Upright epiglottis prevents aspiration in patients with nasopharyngeal carcinoma post-chemoradiation

The risk factors for silent aspiration: A retrospective case series and literature review

AIM

Evidence shows that 20%-30% of patients who aspirate do so silently. Research to date has not demonstrated clear evidence to indicate which patients are at higher risk of silent aspiration. Our aim was to use univariate logistic regression analysis of retrospective case review to determine potential patterns of silent aspiration.

MATERIALS AND METHODS

We conducted a retrospective analysis of 455 fiberoptic endoscopic evaluation of swallowing (FEES) reports. The patients were divided into four groups: G1 - neurological diseases (n = 93), G2 - head and neck surgery (n = 200), G3 - gastroenterological diseases (n = 94) and G4 - other patients (n = 68). Data included the occurrence or absence of saliva penetration or aspiration, of silent fluid/solid food penetration or aspiration, type of penetration or aspiration, occurrence of cranial nerve paresis, radiotherapy and tracheostomy. Univariate logistic regression was used to evaluate independent risk factors of silent aspiration in the study population. Three models with different independent variables were considered.

RESULTS

There is a statistically significant difference in the frequency of occurrence of silent penetration and aspiration within the groups (p < 0.001), with intraglutative being most frequent. Fluid and food penetration and aspiration correlated with saliva penetration and aspiration in all groups (p < 0.001). Cranial nerve paresis (IX and X), radiotherapy and tracheostomy correlate with saliva penetration and aspiration (p = 0.020 for cranial nerve paresis; p = 0.004 for radiotherapy; p < 0.001 for tracheostomy). One hundred and fifteen patients (45.81%) in the subgroup of patients with intraglutative aspiration had cranial nerve paresis (IX, X or IX-X).

CONCLUSIONS

Patients who should be prioritised or considered to be at a higher need of instrumental swallowing evaluation are those with IX and X cranial nerve paresis, tracheostomy and those who have had radiotherapy, with saliva swallowing problems, especially after paraganglioma, thyroid and parathyroid glands and middle and posterior fossa tumour surgery.

WHAT THIS PAPER ADDS

What is already known on the subject Clinical signs of penetration or aspiration include coughing, throat clearing and voice changes, while silent penetration or aspiration patients aspirate without demonstrating any clinical symptoms. The most common consequences of silent aspiration include aspiration pneumonia, recurrent lower respiratory tract infections and respiratory failure. Additionally, malnutrition and dehydration can be indicators of silent aspiration. Patients may unknowingly reduce their oral intake and lose weight. Retrospective studies have shown that 20%-30% of patients aspirate silently (e.g. patients after stroke, acquired brain injury, head and neck cancer treatment, prolonged intubation). Clinical examination of swallowing can miss up to 50% of cases of silent aspiration. What this paper adds to existing knowledge Currently, silent aspiration is often discussed in neurological literature, but its applications to head and neck surgery are limited. In this study, we identify head and neck surgery patients who should be prioritised or considered to be in higher need of instrumental swallowing evaluation due to a higher risk of silent aspiration. What are the potential or actual clinical implications of this work? Post-treatment structural changes can result in lower cranial nerve paresis (IX, X, XII) and face injury, in which vagus and glossopharyngeal nerves are injured. After tracheostomy and radiotherapy, patients with problems swallowing saliva need careful clinical examination, particularly cranial nerve examination.

Types of Epiglottic Collapse in Breathing Sleep Disorder and Their Impact in Clinical Practice

Introduction  Obstructive sleep apnea (OSA) is a severe form of sleep-disordered breathing (SDB) that is strongly correlated with comorbidities, in which epiglottic collapse (EC) and other contributing factors are involved. Objectives  To evaluate the occurrence of EC in OSA patients through drug-induced sleep endoscopy (DISE) and to determine the factors contributing to EC. Methods  A retrospective study of 37 adult patients using medical history. Patients were assessed for laryngopharyngeal reflux (LPR) and lingual tonsil hypertrophy (LTH) using reflux symptom index and reflux finding score (RFS); for OSA using polysomnography, and for airway collapse through DISE. An independent t -test was performed to evaluate risk factors, including the involvement of three other airway structures. Results  Most EC patients exhibited trap door epiglottic collapse (TDEC) (56.8%) or pushed epiglottic collapse (PEC) (29.7%). Lingual tonsil hypertrophy, RFS, and respiratory effort-related arousal (RERA) were associated with epiglottic subtypes. Laryngopharyngeal reflux patients confirmed by RFS (t(25) = -1.32, p  = 0.197) tended to suffer PEC; LTH was significantly associated (X2(1) = 2.5, p  = 0.012) with PEC (odds ratio [OR] value = 44) in grades II and III LTH patients; 11 of 16 TDEC patients had grade I LTH. Pushed epiglottic collapse was more prevalent among multilevel airway obstruction patients. A single additional collapse site was found only in TDEC patients. Conclusion  Laryngopharyngeal reflux causes repetitive acid stress toward lingual tonsils causing LTH, resulting in PEC with grade II or III LTH. Trap door epiglottic collapse requires one additional structural collapse, while at least two additional collapse sites were necessary to develop PEC. Respiratory effort-related arousal values may indicate EC.

A Large Cohort Analysis of Epiglottic Phenotypes and Pharyngeal Residue

OBJECTIVE

To describe the phenotypic characteristics of the epiglottis at rest and their impact on vallecular residue.

METHODS

Videofluoroscopic studies (VFSS) were pooled from 2 Laryngology practices, and Image J was used to measure epiglottic anatomic features at rest. Studies were rated by the MBSImp and presence of vallecular residue following swallow of thin and puree boluses. A conditional inference tree analysis was performed to isolate which epiglottic parameters were risk factors for presence of vallecular reside followed by logistic regression.

RESULTS

The majority of patients had a normal shaped epiglottis, followed by omega shape. The mean angle of the epiglottis from the hyoid was approximately 90°. Only abnormal epiglottic movement was associated with increased risk of residue for thin boluses (OR 35.09, CI 10.93-158.66, P < .001). However, in those with normal epiglottic movement, age >70 years old was associated with increased risk of residue (OR 3.98, CI 1.73-9.23, P = .001). For puree boluses, a normal or omega shaped epiglottis was associated with residue (OR 5.19, CI 2.41-11.51, P < .001), and this relationship was further modulated by increased distance of the epiglottic tip from the posterior pharyngeal wall. No other anatomic features of the resting epiglottis were associated with residue. Comorbidities potentially affecting swallow were infrequent in the cohort and were not associated with residue.

CONCLUSION

Abnormal epiglottic movement is associated with aspiration, and in this study we find that abnormal epiglottic movement increases the risk of vallecular residue and that older age is a risk factor for residue. The resting properties of the epiglottis do not appear to be associated with abnormal epiglottic movement or residue.

Relationship Between Pharyngeal Residues Assessed by Bolus Residue Scale or Normalized Residue Ratio SCALE and Risk of Aspiration in Head and Neck Cancer Who Underwent Videofluoroscopy

Dysphagia affects 60-75% of patients treated for head and neck cancer (HNC). We aimed to evaluate the association between residue severity and airway invasion severity using a videofluoroscopic swallowing study and identify risk factors for poor penetration-aspiration outcomes in patients with dysphagia treated for HNC. Penetration-Aspiration Scale (PAS) was used to assess airway invasion severity, while residue severity was assessed using both the Bolus Residue Scale (BRS) for residue location and the Normalized Residue Ratio Scale (NRRS) for residue amount. Relevant covariates were adjusted in the logistic regression models to account for potential confounding. Significantly higher abnormal PAS was reported for increased piriform sinus NRRS (NRRSp) [odds ratio (OR), 4.81; p = 0.042] with liquid swallowing and increased BRS value (OR, 1.52; p = 0.014) for semi-liquid swallowing in multivariate analysis. Tumor location, older age, and poorer Functional Oral Intake Scale (FOIS) were significant factors for abnormal PAS in both texture swallowings. After adjusting for confounding factors (sex, age, and FOIS score), NRRS model in liquid swallowing (area under the curve [AUC], 0.83; standard error = 0.04, 95% confidence interval [CI]: 0.75, 0.91) and BRS in semi-liquid swallowing (AUC, 0.83; SE = 0.04; 95% CI: 0.76, 0.91) predicted abnormal PAS. The results indicate that while assessing residue and swallowing aspiration in patients with HNC, it is important to consider age, tumor location, and functional swallowing status. The good predictability of abnormal PAS with BRS and NRRS indicated that residue location and amount were both related to the aspiration event in patients with HNC.

Effects of CIK Cell Therapy Combined with Camrelizumab on the Quality of Life in Patients with Nasopharyngeal Carcinoma and Analysis of Prognostic Factors

Objective

To investigate the effects of CIK (cytokine-induced killer) cell therapy combined with camrelizumab on the quality of life in patients with nasopharyngeal carcinoma and prognostic factors.

Methods

In this retrospective study, the materials of 80 patients with nasopharyngeal carcinoma treated in our hospital (February 2017-February 2019) were retrospectively analyzed, and they were equalized into experimental group (n = 40) and control group (n = 40) according to the order of admission. Both groups received 200 mg of camrelizumab on day 1 combined with 10 mg of anrotinib from day 2 to day 4. The patients received the above program every 3 weeks and 4 treatment cycles. The experimental group also received CIK cell therapy simultaneously. The patients' quality of life, immune indexes, local control, metastasis, and survival rate were compared between the two groups, and the prognostic factors were analyzed by logistic analysis.

Results

Compared with the control group, the experimental group achieved much higher scores of physical well-being (18.38 ± 2.31), social/family well-being (16.40 ± 2.24), emotional well-being (15.35 ± 2.30), functional well-being (17.30 ± 2.20), and head and neck cancer subscale (15.40 ± 2.01, P < 0.001) and eminently better immune indexes (P < 0.001) after treatment. During the 24-month follow-up, there were 2 recurrent cases (5.0%) and 2 cases (5.0%) with distant metastasis among the 40 patients in the experimental group; there were 8 recurrent cases (20.0%) and 7 cases (17.5%) with distant metastasis among the 40 patients in the control group. In the experimental group, the median survival period was 18 months and the 2-year survival rate was 97.5% (39/40). In the control group, the median survival period was 14 months and the 2-year survival rate was 85.0% (34/40). Among the 80 patients, 7 cases (8.75%) died and 73 cases (91.25%) survived. After conducting the single-factor analysis, remarkable differences in the cases of IV stage, quality of life after treatment, and immune indexes after treatment between the survival group and the death group were observed (P < 0.05). According to the multiple-factor analysis, the clinical stage and immune indexes were identified as the prognostic factors.

Conclusion

CIK cell therapy combined with camrelizumab can enhance the life quality and immune function of the patients with nasopharyngeal carcinoma, thus improving their prognoses.