EAT-10 Scores and Fiberoptic Endoscopic Evaluation of Swallowing in Head and Neck Cancer Patients

Habitual intake of carbonated drinks is associated with subjective difficulty in swallowing in community-dwelling older adults: a survey-based cross-sectional study

Carbonated drinks have been reported to increase muscle activity during swallowing compared with water. Older adults who habitually consume carbonated drinks may use their swallowing-related muscles to a greater extent, thereby preserving their swallowing function. This study investigated the relationship between habitual carbonated drink intake, amount of carbonated drink consumed, and subjective difficulty in swallowing in community-dwelling older adults. We administered a questionnaire to determine subjective difficulty in swallowing, nutritional status, presence of sarcopenia, and habitual intake of carbonated drinks. Statistical analysis of the subjective difficulty in swallowing was performed using logistic regression analysis with the presence or absence of suspected dysphagia, using the Eating Assessment Tool-10 as the dependent variable. The results showed that older age (odds ratio [OR]: 1.077; p = 0.011), nutritional status (OR: 0.807; p = 0.040), systemic sarcopenia (OR: 1.753, p < 0.001), and habitual intake of carbonated drinks (OR: 0.455; p = 0.039) were associated with subjective difficulty in swallowing. In conclusion, the daily habits of community-dwelling older adults impact their swallowing function.

The discriminant ability of the Eating Assessment tool-10 to detect swallowing efficiency in neurogenic dysphagia

PURPOSE

Neurogenic dysphagia causes complications such as malnutrition, dehydration, and aspiration pneumonia. Therefore, early detection with clinically valid tools is essential. This study aimed to investigate the Eating Assessment Tool-10 (EAT-10) ability to detect swallowing efficiency at three different consistencies in neurogenic dysphagia.

METHODS

One hundred twelve patients with neurogenic dysphagia (74 males and 38 females, mean ± SD age 61.83 ± 9.72 years) were included in the study. A Fiberoptic Endoscopic Evaluation of Swallowing (FEES) was performed in the clinic following EAT-10 to assess swallowing efficacy at International Dysphagia Diet Standardization Initiative (IDDSI) consistencies of 0, 3, and 7. The swallowing efficiency of the patients was assessed using the Yale Pharyngeal Residue Severity Rating Scale (YPRSRS). Area under the curve, sensitivity, and specificity values were calculated to evaluate the ability of EAT-10 to discriminate between participants with and without residue and between participants with and without moderate-to-severe residue.

RESULTS

The EAT-10 significantly detected participants with and without residues for three IDDSI consistent: for IDDSI 0 residue in the vallecula and pyriform sinus (cutoff score ≥ 14, p < 0.001), for IDDSI 3 residue in the vallecula and pyriform sinus (cutoff score ≥ 13, p < 0.001), for IDDSI 7 residue in the vallecula and pyriform sinus (respectively, cutoff score ≥ 13, cutoff score ≥ 14, p < 0.001). Additionally, the EAT-10 significantly detected those with and without moderate-to-severe residue.

CONCLUSIONS

The EAT-10, frequently used in swallowing clinics, can determine swallowing efficiency in individuals with neurogenic dysphagia. Additionally, it has the power to detect moderate-to-severe pharyngeal residue.

Pilot study on the relationship between oral function or subjective symptoms and appetite

OBJECTIVE

This pilot study evaluated the relationships between appetite and oral function, and between appetite and the subjective symptoms of decreased oral function.

METHODS

Seventy-one adult dental clinic patients (22 males, 66.0 ± 14.0 years) participated in this study. A Council on Nutrition Appetite Questionnaire score of ≤28 indicated anorexia, and the Mini Nutritional Assessment Short-form, body mass index and skeletal muscle mass index were used to define subject characteristics. Seven oral function tests and seven subjective symptoms related to oral function were evaluated. The relationship between subject characteristics, oral function tests, subjective symptoms and anorexia was analysed using the chi-square test and univariate and multivariate logistic regression.

RESULT

There were significant differences between the normal appetite group and the anorexia group for the 10-item Eating Assessment Tool (EAT-10) survey and the question 'Food remains in the oral cavity after eating' (p < .05). Univariate logistic regression found significant differences in the items of masticatory function, the EAT-10 survey and the question 'Food remains in the oral cavity after eating'. Multivariate logistic regression revealed significant differences in masticatory function (AOR 4.35; 95% CI: 1.03-18.35; p = .045) and EAT-10 (AOR 6.27; 95% CI: 1.40-24.02; p = .016).

CONCLUSION

This pilot study investigated the influence of factors related to oral function on appetite. Relationships were found among poor masticatory function, poor swallowing function and anorexia.

Screening oropharyngeal dysphagia in patients with head and neck cancer in a radiation oncology department

Background

Oropharyngeal dysphagia (OD) occurs in up to 40% of head and neck cancer (HNC) patients before treatment and remains a common symptom (23-60%) after oncological treatments, leading to several consequences. Early detection is essential for effective swallowing-rehabilitation and nutritional-support. The increased radiosensitivity of tumors associated with human papillomavirus (HPV) and advances in imaging techniques have stimulated research into deintensified strategies to minimize radiotherapy (RT) side effects. The purposes of the study are to establish the percentage of patients with HNC who are candidates to RT who are at risk of dysphagia [Eating Assessment Tool (EAT) score ≥ 3], determine if tumor location and previous surgery were related to a higher risk of dysphagia and if patients suffering severe toxicity during cancer therapy are at greater risk of posttreatment-dysphagia.

Materials and methods

Patients diagnosed of HNC who were referred to RT treatment at our Radiation Oncology Department were prospectively included. Questionnaire EAT-10 was filled in the first assessment used as a screening tool and repeated one month after treatment. Treatment toxicity was established according to common toxicity criteria adverse effects (CTCAE4.03).

Results

From November 2019 to January 2021, 72 patients were included. All completed pretreatment EAT-10 questionnaire. The mean (SD) score of the pretreatment EAT-10 was 7.26 ± 11.19 and 43.1% were at dysphagia risk. Patients with tumors located in the oral cavity, oropharynx and those that had received surgery prior to RT had higher risk than the rest of locations or those who had not previous surgery (p = 0.001 and p = 0.002, respectively). After oncological treatment 95.83% completed EAT-10 post-treatment and 45,6% showed positive EAT-10 score.

Conclusions

Patients with tumors in the oral cavity or oropharynx, presenting in advanced stage, and who previously received surgery are at higher risk of developing dysphagia. The EAT-10 is a simple tool that can help us identify those patients and refer them for an intensive evaluation to reduce dysphagia-consequences.

Head and Neck Cancer: A Study on the Complex Relationship between QoL and Swallowing Function

Head and neck squamous cell carcinoma (HNSCC) is linked to significant morbidity, adversely affecting survival and functional capacity. Post-treatment challenges such as pain, dysphonia, and dysphagia are common, prompting increased attention in survivorship research. Quality of Life (QoL) questionnaires, especially the MD Anderson Dysphagia Inventory (MDADI), are prevalent outcome measures in clinical studies but often lack parallel objective swallowing function evaluations, leading to potential outcome discrepancies. This study aimed to illuminate the relationship between subjective QoL (EQ-5D-5L and MDADI) measures and objective swallowing function (evaluated via Fiberoptic Endoscopic Evaluation of Swallowing, FEES) in patients with HNSCC. The analysis revealed a notable discordance between objective measures of swallowing function, such as the Penetration-Aspiration Scale (PAS) and residue ratings in the vallecula or piriform sinus, and patients' subjective QoL assessments (p = 0.21). Despite the lack of correlation, swallowing-related QoL, as measured by the MDADI, was more indicative of disease severity than generic QoL assessments. Generic QoL scores did not demonstrate substantial variation between patients. In contrast, MDADI scores significantly declined with advancing tumor stage, multimodal therapy, and reliance on feeding tubes. However, the clinical significance of this finding was tempered by the less than 10-point difference in MDADI scores. The findings of this study underline the limitations of QoL measures as standalone assessments in patients with HNSCC, given their reliance on patient-perceived impairment. While subjective QoL is a crucial aspect of evaluating therapeutic success and patient-centric outcomes, it may fail to capture critical clinical details such as silent aspirations. Consequently, QoL assessments should be augmented by objective evaluations of swallowing function in clinical research and practice to ensure a holistic understanding of patient well-being and treatment impact.

Can EAT-10 Become EAT-5? Improving Measurement Efficiency of Dysphagia with Item Response Theory

OBJECTIVES

To assess: (1) the Eating Assessment Tool (EAT-10) with item response theory (IRT) to determine which individual items provide the most information, (2) the extent to which dysphagia is measured with subsets of items while maintaining precise score estimates, and (3) if 5-item scales have the differing discriminatory ability, as compared to the parent 10-item instrument.

METHODS

Prospectively collected data from 2,339 patients who completed the EAT-10 questionnaire during evaluation at a tertiary care otolaryngology clinic were utilized. IRT analyses provided discrimination and location parameters associated with individual questions. Residual item correlations were also assessed for redundant information. Based on these results, three 5-item subsets were further evaluated using item information function curves. Areas under receiver-operator characteristic curves (ROC-AUC) were also calculated to evaluate the discriminatory ability for dysphagia-related clinical diagnoses.

RESULTS

Item discrimination parameter estimates ranged from 1.71 to 5.46, with higher values indicating more information. Residual item correlations were determined within item pairs, and location parameters were calculated. Based on these data, in combination with clinical utility, three 5-item subsets were proposed and assessed. ROC-AUC analyses demonstrated no significant difference between the EAT-5-Alpha subset and the original 10-item instrument for discriminating dysphagia as a primary diagnosis (0.88, 0.88). The EAT-5-Clinical subset outperformed the original 10 instruments in ROC-AUC for aspiration. The EAT-5-Range subset was significantly associated with problems with thin liquids.

CONCLUSIONS

IRT analyses distinguished three proposed 5-item subsets of the EAT-10 instrument, supporting shorter survey options, while still reflecting the impact of dysphagia without significant loss of discrimination.

LEVEL OF EVIDENCE

3 (Diagnostic testing with consistently applied reference standards, partial blinding). Laryngoscope, 133:3327-3333, 2023.

Development and Evaluation of the Psychometric Properties of the Tamil Version of Eating Assessment Tool - 10 (EAT-10): Preliminary Findings from Persons with Head and Neck Cancer

Aims: This study aimed to develop and evaluate the psychometric properties of the Tamil version of the Eating Assessment Tool (EAT-10). Setting & Study Design: Prospective cross-sectional study on persons with Head and Neck Cancer (HNC) during their follow-up for oncological and swallowing consultation at a tertiary care hospital and healthy individuals recruited from the community. Methods: The study was conducted in two phases: (1) translation and development of the Tamil version of EAT-10 and (2) administration of Tamil EAT-10 to assess internal consistency reliability, test-retest reliability and known-group validity. 92 participants with HNC in the clinical group and 149 healthy adults in the control group completed the Tamil EAT-10. In addition, a subgroup of 20 participants with HNC repeated the questionnaire within a week to assess test-retest reliability. Results: The Cronbach alpha for the 10 items was 0.96 indicating high internal consistency reliability. The test-retest reliability of the individual items and the total scores (r = 0.98) of the Tamil version of EAT-10 were high. The total EAT-10 scores for the HNC group (14.4 ± 11.5) were significantly higher (p < 0.001) than the scores for healthy adults (0.72 ± 2.0). Conclusion: The Tamil version of the EAT-10 developed in this study is a reliable and valid self-administered tool for identifying concerns related to swallowing among persons treated for HNC and healthy adults. This tool can be implemented for clinical practice and research in dysphagia among a Tamil-speaking population.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12070-022-03376-8.

The discriminant ability of the eating assessment tool-10 questionnaire to detect residue and aspiration in patients with mixed etiology of dysphagia

PURPOSE

To investigate the discriminant ability of the eating assessment tool-10 (EAT-10) to detect postswallow residue and aspiration for different consistencies.

METHODS

Seventy-two consecutive patients with mixed etiology of dysphagia (42 males and 30 females, mean ± sd age of 60.42 ± 15.82) were included. After completing the EAT-10, Fiberoptic Endoscopic Evaluation of Swallowing (FEES) was performed to assess the efficiency and safety of swallowing for the following consistencies: thin liquid, nectar thick, yogurt, and solid. While swallowing efficiency was evaluated using the Yale Pharyngeal Residue Severity Rating Scale (YPRSRS), the Penetration-Aspiration Scale (PAS) was used to evaluate swallowing safety.

RESULTS

The EAT-10 questionnaire significantly identified the patients with residue from those without residue for the following consistencies and anatomic locations: thin liquid residue in the pyriform sinus (cutoff score ≥ 10, p = 0.009), nectar thick residue in the vallecula (cutoff score ≥ 15, p = 0.001), yogurt residue in the vallecula (cutoff score ≥ 15, p = 0.009), yogurt residue in the pyriform sinus (cutoff score ≥ 9, p = 0.015), and solid residue in the vallecula (cutoff score ≥ 13, p = 0.016). However, the same discriminant ability of EAT-10 was not found for detecting aspiration in any consistency.

CONCLUSIONS

The EAT-10 questionnaire can be used as an assessment tool to judge swallowing efficiency in patients with mixed etiology of dysphagia, but the same is not evident for swallowing safety.

Trans-Adaptation and Analysis of Psychometric Properties of Hindi Version of Eating Assessment Tool-10 (EAT-10H)

The present study aims to trans-adapt the Eating Assessment Tool-10 (EAT-10) to the Hindi language and assess its psychometric properties. The original EAT-10 was translated into Hindi language using the forward-backward translation method. A total of 201 participants were included in the study. Among 201 participants, 83 were controls, and 118 were dysphagic. Internal consistency, reliability, and clinical validity were measured. Results revealed that the Hindi version of EAT-10 exhibited an excellent internal consistency (i.e., 0.86). A significant difference was found between the mean scores of both groups, and an excellent reliability score (i.e., 0.96) was obtained. From the present study's findings, it can be delineated that the Hindi version of EAT-10 exhibited good psychometric properties. So, the developed tool is a quick, reliable, and valid tool.

Treatment with head-lift exercise in head and neck cancer patients with dysphagia: results from a randomized, controlled trial with flexible endoscopic evaluation of swallowing (FEES)

BACKGROUND

This randomized study aimed to evaluate the effects of the Shaker head-lift exercise (HLE) to improve dysphagia following oncologic treatment for head and neck cancer (HNC).

METHODS

Patients with dysphagia following oncologic treatment for HNC were randomly assigned to intervention (n = 23) or control (standard dysphagia management, n = 24) groups. Swallowing was evaluated at baseline and at 8-week follow-up using flexible endoscopic evaluation of swallowing (FEES) and self-perceived swallowing with the Eating Assessment Tool (EAT-10). Analysis was performed regarding secretion, initiation of swallow, residue after swallowing, and penetration/aspiration.

RESULTS

Few statistically significant differences were found in the FEES analysis. Some improvement of self-perceived swallowing function was found in both groups. Adherence to training was high.

CONCLUSIONS

This randomized study regarding the effect of the HLE demonstrated that swallowing outcome measures used in assessment of FEES did not improve in patients treated with radiotherapy for patients with dysphagia following HNC.

Oral Health Management and Rehabilitation for Patients with Oral Cancer: A Narrative Review

Surgery is the current first choice for oral cancer treatment. Intensity-modulated radiation therapy, molecular targeted drugs, and immune checkpoint inhibitors are still used as adjuvant therapy for advanced cancer. In addition, postoperative rehabilitation and multidisciplinary treatment have also been developed in recent years. Multidisciplinary team approaches and supportive care in oral cancer treatment reportedly shorten the time to treatment and improve outcomes. Although there is enough evidence confirming the role of oral and maxillofacial surgeons, dentists, and dental hygienists in supportive care in oral cancer treatment, there are very few systematic studies. In particular, oral health management is a concept that encompasses oral function management, oral hygiene management, and oral care during oral cancer treatment. We provide a narrative review focusing on oral health management from a multidisciplinary and supportive care perspective, applicable in oral cancer treatment.

Patient Benefit and Quality of Life after Robot-Assisted Head and Neck Surgery

Robotic systems for head and neck surgery are at different stages of technical development and clinical application. Currently, robotic systems are predominantly used for transoral surgery of the pharynx and larynx. Robotic surgery of the neck, the thyroid, and the middle and inner ear is much less common; however, some oncological and functional outcomes have been reported. This article provides an overview of the current state of robot-assisted head and neck surgery with a special emphasis on patient benefit and postoperative quality of life (QoL). The focus is placed on the role of transoral robotic surgery (TORS) for the resection of oropharyngeal carcinomas. For this application, reported long-term outcomes show functional post-operative advantages for selected oropharyngeal cancer patients after TORS compared to open surgery and primary radiotherapy. Since TORS also plays a significant role in the context of potential therapy de-escalation for HPV-positive oropharyngeal cancer patients, ongoing trials are presented. Regarding the evaluation of the therapeutic benefit and the QoL of cancer patients, special attention has to be paid to the large degree of variability of individual patients' preferences. Influencing factors and tools for a detailed assessment of QoL parameters are therefore detailed at the beginning of this article. Notably, while some robotic systems for ear and skull base surgery are being developed in Europe, TORS systems are mainly used in North America and Asia. In Europe and Germany in particular, transoral laser microsurgery (TLM) is a well-established technology for transoral tumor resection. Future trials comparing TORS and TLM with detailed investigation of QoL parameters are therefore warranted and might contribute to identifying suitable fields for the application of the different techniques.

Validation and Cultural Adaptation of an Arabic Version of Pediatric Eating Assessment Tool (Pedi-EAT-10Arabic)

Pediatric eating assessment tool (Pedi-EAT-10_Arabic) is a validated and reliable caregiver administered outcome instrument designed for detection of children at high risk of penetration/aspiration. The objective of this study is to translate and validate the Arabic version of Pedi-EAT-10 and to correlate its results with pharyngeal residue and aspiration on fiber optic endoscopic examination of swallowing (FEES). A cross-sectional study including 202 children selected randomly from those attending the swallowing clinic in phoniatrics unit, Otorhinolaryngology department (ORL) at main university hospital between February 2019 and October 2020 complaining of dysphagia. For test-retest reliability, one hundred caregivers refilled the Pedi-EAT-10_Arabic after a 2-week period following their first visit. Validity was established by comparing the scores of dysphagia patients to healthy controls. Internal consistency of Pedi-EAT-10_Arabic was high (Cronbach's alpha 0.986). Intra class correlation showed excellent test-retest reliability (r = 0.968). The median Pedi-EAT 10_Arabic score was significantly higher in dysphagia group compared to healthy controls. (Median 27 IQR 21-34 for cases compared to median zero IQR 0-2 points for healthy controls, P less than 0.001). A strong correlation was found between Pedi-EAT 10_Arabic scores and PAS scores with Spearman's correlation coefficient r = 0.803 and P < 0.001. The ROC for evaluating the discriminatory capacity of Pedi-EAT 10 for aspiration showed an AUC of 0.92 (95% CI of 0.89 to 0.96)_. Conclusion: Pedi-EAT 10_Arabic was found to be a valid and reliable screening tool for further instrumental assessment of risk of dysphagia in pediatric population.

Development of a Subjective Symptom Rating Scale for Postoperative Oral Dysfunction in Patients with Oral Cancer: Reliability and Validity of the Postoperative Oral Dysfunction Scale-10

Currently, there is no scale to subjectively assess postoperative oral dysfunction in patients with oral cancer. The purpose of this study was to evaluate the reliability and validity of the Postoperative Oral Dysfunction Scale (POD-10) that we developed. Between September 2019 and August 2021, 62 eligible oral cancer patients (median age, 72 years; 42 men and 20 women) were enrolled in the study. The Cronbach’s alpha coefficient, which indicates the internal consistency of the scale, was 0.94, and the intraclass correlation coefficient, which indicates reproducibility, was 0.85 (95% confidential interval: 0.40–0.96, p < 0.05). Concurrent validity testing showed a statistically significant correlation between POD-10 and Eating Assessment Tool (EAT-10) (r = 0.89, p < 0.05). To test discriminant validity, statistically significant differences were found between early-stage cancer (stage I and II) and advanced-stage cancer (stage III and IV) (p < 0.05). Twenty-four points were calculated as the cutoff value for POD-10 using receiver operating characteristic analysis to calculate the cutoff value. The POD-10 was shown to be a clinically reliable and valid scale that can be used to subjectively assess postoperative oral dysfunction in patients with oral cancer and is expected to be used as a simple diagnostic tool.

Asymptomatic swallowing disorders may be present in individuals with laryngeal and hypopharyngeal cancer treated with chemo-radiotherapy

PURPOSE

Patients with advanced laryngeal and hypopharyngeal cancer are often treated with chemo-radiotherapy to avoid total laryngectomy. Subclinical swallowing disorders could be present in these patients even though patients do not complain of any symptoms. We sought to evaluate the impact of chemoradiation on swallowing and quality of life.

METHODS

We studied 21 patients undergoing chemo-radiotherapy for advanced laryngeal and hypopharyngeal cancer. All patients were tumor-free and none reported symptoms related to dysphagia during follow-up or showed altered routine screening tests (EAT-10) to detect it. Swallowing functions were assessed using volume-viscosity swallow test (V-VST) and fiberoptic endoscopic evaluation of swallowing (FEES). Quality of life was assessed with the EORT-H&N35, and SWAL-QOL scales.

RESULTS

Frequent alterations in swallowing efficacy (100%) and safety (85.5%) were detected with V-VST and FEES. Quality-of-life scales showed a reduction in their scores between 12 and 17%, mainly in the areas of symptoms.

CONCLUSION

Swallowing disorders are common after chemo-radiotherapy, even in patients who do not clinically manifest these disorders, contributing to a decrease in patients' quality of life. FEES and V-VST are useful procedures to detect asymptomatic swallowing disorders.

Identification and management of late dysfunction in survivors of head and neck cancer: Implementation and outcomes of an interdisciplinary quality of life (IQOL) clinic

BACKGROUND

Identifying and treating late dysfunction in survivors of head and neck cancer (HNC) is important; however, an effective way to do so is not established.

METHODS

A quality improvement initiative altering our HNC survivorship clinic to include surveillance by rehabilitation providers was undertaken. The nature of dysfunction identified, along with the number and type of referrals to ancillary/support services were collected and compared to baseline.

RESULTS

The baseline, single-provider, clinic evaluated 61 patients and referred 2 (3%) to ancillary/support services. Fifty-seven patients were evaluated in the interdisciplinary clinic, with 36 (63%) referred to at least one ancillary/support service for new/progressive dysfunction. Of 59 referrals made, 22 (37%) were for dysphagia, 17(29%) were for neck/shoulder dysfunction, and 28 (47%) were attended by the patient.

CONCLUSION

Many HNC survivors exhibit late dysfunction appropriate for referral to ancillary/support services. A survivorship clinic including surveillance by rehabilitation specialists may optimize identification of dysfunction.

Quality of Life Implications After Transoral Robotic Surgery for Oropharyngeal Cancers

Oropharyngeal cancers and their treatment can exquisitely affect a patient's quality of life and functional outcome. Transoral robotic surgery offers a minimally invasive surgical approach that mitigates injury from traditional open surgical approaches and offers a treatment more likely to have short-term side effects compared with nonsurgical treatment. Feeding tube dependence, oral intake, and swallowing questionnaires, in addition to swallowing evaluations provide a snapshot of a patient's current swallowing function. Investigation of patient-reported quality-of-life outcomes allows for understanding of their symptomatology and the comparison of different treatment strategies.