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The International Dysphagia Diet Standardisation Initiation is here and being utilized in many facilities.

IDDSI was created to replace the National Dysphagia Diet and to standardize food and liquid consistencies.

I’m sure you have probably been in a number of facilities that interpret Mechanical Soft, Dysphagia Soft, etc a little different than other facilities.   Some facilities allow a number of food items on one diet level that another facility adds into a different level.


IDDSI involves 5 food consistency levels and 5 liquid levels.

So what do these levels mean?

Level 0 (Thin) is a liquid that flows like water.   (Flow test 1 ml or less in the syringe.)

Level 1 (Slightly Thick) Thicker than water, but is not quite Mildly Thick (formerly Nectar Thick).   (Flow test 1-4 ml remains in syringe).   This may include formula or commercially available nutrition drinks such as Boost or Ensure.

Level 2 (Mildly Thick formerly Nectar Thick).   Flows off a spoon but is thicker than water.   Requires increased effort to drink from a straw.   (Flow test 4-8 ml left in the syringe.)

Level 3 (Moderately Thick formerly Honey Thick).  This level takes a moderate effort to drink through a straw, but can be drunk from a cup.   This level can be taken from a spoon, but is too thin for a fork.   (Flow test 8-10 ml left in the syringe.)

Level 4 (Pureed/Extremely Thick formerly Pudding Thick).  Usually can be administered via spoon, however may also be eaten via fork.  Cannot be taken through a straw, usually taken via spoon.   There should be no lumps, requires no chewing and the liquid should not separate.   (Flow Test 10 ml remains in the syringe.)   Spoon tilt test-should fall off the spoon in single spoonful.   Should sit in a mound on top of the spoon/fork with minimal dripping through the fork.

Level 5 (Minced and Moist) Small lumps in the bolus (no larger than 4mm width and 15mm length for adults), can be eaten using spoon or fork.   Liquid should not separate from food.   (Fork test minimal pressure to mash with no blanching of the thumbnail  to white while pressing.)  (Spoon test should fall off the spoon in a cohesive mound with little to none left on the spoon.)

Level 6 (Soft and Bite Sized) Can be eaten with a fork, spoon or chopsticks.   Each piece should be no larger than 15mm.   Chewing is required with this consistency, however biting or cutting is not required.   (Fork test, when a fork is pressed against the food, the thumbnail should blanch or turn white to squash or break apart the food).   (Spoon test pressure from the spoon can cut, squish, mash or break apart the food and it will not return to its shape.)

Level 7 (Easy to Chew) Normal, everyday soft foods.   Size of food is not restricted.   Requires the ability to bite/chew food.   (Fork/Spoon Test food is easily cut with pressure from a fork/spoon, thumbnail blanches or turns white when applying pressure to the food until it smashes, breaks apart or crumbles without resuming its original shape.

Level 7 (Regular) Normal, everyday food.

Transitional Foods (Fork/Spoon test, add 1 ml water, wait 1 minute, when applying pressure on the fork/spoon on the food, thumbnail blanches while applying pressure until the food breaks or smashes.)

Some examples of transitional foods?

Ice chips
Ice cream/Sherbet if assessed as suitable by a Dysphagia specialist
Japanese Dysphagia Training Jelly sliced 1 mm x 15 mm
Wafers (also includes Religious Communion wafer)
Waffle cones used to hold ice cream
Some biscuits/ cookies/ crackers
Some potato crisps – only ones made or formed from mashed potato (e.g. Pringles)
Prawn crisps
Veggie Stix™
Cheeto Puffs™
Rice Puffs™
Baby Mum Mums™
Gerber Graduate Puffs™

For everything you need to know regarding IDDSI, visit the website here.

Do you want easily printable information sheets for each level and testing for each level?    Find that here.

Want samples and examples for testing liquids/foods?   Find that here.

Evidence supporting IDDSI can be found here.

IDDSI documentation has been translated in multiple languages that you can download here.

Available languages:

  • Chinese
  • Farsi
  • French
  • German
  • Greek
  • Italian
  • Norwegian
  • Portuguese
  • Spanish
  • Swahili

Need help with implementation of IDDSI into your facility?   You can download documents here.




Supplementary Notice: Modification of the diagrams or descriptors within the IDDSI Framework is DISCOURAGED and NOT RECOMMENDED. Alterations to elements of the IDDSI framework may lead to confusion and errors in diet texture or drink selection for patients with dysphagia. Such errors have previously been associated with adverse events including choking and death.

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Measuring Outcomes for Success…..What are You Using?

The Dysphagia Toolbox

I have written about the Dysphagia Toolbox before.    The Dysphagia Toolbox used to be a website that offered links to standardized and reliable tools that you can use in dysphagia assessment and with reassessment.  




Why a toolbox?

The one thing I can’t help thinking is why we call it a toolbox.  Do most of you actually carry a toolbox full of your must-have dysphagia assessment/treatment equipment?  Mine is usually jammed in my lab coat pockets or on top of my clipboard, if I remember to even bring that with me!  Although I often imagine SLPs running around with a toolbox.   


Dysphagia Apron?

Maybe saying our dysphagia “apron” would be more appropriate??  Now, I have recently seen the SLP fanny pack, which may also be an option!




Anway, I digress…

 Outcome Measures

There are several outcome measures that are freely available for us to use for your Dysphagia Toolbox.  Outcomes should be taken at baseline, when therapy is initiated and can be used to show progress during reassessment and to show progress for discharge. 

There are questionnaires that the patient completes, indicating current symptoms when eating/drinking including:

  Continue reading Measuring Outcomes for Success…..What are You Using?

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Dysphagia Following Extubation Part 1

When it comes to patients that are intubated, there are a lot of factors to consider.

What is their current diagnosis, why are they intubated, how long were they intubated?   Was intubation traumatic?   Have they self-extubated?

There is a lot of discussion over the timing of the evaluation.   Traditionally, it has been thought that there needs to be a period of 24 hours following extubation to allow for recovery.

This series of posts will break down what the evidence tells us regarding post extubation dysphagia.

Continue reading Dysphagia Following Extubation Part 1

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Respiratory Muscle Strength Training

Inspiratory Muscle Strength Training

 Inspiratory strength training works on the muscles of inspiration the diaphragm, the intercostals. Inspiration involves contractions of the diaphragm and external intercostals, which increase intrathoracic volume and decreased volume in pressure.

 Respiration is a recoil from inspiration. Exhalation involves relaxation of the inhalation muscles, recruitment of abdominal and internal intercostals to force air out of the lungs.

Under Pressure

Pressure Threshold Devices are recommended for RMST. There are devices for Inspiratory Muscle Strength Training (IMST) and for Expiratory Muscle Strength Training (EMST).

For Dysphagia

 In dysphagia, EMST was found not only to increase greater force with the cough, enabling the patient to produce a more productive cough forcing material from the airway, but also was found to increase hyolaryngeal excursion and velar closure.

 EMST is not recommended for those on supplemental oxygen, those with COPD or people with untreated GERD.

 The EMST 150 device is a pressure threshold device with a high number of settings, AND it is the device that was used during the study. The EMST 150 is is found on the here and is relatively inexpensive at $54.95 each.  The patient used the device 5 times, 5 times a day for 5 weeks, using the “Rule of 5.”

When focusing on EMST and IMST in your therapy, you want to find a pressure threshold device to achieve maximum results similar those found in the research as referenced below.  Resistive devices may offer various levels of resistance, or a number of holes/notches which to increase the device.  Resistance can be increased or decreased depending on patient needs and function.  The Pressure Threshold Devices offer more.  Resistive devices are:  Expand-a-Lung, The Breather, PFlex and BreathBuilder.

 RMST is also indicated for voice disorders, bilateral vocal fold paralysis, professional voice users, sedentary elderly, Parkinson’s Disease (PD), Multiple Sclerosis (MS), Huntington’s, Progressive Supranuclear Palsy (PSP), stroke, healthy elderly.  RMST can also be used for ventilator weaning.

Read More 

For more information on RMST please read the following:

 EMST and Parkinson’s Disease


EMST with MS

A large number of articles regarding RMST

EMST Swallowing and PD

 Sapienza, C.M., Davenport, P.W., & Martin, A.D. (2002).  Expiratory muscle training increases pressure support high school band students.  Journal of Voice, 16, 495-501.

 Burkhead, L.M., Sapienza, C.M. & Rosenbek, J.C. (2007).  Strength-Training Exercise in Dysphagia Rehabilitation:  Principles, Procedures and Directions for Future Research.  Dysphagia 22, 251-265.

 Sapienza, C.M. (2008).  Respiratory Muscle Strength Training Applications.  Current Opinion in Otolaryngology & Head and Neck Surgery, 16, 216-220.

 Pitts, T. et al.  (2009).  Impact of Expiratory Muscle Strength Training on Voluntary Cough and Swallow Function in Parkinson’s Disease.  Chest, 135(5), 1301-1308.

 Wheeler-Hegland K.M., Rosenbek J.C. & Sapienza, C.M. (2008).  Submental sEMG and Hyoid Movement During Mendelsohn Maneuver, Effortful Swallow, and Expiratory Muscle Strength Training.  JSLHR 51, 1072-1087.

You can also read more on the EMST 150 Website.

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Modified Barium Swallow Study: Gold Standard or Old News?

The Modified Barium Swallow Study, no matter what name is used, has been considered a gold standard for many years in the assessment of dysphagia.  

Recently there has been a lot of debate about whether the MBSS continues to be the gold standard or if FEES (Flexible Endoscopic Evaluation of Swallowing) has taken the place as the gold standard evaluation.

For some reason, it’s become an either/or world that you only get FEES or you only do MBSS.   This is just absurd!

Both tests can provide valuable information.

The MBSS can give you valuable information (FEES posts coming soon!)  You can visualize the oral cavity as the patient prepares to swallow the bolus.  You can visualize as the bolus passes through the pharynx and hopefully through the esophagus.

You can view the patient laterally, you can use an anterior-posterior view or even an oblique view as needed to gather as much information as possible regarding the swallow.

Communication is key.

As the treating SLP, it is so important to get information to the SLP completing the instrumental assessment regarding patient history, why you are ordering the study and possibly even some information about your tentative treatment plan, current diet level, etc.  Most patients are not able to relay the information the same way an SLP would, if at all.

Are there any strategies you think might be beneficial?

Are there any consistencies you want trialed?  Let the SLP know!!

The SLP completing the MBSS doesn’t quite get off the hook.

As the assessing SLP or the SLP completing the instrumental assessment, it is critical that the treating SLP receive a report they can use to build a treatment plan.  It is impossible to educate a patient on why they are on an altered diet or why they need to use such and such compensation when the SLP is unsure.  The report needs to include compensations trialed and effective or ineffective.  It’s also very difficult to know what consistencies, amounts, etc to use for therapeutic trials if the study was discontinued after one instance of aspiration on a teaspoon of thin.

Remember though, sometimes the report never gets to the treating SLP.   Sometimes they try like crazy to get it, but they are never able to do so.

Download your Communication Guide:

Untitled Design

You won’t get an instrumental assessment if you don’t request it.

Often instrumental assessments are not recommended for a variety of reasons.  Maybe you have sent multiple patients out for an MBSS and the report is not what you need to create a solid treatment protocol.  Maybe the patient refuses or the doctor refuses or the facility refuses.

It is time that we educate physicians, nurses and other medical professionals on the purpose of the MBSS.  Physicians often know or have a good idea that a patient had a stroke.  They still use the CT scan and/or MRI to determine size of stroke, location of stroke and whether the stroke is acute or an old infarct.

We need the same diligence in our field to assess dysphagia beyond just penetration/aspiration and diet selection.  Whether the physician orders the MBSS or the patient participates should be irrelevant to our recommendation for MBSS.  If we believe the MBSS is an important tool to our patient’s care, document and recommend.

Theresa Richard created a great guide for gaining access to instrumental assessment.   The Step-by-Step Guide to Advocating For Access to Instrumentation for Our Patients



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What’s In A Name

Seriously, how many names can we have for one test?

We typically do the same thing…..assess swallowing function, so why a million different names?

In the early days, the swallowing assessment using x-ray was called a Cookie Swallow Test.

You can read more about the history of the MBSS:

untitled design-1

The same test is more recently called:

  • Modified Barium Swallow Study (MBSS)
  • Modified Barium Study (MBS)
  • Videofluoroscopic Swallow Study (VFSS)
  • Swallow Study
  • Rehab Swallow Study

No matter what it is called, the procedure should be the same.  A variety of consistencies will be presented with an SLP assessing the swallow.  Compensatory strategies may be trialed (more to come soon), various presentation methods may be trialed, sensory techniques may be trialed.

No matter what the name, the SLP will be assessing the physiology of the swallow so that an accurate treatment plan can be developed.

What other names have you heard that X-Ray swallow study called?

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For those of you that don’t know what the heck the MBSImP is, it stands for the Modified Barium Swallow Impairment Profile.  What it is, an answer to everyone’s prayers to FINALLY have a standardized method for swallow studies.

Where Can I Find MBSImP

This protocol for MBSS is based on more than 10 years of work and research.    Northern Speech Services is the company that provides the MBSImP training which can be taken wholly or partially online.

The 17 Components

The MBSImP consists of 17 components from labial seal to esophageal clearance.  Each component is scored from 0 to either 3, 4 or 5, with the higher number indicating a worse impairment.  

The Training 

The nice part of the MBSImP is the training slides.  Each MBS frame has a corresponding animation making each component of the swallow easy to see for the training purposes.  The animations are used in the live course and the online module.  With the online module, you go through a training section, a practice section and then a test.  With the test, you have to have 80% reliability on your scoring.  Once you reach the 80% (you can take the test as many times as needed), you become a registered user and have access to a database.  This database allows you to input your patient information, which is de-identified to create a comprehensive report for each swallow study you complete.

 Part of the training is respiration and respiration in relation to swallowing.  One thing we learned is that most people will inhale and partially exhale before swallowing.  When the swallow is complete they will finish the exhalation.  It is important that we as therapists evaluate the respiratory pattern of the patient and take that into account.  One point that was emphasized was to teach an expiratory cough to clear and not cue the patient to inhale then cough.  Also to force “audible” vocal closure, or take a deep breath with an audible “huh”.

How In the Heck Do You Even Administer This Protocol? 

There is a complete outline including instruction to patient, what barium to present, when to present each consistency and how much to present.  This is done in a precise manner, however it was emphasized that you DO NOT HAVE TO FOLLOW THE PROTOCOL.  There will be times that you have to use your clinical judgement.  Now, with the database, Bonnie will have access to all of the inputed data, remember, it is de-identified.  To be a part of her collection of data, she needs to protocol to be standardized, but if it is not necessary or safe to standardize it for your patient, then you do it how you need to do it.

Scoring the MBSImP

With the MBSImP, you score each component with the given scale.  You are working to capture IMPAIRMENT.  This is not focusing on aspiration, penetration or testing every consistency known to man.  This is focusing on the function of the swallow and the dysfunction to create an appropriate therapy plan to rehabilitate the swallow.

This gives you a standardized score for the swallow study by entering all MBSS information and findings into a database, which creates your report.  This score allows you to demonstrate improvement and to focus on more than just penetration/aspiration, diet consistency, pooling, etc.  You focus more on the actual dysfunction.  The decreased tongue base retraction (TBR), the decreased pharyngeal stripping wave, they opening of the Pharyngeal Esophageal Segment (PES).  Dr. Martin-Harris uses PES rather than Upper Esophageal Sphincter (UES).

Thoughts on the MBSImP 

I think that this Profile came at the right time.  More than ever, we as SLP’s need to stand our ground and maintain our status as dysphagia experts.  We are the ones that study this mechanism.  We need to evaluate properly.  A modified should not be merely to determine aspiration or to see if the person if “safe” with thin liquids.  We need to determine dysfunction, rehabilitate the swallow system and re-evaluate to determine improvement of the function.  This will not only create a much nicer and less subjective study (really, what does mild, moderate and severe tell me?)

We don’t treat aspiration, penetration or premature spillage. We treat the dysfunction, the decreased hyoid protraction, the decreased laryngeal elevation.

 I think when we realize that dysphagia is muscle-based function of the body that works as a system, we can effectively diagnose and treat the dysphagia, the dysfunction instead of worrying so much about the actual aspiration or sticking our tongues out 10 times.  Then and only then can we call ourselves a dysphagia expert.

 All-in-all I’m still very excited about this protocol and the direction in which it takes our field.  I have been using this protocol since 2010 and I highly recommend it to all SLPs treating dysphagia, whether you actually are responsible for MBSS or not, you can still learn quite a lot about the swallow function and I believe it will be much easier to interpret the results if you have a therapist that uses the protocol.


Martin-Harris, B., Brodsky, M. B., Michel, Y., Castell, D. O., Schleicher, M., Sandidge, J., … & Blair, J. (2008). MBS measurement tool for swallow impairment—MBSImp: establishing a standard. Dysphagia23(4), 392-405.

Sandidge, J. (2009). The Modified Barium Swallow Impairment Profile (MBSImP): a new standard physiologic approach to swallowing assessment and targeted treatment. Perspectives on Swallowing and Swallowing Disorders (Dysphagia)18(4), 117-122.

Gullung, J. L., Hill, E. G., Castell, D. O., & Martin-Harris, B. (2012). Oropharyngeal and Esophageal Swallowing Impairments: their association and the predictive value of the modified barium swallow impairment profile and combined multichannel intraluminal impedance—esophageal manometry. Annals of Otology, Rhinology & Laryngology121(11), 738-745.

Martin-Harris, B., Humphries, K., & Garand, K. L. (2017). The Modified Barium Swallow Impairment Profile (MBSImP™©)–Innovation, Dissemination and Implementation. Perspectives of the ASHA Special Interest Groups2(13), 129-138.

Martin-Harris, B. (2017). MBSImP™ Web Based Learning Module. Northern Speech Services.

Tran, T. T. A., Martin Harris, B., & Pearson Jr, W. G. (2018). Improvements resulting from respiratory-swallow phase training visualized in patient-specific computational analysis of swallowing mechanics. Computer Methods in Biomechanics and Biomedical Engineering: Imaging & Visualization6(5), 532-538.

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The History of the Modified Barium Swallow Study

No matter what you call it…there is a history behind the Modified Barium Swallow Study (MBSS).

Gold Standard?

The Modified Barium Swallow Study has long been called THE gold standard in dysphagia evaluation, however it does have its limitations.   The MBSS definitely continues to be A gold standard in swallowing evaluation.


Early Days

In the 1970’s, Dr. Jeri Logemann developed the MBSS or the Cookie Swallow Test.  She presented on this test at the ASHA convention in 1976.

During the Cookie Swallow Test, patients were given 2 cc of radiopaque liquid, 2 cc of paste, and 1/4 of a cookie coated with barium.  The liquid barium was given first, then paste, and last,  the cookie.   Patients were recorded with 2 swallows of each consistency.

Dr. Logemann then described liquid/food presentation as 3 swallows each of:

  • 1 ml thin liquid by spoon
  • 3 ml thin liquid by spoon
  • 5 ml liquid by syringe
  • 10 ml liquid by syringe
  • (can give larger amounts also)
  • Cup drinks
  • Saliva Swallow (no barium, just watch muscles move with swallow)
  • Pudding with barium (1/3 tsp or 1 ml of 2 parts pudding to 1 part barium)
  • Other food textures mixed with barium

Linden and Siebens,  developed a new approach to the VFSS which was based on patient specific deficits.  They used representative radiopaque foods similar to those the patient ordinarily ate.   The  study started with the food which would be safest for the patient to swallow, as determined by the SLP.  The study then progressed to increasingly difficult foods/liquids ending with those the patient was most likely to aspirate. Compensatory maneuvers (such as modifications of feeding or positioning) were tested  as a basis for developing recommendations for diet and treatment.

Standardized MBSS

Dr. Bonnie Martin Harris recently developed the Modified Barium Swallow Impairment Profile (MBSImP) which is the first standardized assessment of the MBSS.  (More on that to come!)

The Study

The MBSS consists of the patient, usually seated in a special seat, having an X-ray study, examining the oropharyngeal cavity.  The patient is given a variety of liquids and food, all mixed with barium as the barium can be viewed during the real-time video of the study.

The study is typically (should be) recorded for review of the test later.   The video can be slowed down for more accurate view of the swallowing structures.

Often, the MBSS is started and once the patient aspirates on the first consistency, the exam is discontinued.  This should not be the case as modifications can be made to:

  • amount presented
  • method of presentation
  • posture
  • position of head when swallowing
  • texture
  • temperature
  • taste

Although at one point, most SLP’s were completing the MBSS study to determine penetration/aspiration and what the best diet consistency is for the patient to safely consume, we now know better.

The MBSS is a test that allows us to view the oropharyngeal structure from the side (lateral) and from the front (A-P view) to determine the physiology of the swallow, meaning that we determine what muscles are moving and how.

Although we may test a wide variety of consistencies, thin liquid, nectar thick (mildly thick), honey thick (moderately thick) liquids, pureed, mixed consistencies, soft foods and regular foods, there is no way for us to possibly test every single consistency the person may consume.

But Why MBSS?

That is why it is important to look beyond penetration and aspiration and to look at the physiology of the swallow including what is functional and what is not.   This is what leads us to accurate diagnosis and treatment planning for patients.

More to come on the MBSS!


Logemann JA. Manual for the videofluorographic study of swallowing. 2nd ed. ProEd; Austin, TX: 1993.

Logemann JA. Evaluation and treatment of swallowing disorders. ProEd; Austin, TX: 1998.

Martin-Harris, B., Brodsky, M. B., Michel, Y., Castell, D. O., Schleicher, M., Sandidge, J., … & Blair, J. (2008). MBS measurement tool for swallow impairment—MBSImp: establishing a standard. Dysphagia23(4), 392-405.

Linden PL, Siebens AA: Dysphagia: predicting laryngeal penetration. Arch Phys Med Rehab 64:281-284, 1983.

Siebens AA, Linden PL: Dynamic imaging for swallowing reeducation. GastrointestRadio110:251-253, 1985.

Linden P: Videofluoroscopy in the rehabilitation of swallowing dysfunction. Dysphagia 3:189-191, 1989.

Palmer, J. B., Kuhlemeier, K. V., Tippett, D. C., & Lynch, C. (1993). A protocol for the videofluorographic swallowing study. Dysphagia8(3), 209-214.

Martin-Harris, B., Brodsky, M. B., Michel, Y., Castell, D. O., Schleicher, M., Sandidge, J., … & Blair, J. (2008). MBS measurement tool for swallow impairment—MBSImp: establishing a standard. Dysphagia23(4), 392-405.

Martin-Harris, B., Logemann, J. A., McMahon, S., Schleicher, M., & Sandidge, J. (2000). Clinical utility of the modified barium swallow. Dysphagia15(3), 136-141.

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Laryngeal Palpation


Why Are You Strangling the Patient?

Relax…..  You may walk in to observe a Clinical Swallow Evaluation and see an SLP with 3 fingers on a patient’s neck as the patient is swallowing.

What in the World are they Doing??

It’s called laryngeal palpation.   The ring finger goes on the patient’s cricoid notch, the middle finger is on the Adam’s Apple and the index finger is on the hyoid bone.  As the patient swallows, the SLP “feels” the hyolaryngeal movement and judges the speech of elevation.

What in the Heck is Hyolaryngeal ExWhatsion?

There are many factors to examine during hyolaryngeal excursion.   Hyoid “burst”, superior and anterior excursion of the hyolaryngeal complex.   Many of these key factors have to be viewed during MBSS using frame by frame imaging to determine amount of hyolaryngeal excursion.

The Evidence

One study (Brates, et al 2019) examined 87 patients through laryngeal palpation and Modified Barium Swallow Study to examine Hyolaryngeal Excursion (HE).   In 16 of the patients, HE was thought to be normal at bedside, but was found to be reduced during MBSS.   17 of the patients were thought to have reduced HE at bedside, but found to have normal HE during MBSS.   29 patients were judged to have normal HE at both bedside and during MBSS.

Te authors also stated that “Perceptual judgment is typically used in clinical settings to assess adequacy of hyolaryngeal excursion (HE), though the validity of perceptual techniques for assessing this physiologic component of swallowing has not been established.”

(McCullough and Martino 2003)  “The larynx should be palpated for timing and completeness of the swallow, as well as the number of swallows.” Poor laryngeal elevation on palpation can be an indicator of reduced laryngeal elevation or closure, particularly when combined with coughing or wet voice.

Bretan and Henry 1997 assessed 14 dysphagic patients and a group with normal swallows by palpating both to determine deviance of the dysphagic group.  They found that direct measurement and palpation of laryngeal mobility during swallowing tasks is noninvasive and can be used to evaluate dysphagia and the risk for aspiration as well as to physically monitor progression of dysphagia.

But Can You See It?

Palpation can be a part of your Clinical Swallow Evaluation, however remember that to truly understand hyolaryngeal excursion, you need to be able to visualize the movement of the structures.


Brates, D., Molfenter, S. M., & Thibeault, S. L. (2019). Assessing hyolaryngeal excursion: comparing quantitative methods to palpation at the bedside and visualization during videofluoroscopy. Dysphagia34(3), 298-307.

McCullough, G. H., & Martino, R. (2013). Clinical evaluation of patients with dysphagia: Importance of history taking and physical exam. In Manual of diagnostic and therapeutic techniques for disorders of deglutition (pp. 11-30). Springer, New York, NY.

Bretan, O., & Henry, M. A. (1997). Laryngeal mobility and dysphagia. Arquivos de gastroenterologia34(3), 134-138.