**3.2 Methods**

All patients underwent physical examination, Ear, Nose and Throat (ENT) assessment with a detailed evaluation of the cranial nerves, in particular V, VII, IX, X, and XII cranial nerve, and Fiberoptic Endoscopic Evaluation of Swallowing disorders (FEES). Pulmonary counseling and allergy tests were also performed in each participating patient.

All patients completed a Reflux Symptom Index questionnaire (RSI). RSI consists of nine questions regarding extraesophageal symptoms of gastroesophageal reflux disease, assessed on a scale of 0–5. A score of over 13 points is interpreted as abnormal and indicates the need for further investigation e.g. gastroscopy, esophageal impedance test [15].

Phoniatric assessment included careful visual inspection of the oral cavity, pharynx and the larynx, videolaryngoscopic evaluation (VLS) and functional assessment of the larynx. The changes noticed in the larynx were assessed using the Reflux Finding Score (RFS) that rates objectively the laryngeal reflux changes. The scale ranges from 0 to 22 points where the result of 7 and more points indicates laryngopharyngeal reflux [16].

On physical examination, particular attention was drawn to: pharyngeal reflexes, strength, range and coordination of the oral cavity and pharyngeal muscles, and elevation of the larynx during swallows.

In the functional assessment the following was evaluated:


For the screening assessment of dysphagia the water-swallow test (WST) was used in following steps (liquid volume): 5, 10, 20, and 90 ml of non-carbonated water. After each step the presence of indirect signs of penetration/aspiration of the liquid into the larynx, i.e. coughing, change in voice quality, throat clearing, portioning or test termination [17].

Fiberoptic Endoscopic Examination of Swallowing (FEES) was used for a static and dynamic evaluation of the upper airways and upper digestive tract structures with the anatomy and physiology of the pharynx and larynx during swallows. FEES also gives opportunity to evaluate pharyngeal walls movements during phonation

(squezee maneuver) and swallowing of different food consistency. Food consistency was gradually changed from liquid (non-carbonated water), puree (water thickened to the consistency of pudding), and solid food (rucks). In FEES the efficiency of swallowing and penetration/aspiration were assessed using Penetration-Aspiration Scale (PAS). According to Rosenbeck's criteria the scale ranges from 1 to 8, where 1 means no problem, 2–5 means different degree of penetration with or without cough, 6–8 means different degree of aspiration with or without the cough [18–21].
