Swallowing Exam 2

Swallowing Severity Scale 10 (Normal Eating Habits)

“Normal swallowing”; patient denies any difficulty chewing or swallowing; examination demonstrated no abnormality

Swallowing Severity Scale 9 (Normal Eating Habits)

“Nominal Abnormality”; Only patient notices slight indicators such as food lodging in the recesses of the mouth or sticking in the throat

Swallowing Severity Scale 8 (Early Eating Problems)

“Minor Swallowing Problems”; Complains of some swallowing difficulties; maintains an essentially regular diet; isolated choking episodes

Swallowing Severity Scale 7 (Early Eating Problems)

“Prolonged Time or Smaller Bite Size”; mealtime has significantly lengthened and smaller bite sizes are necessary; patient must concentrate on swallowing liquids

Swallowing Severity Scale 6 (Dietary Consistency Changes)

“Soft Diet”; diet is limited to primarily soft foods; requires some special meal preparation

Swallowing Severity Scale 5 (Dietary Consistency Changes)

“Liquefied Diet”; Oral (PO) intake is adequate; nutrition is limited primarily to a liquified diet; adequate thin liquid intake is usually a problem; patient may force self to eat

Swallowing Severity Scale 4 (Needs Tube Feeding)

“Supplemental Tube Feeding”; PO intake alone is no longer adequate; patient uses or needs a tube to supplement intake; patient continues to take more than 50% of nutrition PO

Swallowing Severity Scale 3 (Needs Tube Feeding)

“Tube Feeding with Occasional PO Nutrition”; Primary nutrition and hydration are accomplished by tube; patient receives less than 50% of nutrition PO

Swallowing Severity Scale 2 (NPO)

“Secretions Managed with Aspirator/Medication”; Patient cannot safely manage any PO intake; secretions are managed by an aspirator, medication, or both; patient swallows reflexively

Swallowing Severity Scale 1 (NPO)

“Aspiration of Secretions”; Secretions cannot be managed noninvasively; patient rarely swallows

Other neurologic conditions resulting in dysphagia

Myasthenia gravis, polyneuropathy, polymyositis, fibromyalgia, muscular dystrophy, CP, post-polio syndrome

Myasthenia Gravis impacts on swallowing

Depletion of neurotransmitter over time, progressive muscle weakness, dysphagia results from weakness and fatigue

Polyneuropathy impacts on swallowing

Occurs from diabetes of radiation tx for laryngeal carcinoma; weakness in peripheral nerves; may have sensory deficits that affect initiation of swallow and awareness of bolus

Polymyositis impacts on swallowing

Inflammatory muscle and connective tissue disease; nasal regurgitation; residue; airway protection issues

Fibromyalgia impacts on swallowing

Inflammatory muscle and connective tissue disease; may c/o increase effort in swallow; sensation of residue

Muscular dystrophy, CP, Post-polio syndrome impacts on swallowing

Weakness and incoordination

Multidisciplinary dysphagia team

SLP, dietitian, medical specialists, dentist, OT, PT, nurse, social worker

Clinical Examination of Dysphagia

Screening tool; contributes to determining etiology; evaluate aspiration risk/swallow safety; need for alternative means of providing nutrition; investigate diet change; determine impact on QOL; need for additional tests/procedures

Scope of Dysphagia according to ICF Framework

Body structures and functions related to swallowing; body functions that may influence eating or drinking; swallowing activities and participation; activities and participation in events related to eating or drinking; personal and environmental factors that may affect swallowing

Dysphagia Screeners

TOR-BSST, Water Swallow Test, MGH-SST

Dysphagia Self-Assessment Instruments

SWAL-QOL, EAT-10, MD Anderson Dysphagia Inventory

Clinical observations

Feeding tube, tracheostomy, drooling, nutrition/hydration, attention, orientation, vocal quality

Subjective complaints

Duration, frequency, influencing factors, consistency, temperature

Case history

General health, family history, previous swallow exams, neurologic history, psychiatric history, surgeries, radiation, current treatments, medications

Associated symptoms

Obstruction, mouth/throat pain, nasal regurgitation, mouth odor, coughing/choking, pneumonia history, other respiratory problems, GE reflux, chest pain

Aspiration risk factors

Depressed consciousness, flat positioning, GE dysfunction, NG tube, tracheal intubation

Ancillary Symptoms

Weight loss, change in eating habits, increased time to eat, taste change, saliva change, sleep disturbance, speech or voice change

Signs of dehydration

Dry mucosa, sunken eyeballs, elevated temperature, hypotension, decreased urine output, constipation, nausea/vomiting, confusion, fatigue/weakness

Signs of Malnutrition

Unplanned weight loss, loss of appetite, inability to focus and concentrate, feeling tired all the time, a general feeling of being weaker than usual, getting sick often and taking a longer time to recover

CED Clinical Examination

Cognitive/language abilities (mental status, receptive/expressive language, visuo-motor/perceptual function, memory)

CED Physical Examination

Oral-facial examination (mucosa, dentition, palate, tongue, sensation, reflexes); Facial muscle evaluation (facial expression, mastication); Voice production; Voluntary cough; Motor speech evaluation; Indirect laryngoscopy

CED Test Swallows

Substances (ice-chips, puddings); Positions (upright, supine); Number (multiple, limited)

CED Observations During Test Swallows

Mastication, bolus propulsion, laryngeal elevation, duration, sounds, coughing/choking, vocal quality

ASHA objectives for instrumental assessment

Visualize the swallowing and respiratory-related structures; Assess the physiologic functioning, sensation, coordination, and effectiveness of swallowing-related structures and muscles; Determine the presence, cause, and patterns of aspiration; Visualize the management of secretions; Screen the anatomy and physiology of the esophageal area; Assist in determining oral vs. non-oral feeding; Determine the safety and efficiency of management options

ASHA Indications for Instrumental Swallowing Evaluation

Inconsistent findings from clinical swallow examination; A need to confirm diagnosis or cause of dysphagia; Past history of nutritional or pulmonary complications that may be a result of dysphagia; A need to confirm swallow safety and efficiency; Dysphagia is confirmed; further information needed to guide rehabilitation/management

Cases where instrumental evaluation is not recommended

Unstable medical conditions; Inability to cooperate or participate in the instrumental evaluation; Swallowing rehabilitation or management strategies will not be affected by the results of the instrumental evaluation

Types of Instrumental Evaluation

VFSS, FEES, Cervical Ascultation, Manometry, Ultrasound, MRI, EGD, EMG

FEES

Fiberoptic Endoscopic Evaluation of Swallowing; Designed as a secondary procedure used when VFSS is not available or feasible (ex. ICU, ECF, Pt too large for fluoroscope or unable to transfer)

Components of the FEES Procedure

Evaluation of structural movement, sensory status, and anatomical support for swallowing; Determine the ability to swallow food and liquids; Observe the response to postural, dietary, or behavioral alterations on the bolus path

FEES Supplies and Equipment

Flexible nasolaryngoscope, lubricant, alcohol prep pads, nasal decongestant, food and liquids, food coloring (blue or green), spoons, straw, gloves

FEES Instrumentation

Laryngoscope, camera, light source, video or digital recording equipment

FEES Procedure Part 1

“Preswallowing”; Assess anatomy relative to swallowing; Presence, amount and location of secretions; Assess movement of laryngeal, velopharyngeal, and lingual structures; Sensorimotor functions

FEES Procedure Part 2

“Ability to swallow food and liquid”; 5 ml thin liquid, 5 cc applesauce, bit of cracker, continue with other foods/consistencies problematic for pt or desired items; If aspiration observed or suspected then a bolus of milk and barium should be completed; Can include compensatory techniques and rehabilitative techniques as part of procedure

FEES Abnormal Part 1 Findings

Excess secretions (valleculae vs. pyriforms vs. aryepiglottic folds vs. laryngeal vestibule); Laryngeal trauma or irritation (GERD, Post-radiation, Post-surgical); Abnormal laryngeal closure; Structural deviations (Congenital, Post-surgical)

FEES Abnormal Part 2 Findings

Inability to prepare the food orally; Inability to initiate the swallow in a timely or coordinated manner; Inadequate airway protection or velopharyngeal closure; Incomplete bolus clearance

VFSS

Videofluoroscopic Swallow Study; Considered the “Gold Standard” of instrumental methods; Studies the anatomy and physiology of all phases of the swallow; Can identify presence/absence of penetration or aspiration; Assesses structural and physiologic problems with bolus control; Determines effectiveness of management strategies

VFSS Procedure

Liquids, purrees, solids in order; Small boluses are tested with gradual increase in size; At least 3 presentations for each consistency and size of consistency; All material is coated in barium for visualization; Can test specific foods/liquids that are problematic; Have pt self-feed if possible

Oral Preparatory Phase VFSS Observations (Lateral View)

Cannot hold food anteriorly; Cannot form bolus; Premature bolus loss; Material falls into anterior sulci; Material falls into lateral sulci; Abnormal hold position

Oral Phase VFSS Observations (Lateral View)

Delayed onset; Searching tongue movements; Forward tongue movements to start; Residue in anterior/lateral sulci, tongue, hard palate; Disorganized A-P movement; Repetitive tongue rolling; Premature spillage/poor bolus containment; Piecemeal deglutition; Increased duration

Pharyngeal Phase VFSS Observations (Lateral View)

Premature spillage into vallecula or pyriforms; Delayed trigger; Nasal penetration; Penetration into airway; Aspiration; Increased pharyngeal transit time; Coating of pharyngeal walls after swallow; Residue in vallecula, pyriforms, or top of airway

Esophageal Phase VFSS Observations (Lateral View)

Esophageal to pharynx backflow; Tracheoesophageal Fistula; Zenker’s Diverticulum

Oral preparatory and Oral Phase VFSS Observations (Anterior-Posterior View)

Unable to align teeth; Unable to lateralize material; Unable to mash material; Reduced rotary chew; Material falls to lateral sulci; Bolus spread across mouth

Pharyngeal Phase VFSS Observations (Anterior-Posterior View)

Unilateral vs. bilateral (premature spillage, vallecula and pyriform residue)

Scale for Penetration-Aspiration 1

Material does not enter airway

Scale for Penetration-Aspiration 2

Enters airway, remains above VFs, is ejected from airway

Scale for Penetration-Aspiration 3

Enters, remains above VFs, is not ejected

Scale for Penetration-Aspiration 4

Enters, contacts VFs, is ejected

Scale for Penetration-Aspiration 5

Enters, contacts VFs, is not ejected

Scale for Penetration-Aspiration 6

Enters, passes below VFs, is ejected into larynx or out of the airway

Scale for Penetration-Aspiration 7

Enters, below VFs, not ejected from trachea despite effort

Scale for Penetration-Aspiration 8

Enters, below VFs, no effort made to eject

VFSS Positives

Visualizes bolus during entire pharyngeal phase; Analyzes oral phase; Can evaluate esophageal phase; Can determine effectiveness of tongue retraction; Can observe UES opening, laryngeal elevation, extent of aspiration, effects of submucosal changes

FEES Positives

Visualizes secretions; Direct visualization of surface anatomy; Observation of mucosal abnormalities; Can determine effect of altered anatomy on bolus flow and airway protection; Can evaluate glottic closure; Can track bolus path and location in hypopharynx

Cervical Auscultation

Tracking the “sounds of swallowing” by stethoscope, accelerometers, laryngograph, era probes, and digital recording and display; Three components; Possible observations (perceived crispness, penetration/aspiration, timing of the swallow, relative strength of the swallow, adjacent respirations, presence of inaudible vocalizations

Ultrasound

Uses high frequency sounds to obtain a dynamic image of soft tissues; Does not use radiation; Non-invasive; Does not image bone or cartilage; Used to examine oral cavity and parts of oropharynx; Can be useful if multiple studies are needed; Uses normal foods/liquids; Does not provide information regarding pharyngeal or laryngeal aspects of swallowing

Manometry

Usually performed by gastroenterologist; Qualitative and Quantitative Assessment of Esophageal Motility; Evaluates the pressure generated by muscle contractions

EGD

Esophagogastroduodenoscopy; completed by a gastroenterologist; Can dilate esophagus during study

Scintigraphy

Completed by nuclear medicine; Radioactive material is placed in a carrier (egg whites); Radiation detector measures radiation before, during, and after swallow providing objective measures of amount and location of material

Goals of dysphagia management

Eliminate or reduce aspiration risk; Provide pt with most advanced diet possible

Generalized considerations in dysphagia treatment

Safe and adequate; Quality of Life

Patient-specific considerations in dysphagia treatment

Diagnosis; Prognosis; Reaction to compensatory strategies; Severity of the dysphagia; Ability to follow directions; Respiratory function; Caregiver and staff support; Pt motivation

Dysphagia treatment - medical options

Dietary adjustments, pharmacological (reflux meds, gastric motility, saliva management); Prosthetics

Physician’s order diets, SLPs recommend _______

Consistencies

T/F Coughing does not clear residue

True

Dysphagia treatment - surgical options

Improved airway protection, PE segment opening

When do you not consider oral intake for a patient?

Greater than 10 seconds to swallow; More than 10% aspiration; Presence of silent aspiration; Excessive coughing

Dysphagia treatment - behavioral

Dietary; Liquid thickness, solid consistencies, bolus volume, temperature, taste; Postural strategies; ROM and strengthening exercises; Sensory stimulation; Swallow modifications

Rheology

Study of the deformation and flow of matters

Density

Compactness of a substance

Viscosity

Resistance to flow or alteration of shape

IDDSI

International Dysphagia Diet Standardization Initiative

IDDSI 0

Thin liquids

IDDSI 1

Slightly thick liquids

IDDSI 2

Mildly thick liquids

IDDSI 3

Moderately thick liquids; Liquidized foods

IDDSI 4

Extremely thick liquids; Pureed Foods

IDDSI 5

Minced and moist foods

IDDSI 6

Soft and bite sized foods

IDDSI 7

Regular foods

NDD

National Dysphagia Diet; Created by a consensus group created by the American Dietetics Association

NDD Level 1

Dysphagia-pureed; Homogenous, very cohesive, pudding-like, requiring very little chewing ability

NDD Level 2

Dysphagia-mechanical altered; Cohesive, moist, semisolid foods, requiring some chewing

NDD Level 3

Dysphagia-advanced; Soft foods that require more chewing ability

NDD Regular

All foods allowed

NDD Thin Liquids

1-50 cP

NDD Nectar-like

51-350 cP

NDD Honey-like

351-1750 cP

NDD Spoon-thick

>1750 cP

Other Diet Classifications - Level 1

Pureed foods and thickened liquids

Other Diet Classifications - Level 2

Pureed, mechanically altered foods, and food requiring minimal mastication, thickened liquids