Clinical Bedside Swallow Exam

Question 1

What is the first thing you do when you begin a bedside swallow exam?

Answer 1

Collect clinical case history!

Question 2

What are the three components of a bedside swallow exam?

Answer 2

Case History
CN Exam/Physical Exam
Trial Swallows

Question 3

What are the two main client-reported symptoms we will hear?

Answer 3

“I feel like something is stuck in my throat” (residue)

“I keep coughing when I drink…eat…”

Question 4

What are the 4 purposes listed in class for a bedside swallow exam?

Answer 4

Determine candidacy for an instrumental evaluation.

Detect possible laryngeal penetration/aspiration.

It determines which textures are safe for the patient to swallow.

Used to monitor the progress of therapy and to determine the possibility of upgrading recommendations.

Question 5

When you first walk into a patient’s room what kind of observations should you be making?

Answer 5

Cues to three major concerns in a CSE—mental status, nutritional status, and respiratory status.

Making observations about alertness (i.e., wakefulness and initial communication attempts) and posture of the patient.

The presence of a feeding tube would indicate at least partial alternative nutritional support.

The presence of suctioning equipment and/or drooling trigger concerns regarding secretion management.

If the patient has a tracheostomy tube or labored breathing patterns, respiratory status is a concern.

Question 6

Why do you want to know if the patient is alert enough when you’re doing the swallowing exam?

Answer 6

They might not be focusing enough on their swallowing and so penetration or aspiration might occur but not due to a physiological deficiency.

Question 7

What are some topics you should ask about when collecting a case history?

Answer 7

Patient symptoms – Probe further in many instances

Specific symptoms of ‘choking’
Weight loss
Food going down the ‘wrong pipe’
Feeling of food getting stuck

Past and current medical history – Neurological, ENT, GI exam. Some specific concerns like VF paralysis, GERD need to be noted.

Any previous swallowing assessments

Socio-cultural status

Question 8

How can you test the Trigeminal nerve? (CN V)

Answer 8

Test facial sensation using a cotton wisp and a sharp object. Temperature perception.

The corneal reflex, which involves both CN 5 and CN 7, is tested by touching each cornea gently with a cotton wisp and observing any asymmetries in the blink response.

Feel the masseter muscles during jaw clench. Test for a jaw jerk reflex by gently tapping on the jaw with the mouth slightly open. Observe symmetry of jaw opening.

Question 9

How can you test the facial nerve? (CN VII)

Answer 9

Look for asymmetry in facial shape or in depth of furrows such as the nasolabial fold. Also look for asymmetries in spontaneous facial expressions and blinking. Ask patient to smile, puff out their cheeks, clench their eyes tight, wrinkle their brow, and so on.

Check taste with sugar, salt, or lemon juice on cotton swabs applied to the lateral aspect of each side of the tongue.

UMN lesions cause contralateral face weakness of lower part of the face.
LMN lesions typically cause weakness involving the whole ipsilateral face.

Question 10

UMN Lesions cause (?)contralateral/ipsilateral(?) face weakness of the (?)upper/lower(?) part of the face.

Answer 10

UMN lesions cause contralateral face weakness of lower part of the face.

Question 11

What kind of facial weakness is observed with LMN lesions?

Answer 11

LMN lesions typically cause weakness involving the whole ipsilateral face.

Question 12

How can we assess the function of the glossopharyngeal nerve? (CN IX)

Answer 12

Palatal elevation and gag reflex

Does the palate elevate symmetrically when the patient says, “Aah”? Does the patient gag when the posterior pharynx is brushed?

Palate elevation and the gag reflex are impaired in lesions involving CN 9, CN 10, the neuromuscular junction, or the pharyngeal muscles.

Taste in posterior parts of the tongue.

Question 13

What is a reflex?

Answer 13

A nonvoluntary motor response to a stimulus.

Question 14

How do we test the Vagus nerve? (CN X)

Answer 14

Vocal functions – pitch, loudness change, quality.

Ability to cough voluntarily.

Question 15

How do we test the Hypoglossal Nerve? (CN XII)

Answer 15

Note any atrophy or fasciculations. Ask the patient to stick their tongue out and note whether it curves to one side or the other. Ask the patient to move their tongue from side to side and push it forcefully against the inside of each cheek

Fasciculations and atrophy are typically signs of lower motor neuron lesions.

Lesions of the motor cortex (UMS) cause contralateral tongue weakness.

Look for errors in articulation (ones with the tongue)

Question 16

What is fasciculation?

Answer 16

Twitching of muscles due to atrophy.

Question 17

What kinds of consistencies are given in a bedside swallow trial?

Answer 17

Thin: 5 mL— 3 oz
Puree or pudding 5 mL
Solid

Question 18

What kind of observations can we make during a bedside swallow trial?

Answer 18

Laryngeal palpation – the extent of laryngeal elevation
Timing/completeness/number of swallows
Pre-post voice quality
Coughing/clearing
Oral residue

Question 19

If you observe any symptoms of aspiration or penetration at any level of consistency, what should you do?

Answer 19

Refer them for an objective exam.

Question 20

List three Standardized Clinical Bedside Swallow Exams.

Answer 20

Toronto Bedside Swallowing Screening Test (TOR-BSST) - assessment of voice quality, lingual movement, and ability to manage water by teaspoon and cup.

Mann Assessment of Swallowing Ability (MASA).

Functional Oral Intake Scale (FOIS).

Question 21

What are the two other procedures mentioned in class that you can do for a bedside swallow exam?

Answer 21

Ausculation:
Placing a stethoscope over various parts of airway provide indirect evidence of aspiration.

Dye test:
Also known as Blue dye test may be used to determine the presence of aspiration in a tracheotomized patient. A few drops of methylene blue or vegetable coloring are placed in the mouth, tracheotomy cuff is deflated, and the tracheotomy tube is deep sanctioned for secretions that may have been resting on or above level of cuff.

Question 22

What is ausculation?

Answer 22

Placing a stethoscope over various parts of airway can provide indirect evidence of aspiration.

Question 23

Describe the dye test.

Answer 23

Also known as Blue dye test may be used to determine the presence of aspiration in a tracheotomized patient. A few drops of methylene blue or vegetable coloring are placed in the mouth, tracheotomy cuff is deflated, and the tracheotomy tube is deep sanctioned for secretions that may have been resting on or above level of cuff.