Transcript No Slide Title

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
•
•
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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
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–
–
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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
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–
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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
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•
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
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•
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
•
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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
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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.
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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
•
•
•
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•
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