The instrumental assessment provides detailed information which can be analysed to tell the clinician more about the biomechanics and ultimately the pathophysiology of the patient’s dysphagia. Instrumental assessment is a valuable step in the assessment process, as it allows the SLT visual access to structures which are inaccessible during the clinical assessment. Despite some research stipulating that augmentation of clinical assessment findings through measures such as pulse oximetry and cervical auscultation, clinical assessment is believed to be inferior to videofluoroscopy (VFS) and fibreoptic endoscopic evaluation of swallowing (FEES) for detecting aspiration than clinical assessment alone (Smithard et al., 1998) (Hiss and Postma, 2003). Given the high risk of aspiration in patients with bilateral hemispheric stroke, it is highly recommended that an instrumental assessment be performed.
Data acquired from the instrumental evaluation, along with components of the clinical evaluation and the case history, will contribute towards the development of an effective, client-specific and comprehensive course of treatment. Both VFS and FEES are held in high regard in terms of specificity, however it should be noted that FEES has not been in use for as long as VFS and has therefore been subject to less criticism (Langmore, 2003). The decision of which should be utilised for a patient with bilateral hemispheric stroke should take into account what is most suitable for the client, as well as the information inferred from the clinical assessment as to which structures need to be observed.
Videofluoroscopy (VFS)

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Daniels and Huckabee (2008) state that VFS is the preferred method of instrumental evaluation for stroke patients, particularly for the initial assessment. This technique requires the input of an SLT and a radiologist, and involves the patient ingesting solids and/or fluids of varying consistencies which have been impregnated or coated with the contrast agent, barium (Ramsey and Smithard, 2005). The barium allows the SLT and radiologist to observe the patient’s swallow and its functional and structural components in real time (Ramsey and Smithard, 2005). The principle strength of VFS is that it allows the clinician to observe the oral, pharyngeal and oesophageal stages of the swallow in succession(Daniels and Huckabee, 2008). Additionally, the SLT can test the efficacy of any potential compensatory strategies that are recommended to the patient.
As mentioned previously, the VFS is held in high regard for its reliability and sensitivity in terms of the detection of silent aspiration. However, due to the nature of the procedure, which requires the client to leave the ward, and sit at 45-90 degrees while he or she attempts to swallow food and drink of different consistencies repeatedly, this may not be possible until the patient is out of the acute stage and has sufficient levels of energy to complete the examination. Moreover, it is in both the patient’s and the SLT’s best interest to wait until the patient is ready, as, despite the ability to observe multiple swallows during one evaluation, the radiation exposure that is produced during one sitting renders VFS frequent repetitions of the study inappropriate (Ramsey and Smithard, 2005).
Further disadvantages of the VFS include its controlled nature which may negatively influence the patient's swallow (Ramsey and Smithard, 2005). Although, if the patient is capable of feeding him or herself, the clinician should encourage this as it may be more representative of the natural setting and being fed can greatly influence the swallowing process (Daniels and Huckabee, 2008). Also, the brief observation may not be representative of the cumulative effect of fatigue that a patient may experience as he or she eats a meal.
The SLT should endeavour to make use of a recording sheet on which he or she should also record all of the consistencies and volumes of material that were administered to the patient. For scoring the VFS, New Zealand Index for Multidisciplinary Evaluation of Swallowing (NZIMES) is highly recommended. This comprehensive scoring sheet produced by Maggie Lee Huckabee can be viewed by clicking the file below.

Fibreoptic Endoscopic Evaluation of Swallowing (FEES)

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This assessment allows the clinician to view swallowing anatomy and observe the patient swallowing by means of a camera inserted through the patient’s nose by an ENT. The advantages of this technique for a patient with bilateral hemispheric stroke are that it is safe and can be performed at the patient’s bedside. Daniels and Huckabee (2008) state that both physical and cognitive limitations may also restrict the use of VFS and make FEES a more appropriate option. Consequently, this procedure would not have to be delayed until the patient is well enough to leave the ward as might happen with VFS. Further advantages of FEES are that real food can be used and there is no restriction on time (Daniels and Huckabee, 2008).
The main disadvantage of FEES is that it does not give the same sequential view of the swallow that VFS can offer. The oral stage cannot be seen, therefore important sequences of the swallow such as the lingual 'drop and push' cannot be directly assessed (Daniels and Huckabee, 2008). Due to the disparity in visual access, Ramsey and Smithard (2005) suggest that FEES is less reliable than VFS in terms of directly observing aspiration. They add, however, that despite the lack of direct visual access, there are signs which can allow the clinician to infer aspiration including the ejection of food from the trachea and post-swallow residue.
Please note that if the patient has an naso-gastric tube inserted, it may be advantageous to request its removal for the FEES as the presence of an NG tube has been shown to influence the swallowing mechanism (Daniels and Huckabee, 2008).
Writing a Report

The initial assessment process should conclude with a report that summarises significant findings from both the clinical and instrumental components of assessment. The report should describe the symptoms of the patient's dysphagia, the characteristics of their swallowing process and the different phases as observed during the instrumental assessment, as well as documenting the aetiology (Scholten and Grist cited in University of Auckland, 2010). If the patient exhibited any change in his or her swallow due to the variation in volume and consistency, this should also be noted. As much as possible, the SLT should work collaboratively with the radiologist or ENT to compile the report, sharing their respective knowledge and skills. The procedure for report writing can differ between workplaces, but it is recommended that a copy of the report be sent to the patient's doctor, as well as a copy being placed in the patient's file so that members of the multi-disciplinary team may refer to it (Scholten and Grist, cited in University of Auckland, 2010). If you would like to view a report template, please click on the file below.