Original Paper
ORL 2008;70:393–398
DOI: 10.1159/000163036
A Swallowing Evaluation with Simultaneous
Videoendoscopy, Ultrasonography and
Videofluorography in Healthy Controls
Masahiro Komori a Masamitsu Hyodo b Kiyofumi Gyo b
a
Department of Otolaryngology, Takanoko Hospital, Matsuyama, and b Department of Otolaryngology,
Ehime University School of Medicine, To-on, Japan
Key Words
Dysphagia ⴢ Deglutition ⴢ Videoendoscopy ⴢ
Ultrasonography ⴢ Bedside diagnostic method
Abstract
Purpose: A new bedside method for the evaluation of swal-
lowing function was pursued. Procedures: To compare our
technique combining videoendoscopy (VE) and ultrasonog-
raphy (US) with videofluorography (VF) in healthy controls,
these images were displayed simultaneously. Results: The
beginning of laryngeal elevation was identified by VF and
US. Thereafter, the pharynx became invisible with VE. Then
the bolus head passed through the tongue base and reached
the vallecula and the piriform sinus. Laryngeal elevation was
at maximum height for VF and US. The timing of elevation
assessed by VF and US was almost equivalent. The distances
and durations of the maximum laryngeal elevation, mea-
sured by US and VF, were almost equal and significantly pos-
itively correlated (p ! 0.0001). Conclusions: This study sug-
gested that our technique could demonstrate swallowing
function as efficiently as VF. Copyright © 2008 S. Karger AG, Basel
© 2008 S. Karger AG, Basel
0301–1569/08/0706–0393$24.50/0
Fax +41 61 306 12 34
E-Mail karger@karger.ch Accessible online at:
www.karger.com www.karger.com/orl
Received: July 16, 2007
Accepted after revision: January 7, 2008
Published online: November 4, 2008
Introduction
Deglutition consists of three neuroanatomical phases:
oral, pharyngeal and esophageal [1]. Of these three, the
pharyngeal phase involves the finest coordination and
has the greatest clinical significance because abnormali-
ties in this phase are more likely to result in aspiration.
Analyses for dysphagic patients have been based on vid-
eofluorography (VF), videoendoscopy (VE), manometry,
ultrasonography (US) and electromyography [1]. Of these
methods, VF provides a dynamic view of deglutition
from the oral cavity to the lower esophageal sphincter
and is consequently the standard examination for the di-
agnosis and quantitative evaluation of swallowing func-
tion, including the distance and timing of laryngeal ele-
vation, pharyngeal delay time and pharyngeal transit
time [1–5]. However, the clinical utility of VF is compro-
mised by the need to transport gravely ill patients to a
radiology suite and the potential hazard of radiation ex-
posure. Thus, clinicians are often reluctant to repeat the
examination for an individual patient, even if the swal-
lowing function has changed following a swallowing re-
habilitation program or surgical procedure. Because dys-
phagic patients frequently require bed rest due to acute
cerebrovascular disorders or a postsurgical state, VE can
often be performed at the bedside and has been reported
to be as sensitive as, or more sensitive than, VF for the
evaluation of some swallowing parameters such as swal-
200.130.19.143 - 1/18/2023 3:32:27 AM
Masahiro Komori
Department of Otolaryngology, Takanoko Hospital
Univ.Federal da Paraíba
525-1, Takanoko-cho
Matsuyama-shi, Ehime 790-0925 (Japan)
Downloaded by:
Tel. +81 89 976 5551, Fax +81 89 976 5572, E-Mail komori@m.ehime-u.ac.jp
lowing initiation, penetration, aspiration and pharyngeal Table 1. Distance of laryngeal elevation
residue [6–8]. However, VE has a limited ability to assess
swallowing function during the pharyngeal swallowing Subject (age) Examination VF US
mm mm
phase because the field is obscured by epiglottic excur-
sion. This limitation led us to pursue the combination of A (31 years) 1 33.0 31.3
VE and US, which can potentially provide more informa- 2 35.4 31.0
tion in the pharyngeal phase than VE alone. US is occa- 3 33.0 33.1
sionally applied for swallowing assessment by observing B (30 years) 1 30.8 31.3
the movements of the tongue, hyoid bone, thyroid carti- 2 31.0 31.0
lage and pharyngeal wall [9, 10]. In recent years, Sonies et 3 36.7 32.9
al. [11] examined the motion of the hyoid bone during C (30 years) 1 40.6 39.5
deglutition using Doppler shift spectra. Kuhl et al. [12] 2 35.5 32.6
measured the distance between the hyoid bone and thy- 3 36.8 34.4
roid cartilage and evaluated the reduction in the distance D (30 years) 1 38.4 38.5
while swallowing. However, these studies did not direct- 2 32.8 30.9
ly consider laryngeal elevation. 3 35.9 34.9
The present study is the first, to our knowledge, in E (30 years) 1 29.1 27.3
which the three techniques VF, VE and US were per- 2 30.4 27.8
formed simultaneously in healthy control subjects. The 3 28.7 25.8
results indicated that the combination of VE and US F (25 years) 1 35.5 33.2
could be a useful technique for the quantitative evalua- 2 33.4 30.8
3 33.0 30.3
tion of the distance and timing of laryngeal elevation and
its correlation with bolus movement. This paper describes G (31 years) 1 29.8 30.4
the method of the combination of VE and US, the results, 2 31.1 27.3
3 31.4 32.4
and the potential application of this procedure to the as-
sessment of swallowing function in dysphagic patients. H (30 years) 1 33.8 30.6
2 32.3 30.9
3 25.4 24.0
Mean8SD 33.183.4 31.383.5
Materials and Methods

Subjects
Eight healthy male volunteers, aged 25–31 years, were exam-
ined (table 1). They had no subjective or objective swallowing dis-
turbances and gave informed consent to participate in the study.
Procedure
Each subject was positioned in the posture in which he nor-
mally ate. His nasal mucosa was anesthetized with a cotton pad
that had been moistened with a topical anesthetic and wrung out
before the endoscope was inserted. Figure 1a displays the diagram
of the system for this examination. VF, VE and US were simulta-
neously performed while the subject was swallowing 15 ml of
145% (w/v) barium. The images were combined onto a monitor
(PVM-14540, Sony Co., Tokyo, Japan) and stored on a videocas-
sette (SVO-260, Sony Co.) using two double-videocassette record-
ers (WV-SW1, Sony Co.), which received the two inputs from the
two different terminals. VF was performed with a digital subtrac-
tion angiography system (DFA-100, Hitachi Ltd., Tokyo, Japan).
For VE, a flexible endoscope (ENF type P3, Olympus Optical Co.,
Tokyo, Japan) coupled with a CCD camera (ETV-387, Nisco Co.
Ltd., Saitama, Japan) was inserted through the nasal cavity and
placed in the velopharynx to visualize the base of the tongue, lar-
ynx, piriform sinuses and posterior pharyngeal wall. A US to-
mography system (SSD-5000, Aloka Co. Ltd., Tokyo, Japan) was
used for the evaluation. A 5-mm-wide adhesive plaster was stuck
horizontally on each subject’s anterior neck as a landmark of mea-
surement, and then a 7.5-Hz electronic linear probe was placed
vertically on the side of the subject’s neck so that the movement
of the thyroid cartilage could be observed during deglutition
(fig. 1b). Each subject repeated the barium swallowing procedure
3 times.
Analysis of Data
The videotape was fed into a personal computer (VAIO PCV-
RZ72P, Sony Co.) and analyzed frame by frame. Because the
frame rate was 30/s, the duration was measured by a temporal
resolution of 0.03 s. To measure the upward movement of the lar-
ynx in the fluorographic image, a vertical axis was drawn through
the anterior and inferior corners of C3 and C5, as previously de-
scribed [13]. The width of the probe in the image was used as the
standard for the measurement of distance (width of probe: 57
mm; fig. 1c). For US, the horizontal movement of the larynx was
measured on the US monitor. Drawing the laryngeal elevation
curve, the value of laryngeal elevation was adjusted to set the
200.130.19.143 - 1/18/2023 3:32:27 AM

394 ORL 2008;70:393–398 Komori /Hyodo /Gyo

Univ.Federal da Paraíba
Downloaded by:
 a b

Flexible
endoscope

CCD
camera
DSA
US
tomography
system

Double-
videocassette VE US
recorder 1 c

Double-videocassette
recorder 2
VE US VF
Fig. 1. Diagram for examination. a The
images of US, VE and VF were combined
onto a monitor using two double-video-
cassette recorders. DSA = Digital subtrac- Videocassette
tion angiography. b Position of a linear Monitor recorder
probe on the neck. c An image of VF.

maximal laryngeal elevation as 100% [2, 14]. The points and pa-
rameters for analysis were defined as follows:
(1) A = the initial moment the larynx moves from the resting po-
sition;
(2) B = the moment the bolus head passes through the intersection
between the shadow of the lower edge of the mandible and the
tongue base with VF;
(3) C = the moment the bolus head reaches the vallecula with
VF;
(4) D = the moment the bolus head reaches the piriform sinus
with VF;
(5) E = the moment the larynx is maximally elevated;
(6) F = the moment the tail of the bolus passes through the esoph-
ageal entrance with VF;
(7) X = the initial moment the pharynx becomes invisible with
VE;
(8) Y = the initial moment the pharynx becomes dimly visible
with VE again;
(9) distance of the laryngeal elevation = the distance between the
resting position of the larynx and the maximum high point of
the larynx.
Parameters A–F are regarded as the key attributes to evaluate
the correlation of laryngeal elevation with bolus movement on the
quantitative parameters of swallowing [2–5].
Statistical Analysis
Pearson’s correlation coefficient test was used for evaluating
the correlation between US and VF. p values less than 0.05 were
considered significant.
Results
US demonstrated the motion of laryngeal cartilage
(fig. 2a–e). Figure 3 displays two laryngeal elevation
curves that were measured separately by VF or by VE and
US on the same deglutition. The commencement of la-
ryngeal elevation was identified (A, fig. 2a, f). Thereafter,
the pharynx became invisible with VE due to the con-
striction of the pharyngeal wall (X). Next, the bolus head
passed through the intersection between the shadow of
the lower edge of the mandible and the tongue base (B)
and reached the vallecula (C) and then the piriform sinus
(D). After that, the laryngeal elevation was at its maxi-
mum height (E, fig. 2d). The tail of the bolus then passed
through the esophageal entrance (F), and the pharynx
reappeared dimly with VE (Y, fig. 2g). The two curves
were almost equivalent.
The average distances of laryngeal elevation by VF
and US were 33.1 8 3.4 and 31.3 8 3.5 mm, respectively,
and the difference between the two measures was 1.7 8
1.5 mm (table 1). The duration of maximum laryngeal
elevation by VF and US was 0.78 8 0.21 and 0.79 8
0.22 s, respectively (table 2). Figure 4 displays the correla-
tion between VF and US, which were significantly posi-
tively correlated for the distance of laryngeal elevation
200.130.19.143 - 1/18/2023 3:32:27 AM

Combination of Videoendoscopy and ORL 2008;70:393–398 395

Ultrasonography
Univ.Federal da Paraíba
Downloaded by:
 a e
TC
Cranial
f
b
c 0
g
d
Fig. 2. Images of US and VE. a–d US demonstrated the motion of
laryngeal cartilage: resting position (a), maximum elevation (d);
arrows = posterior portion of thyroid cartilage. e Illustration of a;
TC = thyroid cartilage. f Image of VE at the initial moment when
the larynx moves from the resting position. g Image of VE at the
initial moment when the pharynx becomes dimly visible with VE
again.
and duration of maximum laryngeal elevation (p !
0.0001). The X–B, X–C and X–D intervals were 0.04 8
0.08, 0.12 8 0.07 and 0.19 8 0.07 s, respectively (table 3).
Y, in turn, overlapped with F in 5 examinations in 4 sub-
jects. The F–Y interval was 0.04 8 0.08 s in all examina-
tions except in 4 examinations in which the pharynx did
not reappear.
Discussion
Several studies have examined the quantitative pa-
rameters of swallowing function in regard to laryngeal
elevation and the correlation of laryngeal elevation with
bolus movement in the pharyngeal phase [2–5]. The
396 ORL 2008;70:393–398
E
100
VF
US
80
Laryngeal elevation (% max.)
60
40
20
B D F
A X C Y
0
10 20 30 40 50 60
Time (frames)
Fig. 3. Laryngeal elevation curve; frame rate: 30/s. The two curves,
which were separately measured by VF or by VE and US on the
same deglutition, were almost equivalent.
quantitative parameters are thought to be useful for eval-
uating the efficacy of rehabilitation programs and the
implementation of surgery. Logemann et al. [4] and Pau-
loski et al. [5] reported that both the A–B interval (pha-
ryngeal delay time) and the B–F interval (pharyngeal
transit time) in dysphagic patients are significantly dif-
ferent from those in healthy controls. Furthermore, Shin
[2] pointed out that the D–F interval (pharyngeal transit
time, which is the same name as above but a different
definition) is prolonged in patients with aspiration and
noted that the D–E interval (delay time of laryngeal ele-
vation) is significantly longer in dysphagic patients. In
addition, Sundgren et al. [3] and Shin [2] demonstrated
that the percentage of total laryngeal elevation at time
point C or D is significantly reduced in dysphagic pa-
tients. Some essential factors for investigating these pa-
rameters are to display the timing and distance of laryn-
geal elevation and the time points A–F.
In this study, we determined that two laryngeal eleva-
tion curves drawn from VF or from US were almost
equivalent, suggesting that US displays the timing of la-
ryngeal elevation and the two key attributes for laryngeal
elevation, the beginning of laryngeal ascent (A) and the
maximum of laryngeal elevation (E). Indeed, the distanc-
es of the maximum laryngeal elevation, measured by US
and by VF, were almost equal and significantly positively
correlated (r = 0.91, p ! 0.0001). The durations of the
200.130.19.143 - 1/18/2023 3:32:27 AM
Komori /Hyodo /Gyo
Univ.Federal da Paraíba
Downloaded by:
 1.5
r = 0.91 r = 0.98

40

VF distance (mm)

VF duration (s)
1.0

20
0.5

Fig. 4. Correlation of techniques between

VF and US. The two techniques were sig- 0 0
nificantly positively correlated in the dis- 0 20 40 0 0.5 1.0 1.5
tance of laryngeal elevation (a, p ! 0.0001, a US distance (mm) b US duration (s)
n = 24), and the duration of maximum la-
ryngeal elevation (b, p ! 0.0001, n = 24).

Table 2. Duration of maximum laryngeal elevation Table 3. Duration of intervals between the time points by VE and
by VF
Subject Examination VF US
s s Sub- Exami- X–B X–C X–D F–Y
ject nation s s s s
A 1 0.87 0.87
2 0.72 0.72 A 1 0.03 0.13 0.17 0.03
3 0.69 0.72 2 –0.03 0.00 0.07 0.03
3 0.10 0.20 0.27 0.03
B 1 1.02 1.11
2 0.75 0.78 B 1 –0.10 0.00 0.07 –
3 0.96 1.02 2 0.13 0.20 0.27 0
3 0.07 0.17 0.20 0.03
C 1 0.72 0.69
2 1.02 1.02 C 1 0.10 0.13 0.23 0.07
3 0.84 0.84 2 0.10 0.17 0.27 0
3 0.07 0.13 0.20 –
D 1 0.90 0.90
2 1.02 1.02 D 1 0.03 0.10 0.17 –
3 0.45 0.42 2 0.07 0.10 0.13 0.07
3 0.07 0.10 0.17 0.07
E 1 0.75 0.69
2 0.48 0.45 E 1 –0.13 0.13 0.20 0.10
3 0.57 0.54 2 0.13 0.20 0.23 0.07
3 0.13 0.23 0.27 –0.17
F 1 0.75 0.72
2 0.75 0.81 F 1 0 0.13 0.23 0.03
3 0.78 0.78 2 0.03 0.07 0.20 0
3 0.10 0.17 0.27 0
G 1 0.72 0.75
2 0.42 0.48 G 1 –0.10 0.00 0.07 0.03
3 0.42 0.48 2 0 0.07 0.17 0.03
3 –0.07 0.00 0.07 0
H 1 1.20 1.20
2 0.96 0.93 H 1 0.13 0.23 0.30 –
3 0.96 1.02 2 –0.07 0.13 0.20 0.27
3 0.07 0.13 0.23 0.03
Mean8SD 0.7880.21 0.7980.22
Mean8SD 0.0480.08 0.1280.07 0.1980.07 0.0480.08

– = B was invisible.
200.130.19.143 - 1/18/2023 3:32:27 AM

Combination of Videoendoscopy and ORL 2008;70:393–398 397

Ultrasonography
Univ.Federal da Paraíba
Downloaded by:
maximum laryngeal elevation, measured by US and by
VF, were also almost equal and significantly positively
correlated (r = 0.98, p ! 0.0001). These findings suggest
that US is effective for investigating the timing and dis-
tance of laryngeal elevation.
B, C and D were 0.03 8 0.08, 0.12 8 0.07 and 0.19 8
0.07 s later than X, respectively, suggesting that each key
attribute for bolus position cannot be seen in healthy con-
trols. However, if a dysphagic patient has a delay in the
swallowing reflex, these time points can be visible. Con-
sequently, the A–B interval, D–E interval and percentage
of total laryngeal elevation can be investigated. Next, Y
coincided with F or appeared slightly later than F (0.04
8 0.08 s). Because the B–F intervals for liquid and paste
are 0.85 8 0.05 and 0.91 8 0.09 s, respectively, in healthy
controls and 0.96 8 0.06 and 2.13 8 0.41 s, respectively,
in patients with stroke [2], and the D–F intervals are 0.550
8 0.126 s in healthy controls and 0.766 8 0.178 s in dys-
phagic patients [4], the F–Y interval is very short and can
be ignored. Accordingly, both the B–Y and the D–Y in-
tervals are thought to be substitutable for the B–F and the
D–F intervals, respectively. Therefore, if B and/or D are
visible, the B–F and/or D–F intervals can be investigated
as well.
Based on the results, our technique can provide details
of swallowing function that were previously only dis-
played by VF and allow the assessment of swallowing
function at an early stage for the treatment of deglutition
even if the patient requires bed rest; the technique could
be useful for evaluating the effectiveness of rehabilitation
programs and deciding when to implement surgical treat-
ment. Although the present study was applied to normal
subjects, further research is needed to clarify the clinical
benefit of this technique in patients with dysphagia.
Conclusions
Our findings suggest that our technique of combining
simultaneous VE and US could precisely demonstrate the
laryngeal movement in association with bolus transport
as efficiently as VF. Moreover, both VE and US are prac-
tical day-to-day methods for assessing dysphagic patients
at their bedside without presenting a radiation hazard.
Consequently, even if a patient requires bed rest, our
technique can be used repeatedly and provide more in-
formation about swallowing function than VE alone.
Acknowledgments
The authors like to thank Dr. Joji Kobayashi, Dr. Shyuichi
Matsumoto, Dr. Hisashi Kohno, Dr. Hayato Komobuchi and Dr.
Suguru Matsumoto, and colleagues in Kosei General Hospital for
their support of the project.

References

1 Schindler JS, Kelly JH: Swallowing disorder
in the elderly. Laryngoscope 2002; 112: 589–
602.
2 Shin T: Neural organization of the swallow-
ing act and its disorder. 7. Swallowing func-
tion test. Otologica Fukuoka 1994; 40: 382–
409.
3 Sundgren P, Maly P, Gullberg B: Elevation of
the larynx on normal and abnormal cinera-
diogram. Br J Radiol 1993;66:768–772.
4 Logemann JA, Shanahan T, Rademaker AW,
Kahrilas PJ, Lazer R, Halper A: Oropharyn-
geal swallowing after stroke in the left basal
ganglion/internal capsule. Dysphagia 1993;
8:230–234.
5 Pauloski BR, Rademaker AW, Logemann JA,
Stein D, Beery Q, Newman L, Hanchett C,
Tusant S, MacCracken E: Pretreatment swal-
lowing function in patients with head and
neck cancer. Head Neck 2000;22:474–482.
6 Langmore SE, Schatz MA, Olsen N: Fiberop-
tic endoscopic examination of swallowing
safety: a new procedure. Dysphagia 1988; 2:
216–219.
7 Bastian RW: Videoendoscopic evaluation of
patients with dysphagia: an adjunct to the
modified barium swallow. Otolaryngol Head
Neck Surg 1991;104:339–350.
8 Hiss SG, Postma GN: Fiberoptic endoscope
evaluation of swallowing. Laryngoscope
2003;113:1386–1393.
9 Shawker TH, Sonies B, Hall TE, Baum BF:
Ultrasound analysis of tongue, hyoid, and
larynx activity during swallowing. Invest
Radiol 1984;19:82–86.
10 Watkin KL: Ultrasound and swallowing. Fo-
lia Phoniatr Logop 1999;51:183–198.
11 Sonies BC, Wang C, Sapper DJ: Evaluation of
normal and abnormal hyoid bone movement
during swallowing by use of ultrasound du-
plex-Doppler imaging. Ultrasound Med Biol
1996;22:1169–1175.
12 Kuhl V, Eicke BM, Dieterich M, Urban PP:
Sonographic analysis of laryngeal elevation
during swallowing. J Neurol 2003; 250: 333–
337.
13 Yokoyama M, Mitomi N, Tetsuka K, Tayama
N, Niimi S: Role of laryngeal movement and
effect of aging on swallowing pressure in the
pharynx and upper esophageal sphincter.
Laryngoscope 2000;110:434–439.
14 Kahrilas PJ, Dodds WJ, Dent J, Logemann
JA, Shaker R: Upper esophageal sphincter
function during deglutition. Gastroenterol-
ogy 1988;95: 52–62.
200.130.19.143 - 1/18/2023 3:32:27 AM

398 ORL 2008;70:393–398 Komori /Hyodo /Gyo

Univ.Federal da Paraíba
Downloaded by: