Always the same……
So many people assess dysphagia in the same manner, at least from my observations. Sit with them while they eat a meal, feel laryngeal elevation and trial diet modifications. I have rarely watched SLPs complete a thorough dysphagia bedside evaluation. There is no standardization of the Clinical Swallow Evaluation (CSE)
Thorough Chart Review
Every evaluation should include a thorough chart review. What complaints does the patient have? What is the reason for hospitalization? Why do they need a speech evaluation?
You will want to ensure that the patient actually has an order for speech. You also want to check past medical history, what contributing diagnoses are there for dysphagia, if there is a history of swallowing difficulty. You want to look at medications, lab results, xray results. Any of this information can be critical in your diagnosis of dysphagia.
If the person has had a stroke, you want to find as much information as possible on the stroke. If the person has head and neck cancer you want to know where the tumor is and the tumor grade. You want to know the course of treatment, if there was surgery, chemotherapy, radiation including how much and what kind.
I have worked to standardize the manner in which I complete my Clinical Swallowing Evaluation. I have started using the SOPE, the MASA, the EAT-10 and the OHAT during every assessment, along with a thorough chart review and assessing dysphagia risk factors. There are many other outcome measures available out there as well. You can find an entire list of outcome measures with links!
I can complete a fairly thorough assessment. The SOPE assesses cranial nerves, taste buds and some muscle function. The OHAT assesses oral cleanliness and need for oral care. The MASA has been a fairly accurate indicator of dysphagia and aspiration. The EAT-10 is a self-assessment tool that the patient can complete.
The Yale Swallow Protocol is a screening tool that can be used by nursing staff and the SLP to determine a need for further evaluation. The Yale can be an indicator of aspiration, as it is believed, people that silently aspirate small amounts of liquid will choke with larger volumes. 3 ounces of water is enough to make a person choke, as it is stated per this protocol that silent aspiration is volume dependent.
It is important to look at cognition when you are evaluating dysphagia. You don’t have to do a complete battery assessment, however you can look at the patient’s ability to answer yes/no questions, answer orientation questions and follow simple, 1 step commands. Leder, Suiter and Warner found that patients that are not oriented x3 are 31% more likely to aspirate. They also found that liquid aspiration is 57% more likely, puree aspiration is 48% more likely and the patient being deemed to be unsafe with any consistency is 69% more likely in patients that are unable to follow 1-step commands.
It is important to assess cranial nerves and to understand the cranial nerves. For instance CN XII, the hypoglossal nerve has no sensory pathways, only motor. This definitely affects the means by which you will assess, treat and write your report.
Another point that can drive your treatment protocol is that sensory input drives motor output. If you can increase the sensory input a person receives you can increase the motoric response.
Cranial nerve assessment is vital in understanding dysphagia. Sensory input such as olfactory and optical help to prepare the person for the swallow by increasing saliva and telling the body that it is going to masticate and swallow food/drink. Changing taste, flavor, temperature, texture and size of bolus can influence a swallow.
You can actually tell a lot about a person by their oral hygiene. You can tell who will qualify for a Free Water Protocol. Also, by oral hygiene, you can make an assumption that the person is at higher risk for aspiration pneumonia because of the poor hygiene of the oral cavity. It is important to let nursing and nursing staff know how often to complete oral cavity for patients that are unable to complete this task with independence.
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It is necessary to assess motoric function. You treat the motor dysfunction, if present, not the symptoms, i.e. aspiration. If you assess a person and can only tell that they are aspirating, but not WHY they are aspirating, you are no better off than you were before the assessment.
There are many areas of function that are vital to swallowing, labial closure, lingual to palate contact, bolus management and propulsion (lingual strength), velar elevation, tongue base retraction, pharyngeal squeeze, hyolaryngeal excursion (laryngeal elevation, hyoid protraction and hyoid thyroid approximation) and UES opening. All of these are areas assessed through the MBSImP.
Observation of a person eating a meal can also a part of the evaluation. Observation of how a patient swallows pills, how many pills a patient takes, do they self-feed? These can all be indications of aspiration pneumonia. Observation should not compromise every treatment session with the patient.
Writing the Report
When you write up your Clinical Swallow Evaluation, make sure you are thorough in your writing. Include all of the observations. You may want to include vital signs, if the person is on O2, how the O2 is presented and at what level. How was the patient position, if they were being fed or able to self feed. Include any information that is helping you to determine dysphagia.
Did You Answer All of Your Questions?
If, at the end of the CSE, you have not answered all questions about the person’s swallowing, you will need to consider instrumental assessment, either Modified Barium Swallow Study or Flexible Endoscopic Evaluation of Swallowing. Either of these assessments will help to give you more information on the patient’s swallow.
A Thorough Evaluation
A thorough dysphagia exam is vital and necessary for treatment. A good Clinical Swallowing Examination with instrumental assessment will aid you in accurate assessment for thorough and appropriate treatment for dysphagia.
Leder, S..B., Suiter, D.M., & Warner, H.L. (2009). Answering orientation questions and following single-step verbal commands: effect on aspiration status. Dysphagia, 24(3), 290-295.
Martin-Harris B, Brodsky MB, Michel Y, Castell DO Schleicher D, et al. MBS Measurement Tool for Swallow Impairment—MBSImp: Establishing a Standard. Dysphagia, 2008, Volume 23, Number 4, Pages 392-405.
Suiter DM, Leder SB. 3 Ounces is All You Need. Perspectives on Swallowing and Swallowing Disorders (Dysphagia). 2009; 18(4): 111-116.
Logemann, J.A. (1998). Evaluation and treatment of swallowing disorders (2nd ed). Austin, TX: Pro-Ed.27 Wijting Y., Freed M. (2009). Training Manual for the use of Neuromuscular Electrical Stimulation in the treatment of Dysphagia.
Hamdy, S. (2006). Role of cerebral cortex in the control of swallowing. GI Motility online.doi:10.1038/gimo8.
Coyle, J. L. (2015). The clinical evaluation: A necessary tool for the dysphagia sleuth. Perspectives on Swallowing and Swallowing Disorders (Dysphagia), 24(1), 18-25.
Langmore, S. E., Kenneth, S. M., & Olsen, N. (1988). Fiberoptic endoscopic examination of swallowing safety: a new procedure. Dysphagia, 2(4), 216-219.
Langmore, S. E., Skarupski, K. A., Park, P. S., & Fries, B. E. (2002). Predictors of aspiration pneumonia in nursing home residents. Dysphagia, 17(4), 298-307.
Leder, S. B., & Espinosa, J. F. (2002). Aspiration risk after acute stroke: comparison of clinical examination and fiberoptic endoscopic evaluation of swallowing. Dysphagia, 17(3), 214-218.
Daniels, S. K., McAdam, C. P., Brailey, K., & Foundas, A. L. (1997). Clinical assessment of swallowing and prediction of dysphagia severity. American journal of speech-language pathology, 6(4), 17-24.
Garand, K. L., McCullough, G., Crary, M., Arvedson, J. C., & Dodrill, P. (2020). Assessment across the life span: The clinical swallow evaluation. American Journal of Speech-Language Pathology, 29(2S), 919-933.