Dysphagia 135by gently placing a tongue blade to the posterior region of the oral cavity. The gag ref lex provides
information about the patient’s oral sensory and motor status. At this stage, pharyngeal peristalsis,
in which the bolus is rhythmically moved by a squeezing motion of muscles, is initiated and
coordinated with other swallowing phases.
In the laryngeal- esophageal stage, assessment involves how well the patient protects the airway
during the swallow and the final movement of the liquid or bolus to the stomach. Velopharyngeal
closure, laryngeal elevation, and vocal cord closure are maintained, and the epiglottis covers the
glottis as a protective ref lex. Many of these functions cannot be observed during the clinical/
bedside evaluation, but information can be obtained by observing voice quality changes, throat
clearing, laryngeal elevation, and whether the patient has a productive cough.
The clinical/bedside evaluation has many limitations in detecting the safety and completeness
of a swallow. This is particularly true of silent aspiration, in which the patient aspirates without
coughing, gagging, or showing other signs that food or liquid has penetrated the lower airways.
With the clinical/bedside evaluation, there is always the risk of false positives and false negatives.
A false positive indicates that the patient has dysphagia when, in fact, he or she swallows normally;
a false negative suggests the opposite. False positives and false negatives can also occur with
instrumental assessments, but the likelihood of error is not as great.
Daniels, McAdams, Brailey, and Foundas (1997) found several factors predicting the severity of
dysphagia and the need for instrumental assessment: dysphonia, dysarthria, abnormal volitional
cough, abnormal gag ref lex, abnormal cough ref lex, cough after swallow, and voice change.
Based on cases involving dysphagia and medical malpractice litigation, it is suggested that an
instrumental swallowing evaluation be routinely conducted.
The clinical practice of artificially separating swallowing into as many as four in de pen dent
and distinct stages— that is, oral preparation, transportation, pharyngeal, and laryngeal-
esophageal—is misleading regarding the actual nature of chewing and swallowing. These
are artificial clinical distinctions used to evaluate the swallow, to show the need for radio-
logic evaluation, and for therapy purposes. The real ity is that people put food in their
mouths, chew, and then swallow it. Artificially dividing swallowing into several in de pen-
dent movements is analogous to viewing running as many in de pen dent movements. For
example, swallowing, as with running, cannot be completed by any of the acts occurring
in de pen dently. Running and swallowing are dynamic acts. When evaluating swallowing,
the bedside examination can only determine “pos si ble” structural, neurological, or mus-
cular deficiencies that may interfere with the movement of the bolus or liquid. There can
be no certainty that a patient will or will not choke or aspirate at any level or stage based
on clinical/bedside swallowing examination. If there is sufficient reason to believe that a
patient has compromised swallowing, regardless of the deficient stage, the prudent clinical
course is to conduct one or more instrumental evaluations of the sequentially occurring
swallow. Neglecting to conduct an instrumental evaluation of the swallow in cases of sus-
pected dysphagia is analogous to refusing to x- ray a leg for suspected fractures. (Tanner,
2003b, p. 86)Instrumental Dysphagia Diagnostics
According to the International Association of Logopedics and Phoniatrics (2015), several
instruments and tools can be used for dysphagia evaluations, including f lexible endoscopic
evaluation, transnasal esophagoscopy, manometry, and pH monitoring. Currently, the primary
instrumental procedure is f luoroscopy performed as part of a modified barium swallow study.
A video swallow study is conducted in the radiology department of the medical fa cil i ty. The
speech- language pathologist is pres ent when the patient swallows the barium liquid or paste.
The real- time image of the patient’s oral, pharyngeal, and laryngeal- esophageal movement of the