Overview of Instrumental Assessment of Dysphagia

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Without imaging, it is like asking a diagnosed CHF with a stethoscope or diagnosed stroke with phrenology
Phrenology 
A pseudo medicine primarily focus on the measurements human skull, based on the brain as the organ of the mind.
Imaging serves as an important tool o To diagnose CHF, CVA, and other diseases
We rely on ultrasound, CT scan, PET scans, all heavily reliant on medical technology to assist, differential diagnosis and disease management.
Ethical Implications 
We should begin to ask "What are the ethical implications of making critical decisions about an internal function that was never seen?"
Imaging enhances the investigation of internal functions such as swallowing.
Imaging does not decipher the layers of causation.
Aspiration = Bolus Flow
Bolus flow ≠ Physiology
Bolus flow infers physiology
Physiology should determine treatment.
Imaging examinations of swallowing are only a part of comprehensive examination of swallowing performance and function.
In general, a thorough clinical examination should precede any imaging examination.
Several name variants for these procedures (Videofluoroscopy)
Modified Barium Swallow (MBS)
Upper Gastrointestinal Series with Hypopharynx
Videofluoroscopic Swallow Study (VFSS)
Videofluoroscopic Barium Examinations (VFBE)
Videofluoroscopic Swallow Examination (VFSE) o Rehabilitation Swallow Study
VFSS is considered a procedure while MBS is an assessment coined by the pioneer of this assessment named Doctor Jerilyn Logemann.
Objectives of VFSS 
To obtain a video image of the upper aerodigestive tract during the act of swallowing.
Other objectives of VFSS
Evaluate anatomy and physiology of the swallowing mechanism.
Evaluate swallow physiology.
Identify patterns of impaired swallow physiology.
Identify consequences of impaired swallow physiology.
Evaluate the effect of compensations.
Confirm px’s symptoms.
Make prediction
Instrumental examination 
1. Indicated for making diagnosis
2. Indicated for planning effective management
3. Indicated for planning effective treatment
4. In patients with suspected oropharyngeal dysphagia
5. In patients who are high risk for oropharyngeal dysphagia
Indication/reason for instrumental examination
Patients are inconsistent with findings on the clinical examination
Need to confirm a suspected medical diagnosis
Need to assist in differential medical diagnosis
Confirmation and/or differential diagnosis of the dysphagia is needed
There is either positive nutritional or pulmonary compromise
The safety and efficiency of the swallow remains a concern
Patient is identified as a swallow rehabilitation candidate and specific information is needed to guide management and treatment
Contraindication for VSS
The px is medically unstable to tolerate a procedure.
Unable to cooperate/participate in an instrumental examination.
In a Speech-Language Pathologist’s judgement, instrumental exams would not change clinical management.
Unable to be adequately positioned.
Size of px prevents adequate imaging/exceeds limit of positioning devices.
Allergy to Barium
1970 (Evolution of MBS)
Dr. Jeri Logemann (speech-language pathologist) - Studies the speech of px with Parkinson’s Disease (PD)
1971 (Evolution of MBS) 
Chairs of Neurology, Radiology, Speech-Language Pathology met to design the test
The term MBS was initially coined by Dr. Logemann and can be interpreted literally and Used to diagnose in any abnormalities in the GI tract
Dr. Logemann has the px sitting upright and the initial protocol has consisted of 3 swallows of:
1 mL thin liquid
1 mL pudding
¼ barium cookie - A cookie coated in Barium paste
1985 (historical MBS practice patterns) The protocol was changed to 2-3 swallows of:
1 mL Thin
3 mL Thin
5 mL Thin
10 mL Thin
Cup drinking
3 mL pudding
¼ Loma Doone Cookie (covered with Barium paste)
Good clinical judgement is needed to determine the order of bolus presentation or modifications to the procedure if the individual appears unable to protect the airway even after the use of therapeutic intervention.
In MBS, if the px is not able to tolerate
Although there is a protocol, consisting of 2-3 swallows of 1 mL Thin, 3 mL Thin, 5 mL Thin, 10 mL Thin, Cup drinking, 3 mL pudding, and ¼ Lorna Doone Cookie, are not necessarily followed and completed as a full protocol
• M - odified • B - arium • S - wallow • Im - pairment • P - rofile
(MBSImP™©) was developed by Dr. Martin-Harris in 2003, consensus validation from experts’ panels of 12 interdisciplinary dysphagia specialists.
They developed and validated this during a five-year national institute of health funded study
They used factor analysis to determine 17 distinct physiological components involved in the swallowing process.
The MBSImP is a research-based standardization of the MBS.
The MBSImP provides the means for SLPs to interpret and communicate results of MBS in a manner that is evidencebased, consistent, specific, and accurate.
A is the lateral view.
The parts highlighted: the mandible, tongue, base of tongue, nasal cavity, velum (soft palette), the posterior pharyngeal wall, epiglottis, hyoid bone, pharyngeal esophageal segment (PES), laryngeal entrance, arytenoid cartilage, and the true vocal folds.
B is the anterior-posterior view, also called the AP view.
When the px is facing forward and you can see the lateral pharyngeal wall, vallecular spaces, mandible, tongue, true vocal folds, trachea, and the piriform recess (or pyriform sinuses both sides, the left and the right).
A swallowing specialist must be familiar with all these as they are viewing the swallowing dynamically during the actual evaluation. Since it is recorded in video, one can pause, rewind, and view in slow motion to analyze the pathophysiology of swallow.
Lateral View (MBSImP Standardized Protocol (VIscosity, Volume, Method of Administration))
Thin - 5 mL via tsp
Thin - 5 mL via tsp
Thin - controlled cup drink
Thin - sequenced cup drink
Nectar - 5 mL via tsp
Nectar - controlled cup drink
Nectar - sequenced cup drink
Honey - 5 mL via tsp
Pudding - 5 mL via tsp
Loma Doone Cookie - ⅕ cookie with 3 mL pudding
It has been used since 1982 by speech language pathologists and radiologists for the assessment of dysphagia.
MBSIMP’S 17 COMPONENTS (Oral Impairment)
Lip closure
Bolus hold position
Bolus preparation/mastication
Bolus transport. Lingual motion
Oral residue
Initiation of pharyngeal swallow
MBSIMP’S 17 COMPONENTS (Pharyngeal Impairment) 
7. Soft palate elevation
8. Laryngeal elevation
9. Anterior hyoid motion
10.Epiglottic movement
11.Laryngeal vestibular closure
12.Pharyngeal stripping wave
13.Pharyngeal contraction
14.Pharyngoesophageal segment opening
15.Tongue base retraction
16.Pharyngeal residue
MBSIMP’S COMPONENTS, SCORES, SCORE DEFINITIONS
Components are scored on a 3-5 Likert Scale based upon interrater reliability.
Score based on component-specific physiology, not the functionality that is often based on compensation.
No severity indicators associated with impairment scores.
VFSS: NORMAL SWALLOW
Px sitting upright for the procedure. Attempts to raise the px’s chin to neutral position should be encouraged to complete viewing of the pharynx.
Fluoroscope: set at pulse rate 29-97/30 pulses per second or continuous mode.
Video capture: set at 29-97/30 frames per second
The lateral view should include lips anteriorly, nasal superiorly, the pharyngoesophageal segment inferiorly, and cervical spine posteriorly.
STRENGTHS OF THE VFSS
The Videofluoroscopic Swallow Study (VFSS) is considered the gold standard in the clinical assessment of dysphagia.
It is a dynamic study that, when recorded, provides a thorough evaluation of the biomechanics of the oropharyngeal swallowing with unlimited review capability.
It provides a comprehensive perspective on swallowing from the lips through the esophagus.
Within the hospital setting, it is typically readily accessible for both pxs and clinicians