Swallowing disorder, aspiration: now what?

Transcription

1 Swallowing disorder, aspiration: now what? Poster No.: C-0691 Congress: ECR 2015 Type: Educational Exhibit Authors: A. Kavka, M. Kysilko, M. Rocek; Prague/CZ Keywords: Swallowing disorders, Dynamic swallowing studies, Fluoroscopy, Management, Head and neck, Ear / Nose / Throat DOI: /ecr2015/C-0691 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. Page 1 of 17

2 Learning objectives to point out continuous importance of fluoroscopy for evaluation of symptomatic or hidden aspirations to demonstrate, that detailed evaluation of laryngeal penetration or aspiration can be obtained with a relative ease to show how to assess key moments in laryngo-pharyngeal function in a high frame swallowing study Background An aspiration with a clinical response does not need to be verified by imaging methods. The goal is to answer the following questions: How do the phases of deglutition look like? Is a penetration/aspiration present? Which consistency leads to a higher risk of aspiration? In case of aspiration, do various maneuvers help to prevent it? For answering these questions, the videofluorographic swallowing study (VFSS), also known as a modified barium swallowing examination (MBS) is considered to be the method of choice. It is usually indicated by clinicians specialized in swallowing disorders, and performed in cooperation with radiologists interested in the same issue. In our practice however, signs of aspiration are sometimes caught as an incidental finding during baryum swallow studies, and even more often during non-ionic agent swallow studies in patients after oro-pharyngeal surgeries. In such cases, any radiologist can still provide a deeper assessment of a swallowing process using just a limited modification of the study like dynamic recording at a minimum of 15 video frames/second (better 30) lateral view focusing on the oro-pharygeal region patient stands or sits as upright as possible Without doubts, keeping radiation exposures "as low as reasonably achievable" is essential, but a minimum of 15 frames/sec is required for detailed structure analysis. Page 2 of 17

3 A typical VFSS protocol utilizes thin liquid, thick liquid, puree, and solid morsels (cookies dipped in a contrast agent), but varies due to actual findings and patients' diet. It is wise to use only consistencies which a patient is used to, or which a clinician needs to test. The VFSS study is usually performed jointly by a clinician and a radiologist. Within time, a lot of effort led to creating standardized protocols. However, used protocols still vary among facilities and more importantly clinicians, who are responsible for the subsequent treatment and thus lead and often modify the procedure as they find necessary. In any case, a radiologist is responsible not only for a technical aspect of the study but also participates in the evaluation. Not to mention situations when it becomes valuable to modify another study after an incidental aspiration is found. That is why, radiologists should be able to assess oropharyngeal function by themselves independently. The normal adult swallowing process includes four phases: oral preparatory phase oral transit phase pharyngeal phase esophageal phase Oral preparatory and transit phases prepare a bolus of food/liquid to the pharyngeal phase. Both depend on a correct function of labial seal, salivation, tongue and soft palate movement, jaw motion, buccal tension etc. Pharynx and larynx stay at rest. Pharyngeal phase play the main role in terms of possible aspiration and so is the key phase to assess. Findings and procedure details The following series of images shows the adequate finding in a swallowing study. Page 3 of 17

4 Fig. 1: Physiological swallow - lateral view. Physiological components usually mentioned in the final report: Page 4 of 17

5 Lip closure is sufficient, tongue is mobile, glossopalatal seal works Velopharyngeal seal is sufficient, bolus does not enter nasopharynx Swallowing reflex is initiated in adequate moment (when the bolus reaches the tongue base / when it passes mandible ramus) Hyoid and larynx move adequately superiorly and anteriorly Pharynx constricts and tongue base moves back to meet pharynx Larynx closes and epiglottis inverts No penetration or aspiration (before/during/after swallow) Upper esophageal sphincter opens enough and in correct time No residue in valleculea, laryngeal inlet or pirimorm sinuses after swallow During pharyngeal phase several of these components occur almost simultaneously, but they can be assesed separately. For better orientation, key structures are highligted and main components showed separately. Fig. 3: Key structures in swallowing (static). Page 5 of 17

6 PURPLE (The laryngeal inlet) This line roughly delimits the laryngeal inlet. If a contrast agent overpasses the line, the "penetration" occurs. RED (Glottis) The red line lies at the level of vocal cords (glottis). Traversing of a contrast agent bellow the glottis means the "aspiration". The line also helps to visualize the cranial hyo-larangeal movement (2,3). BLACK (Hyoid bone body) The hyoid is useful to follow the ventrocranial movement of the hyo-lanryngeal complex (3). WHITE (Epigottis) The epiglottis inverts after the successful laryngeal elevation (3 or 4) helping to prevent a penetration in the laryngeal inlet. BLUE (The soft palate) The soft palate relaxes at first thus the nasopharynx and oropharynx communicate (1). When the pharyngeal phase starts, the soft palate seals the entrance to nasopharynx (2) and prevents a nasal reflux. It returns back to a relaxed position after the end of swallowing (5). GREEN (Pharyngeal walls and the tongue root) A countermovement of pharyngeal walls and the tongue root creates a pressure pushing the morsel downwards (4). It is not a purely anterioposterior movement, so this seal does not need to be obvious from the lateral view clearly. However, movements of the posterior pharyngeal wall (3) and the root of tongue (4,5) are visible. NOT HIGHLIGHTED The relaxation of the cricopharyngeal muscle and opening of the upper esophageal sphincter are evident (3,4). Page 6 of 17

7 Ventral osteophytes (C5-C6) slightly narrow the oesophageal ventrodorsal diameter at that level. Notice very small residue in valecullae and piriform sinuses after the swallow (they were completely cleared after the next swallow without any sign of penetration). The video shows highlighted key components of the pharyngeal phase dynamically for better visualization of each component's movement. Fig. 2: Key structures in swallowing (dynamic). Page 7 of 17

8 The usual pathologies (with videofluoroscopy findings): Premature loss of the bolus/reduced glossopalatal seal (oral phase difficulties) Reduced velopharyngeal closure (nasopharyngeal reflux) Weak/disorganized lingual propulsion (oral trasport phase difficulties) Absent or delayed swallow initiation / weak oral control (aspiration before swallow) Reduced laryngeal closure / reduced or missing epiglottic inversion (aspiration during swallow) Residue in valleculae or laryngeal inlet (due to weak laryngeal elevation) / residue in piriform sinuses (due to reduced pharyngeal propulsion or reduced esophageal sphincter opening) (aspiration after swallow) The following pathological study shows an aspiration before swallow. Fig. 4: Aspiration before swallow (video). Page 8 of 17

9 Fig. 5: Aspiration before swallow (static). The contrast agent freely enters the laryngeal inlet and continues bellow the glottis (2), after that the elevation of the larynx is initiated (3). The example of an aspiration during swallow. Page 9 of 17

10 Fig. 6: Aspiration during swallow (video). Page 10 of 17

11 Fig. 7: Aspiration during swallow (static). The contrast agent enters the laryngeal inlet but stops at the level of the closed glottis (2). So far, only a penetration occured. When swallowing begins and so the larynx starts to elevate, the glottis opens and allows the contrast agent to pass further as an aspirated portion (3). To assess the depth of penetration or aspiration, scoring systems were introduced (the following one by Rosenbek et al.) Cathegory Score Description No penetration 1 Contrast does not enter the airway Penetration 2 Contrast enters the airway, remains above vocal folds; no residue 3 Contrast remains above vocal folds; visible residue remains 4 Contrast contacts vocal folds; no residue 5 Contrast contacts vocal folds; visible residue remains 6 Contrast passes glottis; no subglottic residue visible Aspiration Page 11 of 17

12 7 Contrast passes glottis; visible subglottic residue despite patient's response 8 Contrast passes glottis ; visible subglottic residue ; absent patient response It is important to emphasize, that even an absence of nearly all physiological components of swallowing need not lead to a penetration or aspiration. In the following slow-motion study, a man suffers from oral and pharyngeal hypotonia due to the rare Kearns-Sayre syndrome. Yet he is still able to swallow without signs of penetration, only with vallecular residues after swallowing. Page 12 of 17

13 Fig. 8: Pathological swallow (video). Note completely pathological mechanisms: absent velopharyngeal seal, no swallowing reflex is initiated, hyoid and larynx do not move, insufficient pharyngeal walls and tongue base movement, epiglottis does not invert. Page 13 of 17

14 However, no penetration or aspiration occur. The agent passes around eppiglottis on phrayngeal lateral walls and the upper esophageal sphincter is voluntarily open to allow the agent to follow the gravitation. Large residues did not lead to any penetration even after the swallowing was finished. Finally, any fluoroscopy study is not complete without a frontal projection to evaluate symmetry of swallowing channels and pharyngeal structural shape. The following video shows a physiological symmetrical finding without postdeglutive residues. Page 14 of 17

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16 Fig. 9: Physiological swallow - AP view. Various rehabilitation maneuvers and techniques can be used to prevent or compensate pathological findings. They include postural adjustments (various head tilts, rotations), swallowing maneuvers and facilitation techniques. In our practice, these maneuvers are performed only at the suggestion of swallowing therapists. Conclusion Videofluorographic swallowing study (VFSS) is considered to be the method of choice for an evaluation of swallowing disorders. However, useful information can be obtained even by modifications of baryum or non-ionic agent studies. Any detailed evaluation of swallowing can provide key information for a subsequent care and rehabilitation. It requires experiences, but the most important information can be obtained by assessing just a few key components in a high-frame dynamic recording of a swallowing act. Personal information References Gramigna GD. How to perform video-fluoroscopic swallowing studies. GI Motility online Martin-Harris B, Jones B. The Videofluorographic Swallowing Study. Physical medicine and rehabilitation clinics of North America 2008;19(4): Rosenbek JC, Robbins J, Roecker EB, et al. A penetration-aspiration scale. Dysphagia 1996;11: Page 16 of 17

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