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Egyptian Journal of Ear, Nose, Throat and Allied Sciences (2014) 15, 197203

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Egyptian Society of Ear, Nose, Throat and Allied Sciences

Egyptian Journal of Ear, Nose, Throat and Allied


Sciences
www.ejentas.com

ORIGINAL ARTICLE

The value of bedside tests in dysphagia evaluation


Hatem Ezzeldin Hassan

a,b,*

, Ali Ibrahim Aboloyoun

c,d

Otorhinolaryngology Department, Sohag University, Egypt


King Fahd Hospital, Jeddah, Saudi Arabia
c
ENT Department, King Abdullah Medical City, Holy Makkah, Saudi Arabia
d
Faculty of Medicine, Assiut University, Egypt
b

Received 20 April 2014; accepted 21 July 2014


Available online 14 August 2014

KEYWORDS
Bedside tests;
Oropharyngeal;
Dysphagia;
Fiberoptic endoscope

Abstract Bedside tests are important predictor of aspiration during swallowing and they are the
most widely used tests. Fiberoptic Endoscopic Evaluation of Swallowing (FEES) is one of the
important tests for dysphagia evaluation. The aim of this work is to answer the question, what is
the value of bedside tests in comparison to the results of FEES among our population.
Objective: To assess the value of bedside tests in comparison with FEES.
Patients and methods: 74 patients were presented to phoniatrics clinic for the assessment of
swallowing difculties during the period from May 2011 to August 2013. They were 47 males
and 27 females with a mean age of 52 years and range between 20 and 91 years.
Aspiration correlates were assessed using bedside tests (water swallow test, pulse oximetry and
gag reex). FEES was performed to most of the patients to detect sensitivity and specicity in
comparison with bedside tests.
Results: Dysphagia was recorded in 56% of the patients. Bedside tests showed 73% sensitivity
and 68% specicity when correlated with FEES. Moreover combination of voice change and
chocking/cough results in sensitivity of 86.5% and specicity of 75.2%.
Conclusion: Bedside tests are highly sensitive and specic for the detection of dysphagia.
Combination of chocking/cough and change of voice as parameters of aspiration compared with
FEES showed high sensitivity and specicity.
2014 Hosting by Elsevier B.V. on behalf of Egyptian Society of Ear, Nose, Throat and Allied Sciences.

1. Introduction
* Corresponding author at: King Fahd Hospital, P.O. Box: 8488,
Jeddah-21196, Saudi Arabia. Mobile: +966 594183458; fax: +966
126652263.
E-mail address: hezzm268@yahoo.com (H.E. Hassan).
Peer review under responsibility of Egyptian Society of Ear, Nose,
Throat and Allied Sciences.

Dysphagia is a symptom that refers to pain, difculty or discomfort during the progression of the bolus from the mouth
to the stomach. From an anatomical standpoint dysphagia
may result from oropharyngeal or esophageal dysfunction
and from a pathophysiological standpoint from structurerelated or functional causes.1

http://dx.doi.org/10.1016/j.ejenta.2014.07.007
2090-0740 2014 Hosting by Elsevier B.V. on behalf of Egyptian Society of Ear, Nose, Throat and Allied Sciences.

198
Oropharyngeal dysphagia can be caused by a variety of diseases such as stroke, postirradiation, reux and cricopharyngeal muscle dysfunction. Dysphagia has signicant impacts
on patients life quality, life expectancy, and economic burden.
Early detection of swallowing difculty as aspiration of
ingested materials is important because of the hazards of chest
infection, malnutrition and airway obstruction. The evaluation
of swallowing disorders and their rehabilitative modalities is
an important topic. The benet to the patient, in terms of
improvement in quality of life, cannot be underestimated.
Many studies25 have attempted to assess the utility and
efcacy of various methods used to tackle the problem with
varying degrees of sensitivity and specicity.
Bedside tests might be used to identify patients with oropharyngeal dysphagia and to identify those who are at risk
of aspiration. During bedside testing, the clinical indicators
of dysphagia included abnormal volitional cough, abnormal
gag reex, dysphonia, dysarthria, cough after swallow, and
voice change after swallow.6
Teismann et al.5 stated that, up to 30% of older patients
with dysphagia present with aspiration, half of them without
cough (silent aspiration), and 45%, oropharyngeal residue.
Fiberoptic Endoscopic Evaluation of Swallowing (FEES)
is one of the important tests for evaluation of the anatomy
of the pharynx and larynx and assessment of the process of
swallowing.3,4 FEES was developed and popularized by
Langmore23 and modied by Flaksman et al.24 It has proved
to be a signicant tool in the assessment of the pharyngeal
stage of the swallow process. Numerous studies2528 have
highlighted its utility in visualization of the larynx and diagnosis of aspiration. They reported that FEES became the
procedure of choice as it allows direct visualization of these
structures without the risk of radiation. Also they stated that
FEES is an easy, efcient and reliable method to evaluate the
swallowing status in stroke patients, moreover, in combination with good bedside clinical examination and swallow
exercises, it can be a good tool in assessing patients with
post-stroke dysphagia. Post-stroke rehabilitation and prevention of aspiration pneumonia can be effectively done with the
help of FEES.
1.1. Aim of the work
The aim of this work was to assess the value of various types of
bedside tests in comparison with FEES to evaluate aspiration.
This may help in easy, rapid and accurate diagnosis of aspiration during swallowing, hence better management.
2. Patients and methods
74 patients with different diagnostic entities were presented to
the phoniatric clinic King Fahd Hospital- Jeddah (Tertiary
Care Centre) between May 2011 and June 2013 for the assessment of swallowing troubles as presence or absence of aspiration and possibility of weaning from nasogastric tune (NGT)
or percutaneous endoscopic gastrostomy (PEG). They were
47 men and 27 women. The patients were evaluated according
to the following procedures.

H.E. Hassan, A.I. Aboloyoun


2.1. General examination
The patients were observed for the degree of consciousness,
cooperation, verbal, oral apraxia and articulation. Patients
who cannot obey verbal orders, markedly impaired degree of
consciousness, with receptive aphasia or with signicant
apraxia were excluded from the study.
32 patients were initially on NGT, 11 patients were on PEG
tubes, 13 patients were on both NGT and tracheostomy tubes
and 18 patients were on oral feeding.
2.2. Clinical systematic examination
Bedside evaluation of swallowing was done which included
initial assessment of cognitive status, gag reex, voluntary
cough and throat clearing. If the above steps were possible,
assessment of saliva was done.
Saliva assessment: According to Corinna et al.7
Spontaneous swallowing of saliva and swallowing frequency were assessed. If it is proved impossible to control
and swallow saliva, the examination was terminated.
Water swallow test: According to.810
The patient was examined in the sitting position or in 45
degrees. Some patients were examined in the recumbent position because of difcult positioning. The patient was given
5 ml of water, and when the patient could tolerate that amount
of water, he/she was given 20 ml followed by 50 ml of water
(thin uid) and assessed for cough/chocking during or after
swallowing, wet or weak cough after swallowing. Also the
patient was asked to produce sustained vowel /a/ before and
after swallowing of water and voice change after swallowing
was observed and recorded.
2.3. Pulse oximetry
According to Zaidi et al.11 pulse oximetry was done for the
patients before starting FEES and for 5 min after the test
and results were recorded. 3% or more reduction in oxygen
saturation was considered positive test.
2.4. Fiberoptic Endoscopic Evaluation of Swallowing (FEES)
All patients who passed saliva test were tested by FEES.
Digital Swallowing Workstation by KayPENTAX was used.
The patient was seated for FEES in the sitting position
(whenever possible) However, in some cases, this was not
possible, instead, a semi-upright position on the bed was
adopted. The exible beroptic laryngoscope was inserted
transnasally into the pharynx. It provided detailed information about the anatomy of the nose, pharynx and larynx.
Sensation could be tested by touching the tip of the endoscope to various areas of the larynx and reex adduction
of the vocal folds or reex cough and chocking were
observed. Different food consistencies as uids (water),
semisolids (thick juice/yoghurt) and solids (piece of biscuits
or bread), mixed with blue dye, were used to evaluate swallowing. The salient ndings noted were residue, penetration
and aspiration into the larynx.

The value of bedside tests in dysphagia evaluation


2.5. Ethical standards
The authors assert that all procedures contributing to this
work comply with the ethical standards of the relevant
national and institutional guidelines on human experimentation and with the Helsinki Declaration of 1975, as revised in
2008.
2.6. Statistical analysis
Statistical package for social Sciences version 11 (SPSS, INC,
Chicago, IL) under windows was used for data entry and data
analysis. Descriptive statistics were done for continuous
variables by mean, standard deviation (SD) and range.
The individual bedside tests and combinations of these tests
were subjected to statistical analysis. To examine, the sensitivity, specicity and positive and negative predictive values
(PPV, NPV) were determined. Sensitivity and specicity were
calculated using a 2 2 contingency table. The calculation
was based on a comparison between the results of the bedside
tests and FEES. A 95% condence interval was used for
testing.
3. Results
The bedside tests required an average of 15 min and FEES
required about 10 min.
3.1. Test subjects
74 patients, 47 (63.5%) men and 27 (36.5%) women (mean
age = 46.68, range = 1891), were included in the study with
17 (23%) post Road Trafc Accident (RTA) patients, 26
(35%) with neurological insult patients such as CerebroVascular Accidents (CVA), cerebral hemorrhage, cerebral contusion,
16 (22%) ENT patients following treatment (surgery or radiotherapy) or a result of vocal fold immobility or cancer in the
neck, tongue or larynx and other diseases in 15 (20%) patients
(Fig. 1).
3.2. Bedside tests vs. FEES
To determine sensitivity, specicity and predictive values, the
results of bedside tests were compared with the results
obtained using FEES.
Cough/chocking for all test subjects showed a sensitivity of
74.29%, specicity of 70%, PPV of 69.66 and NPV of 68.7%.
The sensitivity of change of voice was 80.3%, specicity was

20 %
Neurological 35%

35%

22 %

ENT 23 %

23 %

RTA 22%
Other 20 %

Figure 1

Causes of dysphagia.

199
73.3%, PPV was 79.3 and NPV was 72.6%. The sensitivity
of gag reex was 50.4%, specicity was 57.8%, PPV was
60.3 and NPV was 51.7%. The sensitivity pulse oximetry was
48.3%, specicity was 55.6%, PPV was 46.7 and NPV was
57.2% (Table 1, Fig. 1).
In this study aspiration was observed in 75% of patients
with decreased or absent laryngeal sensation tested by touching laryngeal structures by the tip of endoscope during FEES.
However 25% of the patients demonstrated that normal laryngeal sensations in patients showed aspiration during FEES.
3.3. Combination of the clinical tests
For the test population as a whole, combining the cough/
chocking (during or after swallowing) and change of voice
(after swallowing) parameters by addition achieved a sensitivity of 86.5%, specicity of 75.2%, PPV of 80.2 and NPV of
74.9 (Fig. 2, Table 1).
4. Discussion
Diagnosing and treating swallowing disorders represent a
major challenge in everyday clinical practice. The most common diagnostic procedures for oropharyngeal dysphagia are
beroptic endoscopic swallowing examination (FEES) and
videouoroscopy. Because these procedures are technically
demanding, the tendency in everyday practice is to try to
obtain meaningful information on a patients swallowing ability by using standardized simple clinical tests. This is primarily
achieved using swallow tests with water, modied in a variety
of ways.6,12,13 Moreover, Okubo et al.14 mentioned that the
most frequently used swallow test is the bedside swallow
assessment, which covers a number of techniques used in a
ward environment (see Table 2, Fig. 3).
4.1. Characters of the patients
In this study, the most common causes of oropharyngeal dysphagia were neurological insult (35%) followed by RTA and
ENT patients (22%) following treatment (surgery or radiotherapy) as a result of vocal fold immobility or cancer in the
neck, tongue or larynx. Other causes (20%) are also detected
such as sepsis and debilitating diseases.
In a study done by Hoy et al.15 they mentioned that the
mean age of the entire cohort was 62 13.5 years, and 58%
of the cohort was males. The most common identied causes
of dysphagia were laryngo-pharyngeal reux disease (LPRD)
(27%), postirradiation dysphagia (14%), and cricopharyngeal
muscle dysfunction (11%). in 13% of cases. Also3,16
mentioned that, the prevalence of oropharyngeal functional
dysphagia is very high, it affects more than 30% of patients
who have had a cerebrovascular accident; 5282% of patients
with Parkinsons disease; 84% of patients with Alzheimers
disease, and up to 40% adults aged more than 65 years.
The difference between the causes of oropharyngeal dysphagia in the previous study and the current study is that
the aim of our study was to detect penetration of the larynx
and aspiration during testing with different food consistencies
such as liquids, semisolids and solids, however in the previous
study the most common cause was laryngo-pharyngeal reux
disease (LPRD) as the term dysphagia is a wide term and it

200

H.E. Hassan, A.I. Aboloyoun

Table 1

Comparison of bedside tests with FEES%.

Bedside test

Sensitivity%

Specicity%

PPV%

NPV%

Cough/chocking
Change of voice
Gag reex
Pulse oximetry
Cough/chocking + change of voice

74.29
80.3
50.4
48.3
86.5

70.00
73.3
57.8
55.6
75.2

69.66
79.3
60.3
46.7
80.2

68.7
72.6
51.7
57.2
74.9

PPV, positive predictive value; NPV, negative predictive value.

Figure 2

Comparison of bedside tests with FEES%.

may include discomfort, pain, difculty during swallowing or


penetration or aspiration of food particles and saliva.

Figure 3

Combination of 2 bedside tests with FEES%.

4.2. Bedside tests


The primarily used bedside test for swallowing evaluation is
water swallow test (WST) described by Gordon et al.17 the
tests used in everyday clinical practice are various modied
versions of the WST. The literature describes various versions
of the WST with varying results. DePippo et al.18 described the
Burke Dysphagia Screening Test (BDST), the patient was
given 3-oz water and the results were reported. Smithard et al.19
asked the patient to drink water from a glass without interruption. Coughing during or after completion or the presence of a
post swallow wet-hoarse voice quality, or swallow speed of less
than 10 ml/is scored as abnormal. Nathadwarawala et al. and
Westergren20,21 described the standardized bedside swallow
assessment (SBSA), patients are asked to drink 50 ml of water
and the results were reported.
In the current study, four clinical parameters were observed
during the water swallow test compared with FEES namely,
chocking/cough, change of voice, gag reex and pulse oximetry. These parameters represent aspiration of water through
the vocal folds. Two parameters showed high sensitivity and
specicity, chocking/cough (sensitivity 74.29%, specicity

Table 2

70%, PPV 69.66% and NPV 68.7%) and change of voice


(sensitivity 80.3%, specicity 73.3%, PPV 79.3% and NPV
72.6%).
These clinical bedside methods can detect aspiration,
although with differing diagnostic accuracies. Burkes 3-oz
water swallow test identied 80% of patients aspirating during
subsequent VFS examination (sensitivity 76%, specicity
59%).20 The SBSA showed a variable sensitivity (4768%)
and specicity (6786%) in detecting aspiration when used
by speech swallow therapists or doctors.19,22
DePippo et al.18 examined 115 stroke patients and added
the clinical variables swallow capacity and volume per
swallow. With these two clinical variables taken into consideration, they found a sensitivity of 97% and a specicity of 69%.
Excluding these two clinical variables, sensitivity fell to 73%
and specicity to 67%. Daniels et al.6 studied 59 stroke
patients using a 70-ml WST. Patients drank two 5, 10 and
20 ml volumes of water. Sensitivity was 92.3% and specicity
was 66.7%.
In our study, WST achieved different levels of sensitivity
and specicity described in the literatures. The difference in

Combination of 2 bedside tests with FEES%.

Cough/chocking + change of voice

Sensitivity%

Specicity%

PPV%

NPV%

86.5

75.2

80.2

74.9

PPV, positive predictive value; NPV, negative predictive value.

The value of bedside tests in dysphagia evaluation


results between our study and Daniels et al.6 study is that they
examined patients with neurological insults only however we
examined neurological and non-neurological patients.
Several authors18,19,22 mentioned that the validity for most
swallow tests has been determined by comparison with FEES
and detection of aspiration by bedside testing has been variable with sensitivities between 42% and 92% and specicities
between 59% and 91%. Positive predictive values for bedside
swallow testing range from 50% to 75%; negative predictive
values range from 70% to 90%.
In the current study, bedside testing (cough/chocking and
change of voice) was comparable with previously mentioned
studies.18,19,22 However other parameters (gag reex and
oxygen saturation) showed low sensitivity and specicity. Differences in results may be explained by modications of examination procedures and the variables selected. In the current
study, four variables of WST were examined (chocking/cough,
change of voice, gag reex and pulse oximetry) individually
and sensitivity and specicity were calculated for each parameter. However in the previous studies the authors calculated
sensitivity and specicity for all formerly mentioned parameters as one unit.
4.3. Fiberoptic Endoscopic Evaluation of Swallowing (FEES)
In the current study FEES was sufcient to detect penetration
or aspiration of swallowed materials in the larynx. All the
patients examined by FEES tolerated the procedure. None of
our patients had any signicant complications during or after
the procedure. Penetration of laryngeal inlet could be inferred
by the presence of colored material after swallowing. These
materials touch the superior surface of the vocal folds but
not pass below the vocal folds. Aspiration means that the
bolus passed the glottis to a level below the vocal folds. The
occurrence of aspiration in most patients (75%) who have lost
laryngeal sensation reects the importance of intact laryngeal
sensory inputs in the swallowing process.
FESS is a valid, effective, low cost technique that assesses
swallowing in a bedside examination. FEES can give information on anatomy, the swallow process, pharyngeal motility,
and sensory decits.29,30 Although aspiration cannot be seen
directly, it can be inferred from residue left after swallowing
or ejection of material out of the trachea after coughing.31
4.4. Gag reex
Absent gag reex was valuable as stated by some authors22,3133
to assess aspiration, but it was of less signicance to predict
aspiration as considered by other authors.19,3436
In the current study some patients with aspiration detected
by FEES had absent gag reex (40%), moreover, 50% of
patients with disturbed laryngeal sensation had absent gag
reex. This might suggest clinical association between
disturbed gag reex when the laryngeal sensation is affected
however there is no strong correlation between the coincidence
of the two conditions.
Gag reex when compared with FEES showed less sensitivity and specicity than other parameters tested. Gag reex
resulted in sensitivity of 50.4%, specicity of 57.8%, PPV of
60.3% and NPV of 51.7%. These results coincided with those
obtained by Davies et al.37 who demonstrated that up to 30%

201
of healthy younger adults and 44% of healthy older adults
may have unilateral or bilateral absent gag reexes normally.
They added that sensation was also abnormal in 40% of those
not aspirating, and normal swallowing can occur with complete local anesthesia.
Lim et al.38 examined post-stroke patients and performed a
sensorimotor examination, they observed swallowing and
related movements, and found a high incidence of impaired
pharyngeal gag and dysphonia in patients exhibiting laryngeal
penetration. However, in the current study the patients were
stroke patients and non-stroke patients this explains the diversity of results in both studies.
4.5. Pulse oximetry
Pulse oximetry provides a noninvasive method of bedside
swallow testing. Researchers11,39,40 found association between
oxygen desaturation secondary to aspiration during oral feeding in neurologically disabled individuals.
In this study, most of the patients underwent pulse oximetry during FEES and the results were recorded for 5 min after
swallowing. The results showed low sensitivity and specicity
in comparison with FEES and with other parameters as chocking and dysphonia. (Sensitivity 48.3%, specicity 55.6%, PPV
46.7% and NPV 57.2%). This may be explained by that pulse
oximetry in stroke patients might be affected by other factors
as central causes of hypoxemia rather than swallowing.
However swallowing difculties in our patients were caused
by different etiologies (stroke, RTA, ENT causes and others).
Some studies40,41 have found no clear relationship between
desaturation and aspiration, but Smith et al.42 study demonstrated persistently lower saturations in aspirators than nonaspirators. Other researchers have found that desaturation of
3% from baseline predicted aspiration on VF.42,43 also found
correlation between aspiration and oxygen desaturation, they
reported sensitivity values ranged from 73% to 87%, and specicity values ranged from 39% to 87%. Another study done by
Daniels et al.16 compared oxygen desaturation predictions
with aspiration detected by beroptic endoscopy which
obtained better specicities and predictive values, they added
that aspiration causes reex bronchoconstriction and therefore
ventilationperfusion imbalance, leading to hypoxia and
desaturation.
Lim et al.38 have suggested that abnormal swallowing leads
to poor breathing and ventilationperfusion mismatching
because of reduced inspiratory volumes.
4.6. Combination of tests
In this study combination of certain parameters led to high
sensitivity and specicity in comparison with FEES. We found
that combination of chocking/cough and change of voice as
parameters (as indicators of aspiration) compared with FEES
showed high sensitivity, specicity, PPV and NPV (sensitivity
86.5%, specicity 75.2%, PPV 80.2% and NPV 74.9%).
Some studies done by19,31,44 have postulated that a sum of
more than one parameter (as indicators of aspiration) gives
more accuracy to ass patients with aspiration and penetration
during swallowing. Corinna et al.7 have mentioned that
combining water tests with oxygen desaturation led to higher
sensitivities between 73% and 98% and specicities between

202
63% and 76%. Moreover, he added that combination of these
tests is sufcient to detect aspiration in most of their patients.
Also he recommended the use of water test combined with
pulse oximetry using coughing, choking and voice alteration
as endpoints as screening method to detect dysphagia in
patients with neurological disorders.
5. Conclusion
 Bedside tests can be considered as an important, easy, sensitive and specic for the detection of aspiration.
 Combination of chocking/cough and change of voice as
parameters of aspiration compared with FEES showed high
sensitivity and specicity.
 Further research is needed to establish the most effective
combination of bedside tests to detect silent aspiration.

Financial support
This research received no specic grant from any funding
agency, commercial or not-for-prot sectors.
Conict of Interest
None.
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