ASHA Non-Instrumental Swallowing Assessment
The purpose of a non-instrumental swallowing assessment is to observe patient behaviors
associated with swallow function—that is, to observe 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. A non-instrumental assessment may
provide sufficient information for a clinician to diagnose oral dysphagia; however, aspiration
and other physiologic problems in the pharyngeal phase can be directly observed only via
instrumental assessments.
A non-instrumental swallowing assessment may include the following procedures:
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A case history, based on a comprehensive review of medical/clinical records, as well
as interviews with caregivers and other health care professionals
An oral mechanism exam, including one or more of the following:
o Cranial nerve assessment
o Structural assessment of face, jaw, lips, tongue, hard and soft palate, oral
pharynx, and oral mucosa
o Functional assessment of muscles and structures used in swallowing,
including symmetry, sensation, strength, tone, range and rate of motion, and
coordination of movement
o Observation of head–neck control, posture, oral reflexes, and involuntary
movements
Assessment of overall physical, social, behavioral, and cognitive/communicative
status
Assessment of the patient's perception of function, severity, change in functional
status, and quality of life
Assessment of speech and vocal quality at baseline and any changes following
bolus presentations
Monitoring of physiological status, including heart rate and oxygen saturation
Assessment of alterations in bolus delivery and/or use of rehabilitative or
compensatory techniques, as indicated
Evaluation of the method (spoon, cup, self-fed, examiner-fed) and rate of bolus
presentation to assess the effects on swallow function
Assessment of secretion management skills, which might include frequency and
adequacy of spontaneous saliva swallowing and ability to swallow voluntarily
Observation of the patient eating or being fed food items with consistencies typically
eaten by the patient in a natural/typical environment for the patient's situation
Assessment of labial seal and 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
Identification of signs and symptoms of penetration and/or aspiration, such as throat
clearing or coughing before/during/after the swallow
Assessment of consistency of skills across the feeding opportunity to rule out any
negative impact of fatigue on feeding/swallowing safety
Assessment of the ability to clear the airway, and assessment of cough strength
Consideration of the respiratory rate and respiratory/swallowing pattern, which may
vary across individuals and across the lifespan (Martin-Harris et al., 2005)
The effectiveness of various compensatory and rehabilitative techniques may also be
assessed. Assessment may also include monitoring vital signs.
The clinical examination alone may form the basis for recommendations for the
management of dysphagia—or it may serve as a tool for (a) identifying clinical presentations
of dysphagia, (b) determining the potential need for additional instrumental evaluation, and
(c) specifying diagnostic questions to be answered by any instrumental evaluations.