Specific information regarding the Communication Sciences and Disorders' Acute Care Speech Language Pathology practicum led by Carley Evans MS CCC SLP. Carley is a medical speech pathologist at the Evelyn Trammell Institute for Voice and Swallowing of the Medical University of South Carolina in Charleston. If you are new to this practicum, start with the oldest post listed in Archive.

Tuesday, December 11, 2007

Martin-Harris et al., 2007 JSLHR Study

The (Martin-Harris et al., 2007 study showed progressively deeper progression of the 5mL liquid bolus with progressively older subjects. At the onset of maximal hyoid motion (the onset of the pharyngeal response and the starting point for measuring stage transition or pharyngeal delay time), the mean age at which the head of the bolus tended to be at the level of the intersection of the mandibular ramus with the tongue base was about 48 years (looking at their figures-not the raw data), at the vallecular pit it was age about 60, hypopharynx = ~70, and pyriform sinuses was about 72 or 3. However (and a huge however), the ranges for each age group were very wide (meaning that the range of age at which bolus head was at the various sites at swallow onset included individuals between about 40 and 70 years). Interestingly in the second swallow, all of the "pyriform sinus" swallows occurred in patients 80 and older, if I am reading this correctly.

This study also plotted pharyngeal delay time and the plot shows confirmation of a definite lengthening in pharyngeal response onset with progressive aging.

This study is published in JSLHR (50 (3): 585) which is available to all ASHA members online (Martin-Harris et al., 2007)

James L. Coyle
University of Pittsburgh

and response from Bonnie Martin-Harris, PhD:

Dear Jim,
Thank you for citing our work and for your complete summary. I do want to point out the following that we believe was one of the most interesting

"There was, however, one 91-year-old who demonstrated this "timely and safe" position relative to the onset of the swallow. More than 25% of our sample exhibited a bolus head location in the vallecular pits at the onset of hyoid motion. The youngest of these was 26 years old, and the oldest was 89 years old. Thirteen of our participants demonstrated a bolus head location in the hypopharynx superior to the pyriform sinuses at the onset of the pharyngeal swallow. This position was represented by the young (the youngest individual in our sample was
26 years of age) and the old (the oldest individual in our sample was 97 years of age)."

There is some normal variation across ages. Clinicians must understand this variation and can only recognize the threat of related swallowing difficulties via careful evaluation of all functional components of the oropharyngeal swallowing mechanism.

Great to see this dynamic discussion.

Bonnie Martin-Harris, Ph.D., CCC-SLP, BRS-S Director, MUSC Evelyn Trammell Institute for Voice and Swallowing Associate Professor, Otolaryngology-Head and Neck Surgery Medical University of South Carolina
135 Rutledge Avenue
PO Box 250550
Charleston, SC 29425
Phone: (843) 792-7162
Fax: (843) 792-0546

Normal Variation in Pharyngeal Swallow Times in Elderly

Dr. Robbins' work has shown that the duration of stage transition is longer in the elderly. Translated, the bolus head (with liquids) is past the ramus of the mandible for a second or two in some cases, in healthy elderly subjects (Robbins, Hamilton, Lof, & Kempster, 1992). As you know the "top" of the valleculae lie at the plane of the mandibular ramus.

That would be Hiiemae and Palmer (1999), and Saitoh, et al., 2006. These investigators found that with solids and soft solids as well as chewed foods, the bolus head tended to lie anywhere from the valleculae to the pyriform sinuses for up to many seconds, even in non-old subjects. For this reason the measure traditionally used to indicate "pharyngeal delay" (i.e. the duration of stage transition) is no longer valid for solids (Hiiemae & Palmer, 1999; Saitoh et al., 2007).

James L. Coyle

University of Pittsburgh

Hiiemae, K. M. & Palmer, J. B. (1999). Food transport and bolus formation during complete feeding sequences on foods of different initial consistency. Dysphagia, 14, 31-42.
Robbins, J., Hamilton, J. W., Lof, G. L., & Kempster, G. B. (1992). Oropharyngeal swallowing in normal adults of different ages. Gastroenterology, 103, 823-829.
Saitoh, E., Shibata, S., Matsuo, K., Baba, M., Fujii, W., & Palmer, J. B. (2007). Chewing and food consistency: effects on bolus transport and swallow initiation. Dysphagia, 22, 100-107.

Monday, December 10, 2007

Normal Variability in Adult Swallows: Pharyngeal Swallow Initiation

Delayed Initiation of the Pharyngeal Swallow: Normal Variability in Adult Swallows. Journal of Speech, Language, and Hearing Research Vol.50 585-594 June 2007.

by Dr. Bonnie Martin Harris et al.

Friday, December 7, 2007

Barium Standardization for MBS

Catriona M. Steele
Ph.D., M.H.Sc., S-LP(C), CCC-SLP, Reg. CASLPO writes:
Hi everyone!
I wanted to contribute to the discussion on barium standardization.

First let me start by saying that I believe the preferred option here is to use the Varibar products. These products have undergone rigorous testing.

However, if you are in a facility where Varibar is not yet available (which is true for all of us in Canada), then the next best approach is to standardize your barium recipes. I believe that we should be attempting to match the DENSITY of the Varibar products (acknowledging, of course that those products have the advantage of including various suspension agents and emulsifiers that are not part of the procedure I am going to describe below).

To make barium products of a specific DENSITY, you need a good digital scale as well as containers that specify volume (in ML). Density is always reported as a WEIGHT to VOLUME ratio. That means that for a specific VOLUME of liquid, you need to add a particular WEIGHT (in grams) of barium.

The particular amount of barium that you will add depends on the original barium product (is it a powder or already in liquid form?) and what density it is already determined to have. Liquid Polibar, for example, has a 100% weight to volume ratio in the bottle. Liquid Polibar Plus is slightly more dense (105% weight to volume). EZ-HD is intended to yield a 250% weight to volume suspension when you add the specified amount of water marked on the bottle.

So, in the absence of Varibar here in Canada, this is how I suggest that people attempt to standardize their home-made barium recipes (let me reiterate that I believe purchasing Varibar is the preferred option).

a) How to make ~1 cup (250 ml) of 40% w/v liquid barium suspension with Liquid Polibar(100% w/v base):

- Place an empty container on a digital balance and set the weight to 0 g.
- Pour in 100 g of Liquid Polibar.
- Add water until the volume reaches 250 ml.
- Shake well and leave to stand in a refrigerator.

b) How to make ~1 cup (250 ml) of 40% w/v liquid barium suspension with Liquid Polibar Plus (105% w/v base):

- Place an empty container on a digital balance and set the weight to 0 g.
- Pour in 95 g of Liquid Polibar Plus.
- Add water until the volume reaches 250 ml.
- Shake well and leave to stand in a refrigerator.

c) How to make 40% w/v barium products (any consistency) with E-Z-HD powder:

- Calculate the volume of liquid that you want to prepare (e.g. 250 ml)
- Determine the value of 40% of this volume (e.g., 250 X 0.4 = 100). Divide this value by 2.5 (e.g., 100/2.5 = 40).
- Using a digital balance, weigh out this value in grams of EZ-HD powder on a scale.
- Add this amount of powder to your liquid (e.g. 40 g of EZ-HD plus 250 ml of liquid).
- Shake or stir well with a whisk and store in a refrigerator.

Catriona M. Steele
Ph.D., M.H.Sc., S-LP(C), CCC-SLP, Reg. CASLPO

* Research Scientist, Toronto Rehabilitation Institute
* Corporate Practice Leader for Speech-Language Pathology and Audiology, Toronto Rehabilitation Institute
* CIHR New Investigator in Aging
* Assistant Professor, Department of Speech-Language Pathology, University of Toronto
* Coordinator-Elect, Special Interest Division 13 (Swallowing and Swallowing Disorders), American Speech-Language Hearing Association

Mailing Address:
550 University Avenue, #12030,
Toronto, ON, M5G 2A2
Telephone: 416-597-3422 X 7603
Fax: 416-597-7131
E-mail: steele.catriona@torontorehab.on.ca