10.14639/0392-100X-N2289
Objective. In the dysphagic patient, pharyngeal residues (PR) are associated with aspiration and poor quality of life. The assessment of PR using validated scales during flexible endoscopic evaluation of swallowing (FEES) is crucial for rehabilitation. This study aims to validate and test the reliability of the Italian version of the Yale Pharyngeal Residue Severity Rating Scale (IT-YPRSRS). The effects of training and experience in FEES on the scale were also determined. Methods. The original YPRSRS was translated into Italian according to standardised guidelines. Thirty FEES images were selected after consensus and proposed to 22 naive raters who were asked to assess the severity of PR in each image. Raters were divided into two subgroups by years of experience at FEES, and randomly by training. Construct validity, inter-rater, and intra-rater reliability were assessed by kappa statistics. Results. IT-YPRSRS showed substantial to almost perfect agreement (kappa &gt; 0.75) in validity and reliability for both the overall sample (660 ratings), and valleculae/pyriform sinus sites (330 ratings each). No significant differences emerged between groups considering years of experience, and variable differences were observed by training. Conclusions. The IT-YPRSRS demonstrated excellent validity and reliability in identifying location and severity of PR.
text/xml
1827-675X
2289
en
Diego Cazzador
http://creativecommons.org/licenses/by-nc-nd/4.0
ACTA Otorhinolaryngologica Italica
scale
Validity and reliability of the Italian translation of the Yale Pharyngeal Residue Severity Rating Scale
Text.Serial.Journal
https://www.actaitalica.it/
43
Head and neck
2023-02-27
2022-08-30
2023-02-28
2023-02-28
12-19
1
Diego Cazzador
2023/02/27
10.14639/0392-100X-N2289
12
Department of Neuroscience, Section of Otolaryngology, Azienda Ospedale-Università Padova, Padua, Italy
1827-675X
scale
en
19
Validity and reliability of the Italian translation of the Yale Pharyngeal Residue Severity Rating Scale
https://www.actaitalica.it/article/download/2289/913
43
ACTA OTORHINOLARYNGOLOGICA ITALICA 2023;43:12-19; doi: 10.14639/0392-100X-N2289




Head and neck


Validity and reliability of the Italian translation
of the Yale Pharyngeal Residue Severity Rating Scale
Studio di validazione e affidabilità della traduzione italiana della Yale Pharyngeal
Residue Severity Rating Scale
Sara Nordio1, Lorenza Maistrello1, Daniela D’Imperio1, Niccolò Favaretto2, Angela Dellai3, Silvia Montino2,
Anna Agostinelli2, Giulia Ramacciotti2, Flavia Gheller4, Giulia Berta1, Isabella Koch1, Elisabetta Zanoletti2,
Irene Battel5,6, Diego Cazzador2
1
  IRCCS San Camillo Hospital, Venice, Italy; 2 Department of Neuroscience, Section of Otolaryngology, Azienda Ospedale-Università
Padova, Padua, Italy; 3 Unità Operativa Medicina Fisica e Riabilitativa, Ulss 6 Euganea, Ospedale di Conselve, Padua, Italy;
4
  Department of Developmental Psychology and Socialisation (DPSS), University of Padua, Padua, Italy; 5 Unità Operativa Medicina
Fisica e Riabilitativa, Ulss 3 Serenissima, Ospedale Civile di Venezia, Venice, Italy; 6 Department of Clinical Speech & Language
Studies, University of Dublin, Trinity College, College Green, Dublin 2, Ireland


SUMMARY
Objective. In the dysphagic patient, pharyngeal residues (PR) are associated with aspira-
tion and poor quality of life. The assessment of PR using validated scales during flexible
endoscopic evaluation of swallowing (FEES) is crucial for rehabilitation. This study aims to
validate and test the reliability of the Italian version of the Yale Pharyngeal Residue Sever-
ity Rating Scale (IT-YPRSRS). The effects of training and experience in FEES on the scale
were also determined.
Methods. The original YPRSRS was translated into Italian according to standardised
guidelines. Thirty FEES images were selected after consensus and proposed to 22 naive
raters who were asked to assess the severity of PR in each image. Raters were divided into
two subgroups by years of experience at FEES, and randomly by training. Construct valid-
ity, inter-rater, and intra-rater reliability were assessed by kappa statistics.
Results. IT-YPRSRS showed substantial to almost perfect agreement (kappa > 0.75) in                 Received: August 30, 2022
validity and reliability for both the overall sample (660 ratings), and valleculae/pyriform         Accepted: December 18, 2022
sinus sites (330 ratings each). No significant differences emerged between groups consider-
ing years of experience, and variable differences were observed by training.                        Correspondence
Conclusions. The IT-YPRSRS demonstrated excellent validity and reliability in identifying           Diego Cazzador
                                                                                                    Department of Neuroscience, Section of Otolaryn-
location and severity of PR.
                                                                                                    gology, University of Padova, via Giustiniani 2,
KEY WORDS: deglutition, fiberoptic endoscopic evaluation of swallowing, pharyngeal                  35128 Padua, Italy
residue; reliability, scale                                                                         Tel. +39 049 821 8778. Fax +39 049 821 1994
                                                                                                    E-mail: diego.cazzador@unipd.it

RIASSUNTO
                                                                                                      How to cite this article: Nordio S, Maistrello
Obiettivo. Nel paziente disfagico i residui faringei (RF) correlano con rischio di aspira-
                                                                                                      L, D’Imperio L, et al. Validity and reliability
zione e bassa qualità di vita. La loro valutazione durante FEES attraverso scale validate è           of the Italian translation of the Yale Pharynge-
fondamentale. Questo studio mira a validare e testare l’affidabilità della versione italiana          al Residue Severity Rating Scale. Acta Otorhi-
della Yale Pharyngeal Residue Severity Rating Scale (IT-YPRSRS), una scala che valuta i               nolaryngol Ital 2023;43:12-19. https://doi.
RF. Vengono inoltre studiati gli effetti di esperienza professionale e training.                      org/10.14639/0392-100X-N2289
Metodi. La YPRSRS in versione inglese è stata tradotta in Italiano secondo protocollo stan-
dardizzato. Trenta immagini post-deglutitorie sono state selezionate da tre esperti nell’uso        © Società Italiana di Otorinolaringoiatria
della YPRSRS e proposte a 22 valutatori naif, che hanno determinato il livello di gravità           e Chirurgia Cervico-Facciale
dei RF in ciascuna. I valutatori sono stati quindi divisi in due sottogruppi secondo: anni
di esperienza nella FEES e training. La validità di costrutto e l’affidabilità intra- ed inter-                    OPEN ACCESS
operatore sono state studiate con kappa statistics.                                                 This is an open access article distributed in accordance with
Risultati. La IT-YPRSRS ha mostrato un elevato grado di agreement (kappa > 0,75) in ter-            the CC-BY-NC-ND (Creative Commons Attribution-Non-
mini di validità di costrutto e di affidabilità, per la totalità del campione (660 ratings) e per   Commercial-NoDerivatives 4.0 International) license. The
                                                                                                    article can be used by giving appropriate credit and mentio-
le sedi di vallecule e seni piriformi separatamente (330 ratings ciascuno). Non sono state          ning the license, but only for non-commercial purposes and
rilevate differenze significative per gli anni di esperienza, mentre si è osservato un miglior      only in the original version. For further information: https://
agreement nei risultati del gruppo sottoposto a training.                                           creativecommons.org/licenses/by-nc-nd/4.0/deed.en




12
                                                                                                                     Validation of the IT-YPRSRS




Conclusioni. La IT-YPRSRS ha dimostrato un eccellente livello di validità e affidabilità nell’identificazione e nella quantificazione di RF.
PAROLE CHIAVE: deglutizione, FEES, residui faringei, affidabilità, scala



Introduction                                                              Materials and methods
Pharyngeal residues (PR), defined as the retention of liquids             A cross sectional design was selected for the present study.
or food in the pharynx after swallowing, is one of the most               Research methodology recommends following a standard-
relevant signs of oropharyngeal dysphagia 1. This condition               ised translation and validation process of a scale, in order
severely affects patients’ morbidity, due to the high risk of as-         to achieve appropriate linguistic accuracy 20.
piration, malnutrition and dehydration 2, thus decreasing pa-
tients’ quality of life and social participation 3. Accordingly,          Translation
PR may be a predictor of post-swallow penetration and aspira-             After authorisation by the authors of the YPRSRS (Neu-
tion 4-6, so that the accurate identification and quantification of       bauer PD, personal communication), the translation process
the residue severity in the clinical setting is crucial 7.                included the following steps: (i) forward translation and its
Residues can be directly observed through fibreoptic en-                  review for consensus; (ii) backward translations and its re-
doscopic evaluation of swallowing (FEES), which allows                    view for consensus. Three forward translations into Italian
identification of exact anatomical sites and amount 4. FEES               language were produced by two bilingual Otolaryngolo-
and videofluoroscopic swallow study (VFSS) are well-                      gists and two Speech and Language Pathologists (SLP) in-
recognised methods for diagnosis and management of dys-                   volved in the management of patients with dysphagia. The
phagia 8. Although FEES is more sensitive than VFSS in                    three versions were discussed and merged after consensus.
quantifying PR, this procedure can be affected by subjec-                 Next, two external native English speakers with excellent
tive interpretation of the clinician and compared to VFSS                 Italian language skills performed two back translations of
lacks objective tools for PR assessment 9-11. In addition, the            the consensus version into English. The back translations
simple ascertainment of the presence of PR can be insuf-                  were subsequently compared to the original version and
ficient for clinical and rehabilitation management, as well               discussed by the expert committee (the Otolaryngologists
as for research purposes. To overcome these issues, sev-                  and the SLPs) which stated all items of the scale were com-
eral rating scales have been proposed to define dysphagia                 pletely clear. The Italian version of the scale is reported in
and PR severity during FEES 4,12,13. However, a systematic                Appendix I.
review by Neubauer et al. 14 on PR severity rating scales
based on FEES, revealed many methodological flaws in the                  Fibreoptic endoscopic evaluation of swallowing
included studies, and only the Yale Pharyngeal Residue Se-                FEES examination was conducted by otorhinolaryngolo-
verity Rating Scale (YPRSRS) 15 resulted a valid and reli-                gists together with SLPs using a flexible transnasal laryngo-
able tool for residue assessment.                                         scope and Tele Pack system (KARL STORZ SE & Co. KG,
The YPRSRS is an anatomically defined, 5-points ordinal                   Tuttlingen, Germany). Each examination was anonymously
scale (none, trace, mild, moderate, severe) that outlines the             recorded as .AVI files. Fifty-five consecutive patients with
residue severity patterns in the valleculae and pyriform si-              swallowing impairments from neurogenic aetiology were
nuses 15. This scale has already been validated in German 16              recruited, with a prevalent diagnosis of stroke-induced dys-
and Turkish 17. To the best of our knowledge, no such tools               phagia (56.4%), whereas the other diagnoses included brain
are available in Italian to date.                                         injury, brain tumour, multiple sclerosis and amyotrophic
The importance of adopting the same internationally                       lateral sclerosis. FEES was completed with the following
validated instruments for PR evaluation can facilitate the                bolus types, twice each: cracker for solid food (IDDSI 7),
comparability of results across different countries. The                  5-mL yogurt for pureed food (IDDSI 4), and 5-mL milk for
cross-cultural translation process ensures that a translated              liquid food (IDDSI 2) 21.
measurement tool is understood in a cultural context that is
different from the original setting and that does not lose its            Image selection
measurement properties 18,19.                                             Initially, 103 post-swallow images were selected from the
This study aimed to: (i) translate the YPRSRS, (ii) assess                recorded videos. All the frames were captured at the end of
the psychometric properties of the Italian version of the                 the first swallow to have homogeneous data for rating 15.
IT-YPRSRS, and (iii) determine if training and experience                 Ninety of these displayed bolus residues, while 17 images
have an impact on the results of the IT-YPRSRS.                           displayed no residues. The first step of the selection pro-



                                                                                                                                               13
S. Nordio et al.




cess consisted in the categorisation of the 103 images for        on the agreement between the first evaluation of each rater
reference in severity rating. Given the absence of a gold         and that of the experts. The intra-rater reliability was de-
standard reference, three FEES experts with a combined            termined by calculating Cohen’s kappa coefficient with
23 years of expertise (range 6-9 years) independently con-        quadratic weights by the agreement between the first and
ducted the task according to the YPRSRS severity. Only            the second rating. The degree of agreement across several
images with complete agreement among the three experts            raters (inter-rater reliability) was calculated by the Fleiss’
were included (64 images), thus obtaining one reference           kappa with quadratic weights 24. The analyses were per-
value per image for the calculation of the construct validity.    formed for the overall sample and for subgroups of raters to
Finally, a further image selection was conducted following        assess whether there was a difference in outcomes related
the “best-of-the-best” criterion, and 30 images were chosen       to the level of experience, and training status.
by consensus (15 for valleculae and 15 for pyriform sinus-        To interpret the results, the criteria proposed by Landis and
es, with homogeneous distribution of scores, i.e. 3 images        Koch were used for Cohen’s kappa: values between 0.41-
per each score class). Less-defined frames were excluded.         0.60 represent moderate agreement, values between 0.61-
                                                                  0.80 substantial agreement, and values between 0.81-1.00
Rating process                                                    almost perfect agreement 23. The following benchmark was
Ten otorhinolaryngologists and 12 SLPs regularly in-              adopted for the Fleiss kappa: values < 0.40 poor agreement,
volved in FEES, with a minimum professional experience            between 0.40-0.75 intermediate to good, and > 0.75 excel-
of 3 years, were recruited at different Italian institutions.     lent agreement 24. Kappa values of different subgroups were
None of the 22 raters had ever used the English version           compared using Z-statistics 15. All statistical analyses were
of the YPRSRS for either clinical or scientific purposes.         performed using the IBM SPSS software for Windows, ver-
After agreeing to participate, raters were grouped accord-        sion 26.0 (SPSS Inc., Chicago, IL, USA). The significance
ing to training status and years of experience with FEES.         level was set at 0.05.
As for training, raters were randomly assigned (by means
of a computer-generated order using the appropriate Ex-
                                                                  Results
cel function) to receive or not a specific 4-minute training
video in Italian. The video explained the rationale, applica-     Characteristics of raters
tion and clinical significance of the YPRSRS, and provided        Twenty-two raters, including 12 (55%) SLPs and 10 (45%)
images (different from those selected for data collection)        otorhinolaryngologists took part in the study. All raters
for each grade of severity. As for years of experience, raters    completed the grading of FEES images in the given time,
were divided in two subgroups by the median value.                and none left the study. Participants’ characteristics are re-
The colour images (15 for valleculae evaluation, and 15           ported in Table I.
for pyriform sinuses) were sent via email as an editable
pdf file, presenting one image per page at a resolution of        Measures of validity and reliability
720 x 476 pixels. The file included the Italian version of the    Kappa statistic calculated on the entire sample of 660 rat-
YPRSRS. Raters were asked to assess the severity level of         ings reported substantial to almost perfect agreement, with
residue for each image by selecting the considered appro-         no values below 0.75 (Tab. II). Analyses performed on 330
priate value. A second round of rating was performed after        ratings according to the anatomical location confirmed
15 days to assess intra-rater reliability 15. For this purpose,   excellent degrees of validity and reliability (Tab. II). Spe-
the same images were randomly rearranged in a new edit-           cifically, construct validity was almost perfect for both ana-
able pdf file.                                                    tomical sites (kappa = 0.98 ± 0.02). There was excellent
                                                                  inter-rater agreement for the valleculae and pyriform si-
Statistics                                                        nuses locations, with kappa of 0.81 ± 0.01 and 0.78 ± 0.01,
Descriptive statistics were calculated to obtain the demo-        respectively; and an almost perfect intra-rater agreement
graphic and professional characteristics of the raters. As-       for both sites with kappa = 0.95 ± 0.01 in evaluation of val-
sociations of discrete and continuous variables were as-          leculae residues, and kappa = 0.93 ± 0.01 in assessment of
sessed with Fisher’s exact test and Mann-Whitney U test,          pyriform sinus residues.
respectively. Construct validity, intra-rater reliability, and
inter-rater reliability were calculated using kappa statistics,   Ratings by years of experience
standard errors (SEs) and 95% confidence intervals (95%           The 22 raters had a median value of 7 years of FEES ex-
CIs) 22. In particular, construct validity was determined         perience. The 12 less-experienced raters had a median of
with Cohen’s kappa coefficient with quadratic weights 23          5 years experience at FEES (IQR 4.3-6.0), while the 10



14
                                                                                                                                                  Validation of the IT-YPRSRS




Table I. Raters’ characteristics.
                                    Total                                     Experience                                                    Training status
                                  (n = 22)              < 7 years                ≥ 7 years             P-value                No                     Yes           P-value
                                                         (n = 12)                (n = 10)                                   (n = 11)             (n = 11)
 Sex                                                                                                    1.000                                                      0.090
   Female, N (%)                  18 (82%)               10 (56%)                 8 (44%)                                11 (61%)                7 (39%)
   Male, N (%)                     4 (18%)                2 (50%)                 2 (50%)                                 0 (0%)                 4 (100%)
 Profession                                                                                             0.691                                                      1.000
   SLP, N (%)                    12 (55%)                6 (50%)                 6 (50%)                                  6 (50%)                6 (50%)
   MD, N (%)                     10 (45%)                6 (60%)                 4 (40%)                                  5 (50%)                5 (50%)
 Years of experience,           7 [5.0-10.0]            5 [4.3-6.0]            12 [8.8-27.0]               -             6 [5.0-8.5]           8 [6.0-12.0]        0.373*
 median [IQR]
*Mann-Whitney U test; N: number of raters; SLP: speech and language pathologist; MD: otorhinolaryngologist; IQR: interquartile range.



Table II. Construct validity, inter-rater reliability, and intra-rater reliability kappa statistics for valleculae and pyriform sinus ratings across all raters.
                                               Overall                                           Valleculae                                  Pyriform sinus
                                              (N = 660)                                          (N = 330)                                      (N = 330)
                                Kappa (± SE)                 95% CI                Kappa (± SE)                 95% CI                  Kappa (± SE)           95% CI
 Construct validity              0.98 (± 0.01)             0.95; 1.00              0.98 (± 0.02)               0.95; 1.00               0.98 (± 0.02)         0.94; 1.00
 Inter-rater reliability         0.79 (± 0.01)             0.79; 0.81              0.81 (± 0.01)               0.79; 0.83               0.78 (± 0.01)         0.77; 0.80
 Intra-rater reliability         0.94 (± 0.01)             0.93; 0.95              0.95 (± 0.01)               0.94; 0.97               0.93 (± 0.01)         0.91; 0.95
N: number of ratings; SE: Standard Error; 95% CI: 95% confidence interval.



experienced raters had a median of 12 years (IQR 8.8-27.0)                                   nuses, inter-rater reliability agreement was excellent as well
of experience (Tab. I).                                                                      (kappa = 0.78 ± 0.016 vs 0.76 ± 0.019) without significant
Kappa statistic according to years of experience is reported                                 differences by experience at FEES.
in Table III. Construct validity, as well as intra-rater reli-
ability showed almost perfect agreement for both anatomi-                                    Ratings by training status
cal locations. No significant differences were observed                                      Of the 22 rates involved in the study, 11 (50%) were ran-
between groups. The inter-rater reliability for valleculae                                   domly assigned to receive a specific training in the inter-
anatomical site showed excellent agreement in both less-                                     pretation and application of the YPRSRS. There was no
experienced and experienced raters (kappa = 0.79 ± 0.016                                     significant difference in years of FEES experience between
vs 0.83 ± 0.019, respectively; p = 0.184). For pyriform si-                                  trained vs non-trained groups (Tab. I).

Table III. Construct validity, inter-rater reliability, and intra-rater reliability kappa statistics for valleculae and pyriform sinus ratings by years of experience.
                                                          Experience                                                 Experience                              P-value
                                                           < 7 years                                                  ≥ 7 years
                                           Kappa (± SE)                       95% CI                    Kappa (± SE)                        95% CI
 Construct validity
    Valleculae                             0.98 (± 0.015)                    0.95; 1.00                0.98 (± 0.015)                     0.95; 1.00             0.805
    Pyriform sinus                         0.98 (± 0.017)                    0.94; 1.00                0.97 (± 0.019)                     0.93; 1.00             0.909
 Inter-rater reliability
    Valleculae                             0.79 (± 0.016)                    0.76; 0.83                0.83 (± 0.019)                     0.79; 0.87             0.184
    Pyriform sinus                         0.78 (± 0.016)                    0.75; 0.82                0.76 (± 0.019)                     0.72; 0.79             0.314
 Intra-rater reliability
    Valleculae                             0.96 (± 0.009)                    0.95; 0.98                0.94 (± 0.012)                     0.92; 0.97             0.142
    Pyriform sinus                         0.92 (± 0.014)                    0.89; 0.95                0.93 (± 0.014)                     0.90; 0.96             0.801
SE: Standard Error; 95% CI: 95% confidence interval.




                                                                                                                                                                             15
S. Nordio et al.




Kappa statistic according to training status is reported in                            FEES-based PR scales 14. Therefore, in this study we aimed
Table IV. Results showed almost perfect agreement for con-                             to translate and test the psychometric properties of the Ital-
struct validity in both anatomical locations for both raters                           ian version of the YPRSRS.
with and without training (valleculae, p = 0.733; pyriform                             The IT-YPRSRS showed excellent construct validity and
sinus, p = 0.892).                                                                     intra-rater reliability, as well as high inter-rater reliability
Inter-rater reliability in valleculae assessment showed                                for both anatomical sites, valleculae and pyriform sinuses
intermediate-to-good agreement (kappa = 0.72 ± 0.018)                                  (Tab. II). These findings were consistent with that present-
for the training group, and excellent agreement (kap-                                  ed in the original validation of the English version of the
pa = 0.82 ± 0.017) for the subgroup that received train-                               scale 15. The comparable results confirmed the appropriate-
ing. Similarly, in pyriform sinus assessment, intermediate-                            ness of the IT-YPRSRS and its potential inclusion in an
to-good agreement was found for both the non-training                                  Italian clinical context.
group (kappa = 0.56 ± 0.017), and trained group (kap-                                  Similar to what reported for the original YPRSRS 15 as
pa = 0.68 ± 0.018). The differences in the degree of agree-                            well as in the validation of the German and Turkish ver-
ment by training status were significant for PR assessment                             sions 16,17, the current investigation observed that experi-
in both anatomical sites (p < 0.001).                                                  ence does not influence PR ratings. In particular, we cal-
Intra-rater reliability showed almost perfect agreement                                culated similar levels of agreement in both the experienced
by training status. In particular, considering valleculae                              (median < 7 years) and non-experienced (median ≥ 7 years)
residue assessment, trained raters demonstrated a signifi-                             groups of raters, for all psychometric properties analysed
cantly higher agreement than non-trained participants (kap-                            (Tab. III), suggesting that high competence in the use of the
pa = 0.98 ± 0.006 vs 0.93 ± 0.013, p < 0.001).                                         IT-YPRSRS can be achieved by SLPs and physicians with
                                                                                       different levels of expertise.
                                                                                       In the IT-YPRSRS, significantly different values of kap-
Discussion
                                                                                       pa for the valleculae and pyriform sinuses were found
The identification and quantification of PR severity dur-                              for inter-rater reliability between trained and non-trained
ing FEES is of utmost importance in the management of                                  raters, with higher kappa registered in the former group
patients with swallowing disorders 1,6,12. Direct endoscopic                           (p < 0.001). Analogously, higher kappa intra-rater agree-
documentation of PR is currently integrated by the use of                              ment was calculated for valleculae PR assessment by
validated scales for assessment of PR severity 4,12-15. First                          trained raters (p < 0.001). These results coincided with pre-
presented in 2015 15, the YPRSRS is an anatomically de-                                vious data from Neubauer 15 and Gerschke 16, confirming
fined tool for evaluation of residue location (valleculae                              that rating precision might benefit from minimal training
and pyriform sinuses) and residue amount (5-point scale                                before the YPRSRS is applied to patients. We randomly
from none to severe). Among different scales proposed in                               proposed to raters a brief 4-minute training video that ex-
the literature, the YPRSRS is probably the most valid and                              plained the use and rationale of the YPRSRS. This video
reliable, according to a recent systematic review that aimed                           can be adopted in clinics for practitioners who approach the
to compare the qualitative and psychometric properties of                              IT-YPRSRS for the first time.


Table IV. Construct validity, inter-rater reliability, and intra-rater reliability kappa statistics for valleculae and pyriform sinus ratings by training received in the
application of the Yale scale.
                                                             No training received                                    Training received                      p-value
                                                       Kappa (± SE)                  95% CI               Kappa (± SE)                 95% CI
 Construct validity
    Valleculae                                         0.98 (± 0.012)              0.96; 1.00             0.98 (± 0.017)             0.94; 1.00             0.733
    Pyriform sinus                                     0.98 (± 0.017)              0.94; 1.00             0.97 (± 0.019)             0.94; 1.00             0.892
 Inter-rater reliability
    Valleculae                                         0.72 (± 0.018)              0.68; 0.75             0.82 (± 0.017)             0.79; 0.86           < 0.001
    Pyriform sinus                                     0.56 (± 0.017)              0.53; 0.59             0.68 (± 0.018)             0.64; 0.71           < 0.001
 Intra-rater reliability
    Valleculae                                         0.93 (± 0.013)              0.90; 0.95             0.98 (± 0.006)             0.97; 0.99           < 0.001
    Pyriform sinus                                     0.91 (± 0.015)              0.88; 0.94             0.95 (± 0.012)             0.92; 0.97            0.054
SE: Standard Error; 95% CI: 95% confidence interval.




16
                                                                                                                Validation of the IT-YPRSRS




Finally, some limitations of this study need to be noted.        Author contributions
First, as already mentioned in the German Yale validation        All authors contributed to the study conception and design.
study 16, the pre-testing step of the validation process of      SN, NF, FG, GR, SM, DC, GB, IK, AD: material prepara-
the IT-YPRSRS was conducted by consensus with FEES               tion and data collection; LM, DDI, DC: data analysis and
experts 20. Second, as Neubauer and colleagues did in the        results; SN: first draft of the manuscript. All authors com-
original research 15 we selected FEES frames for PR sever-       mented on previous versions of the manuscript. All authors
ity ratings. Undeniably, frames do not represent a real-life     read and approved the final manuscript.
clinical setting, as FEES videos might be more appropri-
ate. However, a recent study based on YPRSRS recognised          Ethical considerations
the substantial complexity in rating PR on videos rather         The study was approved by the Ethics Committee of the
than on frames. The study demonstrated a trend of lower          hospital (Prot.2018.14-YALE) and carried out in accord-
psychometric properties for videos, in comparison to an          ance with the Declaration of Helsinki. All participants
almost perfect agreement for frames 25. Third, the “best-of-     signed an informed consent for their inclusion.
the-best” criterion adopted for the selection of the final im-
ages pool denoted a limitation, as it is not representative of   References
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                                                                      Logemann JA. Evaluation and treatment of swallowing disorders.
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Specific analysis for each consistency rated with the IT-        5
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                                                                 6
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                                                                      tional study in patients with neurogenic dysphagia. Acta Otorhinolaryn-
The psychometric characteristics of the IT-YPRSRS make                gol Ital 2020;40:38-43. https://doi.org/10.14639/0392-100X-2136
it a validated, reliable and valuable tool to integrate FEES
                                                                 7
                                                                      Langmore SE. History of fiberoptic endoscopic evaluation of swal-
                                                                      lowing for evaluation and management of pharyngeal dysphagia:
evaluation. This anatomically defined instrument is easy to           changes over the years. Dysphagia 2017;32:27-38. https://doi.
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of experience of practitioners. We hope that the dissemi-        8
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accuracy of FEES, given the crucial role of characterising       9
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                                                                 10
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The authors would like to thank Paul D. Neubauer, Yale                2006;31:425-432. https://doi.org/10.1111/j.1749-4486.2006.01292.x
School of Medicine, for his support.                             11
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Conflict of interest statement                                        phagia 2013;28:167-177. https://doi.org/10.1007/s00455-012-9426-9
The authors declare no conflict of interest.                     12
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Funding                                                               anorl.2017.12.009
This work was supported by the Italian Ministry of Health        13
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                                                                                                      Validation of the IT-YPRSRS




Appendix I
English version of the Yale Pharyngeal Residue Severity Rating Scale (YPRSRS).

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




Italian version of the Yale Pharyngeal Residue Severity Rating Scale (IT-YPRSRS).

Definitions for severity of vallecula residue
I                       Nessuno                           0%                                 Assenza di residui
II                       Tracce                         1-5%                          Tracce che rivestono la mucosa
III                       Lieve                         5-25%                       Legamento glosso-epiglottico visibile
IV                      Moderato                       25-50%                      Legamento glosso-epiglottico coperto
V                        Grave                         > 50%                  Riempimento fino al margine libero dell’epiglottide


Definitions for severity of pyriform sinus residue
I                        Nessuno                          0%                                 Assenza di residui
II                        Tracce                        1-5%                           Tracce che rivestono la mucosa
III                        Lieve                        5-25%                 Riempimento fino a un quarto della parete del seno
IV                       Moderato                      25-50%                   Riempimento fino a metà della parete del seno
V                         Grave                        > 50%                       Riempimento fino alla plica ariepiglottica




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