Straw Drinking

James L. Coyle, Ph.D., CCC-SLP, BRS-S
(Communication Science and Disorders
University of Pittsburgh) writes:

Stephanie Daniels and her colleagues published an interesting article on straw drinking in normals a few years back that describes three distinct patterns of straw-drinking. I don’t know if straw drinking in patients has been investigated and I am pretty sure that what goes on in the oral cavity has received little attention. This brings up an interesting observation (my own so take it for what it’s worth, and it is something that would make a great study).

Ask yourself this question and answer it: “how do humans establish the intraoral pressure necessary to draw liquid into the mouth through a straw?” before reading on.

Most people that I have asked (mostly students, nursing personnel and other SLP’s), when asked reply that it is through inhalation. In fact, to do so requires tight closure of the linguapalatal valve (tongue base to soft palate through palatoglossus muscles) together with retraction and depression of the anterior tongue and mandible depression (all together), which increases oral cavity volume and thereby decreases intraoral pressure, drawing in the liquid. Try it and attend to what your “parts” are doing.

Arguably, in some cases in which good linguapalatal closure is apparent (evidence: clinical assessment of oral facial sensorimotor function and speech production) and patient has a patent nasal cavity and nasopharynx for ventilation, the use of a straw might be (opinion here – no hard evidence to support) considered beneficial to some individuals who exhibit posterior oral containment impairments with liquids by forcing linguapalatal contact during the oral preparatory and early oral transit stages. I have used this logic successfully in some cases.

If linguapalatal closure is not adequate or evident then indeed inhalation will be used and the bolus directed to the airway.


Daniels, S. K., Corey, D. M., Hadskey, L. D., Legendre, C., Priestly, D. H., Rosenbek, J. C. et al. (2004). Mechanism of sequential swallowing during straw drinking in healthy young and older adults. Journal of Speech Language & Hearing Research, 47, 33-45.

Daniels, S.K. & Foundas, A. L. (2001). Swallowing physiology of sequential straw drinking. Dysphagia, 16, 176-182.

Risks for Dehydration and/or Pneumonia

In the coming year the data from the Protocol 201 study, some of which was presented at the 2006 ASHA meeting, will be published. This study randomized aspirating Parkinson’s and dementia patients to either thin liquid using a chin-down posture, or thickened liquids (nectar or honey) for either three months follow up, or primary clinical end point (outcome of interest) of pneumonia, but hydration and nutritional parameters were also followed.



At the time of the ASHA meeting in 06, one interesting result presented was that patients in this study randomized to the “honey” thickened liquids intervention for managing aspiration of thin liquids, compared to the “nectar” thick and chin-down posture interventions, had significantly longer hospitalizations for pneumonia, than the pneumonia hospitalization durations for the other two interventions. I hope that the authors will clarify this with some data in their manuscripts and discuss this, as this “gel” discussion relates to the exact nature of the 201 finding: does aspirated thick liquid produce worse adverse outcomes than aspirated thin liquid.



The gel discussion aside, another important consideration is whether the patient drinks sufficient liquids once they are prescribed in their thick form. If we shift the risk from a potential respiratory adverse outcome (pneumonia) to a metabolic adverse outcome (inadequate hydration), there may be no net gain.

James L. Coyle

University of Pittsburgh

ASHA Convention 2007 Highlight

I wanted to draw your attention to Jim Coyle's presentation...-- "Ventilation, Respiration, & Pulmonary Diseases: Dysphagia-Related or Not?". It is session 1225 on Thursday from 8a-9a in room 257AB.

Estimating Risk of Pneumonia

James L. Coyle of the University of Pittsburgh wrote on the Dysphagia List-Serve:

"Eisenhuber et al (2002) developed a three point scale, using the height of retention in the vallecular and pyriform sinuses, as scale values.

A score of 1 corresponded to “less than 25% of the height” of the cavity described, 2 to “25-50% height”, and 3 to “>50% height”. They adapted a rating system published earlier by Perlman et al. (1994) by taking the published height values and attributing the values in the 3 point scale to the three measures created by Perlman.

They then used videofluoroscopy to determine whether pharyngeal retention seen on fluoroscopic images was predictive of laryngeal penetration or aspiration. They did not differentiate between the two (penetration, aspiration), instead lumping them together. This makes it difficult for the reader to know with certainty which outcome (penetration, aspiration) should be expected. They also lumped vallecular and pyriform sinus retention together in the attribution of aspiration/penetration risk however 83% of their patients had retention in both.

At any rate, The score “3” for pharyngeal retention was significantly more likely (about 4 to 1 odds of higher likelihood) to be followed by laryngeal penetration or aspiration than scores of 1 or 2. One finding that is a bit easier to swallow (ha ha) was that 93% of patients with pharyngeal retention (valleculae or pyriform sinuses or both) exhibited laryngeal penetration or aspiration whereas only 33% of patients without retention exhibited penetration or aspiration.

Robbins et al. (1999) used the penetration aspiration scale to differentiate between normals, and two groups of disordered swallowers (stroke, head and neck cancer). They found that 21% of normals exhibited high laryngeal penetration (no deeper than the vestibule-PAS scores of 2 or 3). Therefore deep penetration (to vocal folds) is not normal (nor is aspiration).

Combining the two measures, one can attribute risk of laryngeal penetration or aspiration to the height of pharyngeal retention, and the risk of inhalation of swallowed material to the severity of laryngeal penetration and aspiration. Added to the other host risk factors predisposing a patient to pneumonia, the clinician can generate a reasonable likelihood of pneumonia.

We use the two scales together to attribute risk associated with the dysphagia and discuss the additional risk factors to estimate pneumonia risk."

James L. Coyle

University of Pittsburgh

Reference List

Eisenhuber, E., Schima, W., Schober, E., Pokieser, P., Stadler, A., Scharitzer, M. et al. (2002). Videofluoroscopic assessment of patients with dysphagia: pharyngeal retention is a predictive factor for aspiration. American Journal of Roentgenology, 178, 393-398.

Perlman, A. L., Booth, B. M., & Grayhack, J. P. (1994). Videofluoroscopic predictors of aspiration in patients with oropharyngeal dysphagia. Dysphagia, 9, 90-95.

Robbins, J. A., Coyle, J. L., Rosenbek, J. C., Roecker, E. B., & Wood, J. L. (1999). Differentiation of normal and abnormal airway protection during swallowing using the penetration-aspiration scale. Dysphagia, 14, 228-232.