Functional Assessment of Swallowing

Maggie A. Kuhn

Peter C. Belafsky

Dysphagia is common and costly. The prevalence of swallowing disorders in adults over 50 ranges from 7% to 22% (1,2), with estimations as high as 50% in high-risk individuals (3). Dysphagia affects 30% of patients in hospitals and as many as 75% of individuals in nursing homes. Risk factors for dysphagia are numerous and include advancing age, acid reflux, stroke, head and neck cancer, head injury, amyotrophic lateral sclerosis, pseudobulbar palsy, Alzheimer disease, Parkinson disease, multiple sclerosis, muscular dystrophy, and myasthenia gravis. Dysphagia is a leading cause of death in most of these disorders (4,5). The incidence of dysphagia after stroke has been reported to be as high as 81% (3,6). Concurrent chemoradiation for head and neck cancer is associated with a 45% incidence of prolonged feeding tube-dependent dysphagia and an incidence rate for aspiration of 59% (7,8). Complications of dysphagia include malnutrition, dehydration, aspiration pneumonia, pulmonary abscess, and death. In 2001, the yearly expenditure for an individual dependent on tube feeding was $30,000 and Medicare spent 6% of its annual durable medical equipment budget ($670 million) on enteral feeding supplies alone. The cost of treating community-acquired pneumonia in the United States is $4.4 billion annually. The otolaryngologist is frequently the first specialist consulted to evaluate individuals with dysphagia. The purpose of this chapter is to review the indications and techniques for the functional assessment of swallowing.

DYSPHAGIA SYMPTOM INDICES

Dysphagia is a symptom not a disease. The symptoms of dysphagia can range from the isolated sensation of a lump in the throat to profound swallowing dysfunction and complete dependence on nonoral tube feedings. A significant percentage of patients reporting dysphagia will have no objective evidence of swallowing dysfunction. In addition, some patients with profound swallowing dysfunction will report only mild symptoms. Because dysphagia is frequently a symptom-driven disease, it is important to be able to accurately quantify the severity of the patient’s complaints. The 10-item Eating Assessment Tool (EAT-10) is a validated self-administered diseasespecific symptom inventory for dysphagia (Table 57.1) (9). It has proven useful in assessing initial symptom severity and in monitoring treatment efficacy. It has recently been translated into Spanish, Chinese, Japanese, and Portuguese. Dysphonia and reflux often accompany the symptom of dysphagia, and all patients presenting to our center also receive the 10-item Voice Handicap Index and the 9-item Reflux Symptom Index (Tables 57.2 and 57.3) (10,11).

CLINICAL SWALLOW EVALUATION

The clinical swallow evaluation (CSE) is used for the initial assessment of patients with dysphagia. Simply stated, the CSE consists of a comprehensive deglutitionfocused history and physical as well as observing patients as they consume food or liquid. The study is usually performed before proceeding with a diagnostic instrumental swallowing examination as it helps assess and direct the need for further instrumental assessment. The CSE is indicated in patients reporting dysphagia or in individuals with suspected swallowing dysfunction suggested by weight loss, vocal fold immobility, malnutrition, history of prolonged intubation, dementia, head injury, head and neck cancer, recent cardiothoracic or head and neck surgery, stroke, or progressive neurologic disease.

The CSE begins with a comprehensive medical and feeding history from the patient, family member, or collateral source if the patient is incapable of communicating. The history begins with details of the patient’s complaint or indication for the referral. It is important to review the
primary medical diagnosis, past medical and surgical history, comorbid conditions, and medications. A directed review of systems should focus on the presence of any tubes as well as the patient’s airway, pulmonary, gastrointestinal, and neurologic status. History of prior speech or swallow dysfunction and any therapy or medical treatment received is elicited. Attention should also be paid to the individual’s psychiatric and cognitive status, memory, and social history.

TABLE 57.1 THE EATING ASSESSMENT TOOL-10

To What Extent are the Following Scenarios Problematic for you?		0 = No Problem, 4 = Severe Problem
1.	My swallowing problem has caused me to lose weight.	0	1	2	3	4
2.	My swallowing problem interferes with my ability to go out for meals.	0	1	2	3	4
3.	Swallowing liquids takes extra effort.	0	1	2	3	4
4.	Swallowing solids takes extra effort.	0	1	2	3	4
5.	Swallowing pills takes extra effort.	0	1	2	3	4
6.	Swallowing is painful.	0	1	2	3	4
7.	The pleasure of eating is affected by my swallowing.	0	1	2	3	4
8.	When I swallow food sticks in my throat.	0	1	2	3	4
9.	I cough when I eat.	0	1	2	3	4
10.	Swallowing is stressful.	0	1	2	3	4
Total EAT-10

The feeding history helps the clinician establish a differential diagnosis and identify the site of suspected swallowing dysfunction. It begins with a thorough description of the patient’s current feeding practices, specifically the type and amount of substances consumed, methods of feeding (straw, cup, utensils) and timing (duration and frequency) of feeding. Details regarding the onset and severity of the swallowing problem are elicited. When and where the problem occurs, localization of the problem, presence of coughing, choking, pain (odynophagia) or sticking, associated weight loss as well as the impact on the individual’s quality of life are assessed. A patient’s report of “cervical” dysphagia is unreliable, however, as 30% of individuals localizing the swallowing dysfunction to the neck will have a primary esophageal etiology
for their symptom. Alternatively, an individual localizing the dysphagia to the chest will almost always have an esophageal phase swallowing disorder. The effect of diet modification such as food consistency, lubrication, temperature, timing, and postures should also be noted. In general, solid food dysphagia suggests an obstructive problem whereas liquid dysphagia suggests a neurologic disorder.

TABLE 57.2 THE VOICE HANDICAP INDEX (VHI-10)

Check the appropriate response.			Date:
1. My voice makes it difficult for people to hear me.
□ Never	□ Almost never	□ Sometimes	□ Almost always	□ Always
2. People have difficulty understanding me in a noisy room.
□ Never	□ Almost never	□ Sometimes	□ Almost always	□ Always
3. My voice difficulties restrict personal and social life.
□ Never	□ Almost never	□ Sometimes	□ Almost always	□ Always
4. I feel left out of conversations because of my voice.
□ Never	□ Almost never	□ Sometimes	□ Almost always	□ Always
5. My voice problem causes me to lose income.
□ Never	□ Almost never	□ Sometimes	□ Almost always	□ Always
6. I feel as though I have to strain to produce voice.
□ Never	□ Almost never	□ Sometimes	□ Almost always	□ Always
7. The clarity of my voice is unpredictable.
□ Never	□ Almost never	□ Sometimes	□ Almost always	□ Always
8. My voice problem upsets me.
□ Never	□ Almost never	□ Sometimes	□ Almost always	□ Always
9. My voice makes me feel handicapped.
□ Never	□ Almost never	□ Sometimes	□ Almost always	□ Always
10. People ask, “What’s wrong with your voice?”
□ Never	□ Almost never	□ Sometimes	□ Almost always	□ Always

TABLE 57.3 THE REFLUX SYMPTOM INDEX

Within the Last Month, how did the Following Problems Affect you?	0 = No Problem, 5 = Severe Problem
1. Hoarseness or a problem with your voice	0	1	2	3	4	5
2. Cleaning your throat	0	1	2	3	4	5
3. Excess throat mucous or postnasal drip	0	1	2	3	4	5
4. Difficulty swallowing food, liquids, or pills	0	1	2	3	4	5
5. Breathing difficulties or choking episodes	0	1	2	3	4	5
7. Troublesome or annoying cough	0	1	2	3	4	5
8. Sensations of something sticking in your throat or a lump in your throat	0	1	2	3	4	5
9. Heartburn, chest pain, indigestion, or stomach acid coming up	0	1	2	3	4	5
Total

The clinician then performs the examination and observation portion of the CSE. Minimal equipment is required and includes a tongue blade, light source, food, and liquid as well as feeding devices such as a spoon, syringe, or straw. It is useful to have suction available during the observed swallow.

General characteristics of the patient are assessed including level of alertness, ability to participate in the examination as well as overall posture and tone. Careful attention should be paid to the patent’s articulation, resonance, voice quality, and pitch. A wet vocal quality suggests laryngeal penetration and difficulty managing saliva. The presence of dysarthria or hypernasality is an ominous sign and frequently indicates a progressive neurologic disorder. The rate and quality of breathing as well as the presence of a tracheotomy are noted.

Evaluation of the oral cavity and oropharynx includes inspection of the lips, tongue, jaw, teeth, and palate for general structure, quality, symmetry, and sensation. Voluntary movement of the jaw, tongue, lips, and velum is assessed with particular attention to strength, symmetry, accuracy, and range of motion. A tongue blade is used to elicit a gag reflex by touching the tonsillar pillar or tongue base. A normal response involves tongue protrusion, pharyngeal contraction, and jaw extension. The relationship between an intact gag reflex and safe swallowing function, however, has been brought into question (12). Other involuntary movements such as the transverse tongue reflex (lateral tongue motion in response to tactile stimulus on the lateral tongue border) may be assessed. The abnormal presence of primitive reflexes (biting, routing) should be noted. The oral cavity is inspected for the presence, quality, and quantity of secretions.

The remaining structures of the pharynx and larynx are hidden from direct examination during the CSE. The clinician may assess the suppleness of the neck musculature and the movement of the larynx during a dry swallow. If the larynx does not palpably elevate with swallowing, the patient will have a diminished ability to open the upper esophageal sphincter (UES) and deglutition may be affected. The patient is asked to cough and throat clear to confirm the presence of these protective mechanisms. Though the subjective evaluation of cough strength and quality have not been shown to accurately predict swallowing dysfunction (13), objective aerodynamic measures, particularly expiratory phase peak flow during voluntary cough, are associated with penetration and aspiration among those with neurologic disorders (14,15).

For observed swallowing trials, ice chips, water, or food is selected by the clinician based on the suspicion for aspiration given the patient’s history and physical examination. Use of straws, utensils, and syringes may be used by the patient or examiner to facilitate entry into the mouth. The patient’s ability to hold the bolus in the oral cavity is assessed and is best accomplished with pureed and solid foods. During and immediately following the swallow, the examiner monitors for cough, repeated swallows, wet vocal quality, and voice changes. The effort required for swallow as well as a rough timing of the swallow can be assessed. Only one swallow should be required to pass an administered bolus. The presence of a second or third swallow for a single bolus suggests disordered swallowing.

The clinical swallow evaluation serves a variety of purposes. Most critically, it attempts to identify those at risk for aspirating oral intake. Its accuracy for this task is disputed and continues to be studied. The CSE has been criticized for its inability to detect pharyngeal phase swallowing dysfunction and for its poor sensitivity in predicting aspiration (16). Silent aspiration, by definition, is identified only by direct observation of the pharyngeal
phase of swallowing and is reported in up to 59% of dysphagic patients (17). The consequences of missed aspiration on CSE may be significant (18). Videofluoroscopic swallow studies (VFSS) and flexible endoscopic evaluation of swallowing (FEES) may detect silent aspiration in one-quarter to one-third of individuals missed by CSE (19,20,21). When compared with FEES to evaluate dysphagic patients following acute stroke, the presence of two or more positive findings on CSE has revealed a sensitivity for aspiration of 86% and a specificity of only 30% (22). Adding pulse oximetry to a water swallow may improve the sensitivity for aspiration in acute stroke patients (23). Daniels et al. (24) retrospectively reviewed acute stroke patients with fewer than two positive findings on CSE and found that they had no increased risk of poor outcome, namely aspiration pneumonia, than their counterparts who underwent VFSS. However, given the morbidity associated with aspiration, the CSE yields unacceptably high false negative and positive rates to be an effective unimodality screening exam or reliable diagnostic tool for swallowing dysfunction. Dysphagic patients with an abnormal CSE or those with a normal CSE who are at a high risk of aspiration will require further evaluation with an instrumental assessment of swallowing function.

FLEXIBLE ENDOSCOPIC EXAMINATION OF SWALLOWING/FLEXIBLE ENDOSCOPIC EVALUATION OF SWALLOWING WITH SENSORY TESTING

FEES was first described by Susan Langmore et al. (25) in 1988. The study provides direct visualization of the pharynx and larynx immediately before and after a swallow. The equipment required to perform FEES includes a flexible endoscope, viewing monitor, recording equipment, and commercially available food testing materials. Although the examination requires an endoscope and recorder, technologic advances and equipment miniaturization allow the study to be performed in the clinic or at the bedside in a hospital or nursing home setting. The examination can be performed by a solo practitioner but it is easier to have an assistant available to help feed the patient.

The patient is seated upright in a position appropriate for eating. Topical nasal anesthesia is commonly avoided although standardized doses of atomized saline, oxymetazoline, and cocaine have not been shown to have an effect on laryngopharyngeal (LP) sensory thresholds (26). The endoscope is passed through the more patent nasal cavity. The velum and ability of the palate to close against the posterior nasopharyngeal wall is evaluated. The velopalatal port should close completely and can be assessed with a swallow, hum, or nasal phoneme. After assessing the palate, the symmetry of the pharynx at rest and the quantity of pooled secretions in the pyriform sinuses and endolarynx is assessed. Pooled saliva in the pyriforms suggests profound swallowing dysfunction and is predictive of the presence of aspiration (27). The larynx is inspected for lesions, inflammation, and vocal fold mobility. Vocal fold movement is assessed with the patient performing the “/eee/-sniff” maneuver. Vocal fold immobility is highly predictive of aspiration and nearly 25% of individuals with unilateral immobility will aspirate thin liquids (28). The endoscope is positioned in the “home” position in the pharynx just above the tip of the epiglottis (Fig. 57.1). The patient’s ability to close the supraglottis and protect the airway is assessed with the breath hold maneuver. The degree of pharyngeal muscular contraction is evaluated by having the patient perform the pharyngeal squeeze maneuver (PSM) (29). The patient is instructed to deliver a voluntary, forceful, high-pitched “/eee/,” and pharyngeal muscular contraction is evaluated by assessing the motion of the lateral hypopharyngeal walls and corresponding narrowing of the pyriform sinuses (Fig. 57.2). The PSM is classified as normal or abnormal only. Attempts at quantifying the degree or laterality of pharyngeal weakness with the PSM have lacked reproducibility (30). The PSM has been validated with objective assessments of pharyngeal strength on fluoroscopy (31). Patients with an absent PSM are significantly more likely to aspirate. After the assessment of pharyngeal strength, LP sensory testing is performed.

The addition of sensory testing to the FEES procedure is termed flexible endoscopic evaluation of swallowing with sensory testing (FEESST). FEESST directly evaluates LP sensation by assessing the ability of a tactile stimulus to elicit the laryngeal adductor reflex (LAR) (32

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May 24, 2016 | Posted by drzezo in OTOLARYNGOLOGY | Comments Off

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