Odontology (2017) 105:222–228

DOI 10.1007/s10266-016-0248-3

ORIGINAL ARTICLE

Diagnosis and evaluation of 100 dysphagia patients using

videoendoscopy at a core hospital of a local city in Japan
Kazumichi Yonenaga1,2 • Hideyuki J. Majima3 • Shigeto Oyama1 • Kazuya Ishibashi1 •

Hiroaki Tanno1

Received: 22 March 2015 / Accepted: 7 April 2016 / Published online: 11 May 2016
Ó The Society of The Nippon Dental University 2016

Abstract Japan has entered an era of a super-aging pop-
ulation, and given the importance of oral nutrition, the need
to evaluate swallowing function has increased. Herein, we
contribute to continued developments in evaluating eating
and swallowing functions by describing current videoen-
doscopy (VE) usage and trends to evaluate and diagnose
causes of dysphagia. In all, 100 patients (58 men and 42
women; mean age: 79 years) with suspected dysphagia
were enrolled; 15 of these were re-examinations. Exami-
nations were conducted according to the Japanese Society
of Dysphagia Rehabilitation VE examination guidelines for
swallowing. In this study, several patients (77.8 %) with
poor vocalization and a saliva reservoir were unable to eat.
While evaluating the relationship between aspiration and
pharyngeal or laryngeal influx, we found that when pha-
ryngeal and laryngeal influx were present, the risk of
aspiration was high. Some patients (38.9 %) were able to
eat despite lacking a cough reflex; thus, the absence of a
cough reflex does not necessarily equate to an inability to
eat, even in patients unable to ingest nutrition orally. One
case could ingest nutrition, even with no cough reflex. The
6-month survival rate after the examination of patients on
nil per os status was 57.1 %, specifically in patients unable
& Kazumichi Yonenaga
yonenaga-tky@umin.ac.jp
1
Towada City Hospital, Nishi 12-14-8, Towada,
Aomori 034-0093, Japan
2
Department of Oral and Maxillofacial Surgery, Tokyo
University Graduate School of Medicine, Hongo 7-3-1,
Bunkyo-Ku, Tokyo 113-8655, Japan
3
Division of Maxillofacial Radiology, Department of
Oncology, Kagoshima University Graduate School of
Medical and Dental Sciences, 35-1 8-cyhome Sakuragaoka,
Kagoshima 890-8544, Japan
to ingest nutrition orally. These results suggest that
decreased eating and swallowing functions indicate a poor
prognosis for the patient’s quality of life, as eating and
swallowing require smooth passage in the oral phase.
Therefore, actively requesting a dental intervention and
oral rehabilitation is important for a patient presenting
these issues.
Keywords Dysphagia
Oral rehabilitation
Swallowing

Gerontology
Survival rate
Introduction
As Japan has entered an era of a super-aging society, the
importance of both oral nutrition and evaluating swallow-
ing function has increased. Dysphagia is particularly
common in patients with terminal illnesses [1, 2]. In Japan,
a videoendoscopy (VE) swallowing examination is avail-
able and covered by medical insurance. VE can compre-
hensively determine swallowing function in the oral phase
both directly and indirectly, as well as in the pharyngeal
phase and early esophageal phase. Compared with a tra-
ditional videofluoroscopic (VF) swallowing examination,
VE is easy to use, results in fewer pain and discomfort
complaints from patients, incurs relatively lower costs [3,
4], and can be conducted both at the hospital bedside and at
the patient’s home.
However, the usefulness of VE and other available
examination techniques is not widely recognized in Japan.
Guidelines for VE swallowing examinations have been
published by both the Japanese Society of Dysphagia
Rehabilitation [5] and the Japanese Society of Gerodon-
tology [6], but further information is needed for their use in
the evaluation and diagnosis of dysphagia. The elderly

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Odontology (2017) 105:222–228
have an increased prevalence of dysphagia and many suffer
from diseases of old age, including stroke, progressive
neurological disease, and dementia, which are highly
associated with dysphagia.
Our hospital plays a central role in a medical district
with a population of approximately 180,000, but lacks a
dentistry department. As a result, VE using portable na-
sopharyngeal fiberscopes was introduced in the hospital in
April of 2014. In this report, we describe the current usage
and trends in VE to evaluate and diagnose causes of dys-
phagia at our hospital. The purpose was to contribute to the
development of future eating and swallowing function
evaluations.
Materials and methods
We enrolled a total of 100 patients with suspected dys-
phagia who underwent VE examinations from April 2014
to September 2014 at Towada City Hospital, Aomori,
Japan. Among the case population, 15 cases were re-ex-
aminations. The mean patient age was 79.0 ± 11.0 years
(range 44–100 years); 58 men and 42 women were inclu-
ded. Ninety-three examinations were performed on the
hospital ward, 6 in the outpatient clinic, and 1 at a patient’s
home. The following departments requested VE examina-
tions: the General Medicine Department (71 patients), the
Neurosurgery Department (27 patients), and the Urology
and Gastroenterology Departments (1 patient). The dis-
eases of the patients who underwent VE examinations are
listed in Fig. 1.
Examinations were conducted according to guidelines
for a VE swallowing examination [5] developed by the
Japanese Society of Dysphagia Rehabilitation. Videoen-
doscopy was indicated in patients with states of
Fig. 1 Underlying diseases in 4% 1%
the patient population
5%
(n = 100)
5%
10%
16%
223
consciousness up to Japan Coma Scale I-3 [7], and for
patients in whom it was difficult to evaluate basic swal-
lowing function. VE examinations were performed using
the PENTAX FNL-10RBS (HOYA; Tokyo, Japan) endo-
scopy unit with the patient awake and on a reclining bed.
Patients were placed in a sitting position with the bed angle
raised to 60° or higher, and the head was stabilized with
pillows. Nasal anesthesia was not provided, and the
endoscope was inserted with lubricating jelly only. The
standard test foods for examination were jelly (Isocal Jelly
KURINÒ [plum flavor]; Nestle Japan Ltd., Hyogo, Japan),
milk [8], and rice gruel (a 1:5 rice-to-water ratio with a
slightly firm consistency). The test foods were adjusted as
needed for each patient to accommodate allergies and
conditions. According to the examination, we evaluated
each patient’s ability to eat based on multiple factors such
as poor vocalization, the presence of a saliva reservoir, the
form of the food after the examination, survival rate, and
other parameters (Table 1).
We carried out an oral examination before and after the
inspection. It was defined as follows under the guidelines
for VE swallowing examinations by the Japanese Society
of Dysphagia Rehabilitation. The saliva reservoir was
evaluated in the residual state of the pharynx and larynx.
We evaluated it as moderate when the saliva reservoir was
up to the pharynx, and as severe when the saliva reservoir
was up to the larynx. A delay was noted when the swal-
lowing reflex does not occur immediately after the meal
has reached the pharynx or larynx. Clearance was evalu-
ated in the residual meal state of the pharynx and larynx
after swallowing. We evaluated it as moderate when the
meal was up to the pharynx, and as severe when the meal
was up to the larynx. Aspiration was defined as meal
intrusion into the trachea seen after swallowing. Poor
vocalization was an utterance that could not be maintained
Cerebrovascular disease
Respiratory disease (including
aspiration pneumonia)
Disuse syndrome
Cancer
Nerve intractable disease
Dementia
Heart failure
59%
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Table 1 Parameters evaluated in the videoendoscopy swallowing
examination
Nasopharyngeal closure
Vocalization
Cough reflex
Pharyngeal influx
Laryngeal influx
Aspiration (jelly, water, and gruel)
Saliva reservoir
Swallowing-induced delay
Pharyngeal clearance
Nasopharyngeal backflow
Eating was possible or impossible
Eating was possible or impossible with concurrent poor
vocalization and saliva reservoir
Eating was possible or impossible with aspiration
Eating was possible or impossible with an absent cough reflex
The reason of re-examination
The need for a dental examination
The nutrition of patients unable to eat
Discharge destination
The 6-month mortality rate in patients unable to eat
The cause of death
The location of death
for more than 3 s. An absent cough reflex resulted in an
inability to cough up sputum or aspiration products. We
checked cough reflection by inducing light contact with the
epiglottis larynx surface or arytenoid region with the
endoscope. To be able to eat, one must be capable of
swallowing. The presence or absence of aspiration does not
matter. Even if aspiration occurred, a firm cough reflex
made expectoration possible, and we considered them to be
fed. The pharynx and larynx were examined using VE, and
based on the patient’s condition, the examination was ter-
minated without offering food. Suction was performed if
swallowing was bad after the inspection, and it was con-
firmed that there was no intra-oral residue. In addition, it
was confirmed that there was no reduction in SpO2 or lung
noise at auscultation. The 6-month survival rate was cal-
culated in patients who underwent follow-up at our hos-
pital. If patients were examined by VE a second time, the
date of the first examination was set as the initial time for
the survival rate survey.
Results
Two-thirds of the patients exhibited vocalization and
nasopharyngeal closure (Fig. 2a). All of them were
impaired. All patients exhibiting aspiration also exhibited
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Odontology (2017) 105:222–228
pharyngeal and laryngeal influx (Fig. 2a). Overall, patients
found it easiest to swallow jelly, followed by gruel, and
finally, water (Fig. 2a). Among the etiologies identified—a
saliva reservoir, swallowing-induced delay, pharyngeal
clearance, and nasopharyngeal backflow—poor pharyngeal
clearance was the most common (Fig. 2b). During the
examination, 66 % of the patients were able to eat.
Among 38 patients with poor vocalization, 16 were able
to eat (42.1 %). Of the 45 patients with a saliva reservoir,
22 were able to eat (48.9 %). However, only 4 (22.2 %) of
18 patients with concurrent poor vocalization and a saliva
reservoir could eat. Among 52 patients with aspiration, 18
were able to eat (34.6 %); eating was also possible for 7
(38.9 %) of 18 patients with an absent cough reflex.
In the 15 follow-up examinations, improved swallowing
function was expected in 10 patients (66.7 %). In the
remaining 5 patients, swallowing function was expected to
worsen. Among 10 patients unable to eat during the first
examination, 4 were able to eat during the second exami-
nation. VE revealed the need for a dental examination in 25
of the 100 patients. In patients unable to eat at the time of
discharge, nutrition was mainly delivered by gastrostomy
(8 of 26 patients) and central venous catheters (7 of 26
patients) (Fig. 3a). Patients were most commonly dis-
charged to their own homes (46 of 93 patients) (Fig. 3b).
The overall 6-month mortality rate was 29.2 % (14 of 48
patients) (Fig. 4a). Among patients unable to ingest food
orally, the 6-month mortality rate was 42.9 % (6 of 14
patients) (Fig. 4b). The cause of death (n = 15) was a non-
cancerous illness in 11 patients (73.3 %) and cancer in 4
patients (26.7 %). Twelve patients died either at home or in
a nursing institution (80.0 %), and 3 patients died at our
hospital (20.0 %). No complication, such as fainting,
hemorrhage, vocal cord damage, laryngospasm, or allergic
reaction, occurred during the VE examination in any
patient.
Discussion
Based on these cases, we believe that there are 2 indi-
cations for the use of VE in elderly patients. First, VE can
be used to determine when a patient should resume eating
after suffering a cerebrovascular injury. Second, VE can
be used to confirm the presence of aspiration that can
accompany advanced age. In other words, with rehabili-
tation, swallowing disorders developed in an acute man-
ner, such as those in cerebral infarction patients, are likely
to improve. On the other hand, swallowing disorders that
continue to progress gradually in a chronic form, such as
disuse syndrome patients, may improve less, but rehabil-
itation of functional maintenance is important. Patients
experiencing difficulty eating because of cerebrovascular
Odontology (2017) 105:222–228 225

Fig. 2 a The numbers of A

patients exhibiting
nasopharyngeal closure Nasopharyngeal closure 67% 33%
(n = 100), vocalization
(n = 100), a cough reflex Vocalization 62% 38%
(n = 100), pharyngeal influx
(n = 96), laryngeal influx
(n = 96), and aspiration (jelly/ Cough reflex 82% 18%
water/gruel) (n = 96). b The
numbers of patients exhibiting a Pharynx influx 66% 34%
saliva reservoir (n = 100),
swallowing-induced delay
(n = 100), pharyngeal
Larynx influx 56% 44%
clearance (n = 100), and
nasopharyngeal backflow Aspiration 54% 46%
(n = 100)
Water 54% 46%

Gruel 41% 59%

Jelly diet 33% 67%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Yes No

B
55% 36% 9%

49% 36% 15%

41% 45% 14%

3 4
93% % %

Mild Moderate Severe

disease have a high potential for recovery through reha-
bilitation, and VE is useful in determining the appropriate
time to restart meals in these patients. Difficulty with oral
ingestion is also an age-related change in elderly patients
[9], and can be improved through rehabilitation [10].
Thus, VE is useful to assess which foods can be safely
consumed without causing aspiration, as well as to
determine future routes of administration for nutrition
[11].
In this study, nearly 50 % of the patients had poor
vocalization or a saliva reservoir, but were able to eat. This
indicates that the presence of poor vocalization or a saliva
reservoir alone does not determine the ability to eat. In
contrast, several patients with both poor vocalization and a
saliva reservoir were unable to eat, indicating that there is a
high potential for patients to lose the ability to eat when
these 2 conditions are present.
A swallowing-induced delay was observed in 50 % of
the patients. Reportedly, the threshold for swallowing-in-
duced stimulation is significantly higher in elderly patients
than in young patients [12], and as age increases, swal-
lowing speed decreases, thus increasing the risk of dys-
phagia [13, 14]. Swallowing-induced stimulation is
influenced by neither posture nor food temperature [12],
but patients have reported that swallowing while facing
down required more effort [15].
Pharyngeal influx is food that remains in the pharynx. A
laryngeal influx of food flows into the larynx, and stays
above the glottis. We observed that when pharyngeal and
laryngeal influx were present, the risk of aspiration
increased. Jelly was the easiest food for patients to swal-
low, though a few patients who aspirated jelly did not
aspirate water. It has been reported that the hardness of
food affects its passage through the oral phase, and passage

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226 Odontology (2017) 105:222–228

Fig. 3 a Nutrition routes

(n = 26) at the time of
A
discharge in patients unable to
eat. b Locations to which
patients were discharged after
23.1%
the videoendoscopic 30.8%
examination (n = 93) Gastric fistula

Central venous port

Intravenous nutrition
3.8%
Subcutaneous injection

Nasogastric tube
7.7%
Ingestible after rehabilitation

7.7%
26.9%

B
4.3%
7.5%

Home

Facility

Changing hospital

Death discharge

38.7%
49.5%

through the pharynx is affected by its viscosity [16]; thus,
the presence of normal saliva may have also influenced the
patients’ swallowing. In addition, aspiration occurred in
several patients who were still able to eat. Thus, even if
aspiration occurs, eating may be possible if the cough
reflex is strong, although there is an increased risk of
aspiration pneumonia. Some patients were able to eat
despite lacking a cough reflex, indicating that an absent
cough reflex does not always equate to an inability to eat.
The distal end of the endoscope induced a cough reflex by
lightly contacting the epiglottis laryngeal surface or bifida
unit; even without an induced cough reflex, it is believed
that feeding is not impossible. The reasons for VE re-
examination included evaluations for possible deterioration
in eating and swallowing functions and evaluations of
improvement after rehabilitation.
At the time of the initial examination, patients with
poorly fitted dentures, tooth decay, and periodontal dis-
eases were referred for a dental consultation. At the follow-
up examination, 25 % of these patients still required dental
care. Eating and swallowing require appropriate occlusion
[17], sufficient tongue pressure [18], and smooth passage
through the oral phase [19]. Proper oral care is also
important in preventing fever and aspiration pneumonia
[20]; therefore, we feel that it is important to request dental
care proactively.

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Odontology (2017) 105:222–228
A dysphagia. Accordingly, if the patient is ready to be
(%) 100
80
70.8%
60
40
20
0 5 10 15 20 25
(Week)
B eating and swallowing functions indicate a poor prognosis
(%) 100
80
60
57.1%
40
20
0 5 10 46% 15 20 25
(Week)
Fig. 4 The survival rate after the videoendoscopic swallowing
examination (a) and in patients for whom oral ingestion was not
possible (b). Kaplan–Meier method: 95 % confidence interval (lower
limit, upper limit)
Patients undergoing VE often demonstrated reduced
swallowing function and difficulties in oral food ingestion;
thus, the mortality rate after examination was high, par-
ticularly in patients unable to ingest nutrition orally.
Among patients with terminal diseases, pain was the most
frequently reported symptom in patients with cancer, while
reduced oral nutritional intake and anorexia were the most
frequently reported symptoms in patients with non-cancer
illnesses [21]. These results suggest that decreased eating
and swallowing functions indicate a poorer prognosis for
the patient’s quality of life.
At our hospital, we introduced VE as a way to explain
the actual swallowing condition to patients, families, and
medical staff. This procedure allows for swallowing
ability to be determined with stronger evidence, and
allows us to instruct patients in appropriate eating pos-
tures, meal planning, eating methods, and the potential for
aspiration and vomiting. The introduction of VE has also
revealed the necessity of oral care and dental consulta-
tions, as we recognize that cooperation between physi-
cians and dentists is important. Because oral diseases can
cause dysphagia, even though they do not cause direct and
severe swallowing difficulties, such as those caused by
brain and respiratory diseases, dental interventions, oral
cures, and oral rehabilitation can be performed to improve
227
properly fed, it can be expected to improve the coordi-
nation of swallowing [22]. In addition, maintaining oral
hygiene and professional oral care for the prevention of
complications such as fever or aspiration pneumonia can
also be expected to improve dysphagia. While performing
a VE examination is not particularly difficult, aspiration is
a potential complication. Thus, VE should only be per-
formed after the clinician has received sufficient training
on the proper pre-examination assessment, as well as the
appropriate responses to aspiration and asphyxiation dur-
ing the examination. These results suggest that decreased
for a patient’s quality of life, as both eating and swal-
lowing require smooth passage through the oral phase.
Therefore, actively requesting a dental intervention and
oral rehabilitation is important for patients presenting
these issues.
Acknowledgments The present study was not supported by funding.
Compliance with ethical standards
Conflict of interest The authors declare that they have no conflict of
interest.
Ethical standards This study was approved by the institutional
ethical board of Towada City Hospital.
Informed consent Informed consent was obtained from all indi-
vidual participants included in the study.
Ethical approval All procedures performed in studies involving
human participants were in accordance with the ethical standards of
the institutional and/or national research committee and with the 1964
Helsinki declaration and its later amendments or comparable ethical
standards.
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