Flexible Endoscopic Evaluation Of Swallowing With Sensory Testing Research Articles

Advancing Laryngeal Adductor Reflex Testing Beyond Sensory Threshold Detection

Flexible endoscopic evaluation of swallowing with sensory testing (FEESST) is a promising clinical tool to assess airway integrity via the laryngeal adductor reflex (LAR). The current clinical protocol relies on sensory threshold detection, as relatively little is known about the motor response of this sensorimotor airway protective reflex. Here, we focused on characterizing normative LAR motion dynamics in 20 healthy young participants using our prototype high-pressure syringe-based air pulse device and analytic software (VFtrack™) that tracks vocal fold (VF) motion in endoscopic videos. Following device bench testing for air pulse stimulus characterization, we evoked and objectively quantified LAR motion dynamics in response to two suprathreshold air pulse stimuli (40 versus 60mmHg), delivered to the arytenoid mucosa through a bronchoscope working channel. The higher air pressures generated by our device permitted an approximate 1cm endoscope working distance for continual visualization of the bilateral VFs throughout the LAR. Post hoc video analysis identified two main findings: (1) there are variant and invariant subcomponents of the LAR motor response, and (2) only a fraction of suprathreshold stimuli evoked complete glottic closure during the LAR. While the clinical relevance of these findings remains to be determined, we have nonetheless demonstrated untapped potential in the current FEESST protocol. Our ongoing efforts may reveal LAR biomarkers to quantify the severity of laryngeal pathology and change over time with natural disease progression, spontaneous recovery, or in response to intervention. The ultimate goal is to facilitate predictive modeling of patients at high risk for dysphagia-related aspiration pneumonia.

Unusual Presentation of a Laryngeal Mass

Awomaninher50swithahistoryofhypertensionandchronicback painpresented to theemergencydepartment. Shehadbeendiscoveredunresponsive inbed,wasapneic, andwas intubated in the field. Shehadexperiencedmultiple episodesof emesis. Atpresentation, a computed tomographic (CT) scan demonstrated diffuse subarachnoidhemorrhage, intraventricular hemorrhage, andcommunicating hydrocephaluswithtonsillarandcentralherniation.Shereceivedmannitolandanemergentextraventriculardrain.Duringherhospital stay, a cerebral aneurysm was successfully treated by an endovascular route. She required a tracheostomy and percutaneous gastrostomy tube placement. Twenty-eight days after her tracheostomy, a flexible endoscopic evaluation of swallowing with sensory testing (FEESST) revealed a submucosal mass. The mass did not fully obstruct the airway, and the patient tolerated a Passy-Muir valve with no respiratory distress. The primary teamadministered dexamethasonesodiumphosphateandconsultedtheotolaryngologyservice.On examination, her vital signs werewithin normal limits, shewas nonverbalbut innoacutedistress,herbreathingunlaboredandsilent,with no stridor or stertor. Passing a flexible fiber-optic laryngoscope confirmedthepresenceofanapparentsubmucosalmassthateitheroriginated from the epiglottis or deep to a severely edematous right aryepiglottic (AE) fold or arytenoid, or completely obstructed the vocal cords from view. Themass did not respond to steroids. A CT scan of the neck with intravenous contrast was performed (Figure, A). The mass was nonenhancing. Subsequently, a retrospective review of a magnetic resonance imaging (MRI) examination demonstrated the mass compressed by the endotracheal catheter (Figure, B). What is your diagnosis? A

Assessment of laryngopharyngeal sensation in children with dysphagia

To assess laryngopharyngeal sensation, prevalence of laryngopharyngeal sensory deficit and abnormal swallowing function parameters in children with dysphagia. Retrospective chart review. The medical records of children who underwent flexible endoscopic evaluation of swallowing with sensory testing (FEESST) were reviewed. Laryngopharyngeal sensory threshold (LPST) was assessed based on the threshold intensity of air pulse stimulation eliciting laryngeal adductor reflex. Swallowing function parameters including pharyngeal residue, hypopharyngeal pooling of secretions, premature spillage, laryngeal penetration, and aspiration were evaluated. Prevalence of abnormal swallowing function parameters in children with normal and impaired LPST was compared. Forty children with dysphagia (28 male, 12 female; age range, 3 months to 17 years) underwent FEESST. LPST was normal in six patients, moderately impaired in 20 patients, and severely impaired in 10 patients. LPST could not be measured in four patients. Children showed one or more abnormal swallowing function parameters. The prevalence of abnormal swallowing parameters in patients with normal LPST was lower than that of patients with moderately or severely impaired LPST (P < .05). The prevalence of pharyngeal residue, hypopharyngeal pooling of secretions, and spillage in patients with severely impaired LPST was higher than that of patients with moderately impaired LPST (P < .05). The majority of children with dysphagia have impaired LPST. The prevalence of abnormal swallowing function parameters in children with normal LPST is lower than that in children with moderately or severely impaired LPST. Prevalence of aspiration tends to increase when the abnormal swallowing function parameters are associated with severely impaired LPST.

Diagnosis and Treatment of Glossopharyngeal and Vagal Neuropathies in a Patient with Laryngopharyngeal Reflux

In this case report, we describe the case of a patient with glossopharyngeal and vagal neuropathy masked by laryngopharyngeal reflux (LPR). LPR is a common disorder in persons older than 40 yr and is characterized by acid reflux into the upper esophagus and pharynx. Classic symptoms include mucus production, cough, wheezing, hoarseness, throat irritation, and globus sensation.1–5 LPR is clinically differentiated from gastroesophageal reflux disease by the absence of heartburn and presence of prominent laryngopharyngeal symptoms, with laryngoscopy typically showing vocal cord edema and erythema.6 LPR is usually confirmed via pH studies demonstrating prolonged acidic pH in the upper esophagus and/or pharynx.2,7 Vagal and/or glossopharyngeal neuropathies, however, are relatively rare conditions that may present together.8 Glossopharyngeal neuropathy is characterized by paroxysms of lancinating or burning pain in the oropharynx, whereas vagal neuropathy presents similarly but can also include symptoms of vocal cord dysfunction, such as hoarseness. Electromyography can be performed to confirm the diagnosis9 but is uncomfortable to the point of requiring deep sedation and is thus rarely done. Both conditions share some symptoms with LPR, notably inspiratory stridor, hoarseness, and throat pain.10 In our case, the patient’s neuropathy was first diagnosed at the chronic pain center and successfully treated with pregabalin almost a year after its onset.

Sensory Testing in the Assessment of Laryngeal Sensation in Patients with Amyotrophic Lateral Sclerosis

Amyotrophic lateral sclerosis (ALS) is a progressive motor neuron disease of unknown cause. Mortality in the population is frequently due to aspiration pneumonia. Although typically considered to be a disorder limited to motor neuron involvement, some investigators have indicated that decreased sensory function in ALS patients additionally contributes to the disease process. The objective of this study was to evaluate laryngopharyngeal sensation in the ALS population in order to quantify the range of sensory deficits and correlate any abnormalities with demographic data to determine which patients are at risk of having sensory deficits. We examined the sensation of the larynx in 22 patients with ALS to determine whether a sensory deficit was present. After completion of a dysphagia questionnaire and medical history, patients underwent flexible endoscopic evaluation of swallowing with sensory testing (FEESST) to evaluate sensory function. Threshold values were determined and recorded for initiation of the adductor reflex. The results of the sensory and swallowing function assessments performed on 22 patients demonstrate abnormal sensation in 54.5% of the tested population. Asymmetric findings were noted in 75% of these patients. There was no correlation noted between the presence of sensory deficits and the severity or duration of the disease. Progressive dysphagia in the ALS population has typically been attributed to muscle weakness. This study points to the presence of sensory deficits in the larynx, which can further affect proper swallowing function.

Patient‐Controlled Comparison of Flexible Endoscopic Evaluation of Swallowing With Sensory Testing (FEESST) and Videofluoroscopy

The objective of this study was to compare the results of videofluoroscopy (VFS) with flexible endoscopic evaluation of swallowing with sensory testing (FEESST) in dysphagia testing. The authors conducted a retrospective review of data collected over a 4-year period at a tertiary care medical center. The FEESST and VFS results for patients receiving both examinations within a 2-week period were compared with respect to swallowing function. Comparisons were categorized as full agreement, minor disagreement that would not result in a significant difference in diet recommendations, and major disagreement that would result in a significant difference in diet recommendations. Kappa with quadratic weighting was calculated to evaluate the inter-test agreement. Fifty-four patients met inclusion criteria and were reviewed. Forty-one percent of patients were not eating by mouth at the time of FEESST and the mean interval between the two examinations was 5 days. Laryngeal examination revealed edema/erythema in 93%, impaired pharyngeal squeeze in 66%, decreased laryngopharyngeal sensation in 82%, and absent laryngeal adductor reflex in 30%. FEESST with all consistencies revealed pooling in 89%, penetration in 83%, and aspiration in 65% of patients. VFS revealed pooling in 65%, penetration in 67%, and aspiration in 54% of patients. Comparison of FEESST and VFS revealed full agreement in 52%, minor disagreement in 13%, and major disagreement in 35% of patients. A weighted kappa value of 0.324 signified only "fair" agreement between the two tests. FEESST and VFS may not represent comparable tests of dysphagia. Further comparative studies of tests of swallowing function are required to determine the ideal approach to dysphagia testing.

Flexible Endoscopic Evaluation of Swallowing With Sensory Testing in Patients With Unilateral Vocal Fold Immobility: Incidence and Pathophysiology of Aspiration

The objective was to examine the incidence and pathophysiology of aspiration in patients with unilateral vocal fold immobility presenting with dysphagia. Retrospective review of flexible endoscopic evaluation of swallowing with sensory testing (FEESST) data and medical records in two tertiary medical care centers. The data for all patients with unilateral vocal fold immobility who underwent FEESST between 2000 and 2003 were reviewed. Eighty-one patients (45 male and 36 female patients) were included in the study. The mean age was 59 years. The most common causes or origins were iatrogenic (42%), malignancy (23%), and neurological (18%). The immobility was left-sided in 59% of patients. A majority of the patients exhibited laryngeal edema/erythema (90%), difficulty with secretions (60%), and decreased laryngopharyngeal sensation (83%). The laryngeal adductor reflex was absent in 34% of the patients. An aspiration rate of 35% was detected with thin liquids. Trials of purees revealed a 76% rate of pooling, 44% rate of spillage, 32% rate of penetration, 18% rate of aspiration, and 24% rate of regurgitation. Rates of penetration and aspiration with purees were significantly higher in patients who had decreased laryngopharyngeal sensation, absent pharyngeal squeeze, and absent laryngeal adductor reflex. Dysphagia in patients with unilateral vocal fold immobility is demonstrated during FEESST by pooling, spillage, penetration, and aspiration. The pathophysiology of dysphagia is multifactorial with decreased sensation and limitation of airway protective mechanisms both acting as contributing factors.

Flexible Endoscopic Evaluation of Swallowing with Sensory Testing: Patient Characteristics and Analysis of Safety in 1,340 Consecutive Examinations

Flexible endoscopic evaluation of swallowing with sensory testing (FEESST) is a comprehensive endoscopic assessment of the sensory and motor components of a swallow. Previous studies addressing patient safety issues with respect to FEESST included relatively small numbers of patients and paid almost no attention to patient characteristics. The purpose of this study was to determine the incidence of FEESST-related complications in the outpatient and inpatient settings and to analyze patient diagnoses that led to the performance of FEESST. We performed a prospective study of FEESST complications in 1,340 consecutive evaluations performed over a 4 1/2-year period. The primary outcome variables were incidence of epistaxis and airway compromise. The secondary outcome variable was underlying patient diagnoses. The incidence of epistaxis was 1 in 1,340 (0.07%). There were no instances of airway compromise. Stroke was the most common reason for the performance of FEESST (343; 25.6%), followed by cardiac-related dysphagia (298; 22.2%) following open heart surgery (169/298; 56.7%), heart attack, congestive heart failure, or new arrhythmia. The remaining causes were head and neck cancer (207; 15.4%), pulmonary disease (141; 10.5%), chronic neurologic disease (124; 9.3%), and acid reflux disease (80; 6.0%). We conclude that FEESST is a relatively safe procedure for the sensory and motor assessment of dysphagia in a cohort of patients with a wide variety of underlying diagnoses. The emergence of cardiac surgery as a common cause of dysphagia warrants further study.

Laryngeal sensitivity evaluation and dysphagia: Hospital Sírio-Libanês experience

Laryngeal sensitivity is important in the coordination of swallowing coordination and avoidance of aspiration. To briefly review the physiology of swallowing and report on our experience with laryngeal sensitivity evaluation among patients presenting dysphagia. Prospective. Endoscopy Department, Hospital Sírio-Libanês. Clinical data, endoscopic findings from the larynx and the laryngeal sensitivity, as assessed via the Flexible Endoscopic Evaluation of Swallowing with Sensory Testing (FEESST) protocol (using the Pentax AP4000 system), were prospectively studied. The chi-squared and Student t tests were used to compare differences, which were considered significant if p < or = 0.05. The study included 111 patients. A direct association was observed for hyperplasia and hyperemia of the posterior commissure region in relation to globus (p = 0.01) and regurgitation (p = 0.04). Hyperemia of the posterior commissure region had a direct association with sialorrhea (p = 0.03) and an inverse association with xerostomia (p = 0.03). There was a direct association between severe laryngeal sensitivity deficit and previous radiotherapy of the head and neck (p = 0.001). These data emphasize the association between proximal gastroesophageal reflux and chronic posterior laryngitis, and suggest that decreased laryngeal sensitivity could be a side effect of radiotherapy. Even considering that these results are preliminary, the endoscopic findings from laryngoscopy seem to be important in the diagnosis of proximal gastroesophageal reflux. Study of laryngeal sensitivity may have the potential for improving the knowledge and clinical management of dysphagia.

Cost-effectiveness of Two Types of Dysphagia Care in Head and Neck Cancer: A Preliminary Report

We conducted a prospective, preliminary study to compare the cost-effectiveness of two different instrument-based techniques for diagnosing and managing dysphagia in 30 consecutive hospitalized patients with head and neck cancer. The two techniques are videofluoroscopy via modified barium swallow (MBS) and videoendoscopy via flexible endoscopic evaluation of swallowing with sensory testing (FEESST). Medicare was the primary insurer of all patients. Fifteen of these patients had their dysphagia diagnosed and managed by MBS and the other 15 by FEESST. Cost-effectiveness was assessed by determining the average Medicare reimbursement for each procedure. We found that the mean reimbursements were $451.01 (+/- $50.55) for MBS and $321.23 (+/- $3.01) for FEESST. The mean reimbursement for FEESST was significantly lower than that for MBS (p < 0.0001; Mann-Whitney U test). We conclude that FEESST appears to be more cost-effective than MBS for the inpatient management of dysphagia in patients with head and neck cancer.

The safety of flexible endoscopic evaluation of swallowing with sensory testing (FEESST): an analysis of 500 consecutive evaluations.

We assessed the safety of a new office or bedside method of evaluating both the motor and sensory components of swallowing called flexible endoscopic evaluation of swallowing with sensory testing (FEESST). FEESST combines the established endoscopic evaluation of swallowing with a technique that determines laryngopharyngeal sensory discrimination thresholds by endoscopically delivering air-pulse stimuli to the mucosa innervated by the superior laryngeal nerve. Endoscopic assessment of laryngopharyngeal sensory capacity followed by endoscopic visualization of deglutition was prospectively performed 500 times in 253 patients with dysphagia over a 2.5-year period in a tertiary care center. The patients had a variety of underlying diagnoses, with stroke and chronic neurological disease predominating (n = 155). To determine the safety of FEESST, the presence of epistaxis, airway compromise, and significant changes in heart rate before and after the evaluation were assessed. Patients were also asked to rate the level of discomfort of the examination; 498 evaluations were completed. There were three instances of epistaxis that were self-limited. There were no cases of airway compromise. There were no significant differences in heart rate between pre- and posttest measurements (p > 0.05). Eighty-one percent of patients noted either no discomfort or mild discomfort as a result of the examination. In conclusion, FEESST is a safe method of evaluating dysphagia in the tertiary care setting and may also have application for the chronic care setting.