Abstracts

INTRODUCTION

Normal swallowing requires the coordinated action of muscles of the mouth, pharynx, larynx, and esophagus, which are innervated by the central and peripheral nervous systems(¹1. Hammond CAS, Goldstein LB. Cough and aspiration of food and liquids due to oral-pharyngeal dysphagia. ACCP Evidence-Based Clinical Practice Guidelines. Chest. 2006;129(Suppl 1):154S-68S.). The swallowing process is generally divided into phases (oral, pharyngeal, and esophageal), which are modified during normal development due to anatomical and physiological maturation(²2. Thach BT. Maturation and transformation of reflexes that protect the laryngeal airway from liquid aspiration from fetal to adult life. Am J Med. 2001;111(Suppl 8A):69S-77S.). The coordination between the upper digestive and respiratory systems during swallowing is also essential for a safe and efficient feeding process(³3. Delaney AL, Arvedson JC. Development of swallowing and feeding: prenatal through first year of life. Dev Disabil Res Rev. 2008;14(2):105-17.). A lack of coordination of the feeding and breathing processes can result in dysphagia, which includes changes in the swallowing process(⁴4. Falsetti P, Acciai C, Palilla R, Bosi M, Carpinteri F, Zingarelli A, et al. Oropharyngeal dysphagia after stroke: incidence, diagnosis, and clinical predictors in patients admitted to a neurorehabilitation unit. J Stroke Cerebrovasc Dis. 2009;18(5):329-35.,⁵5. Padovani AR, Moraes DP, Mangili LD, Andrade CRF. Protocolo fonoaudiológico de avaliação do risco para disfagia (PARD). Rev Soc Bras Fonoaudiol. 2007;12(3):199-205.).

Swallowing disorders, also called dysphagia, are not considered a disease, but a symptom of some underlying disease. They are associated with increased morbidity and mortality, and may lead to a variety of clinical complications, including dehydration, malnutrition, and aspiration pneumonia(⁶6. Skoretz SA, Flowers HL, Martino R. The incidence of dysphagia following endotracheal intubation: a systematic review. Chest. 2010;137(3):665-73.

7. McHorney CA, Robbins J, Lomax K, Rosenbek JC, Chignell K, Kramer AE, et al. The SWAL-QOL and SWAL-CARE outcomes tool for oropharyngeal dysphagia in adults: III. Documentation of reliability and validity. Dysphagia. 2002;17(2):97-114.

8. Westergren A, Ohlsson O, Rahm Hallberg I. Eating difficulties, complications and nursing interventions during a period of three months after a stroke. J Adv Nur. 2001;35(3):416-26.-⁹9. Robbins J, Gensler G, Hind J, Logemann JA, Lindblad AS, Brandt D, et al. Comparison of 2 interventions for liquid aspiration on pneumonia incidence: a randomized trial. Ann Intern Med. 2008;148(7):509-18.). Thus, an early assessment of dysphagia by a speech therapist is essential to prevent future medical complications and should have a high priority in health-care practices(¹⁰10. Sharma S, Ward EC, Burns C, Theodoros D, Russell T. Assessing swallowing disorders online: a pilot telerehabilitation study. Telemed J E Health. 2011;17(9):688-95.). Some hospitals have instruments such as screenings for early detection of adult dysphagic patients, and refer them for speech evaluation(¹¹11. Blackwell Z, Littlejohns P. A review of the management of dysphagia: a South African perspective. J Neurosci Nurs. 2010;42(2):61-70.,¹²12. Langmore SE, Schatz K, Olsen N. Fiberoptic endoscopic examination of swallowing safety: a new procedure. Dysphagia. 1988;2(4):216-9.).

These instruments, denominated in the literature as screenings, triages, and questionnaires are designed to identify a disease or an unrecognized risk factor through the patient's clinical history, physical examination, laboratory testing, or other procedure that can be applied quickly(¹³13. Newman TB, Browner WS, Cummings SR, Hulley SB. Delineando estudos sobre testes médicos. In: Hulley SB, Cummings SR, Browner WS, Grady DG, Newman TB. Delineando a pesquisa clínica: uma abordagem epidemiológica. 3ª edição. Porto Alegre: Artmed; 2003. p. 201-23.). Screening for dysphagia should have high sensitivity and specificity to identify individuals with an accurate aspiration, so they can be referred for evaluation, while not selecting individuals without dysphagia for intervention(¹⁴14. Leder SM, Espinosa JF. Aspiration risk after acute stroke: comparison of clinical examination and fiberoptic endoscopic evaluation of swallowing. Dysphagia. 2002;17(3):214-9.). The use of a systematic screening for dysphagia can result in a significant decrease in cases of aspiration pneumonia and improvement in the patient's general condition(¹⁵15. Dennis MS, Lewis SC, Warlow C; FOOD Trial Collaboration. Effect of timing and method of enteral tube feeding for dysphagic stroke patients (FOOD): a multicentre randomized controlled trial. Lancet. 2005;365(9461):764-72.).

The screening can be done by questionnaires, observations, physical evidence, among others. Questionnaires have been increasingly used to collect data to characterize symptoms and disorders(¹⁶16. Orenstein SR [Internet]. Oral, pharyngeal, and esophageal motor disorders in infants and children. GI Motility online. 2006 [cited 2014 Aug 26]. Available from: http://www.nature.com/gimo/contents/pt1/full/gimo38.html
http://www.nature.com/gimo/contents/pt1/... ). When identified by the screening tool, the patient should be referred for diagnosis of swallowing disorders, conducted from clinical evaluation and supplemented, when necessary, by objective tests(¹⁷17. Speyer R. Oropharyngeal dysphagia screening and assessment. Otolaryngol Clin North Am. 2013;46(6):989-1008.).

Clinical assessment has an important role in the evaluation of patients with dysphagia and aims to determine its presence, severity, changes that it may cause, and the rehabilitation plan(¹⁸18. Duarte ST. Fatores de risco para disfagia em pacientes submetidos a cirurgia cardíaca [dissertação]. Curitiba: Universidade Tuiuti do Paraná; 2010.). Unlike the evaluation protocols, screening tests are generally designed to be faster (15–20 minutes), relatively non-invasive, and pose little risk to the patient, while identifying the signs and/or symptoms needed for diagnosis (¹⁹19. Logemann JA, Veis S, Colangelo L. A screening procedure for oropharyngeal dysphagia. Dysphagia. 1999;14(1):44-51.).

PURPOSE

The purpose of this study was systematically review the literature on the dysphagia screening tools, and to identify the characteristics and the methods used.

RESEARCH STRATEGY

For this systematic review, the precepts of the Cochrane Handbook(²⁰20. The Cochrane Collaboration [Internet]. Cochrane handbook for systematic reviews of interventions. 2001. [cited 2014 Aug 26]. Available from: http://www.cochrane.org/training/cochrane-handbook
http://www.cochrane.org/training/cochran... ), which involve the formulation of the research question and the location, selection, and critical assessment of scientific articles, were followed. The research question used was: what are the characteristics and methods of screening instruments for dysphagia?

The research was conducted by four researchers, two of which made the search for articles independently and blindly, whereas the other two were instituted as reviewers, being consulted in cases of doubt to establish an agreement between the ideas.

For the selection of studies, the following descriptors were used: "questionários", "questionnaires", "transtornos de deglutição", "deglutition disorders", "programas de rastreamento", and "mass screening". These were selected according to the following lists: Descriptors in Health Sciences (DeCS) and Medical Subject Headings (MeSH). The following online databases were used for the research: PubMed and Virtual Health Library (VHL), which consists of LILACS, IBECS, MEDLINE, Cochrane Library, and SciELO. The search was conducted between April and June 2013, from the intersection between the elected descriptors.

SELECTION CRITERIA

Articles in English, Portuguese, and Spanish, regardless of the year of publication, involving human beings, whose title, abstract, or text had any relation to the purpose of the research, were selected. Repeated articles and those that did not have the abstract or full text, review articles, dissertations, and theses were excluded. Besides these, articles containing validation of a tool in a country other than the source of the study, articles containing screening instruments to identify only esophageal dysphagia, instruments that used functional assessment of swallowing with food in three consistencies, and those with insufficient information on the instrument used were excluded. No search filters were applied.

DATA ANALYSIS

From the selection of the abstracts of studies found, relevant to the proposed question, the retrieval of the literature in full text was conducted. After reading the articles in full, the following data were extracted: authors' names, year of publication, country where the study was conducted, screening instrument used, characterization of the instrument, method of evaluation, research subjects, sample size, search results, Cronbach's α value, and sensitivity and specificity of the instrument. Although the last three items were observed in the articles, it was not possible to conduct statistical methods to summarize the results.

RESULTS

The search conducted from the proposed descriptors, in the databases used, returned 1,012 articles. The search for "Questionnaires" and "deglutition disorders" in the VHL yielded 404 articles and, in PubMed, 435; similarly for "mass screening" and "deglutition disorders", 83 studies were found in the PubMed database and 90 in VHL.

After analyzing the titles and abstracts of articles from the inclusion and exclusion criteria adopted, 81 studies were selected. Of these, 39 articles were also excluded because they were available in more than one database, leaving 42 articles for analysis in full. After going through these articles and the exclusion of those who did not meet the inclusion criteria, 20 studies were selected for the analysis (Table 1). It was not possible to perform meta-analysis because of the diversity of studies.

Analyzing the selected articles, it was observed that articles on tools to identify patients with dysphagia started to be published in 1999(¹⁹19. Logemann JA, Veis S, Colangelo L. A screening procedure for oropharyngeal dysphagia. Dysphagia. 1999;14(1):44-51.). Of the published studies, 50% were carried out in the USA and 20% in the UK. Others were conducted in countries such as Israel, Japan, the Netherlands, and Italy. It may also be noted that 70% of the publications were from the year 2008, which can be justified by the growing presence of speech-language pathologists in the health-care area and the concern with the early identification of dysphagia to ensure a safe and effective feeding, and to avoid respiratory and nutritional complications, thereby decreasing the cost of hospital stay.

Considering the instruments used, two studies made use the 3-ounce water swallow test, two used the Sydney foods of different viscosities Swallow Questionnaire (SSQ), two the Swallowing Disturbance Questionnaire (SDQ), and the others used different instruments.

Among the selected articles, it was found that most of the instruments covered the oral and pharyngeal signs and symptoms and dysphagia together, involving items that analyzed the presence or absence of dysphagia, for example, extraoral loss of food and pain or cough during or after swallowing. In general, the screening instruments for dysphagia were developed to identify patients who meet the criteria, but few tools are designed to identify patients with or without alterations in the oral phase, pharyngeal delay, and problems in the pharyngeal phase of swallowing(¹⁹19. Logemann JA, Veis S, Colangelo L. A screening procedure for oropharyngeal dysphagia. Dysphagia. 1999;14(1):44-51.). These criteria help explain the diversity of screening instruments found in the literature.

Regarding the research subjects, the samples were quite varied and involved children, adults, and elderly persons. The sample size ranged from 25 to 3,000 participants. The article with 3,000 participants(³²32. Suiter DM, Leder SB. Clinical utility of the 3-ounce water swallow test. Dysphagia. 2008;23(3):244-50.) reported a very heterogeneous population, with individuals of both genders, aged between 2 and 105 years, and with various pathologies. Chart 2 shows the characteristics relating to the underlying pathology for each study population selected.

The reason behind a large number of articles containing screening instruments designed to identify dysphagia patients who had a cerebrovascular accident (stroke) may be related to the high rate of prevalence in this population, which can be up to 67% because these patients have limitations for a safe intake of food and fluids, with increased risk for malnutrition and dehydration and/or related to aspiration pneumonia(⁴⁰40. Hinchey JAM. Formal dysphagia screening protocols prevent pneumonia. Stroke. 2005;36(9):1972-6.,⁴¹41. Martino R, Foley N, Bhogal S, Diamant N, Speechley M, Teasell R. Dysphagia after stroke: incidence, diagnosis, and pulmonary complications. Stroke. 2005;36(12):2756-63.). There is evidence that early detection of dysphagia in stroke patients reduces not only these complications, but also the length of the hospital stay and the total expenditure on health(⁴²42. Martino R, Pron G, Diamant NE. Screening for oropharyngeal dysphagia in stroke: insufficient evidence for guidelines. Dysphagia. 2000;15(1):19-30.).

By reading and analyzing the articles on screening devices, we observed the procedures used in each of them. Some studies(²³23. Bergamaschi R, Crivelli P, Rezzani C, Patti F, Solaro C, Rossi P, et al. The DYMUS questionnaire for the assessment of dysphagia in multiple sclerosis. J Neurol Sci. 2008;269(1-2):49-53.

24. Belafsky PC, Mouadeb DA, Rees CJ, Pryor JC, Postma GN, Allen J, et al. Validity and Reliability of the Eating Assessment Tool (EAT-10). Ann Otol Rhinol Laryngol. 2008;117(12):919-24.-²⁵25. Hanayama K, Liu M, Higuchi Y, Fujiwara T, Tsuji T, Hase K, et al. Dysphagia in patients with Duchenne muscular dystrophy evaluated with a questionnaire and videofluorography. Disabil Rehabil. 2008;30(7):517-22.,²⁷27. Boczko F. Patients' awareness of symptoms of dysphagia. J Am Med Dir Assoc. 2006;7(9):587-90.,³¹31. Cox FM, Verschuuren JJ, Verbist BM, Niks EH, Wintzen AR, Badrising UA. Detecting dysphagia in inclusion body myositis. J Neurol. 2009;256(12):2009-13.,³³33. Manor Y, Giladi N, Cohen A, Fliss DM, Cohen JT. Validation of a swallowing disturbance questionnaire for detecting dysphagia in patients with Parkinson's disease. Mov Disord. 2007;22(13):1917-21.

34. Kawashima K, Motohashi Y, Fujishima I. Prevalence of dysphagia among community-dwelling elderly individuals as estimated using a questionnaire for dysphagia screening. Dysphagia. 2004;19(4):266-71.

35. Govender R, Lee MT, Davies TC, Twinn CE, Katsoulis KL, Payten CL, et al. Development and preliminary validation of a patient-reported outcome measure for swallowing after total laryngectomy (SOAL questionnaire). Clin Otolaryngol. 2012;37(6):452-9.

36. Holland G, Jayasekeran V, Pendleton N, Horan M, Jones M, Hamdy S. Prevalence and symptom profiling of oropharyngeal dysphagia in a community dwelling of an elderly population: a self-reporting questionnaire survey. Dis Esophagus. 2011;24(7):476-80.

37. Dwivedi RC, St Rose S, Roe JW, Khan AS, Pepper C, Nutting CM, et al. Validation of the Sydney Swallow Questionnaire (SSQ) in a cohort of head and neck cancer patients. Oral Oncol. 2010;46(4):10-4.-³⁸38. Cohen JT, Manor Y. Swallowing disturbance questionnaire for detecting dysphagia. Laryngoscope. 2011;121(7):1383-7.) used questionnaires that contained items that should be answered by the subjects themselves in affirmative or negative, or marking on intensity scales; others(²¹21. Antonios N, Carnaby-Mann G, Crary M, Miller L, Hubbard H, Hood K, et al. Analysis of a physician tool for evaluating dysphagia on an inpatient stroke unit: the modified mann assessment of swallowing ability. J Stroke Cerebrovasc Dis. 2010;19(1):49-57.,²⁸28. Massey R, Jedlicka D. The massey bedside swallowing screen. J Neurosci Nurs. 2002;34(5):252-3, 257-60.,²⁹29. Schrock JW, Bernstein J, Glasenapp M, Drogell K, Hanna J. A novel emergency department dysphagia screen for patients presenting with acute stroke. Acad Emerg Med. 2011;18(6):584-9.) used instruments with items in which the examiner observed the patient's clinical signs and symptoms and/or asked the patient to perform some movements, and then marked the response on the instrument. Generally, a failure in one of the issues analyzed indicates a risk for swallowing disorders. There are also studies(²⁶26. Suiter DM, Leder SB, Karas DE. The 3-ounce (90-cc) water swallow challenge: a screening test for children with suspected oropharyngeal dysphagia. Otolaryngol Head Neck Surg. 2009;140(2):187-90.,³⁰30. Sitoh YY, Lee A, Phua SY, Lieu PK, Chan SP. Bedside assessment of swallowing: a useful screening tool for dysphagia in an acute geriatric ward. Singapore Med J. 2000;41(8):376-81.,³²32. Suiter DM, Leder SB. Clinical utility of the 3-ounce water swallow test. Dysphagia. 2008;23(3):244-50.) that used instruments that involved only the swallowing test with water for screening. In these studies, the patient had to ingest the liquid and some signs were observed during and after the intake. There were also articles that showed screening instruments with two procedures(¹⁷17. Speyer R. Oropharyngeal dysphagia screening and assessment. Otolaryngol Clin North Am. 2013;46(6):989-1008.,²²22. Turner-Lawrence DE, Peebles A, Price MF, Singh SJ, Asimos AW. A feasibility study of the sensitivity of emergency physician dysphagia screening in acute stroke patients. Ann Emerg Med. 2009;54(3):344-8.,²⁸28. Massey R, Jedlicka D. The massey bedside swallowing screen. J Neurosci Nurs. 2002;34(5):252-3, 257-60.,³⁹39. Weinhardt J, Hazelett S, Barrett D, Lada R, Enos T, Keleman R. Accuracy of a bedside dysphagia screening: a comparison of registered nurses and speech therapists. Rehabil Nurs. 2008;33(6):247-52.), containing one observational part and the other a swallowing test using water or food of different viscosities.

The procedures used in screening instruments were quite varied, showing various possibilities. Children and adults or elderly with some neurological or motor deficits may have limitations in following orders or collaborating on any task requested by the screening instrument. For example, in the study involving children, the instrument of choice was the one that used only the swallowing test with water, perhaps because of the inability of the child to answer questions or perform movements requested by the examiner; studies involving patients who had strokes generally used instruments with two procedures: the first being observational, and the request to perform orofacial movements, and the second being a swallowing test with water or food of different viscosities. This finding can be explained by the possibility of stroke patients to be restricted to orofacial movements and/or presenting speech and language impairment, which can influence or compromise their feeding performance. Therefore, these should be checked before a test that uses food.

It was found that three articles used only one instrument based on the swallowing test with water as a method of screening; the other, which contained swallowing tests, previously used an observational part and the request to perform orofacial movements. Instruments that involve rapid and continuous consumption of water, such as the 3-ounce water swallow test, may put the patient at risk in case they aspire and introduce a large amount of water in their respiratory tract(¹⁹19. Logemann JA, Veis S, Colangelo L. A screening procedure for oropharyngeal dysphagia. Dysphagia. 1999;14(1):44-51.). The authors of the Northwestern Dysphagia Patient Check Sheet, which uses the swallowing test with foods of different consistencies, suggest that the use of this instrument poses no risk to patients, because the intake of the different types of food occurs in small quantities, or, if the patient does not ingest food, observation it can be performed with the swallowing of saliva(¹⁹19. Logemann JA, Veis S, Colangelo L. A screening procedure for oropharyngeal dysphagia. Dysphagia. 1999;14(1):44-51.). However, one must consider that dysphagia is a symptom, and it is essential that it is included in the screening instrument to verify the patient's complaints and the risk of aspiration and to identify subjects who require an assessment and referral for diagnosis of dysphagia(²¹21. Antonios N, Carnaby-Mann G, Crary M, Miller L, Hubbard H, Hood K, et al. Analysis of a physician tool for evaluating dysphagia on an inpatient stroke unit: the modified mann assessment of swallowing ability. J Stroke Cerebrovasc Dis. 2010;19(1):49-57.,²⁴24. Belafsky PC, Mouadeb DA, Rees CJ, Pryor JC, Postma GN, Allen J, et al. Validity and Reliability of the Eating Assessment Tool (EAT-10). Ann Otol Rhinol Laryngol. 2008;117(12):919-24.).

There is no consensus in the researched literature on the best or most correct procedure to be applied; it is up to the professionals to choose the instrument that suits the requirements of their activity, the operation of the service, and the profile of the patients that will be screened.

To verify the reliability of the instruments for the detection of patients with dysphagia, most studies used some method of assessment for data comparison. The Videofluoroscopy Swallow Study was used in five articles(¹⁹19. Logemann JA, Veis S, Colangelo L. A screening procedure for oropharyngeal dysphagia. Dysphagia. 1999;14(1):44-51.,²⁵25. Hanayama K, Liu M, Higuchi Y, Fujiwara T, Tsuji T, Hase K, et al. Dysphagia in patients with Duchenne muscular dystrophy evaluated with a questionnaire and videofluorography. Disabil Rehabil. 2008;30(7):517-22.,²⁹29. Schrock JW, Bernstein J, Glasenapp M, Drogell K, Hanna J. A novel emergency department dysphagia screen for patients presenting with acute stroke. Acad Emerg Med. 2011;18(6):584-9.,³¹31. Cox FM, Verschuuren JJ, Verbist BM, Niks EH, Wintzen AR, Badrising UA. Detecting dysphagia in inclusion body myositis. J Neurol. 2009;256(12):2009-13.,³⁵35. Govender R, Lee MT, Davies TC, Twinn CE, Katsoulis KL, Payten CL, et al. Development and preliminary validation of a patient-reported outcome measure for swallowing after total laryngectomy (SOAL questionnaire). Clin Otolaryngol. 2012;37(6):452-9.); clinical assessment of swallowing was reported in five(²¹21. Antonios N, Carnaby-Mann G, Crary M, Miller L, Hubbard H, Hood K, et al. Analysis of a physician tool for evaluating dysphagia on an inpatient stroke unit: the modified mann assessment of swallowing ability. J Stroke Cerebrovasc Dis. 2010;19(1):49-57.,²²22. Turner-Lawrence DE, Peebles A, Price MF, Singh SJ, Asimos AW. A feasibility study of the sensitivity of emergency physician dysphagia screening in acute stroke patients. Ann Emerg Med. 2009;54(3):344-8.,²⁷27. Boczko F. Patients' awareness of symptoms of dysphagia. J Am Med Dir Assoc. 2006;7(9):587-90.,³⁰30. Sitoh YY, Lee A, Phua SY, Lieu PK, Chan SP. Bedside assessment of swallowing: a useful screening tool for dysphagia in an acute geriatric ward. Singapore Med J. 2000;41(8):376-81.,³⁷37. Dwivedi RC, St Rose S, Roe JW, Khan AS, Pepper C, Nutting CM, et al. Validation of the Sydney Swallow Questionnaire (SSQ) in a cohort of head and neck cancer patients. Oral Oncol. 2010;46(4):10-4.); fiberoptic endoscopic evaluation of swallowing (FEES) was reported in three papers(²⁶26. Suiter DM, Leder SB, Karas DE. The 3-ounce (90-cc) water swallow challenge: a screening test for children with suspected oropharyngeal dysphagia. Otolaryngol Head Neck Surg. 2009;140(2):187-90.,³²32. Suiter DM, Leder SB. Clinical utility of the 3-ounce water swallow test. Dysphagia. 2008;23(3):244-50.,³⁸38. Cohen JT, Manor Y. Swallowing disturbance questionnaire for detecting dysphagia. Laryngoscope. 2011;121(7):1383-7.), and clinical evaluation and FEES were reported in one(³³33. Manor Y, Giladi N, Cohen A, Fliss DM, Cohen JT. Validation of a swallowing disturbance questionnaire for detecting dysphagia in patients with Parkinson's disease. Mov Disord. 2007;22(13):1917-21.). Another study(²⁸28. Massey R, Jedlicka D. The massey bedside swallowing screen. J Neurosci Nurs. 2002;34(5):252-3, 257-60.) conducted the follow-up of patients for a specific time-period and included indicators such as consultation with a speech-language pathologist; special type of diet, and clinical symptoms of aspiration pneumonia to verify the presence of dysphagia. The remaining articles did not use any method of evaluation to compare the results.

Clinical evaluation of swallowing is a subjective evaluation that aims to identify possible causes of dysphagia and evaluate the safety of swallowing or aspiration hazard, decide on the method of feeding (oral versus alternative), and clarify the need for objective evaluation (FEES or videofluoroscopy)(¹⁷17. Speyer R. Oropharyngeal dysphagia screening and assessment. Otolaryngol Clin North Am. 2013;46(6):989-1008.). It should contain the following: clinical history data; assessment of cognition and communication skills; assessment of physiology and anatomy; and oral, pharyngeal and laryngeal functions, with special focus on the examination of the cranial nerves and evaluation of oral intake(⁴³43. Daniels SK, Huckabee ML. Dysphagia following stroke. San Diego (CA): Plural Publishing; 2008.,⁴⁴44. Goodrich SJ, Walker AI. Clinical swallow evaluation. In: Leonard R, Kendall K. Dysphagia assessment and treatment planning: a team approach. San Diego (CA): Plural Publishing; 2008. p. 103-36.). Videofluoroscopy is the main assessment tool that provides a dynamic image of the oral, pharyngeal, and upper esophageal phases of swallowing. One of the purposes of this examination is to define the pharyngeal phase of swallowing and not only to determine the existence of aspiration. This examination shows structural and functional findings that may be related to various swallowing disorders. When aspiration occurs, the speech-language pathologist should check the time and the consistency with which it occurs, in order to plan the intervention(⁴⁵45. Arvedson JC. Assessment of pediatric dysphagia and feeding disorders: clinical and instrumental approaches. Dev Disabil Res Rev. 2008;14(2):118-27.). FEES, which is performed through an endoscope, aims to evaluate the oral and pharyngeal phases of swallowing. Food coloring is used in the food used for assessment, and the events that occur before and after pharyngeal swallowing are analyzed, such as waste in the vallecula and piriform recesses, aspiration, reduction of pharyngolaryngeal sensitivity, change of glottal closure, early rear food loss, and nasal regurgitation(¹²12. Langmore SE, Schatz K, Olsen N. Fiberoptic endoscopic examination of swallowing safety: a new procedure. Dysphagia. 1988;2(4):216-9.,⁴⁵45. Arvedson JC. Assessment of pediatric dysphagia and feeding disorders: clinical and instrumental approaches. Dev Disabil Res Rev. 2008;14(2):118-27.). Knowing that the access of the population to these swallowing tests is restricted, especially in developing countries, the screening instruments capable of accurately detecting dysphagia patients have high importance in clinical and hospital settings, accelerating the process of identification and diagnosis of swallowing disorders.

The indicators or sensitivity, which is the proportion of people with the disease who present a positive test, and specificity, which is the proportion of individuals without the disease who have a negative test result(⁴⁶46. Fletcher RH, Fletcher S. Epidemiologia clínica: elementos essenciais. 4ª edição. Porto Alegre: Artmed; 2006. p. 60-3.), were observed in 10 studies(¹⁹19. Logemann JA, Veis S, Colangelo L. A screening procedure for oropharyngeal dysphagia. Dysphagia. 1999;14(1):44-51.,²¹21. Antonios N, Carnaby-Mann G, Crary M, Miller L, Hubbard H, Hood K, et al. Analysis of a physician tool for evaluating dysphagia on an inpatient stroke unit: the modified mann assessment of swallowing ability. J Stroke Cerebrovasc Dis. 2010;19(1):49-57.,²²22. Turner-Lawrence DE, Peebles A, Price MF, Singh SJ, Asimos AW. A feasibility study of the sensitivity of emergency physician dysphagia screening in acute stroke patients. Ann Emerg Med. 2009;54(3):344-8.,²⁶26. Suiter DM, Leder SB, Karas DE. The 3-ounce (90-cc) water swallow challenge: a screening test for children with suspected oropharyngeal dysphagia. Otolaryngol Head Neck Surg. 2009;140(2):187-90.

27. Boczko F. Patients' awareness of symptoms of dysphagia. J Am Med Dir Assoc. 2006;7(9):587-90.

28. Massey R, Jedlicka D. The massey bedside swallowing screen. J Neurosci Nurs. 2002;34(5):252-3, 257-60.-²⁹29. Schrock JW, Bernstein J, Glasenapp M, Drogell K, Hanna J. A novel emergency department dysphagia screen for patients presenting with acute stroke. Acad Emerg Med. 2011;18(6):584-9.,³²32. Suiter DM, Leder SB. Clinical utility of the 3-ounce water swallow test. Dysphagia. 2008;23(3):244-50.,³³33. Manor Y, Giladi N, Cohen A, Fliss DM, Cohen JT. Validation of a swallowing disturbance questionnaire for detecting dysphagia in patients with Parkinson's disease. Mov Disord. 2007;22(13):1917-21.,³⁸38. Cohen JT, Manor Y. Swallowing disturbance questionnaire for detecting dysphagia. Laryngoscope. 2011;121(7):1383-7.). Most presented the final value of sensitivity and specificity related to the instrument and showed specific values to each item of the questionnaire. An ideal screening tool should have high sensitivity and specificity so that the number of physiological swallowing tests and the costs involved can be reduced(¹⁹19. Logemann JA, Veis S, Colangelo L. A screening procedure for oropharyngeal dysphagia. Dysphagia. 1999;14(1):44-51.,²¹21. Antonios N, Carnaby-Mann G, Crary M, Miller L, Hubbard H, Hood K, et al. Analysis of a physician tool for evaluating dysphagia on an inpatient stroke unit: the modified mann assessment of swallowing ability. J Stroke Cerebrovasc Dis. 2010;19(1):49-57.). For the indicator of sensitivity, the value ranged between 79.70%(³⁸38. Cohen JT, Manor Y. Swallowing disturbance questionnaire for detecting dysphagia. Laryngoscope. 2011;121(7):1383-7.) and 100%(²⁶26. Suiter DM, Leder SB, Karas DE. The 3-ounce (90-cc) water swallow challenge: a screening test for children with suspected oropharyngeal dysphagia. Otolaryngol Head Neck Surg. 2009;140(2):187-90.,²⁸28. Massey R, Jedlicka D. The massey bedside swallowing screen. J Neurosci Nurs. 2002;34(5):252-3, 257-60.). Regarding specificity, described minimum value was 51%(²⁶26. Suiter DM, Leder SB, Karas DE. The 3-ounce (90-cc) water swallow challenge: a screening test for children with suspected oropharyngeal dysphagia. Otolaryngol Head Neck Surg. 2009;140(2):187-90.) and the maximum value was 100%(²⁸28. Massey R, Jedlicka D. The massey bedside swallowing screen. J Neurosci Nurs. 2002;34(5):252-3, 257-60.). The study that had higher sensitivity and specificity, both 100%(²⁸28. Massey R, Jedlicka D. The massey bedside swallowing screen. J Neurosci Nurs. 2002;34(5):252-3, 257-60.), presented a screening instrument with two steps: the first one was observational, and the request to perform some orofacial movements, and the second was a swallowing test with water in two different volumes. In the first phase, the examiner observed and marked "yes" or "no" in response to the to the following questions: alertness, dysarthria, aphasia, dental occlusion, lip occlusion, facial symmetry, position of the tongue and uvula in the midline, gag reflex, voluntary cough, swallowing of secretions, and swallowing reflex. If any of the answers was "no", the screening was interrupted. After this initial phase, the patient underwent the evaluation with water, ingesting a tablespoon of water, and then 60 cc water, and the following signs are observed: coughing during or after swallowing, change in voice quality, and extraoral fluid loss. If the patient had any of these symptoms, the application of the instrument was interrupted.

Another fact observed in some articles was the Cronbach's acoefficient, which estimates the reliability of a questionnaire in a study. In general, a survey instrument is considered satisfactory if it obtains a ≥0.70(⁴⁷47. Freitas ALP, Rodrigues SG [Internet]. A avaliação da confiabilidade de questionários: uma análise utilizando o coeficiente alfa de Cronbach. In: XII SIMPEP; 2005. Bauru (SP), Brasil.). Of the articles analyzed, six(²³23. Bergamaschi R, Crivelli P, Rezzani C, Patti F, Solaro C, Rossi P, et al. The DYMUS questionnaire for the assessment of dysphagia in multiple sclerosis. J Neurol Sci. 2008;269(1-2):49-53.,²⁴24. Belafsky PC, Mouadeb DA, Rees CJ, Pryor JC, Postma GN, Allen J, et al. Validity and Reliability of the Eating Assessment Tool (EAT-10). Ann Otol Rhinol Laryngol. 2008;117(12):919-24.,³⁴34. Kawashima K, Motohashi Y, Fujishima I. Prevalence of dysphagia among community-dwelling elderly individuals as estimated using a questionnaire for dysphagia screening. Dysphagia. 2004;19(4):266-71.,³⁵35. Govender R, Lee MT, Davies TC, Twinn CE, Katsoulis KL, Payten CL, et al. Development and preliminary validation of a patient-reported outcome measure for swallowing after total laryngectomy (SOAL questionnaire). Clin Otolaryngol. 2012;37(6):452-9.,³⁷37. Dwivedi RC, St Rose S, Roe JW, Khan AS, Pepper C, Nutting CM, et al. Validation of the Sydney Swallow Questionnaire (SSQ) in a cohort of head and neck cancer patients. Oral Oncol. 2010;46(4):10-4.,³⁸38. Cohen JT, Manor Y. Swallowing disturbance questionnaire for detecting dysphagia. Laryngoscope. 2011;121(7):1383-7.) used Cronbach's a coefficient, with the lowest value being 0.80(³⁸38. Cohen JT, Manor Y. Swallowing disturbance questionnaire for detecting dysphagia. Laryngoscope. 2011;121(7):1383-7.) and the highest value being 0.96(²⁴24. Belafsky PC, Mouadeb DA, Rees CJ, Pryor JC, Postma GN, Allen J, et al. Validity and Reliability of the Eating Assessment Tool (EAT-10). Ann Otol Rhinol Laryngol. 2008;117(12):919-24.,³⁵35. Govender R, Lee MT, Davies TC, Twinn CE, Katsoulis KL, Payten CL, et al. Development and preliminary validation of a patient-reported outcome measure for swallowing after total laryngectomy (SOAL questionnaire). Clin Otolaryngol. 2012;37(6):452-9.). Despite the variation between values, all instruments can be considered satisfactory for the purpose of identifying patients with dysphagia.

With the analysis of instruments used in each article, the occurrence of certain issues related to the signs, symptoms, and clinical consequences of dysphagia, such as cough during or after ingestion of liquids or foods; globus sensation in the pharynx; difficulty in swallowing food or liquids; nasal regurgitation; need for multiple swallowing; choking during feeding with liquids or foods; difficulty swallowing secretions; weight loss or difficulty in gaining weight and occurrence of aspiration pneumonia can be observed. Screening procedures for dysphagia must focus on the signs and/or symptoms (cough or hoarseness, change in voice quality, multiple swallowing, and oral stasis of food), whereas diagnostic procedures should analyze the anatomy and physiology of swallowing(¹⁹19. Logemann JA, Veis S, Colangelo L. A screening procedure for oropharyngeal dysphagia. Dysphagia. 1999;14(1):44-51.,⁴⁸48. Logemann JA [Internet]. The evaluation and treatment of swallowing disorders. Curr Opin Otolaryngol Head Neck Surg. 1998;6(6) [cited 2014 Sept 10]. Available from: http://journals.lww.com/co-otolaryngology/abstract/1998/12000/the_evaluation_and_treatment_of_swallowing.8.aspx
http://journals.lww.com/co-otolaryngolog... ).

CONCLUSION

Screening instruments in dysphagia are very heterogeneous and were developed for different groups of people — children, adults, and elderly; healthy or with some underlying pathology — with the main objective of identifying swallowing disorders.

In the research literature, there is no consensus on the best or most correct method to be applied; it is up to the professional to choose the instrument that suits the requirement of their activity, the operation of the service, and the profiles of the patients that will be screened.

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