PMC8077515_01
Symptoms of dysphagia in the course of treatment as seen in flexible endoscopic evaluation of swallowing (FEES). Figure demonstrates the photo documentation of FEES examinations in the course of the treatment with Penetration-Aspiration-Scale (PAS) and Yale Pharyngeal Residue Severity Rating Scale for valleculae (YSv) and piriform sinus (YSps) scores: a shows the massive saliva residue in valleculae and piriform sinus in the initial FEES (YSv 5/YSps 5); in b penetration of liquid on the right side (PAS 3) and mild residue of liquid bolus (YSps 3) is perceived in piriform sinus 3 days after admission; c depicts penetration (PAS 3) and massive residue of puree in valleculae and piriform sinus (YSv 5/YSps 5) 2 weeks after stroke; d (24 days post onset) shows massive residue of solid bolus in valleculae and only moderate residue in piriform sinus (YSv 5/YSps 4); in d no pathological results were documented.
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F1
The main symptoms found in the initial FEES were severe saliva residue in piriform sinus and valleculae and the inability to initiate swallowing reflex (Fig. 1a). The underlying symptoms of dysphagia found in FEES (non-elicitable swallowing reflex, severe residue of saliva in valleculae and piriform sinus, Fig. 1a) gave hint of swallowing pathophysiology. We conducted the following high-frequent treatment (Fig. 3): (1) 3x/day ice stimulation of anterior faucial arches five times on each side with an ice stick; (2) each five sets of five repetitions of CTAR and JOE for 10 s with 10 s break between each repetition. To control the effects of the therapy the SLT conducted five FEES examinations within the 7 weeks of therapy, two FEES during the hospital stay, and three follow-up FEES after discharge (Fig. 1, 3, 4).
MRI scan. a Diffusion-weighted imaging. b T2-weighted MRI. Green circle represents reticular formation. Blue circle represents nucleus ambiguus.
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F2
The inability to trigger the swallowing reflex in MMI may be caused by the stroke-related damage caused to RF and NTS (Fig. 2).
Timeline. Figure shows the milestones of symptoms, diagnostics and therapy. FEES, flexible endoscopic evaluation of swallowing; FOIS, Functional Oral Intake Scale; JOAR, Jaw Opening Against Resistance; JOE, Jaw Opening Exercise; MRI, magnetic resonance imaging; mRS, Modified Rankin Scale; NIHSS, National Institutes of Health Stroke Scale; PEG, percutaneous endoscopic gastrostomy; SU, stroke unit.
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F3
We conducted the following high-frequent treatment (Fig. 3): (1) 3x/day ice stimulation of anterior faucial arches five times on each side with an ice stick; (2) each five sets of five repetitions of CTAR and JOE for 10 s with 10 s break between each repetition. To control the effects of the therapy the SLT conducted five FEES examinations within the 7 weeks of therapy, two FEES during the hospital stay, and three follow-up FEES after discharge (Fig. 1, 3, 4).
Dysphagia severity scores as measured by flexible endoscopic evaluation of swallowing (FEES) in the course of 7 weeks of dysphagia therapy with Jaw Opening Exercise (JOE) and Jaw Opening Against Resistance (JOAR). The figure shows the measured dysphagia scores in the consecutive FEES in the course of treatment. Increasing Penetration-Aspiration-Scale (PAS; left upper graph) and Yale Pharyngeal Residue Severity Rating Scale for valleculae (YSv; right upper graph) and piriform sinus (YSps; left lower graph) scores indicate increased dysphagia severity. Increasing Functional Oral Intake Scale (FOIS; right lower graph) scores indicate an improvement in total oral intake.
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F4
To control the effects of the therapy the SLT conducted five FEES examinations within the 7 weeks of therapy, two FEES during the hospital stay, and three follow-up FEES after discharge (Fig. 1, 3, 4). Six weeks after discharge all dysphagia scores showed no relevant aspiration risk (Fig. 4).