The absorb is disconnected into the oral, pharyngeal, and esophageal phases, depending on breadth the bolus is seen. With adjustable laryngoscopy, the structures in appearance accommodate the nasopharynx, oropharynx, and hypopharynx, with a decidedly adequate appearance of the larynx. The assay and advanced of the argot as able-bodied as the articulate atrium are not seen. Thus, the articulate date is alone partially evaluated, admitting the pharyngeal date is the centermost of attention. Similarly, because laryngoscopy has alone bound adeptness to appraise aerial esophageal sphincter (UES) aperture and doesn't extend far into the esophagus, the esophageal appearance is not adjourned in the FEES examination. Transnasal endoscopy, esophagoscopy, or fluoroscopy would accept that role.
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Epistaxis y taponamiento nasal | causas de epistaxis anterior y posterior[/caption]
What aspects of the oropharyngeal absorb and what structural movements can be credible endoscopically adjoin fluoroscopically? A accompanying endoscopic and fluoroscopic examination, credible in Video 1, highlights some of the differences.
When aliment is delivered to the mouth, articulate alertness begins. The argot moves a solid bolus from ancillary to ancillary as it is chewed and formed into a adamant bolus. Pureed aliment and liquids are independent in the average of the mouth. Fluoroscopy can anticipate this date nicely, admitting endoscopy can alone infer what is transpiring from movements of the abject of tongue. However, as sometimes happens during this articulate basic phase, some of the bolus leaks or avalanche into the hypopharynx. This abortive spillage is captured anon with endoscopy as the bolus avalanche over the abject of tongue. The endoscopist can see breadth the bolus avalanche as able-bodied as the laryngeal or pharyngeal acknowledgment to this spillage.
Once the articulate basic appearance has ended, the absorb begins. It acclimated to be anticipation that the articulate and pharyngeal stages of burning were acutely afar but it is now accustomed that the admission of the absorb entails both articulate and pharyngeal movements. In fact, articulate preparation, articulate transfer, and the admission of the absorb may be intertwined, abnormally with food. Palmer et al.2,3 has approved a accustomed arrangement of chewing and alteration masticated aliment to the valleculae, afore the absorb is initiated. The capricious appearance does not aftermost long, however, because aural a bulk of aberrant afterwards "dumping" aliment to the valleculae, the actuality swallows the capacity in the valleculae forth with the bolus in the mouth. Pureed aliment may appearance this arrangement of carriage (dumping) to the valleculae, alike afterwards mastication. However, liquids accept no such preswallow carriage date and are swallowed as a whole. Endoscopy captures any carriage or auctioning of aliment that occurs at the access of the swallow. It additionally visualizes the arch of the aqueous bolus if it enters the oropharynx above-mentioned to admission of the swallow.
Several structures move about accompanying to mark the access of the swallow, including abject of argot retraction, hyolaryngeal elevation, velopharyngeal closure, pharyngeal contraction, UES opening, and airway closure. Fluoroscopy captures abounding of these, admitting endoscopy captures beneath specific movements. Endoscopy does anticipate velopharyngeal cease at the access of the absorb absolute able-bodied if the ambit is positioned aural the nares. With a appearance of the hypopharynx (HP), the laryngoscope captures the access of argot abject retraction, epiglottal retroflexion, and crabbed pharyngeal bank squeeze, but alone briefly afore the appearance is abandoned by "whiteout." Video 2 shows several of these movements in a alternation of baptize swallows accomplished by a accustomed individual.
With a abutting appearance of the larynx, endoscopy can additionally abduction the laryngeal movements that comprise airway closure. Laryngeal cease for burning is about declared in textbooks as occurring from inferior to superior, with the articulate folds adducting aboriginal and the epiglottis accoutrement the arytenoids and glottis last. To absolutely ascertain this important event, Van Daele et al.,4 Ohmae et al.,5 and Shaker et al.6 accept all acclimated endoscopy forth with fluoroscopy, or electromyography (EMG) to actuate the adjustment of contest that act to abutting the airway for swallowing. Although Shaker et al. activate that the absolute arrangement of cease was authentic articulate bond (TVC) adduction aboriginal (66% of the swallows), Ohmae et al. activate a altered absolute adjustment of events. They activate that arytenoid adduction was the aboriginal accident to be empiric (86% of the time) and that TVC cease was not yet accomplished as the appearance was absent endoscopically. They affected that glottic cease was accomplished at some point in the absorb but did not accept the accoutrement to actuate this. Flaherty et al.7 acclimated alluring resonance imaging to abstraction the accord of laryngeal cease and laryngeal elevation. They appear that articulate bond (VC) adduction was not complete until the aiguille of laryngeal elevation. Gay and colleagues8 acclimated EMG to assay thyroarytenoid (TA) action as able-bodied as several laryngeal elevators. They activate a capricious adjustment of events.
In ablaze of these disparate reports, Van Daele et al.4 appear on a accompanying endoscopy and EMG abstraction to assay the adjustment of events. Application four normal, advantageous subjects, they placed bipolar hooked-wire electrodes on several muscles, including the TA, afterwards cricoarytenoid (PCA), which is the alone beef to abduct the articulate cords, and the suprahyoid musculature. A adjustable laryngoscope was afresh amid to a point aloof aloft the epiglottis for bisected of the swallows and aloof aloft the arytenoids for bisected of the swallows. The capacity drank 10-mL swallows of grape abstract 10 times. Two of the capacity additionally drank 10 mL of grape abstract 10 times application the super-supraglottic absorb (hold animation tightly, afresh swallow). After-effects showed the afterwards accustomed adjustment of contest for a accustomed swallow: (1) arytenoid adduction and angle with abeyance of PCA action (2) hyolaryngeal elevation, and (3) articulate bond closure. The authors accustomed that the antecedent medialization of the arytenoids was a acquiescent event, acquired by inhibition of the PCA. Arytenoid adduction was the aboriginal movement to arresting the access of the swallow, occurring as abundant as 340 msec afore laryngeal elevation. The articulate cords did not absolutely acquaintance anniversary added until the larynx was at atomic center to its aiguille elevation. In contrast, for the super-supraglottic swallows, breadth the capacity were voluntarily captivation their animation deeply above-mentioned to swallowing, the adjustment of contest was reversed. The TA beef was activated abundant beforehand and acquired articulate bond cease accompanying with bound arytenoid medialization. This abbreviating was abiding throughout the swallow. These two patterns can be credible in Video 3.
The aboriginal three swallows appearance accustomed airway closure. Agenda the arytenoids mark the access of the absorb and awning the glottis afore the articulate folds absolutely adduct. Accustomed airway cease at the access of the absorb is credible if the accountable holds his animation deeply afore he swallows (the supra-superglottic swallow). Agenda the articulate folds actively adduct in this action above-mentioned to the swallow.
These allegation accept amazing analytic implications. The articulate cords do not accommodate the aboriginal and best important akin of airway aegis for swallowing, as broadly presumed. Rather, it appears that the arytenoid and aryepiglottic folds closing amid and lunging advanced to awning the glottis accommodate the best important band of aegis adjoin assimilation and aspiration. A super-supraglottic absorb provides an aboriginal approach of protection, recruiting aboriginal cease of the articulate cords and "double" aegis for those bodies at accident for aspirating.
After this abrupt attending at the access of the swallow, there is a aeon of about 0.5 to 0.6 aberrant breadth the pharyngeal air amplitude is abandoned by tissue contacting added tissue and the bolus accidental through. The ablaze from the distal end of the endoscope is reflected aback to the eyepiece, consistent in whiteout. During this period, the hyolaryngeal circuitous completes its elevation, the epiglottis absolutely retroflexes, the pharyngeal constrictors clasp the bolus into the accessible UES, and the bolus passes into the esophagus. Back the absorb is over, all structures acknowledgment to blow bound and the air amplitude reopens, acquiescent a appearance of the hypopharynx (HP) again. If the absorb has been a accustomed one, there will be no balance larboard in the HP. The bolus may never accept been seen! This will not be the case for best patients with dysphagia, however, as will be declared shortly.
In Figure 1, the adjustment of contest authoritative up the absorb is depicted, assuming the about time of access and account and continuance of key movements and able-bodied contractions. The aeon of whiteout can be accustomed in gray shadow. Best of the key movements are credible at their access via endoscopy, but absolute anon the appearance is absent to whiteout. The archival adjustment of (1) airway closure, (2) abject of tongue/hyolaryngeal elevation, and (3) pharyngeal cease can be seen, although they acutely overlap.
Timeline of adjustment of contest in burning as aggregate from aggravate electromyography (EMG), endoscopy, fluoroscopy, and submental EMG. Whiteout*: time aeon the videoendoscopic angel is blocked attributable to pharyngeal closure. Genioglossal*: EMG action in the genioglossal beef application intramuscular absorbed wire electrodes. Mylohyoid*: EMG action in the mylohyoid beef application intramuscular absorbed wire electrodes. Geniohyoid*: EMG action in the geniohyoid beef application intramuscular absorbed wire electrodes. Submental**: EMG action from submental credible electrodes. Hyoid ascent***: Acclivity of the hyoid from ultrasound images. Hyoid descent***: Coast of the hyoid from ultrasound images. Epiglottic movement***: Time aeon the epiglottis begins inversion, charcoal inverted, and allotment to accustomed position as credible via videoendoscopy. Aloft constrictor*,**: EMG action in the aloft constrictor beef application intramuscular absorbed wire electrodes. Longitudinal pharyngeal musculature*: EMG action in the afterwards faucial pillars application intramuscular absorbed wire electrodes. Cricopharyngeal relaxation*,**: Decrease in EMG action in the cricopharyngeus beef application intramuscular absorbed wire electrodes. Arytenoids medializing*: Time aeon apery the movement of the arytenoids adjoin the midline as credible via videoendoscopy. Arytenoids medialized*: Time aeon the arytenoids abide in the midline during a absorb as credible with a aggregate of videoendoscopy and fluoroscopy. Arytenoids tilted/vestibular closure****: Time aeon the arytenoids activate movement adjoin the abject of the epiglottis and abide there consistent in vestibular cease as credible via fluoroscopy. Thyroarytenoid*,**: EMG action in the thyroarytenoid beef application intramuscular absorbed wire electrodes. Interarytenoid**: EMG action in the interarytenoid beef application intramuscular absorbed wire electrodes. Key: *McCulloch et al., abstruse data; **Perlman AL, Palmer PM, McCulloch TM, Van Daele DJ. Electromyographic action from animal laryngeal, pharyngeal and submental assay during swallowing. J Appl Physiol 1999;86(5):1663 –1669. ***Perlman AL, Van Daele DJ. Accompanying videoendoscopic and ultrasound measures of swallowing. J Med Accent Lang Pathol 1993;1(4):223 –232. ****Shaker R, Dodds WJ, Dantas RO, Hogan WJ, Arndorfer RC. Coordination of deglutitive glottic cease with oropharyngeal swallowing. Gastroenterology 1990;98:1478–1484. Note: Dashed and attenuate curve represent accustomed deviations. (Source: Langmore53 with permission from Thieme New York)
Otolaryngologists appearance the HP and larynx in patients with burning complaints. They about appraise articulate bond advancement and airway protection, but that is the admeasurement of the physiologic appraisal for burning function. Their primary purpose in analytical abounding patients is to aphorism out an anatomically based botheration such as cancer, which is causing the dysphagia. They may infer a poor absorb in patients with balance secretions in the HP. This assay is not a FEES procedure.
The FEES protocol, as accustomed by Langmore et al.,1 is a absolute appraisal of swallowing, including three aloft components: (1) structural movement, acoustic status, and anatomic abutment for swallowing; (2) adeptness to absorb aliment and liquid; and (3) acknowledgment to postural, dietary, or behavioral alterations to adapt the aisle of the bolus or the way it is swallowed. The FEES assay has a agnate purpose as the adapted barium swallow—to assay and call the absorb and to assay some interventions to allay a dysphagia.
The FEES protocol, aftermost revised in 2004, is presented in Table 2. It guides the examiner through the three phases of the examination.
After interviewing the patient, the examiner may accept to accomplish a FEES examination. Alertness for the assay includes acquisition some aliment and equipment. Aliment accommodate aliment and liquid, aliment appearance (blue or green), adipose for the sheath of the endoscope, booze basic pads, spoons and straw, gloves, and, if indicated, a nasal decongestant (Figure 2).
If the accommodating is an outpatient or in a rehabilitation setting, the assay will adequate be done in the clinic. Inpatients, and abnormally ICU patients, are about done at bedside. Figures 3 and 4 shows both of these settings with a FEES assay in progress. Agenda the position of the adviser and the adjustment of captivation the endoscope for a FEES examination. In my opinion, this "fishing pole" address has been best acknowledged attributable to the adeptness of examiners to move about and to position the ambit abroad from their face. It provides the greatest abundance and adeptness for an assay that may booty 15 account or best to complete.
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Epistaxis. Consideraciones sobre el tratamiento clínico y ... | causas de epistaxis anterior y posterior[/caption]
Setup of a FEES assay actuality done on an inpatient who has a tracheotomy and needs to be activated in bed. Equipment: Pentax laryngoscope, camera and ablaze source, VCR/Mini-DV recorder and video monitor.
Setup of an outpatient FEES assay assuming the accommodating and examiner assay the adviser as the accommodating eats. Equipment: Pentax laryngoscope, camera and ablaze source, VCR/Mini-DV recorder and video monitor.
In the aboriginal phase, the examiner assesses the assay of the accommodating as it relates to abutment of accustomed swallowing, addendum the cachet of any continuing secretions, anon assesses movement of key structures, and assesses sensorimotor action aural the region. All of these observations advice the analyst actuate the abeyant of the accommodating to assassinate a accustomed swallow, and explain any dysphagic patterns that may present.
Notes apropos anatomy. Credible assay aural the nasopharynx, oropharynx, and hypopharynx can be beheld anon in the FEES action with an eye to its adeptness to abutment accustomed swallowing. Altered assay from trauma, surgery, or complete altitude has an appulse on the bolus path, adeptness to bright the bolus, and adeptness to accumulate it out of the adenoids and airway. Adopted bodies and masses are acclaimed and referred to otolaryngology.
Status of continuing secretions. The attendance of balance secretions aural the HP is important to note. Their bendability reveals their antecedent and how connected they accept been present. Their breadth helps to adumbrate the adeptness of the accommodating to absorb aliment and liquid. Murray et al.9 showed that the attendance of balance continuing secretions aural the laryngeal antechamber that are not austere spontaneously by the accommodating are awful predictive of aspiration of aliment or liquids. They announce either a bargain acoustic acquaintance of the secretions (and of a bolus) or bargain adeptness to bright the secretions (and a bolus) back a absorb is attempted.
Rating of movements. Key structural movements bare for burning are adjourned in Allotment I of the FEES acceding as they are accomplished in nonswallow, phonatory tasks: abject of argot retraction, velopharyngeal anchorage closure, laryngeal closure, laryngeal elevation, and pharyngeal bank medialization. Later on, back the accommodating is accustomed aliment and aqueous to eat/drink, these aforementioned movements are rated again. A preswallow appraisal is needed, however, because the appearance during the absolute absorb is fleeting. Epiglottal retroflexion is credible alone during swallowing, however, and this movement needs to be articular during the burning allocation of the assay by the examiner back reviewing the abstraction to actuate whether it occurred.
Sensory testing. In accession to assessing structural movement, the examiner assesses acoustic assay as it relates to swallowing. There are several break throughout the FEES action of candor of this function. Does the accommodating faculty the endoscope in the throat? Does the accommodating faculty arising of bolus, residue, penetration, or aspiration? Finally, if desired, the examiner can anon appraise the patient's acknowledgment to a absolute stimulus. One quick way to appraise this is for the examiner to agilely blow the aryepiglottic bend or the tip of the epiglottis and ask if the accommodating feels it. A accustomed alone will accept a abrupt and audible acumen back affected and accord a absolute acknowledgment or a cough. An accession to absolute blow is for the examiner to administrate a academic acoustic test, whereby an air beating is delivered to the aryepiglottic region, which, at threshold, will arm-twist a laryngeal adductor reflex (LAR). If the FEES assay includes this academic assay of the LAR, it is accustomed as a FEES acoustic assay (FEESST) examination.10 It requires a adjustable laryngoscope that has a additional accessible anchorage or an endosheath that has an accessible anchorage to bear the air pulse. It additionally requires a antecedent of air that can be calibrated, such as the Acoustic Arrangement produced by Kay-Pentax (Morristown, NJ).
The aloft allotment of the assay is spent anon assessing burning of aliment and liquid. Here, the acceding is not specified, as the best is up to the examiner. Examinations accept altered purposes and patients crave altered protocols. My alternative is to accommodate a few accustomed swallows with about every patient, for example, to usually accommodate a 5-cc bolus of applesauce, a 5-mL alcohol of attenuate liquid, and a chaw of cracker (about bisected the cracker) in best exams. This makes comparisons amid patients easier back anticipation the attendance and severity of spillage, and bolus clearance. Then, the examiner would abide with whatever bendability and bolus admeasurement of foods and liquids were adapted to appraise or were appear by the accommodating to be problematic. It is recommended that outpatients accompany in their own aliment to test, and that the cafeteria tray be acclimated to appraise burning with inpatients. At the end of the examination, if there has been any catechism of attendance of aspiration with liquids, the accommodating should be accustomed one final aqueous bolus of milk or a aqueous with barium crumb alloyed in it. This is done because barium coats the film able-bodied and leaves abaft a trace of its path. If the accommodating has aspirated, affirmation of it is credible acutely on the subglottic shelf and in the laryngeal vestibule.
As an aftereffect of a FEES examination, the examiner formulates an authentic aftereffect and makes astute recommendations. Thus, it is important that the examiner accept how the accommodating eats in absolute life. One way to actuate this is to allot allotment of the testing affair to accepting the accommodating self-feed with no instructions as to bolus size, bulk of eating, and back to swallow. If there is balance larboard afterwards the absorb in the HP, the examiner should not acquaint the accommodating to absorb a additional time, but rather should ask if the aliment is gone, acquainted the patient's sensitivity. The accommodating is accustomed to booty added aliment to see if the balance accumulates and how the accommodating handles it.
When examiners accept a adequate abstraction of the attributes of the problem, they can afresh activate to arbitrate with a array of adapted strategies. Compassionate the attributes of the botheration leads the examiner to the rational use of the best strategy, but there is some balloon and absurdity complex as well. One abundant advantage of the FEES assay is the connected time accessible to assay any of a cardinal of altered postures, bolus consistencies and sizes, commitment methods, or behavioral changes. The examiner may ask the accommodating to dry absorb or booty a aqueous ablution to see its aftereffect on abbreviation residue. The accommodating may be accomplished a new way of swallowing, application the angel on the adviser as biofeedback. He may be accomplished a breath-hold action in which the VCs are deeply shut above-mentioned to the swallow. The accommodating may be accomplished a controlled absorb in which the aqueous is independent in the aperture for 1 or 2 aberrant afore it is let go to admit the swallow. The afterwards account illustrates some of the accessible compensatory and antidotal techniques that can be accomplished to patients during this antecedent FEES evaluation:
1. Examples of compensatory techniques
2. Examples of antidotal techniques
Much advice from a FEES assay can be articular as the assay proceeds. The bolus can be credible spilling into the hypopharynx above-mentioned to the swallow, balance can be credible afterwards the swallow, and the acknowledgment of the accommodating to actual in the laryngeal antechamber can be appreciated. However, a added allusive estimation usually requires the examiner to assay the abstraction afterwards by replaying the recorded study. Aberrant allegation from allotment I of the FEES assay advice to explain the dysphagia. In allotment II, four aloft types of dysphagic patterns about occur: (1) affliction to adapt the aliment orally, (2) affliction to admit the absorb in a appropriate and accommodating manner, (3) bare airway aegis or velopharyngeal (VP) cease during the swallow, and (4) abridged bolus clearance. These problems can all be approved on a FEES examination, although oral-stage problems are additionally abased on analytic observations of the patient.
The array of anatomic or physiologic problems that may be credible in a FEES assay is endless. An accomplished examiner is added adequate to ascertain attenuate abnormalities that may be absent by the novice. They are important because they not alone explain the dysphagia, but additionally accommodate a account for the assay plan. Some of this advice is additionally articular during swallowing, and this back-up is valuable. For example, a apathetic laryngeal cease action will adequate be reflected in a delayed admission of the swallow. Balance secretions in the laryngeal antechamber that are not sensed by the accommodating are adequate to be associated with aspiration of aliment or liquid.9 Bargain pharyngeal clasp puts a accommodating at college accident for aspirating food.11
Recent assay has accent the abeyant account of acoustic testing, done as allotment of the FEESST examination. Acutely bargain or absent acquaintance in the laryngopharynx was activate to be decidedly associated with aspiration of liquids in one study,12 and it may additionally be awful associated with laryngopharyngeal reflux.13 The believability of abstract of the LAR, as declared in the aboriginal protocol, has been questioned by some researchers,14 but the accession of the LAR to burning candor is able-bodied accepted.
Figure 5 illustrates some examples of aberrant allegation from a FEES assay that would be advised allotment I allegation because they are credible afore any aliment or aqueous is accustomed to the patient.
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Ciber Revista::.. | causas de epistaxis anterior y posterior[/caption]
a: Intubation trauma. Agenda aberrant film at afterwards commissure. b: Resected epiglottis. c: Agriculture tube directed bottomward airway. d: Edema and balance blubbery secretions post–radiation therapy.
Once patients activate to eat and drink, their "dysphagia profile" emerges. The four best accepted patterns, credible in patients with dysphagia accessory to any basal pathology, are as follows:
1. Bargain adeptness to adapt the aliment orally. Problems in the articulate date are articular from a aggregate of analytic ascertainment of the accommodating eating, articulate motor examination, and interview. Bulk of eating, bolus admeasurement taken, masticatory pattern, and time taken to champ are all readily apparent. The FEES assay can additionally assay the pharyngeal after-effects of an oral-stage problem. For example, aliment or aqueous may aperture into the HP anon or ailing masticated aliment may be larboard abaft in the HP as balance afterwards the swallow. The examiner charge be acquainted that it is accustomed for aliment to be transported to the valleculae during the masticatory appearance for a capricious breadth of time above-mentioned to burning it, but it is aberrant for it to abatement lower in the pharynx and absolutely will not access the laryngeal vestibule.15
2. Affliction to admit the absorb in a appropriate and accommodating manner. Problems at the access of the absorb are acutely accepted in patients with neurologic disorders. The bananas accommodating may eat compulsively afterwards giving the pharyngeal and laryngeal structures time to adapt for the swallow. Alternatively, the accommodating may accept adversity initiating the absorb and authority the bolus in the aperture for an boundless bulk of time. Patients with Parkinson's ache sometimes apparent a tongue-pumping arrangement in which they attempt to admit the swallow. The best austere aftereffect of any of these deficits is that the bolus spills into the larynx afore the airway has bankrupt and the bolus is aspirated. The FEES action can anticipate this botheration anon because whiteout has not yet abandoned the view.
Pharyngeal adjournment is a banausic admeasurement that has been acclimated to quantify this problem. It is a admeasurement of how connected the bolus is in the pharynx afore the absorb begins. This time can be readily affected from endoscopy as able-bodied as fluoroscopy. Assay has accustomed that some spillage is normal, abnormally with solid aliment or back specific instructions are not accustomed to "swallow now."3,15 As a result, the blow for accustomed adjoin pharyngeal adjournment has become clouded. Added assay needs to be done, application altered altitude (e.g., abstinent bolus admeasurement and instructions to absorb vs. accidental eating) and with altered age groups. For the present, rather than absorption alone on a banausic admeasurement of delay, the examiner should acknowledge all the factors that acquiesce one actuality to aspirate added calmly than another. The breadth of time the bolus is in the pharynx, accumulated with how low the bolus spills, the bolus size, and the cogent access of assay on administering the aisle of the bolus, will cumulatively actuate whether a actuality will run into agitation at the admission of the swallow. Although it is not aberrant for a bolus to discharge into the pharynx afore the absorb begins, it is not accustomed for every bolus to discharge to the pyriforms or for a bolus to sit in the pharynx for several (5 ) seconds. If the acoustic arrangement is intact, including its access to college cortical centers, the absorb will consistently be triggered back the bolus touches the laryngeal rim, and appropriately assimilation will be attenuate and aspiration will be prevented. Finally, it goes afterwards adage that this botheration is added adequate to action with liquids than food, artlessly because liquids breeze faster and are added adequate to discharge into the laryngeal antechamber if the arrangement is apathetic to acknowledge to the attendance of a bolus in the hypopharynx.
Video 4 appearance two examples of awkward admission of the swallow, consistent in aspiration.
a: The aboriginal blow shows a accommodating as had his epiglottis resected. He is demography his aboriginal aqueous bolus afterwards surgery. The admission of the absorb appears delayed. Because the vallecular abridged has been alone by abatement of the epiglottis, the baby bulk of aqueous accustomed to him spills anon into the laryngeal antechamber afore the absorb is triggered. b: The additional blow shows a accommodating afterwards a achievement who is not timing the access of the absorb the bolus flow. He directs the bolus into his pharynx a few aberrant afore initiating the absorb and the bolus avalanche anon into the laryngeal vestibule.
3. Bare airway aegis and velopharyngeal valving during the swallow. Bare laryngeal or velopharyngeal valving after-effects in misdirection of the bolus. Of these valves, the laryngeal valve is best critical, because it can advance to aspiration of actual during the swallow. The basal pathophysiology may be weakness or abridged cease of the laryngeal structures (epiglottic retroversion, arytenoids accoutrement the glottis, and articulate bend adduction). Sometimes, however, the botheration lies with mistiming the bolus breeze with airway cease or with delayed laryngeal elevation, which facilitates airway closure. This botheration is absolutely an addendum of the ahead declared botheration of delayed or awkward admission of the swallow.
To array this out, the after-effects from allotment I of the FEES assay should be referenced. In this preswallow allotment of the exam, capability of glottic cease at the akin of the authentic articulate folds was anon assessed. In addition, the activity of laryngeal movements was appreciated, giving the examiner an abstraction of acknowledgment time to bolus spillage.
Penetration or aspiration of the bolus during the acme of the absorb is absurd to be anon beheld during a FEES assay because of whiteout. Affirmation of assimilation or aspiration will charge to be credible by balance of bolus in the laryngeal vestibule, on the articulate folds, or beneath the glottis on the subglottic shelf. Because liquids are best adequate to aperture into the laryngeal vestibule, it is acute that a aqueous that leaves balance be acclimated during the examination. Barium coats the film able-bodied and can be acclimated for this test.
Video 5 shows an archetype of aspiration during the swallow. The bolus acclimated is barium and it is acutely credible subglottally afterwards the swallow.
In accession to laryngeal valving, velopharyngeal valving keeps the bolus from abounding to the nasopharynx and into the nasal passages. This sphincter can be anon adjourned during the absorb by abandoning the tip of the endoscope to the nasal access and assay the VP anchorage during the swallow. A photo of this appearance is credible in Figure 6.
4. Abridged bolus clearance. A accepted blazon of botheration in patients with oropharyngeal dysphagia is abridged bolus propulsion, apparent by balance of bolus larboard abaft afterwards the swallow. If the balance is adequate or if it is not austere and builds up with consecutive bolus swallows, it eventually leaks into the laryngeal antechamber and is aspirated. This is abnormally apt to action at the access of a new swallow, as the larynx begins to drag and the pharyngeal walls activate to contract. It is additionally added adequate to be a botheration with solid aliment than with liquids, and with adhesive aliment or baby $.25 of aliment that can get ashore in the crevices of the pharynx. Liquids can basin in belly but contrarily abatement to the distal pharynx artlessly by gravity.
The account of abridged bolus approval adeptness be bereft able-bodied contraction—base of tongue, pharyngeal walls—to move the bolus caudally to the accessible UES or bereft laryngeal elevation, which decreases UES aperture diameter. Alternatively, the account can be anatomically based, with an obstruction to bolus breeze acquired by the attendance of a adopted assay or an anatomically resected or reconstructed structure. The accomplished appearance of credible assay in a FEES assay should acknowledge any anatomically based problem.
The attendance of residue, the patient's acknowledgment to the residue, and the aisle it eventually takes are acutely credible by endoscopy. If the botheration is basal weakness, anecdotic the specific antecedent of weakness is sometimes difficult and requires some analysis. Fortunately, the breadth of the balance credibility to the antecedent of the problem. For example, if balance is larboard on the abject of tongue, one can accept this arena was not awkward absolutely adjoin the afterwards pharyngeal wall. Assay application accompanying manometry and fluoroscopy has accurate the accord amid breadth of balance and antecedent of the problem.16,17,18,19
Video 6 shows an archetype of aspiration afterwards the absorb in a accommodating who cannot bright the bolus through the HP during the absorb and aspirates as he reopens the airway.
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Epistaxis o hemorragia nasal: aparatoso, pero leve - ORL - Salud y ... | causas de epistaxis anterior y posterior[/caption]
This blow shows a accommodating post-radiation assay for arch and close blight who has acutely bargain adeptness to drive and bright the bolus through the HP. As the airway opens up, he aspirates the residue.
In accession to actuality an accomplished analytic tool, FEES has audible advantages back it comes to administration of patients with dysphagia. During the FEES evaluation, interventions are trialed for their abeyant account and the after-effects are credible immediately. Reevaluations can be done as about as bare at the accessibility of the examiner to adviser progress, to appraise the connected account of an intervention, or to adviser a comestible change. Patients who are transitioning from NPO (nothing by mouth) to PO cachet (or carnality versa) can be monitored consistently with consecutive FEES exams.20 Afterwards the examination, the recorded abstraction can be acclimated to brainwash patients about the attributes of their problem. The added attendance of ancestors members, nurses, or apropos physicians facilitates bigger compassionate of the burning problem, collective accommodation making, and bigger acquiescence with recommendations.
Flexible laryngoscopy can additionally be acclimated anon as a assay tool, abstracted from the appraisal process. With patients scoped and adverse the adviser during the assay session, the beheld angel provides absolute on-line acknowledgment to them about their burning behavior or their adeptness to move laryngeal, pharyngeal, or abject of argot muscles. It can additionally be acclimated to access their acquaintance of residue, spillage, penetration, or aspiration. The amount of biofeedback cannot be underestimated, as it is an accomplished apparatus for acquirements motor behaviors. Denk and Kaider21 activate that back endoscopy was acclimated with arch and close blight patients to advise them absorb strategies, they progressed faster than the patients who did not accept the account of endoscopic biofeedback.
This columnist has activate endoscopy acutely advantageous to advise patients some contest to strengthen the assay acclimated in swallowing. A set of contest application abject of tongue, laryngeal, and pharyngeal assay are commonly accomplished to patients, application endoscopy as biofeedback to ensure that the accommodating is assuming the contest accurately. In addition, new burning behaviors such as application a controlled absorb or a super-supraglottic absorb can be accomplished added calmly application endoscopy as biofeedback. Video 7 illustrates such a biofeedback session.
For an appraisal apparatus to survive and become an accustomed allotment of analytic practice, it needs to accommodated assertive criteria. It needs to be safe, valid, reliable, useful, and efficacious. Assay over the accomplished 15 years has credible that the FEES action does accommodated these criteria.
When FEES was initiated, there were accepted apropos about its safety. Although otolaryngologists had done adjustable laryngoscopy for years, the actuality that speech–language pathologists, who were not accomplished to accommodate emergency medical care, were actuality accomplished to accept the role of the endoscopist was of affair to some people. Also, the dysphagia accommodating citizenry included some absolute fragile, ambiguous aged patients in settings such as the ICU, as able-bodied as adolescent accouchement and alike infants. The charge for contemporary anesthesia was questioned. All of these apropos accept abundantly been put to rest. The assay is done with all-important medical advancement and in a adequate medical environment. Back the charge for contemporary anesthesia arises, able medical cadre administer it.
In four studies accurately attractive at safety, the bulk of complications was beneath than 1%.22,23,24,25 Moreover, none of the complications was serious. The best accepted complications were epistaxis and vasovagal response. Therefore, the cessation is that FEES is a safe assay in any medical setting, with any of the populations appear to date.
There accept been some apropos aloft about the achievability of a speech–language pathologist missing a blight aural the structures viewed. That is absolutely possible, but the purpose of this assay is not to assay medical assay but to abstraction the person's adeptness to swallow. If the catechism of blight is raised, the accommodating needs a adjustable laryngoscopic assay performed by an otolaryngologist. Alternatively, the otolaryngologist may accept to appearance recorded FEES studies and awning for that possibility. The roles of the otolaryngologist and accent pathologist in assuming or interpreting FEES charge to be formed out at the bounded level. Although civic associations may not consistently agree, alone accent pathologists and otolaryngologists abide to assignment together, about in a accommodating accord and in abutment of one other.
Does FEES accurately assay aberrant absorb events? How acute is this procedure? Back FEES was aboriginal done, it was compared to the accustomed action for oropharyngeal dysphagia, which was the adapted barium absorb study, application fluoroscopy. Langmore et al.23 performed both examinations on 21 persons. They archival the attendance of four arresting allegation accompanying to the bolus (aspiration, penetration, spillage, residue) on anniversary patient's assay from both the FEES and the MBS study. After-effects showed a absolute adequate akin of acuteness (0.88 or greater), specificity (0.50 or greater), absolute predictive amount (0.69 or greater), and abrogating predictive amount (0.63 or greater) for FEES as compared to the after-effects of the MBS abstraction done on the aforementioned persons. Since that antecedent study, at atomic eight added assay groups accept compared agnate allegation from the two examinations.19,24,25,26,27,28,29,30 Best of these studies accept assured that FEES and fluoroscopy accept a aerial akin of agreement, abnormally back it comes to audition aspiration. None of the studies, however, has compared allegation application both accoutrement simultaneously. This would be the best assay of college acuteness and specificity. This abstraction begs to be done. Our own alternation of accompanying studies suggests that anniversary apparatus misses some allegation with attention to breadth of the bolus, and that FEES is decidedly acute at acute laryngeal assimilation as against to pharyngeal residue. This is illustrated in Figure 7 breadth the aforementioned appearance of balance is credible via endoscopy and fluoroscopy afterwards a bolus absorb in a neurologically broken patient.
As a aftereffect of the aerial appear akin of acceding amid the two examinations, the use of the appellation gold accustomed to accredit to the MBS abstraction has been challenged by three researchers.31,32,33 They assured that neither one of these examinations represents the "truth" and anniversary one provides a accurate assessment. However, back either one of the active examinations is compared to a clinical, noninstrumental examination, afresh the active assay can appropriately be alleged the gold accustomed because it is bright that chart adds acuteness and specificity to the assessment.
Although the attendance of spillage, residue, penetration, and aspiration is visualized with either tool, there are abounding added allegation that are important for the examiner to identify. Assay studies comparing the amount or acuteness of FEES adjoin fluoroscopy to assay these added allegation are limited.28 Table 2 lists some added allegation that are altered to fluoroscopy and endoscopy. Clearly, both examinations are valuable.
One way to strengthen the validity, reliability, and account of an assay is to assimilate the acceding and scoring of results. This enables clinicians and advisers to use a accepted accent back anecdotic the allegation of the assay or the severity and attributes of dysphagia in a accurate patient. The FEES acceding was connected by Langmore in 1988, and anon afterwards it was absorb protected. This absorb has now expired, but the acceding is still in advanced usage. The acceding is credible in Table 2. The scoring of a FEES assay has not yet been connected and neither has the MBS study.
High interjudge and intrajudge believability is an important footfall in standardizing an assay and partly reflects the affluence with which the assay can be scored. Believability has been accustomed for two ambit of burning that can be denticulate from an MBS study: the Penetration-Aspiration Scale (PAS)34 and the absorb adeptness ratio.35 The PAS has additionally been submitted to believability testing from a FEES examination36 and activate to accept a agnate akin of believability as it did back activated to an MBS study. No added ambit of a FEES assay accept been submitted to believability testing. This would be a advantageous activity and cogent accession to the field.
There is abundant assignment to be done in the breadth of standardization, validity, and believability testing for both the MBS and FEES procedures. The abridgement of abstracts in this attention is startling. Our acreage has not alike appear to acceding about what should ascertain mild, moderate, or astringent dysphagia, abundant beneath anticipation the course of assertive ambit such as spillage of bolus above-mentioned to admission of the swallow.
How advantageous is FEES? Several studies accept declared its account with altered types of accommodating populations, including analgesic bond injury,37, academician injury,38,39 stroke,40,41, pediatrics,45,46,47,48,49 adorning disability,42 arch and close cancer,43,44 and amyotrophic crabbed sclerosis,45,46 It has been benign in altered settings, including the ICU,47 with postsurgical patients,48,49 in a rehabilitation hospital,50 and in abiding care.51 It has been declared not alone as a analytic tool, but additionally to adviser treatment, accurately to alteration a accommodating from NPO to PO agriculture status20,21 and as a biofeedback apparatus to adviser treatment.21
The final assay of a new action is to actuate its efficacy, or its adeptness to aftermath favorable outcomes. For patients with dysphagia, that agency actuality able to eat a greater array of foods and liquid, to advance diet and hydration, and to anticipate pulmonary complications. The studies aloft declared adequate outcomes with patients back FEES was acclimated to adviser their treatment. Agnate letters accept been appear application fluoroscopy or a analytic assay to adviser treatment. However, there has alone been one abstraction to date that has anon compared the adeptness of the MBS adjoin the FEES (or FEESST) action to crop favorable outcomes in patients. Aviv52 did this in his abstraction in which 126 outpatients with dysphagia were accustomed either an MBS or a FEESST test. The after-effects of the assay guided their comestible and behavioral management. The patients were followed for 1 year. At this time, the accident of pneumonia in the two groups was 18% afterwards an MBS and 12% afterwards the FEESST. These ante were not decidedly different. The cessation was that the two examinations were agnate in their adeptness to adviser assay and anticipate pneumonia.
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