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Your first swallow assessment – What to expect

doctor_visit

[Editors note. This article was a collaborative effort by Sharon C. Meier, MS CCC-SLP (Able Speech and Voice in Osprey, Florida), Jan Pryor, MA CCC-SLP BCS-S, and Ellen Conover, MS SLP. Part one is from the patient’s perspective of what to expect during an initial swallowing evaluation; part two is from the therapists’ vantage and provides a list of symptoms that may have precipitated this initial visit along with additional information on what the therapist is assessing. NFOSD would like to thank each of our contributing authors.]

The patient’s perspective

The first visit starts the minute we meet. Are you ambulatory (able to walk), alone or with another? As we walk toward the therapy room, dining room or kitchen table we talk.  I subjectively assess cognition (attention, memory, problem solving), vocal quality, pragmatics (social appropriateness in communication) and medical concerns.  We discuss recent doctor visits. I assess posture, stature and proportional weight.  We converse while establishing rapport.  I ask if you are having eating, chewing and or swallowing issues.

I explain that I will look into their mouths and then watch you breathe, eat, chew and swallow some different food items. If possible, your own kitchen is the BEST place for collecting this information and observing you. I ask about pill taking behaviors. I ask about respiratory or “breathing” activities associated with daily living skills (those reported to your doctor or not reported).  I listen to the quality of your cough, throat clear and vocal quantity and quality.

I look into your mouth for missing teeth, overall dental health, symmetry, strength and functionality of the oral and pharyngeal anatomy to process foods and liquids.

I take your oxygen levels at rest and after swallowing.

I may listen, watch and feel for pain during a dry swallow using a stethoscope.  I listen, watch and feel your breath with your cheeks puffed.

I then proceed to talk about food preferences and difficulties.

I watch, listen and feel the rise and fall of your larynx as we trial foods and liquids of varying consistencies. I ask about prior swallowing exams and finding.

We then discuss my observations and talk through a set of recommended next steps.

The Speech Language Pathologist’s (SLP’s) perspective

Seeing a swallowing specialist for the first time will vary depending on a person’s referral symptoms.  These symptoms may include:

–        Difficulty extracting food/liquid (from utensil or cup)

–        Difficulty chewing food

–        Difficulty initiating a swallow

–        Holding food in the cheeks

–        Remaining food in the mouth after swallowing

–        Frequent coughing/choking/throat clearing during meals

–        Globus – feeling of food/liquid “sticking” in the throat

–        Oral regurgitation – spitting out/vomiting food/liquid

–        Nasal regurgitation – when food/liquid exits through the nose

–        Reliance on liquid in order to swallow solid food

–        Increased time to complete meal

–        More subtle symptoms (listed below) which, combined with clinical signs (recurrent respiratory tract infections, diagnosis of aspiration pneumonia, chronic cough, fever of unknown origin), may also suggest a referral for a swallowing evaluation

  • Increased saliva production/drooling
  • Indifference or resistance to eating
  • Changes in taste
  • Vocal changes (gurgly)
  • Shortness of breath
  • Unanticipated weight loss
  • Mental status changes

These symptoms may impact a person’s quality of life.  They may lead to

–        Aspiration – when food, liquids or saliva enter the lower airway without being coughed out

–        Aspiration pneumonia – when chronic aspiration of food, liquid or saliva causes a pulmonary infection; this may be life-threatening

–        Dehydration

–        Malnutrition – due to fear/reluctance to eat

–        Unanticipated weight loss

–        Feelings of isolation – due to inability to participate in social interactions involved with eating

If you or someone you know is experiencing any of these symptoms, please contact your doctor to obtain a referral to a swallowing specialist immediately.  You may also research a BCS-S (Board Certified Specialist in Swallowing) in your area on our site at http://swallowingdisorderfoundation.com/links/ or email us at info@nfosd.com for additional help.

Typically, an initial appointment would involve a short interview where the SLP would gain case history regarding:

–        Present diet

  • Typical foods the person enjoys and/or avoids
  • Frequency of meals
  • Caloric intake

–        History of dysphagia

  • Symptoms the patient is experiencing
  • Onset, frequency, duration, and severity of symptoms
  • Unintended weight loss or reduced appetite

–        Any altered eating habits

  • Assistance eating
  • Modified food textures or avoidance of certain foods or liquids
  • Consumption of small, frequent meals
  • Postural adjustments to facilitate swallowing
  • Alternates solids and liquids
  • Takes small bites
  • Excessive chewing
  • Family history – neurologic history or history of dysphagia

–        Medical history

  • Current medications
  • Pulmonary history (frequent or recurrent bronchitis, history of pneumonia)
  • Medical diagnoses that may contribute to swallowing problems including, but not limited to:
  • Stroke
  • Parkinson’s
  • Amyotrophic Lateral Sclerosis (ALS)
  • Multiple Sclerosis
  • Muscular Dystrophy
  • Oral, Pharyngeal or Laryngeal cancer
  • Radiation therapy
  • Neurosurgery
  • Cervical Spine Disease
  • Chronic, Pulmonary Disease (such as COPD)
  • Gastroesophageal Reflux

The SLP will likely have the patient undergo an oral mechanism exam to evaluate the structure and function of the body parts involved in swallowing, which may include:

–        Performing different tasks with your face, lips and tongue such as saying “ah” to get the soft palate to elevate to test for strength, coordination and range of motion of the muscles involved in containing, chewing, manipulating and swallowing food.

–        Performing voice and speech tasks, such as sustaining a tone as long as possible and repeating syllables

–        The swallowing specialist may also observe the person swallow food and liquids, like water, applesauce or cracker or may request a person bring in food or liquids that cause swallowing problems in order to evaluate the swallowing first hand.

Based on the above, a speech language pathologist may provide the patient with a set of exercises, maneuvers or postures, change your diet texture and/or refer the patient for further evaluation. The most common include a: 1) Modified Barium Swallow Evaluation, and 2) Flexible Endoscopic Evaluation of Swallowing (FEES) exam. An article on what to expect during each of these exams will be posted in an upcoming NFOSD article.