Full-text - Polski Przegląd Otorynolaryngologiczny

Full-text - Polski Przegląd Otorynolaryngologiczny

artykuł poglądowy/review article
Use of flexible endoscope during evaluation
of swallowing
Zastosowanie endoskopu giętkiego w diagnostyce
zaburzeń połykania
Jamróz Barbara , Sielska-Badurek Ewelina, Niemczyk Kazimierz
Department of Otolaryngology, Medical University of Warsaw
Article history: Received: 20.04.2015 Accepted: 20.04.2015 Published: 30.06.2015
ABSTRACT: FEES (fiberoptic endoscopic examination of swallowing) is a modern diagnostic tool for the evaluation of patients with
swallowing disorders. It allows for the assessment of structure and function of the nose, pharynx, and larynx as well as for
the evaluation of swallowing of foods differing in consistency (during the examination at least three consistencies are tested – liquids, puree, solids). The possibility to assess the degree of residue and to estimate the risk of aspiration is essential for
the subsequent planning of rehabilitation and dietary recommendations that are suited to individual patients. FEES is safe
and well tolerated by patients, and together with videofluoroscopy, should be routinely applied in the diagnostic work-up
of dysphagia.
KEY WORDS: dysphagia, FEES, swallowing problems, aspiration, penetration, residues
STRESZCZNIE: FEES (fiberoptic endoscopic examination of swallowing) jest nowoczesnym badaniem wykorzystywanym w diagnostyce
pacjentów z zaburzeniami połykania. Pozwala ono na ocenę anatomii i fizjologii nosa, gardła i krtani oraz ocenę spożywania pokarmów o różnych konsystencjach (w trakcie badania testuje się przynajmniej trzy z nich – płyn, purée i pokarm stały).
Możliwość oceny stopnia zalegań i ryzyka aspiracji pokarmu jest niezbędna z punktu widzenia ustalania indywidualnego
i optymalnego planu dietetycznego i rehabilitacyjnego. FEES jest badaniem dobrze tolerowanym i bezpiecznym dla pacjentów i powinien wraz z wideofluoroskopią być stosowany rutynowo w diagnostyce dysfagii.
SŁOWA KLUCZOWE: dysfagia, FEES, zaburzenia połykania, aspiracja, penetracja, zalegania
INTRODUCTION
Disorders of swallowing are an interdisciplinary problem that is
found in the clinical practice of laryngologists as well as neurologists, gastroenterologists, pulmonologists, and surgeons.
Patients with swallowing disorders are often malnourished,
which may result in a less favorable treatment outcome of the
underlying disease. Moreover, some of those patients are at
risk of aspiration pneumonia.
In Poland, the barium swallow test constitutes an integral part of
the routine diagnostic workup. However, elsewhere in the world,
the fiberoptic endoscopic examination of swallowing (FEES) has
become the gold standard in such cases. This endoscopic procedure was first described in 1988 by Susan Langmore (1), but the
POLSKI PRZEGLĄD OTORYNOLARYNGOLOGICZNY, TOM 4, NR 2 (2015), s. 1-5
complete protocol was not established until 2001 (2). The protocol divides the examination into three parts: I – evaluation of
the structure and function of the pharynx and larynx; II – evaluation of swallowing of saliva and foods of different consistency;
III – evaluation of the efficacy of therapeutic interventions. One
of the most important goals of FESS is to look for “silent dysfunctions” that increase the risk of aspiration pneumonia. These are:
•
•
•
•
Premature swallowing – bolus enters the base of
the tongue or goes below it before the initiation of
swallowing;
Delayed or absent swallow reflex;
Aspiration – bolus moves below the vocal cords
Residue – bolus remains in the pharynx after
swallowing
DOI: 10.5604/20845308.1150791
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artykuł poglądowy / review article
The aim of this article is to describe FEES the way it is performed
in patients with disorders of swallowing in the Department of
Otolaryngology, Medical University of Warsaw.
PART I: EVALUATION OF STRUCTURE AND
FUNCTION OF THE PHARYNX AND LARYNX
While performing FEES, a flexible endoscope in inserted
through the nose and nasopharynx to the oropharynx where
the base of the tongue, larynx, and piriform sinuses are seen.
During the procedure, local anesthetics (e.g. lidocaine gel)
should not be used as by numbing the examined structures
they can interfere with the evaluation (2,3). First, the following abnormalities are looked for:
Figure 1: Entry to larynx is closed by epiglottis
•
Structural abnormalities of the nose, nasopharynx,
oropharynx, laryngopharynx and larynx (Fig. 1)
• Nasopharyngeal insufficiency during swallowing and
phonation
• Disorders of the constrictive function of the larynx
during cough, Valsalva maneuver, and swallowing
• Abnormal movements of the vocal cords during
breathing and phonation
• Abnormal squeeze maneuver (closure of the side walls
of the pharynx on loud phonation, Fig. 2 and 3)
Subsequently, the number of spontaneous swallows within
one minute is counted. The rate of one swallow per 2 minutes
is considered to be normal. However, due to the presence of
fiberscope at least 2 or 3 swallows should be observed within
1 minute, and at least 1 swallow in the elderly.
PART II: EVALUATION OF SWALLOWING
OF SALIVA AND FOODS OF DIFFERENT
CONSISTENCY
Figure 2: Normal squeeze maneuver. Both side walls of the pharynx are
constricted equally
The next part of FEES is the evaluation of swallowing of saliva
and foods of different consistency: liquid, purée, and solid (Fig.
4-8). The patient swallows each type of food 15 times, which
gives approximately 60-70 swallows during the entire examination. This is important because some abnormalities will not
be evident until certain time has elapsed since the commencement of swallowing.
First, the patient swallows saliva followed by boluses of liquids,
purée, and solids (2,3). At the same time, the examining physician looks for “silent dysfunctions” including bolus residue in
the piriform sinuses, epiglottic valleculae, and in the larynx.
Kelly et al. (4) propose that bolus residue can be graded on the
following scale used during videofluoroscopy: N (none) – no
2
Figure 3: Abnormal squeeze maneuver in a patient with right vocal cord
weakness. The constriction of the right wall of the pharynx is impaired.
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artykuł poglądowy / review article
Figure 4: Residue of saliva in the left piriform sinus in a patient following surgery
and radiotherapy for salivary gland cancer
Figure 5. Swallowing of yoghurt – normal residue.
Figure 6: Residue of yoghurt in the let piriform sinus, on the laryngeal surface of
the epiglottis, and in the retrocricoid area. Left vocal cord weakness
Figure 7: Residue of bread on the right side of the base of the tongue in a patient
following ischemic stroke with left facial and hypoglossal weakness
residue; C (coating) – no reside but food present on the mucous membranes; Mi – mild residue; Mo – moderate residue;
and S – severe residue of clinical significance.
Figure 8: Residue of bread between the epiglottis and the base of the tongue in
a patient with difficulties in swallowing of solid foods. The patient needed 3-4
swallows for each morsel.
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Subsequently, the risk of aspiration is assessed with the use
of the Penetration-Aspiration Scale (PAS) created by Rosenbeck et al. in 1996 (2, 5). They defined penetration and aspiration as bolus advancing to the larynx above or below the
level of vocal cords, respectively. PAS is an eight-grade scale
where grade 1 is assigned when a bolus does not advance to
the airways, whereas grade 8 means that the bolus advances
below the level of vocal cords without any attempt to expectorate (Table 1). For full PAS assessment, the clearance
function according to Murray’s criteria should be evaluated
as well (2,6). The clearance function is described as effective, partially effective, or ineffective (criteria a-c, Table 2)
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artykuł poglądowy / review article
depending on the location of residue and whether the bolus
is expectorated. In both cases the worst score observed on
FEES is assigned.
The last step of FEES is the FEDSS-based (Fibreoptic Endoscopic Dysphagia Severity Scale) determination of the severity
of dysphagia (2, 3). Depending on the size of residue, presence
of bolus aspiration or bolus penetration, and bolus consistency, patients are assigned to appropriate groups (level 1 to
6) for which different diets are recommended. Because the
scale (Table 3) was originally created for neurological patients
(primarily stroke patients), its application in different types of
patients (e.g. in patients who undergo neck surgery) is not always possible. However, the scale is helpful when planning the
rehabilitation program or making dietary recommendations.
Table 1: Penetration-aspiration Scale
1
Material does not enter airway.
2
Material enters the airway, remains above the vocal folds, and is ejected
from the airway.
3
Material enters the airway, remains above the vocal folds, and is not
ejected from the airway.
4
Material enters the airway, contacts the vocal folds, and is ejected from
the airway.
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.
Table 2: Clearance function according to the Murray’s criteria
LEVEL
EFFECTIVENESS OF
CLEARANCE
DESCRIPTION
a
Effective
Material is removed from the trachea,
larynx, and/or the hypopharynx
b
Partially effective
Material is removed from the trachea
and/or larynx but only to the level of
hypopharynx
c
Slightly effective
Material is removed from the trachea but
only to the level of the larynx
d
Ineffective
Material cannot be removed for the
tracheas nor form the hypopharynx
All patients with disorders of swallowing should undergo
physiotherapy as well as neurological speech therapy, which
involve teaching patients to use maneuvers that facilitate swallowing as well as additional feeding techniques, manual therapy, and posture therapy. Patients should also be provided
with specialist dietary recommendations. The rehabilitation
program and dietary recommendations should be tailored to
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Table 3: Fiberoptic Endoscopic Dysphagia Severity Scale (FEDSS)
CLINICAL
CONSEQUENCES
FEDSS PROTOCOL
MAJOR ABNORMALITIES
Saliva
Penetration / aspiration
Level 6
Oral feeding impossible,
gastrostomy, consider
intubation
Puree
Penetration / aspiration with
or without ineffective defense
reflexes
Level 5
Oral feeding impossible,
gastrostomy
Puree
Penetration / aspiration with
effective defense reflexes
Level 4
Gastrostomy, oral
feeding during speech
therapy
Penetration / aspiration with
or without effective defense
reflexes
Level 4
Gastrostomy, oral
feeding during speech
therapy
Penetration / aspiration with
effective defense reflexes
Level 3
Oral feeding with puree,
intravenous fluids
Solid
Penetration / aspiration with
massive residue in epiglottic
vellaculae and/or in piriform
sinuses
Level 2
Oral feeding with puree
and fluids
Solid
No penetration / aspiration and
mild or moderate residue in
epiglottic vellaculae and/or in
piriform sinuses
Level 1
Oral feeding with light
foods and fluids
Liquid
Liquid
individual patients’ needs taking into consideration their specific structural and neurological dysfunctions as well as general condition.
PART III: EVALUATION OF EFFICACY OF
THERAPEUTIC INTERVENTIONS
FEES can be used in order to evaluate the efficacy of therapeutic interventions in patients with swallowing disorders.
FEES allows to determine the effectiveness of speech therapy
as well as physiotherapy that are indispensable to the treatment of such patients.
CONCLUSIONS:
FEES is a modern diagnostic tool that can be used by the
laryngologist-phoniatrist. It allows to evaluate not only the
structure and function of the nose, pharynx, and larynx, but
also to assess the effectiveness of swallowing of foods differing in consistency. FEES enables one to determine the risk of
silent aspiration, that can be life-threatening. For that reason,
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artykuł poglądowy / review article
FEES should become a part of the workup in all patients with
difficulties in swallowing.
risk factor for serious complications such as an impaired healing of surgical wounds.
Not only is FEES useful in the evaluation of rehabilitative efficacy, but it also aides in the preparation of dietary recommendation for patients with dysphagia. Malnourishment is a
FEES is safe and well tolerated by patients. Nose bleeding occurs only in approximately 6% of cases but it does not require
any intervention (2).
References
1.
Langmore S.E., Schatz K., Olsen N.: Fiberoptic endoscopic examination of swallowing safety: a new procedure. Dysphagia, 1988; 2: 216-219.
2.
Dziewas R.: Swallowing endoscopy. W: Ickenstein W.G., Ambrosi D., Clave P., Dziewas R., Ekberg O., Ende F. et al.: Dignosis and treatment of neurogenic
oropharyngeal dysphagia. Uni-MedVerlag AG, Bremen 2014, 48-52.
3.
Dziewas R., Warnecke T., Ölenberg S., Teismann I., Zimmermann J., Kramer C. et al.: Towards a basic endoscopic assessment of swallowing in acute stroke
– development and evaluation of simple dysphagia score. Cerebrovasc. Dis., 2008; 26: 41-47.
4.
Kelly A.M., Leslie P., Beale T., Payten C., Drinnan M.J.: Fiberoptic endoscopic evaluation of swallowing and videofluoroscopy: does examination type influence perception of pharyngeal residue severity? Clin. Otolaryngol., 2006; 31: 425-432.
5.
Rosenbek J.C., Robbins J.A., Roecker E.B., Coyle J.L., Wood J.L.: A Penetration-aspiration acale. Dysphagia, 1996; 11: 93-98.
6.
Murray J., Langmore S.E., Ginsberg S., Dostie A.: The significance of accumulated oropharyngeal secretions and swallowing frequency in predicting aspiration. Dysphagia, 1996; 11: 99-103.
Word count: 1200 Tables: 3 Figures: 8 References: 6
Access the article online: DOI: 10.5604/20845308.1150791 Full-text PDF: www.otorhinolaryngologypl.com/fulltxt.php?ICID=1150791
Corresponding author: Barbara Jamróz, Warszawski Uniwersytet Medyczny, ul. Banacha 1a, 02-097 Warszawa,
e-mail: [email protected],fax: 48 22 599 25 23
Copyright © 2015 Polish Society of Otorhinolaryngologists Head and Neck Surgeons. Published by Index Copernicus Sp. z o.o. All rights reserved Competing interests: The authors declare that they have no competing interests.
Cite this article as: Jamróz B., Sielska-Badurek E., Niemczyk K.: Used of flexible endoscope during evaluation of swallowing. Pol Otorhino Rev 2015; 4(2): 1-5
POLSKI PRZEGLĄD OTORYNOLARYNGOLOGICZNY, TOM 4, NR 2 (2015), s. 1-5
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