Simultaneous Videofluoroscopy and Endoscopy for Dysphagia Evaluation in Preterm Infants-A Pilot Study

Abstract

Introduction: The assessment of dysphagia in preterm infants has been limited to clinical bedside evaluation followed by videofluoroscopic swallow study (VFSS) in selected patients. Recently, fiberoptic endoscopic evaluation of swallowing (FEES) is being described more in literature for preterm infants. However, it is unclear if one test has a better diagnostic utility than the other in this population. Furthermore, it is also unclear if performing FEES and VFSS simultaneously will increase the sensitivity and specificity of detecting dysphagia compared to either test performed independently. Objectives: The primary objective of this study is to evaluate the feasibility of performing VFSS and FEES simultaneously in preterm infants. Our secondary objective is to determine whether simultaneously performed VFSS-FEES improves the diagnostic ability in detecting dysphagia in preterm infants compared to either test done separately. Methods: In this pilot study, we describe the process involved in performing simultaneous VFSS-FEES in five preterm infants (postmenstrual age ≥36 weeks) with dysphagia. A total of 26 linked VFSS-FEES swallows were analyzed, where the same bolus during the same swallow was compared using simultaneous fluoroscopy and endoscopy. The sensitivity and specificity of detecting penetration and aspiration were evaluated in simultaneous VFSS-FEES compared with each test done independently. Results: Our results demonstrated that performing simultaneous VFSS-FEES is feasible in preterm infants with dysphagia. All patients tolerated the procedures well without any complications. Our pilot study in these five symptomatic preterm infants demonstrated a low incidence of aspiration but a high incidence of penetration. Simultaneous VFSS-FEES (26 linked swallows) improved the ability to detect penetration compared to each test done separately. Conclusion: To our knowledge, this study is the first to demonstrate the feasibility of performing VFSS and FEES simultaneously in symptomatic preterm infants with dysphagia resulting in potentially higher diagnostic yield than either procedure done separately.

Keywords: dysphagia; fiberoptic endoscopic evaluation of swallowing (FEES); laryngeal penetration; modified barium swallow study; preterm infant; swallowing dysfunction; tracheal aspiration; videofluoroscopy.

Figure 1

Mock videofluoroscopic swallow study (VFSS)–fiberoptic endoscopic evaluation of swallowing (FEES) procedure with simulated images. (A) Infant; (B) Endoscopist; (C) Feeder; (D) VFSS monitor; (E) FEES monitor.

Figure 2

Mock videofluoroscopic swallow study (VFSS)–fiberoptic endoscopic evaluation of swallowing (FEES) procedure. Note that the endoscopist is inserting the FEES scope while the feeder stabilizes the infant's head and holds the bottle. To avoid radiation exposure and to minimize interference with VFSS, the feeder's arm is arched and the endoscopist stabilizes the FEES scope against the infant's chin. Radiologist employs tight coning to limit radiation field further.

Figure 3

Mock videofluoroscopic swallow study (VFSS)–fiberoptic endoscopic evaluation of swallowing (FEES) procedure. Image offered to demonstrate an alternative way to hold the FEES scope. The endoscopist arches his/her hand and anchors on the forehead while moving the hand out of the VFSS view while the feeder's arm is also arched. This hold was performed on infants who moved their heads more often during the procedure because the endoscopist's hand placement on the infant's forehead helped reduce infant movement.

Figure 4

Overview of swallow analysis. All the swallows from videofluoroscopic swallow study (VFSS) and fiberoptic endoscopic evaluation of swallowing (FEES) procedures were reviewed individually for penetration and aspiration. Swallows not meeting our image quality criteria were excluded. “Linked swallows” include swallows comparing the same bolus during the same swallow on VFSS and FEES simultaneously.

Figure 5

This figure shows an identical swallow on videofluoroscopic swallow study (VFSS) and fiberoptic endoscopic evaluation of swallowing (FEES) still-frame images for subject 1. In this image, FEES images are two frames after VFSS images once the white-out period is over. Anatomic landmarks are identified as noted. Laryngeal penetration could be visualized on both VFSS and FEES. Images were obtained with parental consent.