Until 1980, the primary technique for assessing patients with dysphagia was the modified barium swallow (MBS). It was then that fiberoptic endoscopic evaluation of swallowing was added to the diagnostic armamentarium. In the 1990s, flexible endoscopic evaluation of swallowing with sensory testing (FEESST) added additional options, offering superior technology to assess both bolus transport and airway protection without the radiation exposure that accompanies the MBS. Jonathan E. Aviv, MD, Professor of Otolaryngology–Head and Neck Surgery, Director of the Division of Laryngology, and Medical Director of the Voice and Swallowing Center at Columbia University Medical Center in New York, developed FEESST and is an expert consultant for Medtronic and Vision Sciences. The technique, he said, “expands the diagnostic options—and hence, the therapeutic options—available to patients who present with throat complaints, including cough.”
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December 2007Due to its sensory testing component, FEESST captures more complete information on the swallowing mechanism in a wide range of patients. “Without using sensory testing, we have to infer information based on pooling of secretions or how patients respond to our touching them with the tip of the scope in the larynx or pharynx,” explained speech and language pathologist Lori M. Burkhead, PhD, Assistant Professor in the Department of Otolaryngology at the Medical College of Georgia in Augusta. “FEESST gives us a more objective, quantifiable measurement not only for clinical procedures and clinical information, but also for our research endeavors.”
Quantifying the range of laryngeal sensory deficits is especially important in patients with neurological disorders. It is well known that stroke patients are at high risk for aspiration pneumonia, a leading cause of death following stroke. Many studies have now established the technique’s efficacy in the diagnosis and management of patients who are at risk for aspiration;1,2 a few investigators have also shown the procedure to be safe in children.3
Performing FEESST
In addition to eliminating radiation exposure and the risk of barium aspiration, FEESST’s other advantages include its portability. It is regularly performed in physicians’ offices, clinics, and at the bedside in skilled nursing facilities and nursing homes and even in the ICU. Just prior to performing FEESST, the clinician completes a 30-second calibration with a portable computer and video monitor. He or she then passes an endoscope, which incorporates a sensory stimulator, through the nose and into the oropharynx. The video monitor allows the endoscopist to visually assess velopharyngeal closure, anatomy of the base of the tongue and hypopharynx, abduction and adduction of the vocal folds, status of the pharyngeal musculature, and the patient’s ability to handle his or her own secretions.
To do the sensory evaluation, the endoscope is positioned so that the port is aligned over the aryepiglottic fold. Discrete pulses of air are delivered at sequentially increased pressures to the mucosa innervated by the superior laryngeal nerve (SLN), thus eliciting the laryngeal adductor reflex. This portion of the evaluation establishes the patient’s sensory threshold. The motor evaluation will be completed by giving liquids and foods of varying consistencies while the clinician monitors oral transit time, inhibition of swallowing, laryngeal elevation, spillage, reflux, aspiration, and ability to clear residue, among other factors.
A major reason to do the sensory testing, said Dr. Aviv, is to determine whether reactions to the air pulse are asymmetrical. “Often, when we see asymmetry, this gives us a clue that there could be pressure on the vagus nerve or on a branch of the vagus nerve that governs sensation.” Additional imaging procedures, such as an MRI of the brain, neck, and chest, might be the next step in a diagnostic workup where asymmetrical responses to sensory testing have been recorded.
Dr. Aviv, who trains clinicians in the technique at his center, said that an experienced endoscopist can learn how to do laryngeal sensory testing within 15 to 20 minutes. Dr. Burkhead confirms that the learning curve is negligible.
Who Can Benefit?
FEESST is now a well-established technique for diagnosing problems with swallowing and developing appropriate management plans, said Dr. Aviv. For instance, one randomized prospective study of 164 outpatients revealed that in the subgroup of stroke patients, 29.2% of patients receiving the MBS evaluation developed aspiration pneumonia, versus only 4.76% of those in the FEESST-managed group.4
The technique is especially valuable in the largest dysphagia populations—the elderly and stroke patients. Reimbursement by Medicare is approved in patients with dysphagia who are at risk for aspiration; patients with stroke or other central nervous system derangement and associated impairment of speech and swallowing; patients without CNS disorders, but who have documented difficulty in swallowing; and patients with a history of aspiration or aspiration pneumonia. In the nursing home setting, FEESST can furnish valuable data when making clinical decisions about placement or removal of gastrostomy tubes, dietary management of impaired patients, and planning and evaluation of appropriate therapy programs.
Dr. Aviv finds FEESST beneficial in patients with a variety of laryngeal complaints, such as cough, hoarseness, throat clearing, thick phlegm in the throat, and even postnasal drip. Dr. Burkhead works largely with head and neck cancer patients, and has found FEESST helpful for pre- and post-radiation assessments. “Many of our patients have fibrotic changes due to their radiation treatments,” she explained, “and the sensory testing is valuable in helping us understand how a patient’s sensation is changing over time.”
Dr. Burkhead also employs FEESST with hospital patients in the ICU setting. “Frequently, patients who have been intubated or who have tracheostomy will become desensitized, because they lose airflow through their upper airway. We know that swallowing function in intubated patients can take 24 to 48 hours after extubation to return to normal. Having sensory information is also useful, because we can better estimate the risk for ‘silent aspiration.’” She is often called by the acute medical team to assess patients following extubation.
“Without using sensory testing, we have to infer information based on pooling of secretions or how patients respond to our touching them with the tip of the scope in the larynx or pharynx. FEESST gives us a more objective, quantifiable measurement not only for clinical procedures and clinical information, but also for our research endeavors.”
—Lori M. Burkhead, PhD
Dr. Aviv also emphasizes the role of FEESST in determining the severity of acid reflux disease. “Often, prescribing antacid medication is one of the few things you can do for people with swallowing problems due to neurodegenerative diseases like Parkinson’s,” he said. “FEESST allows you to make that call.” (More information on the specifics of the reflux symptom index and the reflux finding score can be found in Chapter 4 of Dr. Aviv’s book, FEESST: Flexible Endoscopic Evaluation of Swallowing with Sensory Testing, co-written with speech pathologist Thomas Murry, PhD; Plural Publishing, Inc., 2005.)
Dr. Burkhead notes that she can glean information about patients’ physiology and sensation using FEESST without even administering a bolus. This can be especially advantageous in patients at high risk for aspiration, such as those with a compromised pulmonary profile. The endoscope allows her to visually assess how the person is handling secretions, and the sensory testing with the air pulse allows assessment of airway protection. When training other speech pathologists in the technique, she emphasizes that they put their patients at ease by making eye contact during the procedure, moving quickly and projecting confidence. Dr. Aviv notes that patient education materials and video on his center’s Web site (www.voiceandswallowing.com ) can help prepare patients who are to undergo the procedure.
Dr. Burkhead often uses both MBS and FEESST, noting that the latter provides much more information about tissue condition as well as sensation. “Sensory testing,” she said, “is simple, effective, informative, and easy.”
Laryngoscope Highlights
Effects of Smoking on Short-Term QOL After Sinus Surgery
Although much data exist identifying smoking as a risk factor for respiratory diseases, little is known about the effects of smoking on surgical outcomes for chronic rhinosinusitis. As a results of a number of studies and anecdotal findings, many rhinologists recommend against performing endoscopic sinus surgery on active smokers, and most clinicians counsel patients who are smokers to expect worse postoperative outcomes. In a preliminary effort to better understand the exact pathophysiologic mechanisms of smoke damage in patients undergoing endoscopic sinus surgery, Subinoy Das, MD, and associates conducted a review of prospectively collected data on patients who enrolled in a single-institution study on the molecular mechanisms of chronic sinusitis.
A total of 235 patients with chronic rhinosinusitis were enrolled in the study; 50 were smokers and 185 were nonsmokers. Preoperative SNOT-20 differences for smokers and nonsmokers were not statistically significant. At short-term follow-up after surgery, both groups had a significant reduction in SNOT-20 scores, but surprisingly, smokers had a statistically significant greater reduction than nonsmokers.
The investigators surmise that the significant improvement in quality of life that appears in early follow-up deteriorates over time and would not be present at longer-term follow-up; they plan to perform further analyses of this cohort to see if this will be the case.
The researchers point out that the results of this study call into question the idea that smokers are poor candidates for functional endoscopic sinus surgery (FESS), at least in the short term. The pathophysiology of smoke-induced chronic rhinosinusitis may be more amenable to FESS. Ongoing smoking, however, may lead to further damage and scarring, requiring more revision surgery in the long term.
(Laryngoscope 2007;117:2229-32)
References
- Setzen M, Cohen MA, Perlman PW, et al. The association between laryngopharyngeal sensory deficits, pharyngeal motor function, and the prevalence of aspiration with thin liquids. Otolaryngol Head Neck Surg 2003;128(1):99–102.
- Rees CJ. Flexible endoscopic evaluation of swallowing with sensory testing. Curr Opin Otolaryngol Head Neck Surg 2006;14(6):425–30.
- Link DT, Willging JP, Miller CK, et al. Pediatric laryngopharyngeal sensory testing during flexible endoscopic evaluation of swallowing. Ann Otol Rhinol Laryngol 2000;109(10 Pt. 1): 99–905.
- Aviv JE. Prospective, randomized outcome study of endoscopy versus modified barium swallow in patients with dysphagia. Laryngoscope 2000 Apr; 110(4): 563–74.
©2007 The Triological Society