New Horizon in FEES!! A Developmental Disability PerspectivePresentation Transcript
New Horizons in FEES!!
A Developmental Disability Perspective
- Nehal Kothari
Dysphagia & Developmental Disability
Dysphagia is a common finding in infants and children with neuromuscular disabilities. Dysphagia may be developmental, as in the preterm infant, transient, chronic, or progressive.
39- 56% individuals with developmental disability face some kind of feeding difficulty. ( Schwarz, S. et al. (2001). )
When is an evaluation indicated?
Dysphagia evaluation is indicated when:
Nutritional or pulmonary status appears compromised
Child has a medical diagnosis or condition associated with risk of dysphagia.
GERD, Constipation and lung disease.
Development of Feeding and Swallowing
Neonatal period (40 weeks post-conceptional age and followed by 28 days)
Early infancy (1-6 months) and late infancy period (6-12 months)
Early childhood to maturation (2-16 years)
Neurophysiology of swallowing:
- integration of skills from cortical centers in the frontal lobe with modulation from basal ganglia and cerebellum.
- Cranial nerves involved: V, VI, IX, X.
Development of oropharyngeal cavity
PROS and CONS Children with spasticity at increased risk for accidental perforation, bleeding, laryngospasm and allergic reactions to topical anesthetics due to sudden movement/ Hyper reflexia. Not natural posture and food bolus CONS More sensitive in diagnosing laryngeal penetration and aspiration Direct visualization of the larynx Visualizations of all 3 phases PROS FEES MBS
FEES VS MBS for Children with Developmental disability
MBS: Possible reason for not being able to identify silent aspiration could be attributed to lack of longer exposure to MBS
Reasons: concerns regarding exposure to radiation for longer duration and maintaining child’s co-operation.
FEES: Owing to lack of radiation exposure possible to observe the mechanism for longer time
- thus, possible to observe swallowing mechanism when it fatigues and effects of postural changes.
Investigation of Dysphagia
Oro motor function test
Important variables that may influence the exam
-Head control, facial tone and tongue posture.
Adventitious movements of mouth (athetosis/spasticity)
Asymmetry of tone in trunk and neck
If abnormalities detected with regards to the above-
Consider consulting an OTist or a nurse.
A general protocol outlining the clinical aspects of fiber optic examination has been published (Langmore & McCullog, 1997) but strategies for incorporating the clinical procedures with developmental disabilities have not been described.
Possible Procedural modifications:
To maintain adequate posturing child may be strapped to and rotated in specially designed chair.
Prosthetics- collar/head supports
Postural modifications for wheelchair bound patients
- Video fluro scopic chair
Provides safe, stable postural support in an upright position for video fluoroscopic studies, with anterior-posterior, lateral, and rotational views easily performed.
Features a removable headrest, a full back support, armrests, lateral truncal supports, and a patented base which is clamped to the footboard of the radiology table and allows for 200 degrees rotation of the patient.
Children with Down’s or Autism may present with heightened oral sensitivity and may get agitated owing to discomfort.
Distractors while carrying out the evaluation:-
Cartoons or videos
Children friendly instruments and environment
Familiarize with room
Anesthesia – What does research say?
Other non invasive tools (EDAT) – their efficacy?
Prevalence of dysphagia among some specific developmental disabilities
Cerebral palsy: 60% of children were found to have swallowing problems. 41% of these were found to have chronic aspiration problem ( Cass, Hilary. (2005). )
Drooling was found to be associated with dysphagia.
Advantages and disadvantages of Video fluoroscopy and its implications
Role of FEES – Periodic monitoring and long term follow up studies (in conjunction with chest X-rays).
Chest X-ray Chest radiograph of pt. 1 at end of VFS. Chest radiograph of pt.3
Children with CHARGE association
The incidence of CHARGE, reported in a hospital-based study from Ann Arbor, MI, USA (Edwards et al. 1995), ranged from 1 to 11 in every 900 live births.
Functional disturbances are common, for example, feeding, swallowing, and aspiration difficulties.
The severity of life-threatening events varies ( Ferrell E., Norlin B., et al. (2000))
Most children die of aspiration.
Co-existing medical conditions and other disorders such as Autism and MR.
Other conditions – Arnold Chiari Malformation
Implications on scope of FEES
Currently used as a:
Diagnostic and intervention tool
Aids in determining the effectiveness of various therapeutic intervention
Could it be used as a screening tool in medical settings to screen at risk children?
With prevalence of dysphagia being so high in various developmental disabilities----can it be used more extensively in various settings like Hospitals and schools?
Just like, pre mature babies screened for hearing loss, can high risk infants be screened for swallowing disorders using FEES, especially those group of children which are prone to developing aspiration pneumonia?
Example: CHARGE association – aspiration pneumonia may prove to be fatal
- Mainly medical settings such as hospitals, private clinics or medical centers.
- Role of School SLP?
SLPs in schools have found their roles expanding in recent years including management of students with feeding and swallowing disorders.
Many students with autism, developmental delay, MR, TBI may have accompanying or undiagnosed feeding and swallowing disorders.
Inclusion of feeding and swallowing difficulties as a part of IEP
Discuss need of swallowing/ instrumental evaluation at a medical facility.
Can collaborate with SLPs in medical settings, identify and refer children with feeding difficulties and carry out appropriate intervention.
Reduction in diameter of endoscopic optical fiber.
E.g. 400 m diameter optical fibers are readily available.
Advancements in camera technology
Virtual 3D endoscopy- commonly performed in field of Gastrointestinial endoscopy
Virtual colonoscopy (video link)
Bio nano robotics
The Forensic Aspect of Dysphagia
Sued for malpractice can be SLP’s worst nightmare!
Medical malpractice cases involving SLPs and the management of patients with sucking, chewing, and swallowing disorders are increasingly common (Tanner & Guzzino, 2002).
Experts review all pertinent medical information
Your clinical reports and notes become important
Forensic Aspect of Dysphagia
Juries rely on visual evidence as opposed to clinical bed examination findings
VSS vs. FEES
"Neglecting to conduct an instrumental evaluation of the swallow in cases of suspected dysphagia is analogous to refusing to X-ray a leg for suspected fractures'" (Tanner, 2003, p. 86).”
Current Research and its implications
Radiotherapy in Head and Neck cancer patients
Study at University of Wisconsin- 75% presented with dysphagia
Implications- Use of FEES to monitor changes in swallowing function and conduct further research to compare results of new therapeutic approaches with the old, established intervention practices.
Involvement of arytenoids in the prevention of aspiration – Video endoscopy
Diazepam induced swallowing difficulties – Case studies.
Implications- FEES may aid as a tool to promote future research!!
Other interesting findings!!!
Changes were observed in deglutition following tonsillectomy in neurologically impaired children
Use of Blue dye in evaluation?
Inconsistencies in Clinical Assessment and Instrumental exam decision making
Aoyagi, Y., Takashi H. et al. (2005). Diazepam induces pharyngeal dysphagia without impairing level of consciousness. Dysphagia, 20:357–387.
Abe, H., Akio, T., et al. (2005).Observation of arytenoids movement during laryngeal elevation using video endoscopic evaluation of swallowing. Dysphagia, 20:357–387.
Aviv, J., Kim, T., et al. (1998). Fiber optic Endoscopic Evaluation of Swallowing with Sensory Testing (FEESST) in Healthy Controls. Dysphagia 13:87–92.
Cass, Hilary. (2005). Assessing pulmonary consequences of dysphagia in children with neurodevelopment disability. Developmental Medicine & Child Neurology, 47: 347–352.
Conley, S., Kodali, S., Beecher, R. et al. (1996). Changes in deglutition following tonsillectomy in neurologically impaired children. International Journal of Pediatric Otorhinolaryngology, 36: 13-21.
Connor, N., Sullivan, P., et al. (2005). Impact of Conventional Head And Neck Radiotherapy on swallow function, salivary production, auditory capacity and Quality of life. Dysphagia , 20: 344-356.
Dusick, Anna. (2003). Investigation and Management of Dysphagia. Seminars in Pediatric Neurology, 255- 264.
Ferrell, E., Norlin, B., et al. (2000). Autistic disorders in children with CHARGE association. Developmental Medicine & Child Neurology , 42: 617–623 .
Gonçalves Silva, R. (2005). Videoendoscopic and Videofluroscopic evaluation of swallowing with therapeutic intervention. Dysphagia, 20:357–387.
Mathers–Schmidt, B., and Kurlinski (2003). Dysphagia Evaluation Practices: Inconsistencies in Clinical Assessment and Instrumental Examination Decision-Making. Dysphagia 18:114–125.
McCullough, G., Rosenbeck, J., et al.( 2005). Utility of Clinical Swallowing Examination Measures for Detecting Aspiration Post-Stroke. Journal of Speech, Language, and Hearing Research, 48 : 1280–1293.
Mikush, S., Saitoh, E., et al. (2005). A dysphagia screening test by X-ray pictures. Dysphagia,
Perez, I., Smithard, A., David, G., Davies, A., Honor, A., Kalra, (1998). Pharmacological treatment of Dysphagia in stroke. Dysphagia, 13: 12-16.
Rogers, Brian., & Arvedson Joan. (2005). Assessment of Infant Oral Sensorimotor and Swallowing function. Mental Retardation and Developmental Disabilities Research Reviews, 11: 74-82.
Selley, W., Parrott, L. et al. (2000). Non-invasive technique for assessment and management planning of oral-pharyngeal dysphagia in children with cerebral palsy. Developmental Medicine & Child Neurology, 42: 617–623.
Schwarz, S. et al. (2001). Diagnosis and treatment of feeding disorders in children with developmental disability. Pediatrics. 108:671- 675.
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