Examination: Assessing Swallow

In a hospital setting, it is safest for this examination to be undertaken by the Speech and Languange Therapists. However, it is important to understand the principles of the examination, and it could be presented as a whole station in an OSCE or as part of the cranial nerve station.

  • Wash hands
  • Introduce
  • Permission
  • Expose the neck until up to the clavicles
  • Reposition - sitting down. Sit directly opposite the patient so you are eye to eye
  • Don gloves

Inspect:
  • Patient as a whole first:
    • What is their posture? Any obvious asymmetries in keeping with paralysis?
    • Are they clearing their own secretions or is there congestion of secretions?
  • Lips
    • Symmetry
  • Tongue
    • Range of motion: lateral, vertical, protrusion movements
    • Symmetry
  • Velopharynx

Examine the relevant cranial nerves:
  • Ask the patient to...
    • Open jaw - V
    • Laterally move the jaw - V
    • Puff out cheeks - VII
    • Show me your teeth - VII
    • Offer to test the gag reflex - IX

Assessing swallow:
  • Sequence of swallows (progresses from solids to liquids to minimise risk of aspiration during the test)
    • First a dry swallow of the saliva in the person's mouth
    • Approximately 1/2 teaspoon of cracker
    • Check on efficiency of chewing
    • Ask the patient to swallow
    • Then, approximately 1/2 teaspoon of apple sauce or other thickened fluid and repeat
    • Then, approximately 1/2 teaspoon of water that you release from a straw and repeat
    • During each swallow feel the timing of the sequence of movements of the pharynx and larynx. Do this by first asking to take a sip of the fluid into their mouth and hold it there. Then feel their neck on swallow - does the laryngeal apparatus move up and down as expected?
    • After each swallow have the person phonate an 'ah' sound (does this sound normal or can you hear rattles in the throat suggesting an incomplete swallow?)
    • Have the person turn the head from side to side and up and down. Phonating 'ah' after each turn, to assess if there is a unilateral deficit

To conclude the examination:
  • Thank the patient
  • Suggest that further investigation could be achieved with the aid of a barium swallow/videofluoroscopy and a nasendoscopy
  • Offer to refer for review by an ENT surgeon if any signficant abnormality.

written by: celine_lakra; joel_cunningham; saaid_sufi, first posted on: 01/03/12, 17:00

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