Department/team name - RCSLT



465706015358Speech & Language Therapy TeamAddressPhone Number00Speech & Language Therapy TeamAddressPhone NumberPrivate & Confidential FORMTEXT ?????Date of Report: FORMTEXT ?????FEES (Fibreoptic Endoscopic Examination of Swallowing) ReportDate of assessment: FORMTEXT ?????Patient Name: FORMTEXT ????? FORMDROPDOWN FORMTEXT ?????DOB: FORMTEXT ?????Consultant: FORMTEXT ?????Diagnosis: FORMTEXT ?????Treatment history: FORMTEXT ?????Other relevant Medical History: FORMTEXT ?????Summary: FORMTEXT ?????Recommendations: FORMTEXT ?????ASSESSMENT INFORMATIONA-D Indicate if Within Normal Limits (WNL), Outside Normal Limits (ONL) or Unable to Assess (UTA). Comments in box.ANASOPHARYNX & SOFT PALATEAnatomy FORMDROPDOWN FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Symmetry of movement FORMDROPDOWN Speed of movement FORMDROPDOWN Range of movement FORMDROPDOWN BBASE OF TONGUE & OROPHARYNXAnatomy FORMDROPDOWN FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Symmetry of movement FORMDROPDOWN Speed of movement FORMDROPDOWN Range of movement FORMDROPDOWN CHYPOPHARYNX & LATERAL PHARYNGEAL WALLSAnatomy FORMDROPDOWN FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? Symmetry FORMDROPDOWN Speed of movement FORMDROPDOWN Range of movement FORMDROPDOWN Pharyngeal squeeze manoeuvre FORMDROPDOWN DLARYNX AND SUPRAGLOTTIS Anatomy FORMDROPDOWN FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Symmetry at rest FORMDROPDOWN Speed of abduction FORMDROPDOWN Range of movement FORMDROPDOWN Symmetry of closure & phonation FORMDROPDOWN Vocal fold lengthening FORMDROPDOWN Vertical laryngeal movement FORMDROPDOWN Epiglottic retroflexion during swallow FORMDROPDOWN EAIRWAY PROTECTION (Murray 1999) FORMCHECKBOX UTA FORMCHECKBOX Laryngeal closure not achieved FORMCHECKBOX Transient true fold closure FORMCHECKBOX Sustained true fold closure FORMCHECKBOX Transient ventricular fold closure FORMCHECKBOX Sustained ventricular fold closureFSECRETION RATINGNew Zealand Secretion Scale (adapted from Miles et al. 2017):CategorySymptomScoreConsistency FORMDROPDOWN N/ALocation FORMDROPDOWN FORMDROPDOWN Amount in Pyriforms FORMDROPDOWN FORMDROPDOWN Response FORMDROPDOWN FORMDROPDOWN Total Score FORMDROPDOWN /7Was secretion management formally assessed (food dye test)? FORMDROPDOWN If yes, indicate SSRS score: FORMDROPDOWN SECRETION SEVERITY RATING SCALE (Murray 1999)ONormal rating: ranges from no visible secretions anywhere in the hypopharynx, to some transient secretions visible in the valleculae and pyriform sinuses. These secretions are not bilateral or deeply pooled.1Any secretions evident upon entry or following a dry swallow in the protective structures surrounding the laryngeal vestibule that are bilaterally represented or deeply pooled. This rating would include cases in which there is transition in the accumulation of secretions during observation segment.2Any secretions that change from “1”” to a “3” rating during the observation period. 3Most severe rating. Any secretions seen in the area defined as laryngeal vestibule. Pulmonary secretions are included if they are not cleared by swallowing or coughing by the close of the segment.GORAL TRIALS OF FOOD/FLUIDSPENETRATION – ASPIRATION SCALE (PAS) (Rosenbek 1996)Material does not enter the airwayMaterial enters the airway, remains above the vocal folds and is ejected from the airwayMaterial enters the airway, remains above the vocal folds, and is not ejected from the airwayMaterial enters the airway, contacts the vocal folds, and is ejected from the airwayMaterial enters the airway, contacts the vocal folds, and is not ejected from the airwayMaterial enters the airway, passes below the vocal folds, and is ejected into the larynx or out of the airwayMaterial enters the airway, passes below the vocal folds, and is not ejected from the trachea despite effortMaterial enters the airway, passes below the vocal folds, and no effort is made to ejectOVERALL RESIDUE SCORE (ORS) (Boston Medical Centre) 0. Absent or Normal None, coating or trace1. Mild ? valleculae, lateral channels, or pyriforms filled/ beyond coating on BOT, pharyngeal walls2. Moderate nearly or completely fills valleculae, pyriforms, or lateral channels, or ? of several cavities3. Severe nearly or completely fill 2 or more cavitiesItemLowest point of pre-swallow spillagePre-swallow spillage time (secs)ORSClearing swallowsPASTiming of aspiration FORMDROPDOWN FORMDROPDOWN FORMDROPDOWN FORMDROPDOWN FORMDROPDOWN FORMDROPDOWN FORMDROPDOWN FORMDROPDOWN FORMDROPDOWN FORMDROPDOWN FORMDROPDOWN FORMDROPDOWN FORMDROPDOWN FORMDROPDOWN FORMDROPDOWN FORMDROPDOWN FORMDROPDOWN FORMDROPDOWN FORMDROPDOWN FORMDROPDOWN FORMDROPDOWN FORMDROPDOWN FORMDROPDOWN FORMDROPDOWN PHARYNGEAL RESIDUE SEVERITY SCALE (PRSS) (Kelly 2006) 0. None No pharyngeal coating or residue1. Coating Coating of the pharyngeal mucosa; no pooling 2. Mild Mild pooling/residue3. Moderate Moderate pooling/ residue4. Severe Severe pooling/residueResidue Location FORMDROPDOWN FORMDROPDOWN FORMDROPDOWN Lateral pharyngeal wall FORMDROPDOWN FORMDROPDOWN FORMDROPDOWN FORMDROPDOWN FORMDROPDOWN FORMDROPDOWN Posterior pharyngeal wall FORMDROPDOWN FORMDROPDOWN FORMDROPDOWN FORMDROPDOWN FORMDROPDOWN FORMDROPDOWN Tongue base FORMDROPDOWN FORMDROPDOWN FORMDROPDOWN FORMDROPDOWN FORMDROPDOWN FORMDROPDOWN Valleculae FORMDROPDOWN FORMDROPDOWN FORMDROPDOWN FORMDROPDOWN FORMDROPDOWN FORMDROPDOWN Tip of epiglottis FORMDROPDOWN FORMDROPDOWN FORMDROPDOWN FORMDROPDOWN FORMDROPDOWN FORMDROPDOWN Lateral channels FORMDROPDOWN FORMDROPDOWN FORMDROPDOWN FORMDROPDOWN FORMDROPDOWN FORMDROPDOWN Pyriform sinuses FORMDROPDOWN FORMDROPDOWN FORMDROPDOWN FORMDROPDOWN FORMDROPDOWN FORMDROPDOWN Arytenoids FORMDROPDOWN FORMDROPDOWN FORMDROPDOWN FORMDROPDOWN FORMDROPDOWN FORMDROPDOWN Aryepiglottic folds FORMDROPDOWN FORMDROPDOWN FORMDROPDOWN FORMDROPDOWN FORMDROPDOWN FORMDROPDOWN Inter-arytenoid space FORMDROPDOWN FORMDROPDOWN FORMDROPDOWN FORMDROPDOWN FORMDROPDOWN FORMDROPDOWN (Right (R)/Left (L)/Bilateral (B))HMANOEUVRES & STRATEGIES and OUTCOMEStrategyOutcome FORMDROPDOWN FORMTEXT ????? FORMDROPDOWN FORMTEXT ????? FORMDROPDOWN FORMTEXT ?????IBIOFEEDBACKWas biofeedback used? FORMDROPDOWN If yes, was it helpful? FORMDROPDOWN Comments: FORMTEXT ?????J SENSATION Touch Test completed? FORMDROPDOWN If yes, what was outcome? FORMDROPDOWN Overall impression & comments: FORMTEXT ?????K OTHER COMMENTSComments: FORMTEXT ????? FORMDROPDOWN FORMDROPDOWN Speech and Language Speech and Language Therapist Therapist Cc: FORMTEXT ????? ................
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