The use of FEES and MBS studies in head and neck cancer patients

Abstract

Introduction References Conclusions THE USE OF FEES AND MBS STUDIES IN HEAD AND NECK CANCER PATIENTS Susan Langmore PhD, CCC-SLP, BRS-S and Mary Zoccoli M.D. Boston University Medical Center The Modified Barium Swallow test (MBS) and Flexible Endoscopic Evaluation of Swallowing (FEES) are considered to be the most comprehensive tests used to evaluate and manage patients with dysphagia. OBJECTIVES: The purpose of this study is to make extensive use of recorded studies to illustrate the use of both tools and determine the respective advantages of each procedure in assessing and guiding management of dysphagia in head and neck cancer patients. STUDY DESIGN: A retrospective cohort and case series; expert opinion. METHODS: A retrospective review of 107 video recorded studies and written reports over the past year was undertaken where fluoroscopy (MBS) and endoscopy (FEES) were utilized to evaluate and treat patients with dysphagia. Indications for each examination were noted, findings were summarized and the tool that provided the definitive dysphagia diagnosis was tabulated. Indications, unique findings, strengths and weaknesses, and situations for best use of each procedure were summarized. RESULTS: Guidelines for choosing one or the other tool were able to be developed (Table 1). CONCLUSIONS: Both exams provide important diagnostic and complimentary information for swallowing assessment and management of head and neck cancer patients. The overall objective of this retrospective analysis of MBS studies and FEES procedures was to provide an initial determination of the role which FEES and MBS play in evaluating and guiding management of dysphagia in head and neck cancer patients In head and neck cancer patients, dysphagia may be secondary to surgical ablation of essential structures or to radiation and chemotherapy, leading to altered anatomy and reduction of structural mobility. Definitive diagnostic and treatment protocols for swallow function in the HNC population remain to be determined (3). Because of this disparity amongst the literature, comparison of diagnostic and management potential of each test is of great interest. Findings Fluoroscopy Endoscopy 1. Anatomic deviations • Submucosal abnormalities visualized (bone, cartilage) • Inadequate bulk of tongue to contact surrounding structures • Edema, erythema • Altered anatomy post surgery • Changes post radiation • Configuration of entire HP • OP or HP webs • Altered or tethered structures 2. Movement of structures; sensation • Reduced hyolaryngeal elevation , • Reduced base of tongue contact to posterior pharyngeal wall • Reduced UES opening; usually due to stricture • Epiglottic inversion • Oral manipulation of the bolus • Reduced VC mobility; arytenoid movement; • Incomplete glottic closure for volitional breath hold • Sensory awareness of residue, penetration, aspiration 3. Visualizing the bolus • Piecemeal oral handling of the bolus • Bolus directly viewed during the swallow • Aspiration into posterior commisure • Percent of bolus aspirated • Effectiveness of cough to clear aspiration • Percent of bolus cleared to the esophagus • Localize path of bolus spillage within the HP • Bolus location within HP and larynx: amount of residue • Detect small amount of laryngeal penetration and aspiration • Visualization of secretions Results Table 1: Indications for MBS and FEES and unique findings of each tool Guidelines for choosing one or the other tool were able to be developed. As depicted in Table 1, we found fluoroscopy to better identify restricted movement of some structures, such as reduced upper esophageal sphincter opening, laryngeal elevation, base of tongue contact to the posterior pharyngeal wall, epiglottic inversion and visualization/estimation of the percent of the bolus Endoscopy proved better for visualizing anatomical surface abnormalities, postradiation changes, and appreciation of the entire configuration of the hypopharynx. FEES also provided superior assessment of vocal fold mobility and arytenoid movement and proved more sensitive for detecting laryngeal penetration and aspiration, bolus location within the HP, and secretions. Treatment strategies (as depicted in Table 2) utilizing compensatory techniques (such as postural changes or altering the bolus), were better assessed by endoscopy due to the ability to apply biofeedback and an unrestricted amount of time for evaluation. Endoscopy also proved better for assessing the need for and results of laryngeal surgery since only laryngoscopy can visualize the vocal folds directly. MBS and FEES were generally equally effective in assessing the subsequent benefit of swallowing exercises. 1. Aviv JE. Prospective, randomized outcome study of endoscopy versus modified barium swallow in patients with dysphagia. The Laryngoscope 2000; 110: 563-574. 2. Gaziano JE. Evaluation and management of oropharyngeal dysphagia in head and neck cancer. Cancer Control 2002; 9(5): 400-409. 3. Carrau Ricardo L, Murry Thomas. Evaluation and management of adult dysphagia and aspiration. Current opinion in otolaryngology and head and neck surgery 2000; 8(6): 489-496. 4. Langmore SE. Evaluation of oropharyngeal dysphagia: Which diagnostic tool is superior? Curr Opin Otolaryng;, 11:485-489, 2003. Discussion MBS and FEES are both comprehensive diagnostic studies of swallowing and provide the clinician with detailed information regarding the swallow. Patients with head and neck cancer, more than any other group, benefit from the combined use of these two examinations. There were multiple instances where one exam yielded critical findings not visualized by the other exam. The authors concluded that the two examinations complement each other and when used together, give the clinician a superior advantage for best evaluation and management of patients with dysphagia. Dysphagia is a common symptom of head and neck cancer or sequelae of its management, and can profoundly affect post-treatment recovery as it may contribute to aspiration pneumonia, dehydration, malnutrition, poor wound healing and reduced tolerance to medical treatments (2) Both MBS and FEES provide objective information about the structure and function of the swallowing mechanism; however, the efficacy of dysphagia testing remains controversial (2, 3). The most widely used assessment of swallowing is the videofluoroscopic (Modified Barium Swallow) examination. Benefits include the ability to view the complex interaction of the phases of swallowing and dynamics of the swallow and to assess the benefit of many treatment strategies during the study (2). However, fiberoptic endoscopic evaluation of swallowing (FEES) is also an excellent tool for providing excellent visualization of the tumor, postsurgical or postradiation anatomical changes, and as a biofeedback tool to retrain swallowing function (4). FEES also allows assessment of velopharyngeal function and permits inspection of secretion management. There are very few studies in the literature on dysphagia outcomes that evaluate one diagnostic test over another (1). This study found each tool to be valuable. Rather than choose one or the other tool, we found that both tools are valuable and each has its unique strengths. Intervention Fluoroscopy Endoscopy