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Clinical Evaluation of Patients with Dysphagia: Importance of History Taking and Physical Exam

Chapter

Abstract

Assessment of dysphagia may include instrumental or non-instrumental measures—frequently both. The clinical evaluation is a collection of, largely, non-instrumental measures, which may include a comprehensive history, a detailed oral motor and sensory physical exam, and trial swallows of liquids and foods. Each aspect of the clinical evaluation serves a unique purpose yet contributes to a more comprehensive understanding of the swallowing problem. The findings from the clinical evaluation provide information about a patient’s functional feeding and swallowing behaviors and determine the need for therapeutic intervention and/or additional instrumental testing. Patients at risk for dysphagia, and thus in need of a clinical evaluation, can be determined from screening. This chapter will describe each aspect of the clinical evaluation and screening and provide the value of each.

Keywords

Motor Neuron Disease Lower Motor Neuron Tongue Pressure Laryngeal Elevation Speech Language Pathologist 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.

References

  1. 1.
    Martino R, Foley N, Bhogal S, Diamant N, Speechley M, Teasell R. Dysphagia after stroke: incidence, diagnosis, and pulmonary complications. Stroke. 2005;36:2756–63.PubMedCrossRefGoogle Scholar
  2. 2.
    Cavalot AL, Ricci E, Schindler A, Roggero N, Albera R, Utari C, et al. The importance of preoperative swallowing therapy in subtotal laryngectomies. Otolaryngol Head Neck Surg. 2009;140:822–5.PubMedCrossRefGoogle Scholar
  3. 3.
    Rihn JA, Kane J, Albert TJ, Vaccaro AR, Hilibrand AS. What is the incidence and severity of dysphagia after anterior cervical surgery? Clin Orthop Relat Res. 2011;469:658–65.PubMedCrossRefGoogle Scholar
  4. 4.
    Miller N, Allcock L, Hildreth AJ, Jones D, Noble E, Burn DJ. Swallowing problems in Parkinson disease: frequency and clinical correlates. J Neurol Neurosurg Psychiatry. 2009;80:1047–9.PubMedCrossRefGoogle Scholar
  5. 5.
    Langmore SE, Kasarskis EJ, Manca ML, Olney RK. Enteral tube feeding for amyotrophic lateral sclerosis/motor neuron disease. Cochrane Database Syst Rev. 2006;(4):CD004030.Google Scholar
  6. 6.
    Thomas FJ, Wiles CM. Dysphagia and nutritional status in multiple sclerosis. J Neurol. 1999;246:677–82.PubMedCrossRefGoogle Scholar
  7. 7.
    Skoretz SA, Flowers HL, Martino R. The incidence of dysphagia following endotracheal intubation: a systematic review. Chest. 2010;137:665–73.PubMedCrossRefGoogle Scholar
  8. 8.
    Platteaux N, Dirix P, Dejaeger E, Nuyts S. Dysphagia in head and neck cancer patients treated with chemoradiotherapy. Dysphagia. 2010; 25:139–52.Google Scholar
  9. 9.
    Martino R, Silver F, Teasell R, Bayley M, Nicholson G, Streiner DL, et al. The Toronto Bedside Swallowing Screening Test (TOR-BSST©): development and validation of a dysphagia screening tool for patients with stroke. Stroke. 2009;40:555–61.PubMedCrossRefGoogle Scholar
  10. 10.
    Streiner DL. Diagnosing tests: using and misusing diagnostic and screening tests. J Pers Assess. 2003;81:209–19.PubMedCrossRefGoogle Scholar
  11. 11.
    Hinchey JA, Shephard T, Furie K, Smith D, Wang D, Tonn S. Formal dysphagia screening protocols prevent pneumonia. Stroke. 2005;36:1972–6.PubMedCrossRefGoogle Scholar
  12. 12.
    Lindsay PBP, Bayley MM, Hellings CB, Hill MMM, Woodbury EBM, Phillips SM. Canadian best practice recommendations for stroke care (Updated 2008). CMAJ. 2008;179:E1–93.CrossRefGoogle Scholar
  13. 13.
    Duncan PW, Zorowitz R, Bates B, Choi JY, Glasberg JJ, Graham GD, et al. Management of adult stroke rehabilitation care: a clinical practice guideline. Stroke. 2005;36:e100–43.PubMedCrossRefGoogle Scholar
  14. 14.
    Intercollegiate Stroke Working Party. National clinical guidelines for stroke. London: Royal College of Physicians; 2004.Google Scholar
  15. 15.
    National Stroke Foundation. Clinical guidelines for acute stroke management. Melbourne, Australia: National Stroke Foundation; 2007Google Scholar
  16. 16.
    Martino R, Pron G, Diamant NE. Screening for oropharyngeal dysphagia in stroke: insufficient evidence for guidelines. Dysphagia. 2000;15:19–30.PubMedGoogle Scholar
  17. 17.
    Perry L. Screening swallowing function of patients with acute stroke. Part one: identification, implementation and initial evaluation of a screening tool for use by nurses. J Clin Nurs. 2001;10:463–73.PubMedCrossRefGoogle Scholar
  18. 18.
    Bours GJ, Speyer R, Lemmens J, Limburg M, de Wit R. Bedside screening tests vs. videofluoroscopy or fibreoptic endoscopic evaluation of swallowing to detect dysphagia in patients with neurological disorders: systematic review. J Adv Nurs. 2009;65:477–93.PubMedCrossRefGoogle Scholar
  19. 19.
    Lam K, Lam FK, Lau KK, Chan YK, Kan EY, Woo J, et al. Simple clinical tests may predict severe oropharyngeal dysphagia in Parkinson’s disease. Mov Disord. 2007;22:640–4.PubMedCrossRefGoogle Scholar
  20. 20.
    Clave P, Arreola V, Romea M, Medina L, Palomera E, Serra-Prat M. Accuracy of the volume-viscosity swallow test for clinical screening of oropharyngeal dysphagia and aspiration. Clin Nutr. 2008;27:806–15.PubMedCrossRefGoogle Scholar
  21. 21.
    Nathadwarawala KM, Nicklin J, Wiles CM. A timed test of swallowing capacity for neurological patients. J Neurol Neurosurg Psychiatry. 1992;55:822–5.PubMedCrossRefGoogle Scholar
  22. 22.
    Suiter DM, Leder SB. Clinical utility of the 3-ounce water swallow test. Dysphagia. 2008;23:244–50.PubMedCrossRefGoogle Scholar
  23. 23.
    Manor Y, Balas M, Giladi N, Mootanah R, Cohen JT. Anxiety, depression and swallowing disorders in patients with Parkinson’s disease. Parkinsonism Relat Disord. 2009;15:453–6.PubMedCrossRefGoogle Scholar
  24. 24.
    Barker J, Martino R, Reichardt B, Hickey EJ, Ralph-Edwards A. Incidence and impact of dysphagia in patients receiving prolonged endotracheal intubation after cardiac surgery. Can J Surg. 2009;52:119–24.PubMedGoogle Scholar
  25. 25.
    Platteaux N, Dirix P, Dejaeger E, Nuyts S. Dysphagia in head and neck cancer patients treated with chemoradiotherapy. Dysphagia. 2010;25:139–52.PubMedCrossRefGoogle Scholar
  26. 26.
    Ramsey DJ, Smithard DG, Kalra L. Early assessments of dysphagia and aspiration risk in acute stroke patients. Stroke. 2003;34(5):1252–7.PubMedCrossRefGoogle Scholar
  27. 27.
    Mann G. MASA: the Mann assessment of swallowing ability. Clifton Park: Singular; 2002.Google Scholar
  28. 28.
    Crary MA, Mann GD, Groher ME. Initial psychometric assessment of a functional oral intake scale for dysphagia in stroke patients. Arch Phys Med Rehabil. 2005;86:1516–20.PubMedCrossRefGoogle Scholar
  29. 29.
    Martino R, Pron G, Diamant NE. Oropharyngeal dysphagia: surveying practice patterns of the speech-language pathologist. Dysphagia. 2004;19:165–76.PubMedCrossRefGoogle Scholar
  30. 30.
    McCullough GH, Wertz RT, Rosenbek JC, Dinneen C. Clinicians’ preferences and practices in conducting clinical/bedside and videofluoroscopic swallowing examinations in an adult, neurogenic population. Am J Speech Lang Pathol. 1999;8:149–63.Google Scholar
  31. 31.
    Mathers-Schmidt BA, Kurlinski M, Department of Communication S, Disorders WWUBWUSABM-Swe. Dysphagia evaluation practices: inconsistencies in clinical assessment and instrumental examination decision-making. Dysphagia. 2003;18(2):114–25.CrossRefGoogle Scholar
  32. 32.
    Wallace KL, Middleton S, Cook IJ. Development and validation of a self-report symptom inventory to assess the severity of oral-pharyngeal dysphagia. Gastroenterology. 2000;118:678–87.PubMedCrossRefGoogle Scholar
  33. 33.
    Belafsky PC, Mouadeb DA, Rees CJ, Pryor JC, Postma GN, Allen J, et al. Validity and reliability of the eating assessment tool (EAT-10). Ann Otol Rhinol Laryngol. 2008;117:919–24.PubMedGoogle Scholar
  34. 34.
    Cook IJ, Kahrilas PJ. AGA technical review on management of oropharyngeal dysphagia. Gastroenterology. 1999;116:455–78.PubMedCrossRefGoogle Scholar
  35. 35.
    Andrews J. Amyotrophic lateral sclerosis: clinical management and research update. Curr Neurol Neurosci Rep. 2009;9:59–68.PubMedCrossRefGoogle Scholar
  36. 36.
    Calcagno P, Ruoppolo G, Grasso MG, De Vincentiis M, Paolucci S. Dysphagia in multiple sclerosis—prevalence and prognostic factors. Acta Neurol Scand. 2002;105:40–3.PubMedCrossRefGoogle Scholar
  37. 37.
    Gasiorowska A, Fass R. Current approach to dysphagia. Gastroenterol Hepatol. 2009;5:269–79.Google Scholar
  38. 38.
    Mann G, Hankey GJ, Cameron D. Swallowing function after stroke: prognosis and prognostic factors at 6 months [see comments]. Stroke. 1999;30:744–8.PubMedCrossRefGoogle Scholar
  39. 39.
    Gallagher L. The impact of prescribed medication on swallowing: an overview. Perspect Swallow Swallow Disord (Dysphagia). 2010;19:98–102.CrossRefGoogle Scholar
  40. 40.
    Logemann JA. Evaluation and treatment of swallowing disorders. Austin: Pro-Ed; 1998.Google Scholar
  41. 41.
    McCullough GH, Rosenbek JC, Wertz RT, McCoy S, Mann G, McCullough K. Utility of clinical swallowing examination measures for detecting aspiration post-stroke. J Speech Lang Hear Res. 2005;48:1280–93.PubMedCrossRefGoogle Scholar
  42. 42.
    Hughes TAT, Wiles C. Clinical measurement of swallowing in health and in neurogenic dysphagia. Q J Med. 1996;89:109–16.CrossRefGoogle Scholar
  43. 43.
    Lazarus C, Logemann JA, Huang CF, Rademaker AW. Effects of two types of tongue strengthening exercises in young normals. Folia Phoniatr Logop. 2003;55:199–205.PubMedCrossRefGoogle Scholar
  44. 44.
    Yeates EM, Molfenter SM, Steele CM. Improvements in tongue strength and pressure-generation precision following a tongue-pressure training protocol in older individuals with dysphagia: three case reports. Clin Interv Aging. 2008;3:735–47.PubMedGoogle Scholar
  45. 45.
    Hewitt A, Hind J, Kays S, Nicosia M, Doyle J, Tompkins W, et al. Standardized instrument for lingual pressure measurement. Dysphagia. 2008;23:16–25.PubMedCrossRefGoogle Scholar
  46. 46.
    Yoshida M, Kikutani T, Tsuga K, Utanohara Y, Hayashi R, Akagawa Y. Decreased tongue pressure reflects symptom of dysphagia. Dysphagia. 2006;21:61–5.PubMedCrossRefGoogle Scholar
  47. 47.
    McCullough GH, Wertz RT, Rosenbek JC. Sensitivity and specificity of clinical/bedside examination signs for detecting aspiration in adults subsequent to stroke. J Commun Disord. 2001;34:55–72.PubMedCrossRefGoogle Scholar
  48. 48.
    Utanohara Y, Hayashi R, Yoshikawa M, Yoshida M, Tsuga K, Akagawa Y. Standard values of maximum tongue pressure taken using newly developed disposable tongue pressure measurement device. Dysphagia. 2008;23:286–90.PubMedCrossRefGoogle Scholar
  49. 49.
    White R, Cotton SM, Hind J, Robbins J, Perry A. A comparison of the reliability and stability of oro-lingual swallowing pressures in patients with head and neck cancer and healthy adults. Dysphagia. 2009;24:137–44.PubMedCrossRefGoogle Scholar
  50. 50.
    Robbins J, Kays SA, Gangnon RE, Hind JA, Hewitt AL, Gentry LR, et al. The effects of lingual exercise in stroke patients with dysphagia. Arch Phys Med Rehabil. 2007;88:150–8.PubMedCrossRefGoogle Scholar
  51. 51.
    Volonte MA, Porta M, Comi G. Clinical assessment of dysphagia in early phases of Parkinson’s disease. Neurol Sci. 2002;23 Suppl 2:S121–2.PubMedCrossRefGoogle Scholar
  52. 52.
    Mann G, Hankey GJ. Initial clinical and demographic predictors of swallowing impairment following acute stroke. Dysphagia. 2001;16:208–15.PubMedCrossRefGoogle Scholar
  53. 53.
    Pace CC, McCullough GH. The association between oral microorgansims and aspiration pneumonia in the institutionalized elderly: review and recommendations. Dysphagia. 2010;25:307–22.PubMedCrossRefGoogle Scholar
  54. 54.
    Langmore SE, Terpenning MS, Schork A, Chen Y, Murray JT, Lopatin D, et al. Predictors of aspiration pneumonia: how important is dysphagia? Dysphagia. 1998;13:69–81.PubMedCrossRefGoogle Scholar
  55. 55.
    Groher ME, McKaig TN. Dysphagia and dietary levels in skilled nursing facilities. J Am Geriatr Soc. 1995;43:528–32.PubMedGoogle Scholar
  56. 56.
    Chasen M, Bhargava R. A retrospective study of the role of an occupational therapist in the cancer nutrition rehabilitation program. Support Care Cancer. 2010;18:1589–96.PubMedCrossRefGoogle Scholar
  57. 57.
    Murphy BA, Dietrich MS, Wells N, Dwyer K, Ridner SH, Silver HJ, et al. Reliability and validity of the Vanderbilt Head and Neck Symptom Survey: a tool to assess symptom burden in patients treated with chemoradiation. Head Neck. 2010;32: 26–37.PubMedGoogle Scholar
  58. 58.
    Horner J, Massey EW, Riski JE, Lathrop DL, Chase KN. Aspiration following stroke: clinical correlates and outcome. Neurology. 1988;38:1359–62.PubMedCrossRefGoogle Scholar
  59. 59.
    Horner J, Massey EW, Brazer SR. Aspiration in bilateral stroke patients. Neurology. 1990;40:1686–8.PubMedCrossRefGoogle Scholar
  60. 60.
    Daniels SK, Brailey K, Priestly DH, Herrington LR, Weisberg LA, Foundas AL. Aspiration in patients with acute stroke. Arch Phys Med Rehabil. 1998;79:14–9.PubMedCrossRefGoogle Scholar
  61. 61.
    Leder SB. Videofluoroscopic evaluation of aspiration with visual examination of the gag reflex and velar movement. Dysphagia. 1997;12:21–3.PubMedCrossRefGoogle Scholar
  62. 62.
    Linden P, Kuhlemeier KV, Patterson C. The probability of correctly predicting subglottic penetration from clinical observations. Dysphagia. 1993;8:170–9.PubMedCrossRefGoogle Scholar
  63. 63.
    Daniels SK, Ballo LA, Mahoney MC, Foundas AL. Clinical predictors of dysphagia and aspiration risk: outcome measures in acute stroke patients. Arch Phys Med Rehabil. 2000;81:1030–3.PubMedCrossRefGoogle Scholar
  64. 64.
    Logemann JA, Veis S, Colangelo L. A screening procedure for oropharyngeal dysphagia. Dysphagia. 1999;14:44–51.PubMedCrossRefGoogle Scholar
  65. 65.
    Davies AE, Kidd D, Stone SP, MacMahon J. Pharyngeal sensation and gag reflex in healthy subjects. Lancet. 1995;345:487–8.PubMedCrossRefGoogle Scholar
  66. 66.
    Horner J, Buoyer FG, Alberts MJ, Helms MJ. Dysphagia following brain-stem stroke. Arch Neurol. 1991;48:1170–3.PubMedCrossRefGoogle Scholar
  67. 67.
    Schroeder MF, Daniels SK, McClain M, Corey DM, Foundas AL. Clinical and cognitive predictors of swallowing recovery in stroke. J Rehabil Res Dev. 2006;43: 301–10.PubMedCrossRefGoogle Scholar
  68. 68.
    Daniels SK, Schroeder MF, DeGeorge PC, Corey DM, Foundas AL, Rosenbek JC. Defining and measuring dysphagia following stroke. Am J Speech Lang Pathol. 2009;18:74–81.PubMedCrossRefGoogle Scholar
  69. 69.
    DePippo KL, Holas MA, Reding MJ. Validation of the 3-oz water swallow test for aspiration following stroke. Arch Neurol. 1992;49:1259–61.PubMedCrossRefGoogle Scholar
  70. 70.
    Suiter DM, Leder SB, Karas DE. The 3-ounce (90-cc) water swallow challenge: a screening test for children with suspected oropharyngeal dysphagia. Otolaryngol Head Neck Surg. 2009;140:187–90.PubMedCrossRefGoogle Scholar
  71. 71.
    McCullough GH, Wertz RT, Rosenbek JC, Mills RH, Webb WG, Ross KB. Inter- and intrajudge reliability for videofluoroscopic swallowing evaluation measures. Dysphagia. 2001;16:110–8.PubMedCrossRefGoogle Scholar
  72. 72.
    Daniels SK, Brailey K, Foundas AL. Lingual discoordination and dysphagia following acute stroke: analyses of lesion localization. Dysphagia. 1999;14:85–92.PubMedCrossRefGoogle Scholar
  73. 73.
    Groher ME, Crary MA. Dysphagia: clinical management in adults and children. Maryland Heights: Mosby/Elsevier; 2010.Google Scholar
  74. 74.
    Borr C, Hielscher-Fastabend M, Lucking A. Reliability and validity of cervical auscultation. Dysphagia. 2007;22:225–34.PubMedCrossRefGoogle Scholar
  75. 75.
    Leslie P, Drinnan MJ, Zammit-Maempel I, Coyle JL, Ford GA, Wilson JA. Cervical auscultation synchronized with images from endoscopy swallow evaluations. Dysphagia. 2007;22:290–8.PubMedCrossRefGoogle Scholar
  76. 76.
    Wang TG, Chang YC, Chen SY, Hsiao TY. Pulse oximetry does not reliably detect aspiration on videofluoroscopic swallowing study. Arch Phys Med Rehabil. 2005;86:730–4.PubMedCrossRefGoogle Scholar
  77. 77.
    Morgan AT, Omahoney R, Francis H. The use of pulse oximetry as a screening assessment for paediatric neurogenic dysphagia. Dev Neurorehabil. 2008;11:25–38.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2013

Authors and Affiliations

  1. 1.Department of Communication Sciences and DisordersUniversity of Central ArkansasConwayUSA
  2. 2.Department of Speech and Language PathologyUniversity of TorontoTorontoCanada

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