Effects of Puree Type and Color on Ratings of Pharyngeal Residue, Penetration, and Aspiration during FEES: A Prospective Study of 37 Dysphagic Outpatient Adults.

Introduction: Flexible endoscopic evaluations of swallowing (FEES) involve the administration of a variety of foods and liquids to assess outcomes related to pharyngeal residue, penetration, and aspiration. While the type and color of thin liquids used during FEES have been found to significantly affect FEES ratings, it is unknown if similar effects are observed with pureed foods. Therefore, the aims of this study were to assess the effects of puree type (applesauce vs. pudding) and color (natural, blue, green) on ratings of pharyngeal residue, penetration, and aspiration during FEES.

Methods: Pharyngeal residue, penetration, and aspiration were assessed in 37 consecutive outpatient adults undergoing FEES. Patients were presented with two types of puree: 5 mL applesauce and 5 mL pudding. Each puree type was presented once with either blue or green food coloring added to it by a clinician. Each puree type was also presented once with no clinician-added food coloring ("natural"). The order of presentation was randomized between patients and all data were blindly analyzed by pairs of independent raters using the Visual Analysis of Swallowing Efficiency and Safety (VASES). Multilevel statistical models were used to examine the effects of puree type and color on oropharyngeal residue, hypopharyngeal residue, and Penetration-Aspiration Scale scores (PAS).

Results: Pudding trials were associated with higher oropharyngeal residue ratings compared to applesauce trials. Blue-colored applesauce was associated with higher oropharyngeal and hypopharyngeal residue ratings when compared to natural applesauce. Lastly, green-colored applesauce and green-colored pudding were both associated with higher hypopharyngeal residue ratings compared to natural applesauce and natural pudding, respectively.

Conclusion: This study identified statistically significant effects of puree type and color and ratings of pharyngeal residue ratings, but not penetration or aspiration, as seen during FEES. These data suggest that clinicians and researchers should consider standardizing the type and color of pureed food used during FEES.