Early Radiation Effects on Tongue Function for Patients with Nasopharyngeal Carcinoma: A Preliminary Study

Assessing Tongue Strength and Swallowing Function Following Hyoid Bone Resection Surgery

PURPOSE

The tongue and hyoid bone are responsible for the oral phase of swallowing. The purpose of this study was to assess tongue strength and endurance, and to evaluate swallowing functions in patients who underwent hyoid bone resection surgery.

MATERIAL AND METHODS

This was an experimental, non-randomized trial. It included participants who underwent hyoid bone resection surgery, divided into 2 groups; post-Sistrunk procedure and post-total laryngectomy. Swallowing problem history was recorded, and tongue strength and endurance were measured using the Iowa Oral Performance Instrument (IOPI). Post-Sistrunk procedure participants also underwent flexible endoscopic evaluation of swallowing (FEES) to assess objective swallowing function. Descriptive and bivariate statistics were used to analyze the association between the tongue strength and endurance, and the type of surgeries.

RESULTS

The study involved 26 participants, including 16 males and 10 females, with a mean age of 58.4 ± 12.8 years. A total of 10 subjects underwent the Sistrunk procedure and 16 underwent total laryngectomy surgery. The average tongue strength of all participants was 40.8 ± 11.7 kPa and the average tongue endurance was 30.6 ± 13.2 s. The difference in average tongue strength between the post-Sistrunk procedure group and post-total laryngectomy group was not significantly different (37.5 ± 11.6 kPa vs. 44.1 ± 11.3kPa, P = .153). However, there was a statistically significant difference in average tongue strength between male and female participants (46.3 ± 10.0 kPa vs. 32.0 ± 8.5 kPa, P = .001). FEES did not reveal any evidence of objective swallowing abnormalities in the post-Sistrunk group.

CONCLUSION

The resection of the hyoid bone, whether partial or total, did not significantly affect tongue strength and swallowing functions.

Tongue strength and endurance among typically developing children and children with idiopathic speech sound disorders in the United Arab Emirates

BACKGROUND

Tongue strength and endurance in adults have been extensively studied, but data on these parameters in young children remain largely unavailable.

AIMS

This study aimed to collect normative objective tongue strength and endurance data from a pediatric population in the United Arab Emirates (UAE) and to examine the effects of age and sex on these parameters.

METHODS

This normative study included a total of 65 typically developing (TD; n = 36) children and children with idiopathic speech sound disorders (ISSDs; n = 29). The participants were assigned to four age groups (range: 3-8 years) and stratified by sex. Data on their tongue strength and endurance were collected using the Iowa Oral Performance Instrument.

RESULTS

Tongue strength scores and endurance time increased with age in both the TD and ISSD groups. Sex had no statistically significant effects on tongue strength or endurance in either group. Furthermore, tongue strength and endurance time scores were higher in the TD group than in the ISSD group.

CONCLUSIONS

The data obtained in this study would add important normative data to the database of standardized measurements for maximal strength and endurance scores in the pediatric population of the UAE. Future research is encouraged to collect additional data that can help healthcare professionals objectively evaluate children with feeding, swallowing, and speech sound production difficulties.

Quantitative Measurement of Swallowing Performance Using Iowa Oral Performance Instrument: A Systematic Review and Meta-Analysis

Swallowing is a complex but stereotyped motor activity aimed at serving two vital purposes: alimentary function and the protection of upper airways. Therefore, any impairment of the swallowing act can represent a significant clinical and personal problem that needs an accurate diagnosis by means of reliable and non-invasive techniques. Thus, a systematic review and meta-analysis was performed to investigate the reliability of the Iowa Oral Pressure Instrument (IOPI) in distinguishing healthy controls (HC) from patients affected by swallowing disorders or pathologies and conditions that imply dysphagia. A comprehensive search was conducted following the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines and using PubMed, Scopus, Web of Science, Cochrane, and Lilacs databases. Overall, 271 articles were identified and, after a three-step screening, 33 case-control and interventional studies reporting IOPI measurements were included. The methodological quality of the retrieved studies resulted in being at a low risk of bias. The meta-analysis on case-control studies showed that maximum tongue pressure (MIP) values were always higher in HC than in patients, with an overall effect of the MIP difference of 18.2 KPa (17.7–18.7 KPa CI). This result was also confirmed when the sample was split into adults and children, although the MIP difference between HC and patients was greater in children than in adults (21.0 vs. 15.4 KPa in the MIP mean difference overall effect, respectively). Tongue endurance (TE) showed conflicting results among studies, with an overall effect among studies near zero (0.7 s, 0.2–1.1 s CI) and a slight tendency toward higher TE values in HC than in patients. Among the intervention studies, MIP values were higher after treatment than before, with a better outcome after the experimental tongue training exercise than traditional treatments (the MIP mean difference overall effect was 10.8 and 2.3 KPa, respectively). In conclusion, MIP values can be considered as a reliable measure of swallowing function in adults and in children, with a more marked MIP difference between HC and patients for the children population. MIP measures in patients are also able to detect the best outcome on the tongue function after the training exercise compared to traditional training.

Perceptual Voice and Speech Analysis after Supraglottic Laryngeal Closure for Chronic Aspiration in Head and Neck Cancer

OBJECTIVES/HYPOTHESIS

To evaluate the voice and speech outcomes after tubed supraglottic laryngeal closure (TSLC) surgery to treat chronic aspiration after radiotherapy for head and neck cancer.

STUDY DESIGN

A retrospective case-control study.

METHODS

The data of patients who underwent radiotherapy for head and neck cancer and who later required total laryngectomy or TSLC for chronic aspiration between 2004 and 2017 were retrieved from a dysphagia clinic. Preoperative and postoperative voice and speech were assessed by the GRBAS and INFVo rating scales. Control subjects who underwent radiotherapy alone or total laryngectomy with a tracheoesophageal prosthesis for other indications were recruited for comparison.

RESULTS

Of 15 patients who underwent a TSLC with a mean age of 57.3 years (45-75 years), 13 were male and 2 female. All patients had a history of nasopharyngeal carcinoma. The success rate of speech production using their own larynx following an intact TSLC was 64%. There was no statistically significant difference in voice and speech ratings between preoperative and TSLC subjects on the GRBAS (P = .32) and INFVo scales (P = .57), although the quality of voice appeared to deteriorate after TSLC. However, the INFVo scale for impression, intelligibility and unsteadiness of the voice after TSLC was statistically significantly better than for laryngectomy with tracheoesophageal speech.

CONCLUSIONS

A tubed supraglottic laryngeal closure controls chronic aspiration while preserving the larynx for phonation, and results in a better voice and speech quality than a laryngectomy with a voice prosthesis.

LEVEL OF EVIDENCE

4 Laryngoscope, 131:E1616-E1623, 2021.

The Effect of Lingual Resistance Training Interventions on Adult Swallow Function: A Systematic Review

Lingual resistance training has been proposed as an intervention to improve decreased tongue pressure strength and endurance in patients with dysphagia. However, little is known about the impact of lingual resistance training on swallow physiology. This systematic review scrutinizes the available evidence regarding the effects of lingual resistance training on swallowing function in studies using Videofluoroscopic Swallowing Studies (VFSS) with adults. Seven articles met the inclusion criteria and underwent detailed review for study quality, data extraction, and planned meta-analysis. Included studies applied this intervention to a stroke and brain injury patient populations or to healthy participants, applied different training protocols, and used a number of outcome measures, making it difficult to generalize results. Lingual resistance training protocols included anterior and posterior tongue strengthening, accuracy training, and effortful press against hard palate with varying treatment durations. VFSS protocols typically included a thin barium stimulus along with one other consistency to evaluate the effects of the intervention. Swallowing measures included swallow safety, efficiency, and temporal measures. Temporal measures significantly improved in one study, while safety improvements showed mixed results across studies. Reported improvements in swallowing efficiency were limited to reductions in thin liquid barium residue in two studies. Overall, the evidence regarding the impact of lingual resistance training for dysphagia is mixed. Meta-analysis was not possible due to differences in methods and outcome measurements across studies. Reporting all aspects of training and details regarding VFSS protocols is crucial for the reproducibility of these interventions. Future investigations should focus on completing robust analyses of swallowing kinematics and function following tongue pressure training to determine efficacy for swallowing function.

Dysphagia after chemo-radiation for nasopharyngeal cancer: A scoping review

Objective

Nasopharyngeal cancer (NPC) has distinct characteristics regarding its global prevalence, initial presentation, management and patient outcomes compared to other subtypes of head and neck cancer (HNC). The mainstay of NPC treatment is chemo-radiation (C/RT) and while dysphagia is a known early and late toxicity of C/RT treatment, the nature of dysphagia post NPC treatment has had limited investigation. The objective of this review is to summarise the existing evidence regarding dysphagia following NPC to inform the future research agenda for this population. Dysphagia incidence, characteristic deficits observed across the phases of swallowing, efficacy of current dysphagia interventions, and effect on quality of life will be explored.

Data sources

Databases including MEDLINE, CINAHL, Embase, Scopus and Web of Science were included.

Methods

A scoping review was conducted according to PRISMA-ScR guidelines. Two independent reviewers screened selected full text articles.

Results

Of the initial 2495 articles found, 28 articles were included. Reports of penetration and aspiration varied widely (0%–91.6%), with high rates of silent aspiration identified in 2 studies (42%, 66%). Oral, pharyngeal and upper esophageal phase impairments were reported. Of these, upper esophageal stasis and multiple pharyngeal stage deficits were most prevalent. The pharyngeal constrictors were found to have a significant dose–effect relationship and shielding to the anterior neck field was effective to preserve swallowing function. Six treatment studies were identified with limited evidence supporting the use of neuromuscular electrical stimulation, dilatation and swallowing exercises. Quality of life was adversely affected.

Conclusions

Dysphagia is a prevalent early and late problem post NPC treatment, with impairments across all phases of the swallow. Studies on preventing dysphagia and treatment efficacy remain limited. More systematic study of the nature of dysphagia and the efficacy of treatment in this population is warranted.

Effect of tongue-strengthening exercises on tongue strength and swallowing-related parameters in chronic radiation-associated dysphagia

BACKGROUND

Radiation-associated dysphagia (RAD) is highly prevalent in head and neck cancer (HNC) patients, with insufficient tongue strength (TS) as a characteristic of this disabling complication. The effects of tongue-strengthening exercises (TSE) on TS, swallowing, and quality of life (QoL) have not been studied in this population.

METHODS

A prospective phase 2 study using an 8 weeks during TSE protocol was carried out in 15 patients with chronic RAD. Outcome parameters were maximal isometric pressure (MIP), TS during swallowing (Pswal), swallowing function, and QoL. All parameters were evaluated at baseline, after 4 and 8 weeks of training, and 4 weeks after the last training session.

RESULTS

MIP increased significantly, without detraining effects. Pswal did not increase significantly, but relevant effect sizes were measured. Swallowing function ameliorated, but did not result in increased functional oral intake, self-reported outcome or QoL.

CONCLUSION

TSE in patients with RAD results in increased strength and swallowing function.

Effects of Change in Tongue Pressure and Salivary Flow Rate on Swallow Efficiency Following Chemoradiation Treatment for Head and Neck Cancer

Patients treated with chemoradiation for head and neck cancer frequently develop dysphagia. Tissue damage to the oral tongue causing weakness along with decreases in saliva production may contribute to dysphagia. Yet, effects of these variables on swallowing-related measures are unclear. The purpose of this study was (1) to determine effects of chemoradiation on tongue pressures, as a surrogate for strength, and salivary flow rates and (2) to elucidate relationships among tongue pressures, saliva production, and swallowing efficiency by bolus type. Twenty-one patients with head and neck cancer treated with chemoradiation were assessed before and after treatment and matched with 21 healthy control participants who did not receive chemoradiation. Each participant was given a questionnaire to rate dysphagia symptoms. Videofluoroscopic Evaluation of Swallowing (VFES) was used to determine swallowing efficiency; the Saxon test measured salivary flow rate; and the Iowa Oral Performance Instrument (IOPI) was used for oral tongue maximum and endurance measures. Results revealed significantly lower tongue endurance measures for patients post-treatment as compared to controls (p = .012). Salivary flow rates also were lower compared to pre-treatment (p = .000) and controls (p = .000). Simple linear regression analyses showed that change in salivary flow rate was predictive of change in swallow efficiency measures from pre- to post-treatment for 1 mL thin liquid (p = .017), 3 mL nectar-thick liquid (p = .026), and 3 mL standard barium pudding (p = .011) boluses. Based on these findings, it appears that chemoradiation treatment affects tongue endurance and salivary flow rate, and these changes may impact swallow efficiency. These factors should be considered when planning treatment for dysphagia.

Study protocol for a randomized controlled trial: tongue strengthening exercises in head and neck cancer patients, does exercise load matter?

BACKGROUND

Reduced tongue strength is an important factor contributing to early and late dysphagia in head and neck cancer patients previously treated with chemoradiotherapy. The evidence is growing that tongue strengthening exercises can improve tongue strength and swallowing function in both healthy and dysphagic subjects. However, little is known about the impact of specific features of an exercise protocol for tongue strength on the actual outcome (strength or swallowing function). Previous research originating in the fields of sports medicine and physical rehabilitation shows that the degree of exercise load is an influential factor for increasing muscle strength in the limb skeletal muscles. Since the tongue is considered a muscular hydrostat, it remains to be proven whether the same concepts will apply.

METHODS/DESIGN

This ongoing randomized controlled trial in chemoradiotherapy-treated patients with head and neck cancer investigates the effect of three tongue strengthening exercise protocols, with different degrees of exercise load, on tongue strength and swallowing. At enrollment, 51 patients whose dysphagia is primarily related to reduced tongue strength are randomly assigned to a training schedule of 60, 80, or 100% of their maximal tongue strength. Patients are treated three times a week for 8 weeks, executing 120 repetitions of the assigned exercise once per training day. Exercise load is progressively adjusted every 2 weeks. Patients are evaluated before, during and after treatment by means of tongue strength measurements, fiber-optic endoscopic evaluation of swallowing and quality-of-life questionnaires.

DISCUSSION

This randomized controlled trial is the first to systematically investigate the effect of different exercise loads in tongue strengthening exercise protocols. The results will allow the development of more efficacious protocols.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN14447678.

Reliability of measurements of tongue and hand strength and endurance using the Iowa Oral Performance Instrument with elderly adults

PURPOSE

This study investigated the reliability of tongue and hand strength and endurance measurements in old adults using the Iowa Oral Performance Instrument (IOPI).

METHOD

Thirty aged-care residents (6 males and 24 females) aged 79-97 years were tested on four occasions two weeks apart to determine test-retest reliability. The primary outcome measures were isometric anterior and posterior tongue and hand strength (best of three trials) and isometric tongue and hand endurance time at 50% of maximal strength.

RESULTS

Changes in the mean between sessions for tongue and hand strength indicated acceptable (< 10%) reliability particularly with familiarisation. The within-subject variation (mean-typical error expressed as a coefficient of variation, CV) indicated higher than acceptable variation for anterior and posterior tongue and hand strength. Intra-class correlations (ICC) indicated moderate to strong reliability for anterior (ICC 0.58-0.77) and posterior (ICC 0.77-0.84) tongue strength and hand strength (ICC 0.79-0.96). No tongue or hand endurance measures were regarded as reliable.

CONCLUSION

These findings indicate that overall tongue and hand strength values demonstrate acceptable reliability in the elderly, especially where familiarisation with the IOPI is provided. Further investigation to reduce sources of variability in tongue endurance measurements is warranted.

Effects of exercise on swallowing and tongue strength in patients with oral and oropharyngeal cancer treated with primary radiotherapy with or without chemotherapy

Tongue strength is reduced in patients treated with chemoradiotherapy for oral/oropharyngeal cancer. Tongue strengthening protocols have resulted in improved lingual strength and swallowing in healthy individuals, as well as in patients following a neurological event. However, no studies have examined the efficacy of tongue strengthening exercises on tongue strength, swallowing, and quality of life (QOL; Head and Neck Cancer Inventory) in patients treated with chemoradiotherapy. A randomized clinical trial examined the effects of a tongue strengthening programme paired with traditional exercises vs. traditional exercises alone. Dependent variables included tongue strength, swallowing, and QOL in a group of patients with oral and oropharyngeal cancer treated with primary radiotherapy with or without chemotherapy. Differences with regard to tongue strength and oropharyngeal swallow efficiency (OPSE) were not observed within or between groups. QOL in the eating and speech domains improved following treatment in both groups. However, the experimental group demonstrated greater impairment in QOL in the social disruption domain following treatment, whereas the control group demonstrated a slight improvement in functioning. Tongue strengthening did not yield a statistically significant improvement in either tongue strength or swallowing measures in this patient cohort. Patient compliance and treatment timing may be factors underlying these outcomes.

A 2-year follow-up of swallowing function after radiation therapy in patients with nasopharyngeal carcinoma

OBJECTIVE

To evaluate over a 2-year period the serial swallowing function of patients with nasopharyngeal carcinoma (NPC) after completing radiotherapy (RT).

DESIGN

Prospective longitudinal follow-up.

SETTING

University hospital.

PARTICIPANTS

Patients with NPC (N=76) referred for RT: 53 of them at 1 year after RT, and 23 at 2 years after RT.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Participants completed a questionnaire and had a video-recorded fluoroscopic swallowing study before RT and 1 month, 1 year, and 2 years after RT.

RESULTS

The highest incidence of dysphagia symptoms and retropharyngeal soft tissue swelling occurred in the first month after RT and decreased over time. Pharyngeal transit time was prolonged continuously up to 1 year after RT. Epiglottic vallecular stasis and pharyngeal mucosal coating were worst in the first month after RT and stable afterwards. Aspiration was uncommon during the first 2 years after RT.

CONCLUSIONS

At a 2-year follow-up after RT, patients with NPC had a progressively increasing pharyngeal transit time, although the subjectively identified symptoms of dysphagia decreased after the first month after RT.

Effects of dining on tongue endurance and swallowing-related outcomes

PURPOSE

The purpose of this study was to test the hypothesis that eating a meal reduces tongue strength and endurance in healthy old and young adults. It was predicted that older adults would show greater declines in tongue endurance while demonstrating higher perceived effort, longer meal durations, and clinical signs of swallowing difficulty.

METHOD

Twenty-two healthy adults were enrolled into 2 groups (ages 20-35 years and ages 65-82 years; 5 males and 6 females each). Maximum tongue strength (Pmax) and endurance (duration 50% of Pmax could be maintained) were measured twice at baseline and once postmeal. Subjects consumed half of a bagel with peanut butter, carrot sticks, and milk between measures.

RESULTS

All subjects demonstrated reduced tongue strength and endurance postmeal. Young adults showed a greater decline in anterior tongue endurance compared with older adults (p=.05). There was no evidence that changes in tongue strength, perceived effort, or meal duration varied by age or gender. The 3 oldest subjects reported the highest effort and displayed signs of difficulty swallowing while dining.

CONCLUSIONS

Young and old adults demonstrated reduced tongue strength and endurance after dining, but younger subjects showed greater declines in anterior tongue endurance, whereas older adults exhibited signs of swallowing difficulty.