Now keep in mind, I’ve been an SLP for a lot of years and feel that I do a pretty good job. Sometimes, I may even get a little over-confident in my skills and have to examine what I’m doing.
Let’s talk about a patient I’ve had. All identifying information will be withheld.
This person was referred after a family member was concerned with increased choking with food and drinks. This patient has a history of dysphagia, which had resolved.
I get the call to go in and go in prepared for an evaluation. I did everything I would normally do in an evaluation.
I did a cranial nerve exam which all the cranial nerves seem to be intact. I had the person eat and drink while I observed. I even palpated the larynx to see what I could feel. Everything seemed to be quite normal.
I have to do vitals for home health so I went ahead and got out my pulse oximeter to see if there is any change in the person’s sats. They were able to drink some water with no change in 02 saturation.
Everything seemed to check out pretty well however the family was still very concerned, so just to cover my bases and to make sure that I hadn’t missed something I requested a modified barium swallow study.
Now imagine my surprise when I get the report for that swallow study and find out that this person’s actually aspirating multiple consistencies.
The person has timing issues with laryngeal elevation and closure and with oral containment prior to the swallow.
I mean really how can that be?
There was no change in O2 sats for me. The larynx felt like it was moving pretty well. Cranial nerves seem to be intact and functioning.
Where did I go wrong?
I didn’t. I realized my limitation without visualization. I have read my research and know that O2 sats and palpation is not always accurate.
I did right by my patient and pushed for instrumental exams.
I had push-back at first. Do you really need an instrumental? Can’t you just treat? When I told the company I need the instrumentals or I’m referring patients to another company, they started approving my requests.
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!)
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 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.
Swallowstudy.com has a great review of lab values which you can find here.
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 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.
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:
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. Dysphagia, 17(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.
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
delayed oral transit time
pyriform sinus residue
inadequate laryngeal elevation
Of the patients:
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
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.
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 Surgery, 126(3), 378-383.
Son, Y. R., Choi, K. H., & Kim, T. G. (2015). Dysphagia in tongue cancer patients. Annals of rehabilitation medicine, 39(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 Dentistry, 57(6), 715-719.
Donaldson, R. C., Skelly, M., & Paletta, F. X. (1968). Total glossectomy for cancer. The American Journal of Surgery, 116(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 & Laryngology, 101(2), 138-141.
Kothary, P. M., & DeSouza, L. J. (1973). Swallowing without tongue. Bombay Hosp J, 15, 58-60.
Frazell, E. L., & Lucas Jr, J. C. (1962). Cancer of the tongue. Report of the management of 1,554 patients. Cancer, 15(6), 1085-1099.