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122 CLINICAL MANAGEMENT OF SWALLOWING DISORDERS
40. Hendricker RM, DeSilva BW, Forrest LA. Gore-Tex medialization laryngoplasty for treatment of dysphagia. Oto-
laryngol Head and Neck Surg. 2010;142(4)536–539.
41. Zeitels S, Hochman I, Hillman RE. Adduction arytenopexy: a new procedure for paralytic dysphonia with
implications for implant medialization. Ann Otol Rhinol
Laryngol. 1998;173(suppl):2–24.
42. Gross RD, Enloe LD, Reyes SE. Passy-Muir valve decannulation. In: Carrau RL, Murry T, Howell R, eds. Compre-
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43. Sasaki CT, Hundal JS, Kim YH. Protective glottic closure:
biomechanical effects of selective laryngeal denervation.
Ann Otol Rhinol Laryngol. 2005;114(4):271–275.
44. Lazarus C, Logeman JA, Paulowski BR, et al. Effects of
radiotherapy with or without chemotherapy on tongue
strength and swallowing in patients with oral cancer.
Head Neck. 2007;29:632–637.
45. Jensen K, Lambertsen K, Grau C. Late swallowing dysfunction and dysphagia after radiotherapy for pharynx
cancer; frequency, intensity and correlation with dose
and volume parameters. Radiother Oncol. 2007;85(1):
74–82.
46. Cooper JS, Fu K, Marks J, Silverman S. Late effects of
radiation therapy in the head and neck. Int J Radiat
Oncol Biol Phys. 1995;31(5):1141–1164.
47. Schindler A, Denaro N, Russi EG, et al. Dysphagia in head
and neck cancer patients treated with radiotherapy and
systemic therapies: literature review and consensus. Crit
Rev Oncol Hematol. 2015;9(2):372–384.
48. Caudell JJ, Schaner PE, Meredith RF, et al. Factors associated with long-term dysphagia after definitive radiotherapy for locally advanced head-and-neck cancer. Int
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49. Huang TL, Chien CY, Tsai WL, et al. Long-term late toxicities and quality of life for survivors of nasopharyngeal
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Neck. 2016;38(suppl 1):E1026–E1032.
50. Schmidt PJ, Zuckerbraun L. Treatment of Zenker’s diverticula by cricopharyngeus myotomy under local anesthesia. Ann Surg. 1992;58:710–716.
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agement of Swallowing Disorders. 2nd ed. Plural Publishing; 2017:269–275.
Clinical Evaluation of
Swallowing Disorders
CHAPTER OUTLINE
Introduction
Evidence-Based Practice
Multidisciplinary Dysphagia Team
Swallowing Screening
Toronto Bedside Swallowing Screening Test
Modified Mann Assessment of Swallowing
Ability
The 3-oz Water Swallow Test
Yale Swallow Protocol
Burke Dysphagia Screening Test
Royal Brisbane Women’s Hospital Dysphagia
Screening Tool
Modified Blue Dye Test
Clinical Swallow Evaluation
Self-Assessments
The SWAL-QOL and SWAL-CARE
The MD Anderson Dysphagia Inventory
Eating Assessment Tool (EAT-10)
Dysphagia Handicap Index
Related Self-Assessments to Dysphagia
The Reflux Symptom Index and Reflux Finding
Score
Case History
The Physical Examination
Cognitive Assessment
Oral, Pharyngeal, and Laryngeal Examination
Trial Swallows
Silent Aspiration and the Clinical Swallow
Examination
Summary
Chapter
5
123
124 CLINICAL MANAGEMENT OF SWALLOWING DISORDERS
Discussion Questions
Study Questions
References
A Look at the Chapter
Patients who are suspected of having swallowing problems and diagnosed with dysphagia
start with a swallowing assessment before
management strategies can be proposed. The
swallowing assessment is generally divided into
a clinical or bedside screening and examination,
and an instrumental evaluation. This chapter
focuses on the clinical swallow examination.
The scope of clinical screening or assessment
protocols is discussed with reference to the
World Health Organization’s International Classification of Functioning, Disability, and Health
(ICF) framework.1 The current available evidence
in support of the clinical screening or assessment protocols is also presented.
influence eating or drinking behaviors, (3) swallowing activities and participation, (4) activities and
participation in events related to eating or drinking,
and (5) personal and environmental factors that may
affect swallowing.
1
The evaluation of a swallowing disorder may
encompass dysphagia screening, self-assessment,
clinical swallow examination, and instrumental evaluation (when necessary). Instrumental evaluations
are discussed in Chapter 6.
The aims of a swallowing evaluation are as
follows:
n Identify current swallowing functions (typical
and atypical)
n Identify presence and potential causes of
dysphagia
n Identify strategies to ensure immediate
swallow safety
n
Continuation or possible modification of
present diet
n
Effectiveness of compensatory strategies
(see Chapter 7)
n Plan for swallowing management
n Assess the impact on quality of life and third-
party disability
2
INTRODUCTION
Previous chapters have shown that swallowing disorders may occur because of various etiologies, such
as stroke, Parkinson disease, cancer, medication, or
surgery. The complex nature of swallowing disorders calls for the need for careful and comprehensive
assessment by a multidisciplinary team. Aspeechlanguage pathologist (SLP) is often the main health
professional responsible for assessing and managing swallowing functions. It is important for SLPs to
be aware of the roles of other health professionals
so that timely referrals may be made when necessary. According to the International Classification
of Functioning, Disability, and Health (ICF) framework, the scope of swallowing assessment should
include (1) body structures and functions that are
related to swallowing, (2) body functions that may
Based on the swallow evaluation, referrals for
additional tests may be requested.
EVIDENCE-BASED PRACTICE
The American Speech-Language-Hearing Association
(ASHA) published a position statement in 2005 that
recommends SLPs incorporate principles of evidence-
based practice when making clinical decisions.
Evidence-based practice (EBP) promotes the
use of best available research evidence, clinical
expertise, and client’s/caregiver’s values and
perspectives in making clinical decisions.
There are 4 general steps in EBP. The first step
is to generate a clinical question based on the cli-
3
5. CLINICAL EVALUATION OF SWALLOWING DISORDERS 125
ent in need (eg, which screening tool should I use
for acute poststroke individuals?). Then, clinicians
should search for available scientific evidence that
is relevant to the clinical question raised. A number
of organizations have created online platforms for
clinicians to find SLP-related evidence. Table 5–1
lists some examples of such online platforms. The
third step is to review and evaluate the evidence.
The highest level of evidence usually refers to welldesigned randomized controlled trials (RCT) and
well-designed meta-analysis of more than one RCT.
Finally, the last step is to integrate the clinical expertise, client’s perspective, and reviewed scientific evidence to make the necessary client-specific clinical
decisions. It is beyond the scope of this chapter to
go through the detailed steps of EBP; readers are
encouraged to refer to other resources to learn how
to implement EBP into their clinical practice.
MULTIDISCIPLINARY DYSPHAGIA TEAM
Given the complexity of the causes and impacts of
dysphagia, dysphagia is best assessed and managed
by a team of professionals to ensure patients can
swallow safely and have adequate nutritional support. An SLP is often the leader of a dysphagia
team. Other equally important team members may
include dietitian, otolaryngologist, gastroenterologist, radiologist, pulmonologist, neurologist, dentist, occupational therapist, physiotherapist, nurse,
and social worker. The members and roles of the
dysphagia team are likely to differ for individual
patients and for different settings. More information about the roles of related health professionals
is presented in Chapter 7.
Successful and efficient swallowing assessment
and management rely on good communication,
collaboration, and coordination among the team
members.
SWALLOWING SCREENING
A clinician may want to conduct a brief evaluation
(ie, a swallowing screening) to determine the need
to perform a full evaluation and make further referrals. According to ASHA, swallowing screening is a
pass/fail procedure.
questionnaire, observation, and/or trial swallows.
These screening tools and tests should be easy to
administer, be time- and cost-effective, and may be
used by any member of the dysphagia team. Clear
4
It may involve an interview,
TABLE 5–1. Examples of Online Platforms for Gathering Speech-Language Pathology–Related Scientific Evidence
Organization Name of Platform Website
American Speech-LanguageHearing Association
(United States)
Speech Pathology Database for
Best Interventions and Treatment
Efficacy (SpeechBITE)
(Australia)
National Institute for Health and
Care Excellence (NICE)
(United Kingdom)
Taylor & Francis Online Evidence-Based
Evidence Maps https://www.asha.org/Evidence-Maps/
SpeechBITE https://speechbite.com
Evidence search https://www.evidence.nhs.uk
https://www.tandfonline.com/toc/tebc20/current.com
Communication Assessment
and Intervention (journal)
126 CLINICAL MANAGEMENT OF SWALLOWING DISORDERS
guidelines on how to conduct the screening and the
consequences for passing/failing should be provided
to all involved members of the dysphagia team.
An effective screening should allow clinicians
to identify individuals who have dysphagia and
are at risk of having aspiration (high sensitivity)
and screen out individuals who do not have
dysphagia (high specificity).
When using a validated dysphagia screening
test, it is important to remember that sometimes it is
difficult to accurately detect the presence or absence
of penetration and/or aspiration in patients who
have the following conditions:
n Are severely ill
n Have significant communication impairments
and cannot follow directions
n Lack sensitivity in parts of the swallowing
organs and may aspirate without any observable signs
For these patients, it might be to their benefit to
receive a full swallowing assessment instead.
A recent review article highlights that currently
there is no evidence supporting which tool should
be selected for best practice for swallowing screen-
5
ing.
The decision can be made after evaluating the
available evidence as to which health professionals
will be available for conducting the screening and
the type of patients involved. A combination of swallowing and nonswallowing items has shown both
high sensitivity and high specificity. Some commonly
used screening tests are outlined in Table5–2,
6–12
and selected ones are presented in more detail later
in this chapter.
Toronto Bedside Swallowing
Screening Test
als who have completed a standardized training
workshop from certified TOR-BSST trainers. The
screening will be discontinued if the patient fails in
any item of the test. The test takes approximately
10minutes to complete. The test has high sensitivity
and good reliability and validity. However, it has low
specificity. The test is copyrighted, requiring online
training and purchase before use.
Modified Mann Assessment
of Swallowing Ability
The Modified Mann Assessment of Swallowing Ability (MMASA) is a 12-item assessment tool based on
the Mann Assessment of Swallowing Ability.
14
test was originally developed and validated to be
used by physicians; however, the authors proposed
that the test is simple enough to be used by other
health care professionals. No swallowing tasks are
involved in the MMASA. The test has high sensitivity,
specificity, and good reliability. No formal training is
involved, but the test has not been validated against
instrumental swallowing examination.
The 3-oz Water Swallow Test
The 3-oz water swallow test (WST)
swallow test that involves drinking 3 oz (90 cc) of
water without interruption. If the patient shows any
signs of swallowing difficulties, such as inability to
complete the task, coughing, choking or wet voice
within 1 minute, the patient would require further
swallowing assessment. The WST is commonly used
as a dysphagia screening test alone or as part of a
larger screening test.
17
It has high sensitivity but
low specificity. The WST is only recommended for
patients who are able to remain alert, can be seated
upright, are not on tube-feeding, and do not have a
tracheostomy tube.
15,16
is a simple
The
The Toronto Bedside Swallowing Screening Test
(TOR-BSST) is a dysphagia screening test for stroke
survivors in acute and rehabilitative settings.
13
The
test consists of an oral exam and a water swallow.
It can be administered by health care profession-
Yale Swallow Protocol
The Yale Swallow Protocol
(1)exclusion criteria; (2) brief cognitive screen,
oral mechanism examination, and 3-oz water swal-
18,19
includes 3 steps:
5. CLINICAL EVALUATION OF SWALLOWING DISORDERS 127
TABLE 5–2. Characteristics of Selected Dysphagia Screening Tests
Test
Toronto Bedside
Swallowing Screening
Test (TOR-BSST)
13
3-oz Water Swallow
Test (WST)
15,16
Bedside Swallowing
Assessment
6–8
Standardized
Swallowing
Assessment
9,10
Gugging Swallowing
Screen (GUSS)
11
Acute Stroke
Dysphagia Screening
(also called Barnes
Jewish Hospital Stroke
Dysphagia Screen)
12
Inclusion of
Swallowing
Items
3 3
3
3 3
3 3
3 3
3 3
Inclusion of
Nonswallowing
Items
a
X Discipline not
a
a
a
a
Who
Administers Psychometrics Duration
Trained
health care
professionals
Sensitivity 91%;
specificity 67%;
reliability: intraclass
<10 minutes
correlation 92%
stated (SLP in
Sensitivity 97%;
specificity 49%
<5 minutes
papers)
MD and SLP Sensitivity 47% to 70%;
~20 minutes
specificity 66% to 86%;
reliability: k = 0.24–0.79
RN, SLP, and
junior doctors
Sensitivity 0.97;
specificity 0.9
Not specified
(5 practice
sessions)
RN or SLP Sensitivity 100%;
~15 minutes
specificity 50% to 69%;
reliability: 95%
agreement
RN Sensitivity 91%;
2 minutes
specificity 74%;
reliability: k = 93.6
Modified Mann
X
3
Assessment of
Swallowing Ability
(MMASA)
Royal Brisbane
14
3 3
Women’s Hospital
(RBWH) Dysphagia
Screening Tool
a
Discontinue swallowing items if any nonswallowing item is positive/present.
low; and (3) pass/fail criteria. Studies have found
21
Burke Dysphagia Screening Test
the Yale Swallow Protocol to have high sensitivity,
moderate specificity, and high interrater agreement.
It was originally tested to detect aspiration in the
rehabilitation setting for stroke survivors and was
later validated in other settings and populations,
including acute stroke, traumatic brain injury, and
motor neuron disease. The protocol can be implemented by nurses and SLPs.
The Burke Dysphagia Screening Test (BDST), reported
by DePippo et al,
screening tests available in the literature. It is a quick
screening test that consists of 7 items, including a
3-oz water swallow test. If the patient has a positive
response to one or more of the items in the test, the
patient is considered to have failed and is referred
Stroke
neurologists
Sensitivity 90%;
specificity 85%;
reliability: k = 0.76
RN Sensitivity 95%;
specificity 97%
20
was one of the first dysphagia
5 minutes
7 minutes
128 CLINICAL MANAGEMENT OF SWALLOWING DISORDERS
for a complete clinical swallow evaluation (CSE).
The reliability and validity of this test have not been
as rigorously tested as the other screening tests. The
form for BDST is shown in Appendix 3.
Royal Brisbane Women’s Hospital
Dysphagia Screening Tool
The Royal Brisbane Women’s Hospital Dysphagia
Screening Tool was originally developed for nurses
to screen patients at risk of aspiration or dysphagia at acute hospital wards.
21
The screening has 2
phases. Phase 1 involves questions on the patient’s
medical history. If the patient is identified to have
any of the listed at-risk medical conditions, then
phase 2 is conducted. It involves interviewing the
patient or family caregiver, observation of clinical
indicators of dysphagia or aspiration, and a water
swallow (if none of the listed indicators of dysphagia have been identified). The tool also includes a
section on decision-making, indicating the consequences for passing and failing each phase. It has
high sensitivity and high specificity.
Modified Blue Dye Test
The modified blue dye test, also known as the
Modified Evans Blue Dye Test (MEBDT), may be
used to determine the presence of aspiration in a
tracheotomized patient. The general procedures for
the MEBDT involve (1) deflating and suctioning the
tracheotomy tube before the test; (2) conducting
swallow trials of different food and liquid consistencies that are mixed with blue food coloring (with
cuff on or off); and (3) again performing deep suction of the patient’s tracheotomy tube, this time
looking for evidence of dyed material in the airway (this procedure may be repeated over a period
of time). Good sensitivity but low specificity were
reported for the MEBDT.
22,23
CLINICAL SWALLOW EVALUATION
The clinical swallow evaluation (CSE), sometimes
called the bedside swallow evaluation or noninstru-
mental swallowing assessment, provides a road map
for the diagnosis and treatment of swallowing disorders. According to ASHA, the purpose of CSE is
to observe the presence (or absence) of signs and
symptoms of dysphagia, including mealtime performance and environmental conditions. A thorough
CSE should include case history, self-assessment,
physical examination, cognitive assessment, oral,
pharyngeal, and laryngeal examinations, and trial
swallows (if appropriate). A sample CSE form is
shown in Appendix 8.
Clinicians must understand that the CSE has
significant limitations, because it does not include
a direct examination of pharynx and larynx, nor
does it accurately determine if the patient is aspirating silently. Moreover, depending on the status
of the patient (eg, severe impairment from stroke
or extensive trauma), a complete CSE is sometimes
not possible.
Detecting the presence of penetration and aspiration is an important part of the CSE because the
potential consequences of health status and recovery are dependent on nutrition and safe swallowing.
Several investigators have examined the sensitivity
and specificity of the CSE for predicting aspiration.
McCullough, Wertz, and Rosenbek
24
evaluated 60
stroke patients and found that the CSE was not
highly predictive of patients who subsequently
aspirated during the modified barium swallow
instrumental examination. Ramsey and colleagues
8
found that the CSE had highly variable specificity
and sensitivity and also concluded that the CSE was
poor at detecting silent aspiration. Peruzzi and colleagues
25
compared the use of a colored bedside
dye test to the videofluoroscopic studies of swallowing and found that in 20 consecutive patients
with tracheotomy, the videofluoroscopic exam was
significantly better at detecting aspiration than the
colored bedside dye test.
Although the majority of CSE reports in the literature focus on stroke patients, there are reports
that relate findings from the CSE of swallowing to
other patient groups. In general, these findings suggest that for surgical patients, the larger the surgical
excision, the more likely it is that the patient will
exhibit a longer course of dysphagia. Patients in
these categories will require more extensive evaluation and treatments.
5. CLINICAL EVALUATION OF SWALLOWING DISORDERS 129
A thorough CSE will allow clinicians to describe
Once the CSE is completed, the clinician will
be able to establish a reasonable differential
diagnosis and determine if other tests are
needed (Table 5–326).
current healthy and impaired swallowing functions
and form a diagnosis. Based on the findings, clinicians can then make recommendations for diet
modifications, intervention, instrumental assessment, and referral to other professionals. Clinicians
can also identify positive and negative prognostic
factors that may affect treatment outcomes.
TABLE 5–3. Differential Diagnosis
a
Type Possible Etiology
Congenital Dysphagia lusoria
Tracheoesophageal fistula
Laryngeal clefts
Other foregut abnormalities
Inflammatory GERD
Infections:
• Lyme disease with neuropathies/
encephalitis
• Chagas disease
• Candidiasis
Trauma CNS
Upper aerodigestive tract
Spine
Chest
Endocrine Goiter
• Hypothyroidism
• Diabetic neuropathy/gastropathy
Neoplasia Upper aerodigestive tract
• Thyroid
• Central nervous system
SELF-ASSESSMENTS
Self-assessments are tools that allow clinicians to
obtain information on swallowing from the patient’s
perspective.
symptoms of dysphagia, while some also include the
impact of dysphagia on activities and participation.
Clinicians may distribute the questionnaire to patients
while they are waiting to be seen by a clinician. If
a patient does not have adequate communication
or cognitive ability to complete the questionnaire,
the family member or caregiver may be consulted.
However, clinicians should be aware that completing
the questionnaires by proxy may not truly reflect the
patient’s perspectives. Table5–4 shows some examples of existing validated self-assessment tools and
how they may be applied according to the ICF framework. Data from the patient’s perspective provide the
clinician with a guide as to what specific problems
the patient is facing, how severe they are, and what
the impacts are on the patient’s quality of life.
27
Some questionnaires only focus on the
Systemic Autoimmune
• Dermatomyositis
• Scleroderma
• Sjögren’s syndrome
• Mixed connective tissue disorder
• Myopathies
Amyloidosis
Sarcoidosis
Iatrogenic Surgery
Chemotherapy
Other Medications
Radiation therapy
a
Adapted from Carrau et al.
26
When valid and reliable self-assessment tools are
used prior to intervention and following intervention,
an additional avenue of outcome data is available.
There are a number of self-report tools available in the literature. This chapter highlights only
those that are more commonly used.
The SWAL-QOL and SWAL-CARE
The SWAL-QOL and SWAL-CARE are 2 tools for
assessing the swallowing quality of life and quality of care that are completed by the patient.
28–30
130 CLINICAL MANAGEMENT OF SWALLOWING DISORDERS
TABLE 5–4. Common Self-Assessment Tools That Address Different Components of the International
Classification of Functioning, Disability, and Health Framework
Body Functions
Screening Tool
and Structures
Activity and
Participation:
Swallowing (S) and
Related to Eating
and Drinking
Contextual Factors:
Environmental (E)
and Personal (P)
Eating Assessment Tool
(EAT-10)
Swallowing Quality
of Life (SWAL-QOL)
Questionnaire
Sydney Swallow
Questionnaire (SSQ)
The Deglutition Handicap
Index (DegHI)
The Dysphagia Handicap
Index (DHI)
MD Anderson Dysphagia
Inventory
(VHNSS) version 2.0
47
28–30
49
50
48
44–46
51
3 3
3 3 3
3 3
3
3 3
3 3
3 3
They can be used as outcome measures following
treatment. There are 44 items in the SWAL-QOL
and 15 items in the SWAL-CARE. The SWAL-QOL
is divided into 10 scales that assess quality-of-life
concepts, and the SWAL-CARE consists of 15 items
that assess quality of care and patient satisfaction.
Multiple scales are used in the 2 questionnaires. It
takes approximately 20 minutes to complete both.
The scoring of the SWAL-QOL and SWAL-CARE
takes additional clinical time. Studies have shown
that SWAL-QOL can differentiate individuals without swallowing problems from those with oropharyngeal swallowing disorders.
31–33
In addition, the
scales are sensitive to the severity of dysphagia in
those with a swallowing disorder. The SWAL-QOL
and SWAL-CARE have been translated into a number of languages, including Dutch, French, Swedish,
and Chinese.
34–37
{Lam, 2010 #296} Studies have used
SWAL-QOL to assess treatment outcomes in a range
of populations, including individuals with head and
neck cancers, stroke, and
38,39
Parkinson disease.40
SWAL-QOL is one of the few questionnaires that
X
X
X
3
X
X
X
X
fully address multiple ICF domains; however, the
long administration time and complexity of the
wording may limit its use clinically.
41
The MD Anderson Dysphagia Inventory
The MD Anderson Dysphagia Inventory (MDADI) is a
validated self-assessment tool developed specifically to
evaluate the impact of dysphagia on the quality of life
of patients with head and neck cancers.
consists of 20 items that are divided into 4 subscales:
(1) a global measure on the impact of swallowing ability on daily life and (2) emotional, (3) functional, and
(4) physical statements related to swallowing. Each
item is rated on a 5-point ordinal scale. It takes about
10 to 15 minutes to complete and score the questionnaire. The MDADI has been translated to and validated in a number of languages, including Italian,
Swedish, Korean, and Dutch.
44–46
extensively used as an outcome measurement tool in
dysphagia studies. It is shown in Appendix 4.
42
The MDADI
43
MDADI has been
5. CLINICAL EVALUATION OF SWALLOWING DISORDERS 131
Eating Assessment Tool (EAT-10)
The EAT-10 is a 10-item outcome measure of dysphagia symptom severity.
5-point interval scale. The EAT-10 was validated on
7 groups of patients in various diagnostic categories.
The instrument has excellent internal consistency,
test-retest reproducibility, and criterion-based validity. The EAT-10 is shown in Appendix 5.
47
Each item is rated on a
Dysphagia Handicap Index
The Dysphagia Handicap Index (DHI) is a 25-item
self-report questionnaire that evaluates the level of
dysphagia handicap.
48
The items are divided into
3 scales: physical, functional, and emotional. Each
item is rated on a 3-point ordinal scale. DHI has
good internal consistency, reliability, and criterion
and construct validity. The DHI is shown in Appendix 6.
The use of all of these tests is restricted to
patients who have the cognitive abilities to respond
reliably to the statements in the assessments. Thus,
the clinician must be aware of when to use these
assessments and how to interpret the results in lieu
of the patient’s condition. Although self-assessment
tools may provide a way of assessing current status
or severity from the patient’s perspective as well as
for outcomes following intervention, the clinician
must be aware of their limitations in neurologically
disadvantaged patients, as well as in patients who
demonstrate the need to want to swallow despite
obvious safety concerns.
RELATED SELF-ASSESSMENTS TO DYSPHAGIA
and has been found to be a valid index of reflux
severity. Gastroesophageal reflux disease (GERD)
or laryngopharyngeal reflux disease (LPRD) is
often associated with dysphagia, and when treated
maximally, the improvement of GERD and/or LPRD
is usually related to an improvement in swallow
function.
The RSI has been studied in relation to the
reflux finding score (RFS), a clinician-based assessment tool used to score the severity of reflux symptoms as seen on laryngeal endoscopy. The RSI and
RFS are shown in Appendices 1 and 2, respectively.
Case History
Prior to any assessment of the patient, the clinician
should identify the chief complaint or define the current status of the patient. A detailed history should
account for the current physical status and any recent
surgeries, medical conditions, or medications that
may contribute to dysphagia. Clinicians can obtain
such information from medical charts (if available)
before seeing the patient. Table 5–5
49–51
summarizes
the critical components of the case history. Information may be obtained from medical chart review,
interview with patient, family members, significant
others, main caregiver, or health care workers.
Common clinical findings that are associated
with dysphagia and/or aspiration are shown in
Table 5–6. It should be pointed out that even when
the majority of these symptoms are absent, swallow
safety may still be an important issue.
21
Table5–6
emphasizes that observing the patient during mealtimes, reviewing the case history, and acquiring
information from caregivers are important aspects
of the CSE.
The Physical Examination
The Reflux Symptom Index
and Reflux Finding Score
The Reflux Symptom Index (RSI) is a 10-statement
patient self-assessment measure that quantifies a
patient’s perception of their reflux symptoms.
RSI has been validated using a 24-hour pH meter
47
The
A physical examination should include a basic head
and neck and neurological examination, with assessment of gait, balance, sensory and motor function
of the extremities, deep tendon reflexes, and full
assessment of the cranial nerves. This may be done
by an SLP, neurologist, otolaryngologist, gastroenterologist, or a combination of these professionals