Written Exam Flashcards
Advantages of FEES
- Unlimited time
- Can repeat as often as needed
- Portable exam; more accessible to patients
- Don’t need to put patient at risk for aspirating food/liquid
- Direct view; easier to localize spillage, residue
- Better understanding of some abnormal patterns
Disadvantages of FEES
- More limited view
- Technically more difficult to learn
- Some patients find it uncomfortable
- Cannot adequately assess oral phase of swallow
When is FEES exam indicated? (practical/easier to do)
- Patient is bedridden; weak
- Patient has contractures; in pain
- Patient is a quadriplegic, has neck halo
- Patient on cardiac monitors; in ICU
- Patient is on a ventilator
- Need exam that day
- Need repeat exam
- Concern about excess radiation exposure
- Corns about cost of fluoroscopy
Clinical findings better revealed endoscopically
- Incomplete TVD adduction, immobile vocal cord; reduced mobility of arytenoids
- Excess secretions; aspiration of secretions
- Residue building up over several swallows
- Impaired ability to adduct TVF
Advantages of fluoroscopy
- more comprehensive view
- easier to learn; administer
- better understanding of some abnormal patterns
Disadvantages of fluoroscopy
- radiation exposure
- time-limited exam
- inaccessible to some/many patients
- frightening, fatiguing, uncomfortable for some patients
- uses non-physiologic medium
- need to present food/liquid to assess
- more difficult to localize material; identify structures
- more costly
Clinical findings better revealed with fluoroscopy
- impaired tongue control and manipulation of the bolus
- impaired tongue force for bolus thrust
- impaired laryngeal elevation
- reduced cricopharyngeal opening
- reduced airway closure at level of arytenoid to epiglottal contact
- reduced esophageal motility
- aspiration during the swallow
Ability to assess therapeutic maneuvers: head turn/chin tuck
Fluoroscopy = good
FEES = excellent
Ability to assess therapeutic maneuvers: other body position-side lying
Fluoroscopy = fair
FEES = excellent
Ability to assess therapeutic maneuvers: alteration in bolus size, consistency
Fluoroscopy = excellent
FEES = excellent
Ability to assess therapeutic maneuvers: alteration in food delivery
Fluoroscopy = good
FEES = good
Ability to assess therapeutic maneuvers: effortful swallow
Fluoroscopy = excellent
FEES = fair
Ability to assess therapeutic maneuvers: supraglottic swallow
Fluoroscopy = good
FEES = excellent
Ability to assess therapeutic maneuvers: Mendelsohn maneuver
Fluoroscopy = excellent
FEES = good
Ability to assess therapeutic maneuvers: time to try all of these
Fluoroscopy = poor
FEES = excellent
Typical diameter of flexible scope
3-4 mm
Flexible endoscope allows for as much as a __ degree field of view
90
Distance distortion
if you get too close to a structure you are going to lose resolution, if you move further away you will get a crisper image but you wont see every detail
Radial distortion
because of the parallax effect – the center of the image will be the most accurate or symmetrical, and as you move away the angle of the scope the angle may make it look a little distorted
Transnasal placement of the laryngoscope will prevent visualization of the _____ stage of the swallow
oral
Major elements affecting optimum visualization
velar elevation
base of tongue contraction
clouding if the distal lens with bolus residue or oropharyngeal secretions
The velum contributes to both the oral and ________ swallow
pharyngeal
When the distal tip of the endoscope is placed within the hypopharynx, the velum will/will not be in view
will not
Movement of the velum contributes to changes in the visualizations of events _____, _____, and ______ the swallow.
before, during, and after
Scope position to maximize observation of velar function…
- Scope position should allow for a view of the mucosa covering the vomer bone at the left or right periphery
- You should see the superior surface of velum, contact of the velum with the posterior pharyngeal wall, and. the extent of elevation of the velum
For swallowing, the lowest position of the endoscope should be just ______ the level of the tip of the epiglottis.
above
How do you clear a clouded lens?
- retract the scope
- wait for spontaneous swallow
- cue for swallow
- light movement of the scope towards the PPW and score scope
- last resort is to retract scope and clean with water
- if patient has weak swallow keep scope high
When viewing salient features you…
- Want to see anatomic movements, bolus movement, and monitor protections of the airway during the examination
- High scope position to monitor bolus travel, prevent clouding and then advance scope after. the swallow to scan for findings
- You want to see the entire endolarynx
General symptoms of VPD
- Hypernasality
- Nasal air emission
- Compensatory articulation errors
VPD etiologies
- Cleft palate/submucuous cleft
- Large pharynx/short velum
- Neuromotor
- Surgery
- Developmental
- Functional
Quality patient for procedure
- Hypernasality
- Nasal air emission
- Compensatory speech errors
- Absence of functional O-N fistula
- Unresponsive to speech therapy
- Anticipating physical management
What do I want to learn?
- Pattern of closure/attempted closure
- Type of patency
- Approximate degree of patency
- Approximate location of patency
Patterns of VP closure
- Circular - 35%
- Sagittal - 5%
- Coronal - 60%
Types of patency
- Normal speech and resonance and normal VP function
- Consistent VPD
- Task specific VPD
- Irregular VPD
- Abnormal resonance without VPD (e.g. neuromotor, large tonsils)
Degrees of patency relative to breathing
- WNL: 0-10%
- Small: 11-20%
- Moderate: 21-40%
- Large: 41-100%
Typical locations of patency
- Central
- Lateral (one or both sides)
- Transverse
Parts of a flexible endoscope
- fiberoptic cable
- housing
- Insertion tube
- Angular
- Viewing lens
- Focus ring
Advantage of flexible endoscope
- permits viewing of entire vocal tract
- Suitable for VP, voice, and or swallow Dx/Rx
- Well tolerated, usually no gagging
- Permits study of connected speech
Basic procedures of flexible endoscope
- Choose a nostril
- Choose a meatus
- 3 options (proceed, pause, withdraw)
- Position endoscope
- Obtain speech sample or swallow
SLPs do or do not make medical diagnoses
NOT
SLPs are of expertise is _________.
Physiology
SLPs are looking for function of what and what is the purpose?
Function of…
- Oral
- Velopharyngeal
- Pharyngeal
- Respiratory structures
Purpose..
- Speech
- Voice
- Swallowing
Differences between otolaryngologists and SLPs
Otolaryngologists diagnose underlying pathology (anatomy)
- Treat with interventions: Medical, Surgical
SLPs
- assess nature of dysphonia or swallow issues physiology
- treat behaviorally: exercise-based exercises, compensatory techniques, retraining
Documented dysphagia that needs retesting
- Monitor progress
- directly assess pharyngeal and laryngeal anatomy
- Limit radiation exposure
Precautions of FEES (flexible endoscopy)
- Discomfort
- Vomiting
- Epistaxis
- Mucosal perforation
Contraindications for FEES (flexible endoscopy)
- Severe agitation and/or inability to cooperate with the examination
- Severe movement disorders that interfere with safe administration
- Severe bleeding disorders and/or recent severe epistaxis
- Recent trauma to the nasal cavity or surrounding tissue and structures
- Bilateral obstruction of the nasal passages
Clinicians should have a plan regarding?
- Be trained in signs and symptoms of adverse reactions
- Know the facility’s plan for response and intervention to such reactions
- Be prepared to take appropriate actions if they occur
- Have suction equipment and/or personnel trained in the use of such equiptment
- Use a cardiac monitor for patients with significant pulmonary disease, cardiac arrhythmia, seizure disorders
ASHA code of ethics about certification
- SLPs do not require specific certification from ASHA or any other entity to perform instrumental assessments
- SLPs with appropriate training and competence in performing FEES are qualified to use this procedure independently for the purpose of assessing swallow function
- ASHA does not require the presence of a physician for an SLP to perform FEES
Principle Ethics I
Individuals shall honor their responsibility to hold paramount to the welfare of person they serve professionally or who are participants in research and scholarly activities
Principle of Ethics II
Individuals shall honor their responsibility to achieve and maintain the highest level of professional competences and performances
Principle of Ethics IV
Individuals shall uphold the dignity and autonomy of the professions, maintain the collaborative and harmonious inter professional and inter professional relationships, and accept the progression self imposed standards
Five primary purposes
- Identify the physiologic correlates of swallowing
- To document the status of anatomy and physiology correlates during swallow
- To assist in determining if treatment is indicated
- To assist in patient and family education
- Develop a treatment plan
Selecting the best tool…
- The selection of instrumentation that answers the question being posed
- The practical needs to perform an instrumental assessment when other means are available
Which test answers the question: Recently extubated patient with raspy voice?
FEES
Which test answers the question: Suspected oral processing issues
MBSS
Which test answers the question: UES dysfunction
MBSS
Which test answers the question: Patient unable to swallow their secretions
FEES, MBSS
Which test answers the question: Uncontrolled bolus loss
FEES, MBSS
Which test answers the question: Delayed initiation of swallow
FEES, MBSS
Which test answers the question: Sequence of stripping wave
MBSS
Which test answers the question: is epiglottic inverting
MBSS, FEES
Which test answers the question: pathophysiology leading to impaired epiglottic inversion
MBSS
What can be assessed on FEES?
- Bolus hold
- Laryngeal elevaation
- Hyoid excursion
- Laryngeal vestibule closure
- Pharyngeal stripping wave
- Pharyngeal contraction
- Tongue base retraction
- Secretion
- Edma
- Erythema
- Tissue differences
- Structures anomalies
What can be assessed on MBSS?
- Lip closure
- Bolus
- Bolus transport
- Swallow initiation
- Soft palate elevation
- Laryngeal elevation
- Hyoid excursion
- Laryngeal vestibule closure
- Pharyngeal stripping wave
- Pharyngeal contraction
- UES opening
- Tongue base retraction
