Office Evaluation of Dysphagia

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Office Evaluation of Dysphagia TNE 2007

• Robert J. Stachler, M.D.
• Associate Professor
• Department of Otolaryngology, Head and Neck
  Surgery
• Director of the University Swallowing Center,
  Harper Hospital, Detroit, MI.

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Differential Diagnosis

• Multiple etiologies
• Dentition
• Mucosal inflammation atrophy, radiation
  changes, chemotherapy, infections (CMV, herpes,
  strep, candida).
• Impaired salivation (autoimmune, radiation
  induced, drugs (Ach, dehydration)
• Webs, rings, strictures
• Diverticula
• Tumors

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Differential Diagnosis

• Structural defects cleft lip palate, traumatic
  or operative
• Defective support structures
• Local joint mobility, cervical spurs, operative
  interventions of the spine, esophagus,
  oropharynx.
• Arthritis, collagen vascular diseases, skeletal
  deformities.

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Location / Site / Stage

• Oral
• Pharyngeal
• Esophageal

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Aspiration

• passage of food or liquids below the vocal folds
• risk of airway obstruction, aspiration pneumonia
• causes
• impaired laryngeal closure,
• pharyngeal retention
• effects
• variable

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Aspiration Effects

• several factors for pneumonia
• quantitiy larger gt risk
• depth distal gt tracheal asp.
• physical properties solids - airway obstruction,
  acids, GERD - lung parenchyma effects, infectious
  organisms - mouth or other sites
• pulmonary clearance ciliary action, coughing,
  silent asp - resp. sequelae

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Physical Examination

• look for neurologic, respiratory, connective
  tissue disorders
• ant. neck inspect, palpate, rock thyroid
  cartilage, assess laryngeal elevation
• dysphonia, dysarthria (motor dysfx.)
• oral cavity inspect mucosal integrity, masses,
  dentition
• soft palate position, symmetry (at rest, during
  phonation)

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Treatment Principles

• reduce aspiration
• improve ability to eat swallow
• optimize nutritional status
• tx directed to the underlying disorder
• Parkinsons dx, polymyositis
• individualize therapy based on fx structural
  abnormalities
• best therapy for impaired activity is the
  activity itself

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Surgery

• rarely indicated
• cricopharyngeal myotomy (most common)
• enteral feeding for those unable to obtain
  adequate nutrition by mouth
• impaired level of consciousness, massive
  aspiration, silent aspiration, esophageal
  obstruction, recurrent infections
• PEG long term tx

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Radiographic Contrast Exams

• 1898, Cannon Moser goose, cat, dog, horse -
  bismuth
• 7 yr. old child, difficult exam
• 1926, Mosher nl swallow of colleague, dysphagic
  pts.
• cinefluorography (Adrian, Kemp, Link, 1958
  Cleall, 1965 Cohen Wolf, 1968 Donner
  Silbiger, 1966 Ekberg Sigurjonsson, 1982)
• videofluorography most commonly used today,
  structure function exam.

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Videofluorography

• oral and pharyngeal stages of deglutition
• cervical esophagus
• duration completeness of bolus transit
• movement patterns of mandible, tongue, velum,
  larynx, pharyngeal wall, UES
• symmetry of bolus transfer (AP view)
• aspiration penetration

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Videofluorography

• determines if pts can progress to or continue
  safe oral intake
• likelihood of meeting nutritional requirements
  orally
• helps determine underlying causes of aspiration
• therapeutic measures implemented
• disadvantages radiation exposure, 30 frames/sec,
  younger pt. evals - difficult

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Videofluorography

• position seated or standing
• AP and lateral views
• small boluses of varying viscosities 3 to 15 mls.
  at a time

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Videofluoroscopy Set up
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Areas Evaluated with MBSS
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Modified Barium Swallow

• a.k.a. videofluoroscopic examination of
  oropharyngeal swallowing function
• gold standard to assess oral pharyngeal
  stages of swallow
• helps to determine if pt can eat by mouth
• helps to determine compensatory postures,
  particular volumes or viscosities for oral intake

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Limitations of MBS

• radiation exposure
• pt cooperation
• labor intensive, time consuming test
• dynamic study often not adequate to evaluate
  structural abnormality

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Contraindications to MBS

• pts without a pharyngeal swallow
• obtunded pts
• extremely ill pts on tube feeds who are unlikely
  to eat per mouth

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Normal BSS
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Radiographic Esophageal Exam

• barium contrast with or without VHS
• full column, mucosal relief, double contrast,
  motility assessment
• CT (including cine CT)
• MRI

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Esophagram

• positions upright, recumbent, AP, oblique
• 1st swallow, high density barium, AP oblique
  positions - aspiration, stricture, obstruction
• double contrast upright position
• distend stomach with gas producing granules
• high density, rapid swallows, LPO
• recumbent peristalsis, low density barium, LAO
  position

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Esophagram

• mucosal relief spot films of collapsed esophagus
  after barium paste or high density barium
• peristaltic waves inverted V to tail of bolus
• 8 sec to clear esophagus (Castell, 1989)
• important to look at oral pharyngeal stages
• 35 of pts, pharyngeal esophageal disorders

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Esophageal Web
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Lateral Pharyngeal Wall Ca
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Post-Laryngectomy Stricture
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Achalasia
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Pseudo-achalasia
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Candida Esophagitis
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Flexible Endoscopic Exam

• materials needed
• endoscope
• light source
• chip camera
• videotape recorder
• monitor
• video timer printer (optional)
• cart for portability

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Fiberoptic Endoscope
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FEES Cart
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FEEST

• Aviv Setzen pioneers.
• Aviv help develop the technology (mid to late
  nineties).
• Sensory deficits in reflux cases.
• Setzen laryngeal sensory deficits are associated
  with motor losses as a predictor of aspiration
  (OHNS, 2001).
• Setzen Safety of FEEST in outpatient setting
  (Laryngoscope, 2003).

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FEEST Current papers

• Setzen et al., OHNS, 2003 Laryngopharyngeal
  sensory deficits, pharyngeal motor function, and
  the prevalence of aspiration with thin liquids.
• Perlman, Cohen, Setzen et al., OHNS, 2004 Risk
  of aspiration of pureed food as determined by
  FEEST
• Squeeze more important than sensory deficit in
  pureed consistencies.

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Technique

• Assessment of structures
• Nasal cavity (boggy turbinates, edema, erythema)
• Oropharynx (cobblestoning, PND)
• hypopharynx (erythema, edema)
• Glottis (mucous stranding, erythema anteriorly,
  edema)
• subglottis

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Allergic vs. Reflux

• Glottic changes
• Allergic Thick, mucoid secretions, stranding,
  anterior laryngeal edema.
• Reflux posterior edema, pseudo-sulcus,
  interarytenoid edema and erythema.
• Often combination of both.

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Pharyngeal Laryngeal Fx

• Soft palate fx (phonate, dry swallow)
• Tongue base motility (kuh-kuh, kee-kee)
• middle inf. constrictor fx (high pitched, very
  tight ee or grunting with effort)
• Laryngeal activity (respiration max. abduction -
  sniff or inhale deeply max. adduction - hold
  breath, clear throat, cough, vocalize, Valsalva
  sustained breath holding)
• Pharyngeal squeeze.

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Scope in Position
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Normal Variant
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Aspiration of Secretions
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Sensation

• indirectly assessed - behavior to scope, response
  to secretions or retained foods, penetration, or
  aspiration
• direct assessment - lightly touch pharyngeal
  walls, base of tongue, or epiglottis

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FEES - Secretions

• excess secretions in the valleculae /or
  pyriforms, in the laryngeal vestibule, or passing
  beneath the glottis directly reflects a
  dysfunctional swallow.
• Murray, Langmore, Ginsberg, and Dostie, 1996
  secretions retention rating scale.
• 0 no visible secretions in the hypopharynx
• 1 any secretions in the channels surrounding the
  laryngeal vestibule, inc. pyriform or valleculae,
  bilateral or deeply pooled

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FEES - Secretions

• Secretions retention rating scale (cont)
• 2 any secretions that change from 1 to 3
  during observation period
• 3 most severe rating. Any secretions in the
  laryngeal vestibule. (Pulmonary secretions
  included if not cleared by swallowing or
  coughing).
• as secretions rating increased, the likelihood of
  aspiration increased

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Secretions Aspiration

• rating Number of pts Number who
  aspirated
• 0 14 3(21) 1
  15 8(53) 2 5 5(100) 3 13
  13(100)
• Murray, Langmore, Ginsberg, and Dostie,
  secretions retention rating scale. Dysphagia 1995.

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Secretions Scale
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Aspiration
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Practical Indications - FEES

• bedridden pts, extremely weak pts
• contractures, decubitus ulcers
• quadriplegia, /or neck halo
• nursing staff needed to assist pt
• ICU pt monitored, vent, tubes
• demented, confused, fearful pts
• exam needed that day
• need repeat exam (change in status)

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Indications for FEES (Cont)

• need biofeedback to assess postural maneuver
• need to assess swallowing potential were
  aspiration risk is great
• concern about radiation exposure (young)
• cost of fluoroscopy
• transport issues

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Findings seen best with MBS

• tongue control bolus manipulation
• tongue contact to post. pharyn. wall
• hyoid laryngeal elevation
• cricopharyngeal opening
• airway closure at level of arytenoid to
  epiglottal contact
• epiglottal retroversion
• esophageal clearance
• aspiration during the swallow

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Findings seen best with FEES

• airway closure, false VC adduction, arytenoid
  mobility
• amount location of secretions
• frequency of spontaneous swallowing
• pharyngeal / laryngeal sensitivity
• residue buildup
• aspiration before the swallow
• aspiration after the swallow

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Findings seen best with FEES

• coordination of bolus flow airway protection
• coordination of breathing swallowing
• ability to adduct TVF for supraglottic swallow
• TVF adduction over several secs.
• fatigue during meal leading to aspiration
• alterations of anatomy
• effectiveness of postural changes on swallow

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Normal Residual
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Moderate to Severe Residual
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Endolaryngeal Residual
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Severe Aspiration
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Vocal Cord Hemorrhage
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Vocal Cord Cyst
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Vocal Cord Nodule
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Vocal Cord Nodule with Vascular Ectasia
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Vocal Cord Cyst
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Bilateral Vocal Nodules
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Peduculated Vocal Cord Polyp
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Peduculated Vocal Cord Polyp
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Vocal Fold Granuloma
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Vocal Fold Granuloma
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Reinkes Edema
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Papilloma
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Papilloma
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Vocal Fold Leukoplakia
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Leukoplakia
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Early Vocal Cord Cancer
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Billing Codes / Costs

• 92506 Eval of speech, voice, communication
  (185)
• 92507 TX of speech, language, voice,
  communication (125)
• 92610 Evaluation of oral and pharyngeal swallow
  function (210)
• 92611 Motion fluoroscopic evaluation of
  swallowing fx by cine or video recording.
• 92612 FEES with cine or video (285)
• 92613 Physician interpretation report only

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Billing Codes / Costs

• 92616 FEEST (cine or video) (?350)
• 92617 Interpretation of 92616 only.
• 74230 Swallowing fx. Cine or videoradiography
  (160)

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Transnasal Esophagoscopy

• Concept not new
• Introduced GI literature in 1987
• Johnson DA et al, Gastroent Endoscopy
• ENT literature 2000 - 2002

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Traditional Esophagoscopy

• IV sedation.
• Large caliber scope.
• Loss of work on exam day.
• Anesthesiologist, or nurse required.
• Need for expensive monitoring equipment.
• More physician time needed.

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Scope Sizes
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Unsedated TNE vs conventional EGD

• 24 pts (24-65), TNE then EGD.
• Sensitivity of TNE 89, specificity 97.
• TNE more acceptable, less stressful (plt.05), O2
  sat BP no change.
• TNE feasible, safe, reliable, cost-effective.
• Dean R, Dua K, Massey B, Berger W, Hogan W,
  Shaker R. Gastrointest Endosc 199644422-4

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Unsedated transnasal EGD An alternative approach
to conventional EGD for documenting H. pylori
eradication.

• 19 pts. for Hp infection by con EGD then
  treated. Antral biopsies taken.
• No difference between the two techniques in
  documenting H. pylori infection and ulcer
  healing.
• overall acceptability no difference.
• Saeian K, Townsend W, Rochling, Shaker et al.
  Gastroint Endo 199949297-301.

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Transnasal vs transoral endoscopy in unsedated pts

• Prospective study, random assignment, 2 scopes
  used 5.3 and 5.9 mm (video scope).
• 170 pts., 86 transoral (85/86 success), 84
  transnasal (74/84 success) p.004.
• 16 pts mild epistaxis.
• Larger scope higher failures (8/41 vs 2/43)
  p.046, epistaxis greater (12/33 vs 4/41) p.007.
• Gastroint Endos 199949292-96 Craig et al. Aust.

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Transnasal vs transoral endoscopy in unsedated pts

• Transoral shorter than transnasal (13.7mins /-
  0.5min vs.15.2 min /- 0.6 min) p .054.
• Tolerance no difference.
• Transoral easier for endoscopist (p .007).
• Conclusions transnasal harder, less successful,
  larger scope harder, more epistaxis, transoral
  easier endoscopist perspective, once intubation
  achieved patient tolerance the same.
• Gastroint Endos 199949292-96 Craig A, Hanlon J,
  Dent J, Schoeman M. Adelaine Aust.

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Prospective evaluation of transnasal EGD
feasibility and study on performance and tolerance

• 150 pts. 3 groups oral 9.8 video scope, oral 6.0
  mm video scope, nasal 6.0 video scope.
• TNE feasible in 82 (TNE in first 100 pts.)
• epistaxis 6 pts., nasal pain 6 pts., 3 not
  scoped.
• decreased quality with peds video scope.
• nausea, choking signif. reduced with TNE.
• Dumortier et al. Gastroint Endo
  199949285-91. Lyon, France

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Transnasal vs transoral EGD

• TNE faster 15 vs 20 mins.
• Recovery room time faster 7 vs 37 mins.
• TNE 65 reduction of consumable supplies, 92
  reduction of pharmacy costs.
• Brampton PA, Reid DP, Johnson RD, Fitch RJ,
  Dent J. A comparison of transnasal and tranoral
  EGD J Gastro Hepatol 199813579-84.

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Office-based esophagoscopy a preliminary report

• 14 pts.
• esophageal stricture, patulous UES, Zenkers
  diverticulum.
• no epistaxis, airway compromise, changes in heart
  rate. Tolerance 2.0/10, sd 1.2.
• well tolerated, safely performed
• Aviv JA, et al., OHNS 2001125170-5.

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Transnasal Esophagoscopy

• Retrospective review, 100 cases.
• Indications globus/reflux (79), bx of lesion
  (8), screening exam in CA pts (5), tracheoscopy
  bronchoscopy (4), esophageal foreign body (2).
• 4 pts. aborted tight nasal vault
• Belafsky P, Postma G, Daniel E, Koufman J. OHNS
  2001125588-9.

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The role of TNE in head and neck oncology

• retrospective chart review of 17 CA pts.
• 100 accuracy in biopsy staging compared to
  panendo.
• other aspects stricture dilation, TE punctures
• may play vital role in CA management
• ?obviate panendo.
• Postma GN, Bach KK, Belafsky PC, Koufman JA.
  Laryngoscope, 1122242-2243, 2002. (Dec.)

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Indications

• dysphagic pts.
• Laryngopharyngeal exam does not fully explain the
  dysphagia.
• r/o neoplasm, stricture, diverticulum
• reflux and globus
• Barretts screening

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Contraindications

• foreign body removal.
• abnormal coagulation profile.
• poor medical status
• uncontrolled HTN
• poor pulmonary status
• baseline RR and HR if abnl medical clearance.

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Transnasal Esophagoscopy Revisited (over
700 Consecutive Cases)

• 611 pts. vs. 100 pts (1st study)
• Indications reflux, globus,dysphagia (490),
• bx in larynx, trachea, esophagus (42), Head
  and neck CA screen (45), esophageal foreign body
  (12)
• 17 aborted narrow vault.
• 50 of pts (294/592) significant findings
• Esophagitis (98), hiatal hernia
  (47),Barretts E (27)
• TNE safe well tolerated, easy to learn, may
  replace radiographic imaging in the ENT pt.
• Postma et al. Laryngoscope, 115,321-323.
  2005

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Transnasal Esophagoscopy State of the art.
Aviv. 2006 OHNS 135616-619.

• Advantages over traditional oral esophagoscopy in
  the sedated patient
• 1) enhanced patient safety.
• 2) improved survival of esophageal
• adenoCA.
• 3) Increased practice efficiency.
• AdenoCA most rapidly increasing solid tissue CA
  in the western world. Incidence of adenoCA in
  the lower one-third of the esophagus unmatched by
  any other tumor.

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Transnasal Esophagoscopy State of the art.
Aviv. 2006 OHNS 135616-619.

• AdenoCA incidence in the esophagus has
  increased by 350 over the past 30 yrs. In white
  men (300 in white women).
• Risk factors presence of BE and GE.
• Huge public health problem as GERD effects 40 of
  the adults in the US.
• BE develops in 5 to 20 of patients with GERD
  predisposes to esophageal AdenoCA.

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Transnasal small caliber EGD for preoperative
evaluation of the high-risk morbidly obese pt.
Alami RS, et al. Surg Endo 200721758-760.

• 25 pts. Preop assessment prior to bariatric
  surgery. Avg. age 55, BMI 47 Kg/m2.
• Comorbidities HTN (82), DM (80), OSA (68).
  All had cannulation of the 2nd portion of the
  duodenum with excellent tolerance. No sedation
  requirements for 23 (92) of the 25.
• Signif. Path in 14 (56) hiatal hernia (28),
  gastritis (16), esophageal metaplasia (16),
  esophagitis (12), gastric polyps (8), gastric
  ulcer (4), varicies (4).

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Transnasal small caliber EGD for preoperative
evaluation of the high-risk morbidly obese pt.
Alami RS, et al. Surg Endo 200721758-760.

• Biosies indicated in 12 pts. were easily taken
  in all (100).
• TNE (small caliber) EGD is feasible a safe
  alternative to conventional EGD for the patient
  undergoing bariatric surgery.
• Little to no sedation needed in pts. with high
  risk of general anesthesia.
• Should be considered for all MO pts. at risk for
  airway compromise.

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Eosinophilic Esophagitis

• Epidemiology world-wide, Swedish study1000
  adults with and without symptoms, prevalence
  0.1.
• To date 1000 pediatric cases, 250 adult.
• More common in the last decade awareness vs.
  increasing incidence.
• Male predominance. 2/3 cases are boys or adults.
• Adults third or fourth decades, mean age mid
  30s.
• Familial association 7 have family hx. Familial
  concordance between parents children, sibling
  pairs.
• Eosinophilic Esophagitis an Update. Ferguson
  DD, Foxx-Orenstein E. Diseases of the Esophagus
  (2007) 202-8.

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Eosinophilic Esophagitis

• Clinical manifestations
• Children lt 2 yrs. feeding disorders, FTT
• 2 12 yrs. vomiting, abdominal pain, vague
  reflux symptoms.
• gt 12 yrs. dysphagia, esophageal food impaction.
• Has been discribed in assoc. with eosinophilic
  enteritis.
• More common isolated to the esophagus.

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Eosinophilic Esophagitis

• Most pts. history of atopy, allergies, or
  peripheral eosinophilia.
• Endoscopic evaluation of symptomatic pts.
• Strictures or mucosal rings, linear furrowing,
  corrugation, ulceration, white plaques,
  endoscopic polyps.
• Pathogenesis dense infiltration of eosinophils
  into the esophageal mucosa which leads to a
  chronic inflammatory state.

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Eosinophilic Esophagitis

• Pathogenesis EE occurs as a result of an
  interaction between the environment genetic
  predisposition.
• Association between EE other allergic diseases.
• Most patients with EE have another form of atopic
  disease.
• Food may be the trigger or aeroallergens.
• Eosinophilic inflam. may be linked with
  pulmonary inflammation.

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Eosinophilic Esophagitis

• Immune system CD-25, IL-4, IL-5, IL-13, ecotaxin
  1, 2, 3, being studied.
• The gene encoding ecotaxin-3 highly induced in
  EE pts vs nl controls.
• Single nucleotide polymorphism in the human
  ecotaxin-3 gene assoc. with dz susceptibility.
• Ecotaxin important in EE, genetic alteration
  important for genetic susceptibility for EE.

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Corrugated Look plus Rent without Dilation in EE
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Pathophysiology of EE
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Basal Cell Hyperplasia, Spongiosis, Eosinophils
at the Luminal Surface
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Furrows in Eosinophilic Esophagitis
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Normal esophagus
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White Plaques in Eosinophilic Esophagitis
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Circular Rings In EE
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White Specks in EE
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Vertical Lines in EE
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Eosinophilic Esophagitis

• DX eosinophilic infiltration in the esophageal
  squamous mucosa of gt 20 eosinophils per hpf
  (magnification of 400X).
• GERD 5-10/hpf
• Obtain bx from Mid-esophagus.
• Treatment Elimination diets, Systemic or topical
  corticosteroids, montelukast, mepolizumab (human
  monoclonal antibody against IL-5). Relapses
  common up to 40.

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TNE Techniques and Pearls.

• Olympus or Pentax scopes have internal channels
  that require 30 - 45 mins. of downtime to clean
  may need two scopes in this instance.
• Cleaning unit takes up space requires special
  plumbing that may or may not be good in an office
  rental situation.
• Medtronic scope has sheaths and external
  channels. 5 min turn-around time. No need for
  extra scope. Biopsy forceps are available.
• Sheath costs 25-30 dollars, biopsy forceps same.
  Some insurances may reimburse sheath Bx
  forceps costs.

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Technique

• Pt. sitting upright in chair.
• Patients more patent nasal cavity anesthetized /
  decongested.
• Oxymetazoline or neo-synephrine.
• 4 lidocaine. (plegets for 5 -10 mins. in nose
  work best).
• Tessalon Perles (benzonatate) or 20 benzocaine
  (Hurricane) or Cetacaine (combo). (This may
  over-anesthetize the mucosa. Use sparingly.)

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Injection Apparatus
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Technique

• Endoscope lubricated with Viscous Lidocaine (2).
• 3 to 5 min. wait for local anesthetic
• Scope passed into nasal cavity.
• np closure, tongue base, hypopharynx, vocal fold
  motion, pooling of secretions.
• Head flexed forward, pt. belches or swallows.
• Scope advanced esophagus visualized.

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Technique

• Visualize going in and coming out all four
  quadrants.
• Note esophageal gastric junction and
  cricopharyngeus locations.
• Retroflex in the stomach quickly.
• Remove the remaining air in the stomach at the
  end of the procedure.

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Billing

• 92610 Evaluation of oral and pharyngeal
  swallow function 210
• 92611 Motion fluoroscopic eval with
  recording 225
• 92612 FEES with recording 250
• 92613 Physician interpretation and report
  230
• 92614 Fiberoptic eval with sensory testing 70
• 92616 FEEST with recording 325

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Billing

• Flexible esophagoscopy 43200 555
• DL with tracheoscopy 31525 400
• Tracheobronchoscopy thru the stoma
• 31615 370

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