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Diagnosis of Dysphagia

Dysphagia can be diagnosed and monitored with many different screening tools. Common to all these screening tools is the ability to differentiate patients at risk for aspiration and laryngeal penetration from those who can consume solids and/or liquids safely (Papadopolou 2013). One of the most common and initial forms of screening for dysphagia is the Bedside Swallowing Evaluation (BSE). The BSE is important in helping clinicians decide the degree of safety in oral feeding, and foresee warnings about potential complications. The BSE allows speech-language pathologists to conduct a case history interview about the patient’s nutritional and respiratory medical status, and an examination of oral motor abilities including labial, palatal, lingual, pharyngeal wall, and laryngeal muscle control; along with an assessment of swallowing (Workman and Treole 2002). Patients are diagnosed with dysphagia if the speech language pathologist performing the BSE observes signs of aspiration, such as coughing, choking, or liquid and/or food present in or around the tracheostomy stoma, limited or uncoordinated laryngeal movement, or a wet sound in vocal quality after drinking (Shem et al. 2012).

Videofluoroscopic Swallow Studies (VFSS) are considered to be the gold standard for evaluation of oropharyngeal dysphagia as it provides direct visualisation of the movement of the jaw, palate, pharynx, larynx, esophagus and tongue during the swallowing motion (Shem et al. 2012b). Videofluroscopy works by ingestion of different types of foods ranging from very liquid to solid made radiopaque with a small dose of barium sulfate, via syringe or spoon in order to measure muscle movements during swallowing (Ryu et al. 2012). Not only can it be used to diagnose the existence of dysphagia in a patient, it can also be used to determine the etiology of dysphagia and under what conditions the patient can swallow safely (Shem et al. 2012b). Dysphagia is diagnosed if a patient undergoing the VFSS presents with any of the following: pooling of the test material in pyriform sinuses/valleculae, decreased laryngeal elevation, lack of epiglottic inversion, laryngeal penetration and aspiration (Shem et al. 2012b). Not only does this assessment require specially-trained technicians, but patients who are in intensive care, unable to sit in the correct position, or those with a high risk of aspiration may not be suitable to undergo VFSS (Papadopoulou et al. 2013).

The Fiberoptic Endoscopic Evaluation of Swallowing (FEES) is a widely used diagnostic procedure in exploring the swallowing process when patients are not suitable for VFSS. It is performed using a flexible laryngoscope that is fed through the nasal cavity that allows imaging of the epiglottis, sinus piriformis and arytenoid cartilages; consumption of a bolus (liquid or semi-liquid food) allows for examination of the swallowing reflex and presence of aspiration, retention and laryngeal penetration can be observed (Wolf & Meiners 2003). FEES can be performed in a sitting eating position, or for bed-ridden patients the head of the bed is raised 45 degrees or more to compensate (Papadopoulou et al. 2013). FEES is well tolerated, administrable to bed-ridden patients, and can be used repeatedly to monitor therapy progress. FEES is disadvantaged in that the oral and esophageal phase of swallowing cannot be examined; additionally, documentation and reporting of FEES can be time-consuming and difficult to complete (Hey et al. 2009).

Author Year


Research Design

Sample Size

Methods Outcomes
Shem et al. 2012


Prospective Cohort


Population: Mean age: 41.0 yr; Gender: males=31, females=9; Injury etiology: Motor vehicle accident=9, Fall=7, Gunshot wound=3, Diving=6, Bicycle accident=4, Motorcycle accident=2, Other=9; Level of injury: C4 or higher=29, C3 or lower=11; Level of severity: Not reported; Mean time since injury: 14.3 days.
Intervention: Presence of dysphagia was determined in patients using a Bedside Swallowing Examination (BSE), and a Videofluoroscopy Swallow Study (VFSS).
Outcome Measures: Dysphagia incidence. 
1.     16/40 patients were diagnosed with dysphagia by the BSE. While VFSS found 12 cases of dysphagia and four cases of aspiration.
Shem et al. 2012b


Prospective Cohort


Population: Mean age: 41.6 yr; Gender: males=30, females=9; Injury etiology: Motor vehicle accident=9, Fall=7, Gunshot wound=3, Diving=6, Bicycle accident=4, Motorcycle accident=2, Other=8; Level of injury: C4 or higher=28, C3 or lower=11; Level of severity: Not reported; Mean time since injury: 14.1 days.
Intervention: Presence of dysphagia was determined in patients using a Bedside Swallowing Examination (BSE), and a Videofluoroscopy Swallow Study (VFSS). Sensitivity and specificity of the BSE was determined in reference to the VFSS.
Outcome Measures: Dysphagia incidence, sensitivity, specificity, positive predictive value, negative predictive value of the BSE in reference to VFSS. 

1.     15 participants were diagnosed with dysphagia based on the BSE.

2.     11 participants were diagnosed with dysphagia, and four participants with aspiration, based on the VFSS.

3.     Of the 26 participants who underwent both BSE and VFSS, a dysphagia diagnosis was different in only one case.

4.     When comparing the BSE to the VFSS, the BSE’s sensitivity was 100% (95% CI: 71.5% to 100%), specificity was 93.3% (95% CI: 68.1% to 99.8%), positive predictive value was 91.7% (95% CI: 61.5% to 99.8%), and the negative predictive value was 100% (95% CI: 76.8% to 100%).

5.     For diet recommendations, when comparing the BSE to the VFSS, the BSE’s sensitivity was 76.9% (95% CI: 46.2% to 95%), specificity was 84.6% (95% CI: 54.6% to 98.1%), positive predictive value was 83.3% (95% CI: 51.6% to 97.9%), and the negative predictive value was 78.6% (95% CI: 49.2% to 95.3%).

Shem et al. 2011


Prospective Cohort


Population: Mean age: 41.0 yr; Gender: males=22, females=7; Injury etiology: Motor vehicle accident=5, Fall=7, Gunshot wound=3, Diving=3, Bicycle accident=3, Motorcycle accident=3, Other=5; Level of injury: C1=1, C2=3, C3=7, C4=10, C5=4, C6=2, C7=2; Level of severity: Not reported; Mean time since injury: 12.9 days.
Intervention: Presence of dysphagia was determined in patients using a Bedside Swallowing Examination (BSE), and a Videofluoroscopy Swallow Study (VFSS).
Outcome Measures: Dysphagia incidence.
1.     12/29 patients were diagnosed with dysphagia by BSE, and 9/29 with VFSS. VFSS also showed that 4/29 patients had aspiration.
Seidl et al. 2010


Retrospective Cohort


Population: Mean age: 43.5 yr; Gender: males=144, females=31; Injury etiology: Fracture 1 vertebral body=73, Fracture 2 vertebral bodies=47, Fracture >2 vertebral bodies=16, Spondylodiscitis=15, Contusio spinalis=10, Tumour=5, Spinal stenosis=4, Nuclear pulposus prolaps=3, Knife wound=1, Postoperative=1; Level of injury: C0=1, C1=1, C2=4, C3=14, C4=58, C5=53, C6=33, C7=6, C8=5; Level of severity: Frankel A=103, Frankel B=19, Frankel C=21, Frankel D=24, Frankel E=8; Time since injury: Participants were recruited within 8 wk of their injury.
Intervention: Swallowing ability was examined with a clinical bedside bolus-swallowing test by a speech therapist, and an endoscopic-swallowing test.
Outcome Measures: Dysphagia incidence.

1.     Swallowing disorders were identified in 28/175 patients.

2.     Swallowing disorders were most common in patients with the highest grade of sensorimotor deficit, however this was not significant (p>0.05).

Kirshblum et al. 1999


Case Control


Population: Mean age: 44.3 yr; Gender: males=156, females=31; Injury etiology: Fall=64, Motor vehicle accident=65, Gunshot wound=9, Diving=31, Other=18; Level of injury: C7 and below=15, C6=21, C5=43, C4=63, C3=25, C2 and above=20; Level of severity: AIS A=71, AIS B=5, AIS C=59, AIS D=48, AIS E=4; Median time since injury: 30 days (range: 5-264 days).
Intervention: Videofluoroscopic Swallowing Study (VFSS) to confirm the presence of dysphagia.
Outcome Measures: Dysphagia incidence. 
1.     VFSS confirmed the presence of dysphagia in 31 patients.
Chaw et al. 2012




Population: Mean age: 43.0 yr; Gender: males=57, females=11; Injury etiology: Motor vehicle accident=18, Fall=13, Diving=9, Bicycle accident=5, Gunshot wound=5, Motor cycle accident=4, Medical=4, Myelopathy=4, Trauma=4, Other=2; Level of injury: C1=2, C2=6, C3=14, C4=6, C4 (incomplete)=21, C5 (incomplete)=10, C6 (incomplete)=4, C7 (incomplete)=3, C8 (incomplete)=2; Level of severity: Complete=28, Incomplete=40; Mean time since injury: 31.8 days.
Intervention: Bedside Swallowing Examination (BSE), which was followed by Videofluoroscopy Swallow Study (VFSS) within 72 hr.
Outcome Measures: Dysphagia incidence.
1.     BSE results found 21 cases of dysphagia. Of these 21, 14 were diagnosed with dysphagia via VFSS.
Abel, Ruf & Spahn 2004




Population: Mean age: 42.9 yr; Gender: males=51, females=22; Injury etiology: Trauma=56, Spondylitis=5, Tumour=3, Other=9; Level of injury range: C1-C7; Level of severity: AIS A (complete)=41, incomplete=32; Mean time since injury: Not reported.
Intervention: Patients with cervical SCI admitted to an initial care facility between January 1997 to December 2000. Prevalence of pneumonia via x-rays, and dysphagia via methylene blue test and videofluoroscopic swallowing, were determined at intake and discharge. Changes in dysphagia status were observed after tracheostomies, surgery to the cervical spine and dietary restrictions.
Outcome Measures: Dysphagia and pneumonia incidence.

1.     26 cases of dysphagia were confirmed: three cases of severe impairment of deglutition, eight cases of moderate impairment, and 15 of minimal impairment.

2.     24 patients had only one episode of pneumonia, 11 patients experienced early and multiple episodes of late pneumonia.

3.     Incidence of late or multiple late pneumonia was significantly higher for patients with dysphagia (p<0.01).

Wolf & Meiners 2003
Population: Mean age: 43.4 yr; Gender: males=35, females=16; Injury etiology: Not reported; Level of injury: C2=20, C4=19, C5=7, C6=4, C7=1; Level of severity: AIS A=30, AIS B=13, AIS C=7, AIS D=1, AIS E=0; Time since injury: Less than 3 months.
Intervention: Presence of dysphagia was determined by Fiberoptic Endoscopic Examination of Swallowing (FEES) upon admission and was followed-up at intervals of 4 to 6 wk until discharge. Patients were given artificial respiration and supplementary treatments (tracheotomy, nasogastral tube, speech therapy) dependent on their level of dysphagia determined by admission FEES.
Outcome Measures: Prevalence and severity of dysphagia by five levels of laryngeal function (level 1-complete dysfunction, level 2-severly impaired, level 3-moderate impairment, level 4-mild dysfunction, level 5-unimpaired function), risk factors for dysphagia.

1.     The use of the FEES was able to detect severe dysphagia with major aspiration in 21 patients, mild dysphagia with a leading symptom of either laryngeal edema or mild aspiration with sufficient coughing reflex in 20 patients, and no detectable dysphagia in 10 patients.

2.     FEES was not only found to be effective in detecting and classifying patients within the levels of dysphagia, it was also found to be useful in evaluating the treatment program with a high number of patients experiencing successful treatment outcomes.

3.     Multiple FEES examinations were performed with a range of one to nine examinations conducted per patient.


The majority of studies assessing the diagnosis of dysphagia in a SCI population relied on either the BSE or VFSS as their screening tools. Four studies used both measures for diagnosing dysphagia (Chaw et al. 2012, Shem et al. 2012, Shem et al. 2012b, Shem et al. 2011). The incidence of dysphagia for these studies was on average, 40%. Shem et al. (2012b) performed a novel, prospective, psychometric comparison between the BSE and VFSS, for patients recently admitted to acute care for their SCI, to determine if the BSE was as accurate as the VFSS. The sensitivity, specificity, positive predictive and negative predictive values were calculated for the BSE in reference to the VFSS. The BSE performed comparatively well with the VFSS, with a sensitivity of 100% and a specificity of 93.3%. There was only one case of a misdiagnosis of dysphagia by the BSE, which the VFSS ruled out, giving a positive predictive value of 91.7%. Importantly, the BSE was able to rule out to the same extent as the VFSS individuals not at risk of dysphagia, with a negative predictive value of 100%. The results of this study indicate that the BSE can be an excellent screening tool for dysphagia in a SCI population that performs nearly as well as the VFSS. This is important given that the VFSS is more expensive, invasive, requires patients to be seated in a certain way, and protocols for VFSS may vary from facility to facility. However, the authors found when comparing diet recommendations, the BSE did not perform nearly as well as the VFSS, with diets recommended by BSE being more stringent and limiting the amount of safe foods patients can eat. Therefore, the VFSS still has an important clinical role in determining nutrition recommendations after a dysphagia diagnosis.

Wolf and Meiners (2003), was the only study that examined FEES as a method of diagnosis for dysphagia in a SCI population. The authors used FEES to diagnose dysphagia based on five levels of swallowing dysfunction, where levels 1 and 2 indicated severe swallowing impairment, level 3 was presence of aspiration, level 4 was mild aspiration or laryngeal edema, and level 5 was no signs of laryngeal dysfunction. They found a high incidence of dysphagia of 80%; however, only 40% had severe dysphagia whereas 50% had mild dysphagia. Treatment was given to dysphagic individuals proportional to their level of swallowing impairment that included: artificial respiration, positive end expiratory pressure, tracheostomy, nasogastric tubes, and breathing exercises. FEES was useful in that it allowed for repeated administration to track patients’ treatment progress in ICU settings.


There is level 5 evidence (from several observational studies: Chaw et al. 2012Shem et al. 2012Shem et al. 2012b, Shem et al. 2011Seidl et al. 2010Abel, Ruf & Spahn 2004Kirshblum et al. 1999) that VFSS and BSE are adequate measures of diagnosing dysphagia in a SCI population.

There is level 5 evidence (from four observational studies: Chaw et al. 2012Shem et al. 2012Shem et al. 2012bShem et al. 2011) that VFSS and BSE are comparable in diagnosing dysphagia in a SCI population.

There is level 5 evidence (from one observational study: Wolf and Meiers 2003) that FEES is an adequate tool to diagnose dysphagia and monitor treatment progress in a SCI population.

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