Flexible Endoscopic Evaluation Of Swallowing Research Articles

Clinical determinants and neural correlates of presbyphagia in community-dwelling older adults.

Background“Presbyphagia” refers to characteristic age-related changes in the complex neuromuscular swallowing mechanism. It has been hypothesized that cumulative impairments in multiple domains affect functional reserve of swallowing with age, but the multifactorial etiology and postulated compensatory strategies of the brain are incompletely understood. This study investigates presbyphagia and its neural correlates, focusing on the clinical determinants associated with adaptive neuroplasticity.Materials and methods64 subjects over 70 years of age free of typical diseases explaining dysphagia received comprehensive workup including flexible endoscopic evaluation of swallowing (FEES), magnetoencephalography (MEG) during swallowing and pharyngeal stimulation, volumetry of swallowing muscles, laboratory analyzes, and assessment of hand-grip-strength, nutritional status, frailty, olfaction, cognition and mental health. Neural MEG activation was compared between participants with and without presbyphagia in FEES, and associated clinical influencing factors were analyzed. Presbyphagia was defined as the presence of oropharyngeal swallowing alterations e.g., penetration, aspiration, pharyngeal residue pooling or premature bolus spillage into the piriform sinus and/or laryngeal vestibule.Results32 of 64 participants showed swallowing alterations, mainly characterized by pharyngeal residue, whereas the airway was rarely compromised. In the MEG analysis, participants with presbyphagia activated an increased cortical sensorimotor network during swallowing. As major clinical determinant, participants with swallowing alterations exhibited reduced pharyngeal sensation. Presbyphagia was an independent predictor of a reduced nutritional status in a linear regression model.ConclusionsSwallowing alterations frequently occur in otherwise healthy older adults and are associated with decreased nutritional status. Increased sensorimotor cortical activation may constitute a compensation attempt to uphold swallowing function due to sensory decline. Further studies are needed to clarify whether the swallowing alterations observed can be considered physiological per se or whether the concept of presbyphagia may need to be extended to a theory with a continuous transition between presbyphagia and dysphagia.

Dysphagia Management and Cervical Auscultation: Reliability and Validity Against FEES

This study investigated the reliability and validity (sensitivity and specificity) of cervical auscultation (CA) using both swallow and pre-post swallow-respiratory sounds, as compared with Flexible Endoscopic Evaluation of Swallowing (FEES). With 103 swallow-respiratory sequences from 23 heterogenic patients, these swallows sounds were rated by eight CA-trained Speech-Language Pathologists (SLPs) to investigate: (1) if the swallow was safe (primary outcome); (2) patient dysphagia status; (3) the influence of liquid viscosity on CA accuracy (secondary outcomes). Primary outcome data showed high CA sensitivity (85.4%), and specificity (80.3%) with all consistencies for the safe measurement, with CA predictive values of > 90% to accurately detect unsafe swallows. Intra-rater reliability was good (Kappa = 0.65), inter rater reliability moderate (Kappa = 0.58). Secondary outcome measures showed high sensitivity (80.1%) to identify if a patient was dysphagic, low specificity (22.9%), and moderate correlation (rs= 0.62) with FEES. A difference across bolus viscosities identified that CA sensitivities (90.1%) and specificities (> 84.7%) for thin liquids were greater than for thick liquids (71.0–77.4% sensitivities, 74.0–81.3% specificities). Results demonstrate high validity and moderate-good reliability of CA-trained SLPs to determine swallow safety when compared with FEES. Data support the use of CA as an adjunct to the clinical swallow examination. CA should include pre-post respiratory sounds and requires specific training. Clinical implications: The authors advocate for holistic dysphagia management including instrumental assessment and ongoing CSE/review + CA. Adding CA to the CSE/review does not replace instrumental assessment, nor should CA be used as a stand-alone tool.

Nutritional Risk Screening in head-and-neck cancer patients prior to oncological therapy

Head-and-neck cancer patients run a high risk of peri- or post-treatment malnutrition that can severely affect the therapy outcome. However, little is known about malnutrition under the pre-treatment condition. Therefore, this study aimed to provide a systematic description of the pre-treatment nutritional status and risk of malnutrition in this population. Before the onset of the oncological therapy, nutritional status of 102 head-and-neck cancer patients was assessed by body mass index (BMI), their risk of malnutrition by "Nutritional Risk Screening" (NRS). Tumour stage and site, patients' age and sex as well as oropharyngeal dysphagia were analysed as possible influence factors. The latter was quantified by the Flexible Endoscopic Evaluation of Swallowing (FEES). According to BMI, malnutrition (undernutrition) was found in 6% of patients, a risk of malnutrition (NRS) in 27% of patients, and oropharyngeal dysphagia in 15%. In a linear regression, only oropharyngeal dysphagia was identified as a significant influence factor for the risk of malnutrition (β = 0.380/3.776; p < .001). Pre-treatment risk of malnutrition was found in a quarter of head-and-neck cancer patients. For the early identification of this risk and for the introduction of measures that would help to avoid it, a pre-treatment examination of swallowing functions and a systematic malnutrition screening by means of NRS are recommended.

Implementation of Pediatric Flexible-Endoscopic Evaluation of Swallowing: A Systematic Review and Recommendations for Future Research

BackgroundAlthough pediatric flexible-endoscopic evaluation of swallowing (FEES) has developed into a standard in dysphagia diagnostics, there are no valid protocols and procedures for children available to date.ObjectiveThis systematic PROSPERO-registered review aimed to identify implementation protocols for pediatric FEES described in research studies, and to analyze them in detail concerning procedural steps, equipment, and reported outcome.MethodsIncluded were all studies reporting a pediatric FEES protocol for children aged 0–18 years, if they described at least two criteria defined in advance. The databases MEDLINE and CINHAL were searched systematically from January 2000 to February 2021. Risk of bias for included studies was assessed using the National Institutes of Health (NIH) quality assessment tool for observational cohort and cross-sectional studies. A narrative synthesis of the FEES protocols was conducted and the results compared in tabular form.ResultsIn total 22 studies were included, reporting on FEES in 1547 infants, children, and adolescents with a wide range of diagnoses. It was possible to identify protocols related to all age groups in general as well as to particular groups such as breastfed or bottle-fed infants. None of the included studies demonstrated a good methodological quality; all studies had missing data. Uniform implementation for sub-groups could not be determined. The reported outcome of FEES examinations could not be compared.DiscussionNone of the included studies showed good methodological quality and a significant amount of data were missing; the review still offers a systematic basis for future research to close the serious gap in the area of pediatric FEES. A proposal is made for a minimum requirement for pediatric FEES protocols in scientific studies.

Postextubation dysphagia in intensive care patients : Current findings and clinical recommendations

Aconsiderable number of critically ill and mechanically ventilated intensive care patients show pronounced dysphagia after extubation. Many studies have shown that postextubation dysphagia (PED) leads to asignificant decline of outcome. The awareness, timely diagnostic procedures and integration of suitable treatment methods in intensive care units are therefore of great importance. Current basic findings on PED, diagnostic possibilities, therapeutic methods as well as the development of concrete recommendations for clinical practice. Aselective literature search was performed in PubMed, Medline and Cochrane using keywords. In the literature the incidence PED is reported very heterogeneous but is probably at least 10% in intensive care patients after mechanical ventilation. The duration of intubation plays acritical role here. Amultifactorial interaction of several factors is assumed to be the cause, whereby the impairment of laryngeal structures is of particular relevance. A PED leads to longer hospital stays, higher mortality, more reintubation and ahigher number of patients with tube feeding. With respect to diagnostics, screening by trained nurses, clinical swallowing examinations and, in particular, the use of instrumental examinations by flexible endoscopic evaluation of swallowing (FEES) are recommended. The treatment should include adaptive measures in the sense of an adapted diet but also functional exercises. Innovative approaches, such as electrical stimulation are also conceivable. The aim is primarily to avoid penetration and aspiration in order to counteract respiratory complications. In many intensive care units the clinical picture of PED is still neglected despite clear evidence. Asimple algorithm in the treatment of intensive care patients can contribute to early detection and initiation of further steps. These should be integrated into clinical treatment standards.

Dysphagia in Intensive Care Evaluation (DICE): An International Cross-Sectional Survey.

Dysphagia occurs commonly in the intensive care unit (ICU). Despite the clinical relevance, there is little worldwide research on prevention, assessment, evaluation, and/or treatment of dysphagia for ICU patients. We aimed to gain insight into this international knowledge gap. We conducted a multi-center, international online cross-sectional survey of adult ICUs. Local survey distribution champions were recruited through professional and personal networks. The survey was administered from November 2017 to June 2019 with three emails and a final telephone reminder. Responses were received from 746 ICUs (26 countries). In patients intubated > 48h, 17% expected a > 50% chance that dysphagia would develop. This proportion increased to 43% in patients intubated > 7days, and to 52% in tracheotomized patients. Speech-language pathologist (SLP) consultation was available in 66% of ICUs, only 4% reported a dedicated SLP. Although 66% considered a routine post-extubation dysphagia protocol important, most (67%) did not have a protocol. Few ICUs routinely assessed for dysphagia after 48h of intubation (30%) or tracheostomy (41%). A large proportion (46%) used water swallow screening tests to determine aspiration, few (8%) used instrumental assessments (i.e., flexible endoscopic evaluation of swallowing). Swallowing exercises were used for dysphagia management by 30% of ICUs. There seems to be limited awareness among ICU practitioners that patients are at risk of dysphagia, particularly as ventilation persists, protocols, routine assessment, and instrumental assessments are generally not used. We recommend the development of a research agenda to increase the quality of evidence and ameliorate the implementation of evidence-based dysphagia protocols by dedicated SLPs.

Visual Analysis of Swallowing Efficiency and Safety (VASES): Establishing Criterion-Referenced Validity and Concurrent Validity.

The primary aim of this study was to examine the criterion-referenced validity of the Visual Analysis of Swallowing Efficiency and Safety (VASES). As a secondary aim, we examined the concurrent validity of using verbal numerical ratings for VASES as a potential substitute for visual analog scale ratings. Fifty-seven novice raters were prospectively recruited to rate 26 flexible endoscopic evaluations of swallowing (FEES) images (2 times each, randomized)-once using VASES and once using a criterion-referenced scale. Ratings were made for the valleculae, piriforms, epiglottis, laryngeal vestibule, vocal folds, and subglottis. Criterion validity was determined by examining the correlation between VASES and the criterion-referenced scales. The novice raters also provided visual analog scale ratings following verbal numerical ratings. Concurrent validity of using verbal numerical ratings as a potential substitute for visual analog scale ratings was determined by examining the correlation and absolute agreement between both rating methods. Three thousand five hundred eighty-seven ratings were analyzed. Spearman's correlation revealed strong correlations between VASES ratings and criterion-referenced ratings across all anatomic landmarks (ρ = .882-.915). Lin's concordance revealed substantial agreement between numerical ratings and visual analog scale ratings (ρc = .986). The strong correlations between VASES and the criterion-referenced scales suggest that VASES is a valid method for interpreting pharyngeal residue, penetration, and aspiration during FEES. Furthermore, numerical ratings exhibited substantial agreement with visual analog scales. This suggests that clinicians could provide verbal numerical ratings in lieu of visual analog scale ratings as a potential way to enhance the ease and feasibility of implementing VASES into clinical practice. https://doi.org/10.23641/asha.18737072.

Screening of palatopharyngeal incoordination in mechanically ventilated critically ill infants

Objective. Screening of palatopharyngeal incoordination in infants who required mechanical ventilation. Patients and methods. This study included 51 patients admitted to the pediatric intensive care unit (PICU), Faculty of Medicine, Ain Shams University. The study was conducted during the period from February 2021 to February 2022. All patients were divided into five groups according to the results of the Fiberoptic Flexible Endoscopic Evaluation of Swallowing (FEES) postintubation, FEES post-extubation, Videofluoroscopic Swallow Study (VFSS) post-extubation, and dye study: group 1 – not affected infants, group 2 – infants with palatopharyngeal incoordination, group 3 – infants with palatopharyngeal incoordination and gastroesophageal reflux, group 4 – infants with reflux, group 5 – infants with congenital upper air way anomalies. Results. Palatopharyngeal incoordination was detected in 16 (31.3%) patients, congenital upper airway anomalies – in 12 (23.5%) patients, and gastroesophageal reflux – in 10 (19.6%) patients. After three months, palatopharyngeal incoordination was resolved in 92.3% of patients, and 7.7 % had silent aspiration. Conclusion. Palatopharyngeal incoordination is a multifactorial process with the important implications for early diagnosis and interventions to treat this condition in pediatric patients. Key words: silent aspiration, mechanical ventilation, infants, palatopharyngeal incoordination

Deglutition assessment instruments used in critical patients submitted to orotracheal extubation: a scoping review

Purpose: to map, through a literature survey, which instruments are used to assess swallowing in patients after orotracheal extubation. Methods: available evidence was mapped through six electronic databases and gray literature. There were no restrictions regarding gender, ethnicity of the individuals, language of the studies, time of publication, and diagnosis. Results: the most mentioned protocol in the studies was the Dysphagia Risk Evaluation Protocol and the most cited objective assessment exam was the flexible endoscopic evaluation of swallowing. Conclusion: there is a need for a specific protocol to evaluate this profile of patients, in addition to comparative studies of subjective clinical evaluation and instrumental imaging.

Voluntary Cough Effectiveness and Airway Clearance in Neurodegenerative Disease

Voluntary cough dysfunction is highly prevalent across multiple patient populations. Voluntary cough has been utilized as a screening tool for swallowing safety deficits and as a target for compensatory and exercise-based dysphagia management. However, it remains unclear whether voluntary cough dysfunction is associated with the ability to effectively clear the airway. Individuals with neurodegenerative disorders performed same-day voluntary cough testing and flexible endoscopic evaluations of swallowing (FEES). Participants who were cued to cough after exhibiting penetration to the vocal folds and/or aspiration with thin liquids during FEES met inclusion criteria. One-hundred and twenty-three trials were blinded, and the amount of residue before and after a cued cough on FEES was measured with a visual analog scale. Linear and binomial mixed-effects models examined the relationship between cough airflow during voluntary cough testing and the proportion of residue expelled. Peak expiratory flow rate (p = .004) and cough expired volume from the entire epoch (p = .029) were significantly associated with the proportion of aspiration expelled from the subglottis. Peak expiratory flow rate values of 3.00 L/s, 3.50 L/s, and 5.30 L/s provided high predicted probabilities that ≥ 25%, ≥ 50%, and ≥ 80% aspirate was expelled. Accounting for depth of aspiration significantly improved model fit (p < .001). These findings suggest that voluntary cough airflow is associated with cough effectiveness to clear aspiration from the subglottis, although aspiration amount and depth may play an important role in this relationship. These findings provide further support for the clinical utility of voluntary cough in the management of dysphagia.

Upright epiglottis prevents aspiration in patients with nasopharyngeal carcinoma post-chemoradiation.

NPC is the most widely found malignant tumor in the head and neck region in Indonesia. Chemoradiation therapy for NPC can induce swallowing disorders (dysphagia) that adversely affects a patients quality of life. This study aimed to assess the swallowing process by flexible endoscopic evaluation of swallowing in patients with nasopharyngeal carcinoma after chemoradiation. Thirty-nine patients with NPC who had chemoradiation therapy more than one month previously underwent flexible endoscopic evaluation of swallowing and were assessed for oral transport time, sensation, standing-secretion, pre-swallowing leakage, residue, penetration, aspiration, and silent aspiration. The most common structural abnormalities were an upright and swollen epiglottis (89.4%), poor oral hygiene, and velopharyngeal closure defects (56.4%). This examination also revealed a mild degree of standing secretion (38.5%) and aspiration (10.3%). No penetration was observed in 64.1% of the patients, and no silent aspiration was observed in any of the patients. A severe degree of residue (45.7%) was observed when administering oatmeal, while the residue was mild to moderate when administering gastric rice, crackers, and milk. The residue changed to a mild degree (32.3%–51.4%) in all food administrations after the watering maneuver. The highest penetration was noted after oatmeal administration (42.8%), and the highest aspiration was found after milk administration (8.6%). Standing secretion in almost all patients was caused by hyposensitivity of the hypopharynx. Persistent residue and hyposensitivity of the hypopharynx led to aspiration. The low percentage of aspiration and silent aspiration might have been caused by the upright and swollen epiglottis that prevented aspiration. Poor oral hygiene and a dry mouth led to prolonged oral transport. Therefore, most patients had hypopharyngeal abnormalities in the form of a swollen and upright epiglottis. Secretion and food residue were also detected. Drinking helps to expedite the swallowing process by facilitating oral phase transport and reducing residues.

Oro-pharyngo-esophageal radionuclide scintigraphy predicts aspiration pneumonia risk and associated survival in post-irradiated nasopharyngeal carcinoma patients.

ObjectiveTo demonstrate that oro‐pharyngo‐esophageal radionuclide scintigraphy (OPERS) not only detects tracheobronchial aspiration after swallowing, but also quantifies the amount of aspiration and subsequent clearance.MethodsData collected between 2014 and 2019 were reviewed for aspiration pneumonia at 12 and 24‐months after OPERS. The predictive value for aspiration pneumonia on flexible endoscopic evaluation of swallowing (FEES), videofluoroscopic swallowing study (VFSS), and OPERS, and the overall survival of patients with or without aspiration were determined.ResultsThirty‐seven patients treated with radiotherapy for nasopharyngeal carcinoma (NPC) were reviewed. The incidence of aspiration detected on FEES, VFSS, and OPERS was 78.4%, 66.7%, and 44.4%, respectively. Using VFSS as a gold standard, the sensitivity and specificity of OPERS for aspiration was 73.7% and 100%. The positive and negative predictive values for aspiration were 100% and 66.7%, respectively, with an overall accuracy of 82.8%. A history of aspiration pneumonia was one factor associated with a higher chance of subsequent aspiration pneumonia within 12 months (odds ratio: 15.5, 95% CI 1.67–145.8, p < .05) and 24 months (odds ratio: 23.8, 95% CI 3.69–152.89, p < .01) of the swallowing assessment. Aspiration detected by OPERS was a significant risk factor for future aspiration pneumonia at 12 and 24 months respectively. Significantly, better survival was associated with an absence of aspiration on OPERS only, but not on FEES or VFSS.ConclusionOPERS predicts the safety of swallowing, the incidence of subsequent aspiration pneumonia, and the survival prognosis in post‐irradiated NPC dysphagia patients.Level of Evidence3.

Laryngeal sensation and its association with aspiration and cough in children with neurological impairment

Aspirations are frequent in children with neurological impairment. They significantly increase the risk for acute and chronic respiratory insufficiencies leading to high morbidity and mortality. Laryngeal sensation deficits have been linked to aspirations in adults and are a suspected cause for dysphagia in children. In a similar neurological circuit as swallowing, laryngeal receptors trigger coughing as a protective airway reflex. The aim of this study was to examine the association between impaired laryngeal sensation (ILS), aspiration, and coughing in neurologically impaired children. In a retrospective study, 110 children with suspected dysphagia underwent a clinical evaluation of swallowing and a flexible endoscopic evaluation of swallowing (FEES) between 2013 and 2019 in the children's university clinic Düsseldorf were analyzed. Laryngeal sensation was tested by the endoscopic touch method. Associations were computed using χ2 -test. Fifty-four patients (49.1%) had a neurological impairment, 56 patients (50.9%) had no or other comorbidities and served as a control cohort. Children with neurological impairment suffered from ILS significantly more often than children with no or other comorbidities (χ²(1) = 4.63, p = .031). ILS was associated with all other FEES variables but did not correlate with coughing. The symptom coughing correlated with aspiration in the group of neurologically impaired children and in children ILS. ILS is a potential cause of aspirations in children with neurological impairment. Physicians need to pay special attention to the occurrence of coughing in children with neurological impairment and/or ILS since it signals aspirations that took place.

Dysphagia management: Does structured training improve the validity and reliability of cervical auscultation?

Purpose: Cervical auscultation (CA) uses a stethoscope or microphone to complement the clinical swallow examination by interpreting swallowing sounds and swallow-respiratory coordination. This study investigated the effects of structured CA training on CA-rating agreement with Flexible Endoscopic Evaluation of Swallowing (FEES) and CA rater reliability. Method: Thirty-nine speech-language pathologists participated in a structured CA training course at Gothenburg University. They rated nine swallow-respiratory sound recordings which were simultaneously recorded during FEES. Swallow sounds were rated six weeks prior to the CA-workshop using two binary yes/no questions, (1) Safe, (2) Dysphagia, and a third Dysphagia Severity rating. Swallow sounds were rated again (re-randomised) one month post CA-workshop. Result: Agreement with FEES (validity) improved significantly (p < 0.05) pre-post training for the Safe and Dysphagia questions, with post training sensitivities >90% and specificities at 76% and 85% respectively. Dysphagia severity rating improved non-significantly. Intra-rater reliability improved significantly with kappa statistics >0.90 post training. Improvements for inter-rater reliability were noted, though non-significant. Conclusion: Results demonstrate that with structured training, the validity of CA (to detect a Safe/Dysphagic swallow) significantly improves, as does intra-rater reliability. This is congruent with literature identifying the positive effects of structured training improving instrumental dysphagia assessment.

Discriminant Ability of the 3-Ounce Water Swallow Test to Detect Aspiration in Acute Postoperative Cardiac Surgical Patients.

Dysphagia is a common complication of cardiac surgery (CS) contributing to morbidity and mortality. Although early dysphagia detection is important, no current screening guidelines or validated tools exist in the cardiac intensive care setting. We therefore aimed to examine the discriminant ability of the 3-ounce water swallow test (3oz. WST) to detect aspiration in acute postoperative CS patients. 196 postoperative CS patients were enrolled in this prospective single-center study. Participants completed the 3oz. WST and a standardized Flexible Endoscopic Evaluation of Swallowing. Independent duplicate ratings of the penetration aspiration scale (PAS) were performed in a blinded fashion (100% agreement criteria). Receiver operating characteristic curve and area under the curve (AUC) analyses were performed with sensitivity, specificity, positive, and negative predictive values (PPV, NPV) derived. Fifty-four CS patients (28%) were confirmed aspirators (PAS ≥ 6), of whom 48% (n = 26) were silent aspirators (PAS = 8). Both the sensitivity and specificity of the 3oz. WST to identify instrumentally confirmed aspiration was 63% (AUC: 0.63, 95% CI: 0.54, 0.72), and PPV was 39% and NPV 82%. The 3oz. WST demonstrated fair discriminant ability to detect aspiration in acute postoperative CS patients. The high rate of silent aspiration may explain, in part, these findings given that the screening fail criteria include an overt cough response. In isolation, the 3oz. WST does not represent a sensitive screen of aspiration in postoperative CS patients with a need to identify alternative screening tools for this setting.

P 24. Dysphagia in NMOSD and MOGAD: Swallowing endoscopy as a surrogate of brain involvement?

Background. Neuromyelitis optica spectrum disorder (NMOSD) and Myelin oligodendrocyte glycoprotein (MOG) antibody disease (MOGAD) are demyelinating disorders that typically affect the optic nerves and the spinal cord. However, recent studies have demonstrated various forms of brain involvement indicating encephalitic syndromes, which consequently are included in the diagnostic criteria for both. Swallowing is processed in a distributed brain-network and is therefore disturbed in many neurological diseases. Objective. The aim of this study was to investigate the occurrence of oropharyngeal dysphagia in NMOSD and MOGAD and to further assess the value of flexible endoscopic evaluation of swallowing (FEES) as a surrogate parameter of brain involvement. Methods. 13 Patients with NMOSD and MOGAD (mean age 54.2 ± 18.6 years, men: 13) who received FEES during clinical routine were retrospectively reviewed: Their extent of oropharyngeal dysphagia was rated using an ordinal dysphagia severity scale. FEES-results were compared to a control group of healthy individuals. Dysphagia severity was correlated with the presence of clinical and radiological signs of brain involvement, the Expanded Disability Status Scale (EDSS) and the occurrence of pneumonia. Results. Oropharyngeal dysphagia was present in 8/13 patients, including 6 patients without other clinical indication of brain involvement. Clinical or subclinical swallowing impairment was significantly more severe in patients with NMOSD and MOGAD compared to the healthy individuals ( p = 0.009) and correlated with clinical signs of brain involvement ( p = 0.019), higher EDSS ( p = 0.006) and pneumonia ( p = 0.019). Conclusion. Oropharyngeal dysphagia can occur in NMOSD and MOGAD and might be associated with pneumonia and disability. FEES may help to detect subclinical brain involvement.

Dysphagia in amyotrophic lateral sclerosis: Quantification of bulbar motor dysfunction.

Dysphagia as a sequel and possible early sign of amyotrophic lateral sclerosis (ALS) is caused by progressive impaired bulbar motor function. To evaluate bulbar motor dysfunction in patients suffering from ALS compared to a healthy reference group. A clinical study and prospective group comparison was designed. Patients and healthy volunteers were examined in the outpatient clinic of our university medical center. Ten patients with ALS and 20 healthy volunteers were included. All participants underwent a flexible endoscopic evaluation of swallowing (FEES) and a manometric measurement of the maximal sub-palatal atmospheric pressure generated by suction as well as of the prevalent pressure during swallowing. Additionally, the Sydney Swallow Questionnaire (SSQ) was completed by all participants to score the self-rated extent of dysphagia. Comparing maximal suction pressures, the group of patients showed significantly lower values (p<.001). There was a significant correlation between reduced pressures and the degree of dysphagia (SSQ score) (r=-0.73). As the oral cavity is an easily accessible compartment of the upper digestive tract, manometric measurements might serve as a simple instrument in order to detect or to monitor bulbar motor dysfunction. Oral manometry may facilitate early detection and monitoring of dysphagia in ALS. Larger studies are required to confirm our findings.

Enhancing the learning and supervision framework for training in flexible endoscopic evaluation of swallowing.

This article reviews the literature on the development of competency-based training and assessment in endoscopy, comparing gastrointestinal endoscopy and flexible endoscopic evaluation of swallowing (FEES). The discussion focusses on how a robust and explicit learning framework can be translated to the delivery of training in FEES to optimize trainee outcomes and supervisor skill. Specialist Speech and Language Therapists (SLT) carry out FEES to inform the diagnosis and management of swallowing and voice disorders. Taught courses are generally followed by local workplace-based supervised practice to attain the competencies identified in the relevant professional guidelines. However, the curriculum for the workplace-based FEES training lacks a learning and assessment framework and little direction for the workplace-based supervisor. In gastrointestinal endoscopy training, this previously led to less than optimal outcomes for trainees and patients and so new models of training were developed. A new learning framework for FEES underpinned by medical pedagogy has shown early promise in supporting the acquisition of competence. Incorporating a new FEES-specific systematic assessment, the framework provides direction for the supervisor and evidence of trainee progression, which subsequently enhances supervisor confidence to determine trainee competence.

Nutritional intervention after an early assessment by a flexible endoscopic evaluation of swallowing is associated with a shorter hospital stay for patients with acute cerebral infarction: A retrospective study.

It is important to evaluate the swallowing function of patients with acute cerebral infarction. The effects of nutritional intervention after an early assessment by a flexible endoscopic evaluation of swallowing (FEES) were evaluated. This retrospective study included 274 patients who were hospitalized for acute cerebral infarction and underwent a FEES between 2016 and 2018. The effects of early nutritional intervention after an assessment by a FEES within 48 h from admission were evaluated. The patients were divided into a shorter hospital stay group (<30 days) and a longer group (≥30 days). A multivariate analysis was performed to identify the predictive factors for a shorter hospital stay. The overall patient characteristics were as follows: 166 men; median age, 81 years old; and median body mass index (BMI), 21.1 kg/m2. No significant differences in the age, sex, or BMI were found between the shorter and longer hospital stay groups. A FEES within 48 h of admission (odds ratio [OR], 2.040; 95% confidence interval [CI], 1.120-3.700; p=0.019), FILS level ≥6 at admission (OR, 2.300; 95% CI, 1.190-4.440; p=0.013), and an administered energy dose of ≥18.5 kcal/kg on hospital day 3 (OR, 2.360; 95% CI, 1.180-4.690; p=0.015) were independently associated with a hospital stay <30 days. Patients with acute cerebral infarction are more likely to have a shorter hospital stay (<30 days) if they undergo a FEES early after admission and receive optimal nutritional intervention.

Adaptation and Validation of the Dynamic Imaging Grade of Swallowing Toxicity for Flexible Endoscopic Evaluation of Swallowing: DIGEST-FEES.

Purpose While flexible endoscopic evaluation of swallowing (FEES) is a common clinical procedure used in the head and neck cancer (HNC) population, extant outcome measures for FEES such as bolus-level penetration-aspiration and residue scores are not well suited as global patient-level endpoint measures of dysphagia severity in cooperative group trials or clinical outcomes research. The Dynamic Imaging Grade of Swallowing Toxicity (DIGEST) was initially developed and validated for use during videofluoroscopic evaluations as a way to grade safety, efficiency, and overall pharyngeal swallowing impairment. The purpose of this study was to adapt and validate DIGEST for use with FEES. Method A modified Delphi exercise was conducted for content validation, expert consensus, adaptation, and operationalization of DIGEST-FEES. Three blinded, expert raters then evaluated 100 de-identified post-HNC treatment FEES examinations. Intra- and interrater reliability were tested with quadratic weighted kappa. Criterion validity against the MD Anderson Dysphagia Inventory, Functional Oral Intake Scale, Secretion Severity Scale, and Yale Residue Rating Scale was assessed with Spearman correlation coefficients. Results Interrater reliability was almost perfect for overall DIGEST-FEES grade (κw = 0.83) and safety grade (κw = 0.86) and substantial for efficiency grade (κw = 0.74). Intrarater reliability was excellent for all raters (0.9-0.91). Overall DIGEST-FEES grade correlated with MD Anderson Dysphagia Inventory (r = -.43, p < .0001), Functional Oral Intake Scale (r = -.43, p < .0001), Secretion Severity Scale (r = .47, p < .0001), Yale Vallecular Residue (r = .73, p < .0001), and Yale Pyriform Sinus Residue (r = .65, p < .0001). Conclusion DIGEST-FEES is a valid and reliable scale to describe the severity of pharyngeal dysphagia in patients with HNC. Supplemental Material https://doi.org/10.23641/asha.14642787.