Rebecca J. Leonard

Validity and Reliability of the Eating Assessment Tool (EAT-10):

Objectives: The Eating Assessment Tool is a self-administered, symptom-specific outcome instrument for dysphagia. The purpose of this study was to assess the validity and reliability of the 10-item Eating Assessment Tool (EAT-10). Methods: The investigation consisted of 4 phases: 1) line-item generation, 2) line-item reduction and reliability, 3) normative data generation, and 4) validity analysis. All data were collected prospectively. Internal consistency was assessed with the Cronbach alpha. Test-retest reliability was evaluated with the Pearson product moment correlation coefficient. Normative data were obtained by administering the instrument to a community cohort of healthy volunteers. Validity was assessed by administering the instrument before and after dysphagia treatment and by evaluating survey differences between normal persons and those with known diagnoses. Results: A total of 629 surveys were administered to 482 patients. The internal consistency (Cronbach alpha) of the final instrument was 0.960. The test-retest intra-item correlation coefficients ranged from 0.72 to 0.91. The mean (±SD) EAT-10 score of the normal cohort was 0.40 ± 1.01. The mean EAT-10 score was 23.58 ± 13.18 for patients with esophageal dysphagia, 23.10 ± 12.22 for those with oropharyngeal dysphagia, 9.19 ± 12.60 for those with voice disorders, 22.42 ± 14.06 for those with head and neck cancer, and 11.71 ± 9.61 for those with reflux. The patients with oropharyngeal and esophageal dysphagia and a history of head and neck cancer had a significantly higher EAT-10 score than did those with reflux or voice disorders (p < 0.001). The mean EAT-10 score of the patients with dysphagia improved from 19.87 ± 10.5 to 5.2 ± 7.4 after treatment (p < 0.001). Conclusions: The EAT-10 has displayed excellent internal consistency, test-retest reproducibility, and criterion-based validity. The normative data suggest that an EAT-10 score of 3 or higher is abnormal. The instrument may be utilized to document the initial dysphagia severity and monitor the treatment response in persons with a wide array of swallowing disorders.

Timing of Events in Normal Swallowing: A Videofluoroscopic Study

Dynamic videofluoroscopic swallow studies were performed on 60 normal adult volunteers to establish normative data for clinically useful timing measures. The relation of swallowing gesture timing to the timing of actual bolus transit was of particular interest because it provides insight into the physiology of larger bolus volume accommodation. Parameters evaluated include the timing of bolus pharyngeal transit, soft palate elevation, aryepiglottic fold elevation and supraglottic closure, arrival of the bolus in the vallecula, hyoid bone displacement onset and duration, arrival of the bolus at the pharyngoesophageal sphincter, maximum pharyngeal constriction, and pharyngoesophageal sphincter opening. These parameters represent events required for normal deglutition, can be used to identify abnormalities in dysphagic patients, and provide a basis for comparison of swallowing performance both within and between patients. In addition, our experience has shown them to be reliably obtained. Other investigators have reported some of the measurements. However, to our knowledge, normative data for timing of aryepiglottic fold elevation, soft palate elevation and closure, and maximum pharyngeal constriction have not been described. Other measures included in the present study may provide alternatives when conventional measures cannot be obtained in selected patients. The relevance and clinical utility of new and alternative measures, in particular, are discussed.

Structural Displacements in Normal Swallowing: A Videofluoroscopic Study

Dynamic videofluoroscopic swallow studies were performed on 60 normal adult volunteers to establish normative data for displacement of upper aerodigestive tract structures during deglutition. Variables evaluated included hyoid bone displacement, larynx-to-hyoid bone approximation, pharyngeal constriction, and the extent of pharyngoesophageal sphincter (PES) opening during liquid swallows of 1, 3, and 20 cc. Results showed direct relationships between bolus size and hyoid displacement, between bolus size and PES opening, and between bolus size and pharyngeal constriction. Only hyoid-to-larynx approximation remained unchanged across bolus sizes. Sex differences were noted for all variables except PES opening. Reliability for most measurement variables was excellent. To our knowledge, normative data for pharyngeal constriction and larynx-to-hyoid approximation have not previously been described.

Transcutaneous electrical stimulation versus traditional dysphagia therapy: A nonconcurrent cohort study

OBJECTIVE: The purpose of this investigation was to critically evaluate the efficacy of electrical stimulation (ES) in treating persons with dysphagia and aspiration. STUDY DESIGN: Nonconcurrent cohort study. METHODOLOGY: The charts of 40 consecutive individuals undergoing ES and 40 consecutive persons undergoing traditional dysphagia therapy (TDT) were reviewed. Pre- and post-therapy treatment success was compared utilizing a previously described swallow severity scale. A linear regression analysis was employed to adjust for potential confounding variables. RESULTS: The swallow severity scale improved from 0.50 to 1.48 in the TDT group (P < 0.05) and from 0.28 to 3.23 in the ES group (P < 0.001). After adjusting for potential confounding factors, persons receiving ES did significantly better in regard to improvement in their swallowing function than persons receiving TDT (P = 0.003). CONCLUSIONS: The results of this nonconcurrent cohort study suggest that dysphagia therapy with transcutaneous electrical stimulation is superior to traditional dysphagia therapy alone in individuals in a long-term acute care facility.

Structural mobility in deglutition after single modality treatment of head and neck carcinomas with radiotherapy

The results of a preliminary study designed to evaluate swallowing function in patients 1 year after successful treatment of head and neck carcinomas with radiotherapy are reported.

Pharyngeal Constriction in Elderly Dysphagic Patients Compared with Young and Elderly Nondysphagic Controls

This article reports the results of our study to determine the incidence of abnormalities in timing and extent of pharyngeal constriction in an elderly population with complaints of dysphagia. We performed a retrospective analysis of videofluoroscopic studies, i.e., dynamic swallow studies, that were performed between 1996 and 1999. Included in the study were patients over 65 years old without an obvious medical or surgical cause for their dysphagia complaints. The timing of maximum pharyngeal constriction was measured relative to the onset of bolus pharyngeal transit, relative to the arrival of the bolus at the upper esophageal sphincter, and relative to the exit of the tail of the bolus from the upper esophageal sphincter. The extent of maximum pharyngeal constriction was measured from a lateral view. Patient data were compared with data gathered from young (18-62 years old) nondysphagic controls and with data gathered from elderly (67-83 years old) nondysphagic controls. We found that 73% of the patient population demonstrated incomplete pharyngeal constriction relative to controls, although the timing of pharyngeal constriction remained coordinated relative to the position of the bolus in the pharynx. Poor pharyngeal constriction, suggestive of pharyngeal weakness, contributed to 75% of the cases of aspiration.

Prevalence of penetration and aspiration on videofluoroscopy in normal individuals without dysphagia

Objective: To determine the prevalence of penetration and aspiration on videofluoroscopic swallow studies (VFSS) in normal individuals without dysphagia. Study Design: Case series with planned data collection. Setting: A tertiary urban university hospital. Subjects and Methods: Normal adult volunteers without dysphagia, neurological disease, or previous surgery underwent VFSS. Studies were recorded and then reviewed for evidence of penetration or aspiration. The degree of penetration was assessed with the penetration-aspiration scale (PAS). The effect of age, bolus size, and consistency was evaluated. Results: A total of 149 VFSS (596 swallows) were reviewed. The mean age of the cohort was 57 years (±19 years); 56 percent were female. Only one (0.6%) individual aspirated on VFSS. Seventeen (11.4%) individuals demonstrated penetration. The mean PAS for the entire cohort was 1.17 (±0.66). Prevalence of penetration by swallow was 2.85 percent (17/596). Prevalence of penetration was 9.3 percent in elderly individuals aged >65 years and 14.3 percent in adults aged <65 years (P = 0.49). Prevalence of penetration on a liquid bolus was 3.4 percent (15/447) and on paste was 1.3 percent (2/149) (P > 0.05). Prevalence of penetration for a bolus <30 cc was 2.34 percent (7/298) and for a bolus >30 cc was 5.4 percent (8/149) (P > 0.05). Conclusion: Aspiration on VFSS is not a normal finding. Penetration is present in 11.4 percent of normal adults and is more common with a liquid bolus.

Airway protection: evaluation with videofluoroscopy.

During videofluoroscopic swallowing studies performed in the lateral view, the arytenoid cartilages are seen to elevate and approximate the down-folding epiglottis, effectively closing the supraglottic larynx and protecting the airway. This mechanism may be incomplete or delayed in patients complaining of dysphagia and may lead to “penetration” of bolus material into the airway. This study evaluates the timing of supraglottic closure relative to the arrival of the bolus at the upper esophageal sphincter in 60 young control subjects and in 63 elderly control subjects without dysphagia. Event timing was measured in 0.01-s intervals from videofluoroscopic studies for two liquid bolus size categories. Results of the analysis revealed that, in most individuals, the arytenoid cartilages approximate the epiglottis prior to the arrival of the bolus at the upper esophageal sphincter. However, in both bolus size categories, there were individuals who achieved complete supraglottic closure after the bolus had arrived at the sphincter, but never greater than 0.1 s later. No delay in the timing of supraglottic closure relative to bolus arrival at the sphincter was found in the elderly subject group compared with the young subject group. The information from this study has allowed us to objectively determine if supraglottic closure timing is delayed in patients with dysphagia and to address any delay with strategies and exercises designed specifically to correct the delay. A case study is presented to illustrate the clinical significance of this study.

UES Opening and Cricopharyngeal Bar in Nondysphagic Elderly and Nonelderly Adults

The intent of the study was to investigate upper esophageal sphincter (UES) opening and cricopharyngeal bar, and their relationship to other swallowing variables, in elderly, nondysphagic subjects. Extent and duration of UES opening, hypopharyngeal transit time, hyoid displacement, hyoid-to-larynx approximation, and incomplete pharyngeal clearing were determined from fluoroscopic swallow studies in 84 nonelderly control subjects and 88 elderly subjects. No differences in these measures were found between elderly subjects with and without medical conditions, and data were subsequently pooled. Mild, moderate, or marked cricopharyngeal bars were identified in more than 30% of elderly subjects, and subsequent analyses were performed on the control group, the elderly group without bars, and the elderly group with bars. Maximum opening of the UES in the elderly bar group was significantly reduced compared with that of the elderly group without bars and the nonelderly control group. However, timing measures did not differentiate elderly subjects with bars from other elderly subjects and they suggest that prolonged transit times in the elderly cannot be explained by the presence of a cricopharyngeal bar. With the exception of hyoid displacement, all variables investigated differed significantly between the nonelderly and one or both of the elderly groups. With the exception of UES opening, variables examined generally did not differentiate the two elderly groups.

Timing of Swallowing Events after Single-Modality Treatment of Head and Neck Carcinomas with Radiotherapy

This paper reports the results of a preliminary study designed to evaluate swallowing function in 20 patients 1 year after successful treatment of head and neck carcinomas with radiotherapy. The timing of swallowing events was evaluated by videofluoroscopy. The mean values for each measure were compared to the normative data from 60 control subjects. The radiotherapy patients demonstrated prolonged pharyngeal bolus transit and a delay of laryngeal closure. Hyoid bone elevation began late relative to the onset of bolus movement. A strong trend toward a delay in hyoid elevation relative to bolus movement was demonstrated. The time required for the hyoid bone to reach maximal elevation did not differ from that in normals, but the hyoid was held in an elevated position for a longer period of time. As a result of changes in hyoid movement, the upper esophageal sphincter tended to open early relative to the arrival of the bolus. In conclusion, changes in deglutition occur after radiotherapy, presumably as an adaptation to changes in tissue compliance.