How do you palpate a swallow? And what are you assessing as you palpate? In this post, you’ll find step-by-step instructions to help you answer these questions. Plus a free illustrated PDF for laryngeal palpation of a swallow (hyolaryngeal excursion).
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Dysphagia Series
- Swallowing Exercises and Strategies
- Oral Mechanism Examination
- Liquid and Solid Trials
- Swallowing Examination Recommendations
- First Things First
- What Can Laryngeal Palpation Tell You?
- Laryngeal Palpation: Step-by-Step Protocol
- More Palpation Tips
- How to Interpret What You Just Felt
- What To Do When You Suspect Abnormal Hyolaryngeal Excursion?
- Free PDFs
- Palpate After the Initial Examination
- Remember Quality of Life
- References
- Evidence-Based Handouts & Worksheets
First Things First
Evaluating and treating dysphagia require high levels of training and skill.
This article is intended for Speech-Language Pathologists or other qualified therapists with the appropriate training and competency to work with adults with dysphagia.
* If at any time you suspect any pharyngeal or esophageal involvement, contact the patient’s Primary Care Provider (PCP) and request an instrumental evaluation as soon as possible.
What Can Laryngeal Palpation Tell You?
The goal of a bedside swallowing examination, including laryngeal palpation, is to assess a patient’s degree of swallowing impairment, aspiration risk, and need for further testing.
When palpating swallows, you can only feel hyolaryngeal movement. Laryngeal palpation can’t differentiate between elevation and excursion. It also can’t tell us whether the UES is relaxing or not.
Regardless, laryngeal palpation can still be a useful technique to gain information about the patient’s swallow. For example, it can give you an idea about the number of swallows, the timing of swallows, and whether the swallow was initiated or not.
We recommend keeping your interpretation general. More on interpretation below!
Laryngeal Palpation: Step-by-Step Protocol
- SANITIZE YOUR HANDS AND PUT ON NEW GLOVES
- PREPARE LIQUID TRIALS
- HAND PLACEMENT
- First, ask the patient for permission to touch their neck
- “I’m going to feel your swallowing muscles while you’re swallowing. I’ll place one finger here, and one finger here”
- Palpate with your dominant hand
- Place your pointer finger gently along the top of the patient’s thyroid cartilage
- Place your middle finger gently along the bottom of the patient’s thyroid cartilage
- You may place your non-dominant hand gently on top of the patient’s shoulder or upper back
- See palpation tips below for more instructions
- DRY SWALLOW
- “Swallow your saliva”
- Readjust your finger placement as needed
- If the patient has excess adipose tissue on the neck, you may need to press gently into the skin. Ask about the patient’s comfort level while you are pressing. Adjust as needed
- BEGIN LIQUID TRIALS
- OBSERVE THE FOLLOWING (interpret using the tips below)
- Hyolarngeal movement initiation
- Speed of hyolaryngeal movement
- Range of motion of hyolaryngeal complex
- Multiple swallows
- Suspected piecemeal deglutition
- COMPLETE TRIAL & COMPARE. Typically, you can gather all the information you need in as little as 3-5 swallows
- Palpate the first few swallows
- Palpate consecutive swallows (if safe)
- Palate the final few swallows. Note if the final swallows are different (e.g. slower) than the first swallows. This may be a sign of patient fatigue
More Palpation Tips
- Always ask for permission before touching a patient’s neck! It’s a sensitive area and can be jarring to have someone touch it
- Women’s larynges tend to be higher than males
- Hyolaryngeal movement is typically easiest to feel in skinny males
- Laryngeal palpation is more difficult when there’s excess adipose tissue in the neck. Apply more pressure when palpating, but be careful not to choke the patient!
How to Interpret What You Just Felt
Questions to Ask Yourself
- How much time passed between when the patient put liquid in their mouth to the time I felt their hyoid go up?
- Was it clearly delayed (around 3 or more seconds)?
- Was the timing seemingly normal?
- Did they swallow at all?
- How quickly did the hyoid move?
- Was it obviously sluggish?
- Seemingly normal?
- Really quick?
- How much did the hyoid move?
- Was it just a little quiver? A small bobbing motion?
- Was it less than half the length of my finger pad?
- Did it clearly move a lot?
- How consistent was hyoid movement throughout the exam?
- For example, did hyoid movement get slower as the exam continued (which may be a sign of fatigue)?
What to Write in the Oral Examination Report
1. HYOLARYNGEAL MOVEMENT
Laryngeal palpation is not an exact science. Without an instrumental evaluation, we can’t truly know how the structures are moving. That said, it can still give up useful information to inform our assessment.
- Use terms such as “appeared to be” or “suspect” to reflect this
- Focus on general hyolaryngeal movement
- Describe what you felt as “no movement” “minimal movement” “suspect reduced movement” or “WNL”
- Documentation examples
- Swallows palpated. Patient took cup sips of thin liquid and hyolaryngeal movement appeared to be WNL.
- Swallows palpated. Patient took cup sips of thin liquid with some apparent hyolaryngeal movement, although suspect swallow was not initiated. Recommend MBSS to thoroughly evaluate swallowing safety.
2. TIMING
- Speak about timing broadly
- Only record it as delayed if it was obviously delayed
- We can’t know exactly when the bolus was propelled to the back of the mouth and we can’t know when the swallow was initiated
- Use terms such as “appeared to be” or “suspect” to reflect this
- Describe what you felt as “delayed” or “WNL”
- Documentation example
- Swallows palpated. Patient took cup sips of thin liquids (3 oz total). Hyolaryngeal movement appeared to be delayed ~5 seconds. No s/sx dysphagia observed. Patient’s vocal quality was clear and dry post swallows. Suspect bolus holding r/t patient’s apparent attention deficits. Recommend MBSS.
What To Do When You Suspect Abnormal Hyolaryngeal Excursion?
- Were there any signs or symptoms of aspiration?
- Educate about Aspiration Signs & Symptoms. Download a free patient handout below.
- Educate about Aspiration Signs & Symptoms. Download a free patient handout below.
- If yes, recommend an instrumental evaluation
- In the meantime, place the patient on a diet that they can safely swallow independently
- Their goal is to work on the next diet level up while safely swallowing in 80% of opportunities, given use of strategies and cues
- If no s/sx of aspiration, does the patient have a recent history of respiratory issues? (pneumonia, COPD, etc.)
- If yes to recent history of respiratory issues, introduce strategies to protect the airway, just in case
- If no recent history of respiratory issues and no s/sx of aspiration, but the swallow still seems abnormal, consider the following:
- Referral to GI. If you suspect esophageal issues such as UES dysfunction (the hyoid feels weighed or anchored down)
- Screen their voice. If abnormal vocal quality, perhaps muscle tension dysphonia is present
- What else could cause reduced movement? Fatigue, medications, pain? Consider reassessing when the patient is more alert, following up with pharmacy about potential medication side effects, working with nursing to reduce pain, etc.
Free PDFs
1. Laryngeal Palpation PDF
Review these instructions before completing the Clinical Bedside Swallowing Evaluation. Consider having the PDF open (or print it out) to refer to while completing the evaluation.
2. Aspiration Signs & Symptoms Handout PDF
Palpate After the Initial Examination
At minimum, complete laryngeal palpation every progress report to help track progress.
At maximum, palpate weekly. Strength isn’t likely to change significantly in such a short timeframe. An exception is if a patient’s level of consciousness drastically changes since the initial exam. Note any differences.
Remember Quality of Life
Our role as dysphagia therapists is to help patients safely tolerate the least restrictive diet and to stay hydrated and nourished. It’s easy to get tunnel-vision about this important part of our patients’ lives.
But if we zoom out, we remember that our job is also to improve patients’ quality of life. Discuss what matters to the patient. Ask, “What are your goals for therapy?” “For swallowing therapy?” They may not exactly match our dysphagia goals.
Person-centered care asks us to acknowledge that the patient is the expert in their own lives. Their wants and needs are as important as our expert knowledge and observations. Allow your patient to be part of their own health team!
- For more on the topic, read How Can SLPs Practice Person-Centered Care
- For more step-by-step assessment guides, read How to do an Oral Mechanism Exam
References
Brates D, Molfenter SM, Thibeault SL. Assessing Hyolaryngeal Excursion: Comparing Quantitative Methods to Palpation at the Bedside and Visualization During Videofluoroscopy. Dysphagia. 2019 Jun;34(3):298-307
McCullough, G.H., Martino, R. (2013). Clinical Evaluation of Patients with Dysphagia: Importance of History Taking and Physical Exam. In: Shaker, R., Easterling, C., Belafsky, P., Postma, G. (eds) Manual of Diagnostic and Therapeutic Techniques for Disorders of Deglutition. Springer, New York, NY.
The Adult Speech Therapy Workbook, by Chung Hwa Brewer
Evidence-Based Handouts & Worksheets
