P139 - Flexible endoscopic evaluation of swallowing with contrasted oral feeding.Manoel de Nobrega, MD, PhD; Ana Maria Furkim, Phonoaudiologist, PhD; Zelita Caldeira Ferreira Guedes, Phonoaudiologist.

Disciplina de Otorrinolaringologia Pediátrica - Universidade Federal de São Paulo/ Escola Paulista de Medicina - UNIFESP/EPM.Rua dos Otonis, 674 – Vila Clementino - São Paulo.

CEP 04025-001 - Brasiltel/fax: (0XX11) 5576.4395 / 5539.7723

email: mnobrega@terra.com.br

Abstract

Introduction: dysphagia is characterized by any alteration in the course of the alimentary bolus and it can clinically manifest itself in different forms, such as, for instance, difficulty to initiate swallowing, nasal regurgitation, coughing and/or choking during meals, among other symptoms. Objective: to present an alternative exam for the identification and rehabilitation of dysphagia in newborns and children through flexible endoscopic evaluation, combined with contrasted oral feeding. Study Design: Prospective, consecutive. urban, tertiary. Methods: this study evaluated 50 children under 10 years of age, 25 girls and 25 boys who sought the pediatric otolaryngology outpatient clinic for evaluation of swallowing. Results: the stasis of the liquid and/or pasty foodstuff was the most common followed by laryngeal penetration and aspiration. Conclusions: The flexible endoscopic evaluation of swallowing combined with contrasted oral feeding is an exam that provides reliable information about the physiology of swallowing of each patient, permitting the visualization of possible episodes of laryngeal penetration and/or aspiration.

Keywords: dysphagia; flexible endoscopic evaluation of swallowing; newborn; children.

Table 1Table 1 shows the children distributed according to sex. They were appraised 25 children of the masculine sex and 25 of the feminine sex.

Table 2 Table 2 shows the children distributed according to age groups. 24 smaller children 2 years old were examined, 16 children of 2 to 4 years and 10 children above 4 years.

Table 3Table 3 shows the most significant findings of the exam. The stasis of liquids was the most common discovery proceeded by the laryngeal penetration and laryngeal aspiration.

Figure 1Figure shows the arrival of liquid to the glottic region.

Figure 2In Figure 2 the presence of pasty foodstuff can be observed.

Figure 3Figure 3 shows the laryngeal penetration and aspiration.

Results

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3. Langmore SE. Evaluation of oropharyngeal dysphagia: which diagnostic tool is superior? Curr OpinOtolaryngol Head Neck Surg. 2003 Dec; 11(6):485-9. Review.

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Bibliography

To perform FEES combined with contrasted oral feeding, the 3.2mm Machida fiberopticendoscope was used, coupled to a Toshiba micro-camera, with a halogen Ferrari light source and a Sony video monitor to record the exam. It is performed without sedation or topical and/or systemic anesthesia; as such procedures could interfere in obtaining functional responses, as well as with the performance of the exam itself. An otolaryngologist and a specialist in phonology and audiology were in attendance at the performance of the exam. The physician introduced the device into the nasal vault that provides best access, advancing towards the larynx and both professionals interpreted the data obtained from the evaluation of swallowing. To obtain reliable results from the exam, some procedures must be adopted. The exam requires approximately from ten to twenty minutes to be performed and the device must to be introduced with certain precautions. Thus, one can evaluate laryngeal and pharyngeal functioning, the administration of the bolus and the adequate implementation of compensatory techniques, which help in the process of swallowing. During the performance of the exam, the device is located between the soft palate and the base of the tongue, permitting the visualization of the larynx. Thus, the possible occurrence of early escape of the alimentary bolus and/or delay of the swallowing reflex can be observed.For the evaluation of swallowing, two food consistencies are offered: one liquid and another in the form of a thick paste. The foodstuffs offered to the patients were contrasted, with the mucosa promoting better visualization of the structures involved in the swallowing dynamics, and, in addition to that, the inspissators are used with the objective of reaching different consistencies.

Methods and Materials

Figure_1shows the arrival of liquid to the glottic region.

Figure_3 shows the laryngeal penetration and aspiration.

Figure_2 presence of pasty foodstuff can be observed.

The flexible endoscopic evaluation of swallowing combined with contrasted oral feeding is an exam that provides reliable information about the physiology of swallowing of each patient. In addition to that, it permits the visualization of possible episodes de penetration and/or aspiration, permitting the performance of compensatory maneuvers that provide a safe and less restrictive form of oral feeding, an important part of planning the rehabilitation from dysphagia.

Conclusions

Introduction

Dysphagia characterizes itself by any alteration in the course of the alimentary bolus and can manifest itself clinically in different forms, such as, for instance, in the difficulty to initiate swallowing, nasal regurgitation, coughing and/or choking during meals, among other symptoms. Currently, the exam most often used for the diagnosis and evaluation of dysphagia is videofluoroscopy, which permits the visualization of the normal and pathological dynamics of swallowing. Recently, two other exams have also been used with the specific objective of evaluating the function of swallowing: the flexible endoscopic evaluation of swallowing (FEES) and the flexible endoscopic evaluation of swallowing with sensory testing (FEESST).

The objective of this study is to present flexible endoscopic evaluation of swallowing combined with oral feeding, as an alternative exam in the identification and the rehabilitation of dysphagia in newborns and children.

The utilization of patients’ own utensils, foodstuffs and their respective consistencies should be prioritized. Otherwise, the consistencies can be offered with the aid of a spoon or of a syringe. In the latter case, it should be used when alterations in the oral phase. Depending on the medical history, and on the course of the performance of the examination, the selection and the sequence of the types of foodstuffs may vary. In certain cases, maneuvers may be used during the exam, aiming at promoting safe and effective swallowing by the patient. When the foodstuff is offered to the child, one can observe the capability of maintaining the alimentary bolus within the oral cavity (oral control), the presence or absence of the suction reflex, the mobility of the tongue and of the lips, the retro-propulsion of the alimentary bolus by the tongue, the time needed for the swallowing reflex, and, consequently the passage of the bolus from the oral phase to the oropharyngeal one. One can visualize the occurrence of early extra-oral escapes and/or to the pharynx, stasis in valleculas and epiglottis, indirect signs of gastroesophageal reflux, the reflexes of laryngeal protection (coughing and/or choking) in case there is the occurrence of penetration (above the vocal folds) and/or laryngotracheal aspiration (below the vocal folds).

Table 1 shows the children distributed according to sex.

25Female

25Male

NumberSex

Table 2 shows the children distributed according to age groups.

10Over 4 years

16From 2 to 4 years

24Under 2 years

Numberage groups

Table 3 shows the most significant findings of the exam.

12Laryngeal Aspiration12Laryngeal penetration23Stasis of liquid or pasty foodstuff

Numberfindings

Some patient the exam was normal.Some patients they had more than a finding in the exam.