Pediatric Laryngopharyngeal Sensory Testing during Flexible Endoscopic Evaluation of Swallowing: Feasible and Correlative

Abstract

Laryngopharyngeal sensory testing can predict aspiration risk in adult patients. Its feasibility and potential role in the evaluation of pediatric swallowing is undetermined. The goals of this study were to determine the feasibility of performing laryngopharyngeal sensory testing in awake pediatric patients and to assess whether the sensory testing results correlated with aspiration during a feeding assessment or correlated with a history of pneumonia. Fiberoptic endoscopic evaluation of swallowing with sensory testing was performed in 100 pediatric patients who were evaluated for feeding and swallowing disorders. The swallowing function parameters evaluated were pooled secretions, laryngeal penetration, and aspiration. The laryngopharyngeal sensory tests were performed by delivering a pressure-controlled and duration-controlled air pulse to the aryepiglottic fold through a flexible laryngoscope to induce the laryngeal adductor response (LAR). The air pulse stimulus ranged in intensity from 3 to 10 mm Hg. The patients tested ranged from 1 month to 24 years of age, with a median age of 2.7 years. Sensory testing was completed in 92% of patients. Patients who had an LAR at less than 4 mm Hg rarely if ever had episodes of laryngeal penetration or aspiration. Those with an LAR at 4 to 10 mm Hg had variable amounts of aspiration and laryngeal penetration. The LAR could not be elicited at the maximum level of intensity (10 mm Hg) in 22 patients, who demonstrated severe laryngeal penetration and/or aspiration. Elevated laryngopharyngeal sensory thresholds correlated positively with previous clinical diagnoses of recurrent pneumonia, neurologic disorders, and gastroesophageal reflux, and correlated positively with findings of pooled secretions, laryngeal penetration, and aspiration. Laryngopharyngeal sensory testing in children is feasible and correlative.

Initiating Safe Oral Feeding in Critical Care

“…An important caveat, however, is that the Yale Swallow Protocol, which includes a 3 oz water swallow challenge, should not be used for screening patients who require a tracheotomy tube. Silent aspiration occurs more frequently due to laryngeal desensitization from airflow bypassing the upper airway and chronic aspiration of secretions (Link et al 2000;Donzelli et al 2003). Although a tracheostomy is not causal for aspiration (Leder andRoss 2000, 2010) if aspiration occurs, it is often silent, leading to higher false-negative rates.…”

Fiberoptic Endoscopic Evaluation of Swallowing (FEES)

“…The presence of secretions in the laryngeal vestibule has been shown to be highly predictive of aspiration later in the examination [ 25,26 ] . It has also been associated with the development of pneumonia [ 27,28 ] .…”

Advances in the diagnosis and management of chronic pulmonary aspiration in children

“…Other advantages include portability, variability in feeding positions, and an ability to evaluate children who have severe oral aversions or who are not feeding by mouth. Aspiration risk can be evaluated in these children by assessing excessive pooling of oral secretions and laryngeal sensation or by placing a few drops of coloured food dye or chlorophyll on the tongue, and observing for aspiration or penetration [43]. Both FEES and VSS are useful and complementary owing to the different types of information they provide (table 1).…”

“…Three prospective studies attempting to compare LLMI values in children with chronic respiratory symptoms with and without documented GOR [52][53][54] have shown even wider variability than studies for direct aspiration (table 2) [ [42][43][44]. The most striking limitation of these studies is study design.…”

“…Laryngeal sensation can be quantified by applying graded bursts of air to the aryepiglottic fold and documenting the threshold pressure required to elicit the laryngeal adductor reflex. Both pooled oral secretions and decreased laryngeal sensation predict aspiration without challenging the patient with an oral bolus [43,[72][73][74][75].…”