HC4 Endoscopy

Question 1

What’s the overall goal of CSE?

Answer 1

• provides baseline information: makes it easier to track and compare the swallowing ability over time
• can be repeated as much as you want
• specific findings (e.g. posture) that will facilitate the imaging procedure
• determines readiness for further diagnostics

Question 2

Why would you need imaging?

Answer 2

• to assess function and safety of the pharyngeal/laryngeal stage
• to determine specific techniques to manage the swallowing problem, strategies to improve swallow safety/efficiciency
• gives information about the coughing or choking during eating
• if the inability to maintain nutrition or hydration results in weight loss or compromised health
• if there are problems with pulmonary health

Question 3

Explain FEESS and FEEST

Answer 3

• FEESS = flexible endoscopic evaluation of swallowing safety
• FEEST = flexible endoscopic evaluation with sensory testing:
• assess laryngeal sensation
• endoscopic assessment of swallowing

Question 4

Explain why the quality of the endoscopic examination depends on the quality of the instrument

Answer 4

• new technologies: chip in the tip = camera chip in the scope’s tip:
• very close to structures to visualize
• superb image quality
• quite expensive, not available in every setting
• older scope: camera at the scope’s eyepiece
• further away from structures
• light source is limited

Question 5

Explain the bolus materials in the FEES ‘kit’

Answer 5

• range of consistencies and textures (bolus types)
• range of bolus volumes
• multiple options for introducing the foods and liquids (spoon, cup, straw)

Question 6

With FEES, how do we offer more comfort and less pain to the patient. (Dis)advantage(s)?

Answer 6

• Use of topical anestetic agent:
• in one nasal passage (most open)
• gel form applied to the tip of the scope
• spray form

=> disadvantage: interference with sensation??

• lubricating gel on the scope
• antifogging agent

Question 7

Why is the positioning of the scope important (FEES)?

Answer 7

• particular question about velar function or velopharyngeal closure -> scope between inferior and middle turbinates => simultaneous visualization of the velum and lateral and posterior pharyngeal walls
• particular question about the oropharyngeal structures -> scope in the oropharynx at or just below where soft palate would be at rest during quiet nose breathing
• particular question about laryngeal structures -> scope lower, at the epiglottis, with the full length of the true vocal folds visible

Question 8

Which indications demand endoscopy instead of videofluoroscopy, due to the unique type of information provided by FEES?

Answer 8

• concerns about:
• alterations in nasopharyngeal, oropharyngeal or laryngeal anatomy (+ superficial tissue health): larynx and true vocal folds are better evaluated with endoscopy!
• sensory integrity of pharyngeal/laryngeal structures
• patient’s ability to initiate and maintain airway protection
• high risk of aspiration (assess without food or liquid!)
• fatigue by repeated swallows
• symmetry of pharyngeal constriction (simultanous contribution of tongue and pharynx constriction)
• need for ‘online’ visual feedback
• repeatable (no radiation)
• if there the patient can not be transported
• if information is needed quickly (radiographic exam needs to be scheduled)

Question 9

Compare FEES with DSS

Answer 9

see Comparison FEES - DSS

Question 10

What do the specific FEES tasks depend on?

Answer 10

On the individual patient:

• how much is he able to tolerate without fatigue?
• based on previous findings

Question 11

So with FEES we evaluate the integrity of the valves and chambers. Explain.

Answer 11

• Chambers: expand to accomodate bolus material -> compress to propel bolus and clear chamber from bolus material

—–> impairment leads to impaired bolus propulsion + clearing

• Valves: permit or prevent bolus flow from one chamber to the next

—–> impairment leads to early loss of the bolus or inappropriate entrance/reflux or ineffective bolus transmission

Question 12

Which tasks during FEES may be performed to assess the velopharyngeal valve?

Answer 12

• produce 1) sustained vowel 2) sustained /s/ 3) sentence with no nasal sounds
• > observe elevation of the velum and constriction

of the lateral and posterior pharyngeall wall

• > symmetry?
• > contributions of each structure?
• observe closure during dry swallow (different from closure for speech)
• swallow small liquid bolus (1-3 ml) -> any leakage?

Question 13

Which tasks during FEES may be performed to assess the pharyngeal chamber and valve?

Answer 13

• produce ‘ahhhh’ (produce pharyngeal frication) -> observe contact between tongue base and posterior pharynx
• examine piriform sinuses, valleculae, pharyngeall walls, base of tongue and postcricoid area for pooled secretions -> if so (but it shouldn’t), touch lightly the tissue with the scope tip:
• not cleared after swallowing: motor function impaired
• cleared well after swallowing: poor sensation = sensory function impaired
• elevate vocal pitch on “ee” -> observe pharyngeal constriction (should constrict during this task):
• presence or absence of constriction?
• symmetry?
• hold nose -> piriform sinuses should open maximal
• turn head -> piriform sinuses should close at the side the head is turned to (symmetry?)

Question 14

What exactly do we observe when assessing

• the velopharyngeal valve with FEES?
• the pharyngeal chamber and valve with FEES?
• the laryngeal chamber and valve with FEES?

Answer 14

• velopharyngeal valve: assess the valving function of the velum and lateral/posterior pharyngeal walls
• pharyngeal chamber/valve: the patient’s potential for effecting appropriate pharyngeal dynamics -> because during swallowing, sequential changes in size and shape of the pharynx (constriction) help to propel the bolus from mouth to esophagus
• laryngeal chamber/valves: assess the ability of the larynx to close and to elevate, and to respond to bolus materials that may come in contact with its structures

Question 15

Which tasks during FEES may be performed to assess the laryngeal chamber and valve?

Answer 15

• sustain vowel /ee/ or a nasal sound /mmm/ => elevation of the larynx so you can have a good look at the laryngeal structures -> observe
• mobility of the true vocal folds
• completeness of the closure
• time in adducted position
• voice quality (weak? breathy?)

—> may be indicative of vocal fold dysfunction and compromised ability to protect the airway

• low pitch to high pitch -> observe change in length of vocal folds and elevation of laryngeal structures
• repeated series of brief /i/ and inspiration -> observe any asymmetry in abduction and adduction of the true vocal folds (could indicate paralysis or paresis of 1 fold)
• hold breath -> observe degree of adduction of true folds, constriction of false folds and approximation of arytenoids
• effectiveness of true fold adduction for throat clearing and cough

Question 16

What exactly do we observe when assessing the swallow function with FEES?

Answer 16

• Assess several events before and after swallow that are critical to transfer a bolus quickly and safely from the oral cavity through the pharynx to the upper esophagus

Question 17

Which tasks during FEES may be performed to assess the swallow function?

Answer 17

1. Start with 1-3 ml (green) liquid bolus: hold in mouth, count to 3, swallow -> note early loss into the valleculae or piriform sinuses, or penetration/aspiration prior to the swallow
2. after swallow: check sites of residue, estimate how much residue is left
3. if residue -> does patient repeat swallow? If not: ask to swallow -> clearing?
4. if residue on vocal folds -> does patient cough/clears throat? If not: ask to do so and repeat swallow
5. if swallowing is safe -> repeat with:
6. 3-5 ml liquid
7. larger self-selected bolus in a cup
8. paste bolus