Clinical Swallow Evaluation: A Guide for SLPs

Performing a thorough clinical swallow evaluation is foundational to diagnosing and managing dysphagia effectively. A clinical swallow evaluation combines keen observation, patient interaction, and structured assessment methods to identify swallowing disorders and inform appropriate interventions.

In this article, we will guide you through the key steps of a clinical swallow evaluation, providing practical strategies and insights for clinicians to uncover the underlying causes of dysphagia and develop tailored treatment plans.

The importance of a clinical swallow evaluation

An 85-year-old woman walks into an outpatient swallowing clinic for persistent difficulty swallowing. She comes out with a folder full of dietary suggestions, swallow strategies, tongue exercises, and swallowing exercises.

Despite receiving dietary suggestions, tongue and swallowing exercises, and strategies like the Masako Maneuver, she continues to experience a lump-in-the-throat sensation, food regurgitation, and unintentional weight loss. Her challenges highlight the need for a precise clinical swallow evaluation that identifies the root cause of her symptoms rather than merely addressing surface issues.

This case underscores the importance of a methodical approach, combining patient history, careful observation, and diagnostic tools, to uncover the true source of swallowing difficulties. In the next section, we’ll outline the essential steps of a comprehensive clinical swallow evaluation, providing a roadmap for accurate diagnosis and effective management.

From assessment to action: Conducting a clinical swallow evaluation

Step 1: Gathering background information

The swallowing specialist needs a complete understanding of a patient’s swallowing physiology before prescribing swallowing maneuvers and exercises. Without this critical step, there is a risk of treating symptoms rather than addressing their root cause.

If we miss the underlying cause for the difficulty swallowing, “we treat a symptom and not its cause.”¹ Dysphagia is not a disease in itself but rather a symptom of broader issues, often requiring a multidisciplinary approach to uncover and address the underlying dysfunction.

Start the evaluation process with a detailed investigation of the patient’s history and symptoms. This lays the groundwork for accurate diagnosis and effective treatment. Key actions include:

• Reviewing the medical record: Look for pre-existing conditions, surgeries, or medications that might affect swallowing physiology. For example, certain medications can cause dry mouth or reduced muscle function, contributing to dysphagia.
• Conducting interviews: Speak with the patient, caregivers, and medical team to understand the baseline swallowing status and any recent changes. These discussions can reveal critical insights, such as whether the patient experiences symptoms like coughing, regurgitation, or a lump-in-the-throat sensation.
• Tracking symptom evolution: Note how symptoms have progressed over time. Pay attention to patterns, such as difficulty with specific food textures or liquids, unintentional weight loss, or changes in appetite.

By combining this information, clinicians can begin to form a hypothesis about the underlying causes of dysphagia. This approach not only directs the clinical swallow evaluation but also ensures a holistic understanding of the patient’s condition, setting the stage for targeted and effective interventions.

Step 2: The bedside swallow evaluation

The bedside swallow evaluation is an extended assessment, not a screening, and serves as a critical step in understanding a patient’s swallowing mechanics in real time. Unlike many other clinicians who may spend only a few minutes with the patient, the speech-language pathologist often dedicates substantial time—more than 5-10 minutes—to thoroughly evaluate eating and swallowing. This level of attention is crucial for gathering meaningful insights.

During the bedside swallow evaluation, the SLP focuses on the following:

• Interview the patient:
  • Discuss symptoms, diet modifications, and lifestyle factors contributing to swallowing challenges.
  • Ask about their perception of swallowing difficulties (e.g., lump-in-throat sensation, choking episodes) to gather subjective insights.
• Assess cognitive and physical status:
  • Evaluate cognitive-linguistic abilities to determine the patient’s ability to follow instructions and engage in therapy.
  • Examine oral motor strength and coordination, noting deficits in lip closure, tongue mobility, or jaw function that could affect swallowing.
• Perform direct swallowing observation:
  • Introduce controlled volumes of different textures and consistencies (e.g., thin liquids, purees) to assess swallowing mechanics.
  • Observe for signs of aspiration, coughing, or delayed swallowing response.
  • Document compensatory strategies already in use, such as double swallows or chin tucks, and evaluate their effectiveness.
• Identify limitations:
  • Recognize that a bedside swallow evaluation provides valuable initial insights but does not offer information on pharyngeal or esophageal phases of swallowing.
  • Communicate the need for further instrumental testing if symptoms persist or if observations are inconclusive.

It is also important to acknowledge the inherent limitations of a clinical evaluation. As Dr. Stephen Leder, PhD, CCC-SLP, emphasizes, the bedside evaluation cannot reliably comment on pharyngeal and laryngeal anatomy, physiology, or bolus flow characteristics.² Silent aspiration cannot be ruled out, nor can recommendations for diets or swallowing interventions be made with complete confidence without instrumental confirmation.

By combining careful observation, patient interaction, and clear communication about the scope of the evaluation, the bedside swallow evaluation serves as an integral step in diagnosing and managing dysphagia effectively.

Step 3: Instrumental swallow examinations

Instrumental swallow examinations build on the clinical swallow evaluation, providing objective data to confirm or refine hypotheses. When no instrumental examinations are performed, treatment may not only be ineffective but could also be contraindicated, potentially worsening the patient’s condition. These assessments are critical for identifying the root cause of swallowing difficulties, guiding targeted interventions, and ensuring patient safety.

It is important to note that there is no gold standard in the instrumental assessment of swallowing. Each examination has unique strengths and limitations, and an informed clinician with a sound hypothesis will select the test that best answers the clinical questions. For instance, if oropharyngeal and esophageal dysphagia is suspected, the Modified Barium Swallow Study (MBSS) may be the most appropriate choice. Regardless of the type of instrumental examination, clinicians must look beyond aspiration or bolus movement and focus on understanding the underlying biomechanics of swallowing dysfunction.

Common instrumental assessments include:

• Modified Barium Swallow Study (MBSS):
  • Evaluates the oral, pharyngeal, and esophageal phases of swallowing using radiographic imaging.
  • Identifies biomechanical issues, such as delayed swallowing reflex or reduced muscle strength.
  • Assesses the effectiveness of compensatory strategies like the chin tuck or head turn during swallowing.
• Flexible Endoscopic Evaluation of Swallowing (FEES):
  • Provides a direct view of the laryngeal and pharyngeal structures via an endoscope.
  • Useful for identifying residue, penetration, and aspiration in real-time.
  • Allows for repeated trials to evaluate swallowing performance under various conditions and strategies.
• Esophageal sweep or esophagram:
  • Assesses esophageal motility and structural abnormalities that may contribute to dysphagia.
  • Can reveal issues such as esophageal stasis, retrograde flow, or narrowing that might be overlooked during an MBSS or FEES.

Instrumental testing is an essential component of the comprehensive evaluation process. It not only confirms clinical observations but also provides the data needed to tailor interventions effectively, ensuring they address the root cause of swallowing difficulties rather than just treating symptoms.

Step 4: Formulating treatment recommendations

Using the findings from the clinical and instrumental evaluations, develop an individualized treatment plan that addresses the root causes of the patient’s swallowing difficulties. A personalized approach is essential for improving outcomes, as dysphagia can result from a variety of physiological, neurological, or structural issues. Key components of the treatment plan include:

Swallowing exercises

• Design exercises to target specific muscle groups or improve coordination based on the identified deficits.
• For example, if reduced tongue base retraction is observed, exercises to strengthen the tongue base and improve bolus propulsion may be recommended.
• Incorporate exercises to address residue reduction, such as targeting areas where residue remained after swallowing and testing techniques that effectively clear it.

Compensatory strategies

• Introduce techniques such as the chin tuck, head turn, or effortful swallow to address specific swallowing challenges.
• Test strategies during instrumental assessments, using 2-3 trials for each method, to confirm their effectiveness in reducing aspiration or improving bolus clearance.
• Ensure strategies align with the patient’s unique needs and adjust based on their real-time performance during therapy sessions.

Diet modifications

• Adjust food textures and liquid consistencies to promote safe and efficient swallowing.
• Balance safety with quality of life by considering the patient’s preferences and goals when recommending diet changes.
• Recommend adjustments that reflect the patient’s goals of care, creating a spectrum of options from less restrictive modifications to, if necessary, nothing by mouth (NPO).

Referrals to specialists

• Collaborate with gastroenterologists, neurologists, dietitians, or other healthcare providers to address contributing factors.
• For instance, a gastroenterology referral may be needed if esophageal dysmotility or other structural abnormalities are identified.

Practical considerations

• Test the patient with natural drinking volumes, such as 20ml boluses or sequential drinking of 90-100ml, to mimic real-life situations.³ These tests can reveal subtle deficits that smaller sips may not expose, allowing for more accurate recommendations.
• Focus not just on aspiration risk but also on identifying why penetration or aspiration occurred and whether compensatory strategies were successful in mitigating it.
• Use findings from these tests to suggest restorative treatment plans, including exercises designed to strengthen the swallow and strategies to compensate for persistent difficulties.

For example, if the clinical swallow evaluation and instrumental tests reveal esophageal dysmotility, the treatment plan should focus on improving esophageal function. This might involve working with a gastroenterologist to address esophageal health and avoid interventions like pharyngeal exercises that could be ineffective or contraindicated.

A well-rounded treatment plan should not only address immediate swallowing concerns but also consider the patient’s long-term safety, nutritional needs, and quality of life. This collaborative and individualized approach ensures that interventions are meaningful and aligned with the patient’s overall health goals.

Step 5: Collaborating in a multidisciplinary approach

Swallowing disorders often arise from complex, multifactorial issues that benefit from collaboration across disciplines. Speech-language pathologists are instrumental in identifying contributing factors and facilitating coordinated care. Key components of this collaborative approach include:

• Consulting with dietitians: Address nutritional needs and manage concerns such as weight loss by developing tailored dietary plans.
• Referring patients to specialists: Engage otolaryngologists or gastroenterologists for advanced evaluations to address anatomical or physiological abnormalities.
• Addressing modifiable factors: Identify and resolve issues like dry mouth caused by medications or poorly fitting dentures that could exacerbate swallowing difficulties.
• Use findings to coordinate care: Share instrumental assessment results with team members (e.g., dietitians, gastroenterologists) to create a holistic care plan. For example, residue analysis or aspiration patterns may guide nutrition recommendations or suggest further medical intervention.

By working as part of a multidisciplinary team, SLPs help ensure that all aspects of the patient’s condition are addressed, leading to safer, more effective swallowing management and improved overall quality of life.

Building better outcomes through thorough evaluations

A detailed clinical swallow evaluation lays the groundwork for targeted and effective dysphagia management. Combining bedside assessments with instrumental testing ensures that interventions address not just symptoms but their root causes. Always ask, “What else?” and collaborate with the care team to improve swallowing safety and quality of life for your patients.

References

1. 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.
2. Leder, S. (2015, March). Session X: Clinical Conundrum: I Can Tell You About the Pharyngeal Swallow Without Looking. Session presented at the Dysphagia Research Society 23rd Annual Meeting, Chicago, IL.
3. 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 23rd Annual Meeting, Chicago, IL.