Physical Medicine and Rehabilitation Clinics of North America
Fiberoptic Endoscopic Evaluation of Swallowing
Section snippets
History of the laryngoscopic swallowing evaluation
The development of improved camera technology capable of interfacing with arrayed bundles of ever smaller flexible optical fibers has permitted visualization of anatomic areas that were previously too remote to be inspected routinely for the determination of potential medical conditions. The first of these instruments was a flexible transoral gastroscope patented in 1956. In less than 10 years, Sawashima and Hirose [9] reported the development of a smaller flexible array of optical fibers
Purposes of dysphagia testing
The response to a consultation for the evaluation of a patient with suspected dysphagia should always include a complete medical review and clinical assessment. If the clinical evaluation does not provide sufficient information to allow for confident patient management, an instrumental assessment should be performed [11]. The goals of the two most popular instrumental assessments (ie, FEES and VFSS) are similar in construct. In the course of these examinations the clinician attempts to identify
Endoscopic equipment
The flexible laryngoscope is constructed to cast a “cold” light delivered from a halogen or xenon light source. The light travels along fiberoptic bundles which traverse the length of the scope. Depending on the configuration, the light is diffused through one or two lenses at the tip of the scope to illuminate the area of interest. An analog laryngoscope has a separate lens on the distal end of the scope that collects the reflected image and projects it along another bundle of light fibers to
Laryngoscopic visualization of the pharyngeal swallow
The scope is gently inserted transnasally along the path of least resistance in the most patent naris. This path is generally along the nasal floor below the middle turbinate or between the inferior and middle turbinates. Once a passage has been determined, the scope is continuously inserted until the nasopharyngeal vault is visualized. The clinician should position the scope just anterior to the vomer bone, which demarcates the point where the hard and soft palate articulate. It is at this
Indications for the laryngoscopic evaluation of swallowing
Following a carefully conducted clinical examination (eg, a brief assessment of cognitive status and an oral-peripheral examination), the clinician should determine the field of view necessary to most completely reveal the pathophysiology of the suspected dysphagia. If questions regarding oral stage impairments cannot be answered following the clinical examination or if there is a suspicion of an esophageal component to the dysphagia, a fluoroscopic evaluation should be performed.
Numerous
Risk assessment
Following placement of the tip of the laryngoscope into the pharynx but before the administration of any food and liquid, the clinician has the opportunity to survey the anatomy, elicit physiologic movements, observe the management of secretions, and monitor spontaneous swallows. Edema, postsurgical anatomic changes, and tissue changes secondary to radiation treatment can affect the configuration of the protective mechanisms of the pharynx and larynx and influence the size and shape of the
Conducting the examination
The patient can be sitting in a procedure chair or wheel chair, or can be positioned sitting upright (or as upright as possible) in bed with a hospital tray of food before them for self-feeding. The endoscopist may sit or stand during the procedure. It is recommended that the endoscopist master the performance of the examination while standing, using either hand to control the endoscope, and on either side of the patient to allow for greater mobility when the examination is performed at the
Therapeutic interventions with the laryngoscopic swallowing evaluation
FEES is ideally suited for implementation of various diagnostic interventions before recommending oral feedings. The endoscope can be safely and atraumatically inserted via the most patent naris [24] and, if necessary, reinserted during an evaluation for optimal visualization. Scope placement can also be tolerated for relatively long periods of time (eg, 15 minutes or longer) while different food consistencies, bolus sizes, and therapeutic interventions are tried. Thickener can be added to thin
Visual biofeedback with the laryngoscopic swallowing evaluation
The endoscopist can initially be a passive observer to determine if the patient will swallow on their own depending on the bolus location in the pharynx (eg, triggering of the swallow reflex when the bolus contacts the rim of the aryepiglottic folds). Once a pattern of swallowing is observed, the endoscopist can be directive and inform the patient of the most successful swallow steps or strategies. To aid in pharyngeal clearing, the patient may be instructed to swallow hard two times in rapid
The laryngoscopic swallowing evaluation in specific populations
The applicability of FEES to both diagnose and treat pharyngeal swallowing disorders has grown as clinicians have investigated its efficacy in different patient populations. The categories are varied and include broad patient descriptors as well as specific patient diagnoses. Broad patient descriptors include trauma [27], [28], [29], pediatrics [6], [30], nursing home residents [31], and patients in intensive care units [32] as well as long-term care settings [33]. More specific patient
Future research
Regardless of the mechanism used to assess the swallow, precision in establishing the exact pathophysiology of the dysphagia in a patient is poor [11], [43], [44]. Recent research investigating pharyngeal residue [7] and laryngeal penetration and aspiration [8] using simultaneous FEES and VFSS has concluded that the examinations are not interchangeable because of the unequal judgments made by clinicians when judging pharyngeal residue, laryngeal penetration, and tracheal aspiration. Some
Summary
FEES is a mature evaluation technique that allows for the diagnosis of pharyngeal dysphagia and the implementation of appropriate rehabilitation interventions with the goal of promoting safe and efficient swallowing. Patients of all ages, in different environmental settings, and comprising many diverse diagnoses can benefit from a laryngoscopic swallowing evaluation. The skilled endoscopist knows when to recommend additional testing methods to manage appropriately an individual who presents
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