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Comparison between clinical and videofluoroscopic evaluation of swallowing in children with suspected dysphagia

Abstracts

Purpose:

To verify the accuracy of clinical evaluation compared with videofluoroscopic swallowing studies in the detection of isolated laryngeal penetration and laryngeal aspiration in children with suspected dysphagia; to identify clinical signs and symptoms associated with isolated laryngeal penetration and laryngeal aspiration; and to determine the sensitivity and specificity of the clinical signs and symptoms identified.

Methods:

Retrospective analysis of data from clinical and videofluoroscopic evaluations carried out in 55 children from 1 month to 7 years and 11 months old. For clinical assessment, the Protocol for Clinical Assessment of Pediatric Dysphagia was used. The sensitivity, specificity, and positive and negative predictive values of clinical evaluation were analyzed. For statistical analysis, the Fisher's exact and χ2 tests were used.

Results:

Clinical evaluation showed, in general, a sensitivity of 86% and a specificity of 32%. For isolated laryngeal penetration, clinical evaluation showed a sensitivity of 88%. For laryngeal aspiration, clinical evaluation showed a sensitivity of 86%. However, the specificity values were low for both alterations. There was no association between clinical evaluation and videofluoroscopic findings. Choking was the only clinical sign associated with isolated laryngeal penetration thin fluid and showed a sensitivity of 53% and a specificity of 77%.

Conclusions:

Clinical evaluation was sensible to detect isolated laryngeal penetration and laryngeal aspiration in children with suspected dysphagia. However, it showed a low specificity. Choking was the only clinical sign associated with isolated laryngeal penetration of thin fluid. More prospective studies are needed to confirm these findings in this population.

Infant; Child; Fluoroscopy; Deglutition; Disorders; Evaluation; Sensitivity and Specificity


Objetivos:

Verificar a acurácia da avaliação clínica da deglutição comparada à videofluoroscopia na detecção de penetração laríngea isolada e aspiração laríngea em crianças com suspeita de disfagia; identificar os sinais e sintomas clínicos associados à presença de penetração laríngea isolada e aspiração laríngea; e determinar a sensibilidade e a especificidade dos sinais e sintomas clínicos identificados.

Métodos:

Análise retrospectiva de dados de avaliações clínicas e videofluoroscópicas realizadas em 55 crianças de 1 mês a 7 anos e 11 meses de idade. Na avaliação clínica foi utilizado o Protocolo de Avaliação Clínica da Disfagia Pediátrica. Foram analisados: sensibilidade, especificidade e valores preditivos positivo e negativo da avaliação clínica. Também foram utilizados os testes exato de Fisher e do χ2 na análise estatística.

Resultados:

A avaliação clínica apresentou, no geral, sensibilidade de 86% e especificidade de 32%. Para penetração laríngea isolada, a avaliação clínica apresentou sensibilidade de 88%. Para aspiração laríngea, a avaliação clínica apresentou sensibilidade de 86%. Contudo, os valores da especificidade foram baixos para ambas as alterações. Não houve associação significativa entre a avaliação clínica e os achados videofluoroscópicos. O engasgo foi o único sinal clínico associado à penetração laríngea isolada com líquido fino e apresentou sensibilidade de 53% e especificidade de 77%.

Conclusões:

A avaliação clínica foi sensível para detectar penetração laríngea isolada e aspiração laríngea em crianças com suspeita de disfagia, porém, apresentou baixa especificidade. O engasgo foi o único sinal clínico associado à penetração laríngea isolada com líquido fino. São necessários mais estudos prospectivos que confirmem esses achados nessa população.

Lactente; Criança Fluoroscopia; Transtornos de Deglutição; Avaliação Sensibilidade e Especificidade


INTRODUCTION

Children with suspected dysphagia are referred to swallowing assessment, which is performed clinically, and, if necessary, complemented with an objective evaluation, such as videofluoroscopic swallowing study (VFSS).

The VFSS is the gold standard objective evaluation of swallowing for, among other advantages, accurately detecting changes in the pharyngeal phase( 1Hiorns MP, Ryan MM. Current practice in paediatric videofluoroscopy. Pediatr Radiol. 2006;36(9):911-9. ), which is the main objective in children assessments( 2Arvedson JC. Assessment of pediatric dysphagia and feeding disorders: clinical and instrumental approaches. Dev Disabil Res Rev. 2008;14(2):118-27. ). However, this method has some disadvantages such as exposure to radiation, limited test time, which does not simulate a real meal, and the need for patient compliance, which also affects the results( 1Hiorns MP, Ryan MM. Current practice in paediatric videofluoroscopy. Pediatr Radiol. 2006;36(9):911-9.

Arvedson JC. Assessment of pediatric dysphagia and feeding disorders: clinical and instrumental approaches. Dev Disabil Res Rev. 2008;14(2):118-27.
- 3Miller CK. Updates on pediatric feeding and swallowing problems. Curr Opin Otolaryngol Head Neck Surg. 2009;17(3):194-9. ).

In some cases, VFSS may not be necessary or may not be available for professionals in an institution, so they must define their actions based only on clinical judgment( 4DeMatteo C, Matovich D, Hjartarson A. Comparison of clinical and videofluoroscopic evaluation of children with feeding and swallowing difficulties. Dev Med Child Neurol. 2005;47(3):149-57. ), in which the pharyngeal phase of swallowing cannot be assessed objectively and the presence of silent aspiration may not be identified. However, changes can be inferred through clinical signs and symptoms (CSS), suggesting changes in the pharyngeal phase of swallowing and coughing, choking, cyanosis, wet voice, change in cervical auscultation, among others( 5Dusick A. Investigation and management of dysphagia. Semin Pediatr Neurol. 2003;10(4):255-64.

Lefton-Greif MA. Pediatric dysphagia. Phys Med Rehabil Clin N Am. 2008;19(4):837-51.
- 7Silva AB, Piovesana AM, Barcelos IH, Capellini SA. Clinical and videofluoroscopic evaluation of swallowing in patients with spastic tetraparetic cerebral palsy and athetosic cerebral palsy. Rev Neurol. 2006;42(8):462-5. [Spanish]. ).

Some studies have compared the clinical evaluation with VFSS in children with cerebral palsy and showed that clinical evaluation may, at times, not be able to detect changes in the pharyngeal phase in this population( 8Furkim AM, Behlau MS, Weckx LL. Clinical and videofluoroscopic evaluation of deglutition in children with tetraparetic spastic cerebral palsy. Arq Neuropsiquiatr. 2003;61(3A):611-6. [Portuguese]. , 9Araujo BCL. Acurácia do diagnostico clínico da disfagia em crianças com paralisia cerebral [dissertação ]. Recife: Universidade Federal de Pernambuco; 2012. ) due to the low accuracy( 9Araujo BCL. Acurácia do diagnostico clínico da disfagia em crianças com paralisia cerebral [dissertação ]. Recife: Universidade Federal de Pernambuco; 2012. ). In another study, among ten children with CSS suggestive of laryngeal aspiration, eight were identified in the VFSS( 7Silva AB, Piovesana AM, Barcelos IH, Capellini SA. Clinical and videofluoroscopic evaluation of swallowing in patients with spastic tetraparetic cerebral palsy and athetosic cerebral palsy. Rev Neurol. 2006;42(8):462-5. [Spanish]. ).

In children with neurologic disorders, a study found a significant correlation between cervical auscultation and hyoid excursion, and between larynx and the presence of liquid and paste laryngeal aspiration( 1010 Marrara JL, Duca AP, Dantas RO, Trawitzki LVV, Lima RAC, Pereira JC. Swallowing in children with neurologic disorders: clinical and videofluoroscopic evaluations. Pro Fono. 2008;20(4):231-6. ).

A study conducted with children with feeding problems showed that clinical assessment can detect penetration and aspiration of fluids, but had low accuracy with solids( 4DeMatteo C, Matovich D, Hjartarson A. Comparison of clinical and videofluoroscopic evaluation of children with feeding and swallowing difficulties. Dev Med Child Neurol. 2005;47(3):149-57. ).

By comparing CSS suggesting alterations in the pharyngeal phase with the findings of the VFSS, studies have shown that cough was the main indicator of penetration with liquids( 4DeMatteo C, Matovich D, Hjartarson A. Comparison of clinical and videofluoroscopic evaluation of children with feeding and swallowing difficulties. Dev Med Child Neurol. 2005;47(3):149-57. ) and that wet voice, noisy breathing( 1111 Weir K, McMahon S, Barry L, Masters IB, Chang AB. Clinical signs and symptoms of oropharyngeal aspiration and dysphagia in children. Eur Respir J. 2009;33(3):604-11. ), and cough were good clinical indicators of laryngeal aspiration with liquid( 4DeMatteo C, Matovich D, Hjartarson A. Comparison of clinical and videofluoroscopic evaluation of children with feeding and swallowing difficulties. Dev Med Child Neurol. 2005;47(3):149-57. , 1111 Weir K, McMahon S, Barry L, Masters IB, Chang AB. Clinical signs and symptoms of oropharyngeal aspiration and dysphagia in children. Eur Respir J. 2009;33(3):604-11. , 1212 Uhm KE, Yi SH, Chang HJ, Cheon HJ, Kwon JY. Videofluoroscopic swallowing study findings in full-term and preterm infants with dysphagia. Ann Rehabil Med. 2013;37(2):175-82. ). However, no clinical signs were significantly associated with aspiration, penetration, or post-swallow paste residue( 1111 Weir K, McMahon S, Barry L, Masters IB, Chang AB. Clinical signs and symptoms of oropharyngeal aspiration and dysphagia in children. Eur Respir J. 2009;33(3):604-11. ).

There are few studies in literature evaluating the accuracy of clinical assessment compared to the VFSS in children. A study aiming to verify the sensitivity of clinical evaluation to identify aspiration reported 92% sensitivity for liquids and 33% for solids( 4DeMatteo C, Matovich D, Hjartarson A. Comparison of clinical and videofluoroscopic evaluation of children with feeding and swallowing difficulties. Dev Med Child Neurol. 2005;47(3):149-57. ). Another study observed a 91.6% sensitivity in clinical evaluation to detect changes in the pharyngeal phase( 1313 Blanco OFS, Aristizábal DS, Pineda AM, Rodríguez MMM, Escobar PA, Ochoa WC, et al. Características clínicas y videofluoroscópicas de la disfagia orofaríngea em niños entre un mes y cinco años de vida. Iatreia. 2008;21(1):13-20. ).

In children with cerebral palsy, studies have shown that the accuracy of clinical assessment in the diagnosis of dysphagia is low and similar for paste (52.2%) and liquid (53.4%)( 9Araujo BCL. Acurácia do diagnostico clínico da disfagia em crianças com paralisia cerebral [dissertação ]. Recife: Universidade Federal de Pernambuco; 2012. ). Furthermore, the sensitivity of clinical evaluation (80%) is higher than the specificity (47%) to detect penetration or aspiration( 1414 Santos RRD, Sales AVMN, Cola PC, Jorge AG, Peres FM, Furkim AM, et al. Accuracy of clinical swallowing evaluation for oropharyngeal dysphagia in cerebral palsy. Rev CEFAC. 2014;16(1):197-201. ).

Some studies have reported the sensitivity and specificity of CSS associated with changes in the pharyngeal phase found by the VFSS, with the following results: 62% sensitivity and 72% specificity for change in cervical auscultation related to penetration or aspiration( 1515 Furkim AM, Duarte ST, Sacco AFB, Sória FS. O uso da ausculta cervical na inferência de aspiração traqueal em crianças com paralisia cerebral. Rev CEFAC. 2009;11(4):624-9. ), 67% sensitivity and 53% specificity for cough, 67% sensitivity and 92% specificity for wet voice, and 33% sensitivity and 83% specificity for noisy breathing when stating aspiration of thin liquid( 1111 Weir K, McMahon S, Barry L, Masters IB, Chang AB. Clinical signs and symptoms of oropharyngeal aspiration and dysphagia in children. Eur Respir J. 2009;33(3):604-11. ).

On the basis of the earlier-mentioned results, the importance of further studies comparing clinical evaluation with VFSS and verifying the accuracy of clinical assessment to detect changes in the pharyngeal phase in children is highlighted. The objectives of this study were the following:

  1. To check the accuracy of clinical evaluation of swallowing (CES) compared to the VFSS to detect laryngeal penetration and isolated laryngeal aspiration in children with suspected dysphagia.

  2. To identify CSS associated with the presence of laryngeal penetration and isolated laryngeal aspiration.

  3. To determine the sensitivity and specificity of CSS identified.

METHODS

The project was approved by the Research Ethics Committee of the institutions that conducted the study, with protocol numbers 213/11 and 1118/11. This was a retrospective analysis of data and of CES and VFSS carried out from January 2011 to December 2013 in children aging 1 month to 7 years and 11 months, referred from the pediatric intensive care unit, the nursery and Speech Language Pathology and Audiology clinics of the institution.

Participants

As to selection of subjects, the children included aged 1 month to 7 years and 11 months, with clinical suspicion of dysphagia and who had undergone CES and VFSS. Children without CES report, those not submitted to oral and/or pharyngeal phases of swallowing in VFSS, and those assessed by CES with different consistencies compared to VFSS, disabling comparison, were excluded from the study.

Data collected from medical reports were the following: date of birth, gestational age at birth, gender, peri- and postnatal intercurrences, and current medical diagnoses.

Procedures

For CES, we used the Protocol of Clinical Evaluation of Pediatric Dysphagia (PAD-PED)( 1616 Almeida FCF, Bühler KEB, Limongi SCO. Protocolo de avaliação clínica da disfagia pediátrica (PAD-PED). Barueri: Pró-fono; 2014. 34 p. ), which was developed based on the literature addressing clinical evaluation of dysphagia, considering the particularities of the dynamics of child swallowing. This assessment was made by the speech therapist of the institution, experienced and specialized in child dysphagia. In this study, we considered only the items referring to CSS, suggesting alterations in the pharyngeal phase of the consistencies evaluated: change in cervical auscultation, change in voice quality, changes in vital signs (heart rate, respiratory rate, and oxygen desaturation), coughing, choking, cyanosis, paleness, and respiratory distress.

For changes in cervical auscultation, when respiratory sounds were observed after swallowing( 1717 Leslie P, Drinnan MJ, Finn S, Ford GA, Wilson JA. Reliability and validity of cervical auscultation: a controlled comparison using videofluoroscopy. Dysphagia. 2004;19(4): 231-40. ), the following items were considered: basic change with worsening after the offer, change during the offer, and change after the offer.

Similarly, for changes in voice quality in the presence of wet voice, characterized by a bubbling sound that indicates presence of secretions or food in the laryngeal vestibule( 1818 Arvedson JC, Brodsky L. Pediatric swallowing and feeding: assessment and management. 2ª ed. Australia: Singular; 2002. ), the following items were considered: change after the offer with and without spontaneous clearance.

For cough, effective cough and ineffective or late cough were considered.

For the registry of change in vital signs, the following parameters were followed:

  • Change in heart rate: decrease or increase in heart rate during swallowing, based on the values of 80-160 beats per minute (bpm) for the age group 0-2 years, and between 70 and 120 bpm for children aging 2-7 years and 11 months, considered to be adequate( 1919 Souto MB, Lima EC, Brigeiron MK. Reanimação cardiorespiratória pediátrica: uma abordagem multidisciplinar. Porto Alegre: Artmed; 2008. ).

  • Change in respiratory rate: decrease or increase in respiratory rate during swallowing, based on the values of 30-40 breaths per minute for children aged less than 1 year, and between 20 and 30 breaths per minute for those aging 1-7 years and 11 months, considered to be adequate( 1919 Souto MB, Lima EC, Brigeiron MK. Reanimação cardiorespiratória pediátrica: uma abordagem multidisciplinar. Porto Alegre: Artmed; 2008. ).

  • Oxygen desaturation: reduction greater than 5% in the baseline index after swallowing( 1616 Almeida FCF, Bühler KEB, Limongi SCO. Protocolo de avaliação clínica da disfagia pediátrica (PAD-PED). Barueri: Pró-fono; 2014. 34 p. , 2020 Fouzas S, Prifts KN, Anthracopoulos MB. Pulse oximetry in pediatric practice. Pediatrics. 2011;128(4):740-52. ).

The VFSS was performed with an interval of at least 48 hours after CES. The examinations were performed by the radiologist and the speech therapist using Philips Duo Diagnostic equipment, collimated field in the area of interest, with exposure parameters set automatically by ionization chamber, thus capturing the best image with the least fluoroscopic radiation dose.

To record VFSS, infants were placed in the supine position with a compressor belt, for safe retention, and older children in sitting position and side view, as close as possible to the tabletop and to the enhancer, thus avoiding distortion of the fluoroscopic image.

The consistencies evaluated were mixed with barium sulfate contrast and offered to the children with their current use handpiece (bottle with common or orthodontic nipples, cup, or spoon). The focus of the fluoroscopic image was limited to the anterior region by the lips, the upper region through the nasal cavity, in the back of the cervical spine, and the lower region of the airway bifurcation and cervical esophagus.

In VFSS, changes in laryngeal phase that impacted the safety of oral feeding were considered, specifically the following:

• Isolated laryngeal penetration: food in the laryngeal vestibule, but not exceeding the level of the vocal folds( 2121 Robbins J, Coyle J, Rosenbek J, Roecker E, Wood J. Differentiation of normal and abnormal airway protection during swallowing using the penetration-aspiration scale. Dysphagia. 1999;14(4):228-32. ), observed in the absence of aspiration in any swallowing of a given consistency( 1111 Weir K, McMahon S, Barry L, Masters IB, Chang AB. Clinical signs and symptoms of oropharyngeal aspiration and dysphagia in children. Eur Respir J. 2009;33(3):604-11. ). This happens because of the delayed onset of pharyngeal swallowing, decreased pharyngeal contraction, or decreased laryngeal closure( 2Arvedson JC. Assessment of pediatric dysphagia and feeding disorders: clinical and instrumental approaches. Dev Disabil Res Rev. 2008;14(2):118-27. , 1818 Arvedson JC, Brodsky L. Pediatric swallowing and feeding: assessment and management. 2ª ed. Australia: Singular; 2002. , 2222 Newman LA, Petersen M. Swallowing disorders in the pediatric population. In: Carrau RL, Murry T. Comprehensive management of swallowing disorders. San Diego: Plural Publishing; 2006. p. 347-62. ), and is considered a risk factor for aspiration( 6Lefton-Greif MA. Pediatric dysphagia. Phys Med Rehabil Clin N Am. 2008;19(4):837-51. , 1111 Weir K, McMahon S, Barry L, Masters IB, Chang AB. Clinical signs and symptoms of oropharyngeal aspiration and dysphagia in children. Eur Respir J. 2009;33(3):604-11. , 2323 Friedman B, Frazier JB. Deep laryngeal penetration as a predictor of aspiration. Dysphagia. 2000;15(3):153-8. ).

• Laryngeal aspiration: passage of food below the level of vocal folds, reaching the trachea(2,18,21) due to the delayed onset of pharyngeal swallowing, decreased pharyngeal contraction, or decreased laryngeal closure, and can occur before, during, or after swallowing( 2Arvedson JC. Assessment of pediatric dysphagia and feeding disorders: clinical and instrumental approaches. Dev Disabil Res Rev. 2008;14(2):118-27. , 1818 Arvedson JC, Brodsky L. Pediatric swallowing and feeding: assessment and management. 2ª ed. Australia: Singular; 2002. , 2222 Newman LA, Petersen M. Swallowing disorders in the pediatric population. In: Carrau RL, Murry T. Comprehensive management of swallowing disorders. San Diego: Plural Publishing; 2006. p. 347-62. ).

The evaluation of accuracy and association between CES and videofluoroscopic findings was performed in general and according to the food consistency. The association between CSS and videofluoroscopic findings was assessed according to the food consistency.

Statistical analysis

The accuracy of a diagnostic test is evaluated by comparing its results with those of a gold standard, and checking rightness capacity. In this study, verifying the accuracy of CES using VFSS as gold standard was expressed by sensitivity (fraction of true positives among those presenting changes), specificity (fraction of true negatives among those without changes), positive predictive value (proportion of true positives among those presenting clinical sign), and negative predictive value (proportion of true negatives among those without clinical sign) calculations.

In addition to these proportions, to determine the association between the CES, CSS, and videofluoroscopic findings, the Fisher's exact test and the χ2 test were used. The significance level of 0.05 was adopted.

RESULTS

Within 24 months (January 2011 to December 2013), 85 children were submitted to VFSS; of which, 30 were excluded for not meeting the criteria adopted in this study, totaling 55 subjects (30 males and 25 females). The subjects aged from 1 to 81 months, mean 14 months.

Diagnoses were divided into neurological problems, heart and lung, and others (Chart 1).

Chart 1.
Characterization of the subjects with respect to medical diagnoses

In the evaluations, 14 children (25%) were using alternative feeding route (2 gastrostomy, 2 orogastric tube, and 10 nasogastric tube). No child had tracheostomy. The children were evaluated by CES and VFSS with food consistency appropriate for their age group and according to speech treatments. Thus, among 55 children, 45 were evaluated with thin liquid, 21 with thick liquid, and 18 with homogeneous paste.

Overall, 80% children had CSS suggesting changes in the pharyngeal phase at CES, and changes in the cervical auscultation (49%), cough (35%), choking (35%), oxygen desaturation (33%), and respiratory distress (27%) were the most frequent ones.

In VFSS, 15 children had isolated laryngeal penetration with thin liquid (33%) and 3 with thick liquid (14%). No child had isolated laryngeal penetration with homogeneous paste. Laryngeal aspiration was found in 15 children with thin liquid (33%) and in 5 with thick liquid (24%). Among the cases of laryngeal aspiration, 80% were silent with thin liquid and 100% with thick liquid. Only one child had laryngeal aspiration with homogeneous paste, but did not present CSS at CES with this consistency.

Accuracy of CES presented overall 86% sensitivity, with 95% confidence interval (95%CI 78-94), and 32% specificity (95%CI 15-47), and predictive positive value higher than the negative (Table 1). For isolated laryngeal penetration, CES had 88% sensitivity (95%CI 69-98) (Table 2). In laryngeal aspiration, CES had 86% sensitivity (95%CI 70-96) (Table 3). However, specificity values and positive predictive values of CES were low for both changes (Tables 2 and 3). In addition, there was no significant association between CES and the findings of VFSS, in general (Table 1) and in cases of changes (Tables 2 and 3).

Table 1.
Accuracy of clinical examination of swallowing to detect isolated laryngeal penetration and/or aspiration
Table 2.
Accuracy of clinical examination of swallowing to detect isolated laryngeal penetration
Table 3.
Accuracy of clinical examination of swallowing to detect laryngeal aspiration

When the association between CSS and changes in the pharyngeal phase was verified, choking was the only CSS associated with laryngeal penetration with isolated thin liquid (p=0.044) (Table 4). There was no significant association between CSS and laryngeal aspiration (Table 5).

Table 4.
Association between clinical signs and symptoms and presence of isolated laryngeal penetration in swallowing videofluoroscopy
Table 5.
Association between clinical signs and symptoms and presence of laryngeal aspiration in swallowing videofluoroscopy

In detection of isolated laryngeal penetration with thin liquid, choking had a 53% sensitivity (95%CI 31-73), 77% specificity (95%CI 65-87), 53% positive predictive value (95%CI 31-73) and 77% negative predictive value (95%CI 65-87).

DISCUSSION

We highlighted the importance of conducting studies that compare the clinical evaluation with VFSS and the accuracy of CES in the detection of changes in the pharyngeal phase to contribute with scientific evidence for Speech Language Pathology and Audiology treatment in child dysphagia, once few studies comparing these assessments and verifying the accuracy of CES in children have been made.

In addition, identification of CSS associated with changes in the pharyngeal phase is important to increase the accuracy of clinical assessment and detect such changes because in many cases the professionals must define their actions only based on this evaluation, and accurate diagnosis is essential for an appropriate therapeutic planning.

It is important to note that the subjects in this study formed a heterogeneous group of children with different concomitant health problems, with higher prevalence of respiratory and neurological problems, and history of prematurity. Heterogeneous groups of subjects were also found in other studies of clinical and VFSS in children( 4DeMatteo C, Matovich D, Hjartarson A. Comparison of clinical and videofluoroscopic evaluation of children with feeding and swallowing difficulties. Dev Med Child Neurol. 2005;47(3):149-57. , 1313 Blanco OFS, Aristizábal DS, Pineda AM, Rodríguez MMM, Escobar PA, Ochoa WC, et al. Características clínicas y videofluoroscópicas de la disfagia orofaríngea em niños entre un mes y cinco años de vida. Iatreia. 2008;21(1):13-20. , 2424 Salinas-Valdebenito L, Núñez-Farias AC, Milagros A, Escobar-Henríquez RG. Clinical characterisation and course following therapeutic intervention for swallowing disorders in hospitalised paediatric patients. Rev Neurol. 2010;50(3):139-44. ).

In this study, CES presented overall 86% sensitivity and 32% specificity, which confirms the findings of other studies reporting 80-92% sensitivity and 25-47% specificity for clinical evaluation in the change detection in the pharyngeal phase( 1313 Blanco OFS, Aristizábal DS, Pineda AM, Rodríguez MMM, Escobar PA, Ochoa WC, et al. Características clínicas y videofluoroscópicas de la disfagia orofaríngea em niños entre un mes y cinco años de vida. Iatreia. 2008;21(1):13-20. , 1414 Santos RRD, Sales AVMN, Cola PC, Jorge AG, Peres FM, Furkim AM, et al. Accuracy of clinical swallowing evaluation for oropharyngeal dysphagia in cerebral palsy. Rev CEFAC. 2014;16(1):197-201. ). In addition, they found a positive predictive value higher than the negative, which differs from that of other studies showing similar values for both( 1414 Santos RRD, Sales AVMN, Cola PC, Jorge AG, Peres FM, Furkim AM, et al. Accuracy of clinical swallowing evaluation for oropharyngeal dysphagia in cerebral palsy. Rev CEFAC. 2014;16(1):197-201. ) or the opposite( 1313 Blanco OFS, Aristizábal DS, Pineda AM, Rodríguez MMM, Escobar PA, Ochoa WC, et al. Características clínicas y videofluoroscópicas de la disfagia orofaríngea em niños entre un mes y cinco años de vida. Iatreia. 2008;21(1):13-20. ). These findings showed that the CES properly detected 86% children with changes in the pharyngeal phase of swallowing. However, the high proportion of false positives - children with CSS, but without changes - reduced the assessment specificity.

In CES, for isolated laryngeal aspiration and laryngeal penetration, 88% and 86% sensitivities were observed in this study, respectively. Similarly, another study showed 80% sensitivity for penetration and 92% for suction with liquid( 4DeMatteo C, Matovich D, Hjartarson A. Comparison of clinical and videofluoroscopic evaluation of children with feeding and swallowing difficulties. Dev Med Child Neurol. 2005;47(3):149-57. ). When analyzing the accuracy of CES by type of change in the pharyngeal phase, the specificity values and positive predictive values were low, which corroborates the same study's findings( 4DeMatteo C, Matovich D, Hjartarson A. Comparison of clinical and videofluoroscopic evaluation of children with feeding and swallowing difficulties. Dev Med Child Neurol. 2005;47(3):149-57. ). This may be explained by the high proportion of false positives in the variables analyzed.

Overall, in this study, there was no association between CES and the findings of the VFSS, similar to the findings of the other studies( 9Araujo BCL. Acurácia do diagnostico clínico da disfagia em crianças com paralisia cerebral [dissertação ]. Recife: Universidade Federal de Pernambuco; 2012. , 1313 Blanco OFS, Aristizábal DS, Pineda AM, Rodríguez MMM, Escobar PA, Ochoa WC, et al. Características clínicas y videofluoroscópicas de la disfagia orofaríngea em niños entre un mes y cinco años de vida. Iatreia. 2008;21(1):13-20. ). The same was true when food consistencies were considered separately. In contrast, another study showed a significant association between clinical assessment and penetration and aspiration with liquid (4).

Changes in cervical auscultation, cough, oxygen desaturation, and respiratory distress were frequent CSS in this population. The high prevalence of respiratory problems found in the subjects of our sample (93%) may have influenced the assessment of those signals, which may explain the high proportion of false-positive results and the consequent lack of association between the variables.

With regard to identification of CSS associated with changes in the pharyngeal phase of swallowing, choking was the only one associated with isolated laryngeal penetration with thin liquid in this study. In addition, choking also presented higher specificity compared to sensitivity, and the negative predictive value was higher than the positive to detect that change. Other studies have also shown the same difference values when evaluating the accuracy of other CSS to detect changes in the pharyngeal phase( 1111 Weir K, McMahon S, Barry L, Masters IB, Chang AB. Clinical signs and symptoms of oropharyngeal aspiration and dysphagia in children. Eur Respir J. 2009;33(3):604-11. , 1515 Furkim AM, Duarte ST, Sacco AFB, Sória FS. O uso da ausculta cervical na inferência de aspiração traqueal em crianças com paralisia cerebral. Rev CEFAC. 2009;11(4):624-9. ).

Some authors( 4DeMatteo C, Matovich D, Hjartarson A. Comparison of clinical and videofluoroscopic evaluation of children with feeding and swallowing difficulties. Dev Med Child Neurol. 2005;47(3):149-57. ) have reported cough as the main indicator of thin liquid penetration and aspiration; however, another study( 1111 Weir K, McMahon S, Barry L, Masters IB, Chang AB. Clinical signs and symptoms of oropharyngeal aspiration and dysphagia in children. Eur Respir J. 2009;33(3):604-11. ) questioned this finding because the authors did not define laryngeal penetration and aspiration occurred with the same consistency. Therefore, cough may be related only to suction, not to penetration. This study considered the definition of isolated penetration in accordance with the literature( 1111 Weir K, McMahon S, Barry L, Masters IB, Chang AB. Clinical signs and symptoms of oropharyngeal aspiration and dysphagia in children. Eur Respir J. 2009;33(3):604-11. ), and thus, the association found was not related to other changes in the pharyngeal phase.

The literature reports an association between cough, wet voice and noisy breathing, and thin liquid aspiration( 4DeMatteo C, Matovich D, Hjartarson A. Comparison of clinical and videofluoroscopic evaluation of children with feeding and swallowing difficulties. Dev Med Child Neurol. 2005;47(3):149-57. , 1111 Weir K, McMahon S, Barry L, Masters IB, Chang AB. Clinical signs and symptoms of oropharyngeal aspiration and dysphagia in children. Eur Respir J. 2009;33(3):604-11. ). In contrast, in this study, cough and change in voice quality were not associated with any change in the pharyngeal phase. Furthermore, there was no association between CSS and laryngeal aspiration, which may be due to the high prevalence of silent aspiration found in the subjects of this study, also evidenced by the high proportion of false negatives observed in the CSS analyzed.

Some studies showed a significant relationship between change in cervical auscultation and laryngeal penetration and aspiration in children with neurological disorders( 1010 Marrara JL, Duca AP, Dantas RO, Trawitzki LVV, Lima RAC, Pereira JC. Swallowing in children with neurologic disorders: clinical and videofluoroscopic evaluations. Pro Fono. 2008;20(4):231-6. , 1515 Furkim AM, Duarte ST, Sacco AFB, Sória FS. O uso da ausculta cervical na inferência de aspiração traqueal em crianças com paralisia cerebral. Rev CEFAC. 2009;11(4):624-9. ). In this study, although change in cervical auscultation was the most common clinical sign, it was not associated with the changes in pharyngeal phase found at VFSS. This may be explained by the high prevalence of respiratory problems in the subjects in this study (93%), which may have influenced the assessment of the sign.

These findings showed that the CSS evaluated in this study made CES more accurate to detect changes in the pharyngeal phase, but not CSS alone. However, the high proportion of false positives and the high prevalence of silent aspiration support the importance of complementing CES with objective evaluations, such as VFSS, to identify changes in swallowing properly (1,2,7).

The findings of this study are important for speech therapy clinical practice, as they proved CES to be sensitive to detect changes in the pharyngeal phase. In addition, they stressed the importance of observing the presence of choking with thin liquid in CES, for it has been related to isolated laryngeal penetration. However, the high proportion of false positives found in CES and the high prevalence of silent aspiration at VFSS gave support to the need of complementing CES with objective swallowing evaluation, such as VFSS in children with suspected dysphagia.

Despite the fact that this study was limited for being a retrospective analysis, the use of PAD-PED( 1616 Almeida FCF, Bühler KEB, Limongi SCO. Protocolo de avaliação clínica da disfagia pediátrica (PAD-PED). Barueri: Pró-fono; 2014. 34 p. ), a protocol with definitions and parameters defined based on the literature, it was consistent in the collection of clinical evaluation data. To strengthen the care with which the study was conducted, one can point as bias in data collection the fact that speech therapy clinical evaluations and fluoroscopic study were performed by the same researcher.

Further prospective studies with rigorous methodological design and a larger sample are needed to confirm the results of this research. In this way, there will be more scientific evidence for speech therapy clinical practice regarding child dysphagia.

CONCLUSIONS

CES was sensitive to detect isolated laryngeal penetration and aspiration. However, the high proportion of false positives decreased the specificity assessment.

Choking was the only CSS associated with isolated laryngeal penetration with thin liquid and presented a greater specificity compared to sensitivity to detect this change. There was no association between the CSS and laryngeal aspiration.

We must highlight the importance of complementing CES with an objective evaluation of swallowing, such as VFSS, in children with suspected dysphagia due to the high proportion of false positives observed in CES and to the high prevalence of silent aspiration during the VFSS in this population. In addition, the speech therapist should be aware of the presence of choking in CES with thin liquid because of the possible occurrence of isolated laryngeal penetration.

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  • Study carried out at Hospital Universitário da Universidade de São Paulo - USP - São Paulo (SP), Brazil.
  • *
    LFSM was responsible for study conception and design, initial data analysis and interpretation, and writing and final approval of the paper for submission; KEBB participated in design of data collection tools, revision, and final approval of the paper for submission; SCOL participated in design of data collection tools, coordination and supervision of data collection, critical review, and final approval of the manuscript for submission.

Publication Dates

  • Publication in this collection
    Mar-Apr 2015

History

  • Received
    20 Aug 2014
  • Accepted
    16 Dec 2014
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