Symposium „Ernährung und Schluckstörungen
18.7.2004 im Alleesaal Bad Schwalbach
Internationale Standards in der Diagnostik von
task of assessing the dysphagic patient requires
two different skills; the skill of examination
and the skill of classification. Reliability in
one skill does not guarantee reliability in the
other. It is important that procedures used for
both examination and classifications undergo testing
to establish validity and reliability. An examination
of the existing literature would suggest that
reliability for judgments made during the swallow
assessments is poor.
The videofluoroscopic swallowing study (VFSS)
is considered by many to be the "gold-standard"
or “investigation of choice” for identifying
oropharyngeal swallowing abnormalities (Ekberg,
1997; O’Donoghue & Bagnall, 1999). It
has been suggested that by observing the various
physiologic movements and events that comprise
the oropharyngeal swallow, the specific anatomic
or physiologic dysfunction underlying the disorder
can be observed and targeted for treatment and/or
compensation (Palmer, Kuhlemeier, Tippet, &
Lynch, 1993). A multiplicity of events can be
observed during the study, such as the presence
or absence of aspiration or penetration of the
airway or the adequacy or insufficiency of the
excursion of anatomic movements, such as hyoid
elevation, or tongue base retraction. Still other
judgments involve the timing of events, such as
the transition between the oral and pharyngeal
stages. Identifying and integrating these findings
requires skill, as many of these observations
occur nearly simultaneously, some with durations
as short as a few frames of videotape.
Studies of judgments made during the VFSS have
shown that reliability is poor. Eckberg, Nylander,
Fork, Sjoberg, Birch-Iensen, & Hillarp (1988)
found that striking events, such as tracheal penetration
(entry of food or liquid into the trachea) or
conspicuous anatomic anomalies, such as the presence
of a Zenker's diverticulum are reliably identified,
while judgments regarding the adequacy of functional
components of the swallow result in less concordance.
Similarly, Pearlman, Van Daele, & Otterbacher
(1995), found that judgments regarding the adequacy
of laryngeal elevation resulted in poor agreement.
McCullough, Wertz, Rosenbek, Mills, Webb, &
Ross, (2001) found poor interjudge reliability
for most measures commonly employed for the interpretation
of videofluoroscopic swallowing examinations.
In that study, the only measures with acceptable
reliability were binary judgments of aspiration
and penetration. Similarly, Stoeckli, Huisman,
Seifert, & Martin-Harris (2003), found that
only aspiration was evaluated with high reliability
and found that reliability of all other measurements
of the oropharyngeal swallow were poor. Kuhlemeier,
Yates, & Palmer (1998) determined that reliability
was higher for normal findings and lower for abnormal
findings. In that study, clinicians generally
agreed when aspiration was absent, but were unable
to agree on the cause of the altered swallow.
Kuhlemeier suggested that ‘The VFSS appears
to be more useful for determining which foods
a subject can swallow without aspiration than
it is for making definitive pathophysiological
diagnoses.’ (p. 147).
In this presentation the anatomy and physiology
of swallowing as observed in the dysphagic patient
will be discussed. Disorders of bolus propulsion
and airway protection will be described and a
suggested framework for establishing assessment
standards will be discussed.
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Birch-Iensen, M., & Hillarp, B. (1988). Interobserver
variability in cineradiographic assessment of
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Kuhlemeier, K., Yates, P. & Palmer, J. (1998).
Intra- and Interrater Variations in the Evaluation
of Videofluorographic Swallow Studies. Dysphagia
McCullough, G., Wertz, R., Rosenbek, J., Mills,
R., Webb, W., Ross, K., .(2001). Inter
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videofluorographic swallowing study. Dysphagia,
Perlman, A., Van Daele, D., Otterbacher, M.. (1995).
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from video images during swallowing. Journal of
Speech and Hearing Research, 38, 579-585.
Stoeckli S., Huisman T., Seifert B., Martin-Harris
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videofluoroscopic swallow evaluation. Dysphagia,