Low‐risk assessment of swallowing impairment using flexible endoscopy without food or liquid

Will levels of experience of examiners affect the diet provided for patients with swallowing impairment?

OBJECTIVE

Flexible endoscopic evaluation of swallowing (FEES) is widely performed to determine the safety of oral intake. However, evaluation results can vary among examiners depending on their experience. To analyze the impact of such differences, we investigated the diet provided for patients with swallowing impairment evaluated by experienced and inexperienced examiners.

METHODS

We included 20 subjects with swallowing impairment. They underwent FEES twice, once by an experienced examiner (EE) and once by an inexperienced examiner (IE), in random order. The second FEES was generally performed within one month of the first FEES. The diet provided by the EE (EE results) and by the IE (IE results) during and after FEES was investigated and statistically compared. Respiratory and oral intake conditions at each time of FEES were also investigated and the results were included in the corresponding EE or IE results.

RESULTS

The median interval between FEES was 13.5 days. There was no significant difference between the EE and IE results regarding swallowing impairment-related conditions, such as amount of sputum suctioned, oral intake status, or prevalence of fever after FEES. However, there was a significant difference in the texture-modified diet provided after FEES: A close-to-normal diet was provided by the EE compared to the diet provided by the IE.

CONCLUSION

This study demonstrated a difference in the provided diet for patients with swallowing impairment between the examiners with different levels of experience. Our results suggest that EEs may be able to safely recommend patients with swallowing impairment have a close-to-normal diet.

Simple Endoscopic Method of Scoring Swallowing Function After Treatment in Advanced Head and Neck Cancer Patients

The aim of this prospective, observational study was to evaluate the effectiveness of a simple endoscopic method for scoring swallowing function after treatment of advanced head and neck cancer patients. A prospective, observational study was conducted involving 60 patients who had undergone surgery or chemoradiation for advanced head and neck cancer. Endoscopic score of swallowing function, penetration aspiration scale (PAS) score measured by videofluorography, and functional oral intake scale (FOIS) score were recorded, and their correlations were examined. There was a positive correlation between endoscopic and PAS scores. Patients with endoscopic scores of 4 points or more had significantly higher PAS scores and lower FOIS scores than those with scores of 3 points or less. These positive correlations were found only in patients who underwent surgery, and not those who received chemoradiation. This study showed the effectiveness of the simple endoscopic method for scoring swallowing function in patients after surgery for advanced head and neck cancers.

Protocols and assessment procedures in fiberoptic endoscopic evaluation of swallowing: an updated systematic review

INTRODUCTION

Neurological alterations can generate swallowing disorders and fiberoptic endoscopic evaluation of swallowing is one of the tests performed for its diagnosis, as well as assistance in dysphagia management.

OBJECTIVE

To identify and describe a fiberoptic endoscopic evaluation of swallowing standardized protocol for the neurological adult population and its stages.

METHODS

Systematic review registered on the PROSPERO platform (CRD42018069428), carried out on the websites: MEDLINE, Cochrane Library and Scielo; published between 2009 and 2020. Randomized clinical trials, cross-sectional, and longitudinal studies were included. Two independent judges evaluated the study design and extracted the data from the selected studies. Doubts regarding inclusion or not of the studies were evaluated by a third judge. Scientific articles included were those with adult neurological remained patients with outcomes: (1) diagnosis of swallowing disorder (2) change in sensitivity in laryngeal region (3) penetration of food offered (4) aspiration of food offered.

RESULTS

3724 articles were initially selected, after personalized search for patients with neurological alterations 101 studies remained. In the end, 21 qualitative studies from 2009 to 2020 remained in the systematic review and they were described in detail and compared. Seven articles used protocols of the institutions in which the research took place and four mentioned using the same protocol. The reliable reproducibility of the protocols is feasible only in three of the articles, even presenting different protocols.

CONCLUSION

There is no standard or validated protocol to assess the swallowing function of adults with neurological diseases.

Complications during Fiberoptic Endoscopic Evaluation of Swallowing (FEES) in 5680 examinations

OBJECTIVE

To evaluate retrospectively the incidence of complications during Fiberoptic Endoscopic Evaluation of Swallowing (FEES) in 5680 examinations.

PATIENTS AND METHODS

5680 patients were evaluated at the Department of Otorhinolaryngology, Audiology and Phoniatrics of Pisa University Hospital between January 2014 and December 2018, involving both inpatients and outpatients. Most common comorbidities included neurological pathologies such as stroke (11.8%), neurodegenerative diseases (28.9%) and a history of previous head and neck surgery (24.6%). The evaluation was conducted by clinicians with experience in swallowing for a minimum of 10 years with the assistance of one or more speech language pathologists.

RESULTS

In all patients studied the endoscope insertion was tolerated and it was possible to visualize the pharyngo-laryngeal structures. Most patients reported discomfort In a minority of patients, complications were recorded, such as anterior epistaxis, posterior epistaxis, vasovagal crises and laryngospasm. Laryngospasm was recorded in patients affected by Amyotrophic Lateral Sclerosis (ALS). Multivariate binary logistic regression showed that discomfort, chronic gastrointestinal diseases, neurodegenerative diseases and brain tumors were risk factors associated with minor complications.

CONCLUSIONS

FEES proved to be easy to perform, well tolerated by the patients and cost-effective. It can be performed at the patient's bedside and it is characterized by low rate of complications. As a matter of fact, normally only discomfort, gagging and/or vomit are reported. Only rarely complications occur, such as anterior or posterior epistaxis episodes or vasovagal crises, but these are still easily managed. Exceptionally, more severe complications are reported: adverse drug reactions to substances such as blue dye (methylene blue) and local anesthetics (not used in our protocol), and laryngospasm.

The effect of laryngeal elevation training on swallowing function in patients with dysphagia

OBJECTIVE

To investigate the effect of laryngeal elevation training without highly loaded head lifting on swallowing function in patients with dysphagia.

METHODS

Fifty-seven patients with dysphagia (36 men; mean age, 78.5 ± 11.4 years) were included. All participants performed the swallowing forehead exercise and the chin push-pull manoeuvre for two months. Videoendoscopy to assess swallowing function, the peak expiratory flow test and the hand grip strength test were performed at the initial visit (time 1) and two months after the start of the intervention (time 2). We used the Hyodo score, a scoring method for videoendoscopic assessment, for evaluation of swallowing function.

RESULTS

The linear mixed model showed a significant main effect of time (the Hyodo score at time 1 was greater than the score at time 2). The effects of the co-variates were not significant.

CONCLUSION

The present study demonstrated the significant effect of laryngeal elevation training without head lifting on the Hyodo score.

Association between swallowing function and muscle strength in elderly individuals with dysphagia

OBJECTIVE

This study aimed to investigate the association among swallowing function, hand grip strength, and peak expiratory flow in elderly patients with dysphagia.

METHODS

A total of 35 patients (26 men and 9 women, 80.7 ± 8.1 years) were included in the final analysis. They underwent videoendoscopy (VE) for the assessment of swallowing function, hand grip strength test, and peak expiratory flow test. We used the Hyodo score, the objective scale of VE developed by Hyodo et al. (2010), which consists of the following 4 parameters: salivary pooling degree at the vallecula and pyriform sinuses, glottal closure reflex induced by touching of the endoscope to the epiglottis or arytenoid, swallowing reflex initiation assessed by "white-out" timing, and pharyngeal clearance after blue-dyed water is swallowed.

RESULTS

The Hyodo score significantly correlated to hand grip strength and peak expiratory flow, and hand grip strength was significantly correlated to peak expiratory flow. Although a significant correlation was noted between the Hyodo score and hand grip strength after adjustment for peak expiratory flow, no significant correlation was found between the Hyodo score and peak expiratory flow after adjustment for hand grip strength.

CONCLUSIONS

This study indicated that unlike peak expiratory flow, hand grip strength is associated with swallowing function, which was evaluated by an objective scale, and can be used as an indicator for whole body muscle strength. This result may contribute to the investigation of the effect of muscle training on dysphagia.