Instrumental Evaluation

Fluoroscopic Evaluation

Fluoroscopy– Dynamic x-ray– Cinefluoroscopy

Film Frame by frame analysis

– Videofluoroscopy Videotape Immediate playback capabilities Audio recording capabilities

Purpose of Videofluoroscopy

Assess overall swallow function– Oral preparation and transit– Pharyngeal phase– Esophageal phase

Modified Barium Swallow– Determine the presence of aspiration

Why is the pt aspirating Alleviation symptoms

– Consistency– postural

What is fluoroscopy?

Fluoroscopy is an imaging technique that takes live x-ray images of the body by passing a continuous x-ray beam through the structure being studied. The x-ray images appear on a video screen in real time, which allows the radiologist to see how well the structure is functioning.

Type and Amount of Material

Consistencies– Thin/thick liquids– Purees– Cookie/cracker– Food trays

Contrast medium Try all consistencies unless contraindicated Small/large presentations

Patient Positioning

Can be the most-time consuming portion of the evaluation

Standing or seated– As close to 90o as possible– Lateral plane

Image– Oral cavity– Pharynx– Bifurcation of the trachea/esophagus– Superior esophagus

Fluoroscopy Equipment

Measures/observations

Oral transit time Pharyngeal transit time Pharyngeal reflex triggering Stasis/residual material

– Nasal regurgitation– Vallecular stasis– Pyriform sinus

Penetration Aspiration

– Before– During – After the swallow

Anterior-Posterior View

Asymmetries– Collection of material

Unilateral Bilateral Postural changes

– Vocal fold function Gross assessment

Screening of esophageal function

Procedure

Liquid first– Unless otherwise indicated via bedside evaluation or patient

report– Hold in the oral cavity until directed to swallow– Aspiration

Before During After

– Purees– Cookie/cracker

Swallow when masticated

Extras

Therapeutic techniques– Chin press/tuck– Head turns– Head tilts– Mendelsohn maneuver– Liquid modification– Solid-liquid manipulation

Clear pharyngeal stasis

– Supraglottic swallow

Fiberoptic Endoscopic Evaluation of the Swallow (FEES)

Equipment requirements:– Flexible/Fiberoptic endoscope– Camera– Light source– SVHS recorder– Monitor– microphone

FEES Procedures

Flexible scope is inserted transnasally Moved until it is situated above the level of the

valleculae Various bolus consistencies and volumes are

administered Events prior to and subsequent to the swallow

are observed Colored water

– milk

Pros of the FEES

No radiation Can do extensive testing

– Numerous bolus consistencies– Numerous volumes– Pre-post compensatory techniques

Treatment strategies can be studied Feedback Portability Cost effectiveness of procedure

Cons of FEES

Oral phase cannot be viewed Obscures events during the swallow Cost of equipment Cost of training Pt cooperation/tolerance for nasal endoscopy

– Movement disorders contraindicated

Ultrasound

High-frequency sound waves are emitted, reflected and received by an ultrasound transducer and assembled into a video image

Tissues are differentiated by their ability to reflect sound waves

Pros/Cons of Ultrasound

Non-invasive Risk free Can be used for extensive examination with

numerous administrations Easy to use with all age groups Equipment/set-up costs Training Limited to oral cavity/oropharynx

Electromyography

Electromyography (EMG) is the study of muscle activity– Electrical activity is amplified and monitored

Surface electrodes Intramuscular electrodes

– Auditory signal can be monitored

Pros/Cons of EMG

Pros:– Can be non-invasive

Surface electrodes– Indication of muscle activity– Can be used for biofeedback

Cons:– Difficult to compare from session to session– Equipment set-up costs– Training– Interpretation of EMG output– Difficult to pinpoint muscle groups

Cervical Auscultation

Cervical auscultation is relatively new low-tech technique to facilitate accurate bed-side evaluation of the swallow.

Monitors the sounds of the swallow– Stethoscope– Microphone– accelerometer

CA Procedures

Listening/recording device is placed over the thyroid lamina

Listen to air-exchange, respiration before swallow– Turbulence in the flow of air– Evidence of material in the vestibule

Can material be cleared

CA Procedures

Listen during swallow– Normal sequence

Inhalation Apnea Two clumps-clicks exhalation

Abnormal sounds

Changes in respiratory rate No clearing exhalation Delayed clearing exhalation A muffling/melding of the distinct clumps of sound No apnea Prolonged apnea Prolonged swallow sounds Turbulence in the air-exchange

– Stridor bubbling squeaks– Wheeze gurglingcrackling

Upper and Lower Airways

Upper airway– Mechanisms that protect the upper airway

Normal sequence/structures Three valves

– Epiglottic inversion, sealing the laryngeal vestibule– Ventricular fold adduction– True fold adduction

Lower airway– Mechanisms that protect the lower airway

Cough Ciliary action Alveolar macrophages

Lung sounds

Apnea-total cessation of breathing Dyspnea- difficult, labored and/or painful breathing Cheyne stokes- cycles of breathing that increase then

decrease in rate and depth with periods of apnea between cycles.

Rales- discrete crackling sounds typically heard on inspiration when air collides with secretions

– Indicates fluid in lung fields Rhonchi- coarse sounds heard throughout the respiratory cycle

– Exhalation Wheezing- indicates narrowing of the bronchioles, possibly

bronchiospasm