Assessment of Dysphagia: Difference between revisions

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=== Ultrasound ===
=== Ultrasound ===
The other investigations can be ultrasound to look for laryngeal elevation; MRI to look for the anatomical and functional properties of agglutination; electromyography, very difficult to do, done for cricopharyngeal muscles where some neurological or neurogenic cause is being associated. Then pH-metry in reflux cases.


=== Magnetic Resonance Imaging ===
* Can be performed by '''highly skilled SLPs, who completed competency''' to achieve independent practitioner status. <ref>Martin K. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4760570/pdf/10.1177_1742271X14568074.pdf Special issue on education and training in ultrasound]. Ultrasound. 2015 Feb;23(1):5.</ref>
* Allows visualisation of soft tissue structures of the mouth (tongue and floor of the mouth). <ref>Allen JE, Clunie GM, Winiker K. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7611059/pdf/EMS127768.pdf Ultrasound: an emerging modality for the dysphagia assessment toolkit?] Curr Opin Otolaryngol Head Neck Surg. 2021 Jun 1;29(3):213-218. </ref>
* Assess swallowing kinematics of the tongue, hyoid, larynx, and lateral pharyngeal wall.<ref>Hsiao MY, Wahyuni LK, Wang TG. Ultrasonography in assessing oropharyngeal dysphagia. Journal of Medical Ultrasound. 2013 Dec 1;21(4):181-8.</ref>
* Assess the hyoid bone displacement during swallowing.<ref>Chen YC, Hsiao MY, Wang YC, Fu CP, Wang TG. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6029310/pdf/JMU-25-90.pdf Reliability of Ultrasonography in Evaluating Hyoid Bone Movement]. J Med Ultrasound. 2017 Apr-Jun;25(2):90-95.</ref>
* Allows morphometric assessment (measurements of muscle thickness or cross-sectional area) of muscle groups related to swallowing, such as the tongue, masseter, and submental muscles .
* Less invasive than VFSS or FEES
 
=== Real-Time Magnetic Resonance Imaging (RT-MRI) ===
 
* RT-MRI is performed by '''a radiologist or a radiology technologist'''
* No radiation exposure.<ref name=":7">Vijay Kumar KV, Shankar V, Santosham R. [https://www.ejradiology.com/action/showPdf?pii=S0720-048X%2812%2900446-9 Assessment of swallowing and its disorders-a dynamic MRI study.] Eur J Radiol. 2013 Feb;82(2):215-9.</ref>
* Assess symmetry and amplitude of movements of velum, faucial pillars, tongue, epiglottis and cricopharyngeous. <ref name=":7" />
* Provides images from the sagittal, coronal and axial planes: <ref name=":7" />
** sagittal plane: posterior movement of tongue and its compression on soft palate, elevation of hyoid bone, elevation of larynx and lid action of epiglottis
** coronal plane: the symmetrical movements of the faucial pillars and pharyngeal constrictor muscles
** axial plane: assessing three anatomical landmarks based on their role in swallowing: soft palate,  epiglottis and cricopharyngeous muscle.


=== Resources ===
=== Resources ===

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Introduction[edit | edit source]

Dysphagia screening and assessment helps with early identification, management, prevention and mitigation of complications related to swallowing difficulties. It facilitates optimisation of nutritional support and can enhance patient overall health outcomes. However, according to Freeman-Sanderson et al.[1] only thirty percent of practitioners working on the ICU complete a formal dysphagia training and administration of dysphagia protocol. A competency training in dysphagia screening for healthcare practitioners can benefit patients with neurological disorders, cardiopulmonary diseases, gastrointestinal diseases, and patients post endotracheal intubation or tracheostomy who are often affected by oropharyngeal dysphagia. [2] Donovan et al.[3] supports screening dysphagia tests conducted by various healthcare professionals to accelerate the screening process of patients with acute stroke, and stated that the "absence of consensus on the best screening instrument does not mean no screening should be performed."[3] This article discusses most common non-instrumental and instrumental assessments of dysphagia.

Dysphagia Screening[edit | edit source]

Two general types of dysphagia screening and assessments are currently available : non-instrumental and instrumental. Non-instrumental tests include dry swallowing test, water swallowing test, the 3-ounce water swallow test, cough reflex test, and bedside swallowing evaluation. Instrumental examinations include Videofluoroscopic Swallow Study (VFSS) and Fiberoptic Endoscopic Evaluation of Swallowing (FEES). The instrumental assessments are not always available, accessible, or feasible.[4]

For a patient who experiences dysphagia, the first and the most important step is selecting the appropriate test to perform.

Patient History[edit | edit source]

When taking the patient's history the following standardised tools can be helpful:[5]

  • Eating Assessment Tool 10 (EAT 10)
    • It is used to screen for dysphagia and aspiration risk
    • Can be completed by the patient, caregiver, or during an interview with a clinician
    • Each question is rated on a scale of 0 (no problem) to 4 (severe problem)
    • See Eating Assessment Tool 10 (EAT 10) here
  • Dysphagia Handicap Index (DHI)
    • Completed by the patient
    • Self-assessment questionnaire
    • Includes 25 statements to assess functional, physical, and emotional aspects of life of the patients with dysphagia
    • See Dysphagia Handicap Index (DHI) form here

Observation[edit | edit source]

All rehabilitation professionals should become competent to perform this part of the dysphagia evaluation. Key observation points in the evaluation of the patient with dysphagia include (1) general health status, including body mass index, (2) posture, (3) oral-motor skills, (4) inspection of oral cavity for oral cavity ulcerations, exophytic growths, abnormal motion of the palate, mucosal drying, tongue appearance and motion, and dental status, (5) nasal evaluation to rule out local tumours or postnasal drip.[6][7]

Palpation[edit | edit source]

Examination[edit | edit source]

General Rules[edit | edit source]

Non-instrumental Dysphagia Tests[edit | edit source]

Dry Swallowing[edit | edit source]

Water Swallowing Test[edit | edit source]

Modified Water Swallowing Test[edit | edit source]

Bedside Swallowing Evaluation (BSE)[edit | edit source]

  • Completed by the speech language pathologists (SLPs)
  • Assess swallowing function and airway safety during swallowing[8]
  • Helps to identify the risk of aspiration [8]
  • Used by SLPs to provide feeding recommendations
  • According to Moss et al.[8], "BSEs are relatively inaccurate for the detection of aspiration"

Standardised Protocol for BSE evaluation include the following elements:[8]

  • review of the patient’s medical record
  • physical examination:
    • lip movement and seal
    • tongue movement and strength
    • volitional cough strength
    • dentition
    • voice quality
    • amount of assistance required with feeding
  • patient is positioned as upright as possible
  • The SLP administered five standard consistencies: (1) ice chips, (2) nectar thin liquids, (3) pureed solids , (4) thin liquids, and (5) solids in successive boluses that increased in size
  • The SLP administers all boluses unless they consider it unsafe based on the patient's response
  • The SLP observes for five clinical signs for aspiration after each bolus: cough, throat clearing, change in vocal quality, wet breath sounds, or stridor.

Cough Reflex Test (CRT)[edit | edit source]

  • Administered by the speech language pathologists (SLPs)
  • It is a screening tool to evaluate the integrity of the cough response to airway invasion. [9]
  • Evaluates risk of silent aspiration because it provides information about the integrity of upper airway sensation which is one of the factors contributing to patients’ risk of silent aspiration.[9]
  • Patient inhales of a cough evoking mist of citric acid–physiological saline via a nebulizer to induce coughing. [9]
  • Clinicians record presence, absence and number of coughs elicited, and self-reported ratings of the perceived intensity of airway irritation (the urge-to-cough).[9]
  • CRT's methodology and protocols lack consensus in the literature.[10]

Instrumental[edit | edit source]

Videofluoroscopic Swallow Study (VFSS)[edit | edit source]

Videofluoroscopic swallow study is also known as modified barium swallowing test (MBST) and is considered the gold standard in diagnosing oropharyngeal dysphagia. [11]

  • Performed by experienced SLPs with radiologist or medical radiological technologist.[12]
  • May require advanced competency certification in Videofluoroscopic Assessment of Adult Swallowing Disorders.[12]
  • It is a radiographic assessment of swallowing.[12]
  • It should be "custom-tailored technique designed by radiologists and swallowing therapists on the basis of the patient’s clinical history and symptoms."[13]
  • A physician’s order is required to initiate a VFSS.[12]
  • A clinical swallow assessment must be completed before a VFSS is administered.[12]

Fiberoptic Endoscopic Evaluation of Swallowing (FEES)[edit | edit source]

  • Administered by SLPs trained in FEES examination.
  • Because it requires professionals to perform the test, the test might not be feasible for community screening.[14]
  • Fiber-optic or distal chip endoscopes are used for the evaluation.
  • The endoscope is inserted through the nose to observe the pharynx and larynx when the individual is swallowing saliva with and without food of varying consistencies. [14]
  • May induce pain and discomfort.[14]
  • Every institution must develop protocol for FEES administration.
  • Video and sound is recorded and use to determine a penetration-aspiration scale (PAS) score for each of the boluses administered:
    • PAS is an 8-point, equal-appearing interval scale describing penetration and aspiration events: [15]
      • score of 6 or more indicates aspiration
      • score of 6 or 7 indicates nonsilent aspiration
      • score of 8 represents silent aspiration

High-Resolution Pharyngneal Manometry (HRPM)[edit | edit source]

  • Performed by a Speech-Language Pathologists (SLPs) with proper training in HRPM
  • It helps to understand the mechanism of oropharyngeal dysphagia. [11]
  • It identifies individuals at risk for dysphagia in a neurological disorder like Parkison’s disease.[16]
  • It defines pharyngeal lumen occlusive pressures, hypopharyngeal intrabolus pressures, and upper esophageal sphincter (UES) function. [11]
  • Can be performed without ingesting any barium bolus. [11]
  • It is a safe assessment for dysphagia patients at high risk of aspiration.[11]
  • It detects changes in swallowing-related pressures in patients with early Parkinson's disease before the onset of dysphagia's signs and symptoms.[11]

Barium Swallow[edit | edit source]

  • The examination is performed by a radiologist
  • Barium swallow or oesophagogram is the gold standard test in assessing the anatomical characteristic of oesophagus. [7]
  • Evaluates esophageal dysphagia using real-time fluoroscopy and barium.
  • Can help to identify any morphologic and motility abnormalities in the pharynx and esophagus.
  • Rarely used as a stand-alone investigation

Ultrasound[edit | edit source]

  • Can be performed by highly skilled SLPs, who completed competency to achieve independent practitioner status. [17]
  • Allows visualisation of soft tissue structures of the mouth (tongue and floor of the mouth). [18]
  • Assess swallowing kinematics of the tongue, hyoid, larynx, and lateral pharyngeal wall.[19]
  • Assess the hyoid bone displacement during swallowing.[20]
  • Allows morphometric assessment (measurements of muscle thickness or cross-sectional area) of muscle groups related to swallowing, such as the tongue, masseter, and submental muscles .
  • Less invasive than VFSS or FEES

Real-Time Magnetic Resonance Imaging (RT-MRI)[edit | edit source]

  • RT-MRI is performed by a radiologist or a radiology technologist
  • No radiation exposure.[21]
  • Assess symmetry and amplitude of movements of velum, faucial pillars, tongue, epiglottis and cricopharyngeous. [21]
  • Provides images from the sagittal, coronal and axial planes: [21]
    • sagittal plane: posterior movement of tongue and its compression on soft palate, elevation of hyoid bone, elevation of larynx and lid action of epiglottis
    • coronal plane: the symmetrical movements of the faucial pillars and pharyngeal constrictor muscles
    • axial plane: assessing three anatomical landmarks based on their role in swallowing: soft palate, epiglottis and cricopharyngeous muscle.

Resources[edit | edit source]

  • bulleted list
  • x

or

  1. numbered list
  2. x

References[edit | edit source]

  1. ↑ Freeman-Sanderson A, Hemsley B, Thompson K, Rogers KD, Knowles S, Hammond NE. Dysphagia in adult intensive care patients: Results of a prospective, multicentre binational point prevalence study. Australian Critical Care. 2023 Nov 1;36(6):961-6.
  2. ↑ Hsiao MY, Wu CH, Wang TG. Emerging Role of Ultrasound in Dysphagia Assessment and Intervention: A Narrative Review. Front Rehabil Sci. 2021 Aug 11;2:708102.
  3. ↑ 3.0 3.1 Donovan NJ, Daniels SK, Edmiaston J, Weinhardt J, Summers D, Mitchell PH; American Heart Association Council on Cardiovascular Nursing and Stroke Council. Dysphagia Screening: State of the Art. Invitational conference proceeding from the State-of-the-Art Nursing Symposium, International Stroke Conference 2012. Stroke. 2013 Apr;44(4):e24-31.
  4. ↑ Demetriou M, Georgiou AM. Perspective on dysphagia screening, assessment methods, and protocols in intensive care units: an opinion article. Front Hum Neurosci. 2024 Apr 9;18:1375408.
  5. ↑ Jamróz B, Pabian M, Chmielewska, Milewska M, Niemczyk K. Screening tests for dysphagia. Polish Otorhinolaryngology Review Pol Otorhino Rev 2017; 6(4).
  6. ↑ Karkos PD, Papouliakos S, Karkos CD, Theochari EG. Current evaluation of the dysphagic patient. Hippokratia. 2009 Jul;13(3):141-6.
  7. ↑ 7.0 7.1 Banerjee S. Assessment of Dyshagia. Plus course 2024
  8. ↑ 8.0 8.1 8.2 8.3 Moss M, White SD, Warner H, Dvorkin D, Fink D, Gomez-Taborda S, Higgins C, Krisciunas GP, Levitt JE, McKeehan J, McNally E, Rubio A, Scheel R, Siner JM, Vojnik R, Langmore SE. Development of an Accurate Bedside Swallowing Evaluation Decision Tree Algorithm for Detecting Aspiration in Acute Respiratory Failure Survivors. Chest. 2020 Nov;158(5):1923-1933.
  9. ↑ 9.0 9.1 9.2 9.3 Wallace ES, Huckabee M-I, Macrae P. Cough Reflex Testing in Clinical Dysphagia Practice. Advances in Communication and Swallowing 2022; 25(2):73-81.
  10. ↑ Trimble J, Patterson J. Cough reflex testing in acute stroke: A survey of current UK service provision and speech and language therapist perceptions. Int J Lang Commun Disord. 2020 Nov;55(6):899-916.
  11. ↑ 11.0 11.1 11.2 11.3 11.4 11.5 Ghazanfar H, Shehi E, Makker J, Patel H. The Role of Imaging Modalities in Diagnosing Dysphagia: A Clinical Review. Cureus. 2021 Jul 31;13(7):e16786.
  12. ↑ 12.0 12.1 12.2 12.3 12.4 Manitoba Clinical Guideline. Videofluoroscopic study-Adults.(2017). Available from https://wrha.mb.ca/files/slp-guideline-vfss.pdf [last access 18.6.2024]
  13. ↑ Carbo AI, Brown M, Nakrour N. Fluoroscopic Swallowing Examination: Radiologic Findings and Analysis of Their Causes and Pathophysiologic Mechanisms. Radiographics. 2021 Oct;41(6):1733-1749.
  14. ↑ 14.0 14.1 14.2 Lim HJ, Lai DK, So BP, Yip CC, Cheung DSK, Cheung JC, Wong DW. A Comprehensive Assessment Protocol for Swallowing (CAPS): Paving the Way towards Computer-Aided Dysphagia Screening. Int J Environ Res Public Health. 2023 Feb 8;20(4):2998.
  15. ↑ Rosenbek JC, Robbins JA, Roecker EB, Coyle JL, Wood JL. A penetration-aspiration scale. Dysphagia. 1996 Spring;11(2):93-8.
  16. ↑ Omari TI, Ciucci M, Gozdzikowska K, Hernández E, Hutcheson K, Jones C, Maclean J, Nativ-Zeltzer N, Plowman E, Rogus-Pulia N, Rommel N, O'Rourke A. High-Resolution Pharyngeal Manometry and Impedance: Protocols and Metrics-Recommendations of a High-Resolution Pharyngeal Manometry International Working Group. Dysphagia. 2020 Apr;35(2):281-295.
  17. ↑ Martin K. Special issue on education and training in ultrasound. Ultrasound. 2015 Feb;23(1):5.
  18. ↑ Allen JE, Clunie GM, Winiker K. Ultrasound: an emerging modality for the dysphagia assessment toolkit? Curr Opin Otolaryngol Head Neck Surg. 2021 Jun 1;29(3):213-218.
  19. ↑ Hsiao MY, Wahyuni LK, Wang TG. Ultrasonography in assessing oropharyngeal dysphagia. Journal of Medical Ultrasound. 2013 Dec 1;21(4):181-8.
  20. ↑ Chen YC, Hsiao MY, Wang YC, Fu CP, Wang TG. Reliability of Ultrasonography in Evaluating Hyoid Bone Movement. J Med Ultrasound. 2017 Apr-Jun;25(2):90-95.
  21. ↑ 21.0 21.1 21.2 Vijay Kumar KV, Shankar V, Santosham R. Assessment of swallowing and its disorders-a dynamic MRI study. Eur J Radiol. 2013 Feb;82(2):215-9.
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