Comprehensive Assessment: Focus on Components Completed by the SLP
Case History (in Conjunction With Team)
- medical history (e.g., birth history, developmental history, history of digestive conditions, hospitalizations, recurrent pneumonia or respiratory infections, new onset of bronchitis, stroke or other neurological diseases)
- surgical history, including frequency and duration of intubation
- social history (e.g., education, employment)
- instrumental assessment history
- current medications
- exercise and activity habits, including identified triggers of respiratory problems
- dietary habits and nutritional status
- history of constipation
- changes in weight or failure to gain weight
- allergies that might affect voice, swallowing, and laryngeal airway function
- prior history of voice, swallowing, or airway problems, including prior assessment and treatment
Consider factors related to the anatomy and physiology of the aerodigestive tract and the age of the client.
Areas of Concern (in Conjunction With Team)
- presenting complaints (see the Signs and Symptoms section)
- patterns and progression of symptoms, both across time and within an episode (e.g., antecedent behaviors, recovery patterns, variability of symptoms)
- patient or caretaker perception of the severity of their symptoms
- patient goals
- report of variability in symptoms (e.g., intermittent voice change, intermittent reflux)
- report of environmental or activity-based triggers
- voice concerns/changes
- swallowing or feeding difficulties
Orofacial Sensorimotor Examination
- symmetry and movement of structures of the face, oral cavity, oropharynx, head, and neck during rest, during nonspeech tasks, and during speech/swallowing tasks
- sensory response to mechanical stimulation of the face, oral structures, and pharyngeal structures
- sensory response to taste, smell, and temperature
- review of reported laryngeal sensations (dryness, tickling, burning, pain, etc.)
- respiratory pattern (abdominal, thoracic, clavicular), rate, rhythmicity
- coordination of respiration with phonation
- coordination of respiration with swallowing
- phrase length and other speech signs of impaired respiratory rate or tidal volume
- strength of volitional cough
Assess under varied conditions, including while at rest, during light activities such as walking, in challenging conditions such as aerobic activities, or during patient-identified trigger activities.
- auditory–perceptual assessment (subjective)
- voice quality—including roughness, breathiness, strain, pitch, and loudness
- phonation—including voice onset/offset and the ability to sustain voice during speech
- formal acoustic and aerodynamic measures
- instrumental assessment
- laryngoscopy—measures structure and gross function (using flexible or rigid videoendoscopy)
- stroboscopy—measures vibratory function (using flexible or rigid endoscopy)
See the Assessment section of ASHA’s Practice Portal page on Voice Disorders for detailed information.
Feeding and Swallowing
- clinical evaluation of feeding and swallowing
- instrumental assessment
- Fiberoptic endoscopic evaluation of swallowing
- videofluoroscopic swallowing study (also known as “modified barium swallow study” or MBSS)
- high-resolution pharyngeal manometry
See the Assessment section of ASHA’s Practice Portal pages on Dysphagia (Adult) and Dysphagia (Pediatric) – Feeding and Swallowing for detailed information.
Cultural and Individual Considerations
SLPs conduct assessments in a manner that is sensitive to the individual’s cultural background, religious beliefs, dietary beliefs/practices/habits, history of disordered eating behaviors, and preferences for medical intervention. Cultural, religious, and individual beliefs about food and eating practices may affect an individual’s comfort level or willingness to participate in assessment. Some eating habits that appear to be a sign or symptom of an aerodigestive disorder (e.g., avoiding certain foods or refusing to eat in front of others) may, in fact, be related to cultural differences in meal habits or may be symptoms of an eating disorder (National Eating Disorders Association, n.d.).
Individual beliefs and preferences are considered when providing education and recommendations. Ethnographic interviewing strategies can help in gathering useful information (Westby et al., 2003). Collaboration with other professionals (e.g., cultural broker, mental health provider, registered dietitian, etc.) may be beneficial. See ASHA’s Practice Portal pages on Cultural Competence and Collaborating With Interpreters, Transliterators, and Translators for more information.
When completing videofluoroscopic swallow assessments, SLPs need to consider the potential impact of the barium concentration and viscosity of the test stimuli for all individuals. This is particularly important for infants and young children with aerodigestive disorders.
Using the appropriate weight per volume of barium concentrate reduces residual coating, which may affect the diagnosis or interpretation of the study. Viscosity of test fluids should approximate the customary or recommended fluid consistency as closely as possible (Cichero et al., 2011; Dodrill & Gosa, 2015). Use of a standardized flow test ensures that the tested consistency matches the defined consistency.
Potential interventions and treatment recommendations (positioning, utensils, bottle and nipple types, textures and liquid viscosity, and compensatory strategies) should be assessed during the examination. See the Assessment section of ASHA’s Practice Portal pages on Dysphagia (Adult) and Dysphagia (Pediatric) – Feeding and Swallowing for more details.
Paradoxical Vocal Fold Movement (PVFM)
Differential diagnosis of PVFM involves a multidisciplinary approach (Koufman & Block, 2008). Team members may include pulmonologists, allergists, otolaryngologists, gastroenterologists, cardiologists, psychologists, and SLPs (Altman et al., 2000). The SLP is an important member of the team and plays an essential role in diagnosis. They obtain a detailed case history, assess breathing patterns, perform a skilled fiberoptic laryngoscopy, and synthesize test information from all other team members (Reitz et al., 2014).
The SLP gathers the following case history information:
- onset of breathing difficulty—triggers (e.g., allergies and gastroesophageal reflux), duration, sensation, description, attempted treatments, and response
- frequency and length of PVFM attacks
- respiratory struggle during physical exertion
- gastroesophageal reflux
- respiratory allergies
- perception of excessive or different vocal effort
Assessment activities may include the following:
- Observation of breathing pattern at rest or during quiet activity.
- Fiberoptic laryngoscopy (Ibrahim et al., 2007), with nasendoscopy preferred to assess
- structural and functional integrity of the vocal folds;
- laryngeal dynamics across a range of activities;
- breathing patterns at rest and during dyspnea when/if trigger is known
- airway for paradoxical adduction of the true vocal folds with or without involvement of supraglottic structures, present during inhalation (partial adduction of the vocal folds during exhalation is typical for asthma); an
- the presence of a posterior glottal gap usually during inhalation (Morris et al., 2006) with a diamond-shaped glottic gap.
Note: It may be possible to have an asymptomatic larynx and still meet the criteria for PVFM (Olin et al., 2014).
The SLP helps in the differential diagnosis of chronic cough by gathering a detailed case history, performing fiberoptic laryngoscopy, and assessing voice.
For patients presenting with chronic cough, the SLP gathers information about
- the presence of associated causes of the cough, such as gastroesophageal reflux, postnasal drip, asthma, use of angiotensin-converting enzyme inhibitors or other medications, and smoking;
- characteristics of the cough—description, pattern, perceived warning of onset, perception of control of the cough, strategies to control the cough and effectiveness of those strategies;
- the degree of concern about the cough;
- the onset, duration, and progression of the cough;
- previous treatment for the cough and results of the treatment; and
- quality-of-life issues (social isolation, pain, or injury) secondary to the cough (Vertigan, Theodoros, et al., 2007).
Assessment activities may include
- laryngeal visualization;
- observation of breathing patterns and neck/muscle tension; and
- voice assessment, including perceptual description of the voice, discussion of concerns related to voice, and activities such as sustained phonation and pitch glides that may elicit cough.