A documentation system to save time and ensure proper application of the fiberoptic endoscopic evaluation of swallowing (FEES®)

[Pre-treatment dysphagia in head-and-neck cancer patients]

BACKGROUND

The swallowing and nutritional status of head-and-neck cancer patients after oncological therapy have been extensively researched. However, the same topics are seldom scrutinized before the onset of oncological therapy, although they can influence treatment success in the long term.

OBJECTIVE

This study focusses on a systematic assessment of swallowing function and nutritional status in head-and-neck cancer patients prior to oncological therapy.

MATERIALS AND METHODS

In 102 patients, penetration/aspiration (PA scale), limitations of oral intake (Functional Oral Intake Scale, FOIS), and the need for further intervention (NFI) were endoscopically assessed to objectively quantify swallowing function. The subjective evaluation of swallowing function was carried out with the gEAT-10 (German EAT-10) questionnaire, nutritional status was assessed by body mass index (BMI). Possible impact factors for swallowing function and BMI were analyzed by univariate and multivariate methods.

RESULTS

PAS, FOIS, and NFI values were abnormal in ≤ 15% of patients. BMI was more often too high than too low. Objectively assessed swallowing functions depended predominantly on tumor stage and showed moderate correlations with gEAT-10. The latter mostly yielded a "fail" result. The nutritional status depended on the patients' biological sex and NFI.

CONCLUSION

In the pre-treatment setting, neither dysphagia nor malnutrition were found in most patients. Impaired swallowing was associated with higher tumor stages, malnutrition with female sex and NFI. A systematic pre-treatment assessment of swallowing and nutritional status in head-and-neck cancer patients appears necessary for modern oncological therapy and optimal patient outcome.

[Nutritional Risk Screening in head-and-neck cancer patients prior to oncological therapy]

OBJECTIVE

Head-and-neck cancer patients run a high risk of peri- or post-treatment malnutrition that can severely affect the therapy outcome. However, little is known about malnutrition under the pre-treatment condition. Therefore, this study aimed to provide a systematic description of the pre-treatment nutritional status and risk of malnutrition in this population.

MATERIAL AND METHODS

Before the onset of the oncological therapy, nutritional status of 102 head-and-neck cancer patients was assessed by body mass index (BMI), their risk of malnutrition by "Nutritional Risk Screening" (NRS). Tumour stage and site, patients' age and sex as well as oropharyngeal dysphagia were analysed as possible influence factors. The latter was quantified by the Flexible Endoscopic Evaluation of Swallowing (FEES).

RESULTS

According to BMI, malnutrition (undernutrition) was found in 6% of patients, a risk of malnutrition (NRS) in 27% of patients, and oropharyngeal dysphagia in 15%. In a linear regression, only oropharyngeal dysphagia was identified as a significant influence factor for the risk of malnutrition (β = 0.380/3.776; p < .001).

CONCLUSIONS

Pre-treatment risk of malnutrition was found in a quarter of head-and-neck cancer patients. For the early identification of this risk and for the introduction of measures that would help to avoid it, a pre-treatment examination of swallowing functions and a systematic malnutrition screening by means of NRS are recommended.

[Post-operative prevalence of dysphagia in head-and-neck cancer patients in the acute care units]

OBJECTIVE

 Dysphagia constitutes a frequent post-operative functional impairment in head-and-neck cancer patients. This impairment can result in aspiration/penetration and limitations of oral intake. Therefore, often it requires a therapeutic intervention. In this study, prevalence of post-operative dysphagia and its associations with the tumour stage, localisation, patients' age, and biological sex were analysed for the inpatient treatment setting.

MATERIAL AND METHODS

 A total of 201 adult head-and-neck cancer patients (mean age 63 years) were analysed prospectively by FEES in two university hospitals in regard to their penetration/aspiration, limitations of oral intake, and need for therapeutic interventions directly after the operative tumour treatment. Additionally, the influence of the same patients' characteristics on these three parameters were analysed by means of univariate and multivariate statistical methods.

RESULTS

 Out of 201 patients, 66.7 % needed a therapeutic intervention because of their dysphagia, 57.2 % needed a nasogastral or PEG tube due to limitations of oral intake, 45.3 % had an aspiration. In the latter subgroup, 38.5 % had a silent aspiration. Higher tumour stage, patients' higher age and male sex were shown to be significant influence factors for dysphagia, tumour localisation showed only a marginally significant result.

CONCLUSIONS

 The study demonstrated a clinical importance and relevance of the consequent and systematic treatment of post-operative dysphagia in head-and-neck cancer patients in the acute care units as a constituent of a modern oncological therapy.

[The German Sydney Swallow Questionnaire : Reliability and validity in patients with oropharyngeal dysphagia]

BACKGROUND

The Sydney Swallow Questionnaire (SSQ) is a self-report inventory assessing subjective symptoms of oropharyngeal dysphagia with strong content, construct, discriminant, and predictive validity and test-retest reliability in a range of patient populations.

OBJECTIVE

The main aim of this work was to assess the validity and reliability of the German version of the SSQ (SSQ-G).

MATERIALS AND METHODS

In a cross-validation study, 48 adult German-speaking patients (12 women, 36 men) with neurogenic (n = 16), structural (n = 16), and functional (n = 16) oropharyngeal dysphagia were assessed with the SSQ‑G and the MD Anderson Dysphagia Inventory (MDADI). Cronbach's α was applied to assess the reliability. Criteria and construct validity were investigated using the Spearman correlation coefficient.

RESULTS

With Cronbach's α = 0.94, the internal consistency of the SSQ‑G was excellent. The SSQ‑G questions 1 and 17 showed a moderately significant and highly significant correlation coefficient of -0.43 and -0.45, respectively, with MDADI question 1 (p < 0.5, p < 0.001). Between questions 8, 11, and 12 of the SSQ‑G and questions 7, 13, and 10 of the MDADI, coefficients of -0.48 to -0.55 showed a moderate to strong highly significant correlation (p < 0.001). Thus, the reliability and criterion and construct validity were statistically confirmed.

CONCLUSION

The German version of the SSQ (SSQ-G) allows a reliable and valid assessment of functional swallowing difficulties. In combination with questionnaires on symptom-specific quality of life, such as the MDADI, a more differentiated clinical analysis of swallowing problems is thus possible.

Mansoura Fiberoptic Endoscopic Evaluation of Swallowing Residue Rating Scale (MFRRS): An Anatomically Based Tool - A Preliminary Study

OBJECTIVE

The aim of this work was to design an anatomically based scale for judging post-swallow residue in the pharyngeal cavities, for use during the fiberoptic endoscopic evaluation of swallowing (FEES) in patients with dysphagia, and to assess its feasibility.

METHODS

Two 7-point ordinal scales (one for vallecular residue and one for pyriform sinus residue), were developed using detailed anatomic landmarks to denote residue levels. Hard copy color images of a specified frame, from 210 videos of 30 adult FEES evaluations demonstrating the range of all possible residue patterns, were selected (n = 56 valleculae, 62 pyriform sinuses). Half of these images were used to train 4 raters. The remaining half of the images were randomly ordered and rated by the trained raters. Two weeks later the same images were randomized again, and each rater re-analyzed them. The inter- and intra-rater reliability and criterion validity were determined using the kappa statistics and their standard errors. The internal consistency of the items in MFRRS was examined.

RESULTS

MFRRS showed strong inter-rater reliability (valleculae, κ = 0.832 ± 0.038; pyriform sinus, κ = 0.855 ± 0.034), almost perfect intra-rater reliability (valleculae, κ = 0.964 ± 0.018; pyriform sinus, κ = 0.962 ± 0.02), almost perfect concurrent validity (valleculae, κ = 0.968 ± 0.020; pyriform sinus, κ = 0.0971 ± 0.017), and excellent internal consistency (valleculae, Cronbach's α = 0.990; pyriform sinus, Cronbach's α = 0.985).

CONCLUSION

MFRRS is a feasible and reliable, anatomically based tool that can provide more accurate pharyngeal residue judgments. The optimized description of residue accumulation patterns can contribute to a better overall description of the functional problem and future description of dysphagia phenotypes.

The Value of Oro-Pharyngo-Esophageal Scintigraphy in the Management of Patients with Aspiration into the Tracheo-bronchial Tree and Consequent Dysphagia

Context:

Tracheo-bronchial aspiration is the most invalidating condition which can happen to patients affected by dysphagia, especially when caused by central neurologic disorders; the associated pneumonia episodes represent the most frequent cause of death in these patients. Oro-pharyngo-esophageal scintigraphy (OPES) allows both functional imaging and semiquantitative evaluation of the subsequent phases of swallowing.

Case Report:

We evaluated by means of OPES a woman who had previously undergone high-dose external beam radiation therapy for a nasopharyngeal carcinoma, which determined tissue fibrosis and progressive dysphagia.

Conclusion:

In this patient with dysphagia, OPES was a simple, inexpensive, noninvasive, and reliable technique that allowed to show the presence of bolus aspiration and quantified tracheobronchial aspirate.

[Secretion scale by Murray et al. for FEES®: comparison of reliability and validity of the German long and short version]

BACKGROUND

Accumulation of secretions in the hypopharynx, aditus laryngis and trachea constitute a cardinal trait of oropharyngeal dysphagia. For the evaluation of the degree of severity a 4-point secretion scale by Murray et al. is used internationally in a long and a short version. However, a validated German translation of the long version of this scale does not yet exist. Also, it has not yet been scientifically proven that both versions of the scale are equally valid.

OBJECTIVES

This study aimed at the validation of the German translation of the long version of the secretion scale by Murray et al. and at a comparison of reliability and validity of the short and long versions.

MATERIAL AND METHODS

A total of 40 videos of fiberoptic endoscopic evaluation of swallowing (FEES(®)), 10 for each severity level, were rated by 4 otorhinolaryngologists (ENT specialists) independently and with different randomizations for examination of the reliability and validity. Two rating sessions for each of the scale versions were conducted. Intrarater and interrater reliability as well as the agreement of the ratings with a reference standard were analyzed.

RESULTS

Both the intrarater reliability (Spearman correlations: ρs > 0.840***) and the interrater reliability (Krippendorff's alpha: α > 0.850) yielded very good results and the concurrent validity was highly significant (ρs > 0.981***).

DISCUSSION

The German translation of the secretion scale by Murray et al. can be considered reliable and valid, with comparable test accuracy of the short and long versions. Hence, the scale can be recommend for the graduation of pharyngolaryngotracheal secretions and should be integrated into the standardized evaluation of FEES(®) diagnostics for clinical and scientific purposes.

The value of oropharyngoesophageal scintigraphy in the management of aspiration into the tracheobronchial tree in neurological patients

AIM

Dysphagia and bolus aspiration are two of the most frequent and invalidating symptoms of various neurological diseases. Swallowing disorders often lead to tracheobronchial aspiration with consequent pneumonia episodes. Aspiration pneumonia per se constitutes the most frequent cause of death in these patients, with mortality rate ranging from 20% to 62%. Oropharyngoesophageal scintigraphy (OPES) permits functional quantitative assessment of the different stages of swallowing, together with the detection and quantitative measurement of bolus aspiration. In this work, we analyzed the role of OPES in patients with different neurological conditions to evaluate swallowing and to detect and quantify bolus aspiration.

MATERIAL AND METHODS

We enrolled 43 neurological patients (25 women and 18 men, mean age 67.3±12.4 yr) complaining of dysphagia with suspected inhalation. All patients underwent OPES with (99m)Tc-nanocolloid using a liquid bolus first, followed by a semi-solid bolus. We evaluated the following parameters: Oral, Pharyngeal and Esophageal Transit Time, Oro-Pharyngeal Retention Index, Esophageal Emptying Rate, and Aspiration Rate (% AR).

RESULTS

OPES detected some airway aspiration in 26/43 patients. 19 patients had tracheal aspiration (with a mean 18.1% AR) and the remaining 7 patients had bilateral broncho-pulmonary aspiration (mean 44.9% AR).

CONCLUSIONS

OPES is a feasible, repeatable and noninvasive method that allows quantitative assessment of bolus aspiration into the tracheobronchial tract, thus representing a useful and accurate tool to guide the most appropriate treatment and to monitor response to therapy in neurological patients with dysphagia.

[Swallowing examination for ENT specialists]

Dysphagias, together with the diseases resulting therefrom, severely reduce patients' quality of life and substantially increase the costs of public health, making efficient therapy a prime concern. Among pathophysiologically oriented diagnostic procedures, the endoscopic examination of swallowing has emerged within the past 20 years as an indispensable standard examination with high sensitivity and specificity. Thus, every ears, nose, and throat (ENT) physician and phoniatric specialist should be familiar with this procedure, in order to ensure widest possible access to it, not only in hospitals but also in outpatient settings and in healthcare establishments. In this article, the preconditions, execution, and evaluation of the endoscopic examination are described and its relevance for immediate or long-term therapeutic treatment is discussed.

Development, reliability, and validation of an infant mammalian penetration-aspiration scale

A penetration-aspiration scale exists for assessing airway protection in adult videofluoroscopy and fiberoptic endoscopic swallowing studies; however, no such scale exists for animal models. The aim of this study was threefold: (1) develop a penetration-aspiration scale (PAS) for infant mammals, (2) test the scale's intra- and interrater reliabilities, and (3) validate the use of the scale for distinguishing between abnormal and normal animals. After discussion and reviewing many videos, the result was a 7-point infant mammal PAS. Reliability was tested by having five judges score 90 swallows recorded with videofluoroscopy across two time points. In these videos, the frame rate was either 30 or 60 frames per second and the animals were either normal, had a unilateral superior laryngeal nerve (SLN) lesion, or had hard palate local anesthesia. The scale was validated by having one judge score videos of both normal and SLN lesioned pigs and testing the difference using a t test. Raters had a high intrarater reliability [average κ = 0.82, intraclass correlation coefficient (ICC) = 0.92] and high interrater reliability (average κ = 0.68, ICC = 0.66). There was a significant difference in reliability for videos captured at 30 and 60 frames per second for scores of 3 and 7 (P < 0.001). The scale was also validated for distinguishing between normal and abnormal pigs (P < 0.001). Given the increasing number of animal studies using videofluoroscopy to study dysphagia, this scale provides a valid and reliable measure of airway protection during swallowing in infant pigs that will give these animal models increased translational significance.