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Treating Dysphagia: The Role of Speech Language Pathology

Author Taylor Spurgeon-Hess covers Treating Dysphagia: The Role of Speech Language Pathology on BackTable ENT

Taylor Spurgeon-Hess • Jun 21, 2022 • 35 hits

While speech language pathologists (SLP) work to prevent, diagnose, and treat a wide variety of conditions related to speech, communication, and language, they also work closely with dysphagia patients and the management and treatment of swallowing disorders. With a thorough history and proper workup, SLPs can help to increase the quality of life for many patients who face swallowing difficulties.

This article features excerpts from the BackTable ENT Podcast. We’ve provided the highlight reel in this article, and you can listen to the full podcast below.

The BackTable ENT Brief

• Medications such as muscle relaxers and Parkinson’s medication may affect a patient's swallow and should be considered when assessing for dysphagia.

• A typical assessment includes acquiring a solid case history, conducting a cranial nerve exam, and starting clinical swallow evaluations.

• While aspiration increases a patient’s risk for pneumonia, it is unlikely to occur in patients with healthy immune systems and proper oral care.

• When referring patients to speech language pathologists, otolaryngologists should ensure that the SLP receives the patient’s thorough medical history and has a line of contact to other members of the interdisciplinary care team if needed.

A diagram illustrating the path of food for a man with dysphagia.

Table of Contents

(1) Patient History & The Impact of Medications

(2) Working Up Patients with Dysphagia

(3) Aspiration Pneumonia Considerations

(4) Best Practices for ENT Referrals to Speech Language Pathologists

Patient History & The Impact of Medications

To begin treating patients with dysphagia, speech language pathologists must first obtain a normal case history complete with records on surgical interventions, prior medical conditions, and a complete medication history. A variety of medications can greatly impact swallowing and may even be the root cause of the patient’s issues. Examples of medications that frequently impact the swallow include muscle relaxers as well as Parkinson’s medications, such as Levodopa. Additionally, the lemon-glycerin swabs, frequently utilized for oral care in nursing homes, contribute significantly to dry mucosa and a decreased production of saliva in patients which can lead to swallowing issues.

[Ashley Agan MD]
So in your evaluation, I guess we'll just kind of take it from the top, as a patient comes to see you or you're going to see them, if it's mobile, what's the history taking look like? What's important? What are important things to be asking? And I guess, another thing from our side of it, what important things that we need to be asking to, before we're sending patients your way?

[Theresa Richard SLP]
Yeah, yeah. It's sort of all the above, just a normal case history, what surgical interventions have they had? What does their medical history look like? Medications is a huge thing too, as I'm sure you guys know, medications can impact the swallow greatly. So sometimes it's just nothing that we can do therapeutically as much as just recommending, sending them back to the physician, getting a change in their medications.

[Ashley Agan MD]
Are there particular medications that are common ones that stand out that affect the swallow?

[Theresa Richard SLP]
There are, especially a lot of muscle relaxers. If you think of the swallow, it's about 40 different muscles that make the swallow happen. So sometimes if you have patients on Ativan or something like that, or another form of muscle relaxant, and they complain that they can't swallow, that's something to consider. So that's sort of when we work closely with the psychologists and the facility too, to see what can we do to sort of relax this patient or ease the behaviors that they're having, but also still allow them to be able to eat by mouth because it can be very dangerous. There's many cases of patients aspirating or choking while on a muscle relaxant.

The other thing is the Parkinson's medication. So Levodopa. The timing of those, we've seen, it's night and day. If you see a Parkinson's patient before or after they've had their medication, it can be just the most uncoordinated swallow ever, but you give them the medication and it's all of the sudden beautiful. So that's one thing as soon as you see a patient with Parkinson's and if you know that they're on Levodopa regimen, make sure that they're eating about a half an hour after they've been given that medication. So that's something that's very common in that to be an easy solution in nursing homes.

[Gopi Shah MD]
When you do your evaluation, do you have them time the medication so that you get the best possible test?

[Theresa Richard SLP]
Ideally. Yep. Yep. Cause sometimes you just can't get anything. And also just educate them too and just say, Hey, without this medication, you're going to be calling me in again, because it's going to be really ugly. The patient's going to be struggling. So do you want to do it before the medication or after? There's obviously pros and cons to both sides, but you want obviously the patient to be eating and swallowing as effectively and safely as possible.

[Ashley Agan MD]
Do you find that medications that have dry mouth as a side effect of those? Because I tend to blame that a lot because I'm like, well, you just don't have enough saliva. And your mouth is too dry. Do you see that?

[Theresa Richard SLP]
Absolutely. Yeah, Yeah, absolutely. And I think, one thing too, is those lemon swabs. A lot of people tend to in the nursing homes or in the hospitals tend to tell people to use those, to sort of do oral care, which no, we should just be using a toothbrush and toothpaste for oral care, but the lemon swabs too dry out the mucosa immensely. So then people don't have enough saliva to be able to produce a swallow. So usually I just tell everyone, please throw out all the lemon glycerin swabs. And yeah. So if you're a producer of those, please don't come after me, but figure out a way to keep the mouths wetter.

[Gopi Shah MD]
Yeah, that's a good question, Ash. And when I think about it in the peds world, Theresa, do you ever see, in terms of secretion right? Secretion management is a big thing. And every once in a while a patient might be on something like glycopyrrolate or a scopolamine patch to help dry it up a bit. Do you ever find that that can be that dysphasia or something can be a side effect from that medication as well?

[Theresa Richard SLP]
Absolutely. I know the scopolamine patches are such a necessary evil sometimes. I know we see patients, almost for lack of a better term, drowning in their own secretion. So they'll be recommended one of those patches, but then on the flip side, it dries them out so much that they can barely swallow. So that's something that I think is so important for the speech pathologist and the doctors to work so closely together to weigh the pros and cons of that. Because I've seen the scopolamine patches help tremendously, but then I've also seen them tip back the other way and cause all these unwanted side effects. So when I do see that patch, I usually will bring it up and just probe a little bit more. Why did you start using this patch? Have you noticed anything different since? And sometimes patients are like, it's been a lifesaver and other times they’re like I'm so dry. So that's when we'll go back to the doctor and just try to brainstorm it. Is there something else we can do?

[Gopi Shah MD]
It's such a hard balance. Because of secretion management, aspiration, are they eating and drinking that little bit, how much benefit? It's such a tough balance with so many different factors.

[Theresa Richard SLP]
Right, right. Because obviously we don't want them aspirating all their own secretions too. So if it's helping in that aspect, then that’s wonderful.

[Gopi Shah MD]
Yeah, but like, if there's amazing pleasure and that 15 CCS of whatever, four times a day, like that's a little bit of joy that I can bring my kid or my relative. That's still huge too.

Listen to the Full Podcast

Feeding Difficulties in Adults with Theresa Richard, SLP on the BackTable ENT Podcast)
Ep 59 Feeding Difficulties in Adults with Theresa Richard, SLP
00:00 / 01:04

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Working Up Patients with Dysphagia

After acquiring a case history, next steps include conducting a clinical swallow evaluation and a cranial nerve exam. The typical first swallow evaluation, the Yale swallow protocol, involves drinking three ounces of water without breathing or coughing. Successfully doing so is considered a “pass” and no further testing is required. If a patient struggles to pass, the SLP usually requires further testing using video fluoroscopy or a fiberoptic endoscopic evaluation of swallow (FEES). Coughing indicates a positive ability to protect the airway and is viewed as a good sign in patients with swallowing difficulties.

[Ashley Agan MD]
There's always nuances depending on the patient and what you’re trying to treat, what are your expected outcomes and that sort of thing, for sure. Can you walk us through some of the different assessments? So for example, what does a bedside swallow evaluation look like in the ICU, versus the kind of workup you would do when you're in a clinic or seeing patients outpatient.

[Theresa Richard SLP]
Yeah. Yeah. So pretty much going to do the case history, do a clinical swallow examination, do a cranial nerve exam. Those are obviously pretty important for us to figure out is what we're working with. Neurological, what are the impairments there? The clinical swallowing exam, you're going to probably start with the Yale swallow protocol or just a three ounce water challenge. These are actually nurses can even do these, can be a nursing screen. So you take three ounces of water. And if the patient is able to chug the entire thing without stopping, without taking a breath, they are considered passed. So it means they don't have to go on for further swallowing evaluations. I will say the caveat with that is we are finding that for some different patient populations that the test isn't as reliable as we thought. So sort of back to the drawing board with that, but that at least gives us a good foundation because if, like I said, if they had to stop, if they had to cough, if they had to do anything, it should go to an automatic instrumental assessment. So FEES or video fluoroscopy. Yeah, depending on what the patient looks like, we might trial some foods and some liquids with them, obviously if they’re in the ICU, we're not going to go there right away. But if they are coming to the clinic, we'll try some different textures, see how they do. Things that are also important is different coughing. It's a huge thing. If they're able to cough, then that's a good thing. Right. They're able to protect their airway. So, those are things that we assess as well.

[Ashley Agan MD]
And I would think that drinking a cup of water, that challenge is going to be more sensitive for picking up someone who might be at risk for aspiration. Because when you drink water, it's going to go down faster, but you may not catch people who are going to have issues with solids or thicker foods. We have patients who are like, oh, I have trouble swallowing bread or things like that.

[Theresa Richard SLP]
Yup. Yup, Yup, yup. So that's obviously the nuance of the test, right? So, that's part of teasing that out a little bit more and trialing the different food textures. There's a lot that we do and there's sort of a movement away from doing just that from just watching your patients eat as an assessment, to doing a lot of these other tools, we have a lot more rating scales and things like that now that help us get a lot more information about our patients than just sort of like you said, sitting and watching them eat bread and seeing if they can do it or not.

Aspiration Pneumonia Considerations

Before making any recommendations for changes, SLPs often ask patients to explain a typical meal and any cultural considerations related to food and diet. The range of normal for functional swallowing has expanded over time and now findings show that even patients that exhibit “ugly” swallows on a swallow study may be completely functional without modifications. Sometimes patients may cough, indicating aspiration, but that does not automatically indicate that they will develop aspiration pneumonia. Patients most likely to actually develop pneumonia include those with weak immune systems and poor oral care. If a patient remains mobile and talking, indicating a healthy immune system, and maintains proper oral hygiene, the risk of developing aspiration pneumonia is slim.

[Ashley Agan MD]
Moving on kind of through your visit and you've asked your questions and kind of gathered your history. What's next, I guess, it might depend on where you are, right? If you're at bedside or from your office.

[Theresa Richard SLP]
Yeah. If the patient obviously can communicate, and if they can tell you, or if you have access to a family member too, I like to sort of hear what does a normal meal look like? What foods do they typically like to eat? What are some cultural considerations to think of too? Because sometimes we'll make recommendations to slow a patient down or things like that, but it's the way they've been eating for a million years. And a lot of patients with developmental disabilities, especially kids with down syndrome, they eat in a very, for lack of a better term, it looks ugly under a swallow study. You would just say, this is a mess, but for them it's completely functional. And they may have never had an aspiration event. They may have never had a pneumonia. So it's really important to collect that data ahead of time, because what we've seen in our field is sort of just being too conservative by saying, oh my goodness, this is not functional. We need to alter the diet or we need to thicken the liquids. And then you can send the patient to all these behaviors because you've just modified things that they don't understand, or for what reason and decrease the quality of life. I like to take a lot of steps back and just see what is normal, what is considered functional for them? Because we're just learning now that the range of normal is much, much, much bigger than we once thought. So if we can get that information from the patient or a family member, that's something that's really so crucial because we don't want to be thickening a patient’s liquids without knowing for sure that that's absolutely what they need to be on.

[Ashley Agan MD]
I'm glad you brought up pneumonia. Because I think, when I was a junior resident, I kind of thought if a patient coughs, when they eat, then they should be NPO. Like aspiration equals don't eat. Right. But, now it's like, well, if you're not getting pneumonia, then maybe you have a strong cough and if you aspirate a little bit, you can get it out and we don't have to just keep you from eating. Right. Which is probably the worst thing you can do for a patient that's maybe having some issues. Because maybe, I don't know, you don't use it, you lose it and maybe things get worse. I don't know.

[Gopi Shah MD]
I was going to say those little minor modifications might be 20,000 steps back. I feel like, tell us about your experience.

[Theresa Richard SLP]
Yeah. So we know a lot more about sort of the pillars of pneumonia at this point. Now we know that you have to have a lesser functioning immune system. So if you have a well-functioning immune system, your chances of getting pneumonia are a lot less. Another thing to consider is the oral microbiome. What does that look like? If you have healthy oral care, you're brushing your teeth, toothpaste, mouthwash, you're killing all that oral bacteria. So the chances of it, even if it does go into the lungs and you aspirate, the chances of it turning into pneumonia are really slim. And part of the healthy immune system, we say, are they a walkie-talkie? Are they walking and talking? Because if they're up and functional and moving, then obviously they're going to have a stronger immune system. So those are things to consider too, before we even look at, okay, so is this patient aspirating? Okay. Yes they are. But how was their immune system? How is their oral care? These are the things to consider. If those things are poor, then we know that they're at a much higher chance of aspirating.

My son for one, is what we call a functional aspirator. So he does aspirate. We've seen it on a swallow study. He's never had pneumonia. Obviously, he's got severe special needs. So we are religious about brushing his teeth constantly. He doesn't walk on his own. He uses a gait trainer, but we make sure to get him up in it a few times a day, things like that to keep walking, keep his immune system functioning. So there's a lot to consider with that. And then on the flip side, if we do see that patients have recurrent pneumonia or they are in for aspiration pneumonia, what causes it? So then we try to go backwards and figure out that puzzle piece, is it because of a poor immune system or do they have a true dysphasia? That they are aspirating all the time. So we've talked about, this is just a really complex mechanism.

But, Dr. Susan Langmore, who's one of the researchers that created the FEES procedure that I do, actually wrote a seminal paper. I think she wrote two iterations of it, 1998 and 2002, on the predictors of aspiration pneumonia and dysphagia actually was number seven. So, things like dependent for oral care, dependent for feeding, the number of medications, smoking, multiple medical diagnoses, number of decayed teeth and suctioning are all before dysphasia. So these things are all really important to consider as well. And like I said, we for just lack of knowing better, just assume when you aspirate it turns into pneumonia. Right. But there's so many other factors that we have to consider before we just say, oh, you're going to get pneumonia if you aspirate, here's some thickened liquids, good luck.

Best Practices for ENT Referrals to Speech Language Pathologists

When referring to sleep language pathology, otolaryngologists can help to ensure the patient’s experience is as seamless and effective as possible by keeping in mind a select few best practices. Importantly, an ENT can begin by clearing up any questions a patient may have about what exactly an SLP does and their role in treating dysphagia. While a swallow study prior to the visit may provide a solid starting point for treatment, SLPs value a complete case history and accessible communication with the referring physician over all else. Often patients arrive for care with only pieces of the story and SLPs are left attempting to fill in the gaps or repeat testing that may have already been completed.

[Ashley Agan MD]
As far as when we're sending patients to our SLP colleagues, what can I be doing, to kind of help tee up that visit? Are there things that we can have patients start working on or is it good to get some sort of swallow study before they see you? Do you like to have that video fluoroscopy swallow eval during that first visit when you're evaluating a patient or is it better to just, I guess it depends on if the SLP has FEES available to them. Right? But what can we be doing just to help set patients up other than reiterating that speech language pathologists do treat dysphasia.

[Theresa Richard SLP]
I love this question, Ashley. Thank you. I think the fact that you're even asking this just means so much to a lot of SLPs, but I think really the most important thing, a lot of times we get a lot of patients without any sort of paper trail whatsoever. And we have no idea where they came from, what they've been through, what medical intervention they've had, what surgical intervention they've had, what pharmacological intervention they've had. So really just a solid thorough case history is worth its weight in gold to us. If we can get a swallow study ahead of time also, that means so much because that at least gives us a starting point to say, oh wow, it looks like they functionally improved, or it looks like they're going downhill, it gives us a good baseline. So in a perfect world, that would be wonderful, but really, truly just a solid case history. And I think just being accessible. We work as part of a big interdisciplinary team, and sometimes there's just a lot of holes in the story and, oh, could we just call the ENT and get some more information or could we call the pulmonologist and get some more information? I think that's usually, I, for lack of a better term, hate our healthcare system right now in that it's so hard to get ahold of each other. You have to call like the zero line at the hospital and track down everybody. And I just wish there was a way for medical professionals to like, have backdoor communication to, Hey, I've got a question about this patient, what can you tell me? So I think just being accessible or, letting the SLP know, Hey, my name's Ashley, here's the number of my office, let me know how I can help. That's really just so helpful because a lot of times we're just piecing together what we have with a patient that's been dropped in our doorstep for lack of a better term. And we're left to do the solo study with the information that we have in front of us with a very limited amount of time. And then you sort of send them back off into the world, like, did I answer all their questions? Was that the right answer? So, a really solid case history is everything.

[Gopi Shah MD]
Without that communication, it's so interesting that you could be like, as the ENT, I have one idea of what I think is going on, then they have an assessment or an evaluation it's completely different. And then I'm like, I'm obviously missing something. And so that dialogue is so beneficial for the patient. And it's easy when you're on the same Epic system or whatnot, but having to reach out and it can definitely make it real painful for everybody, for the patients too because they're just like, “Can y’all just talk to each other?”

[Theresa Richard SLP]
Yeah, yeah. I even went through that with my own son. He was sent to a rehab center and a speech pathologist evaluated him. And, she called, didn't know I was a speech pathologist and just gave me this whole report of like, he can't do this, we're going to modify his diet to this. He can't do this. And I was like, “Yeah, no crap lady.” And I was so angry because I was like, had they just reached out to me to begin with, I could have given them all this information, But instead, it seemed just like a whole waste of her time and medical resources to go through and do this whole thing and had really nothing to do with how he presents on a daily basis. So, obviously that could be a whole nother episode– interdisciplinary communication.

[Ashley Agan MD]
Absolutely.

Podcast Contributors

Theresa Richard, SLP discusses Feeding Difficulties in Adults on the BackTable 59 Podcast

Theresa Richard, SLP

Theresa Richard is a speech language pathologist and the founder of Mobile Dysphagia Diagnostics in Florida.

Dr. Gopi Shah discusses Feeding Difficulties in Adults on the BackTable 59 Podcast

Dr. Gopi Shah

Dr. Gopi Shah is a practicing ENT at UT Southwestern Medical Center in Dallas, TX.

Dr. Ashley Agan discusses Feeding Difficulties in Adults on the BackTable 59 Podcast

Dr. Ashley Agan

Dr. Ashley Agan is a practicing ENT and assistant professor at UT Southwestern Medical Center in Dallas, TX.

Cite This Podcast

BackTable, LLC (Producer). (2022, May 10). Ep. 59 – Feeding Difficulties in Adults [Audio podcast]. Retrieved from https://www.backtable.com

Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.

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