Skip to main content
Top
Published in: Dysphagia 3/2014

Open Access 01-06-2014 | Original Article

Physiological Factors Related to Aspiration Risk: A Systematic Review

Authors: Catriona M. Steele, Julie A. Y. Cichero

Published in: Dysphagia | Issue 3/2014

Login to get access

Abstract

Penetration–aspiration is considered the most serious component of oropharyngeal dysphagia. Clinicians regularly evaluate the pathophysiology of swallowing and postulate reasons or mechanisms behind penetration–aspiration. In this article we share the results of a two-stage literature review designed to elucidate the association between abnormalities in physiological measures of swallowing function and the occurrence of penetration–aspiration. In the first stage, a broad scoping review was undertaken using search terms for nine different structures involved in oropharyngeal swallowing. In the second stage, based on the results of the initial search, a more focused systematic review was undertaken which explored the association between aspiration and abnormalities in respiratory, tongue, hyoid, and laryngeal function in swallowing. A total of 37 articles underwent detailed quality review and data extraction in the systematic review. The results support measurement of tongue strength, anatomically normalized measures of hyoid movement, bolus dwell time in the pharynx while the larynx remains open, respiratory rate, and respiratory swallow phasing as parameters relevant to aspiration risk.
Literature
1.
go back to reference Daggett A, Logemann J, Rademaker A, Pauloski B. Laryngeal penetration during deglutition in normal subjects of various ages. Dysphagia. 2006;21:270–4.PubMedCrossRef Daggett A, Logemann J, Rademaker A, Pauloski B. Laryngeal penetration during deglutition in normal subjects of various ages. Dysphagia. 2006;21:270–4.PubMedCrossRef
2.
go back to reference Daniels SK, Corey DM, Hadskey LD, Legendre C, Priestly DH, Rosenbek JC, Foundas AL. Mechanism of sequential swallowing during straw drinking in healthy young and older adults. J Speech Lang Hear Res. 2004;47:33–45.PubMedCrossRef Daniels SK, Corey DM, Hadskey LD, Legendre C, Priestly DH, Rosenbek JC, Foundas AL. Mechanism of sequential swallowing during straw drinking in healthy young and older adults. J Speech Lang Hear Res. 2004;47:33–45.PubMedCrossRef
3.
go back to reference Leslie P, Drinnan MJ, Ford GA, Wilson JA. Resting respiration in dysphagic patients following acute stroke. Dysphagia. 2002;17:208–13.PubMedCrossRef Leslie P, Drinnan MJ, Ford GA, Wilson JA. Resting respiration in dysphagic patients following acute stroke. Dysphagia. 2002;17:208–13.PubMedCrossRef
4.
go back to reference Morton R, Minford J, Ellis R, Pinnington L. Aspiration with dysphagia: the interaction between oropharyngeal and respiratory impairments. Dysphagia. 2002;17:192–6.PubMedCrossRef Morton R, Minford J, Ellis R, Pinnington L. Aspiration with dysphagia: the interaction between oropharyngeal and respiratory impairments. Dysphagia. 2002;17:192–6.PubMedCrossRef
5.
go back to reference Sellars C, Dunnet C, Carter R. A preliminary comparison of videofluoroscopy of swallow and pulse oximetry in the identification of aspiration in dysphagic patients. Dysphagia. 1998;13:82–6.PubMedCrossRef Sellars C, Dunnet C, Carter R. A preliminary comparison of videofluoroscopy of swallow and pulse oximetry in the identification of aspiration in dysphagic patients. Dysphagia. 1998;13:82–6.PubMedCrossRef
6.
go back to reference Sherman B, Nisenboum JM, Jesberger BL, Morrow CA, Jesberger JA. Assessment of dysphagia with the use of pulse oximetry. Dysphagia. 1999;14:152–6.PubMedCrossRef Sherman B, Nisenboum JM, Jesberger BL, Morrow CA, Jesberger JA. Assessment of dysphagia with the use of pulse oximetry. Dysphagia. 1999;14:152–6.PubMedCrossRef
7.
go back to reference Smith HA, Lee SH, O’Neill PA, Connolly MJ. The combination of bedside swallowing assessment and oxygen saturation monitoring of swallowing in acute stroke: a safe and humane screening tool. Age Ageing. 2000;29:495–9.PubMedCrossRef Smith HA, Lee SH, O’Neill PA, Connolly MJ. The combination of bedside swallowing assessment and oxygen saturation monitoring of swallowing in acute stroke: a safe and humane screening tool. Age Ageing. 2000;29:495–9.PubMedCrossRef
8.
go back to reference Zaidi NH, Smith HA, King SC, Park C, O’Neill PA, Connolly MJ. Oxygen desaturation on swallowing as a potential marker of aspiration in acute stroke. Age Ageing. 1995;24:267–70.PubMedCrossRef Zaidi NH, Smith HA, King SC, Park C, O’Neill PA, Connolly MJ. Oxygen desaturation on swallowing as a potential marker of aspiration in acute stroke. Age Ageing. 1995;24:267–70.PubMedCrossRef
9.
go back to reference Gross RD, Atwood CW Jr, Grayhack JP, Shaiman S. Lung volume effects on pharyngeal swallowing physiology. J Appl Physiol. 2003;95:2211–7.PubMed Gross RD, Atwood CW Jr, Grayhack JP, Shaiman S. Lung volume effects on pharyngeal swallowing physiology. J Appl Physiol. 2003;95:2211–7.PubMed
10.
go back to reference Brodsky MB, McFarland DH, Dozier TS, Blair J, Ayers C, Michel Y, Gillespie MB, Day TA, Martin-Harris B. Respiratory-swallow phase patterns and their relationship to swallowing impairment in patients treated for oropharyngeal cancer. Head Neck. 2010;32:481–9.PubMedCentralPubMed Brodsky MB, McFarland DH, Dozier TS, Blair J, Ayers C, Michel Y, Gillespie MB, Day TA, Martin-Harris B. Respiratory-swallow phase patterns and their relationship to swallowing impairment in patients treated for oropharyngeal cancer. Head Neck. 2010;32:481–9.PubMedCentralPubMed
11.
go back to reference Butler SG, Stuart A, Pressman H, Poage G, Roche WJ. Preliminary investigation of swallowing apnea duration and swallow/respiratory phase relationships in individuals with cerebral vascular accident. Dysphagia. 2007;22:215–24.PubMedCrossRef Butler SG, Stuart A, Pressman H, Poage G, Roche WJ. Preliminary investigation of swallowing apnea duration and swallow/respiratory phase relationships in individuals with cerebral vascular accident. Dysphagia. 2007;22:215–24.PubMedCrossRef
12.
go back to reference Nilsson H, Ekberg O, Bulow M, Hindfelt B. Assessment of respiration during video fluoroscopy of dysphagic patients. Acad Radiol. 1997;4:503–7.PubMedCrossRef Nilsson H, Ekberg O, Bulow M, Hindfelt B. Assessment of respiration during video fluoroscopy of dysphagic patients. Acad Radiol. 1997;4:503–7.PubMedCrossRef
13.
go back to reference Robbins J, Kays SA, Gangnon RE, Hind JA, Hewitt AL, Gentry LR, Taylor AJ. The effects of lingual exercise in stroke patients with dysphagia. Arch Phys Med Rehabil. 2007;88:150–8.PubMedCrossRef Robbins J, Kays SA, Gangnon RE, Hind JA, Hewitt AL, Gentry LR, Taylor AJ. The effects of lingual exercise in stroke patients with dysphagia. Arch Phys Med Rehabil. 2007;88:150–8.PubMedCrossRef
14.
go back to reference Stierwalt JA, Youmans SR. Tongue measures in individuals with normal and impaired swallowing. Am J Speech Lang Pathol. 2007;16:148–56.PubMedCrossRef Stierwalt JA, Youmans SR. Tongue measures in individuals with normal and impaired swallowing. Am J Speech Lang Pathol. 2007;16:148–56.PubMedCrossRef
15.
go back to reference Fujiu M, Logemann JA. Effect of a tongue-holding maneuver on posterior pharyngeal wall movement during deglutition. Am J Speech Lang Pathol. 1996;5:23–30. Fujiu M, Logemann JA. Effect of a tongue-holding maneuver on posterior pharyngeal wall movement during deglutition. Am J Speech Lang Pathol. 1996;5:23–30.
16.
go back to reference Pouderoux P, Kahrilas PJ. Deglutitive tongue force modulation by volition, volume, and viscosity in humans. Gastroenterology. 1995;108:1418–26.PubMedCrossRef Pouderoux P, Kahrilas PJ. Deglutitive tongue force modulation by volition, volume, and viscosity in humans. Gastroenterology. 1995;108:1418–26.PubMedCrossRef
17.
go back to reference Steele CM, Bailey GL, Molfenter SM. Tongue pressure modulation during swallowing: water versus nectar-thick liquids. J Speech Lang Hear Res. 2010;53:273–83.PubMedCrossRef Steele CM, Bailey GL, Molfenter SM. Tongue pressure modulation during swallowing: water versus nectar-thick liquids. J Speech Lang Hear Res. 2010;53:273–83.PubMedCrossRef
18.
go back to reference Perlman AL, Vandaele DJ, Otterbacher MS. Quantitative assessment of hyoid bone displacement from video images during swallowing. J Speech Hear Res. 1995;38:579–85.PubMed Perlman AL, Vandaele DJ, Otterbacher MS. Quantitative assessment of hyoid bone displacement from video images during swallowing. J Speech Hear Res. 1995;38:579–85.PubMed
19.
go back to reference Steele CM, Bailey GL, Chau T, Molfenter SM, Oshalla M, Waito AA, Zoratto DC. The relationship between hyoid and laryngeal displacement and swallowing impairment. Clin Otolaryngol. 2011;36:30–6.PubMedCentralPubMedCrossRef Steele CM, Bailey GL, Chau T, Molfenter SM, Oshalla M, Waito AA, Zoratto DC. The relationship between hyoid and laryngeal displacement and swallowing impairment. Clin Otolaryngol. 2011;36:30–6.PubMedCentralPubMedCrossRef
20.
go back to reference Wheeler KM, Chiara T, Sapienza CM. Surface electromyographic activity of the submental muscles during swallow and expiratory pressure threshold training tasks. Dysphagia. 2007;22:108–16.PubMedCrossRef Wheeler KM, Chiara T, Sapienza CM. Surface electromyographic activity of the submental muscles during swallow and expiratory pressure threshold training tasks. Dysphagia. 2007;22:108–16.PubMedCrossRef
21.
go back to reference Crary MA, Carnaby Mann GD, Groher ME. Biomechanical correlates of surface electromyography signals obtained during swallowing by healthy adults. J Speech Lang Hear Res. 2006;49:186–93.PubMedCrossRef Crary MA, Carnaby Mann GD, Groher ME. Biomechanical correlates of surface electromyography signals obtained during swallowing by healthy adults. J Speech Lang Hear Res. 2006;49:186–93.PubMedCrossRef
22.
go back to reference Aviv JE, Sacco RL, Mohr JP, Thompson JL, Levin B, Sunshine S, Thomson J, Close LG. Laryngopharyngeal sensory testing with modified barium swallow as predictors of aspiration pneumonia after stroke. Laryngoscope. 1997;107:1254–60.PubMedCrossRef Aviv JE, Sacco RL, Mohr JP, Thompson JL, Levin B, Sunshine S, Thomson J, Close LG. Laryngopharyngeal sensory testing with modified barium swallow as predictors of aspiration pneumonia after stroke. Laryngoscope. 1997;107:1254–60.PubMedCrossRef
23.
go back to reference Setzen M, Cohen MA, Perlman PW, Belafsky PC, Guss J, Mattucci KF, Ditkoff M. The association between laryngopharyngeal sensory deficits, pharyngeal motor function, and the prevalence of aspiration with thin liquids. Otolaryngol Head Neck Surg. 2003;128:99–102.PubMedCrossRef Setzen M, Cohen MA, Perlman PW, Belafsky PC, Guss J, Mattucci KF, Ditkoff M. The association between laryngopharyngeal sensory deficits, pharyngeal motor function, and the prevalence of aspiration with thin liquids. Otolaryngol Head Neck Surg. 2003;128:99–102.PubMedCrossRef
24.
go back to reference Jafari S, Prince RA, Kim DY, Paydarfar D. Sensory regulation of swallowing and airway protection: a role for the internal superior laryngeal nerve in humans. J Physiol. 2003;550:287–304.PubMedCentralPubMedCrossRef Jafari S, Prince RA, Kim DY, Paydarfar D. Sensory regulation of swallowing and airway protection: a role for the internal superior laryngeal nerve in humans. J Physiol. 2003;550:287–304.PubMedCentralPubMedCrossRef
25.
go back to reference Sulica L, Hembree A, Blitzer A. Swallowing and sensation: evaluation of deglutition in the anesthetized larynx. Ann Otol Rhinol Laryngol. 2002;111:291–4.PubMed Sulica L, Hembree A, Blitzer A. Swallowing and sensation: evaluation of deglutition in the anesthetized larynx. Ann Otol Rhinol Laryngol. 2002;111:291–4.PubMed
26.
go back to reference Aviv JE, Spitzer J, Cohen M, Ma G, Belafsky P, Close LG. Laryngeal adductor reflex and pharyngeal squeeze as predictors of laryngeal penetration and aspiration. Laryngoscope. 2002;112:338–41.PubMedCrossRef Aviv JE, Spitzer J, Cohen M, Ma G, Belafsky P, Close LG. Laryngeal adductor reflex and pharyngeal squeeze as predictors of laryngeal penetration and aspiration. Laryngoscope. 2002;112:338–41.PubMedCrossRef
27.
go back to reference Yip H, Leonard R, Belafsky PC. Can a fluoroscopic estimation of pharyngeal constriction predict aspiration? Otolaryngol Head Neck Surg. 2006;135:215–7.PubMedCrossRef Yip H, Leonard R, Belafsky PC. Can a fluoroscopic estimation of pharyngeal constriction predict aspiration? Otolaryngol Head Neck Surg. 2006;135:215–7.PubMedCrossRef
28.
go back to reference Kuhl V, Eicke BM, Dieterich M, Urban PP. Sonographic analysis of laryngeal elevation during swallowing. J Neurol. 2003;250:333–7.PubMedCrossRef Kuhl V, Eicke BM, Dieterich M, Urban PP. Sonographic analysis of laryngeal elevation during swallowing. J Neurol. 2003;250:333–7.PubMedCrossRef
29.
go back to reference Power ML, Hamdy S, Goulermas JY, Tyrrell PJ, Turnbull I, Thompson DG. Predicting aspiration after hemispheric stroke from timing measures of oropharyngeal bolus flow and laryngeal closure. Dysphagia. 2009;24:257–64.PubMedCrossRef Power ML, Hamdy S, Goulermas JY, Tyrrell PJ, Turnbull I, Thompson DG. Predicting aspiration after hemispheric stroke from timing measures of oropharyngeal bolus flow and laryngeal closure. Dysphagia. 2009;24:257–64.PubMedCrossRef
30.
go back to reference Leslie P, Drinnan MJ, Ford GA, Wilson JA. Swallow respiration patterns in dysphagic patients following acute stroke. Dysphagia. 2002;17:202–7.PubMedCrossRef Leslie P, Drinnan MJ, Ford GA, Wilson JA. Swallow respiration patterns in dysphagic patients following acute stroke. Dysphagia. 2002;17:202–7.PubMedCrossRef
31.
go back to reference National Health and Medical Research Council of Australia. How to use the evidence: assessment and application of scientific evidence. Canberra: Biotext; 2000. National Health and Medical Research Council of Australia. How to use the evidence: assessment and application of scientific evidence. Canberra: Biotext; 2000.
32.
go back to reference Whiting P, Rutjes AW, Reitsma JB, Bossuyt PM, Kleijnen J. The development of QUADAS: a tool for the quality assessment of studies of diagnostic accuracy included in systematic reviews. BMC Med Res Methodol. 2003;3:25.PubMedCentralPubMedCrossRef Whiting P, Rutjes AW, Reitsma JB, Bossuyt PM, Kleijnen J. The development of QUADAS: a tool for the quality assessment of studies of diagnostic accuracy included in systematic reviews. BMC Med Res Methodol. 2003;3:25.PubMedCentralPubMedCrossRef
33.
go back to reference Whiting PF, Rutjes AW, Westwood ME, Mallett S, Deeks JJ, Reitsma JB, Leeflang MM, Sterne JA, Bossuyt PM. QUADAS-2 Group. QUADAS-2: a revised tool for the quality assessment of diagnostic accuracy studies. Ann Intern Med. 2011;155:529–36.PubMedCrossRef Whiting PF, Rutjes AW, Westwood ME, Mallett S, Deeks JJ, Reitsma JB, Leeflang MM, Sterne JA, Bossuyt PM. QUADAS-2 Group. QUADAS-2: a revised tool for the quality assessment of diagnostic accuracy studies. Ann Intern Med. 2011;155:529–36.PubMedCrossRef
34.
go back to reference Butler SG, Stuart A, Leng X, Wilhelm E, Rees C, Williamson J, Kritchevsky SB. The relationship of aspiration status with tongue and handgrip strength in healthy older adults. J Gerontol A Biol Sci Med Sci. 2011;66:452–8.PubMedCrossRef Butler SG, Stuart A, Leng X, Wilhelm E, Rees C, Williamson J, Kritchevsky SB. The relationship of aspiration status with tongue and handgrip strength in healthy older adults. J Gerontol A Biol Sci Med Sci. 2011;66:452–8.PubMedCrossRef
35.
go back to reference Singh V, Berry S, Brockbank MJ, Frost RA, Tyler SE, Owens D. Investigation of aspiration: milk nasendoscopy versus videofluoroscopy. Eur Arch Otorhinolaryngol. 2009;266(4):543–5.PubMedCrossRef Singh V, Berry S, Brockbank MJ, Frost RA, Tyler SE, Owens D. Investigation of aspiration: milk nasendoscopy versus videofluoroscopy. Eur Arch Otorhinolaryngol. 2009;266(4):543–5.PubMedCrossRef
36.
go back to reference Rosenbek JC, Robbins JA, Roecker EB, Coyle JL, Wood JL. A penetration-aspiration scale. Dysphagia. 1996;11:93–8.PubMedCrossRef Rosenbek JC, Robbins JA, Roecker EB, Coyle JL, Wood JL. A penetration-aspiration scale. Dysphagia. 1996;11:93–8.PubMedCrossRef
37.
go back to reference Oommen ER, Kim Y, McCullough G. Stage transition and laryngeal closure in poststroke patients with dysphagia. Dysphagia. 2011;26:318–23.PubMedCrossRef Oommen ER, Kim Y, McCullough G. Stage transition and laryngeal closure in poststroke patients with dysphagia. Dysphagia. 2011;26:318–23.PubMedCrossRef
38.
go back to reference Park T, Kim Y, Ko DH, McCullough G. Initiation and duration of laryngeal closure during the pharyngeal swallow in post-stroke patients. Dysphagia. 2010;25:177–82.PubMedCrossRef Park T, Kim Y, Ko DH, McCullough G. Initiation and duration of laryngeal closure during the pharyngeal swallow in post-stroke patients. Dysphagia. 2010;25:177–82.PubMedCrossRef
39.
go back to reference Power ML, Hamdy S, Singh S, Tyrrell PJ, Turnbull I, Thompson DG. Deglutitive laryngeal closure in stroke patients. J Neurol Neurosurg Psychiatry. 2007;78:141–6.PubMedCentralPubMedCrossRef Power ML, Hamdy S, Singh S, Tyrrell PJ, Turnbull I, Thompson DG. Deglutitive laryngeal closure in stroke patients. J Neurol Neurosurg Psychiatry. 2007;78:141–6.PubMedCentralPubMedCrossRef
40.
go back to reference Cvejic L, Harding R, Churchward T, Turton A, Finlay P, Massey D, Bardin PG, Guy P. Laryngeal penetration and aspiration in individuals with stable COPD. Respirology. 2011;16:269–75.PubMedCrossRef Cvejic L, Harding R, Churchward T, Turton A, Finlay P, Massey D, Bardin PG, Guy P. Laryngeal penetration and aspiration in individuals with stable COPD. Respirology. 2011;16:269–75.PubMedCrossRef
41.
go back to reference Goeleven A, Robberecht W, Sonies B, Carbonez A, Dejaeger E. Manofluorographic evaluation of swallowing in amyotrophic lateral sclerosis and its relationship with clinical evaluation of swallowing. Amyotroph Lateral Scler. 2006;7:235–40.PubMedCrossRef Goeleven A, Robberecht W, Sonies B, Carbonez A, Dejaeger E. Manofluorographic evaluation of swallowing in amyotrophic lateral sclerosis and its relationship with clinical evaluation of swallowing. Amyotroph Lateral Scler. 2006;7:235–40.PubMedCrossRef
42.
go back to reference Rofes L, Arreola V, Romea M, Palomera E, Almirall J, Cabre M, Serra-Prat M, Clave P. Pathophysiology of oropharyngeal dysphagia in the frail elderly. Neurogastroenterol Motil. 2010;22(851–8):e230. Rofes L, Arreola V, Romea M, Palomera E, Almirall J, Cabre M, Serra-Prat M, Clave P. Pathophysiology of oropharyngeal dysphagia in the frail elderly. Neurogastroenterol Motil. 2010;22(851–8):e230.
43.
44.
go back to reference Leonard R, Belafsky P. Dysphagia following cervical spine surgery with anterior instrumentation: evidence from fluoroscopic swallow studies. Spine. 2011;36:2217–23.PubMedCrossRef Leonard R, Belafsky P. Dysphagia following cervical spine surgery with anterior instrumentation: evidence from fluoroscopic swallow studies. Spine. 2011;36:2217–23.PubMedCrossRef
45.
go back to reference Kahrilas PJ, Lin S, Rademaker AW, Logemann JA. Impaired deglutitive airway protection: a videofluoroscopic analysis of severity and mechanism. Gastroenterology. 1997;113:1457–64.PubMedCrossRef Kahrilas PJ, Lin S, Rademaker AW, Logemann JA. Impaired deglutitive airway protection: a videofluoroscopic analysis of severity and mechanism. Gastroenterology. 1997;113:1457–64.PubMedCrossRef
46.
go back to reference Nicosia MA, Hind JA, Roecker EB, Carnes M, Doyle J, Dengel GA, Robbins J. Age effects on the temporal evolution of isometric and swallowing pressure. J Gerontol Ser A Biol Sci Med Sci. 2000;55:M634–40.CrossRef Nicosia MA, Hind JA, Roecker EB, Carnes M, Doyle J, Dengel GA, Robbins J. Age effects on the temporal evolution of isometric and swallowing pressure. J Gerontol Ser A Biol Sci Med Sci. 2000;55:M634–40.CrossRef
47.
go back to reference Youmans SR, Youmans GL, Stierwalt JA. Differences in tongue strength across age and gender: is there a diminished strength reserve? Dysphagia. 2009;24:57–65.PubMedCrossRef Youmans SR, Youmans GL, Stierwalt JA. Differences in tongue strength across age and gender: is there a diminished strength reserve? Dysphagia. 2009;24:57–65.PubMedCrossRef
48.
49.
go back to reference Kellen PM, Becker DL, Reinhardt JM, Van Daele DJ. Computer-assisted assessment of hyoid bone motion from videofluoroscopic swallow studies. Dysphagia. 2010;25:298–306.PubMedCrossRef Kellen PM, Becker DL, Reinhardt JM, Van Daele DJ. Computer-assisted assessment of hyoid bone motion from videofluoroscopic swallow studies. Dysphagia. 2010;25:298–306.PubMedCrossRef
50.
go back to reference Hooker EA, O’Brien DJ, Danzel DF, Barefoot JAC, Brown JE. Respiratory rates in emergency department patients. J Emerg Med. 1989;7(2):129–32.PubMedCrossRef Hooker EA, O’Brien DJ, Danzel DF, Barefoot JAC, Brown JE. Respiratory rates in emergency department patients. J Emerg Med. 1989;7(2):129–32.PubMedCrossRef
51.
go back to reference Nave CR, Nave BC. Physics for the health sciences. 3rd ed. Philadelphia: WB Saunders; 1985. Nave CR, Nave BC. Physics for the health sciences. 3rd ed. Philadelphia: WB Saunders; 1985.
52.
54.
go back to reference Molfenter SM, Steele CM. The relationship between residue and aspiration on the subsequent swallow: an application of the normalized residue ratio scale. Dysphagia. 2013;28(4):494–500.PubMedCrossRef Molfenter SM, Steele CM. The relationship between residue and aspiration on the subsequent swallow: an application of the normalized residue ratio scale. Dysphagia. 2013;28(4):494–500.PubMedCrossRef
Metadata
Title
Physiological Factors Related to Aspiration Risk: A Systematic Review
Authors
Catriona M. Steele
Julie A. Y. Cichero
Publication date
01-06-2014
Publisher
Springer US
Published in
Dysphagia / Issue 3/2014
Print ISSN: 0179-051X
Electronic ISSN: 1432-0460
DOI
https://doi.org/10.1007/s00455-014-9516-y

Other articles of this Issue 3/2014

Dysphagia 3/2014 Go to the issue