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European Annals of Otorhinolaryngology, Head and Neck Diseases
Volume 135, n° 1S
pages 17-21 (février 2018)
Doi : 10.1016/j.anorl.2017.12.009
International Consensus (ICON) - IFOS Paris 2017 - ENT World Congress

International consensus (ICON) on assessment of oropharyngeal dysphagia
 

F. Espitalier a, , A. Fanous b, J. Aviv c, S. Bassiouny d, G. Desuter e, N. Nerurkar f, G. Postma g, L. Crevier-Buchman h
a Department of Otolaryngology-Head and Neck Surgery, CHU de Nantes, 44093 Nantes, France 
b Department of Otolaryngology-Head and Neck Surgery, McGill University, Montreal, Quebec, Canada 
c Department of Otolaryngology-Head and Neck Surgery, Icahn School of Medicine, Mount Sinai Hospital, New York, USA 
d Department of Otolaryngology-Head and Neck Surgery, Ain Shams University, Cairo, Egypt 
e Department of Otolaryngology-Head and Neck Surgery, Voice & Swallowing Clinic, Cliniques universitaires Saint-Luc, Université catholique de Louvain, Brussels, Belgium 
f Department of Otolaryngology-Head and Neck Surgery, Bombay Hospital, Mumbai, India 
g Department of Otolaryngology, Center for Voice, Airway and Swallowing Disorders, Medical College of Georgia at Augusta University, Augusta, GA, USA 
h Department of Otolaryngology-Head and Neck Surgery, hôpital européen Geroges-Pompidou, 75015 Paris, France 

Corresponding author. ORL et CCF, CHU Hôtel-Dieu, 1, place Alexis-Ricordeau, 44093 Nantes cedex 1, France.
Abstract
Objective

To present international recommendations regarding the proper evaluation of oropharyngeal dysphagia (OD), both objectively and subjectively (self-evaluation).

Methods

Following a thorough review of the literature, 5 experts in the field from 4 different continents answered separately a questionnaire regarding the work-up of OD. Individual answers were presented and discussed during the world ENT conference that was held in Paris in June 2017. This article will present the recommendations issued from that meeting.

Results

For the initial objective assessment of OD, it is recommended to perform either a functional endoscopic evaluation of swallowing (FEES) or a videofluoroscopic swallowing study (VFSS). FEES is the more popular investigation given its increased ease of use and accessibility. When evaluating for the presence of aspiration during the objective evaluation of OD, it is recommended to perform either a FEES or a VFSS. In this case, FEES is the favored investigation given its likely increased sensitivity. In order to highlight the presence of oropharyngeal food residue following the deglutition process, it is recommended to perform either a FEES or a VFSS; FEES likely being the more sensitive investigation while VFSS allows a better quantification of the amount of pharyngeal residue. Is it also recommended to objectify the quality of the deglutition process by means of a score during the objective evaluation of OD. Finally, it is recommended to utilize a self-evaluation questionnaire during research studies exploring the deglutition process.

The full text of this article is available in PDF format.

Keywords : Oropharyngeal dysphagia, Endoscopic evaluation of swallowing, Swallowing score, Deglutition self-evaluation questionnaire, Videofluoroscopic swallowing study


Introduction

Oropharyngeal dysphagia (OD) is defined as a disturbance in the passage of the food bolus from the mouth to the esophagus [1]. OD puts the patient at risk for aspiration pneumonia, malnutrition and dehydration, all of which increase morbidity [2]. Furthermore, understandingly, OD has a significant impact on patient quality of life [3]. OD has various possible etiologies. Tumors of the aero-digestive tract and their respective treatments can lead to dysphagia. It is estimated that 14 to 18% of these patients suffer from OD prior to any treatment [4, 5]. Excisional surgery is linked to deglutition problems by directly injuring the organs involved. Radiotherapy gives rise to dysphagia early on secondary to oral mucositis, but also as a late complication secondary to muscular fibrosis [6]. When radiotherapy is combined with chemotherapy, the acute oral mucositis is more severe, increasing the likelihood of requiring enteral feeding [7]. Following the treatment of cancers of the aero-digestive tract, the ensuing dysphagia remains stable in 48% of cases, diminishes over time in 32% of cases and worsens in 20% of cases [8]. Furthermore, neck and thoracic surgical interventions, even those not performed for malignant tumors of the aero-digestive tract, can cause OD by injuring the nerves involved in deglutition, mainly the vagus nerve and its branches [9]. OD can also be observed in the context of neurodegenerative or diffuse neuromuscular disorders [10]. Neurovascular pathologies, which may also lead to OD, were voluntarily excluded from this guideline given the significantly varying context and nature of the work-up process.

Amongst the various assessment tools for OD, objective investigations as well as questionnaires evaluating patient quality of life may be offered to the patient. Objective investigations include the functional endoscopic evaluation of swallowing (FEES) and the videofluoroscopic swallowing study (VFSS). Various scores evaluating the quality of deglutition allow for the quantification of the patient's symptomatology. The patient's perspective is another means of assessment, relying on self-evaluation questionnaires regarding swallowing quality of life.

Currently, no consensus exists regarding the proper evaluation of OD. Differing assessment strategies are utilized depending on the center, the country and the practice habits. The objective of this recommendation is to highlight the main points of consensus regarding the evaluation of OD across the globe.

Methods

Given the lack of evidence-based proof by means of randomized controlled trials on the proper evaluation of OD by objective investigations or self-evaluation questionnaires, the opinion of 5 experts from 4 different continents (Europe, Asia, America, Africa) was sought out by means of a questionnaire based on a thorough review of the literature. A counsel of 2 medical experts was appointed in order to perform a systematic review of the literature on the subject. Keywords entered in the MEDLINE database included “oropharyngeal dysphagia assessment, aspiration, penetration, swallowing impairment, head and neck cancer, neurodegenerative pathology, cervical surgery, thoracic surgery, quality of life, scores, self-assessment” between 1995 and 2017. The 2 counsel experts then created a questionnaire consisting of fourteen questions, grouped under 5 headlines:

objective investigations;
food textures utilized;
underlying complications (aspiration/residue);
severity scale;
self-evaluation scales.

The role of objective investigations as well as self-evaluation questionnaires in the work-up of patients presenting with a complaint of OD was successively broached, excluding neurovascular causes of dysphagia (Table 1).

The answers provided by the experts were collected, compared to the data available in the literature, and presented during the world ENT conference that was held in Paris on the 28th of June 2017. Recommendations were then formulated based on these results. The proposed recommendations were classified as grade A, B or C or professional consensus, in decreasing order based on the level of scientific evidence, in accordance with the guidelines for literature analysis and grading recommendations published by the Anaes (January 2000; Table 2).

Recommendations

A multidimensional evaluation of swallowing utilizing various tools is recommended in order to provide complimentary information regarding swallowing physiopathology, but also to aid in therapeutic decision-making. However, investigation methods vary depending on the country, the center and the individuals, mainly influenced by socioeconomic factors [11]. Clinical evaluation of dysphagia is performed first, before instrumental evaluation. Upon questioning, concepts reflecting the quality of swallowing are put to the patient, such as the texture of food ingested, the presence of cough during or after feeding. The duration of the meal is also raised. The severity of swallowing disorders is sought by measuring their impact on nutrition (looking for weight loss), as well as possible pulmonary complications (search for pulmonary infection or pulmonary fibrosis).

In terms of objective investigations for OD, there are 5 main exams cited in the literature (FEES, VFSS, esophageal manometry, pharyngeal pH monitoring, esophageal impedance pH monitoring). FEES and VFSS are considered the 2 most informative exams, allowing the identification of patients at risk for aspiration pneumonia [12]. FEES is more practical to perform in the clinical setting given that the only material requirement is a fiberoptic laryngoscope. In contrast, VFSS necessitates a dedicated radiology room and the use of contrast products. Furthermore, VFSS subjects the patient to radiation, while FEES does not. All of the above stated reasons render FEES the largely preferred initial diagnostic investigation. However, according to some of the experts, VFSS is the preferred initial exam when investigating for certain specific pathologies (Table 1).

The majority of the experts utilize various different textures when testing deglutition during a FEES study (liquid, thick liquid, cream, biscuit). The order of introduction of the textures may vary depending on the patient's pathology. However, in the vast majority of cases, all textures are tested.

Recommendation 1: for the objective investigation of OD, it is recommended to systematically perform either a FEES or VFSS, FEES being the preferred initial investigation given its increased ease of use (professional agreement).

The medical literature has already broached the topic of comparing these 2 diagnostic exams in terms of detecting aspiration and pharyngeal residue. Giraldo-Cadavid et al. [13] listed 6 articles when constructing their meta-analysis. FEES seems to be the most sensitive investigation to detect the presence of penetration (laryngeal aspiration), aspiration (true tracheal aspiration) and pharyngeal residue. There is no significant difference in the sensitivity of FEES or VFSS to detect posterior oral incompetence. The specificity of both exams is comparable.

Three studies have compared FEES and VFSS by simultaneously performing both of these exams on a given patient. In other words, during a VFSS assessment, a fiberoptic laryngoscope is introduced and a FEES is performed in the same setting [14, 15, 16]. These studies also revealed that FEES is more sensitive in detecting laryngeal and tracheal aspiration, as well as pharyngeal residue. However, a limitation of FEES is the overestimation of the amount of pharyngeal residue. VFSS seems to better quantify the amount of residue. A recent study by Adachi et al. has questioned these findings by proposing that the intrusive insertion of a fiberoptic laryngoscope during a FEES exam can negatively affect the quality of the deglutition process [17]. This study performed VFSS exams with and without the simultaneous introduction of a laryngoscope. They showed that the rate of aspiration and pharyngeal residue was increased with the insertion of a laryngoscope. The question then becomes whether FEES is truly the more sensitive exam or whether the insertion of the fiberoptic laryngoscope alters the deglutition process and therefore artificially increases the exam's sensitivity. Importantly, when the FEES exam was normal, so was the VFSS. The authors therefore concluded that if a FEES exam is normal, the deglutition process can be considered normal, thus avoiding the need to perform a VFSS to validate these findings [17].

The experts were questioned regarding the most sensitive exam to detect aspiration and pharyngeal residue. Amongst their answers, most proposed VFSS or FEES, or occasionally both modalities. Regardless of the investigation performed, it is undeniable that the ability to correctly interpret the results remains crucial to increase the exam's sensitivity.

Recommendation 2: in order to highlight the presence of penetration or aspiration during the objective investigation of OD, it is recommended to perform either a FEES or a VFSS. FEES seems to be the more sensitive study, and should therefore be prioritized in centers lacking both of these exams (Grade C).

Recommendation 3: in order to highlight the presence of pharyngeal residue following deglutition, it is recommended to perform either a FEES or a VFSS. FEES seems to be the more sensitive study, while VFSS would allow the better quantification of the amount of pharyngeal residue (Grade C).

A score system can be employed as part of the objective evaluation of OD in order to quantify the dysphagia. Multiple scoring systems have been proposed in the literature, employed in conjunction with either FEES or VFSS. The most famous and probably the most employed one is the Penetration Aspiration Scale (PAS) [18], described in 1996 by Rosenbek et al. [19]. This score can be implemented during a FEES or VFSS. The majority of our experts use this scoring system frequently in order to better objectify the deglutition process.

Recommendation 4: it is recommended to objectify the quality of deglutition with a scoring system as part of the comprehensive objective evaluation of deglutition (professional agreement).

Multiple self-evaluation questionnaires exist, allowing for the evaluation of the patient's swallowing quality of life or to monitor the efficacy of a treatment [20]. In contrast with the previously stated objective investigation assessment tools for OD, these self-evaluation questionnaires have the advantage of being inexpensive, fast and easily reproducible over time. However, one must remember that their sensitivity, specificity and positive predictive value is inferior to that of a FEES [21]. There are four self-evaluation questionnaires specifically dedicated to assessing OD quality of life: the Deglutition Handicap Index (DHI) [22], the Dysphagia Handicap Index (DHI’) [23], the MD Anderson Dyspagia Inventory (MDADI) [24] and the SWAL-QOL [25]. A study by Timmerman et al. revealed that the SWAL-QOL had the best psychometric parameters and that the DHI’ was the easiest to use, with only 25 items and a uniform annotation process [26].

The experts seldom use self-evaluation questionnaires as part of the evaluation of OD. They are mostly employed for research purposes. The DHI is one of the most utilized questionnaires. Translation is an issue regarding these self-evaluation questionnaires. Indeed, they are often initially validated in English, thus needing to be translated and re-validated in different languages in order to be administered to an increased number of patients across the globe. Furthermore, literacy and education level of the target population are important considerations when administering self-evaluation questionnaires in order to avoid bias.

Recommendation 5: during research studies regarding deglutition, it is recommended to administer a self-evaluation questionnaire exploring dysphagia related quality of life (professional agreement).

Disclosure of interest

The authors declare that they have no competing interest.

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