“Dysphagia affects approximately 10% to 33% of adults. It is most commonly seen in the
geriatric population, and in adults who have experienced a stroke or neurodegenerative
diseases such as Alzheimer’s or Parkinson’s Disease.”
https://www.mayoclinicproceedings.org/article/S0025-6196(20)30902-2/fulltext
So what is Dysphagia?
Dysphagia is simply understood as the difficulty in swallowing liquids,
foods, or saliva. When this happens, eating becomes a challenge. Often, dysphagia makes it
difficult to take in enough calories and fluids to nourish the body and can lead to additional
serious medical problems.
My dysphagia training only just began upon completion of my SLT MSc degree and really
reached its peak at my job placement at an acute neuro hospital in Wellington, NZ. At that
hospital, my dysphagia competencies were met after months of dysphagia evaluation and
management to patients with a wide variety of acute and congenital diseases and disorders.
It was, and continues, to be a dimension of my current practice that makes me repeatedly
question myself in a quest to ensure that the most accurate decisions are made for my
patient’s well being and progress. For us Speech-Language Therapists, dysphagia training
occurs each day simultaneous with dysphagia practice. Personally, I have found it to be one
of the most fascinating and complex aspects of my journey as a Speech-Language
Therapist.
The management of patients with swallowing dysfunction is vast and complex. As a
dysphagia practitioner in Trinidad, the need to integrate cultural awareness/expectations,
service availability, disease type variables and medical ethics is integral to ensuring the best
individualised care. Being one of these Speech-Language Therapists who provides such
care to patients locally for the past 9 years, critical thinking has been essential in selecting
diagnostic and intervention options. This has especially been the case in an environment
where we do not always have ready access to instrumental swallow evaluations.
When it comes to diagnosing a patient’s swallowing function, there are two broad best
options to be explored- a clinical/bedside examination and an instrumental examination. I’ll
spend some time explaining what an instrumental swallow examination really is. In an effort
to be succinct, the two broad types of instrumental swallow examinations are the Modified
Barium Swallow study (MBSS)/ Video fluoroscopy study (VFSS) and the Barium Swallow
study (BSS)/ Esophagram. A MBSS/VFSS is used to assess oral (mouth) and pharyngeal
(throat) phases of the swallow. It allows us to look for possible aspiration, penetration of
food/drinks, pooling or residue left over after the swallow and structural abnormalities etc. On
the other hand, BSS/ Esophagram explores the oesophagus. It is entirely different and
usually done for the GI to check for reflux, motility of food and drink etc. Both tests are valid
but useful in different ways and your Speech-Language Therapist will determine which
instrumental evaluation is the best fit for the patient, given their complaint.
Because of the reduced availability and access to the MBSS/VFSS study locally, SLT’s here
more readily use the clinical/ bedside swallowing evaluations. A learning experience for me
after my return to Trinidad was that in order to diagnose a swallow impairment, I did not
need to rely too heavily on either instrumental or clinical examinations and found great
opportunity in what was available in my context of operation. Neither option is superior to the
other but each method provide us with different information. I continue to understand the
benefits of a clinical swallow examination and hope to share some with you in the following
paragraphs.
We must be mindful that “Swallowing difficulties can cause anxiety and / or depression” Eslick, GD., & Tally, N.J. (2008). Dysphagia epidemiology, risk factors and impact on quality of life – a population-based study. Having to now rely primarily on clinical evaluations, I found that it significantly reduced the patient anxieties associated with long waiting times for an MBSS appointment, not to mention, patient discomfort with their physical transfer to and from the radiography lab.
Weeks and even months warded in a hospital can add to patient frustrations. With the clinical swallow evaluation, I have the opportunity to meet the patient and evaluate them in a quicker time frame. Additionally, I am able to glean so much more clinical information at bedside, not to mention, develop a greater rapport with the patient if their communication skills are relatively intact. It is also beneficial to explore the patient’s feeding in a naturalistic scenario: at their home; in their favourite chair; with their chosen companions; when they are relaxed.
On a personal level, clinical evaluations forced me to be more thorough and enhance my own observation skills repertoire, knowing that I may never succeed in getting the patient to a MBSS lab for instrumental verification. While I am occasionally filled with discontent when I am unable to see a patient’s hyoid anterior movement or upper oesophageal sphincter movement or residue in the vallecullae or pyriform sinuses that you gain from an instrumental evaluation, I am comforted in the opportunities to test oral sensory-motor function, sucking in an infant, mastication, bolus control and swallow initiation gained from a thorough clinical evaluation. That being said, Speech-Language Therapists ought to remain mindful of the recommendations they make in the absence of instrumental probes and accept the limitations that may be had.
Despite the numerous benefits of a clinical swallow evaluation, we cannot continue to forgo the instrumental swallowing evaluation. The question remains…How do we question the things we think we know? I do believe that we must continue to hold dysphagia evaluations to the highest standards and lobby for our ready ability to provide instrumental rationale for patient swallowing decision-making.
It is my hope that I was able to shed some greater light on one aspect of Dysphagia. Perhaps my next Dysphagia article could centre around two aspects that I informally and non-clinically coin “The Jell-O-Syndrome” and “The Thickener-Syndrome”.
Your passionate Dysphagia Practitioner
Nadita Maharaj (Msc SLT)
geriatric population, and in adults who have experienced a stroke or neurodegenerative
diseases such as Alzheimer’s or Parkinson’s Disease.”
https://www.mayoclinicproceedings.org/article/S0025-6196(20)30902-2/fulltext
So what is Dysphagia?
Dysphagia is simply understood as the difficulty in swallowing liquids,
foods, or saliva. When this happens, eating becomes a challenge. Often, dysphagia makes it
difficult to take in enough calories and fluids to nourish the body and can lead to additional
serious medical problems.
My dysphagia training only just began upon completion of my SLT MSc degree and really
reached its peak at my job placement at an acute neuro hospital in Wellington, NZ. At that
hospital, my dysphagia competencies were met after months of dysphagia evaluation and
management to patients with a wide variety of acute and congenital diseases and disorders.
It was, and continues, to be a dimension of my current practice that makes me repeatedly
question myself in a quest to ensure that the most accurate decisions are made for my
patient’s well being and progress. For us Speech-Language Therapists, dysphagia training
occurs each day simultaneous with dysphagia practice. Personally, I have found it to be one
of the most fascinating and complex aspects of my journey as a Speech-Language
Therapist.
The management of patients with swallowing dysfunction is vast and complex. As a
dysphagia practitioner in Trinidad, the need to integrate cultural awareness/expectations,
service availability, disease type variables and medical ethics is integral to ensuring the best
individualised care. Being one of these Speech-Language Therapists who provides such
care to patients locally for the past 9 years, critical thinking has been essential in selecting
diagnostic and intervention options. This has especially been the case in an environment
where we do not always have ready access to instrumental swallow evaluations.
When it comes to diagnosing a patient’s swallowing function, there are two broad best
options to be explored- a clinical/bedside examination and an instrumental examination. I’ll
spend some time explaining what an instrumental swallow examination really is. In an effort
to be succinct, the two broad types of instrumental swallow examinations are the Modified
Barium Swallow study (MBSS)/ Video fluoroscopy study (VFSS) and the Barium Swallow
study (BSS)/ Esophagram. A MBSS/VFSS is used to assess oral (mouth) and pharyngeal
(throat) phases of the swallow. It allows us to look for possible aspiration, penetration of
food/drinks, pooling or residue left over after the swallow and structural abnormalities etc. On
the other hand, BSS/ Esophagram explores the oesophagus. It is entirely different and
usually done for the GI to check for reflux, motility of food and drink etc. Both tests are valid
but useful in different ways and your Speech-Language Therapist will determine which
instrumental evaluation is the best fit for the patient, given their complaint.
Because of the reduced availability and access to the MBSS/VFSS study locally, SLT’s here
more readily use the clinical/ bedside swallowing evaluations. A learning experience for me
after my return to Trinidad was that in order to diagnose a swallow impairment, I did not
need to rely too heavily on either instrumental or clinical examinations and found great
opportunity in what was available in my context of operation. Neither option is superior to the
other but each method provide us with different information. I continue to understand the
benefits of a clinical swallow examination and hope to share some with you in the following
paragraphs.
We must be mindful that “Swallowing difficulties can cause anxiety and / or depression” Eslick, GD., & Tally, N.J. (2008). Dysphagia epidemiology, risk factors and impact on quality of life – a population-based study. Having to now rely primarily on clinical evaluations, I found that it significantly reduced the patient anxieties associated with long waiting times for an MBSS appointment, not to mention, patient discomfort with their physical transfer to and from the radiography lab.
Weeks and even months warded in a hospital can add to patient frustrations. With the clinical swallow evaluation, I have the opportunity to meet the patient and evaluate them in a quicker time frame. Additionally, I am able to glean so much more clinical information at bedside, not to mention, develop a greater rapport with the patient if their communication skills are relatively intact. It is also beneficial to explore the patient’s feeding in a naturalistic scenario: at their home; in their favourite chair; with their chosen companions; when they are relaxed.
On a personal level, clinical evaluations forced me to be more thorough and enhance my own observation skills repertoire, knowing that I may never succeed in getting the patient to a MBSS lab for instrumental verification. While I am occasionally filled with discontent when I am unable to see a patient’s hyoid anterior movement or upper oesophageal sphincter movement or residue in the vallecullae or pyriform sinuses that you gain from an instrumental evaluation, I am comforted in the opportunities to test oral sensory-motor function, sucking in an infant, mastication, bolus control and swallow initiation gained from a thorough clinical evaluation. That being said, Speech-Language Therapists ought to remain mindful of the recommendations they make in the absence of instrumental probes and accept the limitations that may be had.
Despite the numerous benefits of a clinical swallow evaluation, we cannot continue to forgo the instrumental swallowing evaluation. The question remains…How do we question the things we think we know? I do believe that we must continue to hold dysphagia evaluations to the highest standards and lobby for our ready ability to provide instrumental rationale for patient swallowing decision-making.
It is my hope that I was able to shed some greater light on one aspect of Dysphagia. Perhaps my next Dysphagia article could centre around two aspects that I informally and non-clinically coin “The Jell-O-Syndrome” and “The Thickener-Syndrome”.
Your passionate Dysphagia Practitioner
Nadita Maharaj (Msc SLT)