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Update on Using Laryngoscopy to Evaluate & Treat Dysphagia Joseph Murray PhD, CCC-SLP, BCS-S Veteran’s Affairs Medical Center/ Wayne State University Ann Arbor Detroit Flexible Fiberoptic Laryngoscopy • Sawashima & Hirose (1968) – New laryngoscopic technique by use of fiber optics Journal of the Acoustical Society of America Jan;43(1):168-9 • First application to swallowing – Langmore, Schatz and Olsen (1988) Laryngoscopic Evaluation of Swallowing – Sensitivity and specificity compares favorably with fluoroscopy • (Langmore, Shatz &Olsen, 1988, 1991) – Replications and similar studies – Reliability • Aspiration/Penetration Scale – Colodny (2003) • Identifying pathophysiology – Probably poor Langmore, Shatz & Olsen • First application to swallowing –Fiberoptic Endoscopic Evaluation of Swallowing –Dysphagia 1988;2(4):216-9 • Description of procedure • No data Langmore, S., Schatz, K. & Olson, N. “Endoscopic and videofluoroscopic evaluations of swallowing and aspiration.” Annals of Otology, Rhinology & Laryngology, Vol. 100, 1991, pp. 678-681. • Compared FEES to VFSS in 21 Patients • Specificity good • • • • Premature spillage Residuals Laryngeal penetration Aspiration Instrumental Evaluation • May include any or all of the following: – Structural and functional assessment – Observation of swallowing using representative food and liquid boluses – Assessment of adequacy of airway protection before, during and after the swallow – Screening of esophageal function as it relates to pharyngeal dysphagia – Assessment of the effect of changes in bolus delivery – Textural alterations – Use of therapeutic postures or maneuvers Indications for Instrumental Evaluation • Necessary if: – Clinical did not yield clear pathway for management • Unnecessary if: • Findings from clinical fail to support a suspicion of dysphagia • Findings from clinical suggest dysphagia but include either of the following: – Patient too medically unstable to complete the instrumental – Patient is unable to cooperate or participate in instrumental – Instrumental would not change the clinical management of the patient Differences in indications FEES vs. VFS • Patient may tolerate bedside FEES rather than trip to fluoroscopy – – – – Bedbound Debilitated Confused by unfamiliar surroundings Refusing unfamiliar foods (barium) • Patient may not tolerate FEES if: – Tactilely defensive – Combative • Must try to emulate natural feeding event How Does One Choose? Projection of possible findings from clinical will guide the choice of instrumentation. The field of view should determine the instrumentation to be used. Choose the instrument that will provide a field of view that reveals the most salient findings. Field of View – Typical fluoroscopic image will include: • oral cavity • pharynx • portions of the striated esophagus Field of View • Typical endoscopic image will include: – Nasal cavity – Nasopharynx – Hypopharynx – Endolarynx – Anterior wall of trachea Indications for Laryngoscopy • Signs or symptoms of laryngeal penetration or aspiration before the swallow is initiated • Abnormal vocal quality and suspected dysphagia. • Increased difficulties with swallowing over the duration of a meal secondary to fatigue. Indications for Laryngoscopy • Hypernasality and suspected nasal regurgitation. • Need for visualization of the hypopharynx/larynx for biofeedback education and/or rehabilitation. Indications for Laryngoscopy • Documented pharyngeal dysphagia on videofluoroscopic swallow study (VFSS) that can be retested with endoscopy to: – Monitor progress. – Better assess underlying etiology. – Limit radiation exposure Indications for Laryngoscopy • Suspected or observed difficulty swallowing saliva/oral secretions. • Difficulty with coordinating suck/swallow and breathing • Inability to tolerate barium (e.g., potential allergy or aversion to barium). • Safety issues associated with radiation exposure (e.g., women with confirmed or possible pregnancy or patient who has radiation limitations). Indications for Laryngoscopy • Difficulty transporting patients to the radiology suite – – – – – – bedridden or weak patients patients with open wounds, contractures, or pain patients with quadriplegia or wearing a halo patients with obesity or positioning difficulties patient on Intensive Care Unit monitors or ventilators). Limited access to radiologic assessment. Limitations of Laryngoscopy • Often must infer the disordered physiology of the swallow. • Cannot see cricopharyngeal function or striated esophagus. • Important events occur as the view is obscured (during white-out). • Patient’s anatomy may not allow for an adequate view. Potential contraindications for use of FEES • Severe agitation and possible inability to cooperate with the examination. • Acute cardiac problem. – Certain patients may require clearance from their medical team prior to the examination. • History of vasovagal episodes or a history of fainting • Severe movement disorders (dyskinesia). Potential contraindications for use of FEES • Severe bleeding disorders and/or recent severe epistaxis (nosebleed). • History of recent acute facial fracture. • Bilateral obstruction of the nasal passages. Indications for Fluoroscopy • Patients being seen for the first time with long-standing dysphagia • Vague complaints and/or confounding signs during the clinical examination • Oral stage impairments not fully understood following the clinical examination Indications for Fluoroscopy • Anticipation of severely inefficient pharyngeal stage • Patients with complaints of food being “stuck” at the level of the thyroid notch or below • Patients with obvious signs of upper esophageal or esophageal dysphagia Strengths of Fluoroscopy • Most comprehensive view available – Can visualize all of the main structures in one image – Can follow bolus from mouth to esophagus • Non-invasive • Widely practiced and accepted – Large body of supporting literature Limitations of Fluoroscopy – Radiation exposure – Time limited study • due to radiation exposure – Unnatural replication of feeding • Taste • Viscosity Limitations of Fluoroscopy – Positioning difficult for many patients • Obese patients • Movement disorders – Staffing and scheduling requirements Madden, C., Fenton J., Hughes, J., & Timon C., (2000) Comparison between videofluoroscopy and milk-swallow endoscopy in the assessment of swallowing function. Clin. Otolaryngology. 25, 504-506 • Compared 20 concurrent vfss and FEES • Similar sensitivity and specificity • Concluded that FEES is adequate substitute for VFSS and can be used when practical Unresolved Clinical Condition Fluoroscopy Endoscopy contraindicated X Oral stage dysphagia X Upper esophageal or esophageal dysphagia X Vague complaints X Clinically inexplicable weight loss X Initial exam for long-standing dysphagia X Food stuck @ thyroid notch or lower X Sudden onset of pharyngeal dysphagia X Food “stuck” above thyroid notch X Retest, pharyngeal dysphagia Biofeedback Aspiration of secretions Mucosal surface anatomic anomalies Assess airway protection patterns Fluoroscopy unavailable Patient positioning problems Endoscopy X X X X X X X X X FEES: Principles and Standards Different Models • ENT as endoscopist • SLP assists/directs – Pulmonologist as endoscopist • SLP assists/directs – SLP as endoscopist • Independently conducts and directs exam Age Range • 6 months and up • Difficulty between 18 months to 2.5 years – Stranger anxiety – Sensory issues Distraction • • • • • Videos Headphones with music Preparatory play with endoscopy dolls Directed play during feeding Placement of scope during feeding Adjustments for pediatric population • Rapid suck –swallow – Remove bottle or pinch straw • Cessation of rapid suck-swallow • Retained bolus after swallow – Place pacifier in mouth after bottle feeding or spoon feeding • Clears retained bolus (or not) Consent • Generally not necessary • Variation in various sites • Typically used in cases where general anesthesia or risk of sentinel event possible • Laryngoscopic Swallow Assessment – No general anesthesia or twilighting – Usually considered to be general routine care – Low risk of adverse outcome Assistance Necessary? • Determine if patient is able to feed himself • If no – Secure assurance of feeding assistance from nursing staff or other assistant well before procedure Equipment Checklist • Chip Camera • Light source • Media Recorder – Must have enough media (blank tape, R/W DVD or hard disk space) available to record 25 minutes • Microphone – Do battery check to insure you will be able to record sound • Monitor Ancillary Equipment/Supplies • • • • 2% Viscous Lidocaine Gel 4 Cotton tipped applicators 4 Packages of alcohol pads Latex/vinyl gloves Insertion into Nasal Cavity • Determine patency of nasal cavity • See which nares will allow for an easier or more comfortable passage • Comfortable start of the exam – More likely to get a natural session of feeding and more accurate results Nasal Entry • Low Entry – The easiest space is usually located between the inferior turbinate and septal wall • Path is both wide and fairly insensitive to intrusion from foreign objects High Entry • Locate space between middle and superior turbinate – While on floor of nose at entry to cavity – Point the scope up 30 to 40 degrees from horizontal • Generally open but sometimes more sensitive to intrusion. Kiesselbach's Plexus Little’s Area Anteroinferior nasal septum Blood supply •Sphenopalatine artery •Greater palatine artery •Superior labial artery •Anterior ethmoid artery Problem Areas/Epistaxis • Kiesselbach's plexus/(Little's area) – 80% to 90% of all epistaxis occurs here • Woodruff's plexus – sphenopalatine artery enters the nasal cavity – posterior aspect of middle turbinate. Problem Areas/Epistaxis • Woodruff’s Plexus – Most posterior nosebleeds occur here • systemic disease • Hypertension – Promotes rigid arteries – weakens vessels – inhibits vasoconstriction Problem Areas/Epistaxis • Epistaxis • Exacerbated by – Coagulopathy – Anticoagulant medication • Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) • Warfarin (other anticoagulants) – Hepatic cirrhosis – Renal failure. Signs of Patient Distress • Advance the scope a few centimeters and determine if the patient is tolerating the passage. • If the patient is showing any of the following signs of distress: – Eye wincing – Tearing – Complaints – Grabbing at endoscope Identifying an Easy Path • The following conditions have been met: – Can see all the way to the rising and falling soft palate at the rear of the nasopharynx. – Patient not complaining or experiencing discomfort • Lighten grip of leading hand – Allow insertion portion of the scope to slide through fingers Boseley, M., Ashland, J., Hartnick, C., (2006) The utility of the fiberoptic endoscopic evaluation of swallowing (FEES) in diagnosing and treating children with Type I laryngeal clefts International Journal of Pediatric Otorhinolaryngology 70, 339—343 • Case Series – Three children type 1 laryngeal cleft – Predominant presenting signs and symptoms • Cough with ingestion of liquids – Posterior to anterior aspiration • Through interarytenoid space Navigation Observation/Inspection of the pharynx • The endoscopist exercises dynamic control of the endoscope, by rotating, inserting, and retracting, to optimize the view of the endolarynx. • Observation of bolus transit • Observation of general swallowing function • Observation of residuals following the swallow White-Out • During the pharyngeal swallow the tongue and velum contact the posterior pharyngeal wall. • The distal tip of the endoscope will be trapped transiently against the posterior pharyngeal wall by the velum or base of tongue. Laryngeal Closure • Laryngeal closure prevents entry of the bolus into the trachea during the swallow. • Conventional wisdom: – Closure is ordered and redundant; inferior to superior – True cords first – False cords second – Anterior movement of arytenoids third – Epiglottal downfolding last redundant closure Airway Closure Shaker et al. (1990) Glottal closure patterns associated with swallowing. • Type 1: The vocal folds are observed to remain in contact along their entire length after laryngeal elevation is initiated. 58% • Type 2: The vocal folds are in contact in the anterior half of their length but slightly separated in the posterior portion, leaving a small gap. 7% • Type 3: The vocal folds are not in contact with each other, leaving a small, elongated triangular opening between the folds. 35% Upper Esophageal Sphincter • Is not typically visualized via laryngoscopy due to white out. • Low positioning of the laryngoscope close to or actually within the UES may allow for consistent visualization. Upper Esophageal Sphincter • Sign of the “Rising Tide” Perie et al. (1999) • Backup of cream visible in the hypopharynx – Perie claims this is specific for Zenker's diverticulum – Can be observed with multitude of esophageal disorders • • • • Esophageal dysmotility Esophageal achalasia Esophageal stricture Reflux High Position •Good for keeping scope clean •Can be poor position for visualizing the bolus prior to the swallow •Dependent on position of epiglottis relative to PPW Nasopharyngeal Position •Good for looking at nasal regurgitation •Poor position for seeing anything else •May need to position here for very weak swallows •Good position during cued coughing Observing Nasal Regurgitation • Complaint of or findings of – nasoregurgitation – hypernasality • Position scope high in nasopharynx • Present food or liquids that relate to complaint Soiling of Scope • Soiling, fogging, filming, shmutzing! • The endoscope will become “gunked” during the examination due to contact with oropharyngeal secretions or food and liquid. Maintaining the View • When soiling occurs – FIRST! • Retract the scope a few centimeters – If this does not work; • Angle the tip of the scope to contact the posterior pharyngeal wall – generally will wipe away the residue – Retract into the nasopharynx • Wait for or request a swallow. Maintaining the field of view • Sustain discipline in positioning before and after the swallow to maximize findings. • Exercise awareness of position of residue and subglottic material before the swallow • Be prepared to mentally compare this picture to the findings after the swallow Dynamic Control/The Deep Look • Deep advancement of the scope. • Look into endolarynx/subglottis/anterior tracheal wall • Essential component of every swallow event • Should become an automatic motor movement after every swallow • Requires a clean lens! Components of the FEES Assessment • Identification of: – Normal and abnormal anatomy – Discrete structural movements – Temporal coordination of anatomic movements relative to bolus advancement – Trajectory of the bolus through the pharynx Components of the FEES Assessment • Evaluation of the efficacy for: Adjustments to: Bolus volume Consistency Rate of delivery Adjustments in positioning Implementation of maneuvers Results of a FEES Exam • Report of procedure should include: – Description of dysphagia: • Attempt to pinpoint pathophysiology • What specific problems were seen, with what consistencies? • What therapeutic alterations helped safety and/ or efficiency of swallow? Results of a FEES Exam (cont.) • Recommendations –PO diet indicated? • If yes, what consistencies are safe? Any postures, maneuvers, other alterations indicated? • Is direct therapy by SLP indicated? • Other recommendations/ referrals Protocol The examination is broken into two sections: • Part One • Observation: – Occurs during the initial passage of the endoscope and is reserved for: • • • • The survey of anatomy Elicitation of anatomic movements Observation of secretion management Monitoring of spontaneous swallows Protocol (cont.) • Part Two • Presentation of food and liquid: – Various consistencies of food are presented – Interventions are attempted Scoring Methods • Hey C, Pluschinski P, Stanschus S, Euler HA, Sader RA, Langmore S, Neumann K.A documentation system to save time and ensure proper application of the fiberoptic endoscopic evaluation of swallowing (FEES®).Folia Phoniatr Logop. 2011;63(4):201-8. Epub 2010 Oct 12 – Reduced time for report writing – More precision in performing FEES protocol • Rehder and Partner (2009) – Digital FEES Protocol – Developed by group under Mario Prosiegel Food Preparation • Use food from tray • Observe natural feeding – Rate – Means of delivery • Nosey cups • May need to use straws • Use light colored foods – Milk – Mashed potatoes Observation Section • Anatomic Notes • Inspect structural barriers to the laryngeal airway. • Symmetry of the structures and cavities should be noted – Special attention to the natural flow path of the bolus. Anatomic Notes • Edema • Surgical changes – Effect on protective barriers should be described. • Appearance of lesions, tumor, or mass effects – Should trigger a consultation for verification by otolaryngology. Postma G, McGuirt W, Butler S, Rees C, Crandall H, Tansavatdi K. Laryngopharyngeal abnormalities in hospitalized patients with dysphagia. Laryngoscope. 2007; 117 :1720–1722. • 99 FEES in hospitalized patients – 79% prevalence of anatomic anomaly • • • • • • • • arytenoid edema (33%) granuloma (31%) vocal fold paresis (24%) mucosal lesions (17%) vocal fold bowing (14%) diffuse edema (11%) airway stenosis (3%) ulcer (6%) – 45% with two or more findings Colton House J, Noordzij J, Burgia B, Langmore S. Laryngeal injury from prolonged intubation; a prospective analysis of contributing factors. Laryngoscope . 2011 121: 596-600. • • • • 61 patients post-extubation 100% showing some laryngeal abnormality Edema and erythema most common 39% had either unilateral or bilateral vocal fold immobility Feeding Tubes • Not a detriment – Leder S, Suiter D. Effect of nasogastric tubes on incidence of aspiration. Arch Phys Med Rehabil . 2008: 89: 648-651 – Dziewas R, Warnecke T, Hamacher C, Oelenberg S, Teismann I, Kraemer C, Ritter M, Ringelstein EB, Schaebitz WR. Do nasogastric tubes worsen dysphagia in patients with acute stroke? BMC Neurology 2008 8:29. Provocative Movements • CN X • RLN – Breath hold – Cough • CN XII – Stylopharyngeus Bastian R. The videoendoscopic swallowing study: an alternative and partner to the videofluoroscopic swallowing study. Dysphagia 1993;8:359–67 • Pharyngeal Squeeze Maneuver (PSM) – Patient produces forceful high pitched/i/ • Pig call – Note degree of pharyngeal wall movement. Pharyngeal Constriction Ratio • Leonard R, Belafsky P, Rees C. Relationship between fluoroscopic and manometric measures of pharyngeal constriction: The pharyngeal constriction ratio. Ann Otol Rhinol Laryngol. 2006;115 :897–901. • Fuller S, Leonard R, Aminpour S, Belafsky P.Validation of the pharyngeal squeeze maneuver. Otolaryngology - Head and Neck Surgery.2009; 140:391-394. PCR Measure • Validated via VFSS – Pharyngeal area visible in lateral radiograph at rest – Divided by – Pharyngeal area at point of maximum constriction • Elevated PCR suggests decreased pharyngeal contractions Pharyngeal Squeeze Maneuver (PSM) • Fuller (2009) – Simultaneous FEES/VFSS – Abnormal PSM • Higher mean PCR (.001) – Indicator for weak pharyngeal contractions Secretions • Characterize the appearance of oropharyngeal secretions as they become visible upon entry into the hypopharynx according to the Secretion severity rating scale. Secretions Contributing factors for accumulation of secretions : – reduction in the frequency of swallowing – reduction in the amplitude of the pharyngeal swallow – combination of reduced frequency and weakness. • Highly predictive of aspiration of food and liquid later in the examination Secretion Severity Rating Scale 0 Normal rating 1 Secretions outside the laryngeal vestibule that are cleared with spontaneous swallows 2 Deeply pooled secretions or any transition between 1 and 3 3 Secretions in the laryngeal vestibule that are not cleared Significance of Accumulated Secretions • Murray J, Langmore S, Ginsberg G, Dostie A. The significance of accumulated oropharyngeal secretions and swallowing frequency in predicting aspiration. Dysphagia 11:99-103 (1996). • Subjects – 47 elderly hospitalized patients – 17 normal nonhospitalized elderly subjects – 5 younger normal subjects Murray et al. 1996 • Methods – Flexible endoscope passed to HP – Observations for 2-5 minutes while assessing anatomy, airway protection (hold breath, phonate, etc.) – before delivery of any food, liquid – Also, noted frequency of spontaneous swallowing Secretion Severity Rating Scale Murray et al. 1996 • Results Hospitalized elderly Normal elderly Normal young Rating Aspiration 0-3 0,1 0,1 47% none none Murray et al. 1996 Hospitalized Subjects’ Secretions Ratings and Subsequent Aspiration of Food/ Liquid Rating of secretions 0 1 2 3 No. of subjects 14 15 5 13 Aspirated 3 (21%) 8 (53%) 5 (100%) 13 (100%) Secretions (cont.) • Link D, Willging J, Miller C, Cotton R, Rudolph C. Pediatric Laryngoscopic Sensory Testing during Flexible Endoscopic Evaluation of Swallowing: Feasible and Correlative Ann Otl Rhinol Laryngol 109: 899-905, 2000 • Performed Laryngopharyngeal sensory Testing (LPST) for 100 pediatric patients Secretions (cont.) • Presence of pooled secretions in children with a feeding or swallowing disorder – Predisposes laryngeal penetration and aspiration during feeding. • Pooled secretions correlated with a history of pneumonia • Significant difference in the amount of pooled secretions – corresponds to an incremental increase in the LPST. Secretions (cont) Secretions/LAR - Statistical Correlation Finding Laryngeal Penetration Aspiration Pneumonia Neurologic Disorder Secretions <.0001 <.0001 <.0001 <.002 Absent LAR <.0001 <.0001 <.004 <.0001 p-values Secretions (cont.) • Secretions in the vestibule should be an immediate visual marker for potential poor performance during the examination. • Link et al. (2000) Suggest this is a marker for poor outcome (pneumonia). • Proceed cautiously: – 1cc ice chips first be presented in lieu of food or liquid. Donzelli,J.Brady, S. Wesling, M. Craney, M. (2003) Predictive Value of Accumulated Oropharyngeal Secretions for Aspiration During Video Nasal Endoscopic Evaluation of the Swallow Ann Otol Rhinol Laryngol 112 469-475 • Replication of Murray et al. (1996) • 5-point scale Donzelli et al. 2003 • Secretions in vestibule • Correlated highly to aspiration – Spearman’s =.516 p<.0001 • Correlated to diet recommendations – Spearman’s= .720 p<.0001 • Patient’s with trach tubes more likely to score high on scale – Spearman’s=.446 p<.0001 Ota, K., Saitoh, E., Baba, M., Sonoda, S. (2011 in press) The Secretion Severity Rating Scale: A Potentially Useful Tool for Management of Acute-Phase Fasting Stroke Patients Journal of Stroke and Cerebrovascular Diseases doi: 10.1016/j.jstrokecerebrovasdis.2009.11.015 • Replication of Murray et al. 1996 • Higher secretions severity scores – More severe swallow dysfunction • Scores of 2-3 on scale – Significantly more likely to acquire pneumonia • Conclusions: – Scale can be useful risk-management tool for predicting aspiration and pneumonia Swallow Frequency • Dry swallows are identified by looking for events of “white out,” or screen obliterations. • Count the number of dry swallows observed during the first few minutes after the placement of the endoscope and before the offering of food or liquid. Swallow Frequency (cont.) • Swallowing Frequency • waking hours 0.612 swallows/minute • during sleep 0.088 swallows/minute – (Lear, Flanagan, & Moorrees, 1965). • The urge to swallow is related generally to the accumulation of secretions in the pharynx. Secretion severity rating scale (cont.) Frequency of spontaneous swallowing Swallows/min Hospitalized elderly 0.89 Normal elderly 2.82 Normal young 2.96 * p < 0.001 Secretion severity rating scale (cont.) Hospitalized Subjects’ Aspiration Status and Swallowing Frequency Swallowing frequency * p = 0.047 Aspirated Did not aspirate 0.72 1.16 Assessing Cough • Voluntary Cough – Initiated and mediated by cortex • Spontaneous/reflexive cough – Reflexive Brainstem Response Sensation • Subjective • Observation Section – Observe the patient’s management of secretions • Following presentation of food and liquid: – Observe patient’s management of residuals • Are there attempts to clear? • Quiz patient re. perception of residuals Sensation (cont.) • Objective Judgement • FEEST (Aviv, Martin, Keen, Debell, & Blitzer, 1993). • Calibrated air puffs are delivered through an instrument channel built into the shaft of the endoscope. • Psychophysical or reflexive response to air puff • Psychophysical response measures sensation • LAR monitoring is sensitive to reflex response • Clinical value – Post irradiation – Post surgical Presentation of Food and Liquid • Maximum Amount/Food Presentation Guidelines • Note size of bolus – in cc’s or functional units • (spoonfuls etc) • Largest bolus presented Penetration-Aspiration • Score the events associated with penetration or aspiration according to the 8-point scale developed by Rosenbek et al. (1996) (Table 4-8). • The traditional description of penetration and aspiration is used when employing this scale • Penetration- The passage of material into the laryngeal inlet without passing below the level of the true vocal folds. • Aspiration- The passage of material below the level of the true vocal folds 8-Point Penetration-Aspiration Scale Score 1 2 3 4 Description of Events Material does not enter the airway Material enters the airway, remains above the vocal folds, and is ejected from the airway Material enters the airway, remains above the vocal folds, and is not ejected from the airway Material enters the airway, contacts the vocal folds,and is ejected from the airway 8-Point Penetration-Aspiration Scale Score Description of Events 5 Material enters the airway, contacts the vocal folds, and is not ejected from the airway 6 Material enters the airway, passes below the vocal folds, and is ejected into the larynx or out of the airway 7 Material enters the airway, passes below the vocal folds, and is not ejected from the trachea despite effort 8 Material enters the airway, passes below the vocal folds, and no effort is made to eject Source: Rosenbek JC, Robbins J, Roecker EV, Coyle JL, Woods JL. A penetrationAspiration Scale. Dysphagia.11:93-98, 1996. Kelly, A., Drinnan, M., Leslie, P., (2007) Assessing Penetration and Aspiration; How do Videofluoroscopy and Fiberoptic Endoscopic Evaluation of Swallowing Compare? Laryngoscope, 117:1723-1727 • • • • • Prospective, Single Blinded 15 Simultaneous VFSS and FEES 15 Independent Raters used PAS PAS scores higher for FEES (<.001) Mean difference between FEES and VFSS - 1.15 points - Penetration and aspiration percieved to be more severe with FEES Kelly et al. (2007) • Inter-rater Reliability – VFSS 0.67 – FEES 0.63 • Intra-rater Reliability – VFSS 0.79 – FEES 0.73 Kelly et al. (2007) • Clinicians perceived greater severity when scoring FEES than VFSS • Mean Penetration/Aspiration Score – Scale scores from FEES 1 point higher than mean score for VFSS Examination VFSS FEES Mean PAS 2.47 3.61 ANOVA F=296, P < .01 Kelly et al. (2007) • Conclusions – Rater’s judgmeent of the severity of the penetration or aspiration is affected by the type of examination performed – Raters consistently scored FEES higher on the PAS scale than VFSS – Serious implications for the interchangeable use of these examinations in clinical practice Gerek, M., Atalay, A., Cekin, F., Ciyiltepe, M., Ozkaptan, Y., (2005) The effectiveness of fiberoptic endoscopic swallow study and modified barium swallow study techniques in diagnosis of dysphagia Kulak Burun Bogaz Ihtis Derg. 2005 Nov-Dec;15(5-6):103-111 • 80 patients with dysphagia – 27 cancer – 26 neurogenic – 27 idiopathic • Advantages – FEES • detection of aspiration – MBS • dynamic evaluation of the oral and esophageal phases Wu, C-H, Hsiao, T-Y, Chen, J-C, Chang, Y-C & Lee, S-Y. “Evaluation of swallowing safety with fiberoptic endoscope: Comparison with videofluoroscopic technique.” Laryngoscope, Vol. 107, 1997, pp. 396-401. • Compared FEES & VFSS in 28 patients • 14.4% disagreement – Penetration – Aspiration • Fees identified aspiration and penetration • MBS did not Butler, S., Stuart, A., Markley, L., Reese, C. (2009) Penetration and Aspiration in Healthy Older Adults as Assessed During Endoscopic Evalution of Swallowing. Annals of Otology, Rhinology & Laryngology, 118(3):190-198 • 20 healthy adults – Mean 78.9 years – 28 swallows • 560 swallows for analysis • Penetration – 75% of subjects • Total=82 events (15%) • Aspiration – 30% of subjects • 18 events (3%) STABILITY OF ASPIRATION STATUS IN HEALTHY OLDER ADULTS Butler, Susan, Todd T, Stuart A, Lintzenich C DRS Toronto 2012 • 18 health adult subjects – 9 aspirators – 9 non-aspirators • Repeat FEES 12 months after initial exam – No change in aspiration status – No difference in pneumonia frequency • Microaspiration may be a normal and stable feature of swallow function in healthy adults Kim, YJ., Koh, ES., Kim. HR., et al. The Diagnostic Usefulness of the Fiberoptic Endoscopic Evaluation of Swallowing J Korean Acad Rehab Med 2011; 35: 14-22 • 69 Subjects – Simultaneous VFSS and FEES – Blinded – Modified PAS Scale • Significantly greater detection of aspiration using FEES Lexicon for Latency – Delayed swallow reflex • (Lazarus & Logemann 1986; Veis & Logemann, 1985) – Delayed pharyngeal response • (Robbins & Levine, 1988) – Pharyngeal delay • (Langmore et al. 1998; Lazarus, Logemann, Rademaker, Kahrilas, Pajak, Lazar, & Halper, 1993). – Duration of stage transition • (Lof & Robbins, 1990; Robbins, Hamilton, Lof, & Kempster, 1992; Rosenbek, Roecker, Wood, & Robbins, 1996; Rosenbek et al., 1998) and Duration of Stage Transition • Time elapsed between – Moment of termination of the oral stage – Moment of onset for the pharyngeal stage of the swallow. Duration of Stage Transition • Arrival of the bolus into the pharyngeal cavity before pharyngeal stage initiation. • Conventional wisdom: – Early arrival indicative of a “delay”! Fluoroscopic Markers for Duration of Stage Transition • Starting point – The moment the bolus head passes the ramus of the mandible. • End Point – The initiation of maximal excursion of the hyoid. Endoscopic Markers for Duration of Stage Transition • Starting point –Bolus head appears at the base of the tongue just superior to the vallecular space • End Point –The initiation of “white out”. STD as a Measure • Concept of a “delayed” swallow is unformed • “Delayed Swallow” is a real problem – Onset of the swallow or the release of the bolus is not coordinated in a safe way (Leonard & McKenzie, 2006). Kern, M., Jaradeh, S., Arnforfer, R.C., & Shaker, R. (2001). Cerebral cortical representation of reflexive and volitional swallowing in humans. Am J Physiol Gastrointest Liver Physiol. 280; G354-G360. • Compared cerebral cortical representation of experimentally induced reflexive swallowing with volitional swallow using fMRI • Reflexive swallowing – Bilateral activity concentrated to the primary sensory/motor regions • Volitional swallowing – Bilateral in the insula and the prefrontal, anterior cingulate and parietooccipital regions in addition to the primary sensory/motor cortex Kern et al. 2001 • Shared areas: – Primary sensory/motor cortex at or near the central gyrus – Significant variability in the volume of activated voxels in each of the four cortical regions of interest for both volitional and reflexive swallowing Daniels, S.K., Schroeder, M.A., DeGeorge, P.C., Corey, D.M., and Rosebek, J.C. (2007). Effect of verbal cue on bolus flow during swallowing. American Journal of Speech-Language Pathology, 16; 140-147. • 12 healthy adults – 6 men – 6 women – Mean age = 68.83 +/- 7.71 years Daniels et al. 2007 • VFSS with cue and no cue – 5 ml thin liquid from cup – 2 trials each • Measurements • Slow motion frame by frame • Duration and scores were averaged across the two trials – – – – – OTT=oral transit time STD=stage transit duration PTT=pharyngeal transit time TSD=total swallow duration Penetration aspiration scale Daniels et al. 2007 • Cued swallow: – Onset of max hyoid movement occurred with the leading bolus edge superior or adjacent to the ramus • Noncued: – Onset of max hyoid movement occurred with the leading bolus edge level with or inferior to the valleculae Butler, S. G., Maslan, J., Stuart, A., Leng, X., Wilhelm, E., Lintzenich, C. R., Williamson, J. and Kritchevsky, S. B. (2011), Factors influencing bolus dwell times in healthy older adults assessed endoscopically. The Laryngoscope, 121: 2526–2534. doi: 10.1002/lary.22372 • Once handed a cup – should swallow all liquid in one swallow when ready • could take more than one swallow if needed. • Bolus dwell time – first frame of bolus head approximation to the vallecula and/or the pyriform sinus(es) until the first frame of completely obscured image Butler 2011 Bolus Dwell Time • Bolus dwell time – first frame of bolus head approximation to the vallecula and/or the pyriform sinus(es) until the first frame of completely obscured image Butler 2011 Bolus Dwell Time • Age and aspiration – 70’s 4/18 – 80’s 8/26 – 90’s 11/32 • no significant relationship between aspiration and bolus dwell time Butler 2011 valleculae dwell time • longest bolus dwell times at the vallecula – straw delivery – small bolus volumes – advanced age • straw delivery was two times more likely than cup delivery to have a greater than zero dwell time (P < .0001). • The effects of liquid type, gender, and aspiration status were not significant (P > .05). Butler 2011 pyriform dwell time • • • • straw delivery small bolus volumes advanced age The effects of liquid type, gender, and aspiration status were not significant (P > .05). Residue • Definition –Retention of material in the pharynx following the pharyngeal swallow. –Retention develops when the driving and clearance forces become deficient Number of swallows • Count events of white-out • Greater than three times per bolus of food or liquid – Inefficient/weak swallow • Number of different causes • Cite Palmer and Leslie Efficiency/ Number of Swallows (cont.) • Number of swallows – Establish a baseline for performance – Can be used to compare performance after intervention or spontaneous recovery. Dziewas R,Warnecke T, Ritter M,Dittrich R, Schilling M, Schäbitz WR, Ringelstein EB,Nabavi DG (2006) Fatigable Swallowing in Myasthenia Gravis – Proposal of a Standardized Test and Report of a Case. J Clin Neuromusc Dis 8:12–15 • Attempt to quantify and monitor fatigue during mealtime in myasthenia gravis patients • Patients were given up to 30 consecutive pieces of bread (3cmx3cmx0.5 cm) • If > 50% of bolus is retained the procedure was stopped • The number of successfully swallowed bread pieces at that point (1 to 30) quantified the degree of fatigable swallowing Warnecke, T. Teismann, I. Zimmermann, J. Oelenberg, S. Ringelstein, E. B. Dziewas, R.J Fiberoptic endoscopic evaluation of swallowing with simultaneous tensilon application in diagnosis and therapy of myasthenia gravisNeurology (2008) 255:224–230 • Case series – Subjects: Four severely affected patients with dysphagia as their leading symptom were examined – Monitored for normalization or improvement of swallowing function shortly after Tensilon administration – Results • Three/four FEES-Tensilon Test positive for MG-related dysphagia. • FEES-Tensilon Test was useful in the differentiation between myasthenic and cholinergic crisis and in guiding treatment decisions. – Conclusion The FEES-Tensilon Test is a suitable tool in the diagnosis and therapy of myasthenia gravis with pharyngeal muscles weakness. Calibration VFSS/FEES • Kelly A.M., Leslie P., Beale T., Payten C., Drinnan M.J. (2006) Fibreoptic endoscopic evaluation of swallowing and videofluoroscopy: does examination type influence perception of pharyngeal residue severity? Clinical Otolaryngology 31 (5), 425–432. Residue Detection (Kelly, 2006) • Prospective, single-blind assessment • Simultaneous videofluoroscopy and FEES recordings • Raters blinded – pairing of the videofluoroscopy and FEES – other raters' scores • 15 Patients • Simultaneous VFSS and FEES Residue Detection (Kelly, 2006) • Pharyngeal residue rated as: – None – Coating – Mild – Moderate – Severe Residue Detection (Kelly, 2006) • Studies scored twice by all raters • Intra- and inter-rater agreement were similar for both examinations • There were significant differences between FEES and videofluoroscopy pharyngeal residue severity scores (, P < 0.001) • FEES residue scores were consistently higher than videofluoroscopy residue scores. Residue Detection (Kelly, 2006) • Pharyngeal residue ratings consistently greater from FEES than from videofluoroscopy • These findings have significant clinical implications • Further research is required to examine the impact of FEES and videofluoroscopy examinations on treatment decisions Interventions Direct Interventions (Risk reduction) • • • • Presentation of food Positioning Maneuvers Diet Modifications Chin Tuck • Direct Intervention – Involves swallowing something • Compensation – Transiently improves physiology of the swallow • Behavioral Intervention – Requires active participation from patient Chin Tuck Benefits –Conventional wisdom • Opened vallecular space • Variable effect (Shanahan et al. 1993) –Subsequent research • Shifts laryngeal and pharyngeal anatomy posteriorly. –Reduces A/P dimensions of pharynx Chin Tuck Benefits • Narrows airway entrance • Pushes tongue base towards posterior pharyngeal wall • Positions bolus (ideally) in more anterior position prior to initiation of swallow Chin Tuck • Pre-swallow segment observations: – Depth of bolus travel is altered in a way that makes the swallow safer. • Post-swallow segment observations: – Discern the presence or absence of residuals in the pharynx Videotaped Examples • Key Visualization –Earlier initiation of the pharyngeal swallow relative to bolus position in oropharynx Head Rotation • Utilized in individuals with unilateral pharyngeal weakness – Logemann, Kahrilas, Kobara, & Vakil, 1989; Logemann et al., 1994 • Closes off the weaker side of the pharynx • Enhance the opening of the upper esophageal sphincter with a resultant decrease in pharyngeal retention. Head Rotation – Pre-swallow segment observations: • Changes to the configuration of the pharynx • Changes in bolus flow – Post-swallow segment observations: • discern the presence or absence of residuals in the pharynx Super Supraglottic Maneuver • Designed to minimize aspiration by producing volitional airway protection before, during and after the swallow (Ohmae et al. 1996). • Instruction: – – – – Tightly hold breath before the swallow Bear down Continue to hold their breath into the swallow Cough at the completion of the swallow. Super Supraglottic Maneuver • Single maneuver can benefit the patient in a number of ways. • Effectively prevents the aspiration of: – penetrated material before the swallow – aspiration during the swallow – aspiration of penetrated material after the swallow. Super Supraglottic maneuver • Produces earlier cricopharyngeal opening • Prolongs the pharyngeal swallow • Changes the extent of vertical laryngeal position before the swallow • All of which promote the transit of the bolus through the UES. Super-Supraglottic Maneuver • Pre-swallow segment observations: – The clinician will be able to visualize the adequacy of airway closure Super-Supraglottic Maneuver • Post-swallow segment observations: – Discern the presence or absence of penetration or aspiration in the subglottis – Discern if cough effectively cleared airway