Clinical Evaluation of Dysphagia


Severity score

Definition

Characteristics

7

Within normal limits

No condition of dysphagia

6

Minimum problem

Some symptoms of dysphagia but no need of rehabilitation or exercise

5

Oral problem

Significant symptoms of oral preparatory or oral stage without aspiration

4

Occasional aspiration

Possible aspiration or aspiration is suspected due to much pharyngeal residue

3

Water aspiration

Aspiration of thin liquid . Changes in food consistency will be effective

2

Food aspiration

Food aspiration with no effect of compensatory techniques or food consistency changes

1

Saliva aspiration

Unstable medical condition because of severe saliva aspiration




Table 5.2
Eating Status Scale , a five-point ordinal

























Score

Characteristics

5

Oral feeding

4

Modified oral feeding

3

Oral > tube

2

Oral < tube

1

Tube feeding only


Both the DSS and ESS are correlated with each other and important for treatment planning, including making recommendations regarding the diet level, independence level, interventions, management plan, and the monitoring of swallowing improvement after exercise therapy.

These scales are helpful in comparing the level of swallowing dysfunction within and across patients and reevaluating swallowing impairment with respect to treatment effectiveness. Use of the DSS in conjunction with the ESS is essential. Although swallowing function (assessed with the DSS ) is not altered during reexamination, the eating status (assessed with the ESS ) can demonstrate improvement if safe swallowing and a decrease in the risk of aspiration are achieved by appropriate food adjustment.


5.1 Dysphagia Screening


Evaluation of swallowing in patients who present to the hospital with swallowing dysfunction begins with screening. The screening of swallowing function is a rapid procedure with the purpose of identifying patients at risk for oropharyngeal dysphagia . Screening should be applied as soon as the patient’s medical condition allows, to guide further assessment and determine whether the patient can safely take food by mouth . Clinicians should understand the importance of this screening and remember that it cannot be used to diagnose dysphagia .

Depending on the setting, screening can be conducted by a physician, nurse , or SLHT . Additionally, various screening tests are used in different work settings. No single dysphagia screening tool can be regarded as the most effective and ready for complete clinical implementation [2, 8].

Patients who undergo a failed initial screening require referral for both clinical (noninstrumental) and instrumental swallow assessments. These evaluations allow clinicians to obtain a more comprehensive, in-depth understanding of the swallow physiology; determine the presence, location, and severity of the impairment; and plan further management.

Screening tools need to involve easy-to-perform protocols, few time-consuming procedures, and noninvasive methods with which to determine the risk of dysphagia and/or aspiration. Above all, the screening tool must have proven reliability and validity [9, 10] for use in the clinical setting. Additionally, because the aim of screening tools is to identify patients at greater risk of dysphagia , these tools must also have high sensitivity and a low rate of false-negative results.

Several dysphagia screening tools are used in Japan. The main screening tests performed on a routine basis at FHUR are described below.


5.1.1 Repetitive Saliva Swallowing Test


The repetitive saliva swallowing test (RSST ) was developed to safely and simply screen patients with functional dysphagia . It detects the patient’s ability to voluntarily swallow repeatedly and correlates the results with the risk of aspiration. The patient stays in a resting posture and is asked to repeatedly swallow saliva (dry swallow ) as many times as possible within 30 s. The examiner counts the number of swallows by palpation or inspection of laryngeal elevation movement during the swallowing reflex (Fig. 5.1). A patient with two or fewer dry swallows within 30 s is likely to have dysphagia associated with aspiration and should be further investigated.

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Fig. 5.1
The examiner places the index and middle fingers on the hyoid bone and thyroid cartilage , respectively, during the repetitive saliva swallowing test

The sensitivity and specificity of the RSST to detect aspiration diagnosed using VF as reference test are 0.98 and 0.66, respectively [11, 12]. However, the RSST has limited clinical applicability in patients with cognitive or linguistic dysfunction because these patients may lack the ability to follow instructions.


5.1.2 Modified Water Swallowing Test


The modified water swallowing test (MWST ) is used to detect aspiration when swallowing water and monitoring the response. A 3-mL volume of cold water is placed on the floor of the mouth with a syringe, and the patient is instructed to swallow the water followed by two saliva swallows (Fig. 5.2). If the patient is unable to swallow or experiences dyspnea , coughing, or wet-hoarse dysphonia after swallowing, a score of 1–3 is recorded and the test is terminated. If the patient is able to swallow the water safely, a score of 4 or 5 is recorded depending on the patient’s ability to perform the two dry swallows afterward.

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Fig. 5.2
The examiner places 3 mL of water into the mouth (under the tongue) with a syringe during the modified water swallowing test

Breathing , coughing, and voice quality are scored using a five-point scale (Table 5.3).


Table 5.3
Scoring system for modified water swallowing test

























Score

Characters

1

No swallow, cough , and/or frequent breathing

2

Swallowed successfully without coughing but with changes in breathing (e.g., frequent breathing )

3

Swallowed successfully with normal breathing but with cough and/or wet-hoarse voice

4

Swallowed successfully with normal breathing , no cough , and no wet-hoarse voice

5

Score 4, plus two or more additional dry swallows in 30 s

The entire procedure is repeated twice more. The final score is determined as the lowest score of any trial. This test is an easy, simple, and safe method with which to evaluate swallowing function.

The sensitivity and specificity of the MWST to detect aspiration using VF for concurrent validity are 0.70 and 0.88, respectively, when the cutoff score is 3 [13, 14].


5.1.3 Food Test


The food test is a modification developed to screen for solid food dysphagia . The procedure and scoring are nearly identical to those of the MWST . A 4-g bolus of pudding or jelly is placed on the dorsum of the tongue with a spoon, and the patient is then instructed to swallow. In addition to scoring the components of MWST, oral residue after swallowing must be inspected (Fig. 5.3; Table 5.4).

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Fig. 5.3
(a) The examiner places a 4-g bolus of jelly into the mouth with a spoon during the food test . (b) Pudding or jelly may be used for the food test ((b) Reproduced from Otsuka Pharmaceutical Factory, Inc. with permission)



Table 5.4
Scoring system for food test

























Score

Characters

1

No swallow, cough , and/or frequent breathing

2

Swallowed successfully without coughing but with changes in breathing (e.g., frequent breathing )

3

Swallowed successfully with normal breathing but with cough and/or wet-hoarse voice and/or moderate residue in oral cavity

4

Swallowed successfully with normal breathing , no cough , no wet-hoarse voice , and almost no residue in oral cavity

5

Score 4, plus two or more additional dry swallows in 30 s

The sensitivity and specificity of the food test to detect aspiration as diagnosed by VF are 0.72 and 0.62, respectively, when the cutoff score is 4 [14].


5.1.4 30-mL Water Swallowing Test


The 30-mL water swallowing test (WST ) was originally described by Kubota [15, 16] using 30 mL of water at room temperature to detect aspiration. The patient is asked to drink water from the cup in the sitting position as usual. The drinking profile is based on a five-point scale, and the occurrence of drinking episodes (described below) and duration of drinking are monitored and assessed (Table 5.5).


Table 5.5
Scoring system for 30-mL water swallowing test

























Score

Characters

1

Drink all the water in one gulp without choking

2

Drink all the water in two or more gulps without choking

3

Drink all the water in one gulp but with some choking

4

Drink all the water in two or more gulps but with some choking

5

Chokes and has difficulty drinking all the water


5.1.4.1 Drinking Episodes


Examples of drinking episodes include sipping, holding water in the mouth while drinking , escape of water from the mouth , a tendency to try to force himself/herself to continue drinking despite choking , and drinking water in a cautious manner.


5.1.4.2 Diagnosis






  • Normal: Completed Profile 1 within 5 s


  • Suspected aspiration: Completed Profile 1 in more than 5 s or completed Profile 2


  • Abnormal: Completed any of Profiles 3 through 5

Nevertheless, because of the high risk of aspiration in patients with stroke and older individuals swallowing large amounts of water, the above-described 3-mL MWST was developed for use on the first attempt; this is followed by the 30-mL WST (Fig. 5.4).

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Fig. 5.4
Degree of test difficulty. *The accuracy of the screening result can be increased by the combination of different screening tests

Notably, the laryngeal movement, timing/completeness/number of swallows, pre–post-voice quality, coughing/throat clearing , absent or delayed swallowing, and oral residue should be observed and recorded during all trial swallows.

At the FHUR, a certified nurse of dysphagia nursing is the main person who administers the swallowing screening test to patients who are at risk of dysphagia or are suspected to have dysphagia . Figure 5.5 shows a diagram of dysphagia screening executed by a certified nurse of dysphagia nursing at the FHUR.

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Fig. 5.5
Guideline of dysphagia screening tests in FHUR. The Dysphagia Severity Scale is used to determine the severity of swallowing dysfunction during the swallowing screening

Safety is an important consideration. A pulse oximeter for monitoring the arterial oxygen saturation, tools for clinical observation, and a suction unit should be ready in case they are needed during the swallow test. Furthermore, these screening tests may not detect silent (subclinical) aspiration and cannot always provide information that is useful for treatment.

Other than the screening tests used at FHUR, a large amount of emerging evidence shows that dysphagia screening tools are sensitive, specific, and easily administered without extensive training (Appendix). Moreover, dysphagia screening can alternatively be performed with the use of questionnaires , which are being increasingly used to collect data that quantify the symptomatic severity of dysphagia as experienced by the patient. These questionnaires also have evidence supporting their clinical use (e.g., the ten-item Eating Assessment Tool, Seirei Questionnaire of Swallowing, Swallow Disturbance Questionnaire).

Another step after screening is a more comprehensive assessment. Patients with suspected dysphagia or who are at high risk of dysphagia require further assessment after the screening test has failed.

Swallowing assessment after screening encompasses a clinical swallow assessment and instrumental measures. The combination of clinical and instrumental measures contributes to a more comprehensive understanding of the patient’s swallowing problem, allowing the clinician to gather useful information for a proper diagnosis and individualized treatment planning. The diagram below illustrates a holistic approach for patients with suspected or confirmed dysphagia (Fig. 5.6).

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Fig. 5.6
Evaluation of patients with suspected dysphagia


5.2 Clinical Swallowing Assessment


A positive (failed) screening result is followed by a clinical swallowing examination. This pathway is very useful in centers with sufficient amounts of clinicians and equipment, like the FHUR. Alternatively, a clinical swallowing examination can be performed before further evaluation or instrumental examination in small centers with a shortage of human resources and/or equipment.

The clinical swallowing assessment serves to validate and identify the severity of dysphagia and guide further management. The main objectives of the evaluation are problem recognition, identification of the pathophysiology involved, and acquisition of data to determine the etiology of the condition.

This information is gathered to gain a more holistic view of the patient, make decisions on his or her swallowing ability, and make predictions regarding the presence or absence of dysphagia and aspiration. Thorough history-taking and physical examination , including medication use, is essential to determine the etiology of dysphagia . Swallowing is a complex process, and dysphagia may result from abnormalities in any of the many steps necessary for deglutition . These various causes can be classified by patient age range or pathophysiology . The pathophysiologic disorders causing dysphagia can be categorized as shown in Table 5.6.


Table 5.6
Major categories of various disorders causing dysphagia


















Neuromuscular disorders

Central nervous system diseases (such as stroke , Parkinson disease ), multiple cranial nerve palsy , bulbar palsy (e.g., multiple sclerosis , motor neuron disease )

Myasthenia gravis , muscular dystrophy, etc.

Mechanical and obstructive disorders

• Head and neck malignancy and their consequences of surgery and/or radiotherapeutic interventions

• Acute inflammation or infections (e.g., retropharyngeal abscesses )

Zenker diverticulum

Cervical osteophytes

• Fibrosis/cricopharyngeal bar

Tracheostomy , etc.

Esophageal disorders

• Structural disorders (tumors, eosinophilic esophagitis, infections , radiation injury, esophageal rings and webs, etc.)

Dysmotility (achalasia , esophageal spasm , scleroderma , connective tissue disease (e.g., myositis))

• Gastroesophageal reflux disease

Others

• Drug-induced, psychogenic, age-related changes, major categories of head and neck disorders causing dysphagia

The pie chart in Fig. 5.7 shows the etiologies of VF -diagnosed dysphagia among 275 patients at FHUR in 2016. The average age of the patients was 66 ± 19 years (range, 10.8 months to 97 years). Poststroke dysphagia was the most common etiologies of dysphagia .

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Fig. 5.7
Etiologies of swallowing disorders diagnosed by VF at FHUR in 2016

The most efficient and precise technique with which to identify dysphagia requires a thorough comprehensive evaluation of the patient’s medical history and a complete physical examination .


5.2.1 Medical History


A comprehensive history must include the information shown in Table 5.7.


Table 5.7
Medical history required for diagnosis





















Patient presenting symptoms

• Difficulty initiating a swallow, repetitive swallowing

• Take extra effort to swallow liquids/solids/pills

• Changes of tastes

• Nasal speech, nasal regurgitation

Drooling

• Coughing and/or choking (before, during, or after swallowing)

Globus pharyngeus (feeling of food stuck in the throat)

• Painful swallow

Dysarthria

• Wet hoarseness (gurgling voice )

• Changes voice /speech after swallow

• Changes in breathing when eating or drinking

• Increasing secretion

Halitosis

• Weight loss, etc.

Past history and current medical status

• Diagnosis of neurological diseases (e.g., stroke , Parkinson disease , myasthenia gravis , cranial nerve -involved diseases)

• Other underlying diseases accompanying dysphagia or related to possible coexisting swallowing disorders (e.g., head and neck cancer, chronic obstructive pulmonary disease , congestive heart failure , gastrointestinal diseases)

• Dental disorder and previous treatment

Current medication

Anticholinergics , antipsychotics , tricyclic antidepressants , antiepileptic drugs , skeletal muscle relaxants , sedative drugs , etc.

Specific swallowing history

• Onset, duration, and course of problem: gradually worse in case of neurological disorders in particular

• Weight loss, loss of appetite

• History of recent and recurrent pneumonia

Eating condition: oral/dental status, feeding dependency, difficult food/liquid items, length of meal time taken, precipitating or alleviating factors, episodes and frequency of choking /coughing, drooling /difficulty of saliva swallowing, energy level

• Previous swallowing assessment (intervention and treatment provided)

Sociocultural status

• Cultural background, personal and environmental support

This information is ideally obtained directly from the patient. However, when the patient is unable to provide this information because of a limited cognitive status or language restriction, the history of the swallowing problem is acquired and validated by the patient’s family or caregiver, the medical team, and/or the medical record. Knowledge of the potential etiology of the dysphagia is critical. A curable or ameliorating etiology , such as infection or stroke , respectively, can suggest the potential to improve the patient’s swallowing ability. Conversely, a progressive disease such as a neurodegenerative disease or amyotrophic lateral sclerosis suggests a poor swallowing prognosis over time. This information affects the ability to establish a feasible and appropriate treatment plan.


5.2.2 Physical Examination


It is important to assess the patient’s physical findings in terms of both structure and function. This assessment consists of various general assessments (described below) and evaluation of the cranial nerves , particularly cranial nerves V, VII, IX, X, and XII because these are strongly associated with the motor and sensory functions of swallowing.


5.2.2.1 General Assessments


The four primary areas of examination in the general assessments are:


  1. 1.


    Mental status



    • Alertness/wakefulness, cooperation, orientation , and communication

     

  2. 2.


    Nutritional status



    • Type of feeding, signs of dehydration , signs of malnutrition , and body mass index

     

  3. 3.


    Respiratory status



    • Respiratory rate, arterial oxygen saturation, breathing patterns, ability to hold breathing , and difficulty of breathing


    • Chest auscultation


    • Weakness of voluntary cough


    • Presence of tracheostomy and type of tracheostomy tube


    • Saliva aspiration and the presence of secretion


    • Suction equipment

     

  4. 4.


    Oral healthcare and dentition



    • Oral hygiene, oral mucosa (moist/dry), food residue , dentures , tooth decay, mucositis/gingivitis, etc.

     

In addition, postural control (ability to maintain the sitting position), mobility function, ambulatory level, and requirement of assistance should be assessed.


5.2.2.2 Assessment of Oromotor Control and Vocal Function






  • Jaw movement, labial function, and cheek and facial movement


  • Lingual function (at rest and during movement)


  • Soft palate and pharynx : weakness, asymmetry, and sensation of the posterior pharyngeal wall


  • Laryngeal function



    • Vocal quality (normal, hoarseness , wet/gurgling voice )


    • Volitional cough (strong, weak, absent)


    • Throat clearing (strong, weak, absent)


    • Phonation time (seconds)


  • Others: dysarthria , oral apraxia , laryngeal elevation , and reflexes (gag reflex , bite reflex )

The evaluation guidelines proposed by the JSDR in 2011 suggest the need to clinically evaluate the patient with respect to at least eight items:


  1. 1.


    Cognition

     

  2. 2.


    Observation of eating

     

  3. 3.


    Range of motion of the head and neck

     

  4. 4.


    Dental prosthesis and oral hygiene

     

  5. 5.


    Oral motor and sensory examination

     

  6. 6.


    Phonation and articulation

     

  7. 7.


    Pulmonary function

     

  8. 8.


    Nutrition and hydration

     

Clinical diagnosis of dysphagia in Japan is performed by physiatrists , SLHTs , and nurses . Nevertheless, it is important to note that the clinical swallowing examination has several limitations. It cannot be used to identify the underlying swallowing impairment, confirm airway invasion, determine the effects of compensatory strategies, or recommend appropriate rehabilitation approaches. Instead, an instrumental swallowing evaluation (VF and/or VE ) is warranted for these purposes and should be implemented.


5.3 Instrumental Swallowing Assessment


The instrumental swallowing assessment helps the clinician to identify the biomechanical aspects of the patient’s swallowing dysfunction, determine the risk of aspiration, assess the patient’s compensatory strategies, and make swallowing rehabilitation training recommendations through the appropriate use and interpretation of a diagnostic swallow procedure. Instrumental swallowing assessment involves any or all of the following procedures to examine a particular aspect of swallowing. Such assessment not only provides valuable information with which to achieve a clinical diagnosis but also facilitates establishment of the most appropriate swallowing rehabilitation training program.



  • Assessment of structural and functional swallow


  • Assessment of adequacy of airway protection


  • Assessment of coordination of respiration and swallowing


  • Screening of esophageal motility and gastroesophageal regurgitation


  • Assessment of the effects of changes in bolus delivery, changes in bolus characteristics (consistency and volume ), and compensatory swallowing strategies using therapeutic postures or maneuvers

Aspiration is concerning because it can lead to aspiration pneumonia or pulmonary disease, which can be fatal in many cases. Therefore, accurate assessment of aspiration and identification of pathophysiology under aspiration is essential.

An instrumental swallowing assessment is indicated to achieve the correct diagnosis and plan appropriate management that ensures safe and effective swallowing in patients who have dysphagia or are at high risk of developing dysphagia when:



  • Signs and symptoms are not consistent with the clinical examination findings.


  • Further detailed information is needed to determine the most likely diagnosis or underlying swallowing impairment.


  • The safety and efficiency of the swallow are being assessed.


  • Compensatory strategies are being assessed, and the most appropriate rehabilitation protocol is being individually recommended, including behavioral and dietary management.


  • The swallow function changes after treatment, or the patient has a chronic degenerative disease that is known to gradually progress.

The two main swallowing diagnostic tools are VF and VE . Both procedures are considered to be the gold standard techniques for swallowing evaluation because they are outstanding treatment-oriented tools and have undergone evidence-based validation. Which procedure is needed for a swallow evaluation is determined by individual patient characteristics and the purpose of the evaluation.


5.3.1 Swallowing Examination by Videofluorography (VF)


Swallowing examination using VF is a treatment-oriented evaluation that provides real-time visualization of the bolus trajectory in the oral cavity, oropharynx , hypopharynx , and esophagus using various consistencies and volumes of barium -coated trial materials.

VF has been proposed as the gold standard assessment method with which to establish a standard for image evaluation and is considered a mandatory tool for swallowing evaluation. It allows for a kinematic evaluation during the study and a more detailed kinematic analysis using the recorded image after the study, contributing to the establishment of a treatment plan.

VF provides two essential feedback parameters for treatment: knowledge of results and knowledge of performance. Knowledge of results is the feedback regarding whether aspiration and/or residue is present. Knowledge of performance is the feedback regarding how to eliminate this aspiration/residue. Thus, for knowledge of results, identifying the least difficulty task that can prevent aspiration and/or residue is essential, and for knowledge of performance, detecting the tip to eliminate aspiration and/or residue is essential. Determining appropriate food modification, postural techniques, and swallowing maneuvers as the least difficulty task and tip are the basis of evaluation. VF also allows the clinician to assess the availability, adequacy, and effect of the intervention in terms of reaching the treatment goal.

Four evaluation points are important when performing VF :



  • Handling bolus in mouth (chewing, bolus formation, bolus propelling)


  • Position of the bolus head


  • Evidence of aspiration/penetration (before, during, or after swallow)


  • Volume and location of the oral and/or pharyngeal residue

The results of these evaluations will help to determine the most effective strategies (e.g., bolus modification or postural techniques during VF ) that ensure efficient and safe swallowing. Other details should also be observed depending on the individual patient’s problems.

Laryngeal penetration and the risk of aspiration associated with the bolus type are observed while performing VF . The order of the tests is not fixed; the clinician adapts the examination to the individual patient. The clinician can select the bolus materials depending on the patient’s swallowing impairment and complaints about foods that are difficult to swallow. According to the differences between eating and drinking , clinicians should evaluate both of these behaviors in terms of the chew–swallow complex . One study demonstrated that the act of chewing was a prime determining factor of the chew–swallow complex during stage II transport of the process model [17].

As seen in Fig. 5.8, the two-phase food (mixed food ) is associated with the highest risk of aspiration because the bolus head is significantly lower in the food pathway at swallowing onset than either liquid or corned beef hash . The leading edge of the two-phase food reaches the vallecula or a lower area of the hypopharynx before swallowing onset . This means that the patient’s chewing manner influences the depth of the leading edge of the bolus at the onset of pharyngeal swallow. This occurs even when drinking liquid by performing chewing . Clinicians should therefore assess the chew–swallow complex in addition to performing conventional VF , and a two-phase food should be used to evaluate the risk of aspiration (Table 5.8).

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Fig. 5.8
The bolus position at the time of the swallowing onset based on the bolus characteristics. A mixed chew–swallow refers to a two-phase food comprising liquid barium and corned beef hash . *This was the result of ten healthy subjects (six male, four female; age, 29 ± 4 years) using 10 mL of liquid barium , 8 g of corned beef hash , 8 g of cookie, and a bolus of mixed consistency (4 g of corned beef hash and 5 mL of liquid barium )



Table 5.8
Paired comparisons to determine risk of aspiration among various types of foods and drinks [18]



































































 
PD

CB

LQ4

LQ10

CUP

MX

PD
 





CB

 




LQ4


 



LQ10



 


CUP




 

MX





 


● More likely to cause aspiration

○ Less likely to cause aspiration

PD pudding -thick texture , CB corned beef hash , LQ4 4 mL of thin liquid , LQ10 10 mL of thin liquid , CUP one swallow from a cup, MX two-phase mixture of 4 g of corned beef hash and 5 mL of thin liquid

Patients with dysphagia should be assessed with caution when eating multi-textured food to clarify the most appropriate bolus types for each patient. Prepared bolus materials should be initially tested from the safest and easiest to the most difficult materials, and the patient should begin the examination using a small amount of liquid barium or a small bolus of food to enable safe assessment of the patient’s basic swallow physiology and clarification of further management. If the bolus can still be safely swallowed after modification of its consistency and volume , the study proceeds by administration of the next bolus with a higher risk of aspiration (more difficult task). This step-by-step administration is continued until the clinician detects the task that results in aspiration. Various foods and liquids that differ in volume , consistency , and texture are used. Liquid barium is administered by syringe for 4- and 10-mL boluses placed under the tongue and by cup or straw for 30-g boluses to observe sequential drinking . **The patient is asked to hold the bolus in his or her mouth until instructed to swallow.

In addition to modification of the boluses administered during VF , postural techniques (e.g., head rotation , trunk rotation , reclining posture, head/neck flexion ) and swallowing maneuvers (e.g., super-supraglottic swallo w, Mendelsohn maneuver , Effortful swallow ) can be utilized to enhance safety and facilitate selection of appropriate treatment. These procedures help to determine how to improve the oropharyngeal swallow and return the patient to full oral intake as quickly as possible (Table 5.9).


Table 5.9
Summary of common bolus materials, postural techniques, and therapeutic maneuvers used during videofluorography











Various foods and liquids

Volume 2 mL and then go further with 4 mL, 10 mL, and cup drinking (30 g)

• Bolus

Thin liquid , nectar-thickened liquid , and honey-thickened liquid

− Semisolid, solid food, and two-phase food (chew–swallow)

Posture strategies

• Head and/or neck flexion (chin tuck)

Head rotation

Reclining

Trunk rotation

Swallowing maneuvers

Effortful swallow

Mendelsohn maneuver

Supraglottic swallow

Super-supraglottic swallow

• Etc.

The most important image of the swallowing study is the lateral view, which enables observation of the movement of the tongue base , soft palate elevation , hyolaryngeal elevation , laryngeal closure , contraction of the pharyngeal constrictor, and opening of the upper esophageal sphincter (UES). However, the anteroposterior view must also be assessed because it provides important clinical information regarding the pharyngeal constriction , the laterality of bolus flow (symmetrical characteristic), the side on which the pharyngeal residue is located, and anatomical abnormalities such as pharyngeal diverticula. This view also allows for assessment of the esophageal stage , including delayed esophageal transit time (<30 s is acceptable) and gastroesophageal regurgitation (Table 5.10).


Table 5.10
Key features observed in the lateral and anteroposterior fluoroscopic views



















Lateral view

AP view

Boundaries of lateral fluoroscopic view

Nasopharynx superiorly

• Cervical esophagus inferiorly (below UES)

Lip anteriorly

Cervical spine posteriorly

Boundaries of AP fluoroscopic view

Nasopharynx superiorly

• Cervical esophagus inferiorly (below UES)

• Lateral pharyngeal walls

Point of view: structural movement

• Lip closure

• Tongue motion

− Base of tongue retraction

− Squeeze back

Soft palate elevation

Epiglottis inversion

• Pharyngeal contraction

• UES opening

Point of view: structural movement

• Tongue motion

− Tongue rotation

Mastication

− Food transport

• Pharyngeal contraction

• Symmetry of bolus trajectory

• UES opening

• Esophageal motion

Bolus flow trajectory and functional abnormalities

• Leakage from lip (drooling )

• Poor bolus formation and transfer

Premature spillage

Penetration /aspiration (before, during, after swallowing)

• Impaired pharyngo-laryngeal elevation

• Residue (oral, pharynx , vallecular, pyriform sinuses )

− Amount

− Location

− Patient response

• Nasal/pharyngeal regurgitation

Bolus flow trajectory and functional abnormalities

• Tongue motion weakness

• Poor bolus formation and transfer

• Impaired pharyngo-laryngeal elevation

• Impaired pharyngeal contraction

• Laterality of bolus flow (asymmetrical property)

• Residue located side

• Incompetent esophageal peristalsis

• Slow esophageal transit through the esophagus

• Esophago-pharyngeal regurgitation and gastroesophageal regurgitatio n


5.3.1.1 Swallowing Study by VF: Anatomical Overview


Figures 5.9 and 5.10

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Fig. 5.9
Overview of oral and pharyngeal lateral fluoroscopic view


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Fig. 5.10
Anteroposterior fluoroscopic images. (Left) overview of oral and pharyngeal view. (Right) esophageal view


5.3.1.2 Three Mandatory Evaluation Points During VF



Position of the Bolus Head at Swallow Initiation

Figure 5.11

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Fig. 5.11
Three leading edges of boluses. In a normal subject, the leading edges vary depending on the bolus type at swallowing onset , (left) liquid; swallowing onset occurs when the bolus head reaches the lower jaw line, (middle) corned beef; swallowing onset occurs when the bolus head reaches the vallecular, (right) two-phase food; swallowing onset occurs when some of the bolus reaches the lower area of the hypopharynx


Aspiration and Penetration

Figures 5.12, 5.13, and 5.14

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Fig. 5.12
Penetration (arrow) during swallowing on the lateral fluoroscopic view. The dotted line indicates the level of the true vocal cords


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Fig. 5.13
Aspiration is demonstrated during a swallow on the lateral fluoroscopic view. The bolus enters the laryngeal vestibule down to the anterior wall of the trachea . Evidence of residue is present throughout the bolus pathway including the oral cavity, pharyngeal wall , vallecula , and pyriform sinus


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Fig. 5.14
Three types of aspiration (during, before, and after swallow), providing information regarding the patient’s physiological abnormalities

Determination of the cause of aspiration is the main purpose of a VF study, as shown in Table 5.11.


Table 5.11
Possible causes of aspiration at three time points during videofluorography





















Aspiration time

Possible causes

Aspiration during the swallow

Impaired laryngeal elevation

Impaired laryngeal closure

Aspiration before swallow reflex triggered

Reduced tongue control, delayed or absent swallow reflex

Aspiration after the swallow (when the larynx lowers and opens for respiration)

Remained residue in the vallecula and pyriform sinuses from any reasons (such as weakened pharyngeal constrictors, reduced hyolaryngeal elevation , cricopharyngeal dysfunctio n), esophago-pharyngeal regurgitation


Pharyngeal residue

Both the amount and location of the residue should be considered because this might allow the clinician to determine the risk of aspiration. The possibly impaired mechanisms may be identified from the location of the residue (Fig. 5.15; Table 5.12).

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Fig. 5.15
Bolus residue at the vallecula and pyriform sinuses on the lateral and anteroposterior fluoroscopic views



Table 5.12
Possibly impaired mechanisms as predicted from the location of the residue




























Location of residue

Impaired mechanism

Oral cavity

Incompetent bolus formation and propulsion (due to oromotor weakness)

Nasopharynx

Incompetent velopharyngeal closure

Tongue base

Inadequate lingual propulsion

Vallecula

Reduced/absent epiglottic retroflexion (due to reduce hyoid elevation), reduced base of tongue retraction

Pyriform sinus

Reduced pharyngeal shortening or reduced UES opening

Posterior pharyngeal wall

Reduced base of tongue retraction , weakened pharyngeal constrictors

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Mar 15, 2018 | Posted by in NURSING | Comments Off on Clinical Evaluation of Dysphagia
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