How do you assess swallowing disorders?

Assessment of Swallowing Disorders

Patients with suspected swallowing disorders should undergo a structured clinical evaluation followed by instrumental assessment with either videofluoroscopic swallow evaluation (VSE) or fiberoptic endoscopic evaluation of swallowing (FEES) to accurately diagnose dysphagia and guide treatment decisions. 1

Initial Clinical Assessment

History and Risk Identification

• Question patients and caregivers about:

  • Association of cough while eating or drinking
  • Fear of choking during meals
  • Unintentional weight loss
  • Drooling
  • Nasal regurgitation
  • Wet voice after swallowing 1

• Identify high-risk groups for aspiration:

  • Neurological disorders (stroke, Parkinson's disease, ALS)
  • Reduced level of consciousness
  • Need for frequent oral/pharyngeal suctioning
  • Respiratory rate > 35 breaths/min 1, 2

Clinical Swallowing Examination

1. Structured screening tools:

   • EAT-10 questionnaire (sensitivity 86%, specificity 76%) 1, 2
   • Volume-Viscosity Swallow Test (V-VST) (sensitivity 92%, specificity 80%) 1, 2

2. Water swallow test:

   • Observe patient drinking 3 oz of water
   • Monitor for cough, throat clearing, or wet/hoarse voice after swallowing
   • Positive signs indicate need for further evaluation 1

3. Voluntary cough assessment:

   • Evaluate strength and quality of voluntary cough
   • Weak voluntary cough is associated with increased aspiration risk
   • Expulsive phase rise time of voluntary cough may predict aspiration in stroke patients 1

4. Physical examination elements:

   • Level of consciousness and alertness
   • Oral motor function (lip closure, tongue strength and mobility)
   • Voice quality (dysphonia)
   • Speech clarity (dysarthria)
   • Ability to manage oral secretions 1

Instrumental Assessment

When to Refer for Instrumental Assessment

• Patients with positive clinical signs of dysphagia
• High-risk populations even without obvious symptoms
• Patients with unexplained weight loss, malnutrition, or recurrent pneumonia 1, 2

Videofluoroscopic Swallow Evaluation (VSE)

• Gold standard for comprehensive swallowing assessment
• Motion picture radiograph visualizing all phases of swallowing
• Patient consumes barium-mixed foods/liquids of various consistencies
• Observed in lateral and anterior-posterior positions
• Detects silent aspiration and evaluates swallowing physiology
• Allows testing of compensatory techniques in real-time 1, 2

Fiberoptic Endoscopic Evaluation of Swallowing (FEES)

• Transnasal passage of flexible nasopharyngoscope
• Direct visualization of pharynx and larynx before/after swallow
• Can be performed at bedside or in clinic
• Identifies:
  • Impaired chewing
  • Tongue muscle deficit
  • Velo-pharyngeal closure competence
  • Laryngeal morphology and motility
  • Pharyngeal residues
  • Cough reflex sensitivity 1, 2, 3

Contraindications for Instrumental Assessment

• Lethargy
• Absent swallow response on command
• Abnormal upper airway sounds
• Inability to manage secretions
• Respiratory rate > 35 breaths/min 1

Special Considerations

Patients with Reduced Consciousness

• Patients with reduced level of consciousness should not be fed orally until consciousness improves
• High risk for aspiration even with minimal oral intake 1, 4

Silent Aspiration

• Many patients, especially those with neurological disorders, may aspirate without obvious clinical symptoms
• Instrumental assessment crucial for detection
• Up to 40% of aspirations may be "silent" (without cough reflex) 1, 2

Clinical Pitfalls to Avoid

• Relying solely on clinical examination without instrumental assessment
• Missing silent aspirations in patients without obvious symptoms
• Overlooking dysphagia in patients with "normal eating habits"
• Delaying referral to speech-language pathologist
• Failing to implement proper swallowing evaluation protocols 1, 2

Referral Recommendations

• Refer patients with suspected dysphagia to speech-language pathologists (SLPs) for comprehensive evaluation
• Implementation of dysphagia screening programs has been shown to dramatically reduce rates of aspiration pneumonia
• The addition of instrumental evaluation (VSE or FEES) needs to reduce pneumonia rates by only 10% to offset the cost of testing 1