Co-Authors by: Daryn Ofczarzak, B.A.; Kristen M. Mumma, B.S;
The evaluation of swallowing is a three-tiered process, especially with acute stroke patients. The process of evaluating swallowing in patients presenting to the hospital with stroke symptoms begins with screening given the American Stroke Association guidelines, which indicates that swallowing must be screened prior to oral intake including medication . Frontline healthcare providers such as registered nurses or physicians typically administer the swallowing screen given the fact that they are available 24/7. A screening is a rapid, non-invasive examination to determine RISK of dysphagia and/or aspiration. It does NOT diagnose dysphagia. A positive (failed) screen should result in an expedited referral to speech pathology.
A positive screening result is followed by a clinical swallowing examination (CSE) completed by a speech-language pathologist (SLP). Screening and the CSE are NOT the same thing. A carefully administered CSE can be an important diagnostic tool in which the SLP gathers information to gain a more holistic view of the patient and make judgments on swallowing ability [2-4]. It is important to note, however, that the CSE cannot be used to determine the underlying impairment of swallowing, confirm airway invasion, identify the effects of compensatory strategies, or recommend appropriate rehabilitative approaches. For this, a third step in evaluation is warranted, the instrumental swallowing evaluation, i. e., videofluoroscopic swallowing study (VFSS), videoendoscopic swallowing study.
The CSE is composed of obtaining a case history, patient/family interview, cognition and communication screening, cranial nerve examination, and direct assessment of swallowing. During the CSE, information is gathered to form a hypothesis regarding the presence/absence of dysphagia and aspiration, the physiological cause of the dysphagia and to determine if an instrumental examination is warranted, and determine the potential compensatory and rehabilitative strategies to implement.
Clinical Swallow Evaluation (CSE): Case History/Patient Interview
If available, the patient’s medical record should be reviewed to obtain case history information prior to meeting with the patient. During the review, current medical status can be identified as well as medical history related to possible coexisting swallowing disorders. This information is considered when determining the structure and content of the interview portion of the CSE. Ample time should be taken to talk with the patient and family concerning the patient’s swallowing problems. Information gathered during the interview can enlighten the SLP to observe specific signs during the clinical and instrumental assessments. The depth of interview will be dependent upon the patient’s condition, that is, his/her responsiveness and awareness of the swallowing problem . The SLP should shape the interview to best fit the patient. Ideally, the SLP structures the interview by initially asking broad, open-ended questions regarding the patient’s swallowing. More specific questions, including yes/no questions, can follow as the interview progresses, particularly if language abilities limit the amount information provided. Interviews with patients admitted to the hospital with stroke may not be lengthy as they may present with anosognosia (unawareness of deficits) or anisodiophoria (unconcerned by deficits), particularly those with right hemispheric damage (RHD) [5, 6]. If limited or negative responses are provided, the SLP can briefly interview a caregiver or nursing staff and continue with the rest of the CSE. Throughout the interview portion of the CSE, the SLP should observe gross motor function such as posture, strength, and movement, as disorders in these areas may affect ingestion.
Clinical Swallow Evaluation (CSE): Cognition and Communication
Information taken from the medical history and patient interview, such as lesion location or medical diagnosis, can facilitate identification of other associated deficits regarding cognition and communication. Particularly for acute stroke patients, screening of cognition and communication is warranted and can easily take place during the CSE. Deficits in cognition and communication will contribute to how the SLP proceeds with the remainder of the assessment process and the selection of appropriate management strategies. For example, a patient with RHD displaying reduced memory and impulsiveness would not be an appropriate candidate for implementation of a posture compensatory strategy (e.g., chin tuck for a delayed pharyngeal swallow resulting in liquid aspiration), even if successful in eliminating aspiration on VFSS, unless constant supervision was available. Short term implementation of nectar thick liquids, if successful at eliminating aspiration on VFSS, may be the more appropriate recommendation until cognition and/or swallowing improves. The depth of this portion of the CSE will vary based on the patient’s diagnosis and level of cognitive and communication abilities. For individuals without neurologic impairment, little to no time can be spent on this part of the CSE. The SLP can informally screen for cognition and communication or use formal screening tools. Ideally the areas screened would include auditory comprehension, verbal output (language, voice, motor speech), attention, memory, and neglect. Research has demonstrated that acute stroke patients with dysphagia who are aware of their swallowing deficit are able to modify their intake of liquids; whereas, those with reduced awareness are not . During the assessment, if the patient presents with reduced comprehension, the SLP can assist by providing auditory cues and visual models. However, if the patient requires such models, this should be considered when determining appropriate management strategies.
Clinical Swallow Evaluation (CSE): Cranial Nerve Examination
Inspection of the oral cavity should be completed making particular note of mucosa integrity, secretion management, and dental hygiene. The cranial nerve examination is necessary to assess the motor and sensory function of the swallow. The SLP asks the patient to perform a series of motor movements while assessing the symmetry, strength, and range of motion of muscles and structures during movement and at rest. Sensation should also be tested using light touch. It is critical that SLPs have knowledge of what muscles are engaged during completion of a specific movement and which cranial nerve innervates that muscle. Excellent cranial nerve and musculature reviews are available to the interested SLP [2, 3, 7]. A thorough cranial nerve examination provides the SLP with inferred insight into pharyngeal phase physiology.
The extent to which the cranial nerve examination can be completed is dependent upon the patient’s responsiveness. Ideally, the patient completes a task without demonstration by the SLP, e.g. “Pucker your lips.” This will allow observation of auditory comprehension as well as movement. If the patient is unable to follow the direction, the movement should be demonstrated. If the patient cannot imitate the movement, comprehension or buccofacial apraxia may be the cause, not motor impairment. If this is the case, if possible, observe the target behavior in a more natural condition, e.g., licking dry lips, rather than tongue lateralization and protrusion.
Clinical Swallow Evaluation (CSE): Assessment of Oral Intake
Direct clinical observation of oral intake yields information about any oral phase impairments and can lead the SLP to an informed hypothesis regarding impairments in the pharyngeal phase. Use of a standard, structured protocol is strongly recommended. Familiarity, practice, and consistent administration of established protocols using calibrated volumes and consistencies increases inter- and intra-rater reliability . It is strongly recommended that the structured protocol be created and adopted by all SLPs at their facility.
The SLP should evaluate liquids, semi-solids, and solids using calibrated volumes and two trials for each volume/consistency. It is suggested that the assessment begin with small liquid volumes (e.g., 5 ml water). Pudding or applesauce and cookies or crackers are appropriate semisolids and solids to use. If there is concern that the patient will aspirate even this very small volume, ice chips may be initially tested. For liquids, a protocol using 5 ml, 10 ml, self-regulated cup sip, and sequential swallowing of 50-90 ml may be implemented. Each volume and consistency should be repeated twice, depending on patient response, to avoid over- or under-estimating the integrity of the patient’s swallow. The SLP should palpate submentally as well as the hyoid and larynx to subjectively assess tongue movement, anterior and superior hyolaryngeal movement, and the number of swallows required to clear the bolus . While an extremely gross measure of hyolaryngeal elevation and timing of oral transfer, in conjunction with other signs such as multiple swallows, it may provide information concerning oral transfer ability and hyolaryngeal elevation. Additionally, the oral cavity should be examined before and after each swallow to assess the presence of oral residue, which may indicate poor efficiency of oral transfer. For each volume and consistency administered, listen for the presence of cough, throat clear, or wet vocal quality during phonation of a prolonged /a/.
Though a protocol such as the one above may be established, it is imperative that the SLP be prepared to deviate from the planned sequence or terminate the examination based on the patient’s response at each step. For example, if the patient shows signs of aspiration (e.g., coughing, wet voice) with each administration of 10 mL of water, it is not necessary to continue to self-regulated cup sips or sequential swallowing; it would be more appropriate to move to a semi-solid to assess functioning of a more viscous bolus.
The CSE cannot be the sole basis for determining compensation and rehabilitation recommendations since the underlying swallowing impairment cannot be identified. Research has demonstrated that an instrumental examination is warranted to determine the effects of compensatory strategies [10, 11]. However, a well-executed CSE can facilitate development of a hypothesis concerning the pathophysiology of the dysphagia and provide valuable information concerning management recommendations upon completion of the instrumental evaluation.
About the Authors
Daryn and Kristen are graduate students in the Department of Communication Sciences and Disorders at the University of Houston.
Stephanie is a Professor in the Department of Communication Sciences and Disorders at the University of Houston and a Research Speech Pathologist at the Michael E. DeBakey VA Medical Center in Houston, TX. Dysphagia Following Stroke 2nd Edition, which Stephanie co-authored with Maggie-Lee Huckabee, has recently been published by Plural.
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