC mechanism, diagnosis, and subsequent treatment options, so as to provide guidance for management of GERC.

Assessment of esophagogastric junction morphology by dynamic real-time MRI: comparison of imaging features to high-resolution manometry

Purpose

To assess the esophagogastric junction (EGJ) on real-time MRI and compare imaging parameters to EGJ morphology on high-resolution manometry (HRM).

Methods

A total of 105 of 117 eligible patients who underwent real-time MRI and high-resolution manometry for GERD-like symptoms between 2015 and 2018 at a single center were retrospectively evaluated (male n = 57; female n = 48; mean age 52.5 ± 15.4 years). Real-time MRI was performed at a median investigation time of 15 min (1 frame/40 ms). On HRM, EGJ morphology was assessed according to the Chicago classification of esophageal motility disorders. Real-time MRI was performed at 3 T using highly undersampled radial fast low-angle shot acquisitions with NLINV image reconstruction. A 10 mL pineapple juice bolus served as oral contrast agent at supine position. Real-time MRI films of the EGJ were acquired during swallowing events and during Valsalva maneuver. Anatomic and functional MRI parameters were compared to EGJ morphology on HRM.

Results

On HRM, n = 42 patients presented with EGJ type I (40.0%), n = 33 with EGJ type II (31.4%), and n = 30 with EGJ type III (28.6%). On real-time MRI, hiatal hernia was more common in patients with EGJ type III (66.7%) than in patients with EGJ type I (26.2%) and EGJ type II (30.3%; p < 0.001). Sliding hiatal hernia was more frequent in patients with EGJ type II (33.3%) than in patients with EGJ type III (16.7%) and EGJ type I (7.1%; p = 0.017). The mean esophagus–fundus angle of patients was 85 ± 31° at rest and increased to 101 ± 36° during Valsalva maneuver.

Conclusion

Real-time MRI is a non-invasive imaging method for assessment of the esophagogastric junction. Real-time MRI can visualize dynamic changes of the EGJ during swallowing events.

Supplementary Information

The online version contains supplementary material available at 10.1007/s11604-021-01210-9.

Dynamic MRI of swallowing: real-time volumetric imaging at 12 frames per second at 3 T

Objective

Dysphagia or difficulty in swallowing is a potentially hazardous clinical problem that needs regular monitoring. Real-time 2D MRI of swallowing is a promising radiation-free alternative to the current clinical standard: videofluoroscopy. However, aspiration may be missed if it occurs outside this single imaged slice. We therefore aimed to image swallowing in 3D real time at 12 frames per second (fps).

Materials and methods

At 3 T, three 3D real-time MRI acquisition approaches were compared to the 2D acquisition: an aligned stack-of-stars (SOS), and a rotated SOS with a golden-angle increment and with a tiny golden-angle increment. The optimal 3D acquisition was determined by computer simulations and phantom scans. Subsequently, five healthy volunteers were scanned and swallowing parameters were measured.

Results

Although the rotated SOS approaches resulted in better image quality in simulations, in practice, the aligned SOS performed best due to the limited number of slices. The four swallowing phases could be distinguished in 3D real-time MRI, even though the spatial blurring was stronger than in 2D. The swallowing parameters were similar between 2 and 3D.

Conclusion

At a spatial resolution of 2-by-2-by-6 mm with seven slices, swallowing can be imaged in 3D real time at a frame rate of 12 fps.

Supplementary Information

The online version contains supplementary material available at 10.1007/s10334-021-00973-6.

3D-CT Evaluation of Swallowing: Metrics of the Swallowing Response Using Swallowing CT

Videofluoroscopy and videoendoscopy dramatically changed the evaluation and management of swallowing disorders. Later advancements in techniques for the instrumental evaluation of swallowing were limited by technique and positioning. The advent of 320-row area detector CT solved previous challenges and allowed for the study of swallowing physiology and dysphagia in greater detail. In this summary, we describe the history and evolution of CT technology and describe research and clinical applications for the evaluation of swallowing physiology and pathophysiology.

Real-time magnetic resonance imaging in pediatric radiology - new approach to movement and moving children

The recent development of highly undersampled radial gradient echo sequences in combination with nonlinear inverse image reconstruction now allows for MRI examinations in real time. Image acquisition times as short as 20 ms yield MRI videos with rates of up to 50 frames per second with spin density, T1- and T2-type contrast. The addition of an initial 180° inversion pulse achieves accurate T1 mapping within only 4 s. These technical advances promise specific advantages for studies of infants and young children by eliminating the need for sedation or anesthesia. Our preliminary data demonstrate new diagnostic opportunities ranging from dynamic studies of speech and swallowing processes and body movements to a rapid volumetric assessment of brain cerebrospinal fluid spaces in only few seconds. Real-time MRI of the heart and blood flow can be performed without electrocardiogram gating and under free breathing. The present findings support the idea that real-time MRI will complement existing methods by providing long-awaited diagnostic options for patients in early childhood. Major advantages are the avoidance of sedation or anesthesia and the yet unexplored potential to gain insights into arbitrary body functions.

Realistic Dynamic Numerical Phantom for MRI of the Upper Vocal Tract

Dynamic and real-time MRI (rtMRI) of human speech is an active field of research, with interest from both the linguistics and clinical communities. At present, different research groups are investigating a range of rtMRI acquisition and reconstruction approaches to visualise the speech organs. Similar to other moving organs, it is difficult to create a physical phantom of the speech organs to optimise these approaches; therefore, the optimisation requires extensive scanner access and imaging of volunteers. As previously demonstrated in cardiac imaging, realistic numerical phantoms can be useful tools for optimising rtMRI approaches and reduce reliance on scanner access and imaging volunteers. However, currently, no such speech rtMRI phantom exists. In this work, a numerical phantom for optimising speech rtMRI approaches was developed and tested on different reconstruction schemes. The novel phantom comprised a dynamic image series and corresponding k-space data of a single mid-sagittal slice with a temporal resolution of 30 frames per second (fps). The phantom was developed based on images of a volunteer acquired at a frame rate of 10 fps. The creation of the numerical phantom involved the following steps: image acquisition, image enhancement, segmentation, mask optimisation, through-time and spatial interpolation and finally the derived k-space phantom. The phantom was used to: (1) test different k-space sampling schemes (Cartesian, radial and spiral); (2) create lower frame rate acquisitions by simulating segmented k-space acquisitions; (3) simulate parallel imaging reconstructions (SENSE and GRAPPA). This demonstrated how such a numerical phantom could be used to optimise images and test multiple sampling strategies without extensive scanner access.

Real-time MRI for dynamic assessment of gastroesophageal reflux disease: Comparison to pH-metry and impedance

PURPOSE

To evaluate the diagnostic potential of real-time MRI for dynamic assessment of gastroesophageal reflux in patients with GERD (gastroesophageal reflux disease)-like symptoms compared to pH-metry and impedance.

METHODS

Patients who underwent real-time MRI and pH-metry between 2015-2018 were included in this retrospective study. Real-time MRI at 3 T was achieved by undersampled radial FLASH acquisitions with iterative image reconstruction by NLINV. Real-time MRI visualized transit of pineapple juice through the gastroesophageal junction and during Valsalva maneuver. MRI results were compared to 24 h pH-metry to assess acidic reflux (following Lyon Consensus guidelines) and to impedance to assess non-acidic reflux. A standard 2 × 2 table was chosen to calculate diagnostic performance.

RESULTS

91/93 eligible patients fulfilled inclusion criteria (male n = 49; female n = 42; median age 55 y). All MRI studies were successfully completed without adverse events at a mean examination time of 15 min. On real-time MRI, reflux was evident in 60 patients (66 %). pH-metry revealed reflux in 41 patients (45 %), and impedance in 54 patients (59 %). Compared to pH-metry and impedance, real-time MRI sensitivity was 0.78 (95 % CI: 0.66-0.87), specificity 0.67 (95 % CI: 0.45-0.84) and PPV 0.87 (95 % CI: 0.75-0.94).

CONCLUSION

Real-time MRI is an imaging method for assessment of gastroesophageal reflux in patients with GERD-like symptoms. Considering its high positive predictive value, real-time MRI can accurately identify patients in which further invasive testing with pH-metry and impedance might be considered.

Assessment of the Food-Swallowing Process Using Bolus Visualisation and Manometry Simultaneously in a Device that Models Human Swallowing

The characteristics of the flows of boluses with different consistencies, i.e. different rheological properties, through the pharynx have not been fully elucidated. The results obtained using a novel in vitro device, the Gothenburg Throat, which allows simultaneous bolus flow visualisation and manometry assessments in the pharynx geometry, are presented, to explain the dependence of bolus flow on bolus consistency. Four different bolus consistencies of a commercial food thickener, 0.5, 1, 1.5 and 2 Pa s (at a shear rate of 50 s-1)-corresponding to a range from low honey-thick to pudding-thick consistencies on the National Dysphagia Diet (NDD) scale-were examined in the in vitro pharynx. The bolus velocities recorded in the simulator pharynx were in the range of 0.046-0.48 m/s, which is within the range reported in clinical studies. The corresponding wall shear rates associated with these velocities ranged from 13 s-1 (pudding consistency) to 209 s-1 (honey-thick consistency). The results of the in vitro manometry tests using different consistencies and bolus volumes were rather similar to those obtained in clinical studies. The in vitro device used in this study appears to be a valuable tool for pre-clinical analyses of thickened fluids. Furthermore, the results show that it is desirable to consider a broad range of shear rates when assessing the suitability of a certain consistency for swallowing.

Swall-E: A robotic in-vitro simulation of human swallowing

Swallowing is a complex physiological function that can be studied through medical imagery techniques such as videofluoroscopy (VFS), dynamic magnetic resonance imagery (MRI) and fiberoptic endoscopic evaluation of swallowing (FEES). VFS is the gold standard although it exposes the subjects to radiations. In-vitro modeling of human swallowing has been conducted with limited results so far. Some experiments were reported on robotic reproduction of oral and esophageal phases of swallowing, but high fidelity reproduction of pharyngeal phase of swallowing has not been reported yet. To that end, we designed and developed a robotic simulator of the pharyngeal phase of human swallowing named Swall-E. 17 actuators integrated in the robot enable the mimicking of important physiological mechanisms occurring during the pharyngeal swallowing, such as the vocal fold closure, laryngeal elevation or epiglottis tilt. Moreover, the associated computer interface allows a control of the actuation of these mechanisms at a spatio-temporal accuracy of 0.025 mm and 20 ms. In this study preliminary experiments of normal pharyngeal swallowing simulated on Swall-E are presented. These experiments show that a 10 ml thick bolus can be swallowed by the robot in less than 1 s without any aspiration of bolus material into the synthetic anatomical laryngo-tracheal conduit.

New application of dynamic magnetic resonance imaging for the assessment of deglutitive tongue movement

Background

Deglutitive motion of the tongue may function to maintain tooth position. However, the causation between abnormal patterns of orofacial muscle function and dental malocclusion remains unclear. To clarify the pathogenic mechanism of malocclusion, it is important to determine the relative positional relationship between the tongue tip and incisor edge or the dorsal tongue and palate during deglutition. Here, we assessed the utility of 3-T segmented cine-magnetic resonance (MR) imaging, combined with static MR images for hard tissue visualization, in assessing the relationship between the tongue and the surrounding tissues during deglutitive tongue movement.

Methods

Cine-MR images were acquired from three healthy female volunteers during deglutition who had no history of swallowing disorder or other chronic illness, normal alignment and occlusion, and a skeletal class I relationship. Three cine-MR images were taken during deglutition in accordance with an auditory cue for each volunteer. During static imaging, custom-made, contrast-medium-filled clear retainers were positioned in the mouth to allow visualization of the upper and lower incisors and hard palate boundaries. Static images were superimposed onto images of the three stages in deglutitive tongue movement, which were selected from a series of cine-MR images. These superimpositions were assessed five times by tracing cephalometric parameters to examine the reproducibility of the method.

Results

Traces varied little across repeated measurements, and all subjects had a similar pattern of dorsal tongue movement. Tongue-to-palate contact increased slightly during the first to second stage of swallowing and abruptly increased during the second to third stage, while the tongue tip position remained constant.

Conclusions

Segmented cine-MR imaging combined with static MR images is useful for assessing soft tissue motion during deglutition. This method is particularly useful in dentistry to evaluate the relationship between tongue function and maxillofacial morphology in terms of orthodontic treatment and orofacial myofunctional therapy, and for improving tongue movement during speech therapy.

Electronic supplementary material

The online version of this article (10.1186/s40510-018-0245-x) contains supplementary material, which is available to authorized users.

Clinical Utility of Continuous Radial Magnetic Resonance Imaging Acquisition at 3 T in Real-time Patellofemoral Kinematic Assessment: A Feasibility Study

PURPOSE

To compare patellar instability with magnetic resonance imaging analysis using continuous real-time radial gradient-echo (GRE) imaging in the assessment of symptomatic patients and asymptomatic subjects.

METHODS

Symptomatic patients with suspected patellofemoral maltracking and asymptomatic volunteers were scanned in real time by a radial 2-dimensional GRE sequence at 3 T in axial orientation at the patella level through a range of flexion-extension. The degree of lateral maltracking, as well as the associated tibial tubercle-trochlear groove distance and trochlea depth, was measured. Patellar lateralization was categorized as normal (≤2 mm), mild (>2 to ≤5 mm), moderate (>5 to ≤10 mm), or severe (>10 mm). The patellofemoral cartilage was also assessed according to the modified Outerbridge grading system.

RESULTS

The study included 20 symptomatic patients (13 women and 7 men; mean age, 36 ± 12.8 years) and 10 asymptomatic subjects (3 women and 7 men; mean age, 33.1 years). The mean time to perform the dynamic component ranged from 3 to 7 minutes. Lateralization in the symptomatic group was normal in 10 patients, mild in 1, moderate in 8, and severe in 1. There was no lateral tracking greater than 3 mm in the volunteer group. Lateral maltracking was significantly higher in symptomatic patients than in asymptomatic subjects (4.4 ± 3.7 mm vs 1.5 ± 0.71 mm, P = .007). Lateral tracking significantly correlated with tibial tubercle-trochlear groove distance (r = 0.48, P = .006). There was excellent agreement on lateral tracking between the 2 reviewers (intraclass correlation coefficient, 0.979; 95% confidence interval, 0.956-0.990).

CONCLUSIONS

The inclusion of a dynamic radial 2-dimensional GRE sequence is a rapid and easily performed addition to the standard magnetic resonance imaging protocol and allows dynamic quantitative assessment of patellar instability and lateral maltracking in symptomatic patients. With a paucity of reported data using this technique confirming that these results reach clinical significance, future work is required to determine how much lateral tracking is clinically significant.

LEVEL OF EVIDENCE

Level III, case control.

Evaluation of normal swallowing functions by using dynamic high-density surface electromyography maps

BACKGROUND

Swallowing is a continuous process with substantive interdependencies among different muscles, and it plays a significant role in our daily life. The aim of this study was to propose a novel technique based on high-density surface electromyography (HD sEMG) for the evaluation of normal swallowing functions.

METHODS

A total of 96 electrodes were placed on the front neck to acquire myoelectric signals from 12 healthy subjects while they were performing different swallowing tasks. HD sEMG energy maps were constructed based on the root mean square values to visualize muscular activities during swallowing. The effects of different volumes, viscosities, and head postures on the normal swallowing process were systemically investigated by using the energy maps.

RESULTS

The results showed that the HD sEMG energy maps could provide detailed spatial and temporal properties of the muscle electrical activity, and visualize the muscle contractions that closely related to the swallowing function. The energy maps also showed that the swallowing time and effort was also explicitly affected by the volume and viscosity of the bolus. The concentration of the muscular activities shifted to the opposite side when the subjects turned their head to either side.

CONCLUSIONS

The proposed method could provide an alternative method to physiologically evaluate the dynamic characteristics of normal swallowing and had the advantage of providing a full picture of how different muscle activities cooperate in time and location. The findings from this study suggested that the HD sEMG technique might be a useful tool for fast screening and objective assessment of swallowing disorders or dysphagia.

Towards MRI temperature mapping in real time-the proton resonance frequency method with undersampled radial MRI and nonlinear inverse reconstruction

BACKGROUND

Optimal control of minimally invasive interventions by hyperthermia requires dynamic temperature mapping at high temporal resolution.

METHODS

Based on the temperature-dependent shift of the proton resonance frequency (PRF), this work developed a method for real-time MRI thermometry which relies on highly undersampled radial FLASH MRI sequences with iterative image reconstruction by regularized nonlinear inversion (NLINV). As a first step, the method was validated with use of a temperature phantom and ex vivo organs (swine kidney) subjected to heating by warm water or a pulsed laser source.

RESULTS

The temperature maps obtained by real-time PRF MRI demonstrate good accuracy as independently controlled by fiber-optic temperature sensors. Moreover, the dynamic results demonstrate both excellent sensitivity to single laser pulses (20 ms duration, 6 J energy output) and high temporal resolution, i.e., 200 ms acquisition times per temperature map corresponding to a rate of 5 frames per second. In addition, future extensions to in vivo applications were prepared by addressing the breathing-related motion problem by a pre-recorded library of reference images representative of all respiratory states.

CONCLUSIONS

The proposed method for real-time MRI thermometry now warrants further developments towards in vivo MRI monitoring of thermal interventions in animals.

Functional disorders of swallowing

Swallowing involves complex coordination of the neuromuscular anatomy and physiology of the oropharynx and esophagus, controlled by the enteric and central nervous systems. Dysphagia is classified as either oropharyngeal or esophageal and results from mechanical or structural disturbances. Videofluoroscopy, fiberoptic endoscopic evaluation of swallowing, barium swallow, manometry, and endoscopy are common modalities utilized in diagnosis, but none is as important as a patient's history. Functional dysphagia is a diagnosis of exclusion and is based on Rome criteria. Its mechanism is unknown but potentially related to visceral hypersensitivity, inappropriate pain perception, or unidentified contraction abnormalities. Its management is mainly supportive; however, there is literature to suggest, but not confirm, benefit with the use of antidepressants. Continued understanding of functional dysphagia and other functional esophageal disorders, including globus sensation, will require further investigation into diagnostic algorithms and finding treatment methods.

Numerical simulation of interaction between organs and food bolus during swallowing and aspiration

The mechanism of swallowing is still not fully understood, because the process of swallowing is a rapid and complex interaction among several involved organs and the food bolus. In this work, with the aim of studying swallowing and aspiration processes noninvasively and systematically, a computer simulation method for analyzing the involved organs and water (considered as the food bolus) is proposed. The shape and motion of the organs involved in swallowing are modeled in the same way as in our previous study, by using the Hamiltonian moving particle simulation (MPS) method and forced displacements on the basis of motion in a healthy volunteer. The bolus flow is simulated using the explicit MPS method for fluid analysis. The interaction between the organs and the bolus is analyzed using a fluid-structure coupling scheme. To validate the proposed method, the behavior of the simulated bolus flow is compared qualitatively and quantitatively with corresponding medical images. In addition to the healthy motion model, disorder motion models are constructed for reproducing the aspiration phenomenon by computer simulation. The behaviors of the organs and the bolus considered as the food bolus in the healthy and disorder motion models are compared for evaluating the mechanism of aspiration.

Real-time MRI of swallowing: intraoral pressure reduction supports larynx elevation

The reduction in intraoral pressure during swallowing has previously been linked to bolus transport, although no such relation has yet been proven. The purpose of this work was to evaluate the time course of intraoral pressure during swallowing using simultaneous real-time magnetic resonance imaging (MRI) and dynamic pressure recordings. Real-time MRI based on highly undersampled radial fast low-angle shot (FLASH) and regularized nonlinear inverse reconstruction was performed at 3 T using a standard head coil and a mid-sagittal section covering the entire oral cavity. Voluntary swallowing (10 mL of pineapple juice or saliva) was monitored for about 30 s in 11 normal subjects at spatial and temporal resolution of 1.3 × 1.3 × 8 mm³ and 40 ms, respectively. Simultaneously, the intraoral atmospheric pressure was recorded at a resolution of 10 ms during the entire course of deglutition. Quantitative measures of bolus transport, larynx elevation and submental muscle changes were obtained from the image series. As a key result, negative intraoral pressure accompanied laryngeal elevation during swallowing in all subjects. A reduction in submental muscle length during swallowing was also observed. No correlations of maximum negative pressure with larynx elevation and submental muscle change were found. In conclusion, intraoral pressure reduction during swallowing is not connected to oral bolus transport, but supports laryngeal elevation by palatal fixation of the tongue.

Oropharyngeal dysphagia: manifestations and diagnosis

Swallowing disorders (dysphagia) have been recognized by the WHO as a medical disability associated with increased morbidity, mortality and costs of care. With increasing survival rates and ageing of the population, swallowing disorders and their role in causing pulmonary and nutritional pathologies are becoming exceedingly important. Over the past two decades, the study of oropharyngeal dysphagia has been approached from various disciplines with considerable progress in understanding its pathophysiology. This Review describes the most frequent manifestations of oropharyngeal dysphagia and the clinical as well as instrumental techniques that are available to diagnose patients with dysphagia. However, the clinical value of these diagnostic tests and their sensitivity to predict outcomes is limited. Despite considerable clinical research efforts, conventional diagnostic methods for oropharyngeal dysphagia have limited proven accuracy in predicting aspiration and respiratory disease. We contend that incorporation of measurable objective assessments into clinical diagnosis is needed and might be key in developing novel therapeutic strategies.

Recommendations for real-time speech MRI

Real-time magnetic resonance imaging (RT-MRI) is being increasingly used for speech and vocal production research studies. Several imaging protocols have emerged based on advances in RT-MRI acquisition, reconstruction, and audio-processing methods. This review summarizes the state-of-the-art, discusses technical considerations, and provides specific guidance for new groups entering this field. We provide recommendations for performing RT-MRI of the upper airway. This is a consensus statement stemming from the ISMRM-endorsed Speech MRI summit held in Los Angeles, February 2014. A major unmet need identified at the summit was the need for consensus on protocols that can be easily adapted by researchers equipped with conventional MRI systems. To this end, we provide a discussion of tradeoffs in RT-MRI in terms of acquisition requirements, a priori assumptions, artifacts, computational load, and performance for different speech tasks. We provide four recommended protocols and identify appropriate acquisition and reconstruction tools. We list pointers to open-source software that facilitate implementation. We conclude by discussing current open challenges in the methodological aspects of RT-MRI of speech.

High-speed real-time magnetic resonance imaging of fast tongue movements in elite horn players

This paper describes the use of high-speed real-time (RT) magnetic resonance imaging (MRI) in quantifying very rapid motor function within the oropharyngeal cavity of six elite horn players. Based on simultaneous sound recordings, the efficacy of RT-MRI films at 30 and 100 frames per second (fps) was assessed for tongue movements associated with double tonguing performance. Serial images with a nominal temporal resolution of 10.0 and 33.3 ms were obtained by highly undersampled radial fast low-angle shot (FLASH) sequences (5 and 17 spokes, respectively) using complementary sets of spokes for successive acquisitions (extending over 9 and 5 frames, respectively). Reconstructions of high-speed images were obtained by temporally regularized nonlinear inversion (NLINV) as previously described. A customized MATLAB toolkit was developed for the extraction of line profiles from MRI films to quantify temporal phenomena associated with task performance. The analyses reveal that for the present setting, which required the use of a temporal median filter to optimize image quality, acquisition rates of 30 fps are inadequate to accurately detect tongue movements during double tonguing, but that rates of 100 fps do allow for a precise quantification of movement. These data for the first time demonstrate the extreme performance of elite horn players. High-speed RT-MRI offers so far unavailable opportunities to study the oropharyngeal movements during brass playing with future potential for teaching and the treatment of patients suffering from dystonia.

Real-time magnetic resonance imaging of cardiac function and flow-recent progress

Cardiac structure, function and flow are most commonly studied by ultrasound, X-ray and magnetic resonance imaging (MRI) techniques. However, cardiovascular MRI is hitherto limited to electrocardiogram (ECG)-synchronized acquisitions and therefore often results in compromised quality for patients with arrhythmias or inabilities to comply with requested protocols-especially with breath-holding. Recent advances in the development of novel real-time MRI techniques now offer dynamic imaging of the heart and major vessels with high spatial and temporal resolution, so that examinations may be performed without the need for ECG synchronization and during free breathing. This article provides an overview of technical achievements, physiological validations, preliminary patient studies and translational aspects for a future clinical scenario of cardiovascular MRI in real time.