1 Preceptor of Medical Residence, Santa Casa and Hospital Irmãos Penteado, Campinas; Ambulatory of Dysphagia at Unicamp.
2 Coordinator of medical residence in Otorhinolaryngology, Santa Casa and Hospital Irmãos Penteado, Campinas.
3 Responsible for the sector of Neonatal Dysphagia, Maternity of Campinas; post-graduation studies under course in the ambulatory of dysphagia, Unicamp.
4 Professor, Ph.D. in Otorhinolaryngology, Medical School, Unicamp.
5 Speech therapist.


Department of ORL, Irmandade de Misericórdia de Campinas: Santa Casa and Hospital Irmãos Penteado.

Address correspondence to: Ari de Paula - Av. Júlio de Mesquita, 960, 18o andar; Bairro Cambuí, Campinas, SP - 13025-061 - Tel: (55 19)3232.4478/3236.8972 - e-mail: aripaula@hotmail.com

Article submitted on August 9, 2001. Article accepted o October 15, 2001.

INTRODUCTION

Infantile dysphagia is becoming increasingly more significant in pediatrics and similar fields such as otorhinolaryngology, speech therapy, pneumology and gastroenterology highlighting the need for an interdisciplinary approach. The first need of a newborn is breathing and the second one is feeding. Any suction disorder in the breathing-swallowing coordination or in neuromuscular control of the mother's milk flow to pharynx, esophagus and stomach may trigger a risky situation that should be immediately diagnosed and controlled few hours after birth. Different illnesses occurring with structural malformation involving the stomatognathic system or neuromotor disorders (central or peripheral) may trigger clinical symptoms of dysphagia during childhood. Certainly, brainstem damage (i.e. cranial-encephalic trauma, ischemia and hemorrhage) is the major cause of dysphagia. According to studies carried out in adults by Langmore (1995) and Smith (1999), the lack of knowledge about dysphagia or the under evaluation of facts may lead to severe clinical consequences such as dehydration, malnutrition and aspiration pneumonia. For this reason, we believe that children are more sensitive to those complications. The evaluation of dysphagia should be carried out with analysis of the oral, pharyngeal and esophageal phases. The objective of this study is to show the evaluation of swallowing function, mainly the pharyngeal phase using a nasofiberscope to view the neuromuscular system involved to choose the management plan. Fiberoptic endoscopic examination of swallowing is an important test to study phonation (Sawashima, 1968) and swallowing disorders (Langmore, 1988) as it can be used repeatedly as much as needed, facilitating therapy effectiveness follow-up. Although it is uncomfortable, Aviv (2000) reported no risks in adult patients in most of the cases. The significance of this method was proved in some studies (Macedo, 1998; De Paula, 2000; Eckey, 2001), and Leder (2000) used a similar method to assess children. However, this group should be studied in detail, particularly in Brazil. Fiberoptic endoscopy is a precise examination, but it is costly and available only in few places, hindering the access to the procedure. Still, radiation emissions should not be neglected (Wright, 1998). The evaluations were carried out by one speech pathologists with expertise in infantile dysphagia disorder as the examination is important for functional diagnostic of dysphagia disorders and has immediate application in therapy follow-up. Ten cases of pediatric dysphagia were evaluated with fiberoptic endoscopy, named by the authors as swallowing videoendoscopy (VED).

OBJECTIVE

Evaluate swallowing function in children with complaints of feeding disorders using VED findings. Demonstrate the feasibility of this examination as an effective evaluating method to indicate speech pathology strategies.

MATERIAL and Method

Ten children with feeding disorders were referred and evaluated. Ages ranged from 45 days to 5 years (mean 1.9 year) with 09 males and only 01 female. First, all patients were clinically evaluated for swallowing dysfunction. Next, patients underwent videoendoscopy. Mothers were systematically instructed to bring their children alert and hungry to the procedure to be fed during the examination. The examination was carried out with the patient seated on his/her mother's lap and was recorded on video. Patients were clinically evaluated before the fiber-swallowing test. The assessment of the oral phase included observation of anatomic structures, coordination of voluntary and involuntary movements and presence or absence of tonus changes. The facial muscles palpated were: buccinator, masseter, submental, tongue, cheeks and soft palate. The evaluation included the level of repulse response, suction, bite, and nauseous reflex and finger-touch palpation. Evaluation in younger children included a suction test carried out by stimulation of the little finger on the hard palate and tongue to assess their strength. Older children were requested to bite the flexed finger of the examiner to evaluate the strength of mastication muscles. Then, Fiberoptic endoscopy examination of swallowing was carried out. The examination equipment was a Machida 3.2 nasofiberscope coupled to a Sony camera connected to a TV and a video system. No anesthetic drugs were used; we used few drops of topical vasoconstrictor in the nostrils to increase permeability while the child was restrained in his/her mother's lap. The intensity of repulse response to the fiber introduction was evaluated at this step.

The aspects evaluated were as follows:

· Crying, rated as strong, weak or nonexistent.
· Permeability of nasal conchae and cavum.
· Mobility of veli palatini.
· Structural aspect of hypo-pharynx, larynx and vocal folds movement.
· Presence of valleculae or pyriform sinuses in vestibule or other glottic regions. The excess of saliva even after some swallowing movements was strong predictor of "clearance" deficit and aspiration; therefore, those patient's examination were discontinued for safety matters.
· Swallowing evaluation was carried out after offering food to the child to deviate the attention from defense instinct against a "Foreign body". The hungry child prioritized food and "forgot" the nasofiberscope.
· "Clearance".
· Penetration.
· Aspiration.
· Cough.

"Clearance" effectiveness was evaluated during bottle-feeding, after swallowing movements and according to food consistency. The presence of food in the laryngeal vestibule was also evaluated and rated as deep penetration (to the extent of approximately half of the laryngeal fascia of epiglottis) and low penetration (involving ventricular folds, which are prone to aspirations). Still, occasional aspirations were evaluated; if food exceeded the glottis with consequent cough or not; if this cough was effective or not. This evaluation should be dynamic and take all clinical history into account, not only a specific step of the diagnostic examination. The evaluation time was approximately 20 minutes. Nasofiberscope was then removed and a last image with the child at habitual breastfeeding posture was recorded. The stress-free environment allowed the evaluation of the hungry child during breastfeeding. In the second step the team studied each phase of the examination recorded using all control tools available including image freezing and slow motion of important events to conclude the picture. Finally, the team planned the most adequate speech pathology therapy for each case.

RESULTS

Detailed Results: Tables 1, 2 and 3.

Table 1 presents each case; patients' initials; age; major complaint or symptoms for the examination; gender; diagnostic hypothesis, since it was not always clear during the evaluation, and significant data from each case. The second row of Table 2 represents occasional changes found during oral phase and VED evaluation. The Oral phase examination included an objective evaluation of the stomatognathic system, both motor and sensitive, and the observation of occasional disorders such as labial leakage, mastication movements and suction.

The third row, with flexible nasofiberscope, was divided in:

· Consistency: type of food consistency used in the evaluation.
· "Clearance": clearance of pharyngeal recesses after swallowing was effective or ineffective. Effective: total hypo-pharyngeal clearance after 3 swallowing movements. Ineffective: more than three movements.
· Deep penetration: Food residues in the upper half of the laryngeal vestibule.
· Low penetration: Food residues in the lower half of the laryngeal vestibule.
· Aspiration: Food and/or saliva residues in the infra-glottic regions.
· Cough reflex: Present or absent, if present its effectiveness or ineffectiveness was evaluated.

DISCUSSION

Traditionally, swallowing is divided in 3 major phases: oral, pharyngeal and esophageal. Sensibility and motor control are essential for the success in the first two phases in order to achieve the major goal that is to take food to stomach safely and with precise coordination. (Marchesan, 1999; Terrant, 1997; Klahan, 1999; Kendall, 2000). Many times children have a sensitive and/or motor disorder of the stomatognathic system and present dysphagia due to several reasons. This study is an opportunity of carrying out a comprehensive assessment of these children. It includes the specific examination (fiberoptic endoscopy), and an interdisciplinary team of professionals to get the best solutions possible to help patients. Certainly, the presence of a foreign body in the nostril of a child is extremely uncomfortable, mainly because this examination should be carried out with no anesthetic drugs. Two measures were adopted to mitigate it: First, the use of topic vasoconstriction drugs right before the examination to maximize the permeability of the best nostril. Second, instruct the mother to bring the child at feeding times. Feeding will be his/her priority and not to be defended from the fiberoptic equipment. Once locked in the position, the equipment causes minor discomfort. Aspects evaluated included: child's body reactions; crying intensity (strong, weak, nonexistent); which means good or poor glottic coaptation. These data provide the clinical picture of the child and of his/her lower airway tract and indicates his/her rehabilitation chances (Pinnington, 2000; Ryalls, 1999).

The excess of saliva found in pharyngeal recesses was a red flag to interrupt or not the examination, since after three swallowing movements if the patient could not effectively eliminate saliva or the food offered, we interrupted the examination as it is a strong predictor of penetration and aspirations risks as reported by Leder (1998) and Robbins (1999). This study evaluated the clearance of pharyngeal recesses after swallowing movements. Children that needed more than three swallowing movements were likely to have pathology (De Paula, 2000). Laryngeal food penetration was reported by the authors and classified as deep and/or low. According to Friedman (2000), there is a significant relation between low penetration and aspiration, for this reason the authors found convenient to routinely use this concept to predict aspirations that were not clearly detected during examination. The authors tried to evaluate aspiration by getting as close as possible to the glottis with the tip of the nasofiberscope and observed if there were any infraglottic food residues. (Leader, 2000). According to Kidder (1995) and Langmore (1997), this maneuver has potential for laryngeal spasms. Thus, these procedures were carried out exclusively in adequate rooms for the case of emergency. The approximate time for each procedures was 20 minutes. It depended on the ongoing evaluation of swallowing movements and occasional events detected during examination. Some disorders were detected at the beginning and others at the end of the evaluation. No complications were reported during the evaluation of these children, although mild easily controlled epistaxis was expected (Aviv, 2000). This study had a customized, specific, unique approach for each child studied and evaluated, consequently it demanded large number of professionals from different areas to interpret data.

This evaluation method of children with dysphagia simulates child's daily routine as much as possible. Child is evaluated on his/her mother's lap and with the same food they regularly take (same food flavor). However, the authors reported environment limitations, as unfamiliar office and people may certainly generate some anxiety in child and evaluation deviations may occur. Still, the authors believe that if the child is hungry this evaluation method will be close to child's normal feeding process and may be repeated as much as needed during the speech pathology therapy to evaluate the success achieved. The authors emphasized functional characteristics of the examination. The method is useful not only to find and detect disorders, but also to identify changes that lead to immediate therapeutic procedures, many times performed at that very moment.

CONCLUSION

This method allows the evaluation of children with dysphagia caused by several diseases. VED is a safe, highly precise examination to detect pathological changes involving feeding disorders. It safely assists the speech therapist in the rehabilitation process of pediatric patients and in therapy effectiveness follow-up.

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