Testing Recommendations for Patients with Dysphagia
June 14, 2022
Decision-making is critical before you order a swallow study
UH Clinical Update | June 2022
For patients over age 50, dysphagia is a common problem. The American Speech Hearing Association estimates that dysphagia rates may be as high as 22 percent in adults over age 50, and as high as 30 percent for these patients who are receiving inpatient medical treatment. Dysphagia is an especially persistent problem for residents of long-term care facilities, affecting nearly seven in 10 residents. However, it also affects older individuals living independently, with between 13 and 38 percent experiencing trouble swallowing.
For the patients in your practice who are experiencing dysphagia, the multidisciplinary team at UH can provide comprehensive care that leverages leading diagnostics and therapies.
“The first step is selecting the appropriate studies to order,” says N. Scott Howard, MD, MBA, Director of the Voice, Airway and Swallowing Center at UH Cleveland Medical Center.
“I like teaching the rule of thirds,” he says. “One-third of oropharyngeal dysphagia symptoms are solely oropharyngeal, one-third are actually esophageal (often with a referred sensation of things sticking in the oropharynx) and the remaining third have both oropharyngeal AND esophageal dysphagia. Because of this, it’s important to ask for an esophageal screen or order a simultaneous barium esophagram and a modified barium swallow (MBS) for initial diagnosis.”
The esophageal screen is a single swallow of contrast evaluating the esophagus and can identify a majority of esophageal issues, but is a limited study.
Dr. Howard and his colleagues, including specialized speech-language pathologists, initiate dysphagia management techniques. “The ultimate goal we want for our patients is that they eat and drink the least restrictive diet without discomfort or complications, says Alexis Nahra, MA, CCC-SLP, Clinical Specialist and Dysphagia Team Lead at University Hospitals. “That being said, one size does definitely not fit all – what may work well for one patient may not be indicated for another. Personalization is key.”
Although dysphagia is common, personalized care is important to ensure patients can adhere to their therapy recommendations.
“The chin tuck may benefit a patient with reduced or delayed airway closure during the swallow,” Dr. Howard says. “However this same chin tuck maneuver may actually increase aspiration risks for a patient who has pharyngeal stasis due to a different breakdown in the mechanics of swallowing.”
Although a “bedside swallow” is helpful in initial evaluation of a majority of patients, that exam will not allow for a provider to diagnose the cause of the dysphagia (such as delayed initiation of the swallow, reduction in laryngeal closure or reduced upper esophageal sphincter opening). Flexible exams done by speech pathologist certified in endoscopy or by ENT providers allows visualization of pharyngeal residues, which may be the cause of frequent throat-clearing or coughing after eating. Again, proper swallow imaging or diagnostics are critical to prescribing the appropriate dysphagia therapy exercises.
With appropriate imaging, the multidisciplinary UH team can prescribe the best course of dysphagia treatment for the patient.
“Pending where the breakdown occurs in the swallow mechanics, the SLP will initiate an exercise program to assist with recovery or compensation of that particular issue,” Dr. Howard says.