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Go With the (Peak) Flow

A Clinical Swallow Evaluation is a series of screens that we use to determine if the patient requires more testing or not.

Let’s face it, whether we like it or not, insurance likes objective data, including numbers indicating a deficit or no deficit.   Peak Flow is a tool that gives us objective numbers to input into our reports.

What is Peak Flow?

A Peak Flow meter measures how fast air is expelled from the lungs in one fast blast.  A Peak Flow meter can be very beneficial to those with asthma.

Peak Flow also gives us information on the cough reflex and function of the cough, in turn, allowing us to determine patients that are at risk for penetration and/or aspiration.

Why do we care about coughing?

Coughing is a mechanism of airway clearance that adds to normal
ciliary function comprised of three events

  • Inspiratory effort
  • Followed by rapid vocal fold adduction
  • Contraction of the expiratory muscles

Respiratory Muscle Strength Training (RMST)

You can also use Peak Flow to determine baseline for RMST and to measure outcomes throughout your therapy using RMST.

So what has research told us about measuring Peak Flow?

We measure using PEF or Peak Expiratory Flow or PEFR Peak Expiratory Flow Rate.

  • Smith-Hammond, et al 2009-Peak flow identified 82% of aspirators
    (stroke patients) at PEF <2.9 L
  • Pitts, et al  2010-Peak flow identified 86% of aspirators (Parkinson’s) at
    PEF <5.2 L
  • Suarez, et al 2002 identified 74% aspirators (ALS) at
    <4.0 L
  • Plowman, et al 2016 identified voluntary cough airflow in patients with ALS at risk for penetration/aspiration

Peak Flow meters can be purchased to use.

PF 1        PF 2

A less expensive Peak Flow model will have a plastic piece on the side that moves as the person exhales or coughs into the device.   You can determine the PEF or PEFR by having the person exhale or cough into the device 3 times and figuring the average rate.

PF 3

You can also purchase a digital device which will give you a more accurate reading, but will cost you a bit more.

These devices can be purchased on Amazon or a medical supply store.   You can often purchase disposable mouth pieces so that you can use the device with multiple patients after cleaning.


Gregory, S. A. (2007). Evaluation and management of respiratory muscle dysfunction in ALS. NeuroRehabilitation22(6), 435-443.

Hammond, C. A. S., Goldstein, L. B., Horner, R. D., Ying, J., Gray, L., Gonzalez-Rothi, L., & Bolser, D. C. (2009). Predicting aspiration in patients with ischemic stroke: comparison of clinical signs and aerodynamic measures of voluntary cough. Chest135(3), 769-777.

Pitts, T., Troche, M., Mann, G., Rosenbek, J., Okun, M. S., & Sapienza, C. (2010). Using voluntary cough to detect penetration and aspiration during oropharyngeal swallowing in patients with Parkinson disease. Chest138(6), 1426-1431.

Plowman, E. K., Watts, S. A., Robison, R., Tabor, L., Dion, C., Gaziano, J., … & Gooch, C. (2016). Voluntary cough airflow differentiates safe versus unsafe swallowing in amyotrophic lateral sclerosis. Dysphagia31(3), 383-390.

Suárez, A. A., Pessolano, F. A., Monteiro, S. G., Ferreyra, G., Capria, M. E., Mesa, L., … & De Vito, E. L. (2002). Peak flow and peak cough flow in the evaluation of expiratory muscle weakness and bulbar impairment in patients with neuromuscular disease. American journal of physical medicine & rehabilitation81(7), 506-511.










The Yale Swallow Protocol

I think that we have all looked for that simple and easy screen that we can use for patients to identify a possible dysphagia.

We want a screen that’s not only easy for us to administer as an SLP, but that we can teach other professionals to utilize to assist in their referrals.

Let’s face it.  If you work in acute care, AND your building is stroke certified, you are probably already getting a referral to assess every single stroke patient that walks in the door.

So maybe we can use a screen, like the Yale Swallow Protocol to assist in screening patients.

The Yale Swallow Protocol was once known as the 3 Ounce Swallow.   This came from research looking at how accurate a screening could be by having a patient drink 3 ounces of water.  There is also a study looking at the efficacy of how much liquid is enough to elicit a cough response and 3 ounces seemed to be that magic number.

When administering the Yale Swallow Protocol, part of the protocol is an oral mech exam.  You really want to take a look at the oral structures and how they are functioning.

You also assess cognition.  How well does the person follow 1 step directions and accuracy of following yes/no questions.   Leder, Suiter and Warner  found that when patients are not oriented x3, they may be 31% more likely to aspirate.

There was also a correlation between aspiration and the ability to follow single step directions.   When unable to follow single step directions, patients likelihood of aspiration of liquids increased to 57%, pureed 48% and deemed unsafe for any oral consistency to 69%.

The Yale Swallow Protocol is easy to administer:

  1.  Give your patient a cup with 3 ounces of water.   (I always given them water that is room temperature.)
  2. Have your patient drink all the water without stopping until it is gone.
  3. They pass if:  they are able to drink all the water without stopping with no coughing or signs of swallowing difficulty.
  4. They fail if:  they are unable to drink all the water without stopping or they cough while drinking the water or immediately after.

Now, there are populations with whom I DO NOT use this screen.  I would not do this with someone who is:

  1.  not medically stable
  2. has severe respiratory issues
  3. severe dysphagia
  4. aspiration on previous bolus administration
  5. unable to manage secretions.

Want more information?

You can earn continuing education with Debra Suiter on Medbridge

Purchase the book on Amazon

Listen to the Swallow Your Pride podcast episode with Debra Suiter


DePippo, K. L., Holas, M. A., & Reding, M. J. (1992). Validation of the 3-oz water swallow test for aspiration following stroke. Archives of neurology49(12), 1259-1261.

Suiter, D. M., & Leder, S. B. (2008). Clinical utility of the 3-ounce water swallow test. Dysphagia23(3), 244-250.

Garon, B. R., Engle, M., & Ormiston, C. (1995). Reliability of the 3-oz water swallow test utilizing cough reflex as sole indicator of aspiration. Journal of Neurologic Rehabilitation9(3), 139-143.

Suiter, D. M., Leder, S. B., & Karas, D. E. (2009). The 3-ounce (90-cc) water swallow challenge: a screening test for children with suspected oropharyngeal dysphagia. Otolaryngology—Head and Neck Surgery140(2), 187-190.

Suiter, D. M., Sloggy, J., & Leder, S. B. (2014). Validation of the Yale Swallow Protocol: a prospective double-blinded videofluoroscopic study. Dysphagia29(2), 199-203.

Suiter, D. M., & Leder, S. B. (2009). 3 Ounces Is All You Need. Perspectives on Swallowing and Swallowing Disorders (Dysphagia)18(4), 111-116.

Warner, H. L., Suiter, D. M., Nystrom, K. V., Poskus, K., & Leder, S. B. (2014). Comparing accuracy of the Yale swallow protocol when administered by registered nurses and speech‐language pathologists. Journal of clinical nursing23(13-14), 1908-1915.

Leder, S. B., & Suiter, D. M. (2014). The Yale Swallow Protocol: An evidence-based approach to decision making. Springer.

Leder, S. B., Suiter, D. M., & Warner, H. L. (2009). Answering orientation questions and following single-step verbal commands: effect on aspiration status. Dysphagia24(3), 290.

Assessing the Swallow: 101

Assessing the Swallow:  101

Assessment of the swallow can be one of the most valuable pieces of information in your treatment plan for a patient with dysphagia.  There are so many factors that need to be considered when you receive an order for a patient with dysphagia.

Clarification of the order

It is vital to get a clarification of your order.  Talk to the nurse for that patient if available or speak to the ordering physician to find out why a swallowing evaluation was ordered in the first place.  There are times that an evaluation is ordered because the person can’t swallow their potassium pill (I’m not sure if there are any people that can actually swallow that enormous pill!)

Chart Review

A thorough chart review should be performed prior to walking in to see that patient.   Personally, I like to review the chart prior to speaking to the nurse, doctor, patient or family member so that I know as much as possible about that patient.

There are several parts of the chart that can provide critical information for assessment of your patient.  The important areas of the chart to review include lab results, chest xray results, medications and patient history/diagnoses.

Lab Results

Lab results can give you an look at your patient’s current medical status.  These are typically drawn daily in the acute care hospital setting and may be taken periodically or as needed in a Skilled Nursing Facility (SNF), Long Term Acute Care Hospital (LTACH) or Home Health setting.  There are several labs that can give you a good overall picture of your patient.

Nutrition:  Body Mass Index (BMI) and Albumin/Prealbumin are numbers that give us good information of the overall nutrition/hydration status of our patients.

White Blood Count (WBC):  The number of WBC can tell us if the patient has an infection (number is high) or if the patient is at risk for infection (number is low).  It is important to note the Neutrophil number as these are the cells that are in the oral cavity and help to eliminate bacteria from the oral cavity.  When Neutrophils are high or low the patient may have an increased risk of developing a pneumonia.

Red Blood Count (RBC):  This number tells us how effective the body is in circulating oxygen through the body.  Important to note is that if Hemoglobin is below 8 or if Hematocrit is below 25%, therapy should be deferred as the patient is not medically stable to participate in therapy at that time.

Sodium, Potassium and Chloride give us a good look at nerve conduction and assist in muscle function.   Sodium, Potassium and Chloride are electrolytes.  These electrolytes also play a role in acid/base balance within the body. has a great review of lab values which you can find here.

Chest Xrays:

While chest xray results can be very valuable, interpretation can be tricky.  Typically the radiologist will indicate if there are infiltrates and which lung lobe the infiltrates are found.  Infiltrates do not always indicate aspiration of food or drink.  To be accurate in determination of what has been aspirated, a culture would have to be completed.   It is important to note as well that aspiration can be from refluxed or vomited material which would need medical management.  It is also important to note that aspiration of food/liquids can occur in either lobe, left or right.


Medication can alter many aspects of a patient’s functioning.  Medication can dry out mucosal membranes (antihistimines, allergy medications, antidepressants, anticholinergics, analgesics, diuretics), affect motor function (Parkinson’s medication, antidepressants, antiepileptics, anticholinergics) or medications such as Haldol can worsen the swallow.  It is important to note changes in function as they correlate with new medications or changes in medication.  Also remember that having the ability to look up medications can be vital as some diagnoses may not be listed for patients and medications can lead you to uncovering diagnoses not listed otherwise in the medical chart.

Patient History:

Patient history can absolutely be the meat of your chart review.   This is where you are looking at patient diagnoses, particularly any diagnosis that can lead to a dysphagia.  It is important to note if the patient has a history or diagnosis of dysphagia, recurrent pneumonia, degenerative diseases such as Parkinson’s or ALS, history of TBI or stroke or even diabetes that has not been managed well.

In the history will often also be a discussion on why the patient was admitted to the hospital or to the facility and may even touch on swallowing, whether the patient has had difficulty for some time or if there is new difficulty with swallowing.  If the history makes no indication of swallowing difficulty and the patient has an infiltrate in either lung, aspiration may not be related to swallowing difficulty.

After a thorough chart review, you are probably ready to see the patient.  It is very important, when possible, to interview the patient to see how they view the problem, whether or not there is a history of dysphagia that is not listed in the chart and the complaint that prompted an SLP evaluation.

Using Vital Signs

Vital signs such as oxygen saturation, heart rate, respiratory rate can all give you valuable information on your patients.  These can all give you an idea of current medical status and if the patient is able to have endurance for a meal or even for your evaluation.   Oxygen saturation and temperature have often been used to determine if a patient is aspirating, however there is no evidence that links a spike in temperature or a drop in oxygen saturation with an aspiration event.

During the Evaluation

During your Clinical Swallowing Evaluation (CSE), it is critical that you assess cranial nerve function.  Not sure how to do that?  We have you covered AND you can catch up on last minute CEU’s at the same time!  Northern Speech Services has a phenomenal cranial nerve course for assessment and treatment of the swallow (yes, I am a little biased!  Yes, I do receive a small amount of money for this course if you choose to purchase it, but no fear, I will not retire from your purchase!)  You can also use screens such as Peak Flow and the 3 ounce swallow in addition to food or meal trials to determine if further, instrumental assessment is required.

You Can’t Do it All During the CSE

It is critical to remember that you will not be able to complete a full, reliable evaluation at bedside.  You cannot reliably assess pharyngeal function, airway protection or the effectiveness of modification, compensation or maneuvers without visualizing all of these areas with instrumental assessment.  The Clinical Swallowing Evaluation can lead you to determine whether an instrumental assessment is required or if there is no need.

Instrumental Assessment

If you feel that the patient needs a modified diet, requires use of compensation, maneuvers or that you need to develop an effective treatment plan for your patient, instrumental assessment would be indicated.  You may only have Modified Barium Swallow Studies (MBSS) or you may only have Flexible Endoscopic Evaluation of Swallowing (FEES) available.  Both can be very effective in determining pathophysiology of the pharyngeal swallow, to determine how the bolus flows throughout the oropharyngeal cavity and into the esophagus, effectiveness of airway protection, diet modification as well as the accuracy and effectiveness of maneuvers and compensations.

If you are looking for guidance through the Clinical Bedside Evaluation (CSE) there is an app for that!  Look for Dysphagia2Go available through the App Store for your iPad.

There is also an app from Tactus Therapy called Dysphagia Therapy that can assist you with cranial nerves, the clinical exam and choosing therapeutic techniques.  You can buy that right here.

You may have also heard about this pocketguide that I helped to write.   It’s called The Adult Dysphagia PocketGuide Neuroanatomy to Clinical Practice.   This is a great guide to help you through the evaluation and treatment planning process.   If you don’t win a copy this year (2019) from my give-away, you can purchase a copy of the Pocketguide here.  Again, small amount of money for me, no fear of retirement from both the book and the apps!

Also, look for articles on Dysphagia Ramblings related to assessment including:

We Can’t Treat What We Don’t Know

Standardizing Dysphagia Assessment and Treatment

Aspiration Risk”

Oral Care

The Interview

  • Leder, S..B., Suiter, D.M., & Warner, H.L. (2009). Answering orientation qustions and following single-step verbal commands: effect on aspiration status.  Dysphagia, 24(3), 290-295.
  • Langmore, S. E., Skarupski, K. A., Park, P. S., & Fries, B. E. (2002). Predictors of aspiration pneumonia in nursing home residents. Dysphagia17(4), 298-307.
  • 57  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.




The Interview

Dysphagia Ramblings The Interview

The Clinical Swallowing Evaluation

One of the most crucial components, at least for me, of the Clinical Swallow Evaluation (CSE), is the interview.

I haven’t found a lot of published research regarding the interview portion of the CSE, so if you’ve found any, please let me know in the comments!

There is a nice example of some interview questions in The Source for Dysphagia by Nancy Swigert.

Chart Review

I probably spend the better half of my evaluation time digging in the chart for information and then interviewing anyone I can find that can answer to questions about the patient.

The chart review gives me an idea of the patient.  You are looking for diagnoses, medications, lab values, history, etc.  (Not to fear, there will be a post on chart reviews!)

The Interview

As I said before, the interview is where I can get an abundance of information!  I typically will try to find the nurse or even the doctor after reading the chart to get more information.  What is the patient doing?  How are they eating their meals, taking their pills?  How alert is the patient?  What is the plan for the patient?

Now, unless you want the person to get all defensive on you, don’t just run into the room and start firing questions at the patient!  You don’t want them to feel ambushed.   Introduce yourself and tell them why you are there.   Maybe ask a couple of questions not swallowing related.   You can comment on who is in the room.  “Oh, you have a lot of visitors today.”  That will usually prompt some introductions as well.

I try to keep it as light as possible.   Don’t go in with the “I think you’re aspirating and you will probably get pneumonia and die” line up and ready to fire.   You have no idea what is going on with this person and they probably had no clue that a Speech Language Pathologist worked with swallowing.

We all know the famous line.   You:  “Hi, I’m Susie/Stan and I’m the Speech Language Pathologist.”  Patient/family:  “There is nothing wrong with my/their speech.   Just listen to me/them talk.”

Make that person comfortable.  Sometimes, they know that we work with swallowing.   Maybe they have had some experience or someone they love has had some experience with dysphagia and they don’t want that thick crap to drink.   Let them know you’re not the thickened liquid police and you just need to see what’s going on so that you know if you can help them with any problem they may be having related to swallowing.

What do I ask?

In a perfect world, the family is present in the room for an evaluation.   Don’t look at the family as judging you and what you’re doing.   Chances are, they have no idea what to expect from you.

If the patient is able to answer questions and the family is available, I interview them all at the same time.   I really have tried to develop a list of interview questions, but have found the interview much more effective if it is patient-driven.

I do ask about the current or most recent hospitalization.   What happened that you had to come to the hospital?  What is your current problem?  Are you having trouble with swallowing your food?   How about those pills?  How do you do when you are at home?  Do you have any trouble swallowing pills at home?

I also like to find out if there are any foods that are avoided or if there is a specific method they use to take pills.   Bonus if the nurse comes in to pass meds so that you can actually observe the patient taking their pills!!


Speaking of pills, I almost always have patients say, well, I do ok with my pills except for one.   It’s huge.  When I ask if it’s the potassium pill, the answer is almost always yes.   I would say nearly every patient I evaluate that takes a potassium pill has trouble with it.

I always ask the patient/family about neurologic diagnoses or even previous surgeries or cancer treatment.   The thing is, the chart can be great as well as the history and physical section of the chart, BUT there can be information missing or inaccurate.

Take for example, the patient I had several years ago that was in the hospital for weakness.  The chart had nothing in it about previous tonsil cancer with 37 sessions of radiation or the fact that the person had a large portion of their stomach removed due to cancer.

I really want my patient to feel like they were interrogated by the FBI.   Now, don’t shine a bright light in their face or slam the table trying to intimidate them, but you need to get down to the heart of the problem, or the lack of a problem with swallowing.

If the person is having trouble with any consistency, how long has this been happening?  Have they ever had an instrumental assessment?  Have they ever had therapy for swallowing?  If so, when, where and for how long?  It’s also nice if they or the family can remember what they did for therapy.

Has the person already had their meal today?  If so, how did they do?   Was there a consistency more difficult than the others?  What happens with that consistency, does it get stuck?  Does it make them cough?  Have them define difficulty as much as possible.

Is it Dysphagia or is it GERD?

Many times, the patient complains that the food gets stuck “right here”.  If I were a betting person, I would bet nearly every time they point to the same spot on their throat.  Which is often associated with GERD.

How do you know which is which?

Well, you don’t without instrumental assessment, but you can do something to find out the probability of GERD or reflux.   Do you use the Reflux Symptom Index?  This is a great way to have the patient answer questions related to GERD.   You can download a free copy right here.

Now what??

Remember to let the interview guide you.   You may have a million more questions based on a particular answer or comment by a patient.    The more comfortable you make the patient, the more they will likely share with you.

If they complain of difficulty with some foods, what foods are they.   Sometimes that patient may be taking pills that cause xerostomia (dry mouth) or they may have had radiation treatment causing xerostomia making it more difficult to swallow foods such as meat, bread or rice.   Maybe they need to include water with their meal.   Sometimes dipping the food in an oil, such as olive oil or adding gravy will help to eliminate the difficulty chewing or swallowing.

The interview process should answer so many questions for you and lead you into the actual hands-on part of the evaluation, maybe giving the patient some trial consistencies, recommending an instrumental assessment, the cranial nerve assessment, etc.

What do YOU ask?

Do you have a list of go-to questions or a questionnaire that you find helpful?  Post it in the comments below!  You can also go to the Internet Resources page and find some downloadable outcome measures to use in your evaluation during the interview.


Clinical Swallow Evaluation

What better way to start June, Dysphagia Awareness Month, than to kick it off with a post about swallowing evaluation.   Heck, the whole month will be dedicated to swallowing evaluation!!

One important part of evaluating a patient is the Clinical Swallowing Evaluation.   I know, all we read or hear anymore is about instrumental exams.   Instrumental exams are crucial to identifying the deficits or lack thereof in the pharynx.   The Clinical Swallow Evaluation is actually the key to identifying those that need the instrumental examination.

The patient/family interview will actually be extremely important during this phase of you evaluation.   I can’t tell you how many times, when working in the acute care hospital, I went to see a patient because they had choked on food.   Upon chart review and interview of the cognitively intact patient, found that the patient had choked once that they can remember.   They choked that morning on a piece of granola bar.   Since the doctor asked them about choking they mentioned that, which prompted a dysphagia evaluation.

Now, I’m not going to be dragging that person down to Xray or pulling out the scope quite yet.   After a thorough Clinical Swallow Evaluation, I determined that this person required no further testing but made sure they knew to speak with their doctor or nurse should they have any further issues.

There’s also the case of the person that was brought down to Xray, from the ICU while a nurse walked with them, bagging them to assist with breathing.   This person may have required a Modified Barium Swallow Study at some point in time, but that was not the time.  Breathing will always trump swallowing and at that moment, the person needed to get the breathing under control.

This month will be filled with all parts of the Clinical Swallow Evaluation.  Parts including the Cranial Nerve Exam, Peak Flow, how to conduct the interview, etc.

Plus, don’t be discouraged if you didn’t win a copy of the Adult Dysphagia Pocketguide!  You have a chance every month for the rest of this year!!!

Thank you for joining me on this wonderful ride!

What’s In Your Dysphagia Toolbox?

With the ever-evolving technology that we have available, there are so many resources now available to therapists.  Dysphagia resources are a growing field as well.  I decided I would list some available resources here.  Please remember that this list will be continually evolving.  If there is a resource that you think should be added, please email the link to

Continuing Education

Northern Speech Services

Speech Pathology.Com





NMES (Neuromuscular Electrical Stimulation)





FEES Equipment







MBSS/VFSS Equipment


Biofeedback Tools

Synchrony 4.0

Promethius Group


VitalStim Plus

Iowa Oral Performance Instrument (IOPI)


Mobile Dysphagia Diagnostics

Swallow Study

Dysphagia Cafe

Eat Speak Think


Dysphagia Therapy




The Adult Dysphagia Pocket Guide:  Neuroanatomy to Clinical Practice

Outcome Measure Tools

Functional Oral Intake Scale

Mann Assessment of Swallowing Ability

Mann Assessment of Swallowing Ability

Mann Assessment of Swallowing Ability-Cancer

MD Anderson Dysphagia Inventory

MD Anderson Symptom Inventory (must complete a consultation before use)

Reflux Symptom Index

Eating Assessment Tool 10

Penetration Aspiration Scale


Dysphagia Research Society

Talk Tools

American Board of Swallowing and Swallowing Disorders

Blue Tree Publishing

Phage In Blue


May Winner

Congratulations Laura Flanagan!!! You are the first winner of the Adult Dysphagia Pocketguide!!!

I will be sending you an email soon to get your information!

If you didn’t win don’t sweat it! You have all year!!

Raffle for New Book!

I did this thing last year and actually created a pocketguide with my friend and colleague Yvette McCoy.

Writing a book can be challenging and very rewarding.

Lucky, for you, I have a lot of extra copies of this book.   That I would love to give you the chance to win!

So, every month, on the last day of the month for the remainder of 2019, every person on my email list will be entered into a raffle to win your very own copy of The Adult Dysphagia Pocketguide:  Neuroanatomy to Clinical Practice.

You can sign up for the email list right here.  Don’t worry, this is just a page for you to sign up.   You may get an email from me once a month.  I promise not to flood your inbox!!  Now you do have to stay on the email list to earn a chance every month.

Want more chances at a book?  Comment on any posts right here on the blog!  Find your favorite post and comment away.   This will earn you more chances to win.

Next month, June, the blog posts will all highlight assessment, The Clinical Swallow Evaluation.

Make sure you sign up to earn a chance to win the book!!  The first drawing is in 3 days!!!



Let’s talk total glossectomy for a minute.   I’ve actually worked with multiple partial glossectomies in my career and recently have had 2 total glossectomy patients.

It seems like a pretty difficult task, right?  Getting someone to eat and drink again with no tongue.

Taking the tongue out of the equation of swallowing makes the entire process very difficult, but not impossible.


I was looking at an article recently, wanting to make sure that I’m doing right by my patient, but also limited to access to most articles.

Son, et al

An article looked at 133 patients from 2007-2012.   There was a study of swallowing ability before and after surgery.

The study found risk factors for aspiration with tongue cancer including:

  • Gender (higher incidence in males)
  • Extensive tumor resection
  • Higher node stage
  • Extensive lymph node dissection

Patients in this study were a mean age of 53.5 with 85 men and 48 women.

Patients with tongue cancer had a higher incidence of:

  • inadequate tongue control
  • inadequate chewing
  • delayed oral transit time
  • aspiration/penetration
  • vallecular residue
  • pyriform sinus residue
  • inadequate laryngeal elevation

Of the patients:

  • 16 hemiglossectomy
  • 82 wide resection
  • 23 partial glossectomy
  • 5 total glossectomy
  • 70 underwent radiation
  • 57 underwent chemotherapy
  • 74 VFSS before surgery
  • 87 VFSS after surgery

Of the patients that had VFSS before and after surgery, after surgery, there was a higher incidence of:

  • lip movement abnormality
  • tongue control
  • chewing
  • oral transit time
  • pharyngeal phase differences with aspiration/penetration in 8 patients before surgery and in 26 patients after surgery
  • 4 patients with nasal regurgitation after surgery
  • vallecular residue in 6 patients before surgery and 39 after surgery
  • pyriform sinus residue in 3 patients before surgery and 16 after surgery
  • inadequate laryngeal elevation in 1 patient before surgery and 12 patients after surgery

Furia, et al

I read an article recently about Videofluoroscopic Evaluation after Glossectomy (cited below).   The study was small, only 15 patients, 5 with partial glossectomy, 2 with subtotal glossectomy and 8 with total glossectomy.

Those patients with partial glossectomy had difficulty with bolus formation, anterior/posterior propulsion and increased oral time particularly with thicker substances.

All patients had increased oral transit time and oral/pharyngeal/esophageal stasis.

2 patients had moderate aspiration, 2/10 had persistent asymptomatic aspiration.

Compensatory strategies that were effective for patients was a head back posture, Supraglottic Swallow, Mendelsohn Maneuver and subsequent swallows following initial swallow of the bolus.   After VFSS, 8 patients had a functional swallow and 2 patients had moderate aspiraiton with residue.

Take Away

I think the biggest take away with our patients with glossectomy, no matter the degree is to not give up on them.  These patients deserve a chance at eating and drinking, even if only small amounts.

Don’t be that SLP that completes the VFSS or FEES with no compensatory strategies, no assistance with anterior/posterior propulsion and only 1-2 trials.   There is evidence to support that these patients may not have a normal swallow, but may have a functional swallow.

Push for prosthesis for your patients.  These can be functional for your patient’s speech and swallowing.  There are multiple studies regarding prosthetics for your patient listed below.   A flap can help to fill the floor of the mouth and give your patient a stronger chance of a functional swallow.


Furia, C. L. B., Carrara-de Angelis, E., Martins, N. M. S., Barros, A. P. B., Carneiro, B., & Kowalski, L. P. (2000). Video fluoroscopic evaluation after glossectomy. Archives of Otolaryngology–Head & Neck Surgery126(3), 378-383.

Son, Y. R., Choi, K. H., & Kim, T. G. (2015). Dysphagia in tongue cancer patients. Annals of rehabilitation medicine39(2), 210.

Davis, J. W., Lazarus, C., Logemann, J., & Hurst, P. S. (1987). Effect of a maxillary glossectomy prosthesis on articulation and swallowing. Journal of Prosthetic Dentistry57(6), 715-719.

Donaldson, R. C., Skelly, M., & Paletta, F. X. (1968). Total glossectomy for cancer. The American Journal of Surgery116(4), 585-590.

Hirano, M., Matsuoka, H., Kuroiwa, Y., Sato, K., Tanaka, S., & Yoshida, T. (1992). Dysphagia following various degrees of surgical resection for oral cancer. Annals of Otology, Rhinology & Laryngology101(2), 138-141.

Kothary, P. M., & DeSouza, L. J. (1973). Swallowing without tongue. Bombay Hosp J15, 58-60.

Frazell, E. L., & Lucas Jr, J. C. (1962). Cancer of the tongue. Report of the management of 1,554 patients. Cancer15(6), 1085-1099.

“Establishing a Multidisciplinary Head and Neck Clinical Pathway: An Implementation Evaluation and Audit of Dysphagia-Related Services and Outcomes”

If you are considering joining or starting a head and neck cancer program, this is the read for you!

I was searching through articles this morning and found this very article stating the importance of a team approach and a systematic approach to head and neck cancer!

“Head and neck cancer guidelines recommend multidisciplinary team monitoring and early intervention.”

Prophylactic treatment for head and neck cancer has been found to increase maintenance of tongue muscle mass, preserve some taste and have an overall improved swallow.   The SLP should be right in there, from the beginning to determine baseline swallowing function and to provide education for what may happen to the swallow.

“We need patient care using a systematic approach for head and neck cancer.”

Read the research.  Keep up with the new approaches and utilize them in  your therapy.  Dysphagia assessment and treatment approaches are ever-evolving and you have to stay current to provide your patients with the best care possible.

With the multidisciplinary Approach:

  • Improved outcomes
  • Better survival rates
  • Maximize results through use of a coordinated pathway
  • Increase efficiency in care delivery
  • Reduce cost
  • Shorten the length of the hospital stay
  • Improve overall patient outcomes

Who should/may be on the multidisciplinary team:

  • Head and Neck Surgeon
  • Medical Oncologist
  • Radiation Oncologist
  • Nursing
  • Speech Language Pathologist
  • Dietician
  • Social Worker
  • Administrative Professionals (Systems Analyst, Clinical Research Coordinator)

“A significant impact of Head and Neck Cancer is typically the impact on swallowing and inadequate nutritional intake.”

The SLP plays a vital role in the assessment and treatment of swallowing.

“Prophylactic and ongoing Speech Language Pathology services can be vital by impacting swallow function, nutritional status and overall quality of life.”

We’re not just one and done.  Even though the patient may not initially have difficulty with swallowing early in their treatment doesn’t mean it will never happen.   You need to check up on the patients throughout their course of treatment and even after their treatment to continue to assess the impact on swallowing.

Collecting Data:

Patients undergo a pre-treatment MBSS (Modified Barium Swallow Study) and/or FEES (Flexible Endoscopic Evaluation of Swallowing).  Also completed with patients:

Prophylactic Exercises Included:

  • Lingual strengthening
  • Masako Maneuver
  • Effortful or Supraglottic Swallow
  • Mendelsohn Maneuver
  • Shaker
  • Therabite (incisal opening less than 40mm)
  • EMST (increase airway clearance/protection)

*Exercises completed 2x/day, 6 days/week


Dance Head and Neck Clinical Pathway (D-HNCP)

Messing, B. P., Ward, E. C., Lazarus, C., Ryniak, K., Kim, M., Silinonte, J., … & Sobel, R. (2019). Establishing a multidisciplinary head and neck clinical pathway: An implementation evaluation and audit of dysphagia-related services and outcomes. Dysphagia34(1), 89-104.