What question did this study set out to answer?

To explore the effects of different liquid types on airway invasion detection during swallowing evaluations.

January 24, 2026European Archives of Oto-Rhino-Laryngology0 citationsOpen Access

The effect of liquid type on the detection of airway invasion during swallow evaluation

EBEiman Abu Bandora LHLiav Hayat YAYarden Ashkenazi

Key Points

To explore the effects of different liquid types on airway invasion detection during swallowing evaluations.
Conducted standardized fiberoptic endoscopic evaluation of swallowing (FEES) with adults using water, cow’s milk, and soy milk.
Assessed outcomes using the Penetration–Aspiration Scale and the Yale Pharyngeal Residue Severity Rating Scale.
Evaluated inter-rater reliability with reassessment of 25% of examinations by additional professionals.
Most swallows were classified as safe across all liquids.
Cow’s milk had a higher frequency of unsafe PAS scores compared to water and soy milk.
Agreement in PAS scores varied from low to moderate, while residue scores showed moderate to high agreement.
Inter-rater reliability was excellent at 0.93, indicating strong agreement among assessors.

Abstract

Abstract Objectives To explore FEES findings obtained using different liquid types, water, cow’s milk, and soy milk, with respect to observed penetration, aspiration, and pharyngeal residue, and to describe agreement across liquids. Methods Adult patients referred to a university-affiliated dysphagia clinic underwent standardized FEES using water, cow’s milk, and soy milk during single and consecutive swallows. Evaluations were performed jointly by a laryngologist and a speech-language pathologist (SLP). Outcome measures included the Penetration–Aspiration Scale (PAS) and the Yale Pharyngeal Residue Severity Rating Scale. Inter-rater reliability was assessed through blinded reassessment of 25% of examinations by an additional laryngologist and two SLPs. Results Most swallows across all liquids were classified as safe. Unsafe PAS scores occurred numerically more frequently with cow’s milk (18.2–25.6%), than with water (6.9–11.6%) or soy milk (9.4–11.6%). For single swallows, a nominal overall difference across liquids was observed (Cochran’s Q = 6.00, p = 0.050), and for consecutive swallows an overall difference was also detected (Cochran’s Q = 8.00, p = 0.018). Pairwise comparisons were not statistically significant after correction for multiple testing. No statistically significant differences were identified between liquids for vallecular or pyriform sinus residue. Agreement in PAS scores across liquids ranged from low to moderate (κ = 0.291–0.609), and agreement for residue scores ranged from moderate to almost perfect (κ = 0.528–0.824). Inter-rater reliability was excellent (ICC = 0.93, 95% CI 0.90-0.95, p < 0.001). Conclusion In this exploratory within-subject study, no statistically significant differences were observed in FEES penetration, aspiration, or pharyngeal residue scores when using water, cow’s milk, or soy milk. These findings provide preliminary descriptive data regarding the behavior of a commonly consumed plant-based liquid during FEES and may inform future research on liquid properties in swallowing assessment.

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