, Volume 31, Issue 2, pp 160–168 | Cite as

Swallowing Kinematics and Factors Associated with Laryngeal Penetration and Aspiration in Stroke Survivors with Dysphagia

  • Han Gil Seo
  • Byung-Mo OhEmail author
  • Tai Ryoon Han
Original Article


The purpose of this study was to investigate swallowing kinematics and explore kinematic factors related with penetration-aspiration in patients with post-stroke dysphagia. Videofluoroscopic images of 68 patients with post-stroke dysphagia and 34 sex- and age-matched healthy controls swallowing a thin liquid were quantitatively analyzed using two-dimensional motion digitization. The measurements included the movement distances and velocities of the hyoid and larynx, and the maximal tilt angles and angular velocities of the epiglottis. All velocity variables were significantly decreased in the stroke patients compared to the controls. There was a significant difference in the maximal horizontal displacement of the larynx, but there were no significant differences in other displacements of the larynx, the maximal displacements of the hyoid bone, and the maximum tilt angle of the epiglottis between the two groups. The maximal tilt angle of the epiglottis was lower in the aspiration subgroup than in the no penetration/aspiration and penetration subgroups as well as the controls. The maximal tilt angle from the y axis showed a dichotomous pattern at 90° of the angle, and all 11 patients with an angle <90° showed either penetration or aspiration. In the ROC curve of the angle for prediction of aspiration, the area under the curve was 0.725 (95 % CI 0.557–0.892, P = 0.008). This study suggested that sluggish rather than decreased hyolaryngeal movements during swallowing are a remarkable feature of post-stroke dysphagia. The association of reduced epiglottic movement with the risk of aspiration in patients with post-stroke dysphagia was supported by the quantitative analysis.


Dysphagia Deglutition Stroke Aspiration Kinematics 


Compliance with Ethical Standards

Conflict of interest

The authors have no conflicts of interest to declare.


  1. 1.
    Perry L, Love CP. Screening for dysphagia and aspiration in acute stroke: a systematic review. Dysphagia. 2001;16:7–18.CrossRefPubMedGoogle Scholar
  2. 2.
    Holas MA, DePippo KL, Reding MJ. Aspiration and relative risk of medical complications following stroke. Arch Neurol. 1994;51:1051–3.CrossRefPubMedGoogle Scholar
  3. 3.
    Singh S, Hamdy S. Dysphagia in stroke patients. Postgrad Med J. 2006;82:383–91.CrossRefPubMedPubMedCentralGoogle Scholar
  4. 4.
    Steele CM, Cichero JA. Physiological factors related to aspiration risk: a systematic review. Dysphagia. 2014;29:295–304.CrossRefPubMedPubMedCentralGoogle Scholar
  5. 5.
    Molfenter SM, Steele CM. Kinematic and temporal factors associated with penetration-aspiration in swallowing liquids. Dysphagia. 2014;29:269–76.CrossRefPubMedPubMedCentralGoogle Scholar
  6. 6.
    Paik NJ, Kim SJ, Lee HJ, Jeon JY, Lim JY, Han TR. Movement of the hyoid bone and the epiglottis during swallowing in patients with dysphagia from different etiologies. J Electromyogr Kinesiol. 2008;18:329–35.CrossRefPubMedGoogle Scholar
  7. 7.
    Kim Y, McCullough GH. Maximal hyoid excursion in poststroke patients. Dysphagia. 2010;25:20–5.CrossRefPubMedGoogle Scholar
  8. 8.
    Bingjie L, Tong Z, Xinting S, Jianmin X, Guijun J. Quantitative videofluoroscopic analysis of penetration-aspiration in post-stroke patients. Neurol India. 2010;58:42–7.CrossRefPubMedGoogle Scholar
  9. 9.
    Kahrilas PJ, Lin S, Rademaker AW, Logemann JA. Impaired deglutitive airway protection: a videofluoroscopic analysis of severity and mechanism. Gastroenterology. 1997;113:1457–64.CrossRefPubMedGoogle Scholar
  10. 10.
    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.CrossRefPubMedPubMedCentralGoogle Scholar
  11. 11.
    Kim Y, McCullough GH. Stage transition duration in patients poststroke. Dysphagia. 2007;22:299–305.CrossRefPubMedGoogle Scholar
  12. 12.
    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.CrossRefPubMedGoogle Scholar
  13. 13.
    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.CrossRefPubMedGoogle Scholar
  14. 14.
    Oommen ER, Kim Y, McCullough G. Stage transition and laryngeal closure in poststroke patients with dysphagia. Dysphagia. 2011;26:318–23.CrossRefPubMedGoogle Scholar
  15. 15.
    Seo HG, Oh BM, Han TR. Longitudinal changes of the swallowing process in subacute stroke patients with aspiration. Dysphagia. 2011;26:41–8.CrossRefPubMedGoogle Scholar
  16. 16.
    Nagy A, Molfenter SM, Peladeau-Pigeon M, Stokely S, Steele CM. The effect of bolus consistency on hyoid velocity in healthy swallowing. Dysphagia. 2015;30:445–51.CrossRefPubMedPubMedCentralGoogle Scholar
  17. 17.
    Matsuo K, Palmer JB. Anatomy and physiology of feeding and swallowing: normal and abnormal. Phys Med Rehabil Clin N Am. 2008;19:691–707.CrossRefPubMedPubMedCentralGoogle Scholar
  18. 18.
    Logemann JA. Evaluation and treatment of swallowing disorders. 2nd ed. Austin: Pro-ed; 1998.Google Scholar
  19. 19.
    Han TR, Paik NJ, Park JW, Kwon BS. The prediction of persistent dysphagia beyond six months after stroke. Dysphagia. 2008;23:59–64.CrossRefPubMedGoogle Scholar
  20. 20.
    American Speech-Language-Hearing Association. National outcomes measurement system (NOMS): adult speech-language pathology user’s guide. Rockville: American Speech-Language-Hearing Association; 2003.Google Scholar
  21. 21.
    Lee SH, Oh BM, Chun SM, Lee JC, Min Y, Bang SH, Kim HC, Han TR. The accuracy of the swallowing kinematic analysis at various movement velocities of the hyoid and epiglottis. Ann Rehabil Med. 2013;37:320–7.CrossRefPubMedPubMedCentralGoogle Scholar
  22. 22.
    Ekberg O, Sigurjonsson SV. Movement of the epiglottis during deglutition. A cineradiographic study. Gastrointest Radiol. 1982;7:101–7.CrossRefPubMedGoogle Scholar
  23. 23.
    Vandaele DJ, Perlman AL, Cassell MD. Intrinsic fibre architecture and attachments of the human epiglottis and their contributions to the mechanism of deglutition. J Anat. 1995;186(Pt 1):1–15.PubMedPubMedCentralGoogle Scholar
  24. 24.
    Curtis DJ, Cruess DF, Dachman AH, Maso E. Timing in the normal pharyngeal swallow. Prospective selection and evaluation of 16 normal asymptomatic patients. Invest Radiol. 1984;19:523–9.CrossRefPubMedGoogle Scholar
  25. 25.
    Fink BR, Martin RW, Rohrmann CA. Biomechanics of the human epiglottis. Acta Otolaryngol. 1979;87:554–9.CrossRefPubMedGoogle Scholar
  26. 26.
    Garon BR, Huang Z, Hommeyer M, Eckmann D, Stern GA, Ormiston C. Epiglottic dysfunction: abnormal epiglottic movement patterns. Dysphagia. 2002;17:57–68.CrossRefPubMedGoogle Scholar
  27. 27.
    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.CrossRefPubMedPubMedCentralGoogle Scholar
  28. 28.
    Molfenter SM, Steele CM. Use of an anatomical scalar to control for sex-based size differences in measures of hyoid excursion during swallowing. J Speech Lang Hear Res. 2014;57:768–78.CrossRefPubMedPubMedCentralGoogle Scholar
  29. 29.
    Ishida R, Palmer JB, Hiiemae KM. Hyoid motion during swallowing: factors affecting forward and upward displacement. Dysphagia. 2002;17:262–72.CrossRefPubMedGoogle Scholar
  30. 30.
    Paolucci S, Antonucci G, Grasso MG, Bragoni M, Coiro P, De Angelis D, Fusco FR, Morelli D, Venturiero V, Troisi E, Pratesi L. Functional outcome of ischemic and hemorrhagic stroke patients after inpatient rehabilitation: a matched comparison. Stroke. 2003;34:2861–5.CrossRefPubMedGoogle Scholar
  31. 31.
    Kelly PJ, Furie KL, Shafqat S, Rallis N, Chang Y, Stein J. Functional recovery following rehabilitation after hemorrhagic and ischemic stroke. Arch Phys Med Rehabil. 2003;84:968–72.CrossRefPubMedGoogle Scholar
  32. 32.
    Inamoto Y, Fujii N, Saitoh E, Baba M, Okada S, Katada K, Ozeki Y, Kanamori D, Palmer JB. Evaluation of swallowing using 320-detector-row multislice CT. Part II: kinematic analysis of laryngeal closure during normal swallowing. Dysphagia. 2011;26:209–17.CrossRefPubMedGoogle Scholar
  33. 33.
    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.CrossRefPubMedGoogle Scholar
  34. 34.
    Butler SG, Stuart A, Wilhelm E, Rees C, Williamson J, Kritchevsky S. The effects of aspiration status, liquid type, and bolus volume on pharyngeal peak pressure in healthy older adults. Dysphagia. 2011;26:225–31.CrossRefPubMedPubMedCentralGoogle Scholar
  35. 35.
    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.CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2015

Authors and Affiliations

  1. 1.Department of Rehabilitation Medicine, Seoul National University College of MedicineSeoul National University Hospital, SeoulSeoulRepublic of Korea
  2. 2.Department of Rehabilitation MedicineGangwon Do Rehabilitation HospitalChuncheon-siRepublic of Korea

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