Muscle Tension Dysphagia: An Expanded Investigation of Clinical Presentations and Swallowing Kinematics.

PURPOSE: This study retrospectively examined patient-reported symptoms, quality of life, and swallowing kinematics in individuals with presumed muscle tension dysphagia (MTDg). METHOD: Twenty-six individuals met the inclusion criteria. Data were gathered from patient-reported outcome measures (PROs), symptomology, clinician reports of palpation, and hyolaryngeal and hyoid movements measured on a 20-ml thin liquid bolus during videofluoroscopic swallowing studies. RESULTS: All PROs were outside of typical limits, except for the Voice Handicap Index-10. Mean hyoid excursion was 1.52 cm (SD = 0.46, range: 0.76-2.43), and hyolaryngeal excursion was 0.77 cm (SD = 0.44, range: -0.42-1.68). A minority of participants (4%-19%) demonstrated atypical hyoid and/or hyolaryngeal excursion compared to the available normative reference value sets. CONCLUSIONS: Individuals demonstrated abnormalities in the clinical evaluation of the areas of palpation and reported perilaryngeal discomfort and symptoms of laryngeal hyperresponsiveness, with a negative impact on their quality of life across various PROs. Atypical hyoid and/or hyolaryngeal excursion during swallowing was rare when compared to available normative reference values. The clinical evaluation of MTDg may be enhanced by including components related to muscle tension and laryngeal hyperresponsiveness in order to differentiate MTDg from idiopathic functional dysphagia and lead the patient to the otolaryngology/speech-language pathology clinic for intervention and management.

Impact of Patient Factors on Attendance at Remote Telehealth Swallow Therapy.

In-person swallow therapy is a primary and effective treatment for dysphagia. However, remote telehealth is now a widely utilized component of healthcare delivery for therapeutic interventions. This study evaluates potential factors influencing attendance at telehealth swallow therapy. Retrospective review of 308 patients referred for telehealth swallow therapy from April 2020-November 2021 included patient referral diagnosis, diagnostic swallowing evaluations, and sociodemographic information including age, race, health insurance, interpreter use, and socioeconomic status. Univariable and multivariable analyses compared patient and appointment factors for those who attended telehealth swallow therapy with those who did not attend. Overall, 71.8% of patients attended at least one telehealth swallow therapy appointment while 28.2% did not attend any. The most common referral diagnoses were "Cancer" (19.2%) and "Dysphagia Unspecified" (19.2%). Patients diagnosed with "Cancer" and "Muscle Tension" were significantly less likely to attend telehealth swallow therapy compared to those with "Dysphagia Unspecified," "Globus," and "Gastroesophageal Reflux Disease/Laryngopharyngeal Reflux" after adjusting for covariates. Lower socioeconomic status (p = 0.023), no interpreter use (p < 0.001), and more diagnostic evaluations (p = 0.001) correlated with higher telehealth swallow therapy attendance. Race and sex did not correlate with attendance. Most patients referred to telehealth swallow therapy attended at least one appointment. Patients with dysphagia associated with cancer and muscle tension, those with higher socioeconomic status, interpreter use, and fewer diagnostic swallowing evaluations were less likely to attend telehealth swallow therapy. Future research should investigate and compare attendance and efficacy of telehealth swallow therapy with in-person therapy.

Socioeconomic Impact on Swallow Therapy Attendance.

Dysphagia negatively impacts quality of life and increases health care costs. Swallow therapy is the primary and effective treatment for dysphagia of various etiologies, and attendance is critical to success. This study seeks to identify barriers to swallow therapy attendance at a tertiary care, safety-net hospital. A total of 309 patients were referred for swallow therapy from January 1, 2018, to April 30, 2019. Patients were divided into those who "Attended" at least one swallow therapy appointment and those who "Did not Attend" any swallow therapy appointment. Demographics, socioeconomic factors, and diagnosis prompting therapy referral were compared between the two groups. Socioeconomic status (SES) was based on insurance status and income. 177 patients (57%) attended at least one swallow therapy appointment and 132 (43%) did not attend any appointments. Overall, 240 (78%) patients had public insurance and 69 (22%) had private insurance. Analysis of SES status identified 106 (34%) patients as double-low SES, 157 (51%) as low SES, and 43 (14%) as high SES. Referral diagnoses were "Dysphagia-unspecified type" (n = 119, 38%), "Cancer" (n = 66, 21%), "Neurologic" (n = 46, 15%), "Globus" (n = 29, 9%), "Aspiration" (n = 17, 6%), "Reflux" (n = 17, 6%), and "Throat Pain" (n = 15, 5%). No patient demographic factors, SES factors, or referral diagnosis correlated significantly with swallow therapy attendance. Overall, swallow therapy attendance was poor. In this group, socioeconomic and demographic factors did not significantly impact swallow therapy attendance. Future research should focus on identifying barriers to swallow care and strategies to improve attendance.

Conceptualizing Adult Dysphagia in the United States Within the International Classification of Functioning, Disability and Health (ICF).

Despite the well-documented safety concerns and effect on quality of life, there does not yet exist a wide-reaching framework that links the etiologies of swallowing disorders to the potential short- and long-term outcomes in the context of International Classification of Functioning, Disability and Health (ICF). This paper introduces an expert-reviewed conceptual framework to highlight common etiologies of dysphagia as well as integrate immediate outcomes of dysphagia with long-term outcomes of dysphagia in terms of medical problems, health-related quality of life, functional effect, and psychosocial features. It also outlines the potential cyclical nature of long-term dysphagia outcomes perpetuating the original dysphagia. This framework serves to inform clinicians of important dysphagic outcomes and to bring awareness to long-term outcomes that should be monitored by health care professionals, caregivers, or people with dysphagia.

Does doffing the FEES Box generate a significant cloud of particles after aerosol-generating procedures? A proof-of-concept study.

PURPOSE: The spread of airborne diseases, including coronaviruses, remains a widespread public health concern. Published studies outline the use of protective barriers to limit the spread of pathogenic particles and droplets resulting from coughing, sneezing, and talking. The findings suggest a role for these barriers during aerosol-generating procedures, such as flexible endoscopic evaluation of swallowing (FEES). However, the question remains of whether doffing a protective barrier will create a concentrated cloud of particles that will increase health professionals' exposure. METHOD: We simulated four clinical scenarios of coughing and sneezing, talking, eating and drinking, and delivering supplemental oxygen to test whether doffing the FEES Box protective barrier would result in a particle cloud. RESULT: For all scenarios simulated, doffing the FEES Box did not result in a significant increase in mean particle count. Further, the manner of FEES Box removal did not significantly influence mean particle counts on a consistent basis. CONCLUSION: These results suggest that doffing the FEES Box does not increase exposure to airborne particles. Although more research is needed to confirm these findings, FEES Box usage should be considered during aerosol-generating procedures, to protect and reassure healthcare professionals who work with patients with COVID-19 or other airborne diseases.

Confidence, Accuracy, and Reliability of Penetration-Aspiration Scale Ratings on Flexible Endoscopic Evaluations of Swallowing by Speech Pathologists.

This study investigated rater confidence when rating airway invasion with the penetration-aspiration scale (PAS) on flexible endoscopic evaluations of swallowing (FEES), raters' accuracy against a referent-standard, inter-rater reliability, and potential associations between clinician confidence, experience, and accuracy. Thirty-one clinicians who use FEES in their daily practice were asked to judge airway invasion with the PAS and to rate their confidence that their score was correct (0-100) for 40 video clips, five in each of the 8 PAS categories. We found that raters were most confident in rating PAS 1, 7, and 8. The average confidence score across all videos was 76/100. Confidence did not have a significant relationship with accuracy against the referent-standard. Accuracy was highest for PAS 1 (92%), followed by PAS 8 (80%), PAS 7 (77%), and PAS 4 (72%). Accuracy was below 60% for PAS 2, 3, 5, and 6, the lowest being for PAS 3 (49%). Mean accuracy for all ratings, compared to referent-standard ratings, was highest for the intermediate group (71%), followed by expert (68%) and novice (65%). In general, we found that certain PAS scores tend to be rated more accurately, and that participating SLPs had varied confidence in PAS ratings on FEES. Potential reasons for these findings as well as suggested next steps are discussed.

Absent epiglottic inversion as seen on flexible endoscopic evaluations of swallowing (FEES) is associated with a gestalt reduction in swallowing mechanics.

PURPOSE: Epiglottic inversion, which provides one layer of the requisite protection of the airway during swallowing, is dependent on a number of biomechanical forces. The aim of this study was to examine the association between swallowing mechanics, as visualized during a Modified Barium Swallow (MBS) exam, and the rating of epiglottic inversion as seen on Flexible Endoscopic Evaluation of Swallowing (FEES). METHODS: This study analyzed twenty-five adult outpatients referred for a simultaneous FEES/MBS exams. Each participant swallowed a 5 mL thin liquid bolus, which was the bolus size analyzed for this study's question. Epiglottic inversion, as seen on FEES, was rated by three independent raters. Additionally, twelve swallowing landmarks tracked the shape change of each participant's swallow on the MBS video using a MatLab-specific tracking tool. Analyses were run to determine mean differences in swallowing shape change between the swallows across 3 groups: complete, reduced, and absent epiglottic inversion, as seen on FEES. Using a Computerized Analysis of Swallowing Mechanics (CASM), canonical variate analyses and discriminant function testing were carried out. Other swallowing mechanics were also analyzed for kinematic movements to isolate the function of the hyoid and larynx. A two-sample t-test was conducted to compare mean hyolaryngeal movement between complete and incomplete epiglottic inversion groups. RESULTS: Overall swallowing shape changes were statistically significantly different between the absent, reduced, and complete epiglottic inversion groups on FEES. Canonical variate analyses revealed a significant overall effect of shape change between the groups (eigenvalue = 2.46, p < 0.0001). However, no statistically significant differences were found on hyoid excursion (p = 0.37) and laryngeal elevation (p = 0.06) kinematic measurements between patients with complete and incomplete epiglottic inversion on FEES. CONCLUSION: Epiglottic inversion on FEES is a valuable rating that infers reduced range of motion of structures that cannot be seen on FEES. This small sample of patients suggests that FEES ratings of absent epiglottic inversion may represent gestalt reduction in swallowing mechanics.

The FEES box: A novel barrier to contain particles during aerosol-generating procedures.

PURPOSE: Due to the COVID-19 pandemic, aerosol-generating procedures (AGPs) such as flexible endoscopic evaluation of swallowing (FEES) have been deemed high-risk and in some cases restricted, indicating the need for additional personal protective equipment. The aim of this study was to erect and study a protective barrier for FEES. MATERIALS AND METHODS: A PVC cube was constructed to fit over a patient while allowing for upright endoscopy. A plastic drape was fitted over the cube, and the protective barrier was subsequently named the "FEES Box." Three different particulate-generating tasks were carried out: sneezing, coughing, and spraying water from an atomizer bottle. Each task was completed within and without the FEES Box, and particulate was measured with a particle counter. The average particles/L detected during the three tasks, and baseline measurements, were statistically compared. RESULTS: Without the FEES Box in place, the sneezing and spraying tasks resulted in a statistically significant increase in particles above baseline (p < 0.001 and p = 0.004, respectively); coughing particulate never reached levels significantly higher than baseline (p = 0.230). With use of the FEES Box, there was no statistically significant increase in particles above baseline in any of the three tasks. CONCLUSION: The FEES Box effectively contained particles generated during sneezes and an atomizer spray. It would also likely mitigate coughing particulate, but coughing did not generate a significant increase in particles above baseline. Further research is warranted to test the efficacy of the FEES Box in containing particulate matter during a complete FEES procedure.

Measuring Vallecular Volume on Flexible Endoscopic Evaluation of Swallowing: A Proof of Concept Study.

Currently, no method exists to measure the size of pharyngeal and laryngeal structures on endoscopy. Imaging for dysphagia diagnostic techniques, for the most part, still relies on qualitative assumptions and cursory visual examinations to induce patients' swallowing safety and function. In this proof of concept study, we measured vallecular cavity volume using simultaneous modified barium swallows (MBS) and flexible endoscopic evaluation of swallowing (FEES). Similar to the three-dimensional image compilation fields of facial reconstruction, medical imagery, and forensic science, this proposed methodology combines the two-dimensional images yielded in FEES and MBS videos to calculate estimates of the valleculae in a 3D perspective. A tracking tool was used to measure distances on MBS, while endoscopic specifications were used to find distances on FEES. This combination of ratio measurements allowed for measurement on both the MBS and FEES. In a sample of n = 37 dysphagia patients referred for MBS/FEES studies, the mean distance from the tip of endoscope to the closest point of epiglottis was 25.38 mm, the mean vallecular area outlined on MBS video was 84.72 mm2, the mean epiglottal width was 18.16 mm, and the mean vallecular volume was 1.55 mL. Future application could include tracking growth of tumors, glottic opening, volume of residue and tracking of any other important outcome involving movement, size, and targets of interest with higher precision.

Pilot Study of Quantitative Methods for Differentiating Pharyngeal Swallowing Mechanics by Dysphagia Etiology.

Quantitative analysis of modified barium swallow (MBS) imaging is useful to determine the impact of various disease states on pharyngeal swallowing mechanics. In this retrospective proof of concept study, kinematic analysis and computational analysis of swallowing mechanics (CASM) were used to demonstrate how these methods differentiate swallowing dysfunction by dysphagia etiology. Ten subjects were randomly selected from four cohorts of dysphagic patients including COPD, head and neck cancer (HNC), motor neuron disease, and stroke. Each subject was age- and gender-matched with healthy, non-dysphagic controls. MBS videos of 5 ml thin and 5 ml thick bolus trials from each subject were used. A MATLAB tracker tool was adapted and updated to collect and compile data for each video (n = 160). For kinematic measurements, a MANOVA was performed with post-hoc analyses to determine group differences. For CASM measurements, a morphometric canonical variate analysis with post hoc analysis was performed to determine group differences. Kinematic analyses indicated statistically significant differences between HNC cohort and controls in distance measurements for hyolaryngeal approximation (p = .001), laryngeal elevation (p = 0.0001), pharyngeal shortening (p = 0.0002), and stage transition duration timing (p = 0.002). Timing differences were noted between the stroke cohort and controls for pharyngeal transit time (p = 0.007). Multivariate morphometric canonical variate analysis showed significant differences between etiology groups (p < 0.0001) with eigenvectors indicating differing patterns of swallowing mechanics. This study demonstrated that swallowing mechanics among cohorts of dysphagic patients can be differentiated using kinematics and CASM, providing different but complementary quantitative methods for investigating the impact of various disease states on swallowing function.

Transcranial direct current stimulation for post-stroke dysphagia: a systematic review and meta-analysis of randomized controlled trials.

BACKGROUND: Transcranial direct current stimulation (tDCS) has been investigated as a tool for dysphagia recovery after stroke in several single-center randomized controlled trials (RCT). OBJECTIVE: The aim of this investigation was to quantitatively evaluate the effect of tDCS on dysphagia recovery after a stroke utilizing a systematic review and meta-analysis. METHODS: Major databases were searched through October 2019 using a pre-defined set of criteria. Any RCT investigating the efficacy of tDCS in post-stroke dysphagia using a standardized dysphagia scale as outcome measure was included. Studies were assessed for risk of bias and quality using the Physiotherapy Evidence Database (PEDro) scale. Effect sizes were calculated from extracted data and entered into a random effects analysis to obtain pooled estimates of the effect. RESULTS: Seven RCTs with a total sample size of 217 patients fulfilled the criteria and were included in the analysis. The overall results revealed a small but statistically significant pooled effect size (0.31; CI 0.03, 0.59; p = 0.03). The subgroup which explored the stimulation intensity yielded a moderately significant effect size for the low-intensity stimulation group (g = 0.44; CI = 0.08, 0.81 vs. g = 0.15, CI - 0.30, 0.61). For the other subgroup analyses, neither comparisons of affected vs. unaffected hemisphere or acute vs. chronic stroke phase revealed a significant result. CONCLUSION: This meta-analysis demonstrates a modest but significant beneficial effect of tDCS on improving post-stroke dysphagia. Whether benefits from this intervention are more pronounced in certain patient subgroups and with specific stimulation protocols requires further investigation.

Swallowing Patterns in the HNC Population: Timing of Penetration-Aspiration Events and Residue.

OBJECTIVE: This study described swallowing patterns in a large head/neck cancer (HNC) cohort. STUDY DESIGN: In a retrospective review of data from a randomized controlled trial, we studied timing of penetration events as they related to aspiration and oral/pharyngeal residue. SETTING: Retrospective review of a multicenter randomized controlled trial. SUBJECTS AND METHODS: In total, 168 patients who were >3 months postradiation received baseline modified barium swallow evaluations. Retrospective analyses of data from these exams were studied, including Penetration-Aspiration Scale (PAS) scores and timing of these events (before, during, or after the swallow), as well as percentage of oral and pharyngeal residue. RESULTS: Aspiration occurred more frequently after than before or during the swallow (P < .05). There were significantly more events of penetration that led to aspiration after the swallow (n = 260) when compared to events before (n = 6) or after (n = 81) the swallow. There was more pharyngeal (16%-25%) than oral residue (5%-20%). Weak correlations were found between thin liquid, nectar-thick liquid, pudding residue, and PAS scores, with varying significance (pharyngeal residue/PAS rs: .26*, .35*, .07*; oral residue/PAS rs: .21*, .16, .3; *P < .05). CONCLUSION: The predominant pattern for this sample of postradiation patients with HNC with dysphagia was aspiration that occurred after the swallow, rather than before or during the swallow. The aspiration was directly caused by penetration events that occurred during the swallow, resulting in aspiration as the airway reopened. Patients demonstrated more pharyngeal residue than oral residue, but a weak relationship was found between residue and penetration/aspiration events. These results guide clinicians in targeting appropriate swallowing interventions.

Inter- and Intra-Rater Reliability of Laryngeal Sensation Testing with the Touch Method During Flexible Endoscopic Evaluations of Swallowing.

OBJECTIVES: Sensation is an integral component of laryngeal control for breathing, swallowing, and vocalization. Laryngeal sensation is assessed by elicitation of the laryngeal adductor reflex (LAR), a brainstem-mediated adduction of the true vocal folds. During Flexible Endoscopic Evaluations of Swallowing (FEES), the touch method can be used to elicit the LAR to judge laryngeal sensation. Despite the prevalence of this method in clinical practice and research, prior studies have yet to examine inter- and intra-rater reliability. METHODS: Four speech-language pathologists rated 125 randomized video clips for the presence, absence, or inability to rate the LAR. Fifty percent of video clips were re-randomized and re-rated 1 week later. Raters then created guidelines and participated in formal consensus training sessions on a separate set of videos. Ratings were repeated post-training. RESULTS: Overall inter-rater reliability was fair (κ = 0.22) prior to training. Pre-training intra-rater reliability ranged from fair (κ = 0.35) to almost perfect (κ = 0.89). Inter-rater reliability significantly improved after training (κ = 0.42, P < .001), though agreement did not reach prespecified acceptable levels (κ ≥ 0.80). Post-training intra-rater reliability ranged from moderate (κ = 0.49) to almost perfect (κ = 0.85). CONCLUSION: Adequate inter-rater reliability was not achieved when rating isolated attempts to elicit the LAR. Acceptable within-rater reliability was observed in some raters 1 week after initial ratings, suggesting that ratings may remain consistent within raters over a short period of time. Limitations and considerations for future research using the touch method are discussed.

Residue Ratings on FEES: Trends for Clinical Application of Residue Measurement.

Considering that measurement is a critical part of diagnostic technique for evaluating swallowing dysfunction, there is a need for a better foundational understanding of what influences residue measurement on flexible endoscopic evaluation of swallowing (FEES). This study investigated two factors and their potential influence on trends in residue ratings on FEES: (1) bolus consistency, and (2) residue severity levels on two different types of rating scales. Thirty-three clinicians were asked to rate their overall impressions of pharyngeal residue on 75 FEES videos representing a wide range of residue severities for thin liquid, applesauce, and cracker boluses. Ratings were made on both a visual analog scale (VAS) and a five-point ordinal scale in a randomized fashion across two sessions about two weeks apart. Statistical correlations were determined to assess the association between residue ratings and severity levels and bolus consistency. A total of 2475 VAS ratings and 2473 ordinal ratings were collected. Residue ratings were statistically different depending on severity level (p < 0.0001) and bolus consistency (p < 0.004). Raters appeared to avoid rating at the severe end of the scales, especially on visual analog scales. This study documented the relationship between clinician ratings of pharyngeal residue on FEES and various factors like severity and bolus type. Other findings, such as differences in ratings depending on the type of rating scale and halo effects on the VAS, are valuable for future scale development for understanding perceptual ratings of residue on FEES.

The pitch glide speech task lacks clinical utility to infer laryngeal lift during swallowing†.

Purpose: To investigate the amount of laryngeal lift during the pitch glide speech task and during a bolus swallow.Method: Modified Barium Swallows (MBS) videos captured speech tasks and bolus trials. Using SwallowTail®, laryngeal elevation was measured by the amount of laryngeal lift from rest to its maximum excursion during each subject's pitch glide and 5 mL thin liquid, 20 mL thin liquid, and 15 mL puree trials. Paired t-tests, with Bonferroni correction, determined if there was a difference in laryngeal lift between the pitch glide and the bolus trials. Two methods were used to compare the methodology of measuring laryngeal lift.Result: Each subject's pitch glide was compared to their swallows. Laryngeal lift during the bolus swallow was greater than the lift during the pitch glide by an average of 1.10 cm, 1.38 cm, and 1.34 cm for 5 mL thin liquid, 20 mL thin liquid, and 15 mL puree, respectively. There was a significant difference in laryngeal lift between the pitch glide task and the 20 mL thin liquid, 5 mL thin liquid, and 15 mL puree swallows. Measurement tracking the posterior cricoid detected greater differences than the previous methodology using the hyoid.Conclusion: In this group of dysphagic patients, the larynx lifted significantly less during a pitch glide than during bolus swallows.

Oral Care Clinical Trial to Reduce Non-Intensive Care Unit, Hospital-Acquired Pneumonia: Lessons for Future Research.

Hospital-acquired pneumonia (HAP) contributes greatly to patient mortality and healthcare costs. Studies have shown that aggressive oral care in intensive care units (ICUs) can significantly reduce pneumonia rates, and hospitals have implemented stringent protocols in this setting. However, little is known about the effectiveness of aggressive oral care in reducing HAP in non-intensive care wards, prompting us to conduct a nonrandomized controlled clinical trial. A structured toothbrushing program was provided to an experimental cohort of patients. A control group received usual care. Patient demographics, toothbrushing frequency, and pneumonia diagnosis were recorded over a 3.5-month period. Difference in pneumonia rates was computed using unadjusted and multivariate logistic regression analyses. No significant difference in pneumonia rates between control and experimental groups was found (1.7% versus 1.8%). Toothbrushing rates increased significantly in the experimental group (p = .002) but fell short of protocol frequency. It became apparent that aggressive toothbrushing program implementation requires nursing-led interdisciplinary involvement, more intensive training, a streamlined documentation system, and efficient compliance tracking. Lessons from this study should be used for future large-scale research. A secondary analysis of these data did, however, suggests that increasing toothbrushing rates may have the potential to reduce pneumonia in the non-ICU acute care setting.

Reliability of Untrained and Experienced Raters on FEES: Rating Overall Residue is a Simple Task.

The purpose of this study was to investigate the reliability of residue ratings on Fiberoptic Endoscopic Evaluation of Swallowing (FEES). We also examined rating differences based on experience to determine if years of experience influenced residue ratings. A group of 44 raters watched 81 FEES videos representing a wide range of residue severities for thin liquid, applesauce, and cracker boluses. Raters were untrained on the rating scales and simply rated their overall impression of residue amount on a visual analog scale (VAS) and a five-point ordinal scale in a randomized fashion across two sessions. Intra-class correlation coefficients, kappa coefficients, and ANOVAs were used to analyze agreement and differences in ratings. Residue ratings on both the VAS and ordinal scales had acceptable inter- and intra-rater reliability. Inter-rater agreement was acceptable (ICC > 0.7) for all comparisons. Intra-rater agreement was excellent on the VAS scale (rc = 0.9) and good on the ordinal scale (k = 0.78). There was no significant difference between expert ratings and other raters based on years of experience for cracker ratings (p = 0.2119) and applesauce ratings (p = 0.2899), but there was a significant difference between clinicians on thin liquid ratings (p = 0.0005). Without any specific training, raters demonstrated high reliability when rating the overall amount of residue on FEES. Years of experience with FEES did not influence residue ratings, suggesting that expert ratings of overall residue amount are not unique or specialized. Rating the overall amount of residue on FEES appears to be a simple visual-perceptual task for puree and cracker boluses.

Clinical Application of Flexible Endoscopic Evaluation of Swallowing in Stroke.

This article aims to review the use of laryngoscopy to assess swallowing function in the stroke population. Since its inception in 1988, fiberoptic endoscopic evaluation of swallowing (FEES) has become an established procedure with distinct objective findings and practical applications, enabling many to choose it as the primary instrumental tool in evaluating poststroke dysphagia. In this article, we outline the decision-making process of when to use FEES. We highlight considerations for the acute stroke patient and visual signs that guide decision making during a FEES, such as secretions, swallowing frequency, and pharyngeal squeeze elicitation. The application of the ice chip protocol for stroke patients who have been nil per os is discussed, along with common observable events on FEES performed on stroke patients like a delay, penetration/aspiration, and bolus retention. Finally, we briefly review testing interventions and follow-up readiness with FEES.

Relationship Between Laryngeal Sensory Deficits, Aspiration, and Pneumonia in Patients with Dysphagia.

The laryngeal adductor reflex (LAR) is an airway protective reflex that manifests as a brief vocal fold closure in response to laryngeal stimulation. This study examined if the absence of the LAR in response to touch delivered by a laryngoscope is associated with penetration/aspiration or pneumonia in patients with dysphagia. Inpatients at a teaching hospital with clinical symptoms of dysphagia were recruited upon referral to the otolaryngology clinic for a swallowing evaluation. Otolaryngologists observed the status of secretions and touched each arytenoid with the tip of the laryngoscope. The patients were then asked to swallow 3-5 mL grape gelatin and 3-5 mL colored water. All procedures were video-recorded. Two independent raters noted absence/presence of the LAR and penetration/aspiration of pharyngeal secretions, gelatin, and water on the recorded videos. A diagnosis of pneumonia during the patient's entire hospital stay was determined by a review of the hospital's medical records. Statistical analyses were performed using Fisher's exact test. Sixty-one patients were included. Twenty-one patients (34.5%) did not exhibit the LAR. No association was found between the absent LAR and penetration or aspiration. There was, however, a significant association between an absence of the LAR and pneumonia development. Patients with an absent LAR had 6.8 times the odds of developing pneumonia as compared to those with a present LAR (OR 6.75; 95% CI 1.76-25.96; p < 0.01). Using the LAR as a marker of laryngeal sensory function appears to be valuable for identifying patients at high risk of pneumonia.

Rethinking Residue: Determining the Perceptual Continuum of Residue on FEES to Enable Better Measurement.

The goal of this work was to better understand perceptual judgments of pharyngeal residue on flexible endoscopic evaluation of swallowing (FEES) and the influence of a visual analog scale (VAS) versus an ordinal scale on clinician ratings. The intent was to determine if perceptual judgments of residue were more accurately described by equal or unequal intervals. Thirty-three speech language pathologists rated pharyngeal residue from 75 FEES videos representing a wide range of residue severities for thin liquid, applesauce, and cracker boluses. Clinicians rated their impression of the overall residue amount in each video on a VAS and, in a different session, on a five-point ordinal scale. Residue ratings were made in two separate sessions separated by several weeks. Statistical correlations of the two rating methods were carried out and best-fit models were determined for each bolus type. A total of 2475 VAS ratings and 2473 ordinal ratings were collected. Residue ratings from both methods (VAS and ordinal) were strongly correlated for all bolus types. The best fit for the data was a quadratic model representing unequal intervals, which significantly improved the r 2 values for each bolus type (cracker r 2 = 0.98, applesauce r 2 = 0.99, thin liquid r 2 = 0.98, all p < 0.0001). Perceptual ratings of pharyngeal residue demonstrated a statistical relationship consistent with unequal intervals. The present findings support the use of a VAS to rate residue on FEES, allowing for greater precision as compared to traditional ordinal rating scales. Perceptual judgments of pharyngeal residue reflected unequal intervals, an important concept that should be considered in future rating scales.