Objective:
Videofluoroscopic swallowing study (VFSS) and fiberoptic endoscopic evaluation of swallowing (FEES) has their strengths and combining these two improved sensitivity of detecting aspiration and residue compared to single study. The aim of the study was to compare the findings of VFSS and FEES.
Method
The 3.0mm flexible fiberoptic endoscope Pentax CP-1000, VNL9-CP (Pentax Japan Inc., Tokyo, Japan) were applied. VFSS was performed using Toshiba Ultimax-I DREX-UI80 (Toshiba America Medical System, Inc., Tustin, USA). We used barium impregnated during 1, 5, 10, 20ml of thin liquid, 2 spoonfuls (3ml) of puree (yogurt).
3 raters judged the severity of residue and laryngeal penetration or tracheal aspiration with blinded to the participant details. The raters scored Penetration-Aspiration Scale (PAS) (Figure 1A). Post-swallow residue during VFSS was measured by Normalized Residue Ratio Scale (NRRS), ratio of residue relative to available valleculae, pyriform sinus space (Figure 2). Residue severity of FEES was scored by Yale Pharyngeal Residue Severity (Table 1) (Figure 1B).
Result
A total of 178 participants (55 females and 123 males; mean age 62.8 yrs ± 14.1 SD) were enrolled. The reasons of dysphagia were stroke in 53 (29.7%), traumatic brain injury in 27 (15.1%) cervical spinal cord injury in 36 (20.2%), head-neck cancer in 5 (2.8%), Parkinson disease in 6 (3.3%), others in 43 (24.1%).
Intra-rater agreement between VFSS and FEES was substantial (κ = 0.655, p = 0.000) for PAS, valleculae retention (κ = 0.638, p = 0.000) and pyriform sinus retention (κ = 0.687, p = 0.000). The mean PAS score on FEES was 0.30 point, valleculae retention score was 0.18 point higher on VFSS, pyriform sinus retention was 0.15 point higher on FEES but all were not statistically significant (Table 2). 16 patients with food coating at true vocal cord during FEES showed tracheal aspiration on VFSS (Table 3). Vocal cord palsy and incomplete contact were significantly associated with tracheal aspiration in FFES findings (Table 4).
Discussion
Recent studies comparing the result of two exams found FEES consistently showed a worse scoring in PAS and residue scale compared to VFSS. However, the standard to define the presence of aspiration and residue severity were ambiguous and not generally quantitative. Our aspiration and retention scaling with recently proved reliable scaling system showed no statistical significant difference between two groups which could be useful to combine interpret the result of both studies and determine most appropriate diet recommendation. Otherwise, food spillage into posterior larynx and invisible residue on the subglottic shelf could not exclude tracheal aspiration.
Conclusion
PAS, post swallow retention severity scores showed substantial agreement and no significant difference between VFSS and FEES. Combining VFSS and FEES considering different advantage of each exam would be desirable for dysphagia evaluation.
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Figure 1A: Residue on the subglottic shelf after liquid diet, Figure 1B: Severe valleculae, Moderate pyriform sinus retention according to Yale Pharyngeal Residue severity rating scale
Figure 2. Post-swallow residue measured by Normalized Residue Ratio Scale (NRRS)
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