International Journal of Pediatric Otorhinolaryngology 125 (2019) 116–121

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International Journal of Pediatric Otorhinolaryngology

journal homepage: www.elsevier.com/locate/ijporl

Natural history of silent aspiration on modified barium swallow studies in T

the pediatric population
Elizabeth O. Shaya, Joseph B. Melecab,*, Samantha Anneb, Brandon Hopkinsb
a
Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH, USA
b
Cleveland Clinic, Head and Neck Institute, Cleveland, OH, USA

A R T I C LE I N FO A B S T R A C T

Keywords: Objectives: To investigate the natural history of silent aspiration in the pediatric population.
Silent aspiration Methods: Retrospective chart review of patients (age < 3 years) who underwent modified barium swallow
Pediatrics studies (MBSS), between January 1, 2007, to December 31, 2017, were studied to compare comorbidities and
Modified barium swallow study determine course of resolution in those with silent aspiration.
Natural history
Results: A total of 148 charts were reviewed. Patients that underwent surgical intervention for laryngeal
Resolution
anomalies causing silent aspiration and those with overt aspiration or oral aversion were excluded. Of the 56
patients in the study, 25 had silent aspiration and 31 demonstrated no silent aspiration on MBSS. There was a
higher rate of overall comorbidities amongst silent aspirators (96.0% vs. 48.4%, p=0.003) in comparison to
patients with no silent aspiration on MBSS. Silent aspirators had higher rates of cerebral palsy (16.0% vs. 0%,
p=0.034), and seizures (36.0% vs. 3.2%, p=0.003). Of the 20 patients with silent aspiration with an MBSS
completed beyond the initial one, 13 (65.0%) experienced resolution, 5 (20.0%) did not experience resolution by
age 5, and 2 (10.0%) had unknown resolution due to being lost to follow up or not yet reaching age 5. No
statistically significant associations were found between comorbidities, gender, presence of a gastrostomy tube
and resolution.
Conclusions: Silent aspiration in children is associated with neurological comorbidities, particularly cerebral
palsy and seizures. More than half of the patients with silent aspiration spontaneously resolve over time.
Expectant management, close surveillance, and clinical assessments can be considered in these patients on an
individual basis.

1. Introduction
Silent aspiration is the intake of material into the airway below the
true vocal folds without the presence of cough or other alerting
symptoms [1]. The etiology of silent aspiration varies and has been
attributed to a range of deficits including impaired cough reflex, dis-
ordered pharyngeal initiation and motor response, reduced lar-
yngopharyngeal sensitivity, and sensory impairment due to neurogenic
disease [1]. Adequate airway protection, during swallowing, requires a
complex series of movements and reflexes, which necessitates a mature
and intact neurological system [2]. Any deficiencies, whether anato-
mical or functional, which compromise the processes involved in
airway protection, make it more likely for a child to aspirate.
Aspiration can cause lung injury and lead to a variety of pulmonary
problems including recurrent pneumonia, chronic lung disease, and
death [3–5]. Silent aspiration poses an even higher risk of
complications, given that the condition may go unnoticed. In the gen-
eral population, children and the elderly have the highest risk of ex-
periencing silent aspiration [1]. Immature swallowing function in in-
fants, particularly in the premature, and the presence of developmental
and congenital disorders account for some of the reasons children are
more at risk for silent aspiration [6,7]. Children are also particularly
vulnerable to long-lasting complications of aspiration given that their
lungs are still maturing. It is thus especially important to appreciate the
natural history of silent aspiration and to understand the factors that
might predispose a child to develop silent aspiration..
Prior groups have found that 34% of children who undergo mod-
ified barium swallow studies (MBSS) demonstrate aspiration, of which
81–89% experience silent aspiration (although not isolated silent as-
piration) [8,9]. Various authors have identified comorbidities asso-
ciated with pediatric silent aspiration. Arvedson et al. found that pe-
diatric patients with neurologically based dysphagia are at high risk for

*
Corresponding author. Cleveland Clinic, 9500 Euclid Ave, A-71, Cleveland, OH, 44195, USA.
E-mail addresses: melecaj@ccf.org, jbmeleca87@gmail.com (J.B. Meleca).

https://doi.org/10.1016/j.ijporl.2019.06.035
Received 29 January 2019; Received in revised form 16 May 2019; Accepted 30 June 2019
Available online 02 July 2019
0165-5876/ © 2019 Elsevier B.V. All rights reserved.
E.O. Shay, et al.
silent aspiration [4]. Weir et al. and Velayutham et al. similarly noted
the association between silent aspiration and neurological disease
[8,9]. These same authors also reported associations between silent
aspiration and other conditions such as laryngeal abnormalities and
congenital heart disease [9]. Many of these comorbidities could con-
ceivably affect swallowing and airway protection responses, and it is
thus not surprising that they have been associated with silent aspira-
tion.
Although physicians may suspect silent aspiration in patients based
on comorbidities, definitive diagnosis requires further testing. The
MBSS, a videofluoroscopic test that allows for observation of the
swallowing mechanism, is commonly used for evaluation [10]. Patients
with silent aspiration on imaging may receive recommendations to
modify their diet. In severe cases, clinicians may recommend dis-
continuation of oral feeds electing instead to utilize a nasogastric or
even a gastrostomy tube. Patients may subsequently receive repeat
studies at varying intervals in an attempt to determine the resolution of
silent aspiration and the appropriate timing to resume a regular diet. In
clinical practice, silent aspiration is seen to improve with time in some
patients; however, the frequency and timing of resolution have been
little studied in the pediatric population. Understanding the natural
history of silent aspiration resolution could aid clinicians in predicting
prognosis, setting parental expectations and deciding the appropriate
timing to reassess patients.
In this study, we retrospectively followed a cohort of pediatric pa-
tients, diagnosed with silent aspiration, to determine the natural history
of this finding. We sought to investigate, which patients were at risk of
silent aspiration, factors associated with the resolution of silent as-
piration, the timing of resolution, diet modifications, as well as results
of in-office flexible laryngoscopy and direct laryngoscopy with
bronchoscopy performed after diagnosis. It is our intention to expand
the knowledge of pediatric silent aspiration beyond risk factors to en-
compass the entire course of the condition.
2. Methods
A list of patients who underwent swallow studies from January 1,
2007, until December 31, 2017, using CPT codes 70370, 70371 and
74230 was obtained. Only patients who had a completed and successful
MBSS performed before three years of age were included. The patient
list was randomized, and a subset of patient charts were reviewed. Basic
patient demographics, past medical history, gestational age at birth,
results of the first two modified barium swallow studies (if performed),
the third or last modified barium swallow study (if performed), clinical
or surgical interventions relating to the swallowing disorder, conclu-
sions from otolaryngological or Speech and Language Pathology (SLP)
visits, diet modifications, complications relating to swallowing diffi-
culties and resolution of swallowing concerns were collected. The chart
was reviewed until the patient turned 5 years of age at which point a
determination was made on whether or not the swallowing concerns
had resolved.
Patients were organized into two dyads: (1) normal modified
barium swallow study (N) and (2) silent aspiration with or without
laryngeal penetration (SA).
Repeat MBSSs were ordered based on recommendations by the SLP
at the initial MBSS or when clinical changes, whether positive or ne-
gative, suggested reassessment might be appropriate. Dietary mod-
ifications and other recommendations were given based on SLP inter-
pretation of MBSS results. These included appropriate positioning,
pacing, use of thickeners, avoidance of all food and liquids by mouth,
insertion of nasogastric tubes, and gastrostomy tube placement,
amongst other options.
2.1. Exclusion criteria
The following types of patients were excluded from the analysis: (1)
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International Journal of Pediatric Otorhinolaryngology 125 (2019) 116–121
patients with trace silent aspiration that did not have a diet modifica-
tion recommendation by SLP and without future reported feeding dif-
ficulties (2) patients that had laryngeal surgeries (e.g. laryngeal cleft
repair, supraglottoplasty), and (3) patients with oral aversion or overt
aspiration were excluded from both arms. Patients who only had one
MBSS (the initial one) were excluded in the time to resolution analysis.
2.2. Definitions of resolution
The following patients with one or more of the following definitions
were considered to have resolution of their silent aspiration: (1) if a
patient with silent aspiration on the initial MBSS had a follow up MBSS
without findings of silent aspiration or (2) if at a future date, patients
with silent aspiration were maintaining a normal diet without need for
thickeners. If not resolved by age 5 or if the patient died before the
resolution of aspiration was determined, it was concluded that the
patient's swallowing difficulties would not or did not resolve. The term
“unknown” resolution was used in patients who were lost to follow up
prior to the age of 5 years old or who had not yet reached the age of 5 at
last chart review.
2.3. Statistical analysis
Comorbidities, demographics and other related patient factors for
SA vs. N groups were compared. Categorical variables were compared
using either Fisher's exact test or the chi-square test. Continuous vari-
ables were compared using the Wilcoxon rank sum test. Univariable
Kaplan Meier analysis was used to investigate resolution and associated
factors. Statistical significance was set at p < 0.05.
IRB Information: Cleveland Clinic Institutional Review Board ap-
proved this study under IRB # 17–1057.
3. Results
3.1. Overall characteristics
A total of 148 electronic medical charts were reviewed, of which 92
were excluded. Of the 56 patients in the study, 27 (48.2%) were female,
and 29 (51.8%) were male (Table 1). The overall median gestational
age was 38.1 weeks (interquartile range (IQR) = 35.0–39.3 weeks).
Median age at first MBSS was 176 days (IQR = 104–379 days). The
median number of MBSS performed per patient was 3 (IQR = 2–3).
Fourteen (56%) SA patients had flexible laryngoscopy completed, while
8 (32%) patients had direct laryngoscopy and bronchoscopy completed
by trained pediatric otolaryngologists. Based on these studies, 9 (36%)
patients were found to have relevant findings, including lar-
yngomalacia, vocal fold paralysis, or tracheomalacia. A modified diet
was recommended by SLP after MBSS in 24 (96%) of silent aspirators.
We do not routinely perform impedance-pH probe testing at our in-
stitution in this age group. Nevertheless, 8 patients, at some point, had
upper gastrointestinal (GI) endoscopy and/or impedance probe testing;
the results of these tests were negative in all but two patients. The SLPs
at our institution evaluate for reflux as part of the MBSS assessment,
and in this cohort, 4 patients showed signs of reflux during the MBSS
procedure. Additionally, 20/25 silent aspirators had been treated
(mostly empirically) for laryngopharyngeal reflux. Of this group, 5
patients underwent Nissen fundoplication.
3.2. Silent aspiration vs. normal cohorts
Of the 25 patients with silent aspiration, 11 (44.0%) were male, and
14 (56.0%) were female. Of the 31 patients with normal MBSS, 16
(51.6%) were female, and 15 (48.4%) were male. There was no sta-
tistically significant difference between the gestational age of the SA
group vs. N group (median = 38.0, IQR = 36.0–39.3 weeks vs.
median = 38.1 weeks, IQR = 34.9–39.7 weeks, p = 0.33). The two
E.O. Shay, et al. International Journal of Pediatric Otorhinolaryngology 125 (2019) 116–121

Table 1
Relevant chart review data for all 25 silent aspirators.
ID# Sex GA (wks.) Modified Barium Swallow Diet Flexible Direct Surgeries Comorbidities Resolution of Silent
Studies Modified? Laryngoscopy Laryngoscopy Aspiration
Findings &
Age of Age of Total # Bronchoscopy GT Open Neuro Musc GI/Pulm Syndrome Age of Time
First Last Findings Heart Resolution Between
(Days) (Days) (Days) MBSS and
Resolution
(Days)

Resolution: YES
1 F 30.0 115 264 3 Yes L VCP N X X X 264 149
2 M 28.9 183 243 2 Yes Sz 243 60
3 F 37.7 26 62 2 Yes X X 62 36
4 M 23.7 135 577 4 Yes N X 577 442
5 M 39.0 155 344 2 Yes X X 344 189
6 F 37.0 233 381 3 Yes LVCP X X 418 185
7 F 22.6 300 503 2 Yes X X
8 F 38.1 182 466 3 Yes X CP, Sz X X X 466 284
9 M 39.3 264 304 3 Yes R VCP Sz 304 40
10 F 36.0 16 140 2 Yes X 140 124
11 M 39.0 10 464 4 Yes X X 238 228
12 M 38.1 345 710 3 Yes LM X X 974 629
13 F 39.3 364 1129 4 Yes N X Sz X 1129 765
14 F 37.0 526 N/A 1 Yes N X X X 961 435
Resolution: NO
15 M 25.0 583 3459 3 Yes LM LM X CP
16 M 40.0 1036 1113 2 Yes LM LM,TM X CP, Sz X
17 M 40.1 293 524 2 Yes N X CP, Sz
18 M 40.0 58 667 5 Yes LM LM Sz X
19 M 38.0 39 310 3 Yes LM N X X
Resolution: UNKNOWN
20 F 38.4 277 N/A 1 Yes TM TEF
21 M 39.4 24 1035 4 Yes N X X X X
22 M 40.3 14 N/A 1 Yes Sz
23 F 37.0 424 879 3 Yes N X
24 M 32.0 108 N/A 1 No
25 F 38.0 146 N/A 1 Yes N LM X Sz X

*F = female, M = male, GA = gestational age, Neuro = neurological, Musc = musculoskeletal, GI = gastrointestinal, Pulm = pulmonary, GT = gastrostomy tube,
LM = laryngomalacia, TM, tracheomalacia, N = normal, L = left, R = right, VCP = vocal cord paralysis, CP = cerebral palsy, Sz = seizures,
TEF = tracheoesophageal fistula, N/A = not applicable.

cohorts also did not differ in when they received their first MBSS
(median = 182 days, IQR = 58–300 days vs. 176 days, IQR = 12–521
days, p = 0.33). Silent aspirators more frequently had comorbidities
than did patients with normal MBSS (96.0% vs. 48.4%, p = 0.003).
Silent aspirators also had higher rates of neurological comorbidity
(64.0% vs. 9.7%, p < 0.001) when compared with non-aspirators.
There were noted higher rates of cerebral palsy (CP) (16.0% vs. 0%,
p = 0.034), and seizures (36.0% vs. 3.2%, p = 0.003) in the SA group
vs. N group. There was no difference in rates of muscular disorders
(p = 0.09), tracheoesophageal fistula (TEF) (p = 0.37), aerodigestive
disorders (p = 0.38), or syndromes (p = 0.39) between groups. Four
(16%) patients in the SA group died as of the last follow-up while no
deaths were reported in the normal group.
Patients with demonstrated silent aspiration had a significantly
higher frequency of gastrostomy tubes than those who had normal
MBSS (52.0% vs. 0.0%, p < 0.001). Gastrostomy tube dependence was
not associated with any clinical factors (Table 3).
3.3. Resolution of silent aspiration
Of the 25 silent aspirators, 20 had an MBSS completed beyond the
initial MBSS. Of these patients, 13 (65.0%) experienced resolution of
symptoms, 5 (25.0%) did not experience resolution of symptoms by age
5, and 2 (10.0%) did not have sufficient follow-up to determine re-
solution (Fig. 1A). The median time between first MBSS and resolution
was 189 days (IQR 124–303 days). Kaplan-Meier curves were used to
analyze differences in time to resolution for variables including gender,
gestational age, age at first MBSS, need for a gastrostomy tube, and the
presence of various comorbidities. There was no statistically significant
relationship between the variables studied and time to resolution
(Table 2). The strongest evidence of associations with increased re-
solution were patients with female gender (p = 0.09), and those who
did not have a diagnosis of CP (p = 0.11), but, again, none of these
associations achieved statistical significance. (Fig. 1B and C).
4. Discussion
The natural history of silent aspiration is not well understood in the
pediatric population. Although a few studies have focused on risk fac-
tors, there are no studies that have investigated the course of resolution
in pediatric patients with silent aspiration. The goal of the study was
not to identify the etiology of the patient's swallowing difficulties, but
to assess long term resolution, without intervention, regardless of silent
aspiration etiology.
Results in this study are suggestive that neurologic disorders are
significantly associated with the risk of silent aspiration. These results
are congruent with prior studies, which have found neurological co-
morbidities to be associated with a diagnosis of silent aspiration [8,9].
Patients with CP may suffer from hypotonia, hypertonia, and sensor-
imotor impairment, all of which may increase the risk of dysphagia and
aspiration [2,4]. Both Weir et al. and Velayutham et al. analyzed the
relationship between CP and silent aspiration. Contrary to our findings,
Weir et al. found no relationship between the two disorders and Ve-
layutham et al. only noted a statistically significant association prior to
adjusting for age and gender [8,9]. Arvedson et al. reported higher
percentages of patients with CP in a cohort of mainly silent aspirators

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Table 2 compared with a cohort of non-aspirators [4]. Given that CP can have a
Kaplan-Meier estimate table: percentage of silent aspirators unresolved at 1 and spectrum of severity, it would be interesting in future studies to in-
2 years. vestigate if silent aspiration varies with CP severity. Like Velayutham
Variable % Silent aspirators % Silent aspirators Log-rank et al., we also found an association between silent aspiration and sei-
unresolved at 1 year unresolved at 2 years P-value zure disorders [9]. We did not find any statistically significant asso-
ciations between silent aspiration and other comorbidities of interest
Gender 0.09
such as aerodigestive disorders (including TEF), musculoskeletal dis-
Male 66.7 50.0
Female 25.0 25.0 orders, and syndromes. These findings underscore the importance of
Gestational Age 0.4 being vigilant about silent aspiration in children with neurological
< = 38 weeks 40.0 30.0 disease.
> 38 weeks 60.0 50.0
Laryngeal abnormalities have been known to cause swallowing
G-tube 0.28
No 50.0 25.0
dysfunction in children [11,12]. Disorders of the larynx not only disrupt
Yes 50.0 50.0 the series of coordinated movements that must occur to complete a
Neuro 0.29 successful swallow but also may interfere with protective reflexes such
No 33.3 16.7 as the laryngeal adductor response (LAR) and the laryngeal cough reflex
Yes 57.1 50.0
(LCR) [2]. In a cohort of patients with laryngomalacia who underwent
Seizures 0.11
No 46.2 30.7 MBSS, Irace et al. noted the prevalence of silent aspiration was 41.5%
Yes 57.1 57.1 [13]. In another study, Irace et al. found 53.6% of a cohort of 28
Muscular 0.99 children with unilateral vocal paralysis were silent aspirators [14]. We
No 46.2 38.5
collected data on the findings of flexible laryngoscopy, direct laryngo-
Yes 57.1 42.9
Aerodigestive 0.87
scopy, and bronchoscopy. Of the 14 patients who underwent these
No 52.9 41.2 studies, 5 were found to have laryngomalacia, and 3 were found to have
Yes 33.3 33.3 unilateral vocal fold paralysis. Our observation of laryngomalacia and
Syndrome 0.74 vocal paralysis in children with silent aspiration, even in this small
No 47.1 41.2
cohort, suggests that clinicians should be aware of the possibility of
Yes 66.7 33.3
Open Heart 0.46 silent aspiration in patients with laryngeal abnormalities. Interestingly,
Surgery 4 out of 5 patients whose silent aspiration did not resolve had lar-
No 56.3 43.8 yngomalacia. These patients did not undergo supraglottoplasty or other
Yes 25.0 25.0 intervention because these patients were thriving with observation
and/or medical therapy. Aspiration has been known to co-occur in
children with laryngomalacia due to disruption of suck-swallow-
Table 3
breathe sequence that is required to protect the airway from aspiration.
Factors associated with gastrostomy tube dependence.
In addition, supraglottoplasty to correct laryngomalacia has been
Variable Gastrostomy Tube P-value shown to worsen aspiration in some studies [15]. Management of silent
aspiration in laryngomalacia is indeed complicated because an im-
No Yes
provement in airway function may worsen feeding. Additionally, these
Presence of G-tube 12 (48.0%) 13 (52.0%) patients who failed to resolve also had neurological disease. It is unclear
Gender 0.82 based on this limited data whether laryngomalacia in isolation would
Female 5 (41.7%) 6 (46.2%)
cause silent aspiration or if its effect is cumulative with neurologic
Male 7 (58.3%) 7 (53.8%)
Gestational age 37.36 (IQR: 38.14 (IQR: 0.57
disease. Further studies will be needed to evaluate the risk of silent
(Weeks) 35–38.64) 37–39.29) aspiration in patients with laryngomalacia in isolation.
Resolution 0.36 There are currently no guidelines on when to reassess for resolution
No 1 (8.3%) 4 (30.8%) of silent aspiration. Patients may thus not resume a regular diet as soon
Unknown 4 (33.3%) 2 (15.4%)
as is safe or undergo a greater number of MBSS, sooner than is neces-
Yes 7 (58.3%) 7 (53.8%)
Neuro 0.69 sary. In the former case, where patients are reassessed relatively late,
N 5 (41.7%) 4 (30.8%) parents may shoulder the burden of diet restrictions for longer than is
Y 7 (58.3%) 9 (69.2%) necessary, and children may miss the benefits of a regular diet. In the
Cerebral Palsy 0.1 latter instance, patients may be exposed to more radiation than is ne-
N 12 (100%) 9 (69.2%)
Y 0 (0%) 4 (30.8%)
cessary. With the ever increasing concern of exposing children to ra-
Seizures 1 diation, there is a need to discuss the level of exposure in these children
N 8 (66.7%) 8 (61.5%) undergoing repetitive MBSSs. Although studies have shown an in-
Y 4 (33.3%) 5 (38.5%) dividual would need approximately 40 MBSSs in a given year to exceed
Muscular 0.41
radiation dose limits, this patient population has a high number of
N 9 (75.0%) 7 (53.8%)
Y 3 (25.0%) 6 (46.2%) comorbidities and may concurrently undergo other tests which involve
Aerodigestive 1 radiation [16]. A prior study has shown that MBSSs done by novice
N 10 (83.3%) 11 (84.6%) clinicians and those done on children with more severe swallowing
Y 2 (16.7%) 2 (15.4%) impairment can increase exposure times in comparison to those com-
TEF 0.48
N 11 (91.7%) 13 (100%)
pleted by experienced clinicians or on children with less severe swal-
Y 1 (8.3%) 0 (0%) lowing impairment [17]. Average exposure time for each MBSS was
Syndrome 0.32 roughly 2.9 minutes in the study [17]. With this in mind, parents must
N 9 (75.0%) 12 (92.3%) be advised of potential risks. In addition, clinicians with experience
Y 3 (25.0%) 1 (7.7%)
should be preferred in performing studies in children. At our institution,
Open Heart Surgery 0.32
N 11 (91.7%) 9 (69.2%) the average exposure time for MBSS is 2.3 minutes, and pulsed
Y 1 (8.3%) 4 (30.8%) fluoroscopy is used to limit radiation dose. Patients undergoing repeat
MBSS are usually only tested on consistencies of concern to reduce
exposure time. In children that have severe aspiration, which likely

119
E.O. Shay, et al.
Fig. 1. Kaplan-Meier curves of (A) years since first MBSS and percentage of unresolved silent aspirators (B) years since first MBSS and gender and (C) years since first
MBSS and diagnosis of cerebral palsy, all with associated p-values.
prolongs studies, consideration should be given for an increased dura-
tion of time between each MBSS. It is unlikely that severe aspiration
will resolve within weeks or a few months and as such, extending time
intervals between studies is reasonable.
Although not statistically significant, this study showed the stron-
gest evidence of associations with increased resolution in patients with
female gender and those who did not have a diagnosis of CP. In a study
of silent aspiration involving children and adults, Smith et al. found
that males were more likely to aspirate [1]. By contrast, Weir et al.
found no difference in risk based on gender [8]. Although this trend
could be spurious, it is of note that males are more vulnerable to CP – a
condition which was found to trend towards a negative association with
resolution [18–20]. Patients with CP experience a multitude of per-
manent physical challenges that may not improve sufficiently, with
time, to facilitate the resolution of silent aspiration. Further studies are
needed to investigate these trends.
Half of the patients in this study's cohort experienced resolution of
silent aspiration within the first year of their MBSS. Less than half of the
patients remained unresolved between one and two years after their
first MBSS and an even smaller portion three years after the initial
MBSS. Our data suggest that overall, many of the patients diagnosed
with silent aspiration will resolve with time. Repeating MBSS by at least
6 months after the initial MBSS would be reasonable based on SLP re-
commendations and clinician based evaluation. Conservative manage-
ment with dietary changes based on SLP recommendations can be used
while monitoring these patients for resolution. Our dataset is, however,
limited and does not fully take into account the differences in resolution
time based on comorbidities and age. Therefore, the decision to follow
these patients with repeat MBSS to assess resolution must be de-
termined on an individual case basis. Larger studies are needed to
provide robust evidence-based guidelines on when to recommend
swallowing reassessment and if and when surgical interventions should
be considered.
One limitation of this study is the retrospective study design,
making it difficult to ascertain if and specifically when patients' silent
aspiration resolved. In addition, there was no standard protocol of
when or why patients underwent an MBSS. Although a small minority,
6 patients’ resolution was undetermined due to being lost to follow up
or not reaching 5 years of age. Lastly, the small sample size limited the
power of the study. However, the strict exclusion criteria strengthened
the study allowing for analysis of only patients that had silent aspira-
tion with no surgical intervention. This permitted investigation into the
natural history of these patients without other variables confounding
the rates of resolution.
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International Journal of Pediatric Otorhinolaryngology 125 (2019) 116–121
5. Conclusion
The natural history and the temporal course of silent aspiration in
the pediatric population are poorly understood. Comparison of silent
aspirators and non-aspirators revealed a significant difference in neu-
rological comorbidities associated with swallowing issues, particularly
a diagnosis of CP and a history of seizures. More than half the patients
with silent aspiration do resolve over time; careful monitoring with
repeat assessments based on clinical suspicious will allow for con-
servative management in some of these patients. Further studies with
larger patient cohorts followed over time will allow the corroboration
of findings in this study.
Conference information
This study was presented as an oral presentation at the Triological
Society Conference 2019, January 24–28, 2019, Coronado, CA, USA.
Financial disclosure
The authors listed above have no financial conflicts to disclose.
Conflicts of interest
The authors listed above have no conflicts of interest to disclose.
Acknowledgments
Jeffery P Hammel
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