assessment

Scoping and scaling

Speech and language therapists use endoscopy to assess the needs of people with dysphagia - but clinical effectiveness is hampered by the lack of a standardised and reliable rating scale. Kirsty Hydes and Paula Leslie discuss why such a scale is needed and how they have kick-started its development with an evidence-based pilot.
hile the endoscopy swallow assessment is within the scope of practice for speech and language therapists with expertise and specialist training in dysphagia (Kelly et al., 2007), the profession lacks an evidence based endoscopy rating scale. Kirstys research study as part of an MPhil degree (Newcastle University) was designed to look at inter-rater reliability of anatomical and swallowing features observed during endoscopy. The first part of the study involved developing a rating form for endoscopic swallow studies, based on clinical practice and robust evidence. This article focuses on why the endoscopic rating scale was needed and how we created it. The scale is available at http://www.speechmag. com/Members/Extras. Swallowing impairment affects eating and drinking safety by increasing the risk of aspiration: material entering the airway below the level of the vocal folds. Complications associated with dysphagia include pneumonia, malnutrition, dehydration, longer hospital stay, and increased health service dependency (Smithard et al., 1996). Clinical practice requires efficient and accurate assessments to plan management. The main instrumental assessment tools are videofluoroscopy and endoscopy (Fibreoptic Examination of Swallowing: FEES). Literature describes the endoscopic procedure and which features of anatomy and physiology should be assessed, but this is based on limited robust evidence and often uses subjective descriptors. Any evidence borrowed from videofluoroscopic assessment should be used with caution because the structures and features seen differ between the two procedures. Videofluoroscopy uses radiographic imaging to track food/liquid from the oral cavity, through the pharynx and into the oesophagus. Patients must be physically stable and able to be transported to the X-ray suite. Patients are exposed to radiation although this can be kept to a minimum (Zammit-Maempel et al., 2007). Endoscopy gives a clear view of the pharynx
Kirsty and Paula

READ THIS IF YOUR ARE INTERESTED IN DEVELOPING A CLINICALLY USEFUL ASSESSMENT TOOL EVIDENCE-BASED OBJECTIVE MEASURES INTER-RATER RELIABILITY

and larynx before and after the swallow but not the oesophagus or the period of whiteout the moment of swallow (Langmore et al., 1988). A fibreoptic camera is passed along the nose, beyond the velopharyngeal port and into the hypopharynx with a view of the tongue base and valleculae. Clinicians can assess anatomical and physiological deficits of the soft palate, pharynx and larynx. There is no radiation exposure and the patient can be examined at bedside or in the outpatient clinic.

Endoscopy gives a clear view of the pharynx and larynx before and after the swallow
Currently there are no standardised descriptors for anatomical and physiological features observed during endoscopic swallow studies and there is insufficient information on how reliable clinicians are at rating swallowing behaviours when using endoscopy. Inter-rater reliability in endoscopic swallow studies is reported to have acceptable levels (83 per cent agreement) for observing oral/pharyngeal transit, laryngeal elevation, laryngeal closure at the airway entrance, and epiglottic contact with the pharyngeal wall (Logemann et al., 1999). Colodny (2002) focused on inter-rater agreement (but not validity) in endoscopy using the Penetration-Aspiration Scale (Rosenbek et al., 1996), and the results showed an acceptable 65-75 per cent. This study only looked at agreement on the degree of laryngeal penetration and therefore results cannot be generalised to other swallow features. The use of the Penetration-Aspiration Scale is questionable because the landmarks used to score are not visible in real time when using endoscopy and timing of events sometimes

Insufficient information

has to be inferred. Recent work has shown that speech and language therapists do judge images of the same swallow differently depending on whether it is from endoscopy or videofluoroscopy (Kelly et al., 2006). Limited research on reliability during swallow endoscopy is partly because no rating form with published reliability and validity exists to measure rater agreement for anatomical and physiological swallow features. So, having been granted favourable ethical opinion by the Local Research Ethics Committee for this project, we started the process of designing an endoscopy rating scale. We searched for existing scoring procedures used with videofluoroscopy and endoscopy using terms: dysphagia, Fibreoptic Endoscopic Examination of Swallowing, videofluoroscopy, rating scales, and reliability. Databases included: AMED, CINAHL, Medline, Pubmed, and The Cochrane Library. We included videofluoroscopy to examine which features are measured, how they are scored and if a similar scoring method could be used with endoscopy. We designed an evidence based rating form using published reports of what could be seen during endoscopic swallow studies - which may not equate to what clinicians can reliably rate. Features included anatomical ratings of the pharynx and larynx, physiological events in the absence of a bolus, and physiological swallow features in the presence of a bolus. Features such as velopharyngeal motion, vocal cord closure during a tight breath hold, ratings of pharyngeal secretions, evidence of premature spillage in pharynx, penetration/ aspiration and residue were included (Langmore et al., 1988; Rosenbek et al., 1996; Bastian, 1991; Murray et al., 1996; Dua et al., 1997; Langmore & McCulloch, 1997; Murray, 1999; Hiss & Postma, 2003). Ordinal scales (normal/mild/moderate/severe) and nominal scales (present/absent) were used. Ordinal scales had descriptors so that raters could decide on feature severity. Nominal scales were used to rate movement of the velum in speech and swallowing, vocal

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fold adduction during phonation, epiglottic retroflexion, laryngeal elevation, and nasoregurgitation. These types of scoring were based on endoscopy (Rosenbek et al., 1996; Langmore & McCulloch, 1997; Murray, 1999) and videofluoroscopy research (McCulloch et al., 2001). Clinical significance may be easier to identify with an ordinal scale (Brunier & Graydon, 1996). We created and discussed several versions of the scale with both academic (Newcastle University) and clinical tutors working in the field of dysphagia and voice and, after two months, a pilot form was ready. 5. The ratings of pharyngeal and laryngeal anatomy were altered to a simplified rating of normal versus abnormal anatomy. This was expanded to comment on presence or absence of a number of normal and abnormal anatomical features. 6. Vocal fold adduction during phonation was removed because this is related to speech and not directly to swallowing. Assessment of vocal fold movement during tight breath hold was kept to view vocal fold mobility and the potential for adduction. 7. Seven point ordinal scales were used to rate the overall swallow, inferred base of tongue movement, timing of swallow initiation, pooling and residue and swallow efficiency. Checklists of features relating to oropharyngeal transit and the location of residue were added. 8. One expert requested that an impression of laryngeal elevation should form part of the assessment. Epiglottic function was included in the checklist of features associated with laryngeal excursion. 9. The Penetration-Aspiration Scale (Rosenbek et al., 1996) was retained, together with a question on when penetration/aspiration occurred. tongue base retraction together with features which might indicate a problem with this movement, but did not include analysis in greater depth. After we had made the changes to the pilot form, we returned the revised version to one expert for further comments if needed.

Feedback from experts

As research clinicians developing skills in the area of endoscopy, we deemed it appropriate to seek feedback from experts in the field of dysphagia. We invited two international experts in dysphagia to comment individually on the pilot scale. Both are trained in endoscopy, and one also provides training and publishes work in this area. We asked them to advise on improvements regarding content of features, scoring, length, presentation and clinical relevance. Our rationale for inviting comments on the rating scale was to check we had included the main features that can be seen during endoscopy and that the scoring systems were familiar, user friendly and had clinical relevance. In addition, this consultation process helped to reduce author bias of scale content. Both experts were happy to make suggestions within an agreed time frame and their comments resulted in a number of improvements: 1. Anatomy/physiology features with and without a bolus trial were divided. Overall swallow rating was moved to the start of the bolus trial section so clinicians would report on the whole swallow before rating specific features in detail. 2. Ordinal scales were kept and one expert recommended that ordinal scales should contain 7 points to improve reliability. 3. Severity descriptors relating to the ordinal scales were removed except for the validated severity scales for tight breath hold, secretion severity and penetration/ aspiration. We decided to remove semantic descriptors - such as swallow frequency where a normal rating was described as swallowing frequently in response to a build up of saliva/residue and mildmoderate impairment was labelled as trace pooling of secretions/residue with delayed swallow response - because they set up artificial guidelines that are not uniformly agreed or evidence based. 4. Velar closure during speech was removed because it does not relate to movement during swallowing. Velar closure during the swallow was kept, changed to velopharyngeal closure on a dry swallow and scored on a 7 point ordinal scale of range of closure as opposed to strength of movement (Murray, 1999).

As would be expected in any collaborative exercise, the experts advice differed at times.
As would be expected in any collaborative exercise, the experts advice differed at times. One suggested that a detailed assessment of lateral pharyngeal wall movement and pharyngeal response to touch should be part of the assessment form. However, our other expert suggested removing the pharyngeal sensation rating because it is a crude measure of sensory impairment in the pharynx. We decided to retain a measure of sensory awareness via the rating of pharyngeal secretions using the Secretion Severity Scale (Murray et al., 1996) and a question on rating the presence/ absence of secretions within and around the pharynx and larynx, and the response or lack of response to secretions. One of the experts advised looking at base of tongue movement at rest, on post vocalic / l/, and on dry swallow. While we acknowledge that examinations using endoscopy may include a more in-depth assessment of the movement of base of tongue, the purpose of this assessment tool was to identify a) which features clinicians could see on FEES and b) how reliably they could rate visible features as a group. As a result, we kept in a general measure of

We found the experts comments relating to the scoring and layout useful in providing structure to the pilot version of the scale. Questions relating to the inference of base of tongue retraction and laryngeal elevation were added since both are vital components of the pharyngeal stage of swallowing. Scoring feature severity is no longer qualified with semantic descriptors, which are often highly subjective and not validated in the literature. Clinicians instead are asked to make a severity judgment on a feature, such as the amount of residue, and then to qualify this by answering a checklist of sub features relating to the overall feature, for example the location of residue. This type of scoring is clinically more useful because people qualify why they rated a particular feature as normal or abnormal. We didnt include all features recommended by the experts because the purpose of this form was to produce an initial clinical tool rather than to rate an entire endoscopic swallow assessment. Other researchers (Rosenbek et al., 1996) have already examined which features are difficult to rate in videofluoroscopy. As part of her MPhil research study, Kirsty has gone on to use the endoscopy rating scale to examine inter-rater reliability on anatomical and physiological features of swallowing, and this will be written up for publication at a later date. It is important to keep research focused and doable, so including questions on compensatory strategies and intervention techniques was beyond the remit of Kirstys study. Examining inter-rater reliability on decisions made following endoscopy assessment should form part of a follow-up. Also to be assessed in further work is the use of the 7 point rating scale. Although Likert scales have good psychometric properties (Brunier & Graydon, 1996), this may be too detailed for clinicians to use reliably. We are limited in our clinical and research assessment and intervention by the lack of published, validated scales and scoring systems for endoscopic swallow studies. We need to focus future research on whether the features identified in this preliminary work can be viewed consistently during endoscopy. Based on results of this type of follow-up study we will be in a better position to know which features should be incorporated on an endoscopic swallow assessment rating scale and how this should be applied in clinic. In the longer term we want to use this preliminary work to design research to develop a standardised tool.

Clinically useful

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Editors choice

So many Journals, so little time! Editor Avril Nicoll gives a brief flavour of articles that have got her thinking.

Our aim to devise a rating form based on clinical practice and supported by robust evidence was achieved. The expert peer review increased the clinical validity of the tool, and both speech and language therapists were happy to do this as part of their expert role. Clinicians should therefore consider the features reported in this rating scale when assessing swallowing. Kirsty Hydes is a consultant speech and language therapist at St Johns Hospital, Livingston, e-mail kirsty.hydes@wlt.scot.nhs.uk. Paula Leslie is Associate Professor, Communication Science and Disorders at the University of Pittsburgh, USA, e-mail pleslie@pitt.edu. Paula is also a specialist advisor in swallowing disorders for the Royal College of Speech & Language Therapists. The endoscopic rating scale described is available at http://www. speechmag.com/Members/Extras.

Acknowledgements Our sincere appreciation to the expert clinicians who advised on this project and to Kirstys thesis tutors Nick Miller and Paul Carding. We also wish to thank Dr James L. Coyle for advice on the manuscript.

Our interest in Attachment Theory is increasing but, in Making Space for Positive Constructions of the Mother-Child Relationship, Natalia Cecelia Charles and Rachel C. Berman draw attention to its limitations. Critical of research methods that accentuate stress and difficulties, they use qualitative oral history interviews of mothers of children with autism. Their findings suggest we can and should foster resilience in such mothers and their relationship with their child. Answers to questions such as What aspects of your relationship with your child do you enjoy the most? help identify strategies that, over time, will support and strengthen it. Hopeful, thought-provoking and moving. (Journal of the Association for Research on Mothering (2009) 11(1), pp.180-198) Do people who stammer have impoverished language? Do they use less language to minimise stammering? In The effect of stuttering on communication: A preliminary investigation, Elizabeth Spencer, Ann Packman, Mark Onslow and Alison Ferguson tackle these questions through Systemic Functional Linguistics, which analyses how people communicate with language and the meanings they convey. It is possible that the extent to which modality (a lexicogrammatical resource that is used to indicate opportunities for verbal engagement) is employed will emerge as an area for therapy and outcome measurement in adults who stammer. (Clinical Linguistics & Phonetics (2009) 23(7), pp.473-488) I am coming to appreciate how systematic reviews focus attention on evidence, its strength, the gaps, and how research procedures can be improved. Effectiveness of Early Phonological Awareness Interventions for Students with Speech or Language Impairments by Stephanie Al Otaiba, Cynthia S. Puranik, Robyn A. Ziolkowski and Tricia M. Montgomery details 18 studies. A stand out recommendation for me is collaborative early intervention for children with speech impairment where speech-language pathologists deliver speech production and phonological training that is linked to explicit early literacy phonological awareness training provided by a classroom teacher in a small group setting. (The Journal of Special Education (2009) 43(2), pp.107-128)

REFLECTIONS DO I CONSIDER ASKING FOR PEER AND EXPERT OPINION TO MAKE MY INFORMAL ASSESSMENTS MORE ROBUST? DO I KEEP CLINICAL EXPLORATION FOCUSED AND ACHIEVABLE? DO I EXERCISE CAUTION WHEN APPLYING EVIDENCE FROM ONE TOOL TO ANOTHER?

Do you wish to comment on the impact Bastian, R. (1991) Videoendoscopic evaluation this article has had on you? Please see the of patients with dysphagia: An adjunct to the information about Speech & Language modified barium swallow, Otolaryngology Therapy in Practices Critical Friends at Head and Neck Surgery, 104, pp.339-350. www.speechmag.com/About/Friends Brunier, G. & Graydon, J. (1996) A comparison of two methods of measuring fatigue in patients on chronic haemodialysis: visual analogue versus Likert scale, International Journal of Nursing, 33, pp.338-348. Colodny, N. (2002) Interjudge and intrajudge reliabilities in Fibreoptic Endoscopic Evaluation of Swallowing (FEES) using the Penetration-Aspiration Scale: A replication study, Dysphagia, 17(4), pp.308-315. Dua, K., Ren, J., Bardan, E., Xie, P. & Shaker, R. (1997) Coordination of deglutitive function and pharyngeal transit during normal eating, Gastroenterology, 112, pp.73-83. Hiss, S. & Postma, G. (2003) Fibreoptic Endoscopic Evaluation of Swallowing, Laryngoscope, 113, pp.1386-1393. Kelly, A.M., Leslie, P., Beale, T., Payten, C. & Drinnan, M.J. (2006) Fibreoptic endoscopic evaluation of swallowing and videofluoroscopy: does examination type influence perception of pharyngeal severity? Clinical Otolaryngology, 31(5), pp.425-432. Kelly A.M., Hydes K., McLaughlin C. & Wallace S. (2007) Fibreoptic Endoscopic Evaluation of Swallowing (FEES): The role of speech and language therapy. RCSLT Policy Statement 2007. London: Royal College of Speech & Language Therapists. Langmore, S. & McCulloch, T. (1997) Examination of the pharynx and larynx and endoscopic examination of pharyngeal swallowing, in Perlman, A. & Schulze-Delrieu, K. (ed.) Deglutition and Its Disorders. San Diego: Singular Publishing, pp.201-226. Langmore, S., Schatz, K. & Olsen, N. (1988) Fibreoptic Endoscopic Examination of Swallowing Safety: A new procedure, Dysphagia, 2, pp.216-219. Logemann, J., Rademaker, A., Pauloski, B., Ohmae, Y. & Kahrilas, P. (1999) Interobserver agreement on normal swallowing physiology as viewed by videoendoscopy, Folia Phoniatrica et Logopaedica, 51, pp.91-98. McCullough, G., Wertz, J., Rosenbek, J., Mills, R., Webb, W. & Ross, K. (2001) Inter- and Intrajudge reliability for videofluoroscopy swallowing evaluation measures, Dysphagia, 16, pp.110-118. Murray, J. (1999) Manual of Dysphagia Assessment in Adults. San Diego: Singular Publishing. Murray, J., Langmore, S., Ginsberg, S. & Dostie, A. (1996) The significance of accumulated oropharyngeal secretions and swallowing frequency in predicting aspiration, Dysphagia, 11, pp.99-103. Rosenbek, J., Robbins, J., Roecker, E., Coyle, J. & Wood, J. (1996) A penetration-aspiration scale, Dysphagia, 11, pp.93-98. Smithard, D., ONeill, P., Park, C., Morris, J., Wyatt, R., Engand, R. & Martin, D. (1996) Complications and outcome after acute stroke: Does dysphagia matter?, Stroke, 27(7), pp.1200-1204. Zammit-Maempel, I., Chapple, C.L. & Leslie, P. (2007) Radiation Dose in Videofluoroscopic Studies, Dysphagia, 22(1), pp.13-15.

References

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Endoscopic Rating Scale Kirsty Hydes & Paula Leslie

Made available to members of Speech & Language Therapy in Practice magazine at www.speechmag.com/Members/Extras to complement the article: Hydes, K. & Leslie, P. (2009) Scoping and scaling, Speech & Language Therapy in Practice Autumn, pp.4-6.
NB questionnaire starts at Q12 because questions 1-11 are biographical.

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Questions relating to Anatomy and Physiology Q12. Subjective impression of velopharyngeal closure on dry swallow: Full velopharyngeal closure achieved Mild compromise in closure Mild-moderate compromise in closure Moderate compromise in closure Moderate-severe compromise in closure Severe compromise in closure Velopharyngeal closure totally incomplete Dont know/cant tell Q13. A) Subjective impression of pharyngeal anatomy and physiology: Normal Abnormal Dont know/cant tell B) Feature relating to anatomy: (Tick all applicable) Healthy/Normal Structural anomaly Please specify ___________________________________________________ Oedema evident Please specify where _____________________________________________ Asymmetry R Asymmetry L Irregular epiglottis Please specify ___________________________________________________ Restricted vallecular space Pharyngeal weakness R Pharyngeal weakness L Other Please specify ___________________________________________________

Q14. A) Subjective impression of laryngeal anatomy and physiology: Normal Abnormal Dont know/cant tell

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B) Inferences relating to anatomy: (Tick all applicable) Healthy/Normal Structural anomaly Please specify ___________________________________________________ Oedema evident Please specify where _____________________________________________ Rotated larynx/Asymmetry of Arytenoids Vocal fold palsy R Vocal fold palsy L Laryngeal weakness/paralysis R Laryngeal weakness/paralysis L Laryngeal pathology Please specify ___________________________________________________ Other Please specify ___________________________________________________ Q15. Subjective impression of glottal adduction during tight breath-hold: Sustained true fold, ventricular fold and aryepiglottic fold closure Transient true fold, ventricular fold and aryepiglottic fold closure Sustained true vocal/ventricular/aryepiglottic fold closure only Transient true vocal/ventricular/aryepiglottic fold closure only Sustained breath-hold with glottis open Transient breath-hold with glottis open Breath-hold not achieved i.e. vocal folds continue to adduct and abduct Dont know/cant tell Q16. A) Subjective impression of pharyngeal secretions (Murray, Langmore et al 1996): No visible secretions in hypopharynx Transient secretions in valleculae/pyriform fossae/channels surrounding laryngeal vestibule Bilateral and/or deeply pooled secretions in valleculae/pyriform fossae/channels surrounding laryngeal vestibule Any secretions fluctuating between a transient-bilateral/deeply pooled rating Any secretions seen in area defined as laryngeal vestibule (see figure 1) Dont know/cant tell

Figure 1

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B) Appearance of secretions: (Tick all applicable) None evident Clear Purulent Sticky Thick Other Please specify __________________________________________________ Dont know/Cant tell Questions relating to Oral Trials Q17. A) Subjective impression of base of tongue movement: Normal range of motion Mild compromise in range of motion Mild-moderate compromise in range of motion Moderate compromise in range of motion Moderate to severe compromise in range of motion Severe compromise in range of motion Dont know/cant tell B) Inferences relating to tongue base movement: (Tick all applicable) Full motion inferred Reduction in swallow efficiency Build up of residue in valleculae/posterior pharyngeal wall Incomplete contact of tongue base to pharyngeal wall Reduction in strength of movement Multiple swallows to clear Other Please specify ___________________________________________________ Dont know/cant tell Q18. A) Subjective impression of the swallow: Normal Mild impairment Mild-Moderate impairment Moderate impairment Moderate-severe impairment Severe impairment Dont know/cant tell

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B) Inferences relating to the overall swallow (Tick all applicable) Normal swallow Premature spillage Reduced oral control Pooling valleculae Pooling pyriform fossae Delay in triggering the swallow Residue valleculae Residue pyriform fossae Residue Posterior pharyngeal wall Penetration Aspiration Incomplete swallow Reduced swallow efficiency/inability to clear material Other Please specify _____________________________________________________ Q19. A) Subjective impression on triggering of the swallow:
Onset: When bolus head appears at base of tongue superior to valleculae Endpoint: First frame of white out

No extension of the duration of stage transition Mild extension of the duration of stage transition Mild-Moderate extension of the duration of stage transition Moderate extension of the duration of stage transition Moderate to Severe extension of the duration of stage transition Severe extension of the duration of stage transition Dont know/cant tell B) Inferences relating to swallow onset: (Tick all applicable) No volitional advancement of bolus Partial closure of vocal cords and/or arytenoids before bolus enters pharynx Partial closure of vocal cords and/or arytenoids once bolus reaches pharynx Bolus passes tip of epiglottisswallow triggered Bolus enters valleculaeswallow triggered Bolus enters pyriform fossaeswallow triggered Delay in onset of epiglottic retroflexion Delay in white out occurring Pooling in of valleculae Pooling in of pyriform fossae Late onset of pharyngeal stage swallow Reduced pharyngeal/laryngeal sensation Laryngeal penetration/aspiration Other Please specify ___________________________________________________ Dont know/cant tell

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Q20. A) Sub bjective imp pression of glottic g closu ure: (Tick al ll applicable e) Aryte enoid and/or r vocal cord d adduction precedes base of tongu ue moveme ent Aryte enoid adduc ction and/or closure bef fore bolus enters e phary ynx Aryte enoid adduc ction and/or closure afte er bolus ent ters pharynx x Onset t of vocal co ord adduction before bolus b enters pharynx Onset t of vocal co ord adduction after bol lus enters ph harynx Maximum vocal cord adduc ction observ ved before obliteration o lottic descen nt observed before obli iteration Epigl Vertic cal approxim mation of arytenoids a to o epiglottis observed be efore obliteration Addu uction of false cords ob bserved befo ore obliterat tion Laryn ngeal vestib bule closure observed before b oblite eration Dont t know/can t tell B) If co ords reached maximum m adduction n, which of the t followin ng best desc cribes their contact c (Mu urray 1999): Type 1: Cords in n contact the eir entire len ngth (see fig gure 2.1) Type 2: Cords in n contact an nterior 2/3, with w a slight t posterior gap g (see figu ure 2.2) Type 3: Cords no ot making full f contact, leaving a small elonga ated narrow w triangle op pening (see fig gure 2.3) Dont t know/can t tell

Figure 2.1

Figu ure 2.2

Figure 2.3

Q21. jective impr ression of pharyngeal p p pooling: A) Subj Norm mal Mild pooling Mild-moderate pooling p Mode erate poolin ng Mode erate-severe e pooling Sever re pooling Dont t know/can t tell

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B) Location of pooling: (Tick all applicable) None observed Valleculae R Valleculae L Pyriform fossae R Pyriform fossae L Laryngeal Vestibule Other Please specify ___________________________________________________ Dont know/can tell Q22. A) Subjective impression of swallow efficiency: Normal Mild reduction in efficiency Mild-moderate reduction in efficiency Moderate reduction in efficiency Moderate-severe reduction in efficiency Severe reduction in efficiency Dont know/cant tell B) Inferences relating to swallow efficiency: (Tick all applicable) Reduced velopharyngeal closure Reduced base of tongue retraction 1-2 swallows taken to clear bolus 3+ swallows taken to clear bolus No swallows taken Trace residue post-swallow; cleared effectively by immediate follow up swallow Trace residue post-swallow; delayed attempt at clearing/no attempt to clear Build up of residue; multiple swallows taken to clear with success Build up of residue; multiple swallows taken to clear without success No response to residue Other Please specify ___________________________________________________ Dont know/cant tell Q23. A) Subjective impression of laryngeal elevation Normal Mild impairment Mild-Moderate impairment Moderate impairment Moderate-severe impairment Severe impairment Dont know/cant tell

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B) Inferences relating to laryngeal elevation: (Tick all applicable) Epiglottic retroflexion appeared complete at end of white out Epiglottic retroflexion incomplete at end of white out Build up of pharyngeal residue Multiple swallows taken to clear bolus and/or residue Other Please specify ___________________________________________________ Dont know/cant tell Q24. A) Subjective impression of pharyngeal residue: Normal Mild residue Mild-moderate residue Moderate residue Moderate-severe residue Severe residue Dont know/cant tell B) Location of residue post swallow: (Tick all applicable) None observed Base on tongue Valleculae R Valleculae L Pyriform fossae R Pyriform fossae L Lateral pharyngeal walls Posterior pharyngeal walls Penetration of Residue Aspiration of residue Other Please specify ___________________________________________________ Dont know/cant tell Q25. A) Timing of aspiration/penetration No evidence Pre-swallow Inferred during the swallow Post-swallow Dont know/cant tell

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B) Aspiration/Penetration Scale: Material does not enter the airway Material enters the airway, remains above the vocal folds, and is ejected from the airway Material enters the airway, remains above the vocal folds, and is not ejected from the airway Material enters the airway, contacts the vocal folds, and is ejected from airway Material enters the airway, contacts the vocal folds, and is not ejected from airway Material enters the airway, passes below the vocal folds, and is ejected from airway Material enters the airway, passes below the vocal folds, and is not ejected from airway despite effort Material enters airway, passes below the vocal folds, and no effort is made to eject

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