Good Dysphagia Evaluation Guides Treatment

(Part 2)

by Karen Sheffler, MS, CCC-SLP, BCS-S, of SwallowStudy.com

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This is Part 2 of a two-part series focusing on the dysphagia evaluation process. I originally created the blog for MedbridgeEducation.com. 

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MedBridge provides clinicians and healthcare organizations a comprehensive education platform that includes clinical education, patient education, and home exercise programs. They have grown a Speech-Language Pathology platform. Subscribers get unlimited access to ASHA-approved CEUs with topics including: Dysphagia, Cognition, Voice, Motor Speech, Pediatrics, and more. Online courses are by industry-leading instructors, such as the following dysphagia experts: Ianessa Humbert, Catriona Steele, Michael Groher, Robert Miller, Michael Crary, Martin Brodsky, Stephanie Daniels, and more 

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Remember our 85 year old woman from “What Am I Treating? (Part 1 on SwallowStudy.com)“?

Part 1 shared a practical clinical example (see our 85 year old woman’s case below) and addressed the process of thoroughly gathering information to formulate a hypothesis.

An 85-year-old woman walks into an outpatient swallowing clinic to get help for her difficulty swallowing. She comes out with a folder full of dietary suggestions, swallow strategies, tongue exercises, and swallowing exercises. She faithfully performs her exercise drill every morning and evening, laughing at herself making faces in the mirror. She tries to hold her tongue out while she is effortfully swallowing saliva (i.e., Masako/Tongue-Hold, Fujiu, M., & Logemann, J. A., 1996). She can only do two repetitions as her mouth is so dry. She wonders how these are going to help her swallow better. During meals, she tucks her chin and effortfully swallows two times after every bite of food. However, she still is bothered by that lump-in-the-throat sensation and the feeling of food stuck. Liquid comes back up on her when she tries to wash foods down. She can only eat a small amount before the food feels like it is coming back up into her throat. Most concerning to her, she is still losing weight. She wonders: “What am I doing wrong?”

We asked: “What are WE doing wrong?” Let’s continue that discussion.

Part 1 covered the Clinical Bedside Swallow Evaluation. The SLP may be the only professional who spends more than 5-10 minutes evaluating a patient’s eating and swallowing, taking in the whole picture. The bedside swallow evaluation is not a screen; it is a valuable billable service performed daily by SLPs. I was glad to hear Giselle Carnaby, MPH, PhD, FASHA at the 2016 Dysphagia Research Society’s (DRS) Post-Graduate Course clarify that our bedside dysphagia evaluation is NOT a screen. She noted that by definition, a screen is used to recognize a problem in a non-referred population (i.e., nursing swallow screen on all patients), whereas your patient was referred to your service by the doctor due to an observed or suspected problem. Your assessment is longer and more than an observational checklist, per Carnaby.

The Importance of Performing Instrumental Testing

As in Part 1 of this blog, without a thorough clinical bedside swallow evaluation followed by instrumental testing, the symptom of food getting stuck in the throat was mistaken as oropharyngeal dysphagia. I purposely painted a clinical picture of an esophageal dysmotility to illustrate how the entire treatment course can be misdirected. A thorough interview and review of medical records could have casted doubt on the oropharyngeal dysphagia hypothesis, at least enough to warrant instrumental testing.

Did the clinician think in a multidisciplinary way?

Did she ask: “What else?”

Did she make appropriate referrals?

When no instrumental examinations are performed, the treatment may not only be ineffective, but it may be contraindicated. Tongue base exercises will do nothing if the problem is in the smooth muscle in the distal two-thirds of the esophagus. Even more detrimental, the act of rapidly double swallowing a solid bolus will interfere with her esophageal peristalsis by potentially disrupting the secondary clearing wave. This can make her issue of food stasis even worse. Additionally, a chin tuck is not always the perfect position, as it could cause aspiration in some cases.

So let’s ask “what else,” and perform an instrumental examination.

Performing Instrumental Dysphagia Evaluation(s)

There is no ONE gold-standard in the instrumental assessment of swallowing. For years the label of “gold- standard” was given to the Modified Barium SwallowStudy.com (MBSS, aka Videofluoroscopic SwallowStudy.com).

However, when comparing the MBSS with the FEES (Fiberoptic Endoscopic Evaluation of Swallowing), one “cannot dichotomize,” said MBSImP creator, Dr. Bonnie Martin-Harris, PhD, CCC-SLP, BCS-S, FASHA. (See Martin-Harris, 2008.)

“It depends on the nature of the question,” stated Dr. Martin-Harris at the 2015 DRS Annual Meeting. 

The informed clinician who thinks critically with a sound hypothesis will choose the exam(s) that best answers the clinical questions. For example, if the clinician suspects there may be a significant cricopharyngeal dysfunction and esophageal backflow, then the MBSS may be the best examination. If the clinician suspects structural abnormalities/asymmetries, fatigue factors, sensory deficits, or if the patient cannot fit into or be transferred to the fluoroscopic equipment, then the FEES may be the best first instrumental assessment.

Regardless of the initial instrumental examination, the treating clinician needs to know about more than just aspiration or what the bolus did. Per Dr. James Coyle, PhD, CCC-SLP, BCS-S, ASHA Fellow, at ASHA’s 2014 Healthcare & Business Institute: the instrumental examination is not only a picture of what is wrong, but also what works. “Here is what happened, what it means, and what we sampled during the exam to fix it,” said Coyle.

10 Necessary Aspects of All Instrumental Examinations of Swallowing:

1. Provide a thorough analysis of the structures, physiology and biomechanics of the swallow.

The MBSImP, for example, rates 17 parameters of the swallow. Coyle noted at the 2015 DRS Annual Meeting that some of these parameters unfortunately evaluate what the bolus is doing. For example, the parameter of “initiation of pharyngeal swallow” rates the location of the bolus head at the onset of the first hyoid movement. Does this tell you why the bolus dropped to that point? Is it really a delayed initiation of the pharyngeal swallow response, or did the patient have an oral containment problem with larger boluses?

2. Identify not only the quantity and location of the residue, but also why the residue remained after the swallow, patient’s sensation of it, and what worked to reduce it.

See Neubauer, Rademaker & Leder (2015) for the Yale Pharyngeal Residue Severity Rating Scale to judge vallecula and pyriform sinus residue during a FEES.

3. Note when and why the penetration and aspiration occurred and the patient’s reaction to it, keeping in mind that penetration above the level of the vocal folds that clears with the swallow is within functional limits, especially in the elderly.

4. Challenge the patient with large bolus sizes (i.e., up to 20ml) to mimic natural drinking.

At the DRS annual meeting in 2015, Catriona Steele, PhD, SLP (C), CCC-SLP, BCS-S, ASHA Fellow stated that “fixed volumes of less than or equal to 10ml are smaller than natural sips, and may under-challenge the swallowing system.” Adults take sips of 11-17ml in volume when allowed to drink naturally from cups, per Steele. However, when testing 20ml size boluses, realize that delays in pharyngeal transit times and esophageal transit times may be within normal limits for healthy elderly over 80 years of age (Miles, et al., 2015, March).

5. Challenge the patient with sequential drinking of 90-100ml, as tolerated.

Gaziano, et al. (2015, March) tested various volumes with individuals with ALS. Aspiration 
occurred most often with the 90cc trials, and only 5% elicited an effective cough to expel the aspirate. Aspiration occurred most often during and after the swallow (71.9%) due to ineffective laryngeal vestibule closure and ineffective or no cough. Aspiration before the swallow was rarely seen; therefore, this directs therapy.

6. The more trials you perform, the more likely you will see aspiration.

Susan Langmore, PhD, CCC-SLP, BCS-S advised more trials during a FEES when she presented at the 2016 Dysphagia Research Society’s Post-Graduate Course. She found only 46% of the patients showed aspiration after 3 trials, whereas 68% of these patients aspirated when given up to 10 trials.

7. Test the swallow strategies with enough trials, making sure the chin tuck, head turn, super-supraglottic swallow, effortful swallow, Mendelsohn Maneuver, etc. are really effective before you recommend that your patient has to perform these all the time.

8. Recommend adjustments to diet as options based on the patient’s goals of care (most aggressive to least aggressive), rather than solely recommending nothing by mouth (NPO).

9. Make suggestions to help customize the restorative and compensatory treatment plan, capitalizing on what worked. This should include exercise suggestions based on physiological deficits and swallow strategies to compensate for structural and functional problems.

10. Making Appropriate Referrals:

The SLP does not diagnose the underlining problem that is causing the dysphagia, but the SLP looks at the big picture. The SLP can guide the medical team and provide focus for further testing. When the SLP is aware of the dysphagic symptoms that are characteristic of various diseases/disorders, as well as the rationale behind other examinations, she/he can contribute significantly to the patient’s puzzle.

a) Consider a consultation with a registered dietitian, especially in our patient’s case above with her weight loss.

b) Consider a review of the patient’s medications that could cause dry mouth, cognitive deficits or dysphagia. Many side-effects of medications and polypharmacy can cause reversible difficulties eating and swallowing (see prior blog).

c) Does the patient need a referral to a neurologist? Did the exam point to unilateral or bilateral neuromuscular deficits? If there is a cognitive component to the dysphagia; is it due to a potentially “reversible dementia?”

d) Does the patient need a referral to an otolaryngologist?

• MBSS includes the anterior-posterior view to determine if there are pharyngeal and/or 
laryngeal asymmetries.
• FEES visualizes the structure and function directly and can point to the need 
for further otolaryngology consultation.

e) Because our analysis of the esophagus during a MBSS is incomplete, our recommendations may say: “Consider further testing with an esophagram for a more complete and diagnostic view of the esophagus.” Is an esophageal dysmotility suspected by the radiologist? An esophagram and/or manometry could be the next step. Is there a suspected obstructive esophageal issue where direct esophageal endoscopy would be the next step? With these suspicions, the patient needs a referral to a gastroenterologist, especially with the additional issue of early satiety (getting full quickly).

• FEES may show post-cricoid residue or a return of the food or liquid back up to the hypopharynx, which could indicate esophageal stasis and retrograde flow.
• MBSS should include an esophageal sweep, using a large liquid 
bolus and a more viscous bolus. JoAnne Robbins, PhD, CCC-SLP, BCS-S advised during discussion at this year’s DRS meeting that esophageal testing is “terribly important in older people to rule-out pneumonia contributed to by what is going on lower down.”

More on the Esophageal Sweep:

With our case in part one, the esophageal sweep would be crucial. We should at least 
provoke the situation described by the patient of a liquid regurgitation when trying to wash down a solid, as she may be aspirating on that liquid backflow.

The radiologist Cheri Canon, MD, FACR advised at the 2016 Dysphagia Research Society’s Post-Graduate Course, that we should not call the esophageal component of our MBSS a screen. Again, that would be finding an undiagnosed issue in a normal patient. She noted what we are doing is “purely therapeutic,” to check for esophageal clearance and aspiration risk. Canon advised: if you have greater suspicions, then recommend a full barium swallow study (aka, esophagram).

More on the Esophagram:

Esophagrams typically perform the following:

• Fully distend the esophagus to evaluate and identify the structure
• Evaluate esophageal motility without the aide of gravity
• Identify issues like tertiary contractions
• Retrograde flow and supraesophageal reflux
• Attempt to provoke gastroesophageal reflux

“Not all esophagrams are created equal,” noted Dr. Peter Belafsky, MD, MPH, PhD at the 2015 DRS Annual Meeting. With 6-9 frames per second, one could miss a “non-obstructing dysphagia.” A web may cause a solid dysphagia when the patient swallows large solid boluses, but the esophagram tests liquids only (and a barium tablet if requested).

If the esophageal lumen narrows down to 14mm or less, there may be dysphagia, per gastroenterologist Dr Dua (2015, March).

Dr O’Rourke, et al. (2015, March) stated, “the esophagram may be useful in the assessment of anatomic abnormalities, but it is a poor examination for the detection of esophageal dysmotility.” Using High-Resolution Manometry (HRM) as the gold-standard, O’Rourke showed that the esophagram had a sensitivity (true positive rate – positive dysmotility correctly identified as such) of only 0.68 and specificity (true negative rate – negatives correctly identified as such) of 0.51. In the future, more otolaryngologists, gastroenterologists, and SLPs around the world will have HRM to more thoroughly assess pressures and timings of the pharyngeal and esophageal swallow.

In Conclusion:

Thank you for reading and always asking tough questions to help your patients. Please add comments below (e.g., sharing your key elements of instrumental examinations).

I want to strongly urge the field to move forward with our experts (Dr Martin-Harris and Dr Langmore), and consider the FEES (Fiberoptic Endoscopic Evaluation of Swallowing) and the MBSS (aka, videofluoroscopic swallow study) equally. The MBSS is not the one and only gold-standard in dysphagia evaluation. There are many reasons why a person may have difficulty swallowing. It is up to the SLP to think critically during and after the bedside dysphagia evaluation to best serve the patient. At times, the SLP’s suspicions are low and further instrumental testing may not be warranted. Other times, the SLP will chose the instrumental examination path that most efficiently answers the clinical questions. The SLP also realizes that one examination may not provide all the answers; therefore, she/he makes appropriate referrals in a multidisciplinary approach.

A prior resource from ASHA called: Clinical Indicators for Instrumental Assessment of Dysphagia, was rescinded in 2017. Please see ASHA’s Practice Portal & Dysphagia Evidence Map.

References

Canon, D. (2016, February). Dysphagia: Misused and Misunderstood, A Radiologist’s Perspective. Session presented at the Post-Graduate Course at the Dysphagia Research Society 24th Annual Meeting, Tucson, AZ.

Carnaby, G. (2016, February). Promoting Evidence and Standards in Clinical Assessment. Session presented at the Post-Graduate Course at the Dysphagia Research Society 24th Annual Meeting, Tucson, AZ. 

Coyle, J.L. (2014, April). IIS5: Dysphagia Interventions: Are We Treating the Bolus, the Patient, or Something Else? Seminar presented at the Healthcare & Business Institute of the American Speech-Language-Hearing Association, Las Vegas, NV.

Dua, K. (2015, March). Session III: Gastroenterology: Endoscopic Management of Refractory Benign Esophageal Strictures: Tools and Techniques. Session presented at the Post-Graduate Course: Integrating the Art and Science of Swallowing with Technology at the Dysphagia Research Society 23^rd Annual Meeting, Chicago, IL.

Fujiu, M., & Logemann, J. A. (1996). Effect of a tongue-holding maneuver on posterior pharyngeal wall movement during deglutition. American Journal of Speech-Language Pathology, 5(1), 23-30.

Gaziano, J., Hendrick, A., Tabor, L., Richter, J. & Plowman, E. (2015, March). Poster #28: Prevalance, Timing and Source of Aspiration in Individuals with ALS. Poster presented at the Dysphagia Research Society 23^rd Annual Meeting, Chicago, IL.

Langmore, S. (2016, February). Fiberoptic Endoscopic Evaluation of Swallowing. Session presented at the Post-Graduate Course at the Dysphagia Research Society 24th Annual Meeting, Tucson, AZ.

Martin-Harris, B., Brodsky, M.B., Michel, Y., Castell, D.O., Schleicher, M., Sandidge, J., Maxwell, R. & Blair, J. (2008). MBS measurement tool for swallow impairment – MBSImP: Establishing a standard. Dysphagia, 23, 392-405.

Miles, A., Jardine, M., Clark, S. & Allen J. (2015, March). Scientific Paper Presentations VII – Physiology: Pharyngeal and Esophageal Bolus Transit Times in Healthy Adults. Paper presented at the Dysphagia Research Society 23^rdAnnual Meeting, Chicago, IL.

O’Rourke, A., Lazar, A., Murphy, B. & Martin-Harris, B. (2015, March). Scientific Paper Presentations VI – Patient Care: Utility of Esophagram versus High Resolution Manometry in the Detection of Esophageal Dysmotility. Paper presented at the Dysphagia Research Society 23^rd Annual Meeting, Chicago, IL.

Steele, C.M., Peladeau-Pigeon, M. Tam, K.L., Zohouri-Haghian, N. & Mukhurjee, R. (2015, March). Poster #97: Variations in Sip Volume as a Function of Pre-Sip Cup Volume. Poster presented at the Dysphagia Research Society 23^rd Annual Meeting, Chicago, IL.