Sounding
“Wet” As a
Diagnostic
Indicator of
Aspiration
By: Lena Ellison
Wayne State University
Introduction
 Bedside
swallow examination is a
screening measure to detect a patient’s
candidacy for a videofluroscopic
evaluation
 It determines which textures are safe for
the patient to swallow
 Used to monitor progress of therapy and
to determine the possibility of upgrading
recommendations
Introduction
 Part
of the bedside swallow examination
is the three-ounce water test, which
assesses vocal quality as a diagnostic
indictor for aspiration
Three-Ounce Water Test
 Patient
drinks 3oz of water without
interruption
 SLP attempts to identify aspiration by
noting throat clearing, coughing, or
change in vocal quality immediately and
one minute after the swallow
 If none of these symptoms are present a
normal diet is recommended.
Reliability of the three-ounce
water test




Various studies have yielded contradicting results
DePippo, Holas, & Reding (1992) conducted a
study comparing the three-ounce water test to
the Modified Barium Swallow (MBS) Examination
Results indicated that the 3oz water test had a
sensitivity of 76% and a specificity of 59%
According to this study the 3oz water test is
sensitive enough to serve as a screening tool to
indicate which patients require further
examination
Reliability of the three-ounce
water test


A study by Suiter & Leder (2006) compared
the 3oz water test to the Fiberoptic
Endoscopic Evaluation of Swallowing (FEES).
Results



Sensitivity of 3oz water test: 96.5%
Specificity of 3oz water test: 48.7%
Patients would be referred for an instrumental
swallow evaluation unnecessarily
Reliability of three-ounce
water test
 Both
studies agree that the 3oz water test
should be used alone as a diagnostic
tool.
 One main reason is that assessment of
vocal quality is generally a criterion-based
measure
Vocal Quality Assessment




The term “wet” can be described as gurgly or
liquid sounding and is due to the voice being
produced through moisture
Ratings are based on listener’s standards,
experience, type of rating scale, and the voice
sample being evaluated
When a patient has a “wet” vocal quality, they
are generally referred for an instrumental
swallowing examination.
Researchers have differing opinions regarding the
perception of a “wet” vocal quality as a
diagnostic indicator for aspiration.
Sounding “wet” as an
indicator for aspiration



Weir, McMahon, Masters, & Chang (2009)
conducted a study, which assessed
diagnostic values of various signs and
symptoms in predicting oropharyngeal
aspiration in children
Results indicated that a “wet” voice was
associated with aspiration on thin liquids
Overall, “wet” vocal quality yielded a 67%
sensitivity and 92% specificity in predicting
oropharyngeal aspiration in children
Sounding “Wet” as an
Indicator for Aspiration
 Irwin
(2006) conducted a study, which
assessed clinician’s perception of “wet”
vocal quality compared to the results of
the videofluoroscopic swallowing study.
 She determined that clinicians are more
likely to identify a voice as sounding “wet”
in patients with a high amount of material
on their vocal folds.
Sounding “Wet” as an
indicator for Aspiration
 Goves-Wright,
Boyce & Kelchner (2010)
compared the results of the
videofluoroscopic swallow study to 5
clinician’s perceptual judgment of “wet”
vocal quality in 78 patients.
 High degree of interrater variability for
perceptual judgments of wetness
 Could be due to lack of perceptual
criteria for “wet” vocal quality
Sounding “Wet” as an
Indicator of Aspiration



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
Goves-Wright, Boyce & Kelchner (2010) continued
Authors suggest a range of perceptual
consequences when material is vibrating in the
larynx
Material in the larynx may disrupt periodic vocal
fold vibration without affecting the phonatory
airstream, which could result in the patient’s voice
sounding like noise
Authors suggest that raters change their judgment
from “wet” and “not wet” to “normal and
“abnormal”
Further research is necessary in order to assess the
reliability of this rating system
Conclusion
 Noninvasive
assessments of dysphagia,
such as the 3oz water test are crucial in
detecting aspiration
 Instrumental procedures are not always
readily available
 It is not practical to expose patients to
instrumental procedures on a regular
basis due to availability and high amounts
of radiation exposure
Conclusion
 Data
suggests that clinicians can
perceive wetness when a sufficient
amount of material is present in the larynx.
 In those cases, instrumental evaluations
are necessary.
Conclusion
 Further
research needs to be conducted
to increase reliability of the perception of
“wet” vocal quality


One suggestion: replace listener’s internal
representations for “wet” vocal quality with
“reference voices,” which correspond to
different vocal qualities.
By training clinicians to use the same
“reference voices” interrater variability will
likely be reduced.
References
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Beckstrom, L. & Hanson, S.K. (2008). Swallow screen [PowerPoint slides]. Retrieved from
www.coloradostroke.org/documents/Swallow.Screen.ppt.
DePippo, Kathleen L., Marlene A. Holas, and Michael J. Reding. "Validation of the 3-oz water
swallow test for aspiration following stroke." Archives of Neurology 49 Dec. (1992):
1259-61. Print.
González-Fernádez, M., Sein, M. T., & Palmer, J. B. (2011, November). Clinical experience
using the Mann assessment of swallowing ability for identification of patients at risk for
aspiration in a mixed-disease population. American Journal of Speech-Language
Pathology, 20, 331-336.
Groves-Wright, K. J., Boyce, S., & Kelchner, L. (2010, June). Perception of wet vocal quality in
identifying penetration/aspiration during swallowing. American Speech-Language Hearing
Association, 53, 620-632.
Irwin, L. (2006). Perceptual evaluation of voice quality with dysphagia and dysphonia
(Master's thesis).
Langmore, S., Schatz, K., & Olson, N. (1991). Endoscopic and videofluoroscopic evaluations
of swallowing and aspiration. Annals of Otology, Rhinology, and Laryngology, 100, 678-681.
Oates, J. (2009, February 10). Auditory-perceptual evaluation of disordered voice quality.
Folia Phoniatrica et Logopaedica, 61, 49-56.
References
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Rosenbek, J. C., Robbins, J., Roecker, E. B., Coyle, J. L., & Wood, J. L. (1996). A penetrationaspiration scale. Dysphagia, 11, 93-98.
Suiter, D. & Leder, S. (2006, September). Can the 3 ounce water swallow test screen for
aspiration?
Swigert, N. B. (2009, May 26). Hot topics in dysphagia. The ASHA Leader.
Warms, T., & Richards, J. (2000). "Wet voice" as a predictor of penetration and aspiration in
oropharngeal dysphagia. Dysphagia, 15, 84-88.
Weir, K., McMahon, S., Barry, L., Masters, I. B., & Chang, A. B. (2009). Clinical signs and
symptoms of oropharyngeal aspiration and dysphagia in children. European Respiratory
Journal, 33(3), 604-611.