Modified Barium Swallow Versus FEES

Answer

A comprehensive modified Barium swallowing evaluation or Barium swallowing examination (MBS; BSE), also called a pharyngogram (PHG), is the 'gold standard' when physiologic assay of cervical swallowing function in patients suspected of aspiration is required (Lundy, Smith, Colangelo, et al., 1999, Otolaryn. - HNS, 120: 474; Bevan and Griffths, 1989, Ann. Otolaryng, 103: 196). Consisting of the use of videofluoroscopy and radio-opaque Barium, a patient stands or is seated between an x-ray emitter and its collector for a left lateral view. The image generated can be viewed on a video monitor immediately or, later, viewed from a video tape or digital video disk recording. The importance of MBS is that one can view all phases of swallow, early and late oral, pharyngeal, and esophageal, both the cervical region and peristaltic activity of the lower two thirds (Perlman and Schulz-Delrieu, 1996, Deglutition and its Disorders, Singular, San Diego). Swallowed barium is seen as a black bolus during mastication, passage out of the oral sphincter and into the pharynx, and finally into the esophagus. Excessive retention of Barium in the oral cavity, and in pharyngeal features such as the vallecula, pyriform sinuses or penetration into the laryngeal opening can be easily viewed. Or, esophageal abnormalities such as cricopharyngeal opening disorders, esophageal wall pouches, or even regurgitation can be documented with PHG. Importantly, PHG firmly and objectively provides documentation of penetration or aspiration of Barium (Broniatowski, Sonies, Rubin, et al., 1999, Otolaryn. - HNS, 120:464).

Limitations of PHG include difficulties with patient cooperation, limited resolution for micro-aspiration, and the exposure to radiation. For these reasons flexible endosocpic examination of swallowing (FEES) is effectively competing with PHG as the gold standard for evaluation swallowing function (Bastian, 1993, Dysph. 8: 359; Langmore and Logeman, 1991, AJSLP 1:13). FEES equipment consists of a flexible endoscope using an endosheath on the flexible end, a video camera mounted on the eyepiece of the endoscope, a camera control box and video monitor, and some means of recording the examination. Additionally, where FEES equipment is available, it is supplanting the subjective bedside swallowing assessment in the acute care setting. Fully two-thirds to three-quarters of swallowing evaluations today are FEES (Kidder, Langmore and Martin, 1994, Dysph., 9:256). There is no radiation exposure, patient's can be seen in their rooms, and it is excellent at discerning the minute aspirations not visualized with fluoroscopy. Limitations of FEES are that it has a learning curve requirings more careful certification because of its invasive nature (Watterson, McFarlane and Brophy, 1990, Sem. Speech and Language, 11:1-7), and it is not physiologic. Regarding the latter limitation, what one is observing is the 'before' and 'after' of swallowing. In contrast, with MBS the entire swallowing process can be observed (Broniatowski, Sonies, Rubin, et al., 1999, Otolaryn. - HNS, 120:464; Kidder, Langmore and Martin, 1994, Dysph., 9:256).

Recently, Kay-Pentax has stopped selling the flexible endoscopic evaluation of swallowing and sensory testing (FEESST) system. The reasons for this are many. But the most important are that is was a flawed system providing inconsistent results and it was prone to breakdown. If one desires to test sensory function the simplest and most useful is tactile. Using the tip of the inserted endoscope one bilaterally touches base of tongue, superior margins of epiglottis and aryepiglottic folds, posterior commissure and vestibular folds superior surfaces, and the lateral and posterior pharyngeal walls. Using a 1-5 scale, the observer notes briskness and magnitude of response on a schematic map.

There is no real limitation when evaluating a patient with tracheostomy ventilation tubes for either type of swallowing evaluation (Parrott, Selley, Brooks, et al., 1992, Dysph., 2:209). It was believed at one time that the presence of the tracheostomy tube impinged on laryngeal elevation excursion during the pharyngeal phase of swallowing. This is true of the very sick and newly intubated, but long term patients readily compensate (Sessile and Henry, 1989, Dysph., 4:61).

Using blue dye or green food coloring when assessing patients for aspiration is no longer considered useful. Indeed, it serves as a marker to prove aspiration occurred in patients with tracheostomy tubes, but plain water can be easily seen as an aspirant endoscopically (Wilson, Hoare and Johnson, 1992, J Laryng. and Otol., 106:525). Of more usefulness, perhaps, when assessing swallowing are food consistencies and textures, head and chin posturing, and mealtime management strategies.

Mr. Charpied is the Director of the Department of Speech Pathology, in the Department of Otolaryngology - Head and Neck Surgery, with the University Rochester's School of Medicine and Dentistry and Strong Memorial Hospital. A clinically certified Speech Pathologist who specializes in voice and swallowing, Mr. Charpied has developed techniques and manuals on the diagnosis, treatment and management of voice and swallowing disorders. He teaches at Nazareth College, as well in the ENT resident program. His research interests include anatomy of the larynx, quantification of laryngeal function through image analysis, and the use of computers as a clinical tool. Besides publications and numerous abstracts, Mr. Charpied's introductory text for Speech Pathology students, Anatomic and Physiologic Elements of Human Communication," has been submitted for publication. He is currently completing a text titled, "Neurologic Basis of Human Communicative Behavior."