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
3. Listen to
the patient's voluntary cough. If it is weak, this is
another indicator of poor vocal fold adduction.
chewing. Use a roll of gauze that has been dipped in a
good-tasting liquid. Check chewing on both sides of the
5. Check the
palatal reflex by stimulating the anterior surface of the
velum. It should elevate and retract, closing against the
tactile sensation in the oral cavity. (Food should be
presented to areas where sensation is most
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.
attentional abilities. How alert are they? Can they use
compensatory strategies? Can they cooperate with a
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
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
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).
include videonasendoscopy (fiberoptics), manometry (measures
pressure), ultrasound (imaging technique), ultrafast
computerized tomography, scintigraphy (radioactive liquid,
galium, is swallowed), and electromyography (examines muscle
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.