Dysphagia
Dysphagia 9:63-68 (1994)
Stethoscope Acoustics and Cervical Auscultation of Swallowing
Sandra Hamlet, PhD,1 David G. Penney, PhD, 2'3 and John Formolo, MD 3
Departments of 1Otolaryngology and 2Physiology, School of Medicine, Wayne State University, Detroit, Michigan; and
Department of Internal Medicine, 3Division of Cardiology, St. John Hospital, Detroit, Michigan, USA
Abstract. Frequency response characteristics of six
popular stethoscopes are reported for the higher fre-
quency range (to 3000 Hz) to supplement equivalent
measurements for the lower frequencies (35-1000 Hz)
published previously. Spectra of the sounds of swallow-
ing from the throat, transduced with an accelerometer,
demonstrate important frequency composition in this
higher range. Two stethoscope models were found to
have superior transmission characteristics for use in cer-
vical auscultation of swallowing sounds.
Key words: Sound of swallowing - - Stethoscope - -
Auscultation - - Deglutition - - Deglutition disorders.
Cervical auscultation (listening at the throat with a
stethoscope) is being adopted by dysphagia clinicians as
a component of clinical evaluation of swallowing [1-9].
As in any observational method, the quality of informa-
tion obtained depends not only on the perceptual skills of
the examiner but on utilization of appropriate instrumen-
tation and technique. Even a seemingly simple procedure
such as listening with a stethoscope contains a source of
instrumental distortion. That is, the stethoscope is not
completely faithful in picking up and transmitting to the
listener's ear the sound quality present at the body sur-
face.
Research studies on the acoustics of swallowing
have generally recorded the sounds using a microphone
or accelerometer [5-7,9-14]. These transducers are de-
signed to have a flat frequency response over a wide
range of frequencies. Clinicians have remarked, when
Address offprint requests to: David G. Penney, Ph.D., Professor, De-
partment of Physiology and Occupational and Environmental Health,
Wayne State University School of Medicine, 540 E. Canfield, Detroit,
M148201, USA
9 Springer-VerlagNewYorkInc, 1994
listening to recordings of swallowing sounds, that they
do not sound quite like what is heard with a stethoscope
[15]. If the results of such research studies are to be
translated into clinical practice, it is important to take into
account the characteristics of the different instruments.
The literature contains limited description of the
spectrum of swallow sounds. Logan et al. [11] published
spectrograms of liquid swallow sounds. Swallow sounds
are broad band, containing transient clicks, with energy
up to 8,000 Hz. It can be appreciated from the illustra-
tions, however, that the greatest intensity is in the fre-
quency range below 3,000 Hz, and that clicks with fre-
quency components higher than this contain energy in the
low frequencies also. Thus, there would be no loss of
temporal detail from filtering out the higher frequencies.
Mackowiak et al. [10] described the spectrum of a "dry"
swallow as having peak energy at 1,000-1,100 Hz for the
entire duration of the swallowing sound. Wet swallow
signals began with a low frequency component (400-600
Hz), then increased in intensity and frequency to a peak
at 1,000 Hz at the end of the signal. They used a contact
microphone over the larynx lateral to the midline. Heinz
et al. [4] and Vice et al. [6] described swallow sounds
recorded from infants, portions of which were periodic
with a high fundamental frequency. Hamlet et al. [ 12,13]
published illustrations of a spectral change within a por-
tion of the sound of swallowing corresponding to fluid
flow through the upper esophageal sphincter. Spectral
information of this type is contained in the frequency
region below 3,000 Hz.
The acoustic spectrum of breath sounds following
swallowing were illustrated by Logan et al. [ 11]. Great-
est intensity is in the lower frequency range, below 1,500
Hz. Similarly, sounds of value in the diagnosis of heart
and lung disease by thoracic auscultation fall in the low
frequency range 20-1,000 Hz [16,17].
A review of the acoustics of stethoscopes, and
frequency response data for several currently available
64 S. Hamlet et al.: Stethoscope Acoustics

Table 1. Six stethoscopes evaluated for frequency response characteristics in their various modes

Diaphragms Bells
Name Abbreviation Name Abbreviation
Littmann Classic II Classic II Littmann Classic II Classic II
Littmann Master Cardiology Mast HW Littmann Master Cardiology Mast LW
Littmann Cardiology II Cardiol II Littmann Cardiology II Cardiol II
Hewlett-Packard, Rappaport-Sprague HP-L Hewlett Packard, Rappaport- HP-L
large diaphragm~ Sprague, large bell
Hewlett-Packard, Rappaport-Sprague HP-S Hewlett-Packard, Rappaport- HP-M
small diaphragm b Sprague, medium bell
Tycos Harvey triple head, smooth Harv S Tycos Harvey triple head, bell Harv T
diaphragm
Tycos Harvey triple head, ribbed Harv R
diaphragm
Allen Medical Series 5-RPS, long tube Allen LT Alien Medical Series 5-RPS, long tube Allen LT
Allen Medical Series 5-RPS, short tube Allen ST
"Adult diaphragm, i3/8inch bell.
bPediatric diaphragm, 1 inch bell.

stethoscopes, have been published recently [18]. This
w o r k only considered f r e q u e n c y response characteristics
in the range 3 5 - 1 , 0 0 0 Hz, focusing on application to
auscultation o f heart and lung sounds. All stethoscopes
tested responded best in the v e r y low frequencies (be-
low 100 Hz). T h e response then falls o f f with increas-
ing f r e q u e n c y a b o v e 100 Hz, being d o w n 1 0 - 2 0 dB at
1,000 Hz.
F r e q u e n c y response or acoustic transfer function
refers to the d e g r e e to which an instrument will process
all frequency c o m p o n e n t s o f a sound equally, without
e n h a n c e m e n t or suppression o f particular f r e q u e n c y re-
gions. Ideally, for faithful reproduction, a uniform or flat
frequency response should exist for the f r e q u e n c y range
o f importance in the sound to be studied. H o w e v e r , if a
particular f r e q u e n c y range in the sound is o f clinical
interest, then a peak in the f r e q u e n c y response s p e c t r u m
corresponding to that selected range will p r o v i d e s o m e
amplification.
T h e r e are two issues addressed in this paper: (1)
H o w well does the f r e q u e n c y response o f a stethoscope
e n c o m p a s s the frequencies present in the sound o f swal-
lowing? (2) A r e there significant differences in f r e q u e n c y
response characteristics a m o n g currently available
stethoscopes, w h i c h w o u l d f a v o r particular types for use
in cervical auscultation of s w a l l o w i n g ?
miniature accelerometer (Vibro-meter model 501M601, frequency re-
sponse 2~-0,000 Hz - 3 dB). The accelerometer was attached to one
side of the throat with double-sided tape, just above the larynx about 2
cm below the angle of the mandible. A mandible rather than laryngeal
reference was used, because the larynx moves upward and forward
during swallowing. The above location of the accelerometer was in-
tended to result in placement approximately over the hypopharynx and
posterior larynx when the larynx was elevated as the bolus was passing
through the pharynx.
Accelerometer recordings were made simultaneously with a
videotape of a modified barium swallow on one audio channel of a
Panasonic AG-6300 video recorder (frequency response 50-12,000
Hz). The simultaneous videotape of the modified barium swallow con-
firmed that the recorded event was a normal swallow.
The recording was played back from the line audio output of the
same videorecorder, and bandpass filtered (80--4000 Hz). A/D conver-
sion (10,000 Hz sampling rate) and spectral analysis was performed
using Micro Speech Lab software on an IBM PC. A 100 ms time
window was located over three nonoverlapping portions of each swal-
low signal (1) in the initial low amplitude portion, (2) centered on the
peak amplitude, (3) in the later low amplitude portion, and (4) from a
silent portion of the recording after the swallow for a comparison to the
noise floor present in the recording. An illustration of the time wave-
form of the swallow signal and selected spectra can be found in Hamlet
et al. [12,13]. Fast Fourier Transform analysis was performed with
"low" smoothing, which is a running average of four sampling inter-
vals. Smoothing reduces the variability in amplitude of spectral compo-
nents between adjacent frequency locations, yielding a spectral display
more representative of the overall contour. Using a cursor, the ampli-
tude value corresponding to particular frequencies was read off the
display. The frequencies chosen were every 200 Hz from 200-4000 Hz.
Composite average spectra across subjects were calculated from these
amplitude measurements.

Methods
Spectrum of Swallow Sounds
High fidelity recordings were made of the sounds of swallowing from
the throat of 10 normal adults, 5 females and 5 males, between the ages
of 34 and 67. One swallow of 10 ml thin barium suspension (40% w/w)
was analyzed from each subject. The sounds were transduced by a
Frequency Response of Stethoscopes
The acoustic transfer function (frequency response) of six stethoscopes
was measured by Western Electro-Acoustics Laboratory, Inc., Santa
Monica, CA (Table 1). The stethoscopes were tested in both their bell
and diaphragm modes. A white noise sound source was generated by an
electrodynamic head phone mounted in a 17 cubic cm coupler. The
S. Hamletet al.: StethoscopeAcoustics
I ~ Max. Amplitude ]
[--C~ First Component /
-10 I + Third Component /
LU
~Z -20-
0
o.
LU -30"
>UJ
-40 -
-6( r T
1000 2000 3000 4000
Frequency (Hz)
Fig. 1. Averagedspectralcharacteristicsof swallow signals recorded
while swallowing 10 rnl of thin liquid barium.
stethoscope chest piece was placed on the coupler. Both earpieces of the
stethoscope were placed at the entrance to artificial ears. Microphone
systems, at the source coupler and the artificial ear, were used to detect
the input and received sound for comparison.
Detailed frequency response data for these stethoscopes in the
low frequencies have been published [ 18]. We are providing summaries
of salient features of those results for low frequencies, and adding
information on frequency response characteristics in the higher range
up to 3000 Hz.
Results
Spectrum of Swallow Sounds
The averaged spectra (Fig. 1) illustrate the frequencies
prominent in the sound of swallowing when transduced
by an aecelerometer and recorded on a tape recorder.
Individual differences and detail in unsmoothed spectra
have been deemphasized so as to provide a general over-
all indication of the characteristics of the signal. The
highest amplitude components in the frequency spectrum
of the acoustic swallow signal were in the low frequen-
cies. Above 2200 Hz the averaged spectrum of the third
component overlapped the noise floor, thus spectral com-
position for this component was limited to below 2200
Hz. Above 3000 Hz the spectra for the first two compo-
nents approximated the noise floor (about 5 dB above).
Thus, in general, significant spectral composition for
the recorded liquid bolus swallowing sounds was below
3000 Hz.
Frequency Response of Stethoscopes
Empirical criteria were chosen for evaluating frequency
response characteristics of stethoscopes. The criteria
were intended to separate the tested stethoscopes into
"better" or "poorer" categories according to particular
response characteristics.
65
Judgment of the suitability of particular stetho-
scope models for auscultation of lowfrequency swallow-
ing sounds relied on the existence of amplification for
very low frequencies, and flatness or uniformity of fre-
quency response in the lower and middle frequencies. In
identifying particular stethoscope models as best suited
for faithful transmission of low frequency signals, the
following criteria were chosen, to be met cumulatively in
sequence:
1. Amplification of sound below 100 Hz
2. Attenuation <10 dB in the range 100-700 Hz, with
variability confined between 0-10 dB
3. Attenuation <15 dB in the range 700-1000 Hz, with
variability confined between 5 and 15 dB.
Evaluation of stethoscopes in the higher frequen-
cies rested on relative lack of attenuation in the high
frequencies and flatness or uniformity of frequency re-
sponse in the middle frequencies. The following criteria
were chosen, to be met cumulatively in sequence:
4. Attenuation <30 dB in the range 1800-3000 Hz
5. Attenuation <20 dB in the range 1000-1800 Hz
6. Attenuation <15 dB in the range 700-1000 Hz, with
variability confined between 5-15 dB.
Bell Mode
Bell chestpieces are most suitable for transmitting very
low frequency sounds [18]. Criterion 1 was met by all of
the stethoscope models tested in the bell mode. Criterion
2 was met by the Littman Cardiology II, the Hewlett-
Packard Rappaport-Sprague large and medium bell, and
the Tycos-Harvey triple head bell. Criterion 3 was not
met by the Tycos-Harvey triple head bell.
High frequency response in the bell mode was
also evaluated. Criterion 4 was met by the Littman Cardi-
ology I! and Classic II, Hewlett-Packard Rappaport-
Sprague large + medium bell and Tycos-Harvey triple
head bell. Criterion 5 was not met by the Tycos-Harvey
triple head bell. Only the Littman Cardiology II and
HP-M met criterion 6.
Figure 2 shows the bell mode frequency response
data in the range 900-3000 Hz. Detailed bell mode low
frequency response data for all the stethoscopes have been
published previously [18]. The stethoscopes not meeting
our performance criteria for bell mode failed because of
extreme variabifity in response (resonances), and response
curves exceeding criterion levels for attenuation.
Diaphragm Mode
Most stethoscopes do not amplify the very lowest fre-
quencies when used in the diaphragm mode [18]. Low
66 S. Hamletet al.: StethoscopeAcoustics

B(~II~ ~aohragms

-10 -10 e, 9 ...... / \

LU
G9 LU
Z '7
O
e~ O
0,..
-20 ~n- -20

~ -30 .j -30 --0-- Cl~,~ie II ......9 ........... 9

m
w
I--~-_ Cardiol "I
l"""* ...... HP-L
l-" J
2'Oo ~8oo
...... " P - '
-4C -40
800 2o'oo 2,'00 23'o0 3200 800 1200 1600 2000 2400 2800 3200

0*

-I0 ILl -10"

LU
~0 03
Z
0 - i
O.
-20" w -20'
........= ............. i' ...... 9
....I ,

"1I.-- ""I ..........9.............

w ~::sF-
"--.o..:~.
~ff\l ~ o '~~ . "-,,"

~ -30 HP-M . '""" I ~ -30

W .........
9 ........

& HaW R ~ '';~''"" "''7',

........O""" Allen LT ~
I'--O-- Alien LT I -"o--~ o .......-Z~...-- Allen ST . ,
-4O -40
800 12'O0 16'O0 2000 24'00 28'O0 3200 800 1200 1800 2000 2400 2800 3200
F R E Q U E N C Y (Hz) F R E Q U E N C Y (Hz)

Fig. 2. Frequencyresponse of stethoscopebells over the range 900- Fig. 3. Frequencyresponseof stethoscopediaphragmsover the range
3000 Hz. Zero dB is the reference input signal level, which was the 900-3000 Hz. ZerodB is the referenceinputsignallevel, whichwas the
same for all stethoscopes. same for all stethoscopes.

frequency response in the diaphragm mode met criterion appeared to be superior: the Littman Cardiology II, and
1 by Littman Classic II, Cardiology II and Master Cardi- the Hewlett-Packard Rappaport-Sprague (medium bell,
ology. Criteria 2 and 3 were met only by Littman Cardi- small diaphragm). Figure 4 provides detailed low fre-
ology II. quency response data for these models, previously pub-
For higher frequency response, stethoscopes lished [18].
meeting Criterion 4 were the Littman Cardiology II and
Classic II, Hewlett-Packard Rappaport-Sprague small di-
aphragm, Allen LT, and the Tycos-Harvey triple head Discussion
smooth diaphragm. Criterion 5 was met by the Hewlett-
Packard Rappaport-Sprague small diaphragm, and the When clinicians listen to the sounds of swallowing with a
Littman Cardiology II. Criterion 6 was only met by the stethoscope, qualitative judgments are made about what
Littman Cardiology II. is heard. The characteristic swishing double-click as the
Figure 3 shows the diaphragm mode frequency bolus passes through the pharynx and into the esophagus
response data in the range 900-3000 Hz. Detailed dia- is judged for normalcy based on "crispness" of the sound
phragm mode low frequency response data for all the [15]. A definition of crispness has not been provided in
stethoscopes have been published previously [18]. physical terms, but in general, sharp, crackling, or bril-
Stethoscopes not meeting the criteria for diaphragm liant sound qualities have high frequency components.
mode performance failed mainly because of greater high In comparison to an accelerometer or micro-
frequency attenuation. phone, any stethoscope is poorly suited for transmitting
high frequencies. Even with the two stethoscopes we
Models Best Meeting Criteria considered most suitable for listening to swallow sounds,
For overall performance according to our criteria relative the higher frequencies were markedly attenuated. Stetho-
to auscultation of swallowing sounds, two stethoscopes scopes are best suited for transmitting extremely low
S. Hamlet et al.: Stethoscope Acoustics
1 Bells
O~ -10
-15
200 400 600 800 1000
~
LU
15"
~> 10-
~ol
,; 5
er 0
-5
-10
-15
-20
-25
2;0 400 600 800 10'00
F R E Q U E N C Y (Hz)
Fig. 4. Low frequency response characteristicsof two selected stetho-
scopes in the bell and diaphragm modes. Zero dB is the reference input
signal level, which was the same for all stethoscopes.
frequency, dull pulsing sounds, with frequency composi-
tion below 1000 Hz.
In the very low frequency range (below 100 Hz),
some stethoscopes actually provide a small amount of
amplification. The particular accelerometer used here has
a fiat frequency response over an extremely wide r a n g e - -
2 - 4 0 , 0 0 0 Hz -+ 3 dB. Certain types of microphones also
respond to very low frequencies. The limiting factor in
the very low frequencies is more likely to be the nature of
the recorder used (audio tape recorder), or the character-
istics of input filtering prior to A/D conversion for a
computer.
The human ear is sensitive in the 2000-3000 Hz
region [19], and the auditory perceptual system is forgiv-
ing of sound distortion. For these reasons it may not be
obvious to the listener when an instrument filters the
higher frequencies---especially when there is no standard
against which to make a comparison. When listening for
the crispness of the sound of swallowing, it is important
to make sure that the stethoscope used is maximally capa-
ble o f transmitting the higher frequency range.
Another auditory judgment made by dysphagia
clinicians relates to the breath sounds immediately after a
swallow. If aspiration or laryngeal penetration o f the
bolus has occurred and there is residue, subtle gurgling or
bubbling may be heard. W e did not analyze such sounds,
not having examples available, so it is only by analogy to
the low frequency range o f breath sounds [11] that we
assume these abnormal respiration sounds are low fre-
quency also. Below 1000 Hz the human threshold of
audibility begins to drop off with decreasing frequency
[19]. If low frequency sounds are of special interest,
using the bell mode of a stethoscope may provide the best
67
listening conditions. It is worth being aware of the differ-
Ill
ences in acoustic capabilities of a stethoscope in the bell
and diaphragm modes.
In summary, two stethoscopes were found to have
superior overall acoustical performance for use in the
cervical auscultation of swallowing sounds based on a
1200
number of criteria: the Littman Cardiology II and the
II
Hewlett-Packard Rappaport-Sprague (medium bell,
small diaphragm). The latter stethoscope is intended for
pediatric use, but could be utilized for adult cervical
auscultation also.
1200 Acknowledgments. This study was supported by a grant from the GME
Biomedical Investigation Committee of St. John Hospital and Medical
Center, and in part by Grant CA-43838 from the National Institutes of
Health. All stethoscopeswere purchased by the Research Committeeof
St. John Hospital and Medical Center through standard medical supply
companies, and no input or monetary support was obtained from stetho-
scope manufacturers or suppliers.
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