key: cord-0964837-jfdujyfo authors: Chang, Joseph; Brown, Sarah K.; Hwang, Chaewon; Kirke, Diana N.; Goldberg, Leanne title: Predictive values of static endoscopic evaluation of swallowing in adults date: 2021-10-23 journal: Laryngoscope Investig Otolaryngol DOI: 10.1002/lio2.615 sha: 79c7f91070836f0812368c697422b8eaa722d15d doc_id: 964837 cord_uid: jfdujyfo OBJECTIVE: Static endoscopic evaluation of swallowing (SEES) is an instrumental evaluation developed for in‐office identification of patients who may benefit from a modified barium swallow study (MBSS). We aim to determine the predictive value of SEES for evaluating dysphagia. METHODS: A retrospective case series was performed on adults evaluated for dysphagia using SEES followed by MBSS at a single tertiary care center. Studies were evaluated by two blinded expert raters. RESULTS: Fifty‐eight patients were included. Thin liquid penetration on SEES had a sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of 0.86 (95% CI 0.70‐0.95), 0.63 (95% CI 0.24‐0.91), 0.91 (95% CI 0.76‐0.98), and 0.5 (0.19‐0.81), respectively, for predicting thin liquid penetration on MBSS, and 1.0 (95% CI 0.59‐1.0), 0.29 (95% CI 0.15‐0.47), 0.23 (95% CI 0.10‐0.41), and 1.0 (95% CI 0.69‐1.0) for predicting thin liquid aspiration on MBSS. Thin liquid aspiration on SEES had a sensitivity, specificity, PPV, and NPV of 0.67 (95% CI 0.09‐0.99), 0.85 (95% CI 0.66‐0.96), 0.33 (95% CI 0.04‐0.78), and 0.96 (95% CI 0.79‐1.0), respectively, for predicting thin liquid aspiration on MBSS. CONCLUSIONS: SEES may be used as an objective in‐office test to screen for aspiration and penetration. Thin liquid penetration on SEES is moderately sensitive for predicting penetration on MBSS. Absence of thin liquid penetration or aspiration on SEES has a high NPV for excluding aspiration on MBSS. Abnormalities on SEES or the need to view the entire swallowing mechanism should prompt an MBSS for a more complete evaluation of dysphagia. Level of Evidence: 4 The primary methods for evaluation of oropharyngeal dysphagia include the fiberoptic endoscopic evaluation of swallow (FEES) and modified barium swallow study (MBSS) . MBSS involves fluoroscopic evaluation of swallowed radiopaque material of various consistencies and requires involvement of a radiologist and speech language pathologist. FEES involves visualizing the passage of food of various consistencies through the pharynx during swallowing using a transnasal endoscopic camera; this study typically requires involvement of multiple personnel including a speech language pathologist. Both studies may not be feasible in the typical otolaryngology visit due to the time and coordination required. Moreover, due to coronavirus precautions in the current era, availability of these studies may be restricted. Screening mechanisms for identifying those patients most in need of comprehensive swallow evaluation are critical. Clinical bedside swallow evaluations, in which patients are given various consistencies to swallow and are monitored for clinical signs of aspiration and penetration, are a common method of screening for dysphagia; however, the sensitivity and specificity of this test vary widely depending on how many clinical signs are used for determining the presence of aspiration 1 with published estimates ranging from 0.65 to 0.86 and 0.30 to 0.96, respectively. [1] [2] [3] [4] Additionally, clinical bedside swallow evaluations cannot distinguish between aspiration and penetration. Recently, an alternative instrumental swallow examination technique, static endoscopic evaluation of swallow (SEES), was proposed in which the pharynx is examined without anesthesia with a transoral endoscope after swallowing various consistencies and was found to correlate significantly with findings of aspiration and penetration on MBSS in a study of 39 patients. 5 As SEES offers evaluation of aspiration and penetration risk in clinic, it has the potential to be used as a screening test to identify the need for additional comprehensive evaluation with MBSS. Potential advantages of SEES over FEES procedures may include a shorter time to complete the evaluation as well as avoidance of topical anesthesia and disruption of nasopharyngeal closure during the swallow, factors thought to artificially increase rates of dysphagia detected by FEES. 6, 7 Given the limited existing data regarding the sensitivity and specificity of SEES in the literature, we hope to further evaluate the diagnostic capability of SEES with regards to MBSS as the gold standard. SEES was performed by having patients swallow substances of various consistencies, including a sip of thin barium, a cup of thin barium, and a bite of cookie, followed by videoendoscopic evaluation of the hypopharynx and larynx with rigid transoral endoscopy. During the SEES, patients are instructed to "take a sip," "drink the entire cup," or "take a bite" of cookie and chew, and "then swallow once" to standardize the swallowing process and avoid multiple swallows. Endoscopy was performed immediately after each consistency was swallowed. Not all consistencies were tested in all patients per the judgment of the clinician at the time of the exam. Volume of residue was graded as absent, trace/minimal, or moderate/ maximal. The anatomic subsites included the valleculae, piriform sinuses, post-cricoid space, upper one third of the laryngeal vestibule, lower two thirds of the laryngeal vestibule, vocal folds, and trachea. As absence and presence of a finding cannot be averaged in cases where raters did not agree, one rater was selected at random to represent the "true" ratings and this set of ratings was used to calculate predictive values. Inter-and intrarater reliability was calculated using weighted kappa. As kappa between 0.6 and 0.8 is considered substantial and above 0.8 is considered almost perfect, 8 Table 1 . Consistencies and locations that did not meet inter-and intrarater reliability are listed in Table 2 . Clinically, SEES may be useful as a rapid instrumental evaluation of swallow that can provide immediate information regarding the swallow in routine clinic visits and which has value as a screening test. Degree of residue at this subsite also had inter-and intrarater kappa ≥0. 6. b No residue was identified on any of the patient exams. detecting aspiration is at the upper limit or higher than published bedside swallow sensitivity albeit with specificity at the mid to low range of published bedside swallow specificity. Disadvantages of SEES are that it requires endoscopic equipment and is more invasive compared to bedside swallow evaluations. FEES is an alternative study that can be performed at bedside. However, studies have found higher rates of dysphagia detection on FEES compared to MBSS. 6, 9, 10 The higher rate of dysphagia detection may in fact be due to worsening of swallow during FEES rather than a higher sensitivity of FEES compared to MBSS. 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Adding endoscopist-directed flexible endoscopic evaluation of swallowing to the videofluoroscopic swallowing study increased the detection rates of penetration, aspiration, and pharyngeal residue VFS interjudge reliability using a free and directed search Inter-rater reliability of videofluoroscopic dysphagia scale Inter-and intrajudge reliability for videofluoroscopic swallowing evaluation measures Interobserver variability in cineradiographic assessment of pharyngeal function during swallow Comparison of trained clinician ratings with expert ratings of aspiration on videofluoroscopic images from a randomized clinical trial The authors declare no potential conflict of interests.