Clinical Swallow Evaluation in 5 Steps

A clinical swallow evaluation or ‘bedside swallow evaluation’ can help you detect dysphasia.

In this article, you’ll learn:

  • The 5 steps of a clinical swallow evaluation
  • The role of a swallowing screen
  • What to do if you suspect dysphagia

What Is A Clinical Swallow Evaluation?

clinical swallow eval

A clinical swallow evaluation helps determine the presence and severity of dysphagia.

If you’re looking for a free template, ASHA made a great one. Download and be on your way!

But if you want step-by-step guidance, keep scrolling.

Since a clinical swallow evaluation is a non-instrumental assessment, your findings will be limited. It can’t tell you if your patient is aspirating or what’s going on with their swallowing physiology or anatomy. 

Only instrumental assessments (modified barium swallow study or flexible endoscopic evaluation of swallowing) can give concrete evidence of aspiration and swallowing anatomy or physiology.

But clinical swallow evaluations are still very helpful!

They can:

  • Determine the clinical presence of swallowing deficits
  • Diagnose dysphagia
  • Determine the need for an instrumental assessment
  • Guide recommendations for safer nutrition and hydration 
  • Guide recommendations for dysphagia therapy, interventions, and support
  • Determine a prognosis 
  • Identify what may be contributing to the dysphagia
  • Help you make referrals 
  • Guide education and training for your patients, healthcare providers, families, and caregivers

(ASHA, n.d.)

More Dysphagia Articles

Clinical Swallow Evaluation vs Swallowing Screen?

A swallowing screen is a quick tool for determining if someone needs a full swallow evaluation. A screen often focuses on identifying overt signs of aspiration.  

There’s strong evidence that early screening of at-risk patients decreases the incidence of pneumonia (Yang et al., 2023). 

A screen can also indicate if a patient needs support from a dietician for their nutrition and hydration (ASHA, n.d.)

Depending on the setting, screens are done by speech-language pathologists, nurses, physicians, or other healthcare providers. SLPs often train other disciplines on how to do the swallow screen.

While there’s no one preferred tool, there are quite a few evidence-based swallowing screens, including:

Who Needs A Clinical Swallow Evaluation?

The following medical conditions may need a clinical swallow evaluation:

  • Stroke
  • Brain injury
  • Respiratory complications (including extubation, respiratory failure, and tracheostomies)
  • Post cardiovascular surgeries
  • Progressive neurologic diseases that affect the swallow (ALS, MS, Parkinson’s disease, etc.)
  • History of head and neck cancer
  • Autoimmune conditions that affect the swallow (Sjogren’s, etc.)
  • Medically fragile or poor nutritional status (multiple hospitalizations, recurrent infections including pneumonia)
  • Impaired cognition or significant changes to cognition that affect the swallow or safety (including dementia)
  • Trauma or surgery to the head or neck (including cervical)

(Puntil & Suiter, n.d.)

Bedside Swallow Evaluation PDF

evaluation pack

See The Evaluation Pack for a ready-made bedside swallow evaluation PDF.

It guides you through a full evaluation, with scripts and reminders of what to observe.

How To Do A Clinical Bedside Swallow Exam

clinical swallow evaluation

Here’s how to do a clinical bedside swallow evaluation.

1. Do A Chart Review

Do a chart review of your patient’s medical and clinical history. Look for:

  • Primary diagnosis and/or the reason for the swallow evaluation
  • Medical status
  • History of head and neck cancer including radiation treatment
  • Current diet/nutritional status
  • Labs and imaging (including brain MRI/CTs, chest X-rays)
  • Current medications
  • Environmental, behavioral, and psychosocial status
  • Check if any previous swallowing evaluations (including FEES or MBSS) were completed

2. Check With Nursing

bedside swallow exam

Ask the patient’s nurse about:

  • Any difficulties swallowing meals or medications
  • Cognition and level of alertness

3. Interview The Patient

Ask the patients and/or caregivers about their swallowing, nutrition and hydrate intake, and any signs and symptoms they have noticed. Confirm relevant medical history.

4. Complete An Oral Mechanism Examination

oral mech exam

Throughout the oral mechanism exam, you’ll observe strength, range of motion, and symmetry.

Asymmetry may signal innervation or neurological issues (stroke, nerve injury, etc.) While decreased strength and range of motion may signal atrophy or dysarthria.

If you suspect underlying structural or neurological issues, refer out to neurology, gastroenterology, or otolaryngology, as appropriate.

And be sure to offer encouragement throughout! Thank your patients and acknowledge their hard work.

OME: Mandible (Cranial Nerve V)

  1. Observe the symmetry of their mouth and jaw at rest.
    • Also observe dentition and oral mucosa.
  2. Say, “Open your mouth.”
    • Observe range of motion and symmetry during opening and while open.
  3. Ask them to close their mouth.
    • Observe symmetry as their mouth closes.
  4. Place a few fingers under their chin and say, “Open your mouth again.”
    • Observe strength, range of motion, and symmetry as you gently apply pressure.
  5. Place a few fingers on their chin (just below their lower lip), and say, “Close your mouth.”
    • Observe strength, range of motion, and symmetry as you gently apply pressure.
  6. Say, “Move your jaw from side to side,” modeling as needed.
    • Observe range of motion and symmetry. For example, are they able to move their jaw over to one side significantly more than the other?
  7. Say, “Jut your jaw out” or “Move your jaw out,” modeling as needed.
    • Observe range of motion.
  8. Then, place a clean gloved hand on their chin and gently push.
    • Observe strength. For example, are they able to maintain protrusion against resistance?
    • Observe symmetry as they release the protrusion.
  9. Say, “Pull your jaw in.”
    • Observe range of motion.

OME: Lips (CN VII)

  1. Observe symmetry of their lips at rest.
    • For example, one side is drooping, one side is drooling, etc.
  2. Say, “Move your lips side to side,” modeling as needed.
    • Observe range of motion and symmetry.
  3. Say, “Pucker your lips like you’re about to whistle,” modeling as needed.
    • Observe range of motion and symmetry.
    • If range of motion seems limited, test their stimulability by prompting them to protrude their lips even more.
  4. Press a tongue depressor or a clean gloved finger on their lips. Say, “Push against this.”
    • Observe strength.
  5. Say, “Smile wide.”
    • Observe range of motion and symmetry.
    • Prompt them to, “Pull your lips back more,” as needed.
  6. Say, “Pucker, smile, pucker, smile,” modeling as needed.
    • Observe coordination, range of motion, and symmetry.
  7. Say, “Puff up your cheeks [with air] [like a blowfish].” Then say, “Keep them puffed up,” as you gently press using a clean gloved finger.
    • Observe strength.
  8. Say, “I’m going to gently touch your cheeks. Please close your eyes and raise your hand when you feel my touch.” Use the stick-end of a cotton swab and touch various parts of their lower face.

OME: Tongue (CN XII)

  1. Say, “Open your mouth,” and observe tongue at rest.
    • Note symmetry, fasciculations, atrophy, etc.
  2. Say, “Stick out your tongue.” Test their stimulability by prompting them to stick their tongue out even further.
    • Observe symmetry and range of motion.
  3. Place a tongue depressor against the tip of their protruded tongue. Say, “Push against this.”
    • Observe strength.
  4. Say, “Stick your tongue out and up.” Test strength using the tongue depressor.
    • Observe range of motion and symmetry.
  5. Say, “Stick your tongue out and down.” Test strength using the tongue depressor.
    • Observe range of motion and symmetry.
  6. Say, “Press your tongue inside your cheek,” modeling as needed. Then, place a clean gloved finger against their cheek and say, “Push against this.”
    • Observe strength.
    • Switch sides and repeat, noting any differences in strength.
  7. Say, “Pull your tongue back.”
    • Observe range of motion and symmetry.
  8. Say, “Lick all around your teeth.”
    • Observe range of motion and symmetry.
  9. Say, “Lick all around your lips.”
    • Observe range of motion and symmetry.
  10. Say, “I’m going to gently touch your tongue and mouth. Please close your eyes and raise your hand when you feel my touch.” Use the stick-end of a cotton swab and touch various parts of their tongue and inner cheeks.

OME: Velum

  1. Say, “Open your mouth,” and use a penlight to observe their velum at rest.
  2. Say, “Say ‘ahhh.’”
    • Observe range of motion and symmetry.
  3. Say, “Say ‘ah ah ah ah ah.’”
    • Observe range of motion and symmetry.

OME: Reflexes (CN IX, X)

  1. Say, “I’m going to place this in your mouth. Open your mouth wide,” then gently touch the back of their throat with a tongue depressor.
    • If you already observed that their gag reflex is intact (e.g. they gagged on a drink earlier), you don’t need to subject them to this.
  2. While their mouth is open, observe faucial arches at rest.

OME: Other Observations

  1. While their mouth is open during any of the above tasks, observe dentition and oral mucosa.
    • Look for dentures, partials, missing teeth, and oral cleanliness.
    • Ask, “Do you use dentures or partials?” if you’re unsure.
    • Note any discoloration of oral mucosa.
    • Provide or assist in oral care at this time, as needed.
  2. Say, “Lift your eyebrows.”
    • Observe range of motion and symmetry.
    • You may also say, “Smile” while they are lifting their eyebrows to test the branches of CN VII.
  3. Say, “Cough.”
    • Observe strength of cough and if cough was productive.
  4. Say, “Clear your throat.”
    • Observe strength of throat clear and vocal quality.
  5. While gathering their case history and completing the patient interview, note any observations about dysarthria, oral apraxia, voice, and resonance.

5. Complete PO trials

Complete oral care before doing PO trials.

And if the patient is NPO, refer to the instrumental evaluation report before doing PO trials.

Depending on the results, you can decide whether you believe your patient will safely complete PO trials

PO Trials: Yale Swallow Protocol or 3-ounce Water Test

3 ounce water test

If your patient is NPO, consider using ice-chips. Make sure to complete oral care beforehand.

Throughout the 3-ounce water test, observe the following:

  • Labial closure while liquid is in the mouth
  • Hyolaryngeal speed and elevation
  • Signs and symptoms of dysphagia:
    • Possible bolus holding
    • Anterior leakage
    • Multiple swallows
    • Coughing and/or throat-clearing
    • Respiration changes
    • Gurgly or wet vocal quality (“Say ahhh” and “Say eee”)
    • Fatigue

PO Trials: Additional Liquid Trials

po trials

If safe for the patient and you’ve deemed it beneficial, move on to additional liquid trials.

  1. Start with the patient’s current liquid consistency.
  2. Start small and gradually provide larger boluses.
    • Teaspoon
    • Tablespoon
    • Regulated straw sips
    • Cup sips
    • Consecutive cup sips

As they drink the boluses of liquid, observe the following:

  • Labial closure while liquid is in the mouth
  • Hyolaryngeal speed and elevation
  • Signs and symptoms of dysphagia:
    • Possible bolus holding
    • Anterior leakage
    • Multiple swallows
    • Coughing and/or throat-clearing
    • Respiration changes
    • Gurgly or wet vocal quality (‘Say ahh,’ and ‘Say ee’)
    • Fatigue

PO Trials: Solid Trials

solid trials dysphagia

Begin with the patient’s current diet texture. Start small and gradually provide larger boluses.

If the patient shows no/minimal signs of dysphagia, attempt more advanced diet textures.

If the patient shows signs or symptoms of dysphagia (including aspiration), attempt less advanced diet textures.

As the patient eats the boluses, observe the following:

  • Mastication adequacy (inadequate, within normal limits, effortful, prolonged)
  • Labial closure
  • Hyolaryngeal speed and elevation
  • Signs and symptoms of dysphagia:
    • Possible bolus holding
    • Anterior leakage
    • Multiple swallows per bolus
    • Coughing and/or throat clearing
    • Respiration changes
    • Gurgly or wet vocal quality (“Say ahhh” and “Say eee”)
    • Fatigue

What To Do If You Suspect Dysphagia?

Remember that a clinical swallow evaluation can’t tell you if your patient is aspirating or not.

So if you saw overt s/sx of aspiration with thin liquids or solids, are concerned about silent aspiration, or aren’t sure what to recommend—then recommend an instrument assessment.

It’s also best practice for your patient to have an instrumental assessment to determine if they’d be safer on a modified liquid or diet.

You can also:

  • Introduce safe swallowing strategies
  • Introduce compensatory strategies (e.g., effortful swallow, slow rate)
  • Consider the Frazier Water Protocol
  • Make diet and liquid modification recommendations for ease of chewing, energy conservation, etc.
  • Make postural, compensatory, and/or environmental recommendations
  • Give patient education about diet, liquids, strategies, etc. including verbal and written handouts
  • Communicate recommendations with nursing and relevant medical staff
  • Plan for dysphagia invention, including writing clinical reports and setting goals

See The Adult Speech Therapy Starter Pack for:

  • Handouts
  • Dysphagia treatment guides
  • Assessments
  • Report templates
See The Starter Pack!

References

Adult Speech Therapy

Alisha Kleindel is an instructor of speech-language pathology at Midwestern University with over 15 years of full-time speech therapy work experience. Miwa Aparo is a researcher, editor, and occupational therapist. Chung Hwa Brewer is an SLP and instructor at Western Washington University’s Communication Science Disorders program. More about us →