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