This week is the first in a series about the Clinical Swallow Examination or CSE. I’ll start by talking about what is involved in the CSE. In future posts, the reliability, sensitivity, and specificity will be examined. (Spoiler alert….it’s not great). I will also discuss what information we can obtain from the CSE and when an instrumental examination is indicated.
So what makes up the CSE?
This is a step that cannot be skipped. A thorough chart review can reveal risk factors for dysphagia and if there are other co-morbidities that may contribute to swallowing difficulty. It is also important to note whether or not the individual has been seen for dysphagia evaluation or treatment in the past. Make sure to also check out the meds list as we know that there are many medications that can contribute to or cause dysphagia (I’ll discuss this in a future post). If you have access to current lab values, make note of those as well (I’ll cover this too).
It’s important to get the information from the source! Questions should be asked to determine what the patient thinks about their swallowing. Many people will initially deny having any difficulty swallowing only to report that they don’t eat meat and straws make them cough and bread sticks in their throat….during the interview. If the patient is unable to report, track down the main caregiver and ask them questions. In long term care, the CNA’s that are in the dining room with these patients hold a wealth of knowledge. During the interview, you can also get a better idea of what the patient’s wishes and goals of care are. Maybe the patient never wants a feeding tube, or maybe that one coke every day is what they live for, or maybe the patient wants to be able to eat a birthday cake on their birthday coming up in a month. (The birthday example is true and this patient was able to celebrate their birthday with a giant piece of chocolate cake!) During the interview, I also observe the patient to obtain even more information.
Cranial Nerve Exam
Remember that one day in grad school where you were quizzed on all of the cranial nerves and what they control and what an impairment looks like? I definitely do! Did you think you would use this information every day? The Cranial Nerve Examination is one of the most important parts of the CSE. Knowing what nerve does what is incredibly important. Sometimes we SLP’s are the only ones to look at the cranial nerves and catch something not noted by the doctors. I make sure that at minimum I evaluate the nerves involved with swallowing. There are some wonderful resources for a review if you aren’t confident with your skills.
Knowing a baseline of the patient’s cognitive abilities can guide the treatment plan. For example, if a patient is found to have mod-severe cognitive deficits, this individual may not be able to remember strategies on their own. Many times we are consulted for both a dysphagia evaluation and a cognitive-linguistic evaluation. I also will evaluate the patient’s ability to follow directions to make the instrumental examination run more smoothly.
It seems like everyone has a different idea of what boluses to administer during the CSE. This is something I will dive into later. Personally, I use the Yale Three Ounce Water Challenge in every CSE. And good news!! It is now validated for use in long term care and other subacute facilities.
That are all the components that I include in a CSE. What do you do differently? What would you add? Would you skip anything? Let me know!
Next time I will discuss what info we can get from the CSE and what to do with it. Stay tuned!
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Until next time,
Garand KLF, McCullough G, Crary M, Arvedson JC, Dodrill P. Assessment Across the Life Span: The Clinical Swallow Evaluation. Am J Speech Lang Pathol. 2020 Jul 10;29(2S):919-933. doi: 10.1044/2020_AJSLP-19-00063. Epub 2020 Jul 10. PMID: 32650662.
Ward, M, et al. Validation of the Yale Swallow Protocol in Post-Acute Care: A Prospective, Double-Blind, Multirater Study. Am J Speech Lang Pathol. 2020 May 1-7. https://doi.org/10.1044/2020_AJSLP-19-00147