Videoendoscopic evaluation of patients with dysphagia: an adjunct to the modified barium swallow

Identification of Respiratory Pauses during Swallowing by Unconstrained Measuring Using Millimeter Wave Radar

Breathing temporarily pauses during swallowing, and the occurrence of inspiration before and after these pauses may increase the likelihood of aspiration, a serious health problem in older adults. Therefore, the automatic detection of these pauses without constraints is important. We propose methods for measuring respiratory movements during swallowing using millimeter wave radar to detect these pauses. The experiment involved 20 healthy adult participants. The results showed a correlation of 0.71 with the measurement data obtained from a band-type sensor used as a reference, demonstrating the potential to measure chest movements associated with respiration using a non-contact method. Additionally, temporary respiratory pauses caused by swallowing were confirmed by the measured data. Furthermore, using machine learning, the presence of respiring alone was detected with an accuracy of 88.5%, which is higher than that reported in previous studies. Respiring and temporary respiratory pauses caused by swallowing were also detected, with a macro-averaged F1 score of 66.4%. Although there is room for improvement in temporary pause detection, this study demonstrates the potential for measuring respiratory movements during swallowing using millimeter wave radar and a machine learning method.

Usefulness of a newly developed endoscope for the observation of the posterior tracheal wall

Objective

Videoendoscopic evaluation of swallowing is an objective swallowing function evaluation method used in dysphagia rehabilitation. However, it is anatomically difficult to detect the entry of foreign substances through the posterior tracheal wall using a conventional endoscope (CE). In this study, we developed an endoscope that can observe the posterior tracheal wall and investigated its reliability and validity in healthy adults.

Methods

Twenty healthy adults were included. The trachea was observed from inside the larynx using a CE and a portable, flexible two-step angulation endoscope (two-AE) with a two-step curved shaft tip. The visibility of the anterior and posterior walls was recorded. The time from the endoscope tip entering the larynx to the posterior tracheal wall was measured. Additionally, discomfort events were assessed after the examination. McNemar's test and a paired t-test were used for statistical analysis. Kappa coefficients and concordance rates were calculated.

Results

The anterior tracheal wall was observed using both endoscopes. The posterior tracheal wall was significantly observed in 18 participants with the two-AE (p < .001), compared to only three of 20 participants with the CE. The time to observation of the posterior tracheal wall for examiners 1 and 2 was 13.3 ± 6.5 and 12.0 ± 6.7 s, respectively, with no difference between groups (p = .400). The kappa coefficients of examiners 1 and 2 and between the examiners were 0.444, 0.643, and 0.643, respectively, with concordance rates of 90%, 95%, and 95%, respectively.

Conclusion

Regardless of the examiner's years of experience, we observed that the two-AE could observe the posterior tracheal wall.

Level of Evidence

Step 5.

Phoniatricians and otorhinolaryngologists approaching oropharyngeal dysphagia: an update on FEES

PURPOSE

Oropharyngeal dysphagia (OD) is a common phenomenon in otorhinolaryngology and phoniatrics. As both sub-disciplines have a strong tradition and clinical experience in endoscopic assessment of the upper aerodigestive tract, the implementation of fiberoptic endoscopic evaluation of swallowing (FEES) was an almost self-evident evolution. This review aims to provide an update on FEES and the role of phoniatricians and otorhinolaryngologists using FEES in Europe.

METHODS

A narrative review of the literature was performed by experts in the field of FEES both in the clinical context and in the field of scientific research.

RESULTS

FEES is the first-choice OD assessment technique for both phoniatricians and otorhinolaryngologists. FEES is becoming increasingly popular because of its usefulness, safety, low costs, wide applicability, and feasibility in different clinical settings. FEES can be performed by health professionals of varying disciplines, once adequate knowledge and skills are acquired. FEES aims to determine OD nature and severity and can provide diagnostic information regarding the underlying etiology. The direct effect of therapeutic interventions can be evaluated using FEES, contributing to design the OD management plan. Standardization of FEES protocols and metrics is still lacking. Technological innovation regarding image resolution, frame rate frequency, endoscopic light source specifications, and endoscopic rotation range has contributed to an increased diagnostic accuracy.

CONCLUSION

The rising number of phoniatricians and otorhinolaryngologists performing FEES contributes to the early detection and treatment of OD in an aging European population. Nevertheless, a multidisciplinary approach together with other disciplines is crucial for the success of OD management.

Complications during Fiberoptic Endoscopic Evaluation of Swallowing (FEES) in 5680 examinations

OBJECTIVE

To evaluate retrospectively the incidence of complications during Fiberoptic Endoscopic Evaluation of Swallowing (FEES) in 5680 examinations.

PATIENTS AND METHODS

5680 patients were evaluated at the Department of Otorhinolaryngology, Audiology and Phoniatrics of Pisa University Hospital between January 2014 and December 2018, involving both inpatients and outpatients. Most common comorbidities included neurological pathologies such as stroke (11.8%), neurodegenerative diseases (28.9%) and a history of previous head and neck surgery (24.6%). The evaluation was conducted by clinicians with experience in swallowing for a minimum of 10 years with the assistance of one or more speech language pathologists.

RESULTS

In all patients studied the endoscope insertion was tolerated and it was possible to visualize the pharyngo-laryngeal structures. Most patients reported discomfort In a minority of patients, complications were recorded, such as anterior epistaxis, posterior epistaxis, vasovagal crises and laryngospasm. Laryngospasm was recorded in patients affected by Amyotrophic Lateral Sclerosis (ALS). Multivariate binary logistic regression showed that discomfort, chronic gastrointestinal diseases, neurodegenerative diseases and brain tumors were risk factors associated with minor complications.

CONCLUSIONS

FEES proved to be easy to perform, well tolerated by the patients and cost-effective. It can be performed at the patient's bedside and it is characterized by low rate of complications. As a matter of fact, normally only discomfort, gagging and/or vomit are reported. Only rarely complications occur, such as anterior or posterior epistaxis episodes or vasovagal crises, but these are still easily managed. Exceptionally, more severe complications are reported: adverse drug reactions to substances such as blue dye (methylene blue) and local anesthetics (not used in our protocol), and laryngospasm.

Treinamento para análise de parâmetros da videoendoscopia da deglutição: um protocolo de revisão de escopo

RESUMO Objetivo: apresentar um protocolo de revisão de escopo para identificar e mapear as evidências disponíveis sobre treinamento para a análise de parâmetros da videoendoscopia da deglutição. Métodos: o protocolo seguirá o método proposto pelo Joanna Briggs Institute e as diretrizes PRISMA-P para relato de protocolos de revisão. A busca será feita na MEDLINE, Cochrane Library, Embase, Web of Science, Scopus, CINAHL e literatura cinzenta. Uma estratégia de busca foi desenvolvida para a MEDLINE, que será adaptada para cada base de dados. Dois revisores independentes rastrearão os artigos pelo título e resumo. Em seguida, farão a leitura do texto completo dos artigos incluídos, considerando os critérios de elegibilidade. Os dados serão extraídos com um formulário padronizado. Os resultados serão apresentados em fluxograma e resumo narrativo, seguindo as diretrizes do PRISMA-ScR. Revisão da literatura: há escassez de pesquisas que descrevam métodos de treinamento perceptivo-visual para analisar parâmetros da VED e dados inconsistentes para orientar a tomada de decisão clínica. Esta revisão fornecerá informações abrangentes sobre o desenvolvimento de treinamento para esse tipo de análise. Conclusão: este protocolo de revisão de escopo apresentará o estado geral das pesquisas sobre o tema e identificará as lacunas existentes na base de evidências.

Training for fiberoptic endoscopic evaluation of swallowing parameter analysis: a scoping review protocol

ABSTRACT Purpose: to present a scoping review protocol to identify and map available evidence on training for fiberoptic endoscopic evaluation of swallowing parameter analysis. Methods: the protocol follows the method proposed by the Joanna Briggs Institute and the PRISMA-P guidelines for review protocol reports. The survey will be made in MEDLINE, Cochrane Library, Embase, Web of Science, Scopus, CINAHL, and grey literature. A search strategy has been developed for MEDLINE, which will be adapted for each database. Two independent reviewers will screen the articles by title and abstract. Then, they will read the full text of the included articles, considering the eligibility criteria. The data will be extracted with a standardized form. The results will be presented in a flowchart and narrative summary, following the PRISMA-ScR guidelines. Literature Review: there is a scarcity of research describing visual-perceptual training methods to analyze FEES parameters and inconsistent data to guide clinical decision-making. This review will provide comprehensive information on developing training for this type of analysis. Conclusion: this scoping review protocol will present the overall state of research on the topic and identify existing gaps in the base of evidence.

European white paper: oropharyngeal dysphagia in head and neck cancer

PURPOSE

To develop a European White Paper document on oropharyngeal dysphagia (OD) in head and neck cancer (HNC). There are wide variations in the management of OD associated with HNC across Europe.

METHODS

Experts in the management of specific aspects of OD in HNC across Europe were delegated by their professional medical and multidisciplinary societies to contribute to this document. Evidence is based on systematic reviews, consensus-based position statements, and expert opinion.

RESULTS

Twenty-four sections on HNC-specific OD topics.

CONCLUSION

This European White Paper summarizes current best practice on management of OD in HNC, providing recommendations to support patients and health professionals. The body of literature and its level of evidence on diagnostics and treatment for OD in HNC remain poor. This is in the context of an expected increase in the prevalence of OD due to HNC in the near future. Contributing factors to increased prevalence include aging of our European population (including HNC patients) and an increase in human papillomavirus (HPV) related cancer, despite the introduction of HPV vaccination in various countries. We recommend timely implementation of OD screening in HNC patients while emphasizing the need for robust scientific research on the treatment of OD in HNC. Meanwhile, its management remains a challenge for European professional associations and policymakers.

Impact of Fiberoptic Endoscopic Evaluation of Swallowing Outcomes and Dysphagia Management in Neurodegenerative Diseases

OBJECTIVES/HYPOTHESIS

To determine the incidence of abnormal fiberoptic endoscopic evaluation of swallowing (FEES) findings in patients with progressive neurologic disorders and identify the most commonly implemented dysphagia management strategies.

STUDY DESIGN

Retrospective Review.

METHODS

A retrospective review was performed of patients with neurodegenerative disease who underwent FEES at a tertiary-care center between 2008 and 2019. Patient demographics, diagnosis, and Eating Assessment Tool-10 (EAT-10) scores were recorded. Rates of penetration, aspiration, and functional change in management (FCIM) to include dietary modifications, home exercises, swallow therapy, surgical intervention (injection augmentation or esophageal dilation), or alternative means of nutrition (i.e., percutaneous enteral gastrostomy [PEG] tube) were calculated.

RESULTS

Two hundred nine FEES assessments were performed in 178 patients with a mean age of 64.8 years (standard deviation = ±14). The most common diagnoses were amyotrophic lateral sclerosis (32%) followed by Parkinson's disease or Parkinsonism (26%). FEES demonstrated penetration in 72.5% of patients and aspiration in 14.6%. Mean EAT-10 scores differed between patients with aspiration versus penetration versus normal FEES (24.7 vs. 14.9 vs. 13.9, respectively, P < .001). An FCIM was recommended in 88% of patients and most commonly included self-directed modifications (43%). Overall, 4.5% of patients underwent surgical intervention. A PEG tube was recommended for either supplemental or sole form of nutrition in 19% of the entire cohort.

CONCLUSIONS

Most patients with neurodegenerative diseases presenting with dysphagia demonstrated abnormal FEES findings necessitating an FCIM, suggesting early dysphagia evaluation may be warranted in this cohort. These findings correlate with worsened EAT-10 scores in patients with aspiration or penetration on FEES.

LEVEL OF EVIDENCE

4 Laryngoscope, 131:726-730, 2021.

Profiling of Oropharyngeal Dysphagia in an Acute Care Hospital Setting

PURPOSE

To identify the main complaints, diagnostic tools, as well as the treatment plan in patients presenting with oropharyngeal dysphagia in the acute care settings.

METHODS

The electronic medical chart of 100 consecutive hospitalized patients who presented an oropharyngeal dysphagia were retrospectively reviewed from January 2017 to January 2019.

RESULTS

The mean age of patients was 76.03 (standard deviation = 16.06) years old with 71% of patients being males. The most common admission diagnosis was pneumonia (30%), followed by stroke (28%). The swallowing evaluation was performed on the regular floor in 85% of patients and in the intensive care unit in 15% of patients. The main reasons for the swallowing evaluation are suspicion of aspiration by the medical or nursing teams (60%), systematic evaluation (20%), ear, nose and throat (ENT) complaints by the patient (14%), and aspiration pneumonia (6%). Fiberoptic endoscopic evaluation of swallowing with sensitivity testing was the most common diagnostic tool used alone in 88% of patients. Diet and postural modifications were prescribed to 71% and 62% of the patients, respectively. Swallowing exercises were performed in 43% of patients. Overall, otolaryngologist interventions resulted in an increased rate of patients getting oral intake compared to nonoral feeding routes (P = .05).

CONCLUSIONS

This study adds knowledge about the causes and characteristics of oropharyngeal dysphagia in an acute tertiary medical setting. It also provides insights regarding the role, and the consequences of a swallowing intervention led by an ENT specialist in collaboration with the members of the health team.

Management of postoperative dysphagia after prosthetic laryngoplasty or arytenoidectomy

OBJECTIVE

To evaluate the efficacy of various treatments for dysphagia after laryngeal surgery.

STUDY DESIGN

Retrospective.

ANIMALS

Horses treated for dysphagia after laryngeal surgery.

METHODS

Medical records of horses treated for dysphagia after prosthetic laryngoplasty (PLP) or partial arytenoidectomy (PA) were reviewed. Signalment, prior surgery, preoperative videoendoscopic diagnosis, and surgical treatments were recorded. Short- and long-term follow-up were obtained. Chi-square and logistical regression were performed to correlate independent variables and outcomes.

RESULTS

Forty-four percent of horses with prior PLP and 88% of horses with prior PA had persistent resting dorsal displacement of the soft palate (DDSP). Vocal fold augmentation (VFA) as a single treatment was most commonly performed (n = 22), followed by laryngoplasty removal (LPR; n = 1). Fifteen horses received a combination of treatments: VFA (n = 15), LPR (n = 4), laryngeal tie-forward (LTF; n = 2), and esophageal release (n = 1). Short-term clinical outcomes were reported; 80% of horses treated with VFA (n = 35) had resolution of dysphagia, and 20% were improved. Among the 33 horses available to long-term follow-up, 31 (94%) returned to some level of work, and DDSP during work was reportedly resolved in 23 of 25 horses.

CONCLUSION

Vocal fold augmentation resulted in resolution of symptoms relating to dysphagia in 81% of horses. Twenty percent of horses treated with LPR had sustained resolution of dysphagia. A combination of LPR, VFA, LTF was performed in 18% of horses.

CLINICAL SIGNIFICANCE

Treatment options directed at altering laryngeal geometry and/or position of the larynx were successful in resolving 86% of dysphagia in horses previously regarded as very difficult to treat.

Precision treatment of post pneumonectomy unilateral laryngeal paralysis due to cancer

Aim: The aim of this study is to assess the efficacy of external laryngeal medialization acquired through a Gore-Tex implant in a 45 patients affected by unilateral vocal fold paralysis in abduction after pneumonectomy. Method: The cohort of patients was made up of 30 male (73.1%) and 11 female patients (26.9%) with an average age of 66.7 years in a range between 46 and 78 years. Results: The results were analyzed with the objective and subjective analysis of voicing and swallowing. In 95.2% of cases, voice and swallow improvement with statistically significant evidences. Conclusion: We can conclude that Gore-Tex implantation is a simple, reproducible and minimally invasive procedure for management of selected cases of vocal fold unilateral paralysis in the abductory position.

In-Office Evaluation and Management of Dysphagia

Dysphagia is a common complaint encountered in otolaryngology clinics. Approaching the patient with dysphagia starts with a comprehensive symptomatic analysis and thorough physical examination. The recent rapid revolution in office-based procedures has a great impact in the evaluation and management of dysphagia. Currently, diagnostic and therapeutic procedures can be performed safely and effectively in the office setting with the advantage of avoidance of sedation or general anesthesia.

Inability to Belch and Associated Symptoms Due to Retrograde Cricopharyngeus Dysfunction: Diagnosis and Treatment

Objective

To propose and test the validity of a new syndrome called retrograde cricopharyngeus dysfunction (R-CPD) that explains inability to belch and the associated symptoms of loud gurgling noises, chest and abdominal pain/distention, and excessive flatulence, as well as to report the results of botulinum toxin (BT) injection into the cricopharyngeus muscle (CPM) for both diagnosis and treatment of R-CPD.

Study Design

To develop a case series of consecutive patients matched to the syndromic features of R-CPD, inject the CPM with BT as a concurrent diagnostic and therapeutic maneuver, and assess results.

Setting

Bastian Voice Institute (Downers Grove, Illinois).

Subjects and Methods

Consecutive (unselected) patients presenting with inability to belch and associated symptoms were matched to the proposed syndrome of R-CPD, treated with BT, and followed for effect on symptoms over time.

Results

All 51 patients achieved ability to belch and relief of associated symptoms, and the majority seem to have “retrained” the ability to belch on a potentially “permanent” basis.

Conclusion

R-CPD can be diagnosed syndromically, using a symptom complex; clinical diagnosis is validated by relief of symptoms after BT injection; and BT into the CPM is an efficacious treatment, whose benefit appears to often last longer than the pharmacologic duration of action of BT.

Desempenho longitudinal da deglutição orofaríngea na distrofia miotônica tipo 1

RESUMO Este estudo teve por objetivo descrever o desempenho longitudinal da deglutição orofaríngea em indivíduo com distrofia miotônica tipo 1. Estudo de caso único de indivíduo de 66 anos, sexo masculino, com diagnóstico neurológico em 2010. Realizou a primeira avaliação clínica e objetiva da deglutição após quatro anos do diagnóstico neurológico. Foram realizadas sete avaliações objetivas da deglutição, por meio de videoendoscopia de deglutição, nas consistências pastosa, líquida espessada e líquida, com 3, 5, 10 ml, durante o processo de diagnóstico e gerenciamento da deglutição, por um ano e dois meses. Foram analisados sensibilidade laríngea, escape oral posterior, resíduos faríngeos, por meio da Yale Pharyngeal Residue Severity Rating Scale, penetração laríngea e/ou aspiração laringotraqueal, com aplicação da Penetration-Aspiration Scale (PAS). Constatou-se, durante o período de estudo, que não houve alteração na sensibilidade laríngea. Escape oral posterior, resíduos faríngeos e penetração laríngea estiveram presentes desde o início das avaliações objetivas. Após quatro meses da primeira avaliação, na consistência pastosa, o nível de resíduos faríngeos passou de vestígio residual para moderado, em recessos piriformes, já em valéculas, e o aumento no índice da gravidade evidenciou-se no último mês. Houve aumento na PAS em todas as consistências de alimento testadas. A presença de aspiração laringotraqueal ocorreu com líquido ralo, no último mês. Durante o período de acompanhamento da deglutição orofaríngea na distrofia miotônica tipo 1, os resíduos faríngeos e a penetração laríngea estiveram presentes desde o início das avaliações, porém, a aspiração laringotraqueal somente ocorreu no último mês do acompanhamento, com líquido ralo.

Resíduos faríngeos nas disfagias orofaríngeas neurogênicas

RESUMO Objetivo Comparar os resíduos faríngeos por consistência de alimento entre indivíduos com disfagia orofaríngea neurogênica. Método Estudo clínico transversal. Realizada análise de 30 exames de videoendoscopia de deglutição de indivíduos com diagnóstico de doenças neurológicas e disfagia orofaríngea, independentemente do tempo ou estágio das doenças. Os indivíduos foram divididos em três grupos: o grupo I composto por 10 indivíduos pós-Acidente Vascular Cerebral, 8 homens e 2 mulheres, faixa etária entre 51 e 80 anos (média 67 anos); o grupo II por 10 indivíduos com Esclerose Lateral Amiotrófica, 5 homens e 5 mulheres, faixa etária entre 39 e 78 anos (média 57 anos), e o grupo III por 10 indivíduos com Doença de Parkinson (DP), 5 homens e 5 mulheres, faixa etária entre 65 e 88 anos (média 74 anos). Para análise dos resíduos faríngeos em valéculas e seios piriformes, foi aplicada a Yale Pharyngeal Residue Severity Rating Scale, considerando a primeira deglutição de 5 mL nas consistências pastosa e líquida espessada, por dois juízes independentes e de forma cega. Resultados Não houve diferença estatística significativa nos resíduos faríngeos, em valéculas (p= 0,25/ p= 0,18) e seios piriformes (p= 1,41/ 0,49), respectivamente nas consistências pastosa e líquida espessada, nas diferentes doenças estudadas. Conclusão Os níveis de resíduos faríngeos na consistência pastosa ou líquida espessada na população estudada foram semelhantes e mais frequentes nos níveis menos grave.

The endoscopic evaluation of the oral phase of swallowing (Oral-FEES, O-FEES): a pilot study of the clinical use of a new procedure

Oral FEES (O-FEES) is an endoscopic procedure conceived to directly visualise the oral phase of swallowing. In the perspective of clinical use, the feasibility, safety and acceptability of O-FEES has been evaluated. Subsequently, the procedure was compared with the radiological gold standard. The acceptability of O-FEES was compared to that of FEES using a 10 point questionnaire submitted to a sample of 52 outpatients complaining of swallowing disorders. Repeated measure analysis of variance (rm-ANOVA) models were used to test the mean difference of acceptability in the same subjects after FEES and O-FEES. Subsequently, another sample of 8 male outpatients underwent a simultaneous O-FEES and videofluoroscopic study (VFSS). The inter-rater reliability using 10 radiological landmarks, compared to O-FEES, was blindly determined between two raters. Inter-rater agreement between the two judges for O-FEES and VFSS scores was assessed with the single score intra-class correlation coefficient (ICC). Differences between FEES and O-FEES answers for each question and among all the items considered overall were statistically significant (rm-ANOVA; F-statistic p < 0.001). The inter-rater agreement concerning endoscopic and radiological evaluations between the two raters showed strong values of intra-class correlation coefficient (ICC) (95% confidence interval): 0.875 (0.373-0.979) and 0.921 (0.542-0.986), respectively. The Bland-Altman test showed a bias of -0.24 (95% limits of agreement; -1.77 to +1.19), which suggests that both methods produced almost identical results. In clinical practice and compared with FEES, O-FEES is a well tolerated and safe procedure. Compared with the radiological gold standard, O-FEES offers reliable information about oral preparation and oral propulsion of the bolus.

A Procedure for the Automatic Analysis of High-Resolution Manometry Data to Support the Clinical Diagnosis of Esophageal Motility Disorders

OBJECTIVE

Degenerative phenomena may affect esophageal motility as a relevant social-health problem. The diagnosis of such disorders is usually performed by the analysis of data from high-resolution manometry (HRM). Inter- and intraobserver variability frequently affects the diagnosis, with potential interpretative and thus therapeutic errors, with unnecessary or worse treatments. This may be avoided with automatic procedures that minimize human intervention in data processing.

METHODS

In order to support the traditional diagnostic process, an automatic procedure was defined considering a specific physiomechanical model that is able to objectively interpret data from HRM. A training set (N = 226) of healthy volunteers and pathological subjects was collected in order to define the model parameters distributions of the different groups of subjects, providing a preliminary database. A statistical algorithm was defined for an objective identification of the patient's healthy or pathological condition by comparing patient parameters with the database.

RESULTS

A collection of HRMs including subjects of the training set has been built. Statistical relationships between parameters and pathologies have been established leading to a preliminary database. An automatic diagnosis procedure has been developed to compare model parameters of a specific patient with the database. The procedure was able to match the correct diagnosis up to 86% of the analyzed subjects.

CONCLUSION

The success rate of the automatic procedure addresses the suitability of the developed algorithms to provide a valid support to the clinicians for the diagnostic activity.

SIGNIFICANCE

The objectivity of developed tools increases the reliability of data interpretation and, consequently, patient acceptance.

Perceived swallowing problems and mortality risk in very elderly people ≥85 years old: Results of the Tokyo Oldest Old Survey on Total Health study

OBJECTIVE

The aim of this study was to clarify whether perceived swallowing problems affect the life expectancy of very elderly individuals.

BACKGROUND

In an ageing society, oral function affects health status. In particular, a decline in swallowing function may increase the risk of various diseases, morbidity and malnutrition.

MATERIALS AND METHODS

We evaluated 526 elderly individuals aged ≥85 years. All participants completed a questionnaire and underwent oral, physical and mental health examinations. The comprehensive oral health assessment comprised a face-to-face interview that included a questionnaire on swallowing function. We estimated hazard ratios and 95% confidence intervals using the Cox proportional hazards model, adjusting for potential confounders between perceived swallowing problems and all-cause mortality over a 3-year period.

RESULTS

Over a 3-year follow-up period, 88 of 526 participants died and 68 participants complained of perceived swallowing problems. Perceived swallowing problems had statistically significant associations with physical status and function and nutrition. In the univariate analysis, perceived swallowing problems had statistically significant associations with an approximately 1.9-fold higher risk of all-cause mortality during the 3-year period (HR: 1.89, 95% CI: 1.14-3.14). In the multivariate analysis, the statistically significant association between perceived swallowing problems and all-cause mortality remained after adjusting for various confounding factors (HR: 1.73, 95% CI: 1.03-2.92).

CONCLUSION

Perceived swallowing disorders should be verified by a clinical examination, as they are associated with other health outcomes and increased all-cause mortality.

Evaluation of a dysphagia screening system based on the Mann Assessment of Swallowing Ability for use in dependent older adults

AIM

Dysphagia is common in dependent older adults. Thus, a method of evaluating eating and swallowing functions that can be used to diagnose and manage dysphagia in a simple and robust manner is required. In 2002, the Mann Assessment of Swallowing Ability (MASA) was introduced to identify dysphagia in acute-stage stroke patients. As the MASA enables easy screening, it might also be applicable to dependent older adults if appropriate MASA cut-off values and the most useful assessment items could be determined. In the present study, we attempted to determine suitable MASA cut-off values, and the most useful assessment items for predicting aspiration and pharyngeal retention in dependent older adults.

METHODS

Using the MASA, we evaluated the eating and swallowing functions of 50 dependent older adults with dysphagia. All of the patients also underwent videoendoscopic-based swallowing evaluations to detect aspiration and pharyngeal retention. The participants' characteristics and the utility of each assessment item were compared between various groups. Using the patients' videoendoscopic findings as a reference, receiver operating characteristic curve analysis was carried out to determine appropriate cut-off values for predicting aspiration and pharyngeal retention in dependent older adults.

RESULTS

The optimal MASA cut-off values for predicting aspiration and pharyngeal retention were 122 points and 151 points, respectively. A total of 17 of the 24 clinical items assessed by the MASA were found to be associated with aspiration in dependent older adults.

CONCLUSIONS

The MASA is a useful screening tool for evaluating eating and swallowing functions in dependent older adults. Geriatr Gerontol Int 2017; 17: 561-567.

Neuromuscular Electrical Stimulation for Treatment-Refractory Chronic Dysphagia in Tube-Fed Patients: A Prospective Case Series

OBJECTIVE

The aim of this study was to evaluate the role of neuromuscular electrical stimulation (NMES) in tube-fed patients with severe and chronic dysphagia refractory to traditional swallowing therapy (TT).

PATIENTS AND METHODS

A total of 11 consecutive dysphagic patients with tube-dependent nutrition and who had not responded to 6 months of TT were enrolled. Each patient received NMES for 30 min and TT for 30 min, twice a day, 5 days per week for 4 weeks. In order to evaluate the swallowing impairment, each patient underwent a fiberoptic endoscopic examination of swallowing immediately before the beginning of the treatment, after 2 weeks and after 4 weeks.

RESULTS

All enrolled patients managed to complete the swallowing treatment protocol for at least 2 weeks. After the 4-week treatment, 6 of 11 enrolled patients passed to a total oral diet with single or multiple consistencies despite specific food limitations or special preparation or compensation. Five patients, all affected by the most severe form of dysphagia, maintained tube-dependent nutrition.

CONCLUSION

NMES as adjunctive treatment to TT may offer a new possibility for the management of tube-fed patients who are refractory to TT.

Pharyngeal Residue Severity Rating Scales Based on Fiberoptic Endoscopic Evaluation of Swallowing: A Systematic Review

Identification of pharyngeal residue severity located in the valleculae and pyriform sinuses has always been a primary goal during fiberoptic endoscopic evaluation of swallowing (FEES). Pharyngeal residue is a clinical sign of potential prandial aspiration making an accurate description of its severity an important but difficult challenge. A reliable, validated, and generalizable pharyngeal residue severity rating scale for FEES would be beneficial. A systematic review of the published English language literature since 1995 was conducted to determine the quality of existing pharyngeal residue severity rating scales based on FEES. Databases were searched using controlled vocabulary words and synonymous free text words for topics of interest (deglutition disorders, pharyngeal residue, endoscopy, videofluoroscopy, fiberoptic technology, aspiration, etc.) and outcomes of interest (scores, scales, grades, tests, FEES, etc.). Search strategies were adjusted for syntax appropriate for each database/platform. Data sources included MEDLINE (OvidSP 1946-April Week 3 2015), Embase (OvidSP 1974-2015 April 20), Scopus (Elsevier), and the unindexed material in PubMed (NLM/NIH) were searched for relevant articles. Supplementary efforts to identify studies included checking reference lists of articles retrieved. Scales were compared using qualitative properties (sample size, severity definitions, number of raters, and raters' experience and training) and psychometric analyses (randomization, intra- and inter-rater reliability, and construct validity). Seven articles describing pharyngeal residue severity rating scales met inclusion criteria. Six of seven scales had insufficient data to support their use as evidenced by methodological weaknesses with both qualitative properties and psychometric analyses. There is a need for qualitative and psychometrically reliable, validated, and generalizable pharyngeal residue severity rating scales that are anatomically specific, image-based, and easily learned by both novice and experienced clinicians. Only the Yale Pharyngeal Residue Severity Rating Scale, an anatomically defined and image-based tool, met all qualitative and psychometric criteria necessary for a valid, reliable, and generalizable vallecula and pyriform sinus severity rating scale based on FEES.

Position paper of the German Society of Oto-Rhino-Laryngology, Head and Neck Surgery and the German Society of Phoniatrics and Pediatric Audiology - Current state of clinical and endoscopic diagnostics, evaluation, and therapy of swallowing disorders in children

Swallowing disorders are frequent. The main concern is mortality due to aspiration-induced pneumonia and malnutrition. In addition, quality of life is severely affected. The demographic trend indicates an increase of dysphagia in the future. Neurodegenerative diseases, tumors of the digestive tract, and sequelae of tumor treatment in the head and neck region are the main pathologic entities.

Predominantly ENT physicians and phoniatricians are asked for diagnostics and therapy, and will coordinate the interdisciplinary treatment according to the endoscopic findings.

A differentiated approach in history, diagnostics, and symptom-oriented treatment is necessary for these mostly complex disorders. Integration of non-medical staff such as speech therapists, physiotherapists, and occupational therapists in planning and executing an effective therapy expands and completes the patient-oriented care. Conservative treatment by these therapists is an important pillar in the treatment. Parts of the specific diagnostics can be taken over in close cooperation.

In particular, an interdisciplinary cooperation with the staff of intensive care medicine is essential.

The diagnostic procedures of specific endoscopy as described in this position paper are part of the primary and fundamental tasks of ENT specialists and phoniatrists.

Endoscopy is a medical service that is basically not delegable. Consequently, substitution of the physician is excluded.

Long-term functional results after open partial horizontal laryngectomy type IIa and type IIIa: A comparison study

BACKGROUND

The purpose of this study was to compare long-term swallowing, voice results, and quality of life (QOL) after open partial horizontal laryngectomy (OPHL) type IIa and type IIIa.

METHODS

Twenty-three patients after OPHL type IIa and 18 patients after OPHL type IIIa were involved. Swallowing skills and neoglottis' motility and vibrations were videoendoscopically assessed. Aerodynamic measures, spectrogram analysis, aspiration pneumonia, body weight variations, and voice perceptual assessment were performed. Generic voice-related and swallowing-related QOL were assessed. Data were statistically compared using Mann-Whitney U test or Fisher exact tests, as appropriate.

RESULTS

Significant differences were found only for the residue with solids and for the intelligibility (I) parameter of the overall quality impression and intelligibility, additive and unnecessary noise, speech fluency, and presence of voiced segments scale with patients of the OPHL type IIIa group showing worse performances than the OPHL type IIa group.

CONCLUSION

Patients who underwent OPHL type IIa and type IIIa show comparable long-term functional outcomes. OPHL type IIIa represents a valid surgical alternative to OPHL type IIa. © 2015 Wiley Periodicals, Inc. Head Neck 38: E1427-E1435, 2016.

Evaluation of swallowing function after supracricoid laryngectomy as a primary or salvage procedure

The primary functional issues following conservative therapy for advanced laryngeal cancer concern swallowing. Here, we evaluated the recovery of swallowing after supracricoid partial laryngectomy (SCL) in patients with primary or recurrent laryngeal cancer. We evaluated the swallowing recovery in 27 SCL patients through oropharyngoesophageal scintigraphy, and we evaluated their quality of life using EORTC questionnaires. Four patients underwent total laryngectomy during follow-up. Patients who retained their larynges were able to feed without nutritional support and without tracheostoma. The only significantly different parameter between the primary and salvage cases was the time elapsed to the removal of nasogastric/PEG tubes, which was longer in salvage cases. SCL has been demonstrated as a valuable option for primary and recurrent laryngeal cancer patients. The present data demonstrate good functional results, particularly in terms of swallowing after previous treatments and in primary settings. The combination of oropharyngoesophageal scintigraphy and questionnaires appears to be an adequate, standardizable approach to assessing swallowing function after SCL.

Application of simple swallowing provocation test with fiberoptic endoscopic evaluation of swallowing in a cross-sectional study

Background

This study aimed to develop a simultaneously swallowing provocation test for dysphagia patients undergoing fiberoptic endoscopic evaluation of swallowing (FEES), as well as to evaluate its efficacy.

Methods

In this test, 0·4 and 2·0 mL volumes of water were dripped into the pharynx under endoscopic examination of swallowing, and determine the latency time (LT) of the swallowing reflex elicited by water. The subjects were 51 bed-bound patients with dysphagia and could be divided into two groups as 35 tube feeding and 16 oral intake subjects. Among the tube feeding subjects, 20 patients who started dysphagia rehabilitation were followed-up to 3 months.

Results

The mean LT was 7·43 ± 7·19 seconds with 0·4 mL of test water and 5·05 ± 5·59 sec with 2·0 mL. When 0·4 mL water was dripped, LT was significantly longer in tube feeding (10·49 ± 7·97 seconds) than oral intake subgroup (5·72 ± 5·16 seconds) (p < 0·05). After the dietary intervention according to the result of FEES, 5 patients were improved in eating, and 15 patients were unchanged or even got worse among 3-months follow-up investigation. LT with 0.4 ml of test water of the Improved group was 3·16 ± 2·69 seconds and that of unchanged/worsened group was 22·6 ± 17·5 seconds, resulting in the significant difference (p < 0·05).

Conclusions

The results of this study suggest that our endoscopic swallowing test as swallowing provocation test with FEES is a useful examination for dysphagia rehabilitation.

[Position paper of the German Society of Oto-Rhino-Laryngology, Head and Neck Surgery and the German Society of Phoniatrics and Pediatric Audiology - current state of clinical and endoscopic diagnostics, evaluation, and therapy of swallowing disorders in children and adults]

Position Paper of the German Society of Oto-Rhino-Laryngology, Head and Neck Surgery and the German Society of Phoniatrics and Pediatric Audiology - Current State of Clinical and Endoscopic Diagnostics, Evaluation, and Therapy of Swallowing Disorders in Children and AdultsSwallowing disorders are frequent. The main concern is mortality due to aspiration induced pneumonia and malnutrition. On the other hand quality of life is severely affected. The demographic trend indicates an increase of dysphagia in the future. Neurodegenerative diseases, tumors of the digestive tract and sequelae of tumor treatment in the head and neck region are the main pathologic entities.Predominantly ENT physicians and phoniatrists, are asked for diagnostics and therapy who will coordinate the interdisciplinary treatment according to the endoscopic findings.A differentiated approach in history, diagnostics, and symptom oriented treatment is necessary for the mostly complex disorders. The integration of non-medical personnel such as logopeds (speech language pathologists), physiotherapists, and occupational therapists in planning and executing an effective therapy expands and completes the patient-oriented care. Conservative treatment by these therapists is an important pillar in the treatment. Parts of the specific diagnostics can be taken over by them in close cooperation.In particular an interdisciplinary cooperation with the staff from intensive care medicine is indispensable.The diagnostic procedures of specific endoscopy as described in this position paper are part of the primary and fundamental tasks of ENT specialists and phoniatrists.Endoscopy is a medical service that is basically not delegable. Consequently substitution of the physician is precluded.

Postextubation Dysphagia

Postextubation dysphagia (PED) is a common problem in critically ill patients with recent intubation. Although several risk factors have been identified, most of them are nonmodifiable preexisting or concurrent conditions. Early extubation, small endotracheal tube size, and small bore of nasogastric tube potentially decrease the risk of PED. The majority of patients receive treatment based on only bedside swallow evaluations, which has an uncertain diagnostic accuracy as opposed to gold standard instrumental tests. Therefore, the treatment decision for patients may not be appropriately directed for each individual. Current treatments are mainly focused on dietary modifications and postural changes/compensatory maneuvers rather than interventions, but recent studies have shown limited proven benefits. Direct therapies in oromotor control, such as therapeutic exercises and neuromuscular stimulations, should be considered as potential effective treatments.

Swallowing, voice, and quality of life after supratracheal laryngectomy: preliminary long-term results

BACKGROUND

The purpose of this study was to report preliminary long-term outcomes after supratracheal laryngectomy (STL).

METHODS

Twenty-two male patients who underwent STL were involved in this study. Swallowing skills, neoglottis motility, and vibrations were videoendoscopically assessed. Aerodynamic measures, spectrogram analysis, aspiration pneumonia, body weight variations, and voice perceptual assessment were performed. Generic, voice-related, and swallowing-related quality of life (QOL) were assessed.

RESULTS

Aspiration was found in 10, 2, and 5 patients, respectively, for liquids, semisolids, and solids. Neoglottis motility was generally preserved, whereas vibration was impaired. Aerodynamic measures showed a poor performance. Perceptual assessment revealed highly dysphonic voices. In only 8 patients, a harmonic structure was visible in the spectrograms. Aspiration pneumonia occurred in 2 patients. Preoperative weight was maintained in 16 patients. Generic, voice-related, and swallowing-related QOL revealed satisfied patients.

CONCLUSION

After STL, swallowing was sufficiently restored and QOL was satisfactory, whereas the voice was severely impaired even if oral communication was well preserved.

Direct laryngoscopy using a videogastroscope: outcome of 119 cases

Direct laryngoscopy is an essential examination for supraglottic and laryngeal pathology. Fibreoptic or videolaryngoscope are not readily available. This study was designed to see the usefulness of Videogastroscope to evaluate laryngeal lesion instead of fibreoptic or videolaryngoscope. Patients with unsuccessful or unsatisfactory indirect laryngoscopic examination referred by ENT surgeons were examined using videogastroscope and anaesthetizing oropharynx and hypopharynx with lidocaine pharyngeal spray. Under direct supervision impressions including still and dynamic images were recorded. Study group comprised of 76 males and 43 females with age varying from 09 to 87 with mean age 44 years. Various abnormalities were detected among 74 (62.2 %) patients. Common pathologies were vocal cord polyps and nodules in 28, laryngitis and laryngeal ulcer in 16, supraglottic growth in 13 and pyriform fossa growth in 10. Direct laryngoscopy using videogastroscope is safe, effective and easily performed newer technique which might be very useful where indirect laryngoscopy is difficult and fibreoptic or videolaryngoscope is not available.

Clinical dysphagia risk predictors after prolonged orotracheal intubation

OBJECTIVES

To elucidate independent risk factors for dysphagia after prolonged orotracheal intubation.

METHODS

The participants were 148 consecutive patients who underwent clinical bedside swallowing assessments from September 2009 to September 2011. All patients had received prolonged orotracheal intubations and were admitted to one of several intensive care units of a large Brazilian school hospital. The correlations between the conducted water swallow test results and dysphagia risk levels were analyzed for statistical significance.

RESULTS

Of the 148 patients included in the study, 91 were male and 57 were female (mean age, 53.64 years). The univariate analysis results indicated that specific variables, including extraoral loss, multiple swallows, cervical auscultation, vocal quality, cough, choking, and other signs, were possible significant high-risk indicators of dysphagia onset. The multivariate analysis results indicated that cervical auscultation and coughing were independent predictive variables for high dysphagia risk.

CONCLUSIONS

Patients displaying extraoral loss, multiple swallows, cervical auscultation, vocal quality, cough, choking and other signs should benefit from early swallowing evaluations. Additionally, early post-extubation dysfunction recognition is paramount in reducing the morbidity rate in this high-risk population.

The effects of neuromuscular electrical stimulation on pharyngeal transit time

[Purpose] The purpose of this study was to identify the effects of Neuromuscular Electrical Stimulation (NMES) on pharyngeal transit time. [Subjects] Subjects were divided into normal old persons aged over 70 (N=18), and normal young persons aged under 30 (N=10). [Method] We measured the Pharyngeal Transit Time (PTT) to determine their swallowing characteristics. NMES was used to stimulate old group's suprahyoid and infrahyoid muscles 60 minutes a day, 5 days a week for 2 weeks using four electrodes. We used SPSS version 14.0 to analyze and compare the data between the 2 groups. [Results] After NMES, PTT of the normal old group became significantly shorter. PTT was much shorter, but was still longer than that of the normal young group. [Conclusion] The PTTs of the two groups classified by age were significantly different.

The modified barium swallow and the functional endoscopic evaluation of swallowing

This article reviews the current standard of care for the instrumental evaluation of swallow function using the modified barium swallow (MBS) and the functional endoscopic evaluation of swallowing (FEES). Both the MBS and FEES are valuable procedures for evaluating dysphagia and show good agreement with diagnostic findings as related to tracheal aspiration, laryngeal penetration, pharyngeal residue, diet level, and compensatory swallow safety strategies. The use of the MBS and FEES has advantages and disadvantages and both should be considered the gold standard for evaluating swallow function.

Effects of topical nasal anesthetic on fiberoptic endoscopic examination of swallowing with sensory testing (FEESST)

Objections to the use of topical nasal anesthesia (TNA) during fiberoptic endoscopic evaluation of swallowing (FEES) with sensory testing (FEESST) have been raised, primarily because of the possibility of desensitizing the pharyngeal and laryngeal mucosa and affecting both the sensory and motor aspects of the swallow. Furthermore, it has been suggested that TNA is not necessary during FEES as it does not improve patient comfort or make the procedure easier for the endoscopist. The purpose of this double-blind, randomized, controlled, crossover clinical trial was to determine how gel TNA during flexible endoscopic evaluation of swallowing with sensory testing affects sensation, swallowing, and comfort rating scores in healthy non-dysphagic participants. Laryngopharyngeal sensory thresholds and swallowing durations were compared between two conditions: TNA and sham. Transition duration decreased statistically significantly during the TNA condition compared to the sham for 10 ml only (p < 0.05). All other swallowing measures did not change between the conditions. Laryngopharyngeal sensory thresholds and perceptions did not change between conditions. No change was observed for subject comfort scores, ease of exam, or quality of view. Future studies should evaluate TNA administration variables, including concentration, dosage amount, and method of application, to determine the optimal strategy for providing comfort while avoiding altered swallowing.

In-office evaluation of swallowing: FEES, pharyngeal squeeze maneuver, and FEESST

Dysphagia matters and endoscopic examination of patients with swallowing complaints is an important part of their evaluation. The 3 key adjuncts to flexible fiber optic laryngoscopy are (1) flexible endoscopic evaluation of swallowing, (2) assessment of pharyngeal squeeze, and (3) sensory testing. Patients undergoing flexible fiber optic laryngoscopy are then challenged with liquid or solid materials for intake. Fundamental clinical signs of swallowing parameters are noted. The threshold at which the laryngeal adductor reflex is triggered is believed to be helpful in predicting swallowing capacity. This report deals solely with adult dysphagia evaluation.

Surgical strategies based on standard templates for microsurgical reconstruction of oral cavity and oropharynx soft tissue: a 20 years' experience

BACKGROUND

Microsurgical reconstruction has become the worldwide gold standard for repairing surgical defects in head and neck cancer. The aim of this article is to describe a standardized reconstructive approach to the oral cavity and oropharynx soft tissue defects.

PATIENTS AND METHODS

Since 1992, the authors have treated 163 patients affected by oral cavity and oropharynx cancer, performing a total of 175 flaps. A systematic postoperative functional study prompted a surgical strategy, in terms of flap choice, shape, and insetting. A two-dimensional template was used to obtain a three-dimensional reconstruction for the best functional and aesthetic outcome. To simplify preoperative planning, surgical resections were divided into a set number of classes. The templates, flap choice, and insetting are described for each region.

RESULTS

Complications consisted of seven partial necroses of the flap which easily resolved with a local toilette and 12 complete necroses of the flap due to vascular thrombosis, these patients required a secondary reconstruction with another free flap. Functional results were systematically evaluated in the first 60 patients of our series with particular attention to the swallowing function, which was analyzed by both videofluoroscopy and functional endoscopic evaluation of swallowing. Results showed a good functional recovery with the described reconstructive techniques.

CONCLUSION

A standardized surgical strategy based on reproducible templates might facilitate less experienced surgeons in analyzing the problem, choosing the best technical solution and foreseeing the functional outcomes.

Computerized monitoring of patient-reported speech and swallowing problems in head and neck cancer patients in clinical practice

Purpose

The purpose of this study is to evaluate computerized monitoring of speech and swallowing outcomes and its impact on quality of life (QoL) and emotional well-being in head and neck cancer patients in an outpatient clinic.

Methods

Sixty-seven patients, treated by single or multimodality treatment, completed the EORTC QLQ-C30 and QLQ-H&N35 questionnaires and the Hospital Anxiety and Depression Scale in an outpatient clinic, using a touch screen computer system (OncoQuest), at baseline (at time of diagnosis) and first follow-up (1 month after end of treatment).

Results

Tumor sites included oral cavity (n = 12), oropharynx (n = 18), hypopharynx (n = 8), and larynx (n = 29). Tumor stage included carcinoma in situ (n = 3), stage I (n = 21), stage II (n = 7), stage III (n = 15), and IV (n = 21). No speech or swallowing problems at baseline or follow-up were noted in 23 % (speech) and 41 % (swallowing) of patients. Twenty-one percent (speech) and 19 % (swallowing) had problems at baseline and returned to normal scores at follow-up, while 16 % (speech) and 19 % (swallowing) had normal scores at baseline and developed problems at follow-up. Forty percent (speech) and 21 % (swallowing) had persistent problems from baseline to follow-up. At baseline, speech problems were significantly related to tumor site and emotional distress. At baseline and follow-up, swallowing problems were significantly related to QoL and emotional distress. At follow-up, speech problems were significantly related to QoL, emotional distress, and swallowing problems.

Conclusions

Monitoring speech and swallowing problems through OncoQuest in an outpatient clinic is feasible. Many patients report speech and swallowing problems, negatively affecting their QoL and emotional well-being.