HC4 Endoscopy Flashcards
1
Q
What’s the overall goal of CSE?
A
- provides baseline information: makes it easier to track and compare the swallowing ability over time
- can be repeated as much as you want
- specific findings (e.g. posture) that will facilitate the imaging procedure
- determines readiness for further diagnostics
2
Q
Why would you need imaging?
A
- to assess function and safety of the pharyngeal/laryngeal stage
- to determine specific techniques to manage the swallowing problem, strategies to improve swallow safety/efficiciency
- gives information about the coughing or choking during eating
- if the inability to maintain nutrition or hydration results in weight loss or compromised health
- if there are problems with pulmonary health
3
Q
Explain FEESS and FEEST
A
- FEESS = flexible endoscopic evaluation of swallowing safety
- FEEST = flexible endoscopic evaluation with sensory testing:
- assess laryngeal sensation
- endoscopic assessment of swallowing
4
Q
Explain why the quality of the endoscopic examination depends on the quality of the instrument
A
- new technologies: chip in the tip = camera chip in the scope’s tip:
- very close to structures to visualize
- superb image quality
- quite expensive, not available in every setting
- older scope: camera at the scope’s eyepiece
- further away from structures
- light source is limited
5
Q
Explain the bolus materials in the FEES ‘kit’
A
- range of consistencies and textures (bolus types)
- range of bolus volumes
- multiple options for introducing the foods and liquids (spoon, cup, straw)
6
Q
With FEES, how do we offer more comfort and less pain to the patient. (Dis)advantage(s)?
A
- Use of topical anestetic agent:
- in one nasal passage (most open)
- gel form applied to the tip of the scope
- spray form
=> disadvantage: interference with sensation??
- lubricating gel on the scope
- antifogging agent
7
Q
Why is the positioning of the scope important (FEES)?
A
- particular question about velar function or velopharyngeal closure -> scope between inferior and middle turbinates => simultaneous visualization of the velum and lateral and posterior pharyngeal walls
- particular question about the oropharyngeal structures -> scope in the oropharynx at or just below where soft palate would be at rest during quiet nose breathing
- particular question about laryngeal structures -> scope lower, at the epiglottis, with the full length of the true vocal folds visible
8
Q
Which indications demand endoscopy instead of videofluoroscopy, due to the unique type of information provided by FEES?
A
- concerns about:
- alterations in nasopharyngeal, oropharyngeal or laryngeal anatomy (+ superficial tissue health): larynx and true vocal folds are better evaluated with endoscopy!
- sensory integrity of pharyngeal/laryngeal structures
- patient’s ability to initiate and maintain airway protection
- high risk of aspiration (assess without food or liquid!)
- fatigue by repeated swallows
- symmetry of pharyngeal constriction (simultanous contribution of tongue and pharynx constriction)
- need for ‘online’ visual feedback
- repeatable (no radiation)
- if there the patient can not be transported
- if information is needed quickly (radiographic exam needs to be scheduled)
9
Q
Compare FEES with DSS
A
see Comparison FEES - DSS
10
Q
What do the specific FEES tasks depend on?
A
On the individual patient:
- how much is he able to tolerate without fatigue?
- based on previous findings
11
Q
So with FEES we evaluate the integrity of the valves and chambers. Explain.
A
- Chambers: expand to accomodate bolus material -> compress to propel bolus and clear chamber from bolus material
—–> impairment leads to impaired bolus propulsion + clearing
- Valves: permit or prevent bolus flow from one chamber to the next
—–> impairment leads to early loss of the bolus or inappropriate entrance/reflux or ineffective bolus transmission
12
Q
Which tasks during FEES may be performed to assess the velopharyngeal valve?
A
- produce 1) sustained vowel 2) sustained /s/ 3) sentence with no nasal sounds
- > observe elevation of the velum and constriction
of the lateral and posterior pharyngeall wall
- > symmetry?
- > contributions of each structure?
- observe closure during dry swallow (different from closure for speech)
- swallow small liquid bolus (1-3 ml) -> any leakage?
13
Q
Which tasks during FEES may be performed to assess the pharyngeal chamber and valve?
A
- produce ‘ahhhh’ (produce pharyngeal frication) -> observe contact between tongue base and posterior pharynx
- examine piriform sinuses, valleculae, pharyngeall walls, base of tongue and postcricoid area for pooled secretions -> if so (but it shouldn’t), touch lightly the tissue with the scope tip:
- not cleared after swallowing: motor function impaired
- cleared well after swallowing: poor sensation = sensory function impaired
- elevate vocal pitch on “ee” -> observe pharyngeal constriction (should constrict during this task):
- presence or absence of constriction?
- symmetry?
- hold nose -> piriform sinuses should open maximal
- turn head -> piriform sinuses should close at the side the head is turned to (symmetry?)
14
Q
What exactly do we observe when assessing
- the velopharyngeal valve with FEES?
- the pharyngeal chamber and valve with FEES?
- the laryngeal chamber and valve with FEES?
A
- velopharyngeal valve: assess the valving function of the velum and lateral/posterior pharyngeal walls
- pharyngeal chamber/valve: the patient’s potential for effecting appropriate pharyngeal dynamics -> because during swallowing, sequential changes in size and shape of the pharynx (constriction) help to propel the bolus from mouth to esophagus
- laryngeal chamber/valves: assess the ability of the larynx to close and to elevate, and to respond to bolus materials that may come in contact with its structures
15
Q
Which tasks during FEES may be performed to assess the laryngeal chamber and valve?
A
- sustain vowel /ee/ or a nasal sound /mmm/ => elevation of the larynx so you can have a good look at the laryngeal structures -> observe
- mobility of the true vocal folds
- completeness of the closure
- time in adducted position
- voice quality (weak? breathy?)
—> may be indicative of vocal fold dysfunction and compromised ability to protect the airway
- low pitch to high pitch -> observe change in length of vocal folds and elevation of laryngeal structures
- repeated series of brief /i/ and inspiration -> observe any asymmetry in abduction and adduction of the true vocal folds (could indicate paralysis or paresis of 1 fold)
- hold breath -> observe degree of adduction of true folds, constriction of false folds and approximation of arytenoids
- effectiveness of true fold adduction for throat clearing and cough
