Spth 365 Dysphagia and Related Disorders: Diagnosis

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Spth 365 Dysphagia and Related Disorders
Diagnosis

• Lecture Five
• Clinical Examination

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  The Clinical Examination

• The clinical or bedside evaluation gathers
  information from patients,
• medical records and health care workers
•  
• It also allows a circumscribed exploration of a
  patients muscle function, sensation, and airway
  protective functions (Murray, 1999).
•  
• In order to effectively administer CSE, examiners
  should
• have deep knowledge in normal and disordered
  swallowing
• mechanisms
• (b) be able to make clinical judgment
  associated with the signs and symptoms
• have CRITICAL THINKING
• The three major components of the clinical
  examination include history taking, meal
  observation, and physical examination (Mills,
  2000).

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History information

• Goals of the history-taking session (Murray,
  1999)
• (a)      to determine if there is a swallowing
  problem
• (b)     the nature and extent of the dysphagia
• (c)      to determine any causal factors that may
  contribute to the dysphagia
• (d)     to determine the patients functional
  abilities and disabilities, with attention to
  adaptations and compensations that exist to make
  up for an impairment
• (e)      to provide a basis for determining the
  scope of the assessment

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McCullough, Wertz, Rosenbek Dinneen
(1999)Clinical examination measures (history)
clinician believe should be employed compared to
other representative research.

• Patient reports Previous surgery
• Family reports Other disease
• History of pneumonia Medications
• Neurological insult Consciousness
• Nutritional status Mental status
• Gastrointestinal anomaly Pulmonary
  clearance
• Structural (nonsurgical) abnormality
  Mechanical devices
• Key black important and have research
  support
• purple - important (use gt70 or greater)
• History information can be obtained from medical
  record review and patient interview.

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Medical Record Review The medical record
can provide the clinician with a bounty of data
that will enhance the initial interview.   Mills
(2000) Because dysphagia can be slowly
progressive, intermittent, and potentially
related to other medical problems, it is
necessary to review not only the recent medical
history but also information that may be as old
as 20 years.  
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Contents of the medical record (Murray,
1999) (a)      The patients medical
history (b)      Findings from the physical
examination performed by the
physician (c)      Reports of laboratory
tests (d)      Findings and conclusions from
special examinations (e)      Findings and
diagnoses from consultants (f)       The
diagnoses from the responsible physician (g)     
Notes on treatment, including medication,
surgical operations, and radiation (h)     
Progress notes by physicians, nurses, and other
care specialists  
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1. Disease process (Yamada, 1995)
Oropharyngeal dysphagia
Neuromuscular disease Diseases of the CNS
Peripheral nervous system Cerebrovascular
accident Peripheral neuropathy Parkinson's
disease Motor end-plate dysfunction Brain
stem tumors Myasthenia gravis Degenerative
diseases Skeletal muscle disease Amyotrophic
lateral sclerosis Polymyositis Multiple
sclerosis Dermatomyositis Huntington's
disease Muscular dystrophy Postinfectious
Cricopharyngeal achalasia Poliomyelitis
Syphilis   Obstructive lesions Tumors
Esophageal webs Inflammatory masses
Extrinsic structural lesions Trauma/surgical
resection Anterior mediastinal masses
Zenker's diverticulum Cervical spondylosis

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2. Surgical Procedure Surgery can be
performed to enhance swallow function and is
frequently affect swallowing function. (a)     
Anterior cervical spine surgery (b)     Carotid
endarterectomy (c)      Esophageal cancer
surgery (d)     Head and neck resection
(e)      Radiotherapy   ? Clinical
indication Oropharyngeal dysphagia
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3. Airway Status (a)      Artificial airway -
endotracheal tube (b)     Ventilation   ?
Clinical indication - Upper airway obstruction
- Lack of airway protective reflex
4. Pulmonary Status (a) Pneumonia -
suspicion of multiple aspiration - upper /
lower respiratory infection -
COPD (b) Radiographs - plain chest film
used to enhance the differential
diagnosis of pneumonia ? Clinical indication
- Pharyngeal dysphagia -
Poor / inadequate laryngeal closure
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55. Nutrition (will be discussed in detail
later) (a) Oral intake - amount and
consistencies of food that the patient
typically prefers - the use of
nutritional supplements (b) 24-hour dietary
recall - amount and types of food consumed
(c)    Enteral intake - nasogastric (NG) tube
- percutaneous
endoscopic gastrotomy (PEG)
jejunostomy (PEJ) tubes (d)   Parenteral
nutrition - delivery of nutrition directly to
the bloodstream (e)   Weight change -
weight change (d)   Lab values / blood
parameters - albumin level (normal 4.1
5.5) 66. Hydration Ways of monitor
dehydration (a)      Monitor fluid in / urine
out (b)     Serum sodium (c)     
Osmolality  ? Clinical indication Diet
restriction that exclude thin liquid intake    
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 Patient Interview 11) Chief Complaint (Mills,
2000) Patient should be given the opportunity
to explain what he / she thinks is the essence
of the swallowing complaint. The onset of the
swallowing complaint should be established.
Interviewer should be able to associate
patients complaint with the information from
the medical report.  
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22) Patients Perception of Problem
Swallowing the patient to express his / her
concerns gives the clinician a headstart in
planning the patient education process that will
follow the assessment. SSometimes the patients
complaint as stated in the medical history is not
consistent with the current complaint (Mills,
2000). TTHUS. How valid a patients perception
of his / her own swallowing problems is?
Huckabee (2002) BUT Patients with mild dysphagia
often complain of swallowing problems, whereas
those with severe dysphagia do not realize they
are dysphagic !!
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3) Character of Complaint A careful review of
the distinctive traits of the swallowing
complaint(s) should follow.
Coughing and choking Food coming out of nose Food
falling from mouth Food stuck in throat after
swallow Something stuck in throat (not
food) Throat burns on swallow Food returns to
mouth in original condition Food spread
throughout mouth Pain on swallowing
Laryngeal penetration or aspiration Poor velar
closure during swallow Poor lip seal / oral
containment Weakened pharyngeal stage Globus
(reflux) Reflux Pharyngeal pocket / Zenkers
diverticulum Poor oral bolus formation /
propulsion Infection, recurrence of cancer,
surgery wound

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4) Course of Complaint Determine
(a)      whether dysphagia was
progressive or rapid in onset
(b)     whether symptom is constant or
intermittent Associated Symptoms
and Possible Etiologies of Dysphagia
(Scott-Brown Kerr, 1997) Condition
Diagnoses to consider   Progressive
dysphagia Neuromuscular dysphagia Sudden
dysphagia Obstructive dysphagia, esophagitis
Difficulty initiating swallow Oropharyngeal
dysphagia Food "sticks" after
swallow Esophageal dysphagia  
Cough Early in swallow Neuromuscular
dysphagia Late in swallow Obstructive
dysphagia Weight loss In the
elderly Carcinoma With regurgitation
Achalasia        

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Condition (cont) Diagnoses to consider
Progressive symptoms
Heartburn Peptic stricture, scleroderma Intermi
ttent symptoms Rings and webs, diffuse
esophageal spasm, nutcracker esophagus Pain
with dysphagia Esophagitis  
Postradiation   Infectious  
Pill-induced Pain made worse by
Solid food only Obstructive dysphagia
Solids and liquids Neuromuscular
dysphagias Regurgitation of old food Zenker's
diverticulum Weakness and dysphagia CVA,
muscular dystrophies, myasthenia gravis,
multiple sclerosis Halitosis Zenker's
diverticulum Dysphagia relieved with repeated
swallows Achalasia Dysphagia made worse with
cold foods Neuromuscular motility disorders
 
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5) Activities of Daily Living Determine (a)
  patients ability to perform activities related
to feeding and oral hygiene (b)  how the
disorder has affected patients lifestyle (such
as changes in meal preparation) (c)  the
manner and frequency of assistance given by the
caregiver Langmore (1998) Being reliant on
another for feeding and oral hygiene puts the
neurologically impaired patient at a
significantly greater risk for developing
pneumonia. 6) Previous Treatment Record any
method of treatment for dysphagia and the success
of these remedies (a)  medication (can be used
to treat dysphagia symptoms but can also
effect swallowing) (b)  compensation (c) diet
modification
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Selected Medications That May Affect Swallowing
Oropharyngeal function Esophageal function
Sedation, pharyngeal weakness, dystonia
Inflammation (irritation by pill)
Benzodiazepines Tetracycline Neuroleptics
Doxycycline (Vibramycin) Anticonvulsants
Iron preparationsMyopathy Quinidine Cor
ticosteroids Nonsteroidal anti-
Lipid-lowering drugs inflammatory drugs
Xerostomia Potassium Anticholinergics
Impaired motility / exacerbated GER
Antihypertensives Anticholinergics
Antihistamines Calcium channel blockers
Antipsychotics Theophylline Narcotics
Esophagitis (immunosuppression)
Anticonvulsants Corticosteroids
Antiparkinsonian agents Antineoplastics Anti
depressants Anxiolytics Muscle
relaxants Diuretics Inflammation/swelling
Antibiotics - Various agents in the
class                 --Various agents in the
class
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CLINICAL SWALLOWING EXAMINATION

• The Physical Examination

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Role of the Clinical Examination
P Perlman Schulze-Delrieu (1997)
Generally, the clinical examination should
identify the most likely sites and mechanisms
for the disordered swallowing as well as the
seriousness of the impairment.
Langmore Logemann (1991) (a) to define
potential etiologic factors for the patients
swallowing disorder (b) to formulate a
tentative hypothesis regarding the nature of the
patients oropharyngeal swallow
disorder (c) to develop a tentative or
partial treatment plan based upon this hypothesis
(d) to develop a list of clinical
questions that need to be answered to complete
the identification of patients swallow
disorders and develop the definitive treatment
plan (e) to determine the patients
readiness and tolerance for other instrumental
assessments
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Advantages Russell H. Mills
(2000) (a) it incorporates more aspects of
swallowing than only the mechanical movements of
mouth, larynx and pharynx (b) it may
provide information about the bigger picture of
ingesting food to sustain nutrition and
hydration (c) it is more available as
an assessment tool than other procedures that
require expensive and elaborate equipment to
complete (d) it is not invasive, has
no known health risks, and is much less
burdensome to fragile patients who may find some
techniques, or the act moving to the
examination room, intolerable
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The CSE Protocol
McCullough, Wertz, Rosenbek Dinneen
(1999) Clinical examination measures clinician
believe should be employed compared to other
representative research. (a)   Oral Motor
Rapid alternating speech Pharyngeal
contraction Tongue strength/range Dysarthria
Lip seal/puckel Speech intelligibility Jaw
strength/lateral Rate/rhythm/stress Soft
palate movement Oral apraxia Palatal
gag Voluntary cough Pharyngeal gag Ability
to follow directions Manage secretions

 
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  (b)   Voice Variations in pitch
loudness Wet/gurgly Breathiness Strained/stra
ngled Harshness Dysphonia/aphonia Resonance

(c)   Trial swallows 3-oz
swallow Larynx elevation 150-mL
test Auscultation Other thin liquid Voice
quality after swallow Thick liquid Ability to
feed self Pudding Swallows per
bolus Puree Spontaneous cough/clearance Ice
chips Estimated penetration/aspiration Solid
Estimated oral stasis Oral transit
estimate 4-finger method Estimated swallow
delay Observe meal Estimated total swallow
duration   K Key black important and
have research support purple -
important (use gt70 or greater)

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The Protocol To organize your exam, start at
the front and work to the back. Be
methodical Overall
status Face Oral Lips motor
Jaw examination Teeth ( CN exam.)
Tongue Palate
Pharynx Larynx
Speech Voice
Dry
swallow Trial
swallow   1)
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o OVERALL STATUS 1) Mental Status There
is an interdependence between safe swallow
function and cognitive and behavioral factors
(e.g. alertness, attention, memory, judgment,
reasoning, orientation, and sequencing
skill). Mills (2000) (a) Level of
Consciousness Refers to patients level of
alertness and responsiveness to the
environment Reduced consciousness
vulnerable to aspiration if being fed
by mouth Procedure - observe patient from
multiple occasions - seek
information from those who care for the
patient on a day-to-day basis
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(b) General Mental Status Refers to
patients general cognitive condition
Procedure - can be obtained during the
interview session of history taking
- Cognitive Performance Test, The
Glasgow Coma Scale Advantages help
guide clinician when recommendations that
require the patients self monitoring are
being contemplated   2) Positioning
Procedure - observe patients habitual body
and head position - examine adaptations
or apparatus used to assist in support
- attempt to elicit alterations in
body and head position Clinical indication
- muscular weakness Signs -
aspiration - difficulty in
self-feeding - lead to fatigue
before nourishment is achieved
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FACE
Procedure (a) Observe facial symmetrical and
expression (b) Ask patient to - close
eyes - wrinkle brow - show teeth -
smile - kiss - whistle - lateralize
lips - flatten cheeks - taste to anterior
2/3 of tongue
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LIPS1)      Lip Sensation Procedure - ask
patient to close his eyes and respond to the
stimulus - apply Light brush with cotton
tip on lip Light pressure with cotton tip on
lip Light pressure with stick on
lip2)      Lip Strength / seal Procedure -
ask patient to purse his lips with as much
pressure as possible - attempt to lift up
the upper lip at several points along its
entire length using a tongue blade -
determine if enough strength is present to
achieve a seal with the lips - repeat with
the lower lip Clinical indication - weakness
of orbicularis oris - resection
and reconstruction of the lips
- reduced elasticity (may be
caused by fibrosis due to radiation
therapy)
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3)     Drooling Procedure - note any loss
of saliva control, site of release,
habitual oral position and patients awareness of
the drooling Clinical indication - poor
oral containment due to lip seal
breakdown - decrease in swallowing frequency
which allows the buildup of oropharyngeal
secretions
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JAW1) Mouth Opening Procedure - ask
patient to open his mouth as widely as it will
open - note the symmetry and wideness of
opening (normal adult 45-50 mm
inter-incisal mouth opening) Clinical
indication - muscles weakness - nerve
paralysis Signs - difficulty placing food
in mouth - patient may abandon oral
solid foods in favor of liquid diets that are
easily consumed by straw
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Muscles of Mastication(a)   Masseter and
Temporalis Procedure - ask patient to
clench down on a tongue blade placed along the
length of the molars on the right or left
side of oral cavity -  palpate the muscle
to determine tone and mass (noticeable
bulging and firmness should be present during
the clench for both the temporalis and
masseter -  pull on the blade to determine
the strength of clench -  repeat on the
opposite side Clinical indication -
weakness of masseter and/or temporalis (?) -
nerve paralysis
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(b)   Lateral and Medial PterygoidProcedure -
Protrusion  place one hand behind patients
head  place base of palm of other hand
against the chin  apply pressure against the
jaw as patient protrudes the jaw -
Lateralization  place one hand on patients
temple  apply resistive pressure to the
lateral jaw using other hand - also
observe patients ability to protrude and
lateralize jaw without resistanceClinical
indication - weakness of lateral and/or medial
pterygoid muscles -
mandibular division of CN V paralysisSigns -
difficulty or inability in grinding of food
- inadequate shape changes of the oral
cavity during manipulation of bolus
- poor reduction of solid food during oral
preparation - fatigue during feeding
and eventually food avoidance
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(c)   Pain Procedure - ask patient regarding
the location and nature of the pain -
note any popping or clicking sounds
accompany jaw opening and closing -
observe any oral habits such as grating or
grinding of the teeth Clinical
indication - temperomandibular joint (TMJ)
impairment
- degenerative joint disease Signs
- reduced mean opening and closing velocities of
the mandible - smaller distance of jaw
movement during chewing - insufficiency of
feeding, risk of fatigue and food
avoidance NB General pain can also be caused
by oral / pharyngeal mucosa inflammation /
injury
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TEETH (Dentition / Periodontium) Procedure
- inspect oral cavity using pen light and
tongue blade - make note of any existing and
missing teeth - make note of removable partial
(replace one/more teeth) or complete dentures
(replace most or all teeth) ? determine
the firmness of fit and food or plaque on the
surface ? note patients report of unworn
existing denture, weight loss and food
avoidance accompanied the disuse
dentureClinical indication - poor oral
hygiene - GERD
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TONGUE1) Salivary Flow / Appearance of Oral
Mucosa Procedure - inspect oral cavity using
pen light and tongue blade - make note of
the color and surface structure of the tongue
and palate Hyposalivation - dry oral
cavity - fissures / cracks on tongue
surface - mucosa of the tongue and palate
may not reflect light from the
penlight Clinical indication xerostomia
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Tongue Movement / StrengthProcedure ? Tongue
maneuvers (a) observe tongue at rest (b)
observe tongue during protrusion (c) - ask
patient to puff his cheeks and breath through
the nose - monitor breaths by
observing thoracic movement (Normal
able to breath many cycles with the cheeks
puffed) - push cheeks in with both hands and
listen for nasal emission (Normal air
should escape through the lips
plossively) ? Tongue strength - place
the cotton tip applicator along the blade of
tongue at level of gingival margin of the
maxillary arch - ask patient to push the
swab against his teeth and palate while
examiner try to retract it
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? Tongue range of motion - ask patient
to ? move the tongue tip along the entire
length of maxillary and mandibular buccal
sulci ? stroke surface of hard palate with tip
of tongue - make note of reduced range of
motion of the tongue Clinical indication
- weakness of tongue muscles - neurologic
disease - motor nerve paralysis - poor
lip seal - poor posterior tongue elevation
- poor coordination of the tongue and
velum - progressive
neuromuscular disease 
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PALATEVelar Elevation Procedure - ask
patient to open his mouth and phonate /?/ -
observe velum elevation from the onset of
phonation (Normal superior arcing of the
soft palate tissue) Clinical indication
- Damage of CN X
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PHARYNXOral / Pharyngeal Sensation /
Gag Procedure - ask patient to close his eyes
and respond to stimulus by vocalizing or
raising hand - stimulate oral and pharyngeal
mucosa by probing surface of tongue, faucial
pillars and posterior pharyngeal wall with a
cotton tipped applicator - record pattern,
amplitude and symmetrical of movementClinical
indication - Damage of CN IX
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LARYNXRespiratory Function / Respiration(a)
Volutional Cough Procedure - ask patient to
produce as great cough as he possibly can
- characterize the cough
according to the type of clearing maneuver and
whether the maneuver is productive Cough,
Forced expiration, Throat clearing,
Hawking, Productive cough - indicate
the effectiveness of the clearing
maneuvers - loudness will provide some
perception of the clearing maneuvers power
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(b) Sustained Expiration While
Counting Procedure ask patient to inhale
as deeply as possible and with a single
breath count as high as he can Clinical
indication - weakened expiratory force
- poor initial inspiratory
effort - poor laryngeal control during
phonation - reduced sustained
attention
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SPEECHSpeech / ArticulationProcedure -
observe / analyses connected speech sample during
interviewClinical indication - muscular
weakness - imprecise motor movements -
possible structural insufficiencyResearch
Martin et al (1990)- significant positive
correlation between dysarthria and dysphagia
(BUT NO 1 to 1 correlation) Ratnaike
Hatherly (2002)- dysarthria may also be a problem
because many of the muscles necessary for
swallowing are required for speechCoates et al
(1997)- speech disturbances are the main
predictors of dysphagia in patients with
Parkinsons disease
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VOICEVoice / ResonanceProcedure - determine
whether dysphonia presence or not, if so,
characterize the dysphoniaNormal voice
should display age and gender appropriate pitch,
volume, and flexibilityHoarse -
leakage of air and aperiodic vibration of the
vocal folds - reduced loudness (maybe), low
pitch, little flexibilityWet dysphonic -
periodic, hoarse or hypophonicHypophonic -
breathy quality, low intensity, periodic
vibration vary from quiet voicing breaking
to a whisperAphonic - consistent
whisper-like voiceHypernasality - less
distinct of oral plosives, nasal emission may
be audibleClinical indication - vocal
fold / CN X paralysis - inadequate
velopharyngeal approximation - pharyngeal
residue - aspiration  
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DRY SWALLOWVolitional SwallowsProcedure -
assess laryngeal elevation during dry swallows by
placing 4 fingers resting over patients
laryngeal sling - request patient to swallow
with fingers lightly resting in this
arrangement - test with 1-2 cc water sip if
needed (if patient does not have enough saliva
to swallow) DO NOT OVERINTERPRETING
what you have obtained from this
assessment!! Clinical indication -
xerostomia - disorganized motor coordination
necessary to generate a swallow
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TRIAL SWALLOWFood and Liquid SwallowsProcedure
- elicit swallow by presenting food and liquid
of varying volumes and consistencies to
patient - observe and record signs and symptoms
that are exposed during this session -
hold safety as the highest priority ? medical
stability (if there is possibility of
aspiration, weigh decision to present food/liquid
carefully) ? alertness ? cough
(confident of patients ability to reject
material from the upper airway before
introducing any material and prepare to
provide upper airway clearance if severe
aspiration is suspected)
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Trial Swallow (cont) - present food in
order ? start with testing materials such as
ice chips (volume is well controlled, the
temperature increases level of alertness and
theoretically triggers pharyngeal
swallow ? begin with small amounts of easily
controlled materials that do not match
patients problematic condition For
example patient complaints of coughing and
choking with thin liquids should not be
presented a full cup of water
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Trial Swallow (cont) - score ? timing /
speed ? no mastication from entry of liquid
into the mouth to the elevation of larynx ?
mastication from cessation of chewing until
initiation of laryngeal elevation BUT. HOW
VALID IT IS? You do not know what is happening
inside there after the lips are
close. ?number of swallows (per bolus) ?
record number of laryngeal elevation (Normal
once / twice per teaspoon of bolus) ? oral
signs ? inspect for oral residue and
drooling ? airway signs ? note any wet
dysphonia and spontaneous cough after food /
liquid presentation ? attempts to clear throat
if dysphonia is present
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THEN.. MEAL OBSERVATION Observe swallowing
behavior during mealtime
FINALLY. Recommend for intervention
techniques OR Further assessment of swallowing
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THE CONTROVERSIES1) Data on reliability of
prediction of aspiration at bedsideGiven these
data, your presentation of BSE to family and
physician needs to emphasize the limitations a
screening test, NOT a diagnostic
assessment.Splaingard, et al. (1988)107
patients evaluated at bedside, within 72 hours,
MBS completed.Results Bedside evaluation
identified 42 of the aspiratorsOf the patients
diagnosed with severe aspiration per MBS, only
30 were identified as aspirating at bedside.
In other words, 70 of the severe aspirators
were missed on bedside swallowing
evaluation.Linden, et al. (1989)9 of 11
patients aspirated on MBS 8 of 9 were silent
aspiratorsall 8 silent aspirators could cough
volitionally5 of aspirators aspirated liquids
but not other textures.
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Horner, et al. (1988)of 47 patients, 51.1
aspiratedof those who aspirated, 54.2 were
silent aspiratorshighest predictor of aspiration
bilateral brainstem or cortical CVA91.3 of
aspirators were dysphonicHorner and Massey
(1988)50 of the population aspirated silent
aspiration in 38.154 of aspirators complained
of dysphagia90 of the nonaspirators complained
of dysphagiaDaniels, et al. (1998)Evaluated 55
consecutive stroke patients within 5 days of
admissionAspiration occurred in 21 of 55
(38)7/21 aspirated overtly (33)14/21
aspirated silently on VFSS (67)Factors related
to aspirationDysphonia, dysarthria, abnormal
gag, abnormal volitional cough, cough after
swallowingRegression revealed that abnormal
volitional cough cough with swallow predicted
aspiration with 78 accuracy  
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Smith Hammond, et al. (2001)Hypothesized that
aspirating patients would have impaired voluntary
cough compared to normals and nonaspiratorsEvalua
ted 43 dysphagics and 18 controlsCough measures
peak flow of inspiration phase, peak flow of
expulsive phase, sound pressure level, expulsive
phase rise time and cough volume acceleration
were significantly impaired in severe aspirators
as compared to non aspiratorsRegression found
only expulsive phase rise time values during
cough related to aspiration status. Langmore
(1998)Pneumonia develops when three events
materialize         Bacteria that are
pathogenic to lungs colonize in the upper
airway         Bacteria are aspirated        
Lungs cannot clear the aspirated bacteriaThus
predicting aspiration pneumonia is a matter of
looking at these three conditions.
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Langmore (1998)Identified major predictors of
aspiration pneumonia in group of elders        
Dependent for oral care, decayed teeth, multiple
medications, tube fed (colonized
oropharynx)         Dependent for feeding
(aspiration into lungs)         Current smoker,
multiple medical conditions (decreased host
resistance)Note the absence of dysphagia or
documented aspiration of food or liquid as
predictors of pneumonia.Thus, aspiration of food
or liquid in the absence of other predictor
variables may be benign.Best predictor
 McCullough et al, (2000)Investigated inter and
intrajudge reliability of clinical exam in
adultsAll prior studies that assess important
clinical factors assume that we can reliably
assess those clinical factors.ResultsFewer
than 50 of the measures clinicians typically
employ are rated with sufficient inter and
intrajudge reliability. Measures of vocal
quality and oral motor function were rated more
reliably than history measure or measures taken
during trial swallows.
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2) The Gag ReflexObservation of presence or
absence of the gag reflex is not used as part of
the clinical assessment. (?) Logemann
(1985)Traditionally, presence or absence of a
gag reflex has been used as a clinical indicator
in determining the patient's readiness and safety
in accepting food orally, however, the gag
reflex-  is not elicited during a normal
swallow -  is not protective for the swallow.
The protective reflex for swallowing is the
cough, which should be triggered when food
enters the larynx. The cough reflex is
frequently not elicited in dysphagic patients.
-  is not elicited when food falls into the
pharynx or airway prematurely or in an
uncontrolled way  Leder (1996)-  86 of
subjects with no gag could safely swallow at
least a puree diet -  13 of normal nondysphagic
subjects had no gag reflex  Davies, Kidd,
Stone, MacMahon (1995)-  37 of normal
subjects had no gag reflex (43 of normal elderly
subjects, 26 of young subjects) -  Presence or
absence of a gag reflex is not a predictor of
swallowing safety.
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BUT..Chusid (1979) as cited in Mills (2000)
The absence of gag reflex can be interpreted as
a diminished touch sensation at the posterior
pharyngeal wall and, when combined with other
abnormal findings, may indicate increased risk
for aspiration and airway obstruction. Horner
(1988) as cited in Spieker (2000)A decreased gag
reflex is associated with an increased risk of
aspiration 
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SLPs Clinical PracticeDixon Lass
(2001)Current trends among SLPs in the diagnosis
of dysphagia need to be explored to determine how
factors such as experience and training influence
diagnostic practices.(a)      What are current
trends in SLPs' clinical practices regarding the
assessment of dysphagia? (b)     Do they
utilize a full bedside exam (BSE) in addition to
a modified barium swallow (MBS)? (c)      Do
they utilize fiberoptic endoscopy? (d)     If
so, do they rely on it alone or in combination
with the BSE? (e)      Or do they rely solely on
the MBS to confirm a diagnosis?
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Wet Voice'' as a Predictor of Penetration and
Aspiration in Oropharyngeal DysphagiaWarms
Richards (2000) Voice samples of 23 subjects
with neurologic oropharyngeal dysphagia were
collected immediately after each subject had
swallowed nine different boluses on
videofluoroscopy.Results there was no
association between the presence of a wet voice
and penetration or aspiration of prandial
material after a swallow. The importance of
detecting wet phonation by itself was therefore
not considered diagnostic in detecting prandial
penetration/ aspiration by the bedside, but a wet
voice may still be useful in identifying those
with dysphagia who may have laryngeal dysfunction
and therefore may be at risk of
penetrating/aspirating any type of material, not
just prandial material.