Swallowing Disorders

see also: Swallowing Disorders Management Protocols swallowingpdf1.pdf

Assessment of patients suspected of having swallowing disorders is accomplished by both clinical/bedside and videofluoroscopic/videoendoscopic methods. Clinical/bedside evaluations ideally precede the physiologic examinations. Standardized methods for each evaluation are used. Observations from the physiologic evaluations are systematically coded as shown in the data-entry form designed for this purpose shown in Figure ID-1. A sample corresponding report is shown in Figure ID-2

swallowingpdf2.pdf

Figure 1 swallowingpdf1.pdf

CLINICAL BEDSIDE SWALLOWING ASSESSMENT

During this portion of the evaluation, the patient's history is reviewed for possible etiologic factors that may contribute to swallowing disorders. These include disease processes such as cancer or treatment of disease processes (ie, surgery or radiation therapy) that may lead to difficulty swallowing safely. The patient is then observed swallowing secretions and, provided that was performed adequately, small amounts (less than 5 cc) of material of various consistencies. Observation of oral bolus control and laryngeal elevation during swallowing is performed. Voice quality after swallowing is noted for signs of wetness, which may indicate inadequate bolus clearance and possible aspiration. Presence of coughing, choking, or gagging is noted and, if severe, may be grounds for limiting or terminating the clinical/bedside swallowing examination.
If the bedside clinical/bedside evaluation yields findings consistent with a swallowing disorder, a physiologic examination is usually recommended. The attending physician completes a separate consult for the speech pathologist and, if videofluoroscopy is performed, for the radiologist requesting the procedure.

OROPHARYNGEAL MOTILITY STUDY (OPMS)

Oropharyngeal motility studies of swallowing attempt to identify abnormal swallowing behavior and determine alternative means of swallowing safely when necessary. Continuation of safe oral feeding is always the goal. Oral bolus control, oral transit, laryngeal elevation, cricopharyngeal dilation, and aspiration are clearly visible. Lateral (sagittal) and frontal (coronal) views are typically recorded as the patient takes small measured amounts of various materials mixed or coated with contrast material. Standardized observations based on previously published methods are coded. A description of the protocol and observations represented in Figure ID-1.) follows.

1. History
   1. A brief description of the patient's history motivating the swallowing evaluation is documented by the speech-language pathologist. This may include information about timing of onset, variability of symptoms, and associated disease processes.
2. Observations
   1. The patient's pre-evaluation diet and use of enteral feeding techniques are coded prior to the assessment. Oral preparatory, oral, pharyngeal, and cricopharyngeal phases of swallowing are each coded from 0 = normal to 3 = severely impaired. When any phase is impaired, a further coding describing the nature of the impairment is documented. In addition, the consistencies of material swallowed when the impairments were observed are coded for each of these phases of swallowing. Oral transit time and pharyngeal transit time are also coded according to standardized procedures.
   2. The presence and timing of aspiration is coded. Among the most important observations is the patient's response to therapy techniques attempted during the examination. These may involve swallowing maneuvers or variations in positioning that are expected to influence the occurrence of aspiration. Additional codings regarding the need for additional follow-up and suctioning are also coded.
   3. Finally, the Swallowing Performance Scale is employed to categorize the severity of the patients swallowing disorder. This leads directly to decisions regarding the need for dietary modifications and/or swallowing precautions and maneuvers. As indicated by the scale descriptions, there are several categories of dysfunction that enable the patient to continue to eat orally at least to a limited or controlled degree. Recommendations that eliminate oral feeding entirely are done only as a last resort when it is clear that no amount of oral feeding can be tolerated safely.
3. Recommendations
   1. Based on the physiologic findings during the evaluation, dietary recommendations, as well as swallowing precautions, may be coded. Ideally, these will be based on the patient's swallowing behavior when swallowing the proposed dietary consistency during the videofluoroscopic examination. Recommendations for swallowing precautions or maneuvers should also be based on demonstrated improvement during the swallowing evaluation when the precaution or maneuver was tested. Additional detail regarding recommendations may be included by the clinician.
4. Report
   1. A report generated on the basis of the coded observations is produced and forwarded to the referring attending physician (see Figure ID-1).