Introduction to the Procedure: ENT and SLP Perspective by Dinesh Chhetri, MD and Andrew Erman, MA, CCC-SLP
Hello. My name is Denise Chetri. I'm an otolaryngologist and my name is Andrew Ackerman. I am a speech pathologist. Today. We're going to discuss a technique for evaluation of your differential dysplasia called flexible endoscopic evaluation of swallowing, also known as fees. And we're going to contrast that with the technique of modified barium swallow evaluation. Because these are the two most common techniques that we use for evaluation of preferential dysplasia. So what is fees uh fees is as a doctor countryside flexible endoscopic evaluation of swallowing. A flexible trans nasal endoscope is inserted through the nasal passage and into the fairing so that we can observe uh swallowing. The procedure should be performed with a camera monitor and recording system so that for easy visualization and so that you can review and we want to establish if there is abnormality and if there is. Are there any interventions that we can do at the time? From a behavioral point of view that could help improve the swallow function of the patient. So the procedure is done by a clinician, either a otolaryngologist or a speech language pathologist and the person doing this technique should be aware of some of the more common causes of order of angel of dysplasia. So these can include neuromuscular disorders after stroke or Parkinson's disease. For example, it can be obstructions of the swallow mechanism uh including upper so fragile uh sphincter dysfunction sinkers, diverticular um patients who have had radiation therapy also suffer from significant aspasia, as do patients with Lawrenceville valve problems such as vocal fold paralysis and other forms of laryngeal dysfunction. What are we trying to learn from an instrumental swallow evaluation in this case fees Number one. Does the patient have an abnormal swallow. If so, we need to describe it in regard to aspiration. Is it occurring? And we need to consider swallow efficiency. The largest question of which is the patient able to sustain themselves from a nutritional and hydration point of view. We would like to be able to recommend the safest diet for the patient and if there is an abnormality, we need to consider what the treatment plan should be, whether it is behavioral or surgical. Now we're going to demonstrate the procedure before we scope. Let's go over some swallowing basics, swallow has several phases oral preparatory, oral for angel and so fragile. The main focus for fees is on Bullis clearance through the for angel phase and lower airway protection. So we'll be looking for residue in the molecular post your fragile wall here from sinus and we'll also be looking for penetration and aspiration. Mhm. The first thing to do is to prepare the patient. The patient is seated comfortably on a chair or seated on a gurney. First thing I would do is to anesthetize the nasal cavity with just a small amount of anesthetic. Typically a combination of 4% lidocaine and 4% Nielsen Efren, I've already prepared the patient's nasal cavity at this point. The next thing is to look at the food. We're going to give to the patient and we're going to instill a small amount of food dye into this liquid. And the period food that we have here so that we can visualize as the food passes through the pharynx for of solid food consistency. We typically use cookies. So after the yeah food is adequately prepared, we are ready to perform the endoscopy and have the patients follow some food bonuses so I always want to make sure that the patient is comfortable. I typically look at boats nasal cavities to see which one is more open for the endoscope. And in this case we've chosen the left side. I'm inserting the scope through the floor of the news towards the nasopharynx and then pass into the junction of the oral pharynx and the nasopharynx here. I'm going to stop at the level of the palette so I can see the entire swallowing apparatus. I'm able to visualize the molecular and the larynx. Generally speaking, if you want to evaluate the function of the larynx, uh you want to go ahead and have the patient phone eight. Could you go ahead and say e so the larynx and the vocal folds are working properly, the larynx uh function is normal. There is no pulling of secretions. So now we're ready to test the patient with different food policies. We typically start with the football is that is the safest and easiest for the patients. So now we're going to start with the pureed food consistency. So while and he's feeding the patient I'm looking at what the food Boulis is doing as it goes down. You can see let's give him one more. We want to test the same bullets at least twice to check for repeatability. During the swallow. There is a white out where you cannot see what is happening. After the swallow. You can observe for residue in the molecular post, your fringe a wall and appear from science. After observing for residue you will insert the endoscope further towards the end of larynx, looking for penetration and aspiration. Go ahead and say E so now after the pureed Football is we will test the patient for liquid. We can start with a small amount of liquid with a teaspoon. If you suspect that the patient may have difficulty swallowing. So let's go and start with a teaspoon great. You can see a small amount of residue in the pharynx, otherwise there is no penetration or aspiration. And then you can go ahead and subsequently try with a sip of the cup or with a straw. Going to try the next palace with a straw. Mhm correct. Go ahead and say e breathe great. Okay so the next bullet will try will be a cookie. We will give the patient a small cokie did bite. And while the patient is chewing you can get a sense of what's happening in the oral cavity by how long it takes for the bulls to be swallowed. And if there's any abnormalities like premature spillage or penetration or aspiration before the swallow. Now he's already swallowed. And at this point I'm looking again for residue. There is minimal residue in the vernacular and again looking for penetration and aspiration go and C. E. So after the swallowing is done. If there are any abnormalities, we can also do compensatory maneuvers to see if the swallowing can be improved with those maneuvers. So after the swallow studies done, you want to remove the scope a traumatically and now we're going to review the recording. Okay so let's analyze johnny swallow. So overall looks like a fairly normal swallow to me, had a little bit of residue in the vernacular. And so probably signifies a little bit of swallowing weakness. He looks like he's got a great swallow. Yeah, there was no penetration, no aspiration. So essentially normal swallow. So let's go over some abnormal fees. Findings here in the figure, you can see the lecturer residue. This is typically do to, for angel weakness, epiglottis dysfunction or oral cavity residue that falls into the vernacular. This figure shows appear from sinus residue if you're from sinus residue without molecular residue, suggests upper sophocles sphincter dysfunction. It can also be due to inferior differential constrictor weakness or from spillage from molecular residue or oral cavity. This figure shows combined, significant appear from sinus and molecular residue. This signifies a more severe for angel weakness such as severe cervical cervical stenosis, severe epiglottis dysfunction or reduced high laryngeal elevation. Let's discuss the findings of penetration and aspiration penetration occurs when food or liquid enters the Lawrenceville vestibule. Aspiration occurs when food or liquid passes below the vocal folds into the trachea. Penetration or aspiration can occur before, during or after the fringe will swallow. And it is important to understand why the patient penetrated or aspirated if penetration or aspiration occurs. It is important to note if the patient has a lower angel cough reflex, absent cough reflex signifies lawrenceville sensory deficit. And it is also important to know if the patient is sensitive to the foreign jal residue. Now that we've demonstrated the fees procedure, let's discuss how does fees compared to M. B. S. S. With fees? Since you're using an endoscope, no radiation is needed and you can spend a lot more time performing the procedure with a modified barium swallow study. The patient is being radiated so we want to keep the procedures short. Occasionally there's a little discomfort because it is an invasive procedure and with a small risk of episode axis. A modified barium swallow study is comfortable because the patient is just sitting in a chair and there is no bleeding, fees can be done in almost any environment at the bedside. In the clinic. In an inpatient hospital bed, modified barium swallow studies are almost always done in a radiology suite and the patient has to be able to sit upright in a chair. Typically with fees, you're getting a superior to inferior view of the swallowing apparatus and with a modified barium swallow study. In contrast, you're getting a lateral view or an anti or post your review and you can also do an oblique view with fees. You get excellent assessment of the swallowing anatomy with a modified barium swallow study. Unfortunately, you only see shades of gray so you can make out structures but not as just as distinctly as can occur. With endoscopy with fees during the swallow there is a white out period and you are unable to see what's happening to the swallowing apparatus during the swallow. But with the modified barium swallow study. In contrast, you can see what's happening during the fringe. This phase of swallowing. You also can see what's happening in the oral cavity, which you cannot see in fees. You can also see the upper esophageal sphincter and the trachea. So what is the best practice for assessment of old referential dysplasia? We perform both fees and MBS. Is frequently and we find that these two tests are complementary in understanding the cause of the patient's swallowing dysfunction by having both the fees and a modified barium swallow study on the same patient. It gives us a much greater depth of understanding of the anatomy and physiology of the patient so that we can piece together what we think is really happening with the patient. Most importantly, what we have found is that a close working relationship between an otolaryngologist and a speech language pathologist allows for more optimal management of the dysplasia patient. Working with swallowing patients is highly rewarding, and both dr Chetri and I would like to wish you the very best in your journey and taking care of this population.
