SAGE: Sink-Aware Grounded Decoding for Multimodal Hallucination Mitigation

Medical Vision-Language Models (VLMs) often hallucinate by generating responses based on language priors rather than visual evidence, posing risks in clinical applications. We propose Visual Grounding Score Guided Decoding (VGS-Decoding), a training-free method to mitigate hallucinations during inference. Our key insight is that hallucinated tokens maintain or increase their probability when visual information is degraded, while visually grounded tokens decrease in probability. We introduce the Visual Grounding Score (VGS), which measures each token's visual dependency by comparing distributions from original and distorted images. During decoding, we reweight probabilities by amplifying visually grounded tokens while suppressing hallucinations. Unlike fixed-weight contrastive methods, VGS-Decoding provides per-token adaptive control. Experiments on MIMIC-Diff-VQA and VQA-RAD across LLaVA-Med, CheXagent, and MedGemma demonstrate consistent improvements, with up to +9.12% overall gain and $+8.98\%$ in open-ended recall, while introducing only $2\times$ inference overhead and no additional training, making it practical for clinical deployment. Upon acceptance, code will be released publicly to facilitate reproducibility.

Large vision-language models (LVLMs) have demonstrated remarkable capabilities in multimodal understanding. However, they remain prone to hallucinations, generating responses that are inconsistent with the visual evidence. Existing mitigation methods largely address language-prior bias or cross-modal imbalance, while progressive visual degradation across perception and memory remains underexplored. In this work, we propose Saliency-Driven Perceptual Realignment (SDPR), a training-free framework that mitigates the degradation of visual awareness throughout inference. Specifically, we first introduce saliency-driven attention redistribution to release attention hijacked by non-semantic sink tokens, thereby recovering critical visual evidence. Second, we identify spatial distortion in the KV cache and propose saliency-driven cache alignment to preserve query-relevant visual features during generation. Finally, we introduce prior-constrained contrastive decoding to penalize unfaithful predictions induced by dominant language priors. Our proposed SDPR is robust against hallucinations due to its holistic alignment of visual awareness across the entire generative trajectory. Extensive experiments across diverse LVLM architectures show that SDPR outperforms state-of-the-art methods on both hallucination and general-purpose benchmarks, requiring no additional training and incurring minimal runtime overhead. The code is available blue{here}.

Large vision-language models (LVLMs) often hallucinate objects that are absent from an image. Despite recent progress, existing mitigation methods still lack reliable object-level grounding diagnostics and therefore tend to apply coarse-grained interventions, which can impair visual understanding, shorten responses, and reduce coverage of genuinely grounded objects. The key challenge is thus to detect, during generation, whether each emerging object mention is supported by reliable visual evidence, so that hallucination can be mitigated selectively. Yet output confidence reflects next-token plausibility rather than visual support, allowing language priors to make absent objects appear certain. We show that the missing diagnostic evidence is encoded in an Intrinsic Grounding Signature (IGS), a distributed signed attention pattern that remains informative for such confident hallucinations. Based on IGS, we propose Verifier-Guided Decoding (VGD), a decoding framework in which a lightweight verifier examines each emerging object mention, rolls back the KV cache when the mention is identified as high risk, suppresses the object and its synonyms, and regenerates the affected continuation. Because VGD intervenes only on object mentions identified as high risk, it reduces object hallucination while preserving the model's original visual understanding and grounded object coverage. Experiments on CHAIR and AMBER-G show that VGD achieves state-of-the-art object hallucination reduction: at @rec90, it cuts AMBER-G CHAIR by 43.6% while retaining 99.6% of grounded-object coverage, and reduces CHAIR-MSCOCO CHAIR$_i$/CHAIR$_s$ by 37.0%/30.4% without shortening captions.