Screening Tests in Evaluating Swallowing Function - Med

1 31 JMAJ, January / February 2011 Vol. 54, No. 1 Research and Reviews*1 Professor, Department of Rehabilitation, School of Allied Health Sciences, Kitasato University, Kanagawa, Japan.*2 Chief, First Section of Otorhinolaryngology, National Rehabilitation Center for Persons with Disabilities, Saitama, article is a revised English version of a paper originally published in the Journal of the Japan Medical Association ( , , 2009,pages 1747 1750). Screening Tests in Evaluating SwallowingFunctionJMAJ 54(1): 31 34, 2011 Satoshi HORIGUCHI,*1 Yasushi SUZUKI*2 AbstractDiagnosis of dysphagia begins with suspecting its presence. When dysphagia is suspected, patients with high riskshould be screened by means of simplified examinations for dysphagia. Many of these Screening Tests arerelatively easy to perform and provide a rough picture of the Swallowing to say, videofluorography and video endoscopic examination of Swallowing are the gold the other hand, highly sensitive, simple Screening Tests that lead to these examinations are extremely usefulwhen examining general outpatients, inpatients at the bedside, and in-home wordsDysphagia, Screening , AspirationIntroductionSwallowing movement is intended not only toobtain nourishment but also to protect the respi-ratory tract.

2 It is therefore important to under-stand dysphagia as a respiratory disorder whendiscussing dysphagia. We must be always awareof the possibility that severe dysphagia patientsmay develop respiratory disorder at any time,such as suffocation or Tests for dysphagia are intendedto select the patients who are strongly suspectedof dysphagia. Needless to say, videofluorographyand video endoscopic examination of swallowingare the gold standards. However, highly sensitive,simple Screening Tests that lead to these exami-nations are useful when examining general out-patients, inpatients at the bedside, and patientsin in-home paper mainly describes the screeningtests performed by the authors on a routine and AspirationAlthough aspiration is not present in all patientswith dysphagia, it is the most important symptomassociated with dysphagia. During early stagesof dysphagia, choking caused by aspiration is aconspicuous symptom that can be noticed objec-tively.

3 However, due attention must be paid sinceaspiration is not always associated with choking,as described at the end of this chocking or coughing occurs in associationwith eating, one must assess the timing of the symp-tom during a meal or Swallowing , the frequency,patient s postures, and the variations on the formof food, either through thorough interviews or byobserving during is a protective reflex induced by theentry of a food bolus (foreign matter) into thetrachea. It is experienced by anyone in some cir-cumstances, and in itself is not a pathologicalmovement. However, since choking obviouslyindicates entry of foreign matter into the lowerrespiratory tract, frequent choking provides a32 JMAJ, January / February 2011 Vol. 54, No. 1 Horiguchi S, Suzuki Ybasis for suspecting dysphagia. At the same time,the fact that the severity of choking (or cough-ing) does not relate to the severity of dysphagiashould be choking does suggest aspiration, anabsence of choking does not suggest an absenceof aspiration.

4 If the lower respiratory tract hasdeveloped hypoesthesia after long-term aspirationor due to other conditions, or if protective reflexof the respiratory tract has been reduced or lost,entry of foreign matter into the respiratory tractmay not induce choking. This is so-called silentaspiration, which we believe is more serious interms of the degree of for Simple Screening TestsAs would be the case with any other pathologicalcondition, an approach to dysphagia begins withsuspecting its presence. The diagnostic procedurefor dysphagia starts from collecting patient infor-mation through history-taking, visual examination,palpation, etc. Patients suspected of having dys-phagia proceed to the Screening Tests listed on test results, high-risk patients who arereasonably suspected of having dysphagia arescreened, and if necessary, these patients proceedto more thorough examination such as video-fluorography or video endoscopic examinationof Swallowing .

5 Table 1 shows the list of criteria forselecting patients with high risk of dysphagia,used by the otorhinolaryngologists often use a laryn-geal endoscope during examination in generalpractice, which allows monitoring of swallowingmovement. Below, we describe 6 Screening meth-ods that use no endoscope, which are thereforeavailable to physicians of other specialties orspeech therapists. When using any of the follow-ing methods in practice, one should make a com-prehensive judgment without insisting on anyone particular swallowingHumans repeat Swallowing at certain intervals inorder to dispose of saliva in the mouth, evenwhen not eating. This dry Swallowing is the basicmovement used to dispose of saliva. It is there-fore necessary to check if the patient can swallowwell before conducting any other Screening saliva Swallowing test (RSST)3 This test is intended to check the patient s abilityto voluntarily swallow repeatedly, which is highlycorrelated with aspiration.

6 The RSST is simpleand also relatively safe to the patient in a resting position, andwet the inside of the patient s mouth with coldwater. Instruct him/her to repeatedly swallowair, and monitor the number of swallows or more dry swallows within 30 seconds isconsidered normal. The number of swallows iscounted by the movement of laryngeal elevation,either visually or by swallow testWater is difficult to swallow for patients withdysphagia, especially in patients with static dys-phagia with poor food transport Function due tocerebrovascular or neuromuscular disease. ThisTable 1 Criteria for assessing the patients with high risk of dysphagia Positive results of Screening Tests Choking while eating, or prolonged coughing after eating Persistent malnutrition or dehydration Presence of wet hoarseness Has a tracheostomy tube The trunk support is poor and cannot maintain a sitting position for long Presence of a high lesion in the brain stem or bilateral high lesions due to cerebrovascular disease Has chronic respiratory disease Presence of gastroesophageal reflux Poor oral care, or ill-fitting dentures Taking psychotropics or other drugs that may affect Swallowing Being 65 years of age or older33 JMAJ, January / February 2011 Vol.

7 54, No. 1 Screening Tests IN Evaluating Swallowing Function test is intended to detect aspiration with highaccuracy by having the patient swallow Japan, 2 methods with different quantityof water have been widely advocated: One uses30 mL, and the other uses 3 mL (Ta ble 2). Accord-ing to the original method as proposed byKubota et al.,3 3mL of water should be used onthe first attempt, followed by additional 30 , since 30 mL of water poses greater riskfor patients at risk of aspiration, Saito4 describeda modified method that use 3 mL of water withclose monitoring of the patient s condition. Ineither method, the patient s Swallowing activityis monitored, and any choking is analyzed interms of its Tests also exist that use custard pud-ding or jelly to evaluate Swallowing water testThis test is used on tracheostomized patients. Thepatient is asked to swallow colored water tomonitor any leakage from the tracheostomy inci-sion.

8 To color water, dyes such as Evans blue,methylene blue, or crystal violet are often patients with a tracheostomy tube, placinga piece of thin gauze or a twisted paper stringbetween the tracheostomy incision and the tubemakes it easier to confirm leakage. When doingso, extreme caution must be exercised to preventsuch gauze or paper string from falling into theincision along with auscultation of swallowingCervical auscultation during or after swallowingallows noninvasive assessment of aspiration orthe presence of residual food in the 2 Procedure for water swallow testsWater swallow test (original version)[Procedure]The patient is asked to sit in a chair, and is handed a cup containing 30 mL of water at normal patient is then asked to Please drink this water as you usually do. Time to empty a cup is measured,and the drinking profile and episodes are monitored and assessed.

9 [Drinking profile]1. The patient can drink all the water in 1 gulp without The patient can drink all the water in 2 or more gulps without The patient can drink all the water in 1 gulp, but with some The patient can drink all the water in 2 or more gulps, but with some The patient often chokes and has difficulty drinking all the water.[Drinking episodes]Sipping, holding water in the mouth while drinking, water coming out of the mouth, a tendency to try toforce himself/herself to continue drinking despite choking, drinking water in a cautious manner, etc.[Diagnosis]Normal: Completed Profile #1 within 5 secSuspected : Completed Profile #1 in more than 5 sec, or Profile #2 Abnormal : Any cases of Profiles #3 through 5(Extracted from Kubota et )Modified water swallow test[Procedure]The patient is given 3 mL of cold water in the oral vestibule, and then instructed to swallow the possible, give more water and ask to swallow 2 more times, and the worst Swallowing activity is to beassessed.

10 If the patient meets Criteria #1 through 4, a maximum of 2 additional attempts (a total of 3attempts) should be made, and the worst assessment will be recorded as the final result.[Assessment criteria]1. Failed to swallow with choking and/or changes in breathing2. Swallowed successfully without choking, but with changes in breathing or wet hoarseness3. Swallowed successfully, but with choking and/or wet hoarseness4. Swallowed successfully with no choking or wet hoarseness5. Criteria #4, plus, 2 successful Swallowing within 30 sec(Extracted and modified from )34 JMAJ, January / February 2011 Vol. 54, No. 1 Changes in breathing sound (mostly expiratorysound) and presence of a respiratory murmur inthe pharynx after Swallowing are particularlyimportant in the assessment, such as moist sound,stenotic sound, wheezing, gargling sound, andliquid vibrating have been studies on Swallowing soundthat can be heard for a short time during swallow-ing.