Medical Articles
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History of Fiberoptic Endoscopic Evaluation of Swallowing (FEES)
Fiberoptic Endoscopic Evaluation of Swallowing (FEES) is a procedure employed to assess the area surrounding larynx and the opening of the pharynx, using a small flexible endoscope passed across the floor of a patient’s nasal passage in order to evaluate the swallowing function and associated pathologies. The modern FEES equipment bears little resemblance to preliminary procedures carried out in the mid 1980s. The modern FEES equipment comprises of a flexible endoscope passed transnasally by a speech-language pathologist into the upper pharynx to observe the swallow and structures involved. Typically, the procedure falls within the scope of practice of speech-language pathology.
Early Procedures
The earliest description of FEES in literature dates back to 1988. Fiberoptic laryngoscope technology was just introduced in the otolaryngology. Around this time, laryngoscopy was performed using a mirror or more invasive equipment comprising of a direct laryngoscope. The exam was not recorded using a camera, the equipment only allowed the speech-language pathologist (SLP) to look through an eye hole, and most of the swallow was missed as it is a dynamic process. Additionally, the SLP being the sole viewer of the procedure, had to remember what they saw in order to prepare a report.
The first fiberoptic laryngoscopy is usually credited to Swashima and Hirose in 1968. They transformed the practice of a laryngoscope by using a transnasal approach while the patient remained conscious during the process. It provided a view of vocal folds during natural speech.
Technological advances over the years
Over the year, technology has drastically improved. Owing to cameras, monitors, video recorders, and other technological advances, the procedure has become far less invasive and much more sophisticated. Using advanced camera chip technology, a high definition video can be obtained, enabling the swallowing structures to be seen on a monitor. The recording can be viewed by multiple viewers in real-time, allowing for a better understanding of anatomy, physiology, or any associated pathology.
Development of modern technology
The development of modern technology is credited to Dr. Susan Langmore (SLP), Dr. Nels Olson (ENT), and Ken Schatz (SLP). Working in an ENT clinic, they came up with the idea to use a laryngoscope to view the process of swallowing. Initially, when flexible nasal endoscopy was used on healthy volunteers, the results were disappointing as there was a lack of characteristic findings. However, when the same equipment was used on patients with dysphagia, the results were promising—the technology allowed for clear visualization of structural movements, secretions, spillage, aspiration, and residue.
At first, FEES was not readily accepted as a standard procedure and was dismissed by many clinicians. However, the situation has drastically changed over the years, and it is now recognized as a gold-standard procedure along with the Modified Barium Swallow Study (MBSS), also known as videofluoroscopic swallow procedure (VFSS).
References
Langmore, S. E. (2017). History of fiberoptic endoscopic evaluation of swallowing for evaluation and management of pharyngeal dysphagia: changes over the years. Dysphagia, 32(1), 27-38.
Langmore, S. E., Kenneth, S. M., & Olsen, N. (1988). Fiberoptic endoscopic examination of swallowing safety: a new procedure. Dysphagia, 2(4), 216-219.
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Comparison of Fiberoptic Endoscopic Evaluation of Swallowing (FEES) with Modified Barium Swallow Study (MBSS)
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Fiberoptic Endoscopic Evaluation of Swallowing (FEES)
Also called video endoscopic evaluation of dysphagia and bedside endoscopic swallowing test, it is a technique performed to assess swallowing function and associated structures by using a flexible fiberoptic laryngoscope passed transnasally. The scope used is not passed between the vocal folds but rather hangs above the vocal folds. The swallowing function can be viewed on a monitor in real-time as the patient is offered a variety of food items with different consistencies. Additionally, the study can be recorded and saved to be viewed later.
The Modified Barium Swallow Study (MBSS)
Also called Videofluoroscopic Swallow Study (VFSS), it is an older procedure compared to FEES. It is still commonly used for the assessment of dysphagia. The process is performed in the videofluoroscopy suite within a hospital and involves a radiologist, a radiology technologist, and a speech-language pathologist. During MBSS, the patient is seated in a functional feeding position while he is fed barium coated food, and an X-ray is being performed. The study is time-limited in order to reduce the radiation exposure for the patient.
FEES VS. MBSS
Following its introduction, FEES was not readily accepted by the skeptics. However, over time, it has repeatedly established its superiority over MBSS by demonstrating a sensitivity higher, or at least equal, to that of MBSS when it comes to determining whether a patient is experiencing aspiration, delay in swallowing initiation, penetration or pharyngeal secretions.
Benefits of FEES Over MBSS
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FEES is not time-limited, and there is no exposure to radiations during the process.
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FEES can be performed by a speech-language pathologist, and there is no need to coordinate with the radiology department.
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FEES equipment is portable and can be used while the patient is sitting in an upright position.
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The patient does not have to swallow unpleasant, barium coated food that often leads to constipation.
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In contrast to MBSS, FEES can be used for morbidly obese patients.
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FEES can be performed on patients under mechanical ventilation and medically complex patients unable to leave the bed, room, ward, or sit in an upright position.
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FEES can be used for surgical purposes.
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The process can be recorded and viewed later that allows for a better understanding of minor details and pathologies that might be missed by unaided eye in real-time.
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Portable FEES equipment allows for the procedure to be performed anywhere i-e hospital, outpatient clinic, the patient's home, wheelchair, or bedside.
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In order to reduce the radiation exposure, the fluoroscope is turned off after each swallow leading to a possibility of missing post-swallowing behaviors.
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FEES can be recorded as both videos and still pictures that can be saved in the patient's record and viewed later.
Additionally, FEES can be cost-effective compared to MBSS. However, it should be kept in mind that usefulness often varies depending upon the individual case and the state of the patient. In some settings, MBSS can be preferable over FEES as FEES fails to assess esophageal stages of swallowing.
Most Common Symptoms Related to Dysphagia
Dysphagia
Dysphagia, or difficulty swallowing, is a condition where it takes more time and effort to move the liquid or solid food from the mouth down into the stomach. The degree of dysphagia may vary from mild discomfort to pain. In extreme cases, swallowing can even become impossible.
Occasional difficulty when eating too fast or swallowing big bolus without chewing well is usually not a cause for concern. However, if the symptoms persist, it might be an indicator of a serious underlying condition requiring medical treatment.
Although anyone can experience dysphagia, older adults are typically more susceptible to it. The underlying cause of dysphagia usually varies, and the treatment modality depends upon the proper diagnosis of the cause. Some of the commonly used techniques to assess dysphagia include Fiberoptic Endoscopic Evaluation of Swallowing (FEES), Modified Barium Swallow Study (MBSS) and other forms of Instrumental Swallowing Assessment. However, FEES is most commonly used and its ergonomically designed and portable equipment is available at PatCom Medical.
Symptoms in Adults
In some cases, dysphagia and associated pathology may be asymptomatic. As a result, it may go undiagnosed and untreated for years leading to an increased risk of aspiration Pneumonia (lung infection following accidental inhalation of saliva and liquid and solid food particles).
Some of the common symptoms related to dysphagia include:
• Drooling
• Pain while swallowing (odynophagia)
• A feeling of fullness in the neck
• Regurgitation
• Hoarse voice
• Solid or liquid food items leaking from the nasal cavity
• Frequent heartburn
• Choking or coughing while swallowing
• Poor oral management
• Food particles persisting in the oral cavity after swallowing
• An inability to properly close the mouth leading to food and drink leaking from the mouth
• Difficulty to coordinate breathing and swallowing
• The feeling of something being stuck in the throat
• Weight loss without trying
• Malnutrition
• dehydration
• Difficulty in chewing solid food
• Extra effort and time spent on chewing and swallowing
• Recurrent aspiration pneumonia
• Having to cut food into smaller pieces
• Avoidance of certain food items
A few or many of these symptoms may be present in a patient, and the diagnosis is usually based on a confirmatory diagnostic test such as Fiberoptic Endoscopic Evaluation of Swallowing (FEES) or other types of Instrumental Swallowing Assessment such as MBSS.
Symptoms in Children
In adults, the symptoms experienced can lead to a visit to the doctor and help establish a diagnosis. In children, however, it is more difficult to pinpoint the problem. The following signs and symptoms may act as an indicator, and diagnostic tests can be performed later to establish a conclusive diagnosis.
• Refusal to eat certain food items
• Regurgitation during meals
• Solid or liquid food leaking from the oral cavity
• Solid or liquid food leaking from the nasal cavity
• Difficulty breathing while swallowing
Diagnosis
If you are experiencing any of these symptoms, you should visit your healthcare provider. After an initial clinical assessment, you may be referred for specialized tests meant for the diagnosis of dysphagia. The test will confirm the underlying cause, which may be because of oral, oropharyngeal, or esophageal pathologies.
The diagnosis of the specific type of dysphagia will simplify the treatment, make it more effective, and decrease the likelihood of dysphagia associated complications, aspiration pneumonia being on the top.
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Swallowing Diagnostics – An International Comparison
The diagnosis of dysphagia and its underlying cause is essential in order to administer effective therapy. Some of the commonly used modalities for Instrumental Swallowing Assessment include Fiberoptic Endoscopic Evaluation of Swallowing (FEES) and Modified Barium Swallow Study (MBSS), while the less common ones are ultrasonography, CT scan, and MRI scan.
Among these methods, studies support the superiority of Fiberoptic Endoscopic Evaluation of Swallowing (FEES). Portable, high-quality equipment is important in order to ensure the procedure is carried out smoothly. Ergonomically designed FEES equipment is available at PatCom Medical.
Swallowing Diagnostics in Different Countries:
United States of America (USA)
In addition to non-instrumental swallowing assessment, Speech-Language Pathologists (SLPs) use instrumental techniques for dysphagia assessment in the USA, FEES, and MBSS being at the top. These are either performed independently by the SLPs (FEES) or in conjunction with other professionals such as radiologists, radiology technicians, physiatrists, etc. (MBSS in particular).
Australia
In Australia, Clinical Swallow Examination (CSE) and Modified Barium Swallow Study (MBSS) are most commonly used by SLPs. In addition, FEES, muscle testing, CT scan, and MRI scan are also used by SLPs and doctors.
Canada
In Canada, MBSS and FEES are frequently used for swallowing diagnostics by SLPs. However, while performing the MBSS presence of a radiologist in addition to an SLP is necessary to establish a diagnosis. Likewise, for FEES, a physician should be present. Other methods of instrumental assessment include ultrasonography, radionuclide scintigraphy, intraluminal pharyngeal manometry, intramuscular electromyography, electromagnetic articulography, esophageal manometry, and the use of electrical or transcranial magnetic stimulation to elicit swallowing evoked potentials. These, however, are beyond the scope of practice of an SLP and are usually performed in teaching hospitals and research facilities.
United Kingdom
After an initial assessment, the physician can refer the patient to an SLP, a gastroenterologist, or a neurologist. In NHS, a swallow test is usually carried out by an SLP. MBSS and FEES are among the most commonly used techniques. Other specific tests include diagnostic gastroscopy and manometry and 24-hour pH study.
Europe
Following the clinical evaluation, the patient is referred for instrumental assessment. Together with MBSS, FEES is the most commonly chosen method considering its numerous merits, such as feasibility and portability, allowing it to be performed at the bedside. Additional diagnostic modality includes manometry, ultrasonography, and structural and functional assessment of muscles involved in swallowing. Indication depends upon the individual case; the tests can be performed by either a doctor or an SLP.
Japan
Dysphagia diagnosis and rehabilitation involves many professionals, nurses, and dental associates being on the top. Videofluorography and videoendoscopy are common instrumental assessments, usually performed by dentists.
China
In China, clinical assessment combined with MBSS is the most commonly used modality. A doctor may refer the patient to an SLP for diagnostics tests to be carried out.
United Arab Emirates (UAE)
In the UAE, a number of different modalities such as MBSS, FEES, dynamic swallow study, orsophagoscopy, manometry, and imagining techniques like CT scan and MRI scan are being used. These are performed by doctors or SLPs.
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Dysphagia in COVID-19 Patients
Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the causative agent of COVID-19, after entering the body, can cause mild asymptomatic disease to severe acute respiratory distress syndrome (ARDS) resulting in dyspnea and apnea, eventually requiring respiratory support. Respiratory support measures may include endotracheal intubation and mechanical ventilation. In addition, enteral feeding through a nasogastric tube is required to provide adequate nutrition to the patient. All these interventions are important risk factors for dysphagia. The swallowing deficit may lead to aspiration and, consequently, aspiration pneumonia (lung infection that develops following inhalation of food, liquid, or vomit into the lungs), resulting in an increased burden on the already damaged lungs.
Causes of Dysphagia in COVID-19 Patients
Several factors play an important role in the development of dysphagia in COVID-19 patients.
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Trauma:
The type of endotracheal tube used, duration intubation lasted for, and the process itself can cause mechanical injuries. Endotracheal tube insertion might lead to any of the following:
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Injury to the lips may result in drooling of saliva.
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Patients with known dental diseases like periodontitis or dental carries can have their teeth damaged.
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Laryngeal edema is very commonly seen in patients after extubation. This impairs the elevation of the hyolaryngeal complex and the laryngeal sphincter, subsequently increasing the risk of aspiration.
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The area of vocal cords, arytenoids, epiglottis, and the base of the tongue can suffer mucosal abrasion, inflammation, hematomas, and ulcerations.
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Intubation may also result in dislocation and subluxation of the arytenoid cartilage, compromising the closure of the laryngeal vestibule.
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Sometimes, the recurrent laryngeal nerve may be injured by the endotracheal tube cuff. This results in vocal cord paresis.
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Direct laryngeal injury can be a risk factor for dysphagia. It can also result in the development of respiratory distress, voice disorders, and swallowing disorders.
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Neuromuscular Weakness:
Long-term intubation may lead to neuromuscular weakness and discoordination of muscles and nerves, leading to impaired swallowing action.
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Gastroesophageal Reflux Disease (GERD):
GERD is one of the most prevalent and chronic disorders. Besides that, the nasogastric tube for nutrition, lying position, and the use of paralytic agents and sedatives in therapy increases the risk of GERD and subsequently, dysphagia.
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Increased Cough Reflex:
Increased coughing, along with shortness of breath, can have a direct impact on swallowing, leading to dysphagia.
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Long term ICU stay:
A long-term stay in an intensive care unit (ICU) may lead to cachexia, reduced sensitivity of upper respiratory tract, and altered sensorium secondary to the use of excessive delirious agents.
However, all these consequences are either less relevant or remain unnoticed until the patient is extubated. Therefore, during the in-patient stay, it is critical to assess the safety and efficacy of swallowing, as tracheal aspiration may lead to worse respiratory outcomes. The diagnostic workup includes an aspiration screening (e.g., water swallow test as implemented in the Bernese ICU Dysphagia Algorithm) and instrumental swallow assessment using fiberoptic endoscopic evaluation of swallowing (FEES).
The incidence, diagnosis, and management of dysphagia in COVID-19 patients have not been discovered. Therefore, after the initial dysphagia assessment, the implementation of first therapeutic interventions like dietary modifications and simple compensatory maneuvers should be made. Further interventions and more refined treatments should be decided following upcoming protocols for this novel disease.
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Oropharyngeal and Esophageal Dysphagia
Swallowing is a complex process requiring coordination of 30 different muscles working together to pass a bolus of food from the mouth into the stomach. After chewing, with the help of salivary lubrication, the bolus of food passes down from oropharynx to esophagus and then stomach. If the bolus of food gets stuck anywhere during its passage to the stomach, each point of obstruction presents with different symptoms and is managed accordingly.
Oropharyngeal Dysphagia
The pharynx is a hollow muscular tube, about 12-14 cm in length that extends from the base of the skull to the upper border of the upper esophageal sphincter. Anatomically, it is divided into three parts: nasopharynx, oropharynx, and hypopharynx. The nasopharynx serves as an airway, while oropharynx and hypopharynx work together to allow passage of food into the stomach. Any kind of disease or spasm of muscles of oropharynx or hypopharynx can result in dysphagia.
Causes:
Several neurological, muscular, and local causes may result in oropharyngeal dysphagia.
• Stroke
• Head trauma
• Parkinson’s disease
• Amyotrophic lateral sclerosis (ALS)
• Polymyositis/dermatomyositis
• Myasthenia gravis
• Muscular dystrophies
• Metabolic disorders (thyroid myopathy)
• Trauma
Symptoms:
The condition ranges from being mildly symptomatic to causing recurrent aspiration pneumonia. Depending on the type and stage of the disease, the patient may present with any of the following:
• The inability to keep the bolus in the mouth
• Difficulty gathering the bolus at the back of the tongue
• Failure to initiate the swallow
• Food sticking in the throat
• Nasal regurgitation
• Inability to propel the food bolus
• Difficulty swallowing solids
• Frequent repetitive swallows
• Frequent throat clearing
• Hoarse voice
• Nasal speech and dysarthria
• Swallow-related cough: before, during, and after swallowing
• Weight loss
• Recurrent pneumonia
Diagnosis:
Modified barium swallow study (MBSS) and fiberoptic evaluation of swallowing (FEES) are two of the best currently available options for diagnostic information and to predict the preferred therapeutic intervention. Besides, these can also be used to evaluate the patient’s response to treatment.
Management:
Currently, there are no drugs that can cure dysphagia. The only option is a surgical intervention to correct the defect. Other modalities that may alleviate the symptoms of oropharyngeal dysphagia are rehabilitation, dietary modification, and physical therapy regimens designed to strengthen the muscles.
Esophageal Dysphagia
The esophagus is a hollow muscular tube about 25 cm long extending from hypopharynx to stomach. Physiologically there are three levels at which esophagus constricts, and these should not be confused with pathological constructions that result in dysphagia. These are cervical, thoracic, and abdominal constrictions at the level C5/6, T4/5, and T10/11, respectively.
Causes:
• Achalasia
• Gastroesophageal reflux disease (GERD)
• Esophagitis
• Esophageal strictures and rings.
• Esophageal tumors.
• Senile causes
• Previous surgery
Symptoms:
The most important complaint of the patient is the feeling of having something stuck in the throat. Other symptoms are:
• Difficulty in swallowing
• Pain
• Regurgitation
• Drooling, coughing, choking
• Wheezing
• Hoarse voice
• Dysphagia for liquid in advance disease
Diagnosis:
The diagnostic approaches are the fiberoptic evaluation of swallowing (FEES) and modified barium swallow study (MBSS) to provide thorough information about the disease and intervention required.
Management:
The patient can be treated with drugs, surgery, or physical dilatation of the esophagus, depending upon the condition. Dietary modification and speech therapy will also help in alleviating symptoms.
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History of Videostroboscopy
What is Videostroboscopy?
There are several diagnostic modalities to view the larynx, including indirect laryngoscopy using a mirror and direct laryngoscopy with the help of either a flexible endoscope or a rigid endoscope. Videostroboscopy is a diagnostic technique designed specifically to observe the vibration of vocal cords/vocal folds. The actual vibration of vocal cords is so fast that the unaided eye cannot observe it unless a slow-motion picture is generated.
The principle of videstroboscopy is to produce a slow-motion picture of the vocal cords vibration so that each vocal cord's vibration properties during the different phases of the vibration cycle can be perceived.
How Videostroboscopy Evolved:
The concept of videostroboscopy was presented long ago when stroboscopic images were generated using a flashing light source. Earlier in the 19th century, a Viennese scientist named Stampfer developed a rotating device to observe apparent motion and called it "stroboscope." All the pulsatile light-generating devices for observing motion come under this terminology.
The idea of examination of the larynx using stroboscopic light was, although conceived in 1874 by Oertal, it did not receive much recognition until the introduction of electricity in 1895. The device introduced by Oertal consisted of a perforated wheel that interrupted the light used to illuminate the vocal folds so that the vocal fold vibration could be appreciated. His device did not receive much recognition from the scientific community because of the limitations in illumination, imprecise control of the flashing frequency, and poor image quality.
Modern Strobolaryngoscopy:
The pioneers of modern strobolaryngoscopy are Dr. J.W. van den Berg, Dr. Rolf Timke, Dr. Hans von Leden, and Dr. Elimar from the University of Groningen, the University of Hamburg, the University of California, and Erlanger, respectively. They have written the first definitive book on stroboscopic examination of the larynx in 1960. Many principles of modern stroboscopic devices are based on the early to mid-1900s innovations in the usage of stroboscopic light for producing still images of moving objects. Plateau, a scientist, suggested that an intermittent flash can be used to illuminate moving objects to produce a stationary image, and H.E. Edgerton developed gas discharge tubes for stroboscopy using an oscillator that controls the frequency of the discharge and the rate of flashing.
The Talbot’s law defines that images linger in front of the retina for 0.2 seconds after exposure; therefore, to produce the illusion of a continuous image, sequential images (representing an object in motion) at the interval of fewer than 0.2 seconds are needed. Another concept is correspondence, in which analysis of a corresponding portion of sequential images produces an illusion of motion on the representation of still images.
A characteristic of the visual system is that it permits the interpretation of a series of slightly-altered still images by filling in the gaps between frames and present it as a continuous image. Based on all these laws, and improvements in audio and video recording technologies, and subsequent innovation in optical image resolution and fiberoptic light-source intensity, modern video stroboscopic unit produces a sharp, brightly illuminated and magnified image of vibrating vocal cords.
How Does it Work?
In strobolaryngoscope, intermittent light flashes depending upon the frequency of vocal cord vibration are thrown on vocal cords. This produces a clear, still image of each vibratory cycle. If the frequency of flashes is less than the vibration frequency of the vocal fold, it results in a delay in the portion of each vibratory cycle illuminated, producing an illusion of slow motion. Healthy vocal cords don't produce periodic vibratory motion. Thus, the pattern viewed by strabolaryngoscope is an average of many successive nonidentical vibratory cycles and is not truly a detailed demonstration of the individual cycle.
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Basic Anatomy:
Laryngopharyngeal Reflux (LPR) Disease
The pharynx is a hollow muscular tube that starts behind the nasal cavity and extends down up to the esophagus. Anterior to the pharynx is another tube- the larynx- made up of cartilaginous rings and muscle, which extends down up to the trachea. The pharynx and larynx have a common opening in the oral cavity serving as a route for the intake of food and passage of air, respectively. To prevent the misguided passage of a bolus of food into the airway, there is a slit-like cap, epiglottis, that closes the larynx during eating and opens it up while speaking and breathing.
Pathophysiology:
The underlying pathology for laryngopharyngeal reflux (LPR) disease is the same as for other reflux diseases. The incompetent lower esophageal sphincter leads to retrograde flow of stomach contents into pharynx and larynx. The stomach pH is highly acidic compared to the aerodigestive tract; the combined organs and tissues of all of the respiratory tract and the upper part of the digestive tract including the lips, mouth, tongue, nose, throat, vocal cords, and part of the esophagus and windpipe. The reflux of gastric fluid into these areas results in irritation, and ultimately inflammation with its dreadful consequences, if chronic.
Risk Factors for LPR:
Certain factors are known to increase the probability of LPR development and enhance disease progression:
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Lifestyle: Unhealthy diet, overeating, tobacco or alcohol use
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Physical Causes: deformed or malfunctioning esophageal sphincter, slow emptying of the stomach, overweight
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Physiological Conditions: pregnancy
Signs and Symptoms:
The clinical manifestations of LPR depend upon the severity and duration of irritation. Depending on these factors, LPR may present with:
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Hoarseness or voice problem
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Frequent need to clear the throat
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Excess mucus production or postnasal drip
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Bad breath
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Difficulty in swallowing solids, fluids or tablets
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Coughing after eating or lying down
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Breathing difficulty or choking episodes
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Chronic cough
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The sensation of a foreign body or lump in the throat
The long-term irritation of larynx may lead to:
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Chronic laryngitis
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Chronic rhinosinusitis
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Laryngeal malacia
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Laryngeal stenosis
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Laryngeal carcinoma
Diagnosis:
Over time, several techniques have evolved to diagnose LPR, but the primary procedure is laryngoscopy. There are two options available:
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Rigid laryngoscopy
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Flexible laryngoscopy
The flexible laryngoscope is more sensitive while rigid is more specific.
Another reflux testing method to diagnose LPR is intraluminal 24 hours pH monitoring, which detects acid and non-acid or gaseous fluid. LPR is confirmed when the total acid exposure time is (pH < 4) > 1% during 24-hour monitoring.
Treatment:
The most common medications used to treat LPR include:
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Antacids
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Proton pump inhibitors (PPIs)
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H2 blockers
These medicines work by decreasing stomach acid production. Lifestyle modification also plays a significant role in the management of LPR. Some common recommendations for patients with LPR are:
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Avoid sleeping immediately after having dinner. The average duration between sleep and dinner should be 3 hours.
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Avoid excessive consumption of food items that increase the risk of reflux. These include chocolate, spicy foods, citrus fruits, fried foods, and tomato-based foods.
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Smoking cessation also dramatically helps.
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Pay attention to stress management.
If all the above interventions fail, then surgery becomes inevitable. The most common surgery performed is lower esophageal sphincter strengthening.
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The Benefits of 24-hours pH Monitoring
The intensity of symptoms caused by reflux diseases ranges from mild discomfort and heartburn to frequent regurgitation, often resulting in dreadful complications. In order to establish the diagnosis of reflux diseases, a 24-hour pH monitoring technique is used. Esophageal 24-hour pH monitoring, also known as reflux impedance monitoring, is performed to measure the pH of the esophagus for 24 hours to correlate symptoms with reflux.
Relevant Anatomy and Physiology
Gastric acid, the HCl, formed by stomach cells, is essential for the digestion of proteins. The normal pH of the stomach ranges between 1.5-3.5, while that of the esophagus, pharynx, and larynx is much higher and falls towards the neutral end. A higher pH is important to protect the mucosa of esophagus, pharynx, and larynx as it is not specialized to withstand the acidic conditions stomach is designed for. The lower esophageal sphincter prevents the reflux of stomach contents into the esophagus, and its incompetency plays a major role in the pathophysiology of all reflux diseases, including laryngopharyngeal reflux (LPR) disease.
The Procedure of 24-hour pH Monitoring
For reflux testing, a catheter with dual sensor probes is used. The distal sensor reaches the lower end of the esophagus and measures pH while the proximal sensor is placed in hypopharyngeal region and measures LPR. The other end of the catheter is connected to a data recorder where it records any small fluctuations in the pH of the esophagus and shows it on the monitor.
In addition to the traditional dual-probe pH testing, wireless pH testing is another method used. In wireless pH testing, a chip like pH capsule is attached to the esophageal wall with the help of an endoscope, where it remains for 48 hours. It is connected to a wireless recording device, which gives readings of fluctuation in the pH of the esophagus. The traditional dual probe, however, is considered a gold standard and is widely used.
Interpretation of Esophageal pH Impedance Monitoring:
There are four subcategories defined according to esophageal pH detected by impedance during reflux, on the basis of which diagnosis is made and severity is established.
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Acid reflux- decrease in pH to <4 (confirm definitive diagnosis of reflux)
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Acid re-reflux- is superimposed acid reflux during the period of acid clearing when the pH is still <4 (before the esophageal pH recovers to >4)
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Weakly acid reflux- pH is >4 but <7 during reflux
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Weakly alkaline reflux- pH is either >7 or increases to >7 during reflux
In healthy individuals, it is noted that about 40 episodes of reflux occur normally over a period of 24 hours. Acid reflux is twice as common as re-reflux while weakly acid and weakly alkaline reflex are rarely seen
The Benefits of 24-hour pH Monitoring:
The test is performed when the symptoms, such as heartburn and regurgitation, do not respond to medicine. Sometimes it is used to evaluate and correlate atypical symptoms of reflux disease like cough, chest pain, wheezing, sore throat, hoarseness, to a decreased pH. The benefits of 24-hour pH monitoring are described below.
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Highly sensitive: It is considered a gold standard procedure for the diagnosis of reflux disease because it is a highly sensitive test. During 24-hour monitoring, even slightest changes in the acidity of the esophagus are noted. It is often combined with esophageal manometry (noticing movements of esophageal muscles) to give more accurate results.
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Before acid reflux surgery: Patients with the refractory disease need surgery to cure acid reflux. Before this surgery, many tests are performed as a standard protocol. These tests are upper gastroesophageal endoscopy, manometry, and 24 hours pH monitoring. The benefit of 24-hour pH monitoring for Preoperative Esophageal Evaluation is that it provides objective evidence of reflux disease and excludes esophageal hypersensitivity.
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Deciding effective medicine: The atypical presentation of reflux disease can be challenging. It also becomes difficult to suggest an appropriate medicine for these patients. Therefore, pH monitoring is crucial to not only confirm the diagnosis but also guide the selection of medicine according to the severity of reflux.
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To understand voice disorders, one should have an idea about the normal physiology of voice production. A normal human being has two sets of vocal cords present in the larynx. In speech production, the air from the lungs passes through the narrow opening between the vocal cords, and the force of the wind causes the vocal cords to vibrate. The vibrating force produces sound waves, and this is how voice production is made possible.
The Most Common Voice Disorders
Voice Disorders
There are several types of voice disorders caused by different pathologies. The most important ones are described below.
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Inflammatory Voice Disorders: Laryngitis is the inflammation of the larynx caused by a number of factors such as overuse, infection, or irritation of the larynx. It may be acute or chronic.
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Neurological Voice Disorders: They occur due to underlying neurological condition examples include multiple sclerosis, Parkinson's, and muscular dystrophy.
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Vocal Cord Paralysis: It occurs when nerve impulses supplying the vocal cords are disrupted.
The Causes
Voice disorders can be caused by a number of different pathologies, and in some cases, the reason remains unknown. Some of the factors which can cause voice disorders include:
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Growths such as polyps, nodules, or cysts.
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Inflammation and swelling of the vocal cords.
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Hormonal imbalance like thyroid issues which often cause hoarseness of voice.
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Misuse of the voice, often seen in certain professionals such as teachers and singers as they use their voice more frequently compared to an average person.
The Signs and Symptoms
Some of the most important indicators of a voice disorder include:
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Hoarseness of voice
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Having a quivering voice
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Vocal fatigue
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Aphonia or voice loss
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Pain while talking
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Sounding strained
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Whispery or breathy voice
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A change in pitch
Diagnoses of Voice Disorders
An otolaryngologist can easily identify the voice disorders by observing the quality of voice in addition to an evaluation of signs and symptoms the patient is suffering from. However, to confirm the diagnosis and to identify the cause, the doctor will have to examine the vocal cords and larynx by performing certain tests. These tests include:
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Laryngoscopy: It is an examination that allows the doctor to see the back of the throat, voice box, and vocal cords with the help of a scope called a laryngoscope. Laryngoscopy is of two types, and each uses the different equipment.
1. Indirect Laryngoscopy: It is performed by using a small mirror and a headlight to look in the throat.
2. Direct Laryngoscopy: It helps visualize deeper structures in the throat. It further divided into two subtypes: rigid and flexible. Flexible endoscopes are more comfortable for the patient and show the throat better, whereas the rigid endoscopes are often used in the surgery.
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Videostroboscopy:This procedure is a gold standard in laryngological diagnostic care. In this procedure, strobe light and video camera are used to see how the vocal cords vibrate during speech.
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Imaging tests: Imaging techniques, such as X-rays and MRI are often used for visualizing tissue growth.
The Treatment
Treatment depends upon the underlying cause of the condition. It may include:
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Lifestyle changes
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Speech therapy
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Medicine for example in laryngitis to treat the infection
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Surgery to remove tissue growth