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DYSPHAGIA ASSESSMENT AND TREATMENT PLANNING: A TEAM APPROACH
Many consider ambulatory pH testing
to be the gold standard for the diagnosis of reflux.
In order to diagnose GER, the pH
sensor must be placed 5 cm above the
upper border of the LES. The location
of the LES is determined by endoscopy
or manometry. The distal sensor may
be hardwired to a transnasal catheter
or may be wireless. However, the hardwired device for reflux testing can be
uncomfortable to position and has been
shown to cause dysphagia and decrease
reflux-provoking behavior. Wireless
pH testing is more comfortable and
has the advantage of routinely collecting 48 hours of data (Belafsky et al.,
2004). A wireless pH telemetry capsule
is placed 5 cm above the LES or 6cm
above the endoscopic determination
of the gastroesophageal junction (Figure9–8). The wireless capsule transmits
to a data receiver. The capsule falls off
spontaneously in 7 to 10 days and is
then passed harmlessly through the
gastrointestinal tract.
In order to objectively diagnose extraesophageal reflux or laryngopharyngeal
reflux, a pH sensor is placed outside
of the esophagus 1 to 2 cm above the
UES in the hypopharynx (Merati et al.,
2005). Most pH labs that use dual-probe
pH testing place a distal sensor 5 cm
above the LES and a proximal sensor 10
or 15 cm cephalad. This places the proximal sensor somewhere in the mid or
upper esophagus. However, in order to
diagnose extraesophageal reflux, a sensor must be outside the esophagus in
the hypopharynx. Figure 9–9 displays
the appropriate placement of the dualprobe pH catheter.
Figure 9–9. Endoscopic view of the proxi-
mal sensor (1 to 2 cm above the UES) in
dual-probe pH testing.
A B
Figure 9–8. A. Wireless pH telemetry capsule (arrow ) with introducer. B. Endoscopic
view of capsule attached to mucosa in the distal esophagus.
9. OTHER TECHNOLOGIES IN DYSPHAGIA ASSESSMENT
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STUDY QUESTIONS
1. What percentage of patients who
localize their site of dysphagia to
the area above the clavicle will
actually have an esophageal etiology to their symptoms?
2. What are the most common find-
ings during unsedated transnasal esophagoscopy in ambulatory
patients with dysphagia?
3. What is considered a “normal”
esophageal transit time in the
supine position?
4. How does high-resolution manom-
etry differ from conventional manometry?
5. Adding impedance testing to tra-
ditional manometry offers what
advantages?
6. What are methods for assessing
gastric emptying time?
7. Does wireless pH testing measure
proximal reflux, distal reflux, or
both?
8. In true dual-probe pH testing, sen-
sors are located where?
REFERENCES
Belafsky, P. C., Allen, K., Castro-Del Rosa-
rio, L., & Roseman, D. (2004). Wireless
pH testing as an adjunct to unsedated
transnasal esophagoscopy: The safety
and efficacy of transnasal telemetry cap-
sule placement. Otolaryngology-Head and
Neck Surgery, 131, 26–28.
Castell, D. O., Knuff, T. E., Brown, F. C., Ger-
hardt, D. C., Burns, T. W., & Gaskins, R.
D. (1979). Clinical conference, Dyspha-
gia. Gastroenterology, 75, 1015–1024.
Falk, M., Van der Wall, H., & Falk, G. L.
(2015). Differences between scintigraphic
reflux studies in gastrointestinal reflux
disease and laryngopharyngeal reflux
disease and correlation with symptoms.
Nuclear Medicine Communication, 36,
625–630.
Farwell, D. G., Rees, C. J., Mouadeb, D. A.,
Allen, J., Chen, A. M., Enepekides, D.
J., & Belafsky, P. C. (2010). Esophageal
pathology in patients after treatment for
head and neck cancer. Otolaryngology–
Head and Neck Surgery, 143, 375–378.
Fujii, N., Inamoto, Y., Saitoh, E., Okada, S.,
Yoshioka, S., Nakai, T., . . . Palmer, J. B.
(2011). Evaluation of swallowing using
320-detector-row multislice CT. Part I:
Single and multiphase volume scanning
for three-dimensional morphological and
kinematic analysis. Dysphagia, 26, 99–107.
Howell, R. J., Pate, M. B., Ishman, S. L.,
Isseroff, T. F., Rubin, A. D., Soliman, A.
M., . . . Pitman, M. J. (2016). Prospective
multi-institutional transnasal esophagoscopy: Predictors of a change in management. Laryngoscope, 126, 2667–2671.
Hoy, M., Domer, A., Plowman, E. K., Loch,
R., & Belafsky, P. C. (2013). Causes of
dysphagia in a tertiary-care swallowing
center. Annals of Otology, Rhinology, and
Laryngology, 122, 335–338.
Huang, Y. H., Chang, S. C., Kao, P. F., Chi-
ang, T. H., Chen, S. L., Lee, M. S., & Wu,
M. C. (2013). The value of pharyngeal
scintigraphy in predicting videofluoroscopic findings. American Journal of Physi-
cal Medicine and Rehabilitation, 92(12),
1075–1083.
Huckabee, M. L., Macrae, P., & Lamvik, K.
(2015). Expanding instrumental options
for dysphagia diagnosis and research:
Ultrasound and manometry. Folia Phoni-
atrica et Logopaedica, 67, 269–284.
Knigge, M. A., Thibeault, S., & McCulloch,
T. M. (2014). Implementation of highresolution manometry in the clinical
practice of speech-language pathology.
Dysphagia, 29, 12–16.
Kuo, B., McCallum, R. W., Koch, K. L., Sitrin,
M. D., Wo, J. M., Chey, W. D., & Parkman, H. P. (2008). Comparison of gastric
emptying of a nondigestible capsule to a
radio-labelled meal in healthy and gastroparetic subjects. Alimentary Pharmacol-
ogy and Therapeutics, 27, 186–196.
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DYSPHAGIA ASSESSMENT AND TREATMENT PLANNING: A TEAM APPROACH
Lafer, M., Achlatis, S., Lazarus, C., Fang,
Y., Branski, R. C., & Amin, M. R. (2013).
Temporal measurements of deglutition
in dynamic magnetic resonance imag-
ing versus videofluoroscopy. Annals of
Otology, Rhinology, and Laryngology, 122,
748–753.
Merati, A. L., Lim, H. J., Ulualp, S. O., &
Toohill, R. J. (2005). Meta-analysis of
upper probe measurements in normal
subjects and patients with laryngopha-
ryngeal reflux. Annals of Otology, Rhinol-
ogy, and Laryngology, 114, 177–182.
Omari, T. I., Ciucci, M., Gozdzikowska, K.,
Hernández, E., Hutcheson, K., Jones, C.,
. . . O’Rourke, A. (2020). High-resolution
pharyngeal manometry and impedance:
Protocols and metrics-recommendations
of a high-resolution pharyngeal manom-
etry international working group. Dys-
phagia, 35(2), 281–295.
Postma, G. N., Cohen, J. T., Belafsky, P. C.,
Halum, S. L., Gupta, S. K., & Bach, K.
K. (2005). Transnasal esophagoscopy:
Revisited (over 700 consecutive cases).
Laryngoscope, 115, 321–323.
Rosen, S. P., Jones, C. A., & McCulloch, T.
M. (2017). Pharyngeal swallowing pres-
sures in the base-of-tongue and hypo-
pharynx regions identified with threedimensional manometry. Laryngoscope.
Advance online publication. https://doi
.org/10.1002/lary.26483
Sasaki, C. T., Ross, D. A., & Hundal, J. (2003).
Association between Zenker’s diverticulum and gastroesophageal reflux disease:
Development of a working hypothesis.
American Journal of Medicine, 115(Suppl.
3A), 169S–171S.
Savarino, E., di Pietro, M., Bredenoord, A.
J., Carlson, D. A., Clarke, J. O., Khan, A.,
. . . Gyawali, C. P. (2020). Use of the functional lumen imaging probe in clinical
esophagology. The American Journal of Gas-
troenterology, 115(11), 1786–1796. https://
doi.org/10.14309/ajg.00000000 00000773
Tutuian, R., & Castell, D. O. (2005). Reflux
monitoring: Role of combined multichannel intraluminal impedance and
pH. Gastrointestinal Endoscopy Clinics of
North America, 2, 361–371.
Yadlapati, R., Kahrilas, P. J., Fox, M. R.,
Bredenoord, A. J., Prakash Gyawali, C.,
Roman, S., . . . Pandolfino, J. E. (2021).
Esophageal motility disorders on highresolution manometry: Chicago classification version 4.0
©
. Neurogastroenterology
and Motility, 33, e14058.
The Treatment Plan:
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Behavioral Approaches
Rebecca Leonard and Deirdre Larsen
(With Addenda by James A. Curtis, Madeline Mills,
Maggie-Lee Huckabee, Ivy Cheng, and Shaheen Hamdy)
Patients referred to the dysphagia team
are evaluated and then presented at a
weekly team meeting. At the team presentation, relevant information from
the patient’s medical history/chart
review, results of current physical
examinations or clinical evaluations,
findings on bedside or clinical swallow
evaluations, and results of videofluoroscopic study are discussed. If related
exams have been completed (i.e.,
esophagram, manometry, endoscopy),
these are considered as well. Patients’
medical records, pertinent test results,
and related information are available
for review by team members who were
not part of the patient’s clinical evaluation. The goal is to identify risk factors to safe and effective swallowing,
as well as potential for oral eating. The
information is assimilated by members
of the team, who then summarize and
prioritize team recommendations. Typi-
cally, the speech pathology members of
the team assume responsibility for presenting patients and preparing reports.
In this chapter, we discuss how recommendations are translated into a treatment plan and review the major categories of therapies that are recommended
for individual patients. In addition,
recordkeeping details that permit the
simultaneous generation of a written
report and entry of information into a
dysphagia database are described.
PRELIMINARY CONSIDERATIONS
As noted, the goal for each patient is to
determine both risks and potential for
oral eating and to then develop a treatment plan appropriate to these considerations. Presented in Figure 10–1 is
a flowchart that illustrates the review
process. Some of the information is of
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DYSPHAGIA ASSESSMENT AND TREATMENT PLANNING: A TEAM APPROACH
TEAM REVIEW
FROM CLINICAL
EVALUATION,
HISTORY
QUESTIONS
(PHYSICIAN
AND PATIENT)
SAFETY,
EFFECTIVENESS
SUBJECTIVE
IMPRESSIONS
EXPLAIN
MECHANICS
ASSESS RISK
PROGNOSIS
IDENTIFY AND
TEST
STRATEGIES
FROM DSS
PHYSICAL
STATUS
ESOPHAGEAL
FROM
SCREEN
COGNITIVE
STATUS
TIMING,
OBSERVATIONS
FURTHER W/U
SOCIAL STATUS
NEED FOR
Figure 10–1. Flowchart illustrating considerations in team review.
course based on our diagnostic tests,
but other insights are also critical — for
example, the patient’s prognosis for
recovery. One patient may be hospitalized but nearing release to home or a
care facility. Another may be seriously
ASSESS
POTENTIAL
TREATMENT PLAN
impaired at the time of evaluation but
be expected to recover, perhaps fairly
rapidly, to a normal or near-normal
level of function. Other individuals may
have progressive conditions likely to
produce further deterioration in swal-
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189
low function. Understanding prognosis
is a key element of treatment planning.
Other factors related to the patient’s
medical and physical status will also influence treatment planning. For example,
recommendations for a fragile patient
with poor pulmonary status are likely
to differ from those for a patient with
similar swallowing difficulties who can
tolerate some degree of aspiration.
Recommendations must also take into
account the patient’s social or living situa-
tion and cognitive status. The impact of
treatment recommendations on human
resources (caregivers and their capabilities), as well as on technical resources
(obtaining and preparing particular
food types), must be considered. If recommendations involve the patient’s
independent participation in feeding,
that is, use of strategies and maneuvers,
then appropriate cognitive and physical
skills are imperative. The team makes
every effort to provide preliminary recommendations and precautions for safe
feeding as soon as sufficient information
is available. In some instances, however,
additional diagnostic studies are required
before a treatment plan can be finalized.
Such studies may be necessary to establish a medical diagnosis, when this is in
question, or to further elaborate or treat
a problem that has been identified. In
infants and young children, special studies
are frequently required before interpreta
tions of findings and recommendations
for treatment can be completed. Some
of these are discussed at greater length
in Chapter 14. Commonly requested
studies, however, include neurodevelopmental assessment and communication skills evaluation. In infants,
pulmonary workup is often needed to
determine the adequacy of respiratory
support for swallowing.
-
Initial team recommendations may
also include a referral of the patient
to other medical specialists for further evaluation. For example, if there
are concerns about esophageal function in swallowing that have not been
addressed, or about the possibility of
serious gastroesophageal reflux (GER)
disease, referral to gastroenterology
or a specialist in esophagology is indicated. Questions about neuromotor integrity or sensation that have not been
previously raised warrant referral to
neurology. Issues regarding laryngeal
function in our particular setting (otolaryngology) are most often considered prior to the team evaluation; if
not, referral to a laryngologist is generated. Similarly, concerns about dentition or oral hygiene may warrant a
dental evaluation. In our experience,
the advantage of having a network of
specialists who act as an extended part
of the dysphagia team is extremely useful. These specialists are familiar with
team functions and objectives, have had
experience with patients with similar
problems, and are typically willing to
see patients as expediently as possible.
Finally, team meetings in our setting
begin with a presentation of the refer-
ring professional’s concerns and questions,
as well as the patient’s questions or com-
plaints, and a successful review typically will have answered these inquiries
or at least made substantial progress in
answering them.
TREATMENT PLAN
Dysphagia team recommendations
directly related to the management
and treatment of dysphagia fall into
several categories. For our purposes,
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DYSPHAGIA ASSESSMENT AND TREATMENT PLANNING: A TEAM APPROACH
treatments can be classified as behavioral, medical, or surgical. Examples of
behavioral treatments and the indications for prescribing them in individual
patients or particular groups of patients
are discussed here. Medical and surgical treatments are addressed in Chapter 11. During the COVID-19 pandemic,
telehealth became a critical avenue for
delivering dysphagia care to many populations. This topic is covered in detail
in Dr. Georgia Malandraki’s chapter
(Bonus Online Chapter). Approaches to
infants and children are discussed by
Dr. Anna Miles in Chapter 14.
BEHAVIORAL APPROACHES
A therapist specializing in oropharyngeal swallowing disorders, most often
a speech-language pathologist, provides behavioral therapy to patients
suffering from dysphagia. Physical
therapists and occupational therapists
may also provide swallowing therapy
and/or other therapies of value. For
example, a physical therapist may be
consulted when there are concerns
about a patient’s head/neck or body
posture in support of respiration and
swallowing or about appropriate seating during eating. Occupational therapists may become involved in rehabilitation of motor skills required for a
particular function related to eating, as
in the use of feeding utensils or adaptive devices used for this purpose. In
some instances, nursing professionals
also participate in swallowing therapy.
In hospitals and other care facilities,
the combined efforts of the swallowing
disorder therapist and nurses charged
with a patient’s care may be used to
“mass” patient trials with various
therapeutic strategies and to monitor
a patient’s response to these strategies.
In general, behavioral therapies
are recommended when the strength,
endurance, and/or mobility of structures involved in swallowing are diminished and when diagnostic probes have
indicated that swallowing may be facilitated, or made safer, by deficit-directed
exercise, bolus manipulation, postural
compensations, facilitative maneuvers,
or adaptive devices. Behavioral therapies are also recommended when it
is believed that more appropriate initiation or timing of bolus transit/swallow gestures, including coordination of
behaviors or events, may be induced by
selective stimulation of particular structures or systems, or when rehabilitation
directed to restoration of function, as
opposed to compensation for dysfunction,
seems indicated and possible. Summaries of the rationale and objectives for
these interventions, and examples of
each, are presented here.
Prior to recommending any particular behavioral treatment for a patient
who is a candidate for such treatment, it
is important for the clinician to understand what, in particular, is aberrant
about a patient’s swallow function.
Simply understanding the primary etiology of dysphagia (e.g., stroke, head
and neck cancer, neuromuscular disease) is not sufficient for an appropriate treatment recommendation. Neither is knowing only whether a patient
aspirates or not. Rather, the decision
of what to apply should be based on a
careful investigation of the individual
patient’s swallow (as well as “preliminary considerations” previously discussed). One of the benefits of a careful
instrumental study, in particular fluoroscopy, is that it can provide quanti-
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tative evidence regarding mechanical
characteristics that are either impaired
and may need to be addressed therapeutically or, rather, are relatively
intact and represent strengths that may
be maximized with therapy. Other
insights are also possible. If there is an
available compensatory mechanism
that seems appropriate — for example,
a chin tuck that may help protect the
airway
the study. If the maneuver appears successful, it can be followed by a swallow without the maneuver. If aspiration
occurs again, this is good evidence of
the effectiveness of the maneuver. If,
rather than a compensatory maneuver,
rehabilitation directed to restoration of
function is indicated, the quantitative
evidence from fluoroscopy can help
target specific mechanical variables
that need to be addressed, such as pharyngeal constriction, hyoid or larynx
displacement, or opening of the upper
esophageal sphincter (UES). It should
also be remembered that an individual
patient’s ability to utilize a particular
treatment strategy is dependent on
many factors, including potential for
restoration of neuromuscular integrity,
which may be realistic in some patients
but not in others, and on ability to manage a strategy, including its use, as well
as training in its use.
— this can be attempted during
Improving Structural Strength/
Mobility/Endurance
Related to the model of swallowing
discussed in earlier chapters, exercise
is directed to improving the effectiveness of valves and chambers involved
in swallowing (i.e., lip seal, breath holding, pharyngeal constriction). Clear evi-
dence of weakness or limited movement
of the mandible, lips, tongue, pharynx,
larynx, or pharyngoesophageal segment (PES) is an indication for therapy
directed to improving the strength,
range of motion, endurance, and agility of the gestures. Specific examples
of this type of problem include failure
to contain bolus material in the mouth
related to an inability to maintain lip
closure and failure to protect the airway related to an inability to elevate the
larynx or close laryngeal valves. Such
findings are typical of certain patient
populations
treated with radiation therapy for head
and neck cancer or patients with muscle
weakness secondary to neurogenic disease. Poor structural mobility and muscular weakness should be documented
by the physical examination and confirmed with diagnostic studies such
as the dynamic fluoroscopic swallow
study (DSS). Specific exercises should
be aimed at improving the capabilities
of residual swallowing gestures and/
or those with the most compensatory
potential. Even with attention to these
details, however, building consensus
regarding the utility, or lack thereof,
of individual therapy approaches is
difficult. Available reviews reveal differences in populations treated with
the same strategy (including normal
subjects and disparate patient groups),
details of assessment, analysis and
treatment protocols (e.g., small subject
numbers or lack of a control group),
and many other variables that complicate the issue. Langmore and Pisegna
(2015) refer further to questions regarding exercise in dysphagia rehabilitation
as it relates to general principles of neuromuscular rehabilitation, including
concepts of “use it or lose it,” specificity,
— for example, patients
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DYSPHAGIA ASSESSMENT AND TREATMENT PLANNING: A TEAM APPROACH
intensity, and transfer. Readers are
encouraged to carefully explore not just
quantity but also quality of available
evidence, with special attention to randomized controlled trials, systematic
and critical reviews, and other sources
of objective information pertinent to
treatments in specific patient groups.
These difficulties notwithstanding,
a number of swallowing exercise programs have shown promise. One, first
described by Shaker et al. (1997), demonstrated increased pharyngoesophageal segment (PES) opening in normal
elderly adults and in a group of nonoral
patients with dysphagia with abnormal
PES function (Shaker etal., 2002). The
“Shaker exercise” as originally described
involves lying on the back and elevating
the head sufficiently to observe the toes
without moving the shoulders. Both
sustained head elevation and repetitive elevations are used. The authors
reported that normal elderly adults who
did the exercise three times a day for a
period of 6 weeks demonstrated significant increases in PES opening, as well as
in anterior excursion of the larynx and
hyoid displacement, as compared with a
sham exercise group. The patient group
demonstrated similar findings and was
also noted to show improvement in
self-assessment of function. The same
exercise also demonstrated promise in
increasing thyrohyoid muscle shortening, an action that contributes to both
PES opening and airway protection
during swallow (Mepani et al., 2009).
Logemann et al. (2009) reported fewer
instances of aspiration in a small group
of patients over a 6-week treatment trial.
One difficulty with the original
Shaker head-lift exercise was an inability of some patients to perform it, with
at least one study demonstrating fairly
high noncompliance even in nondysphagic but elderly adults (Easterling
et al., 2005). One modification of the
exercise involves sitting in an upright
position and applying pressure with
the thumbs (or soft ball or other appropriate device) under the chin while
attempting to tuck the chin (referred
to as CTAR, or chin tuck against resistance) (Yoon et al., 2014). This approach,
likely less strenuous than the Shaker
exercise described, has been reported
by Park and Hwang (2021) to activate
suprahyoid muscles in healthy adults
while also reducing sternocleidomastoid muscle activity. Another variation of the original Shaker exercise,
referred to as forehead against resistance (FAR), involves the application
of manual pressure to the forehead
with the chin tucked. Preliminary findings reported for this approach in some
normal subjects included, on fluoroscopy, increased opening of the UES as
compared to baseline measures, though
not consistently in both anteroposterior
(AP) and lateral view measurements
(Balasubramanian et al., 2019).
Recently, resistance training has
been applied to the pharyngeal muscles. Shaker and colleagues (2016)
have described the sRED, or Swallow
Resistance Exercise Device, that can
be worn on the neck and adjusted to
alter the resistance load of the hyoid
and larynx during swallowing. The
authors report that use of the device
induced fatigue in peristaltic activity
of the pharynx and suggest that it may
thus have the potential to improve pharyngeal constriction during swallow.
The technique Swallowing Against
Laryngeal Resistance (SLAR) has also
demonstrated increases in UES opening and laryngeal excursion (Agrawal
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et al., 2018). Though further investigation is required to demonstrate the specific utility of these strategies in various
patient populations, available evidence
does indicate the potential of resistance
training in dysphagia treatments.
Another exercise approach, this one
designed to increase tongue strength,
was first described by Robbins et al.
(2005). It requires the placement of
a pressure-sensitive bulb (Iowa Oral
Performance Instrument) into the oral
cavity between the tongue and palate.
The goal is to compress the bulb as
completely as possible against the palate with the tongue. In the preliminary
study, normal elderly adults completed
training over an 8-week period. Both
swallowing pressures and isometric
pressures were significantly increased
at the end of the exercise period, and
the authors recommended the use of
lingual resistance exercise in patient
populations with lingual weakness and
swallowing disability, in particular, in
patients whose difficulties are age
related. Evidence of increases in both
anterior and posterior tongue strength
with exercise in healthy older adults
has also been reported by Chien-Ju Lin
et al. (2022).
Of particular interest in the Robbins
et al. (2005) study was the finding of
increased lingual volume after completion of the training, as documented by
magnetic resonance imaging (MRI)
before and after therapy. Addition
of muscle mass is the goal of many
strength training programs traditionally directed to limb and trunk muscles, but evidence of vascular and tissue changes in swallow structures with
exercise is just beginning to emerge,
and evidence of their benefit in actually
improving swallow safety or efficiency
in dysphagic patients is limited (Burkhead et al., 2007; Lazarus, 2006; Lazarus et al., 2014; Sullivan et al., 2001) and
mixed (Cheng & Hamdy, 2021; Steele
etal., 2016).
Another exercise that has been described is the “Masako” maneuver (Fujiu
& Logemann, 1996). Masako involves
swallowing with the tongue held
between the teeth with the intent of
strengthening tongue-pharynx contact
through resistance. To our knowledge,
evidence of the effectiveness of the strategy in a large number of patients with
differing dysphagia etiologies has not
been described (Doeltgen et al., 2011).
At least one report suggests no preand post-differences in normal adults
undergoing a 4-week exercise program
with the maneuver (Oh et al., 2012); a
study of stroke patients by Byeon and
Koh (2016), on the other hand, demonstrated improvement with the exercise
as assessed by the Functional Dysphagia Scale. It should also be noted
that, though tongue-pharynx contact
during swallow is certainly a critical
feature of normal swallow and thus a
desirable therapy goal, contact alone does
not ensure the sequential superior-inferior
action of the tongue and pharynx observed
during normal swallow. In our own prac-
tice, we have observed patients who
do manage contact between the tongue
and pharynx during a swallow but are
still disabled due to poor pharyngeal
peristaltic constriction.
Therapy directed to respiratory muscles has also been investigated in patients with dysphagia (Brooks et al.,
2019). Sapienza and Wheeler (2006) note
that expiratory muscle strength training (EMST) potentially benefits both
airway protection and swallow-related
behaviors such as hyoid and laryngeal
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