What is the preferred initial test between FEES and MBS for a patient with aspiration due to cervical stenosis and patulous esophagus?

Choosing Between FEES and Modified Barium Swallow for Aspiration in Cervical Stenosis and Patulous Esophagus

For patients with aspiration due to cervical stenosis and patulous esophagus, FEES (Fiberoptic Endoscopic Evaluation of Swallowing) is the preferred initial diagnostic test over modified barium swallow (MBS/VSE). 1, 2

Rationale for Choosing FEES

Advantages of FEES in This Specific Case

• Anatomical Considerations: FEES provides direct visualization of the pharynx and larynx, which is particularly valuable in cervical stenosis where structural abnormalities need to be clearly identified 1
• Bedside Availability: Can be performed at the bedside or in a clinic setting, avoiding transportation challenges for patients with cervical stenosis 1
• No Radiation Exposure: Unlike MBS, FEES doesn't expose the patient to radiation, which is beneficial when multiple evaluations may be needed 2
• Real-time Assessment: Allows direct observation of pharyngeal residue and aspiration in patients with structural abnormalities 1
• Minimal Patient Cooperation: Requires less patient positioning and cooperation, which is advantageous in patients with cervical stenosis who may have limited neck mobility 2

Specific Benefits for Cervical Stenosis and Patulous Esophagus

• FEES can identify impaired chewing, tongue muscle deficit, velo-pharyngeal closure competence, laryngeal morphology and motility, and cough reflex sensitivity 1
• Particularly useful for detecting pharyngeal residues, which are common in patients with cervical stenosis 1
• Can directly visualize the structural abnormalities associated with patulous esophagus

Protocol Considerations for FEES

Recommended FEES Protocol

1. Multiple Swallow Trials: Use at least 7-10 swallow trials for thin liquids and thick liquids to avoid underestimating aspiration risk 3
2. Varied Consistencies: Test with multiple food and liquid consistencies (thin liquids, thick liquids, purees, solids) 1
3. Assessment Components:
   • Evaluate pharyngeal and laryngeal anatomy
   • Assess pooling of secretions
   • Test laryngeal sensation
   • Observe swallowing function with different bolus types
   • Evaluate effectiveness of compensatory strategies 1, 2

When to Consider MBS Instead

While FEES is generally preferred for initial evaluation in this case, MBS (also called VSE) may be more appropriate in certain circumstances:

• When detailed assessment of the esophageal phase is critical (MBS provides better visualization of the entire swallowing process) 1
• When quantitative measurements of cervical esophageal stenosis are needed (MBS allows for measurement of esophageal diameters) 4
• When evaluation of the effect of compensatory postures is specifically needed 1

Complementary Testing Approach

In some cases, a complementary approach may be beneficial:

1. Initial FEES to assess pharyngeal and laryngeal structures, aspiration risk, and response to compensatory strategies
2. Follow-up MBS if needed to:
   • Quantify the degree of stenosis (using minimum/maximum ratio <0.50 to define stenosis) 4
   • Evaluate the esophageal phase more comprehensively
   • Assess the effectiveness of specific compensatory maneuvers

Management Following Evaluation

Based on findings from FEES or MBS:

1. Compensatory Strategies:

   • Postural adjustments (chin down, head turn) can reduce aspiration in patients with structural abnormalities 1
   • Swallowing maneuvers to improve pharyngeal clearance 1

2. Dietary Modifications:

   • Adjust food and liquid consistencies based on findings 1
   • Consider thickened liquids if thin liquid aspiration is identified 1

3. Multidisciplinary Approach:

   • Involve speech-language pathologist, neurologist, gastroenterologist, and dietitian 1, 2
   • Regular reassessment to monitor progress and adjust recommendations 2

Common Pitfalls to Avoid

• Insufficient swallow trials: Using too few swallow trials can underestimate aspiration risk, particularly in patients with structural abnormalities 3
• Relying solely on bedside screening: Clinical bedside evaluations alone have insufficient sensitivity (56%) for detecting aspiration in patients with structural abnormalities 4, 5
• Overlooking silent aspiration: Patients with cervical stenosis may have silent aspiration that is not detected without instrumental evaluation 1, 2
• Failure to reassess: Regular reassessment is necessary as swallowing function may change over time 2

By following this approach, clinicians can optimize the diagnostic evaluation and management of patients with aspiration due to cervical stenosis and patulous esophagus.