Assessment of Dysphagia

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Introduction

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. 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. Donovan et al. 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." This article discusses most common non-instrumental and instrumental assessments of dysphagia.

Dysphagia Screening

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.

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

Patient History

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

• 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

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 (rotatory chew movement including lateral chew, jaw jerk or suck and swallow as the patient chews), (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.

Palpation

All rehabilitation professionals can complete palpation examination for the neck area. Look for any tenderness, masses or swelling, which can obstruct the flow of the food.

Speech language pathologists use palpation in clinical swallow evaluation. In 4-finger method one finger is placed behind the mandible, one on the hyoid bone and two on the upper and lower borders of the thyroid cartilage:

• It is used to assess submandibular, hyoid and laryngeal movements.
• It offers informations about "when, and how many times the patient has swallowed and a rough estimate of the timing and completeness of the swallow."

General Rules

• If oral hygiene is not good, the evaluation of swallowing function is performed after oral care.

Neurological Assessment

• Assess the state of arousal state and the cognitive performance of the patient.
• Perform sensory examinations:
  • anterior two-thirds of the tongue
  • posterior one-third of the tongue
  • hard palate
  • soft palate
  • posterior pharyngeal wall
  • laryngeal region.

• Complete a gross neurological examination, specifically cranial nerves 9th to 12th.

Non-instrumental Dysphagia Tests

Dry Swallowing Test

All rehabilitation professionals should become competent to perform a dry swallowing test. General steps are as follows:

• Positioned the patient in a comfortable position. It can be preferably sitting with a well-supported back and feet.
• The mouth of the patient can be moistened with cold water.
• Ask the patient to swallow repeatedly.
• Results: during a period of 30 seconds, three or more dry swallows is normal. The test will provide information about laryngeal elevation.

Water Swallowing Test (WST)

• Physicians, nurses, SLPs or qualified clinicians can perform water swallowing test
• It is a standardised test, but the amount of water given varies depending on the person performing the test.
• The patient drinks 30 ml or 100 ml of water as quickly as possible without interruption

Results:

• The examiner observe the number of swallows
• The average bolus size is counted by dividing 100 mL with a number of swallows.
• >20 mL (100 mL completed with less than five swallows) is considered normal

Patients were asked to drink 100 mL of water as quickly as possible without interruption. The number of swallows was observed, and then the average bolus size was counted by dividing 100 mL with a number of swallows. The interpretation >20 mL (100 mL completed with less than five swallows) was considered normal.15 Time from onset of swallowing to completing the drinking process (when the larynx was decreased back to a resting position after the last swallow) was measured in seconds (s), and the swallowing speed (mL/s) was calculated by dividing 100 mL with the drinking time (s).14 Over 10 mL/s was considered normal.12 The WST was considered passed if the patient did not cough during drinking, 1 min after drinking or interrupted drinking (removing the glass from the lips). If a patient coughed during drinking, the time measurement was interrupted immediately, and the swallowing speed was calculated using the amount of water the patient drank before coughing. The parameters of the water test (coughing during drinking, coughing after drinking, possible wet–hoarse voice after drinking, average drinking bolus size, and swallowing speed) were recorded and compared to the VFS results.

Modified Water Swallowing Test (MWST)

• Speech language pathologists or rehabilitation professionals after competency training can perform this test
• MWST contains the following steps:
  • The patient is given 3 ml of cold water in the oral floor, and instructed to swallow the water
  • If possible, the patient is asked to perform 2 dry (saliva) swallows.
  • If the patient meets score 4, a maximum of 2 additional attempts (a total of 3 attempts) is made.
  • The worst assessment is recorded as the final result.

Results:

1. Inability to swallow with choking and/or breathing changes
2. Swallow occurred, but with breathing changes
3. Swallow occurred, but with choking and/or wet hoarseness
4. Swallow successfully
5. Swallow successfully with ability of additional dry swallowing twice in 30s

Bedside Swallowing Evaluation (BSE)

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

Standardised Protocol for BSE evaluation include the following elements:

• 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)

• Administered by the speech language pathologists (SLPs)
• It is a screening tool to evaluate the integrity of the cough response to airway invasion.
• 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.
• Patient inhales of a cough evoking mist of citric acid–physiological saline via a nebulizer to induce coughing.
• Clinicians record presence, absence and number of coughs elicited, and self-reported ratings of the perceived intensity of airway irritation (the urge-to-cough).
• CRT's methodology and protocols lack consensus in the literature.

Instrumental

Videofluoroscopic Swallow Study (VFSS)

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

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

Fiberoptic Endoscopic Evaluation of Swallowing (FEES)

• Administered by SLPs trained in FEES examination.
• Because it requires professionals to perform the test, the test might not be feasible for community screening.
• 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.
• May induce pain and discomfort.
• 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:
    • 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)

• Performed by a Speech-Language Pathologists (SLPs) with proper training in HRPM

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

Barium Swallow

• The examination is performed by a radiologist
• Barium swallow or oesophagogram is the gold standard test in assessing the anatomical characteristic of oesophagus.
• 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

• Can be performed by highly skilled SLPs, who completed competency to achieve independent practitioner status.
• Allows visualisation of soft tissue structures of the mouth (tongue and floor of the mouth).
• Assess swallowing kinematics of the tongue, hyoid, larynx, and lateral pharyngeal wall.
• Assess the hyoid bone displacement during swallowing.
• 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.
• Assess symmetry and amplitude of movements of velum, faucial pillars, tongue, epiglottis and cricopharyngeous.
• Provides images from the sagittal, coronal and axial planes:
  • 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.

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