[Dysphagia] Cervical Auscultation

[Paula.Leslie at newcastle.ac.uk (Paula leslie)]

Hello All

There are a number of issues with CA.  This is my take on things.  The 
previous emails have made some good points.

I've run several general ebp and evidence in CA workshops and seminars and the 
figures for people having read the literature who practice CA are roughly a 
handful per 100, in different parts of the UK and at ASHA last year.  So we 
have a whole load of people practicing a controversial technique who have 
NEVER read any of the papers.  The papers are generally tough going, they 
investigate different things, they use different terms, they aren't all 
clinically applicable (does acoustic analysis using accelerometers replicate 
human ears and stethoscopes - more research required?), so no easy task but 
people often haven't even tried.  Taking someone's notes from a course is not 
good enough - you just get their interpretation.  What is more worrying is 
that policies are now being formed that say a clinical exam must include CA.

And of the evidence that is out there, its quality ie scientific validity is 
variable.  If you do read a paper do you think critically about what the 
authors have written?  Are the methods replicable?  Is it acceptable to remove 
data that aren't clear?

There are a number of people offering training in this technique who generally 
charge a lot of money.  But very few of these people are ploughing the cash 
back to fund research into CA.  It might be that they have tried and not 
published, struggled because this work is methodologically difficult (I 
know!), or they have no interest in research, or....?  What are their motives?

I'm afraid that the idea that CA adds more to the clinical exam is just a 
belief at present, there is nothing to support this.  There is no evidence 
that a clinical swallow exam WITH CA is in any way superior or inferior to one 
without.  This is an area where we need robust research.

Wearing a stethoscope is a powerful symbol.

I would like to know the proportions of people using CA who routinely do a 
full oral exam, cranial nerve exam, check the medications, check the 
underlying respiratory status etc.  Areas where there IS evidence that such 
things affect the swallow.  I personally know some people who do this.  But I 
also know others who don't.  If we were more diligent with the clinical exam, 
maybe we wouldn't be continually looking for adjuncts to validate it?

There are lots of sounds in swallowing.  Let's leave breath sounds aside which 
is an area that I think shows more promise.  I have listened to hundreds of 
swallows and in healthy people I cannot always detect a double click let alone 
a triple one.  Not that anyone has defined this double click to my 
satisfaction.  So to say that absence indicates abnormality is unfounded.  And 
my very healthy swallow has a squeak on mouthfuls, and goes berserk on 5mls.  
Of course it may be that I'm not a good enough listener.

>In response to your colleague claiming to be able to hear solids pooling in 
the pyriforms...well, me personally...I'm not that good!!

I think this is a typical and sad feeling - "I can't hear what you claim 
because I'm not that good" - there is the possibility that it can't be heard?

We raised the issue of "musical ears" in our reliability paper.  To claim that 
perfect pitch enables proficiency in this area is misleading.  There is no 
evidence that sounds are standardised in an individual.  But to consider how 
good the ear is, is important in any technique using it.  There is more 
research that could be done on this.

Evidence that a technique is detecting things eg aspiration/pooling etc MUST 
be done on simultaneous swallows, not on VF a couple of weeks later.

There is evidence to show that across listeners reliability is poor and not 
much to contest that.

Sounds such as laryngeal clearing and coughing (and I have seen this reported 
as a use of CA) do not need a stethoscope to hear them.

When I first started in swallowology I worked with two clinicians who could 
"feel pooling in the valleculae" and piriforms and tell whether it was liquid 
or solid.  So I felt pretty inadequate for some years.  Now I know that you'd 
have to have a golf ball lodged to be able to "feel" it.  But it is difficult 
for junior staff to stand up to senior ones who are pushing (or dismissing) 
something.  And hard for senior ones when policies are ratified.

I have said this before that jumping on a bandwagon and making unfounded 
claims does us as clinical swallowologist no good.  And it does techniques 
that may have a future no good either.  My stand is that this technique is not 
ready for routine clinical use outside of a research setting.

So for those of you using the technique please think carefully and go and 
evaluate the evidence.  And for those of you not using it - that's fine and 
don't get pushed around by people who might be more vocal but no more 
validated.

Whatever we choose to use or not use we must be able to defend our choice on 
the basis of robust evidence.

Paula

Paula Leslie
Degree Programme Director

Surgical and Reproductive Sciences
Faculty of Medical Sciences
University of Newcastle
Newcastle upon Tyne
NE2 4HH
UK
+44 (0) 191 222 6279(T)/8988(F)
http://www.ncl.ac.uk/sars/postgrad/MSc.htm