Fiberoptic endoscopic evaluation of swallowing (FEES) in pediatrics: A systematic review

OBJECTIVES

The systematic review aimed to provide an overview of the state-of-art regarding the use of fiberoptic endoscopic evaluation of swallowing (FEES) in pediatrics, specifically investigating FEES feasibility, safety, diagnostic accuracy, and protocols.

METHODS

Four electronic databases were searched for original studies on the pediatric population that instrumentally assessed swallowing function using FEES. A hand-search of the references of included studies was performed. Data on the population, feasibility of endoscope insertion and bolus trials, adverse events, sensitivity and specificity, and FEES equipment and protocol were extracted. The quality of the studies was assessed using the checklists of the Johanna Briggs Institute. Selection of the studies, data extraction, and quality appraisal were conducted by two independent researchers.

RESULTS

Eighty-two reports from 81 studies were included. The mean overall quality of the studies was 80 % (17-100 %). The feasibility of endoscope insertion was high (89%-100 %), while the feasibility of bolus trials varied from 40 % to 100 %. Adverse events were excessive crying (8 studies), irritability or agitation (4 studies), transitory oxygen desaturations (3 studies, 1.2-6.7 % of the patients), epistaxis (3 studies, 0.8-3.3 % of the patients), increased heart rate (1 study, 1 patient), vomiting (1 study, 1 patient), hypertonia (1 study), and hypersalivation (1 study). No major complications were reported. Using VFSS as the reference standard, FEES was generally found to be less sensitive (25-94 %) but more specific (75-100 %) for aspiration, whereas the reverse was true for penetration (sensitivity 76-100 %, specificity 44-83 %). FEES protocols were highly heterogeneous with poor reporting.

CONCLUSION

FEES is a safe, accurate, and generally feasible examination in the pediatric population with suspected dysphagia. However, a consensus on the best FEES protocol for clinical practice and research is currently lacking.

Swallowing Characteristics in Patients with Multiple System Atrophy Analyzed Using FEES Examination

Patients with multiple system atrophy (MSA) frequently experience dysphagia but only few studies analyzed its characteristics. The aim of this study was to describe the swallowing characteristics in these patients using fiberoptic endoscopic evaluation of swallowing (FEES). In addition, the swallowing abilities in patients with predominantly cerebellar MSA (MSA-C) and predominantly parkinsonian MSA (MSA-P) were compared. Twenty-five patients with MSA (16 MSA-P and 9 MSA-C) were enrolled. Clinical data including age, sex, functional oral intake scale (FOIS) score, body mass index (BMI) and the results of the global disability-unified MSA rating scale (GD-UMSARS) were collected. Three different textures of food (liquid, semisolid, solid) were provided during FEES examination. The characteristics of dysphagia (safety, efficiency, phenotype) and laryngeal movement alterations were analyzed. Delayed pharyngeal phase (92%) and posterior oral incontinence (52%) were the phenotypes more frequently seen. Penetration was more frequent with Liquid (68%), while aspiration occurred only with Liquid (20%). Residues of ingested food were demonstrated both in the pyriform sinus and in the vallecula with all the consistencies. Vocal fold motion impairment was the laryngeal movement alteration most frequently encountered (56%). No significant differences between patients with MSA-P and MSA-C in the dysphagia characteristics and laryngeal movement alterations were found. Patients with MSA frequently experience swallowing impairment and altered laryngeal mobility. Dysphagia characteristics and laryngeal movements alterations seems to be similar in MSA-C and MSA-P.

Dysphagia characteristics at FEES examination in post-extubation patients with COVID-19

Objective

The aims of this study was to analyse fibreoptic endoscopic evaluation of swallowing (FEES) findings in tube-fed patients with coronavirus disease 2019 (COVID-19).

Methods

Seventeen patients who had been intubated during intensive care unit (ICU) stay were enrolled. Pooling of secretions, dysphagia phenotype, penetration/aspiration and residue after swallow were assessed through FEES. The Functional Oral Intake Scale (FOIS) scores were also collected. Patients with significant swallowing impairment were evaluated again after 2 weeks.

Results

All patients were tube-fed at enrollment. According to the FEES results, 7 started total oral feeding with at least one consistency. The more common dysphagia phenotypes were propulsive deficit and delayed pharyngeal phase. Pooling of secretions, penetration/aspiration, and residue after swallow were frequently documented. A significant improvement in FOIS scores was found during the second FEES examination.

Conclusions

Swallowing impairment in patients with severe COVID-19 after discharge from the ICU is characterised by propulsive deficit and delayed pharyngeal phase. Most of these patients required feeding restrictions even if feeding abilities seem to improve over time.

Oropharyngeal Dysphagia Phenotypes Across Huntington's Disease Stages: Endoscopic Findings and Tongue Pressure Analysis

Background

Oropharyngeal dysphagia (OD) is a common symptom in Huntington's disease (HD) and is associated with severe health and psychosocial consequences. Different OD phenotypes are defined on the basis of characteristic patterns at fiberoptic endoscopic evaluation of swallowing (FEES), and they may vary during disease progression.

Objective

To describe OD phenotypes in different HD stages and to analyze their association with neurological data and tongue pressure measurements.

Methods

Twenty-four patients with HD at different stages of disease progression underwent a FEES. Data on penetration/aspiration, pharyngeal residue, and OD phenotypes were gained. Neurological examination was performed with the Unified Huntington's Disease Rating Scale (UHDRS). Patient Maximum tongue pressure (MTP) and tongue endurance were measured.

Results

We confirmed that the occurrence of penetration/aspiration increased with disease duration and pharyngeal residue increased from 16.7% to 100% , respectively. The most common OD phenotypes were oropharyngeal dyspraxia (91.7% ), posterior oral incontinence (87.5% ), and delayed pharyngeal phase (87.5% ). These types of dysfunctions are already detectable in >80% of patients in the early disease stages. In more advanced stages, we also observed propulsion deficit (66.7% ), resistive issue (54.2% ), and protective deficit (37.5% ). Propulsion deficit was associated with higher disease stage, greater motor dysfunction (UHDRS-I), and lower MTP and tongue endurance (p <  0.05).

Conclusions

OD in HD results from a combination of different swallowing phenotypes. Early assessment of swallowing and periodical follow-ups are necessary to monitor OD severity and phenotypes and to revise diet recommendations.

Validity, reliability and reproducibility of the VLS parameters form for the collection of videolaryngostroboscopic basic findings

OBJECTIVE

The videolaryngostroboscopy parameters form (VLSP form) is a diagnostic tool for the collection of videolaryngostroboscopic basic findings through the evaluation of 12 parameters. The aim of the present study is to preliminarily investigate intra- and inter-rater reliability, validity and responsiveness of the VLSP form.

METHODS

A study on a total amount of 160 forms for the evaluation of VLS basic findings was carried out. 80 forms were scored through the VLSP form and 80 with the Voice Vibratory Assessment with Laryngeal Imaging (VALI) form Stroboscopy (S) by four expert phoniatricians, that blindly scored the VLS recordings of 5 subjects without voice disorders and 5 patients with organic voice disorder before and after successful phonosurgery. Intra-rater and inter-rater analysis have been performed for both forms. The scores obtained through VLSP form and VALI form S have been compared to analyse concurrent validity, while VLSP scores before and after phonosurgery have been compared to analyse responsiveness. Finally, each rater annotated the "difficulty" in rating every parameter and its "importance" for the diagnosis.

RESULTS

The VLSP form showed good inter- and intra-rater reliability. It showed a good accuracy for the documentation of changes of laryngeal anatomy and function after phonosurgery, similarly to the VALI form S. The 12 parameters of the VLSP form were judged "Slightly Important" in 28.3% of the samples, "Very Important" in 64.8% of the samples, "Not Difficult" in 73.1% of the samples.

CONCLUSIONS

The results of the present study suggest that the VLSP form is comparable to the VALI form S for the evaluation of videolaryngostroboscopic parameters and is a valid, reliable and reproducible diagnostic tool. It can help voice clinicians in the evaluation of VLS examinations and it allows for a punctual assessment of modifications in laryngeal anatomy and function in pathological conditions and after phonosurgery.

The Dubai Definition and Diagnostic Criteria of Laryngopharyngeal Reflux: The IFOS Consensus

OBJECTIVE

The objective of this work was to gather an international consensus group to propose a global definition and diagnostic approach of laryngopharyngeal reflux (LPR) to guide primary care and specialist physicians in the management of LPR.

METHODS

Forty-eight international experts (otolaryngologists, gastroenterologists, surgeons, and physiologists) were included in a modified Delphi process to revise 48 statements about definition, clinical presentation, and diagnostic approaches to LPR. Three voting rounds determined a consensus statement to be acceptable when 80% of experts agreed with a rating of at least 8/10. Votes were anonymous and the analyses of voting rounds were performed by an independent statistician.

RESULTS

After the third round, 79.2% of statements (N = 38/48) were approved. LPR was defined as a disease of the upper aerodigestive tract resulting from the direct and/or indirect effects of gastroduodenal content reflux, inducing morphological and/or neurological changes in the upper aerodigestive tract. LPR is associated with recognized non-specific laryngeal and extra-laryngeal symptoms and signs that can be evaluated with validated patient-reported outcome questionnaires and clinical instruments. The hypopharyngeal-esophageal multichannel intraluminal impedance-pH testing can suggest the diagnosis of LPR when there is >1 acid, weakly acid or nonacid hypopharyngeal reflux event in 24 h.

CONCLUSION

A global consensus definition for LPR is presented to improve detection and diagnosis of the disease for otolaryngologists, pulmonologists, gastroenterologists, surgeons, and primary care practitioners. The approved statements are offered to improve collaborative research by adopting common and validated diagnostic approaches to LPR.

LEVEL OF EVIDENCE

5 Laryngoscope, 134:1614-1624, 2024.

Pharyngeal Residue Scoring in Fiberoptic Endoscopic Evaluation of Swallowing: Reliability Comparison and Applicability Among Different Scales

Several scales to assess pharyngeal residue in Fiberoptic Endoscopic Evaluation of Swallowing (FEES) are currently available. The study aimed to compare the reliability and the applicability in real clinical practice among four rating scales: the Pooling Score (P-SCORE), the Boston Residue and Clearance Scale (BRACS), the Yale Pharyngeal Residue Severity Rating Scale (YPRSRS), and the Residue Ordinal Rating Scale (RORS). Twenty-five FEES videos were evaluated four times, once for each scale, by four speech and language pathologists. To test intra-rater reliability, the same raters re-assessed the videos two weeks apart. To test the applicability, raters recorded the time required to complete each assessment and the perceived difficulty/ease on a visual-analog scale (VAS). The intra-rater and the inter-rater reliability were calculated with Cohen's weighted Kappa and the Fleiss weighted Kappa, respectively. Time and perceived difficulty/ease scores were compared. The intra-rater reliability analysis showed almost perfect agreement for YPRSRS (k = 0.91) and RORS (k = 0.83) and substantial agreement for P-SCORE (k = 0.76) and BRACS (k = 0.74). Pairwise comparison showed no significant differences among the scales. The inter-rater reliability for the YPRSRS (k = 0.78) was significantly higher than P-SCORE (k = 0.52, p < 0.001), BRACS (k = 0.56, p < 0.001), and RORS (k = 0.65, p = 0.005). The BRACS required the longest time (p < 0.001) and was perceived as the most difficult scale (p < 0.001). The RORS was perceived as the easiest scale (p < 0.05). In conclusion, the YPRSRS showed the highest reliability, while raters perceived the RORS as the easiest to score. These results will allow clinicians to consciously choose which scale to use in clinical practice.

Effectiveness of Semi-Occluded Vocal Tract Exercises (SOVTEs) in Patients with Dysphonia: A Systematic Review and Meta-Analysis

BACKGROUND

Dysphonia is a disorder characterized by an alteration in the overall quality of the voice which reduces quality of life. Therefore, we assessed the effectiveness of SOVTEs in the management of dysfunctional and organic dysphonia for acoustic, perceptual-auditive, aerodynamic parameters and self-perception of the disease.

METHODS

a systematic review and meta-analysis were conducted. Findings were reported according to the PRISMA statement. Five databases were searched for RCTs and non- or quasi-RCTs. Studies were independently assessed using the Cochrane Risk of bias (RoB) and ROBINS-I tools. Effect sizes (ES) were calculated only at post-treatment. GRADE criteria were used to assess the quality of evidence.

RESULTS

eight articles were included. Studies investigated several SOVTEs, alone or in combination. None of the study was completely judged at low RoB. The quality of evidence resulted very low for each analysis. SOVTEs revealed to be statistically more effective than control interventions in improving F0 (ES: -14.42; CI 95%: -27.16, -1.69); P = 0.03), whereas shimmer did not change significantly (ES: -0.43; CI 95%:-02.02, 1.15; P = 0.59). Not significant changes in favor of control groups were found for jitter (ES: 0.13; CI 95%: -0.14, 0.40; P  = 0.34) and overall gravity in the perceptual-auditory evaluation (ES: 0.13 CI 95%: -0.50, 0.77; P = 0. 68). Among secondary outcomes, evidence suggested that SOVTEs are more effective than control interventions in Psub reduction (ES: -1.47; CI 95%: -2.84, -0.10; P = 0.03); self-assessment resulted not significantly in favor of SOVTEs (VHI/VRQoL: ES -0.23; CI 95% -1.14, 0.69; P = 0.63 and VTDS/VDSI: ES -4.85, CI 95% -25.13, 15.42; P = 0.64).

CONCLUSION

results obtained showed that voice therapy based on SOVTEs is not to consider significantly superior if compared to other treatments, even if a favorable trend was detected and should be taken into consideration. Further high-quality RCTs on specific SOVTEs are recommended to produce better-quality evidence.

Consensus for voice quality assessment in clinical practice: guidelines of the European Laryngological Society and Union of the European Phoniatricians

INTRODUCTION

To update the European guidelines for the assessment of voice quality (VQ) in clinical practice.

METHODS

Nineteen laryngologists-phoniatricians of the European Laryngological Society (ELS) and the Union of the European Phoniatricians (UEP) participated to a modified Delphi process to propose statements about subjective and objective VQ assessments. Two anonymized voting rounds determined a consensus statement to be acceptable when 80% of experts agreed with a rating of at least 3/4. The statements with ≥ 3/4 score by 60-80% of experts were improved and resubmitted to voting until they were validated or rejected.

RESULTS

Of the 90 initial statements, 51 were validated after two voting rounds. A multidimensional set of minimal VQ evaluations was proposed and included: baseline VQ anamnesis (e.g., allergy, medical and surgical history, medication, addiction, singing practice, job, and posture), videolaryngostroboscopy (mucosal wave symmetry, amplitude, morphology, and movements), patient-reported VQ assessment (30- or 10-voice handicap index), perception (Grade, Roughness, Breathiness, Asthenia, and Strain), aerodynamics (maximum phonation time), acoustics (Mean F0, Jitter, Shimmer, and noise-to-harmonic ratio), and clinical instruments associated with voice comorbidities (reflux symptom score, reflux sign assessment, eating-assessment tool-10, and dysphagia handicap index). For perception, aerodynamics and acoustics, experts provided guidelines for the methods of measurement. Some additional VQ evaluations are proposed for voice professionals or patients with some laryngeal diseases.

CONCLUSION

The ELS-UEP consensus for VQ assessment provides clinical statements for the baseline and pre- to post-treatment evaluations of VQ and to improve collaborative research by adopting common and validated VQ evaluation approach.

Daily speaking time and voice intensity before and after hearing aids rehabilitation in adult patients with hearing loss

Introduction Hearing loss (HL) strongly impacts communication abilities and impairs social interactions. Moreover, it modifies the vocal parameters of affected patients. The effects of hearing rehabilitation through hearing aids (HA) on the vocal production of patients suffering from HL have not been thoroughly analyzed in literature. The aim of this study is to use the Ambulatory Phonation Monitor (APM), a portable vocal dosimeter, to evaluate the variations in the vocal production of a group of patients suffering from moderate-to-severe HL treated with HA, and the relationship between such modifications and quality of life (QoL). Materials and Methods Twenty-six patients suffering from a variable degree of HL and treated with HA have been enrolled. Each of them underwent an evaluation before and 4 months after rehabilitation with HA. The analysis of daily voice production was carried out with the APM, while subjective QoL data were collected through the Speech, Spatial, and Qualities questionnaire (SSQ) and the International Outcome Inventory for Hearing Aids (IOI-HA). The differences in phonatory measurements and subjective evaluations before and after HA rehabilitation were assessed using Wilcoxon signed rank test. The Spearman correlation test was used to analyze the correlation between phonatory measurements, auditory measurements and SSQ scores. Results Significant differences in the APM parameters before and after HA rehabilitation were found. After 4 months of HA use, we recorded a significant increase in phonation time and percentage of phonation time, and a significant decrease in average amplitude in dB SPL. We also found a significant increase in the SSQ scores after HA rehabilitation. Finally, we were able to detect low but significant correlations between phonatory measurements and SSQ results. Conclusions The APM proved to be a useful instrument in the evaluation of the benefits of HA and its measurements can be used as indicators of the participation in communication and social life of patients with HL, which are strongly related to QoL.

Prevalence of Laryngopharyngeal Reflux Symptoms, Dysphonia, and Vocal Tract Discomfort in Amateur Choir Singers

INTRODUCTION

Vocal tract discomfort (VTD), dysphonia, and laryngopharyngeal reflux (LPR) symptoms are complaints frequently reported by amateur singers. There are two aims of this study. The first is to evaluate the prevalence of these symptoms using validated questionnaires. The second is to correlate singing-related variables with the questionnaire responses.

METHODS

A total of 392 amateur choir singers (ACS) and 514 control subjects completed an online survey divided into four parts: (1) clinical and demographic characteristics, (2) training in singing and singing experience, (3) history of gastroesophageal reflux disease and LPR symptoms, (4) validated questionnaires. Specifically, the reflux symptom index (RSI), the vocal tract discomfort scale (VTDS), and the voice symptom scale (VoiSS) were included to analyze the actual burden related to LPR symptoms, VTD, and dysphonia.

RESULTS

ACS demonstrated a healthier lifestyle and a lower prevalence of gastroesophageal reflux disease symptoms in comparison with control subjects. ACS scored significantly higher in VTDS and VoiSS than control subjects, while no differences in the RSI results were found. Significant correlations among the questionnaires' results were demonstrated. Occasional professional singing was the variable influencing VTDS and VoiSS results the most.

CONCLUSION

ACS do not evidently manifest a higher impairment connected to LPR (RSI score), while they do report higher levels of voice (VoiSS score) and vocal tract (VTDS score) impairments, in comparison with control subjects. The relevant correlations among the PRO measures suggest that LPR symptoms, VTD, and dysphonia are related to each other. Given the relevant repercussion on the severity of VTD and dysphonia, providers should specifically ask about occasional professional singing when treating amateur singers.

Sirolimus treatment for paediatric head and neck lymphatic malformations: a systematic review

PURPOSE

This PRISMA-compliant systematic review aimed to assess risks and benefits of sirolimus treatment for paediatric lymphatic malformations by focusing not only on treatment efficacy but also on possible treatment-related adverse events, and treatment combinations with other techniques.

METHODS

Search criteria were applied to MEDLINE, Embase, Web of Science, Scopus, Cochrane Library, and ClinicalTrials.gov databases and included all studies published up to March 2022 reporting paediatric lymphatic malformations treated with sirolimus. We selected all original studies that included treatment outcomes. After the removal of duplicates, selection of abstracts and full-text articles, and quality assessment, we reviewed eligible articles for patient demographics, lymphatic malformation type, size or stage, site, clinical response rates, sirolimus administration route and dose, related adverse events, follow-up time, and concurrent treatments.

RESULTS

Among 153 unique citations, 19 studies were considered eligible, with reported treatment data for 97 paediatric patients. Most studies (n = 9) were case reports. Clinical response was described for 89 patients, in whom 94 mild-to-moderate adverse events were reported. The most frequently administered treatment regimen was oral sirolimus 0.8 mg/m2 twice a day, with the aim of achieving a blood concentration of 10-15 ng/mL.

CONCLUSION

Despite promising results for sirolimus treatment in lymphatic malformation, the efficacy and safety profile of remains unclear due to the lack of high-quality studies. Systematic reporting of known side effects, especially in younger children, should assist clinicians in minimising treatment-associated risks. At the same time, we advocate for prospective multicentre studies with minimum reporting standards to facilitate improved candidate selection.

Early predictors of dysphagia in ischemic stroke patients

INTRODUCTION

Post-stroke dysphagia affects outcome. In acute stroke patients, we aimed to evaluate clinical, cognitive, and neuroimaging features associated with dysphagia and develop a predictive score for dysphagia.

METHODS

Ischemic stroke patients underwent clinical, cognitive, and pre-morbid function evaluations. We retrospectively scored dysphagia on admission and discharge with the Functional Oral Intake Scale (FOIS).

RESULTS

We included 228 patients (mean age 75.8; 52% males). On admission, 126 (55%) were dysphagic (FOIS≤6). Age (OR 1.03, 95%CI 1.00-1.05), pre-event modified Rankin scale (mRS) (OR 1.41, 95%CI 1.09-1.84), National Institute of Health Stroke Scale (NIHSS) (OR 1.79, 95%CI 1.49-2.14), frontal operculum lesion (OR 8.53, 95% CI 3.82-19.06), and Oxfordshire total anterior circulation infarct (TACI) (OR 1.47, 95%CI 1.05-2.04) were independently associated with dysphagia at admission. Education (OR 0.91, 95%CI 0.85-0.98) had protective role. At discharge, 82 patients (36%) were dysphagic. Pre-event mRS (OR 1.28, 95%CI 1.04-1.56), admission NIHSS (OR 1.88, 95%CI 1.56-2.26), frontal operculum involvement (OR 15.53, 95%CI 7.44-32.43), and Oxfordshire classification TACI (OR 3.82, 95%CI 1.95-7.50) were independently associated with dysphagia at discharge. Education (OR 0.89, 95%CI 0.83-0.96) and thrombolysis (OR 0.77, 95%CI 0.23-0.95) had protective role. The 6-point "NOTTEM" (NIHSS, Opercular lesion, TACI, Thrombolysis, Education, MRS) score predicted dysphagia at discharge with good accuracy. Cognitive scores had no role in dysphagia risk.

CONCLUSIONS

We defined dysphagia predictors and developed a score to evaluate dysphagia risk during stroke unit stay. In this setting, cognitive impairment is not a predictor of dysphagia. Early dysphagia assessment may help planning future rehabilitative and nutrition strategies.

Position Statement of the Union of European Phoniatricians (UEP): Fees and Phoniatricians' Role in Multidisciplinary and Multiprofessional Dysphagia Management Team

The need for multidisciplinary and multiprofessional management of dysphagia is constantly increasing and creating a major challenge for healthcare professionals and society, especially in terms of professional expertise and human resources. The distribution of tasks among the dysphagia team members, which includes phoniatricians, otolaryngologists, and speech-language therapists, is flexible and overlapping. For assessing dysphagia, the (fibreoptic) flexible endoscopic evaluation of swallowing (FEES), with or without videofluoroscopy, is a pivotal diagnostic tool. This position paper aims to illustrate the phoniatrician's role in performing a FEES, which is an indispensable component of the diagnostic workup of patients suffering from oropharyngeal dysphagia. It is based on the current collaborative expert view of the Swallowing Committee of the Union of European Phoniatricians and a literature review. A FEES is one of the core competences of phoniatricians due to their endoscopic expertise and experience in the field of dysphagia and diseases of the upper aerodigestive tract. Therefore, the phoniatrician is an important member of the dysphagia team, for the medical diagnostics of the aerodigestive tract and dysphagia as well as for FEES. Phoniatric competence is especially important for head and neck cancer patients, infants, and complex cases.

Treatment of relapsing functional and organic dysphonia: a narrative literature review

Information about failure and relapses is critical in deciding whether and how to treat a given condition, as well as during patient counselling before therapy. This paper aims to perform a non-systematic review of relapses and failure of dysphonia treatment in the adult population. Studies on failure and relapses after treatment of benign vocal fold lesions, functional dysphonia and neurogenic dysphonia were analysed. The frequency and the duration of follow-up were heterogeneous, and the management of relapses was reported in only a portion of the studies. Relapses after surgical treatment of benign vocal fold lesions ranged between 1% and 58% of cases, and their management was mainly surgical. Rates of relapse after voice therapy for functional dysphonia and spasmodic dysphonia were 12%-88% and 8%-63%, respectively. Rates of relapse after surgical treatment for unilateral and bilateral vocal fold paralysis were 10%-39% and 6%-25%, respectively; treatment was mainly represented by surgical revision. In conclusion, failure and relapses of functional and organic dysphonias after therapy are not rare, but treatment modalities are seldomly reported. The data from this non-systematic review stresses the need for further research in this area.

The Change in Social Eating over Time in People with Head and Neck Cancer Treated with Primary (Chemo)Radiotherapy: The Role of Swallowing, Oral Function, and Nutritional Status

This study aimed at investigating the change in social eating problems from diagnosis to 24 months after primary (chemo)radiotherapy and its associations with swallowing, oral function, and nutritional status, in addition to the clinical, personal, physical, psychological, social, and lifestyle dimensions. Adult patients from the NETherlands QUality of life and BIomedical Cohort (NET-QUBIC) treated with curative intent with primary (chemo)radiotherapy for newly-diagnosed HNC and who provided baseline social eating data were included. Social eating problems were measured at baseline and at 3-, 6-, 12-, and 24-month follow-up, with hypothesized associated variables at baseline and at 6 months. Associations were analyzed through linear mixed models. Included patients were 361 (male: 281 (77.8%), age: mean = 63.3, SD = 8.6). Social eating problems increased at the 3-month follow-up and decreased up to 24 months (F = 33.134, p < 0.001). The baseline-to-24 month change in social eating problems was associated with baseline swallowing-related quality of life (F = 9.906, p < 0.001) and symptoms (F = 4.173, p = 0.002), nutritional status (F = 4.692, p = 0.001), tumor site (F = 2.724, p = 0.001), age (F = 3.627, p = 0.006), and depressive symptoms (F = 5.914, p < 0.001). The 6-24-month change in social eating problems was associated with a 6-month nutritional status (F = 6.089, p = 0.002), age (F = 5.727, p = 0.004), muscle strength (F = 5.218, p = 0.006), and hearing problems (F = 5.155, p = 0.006). Results suggest monitoring social eating problems until 12-month follow-up and basing interventions on patients' features.

Intra and interobserver agreement of the Dynamic Imaging Grade of Swallowing Toxicity Scale (DIGEST) in fiberoptic endoscopic evaluation of swallowing (FEES): the importance of observer-tailored training

PURPOSE

The Dynamic Imaging Grade of Swallowing Toxicity (DIGEST) is a scale to quantify the severity of pharyngeal dysphagia in head and neck cancer (HNC) patients. This study (1) described the training process of the observers for DIGEST in fiberoptic endoscopic evaluation of swallowing (FEES), (2) determined observer agreement on the DIGEST in FEES, (3) explored the effect of bolus consistency on observer agreement, and 4) explored criterion validity of the DIGEST in FEES.

METHODS

Twenty-seven dysphagic HNC patients were enrolled. Two observers completed a training program for DIGEST in FEES. Observer agreement on the Penetration-Aspiration Scale (PAS), percentage of pharyngeal residue (PPR), and DIGEST grades was determined using linearly weighted Cohen's kappa coefficient (κ).

RESULTS

Due to insufficient observer agreement after the first measurement attempt, additional training was organized using an elaborated manual with descriptions of the visuoperceptual variables, thereby improving observer agreement. Intraobserver agreement was almost perfect on the PAS (κ = 0.86-0.88) and PPR (κ = 0.84-0.86). Interobserver agreement was substantial on the PAS (κ = 0.78), almost perfect on the PPR (κ = 0.82), substantial on the safety grade (κ = 0.64), almost perfect on the efficiency grade (κ = 0.85), and substantial on the summary grade (κ = 0.71). Bolus consistency had an effect on observer agreement. A significant correlation was found between DIGEST efficiency grade and EAT-10.

CONCLUSION

The DIGEST showed to be a reproducible measurement for FEES in terms of observer agreement. However, agreement between novice observers on the DIGEST was only reached after specific observer-tailored training. Observer agreement should be analyzed by taking bolus consistency into account during training, as this might affect the interpretation of the outcome. A manual with well-defined descriptions can optimize the reproducibility of DIGEST measurements.

History and Science behind the Eating Assessment Tool-10 (Eat-10): Lessons Learned

INTRODUCTION

Oropharyngeal dysphagia (OD) is an underdiagnosed medical condition with a high prevalence in populations such as patients with frailty, neurological disease, or head and neck pathology. Potential barriers to its diagnosis include lack of (or low) awareness of the existence and severity of the condition, the hidden nature of the condition within the 'normal ageing' process, clinical limitations, and socioeconomic reasons. Consequently, an effective treatment is not systematically offered in a timely manner, and complications, such as dehydration and respiratory infections or aspiration pneumonia, can arise. To overcome this issue, the early use of screening questionnaires to identify people at risk of swallowing disorders represents the cornerstone of preventive medicine. Several screening tools have been created but few are widely used in clinical practice. The Eating Assessment Tool-10 (EAT-10) was developed as a quick, easy-to-understand, and self-administered screening tool for OD.

METHODS

A literature review was conducted in five databases with no restrictions on the language, date of publication, or design of the study to identify aspects of the validation, applicability, and usefulness of EAT-10.

RESULTS AND CONCLUSIONS

Transcultural adaptation and translation studies, as well as studies involving various types of patients with dysphagia in different settings have shown the validity and reliability of EAT-10 in relation to the gold standard and other validation tools. The use of this standardised screening tool could be used as a primary screening instrument of dysphagia in routine clinical practice across a wide range of diseases and settings and thereby increase the likelihood of early diagnosis and management of a condition that lead to serious complications and impaired quality of life.

On the potential of drug repurposing in dysphagia treatment: New insights from a real-world pharmacovigilance study and a systematic review

Background: Polypharmacy is common in patients with dysphagia. Routinely used drugs may influence swallowing function either improving or worsening it. We aimed to explore the potential effects of three commonly used drug classes on dysphagia and aspiration pneumonia through a systematic review and a real-world data analysis to probe the possibility of drug repurposing for dysphagia treatment. Material and Methods: Five electronic databases were searched. Studies on adults at risk for dysphagia, treated with Dipeptidyl-Peptidase IV Inhibitors (DPP-4i), Adrenergic Beta-Antagonists (beta-blockers), or Angiotensin-Converting Enzyme Inhibitors (ACEi), and reporting outcomes on dysphagia or aspiration pneumonia were included. A nested case/non-case study was performed on adverse events recorded in the FDA Adverse Event Reporting System (FAERS) on patients >64 years. Cases (dysphagia or aspiration pneumonia) were compared between patients only treated with Levodopa and patients who were concomitantly treated with the drugs of interest. Results: Twenty studies were included in the review (17 on ACEi, 2 on beta-blockers, and 1 on DPP-4i). Contrasting findings on the effects of ACEi were found, with a protective effect mainly reported in Asian studies on neurological patients. Beta-blockers were associated with a reduced dysphagia rate. The study on DPP-4i suggested no effect on dysphagia and an increased risk of aspiration pneumonia. The FAERS analysis showed a reduction of the risk for dysphagia/aspiration pneumonia with ACEi, beta-blockers, and DPP-4i. Conclusion: Our study explores the potential drug repurposing of ACEi, beta-blockers and DPP-4i in neurological patients with dysphagia to improve swallowing function and reduce aspiration pneumonia risk. Future randomized controlled studies should confirm these results and clarify the underlying mechanisms of action.

Reliability and Construct Validity of the Yale Pharyngeal Residue Severity Rating Scale: Performance on Videos and Effect of Bolus Consistency

The Yale Pharyngeal Residue Severity Rating Scale (YPRSRS) provides an image-based assessment of pharyngeal residue in the fiberoptic endoscopic evaluation of swallowing (FEES). Its performance was investigated only in FEES frames. This study analyzed the reliability and construct validity of the YPRSRS in FEES videos and the influence of bolus consistency. Thirty pairs of FEES videos and frames, 8 thin liquids (<50 mPa·s), 11 pureed (2583.3 mPa·s at 50 s−1, 697.87 mPa·s at 300 s−1), and 11 solid food; were assessed by 29 clinicians using the YPRSRS; 14 raters re-assessed materials at least 15 days from the first evaluation. Construct validity and intra-rater reliability were assessed using weighted Cohen’s Kappa. Inter-rater reliability was assessed using weighted Fleiss Kappa. Construct validity and inter-rater reliability were almost perfect or excellent for frames (0.82 ≤ k ≤ 0.89) and substantial or intermediate to good for videos (0.67 ≤ k ≤ 0.79). Intra-rater reliability was almost perfect for both frames and videos (k ≥ 0.84). Concerning bolus consistency, thin liquids had significantly lower values of construct validity, intra-, and inter-rater reliability than pureed and solid food. Construct validity and inter-rater reliability were significantly lower for solid food than for pureed food. The YPRSRS showed satisfactory reliability and construct validity also in FEES videos. Reliability was significantly influenced by bolus consistency.

Voice and communication after open partial horizontal laryngectomies: A cross-sectional outcome study

OBJECTIVE

The present study evaluates voice and communication after open partial horizontal laryngectomies (OPHLs), according to surgery and patient-related variables.

METHODS

Fifty-eight patients were included: 18 type I OPHL, 20 type II OPHL and 20 type III OPHL. Acoustic, aerodynamic, endoscopic, perceptual and self-assessment analyses were carried out. Surgery-related variables and patient-related variables were considered for the analysis.

RESULTS

Type I OPHL revealed the best phonatory outcomes. Type II and type III OPHL showed similar and poor results, with a highly deteriorated voice quality. A significant difference in MTP was found for patients who had both arytenoids/cricoarytenoid units preserved. Age and time from surgery showed significant correlations with voice quality after OPHLs.

CONCLUSIONS

Voice and communication outcomes after OPHLs are heterogeneous and might be influenced by several factors. Knowing variables with a substantial impact on phonatory outcomes may help clinicians in the preoperative decision-making process and the postoperative rehabilitative program.