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ACTA oToRhINolARYNgologICA ITAlICA 2007;27:299-305

Round Table S.I.o. naTIonal CongReSS

Clinical non-instrumental evaluation of dysphagia

La valutazione clinica non strumentale della disfagia

A. Ricci MAccARini, A. Filippini 1 , D. pADovAni 2 , M. liMARzi, M. loFFReDo 1 , D. cAsolino 2 Department of surgical specialities, otorhinolaryngology Unit, “Bufalini” Hospital, cesena; 1 Rehabilitation centre “luce sul Mare”, “Franchini” Hospital, santarcangelo; 2 Department of surgical specialities, otorhinolaryngology Unit, “s. Maria delle croci” Hospital, Ravenna, italy

SUMMARY

Clinical non-instrumental evaluation plays an important role in the assessment of the dysphagic patient. This evaluation, called “bedside examination”, aims to establish whether dysphagia is present, evaluating severity, determining the alterations which cause it, planning rehabilitation, testing outcome of treatment. The assessment takes into consideration anamnesis regarding the swallowing problem, evaluation of the anatomy and functionality, of sensitivity and the reflexes, of the swallowing apparatus. Finally, the oral feeding test is performed, which evaluates the oral and pharyngeal phases of swallowing. The examination performed in the neurologic patient is different from that performed in the patient submitted to ENT or maxillo-facial surgery.

KEY woRdS: deglutition • dysphagia • diagnosis • Bedside examination

RIASSUNTo

L’esame clinico non strumentale ha un importante ruolo nella valutazione del paziente disfagico. Tale valutazione, denominata “bedside examination”, ha come scopi: stabilire se è presente disfagia, valutarne la severità, definire le alterazioni che la provocano, programmare la riabilitazione, valutare i risultati del trattamento. La valutazione prevede l’anamnesi riguardante il problema di deglutizione, la valutazione dell’anatomia e della funzionalità, della sensibilità e dei riflessi, dell’apparato deglutitorio. Infine si esegue il test di alimentazione orale, che valuta le fasi orale e faringea della deglutizione. L’esame del paziente neurologico è differente rispetto a quello eseguito nel paziente operato di chirurgia ORL o maxillo-facciale.

PARolE ChIAvE: Deglutizione • Disfagia • Diagnosi • Esame obiettivo

Acta Otorhinolaryngol Ital 2007;27:299-305

Clinical non-instrumental evaluation plays an important

role in the assessment of the dysphagic patient 1-5 . This evaluation, called “bedside examination” 6 , aims to:

– establish whether dysphagia is present;

– evaluate the severity;

– determine the alterations which cause it;

– plan rehabilitation;

– test the outcome of treatment.

dysphagic patients can be divided into two different groups:

– neurologic patients 7 8 , when dysphagia is caused by stroke, cranial trauma, degenerative neurologic diseases, neurosurgical treatment;

– operated patients 9 10 , when dysphagia is caused by al- terations in the anatomical structures involved in swal- lowing, after ENT or maxillo-facial surgery.

The first step in the assessment is the anamnesis, which in- cludes:

– patient’s generic data (age);

– general conditions (nutritional situation, breathing func- tionality);

– neurologic diagnosis (stable, recurrent or degenerative disease);

– description of the surgical procedure on the upper diges-

tive-airways, in the case of dysphagic patient after onco- logic intervention of ENT or maxillo-facial surgery;

– breathing condition;

– vigilance level, neuropsychologic conditions (neurologic patient);

– communicative level (neurologic patient);

– feeding habit (preferences);

– quality of phonation and speech articulation;

– presence of hypersalivation;

– duration of the meal;

– social environment. The schedule used for the detection of data regarding the patient’s general conditions is shown in Table I. The next step concerns the morphodynamic evaluation (Ta- ble II) regarding:

– lips (opening, closing, kissing, cheek sufflating);

– tongue (motility, protrusion and backwards pushing);

– jaw;

– soft palate (cheek sufflating, vocalize with an /a/);

– larynx (morphology and movements of the vocal folds, glottic closure, elevation of the larynx);

– muscular control of the head.

Sensitivity is then evaluated (Table III) of the peribuccal zone (superficial and deep), the lips, the mouth, the tongue

299

A. Ricci Maccarini et al.

Table I. Schedule for general conditions of dysphagic patient.

 

Surname

Name

Date

of Birth (dd/mm/yy)

 

In

Date of Admission (day/month/year)

Diagnosis

 

Appearance of Dysphagia

 

GENERAL CONDITIONS

 

Neurological status:

watchful

watchful

less responsive

less responsive

coma

Neurological status: watchful less responsive coma

Cognitive status:

not evaluable

simple ordersCognitive status: not evaluable complex orders

Cognitive status: not evaluable simple orders complex orders

complex orders

Cognitive status: not evaluable simple orders complex orders

Communication:

absent

Communication: absent Yes/No not verbal   articulated answer

Yes/No

not verbalCommunication: absent Yes/No   articulated answer

not verbal
 

articulated answer

Communication: absent Yes/No not verbal   articulated answer

Attentive status:

not evaluable

limitedAttentive status: not evaluable good

goodAttentive status: not evaluable limited

Attentive status: not evaluable limited good

Status Cranial Nerves:

Notes:

Tracheostomy:

No

Tracheostomy: No Yes Previous

Yes

Tracheostomy: No Yes Previous

Previous

Tracheostomy: No Yes Previous

Tracheostomy tube (TT):

LPC

LPC
 

FEN

Tracheostomy tube (TT): LPC   FEN CFS

CFS

Tracheostomy tube (TT): LPC   FEN CFS

300

CFN

CFN

LGT

300 CFN LGT

Oxygen therapy:

No

Oxygen therapy: No Yes

Yes

Oxygen therapy: No Yes

Removal TT:

No

Removal TT: No Yes

Yes

Removal TT: No Yes

Duration of closure TT

Times

per day

 

TYPE AND MODALITY OF FEEDING (ADMITTANCE)

Dysmetabolism

AllergyDysmetabolism

Dysmetabolism Allergy Intollerance suspected
Intollerance suspected
Intollerance
suspected
Dysmetabolism Allergy Intollerance suspected

Ab ingestis in the past

No

Ab ingestis in the past No   Yes Date
 

Yes

Ab ingestis in the past No   Yes Date

Date

Weight

Height

normohydrated

Weight Height normohydrated dehydrated Oedema

dehydrated

Weight Height normohydrated dehydrated Oedema

Oedema

 

Feeding

Parenteral

Parenteral
dehydrated Oedema   Feeding Parenteral Enteral NGT partially totally   PEG

Enteral

Enteral NGT partially totally

NGT

Enteral NGT partially totally

partially

Enteral NGT partially totally

totally

Enteral NGT partially totally
 

PEG

  PEG partially totally

partially

  PEG partially totally

totally

  PEG partially totally

Oral (previous attempts)

 

partially

Oral (previous attempts)   partially totally

totally

Oral (previous attempts)   partially totally

of:

liquid

of: liquid semi-liquid solid soft-solid pre-chewed solid

semi-liquid

solid

of: liquid semi-liquid solid soft-solid pre-chewed solid

soft-solid

pre-chewed solid

“natural” solid

“natural” solid assisted under control autonomous

assisted

“natural” solid assisted under control autonomous

under control

“natural” solid assisted under control autonomous
autonomous

autonomous

Alimentary preferences

 

Date

Signature

“natural” solid assisted under control autonomous Alimentary preferences   Date Signature

Clinical non-instrumental evaluation of dysphagia

Table II. Schedule for morphologic evaluation of dysphagic patient (after Schindler 1 , modified).

Morphologic evaluation of dysphagic patient

Name

Trunk control

 

Head and neck control

Movements

Absent

Insufficient

Normal

Notes

Flexion

       

Extension

       

Rotation (right)

       

Rotation (left)

       

Tilt (right)

       

Tilt (left)

       

Notes

301

Lips

At rest (with pathology)

(VII CN)

Amimic

Deviation

Atrophy

Hypotonia

Hypertonia

Contracture

Dyskinesia

Sialorrhoea

Movements

Absent

Insufficient

Normal

Notes

Open

       

Extension/Smile

       

Protrusion/Kiss

       

Strength

Absent

Insufficient

Normal

Notes

Hold tongue depressor

       

Counter-resistance

       

Diadochokinesis

       

Notes

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A. Ricci Maccarini et al.

Evaluation of the patient with swallowing disorders Morphologic evaluation of dysphagic patient

Mandible at rest At rest (pathology) (V CN) Down Lock-out Movements Absent Insufficient Normal Notes
Mandible at rest
At rest (pathology)
(V CN)
Down
Lock-out
Movements
Absent
Insufficient
Normal
Notes
Lowering
Lateralization
Anteversion
Teeth
Dentition
Edentulous
partially
totally
Dentures
without dentures
Tongue
At rest (pathology)
(XII
CN)
Asymmetry
Hypotonia
Hypertonia
Tics
Deviation
Tremor
Enlarged
Retracted
Dyskinesia
Movements
Absent
Insufficient
Normal
Notes
Elevation
Protrusion
Lateralization
Counter-resistance
Absent
Insufficient
Normal
Notes
Vertical
Lateral (right)
Lateral (left)
Central
Diadochokinesis
Soft Palate
At rest (pathology)
(XII
CN)
Asymmetry
Dyskinesia
Movements
Absent
Insufficient
Normal
Notes
Symmetry
(during phonation)
Tension (duration)
Diadochokinesis
Date
Signature

Clinical non-instrumental evaluation of dysphagia

Table III. Schedule for evaluation of sensitivity and reflexes in dysphagic patient.

Surname

 

Name

………………………………………………………

 

R

L

R

L

R

L

Face:

soft touch

Face: soft touch pressure temperature
Face: soft touch pressure temperature

pressure

temperatureFace: soft touch pressure

temperature
Face: soft touch pressure temperature
Face: soft touch pressure temperature

Lips:

soft touch

Lips: soft touch pressure temperature
Lips: soft touch pressure temperature

pressure

temperatureLips: soft touch pressure

temperature
Lips: soft touch pressure temperature
Lips: soft touch pressure temperature

Tongue:

soft touch

Tongue: soft touch pressure temperature
Tongue: soft touch pressure temperature

pressure

temperatureTongue: soft touch pressure

temperature
Tongue: soft touch pressure temperature
Tongue: soft touch pressure temperature

Palate:

soft touch

Palate: soft touch pressure temperature v
Palate: soft touch pressure temperature v

pressure

temperaturePalate: soft touch pressure v

temperature
Palate: soft touch pressure temperature v

v

TASTE

Salted

Salted Acid Bitter Sweet

Acid

Salted Acid Bitter Sweet

Bitter

Salted Acid Bitter Sweet

Sweet

Salted Acid Bitter Sweet

FUNCTIONS AND REFLEXES

 

Pathologic reflexes

 

Bite reflexAND REFLEXES   Pathologic reflexes   Suction reflex Cardinal points’ reflex Normal Reflexes

Suction reflexREFLEXES   Pathologic reflexes   Bite reflex Cardinal points’ reflex Normal Reflexes Palatal reflex

Cardinal points’ reflexPathologic reflexes   Bite reflex Suction reflex Normal Reflexes Palatal reflex Vomitus reflex Cough reflex

Normal Reflexes

Palatal reflexSuction reflex Cardinal points’ reflex Normal Reflexes Vomitus reflex Cough reflex Deglutition reflex Cough:

Vomitus reflexCardinal points’ reflex Normal Reflexes Palatal reflex Cough reflex Deglutition reflex Cough: absent absent

Cough reflexreflex Normal Reflexes Palatal reflex Vomitus reflex Deglutition reflex Cough: absent absent

Deglutition reflexNormal Reflexes Palatal reflex Vomitus reflex Cough reflex Cough: absent absent inefficacious reflex

Cough:

absent

absent

Cough: absent absent inefficacious reflex voluntary inefficacious efficacious reflex voluntary efficacious  
Cough: absent absent inefficacious reflex voluntary inefficacious efficacious reflex voluntary efficacious  

inefficacious reflex

voluntary inefficacious

inefficacious reflex voluntary inefficacious

efficacious reflex

voluntary efficacious

efficacious reflex voluntary efficacious
 

Raclage:

absent

Raclage: a b s e n t inefficacious reflex efficacious reflex

inefficacious reflex

efficacious reflex

Respiration:

absent

apnoea

Respiration: absent a p n o e a voluntary inefficacious voluntary efficacious  
Respiration: absent a p n o e a voluntary inefficacious voluntary efficacious  
voluntary inefficacious

voluntary inefficacious

voluntary efficacious

voluntary efficacious

 

coord. apnoea deglut.

coord. apnoea deglut.
 

Water test

 

dry voice

inhalation:

Yes
Yes

No

 

wet voice

wet voice
 

gurgley voice

gurgley voice
 
 
 

Tongue-mouth-facial movements

Opening mouth Communication deficit
Opening mouth
Communication deficit

Aphasiamovements Opening mouth Communication deficit Anarthria Dysphonia Dysarthria Date tongue protrusion puff

Anarthriamovements Opening mouth Communication deficit Aphasia Dysphonia Dysarthria Date tongue protrusion puff out

DysphoniaOpening mouth Communication deficit Aphasia Anarthria Dysarthria Date tongue protrusion puff out Signature blow

DysarthriaOpening mouth Communication deficit Aphasia Anarthria Dysphonia Date tongue protrusion puff out Signature blow cluck 303

Date

tongue protrusion

Communication deficit Aphasia Anarthria Dysphonia Dysarthria Date tongue protrusion puff out Signature blow cluck 303

puff out

Communication deficit Aphasia Anarthria Dysphonia Dysarthria Date tongue protrusion puff out Signature blow cluck 303

Signature

blow

Communication deficit Aphasia Anarthria Dysphonia Dysarthria Date tongue protrusion puff out Signature blow cluck 303

cluck

Communication deficit Aphasia Anarthria Dysphonia Dysarthria Date tongue protrusion puff out Signature blow cluck 303

303

A. Ricci Maccarini et al.

Table IV. Schedule for evaluation of gustative stimulations in dysphagic patient.

CARD GUSTATIVE STIMULATIONS

Name

Date

Food

Taste

Consistency

Temperature

Quantity

Modality

304

REGISTRATION

Modification of swallowing (number, frequency, effectiveness, etc.)

Attentive modifications, vigilance, interference on contact and manifestation of conscience

and the soft palate (superficial, deep and thermic) and re- flexes are evaluated (especially in neurologic patients):

– normal (gag reflex, cough reflex);

– pathologic (bite, cardinal points, suction, swallowing);

– water test 11 , which is very useful and practical; it evalu- ates the characteristics of the voice after drinking some water. A dry, humid or gurgling voice may be present and it is possible to evaluate whether a cough caused by inhalation is present. Gustative function with specific stimulations is evaluated (Table IV). Finally, the oral feeding test is performed (Table V) which evaluates the oral phases of swallowing (suction and chewing) and the pharyngeal phase of swallowing, using

References

1 Schindler o. Manuale operativo di fisiopatologiafisiopatologia delladella degludeglu-- tizione. Torino: Ed. omega; 1990.

2 Schindler o, Ruoppolo g, Schindler A. Deglutologia. Torino:

Ed. omega; 2001.

3 Ruoppolo g, Amitrano A, virdia P, Romualdi P. Semeiotica generale. In: Schindler o, Ruoppolo g, Schindler A, editors. Deglutologia, Torino: Ed. omega; 2001. p. 97-109.

4 Schindler o, Raimondo S. Linee guida sulla gestione del paziente disfagico adulto in foniatria e logopedia. Torino:

Consensus Conference, 29 gennaio 2007. Acta Phoniatrica latina 2007;29:5-31.

5 logemann JA. Evaluation and treatment of swallowing disor- ders. San diego: College-hill Press; 1983.

6 lim Sh, lieu PK, Phua SY, Seshadri R, Uenketasubramanian N,

liquids (thin pipe, spoon, glass) semi-liquids, semi-solids. The assessment is different in the neurologic patient com- pared to the operated patient. In the former, we perform a scrupulous examination of motricity and reflexes and an evaluation is made of coordination, communicative possi- bilities and collaboration ability. In patients submitted to ENT or maxillo-facial surgery, an evaluation is made of the outcome of the surgical treatment on “oral-pharyngeal-oesophageal pulsive pump” func- tion which is moved by the tongue, the pharynx and the oesophagus, which squeezes the bolus from the mouth to the stomach, crossing five unidirectional valves: lips, ve- lum-pharyngeal sphincter, larynx; superior oesophageal sphincter, inferior oesophageal sphincter.

lee Sh, et al. Accuracy of bedside clinical methods compared with fiberoptic endoscopic examination of swallowing (FEES) in determining the risk of aspiration in acute stroke patients. dysphagia 2001;16:1-6.

7 logemann JA. Dysphagia: evaluation and treatment. Folia Phoniatr logop 1995;47:140-64.

8 Rago R, Perino C. La riabilitazione nei trauma cranio encefalico nell’adulto. Milano: Ed. ghedini; 1981.

9 Piemonte M. Fisiopatologia dellaella deglutizionedeglutizione. (Relazione Ufficiale XIv giornate Italiane di otoneurologia. Senigallia, 18 aprile 1997). Milano: Formenti Ed.; 1997.

10 Unnia l. Trattamento logopedicodico deldel pazientepaziente disfagicodisfagico adultoadulto. Torino: Ed.Ed. omega;oomega;mega; 1995.1995.1995.

11 de Pippo Kl, holas MA, Reding MJ. Validation of the 3-oz water swallow test for aspiration following stroke. Arch Neurol

1992;49:1259-61.

Table V. Schedule for oral feeding test in dysphagic patient.

Clinical non-instrumental evaluation of dysphagia

Surname

Name

………………………………………………………

Oral preparatory phase

L

SL

S

Difficulty of food entry
Difficulty of food entry

Difficulty of food entryL SL S Difficulty in keeping food in mouth Difficulty in chewing Persistence of food Difficulty

Difficulty in keeping food in mouth
Difficulty in keeping food in mouth

Difficulty in keeping food in mouthL SL S Difficulty of food entry Difficulty in chewing Persistence of food Difficulty in positioning

Difficulty in chewing
Difficulty in chewing

Difficulty in chewingDifficulty of food entry Difficulty in keeping food in mouth Persistence of food Difficulty in positioning

Persistence of food
Persistence of food

Persistence of foodDifficulty in keeping food in mouth Difficulty in chewing Difficulty in positioning of bolus Predeglutitory aspiration

Difficulty in positioning of bolus
Difficulty in positioning of bolus

Difficulty in positioning of bolusin keeping food in mouth Difficulty in chewing Persistence of food Predeglutitory aspiration Oral phase L

Predeglutitory aspiration
Predeglutitory aspiration

Predeglutitory aspirationin keeping food in mouth Difficulty in chewing Persistence of food Difficulty in positioning of bolus

Oral phase

L SL

S

Alteration of bolus protrusion to the pharynx, repetitively …Predeglutitory aspiration Oral phase L SL S Oral transit prolonged Bolus fall down in hypopharynx before

Oral transit prolongedof bolus protrusion to the pharynx, repetitively … Bolus fall down in hypopharynx before deglutition Aspiration

to the pharynx, repetitively … Oral transit prolonged Bolus fall down in hypopharynx before deglutition Aspiration
to the pharynx, repetitively … Oral transit prolonged Bolus fall down in hypopharynx before deglutition Aspiration
to the pharynx, repetitively … Oral transit prolonged Bolus fall down in hypopharynx before deglutition Aspiration
to the pharynx, repetitively … Oral transit prolonged Bolus fall down in hypopharynx before deglutition Aspiration

Bolus fall down in hypopharynx before deglutitionto the pharynx, repetitively … Oral transit prolonged Aspiration post-deglutition Pharyngeal phase S SL S

prolonged Bolus fall down in hypopharynx before deglutition Aspiration post-deglutition Pharyngeal phase S SL S
prolonged Bolus fall down in hypopharynx before deglutition Aspiration post-deglutition Pharyngeal phase S SL S

Aspiration post-deglutitionprolonged Bolus fall down in hypopharynx before deglutition Pharyngeal phase S SL S Alteration of deglutition

hypopharynx before deglutition Aspiration post-deglutition Pharyngeal phase S SL S Alteration of deglutition
hypopharynx before deglutition Aspiration post-deglutition Pharyngeal phase S SL S Alteration of deglutition

Pharyngeal phase

S

SL

S

Alteration of deglutition reflex:
Alteration of deglutition reflex:

Alteration of deglutition reflex:S SL S   In late Absent Aspiration post-deglutition

 

In late

  In late Absent

Absent

  In late Absent
Aspiration post-deglutition
Aspiration post-deglutition

Aspiration post-deglutitionS SL S Alteration of deglutition reflex:   In late Absent

Notes

305

Legend: S = Solid (biscuit); L = Liquid (milk/bilberry juice); SL = Semi-liquid (yogurt/jelly)

Date

Signature

Address for correspondence: dr. A. Ricci Maccarini, U.o. oRl, os- pedale “M. Bufalini”, viale ghirotti 286, 47023 Cesena, Italy. Fax +39 0547 352799.