The Yale Pharyngeal Residue Severity Rating Scale: An Anatomically Defined and Image-Based Tool

Abstract

Objectives: To develop, standardize, and validate the Yale Pharyngeal Residue Severity Rating Scale.

Methods: The Yale Pharyngeal Residue Severity Rating Scale was developed, standardized, and validated to provide reliable, anatomically defined, and image-based assessment of post-swallow pharyngeal residue severity as observed during fiberoptic endoscopic evaluation of swallowing (FEES). It is a 5-point ordinal rating scale based on residue location (vallecula and pyriform sinus) and amount (none, trace, mild, moderate, and severe). Two expert judges reviewed a total of 261 FEES evaluations and selected a no residue exemplar and three exemplars each of trace, mild, moderate, and severe vallecula and pyriform sinus residue. Hard-copy color images of the no residue, 12 vallecula, and 12 pyriform sinus exemplars were randomized by residue location for hierarchical categorization by 20 raters with a mean of 8.3 years of experience (range 2–27 years) performing and interpreting FEES. Severity ratings for all images were performed by the same 20 raters, 2 weeks apart, and with the order of image presentations randomized. Intra-rater test-retest reliability, inter-rater reliability, and construct validity were determined by pooled multi-category multi-rater kappa statistics.

Results: Residue ratings were excellent for intra-rater reliability for vallecula (kappa = 0.957 + 0.014) and pyriform sinus (kappa = 0.854 + 0.021), very good to excellent for inter-rater reliability for vallecula (kappa = 0.868 + 0.011) and pyriform sinus (kappa = 0.751 + 0.011), and excellent for validity for vallecula (kappa = 0.951 + 0.014) and pyriform sinus (kappa = 0.908 + 0.017).

Conclusions: Clinical uses include accurate classification of vallecula and pyriform sinus residue severity patterns as none, trace, mild, moderate, or severe for diagnostic purposes, determination of functional therapeutic change, and precise dissemination of shared information. Scientific uses include tracking outcome measures, demonstrating efficacy of interventions to reduce pharyngeal residue, investigating morbidity and mortality in relation to pharyngeal residue severity, and improving training and accuracy of FEES interpretation by students and clinicians. The Yale Pharyngeal Residue Severity Rating Scale is a reliable, validated, anatomically defined, and image-based tool to determine residue location and severity based on FEES.

Neubauer PD, Rademaker AW, Leder SB. The Yale pharyngeal residue severity rating scale: An anatomically defined and image-based tool. Dysphagia. 2015;30:521–8. doi:10.1007/s00455-015-9631-4 (Used and modified with kind permission from Springer Science + Business Media).

Appendix

Definitions for severity of vallecula residue
I	None	0 %	No residue
II	Trace	1–5 %	Trace coating of the mucosa
III	Mild	5–25 %	Epiglottic ligament visible
IV	Moderate	25–50 %	Epiglottic ligament covered
V	Severe	>50 %	Filled to epiglottic rim

Definitions for severity of pyriform sinus residue
I	None	0 %	No residue
II	Trace	1–5 %	Trace coating of mucosa
III	Mild	5–25 %	Up wall to quarter full
IV	Moderate	25–50 %	Up wall to half full
V	Severe	>50 %	Filled to aryepiglottic fold