instrumental evaluation

commonly used instrumental evaluations in pediatrics

• Videofluoroscopic Swallow Study (VFSS), also called Modified Barium Swallow Study (MBSS)

• Fiberoptic Endoscopic Evaluation of Swallowing (FEES)

• Ultrasound (less common, indirect)

factors that impact evaluation

• characteristics of the child

• environment/social factors

• age/timing of exposure

what are some possible characteristics of the child

• diagnostic conditions

• comorbidities

• neurodevelopmental status

• feeding experiences

what are some possible environmental/social factors

• feeding techniques

• access to health care and appropriate therapies

age/timing of exposure factors

• growth and development

• susceptibility to injury

• nueroplasticity

what cannot be done bedside (even during feeding)

radiation

FEES is performed by who and what are their roles?

• Performed by ENT and SLP team

• SLP assesses sensorimotor status; ENT passes scope

how can children be positioned during FEES?

Infants may be swaddled; toddlers can sit in caregiver’s lap or chair

what can be used during FEES to help with the procedure?

Topical anesthesia may be used (carefully to avoid suppressing reflexes)

advantages of _____

• can be performed ____

• position of the patient is _____

• observation of structure and function of _______ and ______ is possible

• can be used with _____ who are _______

• investigates ________ funtion of _______ and ______

• no _______ exposure, can be _____ and study may _________

• tests response to _______

• can be performed bedside

• position of the patient is flexible

• observation of structure and function of hypopharynx and larynx is possible

• can be used with infants who are breastfeeding

• investigates sensorimotor funtion of hypopharynx and larynx

• no radiation exposure, can be repeated and study may take as long as needed

• tests response to secretions

disdvantages of _____:

• incomplete examination of _____ phase of swallow because of _______

• visualizes structures only immediately_____ or _____ a pharyngeal swallow

• cannot assess _____ or ______ phases of swallow

• unable to evaluate coordination of _________, _______, and ________

• _________ (potential ________)

FEES

• incomplete examination of pharyngeal phase of swallow because of “white-out”

• visualizes structures only immediately before or after a pharyngeal swallow

• cannot assess oral or esophageal phases of swallow

• unable to evaluate coordination of pharyngeal motility with tongue action, laryngeal elevation or excursion, and upper esophageal function

• minimally invasive (potential nosebleeds)

Dynamic radiologic imaging

VFSS or MBSS

VFSS or MBSS images what phases?

oral, pharyngeal, and upper esophageal phases

where is VFSS or MBSS conducted?

radiology suite using barium contrast

Often considered the “gold standard,” though only one part of a comprehensive evaluation

VFSS or MBSS

what does VFSS or MBSS evaluate?

• Bolus formation, transfer, and oral transit time

• Pharyngeal motility and timing of swallow

• Airway protection: penetration/aspiration events

• Residue in valleculae, pyriform sinuses

• Upper esophageal function (UES/PES)

• Coordination of structures (hyoid, larynx, tongue base)

What parts of the swallow can MBSS visualize?

oral, pharyngeal, and upper esophageal phases

advantages of ____:

• Timing of _______

• Coordination with _________

• Residue in ________ and _______-

• ________ deficits and amount of _______

• Response to ______ (seen and heard via audio)

• Swallowing impairment linked to _____

• _____ and ________ times

• Is ________ in medical settings

MBSS

• Timing of swallow initiation

• Coordination with oropharyngeal structures

• Residue in pharyngeal recesses and pyriform sinuses

• Physiologic deficits and amount of aspiration

• Response to aspiration (seen and heard via audio)

• Swallowing impairment linked to aspiration

• Oral and pharyngeal transit times

• Is widely available in medical settings

disadvantages of _____

• Uses ______, so study time is ______

• Requires _______

• ____ equipment limits _______

• Patient must be ________ (unless portable unit available)

• Needs _______

• Requires ______, which changes ______ of ______

• Only captures a ________ of swallowing—may _______ aspiration risk

• Lack of __________ for infants and young children

MBSS

• Uses ionizing radiation, so study time is limited

• Requires patient cooperation

• Bulky equipment limits positioning options

• Patient must be transported to radiology (unless portable unit available)

• Needs trained personnel (SLP + radiologist)

• Requires barium, which changes taste/texture of foods/liquids

• Only captures a brief snapshot of swallowing—may underestimate aspiration risk

• Lack of standardized tools for infants and young children

prepping for a MBSS

• Positioning and posture critical (optimal alignment)

• Children should be awake, calm, hungry

• Familiar feeding equipment and caregivers helpful

• Minimize distress; non-threatening environment supports success

• Adjustments needed for children with NG/G-tubes, trachs, or sensory challenges

when to recommend a repeat MBSS

Only when clinically indicated (“as seldom as possible” due to radiation)

triggers for repeat MBSS study:

• Significant change in health status

• New symptoms or recurrence of old ones

• Prior silent aspiration

• Trial of new interventions

• Need to evaluate diet/textural changes

how we can help prepare for a repeat MBSS

• Small, monitored trials of thin liquids/reduced consistencies

• Powdered sugar to mimic barium on solid foods

• Social Stories/Videos

• "Taking pictures" during food trials

• Create positive but concrete language around MBSS 

DO NOT let the MBSS be the what?

FIRST trial of new consistency

High-frequency sound waves (2–10 MHz) used to image soft tissues

ultrasound imaging of swallowing (US)

ultrasound imaging of swallowing (US) is _______ and ______

Non-invasive and radiation-free

ultrasound imaging of swallowing (US) provides real-time dynamic imaging of:

• Oral structures (tongue, hyoid, palate)

• Bolus movement during oral prep and oral transit

• Suck-swallow-breathe coordination in infants

advantages of __:

• No __________

• ________ can be used

• _______, ______ sampling possible

• Equipment is __________

• Shows __________of soft tissues

• Can detect ______ with _________

US

• No radiation exposure

• Real food/liquid can be used

• Repeatable, prolonged sampling possible

• Equipment is widely available

• Shows real-time function of soft tissues

• Can detect fluid flow with Doppler (paired mode)

disadvantages of ___:

• Cannot visualize __________

• ______ blocks deeper structures

• Limited to ______; poor _______ imaging

• ________ hard to see

• Requires _________

• __________ in clinical practice

• Cannot visualize penetration/aspiration

• Bone/cartilage blocks deeper structures

• Limited to oral phase; poor pharyngeal imaging

• Laryngeal landmarks hard to see

• Requires specialized training

• Limited current use in clinical practice

Who can administer FEES, MBSS, US?

FEES: SLP + ENT

MBSS: SLP + radiologist

US: SLP + radiologist