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44
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DYSPHAGIA ASSESSMENT AND TREATMENT PLANNING: A TEAM APPROACH
Narhi, T. O., Meurman, J. H., Ainamo, A.,
Nevalainen, J. M., Schmidt-Kaunisaho,
K. G., Siudosaari, P., & Makila, E. (1992).
Association between salivary flow rate
and the use of systemic medication
among 76-, 81-, and 86-year-old inhabitants in Helsinki, Finland. Journal of Den-
tal Research, 71, 1875–1880.
Pedersen, A. M. L., Sorensen, C. E., Proc-
tor, G. B., Carpenter, G. H., & Ekstrom,
J. (2018). Salivary secretion in health and
disease. Journal of Oral Rehabilitation, 45,
730–746.
Shaker, R. (1995). Airway protective mecha-
nisms: Current concepts. Dysphagia, 10,
216–227.
Sreebny, L. M., Yu, A., Green A., & Valdini,
A. (1992). Xerostomia in diabetes melli-
tus. Diabetes Care, 15, 900–904.
Vogel, D., & Carter, J. E. (1995). The effects of
drugs on communication disorders. Singu-
lar Publishing.
continues
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the nasopharynx.
pharyngeal swallow sequence.
Examination/Videofluoroscopic Study Findings
Impact of Deficit on Swallowing Function and Physical
Muscle
Difficulty with chewing and bolus preparation during the oral
Temporalis
Group Muscles
Divided Cranial Nerve Chart for Chapter 2
away from the side of the deficit upon opening of the mouth.
preparatory phase. Poor tongue base stabilization during oral
phase with difficulty in transition to pharyngeal phase. Jaw swings
Masseter
Lateral Pterygoid
Medial Pterygoid
Muscles of
Mastication
Poor elevation of the hyoid bone during the pharyngeal phase
and PE segment seen on videofluoroscopy study.
of swallowing. Impaired movement of the larynx under the
Mylohyoid
Anterior Belly of
Suprahyoid
Lack of strength of nasopharyngeal closure during the
tongue base and failure of opening the pharyngeal chamber
the Digastric
Muscles
oropharyngeal phase with possible reflux of bolus into
Tensor Veli Palatini
Palatal
Muscle
Dry oral mucosa, lack of sensation of the anterior 2/3
of tongue, lack of modulation bolus preparation and of
Poor or incomplete mouth closure. Leakage of bolus and saliva
anteriorly out of oral cavity. Difficulty with oral preparatory phase
Orbicularis Oris
and ability to move bolus into the pharynx during the oral phase.
Facial
Muscles
and teeth on the affected side.
Pocketing of bolus during preparatory phase between cheek
Buccinator
during the pharyngeal phase.
May impact pharyngeal shortening and laryngeal elevation
Stylopharyngeus
Muscles
Pharyngeal
1/3 of the tongue.
Poor swallowing initiation and lack of sensation to posterior
Cranial Nerve Branch
3
V
Nerve
V, Trigeminal
45
Plexus
Pharyngeal
IX,
Nerve
VII, Facial Nerve
Glossopharyngeal
— a risk for aspiration after the
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in the hypopharynx.
during pharyngeal phase.
continued
Examination/Videofluoroscopic Study Findings
Impact of Deficit on Swallowing Function and Physical
Weakness of the posterior oral sphincter. Bolus may not be
contained in the oral cavity during preparatory phase but leak
Palatoglossus
Group Muscles
Muscle
Weak or absent elevation of the palate against the
into the pharynx — a risk for aspiration before the swallow.
nasopharyngeal walls during pharyngeal phase of swallowing,
Palatal
Muscles
allowing reflux of bolus and pressure into the nasopharynx
Levator Veli
seen on exam when patient asked to say “ah.”
during oral and pharyngeal phases. Poor palatal elevation
Palatini
Decrease in pharyngeal shortening and laryngeal elevation
Palatopharyngeus
Muscles
Pharyngeal
nasopharynx during the oral and pharyngeal phase.
Weak velopharyngeal sphincter with bolus reflux into the
Superior
Constrictor
Pharyngeal
Plexus
Pharyngeal
Incomplete clearance of the bolus from the pharynx
during the pharyngeal phase. Residue in the pharynx after
Middle
swallow. Laryngoscopy will show pooling of secretions
completion of the swallow
Constrictor
Pharyngeal
Muscles
Constrictor
Pharyngeal
of secretions will be seen on laryngoscopy.
residue after the swallow. Poor relaxation of the PE segment
results in incomplete opening of the esophageal inlet. Pooling
Incomplete clearance of the bolus from the hypopharynx with
Inferior
Pharyngeal
Constrictor/
Cricopharyngeus
Cranial Nerve Branch
Chart for Chapter 2
X, Vagus Nerve
46
— a risk for aspiration
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Examination/Videofluoroscopic Study Findings
Impact of Deficit on Swallowing Function and Physical
Muscle
Group Muscles
Difficulty in swallow initiation. Decreased approximation of
thyroid cartilage to hyoid bone during the pharyngeal phase.
Cricothyroid
of response if supraglottis touched with the laryngoscope.
Poor laryngeal protection noted on videofluoroscopy and lack
Thyroarytenoid
Incomplete vocal fold closure with swallowing and
vocalization seen during laryngoscopy. Possible aspiration of
Cricoarytenoid
Inner Arytenoid
Laryngeal
Muscles
bolus during the swallow.
Posterior
Cricoarytenoid
Difficulty with movement and positioning of the bolus
results in incomplete contact against the pharyngeal
the pharynx during the oral phase. Tongue base weakness
during preparatory phase. Poor movement of the bolus into
Styloglossus
Genioglossus
Tongue
after the swallow.
decreased expansion of the pharynx and poor PE
constrictors during the pharyngeal phase, resulting in bolus
residue in the pharynx after the swallow
Hyoglossus
Muscles
Poor hyoid elevation during the pharyngeal phase with
Geniohyoid
Elevator
Laryngeal
segment opening.
Thyrohyoid
Muscles
Cranial Nerve Branch
Nerve
Superior
Laryngeal
Nerve
Recurrent
Laryngeal
Nerve
X, Vagus Nerve
XII, Hypoglossal
C1
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Clinical Swallow Evaluation
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Susan J. Goodrich and Alice I. Walker
The “clinical” swallow examination is
done, classically, in the “clinic,” without
medical instrumentation. It involves
clinician-driven gathering of information, including a medical and feeding
history, clinical examination of oral
structures and function, and observational evaluation of patients and their
swallowing function.
SWALLOW “SCREEN” VERSUS
CLINICAL EVALUATION
“Screening” tests related to dysphagia
should be differentiated from standard clinical evaluations. As the term
implies, a swallowing “screen” is
performed, often at bedside, to determine if a patient is dysphagic and,
more particularly, if a patient is aspirating. Primary questions addressed
are whether the patient can eat orally
safely and whether a more comprehensive assessment for dysphagia is
indicated. Screens are frequently mandated in hospitals for acute cerebrovas-
cular accident or head-injured patients,
that is, “at-risk” patient populations.
Although often performed by speechlanguage pathologists, screens may
also be undertaken by nursing staff or
physicians. A number of screening tools
have been described; those noted here
are of interest in that they represent different approaches.
“Water swallow tests,” perhaps one
of the most frequently used bedside
screening approaches, involve giving
a patient some amount of water with
instruction to drink it as quickly as
possible. If coughing or voice change
is noted during or after the swallow
(assuming the task can be completed),
additional monitoring or screening
or, possibly, referral for instrumental
examination will be recommended
(De Pippo et al., 1994; Kidd et al., 1993;
Suiter & Leder, 2008). The VolumeViscosity Swallow Test (VVST) expands
on water swallow tests by requiring the
clinician to present 5- to 20-cc amounts
of thin-liquid and pudding and nectarthick materials, respectively, to the
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DYSPHAGIA ASSESSMENT AND TREATMENT PLANNING: A TEAM APPROACH
patient (Clavé et al., 2008), again monitoring for evidence of aspiration/swallowing difficulty. Other investigators
have reported the use of tartaric acid to
provoke and assess a patient’s cough
reflex and laryngeal sensation (Addington et al., 1999). Martino and colleagues
have described both a screening tool
and an associated training program
for its use (Martino et al., 2009). This
screen, the Toronto Bedside Swallowing Test (TOR-BSST), incorporates both
swallowing tasks and a brief oral-motor
assessment in the bedside screen.
Other techniques that are intriguing
but that to date have produced variable
and sometimes contradictory results
involve the use of cervical auscultation and pulse oximetry, respectively.
The use of cervical auscultation, which
involves recording airway or swallowing sounds via stethoscope or perhaps
laryngeal microphone, is based on the
assumption that sounds associated with
impaired swallowing or aspirate in the
airway can be uniquely identified (Borr
et al., 2007; Leslie et al., 2004; Zenner
et al., 1995). Pulse oximetry has been
used in an attempt to detect changes in
arterial blood oxygenation in response
to aspiration, again with mixed results
(Colodny, 2000; Zaidi et al., 1995).
Arecent review of screening tests, however, suggests that a water swallow test
combined with pulse oximetry may be
of particular value (Rofes et al., 2011).
In contrast to “screens,” the clinical
swallow evaluation consists of a medical and feeding history review, both
written (medical records/chart review)
and oral (including current method and
schedule of feeding), a physical examination of oral-motor anatomy and function, and observation of swallowing. As
in any clinical evaluation, the goal is a
working hypothesis of the problem. In
addition to observations regarding the
patient’s swallow behaviors, the clinical swallow evaluation should be concerned with the patient’s overall health,
cognitive status, and physical limitations. It should also assess appropriateness and readiness to undergo more
in-depth evaluation, such as endoscopy
(Langmore et al., 1988) or fluoroscopy
(Logemann, 1983). The information
obtained in the clinical evaluation
begins the process toward treatment
strategy recommendations (Cherney,
1994; Gelb, 1985; Groher & Crary, 2009;
Steefel, 1981). The remainder of this
chapter deals with the comprehensive
clinical evaluation.
INDICATIONS
A clinical swallow evaluation is indicated in any patient referred for assessment of a suspected swallowing problem. Referral usually takes place when
the patient, the family, caregiver, feeder,
and/or the physician express concerns
regarding eating or swallowing, when
weight loss or nutrition failure occurs,
and/or when pulmonary history suggests aspiration. Crucial to the assessment process is an understanding of the
referral question, so that recommendations may specifically address concerns
raised. For example, the question of
whether a person may be therapeutically fed small amounts differs greatly
from the question of whether a nonoral
source of nutrition may be discontinued.
Knowing the concerns of the patient,
referring health care provider, and the
caregiver, which may be the same or
may differ, will enable the assessor to
provide more helpful information.
3. CLINICAL SWALLOW EVALUATION
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The clinical swallowing evaluation
is a first and critical step toward providing information relevant to both the
diagnostic and therapeutic processes.
It enables the clinician to describe
and elucidate symptomatology, more
thoroughly examine the sensory and
motor aspects of the oral mechanism,
and determine the need and readiness
for further diagnostic workup. Clinical assessment of a patient and the
patient’s presenting complaint is best
performed before any diagnostic swallowing procedure — for example, a fluoroscopic dynamic swallow study (DSS)
or a fiberoptic endoscopic evaluation of
swallowing (FEES).
Clinical assessment also allows the
examiner to determine optimal timing
of further evaluation, if needed. Instrumental exams performed immediately
or very soon after a traumatic or crucial event may, of course, produce quite
different results from exams performed
when the patient’s condition is more
stable. Careful clinical monitoring of a
patient allows for the most efficacious
timing of additional exams and, consequently, the most useful information.
Indications for clinical exam may also
change. For example, if a patient with
a diagnosis of head and neck cancer is
undergoing radiation therapy, repeat
clinical exams may be appropriate at
different intervals throughout the therapy, depending on the patient’s ongoing swallow function.
LIMITATIONS
The clinical swallowing examination
is crucial in any assessment of swallowing function, but it is not all inclusive. It does not allow evaluation of
the entire swallowing tract and thus
cannot provide complete information
regarding oral, pharyngeal, and laryngeal structures and function. Because
the pharynx is not visualized, it cannot provide information about timing
of the swallow through the pharynx, or
pharyngeal strength, or whether residue remains after the swallow. Because
the larynx is not visualized, the clinical
exam cannot provide definitive information about aspiration (Linden et al.,
1993; Splaingard et al., 1988). Clinical
evaluation is not intended as a substitute for an instrumental exam; however,
it should not be bypassed when DSS or
FEES is scheduled but included as part
of the total evaluation. As noted, understanding the patient’s history and careful clinical assessment, combined with
the results of any instrumental exams,
will facilitate and optimize appropriate
treatment decisions.
Limitations of the clinical swallow
evaluation may be imposed by other
factors. For example, if a patient is for
some reason unable to physically cooperate with a full exam, a history may
need to be obtained from other sources
(e.g., chart review, referral source, and a
limited physical evaluation performed).
EQUIPMENT
Paper and pencil for recording history
and patient information are the foundation of the exam, but most useful are
basic supplies such as a small flashlight
and a tongue blade. A lateral view diagram of normal anatomy is useful for
explaining normal swallowing to the
patient. Other supplies may include
the following: small laryngeal mirror
(for tactile and/or cold stimulation);
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DYSPHAGIA ASSESSMENT AND TREATMENT PLANNING: A TEAM APPROACH
feeding apparatus such as a spoon and
cup, possibly a syringe and catheter,
straw, or pipette if observation of other
feeding methods is needed; food and
liquid such as water, ice chips, thick
liquid, puree, cracker, or other similar
solid requiring some chewing; emesis
basin; and washcloth, towel, or paper
towels. Suction should be available (for
example, patient with a tracheotomy
tube) if problems with airway maintenance needs are anticipated. Supplies
helpful for introducing stimuli without
food (and in therapy) include gauze
rolls or gauze to wrap around flexible
straws and lemon juice, sugar water,
and saline. A “clinical swallowing kit”
containing these items may help the
clinician be better prepared for the
evaluation.
TASKS/EVALUATION
Medical History and
Swallowing Complaint
Gathering of a complete and thorough
medical and feeding history is critical. Pertinent medical history should
be gleaned from the patient’s medical
chart and gathered by communication with professionals involved in the
patient’s care, including the referral
source. Written medical information
may come in the form of the medical
chart, progress notes, or referral forms.
Sources of information may include
the patient, patient’s family, and medical personnel. A patient’s primary diagnosis, general medical status, and referral question should be understood and
discussed with the patient, the referral source, and the patient’s physician
when necessary and appropriate, as
each may have a direct bearing on the
reason for referral, decisions regarding
further workup, and forthcoming recommendations. The specific concerns
of the referrer can then be addressed
directly in the assessment report and
recommendations. Equally important
is the patient’s complaint or concerns,
as this sometimes differs from the concerns of the referral source. A number
of tools have been developed that permit patients to objectively describe their
problems and the impact of swallowing
difficulty on their lives (Belafsky et al.,
2008; Chen et al., 2001).
Gathering of case history should follow the model of the standard history
and physical interview, beginning with
identifying information and patient
complaint. The complaint is then elucidated, citing onset time and type, symptoms, precipitating events, and current
manifestations and character (description of the problem[s]). Past medical
history should cover multiple systems,
including cardiac, pulmonary, gastrointestinal, neurological, otolaryngological, and so forth. Cardiac problems or
illnesses of other types should be noted,
as their effect on general patient conditioning and fatigue may prove important (Selnes & McKhann, 2005). Airway
status should be understood, with consultation with the patient’s physician
and/or a pulmonologist or otolaryngologist, if warranted. Pulmonary
problems should be recorded, including history and types of pneumonia, as
well as any disease process that may
contribute to pulmonary compromise
and reduced tolerance for aspiration.
Gastrointestinal information is important, especially a history of gastroesophageal reflux, as problems in this
area may directly or indirectly impact
laryngeal, pharyngeal, and oral symptoms and problems (Groher & Crary,
3. CLINICAL SWALLOW EVALUATION
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53
2009; Koufman, 2002). Neurological
problems could impact sensory and/
or motor systems for swallowing and
should be documented. Information
from otolaryngological, or head and
neck, exam is crucial in understanding
known problems of the oral, pharyngeal, and laryngeal anatomy. Report of
oral care and dental condition is important, if available (Langmore et al., 1998;
Loeb et al., 2003). If structures of the
larynx, including the vocal folds, have
been recently evaluated, this information will be important in assessing the
patient’s airway protection capabilities.
Any other medical problems, hospitalizations, and surgeries should be
recorded, including dates of occurrence. Prior voice, speech, or swallowing problems and intervention given,
whether medical, surgical, or radiological, may impact swallowing and thus
should be noted. Psychiatric and social
history, including independence and
availability of support, may impact the
diagnostic and/or rehabilitative processes and should be included, if relevant. A list of medications currently
taken is important, as medications may
cause xerostomia, drowsiness, or other
symptoms relevant to swallowing. Further questions are guided by knowledge
of the complaint and history. Information presented in the next few sections
represents an abbreviated template of
steps and considerations in performing
a clinical swallow evaluation.
Swallowing History
Method and Schedule
of Feeding or Eating
The current method of nutritional intake is noted, that is, oral with utensils
or syringe, or nonoral feeding tubes,
such as nasogastric, gastrostomy, duodenum, or jejunum tubes. Some of these
methods may be used in combination,
with one supplementing the other (see
Chapter 13). Thus, it is important to ask
the patient or caregiver which feeding
method is used, at what times, and with
what substances.
Diet
Note the type, amount, and frequency
of food and liquid intake, as well as
food preferences. Preferences for certain substances may provide important
information about the patient’s comfort
level managing certain foods. Have the
patient’s eating habits changed because
of their specific complaints? Are particular foods or liquids avoided, or
sought? Changes in eating habits over
the course of a day should also be documented. For instance, does the patient
eat more or less at one time of day than
another? Noting time and amount of
intake for each type of meal will provide baseline information, as well as
give clues to a patient’s compensatory
strategies for eating. The Functional
Oral Intake Scale (FOIS), a 7-point
ordinal scale that describes oral intake,
may be useful in documenting overall functional change over time (Crary
et al., 2005).
Onset of Problem
The time and date of the onset of swallowing problems, and whether gradual
or sudden, should be noted. Were problems concurrent with other medical
problems, or did they occur following
particular incidents? Were there multiple incidents of problems? Have the
problems changed, and in what way,
over time?
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