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Neurogenic Dysphagia: Review and Proposal of Classification System
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Neurogenic dysphagia can be a manifestation in many neurologic diseases and can lead to severe complications. The authors conducted a systematic review of the literature and introduce a classification system based on flexible endoscopic evaluation of swallowing (FEES) findings. The typical FEES findings are presented for each of the major disorders causing dysphagia. The major phenotypic categories proposed are premature bolus spillage, delayed swallowing reflex, predominance of residue in the valleculae, predominance of residue in the piriform sinus, pharyngolaryngeal movement disorders, fatigable swallowing weakness, and complex swallowing disorder. The phenotypic patterns are largely associated with specific disease groups. There was good inter-rater reliability.
- This classification can help physicians accurately diagnose dysphagia and target therapy to the specific pathophysiology.
abstract
This abstract is available on the publisher's site.
Access this abstract nowOBJECTIVE
Introduction and validation of a phenotypic classification of neurogenic dysphagia based on flexible endoscopic evaluation of swallowing (FEES).
METHODS
A systematic literature review was conducted, searching MEDLINE from inception to May 2020 for FEES findings in neurologic diseases of interest. Based on a retrospective analysis of FEES videos in neurologic diseases and considering the results from the review, a classification of neurogenic dysphagia was developed distinguishing different phenotypes. The classification was validated using 1,012 randomly selected FEES videos of patients with various neurologic disorders. Chi-square tests were used to compare the distribution of dysphagia phenotypes between the underlying neurologic disorders.
RESULTS
A total of 159 articles were identified, of which 59 were included in the qualitative synthesis. Seven dysphagia phenotypes were identified: (1) "premature bolus spillage" and (2) "delayed swallowing reflex" occurred mainly in stroke, (3) "predominance of residue in the valleculae" was most common in Parkinson disease, (4) "predominance of residue in the piriform sinus" occurred only in myositis, motoneuron disease, and brainstem stroke, (5) "pharyngolaryngeal movement disorder" was found in atypical Parkinsonian syndromes and stroke, (6) "fatigable swallowing weakness" was common in myasthenia gravis, and (7) "complex disorder" with a heterogeneous dysphagia pattern was the leading mechanism in amyotrophic lateral sclerosis. The interrater reliability showed a strong agreement (kappa = 0.84).
CONCLUSION
Neurogenic dysphagia is not a symptom, but a multietiologic syndrome with different phenotypic patterns depending on the underlying disease. Dysphagia phenotypes can facilitate differential diagnosis in patients with dysphagia of unclear etiology.
Additional Info
Neurogenic Dysphagia: Systematic Review and Proposal of a Classification System
Neurology 2021 Feb 09;96(6)e876-e889, T Warnecke, B Labeit, J Schroeder, A Reckels, S Ahring, S Lapa, I Claus, P Muhle, S Suntrup-Krueger, R DziewasFrom MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine.
Neurology
Neurogenic dysphagia typically occurs in patients with neurological disease of different etiologies and is associated with high mortality, morbidity, and social costs. A correct and early diagnosis and an appropriate management of dysphagia could be useful for improving patient quality of life and may help to prevent or delay death. Flexible endoscopic evaluation of swallowing (FEES) is an assessment using a flexible nasendoscopy tube, which is passed into the nares, over the velum, and into the pharynx in order to perform a functional and morphological study of the velopharyngeal sphincter and assess pharyngeal and laryngeal reflexes. FEES permits the detection of abnormalities in swallowing, laryngeal penetration of bolus, or tracheal aspiration.
The aim of this systematic review was to validate a FEES-based phenotypic classification of neurogenic dysphagia. A total of seven dysphagia phenotypes were identified: 1) “premature bolus spillage” and 2) “delayed swallowing reflex” occurred mainly in the setting of stroke; 3) “predominance of residue in the valleculae” was most common in people with Parkinson disease; 4) “predominance of residue in the piriform sinus” occurred only in patients with myositis, motoneuron disease, and brainstem stroke; 5) “pharyngolaryngeal movement disorder” was found in patients with atypical Parkinsonian syndromes and stroke; 6) “fatigable swallowing weakness” was common in patients with myasthenia gravis; and 7) “complex disorder” with a heterogeneous dysphagia pattern was the leading mechanism in those with amyotrophic lateral sclerosis. Dysphagia phenotypes not only facilitate pathophysiologically driven therapy and research but can also help in the differential diagnosis of unclear dysphagia. This study shows that neurogenic dysphagia is a multi-etiological syndrome with different phenotypic dysphagia patterns that are associated with specific disease groups. The classification introduced complements the existing classifications, which focus primarily on the severity of dysphagia.