Values and limitations of pharyngolaryngoscopy (transnasal, transoral) in patients with dysphagia

Phoniatricians and otorhinolaryngologists approaching oropharyngeal dysphagia: an update on FEES

Purpose

Oropharyngeal dysphagia (OD) is a common phenomenon in otorhinolaryngology and phoniatrics. As both sub-disciplines have a strong tradition and clinical experience in endoscopic assessment of the upper aerodigestive tract, the implementation of fiberoptic endoscopic evaluation of swallowing (FEES) was an almost self-evident evolution. This review aims to provide an update on FEES and the role of phoniatricians and otorhinolaryngologists using FEES in Europe.

Methods

A narrative review of the literature was performed by experts in the field of FEES both in the clinical context and in the field of scientific research.

Results

FEES is the first-choice OD assessment technique for both phoniatricians and otorhinolaryngologists. FEES is becoming increasingly popular because of its usefulness, safety, low costs, wide applicability, and feasibility in different clinical settings. FEES can be performed by health professionals of varying disciplines, once adequate knowledge and skills are acquired. FEES aims to determine OD nature and severity and can provide diagnostic information regarding the underlying etiology. The direct effect of therapeutic interventions can be evaluated using FEES, contributing to design the OD management plan. Standardization of FEES protocols and metrics is still lacking. Technological innovation regarding image resolution, frame rate frequency, endoscopic light source specifications, and endoscopic rotation range has contributed to an increased diagnostic accuracy.

Conclusion

The rising number of phoniatricians and otorhinolaryngologists performing FEES contributes to the early detection and treatment of OD in an aging European population. Nevertheless, a multidisciplinary approach together with other disciplines is crucial for the success of OD management.

Evaluation of swallowing function in patients with oropharyngeal secretions

Background

Several studies have reported a strong association between the presence of oropharyngeal secretions in the laryngeal vestibule and the likelihood of aspiration of food or liquid. However, no previous studies have evaluated the accumulation of saliva and swallowing dynamics.

Objective

The objective of this study was to examine the factors related to decreased function that result in saliva accumulation based on images from videofluoroscopic examination of swallowing (VF) performed on the same day as videoendoscopic examination of swallowing (VE).

Methods

This retrospective study investigated 47 patients with dysphagia who underwent VF and VE on the same day. Saliva accumulation in the pharynx was assessed on VE and classified by the Murray secretion scale. Pharyngeal residue was assessed on VF. In addition, displacement of the hyoid bone and larynx on swallowing and the opening size of the esophageal orifice were measured, and contact between the base of the tongue and the posterior pharyngeal wall was examined on VF.

Results

Moderate correlations were found between saliva accumulation and perpendicular displacement of the larynx and upper esophageal sphincter opening. The percentage of patients showing contact between the base of the tongue and the posterior pharyngeal wall was significantly greater in those with a saliva accumulation score of 0 or 1.

Conclusion

Less laryngeal elevation and upper esophageal sphincter opening and absence of contact between the base of the tongue and the posterior pharyngeal wall when swallowing tended to result in accumulation of saliva in the pharynx.

Position paper of the German Society of Oto-Rhino-Laryngology, Head and Neck Surgery and the German Society of Phoniatrics and Pediatric Audiology - Current state of clinical and endoscopic diagnostics, evaluation, and therapy of swallowing disorders in children

Swallowing disorders are frequent. The main concern is mortality due to aspiration-induced pneumonia and malnutrition. In addition, quality of life is severely affected. The demographic trend indicates an increase of dysphagia in the future. Neurodegenerative diseases, tumors of the digestive tract, and sequelae of tumor treatment in the head and neck region are the main pathologic entities.

Predominantly ENT physicians and phoniatricians are asked for diagnostics and therapy, and will coordinate the interdisciplinary treatment according to the endoscopic findings.

A differentiated approach in history, diagnostics, and symptom-oriented treatment is necessary for these mostly complex disorders. Integration of non-medical staff such as speech therapists, physiotherapists, and occupational therapists in planning and executing an effective therapy expands and completes the patient-oriented care. Conservative treatment by these therapists is an important pillar in the treatment. Parts of the specific diagnostics can be taken over in close cooperation.

In particular, an interdisciplinary cooperation with the staff of intensive care medicine is essential.

The diagnostic procedures of specific endoscopy as described in this position paper are part of the primary and fundamental tasks of ENT specialists and phoniatrists.

Endoscopy is a medical service that is basically not delegable. Consequently, substitution of the physician is excluded.

[Position paper of the German Society of Oto-Rhino-Laryngology, Head and Neck Surgery and the German Society of Phoniatrics and Pediatric Audiology - current state of clinical and endoscopic diagnostics, evaluation, and therapy of swallowing disorders in children and adults]

Position Paper of the German Society of Oto-Rhino-Laryngology, Head and Neck Surgery and the German Society of Phoniatrics and Pediatric Audiology - Current State of Clinical and Endoscopic Diagnostics, Evaluation, and Therapy of Swallowing Disorders in Children and AdultsSwallowing disorders are frequent. The main concern is mortality due to aspiration induced pneumonia and malnutrition. On the other hand quality of life is severely affected. The demographic trend indicates an increase of dysphagia in the future. Neurodegenerative diseases, tumors of the digestive tract and sequelae of tumor treatment in the head and neck region are the main pathologic entities.Predominantly ENT physicians and phoniatrists, are asked for diagnostics and therapy who will coordinate the interdisciplinary treatment according to the endoscopic findings.A differentiated approach in history, diagnostics, and symptom oriented treatment is necessary for the mostly complex disorders. The integration of non-medical personnel such as logopeds (speech language pathologists), physiotherapists, and occupational therapists in planning and executing an effective therapy expands and completes the patient-oriented care. Conservative treatment by these therapists is an important pillar in the treatment. Parts of the specific diagnostics can be taken over by them in close cooperation.In particular an interdisciplinary cooperation with the staff from intensive care medicine is indispensable.The diagnostic procedures of specific endoscopy as described in this position paper are part of the primary and fundamental tasks of ENT specialists and phoniatrists.Endoscopy is a medical service that is basically not delegable. Consequently substitution of the physician is precluded.

The reliability and validity of cervical auscultation in the diagnosis of dysphagia: a systematic review

Objective:

To systematically review the available evidence for the reliability and validity of cervical auscultation in diagnosing the several aspects of dysphagia in adults and children suffering from dysphagia.

Data sources:

Medline (PubMed), Embase and the Cochrane Library databases.

Review methods:

The systematic review was carried out applying the steps of the PRISMA-statement. The methodological quality of the included studies were evaluated using the Dutch ‘Cochrane checklist for diagnostic accuracy studies’.

Results:

A total of 90 articles were identified through the search strategy, and after applying the inclusion and exclusion criteria, six articles were included in this review. In the six studies, 197 patients were assessed with cervical auscultation. Two of the six articles were considered to be of ‘good’ quality and three studies were of ‘moderate’ quality. One article was excluded because of a ‘poor’ methodological quality. Sensitivity ranges from 23%–94% and specificity ranges from 50%–74%. Inter-rater reliability was ‘poor’ or ‘fair’ in all studies. The intra-rater reliability shows a wide variance among speech language therapists.

Conclusion:

In this systematic review, conflicting evidence is found for the validity of cervical auscultation. The reliability of cervical auscultation is insufficient when used as a stand-alone tool in the diagnosis of dysphagia in adults. There is no available evidence for the validity and reliability of cervical auscultation in children. Cervical auscultation should not be used as a stand-alone instrument to diagnose dysphagia.

Oropharyngeal dysphagia in patients with multiple sclerosis: do the disease classification scales reflect dysphagia severity?

Multiple sclerosis is a neurological disease that involves swallowing disorders. Many studies have shown an association between neurological and swallowing performance, but results have been conflicting.

Objective

To identify the frequency of dysphagia in patients with multiple sclerosis and neurological indicators that can represent the performance of swallowing.

Method

In this study (cross-sectional) 120 Multiple Sclerosis patients underwent Functional Assessment of Swallowing by flexible nasal-pharyngo-laryngoscopy and the results were compared with the scores of the rating scales: (Clinical Evolving Forms of Disease, Functional Disability Scale for and Scale Systems Extended Functional Disability [Kurtzke Expanded Disability Status Scale]).

Results

Dysphagia was found in 90% of patients. Among the clinical forms of the disease, the progressive forms (primary progressive and secondary progressive) were more frequently associated with severe dysphagia, while the relapsing-remitting form presented more often mild and moderate dysphagia. Regarding the Disability Scale for Functional Systems, cerebellar function, brainstem function and mental health were associated with dysphagia, especially in the severe form. Regarding the Extended Functional Disability Scale, higher scores were associated with severe dysphagia.

Conclusion

Dysphagia is common in MS patients, especially in those with greater impairment of neurological functions.

Morpho-functional patterns of physiologic oropharyngeal swallowing evaluated with dynamic fast MRI

With the advent of dynamic fast MRI sequences the act of deglutition can be dynamically visualized in cine-mode. Twenty-three healthy volunteers were enrolled in this study to define the morpho-functional patterns of oral and pharyngeal deglutition using new dynamic MRI techniques. All subjects were previously submitted to video endoscopic assessment, to exclude swallowing abnormalities. As contrast material a combination of yogurt mixed with gadolinium-diethylene diamine pentaacetic acid was used. The protocol was divided into three parts: (a) preliminary assessment of the oral cavity, pharynx and laryngeal structures; (b) morphologic assessment of tongue, soft palate, pharynx, epiglottis and larynx-hyoid bone; (c) dynamic assessment of swallowing without administrating any contrast media and, in subsequent phase, by injecting 5 ml of yogurt-based contrast medium in the patient's mouth. The time resolution was 3-4 images/s. The MR protocol revealed to be effective in the evaluation of normal motility patterns of the structures involved in swallowing. Moreover, the evaluation of the bolus progression, slowdown or stagnation, was possible. On the contrary problems were encountered in calculating precisely the bolus progression time, because of the insufficient temporal resolution. However, more energy should be invested to optimize the spatial and temporal resolution of turbo-FLASH sequences, to obtain a better dynamic representation of a complex function such as deglutition.

Swallowing disturbance pattern relates to brain lesion location in acute stroke patients

BACKGROUND AND PURPOSE

The relationship of brain lesion location and swallowing disturbance pattern has been poorly studied in acute stroke patients.

METHODS

Sixty patients with first-ever acute ischemic stroke at clearly assessed location and clinical signs of dysphagia were studied. Swallowing-related parameters rated clinically and fiberendoscopically were attention deficit, buccofacial apraxia, orofacial paresis, gag reflex, delay of pharyngeal swallow, pharyngeal contraction, larynx elevation, function of upper esophageal sphincter (UES), and aspiration severity.

RESULTS

Attention deficit was independently predicted only by parietotemporal infarction, buccofacial apraxia by left-sided parietotemporal infarction, orofacial paresis by infarction encompassing upper motor neuron of cranial nerves, and impaired UES opening by lateral medullary infarction. Other swallowing parameters were not related to lesion topology. On posthoc analysis, pneumonia within 21 days after stroke was predicted only by insular lesion.

CONCLUSIONS

Distinct acute brain lesion locations result in characteristic swallowing disturbance patterns. Dysphagic patients with insular stroke appear to have even higher risk of pneumonia suggesting a further associated factor promoting infection in these subjects.

Fiberoptic endoscopic evaluation of swallowing

Fiberoptic endoscopic evaluation of swallowing is a technique that allows for the assessment of pharyngeal dysphagia and the implementation of rehabilitation interventions with the goal of promoting safe and efficient swallowing. An overview of the equipment needed for the laryngoscopic evaluation, how to conduct the examination, what can be visualized endoscopically, diagnostic parameters, the implementation of therapeutic strategies, and suggestions for future research are discussed herein.

Severe dysphagia in lower cranial nerve involvement as the initial symptom of Wegener's granulomatosis

We observed a 42-year-old woman presenting with severe dysphagia secondary to paralysis of the lower cranial nerves and right phrenic nerve involvement, followed by respiratory failure. An EMG confirmed bilateral denervation of the 9th, 10th, 11th and 12th cranial nerves and right phrenic nerve. Videolaryngoscopy showed bilateral vocal fold immobility. Anemia, elevated ESR, microhematuria and C-ANCA (PR-3) antibodies were detected. Brain MRI and CSF were normal. A chest CT showed bilateral, irregular pulmonary lesions. An 18F-FDG total body scan showed diffuse hypermetabolic regions in both pulmonary bases, in the mediastinic region and in the rhinopharynx, raising the suspicion of a neoplastic process. A transthoracic biopsy disclosed nodular granulomatous aggregates with multinucleated giant cells, supporting the diagnosis of Wegener's granulomatosis. Immunosuppressive therapy achieved complete clinical resolution and cleared the pulmonary lesions. To the best of our knowledge this is the first report of Wegener's granulomatosis presenting with neurogenic dysphagia due to lower cranial nerve palsy.

[Management of oropharyngeal dysphagia. Current status]

The diagnostics and therapy of oropharyngeal dysphagia fall within the competence of ENT, phoniatrics and speech language pathology. Due to etiologic diversity, interdisciplinary management is necessary in many cases. After taking a thorough history, focused on swallowing, dynamic instrumental examination methods, i.e. videoendoscopic and videofluoroscopic swallowing studies, allow an evaluation of the morphology and function of the act of swallowing. Videoendoscopic swallowing studies enable the ENT specialist/phoniatrician to decide on further diagnostic steps, to establish a therapy and to recommend the type of feeding (oral, non-oral). Therefore, in clinical routine, knowledge of the diagnostics and therapy of swallowing disorders is indispensable for the ENT specialist/phoniatrician.

Evaluation of oropharyngeal dysphagia: which diagnostic tool is superior?

PURPOSE OF REVIEW

As flexible endoscopic examinations of swallowing become more widely used to evaluate patients with oropharyngeal dysphagia, it is important to be aware of research regarding the efficacy of this procedure as compared with the videofluoroscopy procedure. A recent evidence-based review of the field threw some long-held findings into question and has stimulated a surge of new research studying the sensitivity of the two instrumental examinations, health outcomes of patients who receive each procedure, and a look at different patient outcomes.

RECENT FINDINGS

Since 1999, one quasi-randomized clinical trial has directly compared outcomes of patients given a fluoroscopy versus a fiberoptic endoscopic evaluation of swallowing (FEES) examination. This study showed no significant difference in pneumonia rates between the two groups of patients. A multitude of studies have shown a high level of agreement between the two instrumental examinations, and the use of the term gold standard as applied to fluoroscopy is no longer appropriate. The attempt to standardize each examination has been slow, and inter-judge reliability of results has come under fire. Several new scales for quality of life and functional status are now ready to be applied to research that can measure outcomes other than pneumonia.

SUMMARY

Research to date has suggested that both instrumental examinations are valuable. It is likely that both will continue to be used and will be seen as complementary rather than competitors.

Treatment of lipid disorders after stroke

The efficacy of lipid disorder therapy for the primary and secondary prevention of coronary heart disease is established. There are, however, no completed studies specifically directed at reducing the risk of stroke with lipid therapy. Although observational cohort studies have failed to demonstrate an association between lipid disorders and stroke incidence, recently completed trials of subjects at risk for coronary heart disease have shown that statins and fibric acid derivatives reduce not only the risk of myocardial infarction and death, but also that of brain infarction and transient ischemic attacks. Lipid drugs are well tolerated and treatment complications are relatively low. It seems prudent to conclude that the stroke patient with an undesirable lipid profile who has a history of coronary heart disease should receive specific treatment for the lipid disorder. Recommendations are more problematic for stroke patients with lipid disorders but no history of coronary heart disease; most should receive therapy for primary prevention of heart disease. Lipid treatment trials focused on stroke risk reduction are urgently needed.

Recent developments in diagnosis and intervention for aspiration and dysphagia in stroke and other neuromuscular disorders

This review discusses the impact of the evidence-based report on dysphagia diagnosis and treatment in stroke patients prepared in 1999 by ECRI under contract with the Agency for Healthcare Research and Quality (AHRQ). Subsequent research findings are highlighted and research design and reporting problems in the field are discussed. Progress has been made toward standardizing training and rating of videofluoroscopic studies of swallowing (VFSS); however, a consensus does not yet exist. A randomized, controlled trial demonstrated that treatment directed by fiber-optic endoscopic evaluation of swallowing with sensory testing (FEESST) or VFSS resulted in approximately equivalent pneumonia rates. These two different methods provide both overlapping and complementary information. There is discussion of the research design problems of mixed patients versus homogeneous populations, case-control diagnostic studies, inappropriate calculations of diagnostic sensitivity/specificity using imperfect "gold standards," the lack of concurrent control groups in treatment studies, and the misuse of statistical significance tests and P values in examining matching of patient characteristics in comparative studies and in identifying important variables in regression analysis.

Esophageal motor disorders

Motor dysfunction is responsible for symptomatic illnesses both in the proximal skeletal muscle region and in the distal smooth muscle esophagus. Practical methods for diagnosing and treating oropharyngeal dysphagia continue to reach consensus. Achalasia, the most significant of the distal motor disorders, is of investigative interest because of the expanded armamentarium of treatment options. Minimally invasive surgical methods have taken an important foothold as a primary treatment of this disorder. Appreciation is growing for sensory dysfunction that accompanies distal motor disorders. Such dysfunction may help explain the observed discrepancies between symptoms and measurable motility abnormality.