Instrumental Swallow Evaluation
Instrumental Diagnostic Procedure
An instrumental examination may be performed after or instead of a clinical exam. A clinical exam should trigger an instrumental procedure if (1) reported symptoms are inconsistent with the findings on the clinical exam, (2) further differential diagnosis is needed to refine the clinical hypothesis or determine appropriate treatment, (3) further information is needed to improve swallow safety, or (4) patient has significant pulmonary compromise and there is a need to rule out any aspects of the swallow deficit that can exacerbate the compromised respiratory function. A patient should NOT receive an instrumental exam if they are not medically stable enough to tolerate the procedure including transporting them to the instrumentation (if needed) or if the instrumental exam will not enhance the knowledge of the swallow deficit or guide in the treatment direction.
Clinical Note
When choosing an instrumental exam consider the following:
- When choosing VFES, consider the risk:benefit ratio of radiation exposure.
a. For VFES, if the acquisition pulse or frame rate is inadequate to answer the clinical questions, then the radiation exposure may not be worthwhile. - How important is it to your evaluation to include the entire system and to observe bolus flow?
- What is the importance of the laryngeal exam? Is laryngeal visualization important?
- How important is it to include the oral cavity and oral bolus manipulation?
a. Does oral opening alter the ability to evaluate the oral cavity during the clinical exam? - Would you like to visualize the cervical esophagus?
a. Are you hoping to differentiate between passive and active UES forces? - Any recent history of nasal surgery? History of fainting?
- Do you need to evaluate velopharyngeal closure?
- Can the patient be transported to the fluorography suite?
- What is the availability of the fluorography suite? Could a FEES be scheduled sooner?
- Has a recent VFES been performed?
- Suspicion of aspiration on secretion.
Activity
Activity 3.2
TASK: Build a mind map that links the concerns listed in the clinical note to the various instrumental exam. In other words, what instrumental exam would you choose if the answer the question was no? If the answer was yes? Why? See Appendix 2 for an example.
Instrumental approaches aid in objectifying and/or visualizing biomechanical and temporal events, as well as pressure gradients associated with bolus flow during swallowing. This information allows the dysphagia clinician to highlight the deviant aspects of the swallow which informs treatment. The two most commonly used instrumental procedures in the evaluation of swallowing disorders are the videofluorographic evaluation of swallowing (VFES) and the fiberoptic endoscopic evaluation of swallowing (FEES). Other instrumental approaches that may be employed in the evaluation and treatment of swallowing disorders include pharyngeal manometry, scintigraphy, ele