Spth 365 Dysphagia and Related Disorders: Diagnosis - PowerPoint PPT Presentation


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Spth 365 Dysphagia and Related Disorders: Diagnosis


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Title: Spth 365 Dysphagia and Related Disorders: Diagnosis

Spth 365 Dysphagia and Related Disorders
  • Lecture Seven
  • Other Diagnostic Examinations

The Diagnostic Dysphagia Exam
  • In general the modified barium swallow or
    videofluoroscopic swallowing study, is considered
    the 'gold standard' in swallowing evaluation.
    This is in part due to it's longevity and it's
    availability. However there are several other
    diagnostic techniques available that provide very
    valuable, and sometimes quite different,

  • Definition
  • Assessment of pressure dynamics of pharynx, UES
    and esophagus.
  • Provides information about
  • pharyngeal or esophageal pressure or tone
  • contraction of pharyngeal constrictors and their
    functional approximation to anterior pharyngeal
  • UES tone
  • the relationship between these events.
  • Can be paired with videofluoroscopy.....manofluoro
  • Greater anatomical interpretation of analog
    manometry signal.

  • Technique
  • Transnasal insertion of catheter housing
  • Exam is usually done by gastroenterologist
    Typically with some topical anesthesia.
  • Water perfusion manometry vs solid state
  • Strengths
  • No radiation exposure,
  • Lower costs
  • Provides information about functional effects of
    observed physiology
  • Weakness
  • Provides information on very few parameters of
  • Cannot evaluate the physiology directly.

  • Definition
  • Radionuclide scanning to assess distribution and
    quantity of radioisotope
  • Provides information about
  • Distribution of ingested materials amount of
  • Technique
  • Radionuclide scanning during and after ingestion
    of a radioactive bolus Technetium Sulphus
    Colloid 99.
  • Place radioactive markers on the skin to identify
    anatomical boundaries, have patient ingest bolus,
    then take an xray.
  • The radioactive isotope is displayed, indicating
    bolus volume and flow.

  • Strengths
  • Quantifies amount of radioactive tracer which you
    are unable to do with other instruments.
  • Most precise technique for documenting amount of
  • Therefore it is gaining in popularity as a tool
    for nursing home/geriatric patients.
  • Weakness
  • Expensive
  • Requires specialized nuclear medicine expertise.
  • Equipment is not frequently available

Scintigraphic image of aspirate into right lung.
Electroglottography EGG
  • Definition
  • device which measures the variable resistance to
    current flow between two electrodes placed over
    the larynx.
  • Provides information about
  • laryngeal excursion, vocal fold closure.
  • Can be used as a therapeutic biofeedback device.
  • Technique
  • Place transducers on either side of thyroid.
  • Signal is transmitted between the two with
    changes in impedence reflecting absence of or
    intervening laryngeal structures.
  • Thus when larynx elevates during swallowing, the
    EGG signal is displaced.
  • Primarily used in research.

  • Strengths
  • Non-invasive, inexpensive exam
  • Weaknesses
  • Provides limited information

  • Definition
  • Examination of electrical impulses produced by a
  • Provides information about
  • Onset and termination of muscle contraction
  • useful in determining resting tone of muscles
    (ie....UES hypertonicity, dennervation patterns,
    relative strength/symmetry)
  • Technique
  • Subcutaneous placement of electrodes directly
    into muscle tissue.
  • Measurements taken during functional activities.
  • Primarily used in swallowing research.
  • May be used to diagnose certain disease
    processes or plan surgical interventions.

  • Strengths
  • Provides very precise, analog information.
  • Only way to assess direct innervation.
  • Weaknesses
  • Invasive.
  • Difficulty in electrode placement of small
  • Surface EMG IS NOT A DIAGNOSTIC TOOL. Much more
    readily available but not diagnostic.

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  • Definition
  • Use of high frequency sound waves emitted into
    body and reflected back.
  • Density of tissue modulates sound wave reflection
  • Provides information about
  • Structure and functional location of soft
    tissues, particularly tongue surface/configuration
    and hyoid excursion.
  • With alternate transducer placement can visualize
    lateral pharyngeal wall displacement during
  • Some information about speech articulation.

  • Technique
  • Crystal transducer placed under the chin and
    physiology observed on screen during swallowing
  • Strengths
  • Noninvasive, no radiation
  • good application in pediatric population
  • Weaknesses
  • Very subjective interpretation
  • image is not clear,
  • expensive equipment with limited use.

Normal Tongue Sagittal View
Ultrasound images courtesy of Dr. Barbara Sonies,
Normal Tongue Coronal View
Ultrasound images courtesy of Dr. Barbara Sonies,
Asymmetrical Tongue Coronal View
Ultrasound images courtesy of Dr. Barbara Sonies,
Fiberoptic Endoscopic Evaluation of Swallowing
  • Definition
  • use of flexible endoscope to evaluate pharyngeal
    and laryngeal anatomy and physiology.
  • Provides information about
  • pharyngeal retention post swallow
  • asymmetry of bolus passage through pharynx
  • aspiration before the swallow
  • aspiration after the swallow
  • pharyngeal sensitivity
  • laryngeal and pharyngeal anatomy
  • laryngeal valving mechanisms
  • delayed pharyngeal swallow or premature spillage
  • isolated velopharyngeal closure

  • Technique
  • Transnasal placement of endoscope into pharynx to
    view pharynx and larynx.
  • Can be done at bedside or in office with any food
  • Usually done by ENT with SLP or SLP
  • Very highly correlated with detection of
    dysphagic symptoms and aspiration 90 agreement
    for detection of aspiration.
  • Significant controversy regarding this as a tool
    for swallowing.

Endoscopic View of Compensatory Techniques
  • Strengths
  • Extraordinary view of laryngeal valving
  • can be done bedside with portable equipment,
  • less expensive than MBS
  • Weaknesses
  • Lose visualization of oral cavity, functional
    palatal elevation and pharyngeal dynamics at the
    peak of the swallow
  • Invasiveness/comfort
  • Training issues

  • Leder SB Ross DA Briskin KB Sasaki CT (1997)
  • Using a prospective, double-blind, randomized
  • 152 consecutive patients were randomly assigned
    to receive a topical anesthetic (N 54),
    vasoconstrictor (N 50), or placebo (N 48).
  • No significant differences were found among the
    three variables.
  • An additional 50 consecutive patients had
    endoscopy performed without administration of any
    substance to the nares, and no significant
    differences were found among the four variables
    (N 202).

  • Aviv JE Sacco RL Mohr JP Thompson JL Levin B
    Sunshine S Thomson J Close LG (1997)
  • Compared false negative rate of predicting
    aspiration pneumonia in dysphagic stroke patients
    using modified barium swallow (MBS) alone and MBS
    combined with laryngopharyngeal sensory
    discrimination testing (MBS LPSDT).
  • MBS and LPSDT were performed within 4 weeks of
    stroke in 20 subjects followed for at least 2
    years to identify aspiration pneumonia
  • MBS identified 10 patients as not at risk based
    on the finding of no aspiration on initial MBS
  • four of these patients developed AP (FNR 40).
  • MBS LPSDT identified five patients as not at
    risk based on the findings of neither aspiration
    nor bilateral sensory deficits
  • none of these patients developed AP (FNR 0).

  • Leder SB Sasaki CT Burrell MI (1998)
  • Assessed aspiration in 400 consecutive, at risk
    subjects by fiberoptic endoscopic evaluation of
    swallowing (FEES).
  • 175 of 400 (44) subjects were without
  • 115 of 400 (29) exhibited aspiration with a
    cough reflex
  • 110 of 400 (28) aspirated silently.

  • Langmore SE Schatz K Olson N (1991)
  • 21 subjects were given both examinations within a
    48-hour period.
  • Good agreement was found, especially for the
    finding of aspiration (90 agreement).
  • Sensitivity was 0.88 or greater for three of the
    four parameters measured.
  • Specificity was lower overall, but was still 0.92
    for detection of aspiration.

  • Wu CH Hsiao TY Chen JC Chang YC Lee SY (1997)
  • 28 chronic dysphagic patients underwent both
    videofluoroscopy and FEES in 2 weeks.
  • Comparison of the results revealed that
    disagreements in premature oral leakage to the
    pharynx (39.3), pharyngeal stasis (10.7),
    laryngeal penetration (14.3), aspiration
    (14.3), effective cough reflex (39.3), and
    velopharyngeal incompetence (32.1)
  • FEES was found to be more sensitive in detecting
    these risky features of swallowing, except with
    respect to premature leakage

  • Périé S Laccourreye L Flahault A Hazebroucq V
    Chaussade S St Guily JL (1998)
  • 34 patients underwent videoendoscopy, manometry
    and videofluoroscopy
  • A total agreement between videoendoscopy and
    videofluoroscopy was found in 76.4 of cases for
    pharyngeal propulsion and in 82.3 for
  • Videoendoscopy detected nearly 90 of impaired
    pharyngeal propulsion.
  • 70 of aspiration events detected by
    videoendoscopy were also observed on

Cervical Auscultation (CA)
  • Definition
  • Defined as listening to the sounds of swallowing
    with a stethoscope (stethoscope or other
    measurement device) at or around the level of the
    larynx to gain information about the pharyngeal
    phase of swallowing and adjacent respirations.
  • Described as consisting of two distinct
    components (bursts or clunks), with or
    without a smaller third component or puff.

Cervical Auscultation
  • May provide information about
  • Perceived crispness of the signal
  • Bolus transit
  • Sound quality of adjacent respirations
  • Penetration/aspiration (coughing, throat clear,
  • Number of swallows
  • Presence of usually inaudible spontaneous
  • Timing of the swallow
  • Relative strength of the swallow
  • Clinicians make perceptual judgements as to the
    functioning of swallowing based on
  • Abnormal noisy breath sounds rattly rapid
    components obscured, non-rhythmical.
  • Normal rhythmical, crisp clunks expiration
    predictable dry sounds.

Cervical Auscultation
  • Technique
  • In dysphagia practice, CA is usually conducted
    with the use of a stethoscope hand held over the
    lateral lamina of the thyroid cartilage.
  • Takahashi et al. (1994) lateral border of
    trachea immediately inferior to the cricoid
    cartilage (site showed greatest averaged
    magnitude of the signal to noise ratio with the
    smallest variance).
  • The sounds of swallow, distortions of swallow and
    respiration may be tape recorded from a
    microphone or accelerometer held over the larynx.
    The samples can then be relayed for further
    auditory analysis, for demonstration to others,
    and for comparison with CA later in the care of
    the patient.

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Cervical Auscultation
  • Theoretical Causes of the Swallowing Signal
  • First component
  • hyolaryngeal excursion and bolus flow through the
    pharynx (Hamlet, Patterson, Fleming Jones,
  • Generated as the bolus under pressure bursts
    through the UES (Selley et al., 1994).
  • Caused by vibrations resulting from simultaneous
    movement of laryngeal valving and BOT-PPW
    approximation (Chichero Murdoch, 1998).

Cervical Auscultation
  • Theoretical Causes of the Swallowing Signal,
  • Second component
  • Bolus flow though the hyopharynx and UES pharynx
    (Hamlet et al., 1992).
  • Generated by the final stages of pharyngeal
    clearance (Selley et al., 1994).
  • Opening of the UES and the pharyngeal peristaltic
    wave to clear the pharynx (Chichero Murdoch,

Cervical Auscultation
  • Theoretical Causes of the Swallowing Signal,
  • Third component
  • Laryngeal descent post swallow pharynx (Hamlet et
    al., 1992).
  • Motion of the epiglottis or lower esophageal
    activity (Mackowiak, Brenman Friedman, 1967).
  • Vibrations generated by airway reopening (i.e.
    mechanical movement of epiglottis, vocal folds
    (true/false), arytenoid cartilages and release of
    subglottic air) (Chichero Murdoch, 1998).

Cervical Auscultation
  • Strengths
  • Easy
  • Available and portable
  • Non-invasive
  • Cost efficient
  • No radiation exposure
  • Can sample swallow repeatedly and for prolonged
    periods of time
  • No contrast required - uses real food/liquid
  • More appropriate referrals to VFS

Cervical Ogulation
  • Weaknesses
  • No definitive data correlating the sounds heard
    with specific physiologic events and
  • Experience dependent
  • Does not view swallowing mechanism directly
  • Dependent on perceptual skills of listener
  • Acoustic characteristics of stethoscopes are not
    well defined
  • Noisy breath sounds in patients with Asthma,
    COAD/COPD may obscure post aspiration respiratory
  • Stubble and clothing may interfere with sounds

Cervical Australia
  • Hamlet, Nelson Patterson (1990) on the basis
    of clinical experience it seems that the sound of
    a normal swallow may be distinguished from the
    sounds of a dysphagic swallow (pp.749).
  • Clinical impressions suggesting that the sound of
    a normal swallow may be distinguished from the
    sound of a dysphagic swallow have been validated
    by efficacy studies

Cervical Auscultation
  • Zenner, Losinski, Mills (1995)
  • Incorporated CA with stethoscope into the CSE to
    enhance the ability to detect aspiration and to
    determine specialised diet management for
    patients in long term care.
  • Subjects 50 patients (males, 23-103yrs) referred
    for assessment of suspected dysphagia.
  • Conducted CSE, with CA, on each patient, followed
    by VFS.

Cervical Auscultation
  • Zenner, Losinski, Mills (1995) cont
  • Results
  • CSE and VFS agreement
  • Oral transit delay 72
  • Oral residuals 62
  • Pharyngeal delay 66
  • Pharyngeal residuals 42
  • Aspiration 76 (stat. sig.)
  • Diet Mgmt
  • Restriction of thin liquids 82
  • Restriction of bread products 88

Results support the use of CA in detecting
aspiration and in diet recommendations for
patients in long term care. the use of CA as a
highly sensitive and specific method of dysphagia
assessment in long term care
Cervical Auscultation
  • Eicher, Manno, Fox, Kerwin (1994)
  • Purpose determine whether a clinical paediatric
    swallowing assessment (incl. CA) can accurately
    predict penetration/aspiration as documented by
  • Subjects 49 children 1-319 months
  • Clinical judgement and VFS agreement re presence
    of penetration and aspiration
  • without CA - 76
  • with CA - 86 (stat.sig.)
  • Authors conclusions
  • CA can be used as an effective screening tool for
    penetration/aspiration as well as follow up in
    the treatment of paediatric dysphagia.
  • Feel confident when recommend to postpone or
    cancel a VFS study when evaluation with CA
    suggests a completely competent swallow.

Oxygen Saturation
  • Definition
  • Non-invasive continuous measure of arterial blood
  • Provides information about
  • Oxygenation of peripheral blood flow
  • Aspiration event vs overall pulmonary status
  • Technique
  • Sensor placed on finger, toe, earlobe
  • As oxygen content of the blood increases, blood
    colour changes
  • Sensors monitor the wavelengths of light emitted
    by small light source as it passes through tissue
  • Measures the amount of light absorbed by the
    blood in the tissue
  • 95-100 normal range lt90 suggests significant

Oxygen Saturation
  • Sherman et al (1999)
  • Patients with aspiration or penetration without
    clearing had a significant decline in Sp02
    compared to those with penetrated but cleared or
    in whom no penetration was observed.
  • Colodny (2000)
  • Aspirators had lower Sp02 levels before, during
    and after feeding compared with nonaspirators.
    Those who aspirated solids were most compromised.
  • Pulse level rose for all patients from before to
    during feeding declined after feeding.
  • No relationship found between levels and
    aspiration events.

Pulse Oximetry
  • Sellars, Dunnet and Carter (1998)
  • Pulse oximetry was undertaken in six patients
    undergoing videofluoroscopic study of swallow.
  • Normal controls also underwent pulse oximetry
    during feeding.
  • No clear-cut relationship between changes in
    arterial oxygenation and aspiration.
  • However, some support is found for the
    association between altered arterial oxygenation
    and oral feeding in dysphagic individuals.

Pulse Ox-in-a-tree
  • Zaidi and a bunch of other people (1995)
  • For 10 weeks all acute stroke admissions were
    seen within 48 hours for oximetry assessment
  • Patients swallowed 10ml water while sitting up
    and SaO2 was noted for 2 minutes.
  • Two control groups underwent the same assessment.
  • Subjects underwent independent assessment of
    swallowing by a speech and language therapist
  • Mean (SD) SaO2 fall in subjects 2.6 (2.9)) was
    significantly more than in control 1.1 (0.8)
    or IP 1.1 (0.9).
  • Mean (SD) SaO2 fall was significantly more in
    SLT-graded 'aspirators' 4.6 (2.7) than
    'nonaspirators' 1.4 (1.0).
  • Conclude that
  • (1) a fall in SaO2 on swallowing fluid is common
    in patients with acute stroke (2) the presence
    or absence of desaturation agrees statistically
    with SLT assessment of aspiration (3) SaO2
    measures may aid bedside assessment of

Pulse Oximetry
  • Collins MJ Bakheit AM (1997)
  • Pulse oximetry was performed simultaneously with
    videofluoroscopy in 54 consecutive dysphagic
    stroke patients.
  • RESULTS Pulse oximetry reliably predicted
    aspiration or lack of it in 81.5 of cases.
  • The predictive value of the test was low in
    patients aged gt or 65 years and possibly those
    with chronic lung disease
  • One smoker also had a false-negative pulse
    oximetry result, ie, normal oxygen saturation
    despite radiological evidence of aspiration.
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