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Dysphagia FEES

April Research Tuesday

SA Swallowing Services is joining Gray Matter Therapy again for this month’s Research Tuesday!  Research Tuesday was created to “increase accountability for reading research, advocate for reading research, and improving exposure to research.” Every second Tuesday of each month, speech-language pathologists from all settings across the world join together at Gray Matter Therapy to share current literature reviews so that we may all benefit from the most up-to-date research.  This month, Kelley Babcock, M.S., CCC-SLP, BCS-S delves into the use of topical anesthetics in endoscopy.

 

 Comfortably Numb?  Does Anesthetic Impact FEES?  
A big debate in the world of flexible endoscopic evaluation of swallowing (FEES) is use of topical anesthetic to numb the nose prior to evaluation.  I have participated in FEES exams and trainings all over the country, and there are a variety of SLP practice preferences when it comes to anesthetic use.  Some SLPs believe that the procedure is too painful to tolerate without numbing,  some ask the patient if they prefer it, some believe that the evaluation is negatively impacted by the use of anesthetic, and some SLPs are not even allowed by their state laws to use it.  The 2004 ASHA Guidelines on the Role of the Speech-Language Pathologist in the Performance and Interpretation of Endoscopic Evaluation of Swallowing state that SLPs may use topical anesthetic alone or in combination with vasoconstrictors to allow for a more comfortable procedure (1). Each state has its own guidelines on who can administer anesthetics to patients, so always check your state rules prior to administration of any anesthetic.
Most ENTs use topical lidocaine spray when performing endoscopy, but numbing is by no means required to complete the evaluation.  I personally find the spray to be horrible in flavor and not very pleasant during administration, so when I am scoped in trainings and exhibitions, I choose to go without.  Butler and colleagues presented a paper at the 2012 Dysphagia Research Society Meeting in Toronto showing negative swallowing outcomes and increased Penetration/Aspiration Scale Scores after administration of 1cc of 4% lidocaine spray (2), so when I know a patient will be seen by the ENT before my FEES, I always ask the ENT not to spray the patient. Viscous lidocaine jelly, which is part of the original Langmore FEES protocol, is quite commonly applied by SLPs during their FEES.  This article took a closer look at swallowing outcomes, ease of exam performance, and patient comfort with the use of 2% lidocaine jelly on FEEST exams.
 Kamarunas, E.E., McCullough, G.H., Guidry, T.J., Mennemeier, M.,  Schluterman, K.  (2014). Effects of Topical Nasal Anesthetic on Fiberoptic Endoscopic Examination of Swallowing with Sensory Testing (FEESST).  Dysphagia.  29:33–43.  (Original article here: Effects of Topical Anesthetic 2014)
This article, which looks at the effect of 2% lidocaine jelly on flexible endoscopic evaluation of swallow with sensory testing (FEESST) outcomes is an excellent addition to the literature on anesthetic use.  Kamarunas and colleagues completed a prospective, double-blind, controlled, randomized, crossover study on healthy, nondysphagic adults who underwent a FEESST exam with .4mL of 2% lidocaine jelly and again with a placebo lubricant.  Though they are not frequently performed in clinic settings anymore, the FEESST exam was chosen for this study as it contains the entire FEES exam as well as the sensory testing of the laryngeal adductor reflex (LAR).  The LAR is an involuntary closure of the vocal folds which occurs as a protective mechanism against aspiration (3).  It is stimulated either via a puff of air to the aryepiglottic folds, as in this study, or via touching the aryepiglottic folds with the tip of the scope.
The examination included a test of LAR as well as 3 trials each of 10mL & 20 mL of milk and 3 trials of one teaspoon of applesauce.  After the exam, each participant completed a comfort scale rating form and the examiner completed a form identifying the quality of the scope performed and the ease with which the scope was passed.
The physiologic aspects of the swallow studied were the LAR, bolus dwell time at the vallecula & pyriform sinuses, pharyngeal closure duration, pharyngeal residue scales, and penetration/aspiration scale scores.  The only physiologic aspect of the swallow which was found to have a significant difference between the sham and true anesthetic was the bolus dwell time at the vallecula and pyriform sinuses with 10mL of liquid.  The laryngeal adductor reflex was determined to be “normal” for both exams for all participants.  The presence of  lidocaine did not improve the participant’s ability to tolerate the sensory testing, nor did it improve patient comfort, ease of exam or the quality of the view.  The chart below shows the score differences between lidocaine and sham testing in patient comfort, ease of exam, and quality of view on a scale of 0-100.
april data
At SA Swallowing Services, we train clinicians to scope without any anesthetic.  We do not believe that it is required for an accurate exam, and this study shows that it does not significantly improve patient comfort, the ease of the scope or the quality of the view.  Because we train clinicians from all over the country, we do not want clinicians to leave our courses feeling dependent upon the use anesthetic to perform a good evaluation, as their state rules may not allow them to use it.  This study shows that if you have the luxury of access to 2% lidocaine jelly, your patients will not have significant swallowing impairment from its use, but they may not be any better from it either.  If you can scope both with and without anesthetic, you as the SLP can make the best judgement for each individual patient to perform the easiest and most comfortable exam. If you have further questions on endoscopy or would like to pursue basic or advanced training in performance of endoscopy, check out our CEU courses  or contact us at john@sasspllc.com.
1. ASHA Special Interest Division 13: Swallowing and Swallowing Disorders (Dysphagia) Committee on Endoscopic Evaluation of Swallowing Guidelines. (2004(. Role of the speech-language pathologist in the performance and interpretation of endoscopic evaluation of swallowing: guidelines.  http://www.asha.org/policy/GL2004-00059.htm Accessed 1 April 2014.
2. Butler S, Lester S, Langmore S, Lintzenich C, Wright S. (March 2012). Effects of topical nasal anesthetic on flexible endoscopic evaluation of swallowing. 20th annual meeting of the Dysphagia Research Society Meeting, Toronto, ON, Canada.
3. Kamarunas, E.E., McCullough, G.H., Guidry, T.J., Mennemeier, M.,  Schluterman, K.  (2014). Effects of Topical Nasal Anesthetic on Fiberoptic Endoscopic Examination of Swallowing with Sensory Testing (FEESST).  Dysphagia.  29:33–43.

 

Kelley Babcock, MS, CCC-SLP, BCS-S, is a voice and swallowing therapist from Nashville, Tennessee.  She works as a clinician and educator for SA Swallowing Services which provides basic, advanced and custom FEES courses for SLPs across the country.  For more information on FEES and dysphagia, check out sasspllc.com or connect with Kelley on Twitter or LinkedIn.

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