During clinical swallow study you will determine diet level, treatment techniques

and dysphasia therapy plan.

Most people dont get an instrumental exam, because clinical swallow study can
yield adequate info.
C Co om mp po on ne en nt ts s o of f a a C Cl li in ni ic ca al l S Sw wa al ll lo ow w S St tu ud dy y
H Hi is st to or ry y
G Gr ro os ss s c cl li in ni ic ca al l o ob bs se er rv va at ti io on n o of f p pa at ti ie en nt t
I In nt te er rv vi ie ew w w wi it th h p pa at ti ie en nt t, , f fa am mi il ly y a an nd d/ /o or r c ca ar re eg gi iv ve er rs s
O Or ra al l- -M Mo ot to or r E Ex xa am mi in na at ti io on n f fo or r s sw wa al ll lo ow wi in ng g
P PO O t tr ri ia al ls s
T Tr re ea at tm me en nt t t te ec ch hn ni iq qu ue e t tr ri ia al ls s
R Re ec co om mm me en nd da at ti io on ns s
O Ob bs se er rv va at ti io on ns s d du ur ri in ng g P PO O t tr ri ia al ls s
O Or ra al l P Pr re ep pa ar ra at ti io on n
Patient readily accepts bolus?
Anterior spillage?
Oral manipulation of bolus?
Mastication ability?

O Or ra al l T Tr ra an ns si it t
Check for residue in oral cavity after the swallow

P Ph ha ar ry yn ng ge ea al l T Tr ra an ns si it t
Prompt triggering of the pharyngeal swallow?
Check vocal quality
Check if there is a sensation of something stuck and note location (sternum?
Pharynx?)
Odynophagia-pain swallowing?
Note any clinical signs of aspiration, when and on which consistency

E Es so op ph ha ag ge ea al l P Ph ha as se e
Suspicious if patient consistently reports feeling something stuck at the level of
the sternum or clavicular notch

M Ma ak ke e t th he es se e o ob bs se er rv va at ti io on ns s c co on ns si is st te en nt t a af ft te er r e ea ac ch h s sw wa al ll lo ow w
r re eg ga ar rd dl le es ss s o of f t th he e c co on ns si is st te en nc cy y y yo ou u a ar re e t te es st ti in ng g
H Ho ow w m ma an ny y s sw wa al ll lo ow ws s n ne ee ed de ed d? ?
C Ch he ec ck k v vo oc ca al l q qu ua al li it ty y
A As sk k p pa at ti ie en nt t i if f a an ny yt th hi in ng g f fe ee el ls s s st tu uc ck k i in n h hi is s t th hr ro oa at t o or r c ch he es st t. .
D Do oe es s p pa at ti ie en nt t r re ep po or rt t o od dy yn no op ph ha ag gi ia a? ?
A As sk k p pa at ti ie en nt t i if f i it t f fe el lt t l li ik ke e i it t w we en nt t d do ow wn n t th he e r ri ig gh ht t w wa ay y
C Ch he ec ck k f fo or r o or ra al l r re es si id du ue e
N No ot te e a an ny y c cl li in ni ic ca al l s si ig gn ns s o of f a as sp pi ir ra at ti io on n
P Pl la an n y yo ou ur r n ne ex xt t 2 2 s st te ep ps s ( (t te ec ch hn ni iq qu ue es s, , c co on ns si is st te en nc ci ie es s, , b bo ol lu us s s si iz ze es s) )
* ** *B Be e a aw wa ar re e o of f y yo ou ur r r ra at ti io on na al le e f fo or r t th he e n ne ex xt t s st te ep ps s
W Wh he en n t to o c co on ns si id de er r a an n I In ns st tr ru um me en nt ta al l E Ex xa am m
I In nc co on ns si is st te en nt t c cl li in ni ic ca al l s si ig gn ns s o of f a as sp pi ir ra at ti io on n w wi it th h a an nd d w wi it th ho ou ut t t tr re ea at tm me en nt t t te ec ch hn ni iq qu ue es s

N No o c cl li in ni ic ca al l s si ig gn ns s o of f a as sp pi ir ra at ti io on n, , b bu ut t p pr re es se en nt ts s w wi it th h s sy ym mp pt to om ms s o of f a a p ph ha ar ry yn ng ge ea al l
d dy ys sp ph ha ag gi ia a n no ot t a al ll le ev vi ia at te ed d b by y t tr re ea at tm me en nt t t te ec ch hn ni iq qu ue es s ( (e e. .g g. .; ; g gl lo ob bu us s, , f fe ee el li in ng g r re es si id du ue e
s st tu uc ck k i in n t th hr ro oa at t) )

C Cl li in ni ic ca al l s si ig gn ns s o of f a as sp pi ir ra at ti io on n a ar re e a al ll le ev vi ia at te ed d w wi it th h t tr re ea at tm me en nt t t te ec ch hn ni iq qu ue es s, , b bu ut t t th he e
p pa at ti ie en nt t r re es sp pi ir ra at to or ry y s st ta at tu us s i is s p po oo or r ( (e e. .g g. .; ; a ac ct ti iv ve e l lu un ng g d di is se ea as se e r re eq qu ui ir ri in ng g m me ed ds s, ,
a ac ct ti iv ve e T TB B, , r re ec ce ei iv vi in ng g > >2 2L L o of f O O2 2 o or r h h/ /o o r re ec cu ur rr re en nt t a as sp pi ir ra at ti io on n P PN NA A s s) )
Chin Tuck-The patient puts their chin to the chest before the swallow and maintains
this position until the swallow is completed.Used with a delayed swallow. Widens
the vallecular space, so that the bolus will hesitate in the valleculae rather than
falling into the airway.*used also to help epiglottis deflection and laryngeal
elevation and BOT retraction, clinically(narrows pharynx)

Head rotation-The patient is asked to turn their head to the paretic side until the
swallow is completed.Turning the head toward the weak side closes off that side
of the pharynx allowing the bolus to descend on the unaffected side.(this is why you
want to do an anterior MBS view. There will be residue on the weaker side.) If you
turn to the left it will narrow left velleculae space and widens the stronger right side
of velleculae.

Head Tilt-Head is tilted toward the stronger side. Food and liquid descend the
stronger side of the larynx
Multiple Swallows-The patient is asked to take 2 or 3 swallows per bolus of food or
liquid.Helps clear the valleculae and/or the pyriform sinuses of any residue that
might be aspirated AFTER the swallow.

Alternating Liquids and solid-The patient is taught to alternate taking a solid then a
liquid bolus. One consistency can help to clear the other from any pharyngeal areas.

Supra-Glottic Swallow-The patient is taught to take a small breath, swallow, cough
immediately and then swallow again.A voluntary breath hold usually adducts the
true vocal folds before the swallow and the immediate cough allows the patient to
expectorate any penetrated material, which is moved into the esophagus by the last
dry swallow.

Super Supra-Glottic Swallow-The patient is asked to hold their breath tightly and
bear down. Then they complete a supraglottic swallow. Effortful breath hold
adducts the true and false folds and can increase the anterior tilt of the arytenoids
for better laryngeal closure.

Effortful Swallow-The patient is instructed to squeeze hard with all your throat
muscles during the swallow. Increases base of tongue retraction which propels the
bolus to descend the pharynx.
Cough/Throat Clear-The patient is taught to cough or throat clear after each bolus.
Any penetrated material is expectorated from the laryngeal vestibule.
Mendlesohn Maneuver-The patient is taught to hold the larynx at the most elevated
position during the swallow for 3 to 5 seconds.
The theory is to increase extent and duration of laryngeal elevation, thereby
increasing the duration and width of cricopharyngeal opening

Modify volume and speech of food presentation-Larger boluses, for some patients
can trigger a faster pharyngeal swallow. Smaller boluses at a slower rate can
significantly reduce risk of aspiration in some patients. A weak pharyngeal swallow
usually requires multiple swallows.

Six valves within the upper digestive tract operate during
swallowing:
1. Lips
2. Tongue (most mobile valve)
3. Velum to back of tongue(prevents premature spillage)
4. Velopharynx (prevents nasal reguritation)
5. Larynx (prevents liquid from getting into the airway)
6. Upper esophageal sphincter(prevent air into esophagus and
food into the esophagus)

Five Cranial Nerves of Swallowing
1. CN V trigeminal-chewing muscles (facial sensation and
anterior 2/3 of tongue)
2. VII Facial nerve(controls lips for sealing oral cavity)
3. CN IX glossopharyngeal(velum and superior pharynx)
4. CN X Vagus(crico pharyngeal, vocal folds, velum
elevation)
5. CN XII Hypoglossal(CONTROLS MOVEMENT OF
TONGUE)
O Or ra al l- -M Mo ot to or r E Ex xa am mi in na at ti io on n f fo or r S Sw wa al ll lo ow wi in ng g
L Li ip ps s ( (s sy ym mm me et tr ry y o of f l li ip p m mo ov ve em me en nt t) ) ( (l la ab bi ia al l c cl lo os su ur re e) )
D De en nt ti it ti io on n ( (t te ee et th h) ) ( (b bi it te er rs s a an nd d c ch he ew wi in ng g t te ee et th h) )
T To on ng gu ue e ( (p pr ro ot tr ru ud de e. . L La at te er ra al l m mo ov ve em me en nt t, , a an nd d r re es si is st ta an nc ce e) ) ( (t th he e t to on ng gu ue e w wi il ll l d de ev vi ia at te e
t to ow wa ar rd ds s t th he e w we ea ak ke er r s si id de e) )
S So of ft t P Pa al la at te e ( (r ri is se e o or r n no ot t) ) ( (d do oe es s t th he e v ve el lu um m d de ev vi ia at te e s si id de es s f fo or r a ah hh hh hh hh h) )( (t th he e s si id de e
w wi il ll l d de ev vi ia at te e t to ow wa ar rd ds s t th he e s st tr ro on ng ge er r s si id de e) )
V Vo oc ca al l Q Qu ua al li it ty y( (w we et t v vo oi ic ce e? ?) )
D Dr ry y s sw wa al ll lo ow w ( (p pu ut t f fi in ng ge er r o on n t th hy yr ro oi id d n no ot tc ch h t to o s se ee e i if f i it t g go oe es s u up p) )


What can we see with FEES? 5 things that you need to know about FEES for
test
1. Anatomy involved in the pharyngeal stage of swallowing.
2. Movement of critical structures within the pharynx and larynx
3. Secretions.
4. Direct assessment of swallowing function for food and liquid.
5. Response to therapeutic maneuvers and interventions to improve the
swallow.

Anatomy:
Velar Elevation(have client hold air in cheeks)
Lateral Pharyngeal Wall Contraction(have the client go EEEE. Larynx will
come close to scope)
Laryngeal Closure(true, false will close and the arytenoids will tilt
interiorly)(Have client bare down)
True vocal fold adduction
False vocal fold adduction
Anterior tilting of arytenoid to petiole of epiglottis
White-Out-(height of swallow and where you test eppiglotis retroflection)the
distal tip of the endoscope will white our because the tissue is coming
together.
During the pharyngeal swallow the tongue and velum contact the posterior
pharyngeal wall.
The distal tip of the endoscope will be trapped transiently against the
Epiglottis returning to resting position after white-out
Secretions:
Murray et al., 1996
Endoscopically visible secretions located within the laryngeal vestibule were
highly predictive of subsequent aspiration of food and liquid.
Hospitalized patients swallowed less frequently than nonhospitalized patients.
Donzelli et al., 2003
Patients with tracheotomy have more secretions
Presence and amount of accumulated oropharyngeal secretions were predictive
of aspiration of food and/or liquid.



Advantages of FEES
Portable to the bedside or in clinic
No radiation unlimited time
Can be done within 10 minutes
Well-tolerated by patients (most do not require anesthetic spray)
Can be done independently by the SLP
Normal foods and liquids
Biofeedback in therapy sessions
C Cl li in ni ic ca al l S Si ig gn ns s o of f A As sp pi ir ra at ti io on n
C Co ou ug gh hi in ng g b be ef fo or re e, , d du ur ri in ng g o or r a af ft te er r t th he e s sw wa al ll lo ow w
T Th hr ro oa at t c cl le ea ar ri in ng g w wi it th h P PO O i in nt ta ak ke e
w we et t p ph ho on na at ti io on n a af ft te er r P PO O i in nt ta ak ke e
Short Term Goals can be written from
the SIGNS observed
Sign Short Term Goal
Poor oral transit cant
move bolus to back of
mouth
Patient will improve oral
transit ability
Patient has residue in
the valleculae
Patient will reduce
residue in the valleculae
Patient loses food from
of mouth (anterior
spillage)
Patient will decrease loss
of food from front of
mouth


Treatment Objectives
Smaller, more measurable steps used to achieve the functional short term goal.
Should be chosen based on the physiologic cause of the sign/symptom.
Often equivalent to treatment techniques


Functional Short Term Goals
Are written in terms that payers, consumers and other health professionals can
understand
Everyone understands improving the patients HEALTH and SAFETY (stop
aspirating)
Should address WHY the skill needs improvement