Flexible Endoscopic Evaluation of Swallowing with Sensory Testing

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Flexible Endoscopic Evaluation of Swallowing with Sensory Testing (FEESST), is essentially a Flexible Endoscopic Evaluation of Swallowing (FEES) procedure with a formal sensory test (also known as laryngopharyngeal sensory testing) protocol included used to elicit the Laryngeal Adductor Reflex (LAR) directly using air pulses or direct touch with an endoscope.

Contents

FEES is currently used as a functional assessment of swallowing to identify and treat patients with swallowing difficulties, called "dysphagia", and to decrease their risk of aspiration (food and liquids going into the lungs instead of the stomach) and choking. FEES was invented by Speech Language Pathologist Dr. Susan Langmore, PhD in 1988, and is used primarily by Speech Language Pathologists throughout the world.

The air pulse sensory test was invented by Dr. Jonathan E. Aviv MD, FACS in 1993, [1] and has been used by otolaryngologists (ear, nose and throat doctors), [2] pulmonologists (lung doctors), [3] gastroenterologists (stomach and digestion doctors), [4] intensivists (intensive care specialists) [5] and speech-language pathologists who perform FEES [6] .

Swallowing consists of two distinct but interrelated processes: 1. Moving food and liquids from the mouth into the stomach through a set of coordinated muscle movements of the mouth larynx, pharynx and the esophagus 2. Protecting the airway to prevent food and liquids from entering the lungs. [7] This natural process of swallowing can be disrupted in many ways. The problem can occur when the movements involved in swallowing are restricted due to a tumor, any type of blockage, or paralysis after a stroke. Besides the motor problems, swallowing can be impaired due to sensory dysfunction, meaning when sensation (the ability to feel) is lost or reduced anywhere in the throat area. The loss of sensation can be caused by a problem originating in the brain, such as what happens after certain types of stroke, or it can be a result of a nerve injury or swelling in the actual throat area.

The laryngeal adductor reflex (LAR), also called the glottic closure reflex, is a brainstem-mediated, involuntary reflex arc mechanism of laryngeal protection, which prevents material from inappropriately entering the upper airway. "Mechanoreceptors and chemoreceptors in the laryngopharyngeal (LP) mucosa receive innervation from the internal branch of the superior laryngeal nerve (SLN), which serves as the afferent component of the LAR. Sensory information is then transduced through the central nervous system via the nucleus tractus solitaries to the ipsilateral nucleus ambiguus in the medulla of the brainstem. The motor neurons within the nucleus ambiguus then project to the recurrent laryngeal nerve (RLN), the efferent component. In response to a unilateral stimulus, a discrete and rapid bilateral contraction of the thyroarytenoid (TA) muscles is produced" [8]


Technique

FEES is a procedure which involves the passing of a thin flexible scope through the nose to the pharynx to assess the function of a swallow. The FEES exam protocol consists of two parts.

The first part consists of pre swallowing tasks and clinical/anatomical observations observations of the larynx and pharynx, including: volitional airway protection, movement of structures, secretion management, spontaneous swallows and obstructions. These findings inform potential impairments that may be seen during the second part of the FEES protocol.

The second part of the FEES protocol involves food, or "bolus" presentation to observe swallow function. [9] Food coloring is typically given in the food to track the food as it travels along the natural pink-colored tissues of the throat. The timing of the swallow and the efficiency of clearing the bolus is assessed along with the ability to protect the airway before, during and after the swallow. If the food that is given is seen to remain in the throat after the swallow it is called “residue”. Food entering the laryngeal area but not passing below the vocal folds is known as "penetration", food passing below the level of the vocal folds is known as "aspiration". The control of the bolus, or timing, relative to the onset of swallowing gestures and the sensory response is assessed to further understand why the residue, penetration, or aspiration occurred and could indicate a lack of sensation and/or motor movement problems.

The addition of a formal sensory test is optional and patient dependent, but use of a sensory test changes the Medicare billing descriptor from FEES to FEESST. The LAR is often included as part of a FEES using the "touch method" as it does not require specialized equipment beyond an endoscope. This was the only method used prior to the invention of the "air pulse" technique feature for FEESST. [10] . Clinical use of the "air pulse" method is currently lacking since this specialized equipment is no longer commercially manufactured. The "touch method" is still used during a comprehensive FEES to assess the LAR, however, studies have shown that while it can identify significant sensory deficits, inter-rater reliability may not always be high. [11] Newer techniques are evolving that may have greater accuracy in assessing sensory responses. [12]



Vagus Nerve Injury

When there is damage to the nerve that innervates the throat, the vagus nerve, both motor and sensory function can be affected since the vagus contains both motor and sensory nerve fibers. However, until sensory testing was developed there was no way to assess sensory loss from a vagus nerve injury. One of the most common symptoms of a vagus nerve injury is chronic cough. If a physician looked into the vocal cords of a patient with chronic cough it would appear they are opening and closing normally, however if sensory testing was performed it would give abnormal results thus indicating that the sensory nerve fibers of the vagus were somehow damaged. This would allow for a more precise diagnosis and treatment. [13] [14] [15]

Another clinical situation where assessment of laryngeal sensation is helpful is in patients complaining of throat pain. Again, when examining the throat of such patients, if everything seemed to be moving well, then clinicians are often befuddled as to what the source of the throat pain is. With sensory testing, one can demonstrate that the throat tissues are numb, signifying some damage to the sensory fibers of the vagus and thereby identify vagus nerve injury as the cause of the patient's pain. This is called vagus nerve neuralgia and treatment for neuralgia can then commence.

One always sensory tests both the right and left sides of throat and the sensory levels should be symmetric, that is, the right side of the throat should normally equal the left side. However, if during sensory testing it is determined that one side is normal and the other side has a sensory deficit, then likely something has injured the vagus nerve somewhere along it lengthy course from the brain into the neck. As a result, when there is asymmetric sensory nerve loss, imaging of the neck and brain must be done to see where along the course of the vagus nerve a blockage or injury might have taken place. [16] [17]

Indications For Sensory Testing of The Throat

Acid Reflux Disease

Over the past 20 years, primarily due to work with sensory testing performed by gastroenterologists (stomach doctors) and pulmonologists (lung doctors), sensory testing and FEESST have been shown to have additional applications beyond assessing swallowing function.

For example, people with acid reflux disease, especially those with Throatburn Reflux usually have swollen vocal cords due to years of acid damage. Untreated acid-injured vocal cords will not have as sharp reflexes as vocal cords that are not swollen. Therefore, aspiration is common in people with chronic acid reflux disease. Sensory testing can quantify and assess the swelling for better treatment. The strength of the air pulse given during sensory testing in acid-injured vocal cords due to acid reflux disease will necessarily be much greater in order to elicit an airway reflex than tissues that are not swollen. [18] [19] [20]

Related Research Articles

<span class="mw-page-title-main">Vagus nerve</span> Main nerve of the parasympathetic nervous system

The vagus nerve, also known as the tenth cranial nerve, cranial nerve X, or simply CN X, is a cranial nerve that carries sensory and motor fibers. It creates a pathway that interfaces with the parasympathetic control of the heart, lungs, and digestive tract.

<span class="mw-page-title-main">Larynx</span> Voice box, an organ in the neck of amphibians, reptiles, and mammals

The larynx, commonly called the voice box, is an organ in the top of the neck involved in breathing, producing sound and protecting the trachea against food aspiration. The opening of larynx into pharynx known as the laryngeal inlet is about 4–5 centimeters in diameter. The larynx houses the vocal cords, and manipulates pitch and volume, which is essential for phonation. It is situated just below where the tract of the pharynx splits into the trachea and the esophagus. The word 'larynx' comes from the Ancient Greek word lárunx ʻlarynx, gullet, throatʼ.

<span class="mw-page-title-main">Esophageal achalasia</span> Inability of the sphincter between the esophagus and stomach to open

Esophageal achalasia, often referred to simply as achalasia, is a failure of smooth muscle fibers to relax, which can cause the lower esophageal sphincter to remain closed. Without a modifier, "achalasia" usually refers to achalasia of the esophagus. Achalasia can happen at various points along the gastrointestinal tract; achalasia of the rectum, for instance, may occur in Hirschsprung's disease. The lower esophageal sphincter is a muscle between the esophagus and stomach that opens when food comes in. It closes to avoid stomach acids from coming back up. A fully understood cause to the disease is unknown, as are factors that increase the risk of its appearance. Suggestions of a genetically transmittable form of achalasia exist, but this is neither fully understood, nor agreed upon.

Swallowing, also called deglutition or inglutition in scientific contexts, is the process in the body of a human that allows for a substance to pass from the mouth, to the pharynx, and into the esophagus, while shutting the epiglottis. Swallowing is an important part of eating and drinking. If the process fails and the material goes through the trachea, then choking or pulmonary aspiration can occur. In the human body the automatic temporary closing of the epiglottis is controlled by the swallowing reflex.

<span class="mw-page-title-main">Gastroesophageal reflux disease</span> Flow of stomach contents into the esophagus

Gastroesophageal reflux disease (GERD) or gastro-oesophageal reflux disease (GORD) is a chronic upper gastrointestinal disease in which stomach content persistently and regularly flows up into the esophagus, resulting in symptoms and/or complications. Symptoms include dental corrosion, dysphagia, heartburn, odynophagia, regurgitation, non-cardiac chest pain, extraesophageal symptoms such as chronic cough, hoarseness, reflux-induced laryngitis, or asthma. In the long term, and when not treated, complications such as esophagitis, esophageal stricture, and Barrett's esophagus may arise.

<span class="mw-page-title-main">Glossopharyngeal nerve</span> Cranial nerve IX, for the tongue and pharynx

The glossopharyngeal nerve, also known as the ninth cranial nerve, cranial nerve IX, or simply CN IX, is a cranial nerve that exits the brainstem from the sides of the upper medulla, just anterior to the vagus nerve. Being a mixed nerve (sensorimotor), it carries afferent sensory and efferent motor information. The motor division of the glossopharyngeal nerve is derived from the basal plate of the embryonic medulla oblongata, whereas the sensory division originates from the cranial neural crest.

<span class="mw-page-title-main">Laryngitis</span> Inflammation of the larynx (voice box)

Laryngitis is inflammation of the larynx. Symptoms often include a hoarse voice and may include fever, cough, pain in the front of the neck, and trouble swallowing. Typically, these last under 2 weeks.

The pharyngeal reflex or gag reflex is a reflex muscular contraction of the back of the throat, evoked by touching the roof of the mouth, back of the tongue, area around the tonsils, uvula, and back of the throat. It, along with other aerodigestive reflexes such as reflexive pharyngeal swallowing, prevents objects in the oral cavity from entering the throat except as part of normal swallowing and helps prevent choking, and is a form of coughing. The pharyngeal reflex is different from the laryngeal spasm, which is a reflex muscular contraction of the vocal cords.

<span class="mw-page-title-main">Nissen fundoplication</span> Surgical procedure to treat gastric reflux and hiatal hernia

A Nissen fundoplication, or laparoscopic Nissen fundoplication when performed via laparoscopic surgery, is a surgical procedure to treat gastroesophageal reflux disease (GERD) and hiatal hernia. In GERD, it is usually performed when medical therapy has failed; but, with a Type II (paraesophageal) hiatus hernia, it is the first-line procedure. The Nissen fundoplication is total (360°), but partial fundoplications known as Thal, Belsey, Dor, Lind, and Toupet fundoplications are alternative procedures with somewhat different indications and outcomes.

<span class="mw-page-title-main">Recurrent laryngeal nerve</span> Nerve in the human body

The recurrent laryngeal nerve (RLN) is a branch of the vagus nerve that supplies all the intrinsic muscles of the larynx, with the exception of the cricothyroid muscles. There are two recurrent laryngeal nerves, right and left. The right and left nerves are not symmetrical, with the left nerve looping under the aortic arch, and the right nerve looping under the right subclavian artery, then traveling upwards. They both travel alongside the trachea. Additionally, the nerves are among the few nerves that follow a recurrent course, moving in the opposite direction to the nerve they branch from, a fact from which they gain their name.

<span class="mw-page-title-main">Ortner's syndrome</span> Medical condition

Ortner's syndrome is a rare cardiovocal syndrome and refers to recurrent laryngeal nerve palsy from cardiovascular disease. It was first described by Norbert Ortner (1865–1935), an Austrian physician, in 1897.

<span class="mw-page-title-main">Oropharyngeal dysphagia</span> Difficulty controlling the mouth or throat for swallowing

Oropharyngeal dysphagia is the inability to empty material from the oropharynx into the esophagus as a result of malfunction near the esophagus. Oropharyngeal dysphagia manifests differently depending on the underlying pathology and the nature of the symptoms. Patients with dysphagia can experience feelings of food sticking to their throats, coughing and choking, weight loss, recurring chest infections, or regurgitation. Depending on the underlying cause, age, and environment, dysphagia prevalence varies. In research including the general population, the estimated frequency of oropharyngeal dysphagia has ranged from 2 to 16 percent.

The cough reflex occurs when stimulation of cough receptors in the respiratory tract by dust or other foreign particles produces a cough, which causes rapidly moving air which usually remove the foreign material before it reaches the lungs. This typically clears particles from the bronchi and trachea, the tubes that feed air to lung tissue from the nose and mouth. The larynx and carina are especially sensitive. Cough receptors in the surface cells (epithelium) of the respiratory tract are also sensitive to chemicals. Terminal bronchioles and even the alveoli are sensitive to chemicals such as sulfur dioxide gas or chlorine gas.

<span class="mw-page-title-main">Globus pharyngis</span> "Lump in the throat" sensation

Globus pharyngis, globus hystericus or globus sensation is the persistent but painless sensation of having a pill, food bolus, or some other sort of obstruction in the throat when there is none. Swallowing is typically performed normally, so it is not a true case of dysphagia, but it can become quite irritating. It is common, with 22–45% of people experiencing it at least once in their lifetime.

Vocal cord paresis, also known as recurrent laryngeal nerve paralysis or vocal fold paralysis, is an injury to one or both recurrent laryngeal nerves (RLNs), which control all intrinsic muscles of the larynx except for the cricothyroid muscle. The RLN is important for speaking, breathing and swallowing.

<span class="mw-page-title-main">Laryngopharyngeal reflux</span> Flow of stomach contents into the throat (larynx and pharynx)

Laryngopharyngeal reflux (LPR) or laryngopharyngeal reflux disease (LPRD) is the retrograde flow of gastric contents into the larynx, oropharynx and/or the nasopharynx. LPR causes respiratory symptoms such as cough and wheezing and is often associated with head and neck complaints such as dysphonia, globus pharyngis, and dysphagia. LPR may play a role in other diseases, such as sinusitis, otitis media, and rhinitis, and can be a comorbidity of asthma. While LPR is commonly used interchangeably with gastroesophageal reflux disease (GERD), it presents with a different pathophysiology.

Cricopharyngeal spasms occur in the cricopharyngeus muscle of the pharynx. Cricopharyngeal spasm is an uncomfortable but harmless and temporary disorder.

Transnasal esophagoscopy (TNE) is a safe and inexpensive way to examine the esophagus in patients at risk for esophageal cancer and other disorders. TNE doesn't require sedation, unlike other techniques widely used to look into the esophagus. This is possible because TNE uses a camera that is passed through the nose, whereas other techniques, such as upper endoscopy, are performed through the mouth, requiring a patient to be sedated. TNE, as it is used today, was developed by Jonathan E. Aviv who published his findings on the first series of TNE that he performed. The origins of the idea to pass the camera through the nose date from 1993 as first described by C. A. Prescott, MD, a pediatrician otolaryngologist in Cape Town, South Africa and further embellished by Reza Shaker, MD, a gastroenterologist in Milwaukee, WI in 1994. However, it wasn't until the year 2000 when Jonathan E. Aviv, MD, published his findings on the first series of TNE he performed, that it began to have a widespread attention by ear, nose, and throat doctors. Since that time it has been used by both otolaryngologists and gastroenterologists as a diagnostic tool to detect globus, dysphagia, laryngopharyngeal reflux (LPR), gastroesophageal reflux disease (GERD). TNE may also be useful in detecting Barrett's, but there is incongruence between TNE findings and biopsy results. Experts in the field suggest that TNE may replace radiographic imaging of the esophagus in otolaryngology patients with reflux, globus, and dysphagia.

Jonathan E. Aviv is an American otolaryngologist–head and neck surgeon and a professor of Otolaryngology–Head and Neck Surgery at Icahn School of Medicine at Mount Sinai Hospital in New York City, New York. He is also Clinical Director of the Voice and Swallowing Center at ENT and Allergy Associates in New York City, New York. An inventor, author, educator, physician and surgeon, he is best known for his invention of Flexible Endoscopic Evaluation of Swallowing with Sensory Testing (FEESST), a medical device that allows office-based assessment of oropharyngeal dysphagia, or swallowing disorders, without the use of X-ray. He is also known for his development of Transnasal Esophagoscopy (TNE), a method of examining the esophagus without using conscious or intravenous sedation. From 1991 to 2009, he was a full-time academic surgeon and director of the division of head and neck surgery at Columbia University College of Physicians and Surgeons.

Endoscopic laser cordectomy, also known as Kashima operation, is an endoscopic laser surgical procedure performed for treating the respiratory difficulty caused as a result of bilateral abductor vocal fold paralysis. Bilateral vocal fold paralysis is basically a result of abnormal nerve input to the laryngeal muscles, resulting in weak or total loss of movement of the laryngeal muscles. Most commonly associated nerve is the vagus nerve or in some cases its distal branch, the recurrent laryngeal nerve. Paralysis of the vocal fold may also result from mechanical breakdown of the cricoarytenoid joint. It was first described in by Kashima in 1989.

References

  1. ↑ Aviv JE, Martin JH, Keen MS, Debell M, Blitzer A. Air-pulse quantification of supraglottic and pharyngeal sensation: a new technique. Ann Otol Rhinol Laryngol 1993; 102: 777-780.
  2. ↑ Ulualp S Brown A, Sanghavi R, Rivera-Sanchez Y. Assessment of laryngopharyngeal sensation in children with dysphagia. Laryngoscope. 2013 Sep;123(9):2291-5.
  3. ↑ Phua SY, McGarvey LPA, Ngu MC, Ing AJ. Patients with gastro-oesophageal reflux disease and cough have impaired laryngopharyngeal mechanosensitivity Thorax 2005; 60:488-491.
  4. ↑ Aviv JE, Johnson LF. Flexible endoscopic evaluation of swallowing with sensory testing (FEESST) to diagnose and manage patients with pharyngeal dysphagia. Practical Gastro 2000; 24: 52-59.
  5. ↑ Clayton NA, Carnaby-Mann GD, Peters MJ, Ing AJ. The effect of chronic obstructive pulmonary disease on laryngopharyngeal sensitivity. Ear Nose Throat J. 2012 Sep;91(9):370-382.
  6. ↑ Setzen M, Cohen MA, Mattucci KF, Perlman PW, Ditkoff MK. Laryngopharyngeal sensory deficits as a predictor of aspiration. Oto Head Neck Surg 2001; 124: 622-624.
  7. ↑ Zamir Z, Ren J, Hogan W, Shaker R. Coordination of deglutitive vocal cord closure and oral-pharyngeal swallowing events in the elderly. European J Gastro Hepatol 1996; 8: 425-429.
  8. ↑ Domer, A. S., Kuhn, M. A., & Belafsky, P. C. (2013). Neurophysiology and Clinical Implications of the Laryngeal Adductor Reflex. Current otorhinolaryngology reports, 1(3), 178–182. https://doi.org/10.1007/s40136-013-0018-5
  9. ↑ Langmore SE, Scarborough DR, Kelchner LN, Swigert NB, Murray J, Reece S, Cavanagh T, Harrigan LC, Scheel R, Gosa MM, Rule DK. Tutorial on Clinical Practice for Use of the Fiberoptic Endoscopic Evaluation of Swallowing Procedure With Adult Populations: Part 1. Am J Speech Lang Pathol. 2022 Jan 18;31(1):163-187. doi: 10.1044/2021_AJSLP-20-00348. Epub 2021 Nov 24. PMID: 34818509.
  10. ↑ Langmore, S.E., Kenneth, S.M.A. & Olsen, N. Fiberoptic endoscopic examination of swallowing safety: A new procedure. Dysphagia 2, 216–219 (1988). https://doi.org/10.1007/BF02414429
  11. ↑ 1. Borders JC, O’Dea MB, McNally E, et al. Inter- and Intra-Rater Reliability of Laryngeal Sensation Testing with the Touch Method During Flexible Endoscopic Evaluations of Swallowing. Annals of Otology, Rhinology & Laryngology. 2020;129(6):565-571. doi:10.1177/0003489419901145
  12. ↑ Ma Y, Kidane J, Gochman GE, Bracken DJ, Strohl MP, Rosen CA, Young VN. Assessment of Laryngeal Sensory Function using a Tactile Aesthesiometer in Healthy Adults. Laryngoscope. 2023 Oct;133(10):2525-2532. doi: 10.1002/lary.30540. Epub 2023 Jan 13. PMID: 36637192.
  13. ↑ Cukier-Blaj S, Bewley A, Aviv JE, Murry T. Paradoxical vocal fold motion: a sensory-motor laryngeal disorder. Laryngoscope 2008; 118:367-70.
  14. ↑ Aviv JE, Murry T. Sensory Testing Alone. In: Aviv JE, Murry T, eds. FEESST: Flexible Endoscopic Evaluation of Swallowing with Sensory Testing. San Diego, CA: Plural Publishing; 2005: 57-70.
  15. ↑ Aviv JE. Cough It Up! Cough and Throatburn Reflux. In Aviv JE. Killing Me Softly From Inside. The Mysteries and Dangers of Acid Reflux and Its Connection to America’s Fastest Growing Cancer with a Diet That May Save Your Life. North Charleston, SC: Create Space Independent Publishing Platform 2014: 23-33.
  16. ↑ Aviv JE, Murry T. Sensory Testing Alone. In: Aviv JE, Murry T, eds. FEESST: Flexible Endoscopic Evaluation of Swallowing with Sensory Testing. San Diego, CA: Plural Publishing; 2005: 57-70.
  17. ↑ Aviv JE, Collins S. Upper Aerodigestive Manifestations Of Gastroesophageal Reflux Disease in: Flint PW, Haughey BH, Lund VJ, Niparko JK, Richardson MA, Robbins KT, Thomas JR, Eds. Cummings Otolaryngology Head And Neck Surgery, 5th Edition, Philadelphia PA, Elsevier Mosby; 2009: 894-903.
  18. ↑ Phua SY, McGarvey LPA, Ngu MC, Ing AJ. Patients with gastro-oesophageal reflux disease and cough have impaired laryngopharyngeal mechanosensitivity Thorax 2005; 60:488-491.
  19. ↑ Clayton NA, Carnaby-Mann GD, Peters MJ, Ing AJ. The effect of chronic obstructive pulmonary disease on laryngopharyngeal sensitivity. Ear Nose Throat J. 2012 Sep;91(9):370-382.
  20. ↑ Botoman VA, Hanft KL, Breno SM, Vickers D, Astor FC, Caristo IB, Alemar GO, Sheth S, Bonner GF. Prospective controlled evaluation of pH testing, laryngoscopy and laryngopharyngeal sensory testing (LPST) shows a specific post inter-arytenoid neuropathy in proximal GERD (P-GERD). LPST improves laryngoscopy diagnostic yield in P-GERD. Am J Gastro 2002; 97: S11-12.
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