Dysphagia

https://doi.org/10.1007/s00455-021-10316-1

ORIGINAL ARTICLE

Validity and Reliability of the Turkish Translation of the Yale

Pharyngeal Residue Severity Rating Scale
Yavuz Atar1   · Sevgi Atar2   · Can Ilgin3   · Melis Ece Arkan Anarat1   · Ugur Uygan1   · Yavuz Uyar1 

Received: 17 January 2021 / Accepted: 13 May 2021

© The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature 2021

Abstract
This study aimed to assess the validity and reliability of the Turkish translation of the Yale pharyngeal residue severity rat-
ing scale. The scale measures the severity of residue in the vallecula and pyriform sinus. The original scale was translated
into Turkish by two bilingual English-Turkish translators, and the Turkish version was translated back into English by two
qualified professional translators to assess accuracy. The evaluators were divided into two groups (training and no-training)
and two subgroups according to their experience. Intra-rater, inter-rater, and intra-class correlation coefficient measurements
were analyzed by calculating agreement rates, kappa, and p values. In the analysis of the reliability, intra-class correlation
coefficient values in the overall ratings for both the vallecula and the pyriform sinus were 0.9996 (95% CI 0.9992–0.9998)
and 0.9997 (95% CI 0.9995–0.9999), respectively (p < 0.01). High agreement (> 95%) and perfect Fleiss kappa values were
obtained for the vallecula and pyriform sinus ratings in the inter-rater initial assessments (κ = 0.959 and κ = 0.967, respec-
tively). Perfect kappa values were found in the intra-rater results for both the vallecula and pyriform sinus (α = 0.9959 and
κ = 0.9959, respectively). In the inter-rater secondary analysis, the vallecula and pyriform sinus kappa values were perfect
(κ = 0.959 and κ = 0.967, respectively). In the intra-rater analysis, perfect kappa values were obtained for the vallecula and
pyriform sinus in the no-training group and less-experience subgroup (κ = 0.9918 and κ = 1.0 for the vallecula, and κ = 1.0
and κ = 0.9902 for the pyriform sinus, respectively) In the inter-rater analysis, perfect kappa values were obtained for the
vallecula and pyriform sinus in the no-training group and less-experience subgroup (κ = 0.9507 and κ = 0.9606 for the val-
lecula, and κ = 0.9836 and κ = 1.0 for the pyriform sinus, respectively). The Turkish translation of the Yale pharyngeal residue
severity rating scale demonstrated high validity and reliability scores in determining pharyngeal residue location and value
in the fiberoptic endoscopic evaluation of swallowing.

Keywords  Pharyngeal residue · Validity · Swallowing · Vallecula · Pyriform sinus · Therapy · Scale

Introduction

The pharyngeal residue (PR) is an important indicator used

* Yavuz Atar
yavuzatar@gmail.com
1
Department of Otorhinolaryngology, Prof. Dr. Cemil
Tascioglu City Hospital, Kaptanpaşa Mah. Darülaceze
Cad. No:25, Sağlık Bilimleri Üniversitesi, Prof. Dr. Cemil
Taşcıoğlu Şehir Hastanesi, KBB Kliniği Kat:6 Blok:5,
Okmeydanı, Şişli, 34384 Istanbul, Turkey
2
Department of Physical Medicine and Rehabilitation,
Prof. Dr. Cemil Tascioglu City Hospital, Kaptanpaşa
Mah. Darülaceze Cad. No:25, Sağlık Bilimleri Üniversitesi,
Prof. Dr. Cemil Taşcıoğlu Şehir Hastanesi, FTR Kliniği
Kat:6 Blok:1, Okmeydanı, Şişli, 34384 Istanbul, Turkey
3
Department of Public Health, Faculty of Medicine, Marmara
University, Istanbul, Turkey
in evaluating, and planning the treatment of the patients with
dysphagia and monitoring the results of swallowing therapy.
The location and amount of pharyngeal residue give impor-
tant information, especially for aspiration risk [1–3]. In a
patient with normal swallowing function, the spontaneous
descent of the bolus takes an unnoticeably short amount of
time, whereas in a patient with neuromuscular disease, the
residue of the bolus can be seen in the oropharyngeal and
the hypopharyngeal sections [2, 4, 5]. Due to the natural
anatomy of the pharynx and larynx, the pharynx contains
three sections that allow the bolus to leave residues in the
presence of pathology. These sections, which can be seen
endoscopically, consist of the right and left pyriform sinus

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in the hypopharynx and a vallecula in the oropharynx [3, 4].
The amount of bolus leaving residue in the pharynx provides
information about the severity of the dysfunction and is use-
ful for evaluating the results of the therapy administered to
the patient [6]. In clinical applications, videofluoroscopic
swallowing studies and fiberoptic endoscopic evaluation of
swallowing (FEES) are the main PR assessment methods [2,
7]. FEES is an evaluation method that allows both the larynx
and the pharynx to be seen at the same time with flexible
endoscopy. It is a practical and reliable method that includes
the evaluation of the pharyngeal phase of swallowing with a
food bolus that has a certain fluidity and color that contrasts
with the mucosa [8, 9].
It is important to use an understandable and useful scale
in the evaluation of the results of PR. However, various
scales have been reported in the literature in attempts to
document this subjective assessment and the measurabil-
ity of its residue. Despite these contributions, there are not
enough validated PR scales [10]. The Yale pharyngeal resi-
due severity rating scale (YPRSRS) has been reported to
be a reliable ordinal scale with high validity based on stud-
ies of its English and German versions [11, 12]. Neubauer
et al. [11] have described how to assess the residues in the
anatomical location on a scale ranging from no residue to
severe amounts.
Laryngeal flexible endoscopic evaluation has been widely
used in Otorhinolaryngology clinics for the last 15 years and
has provided the infrastructure for FEES. In Turkey, swal-
lowing disorder training and the establishment of a speech
and swallowing unit in each training clinic are included in
both the Otorhinolaryngology and Physical Medicine and
Rehabilitation specialty core training programs [13, 14].
Despite all these advancements in the country, the devel-
opment of assessment scales needed in swallowing stud-
ies takes time, so the widespread use of these scales are
delayed and also, may lead to a lack of reliability of scien-
tific studies conducted on deglutition. Validating a scale to
the language we use is a quick and practical solution to these
shortcomings. As far as we know there is nothing similar to
the YPRSRS in the Turkish language.
The ability to use scales created in one language in other
languages can be affected by the expressiveness and cultural
differences of other languages. For this reason, a valid scale
created in a different language should be approved by trans-
lators and professional experts, and then a validation study
should be carried out [15, 16].
This study aimed to assess the validity and reliability of
the Turkish translation of the Yale pharyngeal residue sever-
ity rating scale (T-YPRSRS) and also analyze its relationship
with training and experience for use in FEES studies.
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Yavuz Atar et al.: Turkish version of the Yale Pharyngeal Residue Scale
Methods
Ethics
The study was approved by the Local Ethical Committee
(Approved year/no: 2020/308), registered at ClinicalTri-
als.gov, identifier number: NCT04477174, and performed
according to the Declaration of Helsinki.
Design of the Original Scale
The rating table in the YPRSRS consists of two parts the val-
lecula and pyriform sinus anatomical regions. Ratings from
none to severe are as follows: none (0%), trace (1–5%), mild
(5–25%), moderate (25–50%), and severe (> 50%) (Table 1).
Translation Procedure
The YPRSRS was translated into Turkish by two bilingual
English-Turkish translators, and the Turkish version was
translated back into English by two qualified professional
translators to assess accuracy. The translation was reviewed
in line with the professional terms by two expert clinicians
with experience in the study of swallowing who spoke for-
eign languages. The final version was sent to the author, who
checked if it corresponded to the original scale (Table 1).
Image Selection Process
In the image selection, 84 PR FEES images were obtained
from the original study archive. The original images were
reviewed by two expert clinicians with experience in the
field of swallowing disorders. A total of 25 images were
selected from 84 records. The selected images included one
showing no residue and three showing each level (trace,
mild, moderate, and severe) for both the vallecula (n = 13)
and pyriform sinus (n = 13), there was the same image with
no residue in each part.
Pre‑Evaluation of the Final Version of the Scale
Two experts in FEES evaluated the images in each part
(vallecula (Fig. 1) and pyriform sinus (Fig. 2), respectively)
through random selection. Within the images (n = 26), there
were three images for each level of residual intensity for
each anatomic region, and one showing no residue. Experts
were given 20 min to evaluate the images.
Study Period
The study was completed between 16 July 2020 and 31 July
2020 in the swallowing therapy work office.
Yavuz Atar et al.: Turkish version of the Yale Pharyngeal Residue Scale

Table 1  English and Turkish version of the scale

English version

Vallecula
 I None 0% No residue
 II Trace 1–5% Trace coating of the mucosa
 III Mild 5–25% Epiglottic ligament visible
 IV Moderate 25–50% Epiglottic ligament covered
 V Severe  > 50% Filled to epiglottic rim
Pyriform sinus
 I None 0% No residue
 II Trace 1–5% Trace coating of the mucosa
 III Mild 5–25% Up wall to quarter full
 IV Moderate 25–50% Up wall to half full
 V Severe  > 50% Filled to aryepiglottic fold
Turkish version

Vallekula
 I Yok 0% Rezidü yok
 II Eser miktar 1–5% Mukozayı eser miktarda kaplamış
 III Hafif 5–25% Epiglotik ligaman görülebilir
 IV Orta 25–50% Epiglotik ligaman kaplanmış
 V Şiddetli  > 50% Epiglot kenarına kadar dolmuş
Sinüs piriformis
 I Yok 0% Rezidü yok
 II Eser miktar 1–5% Mukozayı eser miktarda kaplamış
 III Hafif 5–25% Duvarın dörtte birine kadar dolu
 IV Orta 25–50% Duvarın yarısına kadar dolu
 V Şiddetli  > 50% Ariepiglotik foldlara kadar dolmuş

Definitions for severity of vallecula and pyriform sinus residue

Raters vallecula and pyriform sinus images, an information page

A total of 24 raters from different clinics, including ENT
specialists (n = 14) and ENT residents (n = 10), participated
in the study. Voluntary consent was obtained for participa-
tion in the study. Raters were grouped by years of expe-
rience in performing FEES and flexible endoscopy (≥ 5
or ≤ 4 years) and also sub-grouped by the study training.
Methodology of Scale Evaluation
The 14 experienced and 10 less experienced raters were
divided into two groups, with FEES experience threshold
being four years. Each group (n = 12) was randomly selected
by a computer randomization program and included seven
experienced and five less experienced raters. A/B randomiza-
tion was performed again to determine the group to be trained
about the scale. A short briefing was given to each rater on
how to evaluate the fixed images. The objective of the scale
was explained which structure in which part they would
evaluate, and how to mark the rating. Before evaluating the
was displayed indicating which area the evaluators would
mark. One specimen had both the vallecula and pyriform
sinus parts, and only one part was analyzed according to the
instructions. Each rater evaluated the randomized images on
a 24″1920 × 1080 resolution LCD (non-glare) screen. There
was no internet on the computer (so that the image could
not be copied and studied). Mobile phones or devices that
could receive images were restricted. An isolated room was
selected in which the participants would not be disturbed.
The room was illuminated by a ceiling lamp. Each rater had
40 min to comfortably perform an assessment. When addi-
tional time was required, an extra 10 min was given. After
two weeks, the first group without any special training was
evaluated. The second group received special training and
evaluated the scales and images prepared by our experts.
Statistical Analysis
For the inter-rater agreement analysis and agreement per-
centage, Fleiss’s kappa, Gwet’s agreement coefficient (AC),

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 Yavuz Atar et al.: Turkish version of the Yale Pharyngeal Residue Scale

Fig. 1  Vallecula images for each residue level: a none; b trace; c mild; d moderate; and e severe, the residue images (b–e) are property of Dr.
Paul Neubauer and limited permission has been obtained from Dr. Paul Neubauer for publication

Fig. 2  Pyriform sinus images for each residue level: a none; b trace; c mild; d moderate; and e severe, the residue images (b–e) are property of
Dr. Paul Neubauer and limited permission has been obtained from Dr. Paul Neubauer for publication

and Krippendorff’s alpha values were calculated, and safe anatomic part (vallecula and pyriform sinus), measurement
intervals and p values with 95% reliability were determined. (first and second), training status (present vs. absent), and
The inter-rater agreement analyses were performed for each level of experience (≥ 5 vs. ≤ 4 years) status. Participants

13
Yavuz Atar et al.: Turkish version of the Yale Pharyngeal Residue Scale
were divided into two groups according to years of experi-
ence, and the threshold value was four years. For reliability,
the first and second evaluation scores were analyzed using
the intra-class correlation coefficient (ICC). Individual and
average ICC coefficients were reported with 95% confidence
intervals and p values. Similar to the inter-rater agreement,
agreement analyses were performed for each anatomic part
(vallecula and pyriform sinus), training status (present vs.
absent), and level of experience (≥ 5 vs. ≤ 4 years) status.
Finally, the first and second measurements were analyzed by
calculating agreement rates as well as kappa and p values.
The databases were created with Microsoft Excel software,
and all analyses were performed using Stata 15.1 software.
We used the kappaetc, kappa, and ICC modules of the pro-
gram. The demographic characteristics of the raters were
analyzed with SPSS 25.0 software. A p value less than 0.05
was considered statistically significant. Kappa values above
0.8 indicated perfect agreement. ICC coefficient values
above 0.9 were considered excellent reliability (Table 2)
[17, 18].
Results
Turkish Version of the Scale
We worked with a team that had previously been involved
in various validation studies of translations from English to
Turkish. After the translation was completed by the transla-
tors, our experts corrected the scale explanation sections
in terms of compliance with professional terminology. The
scale was sent to the original author for final approval, and
additional opinions were obtained for the explanations on the
scale. Due to the presence of two separate pyriform sinuses
in normal anatomy and cultural differences, the definition
of “aryepiglottic fold” was translated into the plural (-s).
This change was included in the final version after obtaining
approval from the original author.
Table 2  Rater characteristics
Raters n (%) Years of experience
Median (± IQR)
Total 24 (100%) 5.5 (± 3.88)
Experience ≤ 4 10 (42%) 3 (± 1.25)
Experience ≥ 5 14 (58%) 6.5 (± 2.13)
No-training 12 (50%) 5.75 (± 3.88)
Training 12 (50%) 5.25 (± 4.63)
Professional status
 ENT specialist 14 (58%) 6.5 (± 2.13)
 ENT resident 10 (42%) 3 (± 1.25)
Pre‑Rating
Two experts who were experienced in FEES evaluated the
randomized selected images containing PR at levels up to
severe in the final version of the scale. They answered all
items correctly, and the intra- and inter-rater validity was
found to be 100%.
Analysis of Raters
The FEES experience median (± IQR) value of all raters
(n = 24) included in the study was 5.5 (± 3.88) years. The
FEES experience median value of ENT specialist raters
(n = 14), all of whom had at least five years of FEES experi-
ence, was 6.5 (± 2.13) years. The experience median value
of ENT residents, all with less than four years of FEES
experience, was three (± 1.25) years. The FEES experience
median value of the no-training group was 5.75 (± 3.88)
years, and that of the training group was 5.25 (± 4.63) years
(Table 2). All raters completed the scoring in the given time,
and no raters left the study.
Values of Validity and Reliability
At the end of the study, there were 156 ratings for each
group per session, comprising a total of 624 ratings by 24
raters. For the 24 raters and the images, the average ICC
coefficient values for the vallecula (n = 312) and pyriform
sinuses (n = 312) for the initial assessment were 0.9996 (95%
CI 0.9992–0.9998) and 0.9997 (95% CI 0.9995–0.9999),
respectively. A very strong positive correlation was obtained
in both the vallecula (n = 312) and pyriform sinus (n = 312)
ICC coefficients in the initial validity assessment of the
training and no-training groups. Very strong positive corre-
lation results were obtained for both the vallecula and pyri-
form sinus ICC coefficient values, according to the FEES
experience of the study group (≥ 5 vs. ≤ 4 years; 0.9993,
0.9991, 0.9993, and 1.), respectively; Table 3). Overall,
the agreement values of intra-rater κ = 0.9959 and 99.68%
agreement were obtained for both the vallecula and pyri-
form sinus. When the intra-rater reliability of the ratings
of training (n = 312) and no-training (n = 312) groups was
evaluated, the kappa values were 0.9996 and 0.9987 for the
Min.–Max vallecula, and 0.9994 and 0.9997 for the pyriform sinus,
respectively. According to the intra-rater training status,
01-Oct
over 95% agreement was obtained in all subgroups. In the
01-Apr
intra-rater experience analysis, ratings obtained according
05-Oct
to ≥ 5 years (n = 364) and ≤ 4 (n = 260) years of experience
01-Sep
with FEES were evaluated, and the kappa values of 0.9993
01-Oct
and 0.9991 were found for the vallecula, and 0.9993 and
1.0 were found for the pyriform sinus, respectively. For the
05-Oct
intra-rater reliability of FEES experience, an agreement of
01-Apr
over 95% was obtained in all subgroups (Table 4).
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 Yavuz Atar et al.: Turkish version of the Yale Pharyngeal Residue Scale

Table 3  Intra-class correlation Location Group/subgroup Number of ICC p

analysis raters

Vallecula Overall 24 0.9996 (0.9992–0.9999)  < 0.01

Pyriform sinus Overall 24 0.9997 (0.9995–0.9999)  < 0.01
Training status
 Vallecula Training 12 0.9996 (0.9993–0.9999)  < 0.01
 Vallecula w/o Training 12 0.9987 (0.9974–0.9995)  < 0.01
 Pyriform sinus Training 12 0.9994 (0.9987–0.9998)  < 0.01
 Pyriform sinus w/o Training 12 0.9997 (0.9994–0.9999)  < 0.01
Experience status
 Vallecula  ≥ 5 years 14 0.9993 0.9986–0.9997)  < 0.01
 Vallecula  ≤ 4 years 10 0.9991 (0.9981–0.9997)  < 0.01
 Pyriform sinus  ≥ 5 years 14 0.9993 (0.9987–0.9998)  < 0.01
 Pyriform sinus  ≤ 4 years 10 1.0 (1.0–1.0) n/a

Table 4  Intra-rater agreement Location Group/subgroup Number of Agreement (%) Kappa (s.e.)

analysis raters

Vallecula Overall 24 99.68 0.9959 (0.0297)

Pyriform sinus Overall 24 99.68 0.9959 (0.0297)
Training status
 Vallecula Training 12 100 1.00 (0.0420)
 Vallecula w/o Training 12 99.36 0.9918 (0.0420)
 Pyriform sinus Training 12 99.36 0.9918 (0.0420)
 Pyriform sinus w/o Training 12 100 1.00 (0.0420)
Experience status
 Vallecula  ≥ 5 years 14 99.45 0.9930 (0.0389)
 Vallecula  ≤ 4 years 10 100 1.00 (0.0460)
 Pyriform sinus  ≥ 5 years 14 100 1.00 (0.0389)
 Pyriform sinus  ≤ 4 years 10 99.23 0.9902 (0.0460)

In the first (initial) inter-rater evaluation, perfect kappa
values were obtained in the overall results, with a value of
0.9672 for the vallecula and 0.9761 for the pyriform sinus.
In the inter-rater evaluation, less than 95% agreement was
obtained in all subgroups according to training status.
While kappa values of 0.9836 for the vallecula and 0.9672
for the pyriform sinus were reported for the training group,
the perfect kappa values of 0.9507 and 0.9836 were found,
respectively, in the no-training group. According to the
level of FEES experience, greater than 95% agreement
was found in all subgroups. For those with ≥ 5 years of
FEES experience, a kappa value of 0.9719 was found for
the vallecula, and 0.96 was found for the pyriform sinus.
For those with ≤ 4 years of experience, excellent kappa
results were obtained for the vallecula (κ = 0.9606) and
for the pyriform sinus (κ = 1.00), respectively (Table 5).
In the inter-rater secondary analysis, agreement of
greater than 95% was found in all other groups and sub-
groups except for the vallecula of the no-training group
(94.87%). When the kappa values were analyzed, excel-
lent kappa values were found in all groups (n = 312) and
subgroups (n = 156; Table 6).
Discussion
FEES is a reliable swallowing assessment tool [2, 20],
and it can be used to show the location and size of PR
in conjunction with validated scales [2, 11, 20, 22]. The
scales support the use of a common language with the
patients that are followed up after the diagnosis of swal-
lowing disorder and allows for the identification of patient
follow-up parameters and responses to treatment [2, 7, 19,

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Yavuz Atar et al.: Turkish version of the Yale Pharyngeal Residue Scale

Table 5  Inter-rater agreement analysis (initial assessment)

Location Group/subgroup Number of Agreement (%) p Fleiss’ Kappa (κ) p
raters

Vallecula Overall 24 97.44 (95.02–99.86)  < 0.01 0.9672 (0.9358–0.9986)  < 0.01

Pyriform sinus Overall 24 98.13 (95.22–100.0)  < 0.01 0.9761 (0.9386–1.00)  < 0.01
Training status
 Vallecula Training 12 98.72 (95.92–100.0)  < 0.01 0.9836 (0.9478–1.00)  < 0.01
 Vallecula w/o Training 12 96.15 (91.74–100.0)  < 0.01 0.9507 (0.8938–1.00)  < 0.01
 Pyriform sinus Training 12 97.44 (93.65–100.0)  < 0.01 0.9672 (0.9184–1.00)  < 0.01
 Pyriform sinus w/o Training 12 98.72 (95.92–100.0)  < 0.01 0.9836 (0.9494–1.00)  < 0.01
Experience status
 Vallecula  ≥ 5 years 14 97.80 (94.56–100.0)  < 0.01 0.9719 (0.9302–1.00)  < 0.01
 Vallecula  ≤ 4 years 10 96.92 (92.38–100.0)  < 0.01 0.9606 (0.9022–1.00)  < 0.01
 Pyriform sinus  ≥ 5 years 14 96.87 (92.02–100.0)  < 0.01 0.96 (0.8975–1.00)  < 0.01
 Pyriform sinus  ≤ 4 years 10 100.0 (100.0–100.0) n/a 1.00 (1.00–1.00) n/a

Table 6  Inter-rater agreement analysis (secondary assessment)

Location Group/subgroup Number of Agreement (%) p Fleiss’ Kappa (κ) p
raters

Vallecula Overall 24 96.79 (94.24–99.34)  < 0.01 0.9590 (0.9256–0.9923)  < 0.01

Pyriform sinus Overall 24 97.49 (94.41–100.0)  < 0.01 0.9679 (0.9281–1.00)  < 0.01
Training status
 Vallecula Training 12 98.72 (95.92–100.0)  < 0.01 0.9836 (0.9478–1.00)  < 0.01
 Vallecula w/o Training 12 94.87 (90.03–99.71)  < 0.01 0.9343 (0.8716–0.9971)  < 0.01
 Pyriform sinus Training 12 96.15 (91.74–100.0)  < 0.01 0.9508 (0.8936–1.00)  < 0.01
 Pyriform sinus w/o Training 12 98.72 (95.92–100.0)  < 0.01 0.9836 (0.9478–1.00)  < 0.01
Experience status
 Vallecula  ≥ 5 years 14 96.70 (92.92–100.0)  < 0.01 0.9578 (0.9089–1.00)  < 0.01
 Vallecula  ≤ 4 years 10 96.92 (92.38–100.0)  < 0.01 0.9600 (0.8975–1.00)  < 0.01
 Pyriform sinus  ≥ 5 years 14 96.87 (92.02–100.0)  < 0.01 0.9600 (0.8975–1.00)  < 0.01
 Pyriform sinus  ≤ 4 years 10 98.46 (95.11–100.0)  < 0.01 0.9833 (0.9873–1.00)  < 0.01

20]. There may be validated and non-validated scales pre-
viously reported for PR, but the YPRSRS has been shown
to have high validity and reliability in studies conducted
in different languages [2, 10–12, 20–24]. In the original
study of YPRSRS, we found it easier to explain the scale
through descriptive images, and we decided to validate it
in Turkish.
The T-YPRSRS demonstrated high intra-class correlation
and perfect intra-rater and inter-rater reliability and validity
after evaluation in all rater groups for both anatomical loca-
tions (Tables 3, 4, 5, 6). We investigated the software they
used to ensure that our kappa results were as compatible as
possible with the previous two versions. The program used
to calculate the Fleiss kappa values in the original study
was not reported. Therefore, we made our own calcula-
tions with the German version of Stata 15.1. However, in
the German version, Student’s t test was used to express
the kappa comparison, and we specified the results with the
ICC method.
It is important for a scale to be clear enough that it does
not require special training for its use in providing accu-
rate results. Neubauer et al. [11] has shown that there is
no significant difference as statistically between the groups
trained and not trained in the use of the YPRSRS. However,
Gerschke et al. [12], in the German version of the YPRSRS,
obtained high kappa values in both vallecula groups and
found that the kappa value of the untrained group was sig-
nificantly lower than that of the trained group based on the
results of the Student’s t test. In our study, only in the inter-
secondary analysis was the vallecula rating of the untrained
group slightly below the agreement value (94.87%), on the
other hand the other agreement values greater than 95%
(Table  6). Nevertheless, the ICC values we obtained in
the untrained group and the kappa results in the first and

13

secondary inter-rater analyses showed perfect values, and we
concluded that the Turkish version of the scale was suitable
for clinical use without special training (Tables 3, 4, 5, 6).
Neubauer et al. [11] obtained perfect kappa values in both
groups in the intra-rater results, but they found a significant
difference in the evaluations of the experienced group in the
pyriform sinus localization. However, the values were close
for the vallecula. In the study of the German version and our
study, raters with less experience obtained very high kappa
values in both localizations. In our study, high kappa values
were indicated for the less experienced group. This shows
that the scale is a practical use tool that does not require high
levels of experience in evaluating FEES images.
In our study, 26 randomized images were evaluated by cli-
nician raters (n = 24) with a FEES median experience level
of 5.5 years. In the original study published in 2015, 25 ran-
domized images were studied, and the average FEES experi-
ence of the raters (n = 20) was reported to be 8.3 years. In
the German version published in 2018, 30 non-randomized
images were studied with an average FEES experience level
of the raters (n = 28) was reported to be 4.5 years. Although
the image randomization, rater number, and experience
values were different, when the kappa values of the ver-
sions of the same scale in the three different languages were
examined, excellent kappa values were obtained in both the
vallecula and pyriform sinus results of all studies [11, 12].
Except for the very good kappa value in the inter-rater pyri-
form sinus test of the original study. (0.7511 ± 0.011). How-
ever, excellent kappa values were found in all groups in both
the German version translated three years after the original
study and in our study conducted 6 years after the original.
These high kappa values may be associated with the broader
recognition of the scale with the passing of time. Another
reason may be that the widespread use of flexible endoscopy
has increased the use of images among ENT physicians.
The YPRSRS is an ordinal scale containing five levels
ranging from no residue to a severe level. Pisegna et al.
[25] examined the relationship between PR measurements
and parameters in FEES application. They suggested that
the scale should include multiple categories, such as mild-
moderate-severe, when working with an ordinal scale. The
T-YPRSRS is an ordinal scale, it demonstrated high valid-
ity and reliability scores with its five levels ranging from
no residue to a severe and also it had been anatomically
defined. As a result of 624 ratings of the T-YPRSRS, it has
been found to be a useful version with an agreement value
of over 95% among clinicians with 1–10 years of experi-
ence. In the recorded fixed FEES images used in our study,
opaque white-colored food with the consistency of pudding
was used. High agreement and perfect kappa values were
achieved in the evaluations of both untrained raters and inex-
perienced raters.
13
Yavuz Atar et al.: Turkish version of the Yale Pharyngeal Residue Scale
Curtis et al. [8] reported that there might be differences in
the FEES results for foods of different consistency, opacity,
and color. Prospective studies involving FEES studies with
foods of different consistencies to demonstrate the ability to
use the scale in the future may be useful.
Using allusions, phrases, or binary words in scales that
are translated from one language to another may reduce
the correlation between the original and translated ver-
sions of the scale [15, 16]. Two of our experts conducted
a preliminary study to mitigate these issues due to cultural
and linguistic differences. After obtaining the results, the
main study was initiated. Although our study was conducted
with raters of 24 different experiences and characters, we
achieved perfect kappa results in the validation study we
conducted with the final version, which is consistent with the
studies conducted for versions in other languages.
Limitations
There are limitations to this study related to the cultural
adaptation and translation process specific to validation
studies. Another limitation is that we worked with images
selected by experts from the original image archive that the
YPRSRS was published with about six years ago. Thus, cli-
nicians, including the raters, may have accessed the English
version of the original study and used it in FEES studies.
In our study, we developed the rating scale with the fixed
images selected by experts, as was the case with the previous
two versions, but it may be useful to carry out prospective
studies for simultaneous FEES scaling with dynamic.
Conclusions
The T-YPRSRS demonstrated high validity and reliability
in its use to determine PR location and value in FEES. We
believe that the Turkish version will contribute to FEES
studies as a practical scale that has been validated and
published.
Acknowledgements  We would like to thank Mr. Paul D. Neubauer who
shared the original images in his archive with us and also Mr. Marco
Gerschke for his valuable contribution and assistance. We respectfully
commemorate the late Steeven B. Leder, one of the developers of the
scale.
Funding  This research did not receive any specific grant from funding
agencies in the public, commercial, or not-for-profit sectors.
Declarations 
Conflict of interest  The authors declare that they have no conflict of
interest.
Yavuz Atar et al.: Turkish version of the Yale Pharyngeal Residue Scale

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