Assessment of Swallowing: Clinical and Instrumental Evaluations

Signs and Symptoms of Dysphagia

  • Prolonged feeding and/or fatigue
  • Oral expectoration, nasal regurgitation
  • Drooling/increased secretions
  • Coughing/choking/throat clearing
  • Weight loss or changes in diet
  • Dehydration, temperature spike, pneumonia
  • Pocketing of food, mouth odor
  • Gurgly/wet voice or cry
  • Rejection of food, food selectivity, gagging

Screening

  • Screening should be a quick, noninvasive, low-risk procedure
  • Based on chart review and brief patient observation
  • Determine presence of dysphagia – do not inform about patient’s physiology during the swallow

Clinical Exam – Components of Prefeeding Assessment

  • Complete history
  • Oral structural exam, oral motor exam, oral sensory exam
  • Oral reflex exam
  • Laryngeal function exam
  • Observation of patient

Clinical Exam-Prefeeding Assessment: Chart Review

  • Past medical history
  • Current medical status and medications
  • Nutrition/hydration
  • Respiratory status
  • Nursing assessment
  • Cognitive/communicative history
  • Social history
  • Other evaluations

Clinical Exam – Prefeeding Assessment: Observations of Patient and Environment

  • Posture and movement
  • Alertness, reaction to people in room
  • Awareness of and control of secretions
  • Ability to follow directions/answer question (cognitive/communicative status)
  • Auditory & visual acuity
  • Caregiver-patient interaction

Clinical Exam – Prefeeding Assessment: Multisystem Sensorimotor Examination

  • Examination of oral structures
  • Examination of oral function
  • Examination of oral reflexes and sensation Results of exam should reveal any facial paralysis, problems maintaining lip closure,
    limitations in tongue function, area of oral cavity best for food positioning
    & aid in choosing best food consistencies
  • Examination of laryngeal function
    1. Voice quality – gurgly voice, hoarse voice
    2. Strength of voluntary cough/throat clearing
    3. Pitch flexibility and phonation times
    4. Gives idea of extent of laryngeal involvement – may want to teach
    supraglottic swallow prior to continuing with presentation of food
    e.Respiratory Status
    1. Respiratory rate
    2. Timing of saliva swallows in relation to phase of respiratory cycle
    3. Duration of comfortable breath hold
    4. Resting breathing pattern – oral or nasal
    5. Pulmonary function testing

Clinical Exam: Initial Swallowing Examination

  • First must decide whether to proceed with food presentation
  • Reduced alertness, absent swallow, absent productive cough,
    difficulty handling secretions, significant reductions in range and
    strength of oral, pharyngeal and laryngeal movements – high risk
  • Consider position changes, food textures/consistencies, placement of food in mouth

•Clinical Exam: Observations during Trial Swallows ◦Estimate oral transit and pharyngeal delay time
◦Phonate after swallow, pant, phonate again
◦Head rotation, chin elevated, followed by phonation
◦Listen for gurgly voice, coughing
◦Still may miss the 50 – 60 % of pts who are silent aspirators

Clinical Exam – Observation of Eating

◦Reaction to food/self-feeding skills
◦Oral movements in chewing
◦Coughing, clearing throat or struggle behaviors
◦Changes in breathing, secretion levels through meal
◦Duration of meal and total intake
◦Co-ordination of breathing and swallowing

Clinical Exam: Management of Tracheostomized Pts

◦Usually inserted between 3rd and 4th tracheal rings – well below TVC
◦ Inflated cuffed trach tubes may restrict laryngeal elevation, reduced laryngeal
sensitivity, or place pressure on the esophagus
◦Long-term trachs (> 6 mos) may result in scar tissue & reduced closure of vocal folds
◦If medically feasible, cuffs should be deflated prior to exam of swallow
◦Blue-Dye test to screen for aspiration
◦Lightly covering end of trach tube during and for few seconds after swallow may improve the swallow
◦Use of one-way valve may also improve swallowing
◦Pts on ventilator may benefit from presentation of food at beginning of respiratory phase
◦Intubated pts – no swallow assessment

Clinical Exam: Drawing Conclusions

◦Have you obtained enough information or are other assessments needed?
◦Is this patient safe to eat by mouth?
◦Can the patient maintain adequate nutrition and hydration?
◦Should the patient be NPO?
◦What kind of indirect treatment is needed?
◦What else might the staff need to know?

Instrumental Examination: Imaging Procedures

◦Ultrasound images tongue and hyoid bone using sound waves
◦Videoendoscopy (FEES) allows visualization of pharynx/larynx using fiberoptic endoscope
◦Videofluoroscopy (MBS) is a radiological procedure allowing visualization of all stages of swallow
◦Scintigraphy quantifies bolus volume using ingestion of radioactive material

Instrumental Examination: Non-Imaging Procedures

a. EMG measures electrical activity in muscles of swallowing
b.EGG can be used to track laryngeal elevation
c.Cervical auscultation is used to detect presence of swallow &
aspiration by listening to the sounds of swallowing and respiration
d.Pharyngeal manometry examines pressure dynamics in the pharynx
and the timing of the pharyngeal contractile wave

Videofluoroscopy (MBS): Factors of Eligibility

a.Alertness – increased fatigue will interfere with completion or initiation of test
b.Endurance – must be able to sit up at least 15 – 30 minutes
c.Positioning – unless video chair is available – must be able to sit
d.Language skills – must be able to follow simple commands with minimal cuing

Endoscopy (FEES): Factors of Eligibility

a.Pt bedridden, weak, in pain
b.Pt on cardiac monitors, in ICU, on ventilator
c.Pt is demented, confused, fearful
d.Need exam that day
e.Need repeat exam, therapeutic exam, biofeedback

Videofluoroscopy: Advantages/Disadvantages

a.MBS more costly, involves radiation exposure
b.MBS indicated if questions remain re: oral stage disorders,
pt seen for first time with long-standing dysphagia, has vague complaints,
complains of food “stuck” at thyroid notch or lower, or confounding signs seen on clinical exam
c..Provides information re:bolus transit times, motility problems and amt and etiology of aspiration

Endoscopy: Advantages/Disadvantages

a.Able to assess swallowing potential without giving food/liquid by mouth; good for high aspiration risks
b.Pt with sudden onset of pharyngeal dysphagia i.e. pts with pharyngeal signs in acute phase post stroke, TBI or surgery
c.Good for re-test of pts with initial MBS
d.Can’t visualize oral, upper esophageal or esophageal stages
e.Can’t see aspiration during the swallow, but can assess airway protection patterns

Videofluoroscopy: Purpose of Evaluation

a.Measure speed of swallow
b.Measure efficiency of swallow
c.Define movement patterns of structures in oral cavity, pharynx and larynx
d.Determine if aspiration occurs and when, how and how much
e.Examine effectiveness of rehabilitation strategies

Videofluoroscopy: Equipment and Supplies

•a.Fluoroscopy unit with video recorder (VCR)
b.Seating devices to position patients
c.Liquid and paste barium, thickener, cookie/cracker, other foods as desired
d.Spoon, cup, syringe, special implements
e.Forms for recording data

Videofluoroscopy: Procedure

a. Pt viewed laterally, then A – P if needed
b. Lateral view lets you measure oral transit time, pharyngeal transit time,
duration of stage transition (delay), anatomic problems, physiologic problems
c. Anterior view allows you to see asymmetries in residue in valleculae and
pyriform sinuses. Adduction/abduction of vocal folds
d. Begin with 1/3 tsp (1cc) liquid barium, proceed to 3, 5, 10 ml as tolerated
e. 1/3 tsp barium paste (pudding) progressing to larger amts
f. 1/4 cookie
g. Other materials as desired including cup drinking
h. After baseline study select appropriate posture or combinations of postures
i. Select appropriate therapy techniques and evaluate effectiveness under fluoroscopy

Endoscopy (FEES): Procedure

a. Scope is placed transnasally along the floor of the nose
b. Advanced until end of the scope is at base of uvula which allows visualization of
base of tongue, posterior and lateral pharyngeal wallls,and endolarynx
c. Scope can be advanced to the tip of the epiglottis to get a better view
of the pyriform sinuses and endolarynx (protective “cup” that guides material
around the airway until the swallow occurs)
d. Examination composed of two sections: observation and presentation of food/liquids
e. Observation includes survey of the anatomy, observation of secretions and swallow frequency,
ability to hold breath, effectiveness of cough in clearing secretions
f. During swallows measure duration of stage transition, note evidence of penetration /aspiration,
efficiency i.e number of swallows to clear bolus, & extent of airway closure

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Curriculum Vitae Dr Widodo judarwanto, Pediatrician

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