Thirty-five years ago, the flexible endoscopic evaluation of swallowing (FEES) was
described for the first time. FEES is a gold standard instrumental assessment of oropharyngeal
swallowing function using flexible laryngoscopy. FEES usually includes a part 1, in
which the anatomy of the pharynx/larynx is observed and movements of structures are
evaluated through motor tasks. These often include the pharyngeal squeeze maneuver
(sustained/pressed phonation “eee”), velopharyngeal closure (“puh-puh,” “fifty-fifty,”
or swallow), base-of-tongue retraction (words with postvocalic /l/, e.g, “Paul is
tall”), glottic closure/vocal fold and arytenoid mobility (assessed during coughing
or sustained breathing, sustained “ee”, repeated “ee-ee-ee”, and pitch glides); as
well as the observation of epiglottic inversion during a dry swallow. These tasks
allow the clinician to build their working hypotheses regarding intact and problematic
components of the pharyngeal phase of swallowing i.e. pharyngeal constriction for
bolus clearance and vocal fold closure for airway protection. Voice and swallowing
share neural and musculoskeletal substrates. Yet, the strength of evidence for motor
and speech tasks predicting swallowing function is variable making it hard for clinicians
to confidently build working hypotheses during part 1 of their FEES. This results
in some clinicians leaving this part of their FEES out and missing valuable clinical
information about their patient. What is the evidence for these motor speech tasks
components of the FEES procedure?
Pharynx
One of the most validated motor tasks, with the greatest potential to predict swallowing
function, is the pharyngeal squeeze maneuver (PSM), which is considered a substitute
measure of pharyngeal strength during FEES. Recently published, Miles and Hunting
report on 222 inpatients referred for FEES and demonstrated a correlation between
PSM and pharyngeal constriction during videofluoroscopy (in those who had both assessments)
and a strong association between PSM and accumulated secretions, aspiration, residue
and diet on discharge from hospital.
1
PSM also correlated with other motor functions including vocal fold immobility, reduced
cough peak flow and reduced swallow frequency.
1
Velopharyngeal closure
Recently, a modification of PSM, called the Velopharyngeal Squeeze Maneuver (VPSM),
has been studied in patients with dysphagia.
2
The researchers demonstrated that the absent VPSM is able to predict the presence
of aspiration. Patients with absent VPSM also had severe impairment in pharyngeal
contraction. The authors report that this was the first study to demonstrate the clinical
utility of observing velopharyngeal closure during a speech task and its relationship
to functional swallowing.
2
Vocal fold function
Glottic closure is essential for airway protection during swallowing and coughing,
thus, dysphagia/aspiration often occurs in patients with vocal fold paralysis, with
an estimated prevalence of 55%–69%.
3
The relationship between aspiration and vocal fold paralysis is well documented.
3
While vocal fold adduction is an essential component of airway closure for swallowing,
we believe that the clinical utility of these motor tasks may be improved by assessing
other components of airway closure including epiglottic inversion and arytenoid mobility.
This could provide further information about laryngeal valve closure during swallowing,
an event not visible during FEES.
Hyoid and laryngeal displacement
Recently, a study by Jijakli et al. evaluated the association between epiglottic inversion
(observed during FEES) with the biomechanical events of swallowing (observed during
videofluoroscopy) in a small cohort of 25 patients with dysphagia. The researchers
wanted to know whether reduced hyoid and laryngeal excursion on videofluoroscopy would
be associated with absent epiglottic inversion on FEES. Patients were divided into
three groups: complete, reduced, and absent epiglottic inversion. The study demonstrated
that the reduction of base-of-tongue retraction, reduction of hyoid excursion, reduction
of laryngeal elevation and reduction of pharyngeal constriction contribute to the
decrease of epiglottic inversion observed in FEES. However, the assessment of epiglottic
inversion was unable to discriminate between patients with normal versus impaired
hyolaryngeal elevation. This small pilot study perhaps suggests that observations
of epiglottic inversion should be interpreted with caution, and cannot infer the specific
movement of the hyolaryngeal complex.
4
Base-of-tongue retraction
Base-of-tongue retraction, while often included in a FEES protocol, has little scientific
evidence to relate task performance to swallowing function. Langmore et al. studied
the relationship between pre-swallowing tasks assessed during the part 1 of the FEES
(including base-of-tongue retraction) and functional swallowing outcomes in patients
with post-extubation dysphagia. The only task that showed a significant relationship
with aspiration was decreased pharyngeal squeeze. No association was observed between
base-of-tongue retraction and swallowing impairments in this specialized population.
5
To our knowledge, the base-of-tongue retraction motor task has not been explored further.
Clinical implications and future directions
Despite limitations in current evidence, researchers and clinicians recommend that
pre-swallowing tasks are included during FEES (Representatives of the American Board
of Swallowing and Swallowing Disorders; ASHA Special Interest Group 13: Swallowing
and Swallowing Disorders - Dysphagia https://pubs.asha.org/doi/10.1044/2021_AJSLP-20-00348).
While some motor tasks may not been researched extensively, these tasks assess swallowing
related actions in isolation and support clinician diagnostic decision-making. Knowing
there is a vocal fold paralysis or poor pharyngeal squeeze provides valuable information
about how a patient may perform during oral trials, as well as what the underlying
biomechanical cause of functional deficits during oral trials. A deficit observed
during a motor or speech task that has little evidence may need to be interpreted
with caution. For example, if a clinician observes absence of epiglottic inversion
or base of tongue retraction during part 1 of their FEES procedure, they might pay
focused attention to these structures during oral trials during the FEES and may recommend
a videofluoroscopy study to further investigate pharyngeal function. It is also recommended
that clinicians stay current and adapt their clinical practice as new evidence becomes
available over time.
The pre-swallowing tasks assessed in FEES are simple, quick and low risk and provide
valuable information about a patient’s likely performance during oral trials as well
as their underlying biomechanical impairments. The clinical utility of assessing tongue
base retraction, velopharyngeal closure and epiglottic inversion should be a priority
on the research agenda. Researchers should not limit themselves to studying only predictive
values and validity, but also reliability and reproducibility in clinical practice.
The creation and validation of new tools with clear definitions that allow a visual
classification (e.g., normal versus impaired) for all pre-swallowing tasks is warranted.
Conflict of interest
The authors declare no conflicts of interest.
Funding
No funding.