[Dysphagia] VFSS, diagnosis etc.

[eripley at yahoo.com (Irene Campbell-Taylor)]

On reading some recent postings, there seems to be a misunderstanding of the function of VFSS and FEES.  No instrumental examination is, by itself, diagnostic. It is merely a diagnostic tool. See the Merck Manual:
  ?A doctor can often diagnose a disorder based on the symptoms and on the results of a physical examination. Laboratory tests, imaging tests, or other diagnostic procedures are sometimes necessary to help the doctor make or confirm a diagnosis.?
  The literature on diagnosis emphasizes that it depends to degree of almost 60% on the history, followed by clinical examination at which time it is decided whether or not further instrumental tests are required.
  I refer you to the ASHA position paper re knowledge and skills for VFSS:
  Similarity to real foods:
  ?
recipes should be developed within a facility for different liquid consistencies to be used in the VFSS and efforts should be made to match consistencies to those that are available on the dietary menus. If strict mixing methods are not adhered to, there is much room for intra-subject as well as inter-subject variation in preparation. Objective viscosity measurement and reliability is only obtained with instrumentation. A viscometer objectively measures the thickness of a liquid; however, viscometers are not routinely available outside of the laboratory. Various ranges in centipoise have been described in the literature to represent nectar-thick, honey-thick, and pudding-thick liquids. The literature and products on the market are not universal in their centipoise ranges within each of the viscosity levels (Mills, Brown, Daubert, Casper, & Tobochnik, 1998; Pelletier, 1997). Until such research findings are available and industry standards are developed, the clinician
 should be vigilant of uniform liquid thickening techniques and maintaining uniformity between assessment and intervention viscosities.?
  Necessary examinations:
  ?The SLP should probe to understand the variation, progression, and frequency of symptoms. Based on patient reports, medical history, and clinical examination, the SLP should recognize the need for an extended VFSS with an esophageal screening, or a separate esophagram and/or upper gastrointestinal series scheduled either in conjunction with the VFSS, or performed at a later time. An esophageal screening can be incorporated into most VFSSs if the patient can tolerate even a small amount of p.o. contrast. The decision to perform these additional assessments is made with the radiologist, and/or after consultation with the referring physician.?
  Medications:
  ?It is essential that the clinician include medications and medication schedules in the history taking for the individual with dysphagia. Medications may enhance an individual's swallowing ability or interfere with both the oropharyngeal swallow and an individual's appetite and may influence the individual's performance during the VFSS. Many commonly used drugs have an effect on the swallow (Alvi, 1999; Campbell-Taylor, 2001). Also, ?polypharmacy? is generally the norm with the elderly, especially the elderly patient in an acute or extended care setting. In many nursing homes/long-term rehabilitation settings, individuals receive so many medications that they require a special care plan informing all team members of possible drug interactions and side effects.?
   


Dr I Campbell-Taylor
Clinical Neuroscientist
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