Geriatrisches Symposium „Ernährung und Schluckstörungen im Alter"
am 18.7.2004 im Alleesaal Bad Schwalbach

Internationale Standards in der Diagnostik von Schluckstörungen
Joseph Murray

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

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