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Aerodigestive Disorders

See the Assessment section of ASHA’s Evidence Maps on Voice Disorders, Dysphagia (Adult), and Dysphagia (Pediatric) – Feeding and Swallowing for pertinent scientific evidence, expert opinion, and client/caregiver perspectives.

Assessment and treatment of aerodigestive disorders may require use of appropriate personal protective equipment.

Most aerodigestive disorders are identified by a physician on the basis of physical examination and one or more of the following:

  • gastrointestinal evaluation (e.g., esophageal motility study; gastric emptying test; esophagogastroduodenoscopy; esophagram; esophageal manometry; 24-hour pH or impedance test; Raman spectroscopy)
  • instrumental examinations (e.g., endoscopy; videofluoroscopy; airway fluoroscopy; flexible bronchoscopy; bronchoalveolar lavage; direct microlaryngoscopy; high-resolution pharyngeal manometry)
  • pulmonary function tests
  • X-ray and other imaging studies (e.g., chest X-ray; chest computed tomography scan; magnetic resonance imaging; electromyography; ultrasound)

Assessment of impairments caused by aerodigestive disorders often requires a multidisciplinary approach involving the speech-language pathologist (SLP) and other medical, surgical, and rehabilitation specialists. In collaboration with other health care specialists, the SLP provides expertise on feeding, swallowing, voice, and laryngeal airway problems related to aerodigestive disorders.

These collaborations may be a part of an established aerodigestive disorders team or may occur as a result of informed, targeted referrals within or outside the SLP’s area of expertise. See ASHA’s resources on interprofessional education/interprofessional practice [IPE/IPP] and collaboration and teaming.

A multidisciplinary approach may include

  • a team of medical and other professionals,
  • team meetings,
  • combined assessment procedures,
  • care coordination, and
  • follow-up clinic visits.

A core multidisciplinary team may include one or more of the following professionals:

  • allergist
  • anesthesiologist
  • gastroenterologist
  • nurse
  • nurse practitioner
  • oncologist
  • otolaryngologist
  • physician assistant
  • primary care physician (pediatrician in the case of a child, geriatrician in the case of elderly patients)
  • pulmonologist
  • registered dietitian
  • SLP

Depending on the age of the individual and the specific concerns, other team members may include the following:

  • cardiologist
  • coach/athletic trainer
  • medical geneticist
  • neurologist
  • occupational therapist
  • physical therapist
  • psychologist
  • radiologist
  • respiratory therapist
  • sleep specialist
  • social worker or case manager
  • sports medicine physician
  • surgeon

See Boesch et al. (2018) and Piccione and Boesch (2018).

Person- and Family-Centered Care

Person- and family-centered care is a collaborative approach grounded in a mutually beneficial partnership among individuals, families, and clinicians. Each party is equally important in the relationship, and each party must respect the knowledge, skills, and experiences that the others bring to the process. This approach incorporates individual and family preferences and priorities and offers a range of services, including

  • providing counseling and emotional support,
  • providing information and resources,
  • coordinating services,
  • teaching specific skills to facilitate communication, and
  • advocating for services.

See ASHA’s resource on person- and family-centered care.

Screening by an SLP

An SLP may be the first to see an individual who is experiencing voice or swallowing problems. These individuals may or may not have an underlying aerodigestive disorder. The purpose of screening is to identify individuals who require further assessment by an SLP or referral for other professional services. Screening may uncover findings that suggest underlying medical problems. See information about screening in the Assessment section of ASHA’s Practice Portal pages on Voice Disorders, Dysphagia (Adult), and Dysphagia (Pediatric) – Feeding and Swallowing.

It is important for SLPs to

  • be familiar with anatomical structures affected by various aerodigestive disorders;
  • be familiar with changes in feeding, swallowing, voice, and respiration problems that can be caused by aerodigestive disorders;
  • recognize deviations in structure and function that warrant an aerodigestive evaluation by a physician; and
  • make appropriate referrals, as needed.

SLPs screen for the following observed and reported changes:

  • Voice and respiration
    • vocal quality (e.g., rough voice, strained voice)
    • vocal effort (e.g., vocal fatigue, report of pain while voicing)
    • presence of stridor or labored breathing that affects breath support for voicing
    • rapid respiratory rate
    • chronic cough
  • Swallowing and dietary changes
    • clinical signs of feeding and swallowing problems (e.g., coughing, throat clearing, discomfort or globus sensation when swallowing
    • other indicators such as poor weight gain in infants and unintentional weight loss in adults, or purposeful avoidance of previously enjoyed liquids or foods 

SLPs also look for signs of neurologic conditions (e.g., abnormal sensorimotor function) that can affect voice, swallowing, or respiration, or that signal an underlying medical condition.

If screening results indicate feeding, swallowing, or respiratory difficulties that suggest an underlying disease process, referral is made to an appropriate medical professional.

Comprehensive Assessment

Aerodigestive disorders may involve the interaction of multiple systems, including laryngeal, pulmonary, phonatory, digestive, and sensorimotor. Individuals may present with multiple complaints and varied symptoms. A thorough case history and sign/symptom assessment—gathered by members of a multidisciplinary team that includes an SLP—facilitate assessment and differential diagnosis.

Consistent with the World Health Organization’s International Classification of Functioning, Disability and Health framework (ASHA, 2016a; World Health Organization, 2001), comprehensive assessment is conducted to identify and describe

  • impairments in body structure and function, including those related to aerodigestive disorders and the effect of impairments in feeding, swallowing, voice, and laryngeal airway function;
  • limitations in activity and participation, including functional communication and social interactions;
  • contextual (environmental and personal) factors that serve as barriers to or facilitators of successful communication and life participation; and
  • the impact of feeding, swallowing, voice, and laryngeal airway problems on quality of life, including the impact of limitations on the individual’s social roles within their community.

See ASHA’s resources titled Person-Centered Focus on Function: Voice [PDF], Person-Centered Focus on Function: Adult Swallowing [PDF], and Person-Centered Focus on Function: Pediatric Feeding and Swallowing [PDF] for examples of handouts featuring assessment data consistent with the International Classification of Functioning, Disability and Health framework.

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.

Additional Considerations

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).

Chronic Cough

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.

Content Disclaimer: The Practice Portal, ASHA policy documents, and guidelines contain information for use in all settings; however, members must consider all applicable local, state and federal requirements when applying the information in their specific work setting.