Incidence refers to the number of new cases of dysphagia identified in a specified time period. Prevalence refers to the number of people who are living with dysphagia in a given time period.

Each year, approximately one in 25 adults will experience a swallowing problem in the United States (Bhattacharyya, 2014). Dysphagia cuts across so many diseases and age groups that its true prevalence in adult populations is not fully known and is often underestimated.

A number of epidemiologic reports indicate that the prevalence of dysphagia is more common among older individuals and that sarcopenia is positively associated with dysphagia (Barczi et al., 2000; Bhattacharyya, 2014; Bloem et al., 1990; Cabré et al., 2014; Roden & Altman, 2013; Sura et al., 2012; Zhao et al., 2018). Conservative estimates suggest that dysphagia rates may be

• as low as 3% in U.S. inpatients aged 45 years or older to as high as 22% in adults over 50 years of age (Lindgren & Janzon, 1991; National Foundation of Swallowing Disorders, n.d.; Patel et al., 2018; Tibbling & Gustafsson, 1991);
• as high as 30% in elderly populations receiving inpatient medical treatment (Layne et al., 1989);
• up to 68% for residents in long-term care settings (National Institute on Deafness and Other Communication Disorders, n.d.; Steele et al., 1997); and
• 13%–38% among elderly individuals who are living independently (Kawashima et al., 2004; Serra-Prat et al., 2011).

Advanced age is a risk factor for aspiration pneumonia (Loeb et al., 1999). A report by the Agency for Health Care Policy and Research (now the Agency for Healthcare Research and Quality) estimates that approximately one third of patients with dysphagia develop pneumonia and that 60,000 individuals die each year from such complications (Agency for Health Care Policy and Research, 1999). The prevalence of dysphagia in community-dwelling adults over the age of 50 years is estimated to be somewhere between 15% and 22% (Aslam & Vaezi, 2013; Barczi et al., 2000), and in skilled nursing facilities, the prevalence rises to over 60% (Steele et al., 1997; Suiter & Gosa, 2019).

Various neurological diseases are known to be associated with dysphagia. The exact epidemiological numbers by condition or disease also remain poorly defined. This, in part, is due to the concomitant medical conditions being reported and the timing and type of diagnostic procedures being used to identify swallowing disorders across neurological populations. Other studies have such findings as follows:

• A systematic review by Martino et al. (2005) found that the incidence of dysphagia in stroke populations was as low as 37% when identified using cursory screening procedures and as high as 78% when identified using instrumental assessments.
• A later study by Falsetti et al. (2009) found that dysphagia occurs in over one third of patients admitted to stroke rehabilitation units.
• Other studies suggest that dysphagia occurs in 29%–64% of stroke patients (Barer, 1989; Flowers et al., 2013; Gordon et al., 1987; Mann et al., 1999).
• Additional systematic reviews and studies have reported varied estimates of dysphagia prevalence in the following:
  • Amyotrophic lateral sclerosis (ALS) or Parkinson’s disease—ALS is also known as Lou Gehrig’s disease; as high as 90% in individuals diagnosed with Parkinson’s disease or amyotrophic lateral sclerosis (Coates & Bakheit, 1997).
  • Critical illness—3% to 62% in patients recovering from a critical illness (Macht et al., 2013). One study found that 20.6% of patients diagnosed with COVID-19 suffered from dysphagia (Korkmaz et al., 2020)
  • Dementia—13% to 57% (Alagiakrishnan et al., 2013).
  • Endotracheal intubation—3% to 64% (Skoretz et al., 2010). Brodsky et al. (2017) looked more narrowly at dysphagia following endotracheal intubation for acute respiratory distress syndrome (ARDS) and found that 32% of patients reported clinically significant dysphagia symptoms.
  • Gastroesophageal reflux disease (GERD)—approximately 14% (Mold et al., 1991; Spechler, 1999).
  • Head and neck cancer—50% (oropharyngeal dysphagia) in patients with head and neck cancer, with these numbers increasing after chemoradiation treatment (García-Peris et al., 2007).
  • Intellectual disabilities (adult)—5% to 8% (Chadwick et al., 2006).
  • Multiple sclerosis—24% to 58% (Aghaz et al., 2018; Calcagno et al., 2002; De Pauw et al., 2002; Roden & Altman, 2013).
  • Neurologic conditions requiring intubation—may be as high as 93% following extubation (Macht et al., 2013).
  • Parkinson’s disease—35% to 82% (Kalf et al., 2012).
  • Sjögren’s syndrome—32% to 71% (Pierce et al., 2016).
  • Systemic lupus erythematosus—2% to 25% of individuals with systemic lupus erythematosus (Chua et al., 2002). Porto de Toledo et al. (2019) found that aspiration frequency was highest in the first 3 months following treatment.
  • Traumatic brain injury—38% to 65% (Terré & Mearin, 2009).
  • Vocal fold immobility (unilateral)—55% to 69% immobility (Zhou et al., 2019).
  • Whiplash injuries—2% to 28% (Stone et al., 2021).

Not all signs and symptoms are seen in all types of dysphagia, and the evidence supporting the predictive value of these signs and symptoms is mixed. For example, coughing and throat clearing may not be correlated with penetration or aspiration of a bolus but may be the result of gastroesophageal reflux, esophageal dysmotility, and common medications (Elvevi et al., 2014; Madanick, 2013; Tafreshi & Weinacker, 1999). Signs and symptoms of dysphagia include

• drooling and poor oral management of secretions and/or bolus;
• ineffective chewing, in consideration of the individual variability in mastication cycles and time (Shiga et al., 2012);
• food or liquid remaining in the oral cavity after the swallow (oral residue);
• inability to maintain lip closure, leading to food and/or liquids leaking from the oral cavity (anterior loss of bolus);
• extra time needed to chew or swallow;
• food and/or liquids leaking from the nasal cavity (nasopharyngeal regurgitation);
• complaints of food “sticking” or complaints of a “fullness” in the neck (globus sensation);
• complaints of pain when swallowing (odynophagia);
• changes in vocal quality (e.g., wet or gurgly sounding voice) during or after eating or drinking;
• coughing or throat clearing during or after eating or drinking;
• difficulty coordinating breathing and swallowing;
• acute or recurring aspiration pneumonia/respiratory infection and/or fever (Bock et al., 2017; DiBardino & Wunderink, 2015; Marik, 2010);
• changes in eating habits, for example, avoidance of certain foods/drinks (Sura et al., 2012);
• weight loss, malnutrition, or dehydration from not being able to eat enough (Saito et al., 2017; Via & Mechanick, 2013); and
• complaints of discomfort related to suspected esophageal dysphagia (e.g., globus sensation, regurgitation). See ASHA’s Practice Portal page on Aerodigestive Disorders.

Silent aspiration may be present, meaning the patient presents without overt signs or symptoms of dysphagia.

It is important to consider signs and symptoms of dysphagia in the context of other clinical indicators such as the etiology of the dysphagia and the overall health of the patient, rather than relying on a single sign or symptom.

Dysphagia may develop secondary to damage to the central nervous system (CNS) and/or cranial nerves, and to unilateral or bilateral cortical and subcortical lesions, such as

• stroke;
• traumatic brain injury;
• spinal cord injury;
• dementia;
• Parkinson’s disease;
• multiple sclerosis (De Pauw et al., 2002);
• amyotrophic lateral sclerosis (ALS, Lou Gehrig’s disease; e.g., Ruoppolo et al., 2013);
• muscular dystrophy (e.g., Tabor et al., 2018);
• developmental disabilities in an adult population (e.g., intellectual disability; Chadwick & Jolliffe, 2009);
• post-polio syndrome (e.g., Sonies & Dalakas, 1991);
• myasthenia gravis (e.g., Llabrés et al., 2005; Romo González et al., 2010); and
• polymyositis and dermatomyositis (González-Fernández & Daniels, 2008).

Dysphagia may also occur from problems affecting the head and neck, including

• cancer in the oral cavity, pharynx, nasopharynx, or esophagus;
• radiation and/or chemoradiation for head and neck cancer treatment;
• trauma or surgery involving the head and neck;
• decayed or missing teeth; and
• critical care that may have included oral intubation and/or tracheostomy.

Dysphagia may be associated with other factors, such as

• side effects of some medications (e.g., Balzer, 2000);
• metabolic disturbances (e.g., hyperthyroidism);
• infectious diseases (e.g., COVID-19, sepsis, acquired immune deficiency syndrome [AIDS]); Meux & Wall, 2003);
• pulmonary diseases (e.g., chronic obstructive pulmonary disease [COPD]);
• gastroesophageal reflux disease (GERD);
• following cardiothoracic surgery;
• decompensation; and
• frailty (Bahat et al., 2019).

Knowledge, skills, and clinical experience related to the evaluation and management of individuals with swallowing and swallowing problems may be acquired on the graduate or postgraduate level, in formal coursework, and/or via continuing education. The standards for ASHA certification effective in 2020 require competence in dysphagia. The American Board of Swallowing and Swallowing Disorders, under the auspices of ASHA’s specialty certification program, offers clinical specialty certification in swallowing and swallowing disorders. Specialty certification is a voluntary program and is not required by ASHA to practice in any disorder area. Board Certified Specialists in Swallowing and Swallowing Disorders are individuals who hold ASHA certification and have demonstrated advanced knowledge and clinical expertise in diagnosing and treating individuals with swallowing disorders.

SLPs have knowledge of the anatomy, physiology, and functional aspects of the upper aerodigestive tract as they relate to swallowing and speech. SLPs also have expertise in communication disorders that may affect the diagnosis and management of swallowing disorders. SLPs work collaboratively with other professionals, individuals, families, and caregivers. Interprofessional practice (IPP) is critical to successfully achieving the desired improvements and outcomes due to complexities of assessment and treatment of swallowing disorders.

SLPs play a central role in the assessment and management of individuals with swallowing disorders. An SLP’s roles include

• identifying signs and symptoms of dysphagia;
• identifying normal and abnormal swallowing anatomy and physiology supported by imaging;
• identifying indications and contraindications specific to each patient for various assessment procedures;
• identifying signs of potential disorders in the upper aerodigestive and/or digestive tracts and making referrals to appropriate medical personnel;
• assessing swallow function as well as analyzing and integrating information from such assessments collaboratively with medical professionals, as appropriate;
• providing treatment for swallowing disorders, documenting progress, adapting and adjusting treatment plans based on patient performance, and determining appropriate discharge criteria;
• identifying and using appropriate functional outcome measures;
• understanding a variety of medical diagnoses and their potential impact(s) on swallowing;
• recognizing possible contraindications to clinical decisions and/or treatment;
• being aware of typical age-related changes in swallow function;
• providing education and counseling to individuals and caregivers;
• incorporating the client’s/patient’s dietary preferences and personal/cultural practices as they relate to food choices during evaluation and treatment services;
• respecting issues related to quality of life for individuals and/or caregivers;
• practicing interprofessional collaboration;
• educating and consulting with other professionals on the needs of individuals with swallowing and feeding disorders and the SLP’s role in the diagnosis and management of swallowing and feeding disorders;
• advocating for services for individuals with swallowing and feeding disorders;
• performing research to advance the clinical knowledge base; and
• determining the effectiveness and possible impact of current diet on overall health (e.g., positioning, feeding dependency, environment, diet modification, compensations).

As indicated in the ASHA Code of Ethics (American Speech-Language-Hearing Association [ASHA], 2023), SLPs who serve this population should be specifically educated and appropriately trained to do so. SLPs should maintain competency of skills through reading current research and engaging in continuing education.

Dysphagia Teams

The causes and consequences of dysphagia cross traditional boundaries between professional disciplines. Therefore, management of dysphagia may require input of multiple specialists serving on an interprofessional team. Members of the dysphagia team may vary across settings.

The SLP frequently serves as a coordinator for the team management of dysphagia. SLPs lead the team in

• identifying core team members and support services,
• facilitating communication between team members,
• tracking and documenting team activity,
• actively consulting with team members, and
• assisting in discharge planning.

Screening

Screening identifies the need for further assessment and may be completed prior to a comprehensive evaluation. Swallowing screening is a procedure to identify individuals who require a comprehensive assessment of swallowing function or a referral for other professional and/or medical services (ASHA, 2004). Screening for dysphagia may be conducted by an SLP or any other member of the patient’s care team. Individuals of all ages are screened as needed, requested, or mandated or when presenting medical conditions (e.g., neurological or structural deficits) suggest that they are at risk for dysphagia. The purpose of the screening is to determine the likelihood that dysphagia exists and the need for further swallowing assessment (see ASHA’s resource on Swallowing Screening). It is important to note that, currently, no bedside screening protocol has been shown to provide adequate predictive value for the presence of aspiration. Several tools have demonstrated reasonable sensitivity, but reproducibility and consistency of these protocols have not been established (O’Horo et al., 2015). During any screening process, the members of the patient care team may note proper posture and positioning for eating, as well as any potential sensory deficits that may affect swallowing.

Screening may include the following:

• Administration of an interview or a questionnaire that addresses the patient’s perception of and/or concern with swallowing function (e.g., the 10-item Eating Assessment Tool [EAT-10]; Cheney, 2015).
• Monitoring the presence of the signs and symptoms of oropharyngeal and/or esophageal swallowing dysfunction.
• Patient/caregiver report or observation of difficulty with per os (P.O.) intake.
• Administration of standardized screening protocols, such as
• the 3-oz water swallow test (DePippo et al., 1992) and
• the Yale Swallow Protocol (Suiter et al., 2014).
• Administration of the modified Evans blue dye test in patients with a tracheotomy by tinting oral feedings blue/green with the intent to identify aspiration in these patients (Béchet et al., 2016). For further information on the modified Evans blue dye test, please see the FDA public health advisory.

All screening procedures include communication of results and recommendations to the team responsible for the individual’s care and to the patient and caregivers.

Screening may result in

• recommendations for rescreening;
• recommendations for additional assessment to determine whether, and the degree to which, swallowing anatomy and/or physiology may be impaired; and
• referrals for other examinations or services (ASHA, 2004).

The medical team may make temporary recommendations (e.g., no oral intake, stipulation of specific dietary precautions) while the patient is awaiting further assessment.

Comprehensive Assessment

Assessment and treatment of swallowing and swallowing disorders includes consideration of infection control and personal protective equipment (PPE) as necessary. Special considerations may need to be made regarding PPE for COVID-19. For further information see ASHA’s resource on Aerosol Generating Procedures. Consistent with the World Health Organization’s (2001) International Classification of Functioning, Disability and Health 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 capacity for, performance in, and participation in activities; and
• contextual factors that serve as barriers to or facilitators of successful swallowing and participation for individuals with swallowing impairments.

Comprehensive assessment includes non-instrumental and instrumental procedures. Instrumental procedures may not be indicated in select patients (e.g., a patient with ill-fitting dentures resulting in oral dysphagia or some patients with low levels of alertness who are unable to participate in the study). Instrumental procedures are the only method that provides visualization of swallowing physiology and laryngeal, pharyngeal, and upper esophageal anatomy, which help diagnose dysphagia.

Swallowing assessment allows the SLP to integrate information from the following:

• A review of medical/clinical records, including the potential impact of medications and treatment of other medical diagnoses such as
  • radiation treatment protocols in head and neck cancer;
  • metabolic disturbances;
  • medical status;
  • nutritional status; and
  • psychosocial, environmental, and behavioral factors.
• An evaluation of the impact of cognitive deficits on safety/functionality of swallowing. Please see ASHA’s Practice Portal pages on Dementia and Traumatic Brain Injury (Adult) for further information.
• Results of previous screening and non-instrumental and instrumental assessments of swallowing.
• An inspection of the oral mechanism, cranial nerve assessment, and other observations such as
• structural assessment of the face, jaw, lips, tongue, hard and soft palate, oropharynx, 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;
• analysis of head–neck control, posture, oral reflexes, and involuntary movements; and
• assessment of respiratory status, cough, and throat clearing abilities.
• Additional assessment of voice, motor speech patterns, cognition, and communication, as warranted.

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

• description of the characteristics of suspected swallowing status
• diagnosis of dysphagia
• recommendations to support oral and non-oral nutrition and hydration identification of the need for intervention and support
• recommendations for intervention and support
• prognosis for improvement or maintenance of function and identification of relevant factors
• referral for other services or professionals
• counseling, education, and training to the patient, health care providers, and caregivers

Patients with suspected dysphagia may warrant further instrumental assessment to examine the impact of swallowing anatomy and physiology on clinical presentation (McCullough et al., 2005; O’Horo et al., 2015). Patients may also require further assessment or reassessment depending on changes in functional or medical status. SLPs may make recommendations for modifications of texture and viscosity and discuss their implications with other team members (e.g., dietary team, the patient). Ongoing assessment can also include evaluation of changes in patients’ swallow function as a result of intervention, including diet modification, while implementing a plan of care.

SLPs conduct assessments in a manner that is sensitive to the individual’s cultural background, religious beliefs, and preferences for medical treatment (see ASHA’s Practice Portal page on Cultural Responsiveness for additional information). SLPs should consider how culture influences activities of daily living (Riquelme, 2004). For example, spiritual practices that involve food and drink might be impacted by diet modifications. Using ethnographic interviewing strategies during the assessment process is an excellent way to gather information about an individual’s specific needs (Westby et al., 2003). SLPs should discuss any dietary texture/consistency-related changes with the patient and caregivers who prepare food. In some cases, caregivers may be encouraged to bring familiar food and drink.

Non-Instrumental Swallowing Assessment

The purpose of a non-instrumental swallowing assessment is to determine 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. Verification of aspiration and thorough assessment of impairments in swallowing physiology or laryngeal/pharyngeal/upper esophageal anatomy require instrumental assessment.

A non-instrumental swallowing assessment may include a medical chart review as well as an assessment or consideration of

• overall physical, social, behavioral, and cognitive/communicative status;
• the patient’s perception of function, severity, change in functional status, and quality of life;
• vocal quality at baseline;
• physiological status and vital signs, including heart rate, oxygen saturation, and respiratory rate as well as respiratory/swallowing pattern, which may vary across individuals and across the life span (Martin-Harris et al., 2005);
• secretion management skills, which might include frequency and adequacy of spontaneous saliva swallowing and the ability to swallow voluntarily;
• cranial nerve function;
• posture and positioning for feeding; and
• status of oral care.

During or following bolus delivery during per os (P.O.) trials including consistencies typically consumed by the patient in their natural environment, the SLP may assess

• labial seal, 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;
• behavioral signs and symptoms, such as throat clearing or coughing before/during/after the swallow, which may not always be indicators of penetration and/or aspiration;
• the impact of fatigue and/or respiratory function on swallowing;
• changes to physiological status/vital signs/voice quality; and
• the patient’s use of additional equipment, as appropriate (e.g., adaptive drinking cups).

The clinical examination may inform recommendations for the management of dysphagia (Garand et al., 2020), including

• identifying clinical presentations of dysphagia;
• identifying potential risks and benefits initiating or modifying oral intake (e.g., risks of dehydration/malnutrition);
• determining the need for additional instrumental evaluation; and
• specifying diagnostic questions to be answered by instrumental evaluations.

The non-instrumental assessment of swallowing is insufficient to infer specific information about laryngeal, pharyngeal, or upper esophageal anatomy and physiology required to develop effective treatment options and prevent consequences of dysphagia, such as dehydration, malnutrition, pneumonia, and death (Garand et al., 2020).

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. Instrumental procedures are also used to determine appropriateness and effectiveness of treatment strategies.

In clinical settings, SLPs typically use one of two types of instrumental evaluation: the videofluoroscopic swallowing study (VFSS) or the flexible endoscopic evaluation of swallowing (FEES), sometimes also called fiber-optic endoscopic evaluation of swallowing. The VFSS is also known as the modified barium swallow study (MBSS) and is a radiographic procedure used to gain further information regarding dysphagia. Please see ASHA’s resource on the Videofluroscopic Swallowing Study for further information on the VFSS. The FEES is a portable procedure that may be completed in outpatient clinic space or at bedside by passing an endoscope transnasally (Langmore et al., 1988). Please see ASHA’s resource on Flexible Endoscopic Evaluation of Swallowing for further information on the FEES.

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, otolaryngologist). 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 imaging to dysphagia treatment plans and make recommendations and referrals as appropriate. SLPs do not require special certification from any entity to perform instrumental assessments. However, per the ASHA Code of Ethics, SLPs should have appropriate training and demonstrate competency before completing instrumental techniques. Instrumental assessments may be recommended and completed regardless of setting (e.g., hospital, skilled nursing facility) in which the services are delivered.

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
• the need to assist in the determination of a differential medical diagnosis related to the presence of dysphagia
• the presence of a medical condition or diagnosis associated with a high risk of dysphagia
• previously identified dysphagia with a suspected change in swallow function; and
• the 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

General contraindications for an instrumental exam include, but are not limited to, the following:

• The patient is not medically stable enough to participate in the procedure.
• The patient is severely agitated, unable to remain alert, or unable to follow simple commands.
• The patient has anatomical deviations (e.g., head/neck, digestive tract) that preclude use of barium or use of an endoscopy.

Instrumental assessment may include components of non-instrumental swallowing assessment (see above for further details). The purpose of the instrumental examination is to enable the SLP to perform the following tasks:

• Assess the anatomy and physiology of the structures involved in swallowing and to analyze and measure range of motion and coordination or timing of movement. Some inferences may be made concerning sensation and pressure generation of the swallowing mechanism.
• Determine the presence, cause, and severity of dysphagia by visualizing bolus control, the 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 presence and cause(s) of laryngeal penetration and/or aspiration.
• Determine with specificity the relative safety and efficiency of various bolus consistencies and volumes.
• Determine the presence of silent aspiration.
• Visualize the structures of the upper aerodigestive tract.

Implementation of any instrumental procedure requires the SLP to have advanced knowledge and specific skills in order to

• determine an appropriate test protocol;
• make decisions regarding examination administration/procedures during the examination, as necessary;
• integrate knowledge of anatomy and physiology in order to assess oral, pharyngeal, and cervical esophageal swallowing physiology;
• make informed treatment diagnoses and diet consistency recommendations;
• help inform prognosis for imminent and long-term improvement; and
• understand issues relative to radiation equipment, equipment maintenance, and safety.

Qualified SLPs may also screen for esophageal motility and gastroesophageal reflux disease (GERD) to identify the need for appropriate referral. Oropharyngeal function may be potentially affected in some patients with esophageal motility issues.

ASHA recognizes the autonomy of SLPs in completing the VFSS. However, other parties (e.g., state regulatory agencies) may require a radiologist to be present during the VFSS. For further information please see ASHA’s resource on the Videofluroscopic Swallowing Study.

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, such as the tongue and hyoid (Hsiao et al., 2013; Sonies et al., 2003). High-resolution manometry is a technique used to measure pressures generated in the pharynx and esophagus. A thin catheter with pressure sensors < 1 cm apart is placed through the nose, pharynx, and esophagus. Various pressure measures can be calculated and compared to normative data (Omari & Schar, 2018).

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, 24-hr pH monitoring, and esophagoscopy.

The primary goals of dysphagia intervention are to

• support adequate nutrition and hydration and return to oral intake (including incorporating the patient’s dietary preferences and consulting with family members/caregivers to ensure that the patient’s daily living activities are being considered);
• determine the optimum supports (e.g., posture, or assistance) to reduce patient and caregiver burden while maximizing the patient’s quality of life; and
• develop a treatment plan to improve the safety and efficiency of the swallow.

Management of individuals with dysphagia should be based on results of comprehensive assessment, including both instrumental and non-instrumental assessments as applicable. Decision making must take into account many factors about each individual’s overall status and prognosis. This might include information concerning the individual’s health and diagnosis, prognosis, cognition, social situation, cultural values, economic status, motivation, and personal choice. Maintenance and/or maximization of an individual’s health status is a primary concern. The SLP should consider and integrate the patient’s wishes and advocate on behalf of the patient to the health care team, the family, and other relevant individuals.

Treatment Approaches and Principles

Consideration of the underlying neurophysiological impairment is necessary for understanding swallow function and deficits. Different management approaches may be necessary for individuals with dysphagia that has resulted from an acute event, a chronic/stable condition, or a progressive neurological disorder. Treatment targeting a specific function or structure may also affect function in other structures.

Treatment of dysphagia may include restoration of normal swallow function (rehabilitative) and/or modifications to diet consistency and patient behavior (compensatory).

Rehabilitative techniques, such as exercises, are designed to create lasting change in an individual’s swallowing over time by improving underlying physiological function. The intent of many exercises is to provide lasting functional improvement.

Compensatory techniques alter the swallow when used but do not create lasting functional change. An example of a compensatory technique includes a head rotation, which is used during the swallow to direct the bolus toward one of the lateral channels of the pharyngeal cavity. Although this technique may increase swallow safety and/or efficiency during the swallow, there is no lasting benefit or improvement in physiology. The purpose of the technique is to compensate for deficits that cannot be or are not yet rehabilitated sufficiently.

Some techniques may be used for both compensatory and rehabilitative purposes. For example, the super-supraglottic swallow is a rehabilitative technique that increases closure at the entrance to the airway and may also serve as a compensation to protect the airway (McCabe et al., 2009).

Treatment Options and Techniques

Upon completion of the comprehensive assessment, the clinician uses the acquired data to identify which treatment options would be most beneficial. Treatment options for patients with dysphagia are selected on the basis of evidence-based practice, which includes a combination of the best available internal and external evidence. This includes external scientific research as well as data gathered on a specific person. Internal and external evidence may come from

• published literature,
• the patient’s and family’s wishes, and
• the clinician’s experience.

Treatment options should be selected on a case-by-case basis as there are many etiologies of dysphagia. Clinicians should be aware that research into the overall efficacy of dysphagia treatment is ongoing; therefore, treatment options may evolve. Please see ASHA’s Dysphagia Evidence Map.

Biofeedback

Biofeedback incorporates the patient’s ability to sense changes and aids in the treatment of feeding or swallowing disorders. For example, patients with sufficient cognitive skills can be taught to interpret the visual information provided by these assessments (e.g., surface electromyography, ultrasound, flexible endoscopic evaluation of swallowing [FEES], manometry, Iowa Oral Performance Instrument [IOPI], or mirror) and to make physiological changes during the swallowing process.

Diet Texture Modifications

Modifications to diet texture may include changing the viscosity of liquids and/or altering the texture of solid foods using standardized criteria (e.g., International Dysphagia Diet Standardisation Initiative [IDDSI]). Modifications to the taste or temperature may also be made to change the sensory input of a bolus. SLPs examine the influence of diet texture modifications on swallowing physiology, including airway protection, during a comprehensive assessment of an individual’s swallowing status prior to recommending these changes as part of treatment. Clinicians consult with the patients and care partners to identify patient preferences and values for food when discussing modifications to oral intake. Consulting with the interprofessional team, including a dietician and pharmacist, when altering a diet can help ensure that the patient’s nutritional and medication needs continue to be met.

Some factors to consider while evaluating diet texture modifications for patients with dysphagia include:

• Clinical presentation of swallowing difficulties.
• Impact of the modified consistency/viscosity on the individual’s swallowing physiology.
• Aspiration risk – texture modified foods and thickened fluids may not eliminate the risk of aspiration and associated pneumonia (e.g., Kaneoka et al., 2017; Robbins et al., 2008; Wirth et al., 2016). In some cases, more viscous materials (i.e., thickened liquids) may be more likely to be silently aspirated (e.g., Miles et al., 2018).
• Presence and severity of co-morbidities (e.g., dehydration, renal disease, respiratory infections).
• Increased risk of dehydration and associated conditions (e.g., renal failure, gastroparesis, constipation, urinary tract infections, confusion/delirium, and poor recovery from illness (Cichero & Lam, 2014; Leibovitz et al., 2007; Murray et al., 2016, Wheelan, 2001).
• Impact of texture modifications on medications (e.g., some medications may not be available in liquid form, and crushing others may change their effectiveness; Cichero, 2013; Steadman et al., 2022).
• Physical and cognitive ability to follow texture modification procedures.
• Patient/care partner’s access to thickened liquids and/or thickening agents and ability to modify regular texture foods/liquids after discharge.
• Preferences of the person with dysphagia and their care partners, related cultural and/or religious considerations and the impact on the patient’s overall quality of life.

Despite the risk of aspiration, alternatives to liquid consistency modifications may support overall health of persons with dysphagia when pristine oral health can be maintained (e.g., Frazier Free Water Protocol; Gaidos et al., 2023; Kaneoka et al., 2017; Murray et al., 2016).

Electrical Stimulation

Although the body of literature concerning the value of electrical stimulation for swallowing is large, the benefits remain unclear (Carnaby-Mann & Crary, 2007; Clark et al., 2009; Humbert et al., 2012; Sun et al., 2020). Electrical stimulation uses an electrical current in order to stimulate the peripheral nerve. SLPs with appropriate training and competence in performing electrical stimulation may provide the intervention. ASHA does not require any additional certifications.

Equipment/Environmental Modifications

Patients may benefit from the use of adaptive equipment or environmental modifications to more effectively manage the bolus (Granell et al., 2012). SLPs collaborate with other team members in identifying and implementing use of adaptive equipment.

Maneuvers

Maneuvers are specific strategies that clinicians use to change the timing or strength of particular movements of swallowing. Some maneuvers require following multistep directions and may not be appropriate for patients with cognitive impairments. Examples of maneuvers include the following:

• Effortful swallow—The effortful swallow is known to increase orolingual pressure (Fukuoka et al., 2013) increase pressure in the upper pharynx (Huckabee & Steele, 2006) and to improve tongue base retraction. Additionally, the effortful swallow increases the duration of temporal events such as laryngeal vestibule closure, hyoid maximum anterior excursion, upper esophageal sphincter opening, and total swallow time (Hind et al., 2001). There is some evidence to suggest that the effortful swallow may worsen pyriform sinus residue (Molfenter et al., 2018). To perform an effortful swallow, the patient is instructed to swallow hard while pushing hard with the tongue against the hard palate (Huckabee & Steele, 2006).
• Mendelsohn maneuver—The Mendelsohn maneuver is designed to elevate the larynx and open the esophagus during the swallow to prevent food/liquid from falling into the airway. The patient holds the larynx in an elevated position at the peak of hyolaryngeal elevation.
• Supraglottic swallow—The supraglottic swallow is designed to close the vocal folds by voluntarily holding one’s breath before and during swallow in order to protect the airway. The patient is instructed to hold their breath just before swallowing to close the vocal folds. The swallow is followed immediately by a volitional cough (Guedes et al., 2017; Logemann et al., 1997).
• Super-supraglottic swallow—The super-supraglottic swallow is designed to voluntarily move the arytenoids anteriorly, closing the entrance to the laryngeal vestibule before and during the swallow. The super-supraglottic swallow is similar to the supraglottic swallow; however, it involves increased effort during the breath-hold before the swallow, which facilitates glottal closure (Donzelli & Brady, 2004; Vose et al., 2014).

Swallowing Exercises

Swallowing exercises include exercises of the lips, jaw, tongue, soft palate, pharynx, larynx, and/or respiratory muscles to improve function. Some of these interventions can also incorporate sensory stimulation. Oral-motor treatments range from passive to active (e.g., range-of-motion activities, resistance exercises, or chewing and swallowing exercises). Examples of exercises include the following:

• Laryngeal elevation—The patient uses laryngeal elevation exercises to lift and maintain the larynx in an elevated position. This is similar to the Mendelsohn maneuver (described in the Maneuvers section above). The patient is asked to slide up a pitch scale and hold a high note for several seconds. This maintains the larynx in an elevated position.
• Masako or tongue-hold—The patient holds the tongue forward between the teeth while swallowing; this is performed without food or liquid in the mouth, to prevent coughing or choking. Although sometimes referred to as the Masako maneuver, the Masako (tongue-hold) is considered an exercise (not a maneuver), and its intent is to improve movement and strength of the posterior pharyngeal wall during the swallow. However, this maneuver may be contraindicated for those with decreased hyoid displacement and/or poor pharyngeal motility. Participants experienced reduced oral pharyngeal pressures when using this intervention. Studies have also found increased pharyngeal residue (particularly in the vallecula), shortened duration of airway closure, increased pharyngeal delay, and increased time in triggering the pharyngeal swallow (Doeltgen et al., 2011; Fujiu-Kurachi, 2002; Fujiu-Kurachi et al., 2014).
• Shaker exercise, head-lifting exercises—The patient rests in a supine position and lifts their head to look at the toes to facilitate an increased opening of the upper esophageal sphincter and strengthen suprahyoid muscles (Langmore & Pisegna, 2015).
• Resistive lingual isometric exercises—The patient is provided lingual resistance across exercises to increase strength (Kim et al., 2017; Park et al., 2015; Robbins et al., 2007).

Pacing and Feeding Strategies

Specific bolus volumes per swallow may result in faster pharyngeal swallow responses (Barikroo et al., 2015). Clinicians modify bolus size particularly for patients that require a greater volume to adequately stimulate a swallow response (increase bolus size) or for patients that require multiple swallows per bolus (decrease bolus size). Patients may also require cuing and assistance to maintain an appropriate rate during meals. Cognitive deficits (e.g., impulsivity, decreased initiation) may affect a patient’s pace during meals.

Postural/Position Techniques

Postural techniques redirect the movement of the bolus in the oral cavity and pharynx and modify pharyngeal dimensions. Postural techniques may be appropriate to use with patients with neurological impairments, head and neck cancer resections, and other structure damage. Examples of postural techniques include the following:

• Chin-down posture—The chin is tucked down toward the neck during the swallow, which may bring the tongue base closer to the posterior pharyngeal wall, narrow the opening to the airway, and widen the vallecular space. This posture may reduce penetration/aspiration in some patients (Bülow et al., 2001; Ra et al., 2014; Shanahan et al., 1993). The effectiveness of the chin-tuck maneuver is related to the overall severity of dysphagia (i.e., the more severe the dysphagia, the less effective the maneuver; Saconato et al., 2016).
• Chin-up posture—The chin is tilted up, which may facilitate movement of the bolus from the oral cavity. The chin-up posture may improve oral bolus transport (Solazzo, 2012). This posture has a possible rehabilitative impact on pharyngeal swallow (Calvo et al., 2017).
• Head rotation (turn to the side)—The head is turned to either the left or the right side, typically toward the damaged or weak side (although the opposite side may be attempted if there is limited success with the first side) to direct the bolus to the stronger of the lateral channels of the pharynx (Logemann et al., 1989).
• Head tilt—The head is tilted toward the strong side to keep the food on the chewing surface.

Postures and maneuvers may be combined, taking care to minimize patient effort/burden when possible.

Prosthetics/Intraoral Appliances

Prosthetics (e.g., palatal obturator, palatal lift prosthesis) can be used to normalize pressure and movement in the intraoral cavity by providing compensation or physical support for patients with structural deficits/damage to the oropharyngeal mechanism. With this support, swallowing efficiency and function may be improved. Intraoral appliances (e.g., palatal plates) are removable devices with small knobs that provide tactile stimulation inside the mouth to encourage lip closure and appropriate lip and tongue position for improved swallow function. This treatment option is most often used with patients following treatment for head and neck cancer; however, it may be implemented with other patients suffering from similar challenges.

Sensory Stimulation

Patients who are tactically defensive may need approaches that reduce the level of sensory input initially, with incremental increases as tolerance improves. Sensory stimulation may be useful for those with reduced response, overactive response, or limited opportunity for sensory experience.

Medical Management of Swallowing Disorders

Due to the interprofessional nature of dysphagia management, clinicians should be aware of multiple options for dysphagia intervention, including medical, surgical, and behavioral treatment. Such knowledge increases pertinent communication with other health care providers and facilitates selection of the best treatment options for individual patients (Groher & Crary, 2010).

Common Medical Options for Dysphagia Treatment

Pharmacologic Management

• anti-reflux medications
• prokinetic agents
• salivary management

Common Surgical Options for Conditions That May Cause Dysphagia

Improved Glottal Closure

• medialization thyroplasty
• injection of biomaterials

Airway Interventions

• stents
• laryngotracheal separation
• laryngectomy
• tracheostomy tubes

Improved Pharyngoesophageal Segment Opening

• dilation
• myotomy
• botulinum toxin injection

Tube Feeding for Dysphagia Treatment

If the individual’s swallowing does not support nutrition and hydration via oral intake, the swallowing and feeding team may recommend alternative avenues of intake (e.g., nasogastric [NG] tube, gastrostomy). In these instances, team members consider whether the individual will need the alternative source for a short or an extended period of time. Education and counseling may be provided concerning issues related to tube feeding, such as appropriate positioning and duration of feeding times.

Alternative feeding does not preclude the need for rehabilitative techniques to facilitate sensory and motor capabilities necessary for oral feeding. Percutaneous endoscopic gastrostomy (PEG) tubes may not be appropriate in all populations and may not necessarily improve outcomes or quality of life (Ayman et al., 2016; Plonk, 2005). Please see ASHA’s resource on Alternative Nutrition and Hydration in Dysphagia Care for further information.

The decision to recommend use of a feeding tube is made in collaboration with the medical team. The physician is ultimately responsible for selecting which type of tube is used, but a brief description of several options is provided below.

• Gastrostomy tube (PEG, G-tube)—inserted through the abdomen to provide non-oral nutrition. A percutaneous endoscopic gastrostomy tube, or PEG tube, is a common type of G-tube.
• Jejunostomy tube (PEJ, J-tube)—inserted through the abdomen and into the jejunum, the second part of the small intestine, to provide non-oral nutrition.
• Nasogastric tube (NG-tube)—inserted through the patient’s nose and passed through the esophagus to the stomach to provide non-oral nutrition. NG-tubes are often the preferred option for short-term use (over G-tubes or J-tubes). Tube size may vary and may influence swallow function.

The patient, with their proxy, then chooses to accept or reject use of alternative nutrition and hydration following a shared decision making, informed consent discussion.

Treatment Considerations Related to Progressive Disorders and End-of-Life Issues

The role of the SLP in treating individuals with progressive neurological disorders is designed to maximize current function, compensate for irreversible loss of function, assess and reassess changes in status, and educate and counsel patients regarding the progression of the disorder and potential options, including non-oral means of nutrition.

SLPs may encounter patients approaching the end of life. These patients may have complex medical conditions related to feeding and swallowing. SLPs may work with these patients and caregivers to develop compensatory strategies that will allow the patients to eat an oral diet for as long as they desire. As a member of the interprofessional team, the SLP may contribute to decision making regarding the use of alternative nutrition and hydration. SLPs may also make recommendations regarding continuing per os (P.O.) intake as pleasure feeds given extensive education to the patient, the patient’s family/caregiver(s), and the clinical/medical team.

Understanding emotional and psychological issues related to death is essential to treating patients with swallowing problems at the end of life. When considering end-of-life issues, it is important for clinicians to respect the patient’s wishes, including social and cultural considerations. Patients and caregivers may not agree with clinical recommendations and may feel that these recommendations do not provide the best quality of life for their loved one.

Ethical Concerns

One model for ethical decision making includes consideration of the following (Jonsen et al., 1992):

• Medical indications—Consider the patient’s medical history, prognosis, and available viable treatment options.
• Patient preferences—Consider the patient’s cultural and personal background influence, their preference to pursue or reject treatment, the patient’s ability to make and communicate these decisions, and the presence of an advance directive.
• Quality of life—Consider if the treatment creates a burden that outweighs the potential benefit.
• Contextual features—Consider the implications for caregiver burden if the patient chooses to pursue or reject treatment and if there are relevant legal ramifications to consider.

Clinicians provide information regarding these considerations without factoring in their own personal beliefs. Conflict may occur when medical recommendations do not match patient preferences. A patient with decision-making capacity, the patient’s family, or other established decision-maker has the right to accept or refuse such recommendations (Krekeler et al., 2018). After being educated about the risks and benefits of a particular recommendation (e.g., oral vs. non-oral means of nutrition, diet level, rehabilitative technique), if a patient (or their decision-maker) chooses an alternate course of action, the SLP makes recommendations and offers treatment as appropriate. The SLP educates involved parties on possible health consequences and documents all communication with the patient and caretakers (Horner et al., 2016). If no treatment is warranted, then the SLP may make recommendations about the safest course of intake (and still document the risks of such action) and may provide training to caregivers and family, as appropriate. The SLP may then decide to discontinue speech-language pathology services to the patient but should avail themselves to additional consultation or communication with the parties involved, as appropriate. Palliative care teams can assist a patient and/or family in establishing goals of care, which can then guide some of these complex decisions. Many facilities have an ethics consultation service that can help clinicians, patients, and families address challenges when an ethical issue arises.

Service Delivery

In addition to determining the type of assessment and treatment that is optimal for adults with dysphagia, SLPs consider other service delivery variables that may affect swallowing outcomes—variables such as format, provider, dosage, and timing.

Format

Format refers to the structure of the assessment or treatment session, such as whether a person is seen for treatment one on one (i.e., individual), as part of a group during mealtime, or via telepractice. Please see ASHA’s Practice Portal page on Telepractice for further detail.

Provider

Provider refers to the person providing the assessment or treatment (e.g., SLP, trained volunteer, caregiver).

Dosage

Dosage primarily refers to the amount of treatment provided (e.g., the frequency, intensity, and duration of service).

Timing

Timing refers to the timing of rehabilitation relative to the onset of dysphagia.

Setting

Setting refers to the location of treatment (e.g., home-based, community-based).

ASHA Resources

• Alternative Nutrition and Hydration in Dysphagia Care
• Aerosol Generating Procedures
• Dysphagia Competency Verification Tool (DCVT) [PDF]
• Flexible Endoscopic Evaluation of Swallowing (FEES)
• International Dysphagia Diet Standardisation Initiative (IDDSI)
• Normal Swallowing Poster (ASHA Store)
• Palliative and End-of-Life Care
• Perspectives of the ASHA Special Interest Groups
• Royal College of Speech and Language Therapists: Statement on Thickened Fluids
• Summary of Systemic Review—Blue Dye
• Swallowing Screening
• The Impact of Prescribed Medication on Swallowing: An Overview
• Videofluoroscopic Swallowing Study (VFSS)

Other Resources

• Evidence-Based Systematic Review: Oropharyngeal Dysphagia Behavioral Treatments. Part V—Applications for Clinicians and Researchers [PDF]
• FDA Public Health Advisory
• Maryland Department of Health and Mental Hygiene Diet Manual for Long-Term Care Residents [PDF]

• RCSLT: New Long COVID Guidance and Patient Handbook

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Acknowledgments

Content for ASHA's Practice Portal is developed through a comprehensive process that includes multiple rounds of subject matter expert input and review. ASHA extends its gratitude to the following subject matter experts who were involved in the development of the Adult Dysphagia page:

• Tara Adducci, MA, CCC-SLP
• Ed Bice, M. Ed, CCC-SLP
• Rebecca Bowen, MA, CCC-SLP
• Martin Brodsky, Ph.D., ScM, CCC-SLP
• James Coyle, Ph.D., CCC-SLP, BCS-S
• Jamie Fisher, Ph.D., CCC-SLP
• Jamila Harley, M.Ed., CCC-SLP
• Tiffany Mohr, MA, CCC-SLP, BCS-S, CBIS
• Karen Wheeler Hegland, Ph.D., CCC-SLP
• Alice Inman, MS, CCC-SLP, BCS-S
• Bonnie Martin-Harris, Ph.D., CCC-SLP, BCS-S
• Samantha Moore, MA, CCC-SLP
• Luis Riquelme, Ph.D., CCC-SLP, BCS-S
• Cesar Ruiz, SLP.D., CCC-SLP, BCS-S
• Monica Sampson, Ph.D., CCC-SLP
• Helen Sharp, Ph.D., CCC-SLP
• Debra Suiter, Ph.D., CCC-SLP, BCS-S
• Nancy Swigert, MA, CCC-SLP, BCS-S
• Lynne Brady Wagner, MA, CCC-SLP

Citing Practice Portal Pages

The recommended citation for this Practice Portal page is:

American Speech-Language-Hearing Association. (n.d.). Adult Dysphagia. (Practice Portal). Retrieved month, day, year, from www.asha.org/Practice-Portal/Clinical-Topics/Adult-Dysphagia/.