The Proof is in the Pudding (Part 3)

We continue with Part 3 of “The Proof is in the Pudding” by Karen Sheffler.


Special Considerations with FEES 

Use of Blue or Green Dye During FEES to Detect Aspiration

In 2005, Leder and his fellow researchers stated that the depth of bolus flow, bolus residue, laryngeal penetration and aspiration are reliably detected without dying foods and liquids blue or green (i.e., using white skim milk and yellow pudding)(17). This was good news; no more need for St Patrick’s Day jokes to convince the patient to drink green water! (Read more about testing with blue and green dyes).

However, in a larger and more recent study by Marvin et al (2016), researchers found that deeper airway invasion (i.e., noting aspiration versus just penetration) was detected more often when green-dye was used instead of plain white milk (29). They noted that the use of only white milk may under-identify penetration and aspiration, particularly when a patient has significant white secretions pooled in the pharynx and larynx prior to oral intake. One reason for the contradicting findings may be due to the volume of boluses tested. Marvin’s study tested up to 90ml, whereas Leder’s study tested only 3-5cc boluses. 

Marvin and colleagues suggested that green-dyed foods and liquids may be additionally beneficial for patients with mild-moderate dysphagia, who may have less frequent airway compromise and may penetrate and aspirate in trace amounts

Identifying and Rating Residue

Langmore, et al (1991) noted that the clinician can visualize and localize the residue better with the FEES versus the VFSS (2,31). Leder and Murray reminded us that Kelly et al found FEES to be more sensitive than VFSS in detecting residue, trace penetration and aspiration (19,20). Leder and Murray speculated that this may be due to the ability to see liquid and food particles that are too small to carry enough barium during a VFSS (22). There is a great picture of this concept in Pisegna and Langmore’s 2016 article in Dysphagia (31, p465). In their simultaneous FEES and VFSS study, residue was more obvious in the FEES picture versus the VFSS image. Clinicians noted residue in more locations on the FEES; this is especially crucial when residue is in and around the laryngeal vestibule (31). The dilemma pointed out by this study was that clinicians rated the residue as more severe when the same image was presented via FEES versus via the VFSS. This may have been due to the clinician raters were from a convenience sample of inexperienced medical professionals who just finished Langmore’s FEES training course (not experienced SLPs). Nevertheless, it does show how residue ratings have been too based on subjective impressions rather than image-based measurable benchmarks. 

Once residue is identified, we need to reliably rate the severity to make sure patients receive an accurate diagnosis regardless of instrumentation (31). Langmore (2016, February) discussed how more research is needed in the standardization of residue scales for FEES during her session at the Post-Graduate Course of the Dysphagia Research Society meeting in Tucson, AZ. She mentioned the following two measures:

  1. The Boston Residue and Clearance Scale (BRACS): which regards the site, amount, and the patient’s response to residue, by Kaneoka AS, Langmore, SE, Krisciunas, GP et al (2014) in Folia Phoniatrica et Logopaedica, 65, 312-7. 
  2. The Yale Pharyngeal Residue Severity Rating Scale: text by Steven Leder and Paul Neubauer, both of the Department of Surgery at the Yale School of Medicine (based on 27,30). 

Per Neubauer, Rademaker and Leder (2015), many scales do not have “adequate reliability, interpretive validity, and ease of administration to be clinically useful (p522).” They demonstrated that the anatomically defined and image-based Yale Pharyngeal Residue Severity Rating Scale is reliable and valid and only minimal training is needed to quickly achieve proficiency in rating residue in the valleculae and pyriforms. Now the proof is in the pictures and the pudding!

Neubauer, Hersey and Leder (2016) went on to perform a systematic review of all rating scales, with inclusion criteria focusing the review on “completed and generalizable pharyngeal residue severity rating scales,” which seems to have left out the BRACS (30). As Sasaki and Leder stated in Comments on Selected Recent Dysphagia Literature in the 2015 Dysphagia journal (p375): “The BRACS shows potential; however, even the authors acknowledge the impracticality of its use in the clinical setting without simplification by removing or merging redundant items.” Neubauer and team (2016) found that only The Yale Pharyngeal Residue Severity Rating Scale met all the following criteria: 

  • qualitative and psychometrically reliable, 
  • valid, 
  • generalizable, 
  • easy to learn by newer and more experienced clinicians, and
  • readily useful in the clinic and in research. 

This spring 2016, Steven Leder and Paul Neubauer published the textbook, The Yale Pharyngeal Residue Severity Rating Scale, just prior to Steven Leder’s passing.

In Summary:

How do you summarize Steven Leder, a researcher who had the stamina to regularly conduct studies with hundreds if not thousands of participants. In talking with some of Dr Steven Leder’s colleagues over the last few weeks, he was certainly not done his work, but there are many amazing researchers who will carry on his legacy. His impact on our field was truly remarkable; he set quite a pace. Many will keep his energy alive remembering him as an intense researcher-friend-mentor-colleague with a great smile, sharp wisdom, incredible humor, and boundless generosity.

A memorial fund has been established to support his ongoing research collaborations with both the speech-language pathologists and the residents at Yale. Donations are tax-deductible; individuals who donate will receive a tax deduction letter.

Donations can be made to:

Yale School of Medicine, Steven B. Leder Memorial Fund.

800 Howard Ave., 4th Floor, Room 422

New Haven, CT  06510

FEES References (listed chronologically):

  1. Langmore, S.E., Schatz, K. & Olsen, N. (1988). Fiberoptic endoscopic examination of swallowing safety: A new procedure. Dysphagia, 2, 216-219.
  2. Langmore, S.E., Schatz, K. & Olson, N. (1991). Endoscopic anad videofluoroscopic evaluations of swallowing and aspiration. Annals of Otology, Rhinology & Laryngology, 100 (8), 678-681. 
  3. Langmore, S.E. & Logemann, J.A. (1991). After the clinical bedside swallowing examination: What next? AJSLP, September, 13-20.
  4. Murray, J, Langmore, S.E., Ginsberg, S. & Dostie, A.(1996). The significance of oropharyngeal secretions and swallowing frequency in predicting aspiration. Dysphagia, 11, 99-103. 
  5. Leder, S.B. & Sasaki, C.T. (1997). Identifying silent aspiration with a fiberoptic endoscopic evaluation of dysphagia (FEED). Dysphagia, 12, 117.
  6. Leder, S.B., Ross, D.A., Briskin, K.B. & Sasaki, C.T. (1997). A prospective, double-blind, randomized study on the use of a topical anesthetic, vasoconstrictor, and placebo during transnasal flexible fiberoptic endoscopy. JSLHR, 40, 1352-1357. 
  7. Leder, S.B. (1998). Serial fiberoptic endoscopic swallowing evaluations in the management of patients with dysphagia. Arch Phys Med Rehabil, 79, 1264-1269.
  8. Leder, S.B., Sasaki, C.T. & Burrell, M.I. (1998). Fiberoptic endoscopic evaluation of dysphagia to identify silent aspiration. Dysphagia, 13, 19-21. 
  9. Leder, S.B., Cohn, S.M. & Moller, B.A. (1998). Fiberoptic endoscopic documentation of the high incidence of aspiration following extubation in critically ill trauma patients. Dysphagia, 13, 208-212. 
  10. Leder, S. (1999). Fiberoptic endoscopic evaluation of swallowing in patients with acute traumatic brain injury. Journal of Head Trauma Rehabilitation, 14 (5), 448-453. 
  11. Aviv, J.E., Kaplan, S.T., Thomson, J.E., Spitzer, J., Diamond, B. & Close, L.G. (2000). The safety of flexible endoscopic evaluation of swallowing with sensory testing (FEESST): An analysis of 500 consecutive evaluations. Dysphagia, 15, 39-44. 
  12. Leder, S.B., & Karas, D. (2000). Fiberoptic endoscopic evaluation of swallowing in the pediatric population. The Laryngoscope, 110, 1132-1136. 
  13. Leder, S.B. & Sasaki, C.T. (2001). Use of FEES to assess and manage patients with head and neck cancer. In Langmore, S.E., editor. Endoscopic evaluation and treatment of swallowing disorders. New York: Thieme; 201-212. 
  14. Leder, S.B. & Espinosa, J.F. (2002). Aspiration risk after acute stroke: Comparison of clinical examination and fiberoptic endoscopic evaluation of swallowing. Dysphagia, 17, 214-218.
  15. Leder, S.B. (2002). Incidence and type of aspiration in acute care patients requiring mechanical ventilation via a new tracheostomy. Chest, 122, 1721. 
  16. Leder, S.B. Novella, S. & Patwa, H. (2004). Use of Fiberoptic Endoscopic Evaluation of Swallowing (FEES) in patients with Amyotrophic Lateral Sclerosis. Dysphagia, 19, 177-181. 
  17. Leder, S.B., Acton, L.M., Lisitano, H.L., Murray, J.T. (2005). Fiberoptic endoscopic evaluation of swallowing (FEES) with and without blue-dyed food. Dysphagia, 20, 157-162. 
  18. Leder, S.B. & Ross, D.A. (2005). Incidence of vocal fold immobility in patients with dysphagia. Dysphagia, 20, 163-167.
  19. Kelly, A.M., Leslie, P., Beale, T, et al. (2006). Assessing endoscopic evaluation of swallowing and videofluoroscopy: Does examination type influence perception of pharyngeal severity? Clinical Otolaryngol, 31, 425-432.
  20. Kelly, A.M., Drinnan, M.J. & Leslie, P. (2007). Assessing penetration and aspiration: How do videofluoroscopy and fiberoptic endoscopic evaluation of swallowing compare? Laryngoscope, 117, 1723-1727.
  21. Leder, S.B., Sasaki, C.T. & Bayar, S. et al. (2007). Fiberoptic endoscopic evaluation of swallowing in the evaluation of aspiration following transhiatal esophagectomy. J Am Coll Surg, 205, 581-585. 
  22. Leder, S.B. & Murray, J.T. (2008). Fiberoptic endoscopic evaluation of swallowing. Phys Med Rehabil Clin N Am, 19, 787-801. 
  23. Leder, S.B. (2012). Nil per os except medications order in the dysphagic patient. QJM: An International Journal of Medicine, 106 (1), 71-75.
  24. Leder, S.B., Suiter, D.M., Duffey, D. & Judson, B.L. (2012). Vocal fold immobility and aspiration status: A direct replication study. Dysphagia, 27, 265-270. 
  25. Kamarunas, E.E., McCullough, G.H., Guidry, T.J., Mennemeier, M. & Schluteman, K. (2014). Effects of topical nasal anesthetic on Fiberoptic Endoscopic Examination of Swallowing with Sensory Testing (FEESST). Dysphagia, 29(1), 33-43. 
  26. O’Dea, M.B., Langmore, S.E., Krisciunas, G.P., Walsh, M. Zanchetti, L.L., Scheel, R., et al (2015). Effect of lidocaine on swallowing during FEES in patients with dysphagia. Ann Otol Rhinol Lanryngol, 124(7), 537-44. doi: 10.1177/0003489415570935
  27. Neubauer, P.D., Rademaker, A.W. & Leder, S.B. (2015). The Yale Pharyngeal Residue Severity Rating Scale: An anatomically defined and image-based tool. Dysphagia, 30, 521-528. 
  28. Leder, S.B., Siner, J.M., Bizzarro, M.J., McGinley, B.M. & Lefton-Greif, M.A. (2016). Oral alimentation in neonatal and adult populations requiring high-flow oxygen via nasal cannula. Dysphagia, 31, 154-159. 
  29. Marvin, S., Gustafson, S. & Thibeault, S. (2016). Detecting aspiration and penetration using FEES with and wtihout food dye. Dysphagia, Published online: 18 March 2016. DOI 10.1007/s00455-016-9703-0 
  30. Neubauer, P.D., Hersey, D.P. & Leder, S.B. (2016). Pharyngeal residue severity rating scales based on Fiberoptic Endoscopic Evaluation of Swallowing: A systematic review. Dysphagia, 31, 352-359.
  31. Pisegna, J.M. & Langmore, S.E. (2016). Parameters of instrumental swallowing evaluations: Describing a diagnostic dilemma. Dysphagia, 31, 462-272.            

  32. Daniels S.K., Schroeder M.F., DeGeorge P.C., Corey D.M. & Rosenbek J.C. (2007). Effects of verbal cue on bolus flow during swallowing. J Am Speech Lang Pathol, 16, 140–16.Daniels S.K., Schroeder M.F., DeGeorge P.C., Corey D.M. & Rosenbek J.C. (2007). Effects of verbal cue on bolus flow during swallowing. J Am Speech Lang Pathol, 16,140–16. 
  33. Gross, R. D., Atwood, C. W.Jr., Ross, S. B., Olszewski, J. W., & Eichhorn, K. A. (2009). The coordination of breathing and swallowing in chronic obstructive pulmonary disease. Am J Respir Crit Care Med179(7), 559–565. doi: 10.1164/rccm.200807-1139OC
  34. Gross, R.D. (2014). Lung volumes and their significance for pharyngeal and esophageal swallowing function. SIG 13 Perspectives on Swallowing and Swallowing Disorders (Dysphagia), 23, 91-99. doi:10.1044/sasd23.3.91
  35. Martin-Harris, et al. (2014). Respiratory-swallow training in patients with head and neck cancer. Arch Phys Med Rehabil, 96, 885-893.

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