Dysphagia readings: Assessment

Huckerbee Ch4

·       No clear association between the site of lesion and dysphagia presentation.

·       Dysphagia occurs in a high proportion of stroke patients (30%?)

·       Clinical swallowing examination is therefore the first step in evaluating all stroke patients.

Patient History

·       Medical History form patient records – medical charts, : Stroke onset, characteristics and complications associated with stroke (e.g. intubation).

·       History of dysphagia – do they have this?

·       Patient interview – rehabilitation setting will warrant a lengthier interview than acute. Find out if swallowing has changed, if different on different consistencies. Initially open ended – may ask more closed questions if the patient has cognitive/comm. Diff.

·       Less than 50% of stroke patients are aware of dysphagia symptoms – limitations of interview.

Groher CH 7

Clinical examination of swallowing (CED) = description of problem, health history, clinical observations and a physical examination.

Warning signs (dysphagia likely):

1.     Confused mental state – may be difficulties with the eating process since requires planning + judgement e.g. speaking while eating, going too quickly, large bolus’.

2.     Dysarthria (slow, labored, slurred articulation, nasal emission, hoarse/breathy voice) = due to inherent weakness/ incoordination of muscles common to swallowing.

3.     Excessive drooling (sialorrhea) – due to motor/sensory impairments of swallowing mechanism.

4.     Frequent coughing episodes – sign of potential aspiration – i.e. pooling into the airway.(protective mechanism to prevent aspiration). – no cough reflex = sign that most foods may be unsafe unless the patient is dysphraxic + has no voluntary cough.

5.     Weightloss

6.     Complaints of pain/ obstruction – common complaint of those with neurologic condition resulting in muscle weakness/ incoordination + those with oesophageal motility disorders. Cricopharyngeal dysfunction – often point to the thyroid cartilage level. Pooling in valleculae/ pyriforms – may point to area adjacent to the larynx. Timing – if early – may be oropharyngeal – if later – oesophageal problem.

7.     History of pneumonia – may be associated with neuromuscular incoordination, weakness of the oropharyngeal swallowing mechanism or esophageal dysfunction.

Clinical observations

·       Mental status –

·       Physical examination:

·       Voice and speech – e.g. ability to sustain a vowel (quality,pitch, intensity) – Hyper-nasality suggests impaired palatopharyngeal function.

·       Weight – nutrition?

·       Muscles of facial expression

·       Muscles of mastication – masseter is the largest (inserts into the mandible), temporalis -  jaw up/ forward/back.

·       Pathologic reflexes e.g. brainstem reflexes – normally inhibited in adults e.g. the bite reflex – often elicited in those with severe neurologic lesions by touching the tongue, teeth or lips with a tongue blade.

·       Oral mucosa – moisture?

·       Dentition

·       Gag reflex – very variable – diminished reflex is  significant in patients with weakened pharyngeal musculature

·       Tongue – coordinated interaction between the tongue and the pharyngeal muscles propels the bolus. Look for atrophy, fasciculations or abnormal reflexes.

·       Sensation – chewing/saliva flow and swallowing = reflexes depending on sensation.

Swallow summary

1.     Bolus moved into the oropharynx by lip/tongue/cheek muscles

2.     Swallow reflex initiated

3.     Muscles suspending the larynx contract – larynx moves up so that the epiglottis can go down into the base of tongue (covering airway).

4.     Pharyngeal constrictors move the bolus towards the cricopharyngeal sphincter muscle. Which opens allowing the bolus to travel to the oesophagus.

Swallowing Assessment

·       Swallowing reflexes are subject to warm up and fatigue.

·       Aspiration is difficult to evaluate – listen for air mixing with liquid as a sign of aspiration. Change in face colour, gurgily breath signs, breathiness or loss of voice may indicate acute aspiration

·       Examine the oral cavity for residue.

·       Ice chips = safe + give sensory stimulus

Logemann chapter 5

Oral –motor control examination

·       Evaluation of the range rate and accuracy of movements of the lips, tongue, soft palate and pharyngeal walls during speech, reflexive activity and swallowing.

·       Swallowing apraxia – usually perform best when no swallowing instructions are given

·       Labial function - /i/ /u/ alternately, drooling/ anterior loss?

·       Tongue – touch mouth corners/ lips + then rapid tongue movement. Posterior tongue function (tongue base) – get patient to say /k/ + repeat /ka/ (DDK).

·       Soft palate – ask patient to produce a strong loud ‘ah’ and to sustain this for a few seconds.

·       Oral sensation  - use an oral sponge – ask the patient if everywhere feels the same

Laryngeal examination

·       Voice quality – gurgily voice = associated with aspiration, hoarsness – may indicate reduced laryngeal closure – cough reflex (although voluntary cough doesn’t mean the patient will have a reflexive cough).

·       Ability to change pitch – pharyngeal swallow + cough reflex may arise from the superior laryngeal nerve – therefore inability to change pitch implies reduced sensitivity around the larynx. Phonation time tasks – info on laryngeal control – e.g. /z/ prolong a /z/ as long as possible. Phonation time = also a test of respiration.

The Swallowing Examination

Observations during swallowing trial

·       Hand under the patients’ chin with fingers spread and in light contact: index finger behind mandible, middle finger on hyoid, little finger at the bottom of the thyroid cartilage.

·       Feel for: tongue movement, hyoid movement, and laryngeal movement. Compare the time between the initiation of tongue movement and the initiation of hyoid/ laryngeal movement.

·       Can’t assess what is occurring physiologically.

·       Ask patient to say ‘ah’ after swallowing – listen to vocal quality. (however consider silent aspiration, potentially 50%).

·       Ask patient to pant + turn head to either side after swallowing – material dislodged from the pharyngeal recesses – and then say ‘ah’.

·       Use small amounts of material

·       If swallow strategies are not feasible – modify consistencies.