ORIGINAL ARTICLE

The value of bed

Hatem Ezzeldin Hassan

a Otorhinolaryngology Department,b King Fahd Hospital, Jeddah, Saudc ENT Department, King Abdullah Md Faculty of Medicine, Assiut Unive

Received 20 April 2014; accepted 2

Available online 14 August 2014

Dysphagia;

Fiberoptic endoscope

the value of bedside tests in comparison to the results of FEES among our population.

Objective: To assess the value of bedside tests in comparison with FEES.

Aspiration correlates were assessed using bedside tests (water swallow test, pulse oximetry and

chocking/cough results in sensitivity of 86.5% and specicity of 75.2%.

Conclusion: Bedside tests are highly sensitive and specic for the detection of dysphagia.

2014 Hosting by Elsevier B.V. on behalf of Egyptian Society of Ear, Nose, Throat and Allied Sciences.

1. Introduction

Dysphagia is a symptom that refers to pain, difculty or dis-

comfort during the progression of the bolus from the mouthto the stomach. From an anatomical standpoint dysphagiamay result from oropharyngeal or esophageal dysfunction

and from a pathophysiological standpoint from structure-related or functional causes.1

* Corresponding author at: King Fahd Hospital, P.O. Box: 8488,

Jeddah-21196, Saudi Arabia. Mobile: +966 594183458; fax: +966

126652263.

E-mail address: hezzm268@yahoo.com (H.E. Hassan).

Peer review under responsibility of Egyptian Society of Ear, Nose,

Throat and Allied Sciences.

Egyptian Journal of Ear, Nose, Throat and Allied Sciences (2014) 15, 197203

HO ST E D BYEgyptian Society of Ear, Nos

Egyptian Journal of Ear,Scien

www.ejenhttp://dx.doi.org/10.1016/j.ejenta.2014.07.007

2090-0740 2014 Hosting by Elsevier B.V. on behalf of Egyptian Society of Ear, Nose, Throat and Allied Sciences.Combination of chocking/cough and change of voice as parameters of aspiration compared with

FEES showed high sensitivity and specicity.gag reex). FEES was performed to most of the patients to detect sensitivity and specicity in

comparison with bedside tests.

Results: Dysphagia was recorded in 56% of the patients. Bedside tests showed 73% sensitivity

and 68% specicity when correlated with FEES. Moreover combination of voice change andPatients and methods: 74 patients were presented to phoniatrics clinic for the assessment of

swallowing difculties during the period from May 2011 to August 2013. They were 47 males

and 27 females with a mean age of 52 years and range between 20 and 91 years.KEYWORDS

Bedside tests;

Oropharyngeal; imside tests in dysphagia evaluation

a,b,*, Ali Ibrahim Aboloyoun c,d

Sohag University, Egypt

i Arabiaedical City, Holy Makkah, Saudi Arabia

rsity, Egypt

1 July 2014

Abstract Bedside tests are important predictor of aspiration during swallowing and they are the

most widely used tests. Fiberoptic Endoscopic Evaluation of Swallowing (FEES) is one of the

portant tests for dysphagia evaluation. The aim of this work is to answer the question, what ise, Throat and Allied Sciences

Nose, Throat and Alliedces

tas.com

Oropharyngeal dysphagia can be caused by a variety of dis-eases such as stroke, postirradiation, reux and cricopharyn-geal muscle dysfunction. Dysphagia has signicant impacts

cough (silent aspiration), and 45%, oropharyngeal residue.

2.1. General examination

The patients were observed for the degree of consciousness,

198 H.E. Hassan, A.I. AboloyounFiberoptic Endoscopic Evaluation of Swallowing (FEES)is one of the important tests for evaluation of the anatomyof the pharynx and larynx and assessment of the process ofswallowing.3,4 FEES was developed and popularized by

Langmore23 and modied by Flaksman et al.24 It has provedto be a signicant tool in the assessment of the pharyngealstage of the swallow process. Numerous studies2528 have

highlighted its utility in visualization of the larynx and diag-nosis of aspiration. They reported that FEES became theprocedure of choice as it allows direct visualization of these

structures without the risk of radiation. Also they stated thatFEES is an easy, efcient and reliable method to evaluate theswallowing status in stroke patients, moreover, in combina-

tion with good bedside clinical examination and swallowexercises, it can be a good tool in assessing patients withpost-stroke dysphagia. Post-stroke rehabilitation and preven-tion of aspiration pneumonia can be effectively done with the

help of FEES.

1.1. Aim of the work

The aim of this work was to assess the value of various types ofbedside tests in comparison with FEES to evaluate aspiration.This may help in easy, rapid and accurate diagnosis of aspira-

tion during swallowing, hence better management.

2. Patients and methods

74 patients with different diagnostic entities were presented tothe phoniatric clinic King Fahd Hospital- Jeddah (TertiaryCare Centre) between May 2011 and June 2013 for the assess-

ment of swallowing troubles as presence or absence of aspira-tion and possibility of weaning from nasogastric tune (NGT)or percutaneous endoscopic gastrostomy (PEG). They were47 men and 27 women. The patients were evaluated according

to the following procedures.on patients life quality, life expectancy, and economic burden.Early detection of swallowing difculty as aspiration ofingested materials is important because of the hazards of chest

infection, malnutrition and airway obstruction. The evaluationof swallowing disorders and their rehabilitative modalities isan important topic. The benet to the patient, in terms of

improvement in quality of life, cannot be underestimated.Many studies25 have attempted to assess the utility andefcacy of various methods used to tackle the problem withvarying degrees of sensitivity and specicity.

Bedside tests might be used to identify patients with oro-pharyngeal dysphagia and to identify those who are at riskof aspiration. During bedside testing, the clinical indicators

of dysphagia included abnormal volitional cough, abnormalgag reex, dysphonia, dysarthria, cough after swallow, andvoice change after swallow.6

Teismann et al.5 stated that, up to 30% of older patientswith dysphagia present with aspiration, half of them withoutcooperation, verbal, oral apraxia and articulation. Patientswho cannot obey verbal orders, markedly impaired degree of

consciousness, with receptive aphasia or with signicantapraxia were excluded from the study.

32 patients were initially on NGT, 11 patients were on PEGtubes, 13 patients were on both NGT and tracheostomy tubes

and 18 patients were on oral feeding.

2.2. Clinical systematic examination

Bedside evaluation of swallowing was done which includedinitial assessment of cognitive status, gag reex, voluntarycough and throat clearing. If the above steps were possible,

assessment of saliva was done.Saliva assessment: According to Corinna et al.7

Spontaneous swallowing of saliva and swallowing fre-

quency were assessed. If it is proved impossible to controland swallow saliva, the examination was terminated.

Water swallow test: According to.810

The patient was examined in the sitting position or in 45

degrees. Some patients were examined in the recumbent posi-tion because of difcult positioning. The patient was given5 ml of water, and when the patient could tolerate that amount

of water, he/she was given 20 ml followed by 50 ml of water(thin uid) and assessed for cough/chocking during or afterswallowing, wet or weak cough after swallowing. Also the

patient was asked to produce sustained vowel /a/ before andafter swallowing of water and voice change after swallowingwas observed and recorded.

2.3. Pulse oximetry

According to Zaidi et al.11 pulse oximetry was done for thepatients before starting FEES and for 5 min after the test

and results were recorded. 3% or more reduction in oxygensaturation was considered positive test.

2.4. Fiberoptic Endoscopic Evaluation of Swallowing (FEES)

All patients who passed saliva test were tested by FEES.Digital Swallowing Workstation by KayPENTAX was used.

The patient was seated for FEES in the sitting position(whenever possible) However, in some cases, this was notpossible, instead, a semi-upright position on the bed wasadopted. The exible beroptic laryngoscope was inserted

transnasally into the pharynx. It provided detailed informa-tion about the anatomy of the nose, pharynx and larynx.Sensation could be tested by touching the tip of the endo-

scope to various areas of the larynx and reex adductionof the vocal folds or reex cough and chocking wereobserved. Different food consistencies as uids (water),

semisolids (thick juice/yoghurt) and solids (piece of biscuitsor bread), mixed with blue dye, were used to evaluate swal-lowing. The salient ndings noted were residue, penetration

and aspiration into the larynx.

2.5. Ethical standards

The authors assert that all procedures contributing to thiswork comply with the ethical standards of the relevantnational and institutional guidelines on human experimenta-

tion and with the Helsinki Declaration of 1975, as revised in2008.

2.6. Statistical analysis

Statistical package for social Sciences version 11 (SPSS, INC,Chicago, IL) under windows was used for data entry and data

The value of bedside tests in dysphagia evaluation 199analysis. Descriptive statistics were done for continuous

variables by mean, standard deviation (SD) and range.The individual bedside tests and combinations of these tests

were subjected to statistical analysis. To examine, the sensitiv-

ity, specicity and positive and negative predictive values(PPV, NPV) were determined. Sensitivity and specicity werecalculated using a 2 2 contingency table. The calculationwas based on a comparison between the results of the bedsidetests and FEES. A 95% condence interval was used fortesting.

3. Results

The bedside tests required an average of 15 min and FEESrequired about 10 min.

3.1. Test subjects

74 patients, 47 (63.5%) men and 27 (36.5%) women (mean

age = 46.68, range = 1891), were included in the study with17 (23%) post Road Trafc Accident (RTA) patients, 26(35%) with neurological insult patients such as CerebroVascu-

lar Accidents (CVA), cerebral hemorrhage, cerebral contusion,16 (22%) ENT patients following treatment (surgery or radio-therapy) or a result of vocal fold immobility or cancer in the

neck, tongue or larynx and other diseases in 15 (20%) patients(Fig. 1).

3.2. Bedside tests vs. FEES

To determine sensitivity, specicity and predictive values, theresults of bedside tests were compared with the resultsobtained using FEES.

Cough/chocking for all test subjects showed a sensitivity of74.29%, specicity of 70%, PPV of 69.66 and NPV of 68.7%.The sensitivity of change of voice was 80.3%, specicity was

35%

23 %

22 %

20 %

Neurological 35%

ENT 23 %

RTA 22%

Other 20 %

Figure 1 Causes of dysphagia.73.3%, PPV was 79.3 and NPV was 72.6%. The sensitivityof gag reex was 50.4%, specicity was 57.8%, PPV was60.3 and NPV was 51.7%. The sensitivity pulse oximetry was

48.3%, specicity was 55.6%, PPV was 46.7 and NPV was57.2% (Table 1, Fig. 1).

In this study aspiration was observed in 75% of patients

with decreased or absent laryngeal sensation tested by touch-ing laryngeal structures by the tip of endoscope during FEES.However 25% of the patients demonstrated that normal laryn-

geal sensations in patients showed aspiration during FEES.

3.3. Combination of the clinical tests

For the test population as a whole, combining the cough/chocking (during or after swallowing) and change of voice(after swallowing) parameters by addition achieved a sensitiv-ity of 86.5%, specicity of 75.2%, PPV of 80.2 and NPV of

74.9 (Fig. 2, Table 1).

4. Discussion

Diagnosing and treating swallowing disorders represent amajor challenge in everyday clinical practice. The most com-mon diagnostic procedures for oropharyngeal dysphagia are

beroptic endoscopic swallowing examination (FEES) andvideouoroscopy. Because these procedures are technicallydemanding, the tendency in everyday practice is to try to

obtain meaningful information on a patients swallowing abil-ity by using standardized simple clinical tests. This is primarilyachieved using swallow tests with water, modied in a varietyof ways.6,12,13 Moreover, Okubo et al.14 mentioned that the

most frequently used swallow test is the bedside swallowassessment, which covers a number of techniques used in award environment (see Table 2, Fig. 3).

4.1. Characters of the patients

In this study, the most common causes of oropharyngeal dys-

phagia were neurological insult (35%) followed by RTA andENT patients (22%) following treatment (surgery or radio-therapy) as a result of vocal fold immobility or cancer in the

neck, tongue or larynx. Other causes (20%) are also detectedsuch as sepsis and debilitating diseases.

In a study done by Hoy et al.15 they mentioned that themean age of the entire cohort was 62 13.5 years, and 58%

of the cohort was males. The most common identied causesof dysphagia were laryngo-pharyngeal reux disease (LPRD)(27%), postirradiation dysphagia (14%), and cricopharyngeal

muscle dysfunction (11%). in 13% of cases. Also3,16

mentioned that, the prevalence of oropharyngeal functionaldysphagia is very high, it affects more than 30% of patients

who have had a cerebrovascular accident; 5282% of patientswith Parkinsons disease; 84% of patients with Alzheimersdisease, and up to 40% adults aged more than 65 years.

The difference between the causes of oropharyngeal dys-phagia in the previous study and the current study is thatthe aim of our study was to detect penetration of the larynxand aspiration during testing with different food consistencies

such as liquids, semisolids and solids, however in the previousstudy the most common cause was laryngo-pharyngeal reuxdisease (LPRD) as the term dysphagia is a wide term and it

70%, PPV 69.66% and NPV 68.7%) and change of voice

Table 1 Comparison of bedside tests with FEES%.

Bedside test Sensitivity% Specicity% PPV% NPV%

Cough/chocking 74.29 70.00 69.66 68.7

Change of voice 80.3 73.3 79.3 72.6

Gag reex 50.4 57.8 60.3 51.7

Pulse oximetry 48.3 55.6 46.7 57.2

Cough/chocking + change of voice 86.5 75.2 80.2 74.9

Figure 3 Combination of 2 bedside tests with FEES%.

200 H.E. Hassan, A.I. Aboloyounmay include discomfort, pain, difculty during swallowing orpenetration or aspiration of food particles and saliva.

4.2. Bedside tests

PPV, positive predictive value; NPV, negative predictive value.

Figure 2 Comparison of bedside tests with FEES%.The primarily used bedside test for swallowing evaluation is

water swallow test (WST) described by Gordon et al.17 thetests used in everyday clinical practice are various modiedversions of the WST. The literature describes various versions

of the WST with varying results. DePippo et al.18 described theBurke Dysphagia Screening Test (BDST), the patient wasgiven 3-oz water and the results were reported. Smithard et al.19

asked the patient to drink water from a glass without interrup-tion. Coughing during or after completion or the presence of apost swallow wet-hoarse voice quality, or swallow speed of lessthan 10 ml/is scored as abnormal. Nathadwarawala et al. and

Westergren20,21 described the standardized bedside swallowassessment (SBSA), patients are asked to drink 50 ml of waterand the results were reported.

In the current study, four clinical parameters were observedduring the water swallow test compared with FEES namely,chocking/cough, change of voice, gag reex and pulse oxime-

try. These parameters represent aspiration of water throughthe vocal folds. Two parameters showed high sensitivity andspecicity, chocking/cough (sensitivity 74.29%, specicity

Table 2 Combination of 2 bedside tests with FEES%.

Sensitivity%

Cough/chocking + change of voice 86.5

PPV, positive predictive value; NPV, negative predictive value.(sensitivity 80.3%, specicity 73.3%, PPV 79.3% and NPV72.6%).

These clinical bedside methods can detect aspiration,although with differing diagnostic accuracies. Burkes 3-ozwater swallow test identied 80% of patients aspirating during

subsequent VFS examination (sensitivity 76%, specicity59%).20 The SBSA showed a variable sensitivity (4768%)and specicity (6786%) in detecting aspiration when used

by speech swallow therapists or doctors.19,22

DePippo et al.18 examined 115 stroke patients and addedthe clinical variables swallow capacity and volume per

swallow. With these two clinical variables taken into consider-ation, they found a sensitivity of 97% and a specicity of 69%.Excluding these two clinical variables, sensitivity fell to 73%and specicity to 67%. Daniels et al.6 studied 59 stroke

patients using a 70-ml WST. Patients drank two 5, 10 and20 ml volumes of water. Sensitivity was 92.3% and specicitywas 66.7%.

In our study, WST achieved different levels of sensitivityand specicity described in the literatures. The difference in

Specicity% PPV% NPV%

75.2 80.2 74.9

results between our study and Daniels et al.6 study is that they of healthy younger adults and 44% of healthy older adults

The value of bedside tests in dysphagia evaluation 201examined patients with neurological insults only however weexamined neurological and non-neurological patients.

Several authors18,19,22 mentioned that the validity for mostswallow tests has been determined by comparison with FEESand detection of aspiration by bedside testing has been vari-

able with sensitivities between 42% and 92% and specicitiesbetween 59% and 91%. Positive predictive values for bedsideswallow testing range from 50% to 75%; negative predictive

values range from 70% to 90%.In the current study, bedside testing (cough/chocking and

change of voice) was comparable with previously mentionedstudies.18,19,22 However other parameters (gag reex and

oxygen saturation) showed low sensitivity and specicity. Dif-ferences in results may be explained by modications of exam-ination procedures and the variables selected. In the current

study, four variables of WST were examined (chocking/cough,change of voice, gag reex and pulse oximetry) individuallyand sensitivity and specicity were calculated for each param-

eter. However in the previous studies the authors calculatedsensitivity and specicity for all formerly mentioned parame-ters as one unit.

4.3. Fiberoptic Endoscopic Evaluation of Swallowing (FEES)

In the current study FEES was sufcient to detect penetrationor aspiration of swallowed materials in the larynx. All the

patients examined by FEES tolerated the procedure. None ofour patients had any signicant complications during or afterthe procedure. Penetration of laryngeal inlet could be inferred

by the presence of colored material after swallowing. Thesematerials touch the superior surface of the vocal folds butnot pass below the vocal folds. Aspiration means that the

bolus passed the glottis to a level below the vocal folds. Theoccurrence of aspiration in most patients (75%) who have lostlaryngeal sensation reects the importance of intact laryngeal

sensory inputs in the swallowing process.FESS is a valid, effective, low cost technique that assesses

swallowing in a bedside examination. FEES can give informa-tion on anatomy, the swallow process, pharyngeal motility,

and sensory decits.29,30 Although aspiration cannot be seendirectly, it can be inferred from residue left after swallowingor ejection of material out of the trachea after coughing.31

4.4. Gag reex

Absent gag reex was valuable as stated by some authors22,3133

to assess aspiration, but it was of less signicance to predictaspiration as considered by other authors.19,3436

In the current study some patients with aspiration detected

by FEES had absent gag reex (40%), moreover, 50% ofpatients with disturbed laryngeal sensation had absent gagreex. This might suggest clinical association betweendisturbed gag reex when the laryngeal sensation is affected

however there is no strong correlation between the coincidenceof the two conditions.

Gag reex when compared with FEES showed less sensitiv-

ity and specicity than other parameters tested. Gag reexresulted in sensitivity of 50.4%, specicity of 57.8%, PPV of60.3% and NPV of 51.7%. These results coincided with those

obtained by Davies et al.37 who demonstrated that up to 30%may have unilateral or bilateral absent gag reexes normally.They added that sensation was also abnormal in 40% of those

not aspirating, and normal swallowing can occur with com-plete local anesthesia.

Lim et al.38 examined post-stroke patients and performed a

sensorimotor examination, they observed swallowing andrelated movements, and found a high incidence of impairedpharyngeal gag and dysphonia in patients exhibiting laryngeal

penetration. However, in the current study the patients werestroke patients and non-stroke patients this explains the diver-sity of results in both studies.

4.5. Pulse oximetry

Pulse oximetry provides a noninvasive method of bedsideswallow testing. Researchers11,39,40 found association between

oxygen desaturation secondary to aspiration during oral feed-ing in neurologically disabled individuals.

In this study, most of the patients underwent pulse oxime-

try during FEES and the results were recorded for 5 min afterswallowing. The results showed low sensitivity and specicityin comparison with FEES and with other parameters as chock-

ing and dysphonia. (Sensitivity 48.3%, specicity 55.6%, PPV46.7% and NPV 57.2%). This may be explained by that pulseoximetry in stroke patients might be affected by other factorsas central causes of hypoxemia rather than swallowing.

However swallowing difculties in our patients were causedby different etiologies (stroke, RTA, ENT causes and others).

Some studies40,41 have found no clear relationship between

desaturation and aspiration, but Smith et al.42 study demon-strated persistently lower saturations in aspirators than nona-spirators. Other researchers have found that desaturation of

3% from baseline predicted aspiration on VF.42,43 also foundcorrelation between aspiration and oxygen desaturation, theyreported sensitivity values ranged from 73% to 87%, and spec-

icity values ranged from 39% to 87%. Another study done byDaniels et al.16 compared oxygen desaturation predictionswith aspiration detected by beroptic endoscopy whichobtained better specicities and predictive values, they added

that aspiration causes reex bronchoconstriction and thereforeventilationperfusion imbalance, leading to hypoxia anddesaturation.

Lim et al.38 have suggested that abnormal swallowing leadsto poor breathing and ventilationperfusion mismatchingbecause of reduced inspiratory volumes.

4.6. Combination of tests

In this study combination of certain parameters led to high

sensitivity and specicity in comparison with FEES. We foundthat combination of chocking/cough and change of voice asparameters (as indicators of aspiration) compared with FEESshowed high sensitivity, specicity, PPV and NPV (sensitivity

86.5%, specicity 75.2%, PPV 80.2% and NPV 74.9%).Some studies done by19,31,44 have postulated that a sum of

more than one parameter (as indicators of aspiration) gives

more accuracy to ass patients with aspiration and penetrationduring swallowing. Corinna et al.7 have mentioned thatcombining water tests with oxygen desaturation led to higher

sensitivities between 73% and 98% and specicities between

63% and 76%. Moreover, he added that combination of these 12. Ramsey DJ, Smithard DG, Kalra L. Early assessments of

202 H.E. Hassan, A.I. Aboloyountests is sufcient to detect aspiration in most of their patients.Also he recommended the use of water test combined with

pulse oximetry using coughing, choking and voice alterationas endpoints as screening method to detect dysphagia inpatients with neurological disorders.

5. Conclusion

Bedside tests can be considered as an important, easy, sen-sitive and specic for the detection of aspiration.

Combination of chocking/cough and change of voice asparameters of aspiration compared with FEES showed highsensitivity and specicity.

Further research is needed to establish the most effectivecombination of bedside tests to detect silent aspiration.

Financial support

This research received no specic grant from any funding

agency, commercial or not-for-prot sectors.

Conict of Interest

None.

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The value of bedside tests in dysphagia evaluation 203

The value of bedside tests in dysphagia evaluationIntroductionAim of the work

Patients and methodsGeneral examinationClinical systematic examinationPulse oximetryFiberoptic Endoscopic Evaluation of Swallowing (FEES)Ethical standardsStatistical analysis

ResultsTest subjectsBedside tests vs. FEESCombination of the clinical tests

DiscussionCharacters of the patientsBedside testsFiberoptic Endoscopic Evaluation of Swallowing (FEES)Gag reflexPulse oximetryCombination of tests

ConclusionFinancial supportConflict of InterestReferences