European Society for Swallowing Disorders FEES Accreditation Program for Neurogenic and Geriatric Oropharyngeal Dysphagia

Flexible Endoscopic Evaluation of Swallowing: A Proposed Checklist

PURPOSE

Flexible endoscopic evaluation of swallowing (FEES) is not only a well-recognized and ubiquitous tool in dysphagia research but also possesses features that make the assessment vulnerable to shortcomings in transparency and rigor in published literature. Therefore, FEES was considered an important addition to the Framework for RigOr aNd Transparency In REseaRch on Swallowing (FRONTIERS), a multisite collective effort to establish a tool for the critical appraisal of reporting in all forms of dysphagia and swallowing-related research on human subjects.

METHOD

From the FRONTIERS collective, a team of three clinician researchers completed a review of FEES-related literature to determine all components crucial for generalizable and reproducible reporting of FEES research. These components were developed and refined through an iterative process.

RESULTS

This review culminated in a 26-item series of "yes/no" questions, forming the FEES section of FRONTIERS. These questions are grouped into the following five components: (a) Equipment, (b) Rater(s), (c) Rating Process, (d) Outcome Metrics, and (e) Miscellaneous Factors.

CONCLUSION

The results of this review support that FEES possesses unique characteristics to other aspects of dysphagia research and is consequently a crucial addition to FRONTIERS to ensure that clinical researchers have access to critical appraisal of FEES-related research inquiry.

Validation of the DIGEST-FEES as a Global Outcome Measure for Pharyngeal Dysphagia in Parkinson's Disease

Flexible Endoscopic Evaluation of Swallowing (FEES) is one of two diagnostic gold standards for pharyngeal dysphagia in Parkinson's disease (PD), however, validated global outcome measures at the patient level are widely lacking. The Dynamic Imaging Grade of Swallowing Toxicity for Flexible Endoscopic Evaluation of Swallowing (DIGEST-FEES) represents such an outcome measure but has been validated primarily for head and neck cancer collectives. The objective of this study was, therefore, to investigate the validity of the DIGEST-FEES in patients with PD. Content validity was evaluated with a modified Delphi expert survey. Subsequently, 66 FEES videos in PD patients were scored with the DIGEST-FEES. Criterion validity was determined using Spearman's correlation coefficient between the DIGEST-FEES and the Penetration-Aspiration Scale (PAS), the Yale-Residue-Rating-Scale, the Functional-Oral-Intake-Scale (FOIS), and the swallowing-related Unified-Parkinson-Disease-Rating-Scale (UPDRS) items. Inter-rater reliability was determined using 10 randomly selected FEES-videos examined by a second rater. As a result, the overall DIGEST-FEES-rating exhibited significant correlations with the Yale-Valleculae-Residue-Scale (r = 0.84; p < 0.001), the Yale-Pyriform-Sinus-Residue-Scale (r = 0.70; p < 0.001), the FOIS (r =  - 0.55, p < 0.001), and the UPDRS-Swallowing-Item-Score (r = 0.42, p < 0.001). Further, the DIGEST-FEES-safety subscore correlated with the PAS (r = 0.63, p < 0.001). Inter-rater reliability was high for the overall DIGEST-FEES rating (quadratic weighted kappa of 0.82). Therefore, DIGEST-FEES is a valid and reliable score to evaluate overall pharyngeal dysphagia severity in PD. Nevertheless, the modified Delphi survey identified domains where DIGEST-FEES may need to be specifically adapted to PD or neurological collectives in the future.

Pharyngeal Electrical Stimulation prior to extubation - Reduction of extubation failure rate in acute stroke patients?

PURPOSE

The aim of our study was to assess if PES before extubation can minimize the extubation failure risk in orally intubated, mechanically ventilated stroke patients at high risk of severe dysphagia.

MATERIALS AND METHODS

Thirty-two ICU patients were prospectively enrolled in this study presenting with a high risk for dysphagia as defined by a DEFISS (Determine Extubation Failure In Severe Stroke) risk score and compared 1:1 to a retrospective matched patient control group. The prospective patient group received PES prior to extubation. Endpoints were need for reintubation, swallowing function as assessed with FEES, pneumonia incidence and length of stay after extubation.

RESULTS

Post-extubation, the Fiberoptic Endoscopic Dysphagia Severity Score (FEDSS, 4.31 ± 1.53vs.5.03 ± 1.28;p = 0.047) and reintubation rate within 72 h (9.4vs.34.4%;p = 0.032) were significantly lower in the PES group than in the historical control group. Pulmonary infections after extubation were less common in PES-treated patients although this difference was not significant (37.5vs.59.4%;p = 0.133). Time from extubation to discharge was significantly shorter after PES compared with the control group (14.09 ± 11.58vs.26.59 ± 20.49 days;p = 0.003).

CONCLUSIONS

In orally intubated and mechanically ventilated stroke patients at high risk of severe dysphagia, PES may improve swallowing function, reduce extubation failure risk and decrease time from extubation to discharge. Further research is required.

Long-term effects on swallowing and laryngeal function after treatment for severe COVID-19 disease in intensive care

PURPOSE

This study aimed to assess swallowing and laryngeal function at long-term follow-up in patients treated for severe COVID-19 in the ICU.

METHODS

Thirty-six patients with severe COVID-19 were prospectively examined with fiberendoscopic evaluation of swallowing (FEES) about 6 and 12 months after ICU discharge. Comparison with initial FEES examinations during the time in hospital was performed in 17 patients. Analysis of swallowing function and laryngeal features was performed from video recordings. Twenty-five participants responded to Eating Assessment Tool, Voice Handicap Index, and the Hospital Anxiety and Depression Scale at follow-up.

RESULTS

Penetration to the laryngeal vestibule (PAS ≥ 3) was seen in 22% and silent aspiration (PAS = 8) in 11% of patients on at least one swallow at follow-up. Fourteen percent had obvious residue in the vallecula and/or pyriform sinuses after swallowing thick liquid or biscuits. Self-reported eating and swallowing difficulties were found in 40% of patients. Abnormal findings in the larynx were present in 53% at follow-up. Thirty-three percent had reduced or impaired vocal fold movement, of whom 22% had bilateral impaired abduction of the vocal folds. Possible anxiety and depression were found in 36% and 24% of responders, respectively.

CONCLUSION

Although a majority of patients appear to regain normal swallowing function by 1 year after treatment for severe COVID-19, our results indicate that dysphagia, abnormal laryngeal function, and anxiety/depression may remain in a substantial proportion of patients. This suggests that swallowing and laryngeal function, and emotional symptoms, should be followed up systematically over time in this patient group.

Difference in the Electromyographic Behavior of the Masticatory and Swallowing Muscles During Cued Versus Spontaneous Swallowing

The risk of dysphagia and/or aspiration is determined using screening tests, such as the repeated saliva swallowing test and modified water swallowing test, which evaluate cued swallowing. However, humans masticate and swallow foods with various consistencies, forms, and amounts, without conscious awareness. Therefore, this study aimed to examine the difference in the behavior of masticatory and swallowing muscles during spontaneous versus cued swallowing through a series of mastication and swallowing processes by evaluating surface electromyogram (sEMG) signals. The effect of the consistency and amount of food on the behavior of these muscles was also investigated. The sEMG recordings of the masseter muscles and anterior belly of the digastric muscle for 12 subjects, and genioglossus muscle for 5 subjects were obtained. The genioglossus activity was recorded using custom-made ball electrodes. The test foods were cookies and tofu, in amounts of 2 g and 4 g. The normalized muscle activity (integrated EMG), duration of the muscle activity, initial activation timepoint of each muscle, and total duration of swallowing were compared among four conditions. The activity of each muscle was significantly higher during the swallowing of cookies than tofu, for 4 g vs 2 g, and for cued versus spontaneous swallowing. The duration of each muscle activity, initial activation timepoint, and total duration of swallowing were significantly longer for cookies versus tofu, for 4 g vs 2 g, and for spontaneous versus cued swallowing. These results suggest that the behavior of the masticatory and swallowing muscles is affected by cued swallowing and by the consistency and amount of food.

Systematic approach to contextualize findings of flexible endoscopic evaluation of swallowing in neurogenic dysphagia- towards an integrated FEES report

Flexible endoscopic evaluation of swallowing (FEES) is one of the most important methods for instrumental swallowing evaluation. The most challenging part of the examination consists in the interpretation of the various observations encountered during endoscopy and in the deduction of clinical consequences. This review proposes the framework for an integrated FEES-report that systematically moves from salient findings of FEES to more advanced domains such as dysphagia severity, phenotypes of swallowing impairment and pathomechanisms. Validated scales and scores are used to enhance the diagnostic yield. In the concluding part of the report, FEES-findings are put into the perspective of the clinical context. The potential etiology of dysphagia and conceivable differential diagnoses are considered, further diagnostic steps are proposed, treatment options are evaluated, and a timeframe for re-assessment is suggested. This framework is designed to be adaptable and open to continuous evolution. Additional items, such as novel FEES protocols, pathophysiological observations, advancements in disease-related knowledge, and new treatment options, can be easily incorporated. Moreover, there is potential for customizing this approach to report on FEES in structural dysphagia.

Training to Analyze Functional Parameters with Fiberoptic Endoscopic Evaluation of Swallowing: A Scoping Review

Analyzing fiberoptic endoscopic evaluation of swallowing (FEES) is challenging and requires training to ensure the proficiency of health professionals and improve reliability. This scoping review aims to identify and map the available evidence on training health professionals to analyze FEES functional parameters. The method proposed by the Joanna Briggs Institute and the PRISMA-ScR guidelines were followed. The search was performed in MEDLINE, Cochrane Library, Embase, Web of Science, Scopus, CINAHL databases, and in the gray literature. Two blinded independent reviewers screened articles by title and abstract. Then, they read the full text of the included reports, considering the eligibility criteria. Data were extracted using a standardized form. Six studies met the established eligibility criteria, published between 2009 and 2022, with few participants. All these studies addressed training as part of the process to validate a rating scale. No standardized criteria were observed regarding the selection of experts and participants, training structure, and outcome measures to assess participants' competence. The reviewed literature indicates that training must be developed to equip students and health professionals who treat dysphagia, enabling them to analyze the functional parameters of the FEES, considering variables that may influence the participants' performance.

Early flexible endoscopic evaluation of swallowing after mechanical thrombectomy in stroke patients

OBJECTIVE

The aims of the study were to (1) characterize the findings of flexible endoscopic evaluation of swallowing (FEES) in stroke patients undergoing mechanical thrombectomy (MT); (2) analyse the screening performance of the Standardized Swallowing Assessment (SSA); and (3) study the impact of FEES-defined dysphagia on 3-month outcomes.

METHODS

This single-centre study was based on a local registry of consecutive acute ischaemic stroke patients undergoing MT during a 1-year period. Patients received FEES within 5 days of admission regardless of the result of dysphagia screening. We compared baseline demographic and clinical characteristics of patients with and without FEES-defined dysphagia. We collected 3-month modified Rankin Scale (mRS) and individual index values of the European Quality of Life 5 Dimensions (EQ-5D-iv). Using univariable and multivariable regression analyses we predicted 3-month outcomes for presence of dysphagia and for FEES-defined dysphagia severity.

RESULTS

We included 137 patients with a median age of 74 years, 43.1% were female, median NIHSS was 12 and successful recanalization was achieved in 92.7%. Stroke-associated pneumonia occurred in 8% of patients. FEES-defined dysphagia occurred in 81% of patients. Sensitivity of the SSA as a dysphagia screening was 67%. Presence of dysphagia and increasing severity of dysphagia were independently associated with increasing 3-month mRS score. Increasing dysphagia severity dysphagia was independently associated with lower EQ-5D-iv.

INTERPRETATION

Early FEES-defined dysphagia occurs in four in every five patients undergoing MT. SSA has a suboptimal dysphagia screening performance. Presence of dysphagia and increasing dysphagia severity predict worse functional outcome and worse health-related quality-of-life.

Tube feeding in advanced dementia: Insights from South African speech-language therapists

BACKGROUND

 Speech-language therapists (SLTs) may recommend tube feeding even with minimal research evidence of its effectiveness, and an understanding of SLTs' perceived practices is warranted.

OBJECTIVES

 To qualitatively describe a sample of South African SLTs' perceived practices regarding feeding tube placement in people with advanced dementia.

METHOD

 Semi-structured online interviews were conducted via Microsoft Teams. Eight South African SLTs with a particular interest in advanced dementia, in public and private settings, were recruited. Data were analysed using inductive reflexive thematic analysis.

RESULTS

 Three main themes were identified: (1) factors influencing SLTs' decisions for feeding tube placement in people with advanced dementia; (2) nature of clinical setting and SLTs' decision-making and (3) SLTs' considerations to improve management of people with advanced dementia. Existing local palliative care guidelines were not employed in decisions about tube feeding. Most participants did not recommend tube feeding during end-of-life care. Perceived burden of care influenced participants' decisions about tube feeding.

CONCLUSION

 Speech-language therapists in South Africa likely have an increased reliance on clinical experience rather than recent research and guidelines for decisions about feeding tube placement. Findings accentuate the importance of clinical supervision, mentoring and continuous professional development in the workplace. The findings are an urgent call to action to improve SLTs' overall practices and ethical service delivery for people with advanced dementia and their families.Contribution: Factors and needs regarding SLTs' decision-making about feeding tubes in people with advanced dementia are highlighted.

The assessment of dysphagia after stroke: state of the art and future directions

Dysphagia is a major complication following an acute stroke that affects the majority of patients. Clinically, dysphagia after stroke is associated with increased risk of aspiration pneumonia, malnutrition, mortality, and other adverse functional outcomes. Pathophysiologically, dysphagia after stroke is caused by disruption of an extensive cortical and subcortical swallowing network. The screening of patients for dysphagia after stroke should be provided as soon as possible, starting with simple water-swallowing tests at the bedside or more elaborate multi-consistency protocols. Subsequently, a more detailed examination, ideally with instrumental diagnostics such as flexible endoscopic evaluation of swallowing or video fluoroscopy is indicated in some patients. Emerging diagnostic procedures, technical innovations in assessment tools, and digitalisation will improve diagnostic accuracy in the future. Advances in the diagnosis of dysphagia after stroke will enable management based on individual patterns of dysfunction and predisposing risk factors for complications. Progess in dysphagia rehabilitation are essential to reduce mortality and improve patients' quality of life after a stroke.

Development of a Visuoperceptual Measure for Fiberoptic Endoscopic Evaluation of Swallowing (V-FEES) in Adults with Oropharyngeal Dysphagia: An International Delphi Study

Visuoperceptual evaluation of fiberoptic endoscopic evaluation of swallowing (FEES) is a commonly used assessment in dysphagia or swallowing disorders. Currently, no international consensus exists regarding which visuoperceptual measures to use for the analysis of FEES recordings. Moreover, existing visuoperceptual FEES measures are limited by poor and incomplete psychometric data, identifying an urgent need for developing a visuoperceptual measure to interpret FEES recordings. Following the COSMIN group's (COnsensus-based Standards for the selection of health Measurement INstruments) psychometric taxonomy and guidelines, this study aimed to establish the content validity of a new visuoperceptual FEES (V-FEES) measure in adults with oropharyngeal dysphagia. Using the Delphi technique, international consensus was achieved among dysphagia experts across 21 countries, resulting in a new prototype measure for V-FEES, comprising 30 items, 8 function testing items (i.e., specific tasks performed by patients while observing and rating items), and 36 unique operationalisations (i.e., defining items into measurable factors that could be measured empirically using visuoperceptual observation). This study supports good content validity for V-FEES, including participants' feedback on the relevance, comprehensiveness, and comprehensibility of the included items. Future studies will continue the instrument development process and determine the remaining psychometric properties using both the classic test theory (CTT) and item response theory (IRT) models.

Position Statement of the Union of European Phoniatricians (UEP): Fees and Phoniatricians' Role in Multidisciplinary and Multiprofessional Dysphagia Management Team

The need for multidisciplinary and multiprofessional management of dysphagia is constantly increasing and creating a major challenge for healthcare professionals and society, especially in terms of professional expertise and human resources. The distribution of tasks among the dysphagia team members, which includes phoniatricians, otolaryngologists, and speech-language therapists, is flexible and overlapping. For assessing dysphagia, the (fibreoptic) flexible endoscopic evaluation of swallowing (FEES), with or without videofluoroscopy, is a pivotal diagnostic tool. This position paper aims to illustrate the phoniatrician's role in performing a FEES, which is an indispensable component of the diagnostic workup of patients suffering from oropharyngeal dysphagia. It is based on the current collaborative expert view of the Swallowing Committee of the Union of European Phoniatricians and a literature review. A FEES is one of the core competences of phoniatricians due to their endoscopic expertise and experience in the field of dysphagia and diseases of the upper aerodigestive tract. Therefore, the phoniatrician is an important member of the dysphagia team, for the medical diagnostics of the aerodigestive tract and dysphagia as well as for FEES. Phoniatric competence is especially important for head and neck cancer patients, infants, and complex cases.

Safety, feasibility and diagnostic value of Clinical Swallow Examination and FEES in children between 0 and 24 months

BACKGROUND

Clinical Swallowing Examination (CSE) and Fiberoptic Endoscopic Evaluation of Swallowing (FEES) are relevant diagnostic methods in pediatric dysphagia. Satisfactory and comprehensive healthcare is still not part of the standard diagnostic process.

AIMS

The purpose of this article is to evaluate the safety, feasibility, and diagnostic value of CSE and FEES in children 0-24 months of age.

STUDY DESIGN

A retrospective cross-sectional study which was conducted at the pediatric clinic of the University Hospital Düsseldorf, Germany, between 2013 and 2021.

SUBJECTS

A total of 79 infants and toddlers with suspected dysphagia were included.

OUTCOME MEASURES

Analyses of the cohort and FEES pathologies were performed. Dropout criterion, complications and change of diet were recorded. Chi-square identified associations between clinical symptoms and FEES results.

RESULTS

All FEES examinations were performed without complications and with a completion rate of 93.7 %. Anatomical abnormalities in the laryngeal region were diagnosed in 33 children. Wet voice was significantly associated with premature spillage (p = .028).

CONCLUSIONS

CSE and FEES are important and uncomplicated examinations for children with suspected dysphagia between 0 and 24 months. They are equally helpful for differential diagnosis of feeding disorders and anatomical abnormalities. The results underline the added value of combining both examinations and their importance for individual nutritional management. History taking and CSE are mandatory as they reflect the everyday eating situation. This study adds essential knowledge to the diagnostic work-up of dysphagic infants and toddlers. Standardizing the examinations and validating dysphagia scales are future tasks.

Relationship between post-stroke dysphagia and pharyngeal sensory impairment

BACKGROUND

Post-stroke dysphagia (PSD) is common and can lead to serious complications. Pharyngeal sensory impairment is assumed to contribute to PSD. The aim of this study was to investigate the relationship between PSD and pharyngeal hypesthesia and to compare different assessment methods for pharyngeal sensation.

METHODS

In this prospective observational study, fifty-seven stroke patients were examined in the acute stage of the disease using Flexible Endoscopic Evaluation of Swallowing (FEES). The Fiberoptic Endoscopic Dysphagia Severity Scale (FEDSS) and impaired secretion management according to the Murray-Secretion Scale were determined, as well as premature bolus spillage, pharyngeal residue and delayed or absent swallowing reflex. A multimodal sensory assessment was performed, including touch-technique and a previously established FEES-based swallowing provocation test with different volumes of liquid to determine the latency of swallowing response (FEES-LSR-Test). Predictors of FEDSS, Murray-Secretion Scale, premature bolus spillage, pharyngeal residue, and delayed or absent swallowing reflex were examined with ordinal logistic regression analyses.

RESULTS

Sensory impairment using the touch-technique and the FEES-LSR-Test were independent predictors of higher FEDSS, Murray-Secretion Scale, and delayed or absent swallowing reflex. Decreased sensitivity according to the touch-technique correlated with the FEES-LSR-Test at 0.3 ml and 0.4 ml, but not at 0.2 ml and 0.5 ml trigger volumes.

CONCLUSIONS

Pharyngeal hypesthesia is a crucial factor in the development of PSD, leading to impaired secretion management and delayed or absent swallowing reflex. It can be investigated using both the touch-technique and the FEES-LSR-Test. In the latter procedure, trigger volumes of 0.4 ml are particularly suitable.

Translation and Validation of the Dysphagia Handicap Index in Polish-Speaking Patients

Dysphagia Handicap Index (DHI) is a self-assessment questionnaire which consists of 25 statements to examine three aspects of dysphagia patients’ quality of life (QoL): functional, physical, and emotional. The patient can get a maximum score of 100 points. The study goal was to validate and translate the Polish version of the DHI (PL-DHI). One hundred and seventy-eight (178) individuals with oropharyngeal dysphagia with different etiology and 35 (thirty-five) asymptomatic adults with no history of swallowing disorders filled out the PL-DHI. Internal consistency was determined using Cronbach alpha coefficient, which was high for the total PL-DHI score (0.962). The reproducibility was high (r-Spearman correlation coefficient was 0.97 for total PL-DHI score). The PL-DHI’s total score and its subscales were significantly higher in the dysphagia patients study group (SG) than in the healthy controls group (CG) (SG median: 36; CG median: 4). A strong correlation was observed between the PL-DHI score and the self-reported dysphagia severity measure (Spearman’s correlation coefficient was 0.859, p < 0.001). The Polish DHI is a reliable and valid questionnaire for assessing dysphagia patients’ QoL.

Accuracy of Dysphagia Standard Assessment (DSA®) bedside screening test: a flowchart for patient eligibility

BACKGROUND

Oropharyngeal dysphagia (OD) screening tests have improved patient management; however, the complex applicability and high percentage of false negatives do not allow these tests to be considered completely reliable if not supported by an instrumental investigation. The aim of the present study is to evaluate an OD screening test, the Dysphagia Standard Assessment (DSA®) with different volumes and viscosities.

MATERIALS AND METHODS

Prospective study of 72 patients evaluated for suspected OD through a double-blind methodology conducted by two operators. All patients underwent fiberoptic endoscopic evaluation of swallowing (FEES) as a reference test and a separate DSA® test. DSA® was performed by administering boluses with different viscosities, with the signal of interruption of the test being: onset of the cough reflex, wet voice after swallowing, and/or desaturation of O2 ≥ 5%. The Penetration-Aspiration Scale (PAS) was evaluated by FEES. The cut-off identified to diagnose OD was PAS ≥ 3.

RESULTS

The test showed an accuracy of 82%, a sensitivity of 0.93 (95% C.I. 0.84-0.97), and a specificity of 0.78 (95% C.I. 0.67-0.87); positive predictive value 0.55 (95% C.I. 0.43-0.67); negative predictive value 0.97 (95% C.I. 0.90-0.99), positive likelihood ratio 4.37 (95% C.I. 3.6-5.2); likelihood negative ratio 0.08 (95% C.I. 0.06-0.09).

CONCLUSIONS

According to the preliminary results, the test showed good outcomes in determining the presence or absence of OD with a wide spectrum of applicability with some limitations that could be overcome by the selection of a target population. For this reason, a flowchart to address patient eligibility was developed.

Phoniatricians and otorhinolaryngologists approaching oropharyngeal dysphagia: an update on FEES

PURPOSE

Oropharyngeal dysphagia (OD) is a common phenomenon in otorhinolaryngology and phoniatrics. As both sub-disciplines have a strong tradition and clinical experience in endoscopic assessment of the upper aerodigestive tract, the implementation of fiberoptic endoscopic evaluation of swallowing (FEES) was an almost self-evident evolution. This review aims to provide an update on FEES and the role of phoniatricians and otorhinolaryngologists using FEES in Europe.

METHODS

A narrative review of the literature was performed by experts in the field of FEES both in the clinical context and in the field of scientific research.

RESULTS

FEES is the first-choice OD assessment technique for both phoniatricians and otorhinolaryngologists. FEES is becoming increasingly popular because of its usefulness, safety, low costs, wide applicability, and feasibility in different clinical settings. FEES can be performed by health professionals of varying disciplines, once adequate knowledge and skills are acquired. FEES aims to determine OD nature and severity and can provide diagnostic information regarding the underlying etiology. The direct effect of therapeutic interventions can be evaluated using FEES, contributing to design the OD management plan. Standardization of FEES protocols and metrics is still lacking. Technological innovation regarding image resolution, frame rate frequency, endoscopic light source specifications, and endoscopic rotation range has contributed to an increased diagnostic accuracy.

CONCLUSION

The rising number of phoniatricians and otorhinolaryngologists performing FEES contributes to the early detection and treatment of OD in an aging European population. Nevertheless, a multidisciplinary approach together with other disciplines is crucial for the success of OD management.

Tutorial on Clinical Practice for Use of the Fiberoptic Endoscopic Evaluation of Swallowing Procedure With Adult Populations: Part 1

PURPOSE

Representatives of the American Board of Swallowing and Swallowing Disorders (AB-SSD) and American Speech-Language-Hearing Association (ASHA) Special Interest Group (SIG) 13: Swallowing and Swallowing Disorders (Dysphagia) developed this tutorial to identify and recommend best practice guidelines for speech-language pathologists who conduct and interpret fiberoptic endoscopic evaluation of swallowing (FEES) procedures in adults. This document also includes proposed training needs and methods for achieving competency. Expert opinion is provided regarding indications for performing the FEES exam, potential contraindications, adverse effects and safety, equipment and personal protection, the exam protocol, interpretation and documentation of findings, and training requirements to perform and interpret the exam.

CONCLUSIONS

This tutorial by the AB-SSD and SIG 13 represents the first update about the FEES procedure since ASHA's position paper and technical report published in 2004. Creation of this document by members of the AB-SSD and SIG 13 is intended to guide professionals who are training for or practicing FEES in the adult population toward established best practices and the highest standards of care.

Treinamento para análise de parâmetros da videoendoscopia da deglutição: um protocolo de revisão de escopo

RESUMO Objetivo: apresentar um protocolo de revisão de escopo para identificar e mapear as evidências disponíveis sobre treinamento para a análise de parâmetros da videoendoscopia da deglutição. Métodos: o protocolo seguirá o método proposto pelo Joanna Briggs Institute e as diretrizes PRISMA-P para relato de protocolos de revisão. A busca será feita na MEDLINE, Cochrane Library, Embase, Web of Science, Scopus, CINAHL e literatura cinzenta. Uma estratégia de busca foi desenvolvida para a MEDLINE, que será adaptada para cada base de dados. Dois revisores independentes rastrearão os artigos pelo título e resumo. Em seguida, farão a leitura do texto completo dos artigos incluídos, considerando os critérios de elegibilidade. Os dados serão extraídos com um formulário padronizado. Os resultados serão apresentados em fluxograma e resumo narrativo, seguindo as diretrizes do PRISMA-ScR. Revisão da literatura: há escassez de pesquisas que descrevam métodos de treinamento perceptivo-visual para analisar parâmetros da VED e dados inconsistentes para orientar a tomada de decisão clínica. Esta revisão fornecerá informações abrangentes sobre o desenvolvimento de treinamento para esse tipo de análise. Conclusão: este protocolo de revisão de escopo apresentará o estado geral das pesquisas sobre o tema e identificará as lacunas existentes na base de evidências.

Training for fiberoptic endoscopic evaluation of swallowing parameter analysis: a scoping review protocol

ABSTRACT Purpose: to present a scoping review protocol to identify and map available evidence on training for fiberoptic endoscopic evaluation of swallowing parameter analysis. Methods: the protocol follows the method proposed by the Joanna Briggs Institute and the PRISMA-P guidelines for review protocol reports. The survey will be made in MEDLINE, Cochrane Library, Embase, Web of Science, Scopus, CINAHL, and grey literature. A search strategy has been developed for MEDLINE, which will be adapted for each database. Two independent reviewers will screen the articles by title and abstract. Then, they will read the full text of the included articles, considering the eligibility criteria. The data will be extracted with a standardized form. The results will be presented in a flowchart and narrative summary, following the PRISMA-ScR guidelines. Literature Review: there is a scarcity of research describing visual-perceptual training methods to analyze FEES parameters and inconsistent data to guide clinical decision-making. This review will provide comprehensive information on developing training for this type of analysis. Conclusion: this scoping review protocol will present the overall state of research on the topic and identify existing gaps in the base of evidence.

European Stroke Organisation and European Society for Swallowing Disorders guideline for the diagnosis and treatment of post-stroke dysphagia

Post-stroke dysphagia (PSD) is present in more than 50% of acute stroke patients, increases the risk of complications, in particular aspiration pneumonia, malnutrition and dehydration, and is linked to poor outcome and mortality. The aim of this guideline is to assist all members of the multidisciplinary team in their management of patients with PSD. These guidelines were developed based on the European Stroke Organisation (ESO) standard operating procedure and followed the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach. An interdisciplinary working group identified 20 relevant questions, performed systematic reviews and meta-analyses of the literature, assessed the quality of the available evidence and wrote evidence-based recommendations. Expert opinion was provided if not enough evidence was available to provide recommendations based on the GRADE approach. We found moderate quality of evidence to recommend dysphagia screening in all stroke patients to prevent post-stroke pneumonia and to early mortality and low quality of evidence to suggest dysphagia assessment in stroke patients having been identified at being at risk of PSD. We found low to moderate quality of evidence for a variety of treatment options to improve swallowing physiology and swallowing safety. These options include dietary interventions, behavioural swallowing treatment including acupuncture, nutritional interventions, oral health care, different pharmacological agents and different types of neurostimulation treatment. Some of the studied interventions also had an impact on other clinical endpoints such as feedings status or pneumonia. Overall, further randomized trials are needed to improve the quality of evidence for the treatment of PSD.

Oropharyngeal Dysphagia and Impaired Motility of the Upper Gastrointestinal Tract-Is There a Clinical Link in Neurocritical Care?

Patients in the neurological ICU are at risk of suffering from disorders of the upper gastrointestinal tract. Oropharyngeal dysphagia (OD) can be caused by the underlying neurological disease and/or ICU treatment itself. The latter was also identified as a risk factor for gastrointestinal dysmotility. However, its association with OD and the impact of the neurological condition is unclear. Here, we investigated a possible link between OD and gastric residual volume (GRV) in patients in the neurological ICU. In this retrospective single-center study, patients with an episode of mechanical ventilation (MV) admitted to the neurological ICU due to an acute neurological disease or acute deterioration of a chronic neurological condition from 2011–2017 were included. The patients were submitted to an endoscopic swallowing evaluation within 72 h of the completion of MV. Their GRV was assessed daily. Patients with ≥1 d of GRV ≥500 mL were compared to all the other patients. Regression analysis was performed to identify the predictors of GRV ≥500 mL/d. With respect to GRV, the groups were compared depending on their FEES scores (0–3). A total of 976 patients were included in this study. A total of 35% demonstrated a GRV of ≥500 mL/d at least once. The significant predictors of relevant GRV were age, male gender, infratentorial or hemorrhagic stroke, prolonged MV and poor swallowing function. The patients with the poorest swallowing function presented a GRV of ≥500 mL/d significantly more often than the patients who scored the best. Conclusions: Our findings indicate an association between dysphagia severity and delayed gastric emptying in critically ill neurologic patients. This may partly be due to lesions in the swallowing and gastric network.

From DYMUS to DYPARK: Validation of a Screening Questionnaire for Dysphagia in Parkinson's Disease

Dysphagia is a common debilitating symptom in people with Parkinson’s Disease (PD), adequate screening of swallowing disorders is fundamental. The DYMUS questionnaire has shown very good characteristics for the screening of dysphagia in Multiple Sclerosis, and it might also prove useful for screening dysphagia in PD. The primary aim was to test and validate the DYMUS questionnaire in PD patients. This is an observational multicentric study involving 103 patients affected by PD. All subjects filled in the DYMUS and the Eating Assessment Tool (EAT-10) questionnaires. A subgroup of patients (n = 53) underwent a fiber-optic endoscopic evaluation of swallowing (FEES) and their dysphagia was scored by means of the Dysphagia Outcome Severity Scale (DOSS). DYMUS showed a relatively high level of internal consistency (Cronbach’s alpha 0.79). A significant positive correlation was found between the DYMUS and the EAT-10 scores (p < 0.001), while a negative correlation was found between the DYMUS and the DOSS scores (p < 0.001). DYMUS showed a good sensitivity and specificity compared to FEES for detecting dysphagia (area under the curve: 0.82, p < 0.001). The ROC curve analysis showed that a DYMUS score ≥ 6 represents a reliable cut-off for the risk of dysphagia. The DYMUS questionnaire proved to be a reliable screening tool to detect dysphagia in patients suffering from PD. It is easy to understand, it can be self-administered and therefore adequate for adoption in the clinical practice with the more convenient name of DYPARK.

Characterization of dysphagia and laryngeal findings in COVID-19 patients treated in the ICU-An observational clinical study

Background

Dysphagia appears to be common in patients with severe COVID-19. Information about the characteristics of dysphagia and laryngeal findings in COVID-19 patients treated in the intensive care unit (ICU) is still limited.

Objectives

The aim of this study was to evaluate oropharyngeal swallowing function and laryngeal appearance and function in patients with severe COVID-19.

Method

A series of 25 ICU patients with COVID-19 and signs of dysphagia were examined with fiberendoscopic evaluation of swallowing (FEES) during the latter stage of ICU care or after discharge from the ICU. Swallowing function and laryngeal findings were assessed with standard rating scales from video recordings.

Results

Pooling of secretions was found in 92% of patients. Eleven patients (44%) showed signs of silent aspiration to the trachea on at least one occasion. All patients showed residue after swallowing to some degree both in the vallecula and hypopharynx. Seventy-six percent of patients had impaired vocal cord movement. Erythema of the vocal folds was found in 60% of patients and edema in the arytenoid region in 60%.

Conclusion

Impairment of oropharyngeal swallowing function and abnormal laryngeal findings were common in this series of patients with severe COVID-19 treated in the ICU. To avoid complications related to dysphagia in this patient group, it seems to be of great importance to evaluate the swallowing function as a standard procedure, preferably at an early stage, before initiation of oral intake. Fiberendoscopic evaluation of swallowing is preferred due to the high incidence of pooling of secretion in the hypopharynx, silent aspiration, and residuals. Further studies of the impact on swallowing function in short- and long-term in patients with COVID-19 are warranted.

Enhancing the learning and supervision framework for training in flexible endoscopic evaluation of swallowing

PURPOSE OF REVIEW

This article reviews the literature on the development of competency-based training and assessment in endoscopy, comparing gastrointestinal endoscopy and flexible endoscopic evaluation of swallowing (FEES). The discussion focusses on how a robust and explicit learning framework can be translated to the delivery of training in FEES to optimize trainee outcomes and supervisor skill.

RECENT FINDINGS

Specialist Speech and Language Therapists (SLT) carry out FEES to inform the diagnosis and management of swallowing and voice disorders. Taught courses are generally followed by local workplace-based supervised practice to attain the competencies identified in the relevant professional guidelines. However, the curriculum for the workplace-based FEES training lacks a learning and assessment framework and little direction for the workplace-based supervisor. In gastrointestinal endoscopy training, this previously led to less than optimal outcomes for trainees and patients and so new models of training were developed.

SUMMARY

A new learning framework for FEES underpinned by medical pedagogy has shown early promise in supporting the acquisition of competence. Incorporating a new FEES-specific systematic assessment, the framework provides direction for the supervisor and evidence of trainee progression, which subsequently enhances supervisor confidence to determine trainee competence.

Fiberoptic endoscopic evaluation of swallowing and videofluoroscopy swallowing assessment in adults in residential care facilities: a scoping review protocol

OBJECTIVE

This scoping review will identify and explore existing evidence on the use of instrumental swallowing assessment in the diagnosis and management of dysphagia in adults living in residential care facilities.

INTRODUCTION

Oropharyngeal dysphagia is prevalent among adults living in residential care facilities. Videofluoroscopy and fiberoptic endoscopic evaluation of swallowing are instrumental assessment procedures commonly utilized in the evaluation of oropharyngeal dysphagia in hospital and community settings. However, little is known about the use of these procedures in residential care facilities. To ensure evidence-based assessment of oropharyngeal dysphagia and to guide future research, exploration of the current use and clinical utility of videofluoroscopy and fiberoptic endoscopic evaluation of swallowing in residential care facilities is needed.

INCLUSION CRITERIA

Published and gray literature written in English from 2000 onward that discusses instrumental swallowing assessment of adults in residential care facilities will be included in the review.

METHODS

A three-step search strategy will be used to explore relevant literature. All citations and articles retrieved during the searches will be imported into a software application for systematic reviews. Once duplicates are removed, two reviewers will screen the titles and abstracts against predefined inclusion criteria. Information will be extracted from literature that meets the selection criteria using a purposefully developed charting form. The search strategy and results will be illustrated through a Preferred Reporting Items for Systematic Reviews and Meta-Analyses diagram. Key findings and their relationship to the research questions will be summarized in a chart and discussed in interpretive narrative form.

Dysphagia in the elderly population: A Videofluoroscopic study

OBJECTIVE

To examine the impact of age and underlying comorbid conditions on swallowing in elderly patients with dysphagia.

METHODS

Charts of consecutive patients aged >64 studied by Videofluoroscopic swallowing study (VFSS) between 2010 and 2018 at our institution were reviewed (n = 731). Patients were categorized based on age into young old (aged 65-74), older old (aged 75-84) and oldest old (aged 85+). The underlying comorbidities and VFSS results were compared between different age groups.

RESULTS

Dysphagia was more likely to be caused by presbyphagia (p < 0.01) and dementia (p < 0.0001) in the oldest old, whereas, head and neck cancers (p < 0.0001) were more common in the young old cohort. In the absence of organic disease (e.g. cancer, stroke, dementia), aging was associated with prolonged oral transit time (OTT) (p < 0.05) and aspiration after swallow (p < 0.05). Compared to those with presbyphagia, patients with organic disease were more likely to have delayed pharyngeal swallow response (p < 0.05) and aspiration during swallow (p < 0.005).

CONCLUSION

There are significant differences in the etiology of dysphagia between different age cohorts amongst the dysphagic elderly population. In addition, organic diseases affect swallowing differently than does mere aging. The rate of prolonged OTT and post-swallow aspiration increase with aging in patients with presbyphagia, likely due to age-related sarcopenia of the swallowing muscles. Whereas, those with organic diseases have a higher rate of delayed pharyngeal swallow response and aspiration during swallow, likely due to sensorineural impairment. Thus, it is important to view the elderly as a heterogeneous group when evaluating patients with dysphagia.

Speech-language pathology managers' perceptions of a videofluoroscopic swallow study eLearning programme to support training and service delivery

PURPOSE

Conducting and interpreting videofluoroscopic swallow studies (VFSS) is a complex, multi-dimensional task, requiring post-qualification training to develop knowledge, skill and competence. Speech-language pathology (SLP) managers must continually ensure staffs are adequately trained to deliver safe and effective VFSS services. However, VFSS training is resource intensive, variable in content and not consistently accessed universally. This study examined managers' perceptions of a new VFSS eLearning programme and its impact on VFSS training and service delivery. The eLearning programme incorporated theoretical and procedural aspects of VFSS, accessed free of charge by speech-language pathologists working in a large public health service in Queensland, Australia.

METHOD

Twenty-two SLP managers participated in semi-structured interviews, which were evaluated using inductive content analysis.

RESULT

Four themes were identified relating to eLearning benefits: (1) design and content facilitated widespread uptake, (2) enhanced training opportunities, (3) increased clinical skill and workforce capacity and (4) benefits and efficiencies for SLP services. A fifth theme described contextual considerations for using the programme.

CONCLUSION

This study contributes information about the benefits of eLearning for delivering consistent, accessible VFSS training, in a resource-efficient manner. Managers perceived the eLearning programme as a valuable resource to supplement practical VFSS training, to ultimately support VFSS service provision.

Laryngeal Movement Disorders in Multiple System Atrophy: A Diagnostic Biomarker?

Background

Multiple system atrophy (MSA) is a rare neurodegenerative disorder, and its parkinsonian variant can be difficult to delineate from Parkinson's disease (PD). Despite laryngeal dysfunction being associated with decreased life expectancy and quality of life, systematic assessments of laryngeal dysfunction in large cohorts are missing.

Objectives

The objective of this study was to systematically assess laryngeal dysfunction in MSA and PD and identify laryngeal symptoms that allow for differentiating MSA from PD.

Methods

Patients with probable or possible MSA underwent flexible endoscopic evaluation of swallowing performing a systematic task protocol. Findings were compared with an age‐matched PD cohort.

Results

A total of 57 patients with MSA (64 [59–71] years; 35 women) were included, and task assessments during endoscopic examination compared with 57 patients with PD (67 [60–73]; 28 women). Patients with MSA had a shorter disease duration (4 [3–5] years vs 7 [5–10]; P < 0.0001) and higher disease severity (Hoehn & Yahr stage 4 [3–4] vs 3 [2–4]; P < 0.0001). Of the patients with MSA, 43.9% showed clinically overt laryngeal dysfunction with inspiratory stridor. During endoscopic task assessment, however, 93% of patients with MSA demonstrated laryngeal dysfunction in contrast with only 1.8% of patients with PD (P < 0.0001). Irregular arytenoid cartilages movements were present in 91.2% of patients with MSA, but in no patients with PD (P < 0.0001). Further findings included vocal fold motion impairment (75.4%), paradoxical vocal fold motion (33.3%), and vocal fold fixation (19.3%). One patient with PD showed vocal fold motion impairment.

Conclusion

Laryngeal movement disorders are highly prevalent in patients with MSA when assessed by a specific task protocol despite the lack of overt clinical symptoms. Our data suggest that irregular arytenoid cartilage movements could be used as a clinical marker to delineate MSA from PD with a specificity of 1.0 and sensitivity 0.9. © 2020 The Authors. Movement Disorders published by Wiley Periodicals LLC on behalf of International Parkinson and Movement Disorder Society

Fiberoptic Endoscopic Evaluation of Swallowing Across the Age Spectrum

Purpose Fiberoptic endoscopic evaluation of swallowing (FEES) is a widely used instrumental procedure used to assess swallowing function in persons of all ages, from infants to older adults. In this article, the history of FEES in adults, the protocol, the scoring system, and the interpretation of abnormal findings are summarized. The use of FEES to guide treatment in adults is also covered briefly. Following this review in adults, the use of FEES in infants and children is presented, including the anatomical-physiological assessment and the assessment of swallowing of food and liquid. Interpretation of findings and therapeutic applications are discussed. Conclusion FEES is a valuable part of the clinical protocol for evaluation and management of dysphagia across the life span. It provides a mechanism for in-depth analysis of swallowing structures and function during intake of liquid and food boluses. Future developments include standardized training content to ensure clinical competency and the development of standardized examination and interpretation protocols.

Inter-rater and test-retest reliability of the "standardized endoscopic swallowing evaluation for tracheostomy decannulation in critically ill neurologic patients"

Background

Removal of a tracheostomy tube in critically ill neurologic patients is a difficult issue, particularly due to the high incidence of oropharyngeal dysphagia. For an objective evaluation of decannulation readiness the "Standardized Endoscopic Swallowing Evaluation for Tracheostomy Decannulation in Critically Ill Neurologic Patients" (SESETD) - a stepwise evaluation of 'secretion management', 'spontaneous swallows' and 'laryngeal sensibility/cough' - has been introduced. With the recent study detailed data on inter-rater and test-retest reliability are presented.

Methods

To obtain inter-rater reliability levels both in a group of raters with at least 5 years of experience ('experts') and in a group of raters with no or only minor experience using the SESETD ('non-experts'), for each single item of the protocol and the sum score α-, respectively κ-levels were determined. The 'experts' assessed the same videos after a four-week interval to determine test-retest reliability. Ten videos from tracheostomized neurological patients completely weaned from mechanical ventilation were assessed independently by six 'experts'. 27 'non-experts' applied the SESETD on 5 videos from the same patient population after introduction to the protocol in a one-hour workshop.

Results

For the items 'secretion management' and 'spontaneous swallows' α-levels were identified at > 0.800 both in the group of 'experts' and 'non-experts'. With regard to the item 'laryngeal sensibility/cough' in both groups, the α-level was ≥0.667. With κ-levels of 1.0 for 'secretion management', 0.93 for 'spontaneous swallows' and 0.76 for 'laryngeal sensibility/cough' test-retest reliability showed at least substantial agreement for each item. Intraclass correlation coefficient for the sum score was excellent in both groups (α ≥ 0.90).

Conclusions

The SESETD demonstrates good to excellent agreement for each single item included as well as the sum score in experienced and unexperienced raters supporting its usefulness for implementation in daily clinical routine and as an outcome measure for clinical trials.

The PhINEST study - Pharyngeal ICU Novel Electrical Stimulation Therapy: Study protocol of a prospective, multi-site, randomized, sham-controlled, single-blind (outcome assessor-blinded) study

INTRODUCTION

Post-extubation dysphagia is commonly observed in ICU patients and associated with increased aspiration rates, delayed resumption of oral intake/ malnutrition, prolonged ICU and hospital length of stay, decreased quality of life, and increased mortality. Conventional therapeutic approaches are limited. Pharyngeal electrical stimulation (PES) was previously shown to improve swallowing function and airway safety in severely dysphagic tracheostomised stroke patients.

METHODS

In a multi-center, single-blind, 1:1 randomized controlled study, up to 400 (360 evaluable) mixed emergency adult ICU patients with recent extubation following mechanical ventilation and confirmed oropharyngeal dysphagia will be enrolled at investigational academic ICUs. Primary objective is to evaluate the effectiveness of PES in reducing the severity of unsafe swallows. Patients will be randomized to receive PES (or sham) treatment on 3 consecutive days in addition to best supportive care. Primary endpoint is a composite of 2 endpoints with hierarchy based on clinical priorities: DISCUSSION:: This study will evaluate the effects of PES on swallowing safety in critically ill ICU patients post mechanical ventilation with oropharyngeal dysphagia.

Exploring Consistency and Variation in Fibreoptic Endoscopic Evaluation of Swallowing Practice in Australia

BACKGROUND

Fibreoptic endoscopic evaluation of swallowing (FEES) is an imaging technique used by speech-language pathologists (SLPs) and some other health professionals to assess swallowing.

OBJECTIVES

The primary aim was to gain an insight into FEES practices in Australia by characterising SLPs who use FEES and identifying areas of consistency and variation in practice. The secondary aim was to explore factors associated with variation in practice.

METHOD

Cross-sectional survey methodology was used. The link to a web-based survey was e-mailed to 351 SLPs who practised in adult dysphagia.

RESULTS

The participation rate for the study was 18.8% (n = 66). Twenty-two SLPs (38.6%) used FEES. These SLPs represented a cross-section of workplace settings, caseloads, clinical and training experiences. Consistency and variation in FEES procedural and assessment practices were identified. Some procedural aspects of FEES varied according to whether a medical practitioner was present, type of FEES training, and number of FEES conducted per month.

CONCLUSION

This research represents a benchmark in the knowledge of how FEES is used in Australia. Despite the small number of participants, the findings provide a foundation from which future research questions can be generated. More extensive examination of the use of FEES by SLPs is warranted. Further research is also required to establish methods for attaining and maintaining competency and to achieve consensus on which aspects of swallowing are assessed when using FEES and how the examination should be conducted.

Safety and clinical impact of FEES - results of the FEES-registry

Background

At present, the flexible endoscopic evaluation of swallowing (FEES) is one of the most commonly used methods for the objective assessment of swallowing. This multicenter trial prospectively collected data on the safety of FEES and also assessed the impact of this procedure on clinical dysphagia management.

Methods

Patients were recruited in 23 hospitals in Germany and Switzerland from September 2014 to May 2017. Patient characteristics, professional affiliation of the FEES examiners (physicians or speech and language therapists), side-effects and cardiorespiratory parameters, severity of dysphagia and clinical consequences of FEES were documented.

Results

2401 patients, mean age 69.8 (14.6) years, 42.3% women, were included in the FEES-registry. The most common main diagnosis was stroke (61%), followed by Parkinson’s disease (6.5%). FEES was well tolerated by patients. Complications were reported in 2% of examinations, were all self-limited and resolved without sequelae and showed no correlation to the endoscopist’s previous experience. In more than 50% of investigations FEES led to changes of feeding strategies, in the majority of cases an upgrade of oral diet was possible.

Discussion

This study confirmed that FEES, even when performed by less experienced clinicians is a safe and well tolerated procedure and significantly impacts on the patients’ clinical course. Implementation of a FEES-service in different clinical settings may improve dysphagia care.

Trial registration

ClinicalTrials.gov NCT03037762, registered January 31st 2017.

[Swallowing in the elderly : Physiological changes, dysphagia, diagnostics and treatment]

Increasing age leads to a number of physiological as well as disease-related pathological changes that among others also affect structures involved in swallowing. These changes not only increase the risk of developing dysphagia but as a result can lead to pneumonia, malnutrition, exsiccosis, a relevant impairment of the quality of life and increased mortality. To evaluate the nature and extent of dysphagia, clinical swallowing tests as well as instrumental approaches, such as the endoscopic evaluation of swallowing are available. Depending on the findings from these examinations, the underlying disease and estimation of the individual patient prognosis, several treatment approaches ranging from diet adaptation, logopedic exercises and compensatory maneuvers up to tube feeding are available. The optimal treatment requires close cooperation of all disciplines involved.

Safety of flexible endoscopic evaluation of swallowing examination in gastroenterological practice

BACKGROUND/AIMS

In South Korea, the flexible endoscopic evaluation of swallowing (FEES) has been increasingly performed by gastroenterologists. The principal concern was the safety of the FEES performed by gastroenterologists without any involvement of speech-language pathologists. We aimed to characterize the safety and tolerance of gastroenterologist-directed FEES examinations (GDFEES).

MATERIALS AND METHODS

We evaluated the GDFEES failures, safety profile (laryngospasm, epistaxis, vasovagal syncope, airway compromise, heart rate, blood pressure, and significant change in cardiovascular function), and discomfort level in patients undergoing GDFEES. These outcomes were also analyzed based on gender, age, and calendar period.

RESULTS

A total 303 examinations in 268 adult patients with dysphagia were performed during the study period. The GDFEES failures occurred in 5 patients (1.7%). The causes of failures were poor co-operation and insertion difficulty. There were no instances of laryngospasm or vasovagal syncope or significant cardiovascular changes in any of the examinations. Self-limiting epistaxis occurred in 22 examinations (7.3%). The discomfort ratings were as follows: 128 examinations (43.0%) rated the overall discomfort of the test as none, 150 (50.3%) as mild, 18 (6.0%) as moderate, and 2 (0.7%) as severe discomfort. The discomfort level was significantly different only between the first and second half periods (p <0.001), but it was related to neither gender nor age.

CONCLUSION

The GDFEES can be endorsed as an appropriate paradigm for clinical practice based on our study investigating its safety and tolerance.