The Clinical Assessment of Swallowing Disorders
- The clinical evaluation of dysphagia typically begins with a non-instrumental clinical examination. This initial evaluation will include a careful review of the patient’s history, evaluation of the strength, range of motion and coordination of the muscles involved in swallowing, and may entail observation of the patient eating and drinking.
- In addition, instrumental assessment of swallowing (Videofluoroscopic Swallow Study and/or Fiberoptic Endoscopic Evaluation of Swallowing) is/are required to completing the oro-pharyngeal swallowing disorders management.
- The Videofluoroscopic Swallowing Study (VFSS) is a dynamic radiographic study. The examination images oral, pharyngeal, and cervical-esophageal bolus flow during swallowing mechanism. Anatomic and/or physiologic abnormalities are identified relative to swallowing. During the study, the effects of modifications in bolus size, bolus texture, patient positioning, compensatory maneuvers, and sensory enhancement techniques on bolus flow are evaluated to determine optimum swallow safety and efficiency.
- In addition, using of Fiberoptic Endoscopic for Evaluation of Swallowing (FEES) instrumentation allows inspection of functions of the swallowing mechanism at the velopharynx, oropharynx, pharynx, and larynx. Endoscopic assessment of swallowing function is not a screening examination but a comprehensive assessment of the upper aerodigestive functions of swallowing. It includes five components:
- Assessment of anatomy involved in the pharyngeal stage of swallowing.
- Assessment of movement and sensation of critical structures within the pharynx.
- Assessment of secretions.
- Direct assessment of swallowing function for food and liquid, and response to therapeutic maneuvers and interventions to improve the swallow.
The purpose of these procedures is the comprehensive evaluation of the swallowing phases to obtain a detailed analysis of the patient’s oropharyngeal swallowing mechanism, correlate these findings with the patient’s dysphagia symptoms. Consequently, the physician will approach care of plan and recommendations regarding the adequacy of the swallow, the advisability of oral feeding, and the use of appropriate interventions to facilitate safe and efficient swallowing.
Fiberoptic Endoscopic Evaluation of Swallowing (FEES)
Fiberoptic endoscopic assessment of swallowing functions is gaining widespread use as an instrumental procedure among speech-language pathologists who engage in the clinical management of dysphagia. FEES is used to evaluate any structural abnormalities in the nasopharynx, laryngopharynx, and hypopharynx, especially in patients who cannot be transported to the radiology suite for the VFSS.
Use of fiberoptic endoscopic instrumentation allows inspection of functions of the swallowing mechanism at the velopharynx, oropharynx, pharynx, and larynx. Endoscopic assessment of swallowing function is not a screening examination but a comprehensive assessment of the upper aerodigestive functions of swallowing. It includes five components:
- assessment of anatomy involved in the pharyngeal stage of swallowing,
- assessment of movement and sensation of critical structures within the pharynx,
- assessment of secretions,
- direct assessment of swallowing function for food and liquid, and
- response to therapeutic maneuvers and interventions to improve the swallow.
The FEES Procedure:
The purpose of the procedure is the comprehensive evaluation of the pharyngeal stage of swallowing, leading to recommendations regarding the adequacy of the swallow, the advisability of oral feeding, and the use of appropriate interventions to facilitate safe and efficient swallowing. It will assess several indicators of abnormal oropharyngeal swallow:
- premature spillage into the hypopharynxlaryngeal vestibule prior to swallowing;
- ability of the vocal folds to adduct during coughing, breath holding, and swallowing;
- presence of residue in the hypopharynx and laryngopharynx after a swallow; and
- presence of supraglottic laryngeal penetration or subglottic aspiration.
These observations can be made when optimal imaging conditions are present (satisfactory equipment, no excess fogging of endoscope tip by secretions, etc.), and the patient has an anatomical configuration which allows for complete visualization of the vocal cords. The study can be videotaped to optimize clinical use and interpretation.
Videofluoroscopy Swallowing Study (VFSS)
A videofluorographic swallowing study is particularly useful for identifying the pathophysiology of a swallowing disorder and for empirically testing therapeutic and compensatory techniques. It has another name that is Modified Barium Swallow (MBS).
The purpose of the test is:
- to examine swallowing function,
- to identify dysfunction and provide some clues as to why these dysfunctions are present,
- to identify the presence and severity of aspiration, and
- to helps determine whether different diets or certain swallowing strategies may improve the efficiency and safety of the swallow.
The VFSS Procedure:
- MBS is conducted by a Speech Pathologist in a radiology fluoroscopy suite using standard procedures for Modified Barium Swallow.
- The patient placed in a chair in a neutral seated position.
- The patient is given different consistencies of food and liquid mixed with barium (5 spoonfuls in 2cc-4cc (1/2 t. – 1 t.) amounts at 4 consistencies and filmed in A/P and/or lateral views) by the speech-language pathologist while the radiologist or technician operates the radiology equipment.
- The whole procedure can take 10 to 20 minutes to complete.
- The equipment records the frames (up to 30 frames per second) either on VHS video or in digital format directly to disc for further analysis and review.
- Both during and after the study, the SLP will formulate and document the impressions about the quality and efficacy of the swallow and about the various normal and abnormal features of the swallow that were visible during the study. The radiologist will either be present during the procedure and formulate and document an opinion immediately or will evaluate the recording later.
- After observing for signs during the MBS, the most critical part starts: the interpretation. The therapist should try to determine the cause or the contributing factor for what is occurring. Is there poor coordination? Is there muscular weakness? Has the patient got difficulty timing the contractions? Are there signs of cricopharyngeal dysfunction? The therapist will not formulate a formal diagnosis but should be able to identify a dysfunction. This dysfunction then becomes the basis for treatment.
- The patient is instructed to swallow while the radiologist or technician attempts to record the swallow as it occurs. Swallows are recorded from mouth to stomach observing for:
- Movement patterns of the bolus through the oral, pharyngeal, and esophageal structures.
- Structural, functional, motility, & abnormalities.
- Swallowing time.