Fiberoptic Endoscopic Evaluation Of Swallowing Research Articles

Comparing Simultaneous Clinical Swallow Evaluations and Fiberoptic Endoscopic Evaluations of Swallowing: Changing Practice Patterns

Purpose The purpose of this study was to investigate if clinicians are using evidence from the literature to guide clinical practice when assessing pharyngeal phase swallowing function. Method Blin...

Voice and swallowing outcomes following reoperative anterior cervical discectomy and fusion with a 2-team surgical approach.

OBJECTIVE Dysphagia and vocal cord palsy (VCP) are common complications after anterior cervical discectomy and fusion (ACDF). The reported incidence rates for dysphagia and VCP are variable. When videolaryngostroboscopy (VLS) is performed to assess vocal cord function after ACDF procedures, the incidence of VCP is reported to be as high as 22%. The incidence of dysphagia ranges widely, with estimates up to 71%. However, to the authors' knowledge, there are no prospective studies that demonstrate the rates of VCP and dysphagia for reoperative ACDF. This study aimed to investigate the incidence of voice and swallowing disturbances before and after reoperative ACDF using a 2-team operative approach with comprehensive pre- and postoperative assessment of swallowing, direct vocal cord visualization, and clinical neurosurgical outcomes. METHODS A convenience sample of sequential patients who were identified as requiring reoperative ACDF by the senior spinal neurosurgeon at the University of Alabama at Birmingham were enrolled in a prospective, nonrandomized study during the period from May 2010 until July 2014. Sixty-seven patients undergoing revision ACDF were enrolled using a 2-team approach with neurosurgery and otolaryngology. Dysphagia was assessed both preoperatively and postoperatively using the MD Anderson Dysphagia Inventory (MDADI) and fiberoptic endoscopic evaluation of swallowing (FEES), whereas VCP was assessed using direct visualization with VLS. RESULTS Five patients (7.5%) developed a new postoperative temporary VCP after reoperative ACDF. All of these cases resolved by 2 months postoperatively. There were no new instances of permanent VCP. Twenty-five patients had a new swallowing disturbance detected on FEES compared with their baseline assessment, with most being mild and requiring no intervention. Nearly 60% of patients showed a decrease in their postoperative MDADI scores, particularly within the physical subset. CONCLUSIONS A 2-team approach to reoperative ACDF was safe and effective, with no new cases of VCP on postoperative VLS. Dysphagia rates as assessed through the MDADI scale and FEES were consistent with other published reports.

Continuum theory: presbyphagia to dysphagia? Functional assessment of swallowing in the elderly.

To investigate whether disclosed symptoms (coughing, choking and throat clearing) can be used as early predictors of swallowing disorders in non-hospitalized elderly population. In addition, to determine the presence of early findings of swallowing disorders through fiber optic endoscopic evaluation of swallowing (FEES). One hundred subjects older than 60years were recruited from local community social meetings for seniors, they fulfilled inclusion criteria, and were given an oral interview and underwent FEES, with findings classified as: (1) saliva stasis; (2) pharyngeal residue; (3) penetration; (4) aspiration; (5) laryngeal sensitivity. Twenty-one percent of subjects declared previous choking, 10% coughing, and 7% throat clearing, 39% had pharyngeal residue; 6% saliva stasis; 9% penetration; 2% aspiration; and 92% laryngeal sensitivity present. Thirty-three percent showed pharyngeal residue without saliva stasis, while only 6% showed positivity for both (p = 0.003). Our data suggest that health care professionals should be aware that among an apparently healthy population, some subjects may have swallowing disorders without clinical complaints and that a nasolaryngoscopy exam may not be enough to predict dysphagia. We suggest that FEES should be performed to look for surrogate of dysphagia such as pharyngeal residue, laryngeal penetration, and aspiration.

Pharyngolaryngeal Sensory Deficits in Patients with Middle Cerebral Artery Infarction: Lateralization and Relation to Overall Dysphagia Severity

Background: Dysphagia is a frequent and dangerous complication of acute stroke. Apart from a well-timed oropharyngeal muscular contraction pattern, sensory feedback is of utmost importance for safe and efficient swallowing. In the present study, we therefore analyzed the relation between pharyngolaryngeal sensory deficits and post-stroke dysphagia (PSD) severity in a cohort of acute stroke patients with middle cerebral artery (MCA) infarction. Methods: Eighty-four first-ever MCA stroke patients (41 left, 43 right) were included in this trial. In all patients, fiberoptic endoscopic evaluation of swallowing (FEES) was performed according to a standardized protocol within 96 h after stroke onset. PSD was classified according to the 6-point fiberoptic endoscopic dysphagia severity scale. Pharyngolaryngeal sensation was semi-quantitatively evaluated by a FEES-based touch technique. Results: PSD severity was closely related to the pharyngolaryngeal sensory deficit. With regards to lateralization of the sensory deficit, there was a slight but significant preponderance of sensory loss contralateral to the side of stroke. Apart from that, right hemispheric stroke patients were found to present with a more severe PSD. Conclusions: This study provides evidence that an intact sensory feedback is of utmost importance to perform nonimpaired swallowing and highlights the key role of disturbed pharyngeal and laryngeal afferents in the pathophysiology of PSD.

Characteristics of Dysphagia in Infants with Microcephaly Caused by Congenital Zika Virus Infection, Brazil, 2015.

We summarize the characteristics of dysphagia in 9 infants in Brazil with microcephaly caused by congenital Zika virus infection. The Schedule for Oral Motor Assessment, fiberoptic endoscopic evaluation of swallowing, and the videofluoroscopic swallowing study were used as noninstrumental and instrumental assessments. All infants had a degree of neurologic damage and showed abnormalities in the oral phase. Of the 9 infants, 8 lacked oral and upper respiratory tract sensitivity, leading to delays in initiation of the pharyngeal phase of swallowing. Those delays, combined with marked oral dysfunction, increased the risk for aspiration of food, particularly liquid foods. Dysphagia resulting from congenital Zika virus syndrome microcephaly can develop in infants >3 months of age and is severe.

The Eating Assessment Tool-10 Predicts Aspiration in Adults with Stable Chronic Obstructive Pulmonary Disease.

Adults with COPD frequently present with dysphagia, which often leads to clinical complications and hospital admissions. This study investigates the ability of the Eating Assessment Tool (EAT-10) to predict aspiration during objective dysphagia evaluation in adults with stable COPD. Thirty adults (20 male, 10 female; mean age=69.07±16.82) with stable COPD attended an outpatient dysphagia clinic for a fiberoptic endoscopic evaluation of swallowing (FEES) in an acute teaching hospital (January 2015-November 2016). During evaluations, individuals completed an EAT-10 rating scale followed immediately by a standardised FEES exam. Aspiration status during FEES was rated using the penetration-aspiration scale by clinicians blinded to EAT-10 scores. Data were retrospectively analysed. Significant differences in mean EAT-10 scores were found between aspirators (16.3; SEM=2.165) and non-aspirators (7.3; SEM=1.009) (p=0.000). The EAT-10 predicted aspiration with a high level of accuracy (AUC=0.88). An EAT-10 cut-off value of >9 presented a sensitivity of 91.67, specificity of 77.78 with positive and negative likelihood ratios of 4.12 and 0.11, respectively. Positive and negative predictive values were 73.30 and 93.30, respectively. Diagnostic odds ratio was 38.50 (p<0.01, CI3.75-395.42). EAT-10 is a quick, easy to administer tool, which can accurately predict the presence of aspiration in adults with COPD. The scale can also very accurately exclude the absence of aspiration, helping clinicians to determine the need for onward referral for a comprehensive dysphagia evaluation. This may ultimately reduce clinical complications and hospital admissions resulting from dysphagia in this clinical population.

Postoperative Swallowing Assessment After Lung Transplantation

Dysphagia, aspiration, and potential pneumonia represent a major source of morbidity in patients undergoing lung transplantation. Conditions that potentiate dysphagia and aspiration include frailty and prolonged intubation. Our group of speech-language pathologists has been actively involved in performance of a bedside evaluation of swallowing, and instrumental evaluation of swallowing with modified barium swallow, and postoperative management in patients undergoing lung transplantation. All lung transplant patients from April 2009 to September 2012 were evaluated retrospectively. A clinical bedside examination was performed by the speech-language pathology team, followed by a modified barium swallow or fiberoptic endoscopic evaluation of swallowing. A total of 321 patients were referred for evaluation. Twenty-four patients were unable to complete the evaluation. Clinical signs of aspiration were apparent in 160 patients (54%). Deep laryngeal penetration or aspiration were identified in 198 (67%) patients during instrumental testing. A group of 81 patients (27%) had an entirely normal clinical examination, but were found to have either deep penetration or aspiration. The majority of patients aspirate after lung transplantation. Clinical bedside examination is not sensitive enough and will fail to identify patients with silent aspiration. A standard of practice following lung transplantation has been established that helpsavoid postoperative aspiration associated with complications.

Dysphagia in Amyotrophic Lateral Sclerosis: Impact on Patient Behavior, Diet Adaptation, and Riluzole Management.

This retrospective study aimed to investigate the clinical features associated with deteriorated swallow in amyotrophic lateral sclerosis (ALS) patients with spinal and bulbar onset, describe the modification of diet and liquid intake, and assess the impact of dysphagia on the use of riluzole. One hundred forty-five patients were observed periodically every 3–6 months. They underwent routinely fiberoptic endoscopic evaluation of swallowing (FEES) and spirometry; dysphagia severity was classified according to the Penetration Aspiration Scale and the Pooling score (P-score) integrated with other parameters such as sensation, collaboration, and age (P-SCA score). During a mean follow-up period of about 2 years, the percentage of ALS patients suffering from dysphagia increased to 85 (rising from 35 to 73% in patients with spinal onset and from 95 to 98% in those with bulbar onset). Also, 8% of patients with dysphagia by FEES did not perceive the disorder. The frequency of normal and semi-solid diets decreased over time, while that of pureed diets and percutaneous endoscopic gastrostomy (PEG) prescription increased. Forty-four percent of dysphagic patients refused thickeners or PEG. A significant difference was observed in the mortality rate between patients untreated with riluzole and patients treated with riluzole oral suspension (p < 0.05). Disease duration mainly impacted on the frequency of dysphagia in spinal onset patients, appearing very early in those with bulbar onset. Riluzole oral suspension would allow the safe administration in dysphagic ALS patients to avoid tablet crushing and consequent dispersion in food, common practices that are inconsistent with the safe and effective use of the drug.

Murray secretion scale and fiberoptic endoscopic evaluation of swallowing in predicting aspiration in dysphagic patients.

The objective of this retrospective review is to evaluate the ability of the Murray secretion scale to predict aspiration as determined by fiberoptic endoscopic evaluation of swallowing. Patients with dysphagia undergoing a fiberoptic endoscopic evaluation of swallowing study between January 2013 and November 2015 from a single, tertiary care institution were retrospectively reviewed. The Murray secretion scale and penetration aspiration scale on fiberoptic endoscopic evaluation of swallowing examination were determined. Spearman's correlation analysis, sensitivity, specificity, predictive values, and relative risk evaluating the relationship between the Murray secretion scale and aspiration on fiberoptic endoscopic evaluation of swallowing were calculated. Subgroups of head and neck cancer patients, penetration group, and aspiration group were also analyzed. The mean age of the cases (N = 212) was 62.4years. Eighty percent were male. There was a strong correlation between Murray secretion scale grade and penetration aspiration scale score (r = 0.785, p < 0.001). The sensitivity and specificity of a Murray secretion scale grade 2 or higher in predicting aspiration were 74 and 90%, respectively. Individuals with a Murray secretion scale grade of 2 or higher were 13.6 times more likely to aspirate than patients with a lower Murray secretion scale grade. All subgroups showed similar trend. Determination of a Murray secretion scale grade, determined by flexible nasopharyngoscopy, may predict patients at high risk for aspiration. In clinical scenarios where more complete assessments of aspiration risk are immediately impossible or impractical, the Murray secretion scale grade may add valuable information to assist in clinical decision-making in patients with dysphagia.

Narrow Band Imaging Enhances the Detection Rate of Penetration and Aspiration in FEES.

Narrow band imaging (NBI) is widely used in gastrointestinal, laryngeal, and urological endoscopy. Its original purpose was to visualize vessels and epithelial irregularities. Based on our observation that adding NBI to common white light (WL) improves the contrast of the test bolus in fiberoptic endoscopic evaluation of swallowing (FEES), we now investigated the potential value of NBI in swallowing disorders. 148 FEES images were analyzed from 74 consecutive patients with swallowing disorders, including 74 with and 74 without NBI. All images were evaluated by four dysphagia specialists. Findings were classified according to Rosenbek's penetration-aspiration scale modified for evaluating these FEES images. Intra- and inter-rater reliability was determined as well as observer confidence. A better visualization of the bolus is the main advantage of NBI in FEES. This generally leads to sharper optical contrasts and better detection of small bolus quantities. Accordingly, NBI enhances the detection rate of penetration and aspiration. On average, identification of laryngeal penetration increased from 40 to 73% and of aspiration from 13 to 24% (each p<0.01) of patients. In contrast to WL alone, the use of NBI also markedly increased the inter- and intra-rater reliability (p<0.01) and the rating confidence of all experts (p<0.05). NBI is an easy and cost-effective tool simplifying dysphagia evaluation and shortening FEES evaluation time. It leads to a markedly higher detection rate of pathological findings. The significantly better intra- and inter-rater reliability argues further for a better overall reproducibly of FEES interpretation.

Measurement of Oxygen Desaturation Is Not Useful for the Detection of Aspiration in Dysphagic Stroke Patients

Background: Dysphagia is one of the most dangerous symptoms of acute stroke. Various screening tools have been suggested for the early detection of this condition. In spite of conflicting results, measurement of oxygen saturation (SpO₂) during clinical swallowing assessment is still recommended by different national guidelines as a screening tool with a decline in SpO₂ ≥2% usually being regarded as a marker of aspiration. This paper assesses the sensitivity of SpO₂ measurements for the evaluation of aspiration risk in acute stroke patients. Methods: Fifty acute stroke patients with moderate to severe dysphagia were included in this study. In all patients, fiberoptic endoscopic evaluation of swallowing (FEES) was performed according to a standardised protocol. Blinded to the results of FEES, SpO₂ was monitored simultaneously. The degree of desaturation during/after swallows with aspiration was compared to the degree of desaturation during/after swallows without aspiration in a swallow-to-swallow analysis of each patient. To minimise potential confounders, every patient served as their control. Results: In each subject, a swallow with and a swallow without aspiration were analysed. Overall, aspiration seen in FEES was related to a minor decline in SpO₂ (mean SpO₂ without aspiration 95.54 ± 2.7% vs. mean SpO₂ with aspiration 95.28 ± 2.7%). However, a significant desaturation ≥2% occurred only in 5 patients during/after aspiration. There was no correlation between aspiration/dysphagia severity or the amount of aspirated material and SpO₂ levels. Conclusions: According to this study, measurement of oxygen desaturation is not a suitable screening tool for the detection of aspiration in stroke patients.

Aspiration and dysphagia screening in acute stroke - the Gugging Swallowing Screen revisited.

The Gugging Swallowing Screen (GUSS) is a tool to screen aspiration risk in acute stroke. We aimed to replicate its validity in a larger second cohort of patients with acute stroke, including the more severe with a National Institutes of Health Stroke Scale (NIHSS) ≥ 15. In a prospective, double-blind design, the GUSS was validated with the Fiberoptic Endoscopic Evaluation of Swallowing scale. Patients were categorized into different stroke severities as assessed by the NIHSS, and the diagnostic properties were calculated separately for each subgroup. A total of 100 patients with acute stroke were evaluated consecutively at a mean 1.7 ± 2.2 days after stroke. With the GUSS cut-off value of 14 points, the GUSS screened aspiration risk with a 96.5% sensitivity and 55.8% specificity (area under the curve, 0.76; 95% CI, 0.67-0.84), which corresponded well with the original publication. In the NIHSS < 5 group, the sensitivity and specificity levels were 71.4% and 88.8%, respectively. In the NIHSS ≥ 15 group, these levels changed to 100% and 20%, respectively. The high failure rate in completing the first part of the GUSS in the latter group was related to the low specificity. Diet recommendations following the GUSS were more conservative than those after Fiberoptic Endoscopic Evaluation of Swallowing. In particular, the GUSS overestimated the need for nasogastric tube feeding. This is the first time that a swallowing screening tool for patients with acute stroke has been revalidated in a larger population from another stroke center. The validity of a swallow screening test may vary according to different stroke severities.

Fiberoptic Endoscopic Evaluation of Swallowing as possible index of ALS clinical development

Our purpose was to assess the relationship between the disease severity of Amyotrophic Lateral Sclerosis (ALS) and the main parameters of Fiberoptic Endoscopic Evaluation of Swallowing (FEES), indirectly hypothesizing for FEES a role as clinical indicator of the progression of ALS. We studied 220 patients (101 women, 119 men) with ALS; of these, 148 had spinal and 72 bulbar onset. They were analyzed according to the Amyotrophic Lateral Sclerosis Functioning Rating Scale (ALSFRS) and the b-ALSFRS subscale (bulbar scale). All subjects underwent FEES. Post-swallowing residue was classified into four classes (0-3); premature spillage and aspiration were considered either present or absent. An in-depth statistical analysis revealed a highly significant relationship between the FEES parameters studied and the severity of the disease assessed through ALSFRS and b-ALSFRS (p < 0.0001), no matter what bolus texture was used. Moreover, statistical analysis showed a highly significant association between the classes of severity in bulbar forms and all the FEES parameters, no matter what type of bolus was administered (p <0.0001), whereas a significant correlation in spinal forms only for post-swallowing residue with solid (p= 0.025) and semisolid (p= 0.034) boluses. FEES is a good indicator of the severity of dysphagia and of its progression in patients with ALS, as well as of the clinical progression of the disease.

Abstract 91: An Objective Screening Tool Predicts Surgical Feeding Tube Placement in Acute Ischemic Stroke Patients

Introduction: Dysphagia is a common post-stroke complication, yet there are no standard tools to guide recommendations for placement of percutaneous endoscopic gastrostomy (PEG) tube. Prior prediction models in acute ischemic stroke (AIS) have had inconsistent findings and have not included objective swallowing assessments. We hypothesized that inclusion of an aspiration-based score would simplify the prediction model and be a strong independent predictor of PEG placement among patients referred for instrumental assessment of swallowing (IAS) after failed bedside swallow. Methods: Consecutive cases of AIS were identified from our inpatient registry (6/14- 4/15). Patients transferred to hospice or dying within 3 days of hospitalization were excluded. NIHSS and sub-items, medical history, and demographic data were included in the full model and subgroup analysis which included patients undergoing IAS. Univariate and multiple logistic regression were used to assess predictors of PEG placement. Penetration-Aspiration (PEN-ASP) scores (1-2 normal; 3-5, penetration, 6-8, aspiration) calculated using Fiberoptic Endoscopic Evaluation of Swallowing and Modified Barium Swallow Studies were included in the model for subgroup analysis. Results: Among 731 AIS patients, 17.9% (131) of patients received a PEG and 200 patients received IAS (39.5 % PEG). In the full model, arrival GCS and NIHSS, NIHSS level of consciousness score, and prior Diabetes Mellitus and ICH (p &lt; 0.05). Among patients receiving IAS, arrival NIHSS, PEN-ASP score, and race (Hispanic v White) was associated with PEG placement. Conclusions: This study represents the largest cohort of AIS patients undergoing PEG placement and IAS. We demonstrated that the PEN-ASP score helps to predict PEG placement in AIS. Race also emerged as a predictor, and in future studies, we will examine patient and provider-level factors to explain this association.

Swallowing disorders among patients with diffuse idiopathic skeletal hyperostosis

Conclusion: Diffuse idiopathic skeletal hyperostosis (DISH) is a cause of swallowing disorders in elderly, and otolaryngologists should be aware of the disease on dealing with old patients complaining of dysphagia. The condition may be treated conservatively in most patients; however, surgical reduction of cervical osteophytes may be needed in severe cases.Objective: Large cervical osteophytes may cause dysphagia; they compress the pharynx leading to mechanical impairment of swallowing. DISH is characterized by ossification of the anterior longitudinal spinal ligament with formation of osteophytes. The aim was to investigate swallowing disorders among patients with DISH.Method: The study included 139 patients with DISH. Their swallowing was evaluated using the eating assessment tool (EAT-10), and patients with swallowing disorders were subjected to fiber-optic endoscopic evaluation of swallowing (FEES), they received conservative treatment for 6 months. Patients were assessed again after treatment using the same measures that were employed before treatment.Results: Twenty-three patients (16.5%) demonstrated swallowing disorder, and FEES showed residues of food in the pharynx after swallow in all of them. Significant overall improvement after conservative treatment was achieved, with two patients resuming their normal regular diet. However, one patient demonstrated no improvement, and he needed surgical reduction of his large cervical osteophytes.

Fiberoptic endoscopic evaluation of swallowing in poststroke dysphagia - Seeing is believing

Background: A bedside scoring to assess swallowing status and the presence of aspiration may sometimes be misleading. Hence, an objective evaluation by endoscopy is desirable. Aims: The aim of this study is to confirm whether a bedside scoring system for poststroke dysphagia correlates well with fiberoptic endoscopic evaluation of swallowing (FEES). Settings and Design: This was an institutional prospective observational pilot study. Materials and Methods: Gugging swallowing screen (GUSS) score, FEES, and patients with dysphagia following stroke were used in this study. Statistical Analysis: Spearman's nonparametric rank correlation test for independent variables was used in this study. Results: A statistically significant positive correlation exists between the bedside score and findings of FEES. FEES is a convenient and convincing method to confirm aspiration in patients with stroke and is also a means for patient education. Conclusions: FEES may be safely and conveniently performed in patients with poststroke dysphagia to confirm the presence or absence of aspiration.

Bulbar Myasthenia Gravis Superimposed in a Medullary Infarction Diagnosed by a Fiberoptic Endoscopic Evaluation of Swallowing With Simultaneous Tensilon Application.

In the elderly, myasthenia gravis (MG) can present with bulbar symptoms, which can be clinically difficult to diagnose from other neurological comorbid conditions. We describe a case of a 75-year-old man who had been previously diagnosed with dysphagia associated with medullary infarction but exhibited aggravation of the dysphagia later on due to a superimposed development of bulbar MG. After recovering from his initial swallowing difficulties, the patient suddenly developed ptosis, drooling, and generalized weakness with aggravated dysphagia. Two follow-up brain magnetic resonance imaging (MRI) scans displayed no new brain lesions. Antibodies to acetylcholine receptor and muscle-specific kinase were negative. Subsequent electrodiagnosis with repetitive nerve stimulation tests revealed unremarkable findings. A diagnosis of bulbar MG could only be established after fiberoptic endoscopic evaluation of swallowing (FEES) with simultaneous Tensilon application. After application of intravenous pyridostigmine, significant improvement in dysphagia and ptosis were observed both clinically and according to the FEES.

食道癌術後の嚥下内視鏡検査の役割

食道癌術後の嚥下内視鏡検査の役割

Benefit from the Chin-Down Maneuver in the Swallowing Performance and Self-Perception of Parkinson's Disease Patients.

Aims. To verify the effectiveness of the maneuver application in swallowing therapy with PD. Materials and Method. We performed an open-label trial, with three groups compounds by PD individuals: the experimental group, control group, and orientation group. The study included PD patients with dysphagia. A cognitive screening, through a questionnaire about depression and quality of life, was conducted. Swallowing assessment was performed through (1) fiberoptic endoscopic evaluation of swallowing (FEES); (2) clinical evaluation and Functional Oral Intake Scale (FOIS); and (3) assessment of the quality life related to swallowing (SWALQOL). A therapeutic program, which consisted of chin-down postural maneuver and orientations on feeding, was applied. Both groups (EG and OG) received on-month therapeutic program. Results. A significant improvement in swallowing, evaluated by clinical assessment, was observed in solid (p < 0.001) and liquid (p = 0.022) consistencies in EG when compared to OG and CG. Patients in EG presented improvement in QoL, with the significant difference in comparison with the other groups, about domain frequency of symptoms (p = 0.029) in SWALQOL questionnaire. Conclusion. The postural maneuver chin-down improved swallowing performance and self-perception, but not the laryngeal signs. This trial is registered with registration number NCT02973698.

Role of Fiberoptic Endoscopic Evaluation of Swallowing (FEES) after Esophagectomy

Role of Fiberoptic Endoscopic Evaluation of Swallowing (FEES) after Esophagectomy