Table of Contents    
Year : 2020  |  Volume : 11  |  Issue : 2  |  Page : 169-175  

How much is too much? Effect of volume on water-swallowing test

1 Department of Audiology and Speech-Language Pathology, Nitte Institute of Speech and Hearing, Mangaluru, India
2 Hearing Health Care Clinic, Bengaluru, Karnataka, India

Date of Submission20-Mar-2020
Date of Decision03-Apr-2020
Date of Acceptance17-Apr-2020
Date of Web Publication22-Jul-2020

Correspondence Address:
Thejaswi Dodderi
Nitte Institute of Speech and Hearing, Deralakatte, Karnataka
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jnsbm.JNSBM_63_20

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Introduction: Water-swallowing test (WST) is a simple, economical bedside screening test practiced for early identification of risk for dysphagia (or swallowing impairment). However, there is no consensus on the right test quantity to assess swallowing ability by WST. Aim of the Study: The aim of the present study was to establish the right quantity of water for WST sufficient to assess sequential swallowing in healthy adults albeit avoiding larger quantity of thin liquids. Subjects and Methods: Thirty healthy young adults (HYA) (20–40 years) and thirty healthy middle-aged adults (HMA) (41–60 years) were enrolled by nonrandom convenient sampling. Four quantities (50, 90, 100, and 150 ml) of room temperature water was gauzed by a measuring cup and randomly presented to the participants to swallow in their natural pace. As per the test standard, volume/swallow (V/S), time/swallow (T/S), and swallow capacity (SC) indices were derived and subjected to further statistical analysis. Results: The results of the study suggested statistically significant increased V/S and SC in a lesser T/S among HYA compared to HMA, and the difference was at P < 0.05. The results also revealed 150 and 50 ml to have statistically significant highest and lowest SC, respectively, at P < 0.05. Pearson's correlation index suggested a positive correlation across swallowing indices between the four test volumes of water. Conclusion: The state of evidence suggests better swallowing performance in HYA, and also, there exists a direct relationship between the quantity of water and indices of WST. The advisory is to use the least of the four test quantity of thin liquids for the WST.

Keywords: 150 ml, 50 ml, middle-aged adults, young adults, swallow capacity

How to cite this article:
Dodderi T, Puthiry M, Thomas S. How much is too much? Effect of volume on water-swallowing test. J Nat Sc Biol Med 2020;11:169-75

How to cite this URL:
Dodderi T, Puthiry M, Thomas S. How much is too much? Effect of volume on water-swallowing test. J Nat Sc Biol Med [serial online] 2020 [cited 2021 Jan 19];11:169-75. Available from:

   Introduction Top

Swallowing assessment by instrumental way determines the underlying anatomical and/or physiological cause of dysphagia (or swallowing impairment) and also helps to chart out an appropriate treatment plan.[1],[2] Videofluoroscopy and flexible fiber-optic endoscopic evaluation of swallowing are popular diagnostic tools that have withstood the test of time. Similar to many developing countries, in India, the gold standard tools of swallowing assessment are confounded by limited access, a dearth of trained professionals, and often are uneconomical. Hence, in clinical practice, the majority of speech and swallowing therapists perform only clinical or non-instrumental swallowing assessment. In this regard, identifying risk for dysphagia using a simple, economical method and the outcome is called “swallowing screen.” The American Speech Language and Hearing Association explicitly defines swallowing screen as “methods to determine the need for comprehensive swallowing investigations.”[3] Four-finger test,[2] dry swallowing,[4] cervical auscultation,[5] and water-swallowing test[6] are fine examples of swallowing screen with global practice.

The water-swallowing test is one among the many swallowing screening tool highly valued and frequently employed by speech and swallowing therapists. The origin of the water-swallowing test traces back to the works of Kubota et al. in 1982.[6] However, the method of using thin liquids for the swallowing screen was popularized by Nathadwarawala et al.[7] and later by Hughes and Wiles.[8] In their review article, Horiguchi and Suzuki state, “water is the preferred test stimuli for assessing swallowing in patients with static dysphagia since thin liquids are the most difficult of all consistencies to consume orally.”[4] Typically, a water-swallowing test involves monitoring swallowing of a predetermined thin liquid quantity and observation for vital clinical signs of aspiration – cough and/or gurgly voice. Later, the “water-swallowing test” was recoined as “timed test of swallowing,” which uses a similar test design and derives three quantitative indices to reflect if the screened population is at risk for dysphagia or not. The standard indices of timed test of swallowing or water-swallowing test are as follows: (1) volume/swallow (V/S), expressed in milliliter; (2) time/swallow (T/S), represented in second; and (3) swallowing capacity (SC) or speed of swallow, represented in milliliter/second.

Since its inception in 1982, the water-swallowing test has been studied closely in the healthy and clinical population. A wealth of information exists on the water-swallowing test, which, in the past measured swallowing using 30,50,90,100,150 ml test capacities.[5],[6],[7],[8],[9],[10],[11] Such diversity in test quantity suggests inconsistencies in the practice of water-swallowing test. The direct consequence of this variability is the dilemma in speech and swallowing therapists on deciding the right test quantity to assess swallowing by water-swallowing test.[12] Therefore, the merit of water quantity is decided by the clinicians experience or guesswork, both of which can set unprecedented risk of clinician compromising the patients' airway safety.[1] Thus the objectives of the study were: first, measure changes in sequential swallowing ability for 30,50,90,100,150 ml test quantity of water in healthy young adults (HYA) and healthy middle-aged adults (HMA); and second, establish correlation between the performance of water-swallowing test across different water quantities; and third, to investigate age and gender effects on different quantities of water on swallowing ability.

   Subjects and Methods Top

Study design

The present study adopted a crossover comparative study design with nonrandom convenient sampling.


Sixty healthy participants from 20 to 60 years of age were recruited for the study. The study included two groups with an equal female–male ratio. Thirty HYA from 20 to 40 (29.5 ± 6.51) years and thirty HMA from 41 to 60 (51.1 ± 5.36) years participated in the study. Participants reporting sensory-motor dysfunction, neurological, and cognitive impairments were not taken up for the study. Upper respiratory tract infections and history of head-and-neck surgery performed on the participants were ruled out by case history. The six-item cognitive impairment test was administered on participants to rule out cognitive dysfunction and/or dementia.[13] According to the standard, a score of 7 and below suggests cognitively intact and participants with this cutoff score were included. The risk for dysphagia (or swallowing impairment) was ruled out using the Eating Assessment Tool-10.[14] As per the test standard, a cutoff score of 3 or higher indicates for risk of dysphagia and participants above the cutoff were excluded from the study. The institute ethics committee clearance was obtained for the study. Informed consent was taken before data collection.


The present study utilized water under room temperature for swallowing assessment. Four test quantities (50, 90, 100, and 150 ml) were chosen based on the findings of the review of literature that suggested the selected water quantities are the most commonly used volume for the water-swallowing test.[9],[10],[15],[16]


Every participant was seated comfortably on a chair (with armrest and back support) with his/her foot placed on the floor.[17] Water quantity was gauzed using a handheld standard measuring cup and transferred to a 170 ml commercially available disposable cup, and the test participants held the cup in their preferred hand. The directions to the participants for swallowing were: “On my command, you have to continuously swallow the water at your natural pace without stopping in between and avoid any oral spillage.” To instigate the participant's natural swallowing style, the study followed this instruction set. During the swallowing session, a researcher skilled in the water-swallowing test monitored two in situ parameters: (1) total number of swallows and (2) total swallowing time. The researcher tallied one swallow each time the hyo-larynx elevated and successively depressed. Likewise, total swallowing time was measured using a handheld digital stopwatch. The onset of swallowing was considered with the rim of the cup touching the lower lip and cessation of swallowing with the cup's withdrawal. This procedure is in accordance with standard guidelines proposed to analyze the water-swallowing test.[8] A total of four swallowing attempts was performed by each participant and the order of water quantities randomized. Water-swallowing test was carried out across four separate days to avoid practice effect. Performing the water-swallowing test on an empty and/or full stomach was also avoided. Participants had a minimum of 2 h of break postmeal before taking the water-swallowing test.

Data analysis

Data of the participants with liquid spillover, residue in the cup, and cessation of swallowing between the tests were excluded. The two real-time data were tabulated in Microsoft Excel sheet and saved in.exe format. Using total number of swallowing and total swallow time, the researcher calculated three swallow indices: (1) V/S, a volumetric data represented in milliliter; (2) T/S, a temporal parameter with seconds as the unit; and (3) SC, a combination of the V/S and SC which is represented in milliliter/second. The three swallowing indices were subjected to statistical testing by Statistical Package for Social Sciences (Version 17) (SPSS Inc., Chicago, IBM Corp).

   Results Top

The Shapiro–Wilk test of normality was administered, and the results revealed no statistical significance at P > 0.05 suggesting the data to be normally distributed. The results of descriptive and inferential statistics are elaborated below.

The mean and standard deviation of participants swallowing indices V/S, T/S, and SC are tabulated in [Figure 1], [Figure 2], [Figure 3], respectively.
Figure 1: Mean and standard deviation of volume/swallow index across different test volumes

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Figure 2: Mean and standard deviation of time/swallow index across different test volumes

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Figure 3: Mean and standard deviation of swallow capacity index across different test volumes

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Comparing the mean values of four test quantities suggests the following. In V/S, the higher intake of thin liquids was obtained for 150 ml, followed by 90 and 100 ml, and the lowest V/S was observed for 50 ml test quantity. On the continuum, for T/S, the results revealed a shorter T/S in the order of 90, 100, and 150 ml and the longest T/S was for 50 ml. Increased SC was noted in the order 150, 90, 100, and least for 50 ml. The overall SC results suggest 150 ml to have increased swallowing performance and 50 ml decreased swallowing performance.

Multiple analysis of variance with age as the factor was applied to the data. The results revealed statistical significance for V/S and SC index at P < 0.05. Statistical values of V/S indices across different test capacities are as follows: F (1357.959) = 5.662, P = 0.02, for 50 ml; F (1628.044) = 6.371, P = 0.01, for 90 ml; F (1820.61) = 9.194, P = 0.05, for 100 ml; and F (1559.937) = 5.288, P = 0.02, for 150 ml. Similarly, for SC index, the statistically significant values were as follows: F (1404.186) = 7.217, P = 0.01, for 50 ml; F (1387.3) = 5.984, P = 0.02, for 90 ml; and F (1324.225) = 4.261, P = 0.04, for 100 ml. There was no statistical significance for any test quantity in T/S index and for 150 ml SC index. Pairwise comparison by Bonferroni post hoc test for revealed statistically significant differences at P < 0.05 and its values are tabulated in [Table 1].
Table 1: Results of pairwise comparison by Bonferroni post hoc analysis

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Repeated measures analysis of variance with different test quantities as the variable was administered, and the results revealed a statistically significant difference for V/S, F (2.335, 428.202) = 7.245, P < 0.001, and SC, F (2.045, 525.177) = 10.204, P < 0.001, indices between 50,90,100, and 150 ml test volume at P < 0.05. Bonferroni post hoc analysis for pairwise comparison also revealed a statistically significant difference at P <0.05 for V/S and SC. The statistical values of V/S and SC are tabulated in [Table 2] and [Table 3], respectively.
Table 2: Results of pairwise comparison by Bonferroni post hoc analysis for volume/swallow index

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Table 3: Results of pairwise comparison by Bonferroni post hoc analysis for swallow capacity index

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Correlation analysis was performed using Pearson correlation index, and overall, the scatter plot of V/S, T/S, and SC is depicted in [Figure 4], [Figure 5], [Figure 6], respectively. As shown in the figure, a strong positive correlation is noted for V/S and SC indices and a moderate positive correlation for T/S at P < 0.05.
Figure 4: Scatter plot of volume/swallow across different test quantities

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Figure 5: Scatter plot of time/swallow across different test quantities

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Figure 6: Scatter plot of swallow capacity across different test quantities

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The results of the study suggest that, in HYA and HMA, across all four test volumes, male participants had higher V/S compared to females. In T/S index, male participants swallowed 100 ml of water in shorter time duration and female participants swallowed in longer time duration. Collectively, the overall mean of SC was highest for male participants compared to females.

Independent t-test was applied to the data with gender as the variable, and the results reveal statistical significance at P < 0.05. Statistical values noted for V/S are as follows: F (3.243, 33) = 2.456, P = 0.003, for 50 ml; F (2.57, 35) = 3.035, P = 0.01, for 100 ml; and F (2.980, 37) = 0.012, P = 0.005, for 150 ml. For the T/S index, the values are as follows: F (−2.424, 33) = 0.714, P = 0.002, for 50 ml; F (−2.493, 32) = 0.007, P = 0.01, for 90 ml; and F (−2.334, 35) = 1.396, P = 0.02, for 100 ml. Finally, the SC index values are as follows: F (3.924, 33) = 4.392, P = 0.000, for 50 ml; F (2.998, 32) = 2.389, P = 0.005, for 90 ml; F (3.754, 35) = 2.649, P = 0.001, for 100 ml; and F (3.442, 37) = 2.995, P = 0.001, for 150 ml. Statistical significance for gender was not noted for V/S index in 90 ml test quantity and T/S index in 150 ml test quantity.

   Discussion Top

The present study measured variations in water-swallowing test across four different test volumes in sixty participants between 20 and 60 years of age. Poststatistical analysis, the results of the study suggest HYA having better swallowing skills and 50 ml having the least SC. The state of evidence suggesting a decrease in swallowing performance by HMA participants is attributed to: variations in oropharynx anatomy,[18] reduced range of swallow structures,[19] decreased isometric tongue pressure,[20] poorly co-ordinated mouth closing-hyoid elevation, and ill-timed upper esophageal opening.[21] The anatomical and physiological changes are ipso facto for smaller V/S in a longer T/S and subsequent decreased SC by HMA, which is also reported in earlier works.[22] On the continuum, better swallowing performance in male over female participants is supported by literature findings that highlight anatomical and physiological variations between the two genders.[23],[24]

The results suggesting least SC in 50 ml and highest SC in 150 ml are due to the difference in the hyolaryngeal movement for test quantities. The physiology of swallowing is distinctly divided into a single sip (or discrete) swallow and sequential swallow. Consuming 1–20 ml of liquids represents the former type of swallowing and for a larger test capacity, such as 30, 50, 90, and 150 ml, defines the latter type of swallowing.[16],[25],[26] By this classification, the water-swallowing test is a measure of sequential swallowing. Some of the differences between single sip and sequential swallow are as follows: bolus parsing, a slightly elevated hyoid during the inter-swallow period, and a more exposed laryngeal vestibule.[25],[26] In addition to these, studies suggest that with an increase in volume, the tongue base elevation is delayed, which, in turn, prolongs the triggering of hyolaryngeal elevation – an aberrant feature in the patient population that leaves the airway patent.[27],[28] Thus, a combination of the altered hyoid elevation and delayed tongue movement gives scope for risk of aspiration with an increase in test volume.

Literature suggests the earliest study on water-swallowing test dates back to Jones and Work,[29] who measured average cc per swallow (or V/S that is equivalent to ml) for 175 cc water in children. Since then, several researchers have adapted the concept in adults – healthy and clinical populations. In a study, SC of 150 ml test volume was compared between healthy adults and individuals having a neurological assault.[7] Healthy adults' performance (32.07 and 20.90 ml/s for males and females, respectively) was reported to be better than neurological assault patients (20.8 and 11.8 ml/s in males and females, respectively). In another study, when 100 ml lukewarm water was used for measuring water-swallowing test, participants between 18 and 34 years had V/S of 37.5 and 18.8 ml, T/S of 1.2 and 1.1 s, and SC of 31.9 and 18.7 ml/s in males and females, respectively. The participants between 35 and 54 years exhibited V/S of 7.5 and 4 ml, T/S of 2.3 and 3.2 s, and SC of 3.1 and 1.6 ml/s, in males and females, respectively.[8]

Normative data for the water-swallowing test in the Indian population were established by Rai and Balasubramanium,[30] who used 150 ml quantity of thin liquids on 480 healthy participants. The results of healthy participants aged between 18 and 40 years were 23.67 and 21.16 ml for V/S, 1.23 and 1.21 s for T/S, and 20.53 and 18.29 ml/s for SC in males and females, respectively. Similarly, for healthy participants aged between 41 and 60 years, the study revealed 24.03 and 19.38 ml for V/S, 1.22 and 1.31 s for T/S, and 20.88 and 15.79 ml/s for SC in males and females, respectively. Finally, in geriatrics of 61–80 years, the authors reported 20.84 and 18.04 ml for V/S, 1.35 and 1.32 s for T/S, and 18.72 and 14.68 ml/s for SC in males and females, respectively. Recently, Ismail et al. reported 11.73 ml of V/S in healthy adults and 12.07 ml in healthy geriatrics. They also reported longer T/S in geriatric, who took 1.83 s, compared to 1.23 s by young adults. Also, SC was reported to be 9.77 ml in HYA as compared to healthy geriatrics who had lower SC of 6.21 ml.[31]

The application of the water-swallowing test is popular in differentiating those with normal swallowing from individuals with swallowing impairment. In the Indian context, Kumar et al.[32] and Kanna and Bhanu[33] used the timed test of swallowing to report differences in individuals with swallowing impairment. In their study, Radish et al. reported statistically significant lower scores, 16.85 ml V/S, 1.32 s T/S, and 12.91 ml/s SC, on swallowing 150 ml water by forty participants with stroke. Comparing the findings of the present study with the gender matched healthy group of Kumar et al.[32] individuals with stroke had lower V/S by and lower SC by 13 ml/s.[32] Similarly, Kanna and Bhanu[31] reported individuals with parkinsonism having 14 ml V/S and 7 ml/s SC in 2.40 s T/S. They also reported a positive correlation between swallowing performance and severity, time course and stage of parkinsonism, and indirect correlation between subjective findings and objective performance of swallowing.[33] These findings directly pinpoint that the health of an individual impacts performance of water swallowing in general and WST in specific. However, it is difficult to comment on the stage of swallowing since the water-swallowing test interprets volumetric and temporal aspects of swallowing.

Comparing the data of the present study with other research investigations in the Indian population, the results are not in congruence with each other. In our study, the mean score of adult males is 10 ml higher and 1 s longer compared to Rai and Balasubramanium findings.[30] Similarly, the SC performance of the young adults of our study is greater by 9 and 2 ml/s in male and female participants, respectively. In old adults, female participants of our study consumed 5 ml higher than the normative. SC of old adults is greater by 2 and 5 ml/s in males and females, respectively. Clinically, there is no difference in the T/S index with the normative. Variations up to 10 ml can be considered as normal variation since all the participants of the study were devoid of swallowing impairment. Nonetheless, increase or decrease in swallowing performance could be attributed to the instructions of the study that directs the participants to swallow water in their comfortable speed.

The present study has its limitation. The test volume(s) considered in the present study did not account for the smallest test quantity of sequential swallowing (30 ml) and the largest test quantity (175 ml) reported in the literature for assessing sequential swallow by water-swallowing test. Second, the study did not hierarchically and/or psychometrically increase the test volume (50, 60, 70 ml, and so on, so forth). Adopting this scientific method could have given a holistic understanding of the changes that may have on the three swallowing indices.

   Conclusion Top

The state of evidence suggests 50 ml thin liquid to be equally sensitive in assessing sequential swallowing. There was a moderate-to-strong correlation across the test quantity. Hence, the advisory is to avoid large test volumes such as 90, 100, and 150 ml and consider 50 ml of water as clinically sufficient test quantity to represent an individual's sequential swallowing ability. The clinical implication of the study findings is to use a higher quantity of thin liquids with precaution since an increase in test volume increases V/S and SC. Further, it is advisory to all speech and swallowing therapists to first consider if the individual is clinically fit for trial (or oral) feeds in critical units such as intensive care and high dependency units, let alone decide the quantity of water for water-swallowing test. Future studies are warranted across larger sample size and also perform the study in geriatrics vulnerable to presbyphagia (or age-related swallowing impairment).

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Conflicts of interest

There are no conflicts of interest.

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