How do you assess swallowing in patients?

Assessment of Swallowing in Patients

Swallowing assessment should begin with a clinical evaluation by a speech-language pathologist (SLP), followed by instrumental assessment when indicated, as bedside evaluations alone are insufficient to determine treatment interventions for dysphagia. 1

Initial Clinical Evaluation

• Signs and symptoms that warrant swallowing assessment include coughing while swallowing, nasal regurgitation of food, wet vocal quality after swallowing, poor secretion management, weak cough, or feeling of food getting stuck 1

• The clinical evaluation should include:

  • Thorough review of medical history 1
  • Interview with patient and/or caregiver 1
  • Cranial nerve examination 1
  • Assessment of lip closure and evidence of saliva pooling 2
  • Evaluation of tongue strength, mobility, and tone, looking for atrophy and fasciculations 2
  • Testing of chewing capacity and jaw strength 2
  • Assessment of palatal movement in response to tactile stimulation 2
  • Evaluation of quality and strength of cough 2
  • Assessment of phonation and speech function 2
  • Administration of liquid and food of varying textures and sizes 1

• Structured screening tools with validated diagnostic performance should be used, such as:

  • EAT-10 questionnaire (sensitivity 86%, specificity 76% for identifying aspiration) 1, 3
  • Water swallow tests or Volume-Viscosity Swallow Test (V-VST) (sensitivity 92%, specificity 80%) 1, 3, 4
  • Gugging Swallowing Screen (GUSS) or Toronto Bedside Swallowing Screening Test (TOR-BSST) 1

Instrumental Assessment

• Bedside clinical evaluations alone have insufficient evidence linking them to clinically meaningful outcomes 1, 5

• Instrumental assessment is indicated when:

  • Signs of dysphagia are present at clinical evaluation 1
  • Silent aspiration is suspected (particularly in older adults) 1
  • The clinical scenario is unclear 1
  • Patient has neurologic or aerodigestive impairments that increase risk 1

• Two main types of instrumental assessment:

1. Videofluoroscopic Swallowing Study (VFSS)

• Most common instrumental assessment 1, 3
• Procedure:
  • Various volumes and viscosities of barium are administered 1
  • Oropharyngeal region is visualized radiographically 1
  • Allows determination of specific swallowing impairments 1
  • Evaluates safety and efficiency of swallow 1
  • Tests effectiveness of intervention strategies 1
• Benefits:
  • Can identify aspiration, which predicts rehospitalization and pneumonia 1
  • Allows visualization of bolus manipulation, tongue movement, hyoid/laryngeal elevation, and pharyngeal constriction 3

2. Fiberoptic Endoscopic Evaluation of Swallowing (FEES)

• Procedure:
  • Flexible endoscope inserted through nose into upper pharynx 1, 3
  • Allows visualization of pharyngeal and laryngeal anatomy 1
  • Can be performed at bedside 3
• Benefits:
  • Direct visualization of pharynx and larynx before and after swallowing 3
  • Can identify impaired chewing, tongue muscle deficit, and cough reflex sensitivity 1

Special Considerations

• Patient must be able to participate in the assessment; performing swallowing assessments on delirious patients may be futile 1
• Older adults have higher rates of silent aspiration, making clinical bedside evaluations less reliable 1
• For patients with suspected esophageal dysphagia, endoscopy or barium swallow (esophagram) is typically used 1
• For patients with both oropharyngeal and esophageal dysphagia, a combined videofluoroscopic swallow study with barium swallow may be utilized 1
• Regular assessment of swallowing function is recommended every 3 months in patients with ALS 2

Common Pitfalls and Caveats

• Relying solely on bedside assessment lacks necessary sensitivity to exclude aspiration (sensitivity 47%, specificity 86%) 5
• Using non-validated dysphagia screening tools should be discontinued 6
• A person may have asymptomatic swallowing disorder; in one study, 55% of patients who aspirated had silent aspiration with absence of protective cough reflex 3
• Aspiration on VFSS predicts rehospitalization but not necessarily pneumonia or pneumonia death in nursing home patients 1
• The diagnostic performance of screening tools varies by population; select tools validated for specific patient groups (stroke, frail elderly, neurological diseases) 6