Optimizing Respiratory-Swallowing Coordination in Patients With Oropharyngeal Head and Neck Cancer

Videofluoroscopic measures of swallowing in people with stable COPD compared to healthy aging

PURPOSE

Swallowing impairment is a serious extra-pulmonary manifestation of Chronic Obstructive Pulmonary Disease (COPD). Previous studies suggest that individuals with stable COPD show atypical values for several videofluoroscopy measures of swallowing, compared to healthy adults under age 60. However, it is unclear to what degree these changes are attributable to healthy aging. In this study, we aimed to clarify how swallowing in people with stable COPD differs from age-matched healthy controls.

METHODS

We performed a retrospective analysis of videofluoroscopy data from two previously-collected datasets: a) a sample of 28 adults with stable COPD (18 male); b) a sample of 76 healthy adults, from which 28 adults were selected, matched for sex and age to participants in the COPD cohort. In both prior studies, participants swallowed 20% w/v liquid barium prepared in different consistencies (thin; mildly, moderately, and extremely thick). Blinded duplicate ratings were performed according to a standard procedure, yielding measures of laryngeal vestibule closure (LVC) integrity and timing, swallow timing, upper esophageal sphincter (UES) opening, pharyngeal constriction and pharyngeal residue. Mann-Whitney U tests and odds ratios were performed to determine significant group differences (p<.05).

RESULTS

Across the consistencies tested, participants with COPD showed significantly shorter durations of LVC, earlier onsets and shorter durations of UES opening, and reduced pharyngeal constriction. No significant differences were seen in other measures.

CONCLUSION

These results point to features of swallowing in people with stable COPD that differ from changes seen with healthy aging, and which represent risks for potential aspiration.

A systematic review of behavioural therapies for improving swallow and cough function in Parkinson's disease

Purpose: This systematic review evaluated the efficacy of therapeutic interventions on improving swallow, respiratory, and cough functions in Parkinson's disease (PD).Method: A PRISMA systematic search was implemented across six databases. We selected studies reporting pre- and post-assessment data on the efficacy of behavioural therapies with a swallow or respiratory/cough outcome, and excluded studies on medical/surgical treatments or single-session design. Cross-system outcomes across swallow, respiratory, and cough functions were explored. Cochrane's risk of bias tools were utilised to evaluate study quality.Result: Thirty-six articles were identified and further clustered into four treatment types: swallow related (n = 5), electromagnetic stimulation (n = 4), respiratory loading (n = 20), and voice loading (n = 7) therapies. The effects of some behavioural therapies were supported with high-quality evidence in improving specific swallow efficiency, respiratory pressure/volume, and cough measures. Only eleven studies were rated with a low risk of bias and the remaining studies failed to adequately describe blinding of assessors, missing data, treatment adherence, and imbalance assignment to groups.Conclusion: Behavioural therapies were diverse in nature and many treatments demonstrated broad cross-system outcome benefits across swallow, respiratory, and cough functions. Given the progressive nature of the condition, the focus of future trials should be evaluating follow-up therapy effects and larger patient populations, including those with more severe disease.

Cross-System Integration of Respiration and Deglutition: Function, Treatment, and Future Directions

Swallowing occurs preferentially in the expiratory phase of the quiet breathing cycle and at mid-to-low tidal volume. This coordinative pattern imparts important biomechanical advantages to swallowing and airway protection and facilitate laryngeal elevation, laryngeal vestibular and vocal fold closure, and cricopharyngeal sphincter opening. This preferred coordinative relationship between breathing and swallowing is impaired in a variety of patient populations, including head and neck cancer survivors with dysphagia. We developed a training protocol to re-establish more optimal phasing of swallowing with breathing in these patients with striking outcomes, including reduced swallowing physiological impairments and improved airway protection. This motivated us to continue to refine and expand this training protocol and develop new assistive technologies for swallowing monitoring outside of the lab. In this review, we highlight the origins of our optimal respiratory-swallowing coordination hypothesis, describe the biomechanical advantages it provides, carefully describe our training protocol and findings, and chart a course for the next phase of this work. Our overall goal is to harness technology combined with carefully constructed learning paradigms to improve the lives of patients with impaired respiratory-swallowing coordination consequent to a variety of pathologies including head and neck cancer and degenerative neurological conditions such as Parkinson's disease.

Determining Swallowing Biomechanics Underlying Modified Barium Swallow Impairment Profile Scoring Using Computational Analysis of Swallowing Mechanics

PURPOSE

The elements of impaired swallowing biomechanics are visually assessed and scored by clinicians using a standardized and validated tool for assessing type and severity of physiological impairments using the Modified Barium Swallow Impairment Profile (MBSImP). However, the functional anatomical correlates that underly noted impairments using MBSImP scoring have not been measured. The purpose of this study was to determine whether differences in MBSImP component scores represent differences in underlying swallowing mechanics as measured by computational analysis of swallowing mechanics (CASM) to better define underlying mechanisms of impairment.

METHOD

A retrospective analysis of modified barium swallow studies from physician-referred adult patients with dysphagia was scored using the MBSImP for laryngeal elevation, anterior hyoid excursion, epiglottic movement, pharyngoesophageal segment opening, and tongue base retraction. A canonical variate analysis (CVA) was performed to determine the movement of anatomical landmarks associated with MBSImP component scores using the CASM method. Mahalanobis distances (D) were then used to detect differences among MBSImP scores for each component assessed.

RESULTS

CVA showed significant differences (p < .0001) in Mahalanobis distance (D > 1) between MBSImP component scores of 0-1, 0-2, 0-3, or 0-4, as applicable, depending on the component. Discriminant function analyses revealed concomitant increase/worsening in MBSImP score with changes in anatomical positioning of structures.

CONCLUSIONS

Ratings of swallowing impairment and physiology using the MBSImP have distinct biomechanical correlates with anatomical movements of swallowing. These data further demonstrate how swallowing mechanics are highly interrelated. Understanding these linkages between anatomical and physiological movement within impaired swallowing biomechanics is essential in more specific characterization and treatment of dysphagia.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.20816788.

Impact of Dysphagia Rehabilitation in Adults on Swallowing Physiology Measured With Videofluoroscopy: A Mapping Review

PURPOSE

The research aims of this review were to (a) map swallowing rehabilitation approaches to specific swallowing impairments using the Modified Barium Swallow Impairment Profile (MBSImP) to develop evidence maps, (b) match desired rehabilitation treatment targets to treatment approaches, and (c) identify gaps in the literature and highlight which rehabilitation approaches require further investigation to support accurate mapping of interventions to physiologic change.

METHOD

A mapping review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses-Scoping Review extension framework. The databases searched were CINAHL, Ovid Medline, and Ovid Embase. Data extracted included swallowing rehabilitation approach details via the Rehabilitation Treatment Specification System framework, study characteristics, and resulting change in swallowing physiology. The resulting change in swallowing physiology was mapped onto MBSImP components, where applicable, and effect sizes were reported where data were available. Extracted data were summarized in the form of evidence maps.

RESULTS

Forty-three unique articles met the inclusion criteria for this review and were divided into single-approach and multi-approach exercise studies. Within single-approach studies, 13 different exercise approaches were investigated, and 117 outcome measures could be mapped to MBSImP components. Within multi-approach studies, 13 different combinations of exercise approaches were investigated and 60 outcome measures could be mapped to MBSImP components.

CONCLUSIONS

This review supports speech-language pathologists in incorporating current best evidence into their practice, as it found there is potential for improvement in many MBSImP components by using rehabilitative exercises. In the future, more intervention studies are needed to ensure that recommended rehabilitation approaches are beneficial for improving the targeted swallowing physiology.

Pilot Study of Respiratory-Swallow Coordination in Amyotrophic Lateral Sclerosis

PURPOSE

Amyotrophic lateral sclerosis (ALS) impacts bulbar and respiratory musculature, which may contribute to impaired swallow function (dysphagia) and respiratory-swallow coordination. The purpose of this pilot study was to examine if respiratory-swallow coordination in individuals with ALS was perturbed compared to healthy controls. We further explored relationships between measures of respiratory function and self-reported swallowing outcomes on respiratory-swallow coordination.

METHOD

We employed a cross-sectional design with eight participants with ALS and eight age- and sex-matched healthy participants. Respiratory inductance plethysmography and a nasal cannula were used to capture respiratory-swallow phase patterns during a standardized clinical swallow examination. The advantageous respiratory-swallow phase pattern was defined if exhalation surrounded the swallow (E-E). Spirometry was used to capture indices of respiratory function (forced vital capacity % predicted, peak cough flow [PCF]). Validated questionnaires were used to collect information regarding ALS-related bulbar functional status and swallowing-related concerns.

RESULTS

Compared to the matched healthy cohort, individuals with ALS demonstrated higher rates of non-E-E respiratory-swallow phase patterning and worse bulbar/swallow dysfunction. Group (ALS), swallow tasks, and PCF were significantly associated with respiratory-swallow phase pattern.

CONCLUSIONS

These preliminary findings support altered respiratory-swallow phase patterning in ALS. Future work should employ an instrumental assessment to quantify swallowing physiology and elucidate the relationship between perturbed respiratory-swallow coordination and swallowing function.

Characterization of dysphagia following anterior cervical spine surgery

BACKGROUND

Post-operative dysphagia is one of the most common complications of anterior cervical spine surgery (ACSS).

OBJECTIVE

Examine post-operative structural and physiologic swallowing changes in patients with dysphagia following ACSS as compared with healthy age and gender matched controls.

METHODS

Videofluoroscopic swallow studies of adults with dysphagia after ACSS were retrospectively reviewed. Seventy-five patients were divided into early (≤2 months) and late (> 2 months) post-surgical groups. Modified Barium Swallow Impairment Profile (MBSImP), Penetration-Aspiration Scale (PAS) scores, and pharyngeal wall thickness (PWT) metrics were compared.

RESULTS

Significant differences were identified for all parameters between the control and early post-operative group. MBSImP Pharyngeal Total (PT) scores were greater in the early group (Interquartile Range (IQR) = 9-14, median = 12) versus controls (4-7, 5, P < 0.001) and late group (0.75-7.25, 2, P < 0.001). The early group had significantly higher maximum PAS scores (IQR = 3-8, median = 7) than both the control group (1-2, 1, P < 0.001) and late post-operative group (1-1.25, 1, P < 0.001). PWT was significantly greater in the early (IQR = 11.12-17.33 mm, median = 14.32 mm) and late groups (5.31-13.01, 9.15 mm) than controls (3.81-5.41, 4.68 mm, P < 0.001).

CONCLUSION

Dysphagic complaints can persist more than two months following ACSS, but often do not correlate with validated physiologic swallowing dysfunction on VFSS. Future studies should focus on applications of newer technology to elucidate relevant deficits.

Tongue strength and swallowing dynamics in chronic obstructive pulmonary disease

Background

Swallowing disorders occur in COPD, but little is known about tongue strength and mastication. This is the first assessment in COPD of tongue strength and a test of mastication and swallowing solids (TOMASS).

Methods

Anterior tongue strength measures were obtained in 18 people with COPD, aged 73±11 years (mean±sd), and 19 healthy age-matched controls, aged 72±6 years. Swallowing dynamics were assessed using an eating assessment tool (EAT-10), timed water swallow test (TWST), and TOMASS. Swallowing measures were compared to an inhibitory reflex (IR) in the inspiratory muscles to airway occlusion (recorded previously in the same participants).

Results

Tongue strength was similar between COPD and controls (p=0.715). Self-assessed scores of dysphagia EAT-10 were higher (p=0.024) and swallowing times were prolonged for liquids (p=0.022) and solids (p=0.003) in the COPD group. During TWST, ∼30% of COPD group showed clinical signs of airway invasion (cough and wet voice), but none in the control group. For solids, the COPD group had ∼40% greater number of chews (p=0.004), and twofold-higher number of swallows (p=0.0496). Respiratory rate was 50% higher in COPD group than controls (p <0.001). The presence of an IR was not related to better swallowing outcomes, but signs of airway invasion were associated with a delayed IR.

Conclusion

Dysphagia in stable COPD is not due to impaired anterior tongue strength, but rather swallowing–breathing discoordination. To address dysphagia, aspiration and acute exacerbations in COPD, therapeutic targets to improve swallowing dynamics could be investigated further.

In this novel study of swallowing in COPD, there was no difference in tongue strength when compared to healthy controls, and in COPD participants with airway invasion, the inhibitory reflex to airway occlusion in inspiratory muscles was delayedhttps://bit.ly/3h4EeKw

Respiratory-swallow coordination in a rat model of chemoradiation

BACKGROUND

Chemoradiation treatment (CRT) for head and neck cancer (HNC) is associated with postswallow inhale events that elevate the risk of penetration/aspiration. The purpose of this study was to assess the validity of a rat model for investigating the effect of CRT on respiratory-swallow coordination.

METHODS

Videofluoroscopic swallow study was performed on 10 Sprague-Dawley rats 3 months post-CRT (3 mg/kg Cisplatin, 10 fractions of 4.5 Gy/day radiotherapy to tongue base), and 10 naïve controls. We examined the effect of CRT on swallow apnea duration, diaphragm movement, and bolus kinematics.

RESULTS

CRT rats had a significant increase in postswallow inhale (p = 0.008), which was associated with significantly longer swallow apnea durations, lower diaphragm displacement at swallow onset, and faster pharyngoesophageal bolus speed.

CONCLUSION

The rat CRT model is valid for the study of respiratory-swallow coordination due to the consistency of findings in this study with those reported in clinical CRT studies in HNC.

Classification of Stroke Patients With Dysphagia Into Subgroups Based on Patterns of Submental Muscle Strength and Skill Impairment

OBJECTIVES

To identify and characterize subgroups of stroke patients with clinical signs of dysphagia, based on swallowing-related strength and skill impairments of the submental muscle group.

DESIGN

Prospective observational study.

SETTING

Inpatient rehabilitation centers and community dwellings.

PARTICIPANTS

Individuals (N=114), including stroke patients with dysphagia (n=55) and 2 control groups including myopathic patients with dysphagia (n=19) and healthy volunteers (n=40) were included in this study.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Novel clinical assessment of strength (force generation) and skill (spatial and temporal precision of muscle activation) of the submental muscle group during swallowing and nonswallowing behaviors, using surface electromyography and dynamometry.

RESULTS

Hierarchical cluster analysis revealed 4 clusters, which could be broadly characterized as cluster 1: intact strength and skill, cluster 2: poor strength and poor nonswallowing skill, cluster 3: poor strength, and cluster 4: poor strength and poor swallowing skill. Membership in cluster was significantly associated with medical diagnosis (P<.001). The majority of healthy and myopathic participants were assigned to clusters 1 and 3, respectively, whereas stroke patients were found in all 4 clusters. Skill outcome measures were more predictive of cluster assignment than strength measures.

CONCLUSIONS

Although healthy and myopathic participants demonstrated predominantly homogeneous swallowing patterns of submental muscle function within their etiology, several subgroups were identified within stroke, possibly reflecting different subtypes of swallowing function. Future research should focus on the nature and rehabilitation needs of these subtypes. Assessment of skill in swallowing may be an important but overlooked aspect of rehabilitation.

Automatic Estimation of Laryngeal Vestibule Closure Duration Using High- Resolution Cervical Auscultation Signals

Purpose

Safe swallowing requires adequate protection of the airway to prevent swallowed materials from entering the trachea or lungs (i.e., aspiration). Laryngeal vestibule closure (LVC) is the first line of defense against swallowed materials entering the airway. Absent LVC or mistimed/ shortened closure duration can lead to aspiration, adverse medical consequences, and even death. LVC mechanisms can be judged commonly through the videofluoroscopic swallowing study; however, this type of instrumentation exposes patients to radiation and is not available or acceptable to all patients. There is growing interest in noninvasive methods to assess/monitor swallow physiology. In this study, we hypothesized that our noninvasive sensor- based system, which has been shown to accurately track hyoid displacement and upper esophageal sphincter opening duration during swallowing, could predict laryngeal vestibule status, including the onset of LVC and the onset of laryngeal vestibule reopening, in real time and estimate the closure duration with a comparable degree of accuracy as trained human raters.

Method

The sensor-based system used in this study is high-resolution cervical auscultation (HRCA). Advanced machine learning techniques enable HRCA signal analysis through feature extraction and complex algorithms. A deep learning model was developed with a data set of 588 swallows from 120 patients with suspected dysphagia and further tested on 45 swallows from 16 healthy participants.

Results

The new technique achieved an overall mean accuracy of 74.90% and 75.48% for the two data sets, respectively, in distinguishing LVC status. Closure duration ratios between automated and gold-standard human judgment of LVC duration were 1.13 for the patient data set and 0.93 for the healthy participant data set.

Conclusions

This study found that HRCA signal analysis using advanced machine learning techniques can effectively predict laryngeal vestibule status (closure or opening) and further estimate LVC duration. HRCA is potentially a noninvasive tool to estimate LVC duration for diagnostic and biofeedback purposes without X-ray imaging.

Isolated and Combined Respiratory Training for Muscle Tension Dysphonia: Preliminary Findings

PURPOSE

The purpose of this study was to determine the feasibility of altering speech breathing patterns and dysphonia severity through training increased levels of lung volume use during speech. It was hypothesized that respiratory-based training would increase lung volume levels during speech as well as improve acoustic voice measures, and that the addition of laryngeal-based treatment would further improve voice acoustics by treatment completion.

METHOD

A multiple baseline, single subject design was replicated over six participants with primary muscle tension dysphonia as a preliminary investigation of novel respiratory treatment methods. Following four baseline probes (1-4), two phases of treatment were implemented over 6 weeks. Respiratory lung volume-based training (RLVT) and subsequent performance was probed at sessions 5 to 7 and laryngeal-based training was added to the RLVT and probed at sessions 8 to 10. Visual biofeedback was used during RLVT to assist the motor learning process. Respiratory outcome measures of lung volume initiation, termination and excursion were objectively measured using respiratory plethysmography (InductoTrace), and cepstral and spectral-based acoustic measures were also determined at each time point.

RESULTS

All participants showed improvement in one or more respiratory measures as well as reduced acoustic dysphonia severity following phase 1 of RLVT alone. Two participants achieved further marked improvement in acoustic voice measures after laryngeal-based training was added in phase 2 of treatment, but this was generally also accompanied by further improvement or stabilization of respiratory measures.

CONCLUSION

Results from this preliminary study support the feasibility of RLVT for improving speech breathing behavior, and suggest that RLVT alone can improve objectively measured dysphonia severity.

Correlation of Temporal Parameters of Laryngeal Excursion by Using Force-Sensing Resistor Sensors with Hyoid Motion in Videofluoroscopic Swallowing Study

Small flexible force-sensing resistor (FSR) sensors can detect laryngeal excursion during swallowing, but the detected laryngeal excursion has not been correlated with videofluoroscopic swallowing study (VFSS) results. Here, we tested the correlation of temporal parameters between the laryngeal excursion recording by FSR sensor and the hyoid motion recording by VFSS under simultaneously swallowing test recordings. Swallowing measurements were recorded in a radiological suite by simultaneously using VFSS and FSR sensors to detect hyoid motion and laryngeal excursion, respectively. Volunteers sat with their head vertical to the Frankfort plane. Two FSR sensors, each for detecting thyroid cartilage excursion and thumb pressing, were placed. VFSS images and FSR sensor signals during single 5-mL barium liquid (30% wt/volume %) bolus swallowing were collected and analyzed for four swallows per participant. In total, 15 men (28.0 ± 4.1 years old); 14 women (28.4 ± 4.2 years old) were recruited. Temporal parameters between VFSS and noninvasive system demonstrated a strong correlation by Pearson's correlation analysis: in men (R = 0.953-0.999) and in women (R = 0.813-0.982), except for VT1-V1 compared with FT1-F1, which demonstrated a moderate correlation in women (R = 0.648; all p < 0.001). Only VT1-V1 and FT1-F1 in women displayed a significant difference (p = 0.001). Therefore, this is the first study to simultaneous record VFSS and noninvasive signals by FSR sensor. The correlation of temporal parameters between these two tests was strong. This finding is valuable for future applications of this noninvasive swallowing study tool.

The experiences of people who receive swallow therapy after surgical treatment of head and neck cancer

OBJECTIVE

This research was initiated to explore the experiences and important elements of swallow therapy in patients after surgery for treatment of head and neck cancer (HNC).

STUDY DESIGN

One-to-one, face-to-face interviews were conducted with patients with HNC 7 to 14 days after oral reconstructive surgery (free, pedicled, or bony flap). Analysis was conducted by using interpretive phenomenology.

RESULTS

Analysis of interviews from 15 patients identified 2 overarching themes: "I never dreamt" and "They look at you, and they speak to you." There was no way for patients to be adequately prepared for the enormity of the surgery and its consequences; however, the way health care professionals interacted and communicated with the person, rather than the altered and disfigured self, was healing and therapeutic.

CONCLUSIONS

There is a need for novel ways to prepare patients for HNC surgery and to support them in recovery, including ways to connect and help patients feel human again.