1
Q
Three basic procedures for SLPs
A
VP Endoscopy for speech
Laryngeal stroboscopy
FEES
2
Q
1992: ASHA first addressed endoscopy
A
Vocal tract visualization and imaging for the purpose of diagnosing and treating patients with voice and resonance disorders (doesn’t mean swallowing)
3
Q
Pannbacker et al., 1993
A
survey asking SLPS found a large portion did not think SLPs should perform nasopharyngoscopy
4
Q
Joint Position Statement 1998
A
- Physicians only ones qualified in medically diagnoses related to the ID of laryngeal pathology as it affects voice
- SLPs with expertise in voice disorders and specialized training could use strobovideolaryngoscopy to ASSESS voice production and vocal function
5
Q
Position statement 1999 (ASHA and AAO)
A
states that SLPs are qualified for swallow endocopy
(they later retracted that statement and now say SLPs should not do endoscopy
6
Q
ASHA Position Statement (2008)
A
SLPs with specialized training in flexible/nasal endoscopy, rigid/oral endoscopy, and/or stroboscopy use these tools for the purpose of evaluated and treating disorders of speech, voice, resonance, and swallow function.
7
Q
Virginia board of Audiology and Speech Language Pathology (June 3, 2010)
A
SLPs cannot perform FEES unless properly trained and in the presence of a physician (retracted a few months later)
8
Q
State Laws that Address Endoscopy
A
federal government doesn’t pass laws about endoscopy (it’s up to the state)
- there are around 17 states that address endoscopy in their laws
9
Q
ASHA Code of Ethics
A
Individuals shall engage in only those aspects of the profession that are within the scope of their professional practice and competence, considering their level of education, training, and experience
10
Q
NRS 637B - Nevada Revised Statute
A
defined the practice of speech pathology
- Prevention, screening,consultation, assessment, diagnostic, dx, counseling, collaboration and referral services
- AAC
- auditory training, speech reading, speech and language intervention secondary to HL
- screening hearing
- vocal tract imaging and visualization by oral/nasal endoscopy
- Selecting, fitting and establishing effective use of prosthetic/adaptive devices for communication
- Providing services to modify or enhance communication
11
Q
ASHA Code of Ethics
A
Need to be practicing within scope of practice and competence considering their level of education, training, and experience
12
Q
Medicare and other payers
A
- Medicare does not pay SLP directly for endoscopy in some states
- Most other insurance companies do
- Reimbursement varies by region, facility, payer
- insurance rules do not restrict your practice
(you can do anything within your scope of practice no matter what insurance covers)
13
Q
MAC’s
A
reimbursement from medicare
Nevadas: Palmetto GBA
- doesn’t pay us directly.
- we bill them for something other than endoscopy and we end up getting paid anyway.
14
Q
A Model Curriculum for VES (what you need to know)
A
- Rationale for performing VES
- Normal and disordered anatomy
- endoscopic equipment and technique
- patient safety
- Interpreting and Reviewing images
- Reporting
- performing the procedure
15
Q
- Rationale
A
why are you doing the procedure
- just because you can do it doesn’t mean you should
- if you already know what’s wrong and you aren’t going to learn anything from it, there is no reason to do it
16
Q
- Normal and disordered anatomy
A
obtained through M.S. degree course work
17
Q
- Endoscopic equipment and technique
A
endoscope light source camera video storage defogger Misc: gloves, eye wear, lubricant, mask (decongestants, topicals)
18
Q
- Patient Safety
A
Anesthetics
- dosage should not be an issue
- some use topical anesthetics in the nose or spray in the mouth
- hospitals use nasal anesthetics prepared by pharmacy before hand with correct dosage for client
- anaphylaxis could be an issue
- allergic reaction to anesthetic
- about 100,000 cases reported annually in US
- about 1% are fatal (1,000)
Topical Anesthesia
- found in many OTC drugs (most people are exposed very early in life)
- first time (child building antibodies - no reaction)
- second time - reaction
5 year old (50lbs) = 1/3 teaspoon
adult = 1 tablespoon
0verdose isn’t really an issue
Topical Sprays
- benzocaine - may cause methemoglobinemia or interference with binding of O2 to hemoglobin (could faint/die)
- rare condition, possibly dose related
Disclosure/Consent form
- nature of proposed procedure
- reason the procedure is recommended
- benefits of the procedure
- risks and complications and frequency
- alternatives to the procedure (if possible)
Contraindications
- why would you decide not to do the procedure?
pt doesn’t sign consent form
pt voices objection
use of anti-coagulant/blood thinning meds
hx of bleeding disorder (nasal)
19
Q
Recent double blind study related to children and endoscopy
A
no signifiant difference in the discomfort experienced by children undergoing flexible nasendoscopy after placebo, decongestant, or topical anesthetic with decongestant
20
Q
- Interpreting and Reviwing Images
A
- different for each of the three types of exams
21
Q
- Reporting
A
summarize and synthesize history, perceptual judgment, acoutic and aerodynamic measures, and endoscopy
22
Q
- Performing the Procedure
A
- didactic learning experiences
- mentoring: one-on-one
- supervised experience
- video review
- individual practice
23
Q
Flexible Endoscopy Parts
A
- Objective lens: eye piece
- look through if you don’t have camera - Diopter adjustment ring:
- adapts the endoscope at the level of the camera
- under the eyepiece is the focus ring
(focus before focusing camera) - Angulator lever: Angulator
- top of the endoscope
- moves the tip
- angulates the tip
- lever used to move tip of endoscope
- navigate small cavity - Cable for the light source: has a metal tip
- adapted to the light source
- plugged into the light source
- May need adaptor depending on which endoscope you use - Insertion tube
- “hose” near the tip of the endoscope
- this section of the scope is mobile
- end of the insertion tube: distal tip - make sure it’s always clean. This is where the light source comes from.
24
Q
Rigid Oral Endoscope
A
- eye piece
- camera adaptor/lens (click onto eye piece)
- attach to light source
Different degrees: 70 and 90
(we typically use 70 degree) - tip of endoscope doesn’t have to go as far into oropharynx
- depth of penetration into the oral cavity is less invasive
90 degree - shoots light at 90 degrees, tip of scope has to be almost touching posterior pharyngeal wall (don’t have in our clinic)
25
Components of stroboscopic system
Monitor
- where you see the exams
- on the cart
- on the wall (so patient can see)
- sometimes helps in pediatrics to see
```
Footswitch
- can use with Xenon and Halogen
- record switch
- switch allows clinician to look at the video strobe
(fast mode, slow mode, locked)
- can freeze frames
```
Digital camera
- camera, lens, lens adapter
- comes in 1 chip and 3 chip (higher is better resolution) - clinic has 3 chip
Printer
- on bottom half
- allows examiner to go through recording and capture a snap shot
- incorporate into a document
- can be sent to referring practicioner
Keyboard
- user friendly, reliable
acoustic microphone
- picks up ambient noise
- mounted on camera
- relatively stable microphone mouth to distance
- external speakers sit next to monitor
halogen/xenon light
150 watts
CPU
- hard drive, storage and retrieval, own software system and cataloging, allows playback, slow motion, regular speed, fast frame, frame by frame analysis, software is user friendly, storage for digital strobe
Microphone (laryngeal)
- plugs into light source
- contact microphone: held firmly against neck
- allows synchronization of intermittent light source and voice
- contact microphone allows for stroposcopic image
Lens adaptor
- adapts the eye piece of the endoscope
26
types of light source
Continuous - always on
| Intermittent - bulb is on and off
27
types of bulbs
Halogen
Xenon
28
Halogen bulb
yellow light source, inexpensive, not as bright as Xenon, only comes in continuous light source
Advantage: less expensive
150 Watts
- accomodates for this type of bulb wattage
option of 300 W (used in high speed imaging)
- 300W only type used for high speed imaging
- 300W cannot be used with fiberoptic endoscope: gets very hot and could burn patient
29
Xenon bulb
- very bright
- white light
- bulbs are very expensive - $68 per use
- intermittent xenon used in stroboscopy
- light is on and off
- synchronizes with fundamental frequency of voice - that is how xenon knows th epulse
- intermittent light source typically 150 W
30
types of scopes
rigid and flexible
light source plugs into the endoscope table...use adaptors to adapts the various scopes and light source
chip on the tip - has own light source
31
flexible fiberoptic rhinopharyngolaryngoscopes
- various diameters
- flexible scopes can be small
- more comfortable
- many types
- smallest in pediatric is made by Olympus
32
Pediatric flexible scope
- insertion tube 1.8 mm is smallest
| used for pediatrics and small women
33
typical endoscope
- diameter and shaft of 3.4 mm
- endocope in our clinic: FNL7R3P = 2.4 diameter
- new chip in the tip camera: camera in distal tip, rather than level of the eyepiece
reduces distance to the anatomy being viewed - better resolution
- bright
- diameter 4.1mm
uncomfortable and rigid
- larger tip diameter - more difficult to insert
- if nasal cavity is sensitive - this may be uncomfortable
- ENTs may have a dissecting channel...in addition to the fiberoptic tube...you have a channel...channel is used for biopsy or suction...diameter is 4.8mm difficult to use
34
cost of different scopes
P4 adult endoscope: $5,000
Pediatric scope: $8,000
chip in the tip: $19,000 (different light source)
35
Operation in clinical setting
- may use for bedside swallows
private setting: may have to start small and add to your system
*need knowledge and experience
*knowledge of anatomy and physiology is very important
- making appropriate recommendtions
- how to manage pathology
- examiner knowledge is key
36
Voice production
Disadvantage: have to have a periodic voice for the light source to synchronize with the pitch
- more dysphonic your patient..the more difficult it is for the strobe to synchronize with Fo
- allows for successive cycles over time
- can play back in video mode
37
The strobe
- makes one think they are looking at one, two, or three successive vibrations
- pieces of tracking
- tacking is crucial
- hard to do with aperiodic or dysphonic voice
- lack of pitch tracking = adjust the contact microphone, 2 seconds for continuous tracking to begin
```
some peeps are harder to scope
- strong gag reflexes
- fear
- small oral cavity
- small nasal passage
use pediatric scope if needed
```
38
Image quality troubleshooting
- instrumentation
- set up of instrumentation
- how bright the image is
- need to be patient and get what you want
- need to be patient
39
artifacts
- pitch tracking is a problem
- quivering VF
- equipment issues
- patient issue
- voice issue
- need to recognize the issues and the etiology
- if VQ is good, try to make changes in microphone position
- if singer, tell them not to use vibrato
40
recording
- make sure you hit the foot switch!
- save image
- new patient
- enter patient information
- save
- ready to retrieve at a later time
41
Human vocal folds
- vibrate at a rate thats faster than the human eye can see
hummingbird: 60/sec
woman VF: 225/sec
man VF: 180/sec
with contant light (halogen) source we can evaluate VF anatomy, mucosal color, gross movements
VF vibrations need special imaging technology
- need to slow down vibration for assessment
- videostroboscopy is most widely used
- assess vibratory characteristics
- accepted and essential component of a comprehensive exam
42
Created stroboscope
Oertel 1895 - widely used until the 20th century
- improved our understanding of VF vibration
- can be applied to voice disorders
- improve the study of VF histology
- learn more about the structures affecting vibratory physiology
43
Stroboscopy is indicated when...
a detailed analysis of VF vibration is desired
performed in addition to:
- indirect or flexible exam of larynx
- par of a complete eval
- expecially for patient with c/o hoarseness
44
Examinations..
- rule out obvious abnormal anatomy (mass or lesion)
- rule out obvious movement disorder (VF paralysis)
- then a futher evaluation of VF characteristics is warranted
VS provides info about VF vibration
Image obtained with VS is magnified
- allows more detailed assessment of VF anatomy
- video camera records a digital high definition with amazing image quality
45
Detailed review of recording after examination
- can use slow motion
- frame by frame analysis
- allows for comprehensive examination
- elucidate VF abnormality that would otherwise be missed by indirect or flexible laryngoscopy
46
who is a candidate for videostroboscopy
any patient with voice problems in whom the diagnosis is unclear
- able to document VF function prior to any treatment
- evaluate outcomes of various interventions
- clinical tool for etiological diagnosis of voice disorders
- results can be compared across settings
- subsequent exams can be compared
- results of TX can be studied
- used during surgical planning and surgical results
**you should not be doing therapy if you haven't SEEN what's going on**
47
How does the stroboscope work?
stethoscope (laryngeal microphone) on patient's neck measures the frequency of strobe flashing
- flashing is to a frequency slightly off and several multiples slower than VF vibration - computer tracks and knows to flash light slightly slower
- allows images from sequential parts of the vibratory cycle to be recorded
- viewed as "virutal" slow motion movie
- recording rates are 30 frames/second
"asynchronized"
48
strobe set to synchronized
strobe flashes at identical frequency of phonation (doesn't look like virtual motion anymore)
- see periodicity this way if you weren't able to see it during regular stroboscopy
- records images from the same point in vibratory cycle
- results in a "still" image
49
Vibratory Parameters
1. Symmetry of Vibration
2. Periodicity of Vibration
3. Phase Closure
4. Amplitude
5. Glottic Configuration
6. Mucosal Wave
50
1. Symmetry of Vibration
- refers to the movement of the right and left VF relative to each other
- normally vibrate as mirror images of one another
- begin to move laterally at the same time and at same speed
- displace laterally to the same extent
- reach lateral displacement at the same time
- begin to close at the same time
differences in mechanical properties of the two VF will result in asymmetric movements
symmetry influenced by differences in position, shape, mass, stiffness, elasticity, and tension of the VF tissue
51
2. Periodicity
- refers to the relative length of the glottal cycle
- should be stable from cycle to cycle
- use of "synchronized" strobe setting can confirm vibration if periodic
- if it's not a still image, the vocal folds are not periodic
- length of vibratory cycle is stable from cycle to cycle...then static image will persist with strobe set to synchronized
- if changes in length of the vibratory cycle are present...there will be movement of vibratory edge in the synchronized mode (look like fluttering)
- periodicity depends on mechanical properties of VF and expiratory force applied to them
52
3. Phase Closure
- refers to percentage of time that the VVF edges are open and/or closed during a single cycle of vibration
- phase characteristics are normally influenced by more of phonation (falsetto, modal phonation, glottal fry) and pitch and loudness.
53
4. Amplitude
- the amount of lateral movement of the VF during vibration
- normally increases with increases in subglottic pressure
- during loud phonation
- amplitude also increases as pitch (frequency) of phonation decreases
54
5. Glottic Configuration
- the shape or contour of the glottic opening
- if there's an opening at point of maximal closure during vibratory cycle.
"contour of glottal margin"
"VF closure pattern"
55
6. Mucosal Wave
- refers to movement of the superficial tissues over the VF as air moves through the glottis
- can be seen as a traveling wave in the superficial tissues over the top of the VF surface (medial to lateral)
- slow motion or frame by frame is usually required to adequately assess mucosal wave
- interrupted by abnormalities of VF mucosal cover...like scarring, lesions, inflammation or edema
56
Value of Video stroboscopy
FUNCTIONAL VOICE DISORDER - patients with voice complaints and no abnormality identified
- Dx changed in 44%
- 20% diagnosed with VF lesions
- 3-5% rate of change in diagnosis in patient with malignant lesions and neurological disorders
- 70% of cases where VS resulted in change in dx, a benign tumor was found
- 19% VF bowing not appreciated on previous exam
BILATERAL VF NODULES - typically demonstrates reduced amplitude of vibration. Normal periodicity. Intact mucosal wave, hourglass glottic opening
VF POLYPS - present with asymmetric vibration, variable periodicity, mucosal wave maybe present or absent, irregular VF margins, glottic closure usually irregular and asymmetric
VF CYSTS - unilateral, cause asymmetric and aperiodic vibration, hourglass glottic configuration, protrusion form the medial VF margin over the cyst, mucosal wave frequently absent over the cyst,
***surgical and VS correlate 100% of the time
57
Limitions of Videostroboscopy
- superficial invasive CA of the larynx cannot be distinguished from a benign process using VS alone
- reduced mucosal wave identified in the area of a suspicious lesion ..the result of a superficial pathological process
epithelial atypical or it could be invasive malignancy in deeper tissues
- VS is two dimensional process
- not a reliable way to diagnose CA or to determine the depth of invastion
- difficult to see medial glottal surfaces - lesions in this area may not be identified
- sulcus vocalis (medial surface VF lesion) may be difficult to dx on VS
- sulcus vocalis maybe present with an absent or decreased mucosal wave...defective glottic closure...VS unable to ID solcus vocalis
mucosal bridges are frequently missed
CANNOT BE USED WITH ALL PATIENTS
- requires stable phonation to activate strobe
- must have periodic phonation for optimal recording of VF vibration
- severe hoarseness...rapid changes in phonation frequency
SEVERAL SECONDS ARE REQUIRED TO ACTIVATE THE STROBE
- patient who cannot phonate for 3-5 seconds at a stable frequency ...VS may not be possible
- patients with gag reflex
- some MTD can be missed because tongue is out and can't evaluate continuous speech
ANALYSIS RELIES ON VISUAL PERCEPTUAL JUDGEMENTS
susceptible to bias, subjective
- avoid over diagnosis or seeing pathology that isn't there
- avoid missing pathology that may be contributing to vocal symptoms
- some vibratory features seen with dysphonia can also be seen with healthy normal (makes it difficult to distinguish)
rating vibratory characteristics (not reliable)
- some studies show improved reliability with experience
- patient hx influences severity rating
- vocal fold edge abnormalities
- mucosal wave abnormalities
- ID of adynamic segments
- phase closure
THERE IS NO STANDARD PROTOCOL
- need a standard protocol - need to do things the same way so that you can track progress over time
- minimizes variation in study parameters secondary to pitch and loudness
- allows for comparison of individual patients over time
- across patient
- standard maybe: low pitch, normal, high pitch in addition to phonation range in speaking voice...document vocal intensity at each pitch range
- loud and soft phonation at various pitches
58
Branches of Vagus Nerve CNX
PHARYNGEAL BRANCH (1st branch)
- sensory and motor branches
- supply mucus membrane, muscles of pharynx, soft palate
SUPERIOR LARYNGEAL NERVE (2nd branch)
- transmits sensory info from base of tongue to membranes in the subra glottis
- motor innervation to the inferior contrictor and cricothyroid -- lengthening of VF (pitch change) helps the cricoid rock forward
Internal division - sensory to larynx
external division - vital to tensing and relaxing TVF, provides motor innervation to the cricothyroid
RECURRENT LARYNGEAL NERVE (3rd branch)
- transmits sensory to the subglottis
- transmits motor to all intrinsic muscles of the larynx except cricothyroid
59
Vagus sensory and motor components
sensory components of larynx and pharynx
motor = velum, base of tongue, superior, middle, and inferior pharyngeal constrictors, larynx, autonomic ganglia of thorax (respiration aspects of phonation)
60
Recurrent Laryngeal Nerve
- vital to adduction and abduction of VF
- innervates 4 of 5 intrinsic laryngeal muscles of the larynx
Cut RLN + atrophy of the TA
- weak vocal fold approximation
- mid-vocal cord bowing
- dysphonia
- lack of subtle pitch changes (ie. for singing)
- paralysis of posterior cricoarytenoid (PCA) paralysis = inability to open the glottis on the involved side (unilateral abductor paralysis)
- Paralysis of lateral cricoarytenoid (LCA) = paralysis in the fixed, paramedian, abducted position
61
CNIX Glossopharyngeal
function includes
- taste in posterior 1/3 of tongue
- sensation to the fauces, tonsils, pharynx, and soft palate
- primary motor innervation - superior pharyngeal contrictor (starts at the base of the skull)
- stylopharyngeus
62
Layers of the TVF
```
epithelium
superficial layer of lamina propria
intermediate layer of lamina propria
deep layer of lamina propria
body (vocalis muscle)
```
63
Reinke's space
space between vocal ligament and overlying mucosa
64
Pharyngeal Plexus
- motor and most sensory innervation - branches of the vagus (X) and glossopharyngeal (IX) nerves
- these 2 nerves form a plexus in the outer fascia of the pharyngeal wall, consisting of:
- the pharyngeal branch of the vagus nerve(X)
- branches from the external laryngeal nerve from superior laryngeal branch of the vagus(X)
- pharyngeal branches of the glossopharyngeal nerve (IX)
65
spaces and cavities
```
vallecular space
lateral channels
vestibule/aditus
ventricle
glottis
interarytenoid space
anterior commissure
ligaments
```
66
conus elasticus
- connects the cricoid cartilage with the thyroid and arytenoid cartilages
- composed of dense fibroconnective tissue with abundant elastic fibers
- having 2 parts
1. Medial cricothyroid ligament - connects the anterior part of the arch of the cricoid cartilage with the inferior border of the thyroid membrane
2. Lateral cricothyroid membranes - originate on the superior surface of the cricoid arch and rise superiorly and medially to insert on the vocal process of the arytenoid cartilages posteriorly, and to the interior median part of the thyroid cartilage anteriorly
- it's free borders form the vocal ligaments
67
Quadrangular Membrane
- extends from the sides of the epiglottic cartilage anteriorly to the anterolateral surface of the arytenoid cartilage and posteroinferiorly to the corniculate cartilage - with its covering of mucous membrane forms the aryepiglottic fold superiorly and vestibular ligament inferiorly
- it forms the medial wall of the piriform recess
68
Hypopharynx
level of hyoid to the epiglottis
| - epiglottis is attached to the thyroid and the hyoid by different ligaments
69
Extrinsic Muscles of the Larynx
9 pairs (attach outside larynx)
- Geniohyoid
- mylohyoid
- stylohyoid
- digastric (anteror-posterior belly)
- hyoglossus
- sternohyoid
- sternothyroid
- omohyoid
70
Intrinsic Muscles of the Larynx
(origin and insertion are inside the larynx)
- cricothyroid
- posterior cricoarytenoid (PCA)
- lateral cricoarytenoid (LCA)
- transverse arytenoid (TA)
- Oblique arytenoid (OA)
- Vocalis muscle
- Thyroarytenoid muscle
71
Parts of Hyoid bone
```
body
lesser horns (lesser conua)
greater horns (greater cornua)
```
72
Pharynx
NASOPHARYNX
- extends from the nasal chonae to the level of the nasopharyngeal isthmus
- nasal part of the pharynx
- uppermost part of the pharynx
- extends from base of skull to upper surface of soft palate
ADENOID PAD
- good to allow them to go away on own
- if possible so that the velum can continue to close
PHARYNGEAL WALL
- posterior pharyngeal wall
- laryngeal pharyngeal wall
73
Muscle that makes up the velum
lavator veli palatini
74
Oral Cavity
- oral cavity
- buccal cavity
- oropharyngeal isthmus - where we see the pharyngeal wall at the level of the pharynx
- anterior faucial arches
- posterior faucial arches
- tonsillar fossa - where your tonsils live
- palatine tonsils - these can get swollen. You should always be looking at the tonsils and be able to rate them 1+, 2+, 3+, 4+ (cultasac resonance)
- oropharynx
- ducts for salivary glands
75
Nasal Cavity anatomy
- nasal passage into narrow chambers
- separated by nasal septum
- circle part of your nose
- base of the external nose
- ANA nasal valve
76
Para-Nasal Cavity - anterior
- floor of the nose
- formed by hard palate
- extends as far back as the soft palate
- same as the roof of the mouth
structure:
- 2 palatine processes
posterior, larges space (aka inferior meatus), easiest way to get through the nose
plate 37
77
Inferior Nasal Turbinate (Concha)
- Long, narrow
- curled bony shelf (like a sea shell)
- protrudes to breathing passage of the nose
- scrolled spongy bones
- larges as long as index finger
airflow is direct
used for humidification
largest plate 37
78
Middle Nasal Turbinate
- smaller (pinky finger)
- projects downward toward and over maxillary and ethmoid sinus
- acts as a buffer to protect sinus from pressured airflow
- most air travels between interior and middle concha
79
Superior Nasal Turbinate (concha)
- smallest of the turbinates
- lies in the superior aspect of the nasal cavity
- underneath is the superior meatus
80
Torus Tubarius
- cushion
- base of the auditory meatus
- behind pharyngeal orifice of tube
- opening of eustachian tube
81
choanae
- posterior part of nasopharynx
- space that is posterior to the meatus
- separated by vomer
Intro to Audiology
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