The Neuroscience on the Web Series:
CMSD 642 Neuropathologies of Swallowing and Speech

CSU, Chico, Patrick McCaffrey, Ph. D


Chapter 6. The Diagnosis of Dysphagia
(Cherney, Pannell, and Cantieri, 1994, Logemann, 1989, 1997, Langmore, 2009, Leder, 2011)


Bed-side evaluation (simulation)

Do an oral peripheral examination. Look for strength, range of motion, and symmetry of structures. Also note any drooling as well as the patient's dentition.

    1. According to Leder et.al. 2011 one can give patients 3 ounces of water to identifiy those who can be advanced to an oral diet including thin liquids.

    2. If the patient can phonate, note the strength and quality of the voice. If the voice is hoarse, this suggest that the vocal folds are not adducting completely. If the voice sounds "wet' or "gurgly," saliva may be pooling in the larynx. (A patient may aspirate his/her own secretions.) How long can the patient sustain phonation? Also, note the patient's articulation. If it is good, this bodes well for swallowing.

    3. Listen to the patient's voluntary cough. If it is weak, this is another indicator of poor vocal fold adduction.

    4. Examine chewing. Use a roll of gauze that has been dipped in a good-tasting liquid. Check chewing on both sides of the mouth.

    5. Check the palatal reflex by stimulating the anterior surface of the velum. It should elevate and retract, closing against the pharyngeal wall.

    6. Check tactile sensation in the oral cavity. (Food should be presented to areas where sensation is most intact.)

    7. Check the dry swallow. This is a test for apraxia of the swallow. You can also note laryngeal excursion by placing your fingers on the larynx and hyoid bone.

    8. Be careful when you check the gag reflex. Although it does not predict the status of the swallow a reduced or absent gag does indicate neurological dysfunction. If the patient vomits, he/she may aspirate the regurgitated food.

    9. Note attentional abilities. How alert are they? Can they use compensatory strategies? Can they cooperate with a radiographic exam?

Radiographic studies (simulation)

The use of radiographic techniques provides a direct view of events in the oral cavity and the pharynx. The procedure used to image the swallowing process is a modified barium swallow, not a true barium swallow. A true barium swallow is used to view the esophagus, which is collapsed unless a bolus is moving through it. It is also used to view the stomach. The patient drinks a barium milkshake which coats the esophagus and the stomach lining. (Barium is not radioactive; it is a contrast material).

In a modified barium swallowing study, the patient consumes foods of varying consistencies that have been coated with barium. Usually, the patient swallows a liquid of water-like consistency. This kind of material may be aspirated if there are swallowing problems, but it will not block the airway. The patient may drink straight from a cup. Drinking from a straw is the easier of the two. If it can be done safely, the patient also swallows food with a paste-like consistency and a cookie or bread during the radiographic study. Logemann (1989) particularly likes the Lorna Doone cookies.

It is a good idea to experiment with different food consistencies and with compensatory postures during the radiographic studies. This allows you to see exactly what is happening when each one is used and helps you to decide what will help the patient the most. If the patient is cognitively intact, you can also try out some airway closure techniques like the supraglottic swallow during the study. Logemann (1989, 1997) recommends checking for the "dry swallow" during radiographic studies. When there is still food left in the pharynx after a swallow, does the patient realize this and swallow again?

Sometimes it is helpful to have family members watch the study. This will help them to understand why the patient is NPO or on a special diet and they will not be inclined to bring the patient food that violates his dietary restrictions. Many family members feel that water is harmless. This is not so. A good number of patients aspirate thin liquids (Cherney, 1994; Logemann, 1989).

Other procedures include videonasendoscopy (fiberoptics), manometry (measures pressure), ultrasound (imaging technique), ultrafast computerized tomography, scintigraphy (radioactive liquid, galium, is swallowed), and electromyography (examines muscle tissue).

Susan E. Langmore, 2009) writes about another procedure for direct assessment of the swallow is FEES: flexible endoscopic evaluation of the swallow. FEES isa non-radioactive alternnative to modified barium swallow studies. FEES will permit direct assessment of the sensory and moter aspects of the swallow in order to guide the dietary management of patients' swallowing problems to decrease the risk od aspiration pneumonia. Velopharyngeal closure, anatomy of the base of the tongue and hypopharynx, abduction and adduction of the vocal folds, pharyngeal musculature and the ability of patients to manage their own secretions are assessed. FEES also permits evaluation of gastro-esophageal reflux.

http://www.asha.org/slp/clinical/dysphagia/talking_points_endoscopy


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Other courses in the Neuroscience on the Web series:
CMSD 620 Neuroanatomy | CMSD 636, Neuropathologies of Language and Cognition

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