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Background: The application of fiberoptic endoscopic evaluation of swallowing (FEES) in the pediatric dysphagia protocol requires specialized knowledge of pediatric conditions that result in dysphagia, recognition of normal and abnormal laryngopharyngeal anatomy and function across ages, and the ability to identify maturational changes in anatomy and function of the aerodigestive tract that pertain to airway protection and swallowing function., Methods: Over the past 25 years, we have performed over 7,000 collaborative Otolaryngology and Speech-Language Pathology FEES examinations in patients ranging from 2 days of age to young adults. During this time period, we have monitored the safety of the procedure, explored the feasibility and utility of FEES across conditions, compared and contrasted FEES to the videofluoroscopic evaluation of swallowing (VFSS), and developed specific pediatric FEES protocols with operational definitions for identification and interpretation of swallowing parameters., Results: FEES has proved to be a safe procedure in patients across ages. There have been no significant adverse events. FEES is comparable to the VFSS in the assessment of events before and after the swallow. It provides unique information regarding laryngopharyngeal anatomy and function, airway protection integrity, sensory threshold, and secretion management ability, as well as pharyngeal swallowing dynamics and the efficacy of compensatory swallowing strategies., Conclusions: There are specific indications and contraindications for pediatric FEES, and unique components that characterize the pediatric FEES protocols across ages and conditions. FEES procedures performed jointly by an Otolaryngologist and Speech-Language pathologist offer a team approach to interpretation and management recommendations.

A case report of a 10 year old male illustrates the effect of damage to the tongue base, hypopharynx, cricopharyngeus, and esophagus on the sensory and motor components of the swallowing mechanism. The characteristics of the dysphagia were manifested clinically, radiographically, and endoscopically. A myectomy was required to restore functional swallowing as scar tissue formation in the cricopharyngeus severely interfered with the dynamic components of swallowing. A collaborative approach facilitated communication and effective treatment planning; the multidisciplinary components in the management of this case are discussed., (Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.)

Fiberoptic endoscopic evaluation of swallowing (FEES) was developed as an adjunct to the videofluoroscopic swallowing study and clinical examination of swallowing function in the adult. The sensory testing aspect of fiberoptic endoscopic evaluation of swallowing with sensory testing (FEESST) utilizes an air pulse stimulus of mechanoreceptors within the larynx. The study can be performed safely in children as young as premature infants and in adults. Adequate levels of cooperation can be obtained in nearly all children requiring FEESST. No cases of laryngospasm or respiratory compromise have been encountered. FEESST was initially applied to patients with dysphagia. It is now used in the study of the effects of gastroesophageal reflux on the larynx and swallowing function. The extent of pooled secretions in the hypopharynx can be used as a surrogate measure of laryngopharyngeal sensory testing. When patients managed by FEESST were compared with patients managed by videofluoroscopic swallow studies, there were no statistical differences in the rates of pneumonia or pneumonia-free interval. A learning curve is present for the operator, but with basic endoscopic skills, FEESST is a skill within the scope of practice of most pediatric endoscopists.

Objective: To design and implement a functional magnetic resonance imaging (fMRI) protocol to investigate the cortical and brainstem patterns of activity in children with regard to the act of swallowing., Study Design: Pilot study to assess the clinical feasibility of the project., Methods: Using a 3T Bruker Biospec 30/60 MRI scanner, images were obtained using the Behavior Interleaved Gradient/Blood Oxygen Level Dependent (BIG-BOLD) image acquisition method. Initially, regions of interest (ROI) were developed to identify the mean time from the onset of a swallow to maximum cortical blood flow in the motor cortex. Using this data to design the BIG-BOLD acquisition method followed by postprocessing of the data, images from two volunteer adults and four volunteer children were obtained., Results: The average time from the onset of a swallow to maximum cortical blood flow was 6 to 8 seconds. Regions of cortical activity include pre- and post-central gyrus (Brodmann's areas 3 and 4), superior motor cortex (B.A. 24), insula, inferior frontal cortex (B.A. 44 and 45), Heschl gyrus (B.A. 41 and 42), putamen, globus pallidus, and the superior temporal gyrus (B.A. 38). Of particular note is the first mapping of the functional activity of swallowing at the level of the brainstem; activity was seen in the region of the nucleus ambiguous., Conclusions: fMRI provides a novel means of studying the central processes of both normal swallowing and its various pathologic forms in children. Further understanding of how a child coordinates a swallow and how this coordination can be altered at the level of the brainstem and cortex may aid in the development of novel rehabilitative strategies.

Pediatric dysphagia is the presenting feature of many underlying diagnoses. Between July 1993 and July 1999, 643 fiberoptic endoscopic evaluations of swallowing (FEES) were performed on 568 patients. The median age of the population was 2.5 years (range, 3 days to 21 years). The principal medical and surgical diagnoses of the patients at the time of presentation to the FEES clinic were prospectively recorded: 36% of the patients presented with a diagnosis of structural abnormalities of the upper aerodigestive tract or airway; 26% with neurologic diagnoses; 12% with gastroenterological disorders; 8% with genetic syndromes; 7% with pulmonary dysfunction; 5% with prematurity; 3% with cardiovascular anomalies; and 2% with metabolic problems. The patients were classified according to the following feeding regimens: 9% normally fed; 38% orally fed with limitations; 13% orally fed, but with required supplemental tube feedings; and 40% prohibited from taking nutrition orally. The FEES enabled the following classification of feeding abnormalities: 15% had normal feeding; 56% exhibited behavioral abnormalities, including sensory-based feeding disorders; 15% exhibited structural abnormalities; 16% exhibited neurologic abnormalities; 1.5% exhibited metabolic abnormalities; and 0.5% exhibited cardiorespiratory abnormalities. The unique aspects of pediatric dysphagia are highlighted, and the role of FEES in the workup of this challenging aspect of pediatric otolaryngology is discussed.

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.