Transnasal endoscopic evaluation of swallowing: a bedside technique to evaluate ability to swallow pureed diets in elderly patients with dysphagia

Pharyngeal Residues Following Swallowing of Pureed Diets Thickened with a Gelling Agent or a Xanthan Gum-Based Thickener in Elderly Patients with Dysphagia

The ideal texture of pureed diets to prevent aspiration pneumonia remains unclear. The aim of this study was to evaluate the effectiveness of a pureed diet with either a gelling agent or a xanthan gum-based thickener to prevent pharyngeal residues in patients with dysphagia. We retrospectively analyzed a randomized, crossover trial of pureed rice with either a gelling agent or a xanthan gum-based thickener in patients with dysphagia. The enrolled patients were classified into mild and moderate-to-severe dysphagia groups. The primary outcome measure was degree of need for cyclic ingestion using test jelly for pharyngeal residuals (cyclic ingestion score). The secondary outcome was the patient's sense of material remaining in the throat following swallowing. Sixty-two patients (58% men; mean age 83 ± 9 years) with dysphagia were included. They were classified into mild dysphagia (n = 26) and moderate-to-severe dysphagia (n = 36) groups. In the moderate-to-severe dysphagia group, pharyngeal residuals were significantly less likely with pureed diets using a gelling agent than with those using a xanthan gum-based thickener, with respective median cyclic ingestion scores (range) of 1 (0-4) vs. 2.5 (0-4) (p = 0.001). There was no significant difference in pharyngeal residuals between the pureed diets in the mild dysphagia group. The multivariate analysis identified gelling agent as an important factor significantly associated with less pharyngeal residual after swallowing of pureed diet in patients with moderate-to-severe dysphagia. Pureed diets thickened by a gelling agent decrease pharyngeal residues in patients with moderate-to-severe dysphagia and may reduce risk of aspiration pneumonia.

Effectiveness of Water Jelly Ingestion for Both Rehabilitation and Prevention of Aspiration Pneumonia in Elderly Patients With Moderate to Severe Dysphagia

BACKGROUND AND AIMS

We evaluated the effectiveness of water jelly ingestion for both rehabilitation and the prevention of aspiration pneumonia in a retrospective analysis of elderly patients with moderate to severe dysphagia.

PATIENTS AND METHODS

Study 1: consecutive patients with borderline ingestion in an endoscopic swallowing evaluation were enrolled (n=36, 18 men and 18 women: mean age 82±9 y) and categorized into a group with water jelly (50 to 100 mL) ingestion training 3×/day or an untrained control group. Their food intake levels were then compared using a Food Intake Level Scale. Study 2: consecutive patients who were hospitalized because of aspiration pneumonia were enrolled (n=64, 35 men and 29 women: mean age 81±9 y) and categorized into a group with cyclic ingestion of water jelly immediately after each meal or a control group. The incidence of aspiration pneumonia that was newly developed during hospitalization was compared between the groups.

RESULTS

In study 1, 36 patients with a Hyodo-Komagane score of 8 were enrolled. Three of the 12 (25%) patients who underwent water jelly ingestion training were able to eat a pureed diet (level 5, 2 patients; level 6, 1 patient) while none of the 24 patients (0%) who did not undergo this training were able to eat any form of diet (levels 5 and 6, no patients) (P=0.011). In study 2, 64 patients were enrolled. No newly developed aspiration pneumonia was observed in the 34 patients (0%) who received cyclic water jelly ingestion, whereas 17% (5/30) of patients not receiving water jelly after meals newly developed aspiration pneumonia during hospitalization (P=0.031).

CONCLUSIONS

Water jelly ingestion was effective for both rehabilitation and the prevention of aspiration pneumonia in elderly patients with moderate to severe dysphagia.

Modifying Puree Meals in Residential Aged Care Facilities: A Multi-Centre Feasibility and Acceptability Study

Purees are often recommended for older adults in residential aged care facilities (RACFs) to target swallowing difficulties and nutrition. However, they lack appeal and may have negative impacts on nutritional intake. This study investigated the subjective experiences and objective swallowing function and safety of older adults in response to a modified puree. Twenty-eight residents from three RACFs whose regular diets consisted of purees were recruited. Purees were modified to improve visual appeal by adding a commercial enzyme gellant. Each participant was observed during three puree and three modified puree meals, and completed a brief questionnaire after each meal. A videofluoroscopic swallowing study (VFSS) was performed with 16 of the participants. Compared to purees, modified purees were observed to be easier for oral processing and intake amount was higher, but participants required assistance more often and mealtimes were longer. Participants did not show preference for either type of puree. VFSS showed similar swallowing responses between the two puree types; however, a distinction was observed for modified pureed meat compared to other ingredients. Modifying puree meals in RACFs is a feasible approach to improve nutritional intake while maintaining swallowing safety, but their appeal to consumers is not definitive.

Pureed diets containing a gelling agent to reduce the risk of aspiration in elderly patients with moderate to severe dysphagia: A randomized, crossover trial

GOALS

The aim of this study was to evaluate the effectiveness of adding a gelling agent to pureed diets to prevent aspiration pneumonia in elderly patients with moderate to severe dysphagia.

BACKGROUND

Pureed diets are often used to reduce aspiration in patients with dysphagia. However, the ideal texture of a pureed diet to prevent aspiration pneumonia remains unclear.

MATERIALS AND METHODS

We prospectively conducted a randomized, crossover trial of pureed rice with or without a gelling agent in patients with moderate to severe dysphagia (ClincialTrials.gov number, NCT03163355). The primary outcome measure was pharyngeal residuals using an endoscopic scoring system. The secondary outcome was the sense of material remaining in the throat following swallowing.

RESULTS

Sixty two patients (58% men), mean age 83 ± 9 years with moderate to severe dysphagia were included. Residuals in the throat were significantly less likely with pureed rice with than without the gelling agent (median cyclic ingestion score (range); 1 (0-4) vs 2 (0-4); P = .001). Irrespective of the presence or absence of the gelling agent, the sense of material remaining in the throat was significantly less frequent in older patients (87 ± 7.6 vs 75 ± 9.1 years, P < .01; 86 ± 7.3 vs 75 ± 8.6 years, P < .01).

CONCLUSIONS

Pureed diets containing a gelling agent may reduce the risk of aspiration pneumonia possibly by decreasing pharyngeal residues in elderly patients with moderate to severe dysphagia.

Surgical treatment of anterior cervical osteophytes causing dysphagia

PURPOSE

Dysphagia due to anterior cervical osteophytes is a rare condition. However, it can become serious enough to permanently impair the quality of life up to making normal food intake impossible. If conservative treatment fails, there is the option of surgical resection of the osteophytes. The objective of this study was to assess the outcomes of resections of anterior cervical osteophytes causing spondylogenic dysphagia, taking literature into consideration.

METHOD

Resection of anterior cervical osteophytes using a standard anterior approach was performed in 14 consecutive patients with spondylogenic dysphagia between 2009 and 2015. Indomethacin or radiation was used to prevent recurrence. Imaging and clinical data were collected in follow-up examinations over an average of 50 months.

RESULTS

The osteophytes were sufficiently resected in all cases. Anterior plates were placed in three patients due to pronounced segmental mobility. Five patients were given recurrence prevention in the form of indomethacin, nine with radiation. One patient required revision surgery for a hematoma. No other serious complications were observed. All patients had significant improvement of their symptoms. No recurrences or signs of increasing instability were found during the follow-up period.

CONCLUSION

When conservative treatment fails, surgical resection of cervical osteophytes is a sufficient method for treating spondylogenic dysphagia. High patient satisfaction and improvement of the quality of life are achieved with a low complication rate. Routine additional stabilization has been discussed as recurrence prevention. Prophylaxis using indomethacin or radiation, known primarily from hip replacement, also appears to be an option.

Percutaneous Endoscopic Gastrostomy versus Nasogastric Tube Feeding: Oropharyngeal Dysphagia Increases Risk for Pneumonia Requiring Hospital Admission

Background: Aspiration pneumonia is the most common cause of death in patients with percutaneous endoscopic gastrostomy (PEG) and nasogastric tube (NGT) feeding. This study aimed to compare PEG versus NGT feeding regarding the risk of pneumonia, according to the severity of pooling secretions in the pharyngolaryngeal region. Methods: Patients were stratified by endoscopic observation of the pooling secretions in the pharyngolaryngeal region: control group (<25% pooling secretions filling the pyriform sinus), pharyngeal group (25–100% pooling secretions filling the pyriform sinus), and laryngeal group (pooling secretions entering the laryngeal vestibule). Demographic data, swallowing level scale score, and pneumonia requiring hospital admission were recorded. Results: Patients with NGT (n = 97) had a significantly higher incidence of pneumonia (episodes/person-years) than those patients with PEG (n = 130) in the pharyngeal group (3.6 ± 1.0 vs. 2.3 ± 2.1, P < 0.001) and the laryngeal group (3.8 ± 0.5 vs. 2.3 ± 2.2 vs, P < 0.001). The risk of pneumonia was significantly higher in patients with NGT than in patients with PEG (adjusted hazard ratio = 2.85, 95% CI: 1.46–4.98, P < 0.001). Cumulative proportion of pneumonia was significantly higher in patients with NGT than with PEG for patients when combining the two groups (pharyngeal + laryngeal groups) (P = 0.035). Conclusion: PEG is a better choice than NGT feeding due to the decrease in risk of pneumonia requiring hospital admission, particularly in patients with abnormal amounts of pooling secretions accumulation in the pyriform sinus or leak into the laryngeal vestibule.

Evaluation of Oropharyngeal Dysphagia in Patients Who Underwent Percutaneous Endoscopic Gastrostomy: Stratification Risk of Pneumonia

BACKGROUND

Aspiration pneumonia is the most common cause of death in patients who undergo percutaneous endoscopic gastrostomy (PEG). This study aims to evaluate the severity of oropharyngeal dysphagia and predict the risk of pneumonia in such patients, using upper gastrointestinal endoscopy.

METHODS

Endoscope examined the pharyngolaryngeal region in patients who underwent PEG. The severity of oropharyngeal dysphagia was evaluated according to the amount and location of pooling of secretions in the pharyngolaryngeal region. Overall, 55 patients showed absent or minimal amount of secretions (control group), 10 patients showed moderate-to-large amounts of secretions filling the pyriform sinus (pharyngeal group), and 23 patients showed secretions entering the laryngeal vestibule (laryngeal group). Demographic data, swallowing level scale, and occurrence of pneumonia were recorded.

RESULTS

The incidence of pneumonia was the highest in the pharyngeal group (70.0%), followed by that in the laryngeal (60.9%) and control groups (30.9%; P = 0.010). Multivariable regression showed that risk of pneumonia was significantly higher in the pharyngeal and laryngeal groups. Cumulative incidence rate of pneumonia was significantly higher in the laryngeal and pharyngeal groups than in the control group (log-rank test, P = 0.001). Mortality rate was significantly higher in patients with suboptimal protective cough reflex than in others (50.0% vs 5.9%, P = 0.034).

CONCLUSION

Accumulation of abnormal amounts of secretions in the pyriform sinus or in the laryngeal vestibule increased the risk of the hospital admission following pneumonia in patients who underwent PEG. The mortality rate was higher in patients with suboptimal protective cough reflex.

Validation of the secretion severity rating scale

Accumulation of secretions within the hypopharynx, aditus laryngis, and trachea is one characteristic of severe dysphagia and is of high clinical and therapeutic relevance. For the graduation of the secretion severity level, a secretion scale was provided by Murray et al. in 1996. The purpose of the study presented here is the validation of this scale by analyzing the intra-rater and inter-rater reliability as well as concurrent validity. For examination of reliability and validity, a reference standard was defined by two expert clinicians who reviewed 40 video recordings of fiberendoscopic swallowing evaluations, with 10 videos for each severity grade. These videos were rated and rerated independently and blinded by 4 ENT-residents with an interval of 4 weeks. Both the intra-rater (Kendall's τ > 0.847***) and inter-rater reliability (Kendall's W > 0.951***) were highly significant and can be considered good or very good. Correlation of the median of all ratings with the reference standard was close to the highest possible value 1 (τ = 0.984***). The scale was proved to be a reliable and valid instrument for graduation of one of the principal symptoms of oropharyngeal dysphagia and is recommended as an evidence-based instrument for standardized fiberoptic endoscopic evaluation of swallowing.

Pharyngeal Residue Severity Rating Scales Based on Fiberoptic Endoscopic Evaluation of Swallowing: A Systematic Review

Identification of pharyngeal residue severity located in the valleculae and pyriform sinuses has always been a primary goal during fiberoptic endoscopic evaluation of swallowing (FEES). Pharyngeal residue is a clinical sign of potential prandial aspiration making an accurate description of its severity an important but difficult challenge. A reliable, validated, and generalizable pharyngeal residue severity rating scale for FEES would be beneficial. A systematic review of the published English language literature since 1995 was conducted to determine the quality of existing pharyngeal residue severity rating scales based on FEES. Databases were searched using controlled vocabulary words and synonymous free text words for topics of interest (deglutition disorders, pharyngeal residue, endoscopy, videofluoroscopy, fiberoptic technology, aspiration, etc.) and outcomes of interest (scores, scales, grades, tests, FEES, etc.). Search strategies were adjusted for syntax appropriate for each database/platform. Data sources included MEDLINE (OvidSP 1946-April Week 3 2015), Embase (OvidSP 1974-2015 April 20), Scopus (Elsevier), and the unindexed material in PubMed (NLM/NIH) were searched for relevant articles. Supplementary efforts to identify studies included checking reference lists of articles retrieved. Scales were compared using qualitative properties (sample size, severity definitions, number of raters, and raters' experience and training) and psychometric analyses (randomization, intra- and inter-rater reliability, and construct validity). Seven articles describing pharyngeal residue severity rating scales met inclusion criteria. Six of seven scales had insufficient data to support their use as evidenced by methodological weaknesses with both qualitative properties and psychometric analyses. There is a need for qualitative and psychometrically reliable, validated, and generalizable pharyngeal residue severity rating scales that are anatomically specific, image-based, and easily learned by both novice and experienced clinicians. Only the Yale Pharyngeal Residue Severity Rating Scale, an anatomically defined and image-based tool, met all qualitative and psychometric criteria necessary for a valid, reliable, and generalizable vallecula and pyriform sinus severity rating scale based on FEES.

A rare cause of abnormal epiglottic mobility and dyspagia: calcification of the epiglottis

The dynamic function of the epiglottis plays an important role in preventing the aspiration of foods into the trachea during deglutition. Abnormal epiglottic movement may cause swallowing and aspiration problems. Epiglottic calcification is a rare cause of abnormal epiglottic movement pattern and dysphagia. In this report, we present a case of epiglottic calcification caused by dysphagia and discuss the clinical and radiologic features of this very rare condition.

Topical anesthetic preparations for rigid and flexible endoscopy: a meta-analysis

Transnasal endoscopy can cause pain or discomfort for the patient. Topical anesthetic has been used in an attempt to reduce this. However, there is no consensus on whether topical anesthetic is effective in optimizing patient experience during the procedure. The goal of this study was to perform a systematic review with meta-analysis of the efficacy of topical anesthetic on pain and comfort outcomes during endoscopy. Two authors independently searched the databases from inception to September 2013. Studies comparing topical anesthetic with placebo where the outcomes of interest were pain, comfort, or side effect outcomes were included. Sufficient data for meta-analysis were retrieved for ten trials with a total of 837 patients. The evidence suggests that local anesthetic alone or in combination with a vasoconstrictor is beneficial to patients' pain [standardized mean difference (SMD) = -0.21; p = 0.045] and comfort (SMD = -0.51; p < 0.001) outcomes when performing transnasal endoscopy. However, the topical anesthetic caused unpleasant sensation with respect to an unpleasant taste (SMD = 0.77; p < 0.001). In addition, there was no significant difference between a topical anesthetic spray and cotton type in pain and discomfort values. Applying topical anesthetic during transnasal endoscopy could reduce pain and discomfort. The spray and cotton type methods of topical anesthetic preparation showed no significant difference in terms of pain and discomfort during the procedure. However, further trials with good research methodology should be conducted to confirm our results.