Adult Dysphagia

See the Assessment section of the Dysphagia evidence map for pertinent scientific evidence, expert opinion and client/caregiver perspective.


Swallowing screening is a pass/fail procedure to identify individuals who require a comprehensive assessment of swallowing function or a referral for other professional and/or medical services (ASHA, 2004b). Screening for dysphagia may be conducted by a speech-language pathologist or other member of the patient's care team. Screening does not provide a detailed description of the patient's swallow function but, rather, identifies individuals who are likely to have swallowing impairments related to function, activity, and/or participation as defined by the World Health Organization (WHO, 2001).

Individuals of all ages are screened as needed, requested, or mandated, or when other evidence (e.g., neurological or structural deficits) suggests that they are at risk for a swallowing disorder involving body structure/function and/or activities/participation.

The purpose of the screening is to determine

  • the likelihood that dysphagia exists and
  • the need for further swallowing assessment

(ASHA, 2009).

Screening protocols may include

  • the administration of an interview or a questionnaire that addresses the patient's perception of and/or concern with swallowing function;
  • observation of the presence of the signs and symptoms of oropharyngeal and/or esophageal swallowing dysfunction;
  • observation of routine or planned mealtime situations, if indicated;
  • administration of the 3-oz Water Swallow Test (DePippo, Holas, & Reding, 1992);
  • recommendation for additional assessment; and
  • communication of results and recommendations to the team responsible for the individual's care and to the patient and caregivers.

The Modified Evans Blue Dye Test (more informally referred to as "blue dye test") is completed in patients with a tracheotomy by tinting oral feedings blue/green with the intent to identify aspiration in these patients. See Frequently Asked Questions (FAQ) About Tracheotomy and Swallowing for additional information specific to this population.

Screening may result in

  • recommendations for rescreening;
  • recommendations for additional assessment—including clinical and/or instrumental examinations—to determine whether, and the degree to which, swallowing physiology may be impaired; and/or
  • referral for other examinations or services (ASHA, 2004b).

It is common for precautions (e.g., no oral intake, stipulation of specific dietary precautions) to be put in place while the patient is waiting for further assessment (ASHA, 2009).


Consistent with the WHO (2001) framework, the purpose of assessment is to identify and describe

  • typical and atypical parameters of structures and functions affecting swallowing;
  • effects of swallowing impairments on the individual's activities (capacity and performance in everyday contexts) and participation; and
  • contextual factors that serve as barriers to or facilitators of successful swallowing and participation for individuals with swallowing impairments.

Swallowing assessment allows the SLP to integrate information from (a) the interview/case history, (b) medical/clinical records including the potential impact of medications, (c) the physical examination, (d) previous screening and assessments, and (e) collaboration with physicians and other caregivers. During assessment, SLPs determine whether the patient is an appropriate candidate for treatment and/or management; this determination is based on findings that include medical stability, cognitive status, nutritional status, and psychosocial, environmental, and behavioral factors.

Assessment may result in one or more of the following outcomes:

  • Description of the characteristics of swallowing function, including any breakdowns in swallow physiology
  • Diagnosis of a swallowing disorder
  • Determination of the safest and most efficient route (oral vs. non-oral) of nutrition and hydration intake
  • Identification of the effectiveness of intervention and support
  • Recommendations for intervention and support for oral, pharyngeal, and/or laryngeal disorders
  • Prognosis for improvement and identification of relevant factors
  • Referral for other services or professionals
  • Counseling, education, and training to the patient, health care providers, and caregivers

Change in a patient's functional or medical status may indicate the need for additional assessment. An SLP may additionally monitor a patient's swallow function at appropriate intervals to determine whether the patient remains safe on the current diet (including adequate intake) and to assess the progress of current intervention strategies. Ongoing assessment may include additional instrumental assessments or may be completed through observation of performance throughout therapy sessions.

SLPs conduct assessments in a manner that is sensitive to the individual's cultural background, religious beliefs, and preferences for medical treatment (See Cultural Competence for additional information). Consider how culture influences activities of daily living (Riquelme, 2004). Discuss dietary changes with the patient and with the family member who prepares the food. In some cases, caregivers may be encouraged to bring familiar food and drink that maintain compatibility with SLP recommendations. Recommendations may affect spiritual practices that involve food and drink. Using ethnographic interviewing strategies during the assessment process is an excellent way to gather information about an individual's specific needs (Westby, Burda, & Mehta, 2003).

There are specific indications for both non-instrumental and instrumental examinations. For patients with signs and symptoms of pharyngeal dysphagia, instrumental procedures can provide more sensitive and objective findings than the clinical examination.

Non-Instrumental Swallowing Assessment

The purpose of a non-instrumental swallowing assessment is to observe patient behaviors associated with swallow function—that is, to observe the presence (or absence) of signs and symptoms of dysphagia, with consideration for factors such as fatigue during a meal, posture, positioning, and environmental conditions. A non-instrumental assessment may provide sufficient information for a clinician to diagnose oral dysphagia; however, aspiration and other physiologic problems in the pharyngeal phase can be directly observed only via instrumental assessments.

A non-instrumental swallowing assessment may include the following procedures:

  • A case history, based on a comprehensive review of medical/clinical records, as well as interviews with caregivers and other health care professionals
  • An oral mechanism exam, including one or more of the following:
    • Cranial nerve assessment
    • Structural assessment of face, jaw, lips, tongue, hard and soft palate, oral pharynx, and oral mucosa
    • Functional assessment of muscles and structures used in swallowing, including symmetry, sensation, strength, tone, range and rate of motion, and coordination of movement
    • Observation of head–neck control, posture, oral reflexes, and involuntary movements
  • Assessment of overall physical, social, behavioral, and cognitive/communicative status
  • Assessment of the patient's perception of function, severity, change in functional status, and quality of life
  • Assessment of speech and vocal quality at baseline and any changes following bolus presentations
  • Monitoring of physiological status, including heart rate and oxygen saturation
  • Assessment of alterations in bolus delivery and/or use of rehabilitative or compensatory techniques, as indicated
  • Evaluation of the method (spoon, cup, self-fed, examiner-fed) and rate of bolus presentation to assess the effects on swallow function
  • Assessment of secretion management skills, which might include frequency and adequacy of spontaneous saliva swallowing and ability to swallow voluntarily
  • Observation of the patient eating or being fed food items with consistencies typically eaten by the patient in a natural/typical environment for the patient's situation
  • Assessment of labial seal and anterior spillage, and evidence of oral control, including mastication and transit, manipulation of the bolus, presence of hyolaryngeal excursion as observed externally or to palpation, and time required to complete the swallow sequence
  • Identification of signs and symptoms of penetration and/or aspiration, such as throat clearing or coughing before/during/after the swallow
  • Assessment of consistency of skills across the feeding opportunity to rule out any negative impact of fatigue on feeding/swallowing safety
  • Assessment of the ability to clear the airway, and assessment of cough strength
  • Consideration of the respiratory rate and respiratory/swallowing pattern, which may vary across individuals and across the lifespan (Martin-Harris et al., 2005)

The effectiveness of various compensatory and rehabilitative techniques may also be assessed. Assessment may also include monitoring vital signs.

The clinical examination alone may form the basis for recommendations for the management of dysphagia—or it may serve as a tool for (a) identifying clinical presentations of dysphagia, (b) determining the potential need for additional instrumental evaluation, and (c) specifying diagnostic questions to be answered by any instrumental evaluations.

Instrumental Swallowing Assessment

SLPs use instrumental techniques to evaluate oral, pharyngeal, laryngeal, upper esophageal, and respiratory function as they apply to normal and abnormal swallowing. In addition, instrumental procedures are used to determine the appropriateness and the effectiveness of a variety of treatment strategies.

Instrumental techniques are usually conducted either independently by the SLP or by the SLP in conjunction with other members of the interprofessional team (e.g., radiologist, radiologic technologist, physiatrist). Competence in videofluoroscopic swallowing study (VFSS) and fiberoptic endoscopic evaluation of swallowing (FEES) requires appropriate training and education. SLPs help guide medical decision making regarding the appropriateness of these procedures given the severity and nature of the patient's swallowing deficits. SLPs interpret and apply the results of objective testing to the formulation of dysphagia treatment plans, and they also determine patient capacity and safety for oral feeding.

Indications for an instrumental exam include the following:

  • Concerns regarding the safety and efficiency of swallow function
    • Contribution of dysphagia to nutritional compromise
    • Contribution of dysphagia to pulmonary compromise
    • Contribution of dysphagia to concerns for airway safety (e.g., choking)
  • The need to identify disordered swallowing physiology to guide management and treatment
  • Inconsistent signs and symptoms in the findings of a non-instrumental examination
  • The need to assist in the determination of a differential medical diagnosis related to the presence of pathological swallowing
  • Presence of a medical condition or diagnosis associated with a high risk of dysphagia
  • Previously identified dysphagia with a suspected change in swallow function that may change recommendations
  • Presence of a chronic degenerative condition with a known progression or the recovery from a condition that may require further information for the management of oropharyngeal function

Contraindications for an instrumental exam include the following:

  • The patient is not medically stable enough to tolerate the procedure.
  • The patient is not able to participate in an instrumental examination (e.g., cognitive difficulties, inability to maintain an appropriate level of alertness).
  • The SLP's clinical judgment indicates that the instrumental assessment would not change the clinical management of the patient.

Similar to non-instrumental assessment, instrumental assessment also includes a thorough case history; an oral mechanism exam; and assessment of overall physical, social, behavioral, and cognitive/communicative status (see previous section on Non-Instrumental Swallowing Assessment for details on these components of an evaluation). The purpose of the instrumental examination is to enable the SLP to

  • visualize the structures of the upper aerodigestive tract;
  • assess the physiology of the structures involved in swallowing and to make observations, measures, and inferences of symmetry, sensation, strength, pressures, tone, range of motion, and coordination or timing of movement to determine the diagnosis of dysphagia;
  • determine presence, cause, and severity of dysphagia by visualizing bolus control, flow and timing of the bolus, and the individual's response to bolus misdirection and residue;
  • 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;
  • determine the cause(s) for laryngeal penetration and/or aspiration; and
  • determine with specificity the relative safety and efficiency of various bolus consistencies and volumes. 

In clinical settings, SLPs typically use one of two types of instrumental evaluations: the videofluroscopic swallowing study (VFSS) or the fiberoptic endoscopic evaluation of swallowing (FEES). The implementation of the VFSS and FEES requires the SLP to have advanced knowledge and specific skills in order to determine an appropriate test protocol; make decisions regarding management options during the examination; assess oral, pharyngeal, and cervical esophageal swallowing physiology; make specific functional diagnoses and diet consistency recommendations; and understand issues relative to radiation equipment, equipment maintenance, and safety.

At some facilities, qualified SLPs may also screen for esophageal motility and GERD to identify the need for appropriate referral.  Oropharyngeal function may be altered in some patients with esophageal motility issues.

Videofluoroscopic Swallowing Study (VFSS)

The videofluroscopic swallowing study (VFSS), also known as the modified barium swallow study (MBSS), is a radiographic procedure that provides a direct, dynamic view of oral, pharyngeal, and upper esophageal function (Logemann, 1986). An SLP completes the VFSS by providing the patient with various consistencies of food and liquid mixed with barium, which allows the bolus to be visualized in real time on an x-ray during the swallow. The VFSS is beneficial not only in identifying whether aspiration has occurred but also in allowing assessment of amount and timing of aspiration as well as assessment of anatomy and pathophysiology of swallow function in the oral and pharyngeal phases. It provides clinically useful information on the influence of compensatory strategies and diet changes (Martin-Harris, Logemann, McMahon, Schleicher, & Sandidge, 2000).

VFSSs are typically performed with both a speech-language pathologist and radiologist present, allowing for professional collaboration. The speech-language pathologist focuses on swallowing physiology and functioning and the radiologist makes medical diagnoses.  The VFSS assessment and report do not include medical diagnoses. The SLP should be aware of state legal and regulatory issues regarding the presence of a radiologist or other physician, as well as third party payer requirements.

The contraindications specific to VFSS may include the following:

  • SLP cannot adequately position the patient.
  • Patient's size and/or posture prevents adequate imaging or exceeds limit of positioning devices.
  • Patient has an allergy to barium and/or other contrast media (e.g., iohexol).
  • Absence of swallow response in patient.

At minimum, a VFSS includes the following protocols:

  • Educating the patient and/or caregiver regarding VFSS procedure, radiation safety, and rationale for the exam
  • Positioning the patient upright, or in the typical eating position if possible, to simulate normal ingestion
  • Using postural supports (e.g., head, trunk) as necessary
  • Identifying the relevant anatomical structures visible on fluoroscopy
  • Obtaining lateral and anterior–posterior views of oral cavity, pharynx, and upper esophagus, as needed, for each of the bolus types
  • Evaluating the oral phase of swallowing
  • Assessing the pharyngeal components of swallowing and related physiological events
  • Assessing the influence and effectiveness in altering bolus delivery and/or the use of rehabilitative or compensatory techniques on the swallow
  • Visually identifying the presence and effectiveness of swallow function and sensory awareness
  • Assessing the presence and effectiveness of the patient's response to laryngeal penetration, aspiration, and/or residue as part of an assessment of the airway integrity

Clinicians select bolus type (e.g., consistency, volume) for each trial carefully, as some consistencies and/or volumes may influence the clinician's overall impression of the swallow function more than others (Martin-Harris et al., 2008; Sandidge, 2009).  Clinicians also evaluate influence of the method and rate of presentations, such as when the patient is a) fed by the examiner, b) self-fed, or c) fed by a caregiver and d) when solids and liquids are alternated.  Clinicians also note any differences in swallow function when the patient is instructed to swallow versus spontaneous swallows.

A complete VFSS requires a sufficient number of swallowing attempts to (a) make a clinically informed decision about route of intake, consistency of oral diet (if appropriate), exercises to improve swallowing function, and compensatory techniques to maintain patient safety while consuming an oral diet and (b) determine the need for additional assessments/interventions through interprofessional team referral(s). Clinicians additionally note the individual's tolerance of and response to the examination (e.g., following directions, fatigue, signs of stress related to medically complex patients, ability to repeat therapeutic interventions).  Indications of an adverse reaction to the examination may include, but are not limited to, agitation, changes in breathing pattern, changes in alertness, changes in coloring, nausea and vomiting, changes in overall medical status which may  be assessed via the pulse oximeter, heart rate monitor, etc.

Given the speed and dynamic nature of swallow function, it is highly beneficial that the SLP record these studies and their results so that review and confirmation of findings can be observed in real time.

Anatomical Structures

During VFSS or review of the recording, clinicians identify the anatomical structures, as illustrated in Table 1, including any anatomical and/or physiological abnormalities.

Anatomical Structures

Table 1. Clinical Observations of Physiologic Swallowing Components During MBS

Aspect of Swallowing Observation
Lip closure Patient's ability to approximate top and bottom lip
Tongue control Volitional and controlled lingual movement
Bolus preparation Patient's ability to create a well-contained bolus
Bolus transport Patient's ability to move the bolus from the oral cavity to the pharyngeal cavity
Oral residue Remaining residue in the oral cavity following oral transport
Initiation of the pharyngeal swallow response Position of the bolus at the initiation of the pharyngeal swallow response
Soft palate elevation Upward movement of the soft palate to create velopharyngeal closure
Laryngeal elevation Extent and timeliness of upward movement of the larynx during the swallow
Anterior hyoid motion Extent and timeliness of forward movement of the hyoid
Epiloglottic movement Extent and timeliness of passive epiglottic inversion to meet with the arytenoids (moving anteriorly and superiorly)
Laryngeal closure Medial movement of the larynx observed at the vocal folds; may only be able to observe from anterior–posterior view
Pharyngeal stripping wave Contraction of the posterior pharyngeal wall from top moving downward
Pharyngeal contraction Approximation of the pharyngeal walls
Pharyngeal esophageal sphincter opening Opening of the pharyngeal esophageal sphincter, including the upper esophageal sphincter, to allow the bolus to move from the pharynx to the esophagus
Tongue base retraction Posterior movement of the tongue base to make contact with the posterior pharyngeal wall
Pharyngeal residue Remaining residue in the pharynx sfollowing the pharyngeal swallow
Esophageal clearance in upright position Residue that is not cleared following swallow

Physiological components of swallowing identified and further discussed by Martin-Harris et al, 2008

Observation of Penetration and Aspiration During VFSS

In addition to observing the physiological components of swallow function, accurate assessment and diagnosis also requires clinicians to note episodes of penetration and aspiration during VFSS in order to appropriately plan for safe and effective treatment. Episodes of both penetration and aspiration can occur before, during, or after the swallow event occurs. The Penetration-Aspiration Scale (Rosenbek, Robbins, Roecker, Coyle, & Wood, 1996) is an eight-point scale used to describe penetration and aspiration events. The clinician observes the bolus and the patient's response to the bolus, including the following scenarios:

  • If the bolus enters the airway, at what level, and how much bolus enters the airway
  • If the patient attempts to clear the bolus (if it does enter) from the airway
  • If the patient is successful in ejecting the bolus from the airway (if clearing is attempted; Rosenbek et al., 1996).
Limitations of the VFSS

Limitations of the VFSS include

  • time constraints due to radiation exposure;
  • a limited sample of swallow function that may not be a representation of mealtime function;
  • challenges in visualizing the swallow due to poor contrast;
  • challenges in viscosity to represent real-life foods;
  • limited evaluation of the effect of fatigue on swallowing unless specifically evaluated; and
  • refusal of the bolus, as barium is an unnatural food source and is not tolerated by some patients (Logemann, 1998).
Considerations Related to Radiation Exposure

The speech-language pathologist should be aware of the principles of ionizing radiation and dosage when performing VFSS. Considerations are detailed in the list below.

  • Acceptable radiation exposure levels are set by the radiology department and controlled by the radiologist.
  • The SLP and radiologist work together to ensure that the observations are completed within the dosage limits for the patient; dosage amount is As Low as Reasonably Achievable (ALARA) as recommended by the International Commission on Radiological Protection (ICRP) without affecting the accuracy of the swallowing assessment (ASHA, 2004a). Frame rates should also be discussed. Consider the patient's cumulative need for radiological procedures given his or her diagnosis, and proceed as clinically reasonable.
  • Individuals in the fluoroscopy suite wear protective equipment to minimize their exposure to scattered radiation.
  • Decreased fluoroscopic pulse rate reduces radiation exposure but may also influence clinician judgments and findings during the assessment (Bonilha et al., 2013a).

Significant swallowing deficits or decreased clinician experience may lead to an increase in fluoroscopy times (Bonilha et al., 2013b).

Federal regulations mandate that all fluoroscopic equipment contain a timer that has a maximum of 5 minutes (U.S. Food and Drug Administration, n.d.). Although the timer may sound during a VFSS, it is not an indication that the VFSS must stop. It is only a reminder to the clinician(s) that 5 minutes of radiation have elapsed. The clinician takes care to reduce radiation beyond this time point, and additional swallow attempts beyond this point are well-justified, allowing for additional information for recommendations.

For additional more information, see ASHA's web page on Radiation Safety for the SLP and the accompanying Radiation Safety Resource Page.  Additional information regarding equipment and radiologic care is also available from the American College of Radiology’s Practice Parameter for the Performance of Modified Barium Swallow .

Fiberoptic Endoscopic Evaluation Of Swallowing (FEES)

Fiberoptic endoscopic assessment of swallowing function (FEES) is a portable procedure that may be completed in outpatient clinic space or at bedside by passing an endoscope transnasally (Langmore, Kenneth, & Olsen, 1988). FEES additionally provides the opportunity for frequent use without concerns of radiation exposure and can be used within therapeutic contexts and for diagnostic therapy to assess current progress and effectiveness of therapy. Unlike assessment via the VFSS, FEES does not permit visualization of either the oral or the esophageal phase of swallowing.

Passage of the bolus and movement of the pharyngeal structures cannot be observed during the swallow because of reflected light from pharyngeal and laryngeal tissues into the endoscope, causing a brief condition referred to as "white-out."

In addition to the general indications for instrumental evaluation, the following indications are specific for FEES:

  • Sensitivity to increased difficulty with swallowing over the course of a meal, secondary to fatigue
  • Sensitivity to velum function for hypernasality and/or suspected nasal regurgitation
  • Need for visualization of the hypopharynx/larynx for biofeedback and/or rehabilitation
  • Documented pharyngeal dysphagia on VFSS that can be retested with endoscopy to
    • monitor progress
    • directly assess pharyngeal and laryngeal anatomy
    • limit radiation exposure
  • Suspected or observed difficulty with swallowing saliva/oral secretions
  • Inability to tolerate contrast media (e.g., barium, iohexol) as a result of allergy or aversion
  • Concerns or safety issues associated with radiation exposure (e.g., pregnancy)
  • Inability by patients (including individuals on a ventilator) to leave the bedside because of mobility and postural deficits
  • Difficulties with obstructed fluoroscopic viewing (e.g., patients wearing a halo, patients wearing a cervical collar)
  • Limited access to radiologic equipment

In addition to the contraindications for all instrumental evaluation, the following are specific to FEES:

  • Severe agitation and possible inability to cooperate with the examination
  • Severe movement disorders (dyskinesia)
  • Severe bleeding disorders and/or recent severe epistaxis (nosebleed)
  • History of recent trauma to the nasal cavity or surrounding tissue and structures secondary to surgery or injury
  • Bilateral obstruction of the nasal passages

The protocol for FEES minimally includes the following:

  • Educating the patient and/or caregiver regarding FEES procedure and rationale for the exam
  • Positioning the patient consistent with typical eating (e.g., upright, supine)
  • Identifying anatomical landmarks and any abnormalities
  • Assessing basic movement abilities of anatomical structures through specific maneuvers (e.g., valsalva to evaluate vocal fold closure, words with no nasal phoneme stimuli to assess velopharyngeal closure)
  • Assessing the influence of fatigue on pharyngeal swallow function over multiple trials
  • Identifying any residue remaining in the pharyngeal or laryngeal cavities after the swallow
  • Introducing strategies to minimize and/or eliminate aspiration
  • Identifying abnormal swallow function and the subsequent effect on laryngeal penetration, residue, sensory awareness, and effectiveness of the patient's response to laryngeal penetration and/or residue—aspiration is inferred based on patient response and/or observation of material below the vocal folds after the swallow
  • Assessing timing of movement of structures for swallow
  • Monitoring for adverse reactions to the examination and responding appropriately

At times, food is minimally colored to assist in assessing secretions and residue in the pharynx after the swallow is completed.

Sensation in the hypopharynx and larynx can be tested directly with a modification of the FEES procedure. The flexible endoscopic evaluation of swallowing with sensory testing (FEESST) requires a two-channel scope and uses pulses of air to assess sensory perception of the larynx and to monitor the laryngeal adductor reflex, characterized by a brief closure of the true vocal folds. FEEST is rarely used.  

SLPs with appropriate training and competence in performing FEES are qualified to use this procedure independently for the purpose of assessing swallow function and related functions of structures within the aerodigestive tract.  Physicians may also be involved in the functional evaluation of swallowing and/or may be present to assess the integrity of the laryngeal and pharyngeal structures in order to provide a medical diagnosis.  SLPs should be aware of state laws, facility policy, and third-party payer requirements related to the presence of a physician during FEES.  See ASHA's page on States with Specific Endoscopy Requirements.

Precautions and Safety Considerations

The patient may, on rare occasions, experience adverse effects when undergoing a FEES. These may include, but are not limited to, discomfort, vomiting, nosebleed, mucosal perforation, allergic reaction/hypersensitivity to topical anesthesia or nasal spray, and laryngospasm.

The overall risk is minimal, but it is recommended that clinicians be well trained in the signs and symptoms of adverse reactions and be ready to take appropriate action if they occur. In developing a FEES program, clinicians should know their facility's proper response to adverse reactions and should develop a plan for reaction and intervention should an adverse reaction occur.

If an SLP performs the examination independently and administers topical anesthesia and/or decongestants in an effort to maximize comfort, it must be approved in writing by the institution. SLPs follow institutional and pharmacy guidelines for administration of topical anesthesia, decongestants, and barium. Because of the risk of anesthetizing the pharyngeal and laryngeal mucosa and compromising the swallow, many clinicians perform FEES with either no anesthesia or only a small amount of a well-placed topical anesthetic in the nares. Use of anesthesia has not been shown to reduce patient discomfort during FEES (Leder, Ross, Briskin, & Sasaki, 1997).

The other area of concern with regard to safety is the possibility that a serious medical condition may be missed if an SLP were to complete the procedure independently; however, FEES is a procedure used to address swallow function and to screen for anatomical and physiological abnormalities in the nasal cavity, pharynx, and larynx. If there are clinical indications for a laryngoscopy evaluation (e.g., hoarse voice, pain on swallowing, etc.), the physician should make a referral to an otolaryngologist to rule out the possibility of disease in the nasal, pharyngeal, or laryngeal region.

SLPs follow universal precautions and facility procedures for infection control (e.g., adequate disinfection of equipment, etc.).  Decontamination, cleaning, disinfection, and sterilization of multiple-use equipment before reuse are carried out according to facility-specific infection control policies and services and according to manufacturer's instructions.  All equipment is used and maintained in accordance with the manufacturer's specifications.

Other Instrumental Procedures

Other instrumental procedures are used primarily in research at this time but may develop into clinical diagnostic tools. Ultrasonography involves the use of a transducer to observe movement of structures used for swallowing, including the tongue and hyoid (Hsiao, Wahyuni, & Wang, 2013). Surface electromyography records electrical activity of the muscles involved in swallowing (O'Kane, Groher, Silva, & Osborn, 2010).

SLPs should also be familiar with other diagnostic procedures performed by different medical specialists that yield information about swallowing function. These include procedures such as the esophagram/barium swallow, manofluorography, scintigraphy, pharyngeal manometry, 24-hour pH monitoring, and esophagoscopy.

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