Mbsimp

Front 1

Overall Impression (OI)

Back 1

OI represents the “worst” (i.e. most impaired) score observed across all consistencies and volumes; however, there are exceptions to this general rule.

The first 5ml tsp. administration of thin liquid (trial #1 on the protocol) should not be considered when formulating the OI score.

For each of the protocol's remaining 11 swallow trials, the OI score is based on the initial swallow of each trial.

The exception are the sequential swallow tasks (trials #4 and #7), during which each swallow is to be considered in formulating the OI score. Residue is scored after the sequential swallowing task is completed.

Front 2

Penetration and Aspiration Score (PAS)

Back 2

Physiologic impairment and PAS scores are both important but different types of clinical information and should be evaluated in tandem. The purpose of the MBS study is not to “pass or fail” a patient based on the presence of aspiration, but rather to identify the physiologic impairment (i.e. airway closure) and to target treatment accordingly.

Front 3

Lip Closure

Back 3

Score a (0) if there is no labial escape of the bolus between the lips.

Score a (1) if there is interlabial escape, but no progression to the anterior lip.

Score a (2) if there is escape from the interlabial space or lateral juncture with no extensions beyond the vermillion border of the lower lip.

Score a (3) if there is escape of contrast material to the mid chin and a

(4) if there is profuse spilling or escape of even small amounts beyond the mid-chin through the open lips.

Front 4

Tongue Control During Bolus Hold

Back 4

only for all liquid boluses when the patient is cued to “hold this in your mouth until I ask you to swallow.” It is scored PRIOR TO initiation of productive tongue movement to propel the bolus through the oral cavity. You are rating the integrity of the patient’s ability to seal the tongue to the hard and soft palate during the oral command, “hold this in your mouth until I ask you to swallow.” It may be argued that this is not a natural drinking task and the argument would be correct. However, demonstration of the ability to control a bolus in the oral cavity is of diagnostic and prognostic value when planning treatment strategies.

Score a (1) if the bolus goes to either or both of the lateral sulci or the floor of mouth, or is spread diffusely throughout the oral cavity.

Score a (2) if any portion less than half of the bolus passes through the tongue-palate seal and

a (3) if more than half of the bolus enters the pharynx.

Front 5

Bolus Preparation/Mastication

Back 5

Score a (0) if the patient demonstrates timely and efficient chewing and mashing.

Score a (1) if the patient demonstrates slow and prolonged chewing and mashing, but complete recollection or formation of the bolus is achieved.

Score a (2) if the bolus is not formed and pieces remain in the oral cavity after the initial swallow. If the patient continues to chew after the first swallow, it is likely that solid pieces remained unchewed and therefore receives a score of (2).

A score of (3) reflects minimal chewing and mashing with a majority of the bolus remaining unchewed.

Front 6

Bolus Transport/Lingual Motion

Back 6

Prolonged holding followed by relatively normal movement is judged as delay (1)

whereas slow (seemingly weak) tongue movement that progresses in a productive, posterior-ward motion is scored as (2).

Repetitive and/or disorganized movement that moves back and forth with varying degrees of repetition is scored as (3). If a patient is slow and repetitive, the component is scored as (3).

A patient receives a score of (4) if there is minimal or no observable movement.

Front 7

Oral Residue

Back 7

Complete clearance is no observable barium remaining in the oral cavity (0).

Trace residue resembles an outline of coated structures (1).

It may be difficult to identify trace residue on the video clip depending on the resolution of your computer screen.

A collection (2) is an amount remaining from the original bolus presentation sufficient to extract or ‘scoop’. It is important to note that there are variations of “collection;” however, we’ve found different variations cannot be reliably scored because they are not distinguishable when making visual judgments.

A majority is more than half of the original bolus remaining and should be given a score of (3).

A score of (4) is minimal or no clearance of the bolus from the oral cavity. Scores of (3) and (4) are relative to the bolus size.

Front 8

Initiation of the pharyngeal swallow

Back 8

based on the position of the bolus head (leading edge) at the time of first initiation of the brisk, superior-anterior hyoid trajectory. Small movements of the hyoid that occur during chewing, bolus manipulation or tongue stabilization should not be confused with the onset of brisk hyoid motion that is the first structural movement signaling the onset of the pharyngeal swallow.

A score of (0) is represented by the bolus head at the region of the posterior angle of the ramus and back of the tongue at the first sign of hyoid excursion.

A score of (1) is indicated by the bolus head at the valleculae at the time of first hyoid excursion.

A score of (2) occurs when the bolus head is at the posterior laryngeal surface of the epiglottis at first onset of hyoid excursion (i.e., between the base of the valleculae and the superior surface of the pyriform sinus).

A score of (3) is represented when the bolus head is in the pyriform sinus at the time of first hyoid excursion and

a score of (4) is indicated by no appreciable initiation at any bolus location.

n rare cases where no hyoid excursion is observed to mark the initiation of the pharyngeal swallow but PES opening is somehow achieved, Component 6 would be scored a (3).

Front 9

Soft Palate Elevation

Back 9

A score of (0) illustrates no bolus between the soft palate and pharyngeal wall.

A score of (1) represents a trace column of contrast or air between the soft palate and pharyngeal wall.

A score of (2) represents escape of contrast material to the level of nasopharynx.

A score of (3) represents escape of contrast material that progress to the level of the nasal cavity and

a score of (4) represents escape of contrast material progressing to the level of the nostril with and without nasal emission.

Front 10

Laryngeal Elevation

Back 10

judged during initial elevation of the larynx and prior to the height of the swallow. Laryngeal elevation is scored at the time the epiglottis reaches a horizontal position. If there is no displacement of the epiglottis to a horizontal position, laryngeal elevation is scored just after initial hyoid motion (signaling the onset of the pharyngeal swallow) when the larynx first moves upward.

A score of (0) is represented by full superior movement of the thyroid cartilage that results in complete approximation of the arytenoids to the epiglottic petiole.

A score of (1) is represented by partial superior movement of the thyroid cartilage resulting in partial approximation of the arytenoids to the epiglottic petiole. Minimal superior movement of the thyroid cartilage resulting in minimal approximation of the arytenoids to the epiglottic petiole is scored as (2).

A score of (3) is illustrated by no superior movement of the thyroid cartilage and no approximation of the arytenoids to the epiglottic petiole.

Front 11

Anterior Hyoid Excursion

Back 11

judged at the height of the swallow.

A score of (0) is complete anterior hyoid movement. Complete anterior displacement corresponds with a more acute angle between the thyroid cartilage and hyoid bone and the height of anterior hyoid movement.

A score of (1) is partial anterior movement often characterized as the thyroid cartilage being in a more direct line with the hyoid and the height of anterior hyoid movement.

A score of (2) is no anterior movement of the hyoid bone.

Front 12

Epiglottic Movement

Back 12

is judged at the height of the swallow at the point of maximal epiglottic movement.

A score of (0) is complete inversion of the epiglottis,

while a score of (1) is movement of the epiglottis to a horizontal position with no progression beyond the horizontal position. A score of (1) would also be given if the epiglottis moves inferiorly but does not reach a horizontal position.

A score of (2) is minimal to no movement of the epiglottis

Front 13

Laryngeal Vestibular Closure

Back 13

is judged at the height of the swallow (point of maximal anterior hyoid movement and maximal laryngeal vestibular closure).

Complete laryngeal vestibular closure with no air or contrast in the laryngeal vestibule is scored as (0).

A score of (1) is characterized by a narrow column of air or contrast in the laryngeal vestibule,

and a score of (2) is characterized by a wide column of air or contrast in the laryngeal vestibule.

Note: Patients may but not always demonstrate entry of contrast into the laryngeal vestibule during early laryngeal elevation receiving a score of (1), but completely or partially expel the penetrated material at the height of the swallow and receive a score of (0).

Front 14

Pharyngeal Stripping Wave

Back 14

is judged along the full length of the pharyngeal wall from the nasopharynx to the PES.

A score of (0) represents a full wave of contraction from the level of the nasopharynx continuing to the level of the PES.

A score of (1) is represented by a diminished or absence of wave along any portion of the posterior pharyngeal wall.

A score of (2) is complete absence with no notable wave, which is often represented by a relatively straight line along the posterior pharyngeal wall.

Front 15

Pharyngeal Contraction

Back 15

is scored in the AP view only.

A score of (0) is symmetrical shortening and complete contraction of the pharynx depicted by lateral walls that shorten, are relatively straight, and compress against the bolus tail through the pharynx, bilaterally.

A score of (1) is incomplete contraction, which is represented by dynamic pouches (i.e. only observed when filled with contrast during the height of the swallow (typically unilateral and in the high to mid-pharynx lateral to the valleculae) that represent pseudo-diverticulae. The functional result of these pouches in patients with no other swallowing impairment is typically a small amount of pharyngeal residue that is efficiently cleared with a double swallow.

A score of (2) is represented by unilateral bulging of one pharyngeal wall and implies changes to unilateral pharyngeal wall function. A score of (3) is bilateral bulging of both pharyngeal walls, which implies changes to the bilateral pharyngeal walls.

Front 16

Pharyngoesophageal Segment (PES) Opening

Back 16

judged during maximum distention of the PES.

Three dimensions: distension (how wide the segment opens), duration (how long the segment stays open), and obstruction to flow (whether or not bolus flow is obstructed).

A score of (0) is the appearance of relatively straight edges through the segment with no appreciable narrowing from pharynx to proximal esophagus. A score of (1) is partial distention/ partial duration with partial obstruction to flow that can be represented by a narrowing of the PES at the esophageal inlet while maintaining opening long enough for most of the bolus to pass; good distention but early collapse of the PES, which is often associated with incomplete anterior movement of the hyoid (Anterior Hyoid Excursion, Component 9); or both narrowing and early collapse of the PES. A score of (2) is minimal distention/minimal duration with marked obstruction as result of significant narrowing of the PES, rapid collapse of the PES, or both that results in resistance to bolus passage. A score of (3) is the absence PES opening and no bolus clearance.

Front 17

Tongue Base Retraction

Back 17

A score of (0) is complete retraction that results in a ‘merging’ of the BOT with the superior and middle PPW.

A score of (1) represents a trace column of contrast that resembles an outline made with a fine tip pen between the BOT and PPW or a small triangle created by the epiglottis, BOT, and PPW.

A score of (2) is a narrow column of contrast or air between the BOT and PPW, which resembles an amount air or contrast similar to “collection” (Components 5 and 16, Oral Residue and Pharyngeal Residue, respectively)

A score of (3) is represented by a wide column of contrast (majority of the bolus) or air between the BOT or PPW.

A score of (4) is no appreciable posterior movement of the base of the tongue.

Front 18

Pharyngeal Residue

Back 18

Complete pharyngeal clearance is scored as (0).

A score of (1) is trace residue of contrast within or on pharyngeal structures.

Collection of residue within or on pharyngeal structures is scored as (2).

A score of (3) is the majority of contrast within or on pharyngeal structures,

and a score of (4) is minimal to no pharyngeal clearance.

Front 19

Esophageal Clearance

Back 19

The component is scored only using nectar and pudding consistencies (similar to Component 13, Pharyngeal Contraction). The goal is to observe esophageal clearance in the position in which the patient eats and drinks (bolus flow assisted by gravity). It must be clear to the attending radiologist that the clinician is not attempting to “diagnosis motility or structural anomalies.” Rather, clearance affects treatment strategies and the process of eating and drinking. Our studies and others have shown that problems with esophageal clearance may negatively influence oropharyngeal swallowing dynamics.

Complete esophageal clearance, even with esophageal coating, is scored a (0).

A score of (1) is represented by mid-to-distal esophageal retention.

Mid-to-distal esophageal retention with retrograde flow below the PES is scored as (2).

Esophageal retention with retrograde flow through the PES is scored as (3).

A score of (4) is minimal to no esophageal clearance.