Swallowing Safety after Remote sub-total Esophagectomy: How Important is Tongue Pressure?

The factors related to oropharyngeal dysphagia after remote esophagectomy (greater than five months) remain unclear. This study aimed to assess patient perception of dysphagia, maximum anterior isometric pressure (MAIP), maximum posterior isometric pressure (MPIP), lingual swallowing pressure (LSP) and radiographic physiological components of the oral and pharyngeal phases of swallowing in patients who are post remote sub-total esophagectomy (SE). Patient perception of dysphagia was assessed using the Eating Assessment Tool (EAT-10). MAIP, MPIP, and LSP were measured using the Iowa Oral Performance Instrument. Videofluoroscopy was used to assess the physiologic components of swallowing with the Modified Barium Swallow Impairment Profile (MBSImP) and the Penetration-Aspiration Scale (PAS). Ten patients were included in the study (53.2% male; mean age 54.5 ± 18.0). The mean postoperative time was 30 months (range, 5.0-72 months). Seven patients had elevated EAT-10 scores (> 3). All patients demonstrated impaired oropharyngeal swallowing on at least three MBSImP components (range 3-12) and two patients aspirated (PAS 8). There was a significant difference in MAIP values when comparing patients with normal versus impaired laryngeal elevation and epiglottic movement (p < 0.001). MPIP values were significantly different in patients with normal versus impaired epiglottic movement as well as normal versus elevated PAS scores (p < 0.001). Decreased lingual pressure and physiological changes in swallowing coexist after SE. Our results indicate that the decrease in tongue strength may be one of the factors related to unsafe swallow. The assessment of lingual pressure provides diagnostic value and should be incorporated as part of a comprehensive assessment in this population.

Association of Tongue Strength and Maximum Incisal Opening with Oral Intake in Persons with Head and Neck Cancer Treated with Radiotherapy: A Retrospective Study

Persons treated with radiotherapy (RT) for cancer of the head and neck (HNC) may experience limited oral intake at treatment completion. The purpose of this retrospective study was to examine the contributions of tongue strength and maximum incisal opening (MIO) to oral intake in a cohort of veterans treated for HNC. Medical records of veterans diagnosed with HNC treated with RT who were seen by the Speech Pathology Service prior to and throughout treatment per usual care were reviewed for this study; eighty-two records met the inclusion criteria for analysis. Tongue strength in kPa, MIO in mm, feeding tube status at completion of RT, and food and liquid consistencies consumed at completion of RT were among the data abstracted from the records. Most veterans (67%) did not have a feeding tube present at the completion of RT and reported drinking thin liquids (84.2%) at treatment completion. Eighteen percent reported including all food consistencies in their diet at the end of treatment. Both MIO and tongue strength decreased after treatment. Greater tongue strength during RT and larger MIO at the completion of RT were predictive of improved functional outcomes for oral intake at the end of treatment. This study provides evidence of the importance of increasing tongue strength and MIO during treatment with RT, and supports an important focus for intervention by speech-language pathologists.

Telemedicine-enabled biofeedback electropalatography rehabilitation (TEBER): A pilot study for patients treated with surgery for oral cavity carcinoma

BACKGROUND

To address the rehabilitative barriers to frequency and precision of care, we conducted a pilot study of a biofeedback electropalatography (EPG) device paired with telemedicine for patients who underwent primary surgery +/- adjuvant radiation for oral cavity carcinoma. We hypothesized that lingual optimization followed by telemedicine-enabled biofeedback electropalatography rehabilitation (TEBER) would further improve speech and swallowing outcomes after "standard-of-care" SOC rehabilitation.

METHOD

Pilot prospective 8-week (TEBER) program following 8 weeks of (SOC) rehabilitation.

RESULTS

Twenty-seven patients were included and 11 completed the protocol. When examining the benefit of TEBER independent of standard of care, "range-of-liquids" improved by +0.36 [95% CI, 0.02-0.70, p = 0.05] and "range-of-solids" improved by +0.73 [95% CI, 0.12-1.34, p = 0.03]. There was a positive trend toward better oral cavity obliteration; residual volume decreased by -1.2 [95% CI, -2.45 to 0.053, p = 0.06], and "nutritional-mode" increased by +0.55 [95% CI, -0.15 to 1.24, p = 0.08].

CONCLUSION

This pilot suggests that TEBER bolsters oral rehabilitation after 8 weeks of SOC lingual range of motion.

Predictors of Swallowing-Related Quality of Life in United States Veterans with Dysphagia

While both dysphagia and poor health-related quality of life frequently occur in United States (US) Veterans, swallowing-related quality of life in this population has not been systematically examined. This retrospective clinical observation study aimed to determine the independent predictors of swallowing-related quality of life for a sample of US Veterans. We examined the following variables in a multivariate analysis to determine the predictors of Swallowing Quality of Life Questionnaire scores: demographic information, Modified Barium Swallow Impairment Profile (MBSImP) scores, Penetration-Aspiration Scale scores, anterior lingual pressures, and Functional Oral Intake Scale scores. MBSImP oral phase score was the only variable that reached statistical significance (p ≤ 0.01), demonstrating that a more severe physiologic impairment in the oral phase of swallowing was independently predictive of worse swallowing-related quality of life. These findings highlight the need for clinicians to consider how impairments in swallowing physiology may impact the quality of life more broadly for patients with dysphagia.

Efficacy of High-Intensity Training in Patients with Moderate to Severe Dysphagia after Glossectomy

Dysphagia is the main impairment arising from glossectomy for tongue cancer treatment. The study aimed to determine if an eight-week training protocol paired with accuracy tasks and swallowing exercises is effective and can improve tongue strength and swallowing in patients after tongue resection. Maximum isometric pressures, tongue endurance, swallowing pressures, mealtime duration, and oropharyngeal swallow function were studied in patients with moderate to severe dysphagia after glossectomy. Twenty-five (25) patients and thirty-one (31) healthy participants were enrolled in the study. The therapy group (TG) consisted of seventeen (17) patients who followed an 8-week treatment protocol and had multiple measurements. The follow-up control group (FUG) consisted of eight non-treated patients who had a baseline and an 8-week follow-up examination. Healthy participants served as the reference group (RF). Maximum isometric pressures, endurance, and swallowing pressures increased significantly in the TG versus the FUG. Significant improvement was documented in the TG regarding the EAT-10 questionnaire, the Penetration-Aspiration Scale scores at thickened and solid boluses, and post-swallow residues at thickened and solid boluses. The treatment protocol with tongue strength exercises combined with accuracy tasks and swallowing exercises improves the post-operative swallowing function in patients after glossectomy. Patients in the TG had more significant and quicker improvement in pressures and endurance compared to FUG.

Optimizing Function and Appearance After Head and Neck Reconstruction: Measurement and Intervention

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.

Glossectomy for the treatment of oral cavity carcinoma: Quantitative, functional and patient-reported quality of life outcomes differ by four glossectomy defects

OBJECTIVE

The goal was to characterize four clinically distinct glossectomy defects to establish significant quantitative cut points using functional metrics, the MD Anderson Dysphagia Index (MDADI) and speech intelligibility.

METHODS

Population included 101 patients treated with surgery, adjuvant radiation per NCCN guidelines, and ≥ 12 months follow-up.

RESULTS

Defect groups: subtotal hemiglossectomy (1), hemiglossectomy (2), extended hemiglossectomy (3) and oral glossectomy (4) were compared: All outcomes supported a four defect model. Intergroup comparison of outcomes with subtotal hemiglossectomy as reference (p value): Tongue Protrusion <0.001,<0.001,<0.001; Elevation <0.001,<0.001,<0.001; Open Mouth Premaxillary Contact Elevation <0.001,<0.001,<0.001; Obliteration 0.6,<0.001,<0.001; Normalcy of Diet, <0.3,<0.001,<0.001; Nutritional Mode, <0.9,<0.8,<0.001; Range of Liquids, <0.4,<0.016,<0.02; Range of Solids, <0.5,<0.004,<0.001; Eating in Public, <0.2,<0.002,<0.03; Understandability of Speech, <0.9,<0.001,<0.001; Speaking in Public, <0.4,<0.03,<0.001; MDADI, <0.4,<0.005,<0.01; Single Word Intelligibility, <0.4,<0.1,<0.001; Sentence Intelligibility, <0.5,<0.08,<0.001; Words Per Minute Intelligibility, <0.6,<0.04,<0.001; Sentence Efficiency Ratio, <0.4,<0.03,<0.002. Proportion of patients by 4 defect groups who underwent: tissue transplantation, 51%,93.9%,100%,100%.Radiation,24%,67%,88%,80%.Between hemiglossectomy and extended hemiglossectomy, the defect extends into the contralateral floor of the mouth and/or the anterior tonsillar pillar; resection of these subunits limits tongue mobility with an impact on functional outcome and MDADI. Between extended hemiglossectomy and oral glossectomy, the defect extends to include the tip of the tongue and appears to impact functional outcome and MDADI.

CONCLUSIONS

Subtotal hemiglossectomy, hemiglossectomy, extended glossectomy and oral glossectomy are associated with quantitative (elevation, protrusion, open mouth premaxillary contact and obliteration), qualitative (speech and swallowing) and MDADI differences, suggesting that these 4 ordinal defect groups are distinct.

Recovery pattern analysis of swallowing function in patients undergoing total glossectomy and hemiglossectomy

OBJECTIVES

To investigate the recovery process of swallowing function and ascertain swallowing pattern in patients undergoing total glossectomy (TG).

MATERIALS AND METHODS

A cohort study was conducted in consecutive patients with tongue squamous cell carcinoma who received TG/hemiglossectomy (HG) from May 2017 to December 2019. Exposure factors included tongue resection range (HG and TG) and postoperative radiotherapy (PRT and non-PRT). The swallowing functions were evaluated by M.D. Anderson dysphagia inventory (MDADI), water swallow test (WST), and tongue pressure (TP) at pretreatment, 1, 4, 7, 12, 18 and 24 months postoperatively. Videofluoroscopy swallowing study (VFSS) was applied to analyze swallowing pattern of TG patients.

RESULTS

A total of 67 patients were enrolled, of which 17 underwent TG and 50 underwent HG. Both MDADI and TP of the TG and PRT group were lower than those of the HG and non-PRT group. TG patients had no evident improvement in MDADI and TP after surgery. There was a higher risk of swallowing unsafety with abnormal WST outcome in TG (P < 0.001, OR = 106.52) than that in HG. VFSS analysis identified prolonged oral and pharyngeal transit time, disorganized swallowing sequence, abnormal hyoid bone movement, and frequent invalid swallows in patients with TG. A shortened OTT (<5066.50 ms) and a larger pharyngeal constriction ratio (PCR > 0.31) were associated with increased risks of penetration and aspiration.

CONCLUSION

Postoperative swallowing pattern is a characteristic of severely impaired safety and efficacy in patients with TG. Impaired OTT and PCR are variables that should be examined when determining the need for rehabilitation treatment.

Dynamic Hemitongue Defect Reconstruction With Functional Gracilis Muscle Free Transfer

BACKGROUND

Because the tongue consists of 26 intrinsic and extrinsic muscles, even hemiglossectomy, which preserves some of the tongue and its muscles, leads to functional morbidity in speech and swallowing. Subsequent reconstruction using a conventional fasciocutaneous flap results in limited functional recovery. This study compared the functional recovery of patients who underwent hemiglossectomy based on the fasciocutaneous free flap with or without dynamic gracilis muscle flap reconstruction.

METHODS

Twenty-three patients were included in the study. Reconstruction was achieved using radial forearm and gracilis conjoined flaps (n = 7), gracilis flaps (n = 7), and radial forearm flaps (RFFFs) (n = 9) between 2014 and 2019. Functional outcome data were collected via videofluoroscopic swallowing, speech analysis, and a tongue movement scale.

RESULTS

In the conjoined flap group, the lingual range of motion in terms of elevation and defect-side lateralization was superior to that of the RFFF group. Furthermore, the conjoined flap was associated with superior protrusion, elevation, and lateralization (on both sides) than the gracilis-only flap. Patients who underwent conjoined-flap reconstruction had better articulation, intelligence, and dysphagia outcomes than patients who underwent reconstruction with RFFFs or gracilis-only flaps.

CONCLUSIONS

Although this was a preliminary study, the findings suggest that using a conjoined free flap with an RFFF and a functional gracilis muscle flap for dynamic hemitongue reconstructions could improve postoperative tongue function.

Examining the Relationships Between Lingual Strength, Perihyoid Strength, and Swallowing Kinematics in Dysphagic Adults: A Retrospective Cross-Sectional Analysis

Purpose The aim of this study was to examine the relationships of clinical measures of lingual and perihyoid strength with displacement swallowing kinematics and swallowing safety in a heterogenous group of dysphagic adults. Method A retrospective analysis was completed of videofluoroscopic swallow studies of consecutive dysphagic outpatient adults presenting to a tertiary swallowing center from January 1, 2015, to December 31, 2017. Videofluoroscopic swallow study records were included if containing displacement swallowing kinematics of a 20-ml single liquid swallow and clinical measures of anterior (L-MIPA) or posterior (L-MIPP) lingual maximal isometric press, saliva mean swallowing pressures (S-MSP), and/or open mouth-maximal isometric press (OM-MIP). Regression analyses were used to examine the relationships between clinical measures of lingual (L-MIPA, L-MIPP, S-MSP) and perihyoid (OM-MIP) strength and displacement swallowing kinematics, and binomial logistic regressions were used to examine the relationships between clinical measures of lingual and perihyoid strength and swallowing safety (Penetration-Aspiration Scale [PAS]). Results Multivariate regressions revealed significant relationships of L-MIPA, L-MIPP, S-MSP, and OM-MIP with group-level changes to the displacement swallowing kinematics. Univariate analyses revealed significant relationships of L-MIPA and L-MIPP with pharyngeal constriction ratio, maximal extent of upper esophageal segment opening, and PAS. Conclusions Weak relationships were identified of clinical measures of lingual and perihyoid strength with displacement swallowing kinematics. These findings suggest that clinical measures of lingual and perihyoid strength do not fully explain impairments in swallowing kinematics across a heterogenous group of dysphagic patients. Weak-to-moderate relationships were identified between clinical measures of lingual strength and PAS, suggesting that they may have value in predicting functional measures of swallowing safety. Further research is needed to examine how findings may differ between specific patient populations.

Predicting Swallowing Outcomes from Objective Videofluoroscopic Timing and Displacement Measures in Head and Neck Cancer Patients

Radiation therapy with or without chemotherapy compromises swallowing efficiency and safety in patients with head and neck cancer (HNC). The resulting dysphagia leads to overall morbidity, with altered diets, reduced nutritional intake, reduced quality of life, and potential interruption of curative cancer treatment. Despite well-documented radiation-related changes in swallowing physiology, scarce research exists on the potential clinical value for measurements of swallowing timing and displacement in this population. This study investigated the discriminatory value of quantitative timing and displacement parameters for the Functional Oral Intake Scale and Penetration Aspiration Scale scores using pre- and post-radiation videofluoroscopy data. Swallowtail Software Version 1 (Belldev Medical, Arlington Heights, IL) was used to obtain objective timing and displacement measurements from the pre- and post-radiation videofluoroscopy data for 31 patients who underwent radiation therapy, with or without chemotherapy, for head and neck cancer. The total pharyngeal transit time (BP2) (p < 0.000, r = 0.43) in pudding bolus trials and the maximal upper esophageal sphincter opening (PESMax/cm) (p = 0.001, r = 0.31) in thin bolus trials were discriminatory for Functional Oral Intake Scale (FOIS). Findings suggest that measurement of post-radiation changes using objective and quantitative parameters may offer some discriminatory value regarding future dysphagia risk and prognosis based on total pharyngeal transit time and degree of UES opening. In addition, the results suggest that different bolus types may offer different discriminatory values in HNC population, and that some timing and displacement variables may have discriminatory value for patients' diet levels independent from any aspiration risk.

Effects of jaw exercise intervention timing on outcomes following oral and oropharyngeal cancer surgery: Pilot study

BACKGROUND

Common in head and neck cancer patients, trismus can make speech and swallowing difficult and can compromise quality of life (QOL). Jaw range of motion exercise therapy may prevent or treat trismus in surgical patients. While the importance of these exercises is well-documented, there is little literature regarding the optimal timing of exercise initiation.

METHODS

A prospective pilot study investigated the effects of early vs late jaw exercise intervention on postoperative jaw opening and QOL measures, which were examined descriptively.

RESULTS

Timing of exercise intervention was not found to significantly impact the measured outcomes. However, provisional, descriptive findings showed that jaw opening was significantly associated with multiple QOL measures, with greater jaw opening associated with improved QOL. For certain QOL measures, this positive association was stronger at earlier time points than at later time points.

CONCLUSIONS

The exploratory findings of this pilot study support further research into possible benefits of early jaw exercise intervention.

Framework for Speech-Language Pathology Services in Patients with Oral Cavity and Oropharyngeal Cancers

This article provides a framework speech-language pathology services to optimize functional outcomes of patients with oral cavity and oropharyngeal cancers. Key principles include (1) a proactive rehabilitation model that minimizes intervals of disuse or inactivity of speech and swallowing systems, (2) standardized evaluation paradigms that combine objective instrumental assessments with patient-reported outcome measures, and (3) systematic methods for surveillance and intensive rehabilitation for late dysphagia.

Open Mouth-Maximal Isometric Press: Development and Norms for Clinical Swallowing Evaluations and Treatment

Purpose The aims of this study were to (a) describe the development and utility of the Open Mouth-Maximal Isometric Press (OM-MIP), a tool designed for the quantitative assessment of suprahyoid-infrahyoid muscle strength; (b) examine the effects of age and sex on the OM-MIP; and (c) establish age- and sex-based OM-MIP norms. Method Two hundred sixteen healthy male and female volunteers were recruited. Participants performed the OM-MIP, and the maximum of 3 trials that were within 10% of each other was recorded. Rest between each trial was allowed to avoid fatigue. Multiple regression examined the influence of age and sex on the OM-MIP. Descriptive statistics outlined normative OM-MIP values for young adult (aged 18-39 years), middle-aged adult (aged 40-59 years), old adult (aged 60-79 years), and very old adult (aged ≥ 80 years) men and women. Two-way analysis of variance determined if normative data differed significantly between the age and sex groups. Results Age and sex significantly influenced the OM-MIP, although no significant interaction effect was identified. Women had lower mean OM-MIPs when compared with men ( p < .0005), and very old adults had lower mean OM-MIPs when compared with young ( p = .001), middle-aged ( p < .0005), and old ( p = .013) adults. Conclusions This study establishes age- and sex-based OM-MIP norms and outlines its potential utility during clinical swallowing evaluations and treatment. By providing these norms, clinicians can begin to quantitatively measure suprahyoid and infrahyoid strength, individualize resistance training programs to patients' OM-MIP 1 repetition maximum, and track strength changes over time in response to therapeutic interventions.

Guidelines for the Surgical Management of Oral Cancer: Korean Society of Thyroid-Head and Neck Surgery

Korean Society of Thyroid-Head and Neck Surgery appointed a Task Force to provide guidance on the implementation of a surgical treatment of oral cancer. MEDLINE databases were searched for articles on subjects related to “surgical management of oral cancer” published in English. Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies. The quality of evidence was rated with use RoBANS (Risk of Bias Assessment Tool for Nonrandomized Studies) and AMSTAR (A Measurement Tool to Assess the Methodological Quality of Systematic Reviews). Evidence-based recommendations for practice were ranked according to the American College of Physicians grading system. Additional directives are provided as expert opinions and Delphi questionnaire when insufficient evidence existed. The Committee developed 68 evidence-based recommendations in 34 categories intended to assist clinicians and patients and counselors, and health policy-makers. Proper surgical treatment selection for oral cancer, which is directed by patient- and subsite-specific factors, remains the greatest predictor of successful treatment outcomes. These guidelines are intended for use in conjunction with the individual patient’s treatment goals.

Objective and subjective hyposalivation after treatment for head and neck cancer: Long-term outcomes

OBJECTIVES/HYPOTHESIS

This study examined saliva weight over time and its association with diet and patient-rated swallowing, dry mouth, sticky saliva, and dysgeusia quality of life in head and neck cancer (HNCA) patients treated with surgery plus adjuvant chemoradiotherapy (CRT), or primary CRT.

STUDY DESIGN

Prospective cohort study in an outpatient HNCA center setting.

METHODS

Patients were seen pretreatment, and 1, 3, 6, 12, 24, and 36 + months post-treatment. All had newly diagnosed oral, oropharynx, nasopharynx, larynx/hypopharynx cancer from 2010 to 2016 and were to undergo surgery + CRT or primary CRT. Stimulated saliva weight was assessed with the Saxon test. Diet, eating, dry mouth, and dysgeusia quality of life were assessed and correlated with saliva weight, treatment modality, and tumor site.

RESULTS

Saliva weight decreased the most within the first 3 months across treatment groups, except for the surgery + CRT group, which continued to decline. Similar trends were seen by tumor site. Performance Status Scale (PSS) Normalcy of Diet and all quality-of-life scores declined following treatment. The European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Head and Neck-35 (EORTC QLQ-H&N35); Eating Assessment Tool (EAT-10); M. D. Anderson Dysphagia Inventory (MDADI) Composite, Global, and subdomain scores; and PSS Diet were significantly correlated with saliva weight.

CONCLUSIONS

Saliva weight worsened post-treatment across groups and tumor site, with improvement by 36 + months. Saliva weight correlated with diet, eating quality of life and perception of dysgeusia across time points. Despite dose-sparing intensity-modulated radiation therapy, newer technologies are needed to preserve saliva production and maintain higher quality of life.

LEVEL OF EVIDENCE

2b Laryngoscope, 128:2732-2739, 2018.

[Systematic retrospective study of oral cancer-related quality of life scale]

OBJECTIVE

The quality of life (QOL) related to oral cancer has recently become a focus of clinical studies. This study aims to systematically review the current research situation of QOL of local and foreign oral cancer patients and explore the existing related problems and future research directions to provide references and solutions.

METHODS

Through relevant key words, PubMed, Wiley InterScience, Science Direct, CNKI, and Wanfang databases were first searched. The related target literature from 2000 to 2017 were screened. Finally, the frequency of oral cancer related to QOL scale used in literature was calculated, and the related scales were briefly introduced.

RESULTS

From the target literature, 218 English target literature, 55 Chinese target literature, 24 English scales, and 12 Chinese scales were selected. The most widely used scales for assessing the QOL of patients with oral cancer were as follows: University of Washington Quality of Life Questionnaire (UW-QOL), European Organization for the Research and Treatment of Cancer Quality of Life Questionnaire Core 30/Head and Neck 35 (EORTC QLQ-C30/H&N35), 36-Item Short-Form Health Survey (SF-36), Functional Assessment of Cancer Therapy-Head and Neck (FACT-H&N), and Oral Health Impact Profile (OHIP).

CONCLUSIONS

The QOL related to oral cancer was well underway, and the study of geographical distribution was widespread. However, the work on self-developed scale remains inadequate. UW-QOL, EORTC QLQ-C30/H&N35, and FACT-H&N can be utilized as the preferred scales for evaluating the QOL of oral cancer patients. A specific disease-related function scale can also be selected according to specific research objectives.

Tongue movement during articulation in magnetic resonance imaging: Findings in 20 healthy volunteers and a patient with anterior floor of the mouth squamous cell carcinoma

PURPOSE

Combined ablative and reconstructive oral maxillofacial surgery involves a multitude of anatomical and functional structures for speech and swallowing. Although there are a few methods to objectively examine swallowing function, this is not true for speech. We describe the development of an objective visualization and measurement tool for magnetic resonance imaging (MRI) to evaluate speech and its first application in a patient.

MATERIAL AND METHODS

A total of 20 healthy patients and one patient with squamous cell carcinoma localized in the anterior floor of the mouth were included in the study. Examination included an MRI examination of a paced, defined set of fictive words representing all sounds of the German language. The patient underwent MRI preoperatively and 1, 3, 6 and 12 months postoperatively. MRI findings were correlated with speech intelligibility.

RESULTS

In sagittal planes, the correct identification of vowels and consonants was feasible and showed a high accordance between two independent observers and repetitions. Measurements for the patient showed significant deviations 1 month postoperatively but gradually decreased over time. Aberrant values were persistent for sound /s/. Findings correlated with clinical findings of speech intelligibility.

CONCLUSION

The presented tool seems to be promising for evaluating articulation in (tumor) patients.

Neurogenic Orofacial Weakness and Speech in Adults With Dysarthria

PURPOSE

This study compared orofacial strength between adults with dysarthria and neurologically normal (NN) matched controls. In addition, orofacial muscle weakness was examined for potential relationships to speech impairments in adults with dysarthria.

METHOD

Matched groups of 55 adults with dysarthria and 55 NN adults generated maximum pressure (Pmax) against an air-filled bulb during lingual elevation, protrusion and lateralization, and buccodental and labial compressions. These orofacial strength measures were compared with speech intelligibility, perceptual ratings of speech, articulation rate, and fast syllable-repetition rate.

RESULTS

The dysarthria group demonstrated significantly lower orofacial strength than the NN group on all tasks. Lingual strength correlated moderately and buccal strength correlated weakly with most ratings of speech deficits. Speech intelligibility was not sensitive to dysarthria severity. Individuals with severely reduced anterior lingual elevation Pmax (< 18 kPa) had normal to profoundly impaired sentence intelligibility (99%-6%) and moderately to severely impaired speech (26%-94% articulatory imprecision; 33%-94% overall severity).

CONCLUSIONS

Results support the presence of orofacial muscle weakness in adults with dysarthrias of varying etiologies but reinforce tenuous links between orofacial strength and speech production disorders. By examining individual data, preliminary evidence emerges to suggest that speech, but not necessarily intelligibility, is likely to be impaired when lingual weakness is severe.

Correlation between swallowing-related quality of life and videofluoroscopy after head and neck cancer treatment

Introduction

The use of symptom-specific questionnaires on head and neck cancer (HNC), together with objective swallowing measures, can be sensitive to changes in quality of life (QoL) resulting from dysphagia, but this tool is not broadly used as a complement to clinical evaluations.

Purpose

To analyze the correlation between the M. D. Anderson Dysphagia Inventory (MDADI) questionnaire and videofluoroscopy (VF) in patients treated for head and neck cancer.

Methods

This is a retrospective study with review of clinical data, VF and MDADI results. The study sample was composed of adult patients (>18 y.o.) treated for tumors at the oral cavity, oropharynx, hypopharynx, and larynx, regardless of treatment type. For the VF examination, swallowing of 5 and 20 ml of nectar-thick liquids were considered. The Mann-Whitney nonparametric test was applied to evaluate the correlations between the MDADI and VF.

Results

Thirty-nine patients, mostly men (87.18%), with mean age of 61 years participated in the study. Most patients (16) presented oral cavity tumors (41.03%). Twenty-two patients were in advanced clinical stage (IV). Surgery was the most prevalent treatment (41.03%). Approximately half of the participants (20) received oral feeding. The total mean (TM) on the MDADI was 63.36. Comparison between VF and MDADI data showed significant correlation between TM, emotional domain (ED), and physical domain (PD) with penetration during the swallowing of 5 ml. Penetration and aspiration with 20 ml determined worse QoL on the global (p=0.018 and p=0.0053), emotional (p=0.0012 and p=0.027) and physical (p=0.0002 and p=0.0051) domains, and TM (p=0.0023 and p=0.0299), respectively. The presence of stasis did not determine worse QoL.

Conclusion

Patients treated for HNC who presented penetration/aspiration showed worse QoL on the emotional and physical domains of the MDADI.

Phonologic and Acoustic Analysis of Speech Following Glossectomy and the Effect of Rehabilitation on Speech Outcomes

PURPOSE

Changes in acoustic features in the perioperative phase for elucidating the mechanisms of articulation disorder and the effect of perioperative rehabilitation were studied prospectively.

MATERIALS AND METHODS

Sixty-two patients with 62 tongue cancer were divided into a partial glossectomy group (n = 40) and a reconstruction group (n = 22). Acoustic characteristics were analyzed during the preoperative and postoperative periods and after rehabilitation using the first and second formants of the vowels /a/, /i/, and /u/; the triangular vowel space area (tVSA); and the slopes of formant transitions.

RESULTS

In the 2 groups, decreases in the tVSA and formant slopes were found from the preoperative to the postoperative period, and the acoustic characteristics of the reconstruction group especially improved to preoperative values after rehabilitation. Analysis of the postoperative period showed that acoustic characteristics were altered at the site of surgical resection.

CONCLUSION

Changes of acoustic variables are related to excision size and site, suggesting the distinctive tongue portion for the articulation of each speech sound. Perioperative rehabilitation could activate the articulators and increase the range of movement of the remaining tongue, especially the preserved anterior tongue.

Decreasing loco-regional recurrence for oral cavity cancer with total Mohs margins technique

Background

The conventional technique for cancer resection margin analysis studies only 0.1% of the surgical margins. Complete frozen section margins - also known as Mohs margins – allows for analysis of 100% of the surgical margins.

Methods

The objective of our study is to compare oral cavity cancer loco-regional recurrence rates when treated by total frozen sections technique (Total Mohs margins) versus conventional margins. We conducted a multicenter retrospective cohort chart review. Loco-regional oral cancer recurrence rates were compared between patients treated with total Mohs margins (2007–2013) and patients treated with conventional margins techniques (2002–2007).

Results

After applying inclusion criteria, a total of 60 patients treated by total Mohs margins and 57 patients with conventional margins were identified. Patients had similar baseline cancer stages, pathological types, past head and neck cancers and comorbidities (all p > 0.05). One-year recurrence rate was lower (10.0% vs 21.1%, p = 0.019) in favor of Mohs total margins and stayed significantly lower at 5 years of follow-up. When adjusted for T grade with N0 disease, Mohs technique was still beneficial in loco-regional recurrence for Tis-T4N0 up to 2 years (10.5% vs 25.7%, z-score 1.849, p = 0.032). The Number Needed to Treat at 2 years of follow-up for this subgroup of patients (Tis-T4N0) is 6.6. Margins had to be retaken more often intra-operatively in Mohs technique (68.3% vs 12.3%, p < 0.0001), mainly for positive deep margins (48.6% of all margins, p = 0.028). Duration of surgery was not increased with Mohs vs conventional technique (380 min vs 475 min respectively, p = 0.025).

Conclusions

Mohs total margins may result in a significant reduction in cancer recurrence rate at 5 years compare to conventional surgery. Moreover, duration of surgery was not increased when using Mohs technique when judiciously performed.

Electronic supplementary material

The online version of this article (doi:10.1186/s40463-016-0176-9) contains supplementary material, which is available to authorized users.

Bedside diagnosis of dysphagia: a systematic review

Dysphagia is associated with aspiration, pneumonia, and malnutrition, but remains challenging to identify at the bedside. A variety of exam protocols and maneuvers are commonly used, but the efficacy of these maneuvers is highly variable. We conducted a comprehensive search of 7 databases, including MEDLINE, Embase, and Scopus, from each database's earliest inception through June 9, 2014. Studies reporting diagnostic performance of a bedside examination maneuver compared to a reference gold standard (videofluoroscopic swallow study or flexible endoscopic evaluation of swallowing with sensory testing) were included for analysis. From each study, data were abstracted based on the type of diagnostic method and reference standard study population and inclusion/exclusion characteristics, design, and prediction of aspiration. The search strategy identified 38 articles meeting inclusion criteria. Overall, most bedside examinations lacked sufficient sensitivity to be used for screening purposes across all patient populations examined. Individual studies found dysphonia assessments, abnormal pharyngeal sensation assessments, dual axis accelerometry, and 1 description of water swallow testing to be sensitive tools, but none were reported as consistently sensitive. A preponderance of identified studies was in poststroke adults, limiting the generalizability of results. No bedside screening protocol has been shown to provide adequate predictive value for presence of aspiration. Several individual exam maneuvers demonstrated reasonable sensitivity, but reproducibility and consistency of these protocols was not established. More research is needed to design an optimal protocol for dysphagia detection.

Anatomic-histologic study of the floor of the mouth: the lingual lymph nodes

OBJECTIVE

The lingual lymph nodes are inconstant nodes located within the fascial/intermuscular spaces of the floor of the mouth. Oral tongue squamous cell carcinoma has been reported to recur and metastasize in lingual lymph nodes with poor prognosis. Lingual lymph nodes are not currently included in basic tongue squamous cell carcinoma surgery.

METHODS

Twenty-one cadavers (7 males, 14 females) were studied, aged from 57 to 94 years (mean age 76.3 years). The gross specimen of the floor of the mouth was divided into blocks: A (median nodes), B, B' (parahyoid), C, C' (paraglandular). Serial histological microslides were cut and stained with hematoxylin-eosin. Frequency of lingual lymph nodes in each block and their microscopic features were assessed.

RESULTS

The lingual lymph nodes in overall number of 7 were detected in 5 of the 21 cadavers (23.8%). The total incidence of lingual lymph node was 33.3% (7 nodes/21 cadavers). Block A failed to demonstrate any lymph nodes (0%); Blocks B, B'-2 nodes (9.5%) and 2 nodes (9.5%), respectively; Blocks C, C'-1 node (4.8%) and 2 nodes (9.5%), respectively. The mean lingual lymph node length was 4.1 mm (from 1.4 to 8.7 mm), the mean thickness was 2.8 mm (from 0.8 to 7.5 mm). Five cadavers (23.8%) revealed mucosa-associated lymphoid tissue. Atrophic changes appeared in 4 (57.1%) lingual lymph nodes.

CONCLUSION

The presence of lymph node-bearing tissue in the floor of the mouth is demonstrated. In account of resection radicalism and better local control the fat tissue of the floor of the mouth should be removed in conjunction to glossectomy. Further anatomic and clinical research is required to establish the role of lingual lymph node in oral squamous cell carcinoma recurrence and metastasis.