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.

Fiberoptic endoscopic evaluation of swallowing (FEES) in pediatrics: A systematic review

OBJECTIVES

The systematic review aimed to provide an overview of the state-of-art regarding the use of fiberoptic endoscopic evaluation of swallowing (FEES) in pediatrics, specifically investigating FEES feasibility, safety, diagnostic accuracy, and protocols.

METHODS

Four electronic databases were searched for original studies on the pediatric population that instrumentally assessed swallowing function using FEES. A hand-search of the references of included studies was performed. Data on the population, feasibility of endoscope insertion and bolus trials, adverse events, sensitivity and specificity, and FEES equipment and protocol were extracted. The quality of the studies was assessed using the checklists of the Johanna Briggs Institute. Selection of the studies, data extraction, and quality appraisal were conducted by two independent researchers.

RESULTS

Eighty-two reports from 81 studies were included. The mean overall quality of the studies was 80 % (17-100 %). The feasibility of endoscope insertion was high (89%-100 %), while the feasibility of bolus trials varied from 40 % to 100 %. Adverse events were excessive crying (8 studies), irritability or agitation (4 studies), transitory oxygen desaturations (3 studies, 1.2-6.7 % of the patients), epistaxis (3 studies, 0.8-3.3 % of the patients), increased heart rate (1 study, 1 patient), vomiting (1 study, 1 patient), hypertonia (1 study), and hypersalivation (1 study). No major complications were reported. Using VFSS as the reference standard, FEES was generally found to be less sensitive (25-94 %) but more specific (75-100 %) for aspiration, whereas the reverse was true for penetration (sensitivity 76-100 %, specificity 44-83 %). FEES protocols were highly heterogeneous with poor reporting.

CONCLUSION

FEES is a safe, accurate, and generally feasible examination in the pediatric population with suspected dysphagia. However, a consensus on the best FEES protocol for clinical practice and research is currently lacking.

[Prevalence of mucosal injuries during flexible endoscopic evaluation of swallowing in the presence of a nasogastric tube]

BACKGROUND

The flexible endoscopic evaluation of swallowing (FEES) is an established low-risk examination method to assess the risk of penetration or aspiration in patients with dysphagia. FEES might be more difficult or of higher-risk when a nasogastric tube is in place.

OBJECTIVE

This study aims to identify whether the prevalence of mucosal lesions is higher when the endoscopy is carried out with a nasogastric tube in place. Pre-existing mucosal lesions were also documented.

METHODS

In a retrospective, monocentric study, a total of 918 FEES procedures routinely performed in hospitalized patients of a university hospital from January 2014 to March 2019 were evaluated. Mucosal lesions were identified and characterized for descriptive statistics.

RESULTS

In the video material analysed here, no endoscopy-related injuries were identified. However, pre-existing mucosal lesions, which often occurred as multiple lesions, were detected in 48.6% of the endoscopies. Further analysis showed that these pre-existing lesions were not worsened by the endoscopy performed.

CONCLUSION

The results demonstrate that transnasal flexible endoscopy is a safe, low-risk examination method, even in patients with a nasogastric tube. A very high number of pre-existing mucosal lesions were found, which is probably related to the previous insertion of the nasogastric tube. Due to the high number of pre-existing lesions, strategies should be developed to minimize injuries when placing nasogastric tubes.

Validation of a Geriatric Bedside Swallowing Screen (GEBS): Protocol of a Prospective Cohort Study

BACKGROUND

Demographic changes will raise the need for specialized care of older patients. Oropharyngeal dysphagia has recently been declared a geriatric syndrome reflecting its multifactorial background. Alongside multimorbidity, sarcopenia, frailty, and disability, swallowing disorders increase with advancing age, with prevalence rates reported to be as high as 44% in acute geriatric hospital settings and 80% in long-term care facilities. Hence, systematic screening of older patients to diagnose dysphagia and initiate treatment is of paramount importance to prevent bolus death, aspiration pneumonia, and malnutrition and improve quality of life. Several screening tools have been evaluated in emergency and stroke units. However, no published dysphagia screening tool has been validated in the hospitalized, older adult population using a gold standard in dysphagia diagnostics as a reference test. The validation of the proposed test is a first step.

OBJECTIVE

The Geriatric Bedside Swallowing Screen (GEBS) study aims to validate a new screening tool developed specifically for older inpatients against an instrumental swallowing evaluation, the flexible endoscopic evaluation of swallowing (FEES), which is considered a gold standard. Primary outcomes to be evaluated are sensitivity and specificity for the GEBS in the detection of dysphagia in a mixed older adult population. The presence of dysphagia will be defined by an instrumental swallowing evaluation (FEES), analyzed by the standardized penetration-aspiration scale.

METHODS

To validate the GEBS, a prospective cohort study will be carried out. Two institutions, an acute geriatric department and a long-term care facility, will aim to recruit a total of 100 patients aged ≥75 years. After giving their informed consent, patients will undergo the full screening protocol described in the GEBS as well as an evaluation of swallowing function using the FEES. Investigators will be blinded to the results of the respective other testing. The analysis of pseudonymized data sets will be done by a third investigator. Outcomes to be considered are sensitivity, specificity, diagnostic odds ratio, positive and negative likelihood quotient, and the reliability of the proposed dysphagia screening tool using the κ coefficient.

RESULTS

Recruitment started in October 2022 and will end in April 2024. Data publication is planned for early 2025.

CONCLUSIONS

If proven to be a valid screening tool for the early detection of dysphagia, further studies including different older adult populations as well as studies to determine the impact of systematic dysphagia screening on parameters, such as rates of aspiration pneumonia or nutritional status, should be planned. Effective screening of dysphagia will lead to earlier detection of patients with impaired swallowing. Those who fail the screening will be referred to speech language pathology for further diagnosis, thus optimizing care while streamlining personnel resources.

TRIAL REGISTRATION

ISCRTN Registry ISRCTN11581931; https://www.isrctn.com/ISRCTN11581931.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/46252.

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.

Tutorial on Clinical Practice for Use of the Fiberoptic Endoscopic Evaluation of Swallowing Procedure With Pediatric Populations: Part 2

PURPOSE

This is Part 2 of a two-part tutorial series establishing clinical guidelines pertaining to the administration of fiberoptic endoscopic evaluation of swallowing (FEES) developed by representatives of the American Board of Swallowing and Swallowing Disorders, all of whom are members of Special Interest Group 13. Whereas Part 1 focused on use of FEES with adults and included general information common to using FEES in any population, the purpose of this tutorial is to provide clinicians with updated best practice clinical guidelines for performing, interpreting, and documenting outcomes when using FEES with the pediatric population. This document has two main sections. The first section discusses the history of pediatric FEES, needed knowledge and skill pertaining to all elements of performing and interpreting the examination including detailed information related to indications and contraindications, developmental anatomical and physiological changes across childhood, preparing for and conducting the examination, medical collaboration, and patient safety. The second section provides detailed guidelines for clinicians who require training for use of FEES with the pediatric population.

CONCLUSIONS

This first of its kind tutorial offers guidelines for clinicians who perform, interpret, and/or want to train to perform FEES in the pediatric population. Important clinical distinctions exist when using FEES with the pediatric population versus with the adult population. Developmental changes, pediatric medical frailty, provider-parent/caregiver interaction, collaboration with physician colleagues, and patient safety are representative of key areas highlighted in this document.

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.

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.

European white paper: oropharyngeal dysphagia in head and neck cancer

PURPOSE

To develop a European White Paper document on oropharyngeal dysphagia (OD) in head and neck cancer (HNC). There are wide variations in the management of OD associated with HNC across Europe.

METHODS

Experts in the management of specific aspects of OD in HNC across Europe were delegated by their professional medical and multidisciplinary societies to contribute to this document. Evidence is based on systematic reviews, consensus-based position statements, and expert opinion.

RESULTS

Twenty-four sections on HNC-specific OD topics.

CONCLUSION

This European White Paper summarizes current best practice on management of OD in HNC, providing recommendations to support patients and health professionals. The body of literature and its level of evidence on diagnostics and treatment for OD in HNC remain poor. This is in the context of an expected increase in the prevalence of OD due to HNC in the near future. Contributing factors to increased prevalence include aging of our European population (including HNC patients) and an increase in human papillomavirus (HPV) related cancer, despite the introduction of HPV vaccination in various countries. We recommend timely implementation of OD screening in HNC patients while emphasizing the need for robust scientific research on the treatment of OD in HNC. Meanwhile, its management remains a challenge for European professional associations and policymakers.

Evaluating the safety of oral methylene blue during swallowing assessment: a systematic review

OBJECTIVE

Methylene blue (MB) is frequently administered during fiberoptic endoscopic evaluation of swallowing (FEES) to enhance visualization of pharyngeal bolus transit. However, the safety of MB is being questioned since serious adverse events (AEs) such as hemodynamic instability, hemolysis, and serotonin syndrome were reported. The aim of this study is a systematic analysis of the literature to obtain an evidence-based overview of AEs due to oral administration of MB and to determine its safety as a food dye during swallowing assessment.

METHODS

A systematic literature search was carried out in PubMed, Embase, and Cochrane Library. Two reviewers independently selected articles describing oral administration of MB as a main diagnostic/therapeutic intervention, dosage, and AEs. Expert opinions, conference papers, sample size < 10, and animal studies were excluded. Level of evidence of the included studies was determined.

RESULTS

A total of 2264 unduplicated articles were obtained. Seventeen studies met the inclusion criteria with 100% agreement between the two reviewers. Among these, twelve studies were randomized controlled trials. In a pooled population of 1902 patients receiving oral MB, three serious AEs were reported related to MB. Non-serious AEs showed a dose-related trend and were usually mild and self-limiting. A meta-analysis could not be performed as studies were methodologically too heterogeneous.

CONCLUSION

Serious AEs due to oral administration of MB are rare (n = 3, 0.16%). MB-related non-serious AEs are mild, self-limiting, and show a dose-related trend. These findings indicate that it is safe to use small amounts of MB as a food dye during swallowing examinations.

Instrumental Swallowing Assessment in Adults in Residential Aged Care Homes: A Scoping Review

OBJECTIVES

To systematically describe evidence on the use of instrumental swallowing assessment for residents of aged care homes.

DESIGN

Scoping review using the Joanna Briggs Institute methodology for scoping reviews.

SETTING AND PARTICIPANTS

Published peer-reviewed and gray literature written in English between 2000 and 2020 about instrumental swallowing assessment (ISA) in adults in residential aged care homes (RACHs).

MEASURES

A systematic, 3-tiered search of databases including Medline, CINAHL, Embase, Scopus, and Cochrane Database of Systematic Reviews, and gray literature databases was conducted. Content analysis identified common themes.

RESULTS

Forty-two sources, 30 from peer-reviewed journals, 12 gray literature publications, and 66 websites of mobile ISA providers that discussed videofluoroscopic swallowing studies (VFSS) and/or fiberoptic endoscopic evaluation of swallowing (FEES) use in RACHs were included. Most peer-reviewed sources were referenced narratives or surveys of speech pathology practice patterns (53.3%). Researchers in 3 studies used onsite mobile FEES and in 2 studies off-site VFSS, with adults living in RACHs, as part of their research design (16.7%). There were 66 mobile instrumental swallowing assessment provider websites, based within the United States. Three countries (Australia, United States, United Kingdom) had professional guidelines that stipulated minimal requirements for the safe and appropriate provision of ISA services across settings. Themes identified across sources included (1) the approach to swallowing management and clinical indicators for ISA, (2) the role of ISA, (3) service and consumer influences on ISA, and (4) mobile FEES.

CONCLUSIONS AND IMPLICATIONS

There is a paucity of quality research on instrumental swallowing assessment in adults living in RACHs. There are broad regional and international variances in the way that videofluoroscopy and FEES are accessed and used. A more robust evidence base is required to guide health professionals to design tailored ISA care pathways for residents of RACHs, to achieve high-quality health, social, and economic outcomes.

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.

Safety and Tolerability of Pharyngeal High-Resolution Manometry

Purpose Pharyngeal high-resolution manometry is an emerging practice for diagnosis of swallowing disorders in the upper aerodigestive tract. Advancement of a catheter through the upper esophageal sphincter may introduce safety considerations. There are no published studies of catheter placement complications, side effects, or tolerability. This study examines patient-reported side effects and tolerability of pharyngeal high-resolution manometry. Method Data were collected prospectively from 133 adult patients who underwent pharyngeal high-resolution manometry for the 1st time. Patients rated tolerability specific to "nose" and "throat" using a visual analog scale for 4 procedure time points: catheter passage, during the procedure, catheter removal, and after the procedure. Complications during catheter passage and removal were recorded. A telephone call was placed to the patient within 6 days to survey side effects experienced after the procedure. Results The patient sample was composed of 91 males and 42 females with a mean age of 66 years ( SD = 14.4). Tolerability scores for catheter passage showed no significant difference ( p = .7288) in the nose versus throat. Tolerability for females was significantly less ( p = .0144) than that for males. Participants with the shortest procedure duration showed greatest discomfort in the nose ( p = .0592) and throat ( p = .0286). Complications included gag response (14%), emesis (2%), and epistaxis (< 1%). Side effects included sore throat (16%), nose discomfort (16%), coughing (11 %), nosebleed (4%), and nausea/vomiting (4%). Conclusions High-resolution manometry appears to have high patient tolerability with low incidence of side effects. Rates of complications and side effects are similar to those reported for other transnasal procedures.

Effect of He's Santong Needling Method on Dysphagia after Stroke: A Study Protocol for a Prospective Randomized Controlled Pilot Trial

Background

Dysphagia is a common complication of stroke, affecting up to 78% of stroke patients. The existence of dysphagia after stroke has been associated with an increased risk for pulmonary complications and even mortality. Previous studies have shown that acupuncture could be potential therapeutic method for treatment of dysphagia after stroke. A prospective randomized controlled pilot trial is designed to evaluate the effect of He's Santong needling method on dysphagia after stroke.

Methods and Design

Sixty eligible participants will be recruited and randomly assigned into treatment group (He's Santong needling method and swallowing rehabilitation training) and control group (swallowing rehabilitation training) in a 1:1 ratio. All treatments will be provided everyday on weekdays with a two-day interval at the weekend, during a total treatment course of four weeks. The Penetration-Aspiration Scale with Fiberoptic Endoscopic Examination of Swallowing will be assessed at baseline and endpoint (Week 4) as primary outcomes. The Saitoh's classification score, Swallowing-Related Quality of Life score, the Modified Mann Assessment of Swallowing Ability score, and Surface Electromyography will be evaluated at baseline and endpoint as secondary outcomes.

Ethics and Dissemination

The trial protocol has been approved by the Research Ethical Committee of Beijing Hospital of Traditional Chinese Medicine Affiliated to Capital Medical University on 9 May 2017 (ethical batch number: 2017BL-013-02). Each participant will be notified regarding the study protocol. Written informed consent will be obtained from each participant.

Trial Registration

ISRCTN registry: ISRCTN68981054; Registered on 25 September 2017.