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Assessment of Aspiration Risk UsingFlexible Endoscopic Evaluation of Swallowing With Sensory Testing; Guest Blog by Dr. Eric Bicker

12/8/2013

 
Flexible Endoscopic Evaluation of Swallowing with Sensory Testing (FEESST) is approved by the United States Food and Drug Administration (FDA) to assess quantitatively laryngopharyngeal sensory perception related to deglutition. Sensory discrimination testing during FEESST is conducted via delivered air pulses to the laryngopharyngeal musculature infiltrated by the internal branch of the superior laryngeal nerve (ISLN). Jafari, Prince, Kim, and Paydarfar (2003) implied that the afferent nerve transmission from the ISLN was essential for a functional pharyngeal swallow, specifically in supplying information to primary efferent neural functions that control adduction of the laryngeal musculature during the pharyngeal phase of the swallow. Their research proposed that ISLN damage was a major factor in the development of dysphagia and aspiration.

During the FEESST procedure protocol, as described in Aviv and Murray (2005), a flexible endoscope is passed transnasally, along the floor of the nose,  past the velopharyngeal port and into the hypopharynx. Sensory discrimination thresholds during FEESST are obtained bilaterally by endoscopically providing air pulse stimuli directly anterior to the arytenoid cartilage at the juncture of the aryepiglottic fold because this mucosa in the laryngopharynx is innervated by the ISLN. The stimulus is designed to trigger a laryngeal adductor reflex (LAR) via direct stimulation of the ISLN (Aviv et al., 1993). Ludlow, Van Pelt, and Koda (1992) found that stimulation of this mucosa elicited the LAR, which was an involuntary, concise closure of the true vocal cords. Aviv et al. (1999) found that this airway defense LAR was maintained by brainstem function. Once the air-pulse testing is done, the patient is then fed food and liquid consistencies mixed with green or
blue food coloring for contrast while the pharyngeal phase of the swallow is assessed evaluating food, liquid, and secretions.

FEESST assessments are performed with patients who demonstrate dysphagia, a difficulty in swallowing, as defined by Logemann (1998). Clinical experience has shown that the presence of dysphagia might place the patient at risk for tracheal aspiration. As described by Marik and Kaplan (2003), the event of tracheal aspiration occurs when a bolus, particulate matter, or patient secretions enter the trachea. Research has shown that further airway entry into the lungs because of tracheal aspiration can become a catalyst for infection and pneumonia (Kalra, Ramsey, & Smithard, 2003). FEESST was designed to obtain data that is more objective regarding laryngopharyngeal sensation, when compared to the clinical bedside swallow evaluation, which is a more subjective evaluation.

Clinical practice has shown that instrumental assessment is especially important in those patients who have silent penetration when the bolus enters the larynx at or above the level of the true vocal cords without a sensory clearing response. As discovered by Logemann (1998), the same importance for instrumental assessment holds true for the identification of silent aspiration, when the bolus enters the trachea without a sensory clearing response. Aviv et al. (1996) suggested that the importance of sensory discrimination testing in these patients might be significant because decreased sensation in the laryngopharynx could contribute to dysphagia and aspiration. Sensory loss in the laryngopharynx might be a catalyst in dysphagia and aspiration, presuming that, if the patient did not sense a bolus or secretions within the laryngopharynx, regular upper airway shielding reflexes might be deficient. Research has shown that patients with more severe sensory
loss in the throat with FEESST have shown a higher frequency and occurrence of silent aspiration into the trachea, suggesting that there is some association between the sensory nerve for the laryngopharynx (ISLN) and the sensory nerve for the trachea (recurrent laryngeal nerve RLN), which are both branches of cranial nerve X, the vagus nerve (Blicker, 2008).

Written by Dr Eric Blicker MA CCC-SLP.D BRS-S

Eric's ASHA approved CE Provider website can be found here:  WWW.CEUALLIEDHEALTH.COM


Kelley Babcock
12/9/2013 06:01:42 am

For what reason would you choose to use FEEST over FEES? I would believe a FEES exam would be more clinically significant as it involves actual food/liquid.

Dr Eric Blicker MA CCC-SLP.D BRS-S link
12/9/2013 02:56:59 pm

The FEESST exam is simply an augmented or enhanced FEES exam. The FEESST exam involves all of the same PO testing as a FEES exam has. The FEESST exam has all of the same protocols as a FEES exam. The difference is the "ST", the air pulse sensory testing. The FEESST exam allows for the quantification of sensory function in the laryngopharynx "prior to" PO delivery. Essentially, they are the same exam, with the exception of the added sensory testing with FEESST.

Kelley
12/10/2013 09:17:42 am

How does the FEEST quantify the sensation thresholds? Is it a binary yes/no of sensation or is there some sort of rating scale? I complete FEES regularly for my job, and I have always wondered about the indication for a FEEST exam. How would the sensory information from the FEEST change your recommendations for treatment? Thanks for your time!

Dr Eric Blicker MA CCC-SLP.D BRS-S link
12/10/2013 01:47:47 pm

As per AVIV FEESST where I was trained at technique:
Air pulse testing is done bilaterally, separately, with measured pulses of air just anterior to the arytenoid cartilage along the aryepiglottic fold. This is innervated by the internal branch of the superior laryngeal nerve, the sensory nerve for the throat. A 50 msec air pulse is delivered at a supr-threshold level (9 mm Hg app) which is millimeters mercury air pulse pressure. If there is no response i.e.: no true vocal cord adduction laryngeal adductor reflex response, then the stimulus is repeated two more times. The air pulses come from an air pulse box, which is connected via plastic tube to an open port in the side of the endoscope. Measured pulses of air and pushed through the distal tip of the endoscope in the throat. If after the delivery of three 50 msec air pulse trials there is no laryngeal adductor reflex LAR, then the patient is given a continuous stronger air pulse lasting one second. If there is no LAR at the continued pulse then the patient is noted to have an absent LAR, which is a severe sensory deficit. These are the categories for grading severity:

Moderate sensory deficit. A sensory loss threshold between 4 and 6 mm Hg air pulse pressure (APP).

Normal sensory function. A sensory loss threshold of less than 4 mm Hg APP.

Severe sensory deficit. A sensory loss threshold over 6 mm Hg APP (Aviv et al., 1993).

Should a positive LAR happen at the original pulse level of 9 mmHg APP, then a pulse is delivered at 2 mm Hg APP, which is less intense pulse of air. The higher the number, the stronger the pulse. It the patient responds at 2 mmHg APP then their sensory threshold is considered to be 2 mmHg and normal.
If the patient does not respond at 2, the air pulse pressure is increased in intensity by 1.0 mm Hg APP increments until a positive response takes place. So if a patient responds at 9, then you turn down the intensity to 2 and they don't respond maybe because it is less intense air, so you move up and slowly give more intensity at 3, 4, 5. Lets say the patient does not respond at 4, but does at 5. Their sensory score is 4.5, which is half way between where they did not respond at 4 and where they did respond at 5. Based on the values I gave above, you have quantified sensory loss, as this example would have "moderate sensory loss"

Indications for FEESST exam and the resultant impact on treatment

1. Known case history of intubation trauma or for patients with clinical dysphagia and vocal changes following prolonged intubation. Excellent method to use to determine if there is bilateral or unilateral sensory loss in the laryngopharynx related to incubation. Can be used in acute care as a method to know when to hold oral feeding and wait for repeat testing based on more time elapsed post extubation.

2. For cases of CVA. When there is hemiplegia or hemiparesis, there is reason to believe that the sensory loss would be present in the throat as well as the rest of the body. Excellent resource to demonstrate differential sensory functions from the effected to unaffected side of the throat. Resultant treatment: if you are sensory testing prior to the po trials on the FEESST test and you see before PO, that there is severe sensory loss on the side impacted by stroke, it helps with your compensatory posture planning for the rest of the test.

For both the intubation trauma and the CVA population, this an excellent measure that can be repeated. If the intubated patient had post extubation edema in the larynx and it is resolving, you may do subsequent exams and get better sensory testing course. Further, if you have follow up exams with the CVA patient, you can measure how sensory loss is or is not improving as a result of time post stroke and treatment.

3. With patients who have known laryngopharyngeal reflux. Research as shown, as well as clinical experience,that edema of the posterior larynopharyngeal mucosa is patent with dysphagia who have laryngopharyngeal reflux frequently have laryngopharyngeal sensory loss. Treatment with proton pump inhibitors appears to objectively reduce the site specific edema seen in these patients. Quantification of the sensory deficits associated with posterior laryngopharyngeal edema can be applied as part of the complex decision making process for these patients. FEESST is ideal with LPR cases as they can be re-tested pre and post medication therapy to determine if there is sensory and edema changes/improvements.

4. Patient's who are known to have "wet" vocal quality in their bedside exams and having acute swallowing changes following certain surgeries known to potentially impact sensory function in the throat: carotid endarterectomy, thyroidectomy, anterior cervical spinal fusion surgery. When these patients have pharyngeal dysphagia acutely post surgery with one of these known conditions, they would be ideal potential FEESST candidates.

Dr Eric Blicker MA CCC-SLP.D BRS-S
ceualliedhealth.com

Bob
3/24/2017 05:20:40 pm

What foods are used for the test?

Can medical limitations on foods be accommodated, such as no fiber or roughage for patients with Crohn's Disease?

Thank you.


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    • Guidelines for Safe Swallowing
    • Imaging Examinations
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    • Hydration
    • Dysphagia Diets
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    • Dysphagia Treatment Strategies >
      • Tube Feeding
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    • Therapy
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    • Oral Motor
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    • Drooling
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