Joseph Donzelli

Effects of the removal of the tracheotomy tube on swallowing during the fiberoptic endoscopic exam of the swallow (FEES).

This study investigated the effects, if any, that the presence of a tracheotomy tube has on the incidence of laryngeal penetration and aspiration in patients with a known or suspected dysphagia. This was a prospective, repeated-measure design study. A total of 37 consecutive patients with a tracheotomy tube underwent a fiberoptic endoscopic evaluation of swallowing (FEES). Patients were first provided with pureed food boluses with the tracheotomy tube in place. The tracheotomy tube was then removed and the tracheostoma site was covered with gauze and gentle hand pressure was applied. The patients were then evaluated without the tracheotomy tube in place with additional puree. Aspiration status was in agreement with and without the tracheotomy tube in place in 95% (35/37) of the patients. The two patients who demonstrated a different swallowing pattern with regard to aspiration demonstrated aspiration only when the tracheotomy tube was removed. Laryngeal penetration status was in agreement with and without the tracheotomy tube in place in 78% (29/37) of the patients. For the majority of the patients, the removal of the tracheotomy tube made no difference in the incidence of aspiration and/or laryngeal penetration. Results of this study do not support the clinical notion that the patient’s swallowing function will improve once the tracheotomy tube has been removed.

The Modified Barium Swallow and the Functional Endoscopic Evaluation of Swallowing

This article reviews the current standard of care for the instrumental evaluation of swallow function using the modified barium swallow (MBS) and the functional endoscopic evaluation of swallowing (FEES). Both the MBS and FEES are valuable procedures for evaluating dysphagia and show good agreement with diagnostic findings as related to tracheal aspiration, laryngeal penetration, pharyngeal residue, diet level, and compensatory swallow safety strategies. The use of the MBS and FEES has advantages and disadvantages and both should be considered the gold standard for evaluating swallow function.

THERMOPROTECTIVE MECHANISMS OF IRRIGATION DURING BIPOLAR CAUTERY

Bipolar cautery is routinely used in operations of the head and neck, as well as in other specialties, both for dissection and for achieving hemostasis. Whereas simultaneous irrigation is frequently used to minimize neuronal injury, its effectiveness has not been tested under controlled conditions. Our objectives in this study were to test the hypothesis that including irrigation during bipolar cautery is thermoprotective and to identify the mechanisms underlying the thermoprotective effect. The thermoprotective role of irrigation with bipolar cautery was tested in a rat model in which the sciatic nerve was exposed and a 1-second stimulus at 40 or 20 watts was applied with bipolar cautery forceps placed directly on the nerve in the presence or absence of simultaneous irrigation. We used the Sciatic Functional Index as used to quantitate the degree of paresis induced. The results showed that simultaneous irrigation reduced the percentage of animals showing paresis. This effect was significant for animals exposed to 40- and 20-watt cautery. The mechanism for the reduction in the degree of paresis by irrigation could not be attributed to a lowering of the maximal temperature achieved after bipolar cautery. Instead, the thermoprotective mechanism of the irrigation involved an enhanced recovery to basal temperatures when measured at 15 seconds after nerve stimulation with 40 or 20 watts. Reducing the power from 40 watts to 20 watts did not significantly lessen the tissue temperature. The results of this study suggest that irrigation done simultaneously with bipolar cautery enhances temperature recovery to basal levels and plays a role in thermoprotection against the effects of cautery.

Pilot Date on Swallow Function in Nondysphagic Patients Requiring a Tracheotomy Tube

Objective. To evaluate the effects of occlusion status (i.e., open, finger, capped) of the tracheotomy tube and removal of the tracheotomy tube that may have upon bolus flow and durational measurements in nondysphagic persons requiring a tracheotomy tube. Study Design. Prospective, single subject, repeated measure design. Methods. Participants had their swallow evaluated with 5 mL pureed boluses using nasal endoscopy with the tracheotomy tube in place, removed, and under the following occlusion conditions: open, finger, and capped. The order of occlusion condition was randomized. Results. Aspiration was never observed but laryngeal penetration was a common finding. Durational measurements for swallow initiation and duration of white out were not significantly different by occlusion status or after removal of the tracheotomy tube. Conclusion. This study provides corroborating evidence demonstrating the lack of a relationship between a tracheotomy tube and swallowing dysfunction.

Third Place—Resident Clinical Science Award 1997 Thermoprotective mechanisms of irrigation during bipolar cautery

Bipolar cautery is routinely used in operations of the head and neck, as well as in other specialties, both for dissection and for achieving hemostasis. Whereas simultaneous irrigation is frequently used to minimize neuronal injury, its effectiveness has not been tested under controlled conditions. Our objectives in this study were to test the hypothesis that including irrigation during bipolar cautery is thermoprotective and to identify the mechanisms underlying the thermoprotective effect. The thermoprotective role of irrigation with bipolar cautery was tested in a rat model in which the sciatic nerve was exposed and a 1-second stimulus at 40 or 20 watts was applied with bipolar cautery forceps placed directly on the nerve in the presence or absence of simultaneous irrigation. We used the Sciatic Functional Index as used to quantitate the degree of paresis induced. The results showed that simultaneous irrigation reduced the percentage of animals showing paresis. This effect was significant for animals exposed to 40- and 20-watt cautery. The mechanism for the reduction in the degree of paresis by irrigation could not be attributed to a lowering of the maximal temperature achieved after bipolar cautery. Instead, the thermoprotective mechanism of the irrigation involved an enhanced recovery to basal temperatures when measured at 15 seconds after nerve stimulation with 40 or 20 watts. Reducing the power from 40 watts to 20 watts did not significantly lessen the tissue temperature. The results of this study suggest that irrigation done simultaneously with bipolar cautery enhances temperature recovery to basal levels and plays a role in thermoprotection against the effects of cautery.

Failures of functional endoscopic sinus surgery and their surgical correction

Endoscopic sinus surgery boasts success rates of 80% to 90%. However, there is a subpopulation of failures who will need to undergo further surgery. The majority of failures can be attributed to anatomic findings that lend themselves to surgical revision with success rates from 69% to 78%. One must, however, be on the lookout for the recalcitrant patient who may have other medical problems complicating his/her sinus disease. Guides to management of the primary functional endoscopic sinus surgery failures are lacking in the literature. These patients must be addressed by isolating the problem area(s) preoperatively with both clinical and radiographic findings. A working knowledge of paranasal sinus surgical anatomy is imperative. Surgical revision can be performed safely after careful preoperative study in a systematic sinus by sinus fashion. Making note of the anatomic landmarks and sinus disease via radiography and examination will prepare the surgeon for the endoscopic diversity and challenge of revision sinus surgery.

Using Modified Evan's Blue Dye Test to predict aspiration.

First we must state, that we have the utmost respect for Dr. Peter C. Belafsky and his colleagues, and we appreciate all the fine work Dr. Belafsky has contributed to the literature over the years. We read with great interest the latest article by Dr. Belafsky and his colleagues entitled, “The Accuracy of the Modified Evans Blue Dye Test in Predicting Aspiration” in the November 2003 issue of The Laryngoscope. Overall, we agree with the conclusions of Dr. Belafsky’s study that support the use of the modified Evans blue dye test (MEBDT) as a screening tool in evaluating swallowing in patients with a tracheotomy tube. We were concerned, however, that Dr. Belafsky and his colleagues failed to identify some recognized limitations of their study when they compared their findings to our previous work. We would like to further explain some additional factors that may also account for the discrepancy in aspiration detection rate between Dr. Belafsky’s study and our previous studies. One obvious reason for the discrepancy between the aspiration detection rates among the Belafsky et al. study and Donzelli et al. and Brady et al. is the time frame in which the MEBDT and the fiberoptic endoscopic exam of the swallow (FEES) or videofluoroscopic swallow study (VFSS) were completed. In Belafsky et al., the examinations were not completed simultaneously, with up to 24 hours between examinations. In Donzelli et al., the MEBDT and FEES were completed simultaneously and in Brady et al., the MEBDT and VFSS were completed simultaneously. The purpose of conducting the examinations simultaneously was to allow the investigators to evaluate how effective the visualization of blue tracheal secretions was in cases of known aspiration as documented by the instrumental assessment. Also, by conducting the exams simultaneously, the same swallow was evaluated at one time rather than relying on inferences from two separate events. As it is well known, individuals with swallowing disorders often exhibit highly variable swallowing patterns, so it is not unusual for a patient on one occasion to exhibit aspiration but on another occasion under the same circumstances not to demonstrate aspiration. In Donzelli et al., the investigators removed the tracheotomy tube and inserted the endoscope through the stoma site and flexed it upward to obtain a view of the subglottal structures and flexed it downward to view the bronchial tree. This technique was not described as being done in the Belafsky et al. study. The addition of the subglottal viewing as described by Donzelli et al. had the advantage of viewing the lower airway at the tracheotomy site by means of endoscopy after each incidence of aspiration. It was noted in our study that only the blue tinged tracheal secretions that were present below the stoma site were detected by means of tracheal suctioning and that blue tinged tracheal secretions located in the area from just above the stoma site to below the subglottis (as view with the endoscope flexed upward) were not detected by means of tracheal suctioning. We feel that the addition of subglottal viewing through the tracheotomy site during the FEES is an important clinical advance and one that deserves widespread adoption. Additionally, we felt that the information provided to us during the subglottal viewing was important as is further explained why the MEBDT may not always be accurate in detecting aspiration (e.g., the aspirated material remaining on top of the tracheotomy tube and/or cuff portion of the tracheotomy tube). Both Donzelli et al. and Brady et al. provided additional information on the clinical judgment of the overall amount of food/liquid that the patient aspirated and reported that the MEBDT was more sensitive in detecting aspiration when the aspiration was in greater than trace amount but 0% accurate in the detection of aspiration in less than trace amounts. Ironically, when Belafsky et al. provided their justification for not analyzing the overall amount of aspiration, they actually echoed our rationale for doing it. They stated, “We chose not to differentiate between the aspiration of trace and gross amounts of material. Given the high acuity of our population, we considered even trace amounts of aspiration to be significant.” In our article, we had previously stated, “In this study, the physical reserve of this patient population for tolerating trace aspiration was judged to be decreased because of their medical acuity as compared to the general population. Therefore, the detection of even trace amounts of aspiration was thought to be significant when considering diet and treatment recommendations and the potential risk of pneumonia.” Additionally, we felt that the added information provided by our studies on the lack of sensitivity of the MEBDT to detect aspiration in trace amounts (0% accurate) was an important clinical finding given the potential significance of trace aspiration and thus further justifying evaluating the overall amount of aspirated material. Belafsky et al. did not provide any information on interrater reliability for the presence of aspiration in this current article. Both Donzelli et al. and Brady et al. reported interrater reliability completed by a blinded rater. From our clinical experience, the MEBDT should be best viewed as a screening tool to detect gross amounts of aspiration of food/liquid. In Belafsky et al., their reported protocol for the MEBDT used only blue ice chips, whereas Donzelli et al. and Brady et al. used actual food dyed blue. In our opinion, using ice chips alone to make clinical decisions regarding diet level and swallowing safety strategies would be very difficult as well as risky to the patient. By

Sensitivity of the Blue Dye Food Test for Detecting Aspiration in Patients with a Tracheotomy

Aims: To explore the sensitivity and specificity values for aspiration with the blue dye food test (BDFT) in tracheotomized patients undergoing inpatient rehabilitation and explore what impact, if any, the accumulated oropharyngeal secretion level has upon the accuracy of the BDFT. Methodology: Simultaneous BDFT and fiberoptic endoscopic evaluation of swallowing (FEES) proced ure were conducted with 21 tracheotomized patients. The patient’s accumulated oropharyngeal secretion level was evaluated first using a 5 - point secretion severity scale. The patients then received ice chips and various boluses which were dyed blue. The B DFT was

Spillage, residue, and penetration in healthy adults while swallowing during a meal

Abstract Problem: To investigate the frequency for premature spillage, pharyngeal residue, laryngeal penetration, and aspiration during videoendoscopy in healthy adults while they are eating a meal. Methods: This was a prospective study involving 40 healthy adults (mean age, 38 years; range, 20 to 52 years) with no known history of neurological, swallowing, or head/ neck abnormality. Subjects were assessed in an upright-seated position and given a 3-inch submarine sandwich and a 12-ounce carbonated drink. Subjects were instructed to eat the meal in a manner similar to that during a regular meal with no structure being provided related to bolus size or rate of oral intake. All examinations were recorded on videotape for further analysis. Results: A total of 967 boluses were evaluated (488 liquid and 479 solids) across the 40 subjects. Premature spillage was present in 64% of all boluses (liquids 64%, solids 65%). The location of the spillage prior to the initiation of the swallowing was 52% valleculae (48% liquids, 56% solids), epiglottic ridge 5% (6% liquids, 6% solids), and pyriform sinuses 4% (7.4% liquids, 0% solids). Residue was present in 19.5% of all boluses (liquids 1.2%, solids 38.4%). Laryngeal penetration was present in 6.8% of all boluses (4.3% liquids, 9.4% solids). Laryngeal penetration was silent (no cough) 89.4% of the time (liquids 85.7%, solids 91.1%). No aspiration was present during any swallowing. Conclusion: Normal variation for premature spillage, pharyngeal residue, and laryngeal penetration is a common finding in the healthy adult while eating a meal. Aspiration was not observed. Significance: The impact of this variation is well compensated for the healthy person but most likely impacts adversely the disabled swallow. Future research should focus on the tolerance of penetration in the disabled swallow. Support: None reported.

S189 – Tracheotomy Tube Occlusion Status and Swallowing Function

Objectives To compare the effects, if any, various types of tracheotomy occlusion conditions may have upon swallowing during either the videofluoroscopic swallow study (VFSS) or fiberoptic endoscopic exam of the swallow (FEES). Methods Prospective, repeated measure design. Patients underwent randomized order of tracheotomy occlusion conditions (open, finger, one-way valve, capped) during selected swallows. Main outcome measures were the presence or absence of aspiration/laryngeal penetration. Results 39 participants have completed the protocol, 19 males/20 females, mean age of 59.41 years (SD=19.31). 20 underwent the VFSS and 19 underwent FEES. The majority of participants (58.9%, 28/39) were able to safely swallow without any airway invasion under all occlusion conditions. Change in swallow function under 1 or more of the occlusion conditions was present in 25.6% (10/39) of the participants. 4 subjects had increased airway invasion with no occlusion (open), 4 with finger occlusion, and 2 while capped. One subject had less airway invasion with the 1-way valve as compared to the other conditions. One subject aspirated under all occlusion conditions. Conclusions No clear patterns for optimal occlusion condition for swallowing were identified. Results of this study suggest that swallowing disorders in patients with a tracheotomy tube is a multifactiorial problem and several factors may be associated with the swallowing dysfunction. Therefore, patients should be evaluated under various occlusion conditions to determine their specific optimal swallowing condition.