This research was supported in part by the McFadden, Harmon, and Mirikitani Endowments.
Fiberoptic Endoscopic Evaluation of Swallowing in the Pediatric Population†
Article first published online: 2 JAN 2009
Copyright © 2000 The Triological Society
Volume 110, Issue 7, pages 1132–1136, 2000
How to Cite
Leder, S. B. and Karas, D. E. (2000), Fiberoptic Endoscopic Evaluation of Swallowing in the Pediatric Population. The Laryngoscope, 110: 1132–1136. doi: 10.1097/00005537-200007000-00012
- Issue published online: 2 JAN 2009
- Article first published online: 2 JAN 2009
- Manuscript Accepted: 9 FEB 2000
- deglutition disorders;
- fiberoptic endoscopy;
Objective To investigate the diagnostic and rehabilitative usefulness of routine fiberoptic endoscopic evaluation of swallowing (FEES) in the pediatric population.
Study Design Prospective, consecutive, blinded.
Patients and Methods Thirty pediatric inpatients from a large, urban, tertiary care teaching hospital participated. Their ages ranged from 11 days to 20 years (mean, 10 years and 4 months). In a random fashion, seven subjects were assessed with both videofluoroscopic evaluation of swallowing (VFES) and FEES and 23 subjects were assessed solely with FEES. Diagnosis of dysphagia was determined by spillage, residue, laryngeal penetration, and aspiration. Rehabilitative strategies, e.g., positioning and modification of bolus consistencies, were based on diagnostic findings.
Results There was 100% agreement between the blinded diagnostic results and implementation of rehabilitative strategies for subjects randomly assigned to receive both VFES and FEES and for subjects who received solely FEES. Of the 23 subjects assessed solely with FEES, 13 of 23 (57%) exhibited normal swallowing and 10 of 23 (43%) exhibited dysphagia. The feeding recommendation for 4 of 10 subjects with dysphagia (40%) was for a non-oral diet because of aspiration. FEES allowed for specific feeding recommendations (i.e., bolus consistency modifications, positioning, and feeding strategies) to reduce aspiration risk in 6 of 10 subjects with dysphagia (60%).
Conclusion FEES can be used routinely to diagnose and treat pediatric dysphagia in the acute care setting.
Fiberoptic technology revolutionized examination of the nasopharynx and larynx because transnasal insertion of the flexible fiberscope allowed for clear visualization of anatomic structures without interfering with normal physiology of respiration and phonation. 1 Fiberoptic assessment, using either analog or digital signals and especially when coupled with video capability, is the current technique of choice for examining the nasopharynx and larynx. 2,3 A recent novel use of fiberoptic laryngoscopy has been to examine reflexive and volitional swallowing events in adults for both diagnostic and rehabilitative purposes, i.e., fiberoptic endoscopic evaluation of swallowing (FEES). 4,5
In adults FEES 4,5 and videofluoroscopic evaluation of swallowing (VFES) 6–8 have been shown to be equally effective for the diagnosis of dysphagia and the implementation of therapeutic techniques to improve and promote safe swallowing. 5,9–12 In the pediatric population, however, VFES has been the only objective technique used routinely for diagnosis of dysphagia and implementation of rehabilitative strategies. 13–18 FEES, being newer technology than VFES, has been slower to gain widespread use in the pediatric population, but its potential ability to diagnose and treat dysphagia in children is just as powerful as with adults.
Transnasal flexible fiberoptic laryngoscopy is performed routinely in children from birth to adolescence to evaluate anatomy and physiology of the upper aerodigestive tract to make medical diagnoses. 19,20 Only pilot data, however, have been reported on the use of FEES to diagnose and treat dysphagia in the pediatric population. FEES was reported to be more sensitive than VFES in assessing prefeeding anatomic and physiological abnormalities, such as pooling of secretions before feeding, and similar to VFES in detecting premature spillage, residue, and aspiration during and after feeding. 21–23 FEES is also very useful for studying prefeeding behaviors of children who are not (yet) oral feeders because the structure and function of the oropharyngolaryngeal complex can be assessed during spontaneous swallowing of secretions without the need for food or barium concentrate. Because of the paucity of information on FEES and pediatric dysphagia, the purpose of the present study was to investigate both the diagnostic and rehabilitative usefulness of FEES in the pediatric population.
MATERIALS AND METHODS
Thirty inpatients from the acute care setting of a large urban tertiary care teaching hospital were included (Tables I and II). There were 19 boys (mean age, 10 years and 5 months; range, 3.5 months to 18 years and 1 month) and 11 girls (mean age, 11 years and 2 months; range, 11 days to 20 years). Seven of 30 subjects (23%) were tested on the same day with both VFES and FEES (Table I) and 23 of 30 subjects (77%) were tested solely with FEES (Table II). The wide variety of diagnoses was consistent with the inpatient pediatric population: motor vehicle crash (8); neurologic, i.e., cerebrovascular accident, encephalitis, tumor, and traumatic brain injury (7); gun shot wound or stabbing (3); laryngotracheal abnormalities, i.e., vocal fold paralysis and subglottic stenosis (3); and 1 each for acetaminophen overdose, bronchopulmonary dysplasia, DiGeorge's syndrome, gastroesophageal reflux disease, patent ductus arteriosis, Lennox-Gastaut syndrome, necrotizing enterocolitis, short Y chromosome, and poor feeding.
The FEES equipment consisted of pediatric (2.2-mm diameter) and adult (3.6-mm diameter) flexible fiberoptic rhinolaryngoscopes (ENF-XP and ENF-P3, Olympus, Melville, NY), disposable endoscope sheaths (Vision Science, Natick, MA); light source (Olympus, CLK-4), camera (ELMO, Plainview, NY, MN401E); and color monitor (Sharp, Mahwah, NJ, 13GM100). VFES equipment consisted of a fluoroscopy unit (Phillips, Germany, 65-CP-H) and wide band X-ray imaging videorecorder (Intermed, Newtown, CT, XR-70U).
Medical history, symptom description, and examination of the structure and function of the oral mechanism were documented. 8 Before the start of FEES, specific characteristics of the oral phase of swallowing were noted to make a diagnosis of oral phase dysphagia. Evaluation of the oral phase of swallowing included examination of labial closure, lingual range of motion and control, palatal motion, facial symmetry and movement, and mastication.
The basic FEES protocol 4,5 was done at bedside, with the patient in an upright position or as upright as tolerated, and without administration of topical anesthesia to the nasal mucosa, thereby eliminating any potential adverse anesthetic reactions and ensuring a reliable physiological evaluation. 24 All food was dyed blue for optimal visualization. For children who were bottle fed, a clear liquid or nectar-thickened liquid was used, and for all other children approximately 5-mL (1 teaspoon) boluses of puree (custard) were given first, followed by 5-mL boluses of liquid (milk), and, if indicated, a solid-consistency food (i.e., cracker).
The basic VFES protocol was followed 7 with all examinations done in lateral projection. Infants were placed in a tumble-form seat and older subjects were positioned in either their habitual posture or as upright as possible. Single-contrast barium, given via bottle or spoon, was used alone or added to formula, puree (custard or apple sauce), or, if indicated, a solid-consistency (cracker).
No attempt was made to select which subjects received both VFES and FEES and which received solely FEES, i.e., the seven subjects who received both VFES and FEES had consults ordered with both diagnostic imaging and speech-language pathology, whereas the remaining 23 subjects had consults for either speech-language pathology or otolaryngology. VFES was always done before FEES. The opportunity to study the same patient on the same day with both VFES and FEES provided a corroborating baseline for identifying laryngeal penetration and aspiration when only FEES was used. Diagnosis of dysphagia, treatment implementation, and feeding recommendations were made based on objective testing with VFES, FEES, or both. Laryngeal penetration was defined as entry of material into the laryngeal vestibule to the level of the true vocal folds and aspiration was defined as entry of material below the level of the true vocal folds. 8 Aspiration precautions were defined as sitting upright in chair/bed (or as high as tolerated), using small bolus sizes, i.e., 5 to 7 mL, and slow feeding, i.e., waiting for a swallow to occur before introducing another bolus.
During VFES one investigator (s.b.l.) and a radiologist made independent assessments of laryngeal penetration and aspiration with a criterion of 100% agreement for all subjects. During FEES both investigators (s.b.l. and d.e.k.) were present, with one investigator (d.e.k.) blinded to the VFES results. Independent assessments of laryngeal penetration and aspiration were made again, with a criterion of 100% agreement between the two investigators for all subjects.
There was 100% agreement between the blinded diagnostic results for the seven subjects randomly assigned to both VFES and FEES (Table I) and for the 23 subjects randomly assigned solely to FEES (Table II). This was true for bolus flow characteristics, i.e., spillage and residue, anatomical sites, i.e., laryngeal penetration and aspiration, and all bolus consistencies, i.e., liquid, nectar-thickened liquid, puree, and solid. Feeding recommendations were also in 100% agreement based on FEES and VFES testing.
Seven subjects were assessed with both VFES and FEES (Table I). Five of seven (71%) subjects were able to tolerate a modified oral diet consistent with age and mental status. A restricted oral diet was recommended for two of seven (29%) subjects, i.e., subject 12 required nectar-thickened liquids and puree consistencies only because of laryngeal penetration and aspiration with clear liquids and subject 18 required a non-oral diet because of severe prefeeding pooling of secretions with laryngeal penetration and aspiration.
Twenty-three subjects were assessed solely with FEES (Table II). Thirteen of 23 subjects (57%) exhibited normal oral and pharyngeal swallowing and were given a diagnosis of being without dysphagia. Feeding recommendations included a regular diet for 12 of 13 subjects and a liquid oral diet, i.e., formula, for the remaining subject who was 11 days old.
Ten of 23 (43%) subjects exhibited abnormal FEES results, i.e., oral dysphagia, pharyngeal dysphagia or both (Table II). The feeding recommendation for 4 of 10 subjects (40%) was for a non-oral diet owing to oral and pharyngeal dysphagia with aspiration. FEES allowed for specific feeding recommendations for 6 of 10 subjects(60%), i.e., bolus consistency modifications and aspiration precautions (see Table II for specific recommendations). Feeding recommendations were successful, because follow-up while subjects were inpatients indicated that no tube feedings were required and no instances of aspiration pneumonia observed.
The present study reported on the first routine use of FEES to diagnose and treat dysphagia in the pediatric population. VFES and FEES were shown to be in 100% agreement for detection of spillage, residue, laryngeal penetration, and aspiration in the pediatric population. This agrees with previous research regarding the accuracy of FEES in detecting two major symptoms of pharyngeal stage dysphagia, i.e., laryngeal penetration and aspiration. 5,11,12 The routine use of FEES to diagnose and treat pediatric dysphagia is supported.
Fiberoptic endoscopic evaluation of swallowing was shown to be sensitive in identifying pooled secretions before feeding in subjects 18 and 25, which agrees with pilot data using FEES in the pediatric population. 21–23 Because observation of pooled secretions in the pyriform sinuses and laryngeal vestibule was shown to significantly increase aspiration risk, 25 these two patients were not permitted feeding trials with FEES, thereby avoiding aspiration of a food bolus. Because VFES was done before FEES, however, both subjects aspirated barium, and although no morbidity occurred, aspiration of barium has been shown to deleteriously impact health, especially in fragile and medically compromised patients. 26
Fiberoptic endoscopic evaluation of swallowing can be repeated as often as necessary because there is no irradiation exposure and favorite foods can be used, 4,5 both important variables when dealing with the pediatric population. Whenever nonoral feeding was recommended, a repeat FEES was scheduled, because serial FEES evaluations have been shown to be effective in determining when best to resume successful oral feeding and what bolus consistencies to use for optimal swallowing success. 27 Determination of when to repeat FEES was dependent on the patient's medical condition and cognitive status, e.g., a repeat FEES could be done in as early as 2 to 3 days if rapid improvement occurred or in 2 to 3 months (or longer) if progress was expected to be slow. For example, during the period of the present study, repeat FEES permitted subjects 14 and 25 to resume a regular oral diet successfully and in a timely manner, i.e., in 1 and 3 months, respectively.
Recently FEES has been shown to be useful in children and young adults presenting with specific diagnoses, e.g., traumatic brain injury 28 and severe developmental disability. 29 As with any procedure, not all children will cooperate with testing. This is true for both VFES and FEES. For example, positioning for fluoroscopy and eating barium sulfate may not be tolerated and, similarly, transnasal passage of the endoscope may not be possible with some children. The examiner must be sensitive to the needs of the individual and use clinical judgment to decide which diagnostic test can be successfully used. Therefore, knowledge of and sensitivity to the special needs of patients are critical to performing successful FEES evaluations in these populations. Using familiar caregivers, environments, and foods can decrease anxiety and increase cooperation. 29
When a swallowing problem is suspected, FEES can be done concurrently with fiberoptic laryngoscopy. The combined expertise of the otolaryngologist and speech-language pathologist provides a thorough physical examination of the pharynx and larynx during normal respiration, phonation, and both reflexive and volitional swallowing. This allows for a medical diagnosis to be made based on the structure and function of the pharynx and larynx, as well as for a diagnosis of dysphagia to be made based on anatomical and physiological criteria from which oral feeding status and need and type of therapeutic interventions are determined. 5 For example, FEES detected true vocal fold pathology in subject 24, i.e., impaired movement bilaterally, which was not appreciated with VFES. This efficient use of personnel, time, and equipment benefits the patient, family, and caregivers.
For the first time, routine use of FEES has been shown to be a valuable and reliable technique for both diagnosis and treatment of pediatric dysphagia in the acute care setting. FEES use with adults originated and was validated in the acute care setting 4,5,12 and later became available in long-term rehabilitation 30 and outpatient settings. 29 As the use of FEES in the pediatric acute care setting becomes more widespread, it is only a matter of time before FEES is used routinely in pediatric rehabilitation and outpatient settings as well.
- 7Manual for Videofluorographic Study of Swallowing. edn 2. Austin, TX: Pro-Ed, 1993..
- 8Evaluation and Treatment of Swallowing Disorders. edn 2. Austin, TX: Pro-Ed, 1998..
- 10Bedside, fluoroscopic, and endoscopic dysphagia evaluations: functional comparisons and discussion. ASHA Leader 1997; 2: 59., .
- 13Instrumental evaluation. In: ArvedsonJ, BrodskyL, eds. Pediatric Swallowing and Feeding: Assessment and Management. San Diego: Singular Publishing Group, 1994:293–326., .
- 14Videofluoroscopy of swallowing in pediatric patients: a component of the total feeding evaluation. In: TuchmanDN, WalterRS, eds Disorders of Feeding and Swallowing in Infants and Children: Pathophysiology, Diagnosis, and Treatment. San Diego: Singular Publishing Group, 1994:187–200., .
- 17Role of the pediatric radiologist in the evaluation of oral and pharyngeal dysphagia. J Neurol Rehabil 1990; 4:103–110..
- 21Fiberoptic endoscopic examination of swallowing in infants and children with feeding disorders. Dysphagia 1994; 9: 266., , , .
- 23Fiberoptic endoscopic evaluation of swallowing in children: a preliminary report of 100 procedures. Dysphagia 1996; 11: 162., , , .