Evaluation of the Modified Barium Swallow Study Conducted With and Without Radiologist Supervision: A Pre- and Post-Observational Study

Purpose: Assess quality metrics of modified barium swallow studies (MBSS) with and without a radiologist present during the procedure. Methods: Retrospective review of MBSS performed on adult inpatients at a tertiary care hospital 6-months pre- and post-institutional change from having to not having a radiologist present during the examination. Factors assessed included: fluoroscopy time; study duration; number of cine loops; number of images; efficiency of collimation (using a 5-point scoring system); time to final report; radiologist-speech language pathologist report disagreement; and recalls for inadequate studies. Statistical analysis was via Welch’s t-test and a test of proportions for continuous and count data under the normal approximation. Results: 106 and 119 MBSS were analyzed from the radiologist present and radiologist absent periods, respectively. No statistically significant differences were found for: average fluoroscopy time (116.1 s vs. 126.9 s; P = 0.161); study duration (400.4 s vs. 417.3 s; P = 0.453); number of cine loops (9.3 vs. 10.2; P = 0.075); number of images (620.5 vs. 581.1; P = 0.350); or report disagreement. There was improved performance without the radiologist present for collimation (1.92 vs. 1.43; P = 0.003) and fewer non-diagnostic images (6.5 vs. 4.5; P = 0.001). Time to final report was longer with the radiologist absent due to more reports with significant delays. There were no repeated studies because of inadequate technique in either group. Conclusion: MBSS performed by technologists without radiologist supervision is not inferior to those performed with radiologist supervision on multiple performance measures. This supports technologist operated MBSS without radiologist supervision, while acknowledging a need to further address radiologist report time delay.

Factors Influencing Initiation of Pharyngeal Swallow in Healthy Adults

Purpose The purpose of this study was to investigate factors influencing the initiation of pharyngeal swallow (IPS) in healthy, nondysphagic adults. Method A total of 195 healthy participants ranging in age from 21 to 89 years participated in a modified barium swallow study. IPS was quantified using the Modified Barium Swallow Impairment Profile standardized scoring system across nine swallowing tasks observed in the lateral viewing plane for each participant. Results Large variability for bolus head location at time of hyoid burst (IPS) was observed within this healthy cohort, ranging from the ramus of the mandible to the pyriform sinuses. Significant effects of bolus volume, viscosity, sex, and race were also observed. Conclusion Study findings indicate that IPS is variable in healthy adults and influenced by volume, viscosity, sex, and race. Thus, variability in IPS may be considered typical in otherwise nondysphagic adults. The clinical significance of high Modified Barium Swallow Impairment Profile IPS scores in dysphagic patients, therefore, must be considered within the context of other swallowing impairments. Supplemental Material https://doi.org/10.23641/asha.12735935

Swallowing dysfunction after minimally invasive oesophagectomy

ObjectivesPatients undergoing oesophagectomy frequently experience malnutrition, which in combination with the catabolic effects of surgery can result in loss of muscle mass and function. Safe swallowing requires preservation of muscle mass. Swallowing dysfunction puts postoperative patients at risk for aspiration and pneumonia. Modified Barium Swallow Study (MBSS) enables assessment of postoperative swallowing impairments. The current study assessed incidence and risk factors associated with swallowing dysfunction and restricted diet at discharge in patients after oesophagectomy in a high-volume surgical centre.MethodsPatients with an MBSS after oesophagectomy were identified between March 2015 to April 2020 at a high-volume surgical centre. Swallowing was quantitatively evaluated on MBSS with the Rosenbek Penetration-Aspiration Scale (PAS). Muscle loss was evaluated clinically with preoperative hand grip strength (HGS). Univariable and multivariable logistic and linear regression analyses were performed.Results129 patients (87% male; median age 66 years) underwent oesophagectomy with postoperative MBSS. Univariate analysis revealed older age, preoperative feeding tube, lower preoperative HGS and discharge to non-home were associated with aspiration or penetration on MBSS. Age and preoperative feeding tube remained as independent predictors in the multivariable analysis. Both univariate and multivariable analyses revealed increased age and preoperative feeding tube were associated with diet restrictions at discharge.ConclusionsSwallowing dysfunction after oesophagectomy is correlated with increased age and need for preoperative enteral feeding tube placement. Further research is needed to understand the relationship between muscle loss and aspiration with the goal of enabling preoperative physiological optimisation and patient selection.

Development of Swallowing Function in Infants with Oral Feeding Difficulties

Background. Discharge of preterm infants is often delayed because of their oral feeding difficulties. Independent oral feeding is the last obstacle to pass after managing acute and chronic morbidities. We conducted this study to determine the prevalence, characteristics, and risk factors of swallowing dysfunction and suggest proper interventions to reduce aspiration and chronic lung injury. Methods. Infants admitted to the neonatal intensive care unit (January 2016 to December 2018) who were performed modified barium swallow study due to oral feeding difficulties were enrolled. Modified barium swallow study was done≥postmenstrual age 37 weeks to limit radiation exposure. Clinical data were collected retrospectively. Swallowing dysfunction was defined as inadequate epiglottic closure, laryngeal penetration, or tracheal aspiration according to result of the modified barium swallow study. Results. Among a total of 54 infants enrolled, nine (16.7%) were term infants, 13 (24.1%) were late preterm infants (gestational age, 34-36 weeks), and 32 (59.3%) were early preterm infants (gestational age<34 weeks). Gestational age and birth weight were smaller in infants with swallowing dysfunction. Total duration of mechanical ventilation and duration of invasive ventilation were longer in infants with swallowing dysfunction. The risk of swallowing dysfunction increased by 11.2 times for infants with gestational age<29 weeks compared to infants with gestational age≥29 weeks. Swallowing dysfunction was improved in most infants after they became matured. They showed different time and rate of maturation with the help of rehabilitation through swallow therapy and dietary modification with thickened formula. Conclusion. Preterm infants with gestational age<29 weeks or with longer ventilation duration are at a higher risk of aspiration. Rehabilitation of swallow therapy and dietary modification with thickened formula can be helpful interventions to prevent aspiration and chronic lung injury and reassure parents until independent oral feeding is possible.

Aging Effects on Esophageal Transit Time in the Upright Position During Videofluoroscopy

Objectives: The purpose of this study was to examine age-related effects on esophageal transit times (ETT) among healthy adult participants. Methods: A total of 175 healthy, non-dysphagic participants underwent a modified barium swallow study (MBSS), and ETT was recorded for two standardized swallowing tasks. Differences across age groups were determined using Kruskal–Wallis test. Relationships between an Esophageal Clearance (Modified Barium Swallow Impairment Profile Component 17) score and ETT were also explored. Results: No significant differences were observed in ETT across age groups for nectar-thickened liquid ( P = .335) or pudding ( P = .231) consistencies. No significant differences were observed between males and females in ETT for either the nectar ( P = .112) or pudding trial ( P = .817). For nectar, the mean ETT for patients with Component 17 scores of 2 or greater were significantly higher than that of participants with a score of 0 ( P < .0001). For pudding, participants with a score >0 demonstrated significantly higher mean ETT compared to participants with a score of 0 (with P = .0008 and P < .0001, respectively). Conclusion: Study findings failed to support age-related or sex-related differences in ETT for two standardized swallowing tasks administered during a MBSS in healthy individuals. The normative values following a standardized protocol in this study provide guidance in clinical interpretation of esophageal function.

Reliability and validity of the neonatal feeding assessment scale (NFAS) for the early identification of dysphagia in moderate to late preterm neonates

Background: A clinical feeding assessment instrument to assist with early identification of oropharyngeal dysphagia (OPD) in neonates was developed.Objective: To investigate the validity and reliability of the Neonatal Feeding Assessment Scale (NFAS) in comparison to the modified barium swallow study (MBSS) as gold standard.Method: A within-subject design was implemented. A group of 48 late premature neonates (mean gestational age 35.5 weeks) were sampled in the neonatal intensive care unit.Results: The NFAS consists of six subsections, including physiological stability, infant state, stress cues, screening of muscle tone and control, oral peripheral examination and feeding/swallowing assessment. 93% of participants (14/15) received confirmatory diagnosis of OPD on MBSS. The NFAS presented with high sensitivity (78.6%) and specificity (88.2%) scores. The positive predictive value was 78.6%. Subsequently the accuracy of the NFAS to identify the presence of OPD accurately was 85.4% when compared to MBSS. Inter-rater reliability was determined on 35% of the sample. The inter-rater agreement on overall instrument outcome was substantial beyond chance.Conclusion: The NFAS may be of use to clinicians to support the early identification of OPD in this population, especially in resource constrained settings working without access to MBSS and to reach under served neonates.Keywords: Inter-rater reliability, modified barium swallow study, Neonatal Feeding Assessment Scale (NFAS), oropharyngeal dysphagia diagnosis, validity.

Laryngomalacia and Swallow Dysfunction

Objectives: Laryngomalacia is an established cause of stridor and sleep-disordered breathing in children. However, the relationship between laryngomalacia and dysphagia has not been well characterized. The objectives of this study were to (1) describe the patient characteristics, symptoms, and prevalence of dysphagia in children with laryngomalacia and (2) examine the effectiveness of supraglottoplasty in improving feeding. Methods: This was a retrospective study of patients with laryngomalacia who underwent a modified barium swallow study (MBSS) at a tertiary academic pediatric medical center between March 1, 2014, and March 1, 2018. Patients were excluded if they did not undergo a MBSS. Comorbidities, airway and feedings symptoms, MBSS results, and surgical history were recorded from each patient’s electronic medical record. Results: Forty-four children met inclusion/exclusion criteria. The median age at presentation was 96 days. There was a male predominance (66%). About one-third had a genetic or neuromuscular comorbidity. Most children had stridor (93%) and feeding difficulty (86%), while 50% had parent-reported poor weight gain. Fifty-seven percent of patients had evidence of penetration or aspiration on MBSS. All patients with a positive MBSS had dysphagia symptoms. Fifty-seven percent of patients underwent supraglottoplasty. Postoperatively, 92% reported improvement in dysphagia symptoms. Conclusion: Dysphagia is prevalent among a subset of children with laryngomalacia. Symptomatic children may benefit from a swallow evaluation to help determine the need for further intervention. Children who undergo supraglottoplasty for laryngomalacia have improved dysphagia at follow-up, though the amount of improvement directly attributable to surgery is unclear and warrants further investigation.