Definition

Dysphagia

Difficulty swallowing foods or liquids, arising from the throat or esophagus, ranging from mild difficulty to complete and painful blockage.

Etiologies

ADULT SPEECH-LANGUAGE PATHOLOGY Name:

SWALLOWING CASE HISTORY ATTACHMENT Date of Birth:

Please describe the swallowing problem:

Onset of swallowing problem: □gradual □ sudden □past few weeks □past few months □ 6 – 12 months

□ over years

Has the problem changed over time? □ Improved □ Gotten worse □ Same

Have you received previous swallowing evaluations and/or treatment? □NO □ YES

If yes, list dates, name, location and phone number:

Please describe the consistency of foods and liquids you are currently eating:

□Regular foods □ Cut up or soft foods □ Finely chopped □ Puree

□Thin liquids □ Nectar thick liquids □ Honey thick liquids

□ Other Do you have a feeding tube? □ No □ Yes (date placed): Amount/type of feeding per day: How do you take Medication? Have you had a recent weight loss? □ No □ Yes # of lbs. over weeks/mos.

Describe your appetite: □Good □ Fair □ Poor

Do you have dietary restrictions or have you eliminated any foods from your diet?

□No □ Yes (Please state restrictions) Food Allergies □No □ Yes Please describe any management strategies you are using to swallow your

current diet:

Length of meal time: □ < 20 minutes □20 - 30 minutes □> 30 minutes

Do you require any assistance with your meals? □NO □ YES (describe)

Do you wear dentures? □ No □Yes Circle: Upper / Lower / Partial What is your current physical status? □ Walk □ Cane □ Wheelchair Can you support: your upper body? □No □ Yes head? □ No □Yes

Please describe your voice: □Normal □ Hoarse □Breathy □Weak □ No voice

Do you experience any of the following? (Check all that apply)

□ Poor morning voice quality □ Throat soreness or burning sensation not related to illness

□ Frequent throat clearing □ Coughing episodes not related to illness/swallowing

□ Increased phlegm in the throat □ Heartburn (If checked, how many times per week? )

□ Tastes repeating after meals □ Feeling of a lump in the throat when swallowing

□ Increased throat/mouth dryness □ Bad taste in the mouth (sour, acidic, metallic)

□ Frequent burping □ Unpredictable/variable voice quality during the day

□ Feeling of throat tightness □ Increased coughing when lying down

Do you take any medication for reflux? □No □ Yes

Please write down any additional information you feel will help us understand your swallowing problem:

Speech Pathologist’s Notes:

SPEECH-LANGUAGE PATHOLOGY- ADULT SWALLOWING CASE HISTORY ATTACHMENT- page 1 of 1

https://www.stonybrookmedicine.edu/sites/default/files/adult_swallowing_case_history_attachment_2.pdf

Pediatric Case History

• Case history, based on a comprehensive review of medical/ clinical records, as well as interviews with the family and other health care professionals.

• Assessment of overall physical, social, behavioral, and communicative development.

• Structural assessment of the face, jaw, lips, tongue, hard and soft palate, oral pharynx, and oral mucosa.

• Functional assessment of muscles and structures used in swallowing, including assessment of symmetry, sensation, strength, tone, range and rate of motion, and coordination of movement.

• Observation of head–neck control, posture, oral and pharyngeal reflexes, and involuntary movements and responses in the context of the child's developmental level.

• Observation of the child eating or being fed by a family member or caregiver using foods from the home and typically used utensils as well as utensils that the child may reject or that may be challenging.

• Functional assessment of swallowing ability, including but not limited to typical developmental skills and task components—suckling and sucking in infants, mastication in older children, oral containment, and manipulation and transfer of the bolus.

• Assessment of behavioral factors, including but not limited to (a) acceptance of pacifier, nipple, spoon, and cup and (b) range and texture of developmentally appropriate foods and liquids tolerated.

• Assessment of consistency of skills across the feeding opportunity to rule out any negative impact of fatigue on feeding/swallowing safety.

• Impression of airway adequacy and coordination of respiration and swallowing.

• Assessment of developmentally appropriate secretion management, which might include frequency and adequacy of spontaneous dry swallowing and ability to swallow voluntarily.

• Assessment of modifications in bolus delivery and/or use of rehabilitative/habilitative or compensatory techniques on the swallow.

• Consideration for interventions and referrals (e.g., medical or surgical specialists, nutritionist, psychologist or social worker, occupational therapist, physical therapist).

https://www.asha.org/practice-portal/clinical-topics/pediatric-dysphagia/#collapse_5

• Swallowing screening is a procedure to identify individuals who require a comprehensive assessment of swallowing function or a referral for other professional and/or medical services

• Individuals of all ages are screened as needed, requested, or mandated or when presenting medical conditions (e.g., neurological or structural deficits) suggest that they are at risk for dysphagia.

• The purpose of the screening is to determine the likelihood that dysphagia exists and the need for further swallowing assessment

• It is important to note that, currently, no bedside screening protocol has been shown to provide adequate predictive value for the presence of aspiration.

• During any screening process, the members of the patient care team may note proper posture and positioning for eating, as well as any potential sensory deficits that may affect swallowing.

ADDITIONAL ASSESSMENTS

During or following bolus delivery during per os (P.O.) trials including consistencies typically consumed by the patient in their natural environment, the SLP may assess

• labial seal, anterior spillage and evidence of oral control, including mastication and transit, manipulation of the bolus, presence of hyolaryngeal excursion as observed externally or to palpation, and time required to complete the swallow sequence;

• behavioral signs and symptoms, such as throat clearing or coughing before/during/after the swallow, which may not always be indicators of penetration and/or aspiration;

• the impact of fatigue and/or respiratory function on swallowing;

• changes to physiological status/vital signs/voice quality; and

• the patient’s use of additional equipment, as appropriate (e.g., adaptive drinking cups).

INSTRUMENTAL ASSESEMENTS

• Assess the anatomy and physiology of the structures involved in swallowing and to analyze and measure range of motion and coordination or timing of movement. Some inferences may be made concerning sensation and pressure generation of the swallowing mechanism.

• Determine the presence, cause, and severity of dysphagia by visualizing bolus control, the flow and timing of the bolus, and the individual’s response to bolus misdirection and residue.

• Visualize the presence, location, and amount of secretions in the hypopharynx and larynx the patient’s sensitivity to the secretions; and the ability of spontaneous or facilitated efforts to clear the secretions.

• Determine the presence and cause(s) of laryngeal penetration and/or aspiration.

• Determine with specificity the relative safety and efficiency of various bolus consistencies and volumes.

• Determine the presence of silent aspiration.

• Visualize the structures of the upper aerodigestive tract

Other instrumental procedures

• Ultrasonography involves the use of a transducer to observe movement of structures used for swallowing, such as the tongue and hyoid.

• High-resolution manometry is a technique used to measure pressures generated in the pharynx and esophagus.

OTHER DIAGNOSTICS

• Other diagnostic procedures performed by different medical specialists that yield information about swallowing function.

• These include procedures such as the esophagram/barium swallow, manofluorography, scintigraphy, 24-hr pH monitoring, and esophagoscopy.

Adult Dysphagia (asha.org)

• Each year, approximately one in 25 adults will experience a swallowing problem in the United States

• A number of epidemiologic reports indicate that the prevalence of dysphagia is more common among older individuals and that sarcopenia is positively associated with dysphagia

• As low as 3% in U.S. inpatients aged 45 years or older to as high as 22% in adults over 50 years of age.

• As high as 30% in elderly populations receiving inpatient medical treatment.

• Up to 68% for residents in long-term care settings.

• 13%–38% among elderly individuals who are living independently.

• Advanced age is a risk factor for aspiration pneumonia.

• A report by the Agency for Health Care Policy and Research (now the Agency for Healthcare Research and Quality) estimates that approximately one third of patients with dysphagia develop pneumonia and that 60,000 individuals die each year from such complications.

• The prevalence of dysphagia in community-dwelling adults over the age of 50 years is estimated to be somewhere between 15% and 22%), and in skilled nursing facilities, the prevalence rises to over 60%.

COMORBIDITY

• Amyotrophic lateral sclerosis (ALS) or Parkinson’s disease—ALS is also known as Lou Gehrig’s disease; as high as 90% in individuals diagnosed with Parkinson’s disease or amyotrophic lateral sclerosis .

• Critical illness—3% to 62% in patients recovering from a critical illness . One study found that 20.6% of patients diagnosed with COVID-19 suffered from dysphagia

• Dementia—13% to 57% .

• Endotracheal intubation—3% to 64%. Brodsky et al. looked more narrowly at dysphagia following endotracheal intubation for acute respiratory distress syndrome (ARDS) and found that 32% of patients reported clinically significant dysphagia symptoms.

• Gastroesophageal reflux disease (GERD)—approximately 14%

• Head and neck cancer—50% (oropharyngeal dysphagia) in patients with head and neck cancer, with these numbers increasing after chemoradiation treatment

• Intellectual disabilities (adult)—5% to 8%.

• Multiple sclerosis—24% to 58%

• Neurologic conditions requiring intubation—may be as high as 93% following extubation

• Parkinson’s disease—35% to 82%

• Sjögren’s syndrome—32% to 71%

• Systemic lupus erythematosus—2% to 25% of individuals with systemic lupus erythematosus

• Traumatic brain injury—38% to 65%

• Vocal fold immobility (unilateral)—55% to 69% immobility

• Whiplash injuries—2% to 28%

PEDIATRIC PREVALENCE

• According to the Centers for Disease Control and Prevention (CDC), survey interviews indicated that within the past 12 months, 0.9% of children (approximately 569,000) ages 3–17 years are reported to have swallowing problems.

• An estimated 116,000 newborn infants are discharged from short-stay hospitals with a diagnosis of feeding problems, according to the National Hospital Discharge Survey from the CDC (National Center for Health Statistics, 2010). Prevalence is estimated to be 30%–80% for children with developmental disorders

• Oropharyngeal dysphagia and/or feeding dysfunction in children with cerebral palsy is estimated to be 19.2%–99.0%. Rates increase with greater severity of cognitive impairment and decline in gross motor function

• The odds of having a feeding problem increase by 5 times in children with autism spectrum disorder (ASD) compared with children who do not have ASD

• ARFID rates are estimated to be 1.5%–13.8% in children between the ages of 8 and 18 years with suspected gastrointestinal problems or eating disorders

• Cases of ARFID are reported to have a greater likelihood in males and children with gastrointestinal symptoms, a history of vomiting/choking, and a comorbid medical condition

• Prevalence rates of oral dysphagia in children with craniofacial disorders are estimated to be 33%–83%

Pediatric Dysphagia (asha.org)

Esophageal Dysphagia

• A Sensation that food is lodged in the esophagus or windpipe

• Treated with swallowing excercises

Treatment Approaches and Principles

Important to consider and understand the underlying neurophysiological impairment and it's effect on the swallow function and deficits

Treatment via restoration (rehabilitative) and/or modification (compensatory)

Rehabilitative Techniques used is designed to create a habitual change and the intent to provide lasting functional improvement

Compensatory Techniques alter the swallow but does not create lasting functional change. Intention is to compensate for the deficiencies that could not or are not yet rehabilited sufficiently.

Some techniques may implement both rehabilitative and compensatory techniques

For the child: health and well-being is the primary concern. Family beliefs and holistic healing practices should be taken into consideration but may not be recommended. Treatment selections dependent on the child's age, cognitive and physical abilities, and specfic swallowing and feeding problems (e.g., changes in the environment or indirect treatment approach).

Pediatric Dysphagia ASHA (2021) and Adult Dysphasia ASHA (2021)