When it comes to managing dysphagia, one of the most powerful tools in your SLP toolbox is a thorough and evidence-based swallow assessment. A comprehensive evaluation not only uncovers the what, but—more importantly—the why behind a patient’s swallowing difficulty.
This guide walks through the full scope of the Clinical Swallowing Evaluation (CSE), from the moment the order hits your inbox to the final decision of whether an instrumental assessment is needed. Grab your chart, your notebook, and your favorite apps—we’re diving deep into the science (with a little humor and real talk along the way).
Clarifying the Referral
Before you even open the chart, take a moment to clarify the referral. Ask the nurse or ordering physician why a swallowing evaluation was requested. Is the patient struggling to swallow food? Pills? Just that infamous potassium horse pill? Clarifying the “why” can shape the entire assessment. How long has this been occurring with the patient?
Chart Review: Your Foundation
A thorough chart review is critical. Think of it as your diagnostic GPS—guiding your observations and helping you avoid false assumptions. Key areas to examine:
1. Lab Values
- Nutritional Markers: BMI, albumin, and prealbumin can help assess malnutrition or dehydration.
- White Blood Cell Count (WBC): Elevated WBC or neutrophil counts can indicate infection risk or immune suppression.
- Red Blood Cell Count (RBC): If hemoglobin is <8 or hematocrit <25%, the patient may not be medically stable for evaluation.
- Electrolytes (Sodium, Potassium, Chloride): Crucial for nerve conduction and muscle function.
2. Chest X-rays
Chest X-rays may indicate infiltrates, but be cautious—these findings don’t always equal food or liquid aspiration. Reflux or vomiting can also be culprits. Aspiration can occur in either lung, not just the right.
3. Medications
Medications can alter:
- Mucosal hydration (e.g., diuretics, antihistamines)
- Motor control (e.g., antiepileptics, antipsychotics)
- Swallowing safety (e.g., Haldol)
Don’t forget to look up unfamiliar meds—sometimes they reveal a diagnosis that didn’t make it into the history.
4. Patient History
Look for any red flags:
- Neurological events (stroke, TBI)
- Neurodegenerative diseases (Parkinson’s, ALS)
- Diabetes, cancer treatments, or prior dysphagia
Check for patterns—recurrent pneumonia? That could be a key piece of the puzzle.
The Interview: Where the Real Story Begins
One of the most revealing parts of the CSE is the patient interview. Introduce yourself gently—nobody wants to feel like they’re being cross-examined by the FBI.
Ask patient- and family-driven questions:
- Have you had trouble swallowing food or pills?
- What foods give you trouble?
- Have you ever had swallowing therapy?
- What brought you into the hospital?
- What do you mean by “trouble swallowing”? (Coughing? Sticking? Pain?)
When patients say food is “getting stuck right here” and point to their lower neck, consider using the Reflux Symptom Index. GERD often mimics or contributes to dysphagia symptoms (Belafsky et al., 2002).
Bonus tip: Always ask about the potassium pill or large antibiotic pills. Chances are, it’s causing drama.
Vital Signs and Medical Status
Vitals can give you clues about the patient’s readiness for evaluation:
- O2 Saturation: Be cautious but don’t over-rely; evidence doesn’t support O2 drop as an aspiration marker (Leder et al., 2009).
- Heart Rate & Respiratory Rate: Helpful for gauging endurance and alertness.
- Temperature: Not a definitive indicator of aspiration.
The Clinical Swallow Evaluation (CSE)
The bedside swallow evaluation isn’t meant to replace instrumental assessments—but it is critical in determining next steps. Your CSE should include:
1. Cranial Nerve Assessment
Understanding which cranial nerves drive which functions is essential. For example, CN XII (hypoglossal) is purely motor. No sensory input means different treatment strategies.
Sensory input—thermal, tactile, olfactory—drives motor output. Use this knowledge to enhance your assessment and therapy planning.
Helpful tools:
- MASA: Validated screening for dysphagia risk (Mann, 2002)
- SAGE: Assesses oral hygiene and risk for aspiration pneumonia
2. 3-Ounce Water Swallow Test
A simple but powerful screen for aspiration risk. A pass (no cough during or after) suggests low risk; a fail suggests the need for further assessment (Suiter & Leder, 2008).
3. Meal and Texture Trials
Observe how the patient self-feeds, chews, and swallows across consistencies. Watch for fatigue, coughing, wet vocal quality, or compensatory behaviors.
Why You Still Need Instrumental Assessment
No matter how seasoned you are, the bedside exam has limits. You can’t:
- Visualize pharyngeal residue
- See laryngeal penetration or silent aspiration
- Measure effectiveness of strategies
If the patient requires a modified diet, compensatory strategies, or a clear treatment plan—instrumental assessment is non-negotiable.
Options include:
- Modified Barium Swallow Study (MBSS): Ideal for assessing bolus flow and pharyngeal biomechanics (Martin-Harris et al., 2008).
- Flexible Endoscopic Evaluation of Swallowing (FEES): Excellent for secretion management, airway protection, and fatigue assessments.
Evidence-Based Tools and Resources
There’s no shame in using your tools—especially when they’re this good:
- Dysphagia2Go app: Walks you through the CSE step-by-step
- Dysphagia Therapy app (by Tactus): Cranial nerves, exercises, and treatment ideas
- The Adult Dysphagia Pocketguide Neuroanatomy to Clinical Practice: A field-tested reference from assessment to treatment planning (McCoy & Wallace)Have you ever wanted a way to create a more standardized protocol for your Clinical Swallow Evaluation? Do you often forget or leave out parts of the CSE, you know, the parts that are important for your Plan of Care? You probably need the Clinical Dysphagia Assessment Toolkit if you answered yes. You can get your copy here.
Moving from Observation to Prescription
We aren’t waiters—we’re clinicians. Sitting in the dining room every day “observing” doesn’t replace skilled therapy. Let’s move toward prescribing evidence-based interventions that actually improve function.
Protocols to know:
- MBSImP (Martin-Harris et al., 2008): Standardized MBSS analysis
- McNeill Dysphagia Therapy Program (MDTP): Exercise-based treatment using food as resistance (Carnaby-Mann & Crary, 2010)
- Pharyngocize: Preventative HNC protocol (Carnaby-Mann et al., 2012)
- EMST: Strengthens respiratory and swallow musculature (Pitts et al., 2009; Kim & Sapienza, 2005)
- The Intensive Dysphagia Rehabilitation Approach: An approach in prescribing exercises related to functional deficits. (Malandraki, et al 2016, 2018)
Final Thoughts
There’s no one-size-fits-all in dysphagia care. The research evolves, and so should we. The CSE is just one piece of a much larger puzzle—but it’s a piece that can set your entire plan in motion.
Let’s get better at asking the right questions, collecting the right data, and leaning into what the research tells us.
Because we can’t treat what we don’t know.
Are you ready for a deeper dive with even more resources available? Join the Dysphagia Skills Accelerator today. You will get so many great tools with new tools being added all the time! Click here to join now!
Have you ever wanted a way to create a more standardized protocol for your Clinical Swallow Evaluation? Do you often forget or leave out parts of the CSE, you know, the parts that are important for your Plan of Care? You probably need the Clinical Dysphagia Assessment Toolkit if you answered yes. You can get your copy here.
References
Belafsky, P. C., Postma, G. N., & Koufman, J. A. (2002). Validity and reliability of the reflux symptom index (RSI). Journal of Voice, 16(2), 274–277.
Carnaby, G. D., & Harenberg, L. (2013). What is “usual care” in dysphagia rehabilitation: A survey of USA dysphagia practice patterns. Dysphagia, 28(4), 567–574.
Carnaby-Mann, G. D., & Crary, M. A. (2010). McNeill dysphagia therapy program: A case-control study. Archives of Physical Medicine and Rehabilitation, 91(5), 743–749.
Carnaby-Mann, G., Crary, M. A., Schmalfuss, I., & Amdur, R. (2012). “Pharyngocise”: Randomized controlled trial of preventative exercises to maintain muscle structure and swallowing function during head-and-neck chemoradiotherapy. International Journal of Radiation Oncology Biology Physics, 83(1), 210–219.
Crary, M. A., Carnaby, G. D., LaGorio, L. A., & Carvajal, P. J. (2012). Functional and physiological outcomes from an exercise-based dysphagia therapy: A pilot investigation of the McNeill Dysphagia Therapy Program. Archives of Physical Medicine and Rehabilitation, 93(7), 1173–1178.
Hamdy, S. (2006). Role of cerebral cortex in the control of swallowing. GI Motility online. https://doi.org/10.1038/gimo8
Kim, J., Davenport, P., & Sapienza, C. (2009). Effect of expiratory muscle strength training on elderly cough function. Archives of Gerontology and Geriatrics, 48(3), 361–366.
Kim, J., & Sapienza, C. M. (2005). Implications of expiratory muscle strength training for rehabilitation of the elderly: Tutorial. Journal of Rehabilitation Research and Development, 42(2), 211–220.
Lan, Y., Ohkubo, M., Berretin-Felix, G., Sia, I., Carnaby-Mann, G. D., & Crary, M. A. (2012). Normalization of temporal aspects of swallowing physiology after the McNeill dysphagia therapy program. Annals of Otology, Rhinology & Laryngology, 121(8), 525.
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.
Logemann, J. A. (1998). Evaluation and treatment of swallowing disorders (2nd ed.). Austin, TX: Pro-Ed.
Malandraki, G. A., Rajappa, A., Kantarcigil, C., Wagner, E., Ivey, C., & Youse, K. (2016). The intensive dysphagia rehabilitation approach applied to patients with neurogenic dysphagia: a case series design study. Archives of Physical Medicine and Rehabilitation, 97(4), 567-574.
Malandraki, G. A., & Hutcheson, K. A. (2018). Intensive therapies for dysphagia: implementation of the intensive dysphagia rehabilitation and the MD Anderson Swallowing Boot Camp Approaches. Perspectives of the ASHA Special Interest Groups, 3(13), 133-145.
Martin-Harris, B., Brodsky, M. B., Michel, Y., Castell, D. O., Schleicher, M., Sandidge, J., … & Blair, J. (2008). MBS measurement tool for swallow impairment—MBSImp: Establishing a standard. Dysphagia, 23(4), 392–405.
McCoy, Y., & Wallace, T. (2018). The adult Dysphagia Pocket Guide: neuroanatomy to clinical practice (Vol. 1). Plural Publishing.
Suiter, D. M., & Leder, S. B. (2008). Clinical utility of the 3-ounce water swallow test. Dysphagia, 23(3), 244–250.
Swigert, N. (2007). The source for dysphagia. LinguiSystems.
Wijting, Y., & Freed, M. (2009). Training manual for the use of neuromuscular electrical stimulation in the treatment of dysphagia.
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