Difficulty swallowing, medically termed “dysphagia,” impacts one in 25 adults each year in the United States, and the prevalence increases with age, affecting as many as 68 percent in patients living in long-term care facilities. Complications caused by potential aspiration due to dysphagia are even sometimes life-threatening.

At the Grabscheid Voice and Swallowing Center of Mount Sinai, Mark S. Courey, MD, and his team expedite the evaluation and management of this swallowing disorder, and reduce overall cost by providing a reliable, in-office instrumental evaluation of patients with complaints of dysphagia. They developed this study as a screening tool to determine the necessity of the typical Modified Barium Swallow (MBS) study. This test, called Static Endoscopic Evaluation of Swallowing (SEES), can be used in addition to or instead of the more traditional Flexible Endoscopic Evaluation of Swallowing (FEES). 

Cost of Management for Dysphagia

Data has demonstrated that patients with dysphagia increase hospital costs by $4,200 per year, per patient, and outpatient expenditures by $7,200 more per patient than their age-related peers. Other studies demonstrate that management of dysphagia reduces the risk of aspiration pneumonia -- the number one event leading to increased morbidity and mortality.

Causes of Dysphagia

The etiology of dysphagia is variable and often multifactorial. Aging, even over the age of 65, results in weakness of the swallowing muscles and reduction in the efficiency of timing of the complicated reflexes required to swallow safely and protect the airway. While most of these events are asymptomatic and do not produce clinically significant disease, the coexistence of neurologic illness, such as Parkinson’s disease, dementia, Alzheimer’s disease, motor neuron diseases, and multiple sclerosis, results in a significant increase in the rate and severity of dysphagia. Prior history of head and neck cancer treatment, particularly with chemotherapy and radiation therapy, is also associated with increased incidence and severity in dysphagia. Although the ability to enjoy meals with family and peers is recognized as a major determinant in overall quality of life, few treatments are recommended or performed to help patients with significant loss of swallow function.

Dysphagia Symptoms: Who Needs Evaluating?

Since difficulty swallowing can often present with vague symptoms, such as unexplained cough, throat clearing and globus sensation (feeling of a lump or foreign body in the throat), and may be associated with changes in voice, physicians should evaluate not only the larynx, but also the entire speech mechanism, oropharynx and hypopharynx to assess changes in structure and function.

At the Grabscheid Voice and Swallowing Center, we take a detailed medical history of each patient to fully understand the presence and severity of her or his swallowing disorder. This includes:

1. Documenting the length of mealtime; normal meals should be consumed within 15 to 30 minutes. If longer, this is an indicator of dysphagia.
2. Determining if the patient has altered his/her diet.
3. Asking the patient if she/he is choking or coughing more with certain substance than other. 

Difficulty with liquids over solids indicates a problem with swallow control, swallow reflexes or the timing of solids. Difficulty with solids over liquids may indicate weakness of the muscles involved in swallowing.

The clinical evaluation of swallowing includes assessing for evidence of secretions on the vocal folds (cords) producing a rough or wet quality, a thorough examination of the speech mechanism, assessment of oro-motor control and strength through visualization, strength testing, and testing of rapid alternating movements. Strength of tongue is evaluated in all directions. Hyolaryngeal elevation is evaluated for completeness and rapidity on both dry and wet swallows. While this form of testing is important, it is no better than flipping a coin. Studies indicate that it is only 50 percent sensitive in identifying laryngeal penetration or aspiration.  That is why instrumental evaluation is important. Traditional MBS or FEES do not stress the importance of these physical exam findings.

SEES Evaluation

SEES is an instrumental evaluation of swallowing that encompasses three components:

1. Indirect transoral endoscopy, during which pre-swallow patterns of secretion pooling, pharyngeal strength testing, and laryngeal function are assessed.
2. Assessment of solid food swallowing by removing the scope and having the patient consume a dry, solid substance (i.e. graham cracker). The rigid endoscope is reinserted to assess the absence and quantitative presence, as well as location of post-swallow pooling, aspiration and/or penetration.
3. Assessment of liquid swallowing on single sips and clinically appropriate liquid boluses. Again, the endoscope is removed during this portion of the exam and reinserted to assess the post-swallow residue, penetration and/or aspiration.

Dr. Courey developed this test with colleagues at UCSF and conducted a study to validate it against the gold standard MBS.  The studies demonstrated that SEES is well-tolerated addition to the standard evaluation and provides valuable, functional information about the status of swallowing in patients with problems related to dysphagia.

Benefits of SEES versus FEES and MBS

The following points surmise the benefits of employing SEES, versus FEES and MBS:

• Improves detection of the presence of penetration and aspiration.
• Avoids need for invasiveness instrumentation during the swallow.
• Negates the need for local anesthesia in the outpatient setting of FEES, which can affect swallow function.  
• Reduces scheduling time and travel burden for patients needing to return for radiographing study.

To surmise, SEES is a quick and accurate swallow assessment that can assist with directing specific follow-up care. SEES also negates the need for more expensive and time-consuming testing, and can be performed by otolaryngologists to accurately assess their complaints of dysphagia.