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McDowell L, King MT, Hutcheson KA, Ringash J, Yom SS, Corry J, Henson C, Mehanna H, Rischin D. A Hard Truth to Swallow: Critically Evaluating the MD Anderson Dysphagia Inventory (MDADI) as an Endpoint in Human Papillomavirus-associated Oropharyngeal Cancer Trials. Int J Radiat Oncol Biol Phys 2024; 120:805-822. [PMID: 38740309 DOI: 10.1016/j.ijrobp.2024.05.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Revised: 04/16/2024] [Accepted: 05/01/2024] [Indexed: 05/16/2024]
Abstract
The MD Anderson Dysphagia Inventory (MDADI), a measure of swallowing-related quality of life, has become the preferred patient-reported outcome measure (PROM) in contemporary clinical trials evaluating the experience of human papillomavirus-associated oropharyngeal squamous cell carcinoma (HPVOPSCC) survivors. With many potentially practice-changing studies using the MDADI composite score as either a primary or coprimary endpoint, or as a key secondary endpoint, it is important to understand its psychometric properties as judged by contemporary PROM standards, with a particular focus on its application to contemporary HPVOPSCC populations. In this critical review, we evaluate contemporary HPVOPSCC studies reporting MDADI outcomes, followed by a detailed evaluation of the psychometric properties of the MDADI. Although the focus of this review was the MDADI, the issues discussed are not unique to the MDADI and have broader applicability to the evaluation and assessment of other PROMs currently in use. First, it may be possible to improve administration of the instrument, as related to missing items, scoring, and the number of items required. Second, although in many instances, the MDADI has been intended as a direct or surrogate measure of swallowing physiology, the MDADI composite score captures a broader health-related quality of life construct affected by both swallowing and eating, the latter of which may be affected by a range of nonswallowing treatment-related toxicities. Finally, a clinically meaningful change of 10 in the MDADI composite score, widely accepted and applied to the clinical trial setting, represents an undoubtably clinically relevant difference in unselected head and neck cancer survivors. However, the smallest difference that might be clinically important to a highly functional HPVOPSCC cohort remains uncertain. Understanding the purpose and properties of the MDADI instrument and furthering the sophistication with which we apply it in this population would improve its interpretation in clinical trials.
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Affiliation(s)
- Lachlan McDowell
- Department of Radiation Oncology, Princess Alexandra Hospital, Brisbane, Australia.
| | - Madeleine T King
- University of Sydney, School of Psychology, Sydney, New South Wales, Australia
| | - Katherine A Hutcheson
- Department of Head and Neck Surgery, Division of Surgery, and Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Jolie Ringash
- Department of Radiation Oncology, Princess Margaret Cancer Centre, University of Toronto, Toronto, Ontario, Canada
| | - Sue S Yom
- Department of Radiation Oncology, University of California San Francisco, San Francisco, California; Helen Diller Family Comprehensive Cancer Center, San Francisco, California
| | - June Corry
- Genesiscare St Vincent's Hospital, Melbourne, Australia; Department of Medicine, University of Melbourne, Melbourne, Australia
| | - Christina Henson
- Department of Radiation Oncology, Stephenson Cancer Center, University of Oklahoma, Oklahoma City, Oklahoma
| | - Hisham Mehanna
- Institute for Head and Neck Studies and Education (InHANSE), University of Birmingham, Birmingham, United Kingdom
| | - Danny Rischin
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Australia; Department of Medical Oncology, Peter MacCallum Cancer Centre, Melbourne, Australia
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Neijman M, Hilgers F, van den Brekel M, van Son R, Stuiver M, van der Molen L. Dysphagia After Total Laryngectomy: An Exploratory Study and Clinical Phase II Rehabilitation Trial with the Novel Swallowing Exercise Aid (SEA 2.0). Dysphagia 2024; 39:916-936. [PMID: 38558177 PMCID: PMC11449961 DOI: 10.1007/s00455-024-10673-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Accepted: 01/15/2024] [Indexed: 04/04/2024]
Abstract
The aims of this exploratory study and clinical phase II trial were to assess the specific nature and extent of dysphagia in laryngectomized patients with self-reported dysphagia, and its rehabilitation potential using the novel Swallowing Exercise Aid (SEA 2.0). Twenty laryngectomized patients participated in a six-week exercise program with the SEA 2.0. Exercises consisted of Chin Tuck Against Resistance (CTAR), Jaw Opening Against Resistance (JOAR), and Effortful Swallow Against Resistance, conducted three times per day. Swallowing was assessed at baseline (T0), six (T1) and 14 (T2) weeks, consisting of patient-reported outcomes, BMI, videofluoroscopy, swallowing capacity, and muscle strength measurements. Dysphagia significantly impacts quality of life, with impaired swallowing speed and bolus propulsion as main reported issues. Subjective dysphagia parameters, swallowing capacity, and pharyngeal residue clearance were reduced, but BMI was normal. Muscle and tongue strength were within normal ranges. All participants managed to use the SEA 2.0. Adherence was 95%. At T1, subjective swallowing parameters (MDADI and EAT-10) showed clinically relevant improvements. Objectively, CTAR and JOAR strength increased with 27.4 and 20.1 Newton, respectively. Also, swallowing capacity (from 2.4 g/s to 3.8 g/s) and pharyngeal residue clearance improved. At T2, results were slightly lower than at T1, but still better than at baseline. Dysphagia in laryngectomized patients affects quality of life, but swallowing can be improved with a six-week rehabilitation program using the novel SEA 2.0. Adherence was excellent and several subjective and objective swallowing parameters improved.
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Affiliation(s)
- Marise Neijman
- Department of Head and Neck Oncology and Surgery, The Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands
- Amsterdam Center for Language and Communication (ACLC), University of Amsterdam, Binnengasthuisstraat 9, 1012 ZA, Amsterdam, The Netherlands
| | - Frans Hilgers
- Department of Head and Neck Oncology and Surgery, The Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands
- Amsterdam Center for Language and Communication (ACLC), University of Amsterdam, Binnengasthuisstraat 9, 1012 ZA, Amsterdam, The Netherlands
| | - Michiel van den Brekel
- Department of Head and Neck Oncology and Surgery, The Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands.
- Amsterdam Center for Language and Communication (ACLC), University of Amsterdam, Binnengasthuisstraat 9, 1012 ZA, Amsterdam, The Netherlands.
- Department of Oral and Maxillofacial Surgery, Amsterdam University Medical Center, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.
| | - Rob van Son
- Department of Head and Neck Oncology and Surgery, The Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands
- Amsterdam Center for Language and Communication (ACLC), University of Amsterdam, Binnengasthuisstraat 9, 1012 ZA, Amsterdam, The Netherlands
| | - Martijn Stuiver
- Department of Head and Neck Oncology and Surgery, The Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands
- Center for Quality of Life and Division of Psychosocial Research and Epidemiology, The Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands
| | - Lisette van der Molen
- Department of Head and Neck Oncology and Surgery, The Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands
- Amsterdam Center for Language and Communication (ACLC), University of Amsterdam, Binnengasthuisstraat 9, 1012 ZA, Amsterdam, The Netherlands
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da Costa Miranda Barbosa R, de Freitas AS, Cerqueira RBA, Mancopes R, Dias FL, Steele CM. Dysphagia in Open Partial Horizontal Laryngectomy Type IIa: Quantitative Analysis of Videofluoroscopy using the ASPEKT Method. Dysphagia 2024; 39:964-973. [PMID: 38431893 PMCID: PMC11369121 DOI: 10.1007/s00455-024-10677-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2023] [Accepted: 01/30/2024] [Indexed: 03/05/2024]
Abstract
Open Partial Horizontal Laryngectomy (OPHL) Type IIa surgery is a conservative surgical technique used in the treatment of laryngeal carcinomas. In this pilot study, we aimed to characterize swallowing function and physiology in a series of patients after OPHL Type IIa surgery through comparison to healthy reference values for quantitative measures for videofluoroscopy. We performed retrospective quantitative analysis of videofluoroscopy recordings of thin liquid swallows for a preliminary sample of 10 male patients. Each videofluoroscopy clip was rated in triplicate by trained blinded raters according to the ASPEKT Method (Analysis of Swallowing Physiology: Events, Kinematics and Timing). This preliminary sample of patients with previous OPHL surgery showed functional airway protection, with only 2 patients showing incomplete laryngeal vestibule closure (LVC) and associated airway invasion. However, the majority of patients (90%) showed prolonged latencies to LVC and upper esophageal sphincter (UES) opening. Prolonged durations of LVC and UES opening were also noted, but these were in the direction of compensation rather than impairment. Reduced pharyngeal area at rest was seen in 70% of the sample, and all patients showed poor pharyngeal constriction. Post-swallow residue was a prominent finding in ≥ 75% of these patients. In particular, reduced or absent constriction of the hypopharynx in the region of the pyriform sinuses was noted as a characteristic of swallowing in this sample. The data from these patients suggest that despite functional airway protection, severe swallowing dysfunction involving poor pharyngeal constriction and bolus clearance may be likely after OPHL surgery.
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Affiliation(s)
| | | | | | | | | | - Catriona M Steele
- KITE Research Institute-UHN, Toronto, Canada
- Rehabilitation Sciences Institute, Temerty Faculty of Medicine, University of Toronto, Toronto, Canada
- Canada Research Chair (Tier 1) in Swallowing and Food Oral Processing, Canada Research Chairs Secretariat, Ottawa, Canada
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Demir N, Pişiren B, Arslan SS, Boybeyı-Turer O, Soyer T. Dynamic Imaging Grade of Swallowing Toxicity in Children with Esophageal Atresia. Eur J Pediatr Surg 2024; 34:392-397. [PMID: 37748722 DOI: 10.1055/a-2181-2293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/27/2023]
Abstract
INTRODUCTION The Dynamic Imaging Grade of Swallowing Toxicity (DIGEST) scale was developed to evaluate the safety, efficiency, and overall pharyngeal swallowing performance in patients with dysphagia (DIGESTs, DIGESTe, and DIGESTt, respectively). Although various types of swallowing dysfunction are encountered in children with esophageal atresia (EA), oropharyngeal dysphagia poses risk for aspiration. Therefore, a retrospective study was performed to evaluate the safety and efficacy of swallowing by using DIGEST score in children with EA. PATIENTS AND METHODS Thirty-nine EA patients were included. The demographic features, respiratory problems, results, and outcomes of surgical treatment were evaluated from medical records. The videofluoroscopic swallowing evaluation investigated for both airway protection and bolus residuals at the level of vallecula, posterior pharyngeal wall, and pyriform sinus at liquid and pudding consistencies. The penetration and aspiration scale (PAS) was used to define penetration and aspiration severity, and DIGEST was used to evaluate DIGESTs, DIGESTe, and DIGESTt. RESULTS The median age of the patients were 13 months (7-39 months), and male-to-female ratio was 25:14. Sixty-seven percent of patients were type-C EA and 61% of them has associated anomalies; 38% of patients had aspiration (PAS = 6-8) in liquids and 10% in pudding consistency. Life-threatening/profound swallowing dysfunction in DIGESTe (DIGEST = 4) was seen in 13% (n = 5) of patients; 40% of EA patients showed severe problems in DIGESTt. CONCLUSION DIGEST is a valid and reliable tool to define the efficacy and safety of swallowing in children with EA.
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Affiliation(s)
- Numan Demir
- Faculty of Physical Medicine and Rehabilitation, Hacettepe Universitesi, Ankara, Turkey
| | - Begüm Pişiren
- Department of Pediatric Surgery, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Selen Serel Arslan
- Faculty of Physical Medicine and Rehabilitation, Hacettepe Universitesi, Ankara, Turkey
| | - Ozlem Boybeyı-Turer
- Department of Pediatric Surgery, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Tutku Soyer
- Department of Pediatric Surgery, Hacettepe University Faculty of Medicine, Ankara, Turkey
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Petersson K, Finizia C, Pauli N, Tuomi L. Validation of the Swedish Dynamic Imaging Grade of Swallowing Toxicity for Flexible Endoscopic Evaluation of Swallowing (DIGEST-FEES). Dysphagia 2024:10.1007/s00455-024-10759-2. [PMID: 39331200 DOI: 10.1007/s00455-024-10759-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2024] [Accepted: 09/09/2024] [Indexed: 09/28/2024]
Abstract
In the head and neck cancer (HNC) population around 45% suffer from chronic swallowing difficulties after cancer treatment. Previously a measure for flexible endoscopic evaluation of swallowing (FEES) where swallowing efficiency, safety and overall ability is evaluated within the same framework has been lacking. The Dynamic Imaging Grade of Swallowing Toxicity for FEES (DIGEST-FEES) was developed in 2021 and provides such a measure for patients with HNC. The aim of this study was to translate and validate the DIGEST-FEES into Swedish (Sw-DIGEST-FEES). A translation of the protocol to Swedish was done through forward-backward translation. Two raters rated eighty-nine FEES recordings according to the Sw-DIGEST-FEES and five reference measures of swallowing ability: Yale Pharyngeal Residue Severity Rating Scale, Swallowing Performance Scale, Murray Secretion Scale, MD Anderson Dysphagia Inventory and Penetration Aspiration Scale. Intra- and interrater reliability was analyzed. Construct validity was evaluated by correlating the Sw-DIGEST-FEES ratings to the reference measures. A priori hypothesis was that the correlations would correspond to those of the reference measures included in the original English version. The Sw-DIGEST-FEES demonstrated retained psychometric properties. Construct validity was good. 79% of correlations to the reference measures were equal to or stronger than those in the original development. Inter-rater agreement of the Sw-DIGEST-FEES ranged from substantial to almost perfect (0.76-0.81). Intra-rater reliability was in general almost perfect (0.8-1). The Sw-DIGEST-FEES can be considered a valid and reliable protocol for use in evaluation of swallowing function in HNC patients.
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Affiliation(s)
- Kerstin Petersson
- Department of Otorhinolaryngology, Head and Neck Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
- Department of Otorhinolaryngology, Head and Neck Surgery, Sahlgrenska University Hospital, Region Västra Götaland, Gothenburg, SE-41345, Sweden.
| | - Caterina Finizia
- Department of Otorhinolaryngology, Head and Neck Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Otorhinolaryngology, Head and Neck Surgery, Sahlgrenska University Hospital, Region Västra Götaland, Gothenburg, SE-41345, Sweden
| | - Nina Pauli
- Department of Otorhinolaryngology, Head and Neck Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Otorhinolaryngology at Högsbo Specialist Hospital, Region Västra Götaland SV Hospital group, Gothenburg, Sweden
| | - Lisa Tuomi
- Department of Otorhinolaryngology, Head and Neck Surgery, Sahlgrenska University Hospital, Region Västra Götaland, Gothenburg, SE-41345, Sweden
- Institute of Neuroscience and Physiology, Speech and Language Pathology Unit, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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Gandhi P, Mancopes R, Steele CM. Videofluoroscopic Swallowing Studies: A Proposed Checklist. AMERICAN JOURNAL OF SPEECH-LANGUAGE PATHOLOGY 2024; 33:2157-2166. [PMID: 39151053 DOI: 10.1044/2023_ajslp-22-00167] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/18/2024]
Abstract
PURPOSE The videofluoroscopic swallowing study (VFSS) is used widely in dysphagia research. However, variations exist in the conduct and interpretation of VFSS, including differences in contrast agents, food and fluid consistencies tested, patient positioning, intervention strategies trialed, fluoroscopy settings, resolution, and image storage solutions. It cannot be assumed that VFSS exams yield directly comparable results across different studies. It is essential that relevant elements of VFSS be clearly reported in research. The goal of this article is to outline optimal VFSS reporting as part of the Framework for RigOr aNd Transparency In REseaRch on Swallowing (FRONTIERS), a critical appraisal tool intended to promote rigor and transparency in dysphagia research. METHOD We developed a set of 27 questions regarding the rigor and transparency of VFSS reporting, based on review of previous research articles. These were reviewed by all members of the FRONTIERS Framework collaborative, to determine which questions were mandatory, unnecessary, or needed revision, prior to inclusion in the final critical appraisal tool. RESULTS The final FRONTIERS Framework tool contains 20 questions and seven subquestions regarding VFSS. These are grouped into four themes: patient/participant positioning, equipment and recording settings, contrast agents, and rating methods, including operational definitions and reliability. CONCLUSIONS The VFSS section of the FRONTIERS Framework tool is intended to facilitate and promote rigorous and transparent reporting of all elements that may influence the interpretation of VFSS in research. This critical appraisal tool can also be used to guide research design and the evaluation of study outcomes contributing to best practices in the field of dysphagia research.
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Affiliation(s)
- Pooja Gandhi
- KITE Research Institute - Toronto Rehabilitation Institute, University Health Network, Ontario, Canada
- Rehabilitation Sciences Institute, Temerty Faculty of Medicine, University of Toronto, Ontario, Canada
| | - Renata Mancopes
- KITE Research Institute - Toronto Rehabilitation Institute, University Health Network, Ontario, Canada
| | - Catriona M Steele
- KITE Research Institute - Toronto Rehabilitation Institute, University Health Network, Ontario, Canada
- Rehabilitation Sciences Institute, Temerty Faculty of Medicine, University of Toronto, Ontario, Canada
- Canada Research Chair in Swallowing and Food Oral Processing, University of Toronto, Ontario
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Rogus-Pulia N, Affoo R, Namasivayam-MacDonald A, Noad B, Steele CM. A Proposed Framework for Rigor and Transparency in Dysphagia Research: Prologue. AMERICAN JOURNAL OF SPEECH-LANGUAGE PATHOLOGY 2024; 33:2130-2156. [PMID: 39151061 PMCID: PMC11427740 DOI: 10.1044/2024_ajslp-23-00368] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Revised: 02/24/2024] [Accepted: 03/26/2024] [Indexed: 08/18/2024]
Abstract
PURPOSE Scientific transparency and rigor are essential for the successful translation of knowledge in clinical research. However, the field of oropharyngeal dysphagia research lacks guidelines for methodological design and reporting, hindering accurate interpretation and replication. This article introduces the Framework for RigOr aNd Transparency In REseaRch on Swallowing (FRONTIERS), a new critical appraisal tool intended to support optimal study design and results reporting. The purpose of introducing FRONTIERS at this early phase is to invite pilot use of the tool and open commentary. METHODS FRONTIERS was developed by collaborating researchers and trainees from six international dysphagia research labs. Eight domains were identified, related to study design, swallowing assessment methods, and oropharyngeal dysphagia intervention reporting. Small groups generated questions capturing rigor and transparency for each domain, based on examples from the literature. An iterative consensus process informed the refinement and organization of primary and subquestions, culminating in the current initial version of FRONTIERS. RESULTS FRONTIERS is a novel tool, intended for use by oropharyngeal dysphagia researchers and research consumers across disciplines. A web application enables provisional use of the tool, and an accompanying survey solicits feedback regarding the framework. CONCLUSION FRONTIERS seeks to foster rigor and transparency in the design and reporting of oropharyngeal dysphagia research. We encourage provisional use and invite user feedback. A future expert consensus review is planned to incorporate feedback. By promoting scientific rigor and transparency, we hope that FRONTIERS will support evidence-based practice and contribute to improved health outcomes for individuals with oropharyngeal dysphagia.
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Affiliation(s)
- Nicole Rogus-Pulia
- Division of Geriatrics and Gerontology, Department of Medicine, University of Wisconsin–Madison
- Geriatric Research Education and Clinical Center, William S. Middleton Memorial Veterans Hospital, Shorewood Hills, WI
| | - Rebecca Affoo
- School of Communication Sciences and Disorders, Dalhousie University, Halifax, Nova Scotia, Canada
| | | | - Brandon Noad
- Independent Software Developer, Halifax, Nova Scotia, Canada
| | - Catriona M. Steele
- KITE Research Institute - Toronto Rehabilitation Institute, University Health Network, Canada
- Rehabilitation Sciences Institute, Temerty Faculty of Medicine, University of Toronto, Canada
- Canada Research Chair in Swallowing and Food Oral Processing, Ottawa, Ontario, Canada
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Barbon CEA, Warneke CL, Ledger B, Rogus-Pulia N, Cunningham L, Coyle JL, Levesque-Boissonneault C, Alvarez C, Valencia D, Hutcheson KA. Reliability and Confidence of Dynamic Imaging Grade of Swallowing Toxicity (DIGEST) Rating Among Research and Clinical Speech Pathologists Before and After Implementation of a Training Manual: A Multi-site Study. Dysphagia 2024:10.1007/s00455-024-10733-y. [PMID: 39181934 DOI: 10.1007/s00455-024-10733-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Accepted: 07/05/2024] [Indexed: 08/27/2024]
Abstract
DIGEST is a validated, open-source method to grade the severity of pharyngeal dysphagia from the modified barium swallow (MBS) study. Dissemination and implementation of DIGEST is rising, making it critical to understand reliability and facilitators of accurate implementation among users. The aim was to assess reliability of the tool among speech-language pathology (SLP) raters practicing at multiple sites before and after review of a DIGEST training manual and evaluate confidence of DIGEST use pre-and post-training. Thirty-two SLPs from 5 sites participated in a blinded longitudinal DIGEST rating study. Raters were provided a standardized training set of MBS (n = 19). Initial SLP ratings (round 1, R1) were followed by a 2-4 week break before raters rated a re-keyed MBS set (round 2, R2). A minimum 4-8 week wash-out period then preceded self-study of the DIGEST training manual which was followed by a final rating (round 3, R3) and a post-manual survey afterwards. Baseline reliability (R1) of overall DIGEST was on average k = 0.70, reflecting agreement in the substantial range. Seventy-five percent of raters (24/32) demonstrated reliability ≥ 0.61 in the substantial to almost perfect range prior to training. Inter-rater reliability significantly improved from R1 to R3 after review of the DIGEST manual, with the largest change in DIGEST-Efficiency (mean change: DIGEST k = .04, p = .009, DIGEST-Safety k = .07, p = 0.03, and DIGEST-Efficiency k = .14, p = 0.009). Although DIGEST reliability at baseline was adequate in the majority of raters, self-study of the DIGEST training manual significantly improved inter-rater reliability and rater confidence using the DIGEST method, particularly when assigning DIGEST-Efficiency grade. These early data show promise that provider training may be useful to aid in fidelity of DIGEST implementation among SLP clinical users with varying DIGEST experience.
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Affiliation(s)
- C E A Barbon
- Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - C L Warneke
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - B Ledger
- Department of Speech, Language, and Hearing Sciences, Purdue University, West Lafayette, IN, USA
| | - N Rogus-Pulia
- Geriatric Research Education and Clinical Center, William S. Middleton Memorial Veterans Hospital, Madison, WI, USA
- Division of Geriatrics and Gerontology, Department of Medicine, University of Wisconsin-Madison, Madison, WI, USA
- Department of Surgery, University of Wisconsin-Madison, Madison, WI, USA
| | - L Cunningham
- Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - J L Coyle
- Department of Communication Science and Disorders, School of Health and Rehabilitation Sciences, University of Pittsburgh, Pittsburgh, PA, USA
| | | | - C Alvarez
- Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - D Valencia
- Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - K A Hutcheson
- Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
- Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
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Islam S, Gleber-Netto FO, Mulcahy CF, Glaun MDE, Srivastava S, Hunt PJ, Williams MD, Barbon CE, Spiotto M, Zhao W, Adebayo A, Akhter S, Xie T, Debnath KC, Sathishkumar HN, Myers B, Lothumalla S, Yaman I, Burks JK, Gomez J, Rao X, Wang J, Woodman K, Mansour J, Arenkiel B, Osman KL, Haxton C, Lever TE, Hutcheson KA, Amit M. Neural landscape is associated with functional outcomes in irradiated patients with oropharyngeal squamous cell carcinoma. Sci Transl Med 2024; 16:eabq5585. [PMID: 39083586 DOI: 10.1126/scitranslmed.abq5585] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2022] [Revised: 01/02/2024] [Accepted: 07/03/2024] [Indexed: 08/02/2024]
Abstract
The incidence of human papilloma virus-mediated oropharyngeal squamous cell carcinoma (OPSCC) has increased over the past 40 years, particularly among young individuals with a favorable prognosis; however, current therapy often leads to unfortunate side effects, such as dysphagia. Despite the emphasis on dysphagia in previous studies, there is an important research gap in understanding the correlation between neuronal changes and patient-reported and functional outcomes in patients with OPSCC. To address this issue, we examined pathologic tissue samples from patients with OPSCC using multiplex immunofluorescence staining and machine learning to correlate tumor-associated neuronal changes with prospectively collected patient-reported and functional outcomes. We found that tumor enrichment of adrenergic (TH+) and CGRP+ sensory-afferent nerves correlated with poorer swallowing outcomes. Functional electromyography recordings showed correlations between growing (GAP43+) and immature cholinergic (ChAT+DCX+) nerves and denervation patterns in survivors of OPSCC. A murine model of radiation-induced dysphagia further confirmed that immature cholinergic and CGRP+ nerves were correlated with impaired swallowing. Preclinical interventional studies also supported the independent contributions of CGRP+ and cholinergic (ChAT+) nerves to dysphagia in treated mouse models of OPSCC. Our results suggest that CGRP+ and ChAT+ neuronal signaling play distinct roles in tumor- and radiation-induced dysphagia in OPSCC and offer a comprehensive dataset on the neural landscape of OPSCC. These insights may guide early interventions for swallow preservation and the repurposing of neurology-related drugs, such as CGRP blockers, in clinical oncology and survivorship.
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Affiliation(s)
- Shajedul Islam
- Department of Head and Neck Surgery, University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Frederico O Gleber-Netto
- Department of Head and Neck Surgery, University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Collin F Mulcahy
- Department of Head and Neck Surgery, University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Mica D E Glaun
- Department of Head and Neck Surgery, University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
- Department of Otolaryngology-Head and Neck Surgery, Baylor College of Medicine, Houston, TX 77030, USA
| | - Snigdha Srivastava
- Medical Scientist Training Program, Baylor College of Medicine, Houston, TX 77030, USA
| | - Patrick J Hunt
- Department of Head and Neck Surgery, University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
- Medical Scientist Training Program, Baylor College of Medicine, Houston, TX 77030, USA
| | - Michelle D Williams
- Department of Pathology, University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Carly E Barbon
- Department of Head and Neck Surgery, University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Michael Spiotto
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Weilu Zhao
- Department of Head and Neck Surgery, University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
- Department of Biostatistics and Data Science, University of Texas Health Science Center at Houston (UTHealth Houston) School of Public Health, Houston, TX 77030, USA
| | - Adewale Adebayo
- Department of Head and Neck Surgery, University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Shamima Akhter
- Department of Head and Neck Surgery, University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Tongxin Xie
- Department of Head and Neck Surgery, University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Kala Chand Debnath
- Department of Head and Neck Surgery, University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Hinduja Naidu Sathishkumar
- Department of Head and Neck Surgery, University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Blake Myers
- Department of Head and Neck Surgery, University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
- Department of Psychology and Neuroscience, University of Colorado Boulder, Boulder, CO 80309, USA
| | - Sahana Lothumalla
- Department of Head and Neck Surgery, University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
- Department of Pharmacy, University of Michigan, Ann Arbor, MI 48109, USA
| | - Ismail Yaman
- Department of Head and Neck Surgery, University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Jared K Burks
- Department of Head and Neck Surgery, University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
- Department of Leukemia and Division of Cancer Medicine, University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Javier Gomez
- Department of Leukemia and Division of Cancer Medicine, University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Xiayu Rao
- Department of Bioinformatics and Computational Biology, University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Jing Wang
- Department of Bioinformatics and Computational Biology, University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Karin Woodman
- Department of Neuro-Oncology, University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Jobran Mansour
- Department of Head and Neck Surgery, University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
- Department of Otolaryngology-Head and Neck Surgery, Louisiana State University Shreveport Medical Center, Shreveport, LA 71103, USA
| | - Benjamin Arenkiel
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, TX 77030, USA
| | - Kate L Osman
- Department of Otolaryngology-Head and Neck Surgery, School of Medicine, University of Missouri, Columbia, MO 65211, USA
| | - Chandler Haxton
- Department of Otolaryngology-Head and Neck Surgery, School of Medicine, University of Missouri, Columbia, MO 65211, USA
| | - Teresa E Lever
- Department of Otolaryngology-Head and Neck Surgery, School of Medicine, University of Missouri, Columbia, MO 65211, USA
| | - Katherine A Hutcheson
- Department of Head and Neck Surgery, University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Moran Amit
- Department of Head and Neck Surgery, University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
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10
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Gillman A, Hayes M, Walsh I, Walshe M, Reynolds JV, Regan J. Long-term impact of aerodigestive symptoms on adults with oesophageal cancer: A qualitative study. INTERNATIONAL JOURNAL OF SPEECH-LANGUAGE PATHOLOGY 2024:1-12. [PMID: 39028205 DOI: 10.1080/17549507.2024.2360065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/20/2024]
Abstract
PURPOSE The impact of long-term aerodigestive symptoms following oesophageal cancer surgery is still not well understood. This study aimed to qualitatively understand the long-term impact of aerodigestive symptoms on quality of life in adults post-oesophagectomy. METHOD Participants who received curative transhiatal/transthoracic surgery for oesophageal cancer in Ireland's National Oesophageal Cancer Centre were invited to attend semi-structured interviews. Surgery had to be completed at least 12 months prior. Reflexive thematic analysis was conducted. RESULT Forty participants were interviewed individually face-to-face. Four key themes were identified: (a) isolation, reflecting the reported solitude experienced by oesophageal cancer survivors when attempting to manage their ongoing aerodigestive symptoms; (b) fear, including fear of choking and fear that dysphagia symptoms may indicate recurrence of oesophageal cancer; (c) altered work capacity, caused by ongoing aerodigestive symptoms; and (d) avoidance of social situations involving food, due to the pain, discomfort, and embarrassment caused by these symptoms. CONCLUSION Oesophageal cancer treatment can be lifesaving, however, such medical interventions can result in distressing physiological aerodigestive symptoms throughout survivorship, which can significantly impact quality of life. Our findings indicate a need for greater community support to manage aerodigestive symptoms and reduce the impact these have on quality of life.
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Affiliation(s)
- Anna Gillman
- Department of Clinical Speech and Language Studies, Trinity College Dublin, Dublin 2, Ireland
| | - Michelle Hayes
- Department of Clinical Speech and Language Studies, Trinity College Dublin, Dublin 2, Ireland
| | - Irene Walsh
- Department of Clinical Speech and Language Studies, Trinity College Dublin, Dublin 2, Ireland
| | - Margaret Walshe
- Department of Clinical Speech and Language Studies, Trinity College Dublin, Dublin 2, Ireland
| | - John V Reynolds
- Department of Surgery, St James' Hospital, Dublin 8, Ireland
- Department of Surgery, Trinity Translational Medicine Institute, Trinity College Dublin, Dublin 2, Ireland
| | - Julie Regan
- Department of Clinical Speech and Language Studies, Trinity College Dublin, Dublin 2, Ireland
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11
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Yabe K, Kudo T, Horiuchi I, Nishimoto S, Horiuchi A. Pharyngeal Residues Following Swallowing of Pureed Diets Thickened with a Gelling Agent or a Xanthan Gum-Based Thickener in Elderly Patients with Dysphagia. Dysphagia 2024:10.1007/s00455-024-10734-x. [PMID: 39017926 DOI: 10.1007/s00455-024-10734-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2023] [Accepted: 07/12/2024] [Indexed: 07/18/2024]
Abstract
The ideal texture of pureed diets to prevent aspiration pneumonia remains unclear. The aim of this study was to evaluate the effectiveness of a pureed diet with either a gelling agent or a xanthan gum-based thickener to prevent pharyngeal residues in patients with dysphagia. We retrospectively analyzed a randomized, crossover trial of pureed rice with either a gelling agent or a xanthan gum-based thickener in patients with dysphagia. The enrolled patients were classified into mild and moderate-to-severe dysphagia groups. The primary outcome measure was degree of need for cyclic ingestion using test jelly for pharyngeal residuals (cyclic ingestion score). The secondary outcome was the patient's sense of material remaining in the throat following swallowing. Sixty-two patients (58% men; mean age 83 ± 9 years) with dysphagia were included. They were classified into mild dysphagia (n = 26) and moderate-to-severe dysphagia (n = 36) groups. In the moderate-to-severe dysphagia group, pharyngeal residuals were significantly less likely with pureed diets using a gelling agent than with those using a xanthan gum-based thickener, with respective median cyclic ingestion scores (range) of 1 (0-4) vs. 2.5 (0-4) (p = 0.001). There was no significant difference in pharyngeal residuals between the pureed diets in the mild dysphagia group. The multivariate analysis identified gelling agent as an important factor significantly associated with less pharyngeal residual after swallowing of pureed diet in patients with moderate-to-severe dysphagia. Pureed diets thickened by a gelling agent decrease pharyngeal residues in patients with moderate-to-severe dysphagia and may reduce risk of aspiration pneumonia.
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Affiliation(s)
- Kiyoaki Yabe
- Digestive Disease Center, Showa Inan General Hospital, 3230 Akaho, Komagane, 399-4117, Japan
| | - Takahiro Kudo
- Department of Pediatrics, Juntendo University Faculty of Medicine, Tokyo, Japan
| | - Ichitaro Horiuchi
- Department of Gastroenterology, Shinshu University Hospital, Matsumoto, Japan
| | - Satomi Nishimoto
- Department of Pediatrics, Osaka Medical and Pharmaceutical University, Takatsuki, Osaka, Japan
| | - Akira Horiuchi
- Digestive Disease Center, Showa Inan General Hospital, 3230 Akaho, Komagane, 399-4117, Japan.
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12
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Gandhi P, Barrett E, Mancopes R, Peladeau-Pigeon M, Panes V, Simmons MM, Steele CM. A Preliminary Study of Vallecular Bolus Aggregation in Healthy Swallowing of Solid Food Boluses. JOURNAL OF SPEECH, LANGUAGE, AND HEARING RESEARCH : JSLHR 2024; 67:2077-2085. [PMID: 38843437 PMCID: PMC11253801 DOI: 10.1044/2024_jslhr-24-00066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/30/2024] [Revised: 03/26/2024] [Accepted: 04/10/2024] [Indexed: 07/11/2024]
Abstract
OBJECTIVE The pharyngeal swallow typically begins within 400 ms following the arrival of a liquid bolus in the pharynx. By contrast, processed food particles aggregate in the valleculae prior to swallow initiation. With solid foods, swallow reaction time (SRT), the interval between bolus passing the ramus of mandible and hyoid burst onset (HYB) can be subdivided into components of vallecular aggregation time (VAT) and the subsequent end of aggregation to hyoid burst interval (EOA-to-HYB). However, expected durations of these timing measures remain unclear. We aimed to study bolus aggregation in healthy swallowing for International Dysphagia Diet Standardisation Initiative Food Levels 5 (minced and moist [MM5]), 6 (soft and bite-sized [SB6]), and 7 (regular [RG7]). Understanding typical patterns and durations of vallecular aggregation with solids in healthy swallowing will inform the identification of impaired swallow timing in patient populations. DESIGN Twenty healthy adults (10 males, Mage = 28 years, range: 23-55 years) swallowed two boluses each of MM5, SB6, and RG7 foods in videofluoroscopy. Blinded duplicate ratings determined bolus location at swallow onset, SRT, VAT, and EOA-to-HYB. Texture-based differences were measured using Friedman's tests. Bolus location was at/above the valleculae at swallow onset for 85% of boluses, with no differences by texture. SRT, VAT, and EOA-to-HYB did not vary by texture, with overall median values (interquartile range) of 99 ms (-66 to 743 ms) for SRT, 347 ms (66 to 891 ms) for VAT, and -132 ms (-231 to -83 ms) for EOA-to-HYB. CONCLUSIONS These data corroborate prior evidence that it is not unusual for food particles to aggregate in the valleculae prior to swallow initiation in healthy swallowing. However, durations of vallecular aggregation are typically < 1 s in healthy adults.
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Affiliation(s)
- Pooja Gandhi
- Swallowing Rehabilitation Research Laboratory, KITE Research Institute, KITE Research Institute – University Health Network, Toronto, Ontario, Canada
- Rehabilitation Sciences Institute, Temerty Faculty of Medicine, University of Toronto, Ontario, Canada
| | - Emily Barrett
- Swallowing Rehabilitation Research Laboratory, KITE Research Institute, KITE Research Institute – University Health Network, Toronto, Ontario, Canada
| | - Renata Mancopes
- Swallowing Rehabilitation Research Laboratory, KITE Research Institute, KITE Research Institute – University Health Network, Toronto, Ontario, Canada
| | - Melanie Peladeau-Pigeon
- Swallowing Rehabilitation Research Laboratory, KITE Research Institute, KITE Research Institute – University Health Network, Toronto, Ontario, Canada
| | - Vanessa Panes
- Swallowing Rehabilitation Research Laboratory, KITE Research Institute, KITE Research Institute – University Health Network, Toronto, Ontario, Canada
| | - Michelle M. Simmons
- Swallowing Rehabilitation Research Laboratory, KITE Research Institute, KITE Research Institute – University Health Network, Toronto, Ontario, Canada
| | - Catriona M. Steele
- Swallowing Rehabilitation Research Laboratory, KITE Research Institute, KITE Research Institute – University Health Network, Toronto, Ontario, Canada
- Rehabilitation Sciences Institute, Temerty Faculty of Medicine, University of Toronto, Ontario, Canada
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13
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Donohue C, Vasilopoulos T, Wymer JP, Plowman EK. Relationship between pulmonary, cough, and swallowing functions in individuals with amyotrophic lateral sclerosis. Muscle Nerve 2024; 70:140-147. [PMID: 38742544 DOI: 10.1002/mus.28113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Revised: 04/08/2024] [Accepted: 04/28/2024] [Indexed: 05/16/2024]
Abstract
INTRODUCTION/AIMS Evaluations of pulmonary, cough, and swallow function are frequently performed to assess disease progression in amyotrophic lateral sclerosis (ALS), yet the relationship between these functions remains unknown. We therefore aimed to determine relationships between these measures in individuals with ALS. METHODS One hundred individuals with ALS underwent standardized tests: forced vital capacity (FVC), maximum expiratory/inspiratory pressure (MEP, MIP), voluntary cough peak expiratory flow (PEF), and videofluoroscopic swallow evaluation (VF). Duplicate raters completed independent, blinded ratings using the Dynamic Imaging Grade of Swallowing Toxicity (DIGEST) scale. Descriptives, Spearman's Rho correlations, Kruskal-Wallis analyses, and Pearson's chi-squared tests were completed. RESULTS Mean and standard deviation across pulmonary and cough measures were FVC: 74.2% predicted (± 22.6), MEP: 91.6 cmH2O (± 46.4), MIP cmH2O: 61.1 (± 28.9), voluntary PEF: 352.7 L/min (± 141.6). DIGEST grades included: 0 (normal swallowing): 31%, 1 (mild dysphagia): 48%, 2 (moderate dysphagia): 10%, 3 (severe dysphagia): 10%, and 4 (life-threatening dysphagia): 1%. Positive correlations were observed: MEP-MIP: r = .76, MIP-PEF: r = .68, MEP-PEF: r = .61, MIP-FVC: r = .60, PEF-FVC: r = .49, and MEP-FVC: r = .46, p < .0001. MEP (p = .009) and PEF (p = .04) differed across DIGEST safety grades. Post hoc analyses revealed significant between group differences in MEP and PEF across DIGEST safety grades 0 versus 1 and grades 0 versus 3, (p < .05). DISCUSSION In this cohort of individuals with ALS, pulmonary function, and voluntary cough were associated. Expiratory metrics (MEP, PEF) were diminished in individuals with unsafe swallowing, increasing their risk for effectively defending the airway.
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Affiliation(s)
- Cara Donohue
- Aerodigestive Research Core Laboratory, The Ohio State University, Columbus, Ohio, USA
- Department of Hearing and Speech Sciences, Vanderbilt University, Nashville, Tennessee, USA
| | - Terrie Vasilopoulos
- Department of Anesthesiology, University of Florida, Gainesville, Florida, USA
| | - James P Wymer
- Department of Neurology, University of Florida, Gainesville, Florida, USA
| | - Emily K Plowman
- Aerodigestive Research Core Laboratory, The Ohio State University, Columbus, Ohio, USA
- Department of Otolaryngology-Head and Neck Surgery, The Ohio State University, Columbus, Ohio, USA
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14
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Hutcheson KA, Aldridge EF, Warneke CL, Buoy SN, Tang X, Macdonald C, Alvarez CP, Barringer DA, Barbon CEA, Ebersole BM, McMillan H, Montealegre JR. Clinical Implementation of DIGEST as an Evidence-Based Practice Tool for Videofluoroscopy in Oncology: A Six-Year Single Institution Implementation Evaluation. Dysphagia 2024:10.1007/s00455-024-10721-2. [PMID: 38935170 DOI: 10.1007/s00455-024-10721-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Accepted: 05/22/2024] [Indexed: 06/28/2024]
Abstract
Clinical implementation of evidence-based practice (EBP) tools is a healthcare priority. The Dynamic Grade of Swallowing Toxicity (DIGEST) is an EBP tool developed in 2016 for videofluoroscopy in head and neck (H&N) oncology with clinical implementation as a goal. We sought to examine: (1) feasibility of clinical implementation of DIGEST in a national comprehensive cancer center, and (2) fidelity of DIGEST adoption in real-world practice. A retrospective implementation evaluation was conducted in accordance with the STARI framework. Electronic health record (EHR) databases were queried for all consecutive modified barium swallow (MBS) studies conducted at MD Anderson Cancer Center from 2016 to 2021. Implementation outcomes included: feasibility as measured by DIGEST reporting in EHR (as a marker of clinical use) and fidelity as measured by accuracy of DIGEST reporting relative to the decision-tree logic (penetration-aspiration scale [PAS], residue, and Safety [S] and Efficiency [E] grades). Contextual factors examined included year, setting, cancer type, MBS indication, and provider. 13,055 MBS were conducted by 29 providers in 7,842 unique patients across the lifespan in diverse oncology populations (69% M; age 1-96 years; 58% H&N cancer; 10% inpatient, 90% outpatient). DIGEST was reported in 12,137/13,088 exams over the 6-year implementation period representing 93% (95% CI: 93-94%) adoption in all exams and 99% (95% CI: 98-99%) of exams excluding the total laryngectomy population (n = 730). DIGEST reporting varied modestly by year, cancer type, and setting/provider (> 91% in all subgroups, p < 0.001). Accuracy of DIGEST reporting was high for overall DIGEST (incorrect SE profile 1.6%, 200/12,137), DIGEST-safety (incorrect PAS 0.4% 51/12,137) and DIGEST-efficiency (incorrect residue 1.2%, 148/12,137). Clinical implementation of DIGEST was feasible with high fidelity in a busy oncology practice across a large number of providers. Adoption of the tool across the lifespan in diverse cancer diagnoses may motivate validation beyond H&N oncology.
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Affiliation(s)
- Katherine A Hutcheson
- Department of Head & Neck Surgery, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd., Unit 1445, Houston, Texas, 77030-4009, US.
- Division of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas, USA.
| | - Ella F Aldridge
- Department of Head & Neck Surgery, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd., Unit 1445, Houston, Texas, 77030-4009, US
| | - Carla L Warneke
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd., Unit 1689, Houston, Texas, 77030, US
| | - Sheila N Buoy
- Department of Head & Neck Surgery - Research, The University of Texas MD Anderson Cancer Center, 1400 Pressler, Unit 1445, Houston, Texas, 77030, US
| | - Xiaohui Tang
- Department of Head & Neck Surgery - Research, The University of Texas MD Anderson Cancer Center, 1400 Pressler, Unit 1445, Houston, Texas, 77030, US
| | - Cameron Macdonald
- Qualitative Health Research Center, 111 King St., Suite 23, Madison, WI, 53703, US
| | - Clare P Alvarez
- Department of Head & Neck Center, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd., Unit 0340, Houston, Texas, 77030, US
| | - Denise A Barringer
- Department of Endoscopy Center, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd., Unit 0385, Houston, Texas, 77030, US
| | - Carly E A Barbon
- Department of Head & Neck Surgery, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd., Unit 1445, Houston, Texas, 77030-4009, US
| | - Barbara M Ebersole
- Department of Head & Neck Center, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd. (R10.1810), Houston, Texas, 77030, US
| | - Holly McMillan
- Department of Head & Neck Center, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd. (R10.1824), Houston, Texas, 77030, US
| | - Jane R Montealegre
- Department of Behavioral Science, The University of Texas MD Anderson Cancer Center, 1155 Pressler (CPB3.3253), Houston, Texas, 77030, US
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15
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Govender R, Gilbody N, Simson G, Haag R, Robertson C, Stuart E. Post-Radiotherapy Dysphagia in Head and Neck Cancer: Current Management by Speech-Language Pathologists. Curr Treat Options Oncol 2024; 25:703-718. [PMID: 38691257 PMCID: PMC11222272 DOI: 10.1007/s11864-024-01198-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/08/2024] [Indexed: 05/03/2024]
Abstract
OPINION STATEMENT Dysphagia, difficulty in eating and drinking, remains the most common side effect of radiotherapy treatment for head and neck cancer (HNC) with devastating consequences for function and quality of life (QOL). Over the past decade, 5-year survival has improved due to multiple factors including treatment advances, reduction in smoking, introduction of the human papillomavirus (HPV) vaccine and more favourable prognosis of HPV-related cancers. Increased prevalence of HPV-positive disease, which tends to affect younger individuals, has led to an elevated number of people living for longer with the sequelae of cancer and its treatment. Symptoms are compounded by late effects of radiotherapy which may lead to worsening of dysphagia for some long-term survivors or new-onset dysphagia for others. Speech-language pathology (SLP) input remains core to the assessment and management of dysphagia following HNC treatment. In this article, we present current SLP management of dysphagia post-radiotherapy. We discuss conventional treatment approaches, the emergence of therapy adjuncts and current service delivery models. The impact of adherence on therapy outcomes is highlighted. Despite treatment advancements, patients continue to present with dysphagia which is resistant to existing intervention approaches. There is wide variation in treatment programmes, with a paucity of evidence to support optimal type, timing and intensity of treatment. We discuss the need for further research, including exploration of the impact of radiotherapy on the central nervous system (CNS), the link between sarcopenia and radiotherapy-induced dysphagia and the benefits of visual biofeedback in rehabilitation.
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Affiliation(s)
- Roganie Govender
- Head & Neck Academic Centre& UCL Division of Surgery & Interventional ScienceGround Floor Central, University College London Hospital, 250 Euston Road, London, NW1 2PQ, UK.
| | - Nicky Gilbody
- North Middlesex University Hospital NHS Trust, London, UK
| | | | | | - Ceri Robertson
- Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Emma Stuart
- Barking, Havering and Redbridge University Hospitals NHS Trust, Romford, UK
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16
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Dziewas R, Warnecke T, Labeit B, Claus I, Muhle P, Oelenberg S, Ahring S, Wüller C, Jung A, von Itter J, Suntrup-Krueger S. Systematic approach to contextualize findings of flexible endoscopic evaluation of swallowing in neurogenic dysphagia- towards an integrated FEES report. Neurol Res Pract 2024; 6:26. [PMID: 38720388 PMCID: PMC11080162 DOI: 10.1186/s42466-024-00321-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2024] [Accepted: 04/01/2024] [Indexed: 05/12/2024] Open
Abstract
Flexible endoscopic evaluation of swallowing (FEES) is one of the most important methods for instrumental swallowing evaluation. The most challenging part of the examination consists in the interpretation of the various observations encountered during endoscopy and in the deduction of clinical consequences. This review proposes the framework for an integrated FEES-report that systematically moves from salient findings of FEES to more advanced domains such as dysphagia severity, phenotypes of swallowing impairment and pathomechanisms. Validated scales and scores are used to enhance the diagnostic yield. In the concluding part of the report, FEES-findings are put into the perspective of the clinical context. The potential etiology of dysphagia and conceivable differential diagnoses are considered, further diagnostic steps are proposed, treatment options are evaluated, and a timeframe for re-assessment is suggested. This framework is designed to be adaptable and open to continuous evolution. Additional items, such as novel FEES protocols, pathophysiological observations, advancements in disease-related knowledge, and new treatment options, can be easily incorporated. Moreover, there is potential for customizing this approach to report on FEES in structural dysphagia.
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Affiliation(s)
- Rainer Dziewas
- Department of Neurology and Neurorehabilitation, Klinikum Osnabrück- Academic Teaching Hospital of the University of Münster, Am Finkenhügel 1, 49076, Osnabrück, Germany.
- Department of Neurology with Institute for Translational Neurology, University Hospital Münster, Münster, Germany.
| | - Tobias Warnecke
- Department of Neurology and Neurorehabilitation, Klinikum Osnabrück- Academic Teaching Hospital of the University of Münster, Am Finkenhügel 1, 49076, Osnabrück, Germany
- Department of Neurology with Institute for Translational Neurology, University Hospital Münster, Münster, Germany
| | - Bendix Labeit
- Department of Neurology, Medical Faculty, University Hospital Düsseldorf, Düsseldorf, Germany
| | - Inga Claus
- Department of Neurology with Institute for Translational Neurology, University Hospital Münster, Münster, Germany
| | - Paul Muhle
- Department of Neurology with Institute for Translational Neurology, University Hospital Münster, Münster, Germany
| | - Stephan Oelenberg
- Department of Neurology with Institute for Translational Neurology, University Hospital Münster, Münster, Germany
| | - Sigrid Ahring
- Department of Neurology with Institute for Translational Neurology, University Hospital Münster, Münster, Germany
| | - Christina Wüller
- Department of Neurology with Institute for Translational Neurology, University Hospital Münster, Münster, Germany
| | - Anne Jung
- Department of Neurology with Institute for Translational Neurology, University Hospital Münster, Münster, Germany
| | - Jonas von Itter
- Department of Neurology with Institute for Translational Neurology, University Hospital Münster, Münster, Germany
| | - Sonja Suntrup-Krueger
- Department of Neurology with Institute for Translational Neurology, University Hospital Münster, Münster, Germany
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17
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Gillman A, Kenny C, Hayes M, Walshe M, Reynolds JV, Regan J. Nature, severity, and impact of chronic oropharyngeal dysphagia following curative resection for esophageal cancer: a cross-sectional study. Dis Esophagus 2024; 37:doae003. [PMID: 38266037 PMCID: PMC11060100 DOI: 10.1093/dote/doae003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Revised: 12/18/2023] [Accepted: 01/06/2024] [Indexed: 01/26/2024]
Abstract
Chronic oropharyngeal dysphagia (COD) and aspiration after esophageal cancer surgery may have clinical significance; however, it is a rarely studied topic. In a prospective cross-sectional observational study we comprehensively evaluated the nature, severity, and impact of COD, its predictors, and the impact of the surgical approach and site of anastomosis. Forty participants were recruited via purposive sampling from the (Irish) National Center between November 2021 and August 2022. Swallow evaluations included videofluoroscopy [Dynamic Imaging Grade of Swallowing Toxicity v2 (DIGESTv2), MBS Impairment Profile, Penetration-Aspiration Scale)]. Functional Oral Intake Scale (FOIS) identified oral intake status. The patient reported outcome measures of swallowing, and Quality of Life (QL) included EAT-10 and MD Anderson Dysphagia Inventory (MDADI). Fourteen (35%) participants presented with COD on DIGESTv2 and 10% had uncleared penetration/aspiration. Avoidance or modification of diet on FOIS was observed in 17 (42.5%). FOIS was associated with pharyngeal dysphagia (OR = 4.05, P = 0.046). Median (range) EAT-10 and MDADI Composite results were 3(0-30) and 77.9(60-92.6), respectively. Aspiration rates significantly differed across surgical groups (P = 0.029); only patients undergoing transhiatal surgery aspirated. Survivors of esophageal cancer surgery may have COD that is undiagnosed, potentially impacting swallow-related QL. Given the small number of aspirators, further research is required to determine whether aspiration risk is associated with surgical approach. A FOIS score below 7 may be a clinically useful prompt for the MDT to refer for evaluation of COD following curative intent surgery. These data present findings that may guide preventive and rehabilitative strategies toward optimizing survivorship.
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Affiliation(s)
- Anna Gillman
- Department of Clinical Speech and Language Studies, Trinity College Dublin, Dublin, Ireland
| | - Ciaran Kenny
- Department of Clinical Speech and Language Studies, Trinity College Dublin, Dublin, Ireland
| | - Michelle Hayes
- Department of Clinical Speech and Language Studies, Trinity College Dublin, Dublin, Ireland
| | - Margaret Walshe
- Department of Clinical Speech and Language Studies, Trinity College Dublin, Dublin, Ireland
| | - John V Reynolds
- Department of Clinical Speech and Language Studies, Trinity College Dublin, Dublin, Ireland
- Department of Surgery, St James’ Hospital, Dublin, Ireland
| | - Julie Regan
- Department of Clinical Speech and Language Studies, Trinity College Dublin, Dublin, Ireland
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18
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Curtis JA, Tabor Gray L, Arrese L, Borders JC, Starmer H. Characterizing the Validity of Using VASES to Derive DIGEST-FEES Grades. Folia Phoniatr Logop 2024:1-10. [PMID: 38631299 DOI: 10.1159/000538935] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Accepted: 04/14/2024] [Indexed: 04/19/2024] Open
Abstract
INTRODUCTION Visual Analysis of Swallowing Efficiency and Safety (VASES) and Dynamic Imaging Grade of Swallowing Toxicity for Flexible Endoscopic Evaluation of Swallowing (DIGEST-FEES) are two complimentary methods for assessing swallowing during FEES. Whereas VASES is intended to facilitate trial-level ratings of pharyngeal residue, penetration, and aspiration, DIGEST-FEES is intended to facilitate protocol-level impairment grades of swallowing safety and efficiency. The aim of this study was to assess the validity of using VASES to derive DIGEST-FEES impairment grades. METHODS DIGEST-FEES grades were blindly analyzed from 50 FEES - first using the original DIGEST-FEES grading method (n = 50) and then again using a VASES-derived DIGEST-FEES grading method (n = 50). Weighted Kappa (κw) and absolute agreement (%) were used to assess the relationship between the original DIGEST-FEES grades and VASES-derived DIGEST-FEES grades. Spearman's correlations assessed the relationship between VASES-derived DIGEST-FEES grades with measures of construct validity. RESULTS Substantial agreement (κw = 0.76-0.83) was observed between the original and VASES-derived grading methods, with 60-62% of all DIGEST-FEES grades matching exactly, and 92-100% of DIGEST-FEES grades within one grade of each other. Furthermore, the strength of the relationships between VASES-derived DIGEST-FEES grades and measures of construct validity (r = 0.34-0.78) were similar to the strength of the relationships between original DIGEST-FEES grades and the same measures of construct validity (r = 0.34-0.83). CONCLUSION Findings from this study demonstrate substantial agreement between original and VASES-derived DIGEST-FEES grades. Using VASES to derive DIGEST-FEES also appears to maintain the same level of construct validity established with the original DIGEST-FEES. Therefore, clinicians and researchers may consider using VASES to increase the transparency and standardization of DIGEST-FEES ratings. Future research should seek to replicate these findings and explore the simultaneous use of VASES and DIGEST-FEES in a greater sampling of raters and across other patient populations.
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Affiliation(s)
- James A Curtis
- Aerodigestive Innovations Research Lab (AIR), Department of Otolaryngology-Head and Neck Surgery, Weill Cornell Medical College, Cornell University, New York, New York, USA
| | - Lauren Tabor Gray
- Dr. Kiran C. Patel College of Allopathic Medicine, Center for Collaborative Research, NOVA Southeastern University, Fort Lauderdale, Florida, USA
| | - Loni Arrese
- Department of Speech and Hearing Science, Ohio State University, Columbus, Ohio, USA
| | - James C Borders
- Laboratory for the Study of Upper Airway Dysfunction, Department of Biobehavioral Sciences, Teachers College, Columbia University, New York, New York, USA
| | - Heather Starmer
- HOPES Lab, Department of Otolaryngology - Head and Neck Surgery, Stanford University, Palo Alto, California, USA
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Donohue C, Robison R, Steele CM, Wymer JP, Plowman EK. Profiling Number of Swallows per Bolus and Residue in Individuals With Amyotrophic Lateral Sclerosis. JOURNAL OF SPEECH, LANGUAGE, AND HEARING RESEARCH : JSLHR 2023; 66:3763-3772. [PMID: 37591233 PMCID: PMC10713014 DOI: 10.1044/2023_jslhr-23-00209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Revised: 05/11/2023] [Accepted: 06/13/2023] [Indexed: 08/19/2023]
Abstract
PURPOSE Swallowing efficiency impairments are the most prevalent and earliest manifestation of dysphagia in people with amyotrophic lateral sclerosis (pALS). We aimed to profile number of swallows elicited in pALS across thin liquid, moderately thick liquid, extremely thick liquid, and crackers compared to expected healthy reference data and to determine relationships between degree of pharyngeal residue, number of elicited swallows, and swallowing safety. METHOD pALS underwent standardized videofluoroscopic swallowing studies of 10 bolus trials. Trained raters performed duplicate, independent, and blinded ratings to derive Dynamic Imaging Grade of Swallowing Toxicity (DIGEST) efficiency and safety grades and Analysis of Swallowing Physiology: Events, Kinematics, and Timing (ASPEKT) percent total pharyngeal residue. Number of swallows per bolus was quantified (1 = typical, 2 = atypically high, 3 = extremely high). Kruskal-Wallis, Pearson chi-square, and odds ratio analyses were performed at bolus and participant levels. KEY RESULTS At the bolus level (N = 2,523), number of swallows per bolus was observed to be, in rank order, as follows: atypically high (49.1%), extremely high (28.5%), and typical (22.4%). Mean number of swallows significantly differed by International Dysphagia Diet Standardisation Initiative level (p < .0001), with a higher number of swallows elicited in pALS for moderately thick versus thin liquids, extremely thick liquids, and crackers, p < .0001. Number of swallows per bolus increased with increasing DIGEST efficiency grades (p < .0001). Positive correlations were observed between ASPEKT percent residue and number of swallows for thin (r = .24) and moderately thick (r = .16) liquids, p < .05. DIGEST efficiency and safety grades were not significantly associated (p > .05). CONCLUSION AND INFERENCES pALS demonstrated a higher number of swallows per bolus compared to healthy reference data that may represent a compensation for reductions in swallowing efficiency to clear pharyngeal residue.
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Affiliation(s)
- Cara Donohue
- Aerodigestive Research Core Laboratory, University of Florida, Gainesville
- Department of Speech, Language, and Hearing Sciences, University of Florida, Gainesville
- Breathing Research and Therapeutics Center, University of Florida, Gainesville
- Department of Hearing and Speech Sciences, Vanderbilt University, Nashville, TN
| | - Raele Robison
- Aerodigestive Research Core Laboratory, University of Florida, Gainesville
- Department of Speech, Language, and Hearing Sciences, University of Florida, Gainesville
- Department of Medicine, University of Wisconsin-Madison
- Center for Health Disparities Research, University of Wisconsin-Madison
| | - Catriona M. Steele
- KITE Research Institute, University Health Network, Toronto, Ontario, Canada
- Rehabilitation Sciences Institute, Temerty Faculty of Medicine, University of Toronto, Ontario, Canada, Toronto, Ontario, Canada
- Canada Research Chairs, Toronto, Ontario, Canada
| | - James P. Wymer
- Department of Neurology, University of Florida, Gainesville
| | - Emily K. Plowman
- Aerodigestive Research Core Laboratory, University of Florida, Gainesville
- Department of Speech, Language, and Hearing Sciences, University of Florida, Gainesville
- Breathing Research and Therapeutics Center, University of Florida, Gainesville
- Department of Neurology, University of Florida, Gainesville
- Department of Surgery, University of Florida, Gainesville
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Noorani M, Bolognone RK, Graville DJ, Palmer AD. The Association Between Dysphagia Symptoms, DIGEST Scores, and Severity Ratings in Individuals with Parkinson's Disease. Dysphagia 2023; 38:1295-1307. [PMID: 36692654 DOI: 10.1007/s00455-023-10555-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Accepted: 01/10/2023] [Indexed: 01/25/2023]
Abstract
The Swallow Disturbance Questionnaire (SDQ) is a screening tool developed to identify patients with Parkinson's Disease (PD) in need of objective swallowing evaluation. In a previous investigation, the SDQ did not predict abnormal airway protection on a videofluoroscopic swallowing study (VFSS). This investigation was undertaken to determine whether SDQ scores were more accurate when a global measure was used. The Dynamic Imaging Grade for Swallowing Toxicity (DIGEST) is a validated measure that provides a safety, efficiency, and total severity grade based on VFSS. A secondary analysis was performed using data from 20 patients with PD who had participated in a standardized VFSS protocol. The study sample was predominantly male (80%) with an average age of 71 years, and an average PD duration of 9 years. Using an established cut-off score, participants were subdivided into those with "normal" (n = 10) and "abnormal" SDQ scores (n = 10). Recordings were scored using the DIGEST protocol by two blinded raters who also rated overall dysphagia severity from the VFSS. There was good agreement between the two raters on the DIGEST and strong correlations between DIGEST scores and clinician perceptions of dysphagia severity. Higher SDQ scores were associated with poorer Efficiency on the DIGEST but not Safety or Total scores. Consistent with other PD studies, subjective perceptions of dysphagia were poorly predictive of objective findings on VFSS. There is little information about the validity of the DIGEST for rating neurogenic dysphagia. Our study provides preliminary support for the use of the DIGEST in the PD population.
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Affiliation(s)
- Mehak Noorani
- Deptartment of Otolaryngology-Head & Neck Surgery, NW Center for Voice & Swallowing, Oregon Health & Science University, 3181 SW Sam Jackson Park Rd, Portland, OR, 97239, USA
| | - Rachel K Bolognone
- Deptartment of Otolaryngology-Head & Neck Surgery, NW Center for Voice & Swallowing, Oregon Health & Science University, 3181 SW Sam Jackson Park Rd, Portland, OR, 97239, USA
| | - Donna J Graville
- Deptartment of Otolaryngology-Head & Neck Surgery, NW Center for Voice & Swallowing, Oregon Health & Science University, 3181 SW Sam Jackson Park Rd, Portland, OR, 97239, USA
| | - Andrew D Palmer
- Deptartment of Otolaryngology-Head & Neck Surgery, NW Center for Voice & Swallowing, Oregon Health & Science University, 3181 SW Sam Jackson Park Rd, Portland, OR, 97239, USA.
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Tabor Gray L, Locatelli E, Vasilopoulos T, Wymer J, Plowman EK. Dextromethorphan/quinidine for the treatment of bulbar impairment in amyotrophic lateral sclerosis. Ann Clin Transl Neurol 2023; 10:1296-1304. [PMID: 37265174 PMCID: PMC10424659 DOI: 10.1002/acn3.51821] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Revised: 05/10/2023] [Accepted: 05/19/2023] [Indexed: 06/03/2023] Open
Abstract
OBJECTIVE No efficacious treatments exist to improve or prolong bulbar functions of speech and swallowing in persons with amyotrophic lateral sclerosis (pALS). This study evaluated the short-term impact of dextromethorphan/quinidine (DMQ) treatment on speech and swallowing function in pALS. METHODS This was a cohort trial conducted between August 2019 to August 2021 in pALS with a confirmed diagnosis of probable-definite ALS (El-Escorial Criteria-revisited) and bulbar impairment (ALS Functional Rating Scale score ≤ 10 and speaking rate ≤ 140 words per minute) who were DMQ naïve. Efficacy of DMQ was assessed via pre-post change in the ALS Functional Rating Scale-Revised bulbar subscale and validated speech and swallowing outcomes. Paired t-tests, Fisher's exact, and χ2 tests were conducted with alpha at 0.05. RESULTS Twenty-eight pALS enrolled, and 24 participants completed the 28-day trial of DMQ. A significant increase in ALSFRS-R bulbar subscale score pre- (7.47 ± 1.98) to post- (8.39 ± 1.79) treatment was observed (mean difference: 0.92, 95% CI: 0.46-1.36, p < 0.001). Functional swallowing outcomes improved, with a reduction in unsafe (75% vs. 44%, p = 0.003) and inefficient swallowing (67% vs. 58%, p = 0.002); the relative speech event duration in a standard reading passage increased, indicating a greater duration of uninterrupted speech (mean difference: 0.33 s, 95% CI: 0.02-0.65, p = 0.035). No differences in diadochokinetic rate or speech intelligibility were observed (p > 0.05). INTERPRETATION Results of this study provide preliminary evidence that DMQ pharmacologic intervention may have the potential to improve or maintain bulbar function in pALS.
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Affiliation(s)
- Lauren Tabor Gray
- Aerodigestive Research CoreUniversity of FloridaGainesvilleFloridaUSA
- Center for Collaborative ResearchNova Southeastern UniversityFort LauderdaleFloridaUSA
- Dr. Kiran C. Patel College of Allopathic MedicineNova Southeastern UniversityFort LauderdaleFloridaUSA
| | - Eduardo Locatelli
- Center for Collaborative ResearchNova Southeastern UniversityFort LauderdaleFloridaUSA
- Dr. Kiran C. Patel College of Allopathic MedicineNova Southeastern UniversityFort LauderdaleFloridaUSA
| | | | - James Wymer
- Aerodigestive Research CoreUniversity of FloridaGainesvilleFloridaUSA
- Department of NeurologyUniversity of FloridaGainesvilleFloridaUSA
| | - Emily K. Plowman
- Aerodigestive Research CoreUniversity of FloridaGainesvilleFloridaUSA
- Department of NeurologyUniversity of FloridaGainesvilleFloridaUSA
- Department of Speech, Language and Hearing SciencesUniversity of FloridaGainesvilleFloridaUSA
- Department of SurgeryUniversity of FloridaGainesvilleFloridaUSA
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22
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Graboyes EM, Barbon CEA. Optimizing Function and Appearance After Head and Neck Reconstruction: Measurement and Intervention. Otolaryngol Clin North Am 2023; 56:835-852. [PMID: 37246027 PMCID: PMC10330938 DOI: 10.1016/j.otc.2023.04.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
Approximately 50% of head and neck cancer (HNC) survivors are left with dysphagia as a result of treatment sequele, and 25% of survivors experience clinically significant body image distress (BID). Both dysphagia and BID adversely affect quality of life and should be tracked using validated clinician- and patient-reported outcome measures such as the Performance Status Scale for Head and Neck Cancer, MD Anderson Dysphagia Inventory, and Inventory to Measure and Assess imaGe disturbancE-Head & Neck (IMAGE-HN). Subjective and objective evaluation measures are critical to dysphagia workup and management. Building a renewed image after head and neck cancer treatment, a brief telemedicine-based cognitive behavioral therapy, has become the first evidence-based treatment for BID among HNC survivors.
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Affiliation(s)
- Evan M Graboyes
- Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, 135 Rutledge Avenue, MSC 550, Charleston, SC 29425, USA; Department of Public Health Sciences, Medical University of South Carolina
| | - Carly E A Barbon
- Department of Head & Neck Surgery, University of Texas MD Anderson Cancer Center, Unit 1445, 1515 Holcombe Boulevard, Houston, TX 77030-400, USA.
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23
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Reedy EL, Simpson AN, O'Rourke AK, Bonilha HS. Characterizing Swallowing Impairment in a Post-Lung Transplant Population. AMERICAN JOURNAL OF SPEECH-LANGUAGE PATHOLOGY 2023; 32:1236-1251. [PMID: 37000923 DOI: 10.1044/2023_ajslp-22-00266] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/06/2023]
Abstract
BACKGROUND Lung transplant recipients carry significant pre- and post-lung transplant dysphagia risk factors related to altered respiratory-swallow coordination as well as acute injury and decompensation resulting in the acute post-lung transplant recovery period. However, we are only beginning to understand the potential physiological contributors to altered swallowing in this population. METHOD A retrospective, cross-sectional, cohort study of post-lung transplant patients was performed. All participants received a modified barium swallow study (MBSS) as part of standard care during their acute hospitalization using the Modified Barium Swallow Impairment Profile (MBSImP) protocol and scoring metric. A combination of MBSImP scores, Penetration-Aspiration Scale (PAS) scores, Functional Oral Intake Scale (FOIS) scores, International Dysphagia Diet Standardization Initiative (IDDSI) scale levels, and the time from lung transplant to MBSS was collected, as well as measures of swallowing impairment and swallowing-related outcomes. Differences in swallowing physiology and swallowing-related outcomes between participants with typical versus atypical PAS were explored. RESULTS Forty-two participants met our prespecified inclusion criteria. We identified atypical laryngeal penetration and/or aspiration in 52.4% of our post-lung transplant cohort. Silent aspiration occurred in 75% of those patients who aspirated. Comparing typical versus atypical PAS scores, we found statistically significant associations with laryngeal elevation (Component 8), p < .0001; anterior hyoid excursion (Component 9), p = .0046; epiglottic movement (Component 10), p = .0031; laryngeal vestibule closure (Component 11), p < .0001; pharyngeal stripping (Component 12), p = .0058; pharyngeal total scores, p = .0001; FOIS scores, p = .00264; and IDDSI liquid levels, p = .0009. CONCLUSIONS Swallowing impairment resulting in abnormal bolus invasion is prevalent in post-lung transplant patients. Airway invasion in this cohort was related to pharyngeal swallow impairment and resulted in modified oral intake. Our findings help expand upon prior literature, which only reported the incidence of aspiration and pathological laryngeal penetration. Our results suggest that the potential for aerodigestive system impairment and negative sequela should not be underestimated in the post-lung transplant population.
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Affiliation(s)
- Erin L Reedy
- Health Sciences and Research, The Medical University of South Carolina, Charleston
| | - Annie N Simpson
- Health Sciences and Research, The Medical University of South Carolina, Charleston
- Department of Otolaryngology-Head & Neck Surgery, The Medical University of South Carolina, Charleston
| | - Ashli K O'Rourke
- Department of Otolaryngology-Head & Neck Surgery, The Medical University of South Carolina, Charleston
| | - Heather Shaw Bonilha
- Health Sciences and Research, The Medical University of South Carolina, Charleston
- Department of Otolaryngology-Head & Neck Surgery, The Medical University of South Carolina, Charleston
- Department of Rehabilitation Medicine, Emory University, Atlanta, GA
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24
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Starmer HM, Hutcheson K, Patterson J. Internal oedema and dysphagia characteristics in patients with head and neck cancer. Clin Otolaryngol 2023. [PMID: 36918287 DOI: 10.1111/coa.14046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Revised: 01/14/2023] [Accepted: 02/05/2023] [Indexed: 03/16/2023]
Affiliation(s)
- Heather M Starmer
- Department of Otolaryngology, Head and Neck Surgery, Stanford University, Stanford, California, USA
| | - Katherine Hutcheson
- Department of Head and Neck Surgery, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Joanne Patterson
- School of Health Science Research, University of Liverpool, Liverpool, UK
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Hutcheson KA, Starmer H. Letter to the Editor re: 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. Eur Arch Otorhinolaryngol 2023; 280:3045-3046. [PMID: 36912933 DOI: 10.1007/s00405-023-07902-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Accepted: 02/23/2023] [Indexed: 03/14/2023]
Affiliation(s)
- Katherine A Hutcheson
- Department of Head and Neck Surgery, Section of Speech Pathology and Audiology, The University of Texas MD Anderson Cancer Center, 1400 Pressler St., Unit 1445, Houston, TX, 77030, USA.
- Division of Radiation Oncology, The University of Texas M.D. Anderson Cancer Center, Houston, TX, USA.
| | - Heather Starmer
- Department of OHNS/Head and Neck Surgery Divisions, Stanford Cancer Center, Stanford, CA, USA
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Valenzano TJ, Smaoui S, Peladeau-Pigeon M, Barbon CEA, Craven BC, Steele CM. Using Reference Values to Identify Profiles of Swallowing Impairment in a Case Series of Individuals With Traumatic Spinal Cord Injury. AMERICAN JOURNAL OF SPEECH-LANGUAGE PATHOLOGY 2023; 32:688-700. [PMID: 36812476 PMCID: PMC10171848 DOI: 10.1044/2022_ajslp-22-00298] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Revised: 11/28/2022] [Accepted: 12/09/2022] [Indexed: 05/12/2023]
Abstract
PURPOSE In this article, we illustrate use of a systematic approach to rating videofluoroscopic swallowing studies (VFSS), the Analysis of Swallowing Physiology: Events, Kinematics and Timing (ASPEKT) method. The method is applied to a clinical case series of individuals with a history of traumatic spinal cord injury (tSCI) requiring surgical intervention using a posterior approach. Previous studies suggest that swallowing is highly variable in this population given heterogeneity in mechanisms, location and extent of injury, and in surgical management approaches. METHOD The case series involved 6 individuals who were at least 1 month postsurgery for management of tSCI. Participants completed a VFSS using a standardized bolus protocol. Each VFSS was blindly rated in duplicate using the ASPEKT method and compared with published reference values. RESULTS The analysis revealed considerable heterogeneity across this clinical sample. Penetration-aspiration scale scores of 3 or higher were not observed in this cohort. Of note, patterns of impairment did emerge, suggesting there are some commonalities across profiles in this population, including the presence of residue associated with poor pharyngeal constriction, reduced upper esophageal opening diameter, and short upper esophageal sphincter opening duration. CONCLUSIONS Although the participants in this clinical sample shared a history of tSCI requiring surgical intervention using a posterior approach, there was great heterogeneity in swallowing profile. Using a systematic method to identify atypical swallowing parameters can guide clinical decision making for determining rehabilitative targets and measuring swallowing outcomes.
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Affiliation(s)
- Teresa J. Valenzano
- KITE Research Institute, Toronto Rehabilitation Institute – University Health Network, Ontario, Canada
- Rehabilitation Sciences Institute, Faculty of Medicine, University of Toronto, Canada
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health Toronto, Ontario, Canada
- Department of Speech-Language Pathology, Faculty of Medicine, University of Toronto, Ontario, Canada
| | - Sana Smaoui
- KITE Research Institute, Toronto Rehabilitation Institute – University Health Network, Ontario, Canada
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health Toronto, Ontario, Canada
| | - Melanie Peladeau-Pigeon
- KITE Research Institute, Toronto Rehabilitation Institute – University Health Network, Ontario, Canada
| | - Carly E. A. Barbon
- KITE Research Institute, Toronto Rehabilitation Institute – University Health Network, Ontario, Canada
- Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston
| | - B. Cathy Craven
- KITE Research Institute, Toronto Rehabilitation Institute – University Health Network, Ontario, Canada
- Rehabilitation Sciences Institute, Faculty of Medicine, University of Toronto, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Ontario, Canada
- Division of Physiatry, Department of Medicine, University of Toronto, Ontario, Canada
| | - Catriona M. Steele
- KITE Research Institute, Toronto Rehabilitation Institute – University Health Network, Ontario, Canada
- Rehabilitation Sciences Institute, Faculty of Medicine, University of Toronto, Canada
- Canada Research Chair (Tier 1) in Swallowing and Food Oral Processing
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Patterson JM, Lawton M. Dysphagia Advances in Head and Neck Cancer. CURRENT OTORHINOLARYNGOLOGY REPORTS 2023; 11:1-8. [PMID: 36816911 PMCID: PMC9930077 DOI: 10.1007/s40136-023-00445-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/27/2023] [Indexed: 02/19/2023]
Abstract
Purpose of Review This review summarises the current literature regarding head and neck cancer-associated dysphagia. Up-to-date evidence for dysphagia outcome measurement for this population is provided, in addition to recent innovations that aim to prevent, reduce or remediate the common and debilitating side effects of treatment. Recent Findings Both patient-reported outcomes and clinical measures are necessary to capture the multi-dimensional nature of swallowing. A minimally important difference in scores has been calculated for some of these measures, to aid interpretation and powering of clinical trials. The number of dysphagia-related trials has increased, predominantly investigating optimal treatment for oropharyngeal HPV-positive disease, and speech and language pathology interventions using an impairment-based approach. Summary Although substantial progress has been made, further work is necessary to establish a consensus over outcome measures. Modifying treatments may improve outcomes. Several trials are underway to establish the effectiveness of speech and language pathology dysphagia interventions.
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Affiliation(s)
- J. M. Patterson
- School of Health Sciences, Institute of Population Health/Liverpool Head and Neck Centre, University of Liverpool, 1.17 Thompson Yates Building, The Quadrangle, Brownlow Hill, Liverpool, L69 3GB USA
| | - M. Lawton
- School of Health Sciences, Institute of Population Health/Liverpool Head and Neck Centre, University of Liverpool, 1.17 Thompson Yates Building, The Quadrangle, Brownlow Hill, Liverpool, L69 3GB USA
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Simon SR, Wieland MWM, Hendriks C, Pilz W, Schindler A, Winkens B, Baijens LWJ. 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. Eur Arch Otorhinolaryngol 2023; 280:2865-2876. [PMID: 36705725 PMCID: PMC10175403 DOI: 10.1007/s00405-023-07840-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Accepted: 01/15/2023] [Indexed: 01/28/2023]
Abstract
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.
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Affiliation(s)
- Sorina R Simon
- Department of Otorhinolaryngology, Head and Neck Surgery, Maastricht University Medical Center, P.O. Box 5800, 6202 AZ, Maastricht, The Netherlands.
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Center, Maastricht, The Netherlands.
- GROW-School for Oncology and Reproduction, Maastricht University Medical Center, Maastricht, The Netherlands.
| | - Monse W M Wieland
- Department of Otorhinolaryngology, Head and Neck Surgery, Maastricht University Medical Center, P.O. Box 5800, 6202 AZ, Maastricht, The Netherlands
| | - Charlotte Hendriks
- Department of Otorhinolaryngology, Head and Neck Surgery, Maastricht University Medical Center, P.O. Box 5800, 6202 AZ, Maastricht, The Netherlands
| | - Walmari Pilz
- Department of Otorhinolaryngology, Head and Neck Surgery, Maastricht University Medical Center, P.O. Box 5800, 6202 AZ, Maastricht, The Netherlands
- GROW-School for Oncology and Reproduction, Maastricht University Medical Center, Maastricht, The Netherlands
- School for Mental Health and Neuroscience-MHeNs, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Antonio Schindler
- Department of Biomedical and Clinical Sciences "L. Sacco", University of Milan, Milan, Italy
| | - Bjorn Winkens
- Department of Methodology and Statistics, Maastricht University, Maastricht, The Netherlands
- Care and Public Health Research Institute-CAPHRI, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Laura W J Baijens
- Department of Otorhinolaryngology, Head and Neck Surgery, Maastricht University Medical Center, P.O. Box 5800, 6202 AZ, Maastricht, The Netherlands
- GROW-School for Oncology and Reproduction, Maastricht University Medical Center, Maastricht, The Netherlands
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Donohue C, Gray LT, Anderson A, DiBiase L, Wymer JP, Plowman EK. Profiles of Dysarthria and Dysphagia in Individuals With Amyotrophic Lateral Sclerosis. JOURNAL OF SPEECH, LANGUAGE, AND HEARING RESEARCH : JSLHR 2023; 66:154-162. [PMID: 36525626 PMCID: PMC10023186 DOI: 10.1044/2022_jslhr-22-00312] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/29/2022] [Revised: 07/22/2022] [Accepted: 09/21/2022] [Indexed: 06/17/2023]
Abstract
PURPOSE While dysarthria and dysphagia are known bulbar manifestations of amyotrophic lateral sclerosis (ALS), the relative prevalence of speech and swallowing impairments and whether these bulbar symptoms emerge at the same time point or progress at similar rates is not yet clear. We, therefore, sought to determine the relative prevalence of speech and swallowing impairments in a cohort of individuals with ALS and to determine the impact of disease duration, severity, and onset type on bulbar impairments. METHOD Eighty-eight individuals with a confirmed diagnosis of ALS completed the ALS Functional Rating Scale-Revised (ALSFRS-R), underwent videofluoroscopy (VF), and completed the Sentence Intelligibility Test (SIT) during a single visit. Demographic variables including disease duration and onset type were also obtained from participants. Duplicate, independent, and blinded ratings were completed using the Dynamic Imaging Grade of Swallowing Toxicity (DIGEST) scale and SIT to index dysphagia (DIGEST ≥ 1) and dysarthria (< 96% intelligible and/or < 150 words per minute) status. Descriptive statistics, Pearson chi-squared tests, independent-samples t tests, and odds ratios were performed. RESULTS Dysphagia and dysarthria were instrumentally confirmed in 68% and 78% of individuals with ALS, respectively. Dysarthria and dysphagia were associated (p = .01), and bulbar impairment profile distributions in rank order included (a) dysphagia - dysarthria (59%, n = 52), (b) no dysphagia - dysarthria (19%, n = 17), (c) no dysphagia - no dysarthria (13%, n = 11), and (d) dysphagia - no dysarthria (9%, n = 8). Participants with dysphagia or dysarthria demonstrated 4.2 higher odds of exhibiting a bulbar impairment in the other domain than participants with normal speech and swallowing (95% CI [1.5, 12.2]). There were no differences in ALSFRS-R total scores or disease duration across bulbar impairment profiles (p > .05). ALSFRS-R bulbar subscale scores were significantly lower in individuals with dysphagia versus no dysphagia (8.4 vs. 10.4, p < .0001) and dysarthria versus no dysarthria (8.5 vs. 10.9, p < .0001). Dysphagia and onset type (p = .003) and dysarthria and onset type were associated (p < .0001). CONCLUSIONS Over half of the individuals with ALS in this study demonstrated both dysphagia and dysarthria. Of those with only one bulbar impairment, speech was twice as likely to be the first bulbar symptom to degrade. Future studies are needed to confirm these findings and determine the longitudinal progression of bulbar impairments in this patient population.
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Affiliation(s)
- Cara Donohue
- Aerodigestive Research Core Laboratory, University of Florida, Gainesville
- Department of Speech, Language, and Hearing Sciences, University of Florida, Gainesville
- Breathing Research and Therapeutics Center, University of Florida, Gainesville
| | - Lauren Tabor Gray
- Aerodigestive Research Core Laboratory, University of Florida, Gainesville
- Department of Speech, Language, and Hearing Sciences, University of Florida, Gainesville
- Breathing Research and Therapeutics Center, University of Florida, Gainesville
- Center of Collaborative Research, NOVA Southeastern University, Fort Lauderdale, FL
| | - Amber Anderson
- Aerodigestive Research Core Laboratory, University of Florida, Gainesville
- Department of Speech, Language, and Hearing Sciences, University of Florida, Gainesville
| | - Lauren DiBiase
- Aerodigestive Research Core Laboratory, University of Florida, Gainesville
- Department of Speech, Language, and Hearing Sciences, University of Florida, Gainesville
| | - James P. Wymer
- Department of Neurology, University of Florida, Gainesville
| | - Emily K. Plowman
- Aerodigestive Research Core Laboratory, University of Florida, Gainesville
- Department of Speech, Language, and Hearing Sciences, University of Florida, Gainesville
- Breathing Research and Therapeutics Center, University of Florida, Gainesville
- Department of Neurology, University of Florida, Gainesville
- Department of Surgery, University of Florida, Gainesville
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Barbon CEA, Peterson CB, Moreno AC, Lai SY, Reddy JP, Sahli A, Martino R, Johnson FM, Fuller CD, Hutcheson KA. Adhering to Eat and Exercise Status During Radiotherapy for Oropharyngeal Cancer for Prevention and Mitigation of Radiotherapy-Associated Dysphagia. JAMA Otolaryngol Head Neck Surg 2022; 148:956-964. [PMID: 36074459 PMCID: PMC9459910 DOI: 10.1001/jamaoto.2022.2313] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Accepted: 07/08/2022] [Indexed: 01/01/2023]
Abstract
Importance Previously published work reported independent benefit of maintenance of oral intake (eat) and swallowing exercise adherence (exercise) during radiotherapy (RT) on diet and functional outcomes. The current study seeks to validate the authors' previously published findings in a large contemporary cohort of patients with oropharynx cancer (OPC) and address limitations of the prior retrospective study using prospective, validated outcome measures. Objective To examine the longitudinal association of oral intake and swallowing exercise using validated, clinician-graded and patient-reported outcomes. Design, Setting, and Participants Secondary analysis of a prospective OPC registry including patients who underwent primary RT/chemoradiotherapy (CRT) or primary transoral robotic surgery plus RT/CRT for OPC at a single-institution comprehensive cancer center. Exposures Adherence to speech pathology swallowing intervention during RT coded as (1) eat: oral intake at end of RT (nothing by mouth [NPO]; partial oral intake [PO], with feeding tube [FT] supplement; full PO); and (2) exercise: swallowing exercise adherence (nonadherent vs partial/full adherence). Main Outcomes and Measures Feeding tube and diet (Performance Status Scale for Head and Neck Cancer) patient-reported swallowing-related quality of life (MD Anderson Dysphagia Inventory; MDADI) and clinician-graded dysphagia severity grade (videofluoroscopic Dynamic Imaging Grade of Swallowing Toxicity; DIGEST) were collected at baseline, 3 to 6 months, and 18 to 24 months post-RT. Results A total of 595 patients (mean [SD] age, 65 [10] years; 532 [89%] male) who underwent primary RT (111 of 595 [19%]), CRT (434 of 595 [73%]), or primary transoral robotic surgery plus RT/CRT (50 of 595 [8%]) were included in this cohort study. At the end of RT, 55 (9%) patients were NPO, 115 (19%) were partial PO, 425 (71%) were full PO, and 340 (57%) reported exercise adherence. After multivariate adjustment, subacute return to solid diet and FT were independently associated with oral intake (odds ratio [OR], 2.0; 95% CI, 1.0-4.1; OR, 0.1; 95% CI, 0.0-0.2, respectively) and exercise (OR, 2.9; 95% CI, 1.9-4.5; OR, 0.3; 95% CI, 0.1-0.5, respectively). Subacute MDADI (β = 6.5; 95% CI, 1.8-11.2), FT duration (days; β = -123.4; 95% CI, -148.5 to -98.4), and less severe dysphagia per DIGEST (OR, 0.6; 95% CI, 0.3-1.0) were independently associated with oral intake, while exercise was independently associated with less severe laryngeal penetration/aspiration per DIGEST-safety (OR, 0.7; 95% CI, 0.4-1.0). DIGEST grade associations with oral intake were not preserved long-term; however, exercise was associated with a higher likelihood of solid diet intake and better swallow safety per DIGEST. Conclusions and Relevance The findings of this cohort study extend the authors' previously published findings that oral intake and swallowing exercise during RT are associated with favorable functional outcomes, now demonstrated with broader domains of function using validated measures. Patterns of benefit differed in this study. Specifically, better subacute recovery of swallow-related quality of life and less severe dysphagia were found among patients who maintained oral intake independent of exercise adherence, and shorter FT utilization and better long-term diet and swallowing safety were found among those who exercised independent of oral intake.
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Affiliation(s)
- Carly E. A. Barbon
- Department of Head and Neck Surgery, University of Texas MD Anderson Cancer Center, Houston
| | - Christine B. Peterson
- Department of Biostatistics, University of Texas MD Anderson Cancer Center, Houston
- Graduate School of Biomedical Sciences, Baylor College of Medicine, Houston, Texas
| | - Amy C. Moreno
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston
| | - Stephen Y. Lai
- Department of Head and Neck Surgery, University of Texas MD Anderson Cancer Center, Houston
- Graduate School of Biomedical Sciences, Baylor College of Medicine, Houston, Texas
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston
| | - Jay P. Reddy
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston
| | - Ariana Sahli
- Department of Head and Neck Surgery, University of Texas MD Anderson Cancer Center, Houston
| | - Rosemary Martino
- Department of Speech-Language Pathology, University of Toronto, Toronto, Ontario, Canada
- Krembil Research Institute, University Health Network, Toronto, Ontario, Canada
- Rehabilitation Sciences Institute, University of Toronto, Toronto, Ontario, Canada
- Department of Otolaryngology–Head and Neck Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Faye M. Johnson
- Graduate School of Biomedical Sciences, Baylor College of Medicine, Houston, Texas
- Department of Thoracic–Head & Neck Medical Oncology, University of Texas MD Anderson Cancer Center, Houston
| | - Clifton David Fuller
- Graduate School of Biomedical Sciences, Baylor College of Medicine, Houston, Texas
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston
| | - Katherine A. Hutcheson
- Department of Head and Neck Surgery, University of Texas MD Anderson Cancer Center, Houston
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston
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