[FEES for neurogenic dysphagia: training curriculum of the German Society of Neurology and the German Stroke Society]. / FEES für neurogene Dysphagien : Ausbildungscurriculum der Deutschen Gesellschaft für Neurologie und Deutschen Schlaganfall-Gesellschaft.

Neurogenic dysphagia is one of the most frequent and prognostically relevant neurological deficits in a variety of disorders, such as stroke, parkinsonism and advanced neuromuscular diseases. Flexible endoscopic evaluation of swallowing (FEES) is now probably the most frequently used tool for objective dysphagia assessment in Germany. It allows evaluation of the efficacy and safety of swallowing, determination of appropriate feeding strategies and assessment of the efficacy of different swallowing manoeuvres. The literature furthermore indicates that FEES is a safe and well-tolerated procedure. In spite of the huge demand for qualified dysphagia diagnostics in neurology, a systematic FEES education has yet not been established. The structured training curriculum presented in this article aims to close this gap and intends to enforce a robust and qualified FEES service. As management of neurogenic dysphagia is not confined to neurologists, this educational program is applicable to other clinicians and speech language therapists with expertise in dysphagia as well.

[FEES in the stroke unit: recommendations for implementation in the clinical routine]. / FEES auf der Stroke-Unit : Empfehlungen zur Umsetzung im klinischen Alltag.

Dysphagia occurs in about 50 % of patients with acute stroke, is strongly related to early complications, such as aspiration pneumonia and is a major cause of increased morbidity and mortality in acute stroke. Flexible endoscopic evaluation of swallowing (FEES) has proven to be an easy to use, non-invasive tool for assessment of dysphagia in acute stroke, significantly adding accuracy to the clinical evaluation of dysphagia. With respect to the growing use of FEES in German stroke units this article summarizes recommendations for implementation and execution.A 3-step process is recommended to acquire the relevant knowledge and skills for carrying out FEES. After a systematic training (first step), swallowing endoscopy should be done under close supervision (second step) which is then followed by independent practice coupled with indirect supervision (third step). In principle, FEES should adopt a team approach involving both neurologists and speech language pathologists (SLP) or alternatively speech therapists. The allocation of responsibilities between these two professions should be kept flexible and should be adjusted to the individual level of education. Reducing the role of the SLP to mere assistance work in particular should be avoided. To enhance interprofessional communication and to allow for a smooth and efficient workflow, endoscopic grading of stroke-related dysphagia should adopt a standardized score that also includes protective and rehabilitative measures as well as nutritional recommendations. A major task for the future is to develop an educational curriculum for FEES that takes the specific needs of stroke unit care into account and is applicable to both physicians and SLPs.

[Management of dysphagic patients with acute stroke]. / Dysphagiemanagement in der akuten Schlaganfallphase.

This article describes expert recommendations on the management of patients with acute stroke, who might suffer from dysphagia. The main goal is to reduce the risk of aspiration pneumonia (AP). Nurses or physicians should perform the standardized swallowing assessment (SSA) as soon as possible and speech-language therapists have to perform examinations comprising assessment of predictors for aspiration and for AP as well as the clinical swallowing assessment. Dependent on the results, flexible endoscopic or video fluoroscopic evaluation of swallowing has to be performed so that indications for enteral or oral feeding can be made. Furthermore, the risk of AP can be minimized. This article presents algorithms which enable decision-making with regard to diagnostic and therapeutic measures.

Automated anatomical demarcation using an active shape model for videofluoroscopic analysis in swallowing.

The current gold standard method in the clinical assessment of swallowing is the visual inspection of videofluoroscopic frames. Specific clinical measurements are estimated based on various anatomical and bolus positional information with respect to time (or frame number). However, due to the subjective nature of visual inspection clinicians face intra- and inter-observer repeatability issues and bias when making these estimations. The correct demarcations of reference lines highlighting the positions of important anatomical landmarks would serve as a visual aid and could also be used in conjunction with bolus detection methods to objectively determine these desirable measurements. In this paper, we introduce and test the reliability of applying a 16-point Active Shape Model as a deformable template to demarcate the boundaries of salient anatomical boundaries with minimal user input. A robust end and corner point detection algorithm is also used to provide image information for the suggested movement of the template during the fitting stage. Results show the model deformation constraints calculated from a training set of images are clinically coherent. The Euclidean distances between the fitted model points against their corresponding target points were measured. Test images were taken from two different data sets from frames acquired using two different videofluoroscopy units. Overall, fitting was found to be more reliable on the vertebrae and inferior points of the larynx compared to the superior laryngeal points and hyoid bone, with the model always fitting the C7 vertebra with discrepancies no higher than a distance of 23 pixels (3.2% of the image width, approximately 7.6mm).