Sounding “Wet” As a Diagnostic Indicator of Aspiration By: Lena Ellison Wayne State University

Introduction  Bedside swallow examination is a screening measure to detect a patient’s candidacy for a videofluroscopic evaluation  It determines which textures are safe for the patient to swallow  Used to monitor progress of therapy and to determine the possibility of upgrading recommendations

Introduction  Part of the bedside swallow examination is the three-ounce water test, which assesses vocal quality as a diagnostic indictor for aspiration

Three-Ounce Water Test  Patient drinks 3oz of water without interruption  SLP attempts to identify aspiration by noting throat clearing, coughing, or change in vocal quality immediately and one minute after the swallow  If none of these symptoms are present a normal diet is recommended.

Reliability of the three-ounce water test  Various studies have yielded contradicting results  DePippo, Holas, & Reding (1992) conducted a study comparing the three-ounce water test to the Modified Barium Swallow (MBS) Examination  Results indicated that the 3oz water test had a sensitivity of 76% and a specificity of 59%  According to this study the 3oz water test is sensitive enough to serve as a screening tool to indicate which patients require further examination

Reliability of the three-ounce water test  A study by Suiter & Leder (2006) compared the 3oz water test to the Fiberoptic Endoscopic Evaluation of Swallowing (FEES).  Results  Sensitivity of 3oz water test: 96.5%  Specificity of 3oz water test: 48.7%  Patients would be referred for an instrumental swallow evaluation unnecessarily

Reliability of three-ounce water test  Both studies agree that the 3oz water test should be used alone as a diagnostic tool.  One main reason is that assessment of vocal quality is generally a criterion-based measure

Vocal Quality Assessment  The term “wet” can be described as gurgly or liquid sounding and is due to the voice being produced through moisture  Ratings are based on listener’s standards, experience, type of rating scale, and the voice sample being evaluated  When a patient has a “wet” vocal quality, they are generally referred for an instrumental swallowing examination.  Researchers have differing opinions regarding the perception of a “wet” vocal quality as a diagnostic indicator for aspiration.

Sounding “wet” as an indicator for aspiration  Weir, McMahon, Masters, & Chang (2009) conducted a study, which assessed diagnostic values of various signs and symptoms in predicting oropharyngeal aspiration in children  Results indicated that a “wet” voice was associated with aspiration on thin liquids  Overall, “wet” vocal quality yielded a 67% sensitivity and 92% specificity in predicting oropharyngeal aspiration in children

Sounding “Wet” as an Indicator for Aspiration  Irwin (2006) conducted a study, which assessed clinician’s perception of “wet” vocal quality compared to the results of the videofluoroscopic swallowing study.  She determined that clinicians are more likely to identify a voice as sounding “wet” in patients with a high amount of material on their vocal folds.

Sounding “Wet” as an indicator for Aspiration  Goves-Wright, Boyce & Kelchner (2010) compared the results of the videofluoroscopic swallow study to 5 clinician’s perceptual judgment of “wet” vocal quality in 78 patients.  High degree of interrater variability for perceptual judgments of wetness  Could be due to lack of perceptual criteria for “wet” vocal quality

Sounding “Wet” as an Indicator of Aspiration  Goves-Wright, Boyce & Kelchner (2010) continued  Authors suggest a range of perceptual consequences when material is vibrating in the larynx  Material in the larynx may disrupt periodic vocal fold vibration without affecting the phonatory airstream, which could result in the patient’s voice sounding like noise  Authors suggest that raters change their judgment from “wet” and “not wet” to “normal and “abnormal”  Further research is necessary in order to assess the reliability of this rating system

Conclusion  Noninvasive assessments of dysphagia, such as the 3oz water test are crucial in detecting aspiration  Instrumental procedures are not always readily available  It is not practical to expose patients to instrumental procedures on a regular basis due to availability and high amounts of radiation exposure

Conclusion  Data suggests that clinicians can perceive wetness when a sufficient amount of material is present in the larynx.  In those cases, instrumental evaluations are necessary.

Conclusion  Further research needs to be conducted to increase reliability of the perception of “wet” vocal quality  One suggestion: replace listener’s internal representations for “wet” vocal quality with “reference voices,” which correspond to different vocal qualities.  By training clinicians to use the same “reference voices” interrater variability will likely be reduced.

References  Beckstrom, L. & Hanson, S.K. (2008). Swallow screen [PowerPoint slides]. Retrieved from  DePippo, Kathleen L., Marlene A. Holas, and Michael J. Reding. "Validation of the 3-oz water swallow test for aspiration following stroke." Archives of Neurology 49 Dec. (1992): Print.  González-Fernádez, M., Sein, M. T., & Palmer, J. B. (2011, November). Clinical experience using the Mann assessment of swallowing ability for identification of patients at risk for aspiration in a mixed-disease population. American Journal of Speech-Language Pathology, 20,  Groves-Wright, K. J., Boyce, S., & Kelchner, L. (2010, June). Perception of wet vocal quality in identifying penetration/aspiration during swallowing. American Speech-Language Hearing Association, 53,  Irwin, L. (2006). Perceptual evaluation of voice quality with dysphagia and dysphonia (Master's thesis).  Langmore, S., Schatz, K., & Olson, N. (1991). Endoscopic and videofluoroscopic evaluations of swallowing and aspiration. Annals of Otology, Rhinology, and Laryngology, 100,  Oates, J. (2009, February 10). Auditory-perceptual evaluation of disordered voice quality. Folia Phoniatrica et Logopaedica, 61,

References  Rosenbek, J. C., Robbins, J., Roecker, E. B., Coyle, J. L., & Wood, J. L. (1996). A penetration- aspiration scale. Dysphagia, 11,  Suiter, D. & Leder, S. (2006, September). Can the 3 ounce water swallow test screen for aspiration?  Swigert, N. B. (2009, May 26). Hot topics in dysphagia. The ASHA Leader.  Warms, T., & Richards, J. (2000). "Wet voice" as a predictor of penetration and aspiration in oropharngeal dysphagia. Dysphagia, 15,  Weir, K., McMahon, S., Barry, L., Masters, I. B., & Chang, A. B. (2009). Clinical signs and symptoms of oropharyngeal aspiration and dysphagia in children. European Respiratory Journal, 33(3),