Assessment of dysphagia

There are several signs and symptoms associated with dysphagia:

Signs and symptoms of dysphagia9

  • History of choking
  • Cough before, during or after the swallow
  • History of chest infections
  • Change in breathing pattern or shortness of breath when eating / drinking
  • Wet, bubbly voice quality
  • Weight loss
  • Prolonged mealtimes
  • Refusal to eat / drink
  • Regurgitation

Patients raising any suspicion of dysphagia or aspiration may initially be referred for a bedside assessment. If a bedside assessment raises suspicion of dysphagia eg. if coughing or wet voice occurs, the patient should then be referred for a diagnostic assessment37.

Standardised bedside assessment38

  • Step 1: examine patient’s level of consciousness, posture, voluntary cough, voice quality, and saliva control.
  • Step 2: drink teaspoon of water
  • Step 3: drink small glass of water if teaspoon cleared safely

Associated disorders are a useful indicator in differentiating oropharyngeal from oesophageal dysphagia and a thorough history is central to revealing the diagnosis in the majority of cases39. Patients with oral dysphagia most often have problems initiating the swallow or in controlling the food in their mouth. Pharyngeal dysphagia can manifest with drooling or spillage of food, post-nasal regurgitation, hoarseness, shortness of breath, coughing, choking, and dysphonia. Patients with oesophageal dysphagia often complain of food sticking in their lower neck or mid-chest region.

Patients may use different manoeuvres to help the food pass through the oesophagus, or they may sip water to relieve the obstruction36.

If the patient has oropharyngeal dysphagia they may be referred to a speech and language therapist (SLT) for a swallowing assessment and clinical assessment of oral and pharyngeal structure and function9. If the SLT considers it safe, they may undertake trials of various food and drink consistencies to determine which the patient is able to swallow with minimal risk of aspiration.

A resource manual, detailing the role of SLTs in identifying and managing oropharyngeal dysphagia, is available from the Royal College of Speech and Language Therapists74.

Instrumental assessments of dysphagia can provide further useful information; the most established being a modified barium swallow (MBS) also known as videofluoroscopy (VFS)40. In this instance, patients are given trials of different consistencies of food or drink mixed with a radio-opaque material such as barium. This allows the clinician to see where swallowed material actually goes; ie. if food or fluid is entering the respiratory tract and if so how much, and whether pharyngeal or oesophageal muscles are functioning properly. For this reason VFS is regarded as being a more sensitive diagnostic tool than bedside assessment41.

Another assessment which is commonly used is fibre-endoscopic evaluation of swallowing (FEES)42. An endoscope is passed nasally and positioned below the soft palate thus providing a direct view of the pharynx and larynx. The patient is required to swallow various consistencies and is then observed for the presence of aspiration which will help determine the likely cause. The assessment may also include sensory testing (FEESST) using air or pressure. Air is blown through an endoscope onto the affected muscles, or pressure is applied to the pharyngeal muscles, to trigger a swallowing response.