Semin Speech Lang 2018; 39(01): 003-014
DOI: 10.1055/s-0037-1608855
Review Article
Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

Clinical Application of Flexible Endoscopic Evaluation of Swallowing in Stroke

Jessica M. Pisegna
1   Boston Medical Center, Boston, Massachusetts
,
Joseph Murray
2   VA Ann Arbor Healthcare System, Ann Arbor, Michigan
› Author Affiliations
Further Information

Publication History

Publication Date:
22 January 2018 (online)

Abstract

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.

 
  • References

  • 1 Langmore SE, Schatz K, Olsen N. Fiberoptic endoscopic examination of swallowing safety: a new procedure. Dysphagia 1988; 2 (04) 216-219
  • 2 Langmore SE, Schatz K, Olson N. Endoscopic and videofluoroscopic evaluations of swallowing and aspiration. Ann Otol Rhinol Laryngol 1991; 100 (08) 678-681
  • 3 Langmore SE. Endoscopic Evaluation and Treatment of Swallowing Disorders. 2nd ed. New York, NY: Thieme; 2001
  • 4 Aviv JE, Kaplan ST, Thomson JE, Spitzer J, Diamond B, Close LG. The safety of flexible endoscopic evaluation of swallowing with sensory testing (FEESST): an analysis of 500 consecutive evaluations. Dysphagia 2000; 15 (01) 39-44
  • 5 Ad Hoc Committee on Advances in Clinical Practice. American Speech-Language-Hearing Association. Instrumental diagnostic procedures for swallowing. ASHA Suppl 1992; 34 (07) 25-33
  • 6 Ad Hoc Committee on Advances in Clinical Practice. American Speech-Language-Hearing Association. Sedation and topical anesthetics in audiology and speech-language pathology. ASHA Suppl 1992; 34 (07) 41-42
  • 7 Geeganage C, Beavan J, Ellender S, Bath PM. Interventions for dysphagia and nutritional support in acute and subacute stroke. Cochrane Database Syst Rev 2012; 10: CD000323
  • 8 Schepp SK, Tirschwell DL, Miller RM, Longstreth Jr WT. Swallowing screens after acute stroke: a systematic review. Stroke 2012; 43 (03) 869-871
  • 9 Kumar S, Doughty C, Doros G. , et al. Recovery of swallowing after dysphagic stroke: an analysis of prognostic factors. J Stroke Cerebrovasc Dis 2014; 23 (01) 56-62
  • 10 Colton House J, Noordzij JP, Murgia B, Langmore S. Laryngeal injury from prolonged intubation: a prospective analysis of contributing factors. Laryngoscope 2011; 121 (03) 596-600
  • 11 Scheel R, Pisegna JM, McNally E, Noordzij JP, Langmore SE. Endoscopic assessment of swallowing after prolonged intubation in the ICU setting. Ann Otol Rhinol Laryngol 2016; 125 (01) 43-52
  • 12 Pelosi P, Ferguson ND, Frutos-Vivar F. , et al; Ventila Study Group. Management and outcome of mechanically ventilated neurologic patients. Crit Care Med 2011; 39 (06) 1482-1492
  • 13 Steidl C, Boesel J, Suntrup-Krueger S. , et al. Tracheostomy, extubation, reintubation: airway management decisions in intubated stroke patients. Cerebrovasc Dis 2017; 44 (1–2): 1-9
  • 14 Warnecke T, Suntrup S, Teismann IK, Hamacher C, Oelenberg S, Dziewas R. Standardized endoscopic swallowing evaluation for tracheostomy decannulation in critically ill neurologic patients. Crit Care Med 2013; 41 (07) 1728-1732
  • 15 Santos PM, Afrassiabi A, Weymuller Jr EA. Risk factors associated with prolonged intubation and laryngeal injury. Otolaryngol Head Neck Surg 1994; 111 (04) 453-459
  • 16 Tadié JM, Behm E, Lecuyer L. , et al. Post-intubation laryngeal injuries and extubation failure: a fiberoptic endoscopic study. Intensive Care Med 2010; 36 (06) 991-998
  • 17 Marvin S, Gustafson S, Thibeault S. Detecting aspiration and penetration using FEES with and without food dye. Dysphagia 2016; 31 (04) 498-504
  • 18 Afkari S. Measuring frequency of spontaneous swallowing. Australas Phys Eng Sci Med 2007; 30 (04) 313-317
  • 19 Lear CS, Flanagan Jr JB, Moorrees CF. The frequency of deglutition in man. Arch Oral Biol 1965; 10: 83-100
  • 20 Tanaka N, Nohara K, Kotani Y, Matsumura M, Sakai T. Swallowing frequency in elderly people during daily life. J Oral Rehabil 2013; 40 (10) 744-750
  • 21 Murray J, Langmore SE, Ginsberg S, Dostie A. The significance of accumulated oropharyngeal secretions and swallowing frequency in predicting aspiration. Dysphagia 1996; 11 (02) 99-103
  • 22 Sato K, Umeno H, Chitose S, Nakashima T. Deglutition and respiratory patterns during sleep in younger adults. Acta Otolaryngol 2011; 131 (02) 190-196
  • 23 Linden P, Siebens AA. Dysphagia: predicting laryngeal penetration. Arch Phys Med Rehabil 1983; 64 (06) 281-284
  • 24 Ryu JS, Park SR, Choi KH. Prediction of laryngeal aspiration using voice analysis. Am J Phys Med Rehabil 2004; 83 (10) 753-757
  • 25 Warms T, Richards J. “Wet voice” as a predictor of penetration and aspiration in oropharyngeal dysphagia. Dysphagia 2000; 15 (02) 84-88
  • 26 Donzelli J, Brady S, Wesling M, Craney M. Predictive value of accumulated oropharyngeal secretions for aspiration during video nasal endoscopic evaluation of the swallow. Ann Otol Rhinol Laryngol 2003; 112 (05) 469-475
  • 27 Ota K, Saitoh E, Baba M, Sonoda S. The secretion severity rating scale: a potentially useful tool for management of acute-phase fasting stroke patients. J Stroke Cerebrovasc Dis 2011; 20 (03) 183-187
  • 28 Pluschinski P, Zaretsky E, Stöver T, Murray J, Sader R, Hey C. Validation of the secretion severity rating scale. Eur Arch Otorhinolaryngol 2016; 273 (10) 3215-3218
  • 29 Takahashi N, Kikutani T, Tamura F, Groher M, Kuboki T. Videoendoscopic assessment of swallowing function to predict the future incidence of pneumonia of the elderly. J Oral Rehabil 2012; 39 (06) 429-437
  • 30 Warnecke T, Ritter MA, Kroger B. , et al. Fiberoptic endoscopic dysphagia severity scale predicts outcome after acute stroke. Cerebrovasc Dis 2009; 28 (03) 283-289
  • 31 Helm JF, Dodds WJ, Hogan WJ, Soergel KH, Egide MS, Wood CM. Acid neutralizing capacity of human saliva. Gastroenterology 1982; 83 (1 Pt 1): 69-74
  • 32 Crary MA, Carnaby GD, Sia I. Spontaneous swallow frequency compared with clinical screening in the identification of dysphagia in acute stroke. J Stroke Cerebrovasc Dis 2014; 23 (08) 2047-2053
  • 33 Crary MA, Carnaby GD, Sia I, Khanna A, Waters MF. Spontaneous swallowing frequency has potential to identify dysphagia in acute stroke. Stroke 2013; 44 (12) 3452-3457
  • 34 Murray J. Manual of Dysphagia Assessment in Adults. San Diego, CA, London, UK: Singular Publishing Group; 1999
  • 35 Bastian RW. The videoendoscopic swallowing study: an alternative and partner to the videofluoroscopic swallowing study. Dysphagia 1993; 8 (04) 359-367
  • 36 Logemann JA. Evaluation and Treatment of Swallowing Disorders. 2nd ed. Austin, TX: Pro-Ed; 1997
  • 37 Miloro KV, Pearson Jr WG, Langmore SE. Effortful pitch glide: a potential new exercise evaluated by dynamic MRI. J Speech Lang Hear Res 2014; 57 (04) 1243-1250
  • 38 Pearson Jr WG, Hindson DF, Langmore SE, Zumwalt AC. Evaluating swallowing muscles essential for hyolaryngeal elevation by using muscle functional magnetic resonance imaging. Int J Radiat Oncol Biol Phys 2013; 85 (03) 735-740
  • 39 Fuller SC, Leonard R, Aminpour S, Belafsky PC. Validation of the pharyngeal squeeze maneuver. Otolaryngol Head Neck Surg 2009; 140 (03) 391-394
  • 40 Leonard R, Belafsky PC, Rees CJ. Relationship between fluoroscopic and manometric measures of pharyngeal constriction: the pharyngeal constriction ratio. Ann Otol Rhinol Laryngol 2006; 115 (12) 897-901
  • 41 Verkman AS, Mitra AK. Structure and function of aquaporin water channels. Am J Physiol Renal Physiol 2000; 278 (01) F13-F28
  • 42 Verkman AS, Matthay MA, Song Y. Aquaporin water channels and lung physiology. Am J Physiol Lung Cell Mol Physiol 2000; 278 (05) L867-L879
  • 43 Feinberg MJ, Knebl J, Tully J, Segall L. Aspiration and the elderly. Dysphagia 1990; 5 (02) 61-71
  • 44 Feinberg MJ, Knebl J, Tully J. Prandial aspiration and pneumonia in an elderly population followed over 3 years. Dysphagia 1996; 11 (02) 104-109
  • 45 Splaingard ML, Hutchins B, Sulton LD, Chaudhuri G. Aspiration in rehabilitation patients: videofluoroscopy vs bedside clinical assessment. Arch Phys Med Rehabil 1988; 69 (08) 637-640
  • 46 Simonelli M, Ruoppolo G, de Vincentiis M. , et al. Swallowing ability and chronic aspiration after supracricoid partial laryngectomy. Otolaryngol Head Neck Surg 2010; 142 (06) 873-878
  • 47 Robbins J, Gensler G, Hind J. , et al. Comparison of 2 interventions for liquid aspiration on pneumonia incidence: a randomized trial. Ann Intern Med 2008; 148 (07) 509-518
  • 48 Pisegna JM, Langmore S. The ice chip protocol: a description of the protocol and case reports. SIG 13, Swallowing and Swallowing Disorders (Dysphagia) 2017; In press
  • 49 Malandraki GA, Sutton BP, Perlman AL, Karampinos DC, Conway C. Neural activation of swallowing and swallowing-related tasks in healthy young adults: an attempt to separate the components of deglutition. Hum Brain Mapp 2009; 30 (10) 3209-3226
  • 50 Michou E, Hamdy S. Cortical input in control of swallowing. Curr Opin Otolaryngol Head Neck Surg 2009; 17 (03) 166-171
  • 51 Mosier KM, Liu WC, Maldjian JA, Shah R, Modi B. Lateralization of cortical function in swallowing: a functional MR imaging study. AJNR Am J Neuroradiol 1999; 20 (08) 1520-1526
  • 52 Hamdy S, Rothwell JC, Aziz Q, Thompson DG. Organization and reorganization of human swallowing motor cortex: implications for recovery after stroke. Clin Sci (Lond) 2000; 99 (02) 151-157
  • 53 May NH, Pisegna JM, Marchina S, Langmore SE, Kumar S, Pearson Jr WG. Pharyngeal swallowing mechanics secondary to hemispheric stroke. J Stroke Cerebrovasc Dis 2017; 26 (05) 952-961
  • 54 Teismann IK, Suntrup S, Warnecke T. , et al. Cortical swallowing processing in early subacute stroke. BMC Neurol 2011; 11: 34
  • 55 Dziewas R, Teismann IK, Suntrup S. , et al. Cortical compensation associated with dysphagia caused by selective degeneration of bulbar motor neurons. Hum Brain Mapp 2009; 30 (04) 1352-1360
  • 56 Pearson Jr WG, Molfenter SM, Smith ZM, Steele CM. Image-based measurement of post-swallow residue: the normalized residue ratio scale. Dysphagia 2013; 28 (02) 167-177
  • 57 Steele C, Sasse C, Bressmann T. Tongue-pressure and hyoid movement timing in healthy liquid swallowing. Int J Lang Commun Disord 2012; 47 (01) 77-83
  • 58 Leonard R, Kendall K. Dysphagia Assessment and Treatment Planning: A Team Approach. San Diego, CA: Singular Publishing Group; 1997
  • 59 Kaneoka AS, Langmore SE, Krisciunas GP. , et al. The Boston Residue and Clearance Scale: preliminary reliability and validity testing. Folia Phoniatr Logop 2013; 65 (06) 312-317
  • 60 Farneti D. Pooling score: an endoscopic model for evaluating severity of dysphagia. Acta Otorhinolaryngol Ital 2008; 28 (03) 135-140
  • 61 Neubauer PD, Rademaker AW, Leder SB. The Yale pharyngeal residue severity rating scale: an anatomically defined and image-based tool. Dysphagia 2015; 30 (05) 521-528
  • 62 Kelly AM, Leslie P, Beale T, Payten C, Drinnan MJ. Fibreoptic endoscopic evaluation of swallowing and videofluoroscopy: does examination type influence perception of pharyngeal residue severity?. Clin Otolaryngol 2006; 31 (05) 425-432
  • 63 Tohara H, Nakane A, Murata S. , et al. Inter- and intra-rater reliability in fibroptic endoscopic evaluation of swallowing. J Oral Rehabil 2010; 37 (12) 884-891
  • 64 Pilz W, Baijens LW, Passos VL. , et al. Swallowing assessment in myotonic dystrophy type 1 using fiberoptic endoscopic evaluation of swallowing (FEES). Neuromuscul Disord 2014; 24 (12) 1054-1062
  • 65 Park WY, Lee TH, Ham NS. , et al. Adding endoscopist-directed flexible endoscopic evaluation of swallowing to the videofluoroscopic swallowing study increased the detection rates of penetration, aspiration, and pharyngeal residue. Gut Liver 2015; 9 (05) 623-628
  • 66 Martin-Harris B, Brodsky MB, Michel Y, Lee FS, Walters B. Delayed initiation of the pharyngeal swallow: normal variability in adult swallows. J Speech Lang Hear Res 2007; 50 (03) 585-594
  • 67 Daniels SK, Huckabee ML. Dysphagia Following Stroke. San Diego, CA: Plural Publishing; 2008
  • 68 Kelly AM, Drinnan MJ, Leslie P. Assessing penetration and aspiration: how do videofluoroscopy and fiberoptic endoscopic evaluation of swallowing compare?. Laryngoscope 2007; 117 (10) 1723-1727
  • 69 Gerek M, Atalay A, Cekin E, Ciyiltepe M, Ozkaptan Y. [The effectiveness of fiberoptic endoscopic swallow study and modified barium swallow study techniques in diagnosis of dysphagia]. Kulak Burun Bogaz Ihtis Derg 2005; 15 (5–6): 103-111
  • 70 Wu CH, Hsiao TY, Chen JC, Chang YC, Lee SY. Evaluation of swallowing safety with fiberoptic endoscope: comparison with videofluoroscopic technique. Laryngoscope 1997; 107 (03) 396-401
  • 71 Butler SG, Stuart A, Castell D, Russell GB, Koch K, Kemp S. Effects of age, gender, bolus condition, viscosity, and volume on pharyngeal and upper esophageal sphincter pressure and temporal measurements during swallowing. J Speech Lang Hear Res 2009; 52 (01) 240-253
  • 72 Rommel N, Borgers C, Van Beckevoort D, Goeleven A, Dejaeger E, Omari TI. Bolus residue scale: an easy-to-use and reliable videofluoroscopic analysis tool to score bolus residue in patients with dysphagia. Int J Otolaryngol 2015; 2015: 780197
  • 73 Eisenhuber E, Schima W, Schober E. , et al. Videofluoroscopic assessment of patients with dysphagia: pharyngeal retention is a predictive factor for aspiration. AJR Am J Roentgenol 2002; 178 (02) 393-398
  • 74 Dejaeger E, Pelemans W, Ponette E, Joosten E. Mechanisms involved in postdeglutition retention in the elderly. Dysphagia 1997; 12 (02) 63-67
  • 75 Lee TH, Lee JS, Park JW. , et al. High-resolution impedance manometry facilitates assessment of pharyngeal residue and oropharyngeal dysphagic mechanisms. Dis Esophagus 2014; 27 (03) 220-229
  • 76 Yeates EM, Molfenter SM, Steele CM. Improvements in tongue strength and pressure-generation precision following a tongue-pressure training protocol in older individuals with dysphagia: three case reports. Clin Interv Aging 2008; 3 (04) 735-747
  • 77 Logemann JA. Role of the modified barium swallow in management of patients with dysphagia. Otolaryngol Head Neck Surg 1997; 116 (03) 335-338
  • 78 Logemann JA, Pauloski BR, Rademaker AW, Colangelo LA. Super-supraglottic swallow in irradiated head and neck cancer patients. Head Neck 1997; 19 (06) 535-540
  • 79 Van Daele DJ, McCulloch TM, Palmer PM, Langmore SE. Timing of glottic closure during swallowing: a combined electromyographic and endoscopic analysis. Ann Otol Rhinol Laryngol 2005; 114 (06) 478-487
  • 80 Leder SB, Murray JT. Fiberoptic endoscopic evaluation of swallowing. Phys Med Rehabil Clin N Am 2008; 19 (04) 787-801 , viii–ix