Clinical Indicators for Instrumental Assessment of Dysphagia
Special Interest Division 13, Swallowing and Swallowing Disorders Task Force on Clinical Indicators
About this Document
These guidelines are an official statement of the American Speech-Language-Hearing Association (ASHA). They provide guidance, but are not official standards of the Association. They were developed by the Task Force on Clinical Indicators of Special Interest Division 13, Swallowing and Swallowing Disorders: Robert M. Miller (chair), Rebecca Barker, Joe Caniglia, Nancy Colodny, Cynthia D. Hildner, Brad Hutchins, Kurt Kitselman, Susan L. Langmore, Cathy Lazarus, Maureen Lefton-Greif, Richard Robinson, Gina Shelley, Marsha Sullivan, and Mark L. Kander (National Office staff). The document was further modified by the steering committee of Division 13, Bonnie Martin-Harris (coordinator), Joan Arvedson, Rona Alexander, Michael Crary, Cathy Lazarus, and staff of the Governmental Relations and Public Policy Unit. Nancy Creaghead (Vice President for Professional Practices in Speech-Language Pathology, 1997–1999) served as monitoring vice president.
The purpose of this document is to provide guidelines for the use of instrumentation in the assessment, diagnosis, management, and treatment of patients with oral, pharyngeal, and upper esophageal dysphagia. Indications and contraindications for the use of instrumentation will be discussed.
Previous ASHA policy statements on this topic have determined the role of speech-language pathologists in the area of dysphagia (ASHA, 1983), have provided guidelines for knowledge and skills needed by speech-language pathologists providing services to patients with dysphagia ( Asha, 32, 1990), and have determined that instrumental diagnostic procedures for swallowing are within the scope of practice of speech-language pathologists (Asha, 34, 1992). ASHA Preferred Practice Patterns for the Profession of Speech-Language Pathology (ASHA, 1997) outlined clinical indications for assessment and treatment and have described the components of a clinical (noninstrumental) and instrumental examination, but to date no practice guidelines have been disseminated regarding the use of instrumental assessment procedures when evaluating patients with dysphagia.
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In the past decade, the profession of speech-language pathology has witnessed an increase in technology developed to assist in the assessment and treatment of dysphagia. This technology has resulted in increasing sophistication in the assessment skills of speech-language pathologists and more frequent use of this instrumentation. Increasing cost-containment and quality of life concerns argue for the most effective and efficient method of diagnosis and management of dysphagia, including the determination of whether an instrumental examination will best serve the patient.
Evidence-based research studies, published clinical reports, clinical experience, and clinical scenarios provided the basis for the development of these guidelines. It should be emphasized that these are practice guidelines only. Exceptions to these guidelines will occur as the speech-language pathologist takes into consideration knowledge of all the circumstances surrounding a patient's condition. This knowledge will sometimes lead to recommendations other than those presented in this document. Therefore, clinical judgment will, at times, supersede these indications. Inherent in this premise is the expectation that the speech-language pathologist making the decision is experienced and competent in the area of dysphagia.
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Management. An intervention that involves changing the variables of the environment or changing behaviors of others relative to the patient's dysphagia; may be intermittent; may include establishment of maintenance programs that are implemented by others; may be done by educating caregivers or patients; ongoing activities done by other caregivers may be supervised by the speech-language pathologist; and requires a speech-language pathologist to develop, revise, and update the plan.
Treatment. An intervention that is intended to change the physiology or behavior of the patient is implemented for some behavior(s) that require(s) training by applying the principles of learning theory; requires direct intervention by the speech-language pathologist to the patient; and is goal-oriented with measurable outcomes.
Clinical/Bedside Dysphagia Examination (hereafter referred to as the clinical examination). As described in the Preferred Practice Patterns for the Profession of Speech-Language Pathology (ASHA, 1997), includes a case history, review of medical/clinical records, assessment protocols, and observations. Includes a structural and functional assessment of the muscles and structures used in swallowing, functional assessment of actual swallowing ability, and judgments of adequacy of airway protection and coordination of respiration and swallowing. It may also include an assessment of the effect of alterations in bolus delivery or use of therapeutic postures or maneuvers on the swallow. The clinical examination may include use of tools and techniques (such as cervical auscultation and pulse oximetry) to detect and monitor clinical signs of dysphagia.
Instrumental Dysphagia Examination (hereafter referred to as the instrumental examination). As described in the Preferred Practice Patterns for the Profession of Speech-Language Pathology (ASHA, 1997), includes fluoroscopy, endoscopy, ultrasound, and manometry. The guidelines may also refer to other instrumental procedures that may be developed in the future. Instrumental assessment includes any or all of the following: structural and functional assessment of the muscles and structures used in swallowing; functional assessment of actual swallowing ability; assessment of adequacy of airway protection and coordination of respiration and swallowing; screening of esophageal motility and gastroesophageal reflux; and assessment of the effect of changes in bolus delivery, textural alterations/bolus characteristics, or use of therapeutic postures or maneuvers on the swallow. Some instrumental procedures provide comprehensive information; others provide specific information about a particular aspect of swallowing. No attempt has been made in this document to provide guidance for the use of any specific instrumental procedure.
Symptoms and Signs. Symptoms refer to complaints or sensations reported by the patient and/or caregivers; signs refer to observable evidence of the dysphagia. Signs may also refer to any variable derived from the medical history, including reported symptoms by the patient.
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There are specific indications for both the clinical and instrumental examination. For patients with signs and symptoms of oropharyngeal dysphagia, instrumental procedures can provide more sensitive and objective documentation of findings than the clinical examination. Information gleaned from these exams can be used to make appropriate referrals and to determine appropriate management and treatment of dysphagia.
The purposes of the clinical examination are to enable the speech-language pathologist to:
Integrate information from the interview/case history, review of medical/clinical records, standardized protocols, observations from the physical examination, and collaboration with physicians and other caregivers.
Observe and assess the integrity and function of the following structures of the upper airway and digestive tract: face, jaw, lips, oral mucosa, tongue, teeth, hard palate, soft palate during nonspeech, speech, and swallowing tasks.
Identify the presence and observe the characteristics of a dysphagia based on clinical signs and symptoms. This may include identifying factors that may affect swallowing function such as bolus size, bolus consistency, fatigue during a meal, posture, positioning, and environmental conditions.
Identify clinical signs and symptoms of esophageal dysphagia or gastroesophageal reflux in order to make an appropriate referral to another specialty.
Determine the need for an instrumental evaluation following the clinical examination.
Identify and follow up with patients who may require reevaluation, instruction, intervention, or other evaluation procedures prior to instrumental evaluation.
Determine whether the patient is an appropriate candidate for treatment and/or management, based on clinical examination findings such as medical stability, cognitive status, nutritional status, psycho-social-environmental and behavioral factors.
Recommend, as appropriate, the route of nutritional management (i.e., oral vs. nonoral).
Recommend clinical interventions (e.g., positioning, food and liquid consistency modifications, feeding routine alterations) and other clinical strategies designed to enhance the efficiency and safety of swallowing.
Provide counseling, education, and training to the patient, health care providers, and care givers.
The purposes of the instrumental examination are to enable the speech-language pathologist to:
Visualize the structures of the upper airway and digestive tract, including the oral cavity, velopharyngeal port, pharynx, larynx, and esophagus.
Assess the physiologic functioning of the muscles and structures involved in swallowing and to make observations, measures and inferences of symmetry, sensation, strength, pressures, tone, range, rate of motion, and coordination or timing of movement.
Assess coordination and effectiveness of lingual, velopharyngeal, pharyngeal, and laryngeal movement during swallowing.
Determine presence, cause, severity, and timing of aspiration by visualizing bolus control, flow and timing, and the response to bolus misdirection.
Visualize the presence, location, and amount of secretions in the hypopharynx and larynx, the patient's sensitivity to the secretions and the ability of spontaneous or facilitated efforts to clear the secretions.
Screen esophageal anatomy and function for evidence of dysphagia.
Assist in determining the safest and most efficient route (oral vs. nonoral) of nutrition and hydration intake.
Determine with specificity the relative safety and efficiency of various bolus consistencies and volumes.
Determine the rate or method of oral intake delivery (i.e., selection of utensils, bolus placement, bolus modifications).
Determine the postures, positioning, maneuvers, and/or other management/treatment techniques that enhance the safety and efficiency of feeding.
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An instrumental examination is indicated for making the diagnosis and/or planning effective management and treatment in patients with suspected, or who are at high risk for, oropharyngeal dysphagia based on the clinical examination when:
The patient's signs and symptoms are inconsistent with findings on the clinical examination. (Baker et al., 1991; Frederick et al., 1995; Lindgren & Ekberg, 1988).
There is a need to confirm a suspected medical diagnosis and/or assist in the determination of a differential medical diagnosis. (Buchholz, 1993, 1994, 1995; Celifarco et al., 1990; Ekberg et al., 1986; Ekberg et al., 1989; Gregory et al., 1992; Hayashi et al., 1997; Hogue et al., 1995; Khan & Campbell, 1994; Kluin et al., 1996; Nilsson et al., 1993; Papadopoulos et al., 1989; Putnam et al., 1992; Riminton et al., 1993; Shapiro et al., 1996, 1997; Silbergleit et al., 1991; Sliwa & Lis, 1993; Sonies & Dalakas, 1991; Watanabe et al., 1984).
Confirmation and/or differential diagnosis of the dysphagia is needed. (Ali et al., 1996; Aviv et al., 1996; Bazemore et al., 1991; Celifarco et al., 1990; Coelho, 1987; DiVito, 1998; Horner et al., 1992; Jennings et al., 1992; Jones et al., 1993; Kagel & Leopold, 1992; Lazarus et al., 1996; Lazarus & Logemann, 1987; Leopold & Kagel, 1996; Litvan et al., 1997; Logemann et al., 1993, 1994; Martin et al., 1997; Mirrett et al., 1994; Newton et al., 1994; Nilsson et al., 1996; Pauloski, 1995; Plaxico & Loughlin, 1981; Pollack et al., 1992; Putnam et al., 1992; Robbins et al., 1993; Skinner & Shorter, 1992; Sonies, 1997; Veis & Logemann, 1985; Yang et al., 1997; Zerhouni et al., 1987).
There is either nutritional or pulmonary compromise and a question of whether the oropharyngeal dysphagia is contributing to these conditions. (Aviv et al., 1997a, 1997b; Granger & Craig, 1990; Holas et al., 1994; Keller, 1993; Kidd et al., 1995; Johnson et al., 1993; Langmore et al., 1998; Martin et al., 1994; Schmidt et al., 1994; Sheppard et al., 1988; Taniguchi & Moyer, 1994; Veldee & Peth, 1992; Volicer et al., 1989; Woratyla et al., 1995).
The safety and efficiency of the swallow remains a concern. (Arvedson et al., 1994; Collins & Bakheit, 1997; Daniels et al., 1998; DePippo et al., 1992; Griggs et al., 1989; Horner & Massey, 1988; Horner et al., 1990, 1991; Kidd et al., 1993; Linden & Siebens, 1983; Linden et al., 1993; Morton et al., 1993, 1997; Marie et al., 1997; Murray et al., 1996; Rogers, 1993, 1994a, 1994b; Splaingard et al., 1988)
The patient is identified as a swallow rehabilitation candidate and specific information is needed to guide management and treatment.(Bisch et al., 1994; Ekberg, 1986; Feinberg et al., 1992; Fujiu et al., 1995; Fujiu & Logemann, 1996; Griggs et al., 1989; Helfrich-Miller et al., 1986; Kahrilas et al., 1991; Larnet & Ekberg, 1995; Lazarra et al., 1986; Lazarus, 1993; Lazarus et al., 1993; Logemann, 1994; Logemann & Kahrilas, 1990; Logemann et al., 1989, 1995; Martin et al., 1993, Mendelsohn & Martin, 1993; Mirrett et al., 1994; Morton et al., 1993; Omae et al., 1996; Rasley et al., 1993; Rosenbek et al., 1991, 1996; Shanahan et al., 1993; Welch et al., 1993).
An instrumental examination may be indicated [*] for making the diagnosis and/or planning effective treatment in patients with suspected dysphagia based on the clinical examination and the presence of one or more of the following:
The patient has a medical condition or diagnosis associated with a high risk for dysphagia, including but not limited to neurologic, pulmonary or cardiopulmonary, gastrointestinal problems; immune system compromise; surgery and/or radiotherapy to the head and neck; and craniofacial abnormalities. (Gordon et al., 1987; Groher & Bukatman, 1986; Hartelius & Svensson, 1994; Kuhlemeier, 1994).
The patient has a previously diagnosed dysphagia and a change in swallow function is suspected. (Barer, 1989; Crary, 1995; Lazarus et al., 1994; McConnel et al., 1994; Pauloski et al., 1994; Rademaker et al., 1993; Wade & Hewer, 1987).
The patient has a condition such as cognitive or communication deficits that preclude completion of a valid clinical examination.
The patient has a chronic degenerative disease or a disease with a known progression, or is in a stable or recovering condition for which oropharyngeal function may require further definition for management. (Colice, 1992; Colice et al., 1989; de Larminat et al., 1995; Hillel et al., 1989; Kagel & Leopold, 1992; Litvan et al., 1997; Morton et al., 1997; Strand et al., 1996; Sonies & Dalakas, 1995).
An instrumental examination is not indicated when findings from the clinical examination fail to identify dysphagia or when findings from the clinical examination suggest dysphagia and include one or more of the following:
The patient is too medically unstable to tolerate a procedure.
The patient is unable to cooperate or participate in an instrumental examination. (Burton et al., 1992a, 1992b)
In the speech-language pathologist's judgment, the instrumental examination would not change the clinical management of the patient. (Ackerman, 1996; Campbell-Taylor & Fisher, 1987; Croghan et al., 1994; Gottlieb et al., 1996; Leff et al., 1994; Logemann et al., 1992; McCann et al., 1994; Mitchell et al., 1997; Odderson et al., 1995; Peck et al., 1990; Smithard et al., 1996).
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Guidelines for the appropriate use of instrumental procedures for the assessment of oropharyngeal dysphagia are based on a critical review of the available data and expert consensus. Clinical considerations may justify a course of action at variance from these recommendations and speech-language pathologists are bound by their Code of Ethics at all times. Controlled clinical studies are needed to continue to add to the body of knowledge regarding the use of instrumentation in the assessment of dysphagia and revision may be necessary as new data are published.
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Ackerman, T. F. (1996). The moral implications of medical uncertainty: Tube feeding demented patients. Journal of the American Geriatric Society, 44, 1265–1267.
Ali, G. N., Wallace, K. L., Schwartz, R., DeCarle, D. J., Zagami, A. S., & Cook, I. J. (1996). Mechanisms of oral-pharyngeal dysphagia in patients with Parkinson's disease. Gastroenterology, 100, 383–392.
American Speech-Language-Hearing Association. (1983). Dysphagia (ASHA Technical Report). Rockville, MD: Author.
American Speech-Language-Hearing Association. (1990). Skills needed by speech-language pathologists providing services to dysphagic patients/clients. Asha, 32(Suppl. 2), 7–12.
American Speech-Language-Hearing Association. (1996). Scope of practice in speech-language pathology. Asha, 38(Suppl. 16), 16–20.
American Speech-Language-Hearing Association. (1997). Preferred practice patterns for the profession of speech-language pathology. Rockville, MD: Author.
Arvedson, J., Rogers, B., Buck, G., Smart, P., & Msall, M. (1994). Silent aspiration prominent in children with dysphagia. International Journal of Pediatric Otorhinolaryngology, 28, 173–181.
Aviv, J. E., Martin, J. H., Sacco, R. L., Zagar, D., Diamond, B., Keen, M. S., & Blitzer, A. (1996). Supraglottic and pharyngeal sensory abnormalities in stroke patients with dysphagia. Annals of Otology Rhinology and Laryngology, 105, 92–97.
Aviv, J. E., Sacco, R. L., Thomson, J., Tandon, R., Diamond, B., Martin, J. H., & Close, L. G. (1997a). Silent laryngopharygeal sensory deficits after stroke. Annals of Otology Rhinology and Laryngology, 106, 87–93.
Aviv, J. E., Sacco, R. L., Mohr, J. P., Thompson, J. L. P., Levin, B., Sunshine, S., Thomson, J., & Close, L. G. (1997b). Laryngopharyngeal sensory testing with modified barium swallow as predictors of aspiration pneumonia after stroke. Laryngoscope, 107, 1254–1260.
Baker, B. M., Fraser, A. M., & Baker, C. D. (1991). Long-term postoperative dysphagia in oral/pharyngeal surgery patients: Subjects' perceptions vs. videofluoroscopic observations. Dysphagia, 6, 11–16.
Barer, D. H. (1989). The natural history and functional consequences of dysphagia after hemispheric stroke. Journal of Neurosurgery and Psychiatry, 52, 236–241.
Bazemore, P. H., Tonkonogy, J., & Ananth, R. (1991). Dysphagia in psychiatric patients: Clinical and videofluoroscopic study. Dysphagia, 6, 2–5.
Bisch, E. M., Logemann, J. A., Rademaker, A. W., Kahrilas, P. J., & Lazarus, C. L. (1994). Pharyngeal effects of bolus volume, viscosity, and temperature in patients with dysphagia resulting from neurologic impairment and in normal subjects. Journal of Speech, Language, and Hearing Research, 37, 1041–1049.
Buchholz, D. W. (1993). Clinically probable brainstem stroke presenting primarily as dysphagia and nonvisualized by MRI. Dysphagia, 8, 235–238.
Buchholz, D. W. (1994). Neurogenic dysphagia: What is the cause when the cause is not obvious? Dysphagia, 9, 245–255.
Buchholz, D. W. (1995). Oropharyngeal dysphagia due to iatrogenic neurological dysfunction. Dysphagia, 10, 248–254.
Burton, L. C., German, P. S., Rovner, B. W., Brant, L. J., & Clark, R. D. (1992). Mental illness and the use of restraints in nursing homes. Gerontologist, 32(2), 164–170.
Burton, L. C., German, P. S., Rovner, B. W., & Brant, L. J. (1992). Physical restraint use and cognitive decline among nursing home residents. Journal of the American Geriatric Society, 40, 811–816.
Campbell-Taylor, I., & Fisher, R. H. (1987). The clinical case against tube feeding in palliative care of the elderly. Journal of the American Geriatric Society, 35, 1100–1104.
Celifarco, A., Gerard, G., Faegenburg, D., & Burakoff, R. (1990). Dysphagia as the sole manifestation of bilateral strokes. American Journal of Gastroenterology, 85(5), 610–613.
Colice, G. L., Stukel, T. A., & Dain, B. (1989). Laryngeal complications of prolonged intubation. Chest, 96, 877–884.
Colice, G. L. (1992). Resolution of laryngeal injury following translaryngeal intubation. American Review of Respiratory Diseases, 145, 361–364.
Coelho, C. A. (1987). Preliminary findings on the nature of dysphagia in patients with chronic obstructive pulmonary disease. Dysphagia, 2, 28–31.
Collins, M. J., & Bakheit, A. M. O. (1997). Does pulse oximetry reliably detect aspiration in dysphagic stroke patients? Stroke, 218, 1773–1775.
Crary, M. A. (1995). A direct intervention program for chronic neurogenic dysphagia secondary to brainstem stroke. Dysphagia, 10, 6–18.
Croghan, J. E., Burk, E. M., Caplan, S., & Denman, S. (1994). Pilot study of 12-month outcomes of nursing home patients with aspiration on videofluoroscopy. Dysphagia, 9, 141–146.
Daniels, S. K., Brailey, K., Priestly, D. H., Herrington, L. R., Weisberg, L. A., & Foundas, A. L. (1998). Aspiration in patients with acute stroke. Archives of Physical Medicine and Rehabilitation, 79, 14–19.
de Larminat, V., Montravers, P., Dureuil, B., & Desmonts, J. M. (1995). Alteration in swallowing reflex after extubation in intensive care unit patients. Critical Care Medicine, 23(3), 486–490.
DePippo, K. L., Holas, M. A., & Reding, M. J. (1992). Validation of the 3-oz water swallow test for aspiration following stroke. Archives of Neurology, 49, 1259–1961.
DiVito, J. (1998). Cervical osteophytic dysphagia: Single and combined mechanisms. Dysphagia, 13, 58–61.
Ekberg, O. (1986). Posture of the head and pharyngeal swallowing. Acta Radiologica Diagnosis, 17, 691–696.
Ekberg, O., Lindgren, S., & Schultze, T. (1986). Pharyngeal swallowing in patients with paresis of the recurrent nerve. Acta Radiologica Diagnosis, 27, 697–700.
Ekberg, O., Bergqvist, D., Takolander, R., Uddman, R., & Kitzing, P. (1989). Pharyngeal function after carotid endarterectomy. Dysphagia, 4, 151–154.
Feinberg, M. J., Ekberg, O., Segall, L., & Tully, J. (1992). Deglutition in elderly patients with dementia: findings of videofluorographic evaluation and impact on staging and management. Radiology, 183, 811–814.
Frederick, M. G., Ott, D. J., Grishaw, E. K., Gelfand, D. W., & Chen, M. Y. M. (1996). Functional abnormalities of the pharynx: a prospective analysis of radiographic abnormalities relative to age and symptoms. American Journal of Radiology, 166, 353–357.
Fujiu, M., Logemann, J. A., & Pauloski, B. R. (1995). Increased postoperative posterior pharyngeal wall movement in patients with anterior oral cancer: Preliminary findings and possible implications for treatment. American Journal of Speech-Language Pathology, 4, 24–30.
Fujiu, M., & Logemann, J. A. (1996). Effect of a tongueholding maneuver on posterior pharyngeal wall movement during deglutition. American Journal of Speech-Language Pathology, 5, 23–30.
Ganger, D., & Craig, R. M. (1990). Swallowing disorders and nutritional support. Dysphagia, 4, 213–219.
Gordon, C., Hewer, R. L., & Wade, D. T. (1987). Dysphagia in acute stroke. British Medical Journal, 295, 411–414.
Gottlieb, D., Kipnis, M., Sister, E., Vardi, Y., & Brill, S. (1996). Validation of the 50 ml3 drinking test for evaluation of post-stroke dysphagia. Disability Rehabilitation, 18, 529–532.
Gregory, R. P., Smith, P. T., & Rudge, R. (1992). Tardive dyskinesia presenting as severe dysphagia. Journal of Neurology Neurosurgery and Psychiatry, 55, 1203–1204.
Griggs, C. A., Jones, P. M., & Lee, R. E. (1989). Videofluoroscopic investigation of feeding disorders of children with multiple handicap. Developmental Medicine and Child Neurology, 31, 303–308.
Groher, M. E., & Bukatman, R. (1986). The prevalence of swallowing disorders in two teaching hospitals. Dysphagia, 1, 3–6.
Hartelius, L., & Svensson, P. (1994). Speech and swallowing symptoms associated with Parkinson's disease and multiple sclerosis: A survey. Folia Phonatrica et Logopaedica, 46, 9–17.
Hayashi, T., Nishikawa, T., Koga, I., Uchida, Y., & Yamawaki, S. (1997). Life-threatening dysphagia following prolonged neuroleptic therapy. Clinical Neuropharmacology, 20(1), 77–81.
Helfrich-Miller, K. R., Rector, K. L., & Straka, J. A. (1986). Dysphagia: Its treatment in the profoundly retarded patient with cerebral palsy. Archives of Physical Medicine and Rehabilitation, 67, 520–525.
Hillel, A. D., & Miller, R. (1989). Bulbar amyotrophic lateral sclerosis: Patterns of progression and clinical management. Head and Neck, 11, 51–59.
Hogue, C. W., Lappas, G. D., Creswell, L. L., Ferguson, T. B., Sample, M., Pugh, D., Balfe, D., Cox, J. L., & Lappas, D. G. (1995). Swallowing dysfunction after cardiac operations. Journal of Thoracic and Cardiovascular Surgery, 110, 517–522.
Holas, M. A., DePippo, K. L., & Reding, M. J. (1994). Aspiration and relative risk of medical complications following stroke. Archives of Neurology, 51, 1051–1053.
Horner, J., & Massey, E. W. (1988). Silent aspiration following stroke. Neurology, 38, 317–319.
Horner, J., Massey, E. W., & Barzer, S. R. (1990). Aspiration in bilateral stroke patients. Neurology, 40, 1686–1688.
Horner, J., Buoyer, F. T., Alberts, M. J., & Helms, M. J. (1991). Dysphagia following brainstem stroke: Clinical correlates and outcome. Archives of Neurology, 48, 1170–1173.
Horner, J., Riski, J. E., Ovelmen-Levitt, J., & Nashold, B. S. (1992). Swallowing in torticollis before and after rhizotomy. Dysphagia, 7, 117–125.
Jennings, K. S., Siroky, D., & Jackson, C. G. (1992). Swallowing problems after excision of tumors of the skull base: Diagnosis and management in 12 patients. Dysphagia, 7, 4–44.
Jones, B., Ravich, W. J., & Donner, M. W. (1993). Dysphagia in systemic disease. Dysphagia, 8, 368–383.
Kagel, M. C., & Leoppold, N. A. (1992). Dysphagia in Huntington's disease: A 16-year retrospective. Dysphagia, 7, 106–114.
Kahrilas, P. J., Logemann, J. A., Krugler, C., & Flanagan, E. (1991). Volitional augmentation of upper esophageal sphincter opening during swallowing. American Journal of Physiology (Gastrointestinal Liver Physiology), 23, G450–G456.
Keller, H. H. (1993). Malnutrition in institutionalized elderly: how and why? Journal of the American Geriatric Society, 41, 1212–1218.
Khan, O. A., & Campbell, W. W. (1994). Myasthenia gravis presenting as dysphagia: Clinical considerations. American Journal of Gastroenterogy, 89(7), 1083–1085.
Kidd, D., Lawson, J., Nesbitt, R., & MacMahon, J. (1993). Aspiration in acute stroke: A clinical study with videofluoroscopy. Quarterly Journal of Medicine, 86, 825–829.
Kidd, D., Lawson, J., Nesbitt, R., & MacMahon, J. (1995). The natural history and clinical consequences of aspiration in acute stroke. Quarterly Journal of Medicine, 88, 409–413.
Kuhlemeier, K. V. (1994). Epidemiology and dysphagia. Dysphagia, 9, 209–217.
Johnson, E. R., McKenzie, S. W., & Sievers, A. (1993). Aspiration pneumonia in stroke. Archives of Physical Medicine and Rehabilitation, 74, 973–976.
Kluin, K. J., Bromberg, M. B., Feldman, E. L., & Simmons, Z. (1996). Dysphagia in elderly men with myasthenia gravis. Journal of the Neurological Sciences, 138, 49–52.
Langmore, S. E., Terpenning, M. S., Schork, A., Chen, Y., Murray, J. T., Lopatin, D., & Loesche, W. J. (1998). Predictors of aspiration pneumonia: How important is dysphagia? Dysphagia, 13(2), 69–81.
Larnert, G., & Ekberg, O. (1995). Positioning improves the oral and pharyngeal swallowing function in children with cerebral palsy. Acta Paediatrica, 84, 689–692.
Lazzara, G. D. L., Lazarus, C., & Logemann, J. A. (1986). Impact of thermal stimulation on the triggering of the swallowing reflex. Dysphagia, 1, 73–77.
Lazarus, C., & Logemann, J. A. (1987). Swallowing disorders in closed head trauma patients. Archives of Physical Medicine and Rehabilitation, 68, 79–84.
Lazarus, C. L. (1993). Effects of radiation therapy and voluntary maneuvers on swallow functioning in head and neck cancer patients. Clinics in Communication Disorders, 3, 11–20.
Lazarus, C., Logemann, J. A., & Gibbons, P. (1993). Effects of maneuvers on swallowing function in a dysphagic oral cancer patient. Head and Neck, 15, 419–424.
Lazarus, C., Logemann, J., Kahrilas, P., & Mittal, B. (1994). Swallow recovery in an oral cancer patient following surgery, radiotherapy, and hyperthermia. Head and Neck, 16, 259–265.
Lazarus, C. L., Logemann, J. A., Pauloski, B. R., Rademaker, A. W., & Mittal, B. (1996). Swallowing disorders in head and neck cancer patients treated with radiotherapy and adjuvant chemotherapy. Laryngoscope, 106, 1157–1166.
Leff, B., Cheuvront, N., & Russel, W. (1994). Discontinuing feeding tubes in a community nursing home. Gerontologist, 34(1), 130–133.
Linden, P., & Siebens, A. A. (1983). Dysphagia: Predicting laryngeal penetration. Archives of Physical Medicine and Rehabilitation, 64, 281–284.
Linden, P., Kuhlemeier, K. V., & Patterson, C. (1993). The probability of correctly predicting subglottic penetration from clinical observations. Dysphagia, 8, 170–179.
Lindgren, S., & Ekberg, O. (1988). Swallowing complaints and cineradiographic abnormalities. Dysphagia, 3, 97–101.
Litvan, E., Sastry, N., & Sonies, B. C. (1997). Characterizing swallowing abnormalities in progressive supranuclear palsy. Neurology, 48, 1654–1662.
Leopold, N. A., & Kagel, M. C. (1996). Prepharyngeal dysphagia in Parkinson 's disease. Dysphagia, 11, 14–22.
Logemann, J. A., Kahrilas, P. J., Kobara, M., & Vakil, N. B. (1989). The benefit of head rotation on pharyngoesophageal dysphagia. Archives of Physical Medicine and Rehabilitation, 70, 767–771.
Logemann, J. A., & Kahrilas, P. J. (1990). Relearning to swallow after stroke: application of maneuvers and indirect biofeedback: A case study. Neurology, 40, 1136–1138.
Logemann, J., Pauloski, B. R., Rademaker, A., Cook, B., Graner, D., Milianti, F., Beery, Q., Stein, D., Bowman, J., Lazarus, C., Heiser, M., & Baker, T. (1992). Impact of the diagnostic procedure on outcome measures of swallowing rehabilitation in head and neck cancer patients. Dysphagia, 7, 179–186.
Logemann, J. A., Shanahan, T., Rademaker, A. W., Kahrilas, P. J., Lazar, R., & Halper, A. (1993). Oropharyngeal swallowing after stroke in the left basal ganglion/internal capsule. Dysphagia, 8, 230–234.
Logemann, J. A., Gibbons, P., Rademaker, A. W., Pauloski, B. R., Kahrilas, P. J., Bacon, M., Bowman, J., & McCracken, E. (1994). Mechanisms of recovery of swallow after supraglottic laryngectomy. Journal of Speech and Hearing Research, 37, 965–974.
Logemann, J. A., Rademaker, A. W., Pauloski, B. R., & Kahrilas, P. J. (1994). Effects of postural change on aspiration in head and neck surgical patients. Otolaryngology Head and Neck Surgery, 110, 222–227.
Logemann, J. A., Pauloski, B. R., Colangelo, L., Lazarus, C., Fujio, M., & Kahrilas, P. J. (1995). Effects of a sour bolus on oropharyngeal swallowing measures in patients with neurogenic dysphagia. Journal of Speech and Hearing Research, 38, 556–563.
Mari, F., Matei, M., Ceravolo, M. G., Pisani, A., Montesi, A., & Provinciali, L. (1997). Predictive value of clinical indices in detecting aspiration in patients with neurological disorders. Journal of Neurology Neurosurgery and Psychiatry, 63, 456–460.
Martin, B. J. W., Logemann, J. A., Shaker, R., & Dodds, W. J. (1993). Normal laryngeal valving patterns during three breath-hold maneuvers: A pilot investigation. Dysphagia, 8, 11–20.
Martin, B. J. W., Corlew, M. M., Wood, H., Olson, D., Golopol, L. A., Wingo, M., & Kirmani, N. (1994). The association of swallowing dysfunction and aspiration pneumonia. Dysphagia, 9, 1–6.
Martin, R. E., Neary, M. A., & Diamant, N. E. (1997). Dysphagia following anterior cervical spine surgery. Dysphagia, 12, 2–8.
McCann, R. M., Hall, W. J., & Groth-Juncker, A. (1994). Comfort care for terminally ill patients. Journal of the American Medical Association, 272, 1263–1266.
McConnel, F. M. S., Logemann, J. A., Rademaker, A. W., Pauloski, B. R., Baker, S. R., Lewin, J., Shedd, D., Heiser, M. A., Cardinale, S., Collins, S., Graner, D., Cook, B. S., Milianti, F., & Baker, T. (1994). Surgical variables affecting postoperative swallowing efficiency in oral cancer patients: A pilot study. Laryngoscope, 104, 87–90.
Mendelsohn, M. S., & Martin, R. S. (1993). Airway protection during breath-holding. Annals of Otology Rhinology and Laryngology, 102, 941–944.
Mirrett, P. L., Riski, J. E., Glascott, J., & Johnson, V. (1994). Videofluoroscopic assessment of dysphagia in children with severe spastic cerebral palsy. Dysphagia, 9, 174–179.
Mitchell, S. L., Kiely, D. K., & Lipsitz, L. A. (1997). Risk factors and impact of survival of feeding tube placement in nursing home residents with severe cognitive impairment. Archives of Internal Medicine, 157, 327–332.
Morton, R. E., Bonas, R., Fourie, B., & Minford, J. (1993). Videofluoroscopy in the assessment of feeding disorders of children with neurological problems. Developmental Medicine and Child Neurology, 35, 388–395.
Morton, R. E., Bonas, R., Minford, J., Kerr, A., & Ellis, R. E. (1997). Feeding ability in Rett syndrome. Developmental Medicine and Child Neurology, 39, 331–335.
Murray, J., Langmore, S. E., Ginsberg, S., & Dostie, A. (1996). The significance of accumulated oropharyngeal secretions and swallowing frequency in predicting aspiration. Dysphagia, 11, 99–103.
Newton, H. B., Newton, C., Pearl, D., & Davidson, T. (1994). Swallowing assessment in primary brain tumor in patients with dysphagia. Neurology, 44, 1927–1932.
Nilsson, H., Ekberg, O., Sjoberg, S., & Olsson, R. (1993). Pharyngeal constrictor paresis: An indicator of neurologic disease? Dysphagia, 8, 239–243.
Nillson, H., Ekberg, O., Olsson, R., & Jindfelt, B. (1996). Swallowing in hereditary sensory ataxia. Dysphagia, 11, 140–143.
Odderson, L., Keaton, J., & McKenna, B. (1995). Swallow management in patients on an acute stroke pathway: Quality is cost effective. Archives of Physical Medicine and Rehabilitation, 76, 1130–1133.
Omae, Y., Logemann, J. A., Kaiser, P., Hanson, D. G., & Kahrilas, P. J. (1996). Effects of two breath-holding maneuvers on oropharyngeal swallow. Annals of Otology Rhinology and Laryngology, 105, 123–131.
Papadopoulos, S. M., Chen, J. C., Feldenzer, J. A., Bucci, M. N., & McGillicuddy, J. E. (1989). Anterior cervical osteophytes as a cause of progressive dysphagia. Acta Neurochirurgica, 101, 63–65.
Pauloski, B. R., Logemann, J. A., Rademaker, A. W., McConnel, F. M. S., Stei, D., Beery, Q., Johnson, J., Heiser, M. A., Cardinale, S., Shedd, D., Graner, D., Cook, B., Milianti, F., Collins, S., & Baker, T. (1994). Speech and swallowing function after oral and oropharyngeal resections: One-year follow-up. Head and Neck, 16, 313–322.
Pauloski, B. R., Logemann, J. A., Fox, J. C., & Colangelo, L. A. (1995). Biomechanical analysis of the pharyngeal swallow in postsurgical patients with anterior tongue and floor of mouth resection and distal flap reconstruction. Journal of Speech, Language, and Hearing Research, 39, 110–123.
Peck, A., Cohen, C. E., & Mulvihill, M. N. (1990). Long-term enteral feeding of aged demented nursing home patients. Journal of the American Geriatric Society, 38, 1195–1198.
Plaxico, D. T., & Loughlin, G. M. (1981). Nasopharyngeal reflux and neonatal apnea. American Journal of Diseased Children, 135, 793–794.
Pollack, I. F., Pang, D., Kocoshis, S., & Putman, P. (1992). Neurogenic dysphagia resulting from Chiari malformations. Neurosurgery, 30(5), 709–719.
Putnam, P. E., Orenstein, S. R., Pang, D., Pollack, I. F., Proujansky, R., & Kocoshis, A. (1992). Cricopharyngeal dysfunction associated with Chiari malformations. Pediatrics, 89(5), 871–876.
Rademaker, A., Logemann, J., Pauloski, B. R., Bowman, J., Geopfert, H., Lazarus, C., Sisson, G., Milianti, F., Graner, D., Cook, B., Collins, S., Stein, D., Beery, Q., Johnson, J., & Baker, T. (1993). Recovery of postoperative swallowing in patients undergoing partial laryngectomy. Head and Neck, 15, 325–334.
Rasley, A., Logemann, J. A., Kahrilas, P. J., Rademaker, A. W., Pauloski, B. R., & Dodds, W. J. (1993). Prevention of barium aspiration during videofluoroscopic swallowing studies: Value of change in posture. American Journal of Roentgenology, 160, 1005–1009.
Riminton, D. S., Chambers, S. T., Parkin, P. J., Pollock, M., & Donaldson, I. M. (1993). Inclusion body myositis presenting solely as dysphagia. Neurology, 43, 1241–1243.
Robbins, J., Levine, R. L., Maser, A., Rosenbek, J. C., & Kempster, G. B. (1993). Swallowing after unilateral stroke of the cerebral cortex. Archives of Physical Medicine and Rehabilitation, 74, 1295–1300.
Rogers, B. T., Arvedson, J., Msall, M., & Dermerath, R. R. (1993). Hypoxemia during oral feeding of children with severe cerebral palsy. Developmental Medicine and Child Neurology, 35, 3–10.
Rogers, B., Arvedson, J., Buck, G., & Smart, M. (1994a). Characteristics of dysphagia in children with cerebral palsy. Dysphagia, 9(1), 69–73.
Rogers, B., Stratton, P., Msall, M., Andres, M., Champlain, M. K., Koerner, P., & Plazza, J. (1994b). Longterm morbidity and management strategies of tracheal aspiration in adults with severe developmental disabilities. American Journal of Mental Retardation, 98(4), 490–498.
Rosenbek, J. C., Robbins, J., Fishback, B., & Levine, R. L. (1991). Effects of thermal application on dysphagia after stroke. Journal of Speech, Language, and Hearing Research, 34, 1257–1268.
Rosenbek, J. C., Roecker, E. B., Wood, J. B., & Robbins, J. (1996). Thermal application reduced the duration of stage transition in dysphagia after stroke. Dysphagia, 11, 225–233.
Schmidt, J., Holas, M., Halvorson, K., & Reding, M. (1994). Videofluoroscopic evidence of aspiration predicts pneumonia and death but not dehydration following stroke. Dysphagia, 9, 7–11.
Shanahan, T. K., Logemann, J. A., Rademaker, A. W., Pauloski, B. R., & Kahrilas, P. J. (1993). Chin-down posture effect on aspiration in dysphagic patients. Archives of Physical Medicine and Rehabilitation, 74, 736–739.
Shapiro, J., DeGirolami, U., Martin, S., & Goyal, R. (1996). Inflammatory myopathy causing pharyngeal dysphagia: A new entity. Annals of Otology Rhinology and Laryngology, 105, 331–335.
Shapiro, J., Franko, D. L., & Gagne, A. (1997). Phagophobia: a form of psychogenic dysphagia: a new entity. Annals of Otology Rhinology and Laryngology, 106, 286–290.
Sheppard, J. J., Liou, J., Hochman, R., Laroia, S., & Langlois, D. (1988). Nutritional correlates of dysphagia in individuals institutionalized with mental retardation. Dysphagia, 3, 85–89.
Silbergleit, A. K., Waring, W. P., Sullivan, M. J., & Maynard, F. M. (1991). Evaluation, treatment, and follow-up results of post-polio patients with dysphagia. Otolaryngology Head and Neck Surgery, 104, 333–338.
Sliwa, J. A., & Lis, S. (1993). Drug-induced dysphagia. Archives of Physical Medicine and Rehabilitation, 74, 445–448.
Skinner, M. A., & Shorter, N. A. (1992). Primary neonatal cricopharyngeal achalasia: A case report and review of the literature. Journal of Pediatric Surgery, 27(12), 1509–1511.
Smithard, D., O'Neill, P., Park, C., Morris, J., Wyatt, R., England, R., & Marin, D. (1996). Complications and outcome after acute stroke: Does dysphagia matter? Stroke, 27, 1200–1204.
Sonies, B. C., & Dalakas, M. C. (1991). Dysphagia in patients with the post-polio syndrome. New England Journal of Medicine, 324, 1162–1167.
Sonies, B. C., & Dalakas, M. C. (1995). Progression of oral-motor and swallowing symptoms in the postpolio syndrome. Annals of the New York Academy of Sciences, 753, 87–95.
Sonies, B. C. (1997). Evaluation and treatment of speech and swallowing disorders associated with myopathies. Current Opinion in Rheumatology, 9, 486–495.
Splinagard, M. L., Hutchins, B., Sulton, L. D., & Chaudhuri, G. (1988). Aspiration in rehabilitation patients: videofluoroscopy vs bedside clinical assessment. Archives of Physical Medicine and Rehabilitation, 69, 637–640.
Strand, A. S., Miller, R. M., Yorkston, K. M., & Hillel, A. D. (1996). Management of oral-pharyngeal dysphagia symptoms in amyotrophic lateral sclerosis. Dysphagia, 11, 129–139.
Taniguchi, M. H., & Moyer, R. S. (1994). Assessment of risk factors for pneumonia in dysphagic children: Significance of videofluoroscopic swallowing evaluation. Developmental Medicine and Child Neurology, 36(6), 495–502.
Veis, S. L., & Logemann, J. A. (1985). Swallowing disorders in persons with cerebrovascular accident. Archives of Physical Medicine and Rehabilitation, 66, 372–375.
Veldee, M. S., & Peth, L. D. (1992). Can protein-calorie malnutrition cause dysphagia? Dysphagia, 7, 86–101.
Volicer, L., Seltzer, B., Rheaume, Y., Karner, J., Glennon, M., Riley, M. E., & Crino, P. (1989). Eating difficulties in patients with probable dementia of the Alzheimer type. Journal of Geriatric Psychiatry and Neurology, 2(4), 188–195.
Wade, D. T., & Hewer, R. L. (1987). Motor loss and swallowing difficulty after stroke: Frequency, recovery, and prognosis. Acta Neurologica Scandinavia, 76, 50–54.
Watanabe, H., Makishima, K., Arima, T., & Mitsuyama, S. (1984). Dynamics of swallowing in tetanus. Journal of Laryngology and Otology, 98, 953–956.
Welch, M. V., Logemann, J. A., Rademaker, A. W., & Kahrilas, P. J. (1993). Changes in pharyngeal dimensions effected by chin tuck. Archives of Physical Medicine and Rehabilitation, 74, 178–181.
Woratyla, S. P., Morgan, A. S., Mackay, L., Bernstein, B., & Barba, C. (1995). Factors associated with early onset pneumonia in the severely brain-injured patient. Connecticut Journal of Medicine, 59(11), 643–647.
Yang, W. T., Loveday, E. J., Metreweli, C., & Sullivan, P. B. (1997). Ultrasound assessment of swallowing in malnourished disabled children. British Journal of Radiology, 70, 992–994.
Zerhouni, E. A., Bosma, J. F., & Donner, M. W. (1987). Relationship of cervical spine disorders to dysphagia. Dysphagia, 1, 129–144.
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[*] May be indicated implies that the instrumental examination is subject to individual consideration of its indications for and usefulness by a speech-language pathologist with expertise in dysphagia.
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