Today I let people jam a foot of tubing through my nasal passages and down my throat, then yank it out. In and out, in and out. 16 times. And I did it to each of them too. Fun, huh? But I’ll get back to that.
First, a little knowledge…
Difficulty swallowing (or “dysphagia” as it is more technically known) is an incredibly common occurrence in people who have had strokes, brain injuries, Parkinson’s disease, certain cancers, cervical spinal surgeries, and many other conditions. Even normal aging can take a toll on swallowing. Dysphagia is a significant concern because it impacts nutrition, quality of life, and very notably it’s a huge risk factor for aspiration pneumonia, which is when food or drink go down the wrong way (as in, into the lungs) and cause an infection. This study from 2002 says that mortality from aspiration pneumonia has been reported to be as high as 70%, so it’s kind of a big deal.
There are a lot of low-tech ways that SLPs can judge how safely someone is swallowing, but the best practice is to have an objective examination. Two different procedures fit the bill: FEES (Fiberoptic Endoscopic Evaluation of Swallowing) and VFSS (Videofluoroscopy Swallowing Studies).
In short, FEES involves threading a scope through the (surprisingly complex) nasal passages and pointing the camera down the throat while you give your patient different consistencies to eat and drink. You get to directly visualize the structures and see what happens before and after the swallow. Here’s a picture of what it looks like down there.
You might even want to take a look at this video of a FEES. (If you’re easily skeeved, maybe you should skip this one.)
How cool, right?? A quick narrative of what you’re seeing: The popcorn falls down the base of the tongue behind the epiglottis into what’s called the vallecula (at the bottom of the screen). Then the knobby things (the arytenoids) come together and pull the vocal cords together (in the middle of the screen) while the epiglottis flips over and makes the screen go white. In that split second, the food has sneaked down a hidden sphincter at the top of the screen (the upper esophageal sphincter) to make its way toward the stomach.
Look at how complicated swallowing is. And that’s only one small part of it!
Now the other method: The Videofluoroscopic Swallowing Study (or Modified Barium Swallowing Study- same thing). VFSS is my usual method of objective swallow assessment. It observes the same exact event (swallowing) and most of the same structures but from a perspective completely different from FEES. Again patients are given different consistencies to eat and drink, but this time all food is mixed with barium so that an xray can capture a video of the patient swallowing each item (usually from the lateral view). Compared to a FEES you see more of the mouth and the esophagus but it lacks the detail of a direct, color image. Take a look at this:
That was a video of someone’s VFSS in both lateral and anterior views (I rarely do an anterior view). This time we see someone’s profile, which is definitely easier to place than that vaguely vaginal structure from the last video. But a lot of the same structures are there. For example, that big pringle-like structure from the FEES (the epiglottis) is now a tiny curved protrusion just south of the jaw (see it?). The 2 pyriform sinuses (see image above) are morphed into one general area near the back of the throat.
Both evaluations have their merits and one is not considered the gold standard over the other. The advantages and disadvantages of each is a serious topic, but my goal here is not to write a clinical essay. This is simply an introduction for people who’ve probably never thought that much about their swallowing. And I hope you never have to!
Okay, so back to that giant invasion of personal space I mentioned earlier. No, I’m not a masochist. By this point you probably have guessed that I attended a course on Fiberoptic Endoscopic Evaluation of Swallowing over the weekend. And despite the slight irritation I still feel on my posterior pharyngeal wall, it was pretty interesting. I will leave you with some pictures of me being scoped by one of the doctors I work with. (I guess nothing encourages team-building like sticking tubes in each other…)
If you have any questions about swallowing or the role of an SLP, please ask! And if you’re an SLP who somehow stumbled onto here, I’d love to hear how you use these evaluations in your practice. Happy swallowing!