Bedside Evaluation

of Dysphagia
Rafia Mubeen
Assessment of dysphagia may include instrumental
or non instrumental measures—frequently both.
Bedside Clinical evaluation is a collection of,
largely, non-instrumental measures, which may
include
• comprehensive history,
•a detailed oral motor and sensory physical exam,
•and trial swallows of liquids and foods
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.
1st slide foot note: Assessment of dysphagia may include
instrumental or noninstrumental 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.
Rationale
•Allows observation of oral stage
dysphagia symptoms
•Provides clues about pharyngeal
stage swallowing difficulties
•Helps identify behavioral
characteristics which may
determine the patient’s candidacy
for further evaluation or treatment.
 OUTLINE
1. Before meeting the patient
2.Meeting the patient
3.Oral motor examination
4.Speech Screening
5.Swallowing Assessment
6.Report writing
 I. Before Meeting the Patient
A.Consultation Review
• Who ordered the Evaluation ?
• Why was the evaluation
ordered ?
• When are you expected to
respond to the consult?
B. Chart Examination
1. Recent medical history
2. Symptom type  S/S of dysphagia
 drooling/increased secretions
Weight loss
Coughing/choking
pocketing
Pneumonia
Changes in diet
Patient complaint
Dehydration
3. Time of onset
4. Duration
1)Medical History (foot note):
1)Admit diagnosis  determine if the pt has
a dx that might account for the dysphagia
(e.g. recent stroke, progressive disorder)
2)If pt in acute care setting  admit dx
might not be related to the dysphagia, 
dig deeper..what might have happened?
3)Functional problems observed  obtained
from notes  look for terminology such as
coughing, choking when drinking, refusing
to take certain foods, drooling
Symptom type  s/s of dysphagia
•drooling/increased secretions
•Pt showing drooling or complaining of “excess saliva”
 usually means he isnt swallowing his secretions as
well as he did previously  may indicate dysphagia
•Weight loss
•If pt has experienced unintentional wt loss 
dysphagia is a possible cause  difficulty swallowing
certain consistencies might not eat that much
•Coughing/choking
•Pocketing  if poor oral skills, nurse might write 
have to clean food out of the pt’s mouth long after a
meal
Pneumonia (foot note cont.)
If the pt has aspirated, he may develop pneumonia within several
hours or it may be several weeks/months b4 it develops
Some pts who aspirate may not develop pneumonia
Its very difficult for a physician to determine if pneumonia is due to
aspiration unless the pneumonia developed soon after an observable
episode of aspiration
Changes in diet
Recent changes in eating or drinking habits may be an unconscious
reaction to difficulty handling certain textures or types of foods
Patient complaint – a pt’s complaint about difficulty swallowing
might spur a referral
• Dehydration
• Pts who have developed dysphagia may begin to avoid
liquids and become dehydrated. The dehydration may not be
mentioned specifically in the chart
• If not, some signs that the pt might be dehydrated:
confusion, constipation, poor skin turgor/skin breakdown,
and renal insufficiency
• Dehydration may contribute to pt falls, stroke and renal
faliure
• Conditions that
• cause water loss: fever/infection, high enviornmental
temperation, low enviornmental humidity, dry oxygen
therapy, diuretic therapies
• Cause water and electrolyte loss: vomiting, diarrhea,
food/fluid malabsorption, or losses through a fistula or an
ostomy)
5. Severity, Previous treatment
6. Pulmonary function
7. History of pneumonia
8. Tracheostomy tube
9. Nutritional Status
10. Current Diet
11.Presence of feeding tube
12.General Functional Status
13.History of weight loss
14. premorbid status
15. Medications specific to disorders
Foot Note Previous Slide:
•12) Presence of feeding tube
• a) Nasogastric Tube
b) Gastric Tube
c) Jejunum Tube
•13. General Functional Status
a.Awake
b.Alert
c.Sensitive to Symptoms
d. if isn't alert  may be better to delay the intervention until later
•14. History of weight loss
•15. Premorbid status  what was his status before the most recent event that caused
dysphagia. If pt was eating pureed foods for some time, it may not be reasonable to
expect the patient to return to a regular diet at this time.
•16. Medications specific to disorders: if pt is on medication find out if that medicine
has any effect on enhancing or interfering with the swallow function
Foot note cont.
1. Parkinsons treated with levodopa,
(commonly called sinemet). One case study
reports an improvement in swallowing with
adjustment of timing of medication. Sinemet
seems to have its peak effect one hour after
administration, some pts with PD do show an
improvement if given their medication one hour
prior to meals
2. Myasthenia gravis  typically treated with
mestinon  has peak effect at two hours post
administration..therefore changing the timing of
medication may improve the pts ability to
swallow
II. Meeting the Patient
A. Patient posture
B. Alertness
C. Responsive
D. Follows Directions
E. Manages own secretions
GLASCOW COMA SCALE
Note: Correspondence of observations with
information from chart and nursing
Respiratory function
• Volitional cough
• Type of clearing maneuver
• Production
• Loudness
• Sustained expiration while
counting
 IV. Speech Screening
A. Articulation -Speech articulation
• Speech intelligibility
• Rate
• Predominant error
B. Voice - Laryngeal Function Studies
• Vocal quality
• ddk tasks with ha ha ha
• Throat clearing and coughing on command
• If they cough on command, doesn’t mean s/he will definitely cough
on aspiration
C. Resonance - Velopharyngeal function
 II. Meeting the Patient (cont)
• G. Bedside History (Provided by patient, family member, or health
care professional)
• H. Bedside History
• 1. Are symptoms stable?
• 2. Are changes rapid or gradual?
• 3. Do symptoms vary depending on food consistency ?
• 4. What are the patient’s complaints when swallowing is
attempted?
a) Coughing and choking
b) Food coming out of nose
c) Food falling from mouth
d) Food stuck in throat
e) Throat burning
f) Wet voice
g) Does material seem to stop? If so, where
h) Pain associated with swallowing (odynophagia)?
i) Difficulty with swallow onset
III. Oral Motor Control Examination

•tongue blade
•cotton swab
•gauze pads
•stop watch
•stethoscope
•light
 A. Lip mobility
Reduced lip sensation, strength and range of motion
may result in drooling, biting the lip, pocketing
material in the anterior sulcus and spilling material
Foot note:
out of the front of the mouth.
1. protusion
2. retraction spread and pucker
symmetry
3. open/closure
repeat "pa"
4. movement
5. lip seal (CN VII)
6. sensation (CN V)
B. Lingual Function
Reduced tongue sensation, strength and range of motion
may result in an inability to manipulate material in the oral
cavity and form material into a bolus . It may also result in
food residue on the hard palate and pocketing material in the
anterior and/or lateral sulci. It may cause the patient to bite
her tongue as well.
Foot note: protrusion & retraction (anterior tongue)
2. elevation (intra and extra orally)
3. lateralization (intra and extra orally )
4. extend tip into sucli and palate
5. Posterior tongue
Prolonged hold of /k/ without the sound
Ddk task (K2 k2 k2)
6. sensation (general CN V, taste CN VII)
 Soft palate mobility
Reduced soft palate sensation, strength
and range of motion may result in a
decreased gag reflex, hypernasal speech
and/or nasal reflux. Poor soft palate
function may also cause premature spillage
of material over the back of the tongue
prior to the triggering of the pharyngeal
swallow.
open mouth, say /a/, and then /a/, /a/, /a/.
Function of cheeks
•Reduced cheek sensation, strength
and range of motion may result in
pocketing food in the lateral sulcus
and biting the cheek.
•Before beginning the exercises,
observe the patient’s facial
musculature at rest. Note any
asymmetries such as facial droop.
•Patients' ability to puff cheek: have
patient to puff his/her cheek. Look
for symmetrical bulging of right
and left cheeks. Be sure to check
the function of velum prior to this
exercise because reduced
velopharyngeal seal can result in
decreased oral pressure.
•Sensitivity
 Function of mandible
•Open the mouth as wide as possible, hold
for 3 seconds, then close. Check the
extent of jaw movement.
•Open and close the mouth 5 times as
quickly as possible. Note any slowness or
discordination.
•Move the mandible to the let, then to the
right. Observe the patient’s ability to
move the jaw form side to side.
Muscles of mastication
A.Masseter
B.Temporalis

C.Pterygoids

Lateralization
Protrusion
 Oral Reflexes
1.Palatal
Not very reliable to ellicit
00 laryngeal mirror
•Ellicit it right @ the soft palate  get upward and
backward movement of SP w/o pharyngeal wall
movement
2. Gag
Can use oo laryngeal mirror or tongue blade
Will get palatal contraction and strong bilateral
pharyngeal wall contraction
 Identification of optimal oral-sensory
stimuli and bolus types
• Using variety of combinations of taste and temp…clinician
can identify the particular combo of stimuli that elicits the
most oral movements that are characteristic of chewing or
a normal oropharyngeal swallow.
(Foot note): Some pts with cognitive impairments produce most
oral activity in response to particular combinations of taste,
texture, and temp
Can uses 4” X 4” pieces of cloth (gauze)..rolled around a flexible,
disposable plastic straw, to present various textures in the mouth.
One end  dipped into liquid of various temp (cold, room temp)
and flavours (sour, sweet, bitter, salty) to present a variety of
stimuli in the patient’s cavity. Excess liquid can be squeezed
from the cloth before presenting it to the patient’s mouth.
 F. Apraxia
•They will have difficulty following motor
commands, but might be able to just eat
on their own
Pt with swallowing apraxia performs best at
the bedside when no verbal directions are
given regarding eating or swallowing.
When food tray presented, will pick up
fork/spoon and begins eating normally with
apparently normal swallowing.
V. Laryngeal Function Exam
1.Assessment of voice quality
2.Laryngeal DDK
3.Cough as hard as possilbe, clear throat
as strongly as possible
4.Ask pt to slide up and down a vocal
scale  checking the cricothyroid muscle
and intrinsic muscles, and the superior
laryngeal nerve
5.Phonation time tasks 
1.Assessment of voice quality (FOOT NOTE OF PREVIOUS SLIDE)
1.Gurgly voice has been associated with aspiration and is an
important enough sign of possible aspiration to warrant
referral for a radiographic examination
2.A pt with hoarsness  should be suspected of having
reduced laryngeal closure during the swallow (not to say
that pts who are hoarse automatically have swallowing
problems, but pts with swallowing and hoarseness 
careful laryngeal exam  ENT)
2.Laryngeal DDK
1.Rapid repetions of syllable /ha/
2.Listen for clear production of the vowel and voiceless
production of h
3.(neurological impairment: pt might give single haaaa…and
not individual ha syllables)
3.Cough as hard as possilbe, clear throat as strongly as possible
Foot note cont.
1.Ask pt to slide up and down a scale  checking the cricothyroid muscle and
intrinsic muscles, and the superior laryngeal nerves
1.Pharyngeal swallow and cough reflex may trigger from superior laryngeal
nerve
2.Inability to change pitch may imply reduced sensitivity within and
surrounding the larynx
2.Phonation time tasks 
1.Sustain a or s or z
2.Can provide some info on the relative control of the larynx and also test
of respiration
•If laryngeal function appears to be borderline, clinican may decide to teach
the pt supraglottic or super-supraglottic swallow in attempt to increase the
pt’s airway protection prior to intitaing any swallows
Info collected from prep exam
•1) posture that may result the best
swallowing
•2) best position for food in the
mouth
•3) potentially best food consistency
•4) some indication of the nature of
the patient’s swallowing disorder
FOOT NOTE: 2. depends on information on oral sensitivity
and oral function
•Food should be positioned on side of best function and best
sensitivity
•If liquid must be placed posteriorly in oral cavity a straw used
as a pipette or a syringe may be used. Tongue blade is often
helpful in positioning thicker foods in particular places on
tongue.
•3. Patients with: delayed pharyngeal swallow will do best
with thicker consistency- applesauce or mashed potatoes; 
Reduced tongue base or pharyngeal wall contraction will do
best with liquids;
•reduced laryngeal elevation or reduced upper esophageal
sphincter opening will do better with liquids;
•reduced closure of laryngeal entrance will do best with
thicker consistency
VI. Swallowing Assessment
•A. Spontaneous swallow
•B. Dry Volitional Swallow
•C. Chewing
•1. Non -food
•2. Gauze pad dipped in liquid
Consider the risk-benefit ratio in
determining whether trial swallows
should be attempted at the bedside or
go directly for modified barium
•D. Bolus Swallows
1.Aspiration Risk?
• Trial swallows
•Risk/benefit ratio
•Safety is utmost concern
•Where risks are very high 
•if a pt is very old and has other medical
conditions
•A weak voluntary cough is very risky,
•A pt with reduced pulmonary function
If currently on oral foods then observe during
a meal:
•Reaction to food
•Oral movements for manipulation of bolus and
chewing
•Coughing, throat clearing, change in vocal quality,
change in breathing/ respiration
•See if they swallow their own medicines
•Change in secretion levels
•Duration of a meal
•Coordination of swallowing and breathing
•If benefits outweigh risks,
then
•Four finger test
•Index  lightly behind the
mandible anteriorly
•Middle  at hyoid bone
•Third  top of thyroid cartilage
•4th  bottom of thyroid
cartilage
During Trial Swallow
•Ask patient to say “aaaa”
•Four finger placement
•take a bolus of water in mouth, asked to
swallow
•Four finger technique
•Can give a rough estimate of oral delay time
and a gross estimate of pharyngeal delay time
•coordination of swallowing & breathing
•Signs of aspiration?
•Vocal quality after swallow (Wet voice)
•Watery eyes
•cough
2. Bolus consistency
Try other consistencies if no signs
of aspiration

3. Posture
Try different postures if signs of
aspiration
 VII. Report Writing
•Complete history, include all of
the information
•Information about the anatomy
etc.
•Any observations made
•Recommendations