The Bedside Clinical Examination as a key element of the swallowing assessment during the COVID 19 Pandemic

Dear editor in chief, in a recent issue of the European Annals of Otorhinolaryngology, Head and Neck Diseases [1], eminent exponents of the French Society of Otorhinolaryngology, Head, Neck Surgery and of the French Society of Phoniatrics, presented careful devised guidelines of clinical practice for the management of swallowing disorders and dysphonia during the COVID 19 Pandemic.

The authors recommend to consider all patients as potentially positive, due to not absolute reliability of the tests used for the SARS-Cov-2 detection, and rightly underline the high risk of contamination from droplets emitted by the patient during instrumental diagnostic procedures such as flexible endoscopy. Consequently, they recommend running swallowing assessment only in case of emergency, postponing the majority of investigations, possibly using a teleconsultation.

While agreeing with all the recommendations of caution indicated in the guidelines, we believe that in several patients, according to literature, the evaluation of swallowing cannot be postponed, in particular in dysphagic post-extubation patients [2] and in neurodegenerative patients suffering from severe dysphagia [3].

Considering the inopportunity to move the patient to other wards to undergo radiological examination and the need to reduce the number of endoscopic evaluations, we transitory made the clinical (bedside) swallow examination (BSE) the key element of the swallowing assessment process. The BSE is performed by our speech-therapists according with the American Speech-Language-Hearing Association recommendations. Only conscious and collaborative patients are examined. The evaluation is focused on the observation of voice and articulation quality, head–neck control and posture, cough strength, oral phase functionality, hyolaryngeal excursion during dry swallowing and finally on the identification of signs and symptoms of penetration and/or aspiration, such as throat clearing or coughing before, during and after the swallow of different textures of fluids and semisolid foods. In our preliminary experience, BSE allowed us to restore oral nutrition to 35 out of the 43 examined subjects, limiting oral intake to semi-solid and semi-liquid food in 22 cases. Eight subjects were referred to endoscopic examination. Due to lack of an instrumental reference test, it is not possible to evaluate the reliability of our data, it must however be considered the volume viscosity test alone reach a sensitivity of 0.94 [4].

Finally, we are aware that also BSE exposes to saliva droplets produced by coughing, however the speech pathologist, unlike the ENT or Phoniatrician who performs endoscopy, can defend himself wearing not only a protective mask, but also a shield for face. Right now, no one out of the four speech therapists involved in the BSE in two large hospitals from our city, showed symptoms of COVID 19 infection.

Disclosure of interest

The authors declare that they have no competing interest.