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Table of Contents
ORIGINAL ARTICLE
Year : 2017  |  Volume : 7  |  Issue : 1  |  Page : 11-13

Fiberoptic endoscopic evaluation of swallowing in poststroke dysphagia - Seeing is believing


1 Department of ENT, Pondicherry Institute of Medical Sciences, Puducherry, India
2 

Date of Web Publication14-May-2018

Correspondence Address:
Dr. Jayita Das Poduval
Department of ENT Pondicherry Institute of Medical Sciences, Puducherry
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jlv.JLV_2_17

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   Abstract 


Background: A bedside scoring to assess swallowing status and the presence of aspiration may sometimes be misleading. Hence, an objective evaluation by endoscopy is desirable. Aims: The aim of this study is to confirm whether a bedside scoring system for poststroke dysphagia correlates well with fiberoptic endoscopic evaluation of swallowing (FEES). Settings and Design: This was an institutional prospective observational pilot study. Materials and Methods: Gugging swallowing screen (GUSS) score, FEES, and patients with dysphagia following stroke were used in this study. Statistical Analysis: Spearman's nonparametric rank correlation test for independent variables was used in this study. Results: A statistically significant positive correlation exists between the bedside score and findings of FEES. FEES is a convenient and convincing method to confirm aspiration in patients with stroke and is also a means for patient education. Conclusions: FEES may be safely and conveniently performed in patients with poststroke dysphagia to confirm the presence or absence of aspiration.

Keywords: Dysphagia, fiberoptic endoscopic evaluation of swallowing, stroke


How to cite this article:
Grandhe S, Thomas RM, Poduval JD. Fiberoptic endoscopic evaluation of swallowing in poststroke dysphagia - Seeing is believing. J Laryngol Voice 2017;7:11-3

How to cite this URL:
Grandhe S, Thomas RM, Poduval JD. Fiberoptic endoscopic evaluation of swallowing in poststroke dysphagia - Seeing is believing. J Laryngol Voice [serial online] 2017 [cited 2018 Aug 20];7:11-3. Available from: http://www.laryngologyandvoice.org/text.asp?2017/7/1/11/232353




   Introduction Top


Swallowing is a very complex physiological action that is rapid from beginning to end. Patients suffering from stroke may have swallowing problems and an increased risk of aspiration. They normally have to be maintained on nasogastric tube feeding until normal swallowing capacity is restored. A bedside scoring to assess swallowing status and the presence of aspiration may sometimes be misleading. Hence, an objective evaluation by endoscopy is desirable.


   Materials and Methods Top


This is a prospective observational pilot study carried out to confirm feasibility, safety, and efficacy for performing fiberoptic endoscopic evaluation of swallowing (FEES) in patients who have suffered a posterior circulation stroke. All of them had difficulty in swallowing or dysphagia and were being maintained on nasogastric tube feeding before being referred for an ear, nose, and throat (ENT) consultation.

The bedside scoring with gugging swallowing screen (GUSS) involves an indirect swallowing test with the patient's ability to clear his or her own saliva and a direct swallowing test using semisolid, liquid, and solid food items, in that order. Speed of swallowing, cough, drooling, and change in voice are the parameters noted. A scale of 1–5 per test is given to denote efficiency of swallowing and the need for further testing, if any.

A routine ENT examination as well as FEES, as per clinical guidelines using foods of various consistencies, was performed in the above patients by the senior consultant assisted by the postgraduate student and without any local anesthetic or fluorescent dye, using a pediatric nasopharyngolaryngoscope. White bread was used as a solid food item, curd rice as semisolid, and plain milk as liquid.

Bedside grading of dysphagia and aspiration was done simultaneously by the undergraduate student, using the GUSS scoring method, and all the scores were tabulated separately. The food residue, if any, present in the pharynx and larynx was visualized using the pediatric flexible fiberoptic nasopharyngolaryngoscope. Counseling and swallowing therapy were provided. The results of the findings on endoscopy were compared with the GUSS scoring.

The FEES scoring was done using 4 levels of clearance of the swallow-pharyngeal residue, pharyngeal spillover, laryngeal penetration, and laryngeal aspiration. In this study, swallowing efficiency using FEES was scored according to the ability to clear the food item. In other words, aspiration if present was noted as 1, laryngeal penetration as 2, pharyngeal spillover as 3, and pharyngeal residue as 4. This was done purposefully to bring about coherence with the scale for swallowing efficiency using the GUSS score, that is, higher the score higher is the efficiency of the swallow.


   Results Top


[Table 1] denotes the swallowing score using each element of the GUSS and FEES for each of the 10 patients numbered 1–10.
Table 1: Gugging swallowing screen and fiberoptic endoscopic evaluation of swallowing scores

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The data were entered in Microsoft Excel and the appropriate statistical test applied. The Spearman's nonparametric rank correlation test was used for statistical analysis and the two procedures were correlated. Significance was defined as the rho or R value which was 0.76376 for every element of the GUSS score vis-à-vis the FEES score. The two-tailed P value was 0.01013; significance was set at P < 0.05. A positive correlation was thus found between the GUSS and FEES scores.

The FEES procedure was performed by the primary consultant, who is also the third author of this paper. The second author, a postgraduate student in ENT, assisted with the procedure while the first author, an undergraduate medical student, performed the bedside scoring for the patient independently. The video recording was assessed separately by the consultant and PG student to determine inter-rater variability. There was a 100% inter-rater correlation even though no fluorescent dye had been used since the white-colored food substance was clearly noticed against the pink mucosa of the pharynx and larynx.


   Discussion Top


FEES was popularized by Susan E. Langmore in 1988 and uses flexible laryngoscopy to evaluate oropharyngeal dysphagia.[1] It is now a standard procedure in swallowing disorders where videofluoroscopy is not available and is convenient even for patients in the intensive care unit or in a nursing home and in extremely obese patients. FEES is currently the first choice for dysphagia evaluation because it is easy to use, very well tolerated, allows bedside examination, avoids radiation hazards, and is economical. General practitioners and specialists in otorhinolaryngology, phoniatrics, neurology, neurosurgery, and so on are the usual base for ordering dysphagia evaluation. However, the use of FEES as a diagnostic procedure is not widely known or popular in multidisciplinary settings and is only in recent times trying to emerge as a standard procedure even within the subspecialty of laryngology. The classical FEES procedure is rather elaborate, labor intensive, and time consuming, and this may be one of the reasons for it being relatively little used.

Internists and neurologists are more commonly seen to use bedside methods of evaluation for aspiration, such as GUSS,[2],[3] in patients who have suffered a stroke. Even then, there are a sizeable number of patients who are discharged from the hospital with nasogastric tube feeding and remain on tube feeding for indefinite periods of time. This naturally causes low morale for the patient and the caregivers. Some major and minor potential issues exist with FEES though no serious complications have been reported in the literature. These are discomfort, gagging and/or vomiting, adverse drug reactions to topical anesthetics, mucosal perforation, epistaxis, vasovagal syncope, and laryngospasm.

We therefore aimed to study whether FEES could be abridged in a subset of patients without overt aspiration and thereby help to make a decision regarding the appropriateness of resuming oral feeding in patients who have suffered a stroke. Any indication of the presence of aspiration would require a complete and detailed FEES procedure [4],[5],[6] and continuation of tube feeding until normal neurological status is restored.

If copious secretions were present in the laryngeal vestibule as seen on laryngoscopy or there was a nonprotective cough, then FEES was not carried out in those patients. By offering food substances of a consistency well tolerated by the patient and with a color contrasting that of the mucosa, we were able to carry out the procedure without the use of a dye. The food items commonly used were white bread, curd rice, or milk, which was administered last. Liquids were always administered last in the sequence of testing to minimize the chances of aspiration, which would be highest in the case of liquids. However, both the FEES procedure as well as the GUSS evaluation allow for liquid or semisolid food to be given first and also tailored to the needs of the patient and the general assessment of the clinician.

Methylene blue or fluorescent green food dye may be used to color foods, but no guidelines exist as to the amount used or the titration, and the risk of allergic or hypersensitivity reactions exist with this method. We also avoided using local anesthetic for the same reason by resorting to a pediatric endoscope, which was well tolerated and at the same time afforded adequate visualization. The patient and the caregivers, as well as the referring physician, were reassured about the safety of resuming oral feeding in these patients. The whole procedure took roughly 5–10 min.

A statistically significant positive correlation exists between the bedside score and findings of FEES in this study, which is also borne out by the existing literature on this topic. Inter-rater variation in FEES was absent even when no fluorescent dye had been used. The use of a pediatric endoscope was not found to be a limiting factor for the detection of aspiration. FEES may be safely and conveniently performed this way in patients with poststroke dysphagia to confirm the presence or absence of aspiration.

However, if the clinical evaluation or bedside scoring was to suggest aspiration, then the authors doubt if such an abridged form of FEES as done in this study would be sufficient. Since this limited sample did not include any patient with obvious or probable aspiration, a larger sample size with a randomized design is necessary to decide if a mini or abridged FEES is adequate for the evaluation of dysphagia in stroke patients and also whether it should be used in addition to a bedside screening.


   Conclusions Top


Although GUSS correlates well with FEES, the latter helps to objectively demonstrate the presence or absence of aspiration to the patient and family, guiding appropriate treatment and greater involvement of caregivers in the rehabilitation process. FEES is a safe and efficient procedure that is useful for patient education, counseling and biofeedback, and facilitates timely return to oral feeding. A full and more detailed FEES procedure is recommended for those who demonstrate signs of aspiration. A larger sample size with a randomized design could establish the cost-effectiveness of a mini FEES for patients with stroke.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Langmore SE, Schatz K, Olson N. Endoscopic and videofluoroscopic evaluations of swallowing and aspiration. Ann Otol Rhinol Laryngol 1991;100:678-81.  Back to cited text no. 1
[PUBMED]    
2.
Trapl M, Enderle P, Nowotny M, Teuschl Y, Matz K, Dachenhausen A, et al. Dysphagia bedside screening for acute-stroke patients: The gugging swallowing screen. Stroke 2007;38:2948-52.  Back to cited text no. 2
[PUBMED]    
3.
Dziewas R, Warnecke T, Olenberg S, Teismann I, Zimmermann J, Kramer C, et al. Towards a basic endoscopic assessment of swallowing in acute stroke – Development and evaluation of a simple dysphagia score. Cerebrovasc Dis 2008;26:41-7.  Back to cited text no. 3
[PUBMED]    
4.
Warnecke T, Teismann I, Oelenberg S, Hamacher C, Ringelstein EB, Schäbitz WR, et al. Towards a basic endoscopic evaluation of swallowing in acute stroke – Identification of salient findings by the inexperienced examiner. BMC Med Educ 2009;9:13.  Back to cited text no. 4
    
5.
Park WY, Lee TH, Ham NS, Park JW, Lee YG, Cho SJ, 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;9:623-8.  Back to cited text no. 5
[PUBMED]    
6.
Warnecke T, Ritter MA, Kroger B, Oelenberg S, Teismann I, Heuschmann PU, et al. Fiberoptic endoscopic dysphagia severity scale predicts outcome after acute stroke. Cerebrovasc Dis 2009;28:283-9.  Back to cited text no. 6
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