Dysphagia Test Two.

Advantages and Disadvantages of sEMG

*Advantages* 1. Identifies abnormal deglutition 2. Non-invasive 3. Easy to administer 4. Radiation-free examination 5. Well tolerated by the patient *Disadvantages* 1. Does not visualizes swallow (nonimaging exam) 2. Does not record individual muscle activity a. To record specific muscle activity it is necessary to use subcutaneous electrodes (needle EMG) 3. Sensitive to environmental factors (it might influence in the EMG signal)- a. Improperly grounded outlet b. Electrodes not properly placed c. Magnetic fields in close proximity to the instrument

Advantages and Disadvantages of FEES

*Advantages* 1. No radiologist needed, just slp a. But may be good to have someone around in case pt. reacts to the anesthetic (nurse) b. Avoids radiation exposure 2. No barium needed (doesn't change texture) 3. Uses normal food color for better viewing- green or blue 4. Cheaper, portable, can be used frequently (even as biofeedback) 5. May be repeated as often as needed 6. Allows for more efficient dx and tx 7. May be videotaped 8. Good visualization of- a. Residue b. Laryngeal penetration c. Signs and symptoms of aspiration -Immediate or delayed cough after swallowing -Throat clearing -Wet vocal quality d. Silent aspiration -Red flags- Weak volitional cough, breathy or wet vocal quality, pneumonia, respiratory status e. Effects of different tx's 9. Can visualize pharynx and larynx without food (how they handle secretions) 10. Can visualize velopharyngeal closure from above a. Say "pa-pa-pa" or "Buy Bobby a puppy." 11. Laryngeal function a. Vocal fold adduction - say "eee" b. Vocal fold abduction - sniff c. Cough 12. Flexible endoscopic evaluation of swallowing with sensory testing (FEEST) a. FEES with sensory and motor test 13. A calibrated puffs of air is delivered to the aryepiglottic fold (supraglottic) to test sensation a. Carried out before trial swallows *Disadvantages* 1. Moment of actual swallow (pharyngeal phase) is not visible a. Whited out as tongue and pharyngeal wall close around the tube and reflects the light back up b. Aspiration during swallow won't be seen (about 7%), but could be inferred from residue in trachea 2. Oral cavity is not visualized 3. Doesn't indicate why there is residue, penetration, aspiration 4. Kids under 6 and adults with cognitive problems, movement disorders, nosebleeds, and/or agitation may not be good candidates.

Advantages and Disadvantages of MBS

*Advantages* 1. Visualizes the swallow (anatomy and bolus transport) a. Focuses on the oral, oropharyngeal and hypopharyngeal phases of swallowing b. Including opening of the upper esophageal sphincter (UES), formation of bolus in the oral cavity, tongue and laryngeal movement 2. Sees whether aspiration or laryngeal penetration occurs and why (can often identify the cause of aspiration). Also good for examining residue. c. Frontal and lateral views are obtained during MBS a. Because the entire fluoroscopic study is recorded on videotape, the study can provide a highly detailed analysis of the coordination and timing of swallowing 3. Sees effect of different treatments 4. Considered the gold standard method of swallowing evaluation *Disadvantages* 1. Radiation exposure (pt and staff) a. 5 min., 25-30 swallows 2. Requires the ingestion of barium-coated material (not a very natural diet) 3. Take the patient to the equipment a. Now there are traveling companies 4. Minimal use during treatment (best ones are)- 1. ultrasound; 2. cervical auscultation and FEES 5. Expensive (radiologist, equipment, about $400).

MBS versus FEES

*MBS* 1. Real-time fluoroscopy of swallow 2. Assess oral, pharyngeal, and esophageal phases 3. Must go to radiology 4. Diagnose presence and etiology of aspiration 5. Test effectiveness of therapeutic postures and maneuvers 6. SLP (or OT) *FEES* 1. Real-time flexible endoscopy of larynx 2. Assess vocal cord strength and mobility 3. Can be performed bedside 4. Diagnose presence and etiology of aspiration 5. Test effectiveness of therapeutic postures and maneuvers 6. SLP only

Trial Swallows

1. *What to do and observe during each food swallow-* a. Laryngeal elevation (by palpation of the thyroid prominence) b. After each swallow, ask the patient to sustain the /a/ vowel for a few seconds or count from 1 to 5 to determine if there is wet voice quality -Wet voice quality or weak cough are signs of increased risk for aspiration; If aspiration is suspected, the patient should be referred for further instrumental swallow evaluation. -Observe for other signs, e.g., multiple swallows, weak cough, lips seal 2. Oral a. Anterior leakage b. Impaired bolus control and organization c. Oral residue 3. Pharyngeal a. Nasal regurgitation b. Delayed laryngeal excursion c. Coughing and choking d. Wet vocal quality

Manometry- Nonimaging

1. Assess pressure dynamics within pharynx and esophagus 2. Uses transnasally inserted catheter housing pressure transducers, by ENT 3. Usually placed at tongue base, UES, cervical esophagus 4. Results best interpreted along with MBS to see why pressure changes are happening.

Dysphagia Screening

1. Brief dysphagia assessment that helps determine if- a. Full assessment is needed b. Further referral is needed. 2. High sensitivity a. Able to identify those with dysphagia 3. High specificity a. Able to screen out those without dysphagia

FiberOptic (Flexible) Endoscopic Evaluation of Swallowing (FEES) - Imaging

1. Brief introduction to endoscopic instrumentation and equipment needed- a. Flexible scope b. Camera c. Light source d. Video recording e. Monitor f. Video printer

Cervical Auscultation- Nonimaging

1. Cervical auscultation involves the placement of a sensor (stethoscope) on the neck at the lateral portion of the thyroid cartilage. a. Listening for the sounds of swallowing b. Use a stethoscope on the neck, at larynx c. Characteristic double click for normal sw- d. Other sounds may suggest penetration, aspiration e. Connect to amplifier for biofeedback f. Questionable screening tool 2. Sounds can be reported with descriptive words pertaining to the speed, strength and ending sounds. a. Fast/slow b. Strong/weak c. Clear/wet *Advantages* 1. Cervical auscultation is a non-invasive way to evaluate a swallow. 2. Using a stethoscope is inexpensive and portable. 3. A specific doctor's order is not necessary. 4. It does not expose the patient to radiation or other harmful toxins. *Disadvantages* 1. Aspiration cannot be diagnosed. 2. Anatomy and physiology of swallow cannot be visualized.

Pulse Oximetry "Pulse Ox-" Nonimaging

1. Detects changes in oxygenation level in the blood within 20 seconds 2. 95-100% is normal, a drop of 4% (or below 90%) is abnormal-may reflect aspiration 3. Aspiration leads to bronchoconstriction that reduces oxygen uptake 4. Can be affected by a. Heavy smoking b. Lung disease c. Movement d. Dark finger nail polish e. Diseases that affect circulation f. Thus, lots of false positives, not particularly reliable.

MBSImP

1. Developed by Martin-Harris et al. (2008) 2. Qualitative measurement tool that contains 17 measures 3. Prior training and regular renewal of certificate is required

Penetration-Aspiration Scale

1. Developed by Rosenbek et al. (1996) 2. The 8 steps of the Penetration-Aspiration Scale (PAS) are as follows- a. Material does not enter airway. b. Remains above folds/ejected from airway. c. Remains above folds/not ejected from airway. d. Contacts fold/ejected from airway. e. Contacts fold/not ejected from airway. f. *Passes below folds/ejected into larynx or out of airway* g. *Passes below folds/not ejected despite effort* h. Passes below folds/no spontaneous effort to eject

Modified Barium Swallowing- Imaging

1. Dynamic assessment of the oral, pharyngeal, and esophageal phases of swallowing...or 2. Radiographic examination that allows the visualization of the mastication and swallowing processes a. See whether aspiration occurs and why b. See effect of different treatments c. Measure oral transit time, pharyngeal delay time, pharyngeal transit time... 3. Also called videofluoroscopy swallowing study (VFSS) 4. There will be a question on the test about how to explain an MBS to a family in simple terms 5. Where it is done a, Radiology clinic or hospital (videofluoroscopy unit) 6. Who does it a. Speech Language Pathologist, and radiologist together 7. How long it takes a. 30 min. to 1 hour (depending on findings) 8. Equipment a. Requires a fluoroscopic unit, video recorder, a suitable chair and foods and liquids coated or mixed with barium 9. Purpose of MBS Studies a. To determine the abnormalities in anatomy or physiology causing the patient's symptoms of dysphagia b. To assess and identify specific treatment postures and strategies that may facilitate safe and efficient swallowing on an oral diet c. To find out if and why the patient is aspirating d. To evaluate whether the patient can continue on oral intake or if the diet or liquid consistencies can be advanced to the next level

Oral Hygiene and Dysphagia

1. Explain to the patient what and why you are doing an oral hygiene; 2. Use patient products (toothbrush, toothpaste, floss) and set up these on a clean paper towel; 3. Wash your hands and put on gloves; 4. Lubricate persons lips (if needed); 5. If the person is bed bound, elevate the head of bed; 6. Place a towel around the person's neck; 7. Choose a toothbrush with soft bristles and a small head to clean the teeth and gums, and use a pea sized amount of low foaming toothpaste on a soft or medium dry toothbrush; 8. Clean the entire mouth (tongue, teeth, gums, roof of the mouth) for 2 minutes 9. Follow with mouthwash, if the patient is unable to rinse and spit and/or has dysphagia diet restriction, follow with wiping the mouth with a toothette (sponge swab) or gauze moistened with alcohol-free mouthwash. 10. Use oral suctioning to remove excess debris from the mouth if the patient is unable to spit it out. 11. Dry the mouth and face with a clean towel. Lubricate lips; 12. Clean dentures and partials daily and remove them at night.

Clinical Observations

1. Feeding Tubes a. Nasogastric tubes -Inserted through the nose and into to stomach -Larger tube my be needed to pass medication without clogging -May slow the sequence of the pharyngeal swallow 2. PEG Tube a. Placed in the stomach (gastrostomy) or jejunum (jejumnostomy) 3. Tracheostomy Tubes a. Often placed- -When the patient is in respiratory distress -When the upper airway is blocked after trauma or surgery 4. Respiratory Pattern a. Respiration rate and saturation levels greater than 90% are good! -Less than 90% may be an indicator that some patients are at risk for swallowing impairment 5. Bedside monitor tracking- Heart rate blood pressure and oxygen saturation 6. Mental Status a. Sleeping b. Awake c. Alert d. Somnolent- Sleepy, Drowsy e. Confused f. Oriented/Disoriented g. Cooperation h. Attention (able to sustained/focus attention)

Subjective versus Objective

1. Goal is to obtain information on the structure and physiologic parameters of the swallow 2. Subjective a. Commonly referred to as Clinical Examination of Swallowing b. Make inferences about the swallow parameters 3. Objective a. More appropriately referred to as instrumental assessment [Videofluoroscopy swallowing study (VFSS) a.k.a. Modified Barium Swallow (MBS), Fiberoptic Endoscopic Evaluation of Swallowing (FEES)] b. Potentially measurable data about swallow parameters

Instrumentation

1. Imaging a. Modified Barium Swallowing (MBS) b. Flexible Endoscopy Evaluation Swallowing (FEES) c. Ultrasound d. Scintigraphy 2. Non-Imaging a. Manometry b. Cervical Auscultation (CA) c. Surface Electromyography (sEMG) d. Lingual Pressure e. Pulse Oximetry

Observation of Swallowing with Food Trials- CSE Protocols

1. Include the following procedures- a. Monitoring of physiological status, including heart rate and oxygen saturation; b. Evaluation of the method (spoon, cup, self-fed) and rate of bolus presentation to assess the effects on swallow function; c. Assessment of secretion management skills -Frequency and adequacy of spontaneous saliva swallowing -Ability to swallow voluntarily d. Observation of the patient eating or being fed food items with consistencies typically eaten by the patient in a natural and typical environment for the patient's situation 2. Include the following procedures- a. Assessment of labial seal and anterior spillage, and evidence of oral control, including mastication and transit, manipulation of the bolus, presence of hylolaryngeal excursion as observed externally or to palpation, and time required to complete the swallow sequence; b. Identification of signs and symptoms of penetration and/or aspiration, such as throat clearing or coughing before/during/after the swallow; c. Assessment of the ability to clear the airway, and assessment of cough strength; d. Consideration of the respiratory rate and respiratory/swallowing pattern, which may vary across individuals and across lifespan. 3. Materials Needed a. Measurement equipment- -Teaspoon -Tablespoon -Spoon -Cup (Plastic or Styrofoam) b. Various consistencies (Thin to thick) c. Gel or Powder to thicken liquids d. Stethoscope (May need with obese patients or infants)

ASHA Indications for Instrumental Swallowing Evaluation

1. Inconsistent findings from clinical swallow examination; 2. A need to confirm diagnosis or cause of dysphagia; 3. Past history of nutritional or pulmonary complications that may be a result of dysphagia; 4. A need to confirm swallow safety and efficiency; 5. Dysphagia is confirmed; further information needed to guide rehabilitation/management. 6. Unstable medical conditions; 7. Inability to cooperate or participate in the instrumental evaluation; 8. Swallowing rehabilitation or management strategies will not be affected by the results of the instrumental evaluation

Measurement Scales

1. Interpretation is usually subjective 2. Three common scales- a. Penetration-Aspiration Scale b. Modified Barium Swallow Impairment Profile (MBSImP) c. Quantitative Analysis

Structures and Functions of Oral Mechanism

1. Jaw open 2. Jaw close 3. Lip retract 4. Lip round 5. Tongue elevation 6. Tongue protrusion 7. Tongue left 8. Tongue right 9. Velum 10. Cough 11. /i/ /i/ /i/ /i/ 12. AMR- Rhythm, Rate 13. SMR

Oral Cavity Inspection

1. Lesions 2. Thrush 3. Moisture 4. Dentition 5. Atrophy

Lingual Pressure- Nonimaging

1. Lingual pressure is most often used to propel the bolus from the oral cavity by pressing the bolus against the palate and moving it posteriorly into the oropharyngeal vestibule in preparation for a swallow. 2. How its measured a. Lingual pressure may be measured through a rubber strip with air-filled pressure bulbs adhered to the palate. The pressure bulbs are connected to an external reading device which records or measures the amount of pressure the tongue places against the palate. Lingual pressure may also be measured through electrodes placed upon the palate. b. In summary, it is a measuring device attached to either the palate or tongue to register the amount of pressure produced between the tongue and palate. *Advantages* 1. Lingual measurements can be recorded from a variety of positions with different equipment (force sensitive resisters, air-filled pressure bulbs, electromagnetic midsagittal articulography). 2. SLP can perform for evaluation and treatment. 3. Less expensive than other tests. 4. Can measure movements that other tests cannot. *Disadvantages* 1. The feeling of the appliance within the oral cavity might hinder the true readings, cause a gag reflex, and cannot test for solid foods because wires do not allow for mastication. 2. This is a test specifically to measure tongue pressure, nothing else.

FEES Procedures

1. Observe quiet and forced respiration, coughing, speaking, and dry swallows 2. Check for structural and physiological abnormalities and secretions management 3. Trial swallows with foods and liquids treated with food dye

MBS Protocol

1. Often start with small amount of thin liquid (less likely to block the airway or cause pneumonia) unless there is evidence of choking on liquids. a. Thickened barium liquid (nectar, honey), pudding, and solids. b. Should also include foods that are specific for the patient's culture and religion 2. Patient standing or sitting during evaluation 3. 1-3-5-10 ml 4. 1/3 teaspoon paste material 5. With liquids and paste, often have the patient wait to swallow until instructed (why? To verify how well will the patient maintain the bolus and also to watch when the patient is swallowing) 6. Do two swallows at each level (to make sure what you are looking at) 7. Proceed to larger amounts, thicker liquids, puree, and solid (cookie on marshmallow coated with barium) 8. May start with something else depending on specific purpose 9. Can show tape to pt. to enhance understanding and compliance with tx 10. The SLP is responsible for observing, interpreting movement of the structures involved in swallowing, and writing the report (the radiologist work together) 11. MBS questions to diet modification a. Are you aspirating? b. Do you feel it? c. Can you get it out?

Silent Aspiration

1. Penetration of food, liquid or saliva to the subglottic area without the elicitation of a cough 2. The food and drink has to fall below the level of the vocal folds without coughing

What does MBS Measure?

1. Permits observation of the oral preparatory, oral, pharyngeal, and esophageal aspects of the swallow, before, during and after the event 2. Measures (1) oral transit time, (2) pharyngeal delay time, (3) pharyngeal transit time (1) time from initiation of tongue movement to push bolus to time the leading edge reaches the trigger point (faucial archers, juncture of jaw and tongue base) about 1 sec. (2) begins when bolus reaches the trigger point and ends when hyoid bone and larynx begin to elevate (gets longer with age - .2 to .5 sec and longer than 2 sec is abnormal). (3) from triggering of swallow to the time "tail" of bolus passes through UES. (usually .35 to .48s, maximum of 1 second) 3. General room set-up a. Setup of the patient within the machine b. Lateral view and anterior-posterior view 4. Materials a. Barium, food, cups, spoons, straws, washcloth and towels, oral care materials b. The patient ingests barium-coated boluses or liquid barium of varying consistencies offered at the discretion of the SLP.

Pharyngeal and Laryngeal Elevation

1. Phonation a. Volume b. Pitch c. Vocal quality 2. Breathing pattern 3. Laryngeal Elevation a. The examiner palpates at the level of the thyroid notch to feel for laryngeal excursion as a sign of swallowing response has been elicited. b. Lack of laryngeal elevation usually suggests a nerve injury at the laryngeal level

Oral Hygiene

1. Poor oral care can lead to a. Cavities b. Bad breath c. Oral infections d. *Plaque and residue build up in the mouth, creating a breeding ground for bacteria.* 2. *Aspiration Pneumonia* a. Patients with dysphagia are at risk for developing aspiration pneumonia because they can aspirate liquids, food, and even their saliva, allowing the bacteria from their mouths to enter their lungs. 3. Oral hygiene should be done at least 2 times a day- morning and evening (and after meals as needed), especially on those who are NPO, to prevent aspiration pneumonia. a. It also should be done *before your swallowing evaluation with food trials.*

Types of Clinical Swallowing Evaluations

1. Pre-feeding assessment a. Chart review and Interview, medical status (Current/past dx.), respiratory status, Hx. of aspiration, tracheostomy, current method of intake 2. Bedside swallowing evaluation a. Physical inspection of the swallowing musculature b. Observations of swallowing competence with test swallows

Radiation Safety of MBS

1. Radiation dose level typically low and safe for patients; 2. Clinicians must wear protective shields and dosimetry badge; 3. Thyroid shield, lead apron, protective glasses and protective gloves; 4. Clinicians should keep a distance from the x-ray tube; 5. It is estimated that a patient may receive up to 15 to 40 MBSs annually before exceeding the National Institutes of Health recommended annually radiation dose limit.

Scintigraphy- Imaging

1. Radionuclear scanning following ingestion of a radioactive bolus 2. Requires physician trained in nuclear med. 3. Quantifies amount of radioactive tracer in tissues or structures, precise measure 4. Physiology is not visualized 5. Expensive

Clinical Swallowing Evaluations- Protocols

1. Review the patient's medical chart 2. Interview *patient,* family members, and staff 3. Complete Oral Mechanism Examination 4. Observation of Swallowing with Food Trials 5. Make recommendations based on your observations a. If not sure, request videofluoroscopy (MBS); Make the determination to a videofluoroscopy based on observation of eating foods and drinking liquids; Hear aspiration or wet vocal fold quality b. Diet modification c. Speech Therapy (swallowing therapy) 6. Provide patient and family education 7. Review Medical Chart and Case History a. Is the patient currently eating by mouth (if so, what is the current diet) or is he or she relying on nonoral feeding? b. Is there a history of aspiration pneumonia? c. Was the patient recently hospitalized and if so, for what reasons? d. Does the patient have other associated medical conditions (including, COPD, past surgery, trauma, etc.)? e. Is the patient thriving or maintaining his or her general health and nutrition status based on the current diet and method of eating? 8. Interview patient, family and staff a. Do you think you are having any trouble swallowing? b. Are you having any trouble with your saliva? c. Do you have any chewing problem associated with swallowing? d. Are you taking any medicine by mouth? Do they ever giving you any trouble? e. Pills crushed or taking them full f. Does food get stuck in your throat? When does it happens, what do you do? g. Any changes in your voice or speech since you are in the hospital? h. Do you have dry mouth? i. Do you have any pain associated with swallowing? j. Do you cough or choke after drinking liquids or eating food? If so, explain. k. When swallowing, do you have food or liquids coming out of your nose? l. Has your weight changed lately? Lost 8 pounds in what time frame? m. Are you taken any nutritional boost? n. Have you had any respiratory or infection or pneumonia? o. Dentures? p. Lack of saliva, smell? q. Do you ever drink water or they thicken that for you? r. Are you doing any technique when you drink water? - like chin tuck s. Have you been getting any swallowing therapy t. Can you tell me about your swallowing exercises 9. Complete Oral Mechanism Examination and Physical Examination a. Structural/Functional/Oral Examination b. Pharyngeal and Laryngeal Examination c. Cranial Nerve Examination

Surface Electromyography (sEMG)- Nonimaging

1. Screening test that uses surface electrodes to measure electrical activity of muscles (mainly hyoid elevations muscles) 2. Purpose of the sEMG a. To identify the presence of swallowing activity b. To analyze swallowing functions (timing and amplitude) c. As a biofeedback strategy in the treatment of swallowing disorders 3. What it measures a. Ionic voltages that occur as a result of electrochemical reactions in muscle cells -Muscle activity in an anatomic area b. Duration (in sec) of the swallowing act c. Amplitude of the electric activity d. Graphic patterns e. Number of swallows (in a continues drinking test) 4. Components a. EMG cable (gray or black connector, and three clips - two active leads and one ground lead) b. Disposable electrode disks c. Electrode gel 5. Guidelines a. Clean area of skin before placing the electrodes (use rubbing isopropyl alcohol) b. Attach the clips from the cable onto the snaps of the electrodes c. Place an amount of gel on the three electrodes d. Peel off the backing and place electrodes on the skin

Purpose of Clinical Swallowing Evaluations

1. Swallow safety and signs and symptoms of dysphagia 2. To determine candidacy for videofluoroscopic evaluation a. The procedure is expensive, so a swallow screening is completed first 3. To determine optimum food and liquid recommendations a. Continuation or possible modification of present diet 4. To monitor the progress of therapy and to determine the possibility of upgrading recommendations 5. Impact on the quality of life

Test Swallows and Feeding Protocols

1. Thin liquid a. Water, tea, coffee b. Ice chips c. 1 tsp of water d. 3 ounces of water e. About 10 to 20mL (larger sip of water from a cup) f. Sequential swallows using a straw 2. Thick liquid a. Nectar, honey b. Fluid consistencies may be thickened or thinned according to the patient's performance 3. Puree a. Applesauce 4. Pudding consistency a. Jell-O pudding cups 5. Semisolid a. Pear, peaches diced cubes 6. Solid a. Cookie, water cracker 7. Start with ice chips a. If they aspirate a little bit of water, it is not going to cause pneumonia b. The lungs can absorb the water because of the neutral Ph c. Never give them a straw because if they have a lack of control, it could hurt the patient d. If it is only oral phase dysphagia, especially with difficulty propelling the bolus to the back of the mouth and intact velopharyngeal phase, then a straw is appropriate

Dysphagia Screening Protocols

1. Toronto Bedside Swallowing Screening Test (TOR-BSST) 2. Modified Mann Assessment of Swallowing Ability (MMASA) 3. 3-oz Water Swallow Test (WST) 4. Burke Dysphagia Screening Test (BDST) 5. The Modified Blue Dye Test

What is FEES?

1. Transnasal flexible laryngoscope to evaluate the swallow before and after the pharyngeal swallow 2. First described to assess dysphagia by Susan Langmore in 1988 3. Performed by Speech Language Pathologist trained in endoscopy or jointly by SLP and ENT 4. Visualizes pharynx and larynx *before* and *after* the swallow, but *not during* (white out) a. Whiteout phase happens during the swallow and airway closure, the pharyngeal walls contract and blocks the view of the endoscope 5. Often requires a light topical anesthetic in nose for placement (4% Lidocaine), but not always a. Studies on effects of patient tolerance are equivocal b. Reduced sensation could increased risk of aspiration

Quantitative Analysis

1. Using image editing software to quantitatively analyze the MBS 2. Common Procedures- a. Digitize the MBS. b. Identify certain frames in the video clip that correspond to specific moments of the swallow c. Identify and delineate anatomical landmarks or bolus size. d. Use the measures obtained from the steps above to calculate specific swallowing-related outcomes

ASHA Objectives for Instrumental Assessment

1. Visualize the swallowing and respiratory-related structures; 2. Assess the physiologic functioning, sensation, coordination, and effectiveness of swallowing-related structures and muscles; 3. Determine the presence, cause, and patterns of aspiration; 4. Visualize the management of secretions; 5. Screen the anatomy and physiology of the esophageal area 6. Assist in determining oral versus non-oral feeding 7. Determine the safety and efficiency of management options

Ultrasounds- Imaging

1. Visualizes oral cavity and oro-pharynx a. Hard to see hypopharynx 2. Best for seeing tongue function and motion of hyoid bone 3. Noninvasive, no radiation 4. Flexible from any angle 5. Use with any food 6. Can use as biofeedback *Limitations* 1. Hard to read and interpret 2. Cannot visualize pharyngeal phase 3. Cannot see aspiration