7.1 CLINICAL BEDSIDE SWALLOWING EXAM Flashcards
What are the two types of swallowing assessments?
Subjective
Objective
What are three subjective assessments of swallowing?
CSE (Clinical Swallowing Evaluation)
CBS (Clinical Bedside Swallow)
BSE (Bedside Swallow Evaluation)
Are subjective assessments of swallowing the same as screenings?
No - screenings check to see if more intensive assessment is required
What are we looking for in subjective assessments of swallowing?
Visible signs of aspiration
What can we not evaluate in subjective assessments of swallowing?
(2)
Silent aspiration
Root cause of swallowing issues (no visibility)
What are two objective measures of swallowing?
MBSS
FEES
What three things do we perform during the first swallowing exam?
Patient History (we want to know everything
Cranial Nerve Evaluation
Trial Swallows (What happens when pt. swallows?)
What is the purpose of a swallowing exam?
5
Determine candidacy for an instrumental evaluation
Detect possible laryngeal penetration/aspiration (Cough, Wet Voice, etc.)
Detect which textures are safe for the patient to swallow.
Monitor progress of therapy
Determine the possibility of upgrading recommendations.
What are the three major concerns in a Clinical Swallowing Evaluation?
Mental status
Nutritional status
Respiratory status
What do we want to make observations about during a swallowing evaluation?
(2)
Alertness (i.e., wakefulness and initial communication attempts)
Posture of the patient
In a swallowing evaluation, what would the presence of a feeding tube indicate?
At least partial alternative nutritional support
In a swallowing evaluation, what would the presence of suction equipment and/or drooling trigger?
Concerns regarding secretion management.
What is always a concern if the patient has a tracheostomy tube or labored breathing patterns?
Respiratory status
What kind of swallowing assessments are trach patients always referred to?
Objective swallowing assessment
What four things are we looking for when we ask for the patient’s history?
Patient symptoms
Past + current medical history
Previous swallowing assessments
Socio-cultural status
What Patient Symptoms do we want to know about in the history portion of a swallowing assessment?
(4)
Specific symptoms of ‘choking’ (Residue vs. Penetration)
Weight loss
Food going down the ‘wrong pipe’
Feeling of food getting stuck
What parts of the patient’s past and current medical history do we want to know about in the history portion of a swallowing assessment?
(5)
Neurological
ENT
GI exam
VF paralysis
GERD
Why do we want to know about Socio-Cultural Status for the history portion of a swallowing assessment?
To make sure we understand what the patient normally eats
What is our job to determine during a swallowing assessment?
What consistency patient can eat - everything else goes to the nutritionist
What facial nerves do we test during a swallowing examination?
Trigeminal
How do we test the Trigeminal Nerve (V) during a CN Examination?
(3)
Test facial sensation
Test corneal reflex
Feel the masseter muscles during jaw clench
How do we test facial sensation?
2
Use a cotton wisp and a sharp object to test sensation
Can use objects of different temperatures to test perception
How do we test the corneal reflex?
What are we observing?
By touching each cornea gently with a cotton wisp
Any asymmetries in the blink response
What nerves are involved in the the corneal reflex?
2
CN 5 (Trigeminal)
CN 7 (Facial)
How do we test the masseter muscles during jaw clench?
What are we observing?
By gently tapping on the jaw with the mouth slightly open
Symmetry of jaw opening.
How do we test the Facial Nerve (VII) during a CN Examination?
(2)
Look for asymmetry in facial shape
Check taste
How do we look for asymmetry in facial shape?
3+4
Examining depth of furrows such as the naso-labial fold.
Examining asymmetries in spontaneous facial expressions and blinking.
Ask patient to
- Smile - Puff out their cheeks - Clench their eyes tight - Wrinkle their brow
Why do we ask someone to puff out their cheeks?
To see if they can maintain adequate intraoral pressure
How do we check taste?
2
Using sugar, salt, or lemon juice on cotton swabs
Apply each to the lateral aspect of each side of the tongue
What kind of lesions cause single-sided weakness of the LOWER face?
Contralateral UMN lesion
What does Bilateral UMN Lesions cause?
Whole body spaticity
What kind of lesions cause weakness to one side of the face?
Ipsilateral LMN lesion
What kind of lesions cause weakness of the entire face?
Bilateral LMN lesion
How do we test the Glossopharyngeal Nerve (IX) during a CN Examination?
(3)
Palatal elevation and gag reflex
Symmetry of palate elevatation
Taste in posterior parts of the tongue
What nerves are involved when there is impairment in palate elevation and the gag reflex?
(3)
CN 9 (Glossopharyngeal)
CN 10 (Vegus)
The neuromuscular junction
Can we isolate that only the Glossopharyngeal Nerve (IX) is impaired?
No - too many other nerves are involved.
How do we test the Vegus Nerve (X) during a CN Examination?
2
Vocal functions (pitch, loudness change, quality)
Ability to cough voluntarily.
How do we test the Hypoglossal Nerve (XII) during a CN Examination?
(2)
Looking for atrophy or fasciculations (twitching)
Errors in articulation
How do we test for atrophy?
3
Ask patient to stick out their tongue and see if it curves to one side
Ask patient to move their tongue from side to side
Ask patient to push tongue forcefully against the inside of each cheek
What are atrophy or fasciculations (twitching) signs of?
LMN lesions
What consistencies do we use in trial swallows?
3
Thin: 5 mL—3 oz
Puree or pudding 5 mL
Solid
What are we observing during trial swallows?
5
Extent of laryngeal elevation (laryngeal palpitation)
Timing/completeness/number of swallows
Pre/Post voice quality
Coughing + clearing of the throat
Oral residue
What is Test Sensitivity?
How accurately a test identifies a true disorder
What is Test Specificity?
How accurately does test correctly identify those without a disorder
What are 3 Standardized CSE Tests?
Toronto Bedside Swallowing Screening Test (TOR-BSST)
Mann Assessment of Swallowing Ability (MASA)
Functional Oral Intake Scale (FOIS)
What does the Toronto Bedside Swallowing Screening Test (TOR-BSST) assess?
(3)
Voice quality
Lingual movement
Ability to manage water by teaspoon and cup.
What are two other common procedures done in a subjective swallowing assessment?
Auscultation
Dye test
What is Auscultation?
Placing a stethoscope over various parts of airway provide indirect evidence of aspiration
What is a Dye Test?
3
A few drops of methylene blue or vegetable coloring are placed in the mouth
The tracheotomy cuff is deflated
The tracheotomy tube is deep sanctioned for secretions that may have been resting on or above level of cuff.
What does the Dye Test do?
What is it also called?
Determines the presence of aspiration in a tracheotomized patient
Blue dye test
