New Horizons in FEES!!New Horizons in FEES!!

A Developmental A Developmental Disability PerspectiveDisability Perspective

- Nehal Kothari- Nehal Kothari

Dysphagia & Dysphagia & Developmental DisabilityDevelopmental Disability

Dysphagia is a common finding in infants and children with neuromuscular disabilities. Dysphagia may be developmental, as in the preterm infant, transient, chronic, or progressive.

39- 56% individuals with developmental 39- 56% individuals with developmental disability face some kind of feeding disability face some kind of feeding difficulty. (difficulty. (Schwarz, S. et al. (2001). )

When is an evaluation When is an evaluation indicated?indicated?

Dysphagia evaluation is indicated Dysphagia evaluation is indicated when:when:

- Nutritional or pulmonary status Nutritional or pulmonary status appears compromisedappears compromised

- Child has a medical diagnosis or Child has a medical diagnosis or condition associated with risk of condition associated with risk of dysphagia.dysphagia.

- Associated conditions:Associated conditions:- GERD, Constipation and lung disease.GERD, Constipation and lung disease.

Development of Feeding Development of Feeding and Swallowingand Swallowing

Neonatal period (40 weeks post-Neonatal period (40 weeks post-conceptional age and followed by 28 days)conceptional age and followed by 28 days)

Early infancy (1-6 months) and late Early infancy (1-6 months) and late infancy period (6-12 months)infancy period (6-12 months)

Early childhood to maturation (2-16 years)Early childhood to maturation (2-16 years) Neurophysiology of swallowing:Neurophysiology of swallowing:

- integration of skills from cortical centers in the frontal lobe with modulation from basal ganglia and cerebellum.

- Cranial nerves involved: V, VI, IX, X.

Development of Development of oropharyngeal cavityoropharyngeal cavity

PROS and CONSPROS and CONS

MBSMBS FEESFEES

PROSPROS Visualizations Visualizations of all 3 phasesof all 3 phases

More sensitive in More sensitive in diagnosing diagnosing laryngeal laryngeal penetration and penetration and aspirationaspiration

Direct Direct visualization of visualization of the larynxthe larynx

CONSCONS Not natural Not natural posture and posture and food bolusfood bolus

Children with Children with spasticity at spasticity at increased risk for increased risk for accidental accidental perforation, perforation, bleeding, bleeding, laryngospasm and laryngospasm and allergic reactions allergic reactions to topical to topical anesthetics due to anesthetics due to sudden sudden movement/movement/

Hyper reflexia.Hyper reflexia.

FEES VS MBS for Children FEES VS MBS for Children with Developmental with Developmental

disabilitydisability MBS: Possible reason for not being able to MBS: Possible reason for not being able to

identify silent aspiration could be attributed to identify silent aspiration could be attributed to lack of longer exposure to MBSlack of longer exposure to MBS

Reasons: concerns regarding exposure to Reasons: concerns regarding exposure to radiation for longer duration and maintaining radiation for longer duration and maintaining child’s co-operation.child’s co-operation.

FEES: Owing to lack of radiation exposure FEES: Owing to lack of radiation exposure possible to observe the mechanism for longer possible to observe the mechanism for longer timetime

- thus, possible to observe swallowing mechanism - thus, possible to observe swallowing mechanism when it fatigues and effects of postural changes.when it fatigues and effects of postural changes.

Investigation of Investigation of DysphagiaDysphagia

Oro motor function testOro motor function test Physical examination: Physical examination: Important variables that may influence the Important variables that may influence the

examexam -Head control, facial tone and tongue -Head control, facial tone and tongue

posture.posture. -Micrognathia-Micrognathia- Adventitious movements of mouth Adventitious movements of mouth

(athetosis/spasticity)(athetosis/spasticity)- Asymmetry of tone in trunk and neckAsymmetry of tone in trunk and neckIf abnormalities detected with regards to the If abnormalities detected with regards to the

above- above- Consider consulting an OTist or a nurse.Consider consulting an OTist or a nurse.

Special accommodationsSpecial accommodations A general protocol outlining the clinical A general protocol outlining the clinical

aspects of fiber optic examination has aspects of fiber optic examination has been published (Langmore & McCullog, been published (Langmore & McCullog, 1997) but strategies for incorporating 1997) but strategies for incorporating the clinical procedures with the clinical procedures with developmental disabilities have not developmental disabilities have not been described.been described.

Possible Procedural modifications:Possible Procedural modifications:- To maintain adequate posturing child To maintain adequate posturing child

may be strapped to and rotated in may be strapped to and rotated in specially designed chair.specially designed chair.

- Prosthetics- collar/head supportsProsthetics- collar/head supports- Postural modifications for wheelchair Postural modifications for wheelchair

bound patients bound patients

--Video fluro scopic chairVideo fluro scopic chair Provides safe, stable postural support Provides safe, stable postural support

in an upright position for video in an upright position for video fluoroscopic studies, with anterior-fluoroscopic studies, with anterior-posterior, lateral, and rotational views posterior, lateral, and rotational views easily performed.easily performed.

Features a removable headrest, a full Features a removable headrest, a full back support, armrests, lateral truncal back support, armrests, lateral truncal supports, and a patented base which is supports, and a patented base which is clamped to the footboard of the clamped to the footboard of the radiology table and allows for 200 radiology table and allows for 200 degrees rotation of the patient. degrees rotation of the patient.

Children with Down’s or Autism may present Children with Down’s or Autism may present with heightened oral sensitivity and may get with heightened oral sensitivity and may get agitated owing to discomfort.agitated owing to discomfort.

Distractors while carrying out the evaluation:-Distractors while carrying out the evaluation:-

Cartoons or videosCartoons or videos Children friendly instruments and Children friendly instruments and

environmentenvironment Familiarize with roomFamiliarize with room Anesthesia – What does research say?Anesthesia – What does research say? Other non invasive tools (EDAT) – their Other non invasive tools (EDAT) – their

efficacy?efficacy?

Prevalence of dysphagia Prevalence of dysphagia among some specific among some specific

developmental disabilitiesdevelopmental disabilities Cerebral palsy: 60% of children were Cerebral palsy: 60% of children were found to have swallowing problems. found to have swallowing problems. 41% of these were found to have 41% of these were found to have chronic aspiration problem (chronic aspiration problem (Cass, Hilary. Cass, Hilary. (2005). )(2005). )

Drooling was found to be associated Drooling was found to be associated with dysphagia.with dysphagia. Case studiesCase studies (Images)(Images) Advantages and disadvantages of Advantages and disadvantages of Video fluoroscopy and its implicationsVideo fluoroscopy and its implicationsRole of FEES – Periodic monitoring Role of FEES – Periodic monitoring and long term follow up studies (in and long term follow up studies (in conjunction with chest X-rays).conjunction with chest X-rays).

Chest X-rayChest X-ray

Chest radiograph of pt. 1 at end of VFS.

Chest radiograph of pt.3

Children with CHARGE associationChildren with CHARGE association The incidence of CHARGE, reported in a

hospital-based study from Ann Arbor, MI, USA (Edwards et al. 1995), ranged from 1 to 11 in every 900 live births.

Functional disturbances are common, for example, feeding, swallowing, and aspiration difficulties.

The severity of life-threatening events varies (Ferrell E., Norlin B., et al. (2000))

Most children die of aspiration. Co-existing medical conditions and other

disorders such as Autism and MR. Other conditions – Arnold Chiari Malformation

Implications on scope of Implications on scope of FEESFEES

Currently used as a:Currently used as a: Diagnostic and intervention tool Diagnostic and intervention tool Aids in determining the effectiveness of various therapeutic Aids in determining the effectiveness of various therapeutic

interventionintervention Could it be used as a screening tool in medical settings to Could it be used as a screening tool in medical settings to

screen at risk children?screen at risk children?

With prevalence of dysphagia being so high in various With prevalence of dysphagia being so high in various developmental disabilities----can it be used more extensively developmental disabilities----can it be used more extensively in various settings like Hospitals and schools?in various settings like Hospitals and schools?

Just like, pre mature babies screened for hearing loss, can Just like, pre mature babies screened for hearing loss, can high risk infants be screened for swallowing disorders using high risk infants be screened for swallowing disorders using FEES, especially those group of children which are prone to FEES, especially those group of children which are prone to developing aspiration pneumonia?developing aspiration pneumonia?

Example: CHARGE association – aspiration pneumonia may Example: CHARGE association – aspiration pneumonia may prove to be fatalprove to be fatal

SettingsSettings - Mainly medical settings such as hospitals, private - Mainly medical settings such as hospitals, private

clinics or medical centers.clinics or medical centers. - Role of School SLP? - Role of School SLP?

SLPs in schools have found their roles SLPs in schools have found their roles expanding in recent years including expanding in recent years including management of students with feeding and management of students with feeding and swallowing disorders.swallowing disorders.

Many students with autism, developmental Many students with autism, developmental delay, MR, TBI may have accompanying or delay, MR, TBI may have accompanying or undiagnosed feeding and swallowing disorders.undiagnosed feeding and swallowing disorders.

Inclusion of feeding and swallowing difficulties Inclusion of feeding and swallowing difficulties as a part of IEPas a part of IEP

Discuss need of swallowing/ instrumental Discuss need of swallowing/ instrumental evaluation at a medical facility.evaluation at a medical facility.

Can collaborate with SLPs in medical settings, Can collaborate with SLPs in medical settings, identify and refer children with feeding identify and refer children with feeding difficulties and carry out appropriate difficulties and carry out appropriate intervention.intervention.

Future OutlookFuture Outlook Technological AdvancesTechnological Advances Reduction in diameter of Reduction in diameter of

endoscopic optical fiber.endoscopic optical fiber. E.g. 400 E.g. 400 m diameter optical fibers m diameter optical fibers

are readily available.are readily available. Advancements in camera Advancements in camera

technologytechnology Virtual 3D endoscopy- commonly Virtual 3D endoscopy- commonly

performed in field of performed in field of Gastrointestinial endoscopyGastrointestinial endoscopy

Capsule endoscopyCapsule endoscopy MRCPMRCP

Future outlookFuture outlook VideoVideo

Virtual colonoscopy(video link)

Virtual NasendoscopyVirtual Nasendoscopy

Future outlookFuture outlook

Bio nano roboticsBio nano robotics

Video clip

Different perspectiveDifferent perspective

The Forensic Aspect of DysphagiaThe Forensic Aspect of Dysphagia Sued for malpractice can be SLP’s worst Sued for malpractice can be SLP’s worst

nightmare!nightmare! Medical malpractice cases involving SLPs

and the management of patients with sucking, chewing, and swallowing disorders are increasingly common (Tanner & Guzzino, 2002).

Experts review all pertinent medical information

Your clinical reports and notes become important

Forensic Aspect of Forensic Aspect of DysphagiaDysphagia

Juries rely on visual evidence as Juries rely on visual evidence as opposed to clinical bed examination opposed to clinical bed examination findingsfindings

VSS vs. FEESVSS vs. FEES "Neglecting to conduct an

instrumental evaluation of the swallow in cases of suspected dysphagia is analogous to refusing to X-ray a leg for suspected fractures'" (Tanner, 2003, p. 86).”

Current Research and its Current Research and its implicationsimplications

Radiotherapy in Head and Neck cancer patientsRadiotherapy in Head and Neck cancer patients Study at University of Wisconsin- 75% presented Study at University of Wisconsin- 75% presented

with dysphagiawith dysphagia Implications- Use of FEES to monitor changes in Implications- Use of FEES to monitor changes in

swallowing function and conduct further swallowing function and conduct further research to compare results of new therapeutic research to compare results of new therapeutic approaches with the old, established approaches with the old, established intervention practices.intervention practices.

Involvement of arytenoids in the prevention of Involvement of arytenoids in the prevention of aspiration – Video endoscopyaspiration – Video endoscopy

Diazepam induced swallowing difficulties – Case Diazepam induced swallowing difficulties – Case studies.studies.

Implications- FEES may aid as a tool to promote Implications- FEES may aid as a tool to promote future research!!future research!!

Other interesting findings!!!Other interesting findings!!! Changes were observed in deglutition Changes were observed in deglutition

following tonsillectomy in following tonsillectomy in neurologically impaired childrenneurologically impaired children

Use of Blue dye in evaluation?Use of Blue dye in evaluation? FEESTFEEST VA settingsVA settings Inconsistencies in Clinical Inconsistencies in Clinical

Assessment and Instrumental exam Assessment and Instrumental exam decision makingdecision making

ImplicationsImplications

ReferencesReferences Aoyagi, Y., Takashi H. et al. (2005). Diazepam induces pharyngeal

dysphagia without impairing level of consciousness. Dysphagia, 20:357–387.

Abe, H., Akio, T., et al. (2005).Observation of arytenoids movement during laryngeal elevation using video endoscopic evaluation of swallowing. Dysphagia, 20:357–387.

Aviv, J., Kim, T., et al. (1998). Fiber optic Endoscopic Evaluation of Swallowing with Sensory Testing (FEESST) in Healthy Controls. Dysphagia 13:87–92.

Cass, Hilary. (2005). Assessing pulmonary consequences of Cass, Hilary. (2005). Assessing pulmonary consequences of dysphagia in children with neurodevelopment disability. dysphagia in children with neurodevelopment disability. Developmental Medicine & Child Neurology, 47: 347–352.

Conley, S., Kodali, S., Beecher, R. et al. (1996). Changes in Conley, S., Kodali, S., Beecher, R. et al. (1996). Changes in deglutition following tonsillectomy in neurologically impaired deglutition following tonsillectomy in neurologically impaired children. children. International Journal of Pediatric Otorhinolaryngology, International Journal of Pediatric Otorhinolaryngology, 36: 13-21.36: 13-21.

Connor, N., Sullivan, P., et al. (2005). Impact of Conventional Connor, N., Sullivan, P., et al. (2005). Impact of Conventional Head And Neck Radiotherapy on swallow function, salivary Head And Neck Radiotherapy on swallow function, salivary production, auditory capacity and Quality of life. production, auditory capacity and Quality of life. DysphagiaDysphagia, 20: , 20: 344-356.344-356.

Dusick, Anna. (2003). Dusick, Anna. (2003). Investigation and Management of of Dysphagia. Dysphagia. Seminars in Pediatric Neurology, 255- 264.

ReferencesReferences Ferrell, E., Norlin, B., et al. (2000). Autistic disorders in children with

CHARGE association. Developmental Medicine & Child Neurology, 42: 617–623.

Gonçalves Silva, R. (2005). Videoendoscopic and Videofluroscopic evaluation of swallowing with therapeutic intervention. Dysphagia, 20:357–387.

Mathers–Schmidt, B., and Kurlinski (2003). Dysphagia Evaluation Practices: Inconsistencies in Clinical Assessment and Instrumental Examination Decision-Making. Dysphagia 18:114–125.

McCullough, G., Rosenbeck, J., et al.( 2005). Utility of Clinical Swallowing Examination Measures for Detecting Aspiration Post-Stroke. Journal of Speech, Language, and Hearing Research,48 : 1280–1293.

Mikush, S., Saitoh, E., et al. (2005). A dysphagia screening test by X-ray pictures. Dysphagia,

Perez, I., Smithard, A., David, G., Davies, A., Honor, A., Kalra, (1998). Pharmacological treatment of Dysphagia in stroke. Dysphagia, 13: 12-16.

Rogers, Brian., & Arvedson Joan. (2005). Assessment of Infant Oral Sensorimotor and Swallowing function. Mental Retardation and Developmental Disabilities Research Reviews, 11: 74-82.

ReferencesReferences Selley, W., Parrott, L. et al. (2000). Non-invasive technique

for assessment and management planning of oral-pharyngeal dysphagia in children with cerebral palsy. Developmental Medicine & Child Neurology, 42: 617–623.

Schwarz, S. et al. (2001). Diagnosis and treatment of feeding disorders in children with developmental disability. Pediatrics. 108:671- 675.

www.ASHA.org ( Articles from ASHA LEADER and ASHA Desk Reference)

www.wikipedia.org www.googlevideos.com