Aspiration is NOT the Main Focus of a Swallow Evaluation
"Did he aspirate?" or "Did they pass?" is probably the question I get asked the most after completing a clinical or instrumental swallow evaluation. Although aspiration is a very serious thing, someone can have severe dysphagia and NOT be aspirating.
I had a patient in his 50's with a complex medical history including drug use. When he came to see me for a modified barium swallow study, the only consistency that he was safe to have was THIN LIQUIDS. Why? Because his pharyngeal muscles and upper esophageal sphincter were not working properly and anything thicker than water consistency basically just jung out in his throat and he had to swallow multiple times to get it down. It was a scary situation and I was immediately on the phone calling the primary care physician. Did he aspirate? Nope! Well at least not on the small amount of the thicker liquid that I gave him. He did however have severe dysphagia though.
This a prime example for a circumstance where THICKER is not always BETTER. My focus during a clinical swallow exam is to do a thorough cranial nerve exam, oral mechanism exam, trials of foods and liquids, compensatory strategies and determine if I am seeing any signs of DYSPHAGIA, not just ASPIRATION. When I do an instrumental exam (modified barium swallow study, fiberoptic endoscopic evaluation of swallowing) I am looking at how all the muscles are moving and the timing and coordination of the muscles and structures associated with swallowing. It is a very complex process and it can take me a good chunk of time to evaluate each aspect of the swallow.
Here is another case study. I saw a woman in her 60's who did not have any signs of aspiration during a clinical swallow evaluation but was starting to have trouble swallowing certain textures and felt like food was deviating to one side of the throat. We don't know exactly is going on yet, but I will keep you updated once we complete a flexible endoscopic evaluation of swallowing with her soon!