Head and neck cancer patients treated with concomitant chemoradiotherapy involving the oral cavity and oropharynx: is another choice possible than prophylactic gastrostomy?

PURPOSE OF REVIEW

Recent recommendations on cachexia highlight, in head and neck cancers, the heterogeneity of studies, focusing on weight loss and sequelae including swallowing disorders. The current national guidelines emphasize that, in cases of concurrent chemoradiotherapy (cCRT) involving the oral cavity and oropharynx, prophylactic gastrostomy placement should be carried out systematically. We review why this technique is particularly relevant in this specific location for the feasibility of cCRT.

RECENT FINDINGS

A randomized trial is underway on swallowing disorders and the quality of life of patients after prophylactic vs. reactive gastrostomy in advanced oropharyngeal cancer patients treated with CRT. Concurrently, recent literature reviews emphasize the importance of the cumulative dose of chemotherapy for local control and survival. In cases of cCRT involving the oral cavity or the oropharynx, nutritional support could have a beneficial or detrimental impact on chemotherapy.

SUMMARY

Specifically for patients treated with cCRT involving the oral cavity and oropharynx, prophylactic gastrostomy would be able to fulfill the three objectives of local control, survival, and quality of life, minimizing complications related to nutritional support. Studies need to be more homogeneous. In clinical practice, nutrition should primarily assist in carrying out cancer treatment when survival is the main goal.

Intraoperative Protection of Pharyngeal Autonomic Nerves: Preventing Dysphagia After Anterior Cervical Decompression and Fusion Surgery

OBJECTIVE

The study aims to investigate whether intraoperative protection of the pharyngeal autonomic nerve can effectively reduce the incidence of postoperative dysphagia following anterior cervical decompression and fusion surgery (ACDF).

METHODS

A retrospective analysis was conducted on 130 cases that underwent ACDF from January 2018 to June 2022 at our hospital. Divided into nonautonomic neuroprotection (NANP) group and autonomic neuroprotection group based on whether receive protective measures for the pharyngeal autonomic nerve during surgery. General data were recorded and compared between the 2 groups. Postoperative outcomes were evaluated using Neck Disability Index, Japanese Orthopaedics Association (JOA) score, and JOA improvement rate. The incidence and severity of postoperative dysphagia were assessed using Bazaz dysphagia assessment criteria and swallowing-quality of life questionnaire.

RESULTS

There were no significant differences in general data (P > 0.05). The average operation time and intraoperative blood loss also showed no significant differences (P > 0.05). Both groups showed significant improvements in Neck Disability Index and JOA scores at all follow-up time points compared to preoperative scores (P < 0.01). The incidence of postoperative dysphagia in the autonomic neuroprotection group was significantly lower than that in the NANP group at all follow-up time points (P < 0.05). Both group showed a significant reduction in scores 3 days postoperatively compared to preoperative scores (P < 0.01), and the NANP group also showed significant reductions in scores at 3 month and 1 year postoperative follow-up time points compared to preoperative scores (P < 0.01).

CONCLUSIONS

The adoption of pharyngeal autonomic nerve protective measures during ACDF can effectively lower the probability of postoperative dysphagia.

Application of Intraoperative Neurophysiological Monitoring (IONM) for Preventing Dysphagia After Anterior Cervical Surgery: A Prospective Study

OBJECTIVE

To evaluate the clinical value of intraoperative nerve monitoring (IONM) for dysphagia after anterior cervical surgery with and without IONM.

METHODS

A prospective, randomized, controlled study was conducted on 46 patients who underwent anterior cervical spine surgery by an experienced orthopaedic surgeon. Twenty-three patients who underwent anterior cervical surgery did not undergo IONM (non-IONM group), while the other 23 patients who underwent anterior cervical surgery did ("IONM group"). The swallowing function of patients was evaluated using the EAT-10 and endoscopic evaluation of swallowing (FEES) after surgery.

RESULTS

There was no difference in the incidence of swallowing difficulties between the intervention group and the control group on the third day or sixth week after surgery. At the 12th week after surgery, the incidence of swallowing difficulties in the intervention group and the control group was significantly different (43.5% vs. 13.0%, P = 0.024).

CONCLUSIONS

IONM is a promising tool for identifying and protecting the spinal cord and nerves during anterior cervical surgery. Our research revealed that IONM significantly reduced the occurrence of swallowing disorders 12 weeks after surgery, but the effect was not significant at the third or sixth week after surgery.

Prophylactic Swallowing Therapy During Head-and-Neck Cancer Radiotherapy: Effect of Service-Delivery Mode and Overall Adherence Level on Swallowing Function and Muscle Strength-the PRESTO Trial

Prophylactic swallowing exercises (PSE) during head-and-neck cancer (HNC) (chemo)radiotherapy (CRT) have a positive effect on swallowing function and muscle strength. Adherence rates to PSE are, however, moderate to low, undermining these effects. PRESTO already showed that the service-delivery mode (SDM), the way the exercises are offered, can influence adherence. The aim of this study was to investigate the effect of SDM on swallowing function and muscle strength during and post-CRT. In addition, the effect of overall adherence (OA), independent of SDM, was also investigated. A total of 148 HNC patients, treated with CRT, were randomly assigned to one of the three SDM's (paper-supported, app-supported, or therapist-supported PSE) and performed a 4-week PSE program. OA was calculated based on the percentage of completed exercises. Patients were divided into OA levels: the OA75+ and OA75- group performed respectively ≥ 75 and < 75% of the exercises. Swallowing function based on Mann Assessment of Swallowing Ability-Cancer (MASA-C), tongue and suprahyoid muscle strength during and up to 3 months after CRT were compared between the SDM's and OA levels. Linear Mixed-effects Models with post hoc pairwise testing and Bonferroni-Holm correction was used. No significant differences were found between the three SDMs. Significant time effects were found: MASA-C scores decreased and muscle strength increased significantly during CRT. By the end of CRT, the OA75+ showed significantly better swallowing function compared to OA75-. Muscle strength gain was significantly higher in the OA75+ group. SDM had no impact on swallowing function and muscle strength; however, significant effects were shown for OA level. Performing a high level of exercise repetitions is essential to benefit from PSE.Trial registration ISRCTN, ISRCTN98243550. Registered December 21, 2018-retrospectively registered, https://www.isrctn.com/ISRCTN98243550?q=gwen%20van%20nuffelen&filters=&sort=&offset=1&totalResults=2&page=1&pageSize=10&searchType=basic-search.

The effects of Phoniatric PREhabilitation in Head and Neck Cancer patients on Aspiration and Preservation of Swallowing (PREHAPS): study protocol of a monocentric prospective randomized interventional outcome-blinded trial

BACKGROUND

Dysphagia, with its negative impact on life expectancy and quality of life, is a major side effect of head and neck squamous cell carcinoma (HNSCC). In a typical Head and Neck Cancer Center, more than half of patients are affected. Improving treatment, and ideally prevention respectively prehabilitation, therefore seems more than desirable.

METHODS

The study is planned as a monocentric, prospective, outcome-blinded, randomized interventional study comparing an advanced phoniatric-logopedic prehabilitation with a control (standard of care). Seventy patients (30 control group, 30 intervention group, 10 drop-out rate of 15%) with an initial diagnosis of invasive HNSCC and curative treatment intention will be included over a period of 17 months. In addition to the previous standard, both groups will undergo both detailed subjective assessment of swallowing function and quality of life by means of various questionnaires and objective analyses by bioelectrical impedance measurements and phoniatric endoscopic swallowing examinations. In the intervention group, risk-related nutritional counseling (face-to-face) and phoniatric-logopedic prehabilitation are provided: detailed counseling with video demonstration and exercises to strengthen and improve the range of motion of the oral, pharyngeal, and laryngeal muscles (guided by exercise diary). Controls are performed at 6 weeks, 3 and 6 months, and 9 or 12 months after the end of therapy during the regular tumor follow-up. Primary study endpoints are swallowing function and emotional distress at 6 weeks of control visit.

DISCUSSION

Prehabilitation measures have already proven successful in other patient groups, e.g., transplant patients. In the field of head and neck oncology, interest in such concepts has increased significantly in recent years. However, usually, only subgroups, e.g., patients with swallowing problems after radiochemotherapy alone, are in focus. Our study aims to investigate the general benefit of prehabilitation with regard to swallowing function, which is so important for protection of aspiration and quality of life.

TRIAL REGISTRATION

German Clinical Trials Register DRKS00029676 . International Clinical Trials Registry Platform DRKS00029676 . Registered on 19 July 2022.

Study protocol of the OrkA project: orofacial and communicative activation in old age- a cluster randomized prevention study in long-term care facilities in Lower Saxony, Germany

BACKGROUND

The process of aging involves numerous changes in the body, influencing physical, mental, and emotional well-being. Age-related changes and degradation can impact various functions of the swallowing process and lead to delayed word retrieval. Individuals with limited linguistic stimulation may experience a more rapid decline in cognitive performance. Thus, this project explores a preventive training program targeting swallowing and linguistic-communicative skills, aimed at preserving the social participation of older individuals residing in nursing homes.

METHODS

A preventive intervention program, combining orofaciopharyngeal and linguistic-communicative components, will be offered twice weekly over 12 weeks in long-term care facilities in the greater Hanover area. The program will aim at: (a) activating sensitive and motor skills in the orofaciopharyngeal area to counter age-related swallowing disorders, and (b) enhancing communicative abilities through semantic-lexical activation. A cluster randomized controlled trial will be conducted to investigate whether the intervention program improves swallowing skills in older adults. Additionally, a secondary analysis will explore the impact on language skills and social participation, as well as program acceptance.

DISCUSSION

The results will provide valuable insight into the effectiveness of preventive measures addressing swallowing and speech issues in older individuals.

TRIAL REGISTRATION

The trial was registered with DRKS (German register for clinical trials) in June 2023 (study ID: DRKS00031594) and the WHO International Clinical Trail Registry Platform (secondary register).

Efficacy of Tracheal Traction Exercise for Prevention of Laryngopharyngeal Complications Following Anterior Cervical Discectomy and Fusion: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

OBJECTIVE

Tracheal traction exercise (TTE) has been proposed as a preventative measure for laryngopharyngeal complications following anterior cervical discectomy and fusion. However, the exact effects of TTE remain controversial. Therefore, we conducted a systematic review and meta-analysis of randomized controlled trials to evaluate the efficacy of TTE.

METHODS

We systematically searched PubMed, Web of Science, Embase, Cochrane, ClinicalTrials.gov, China National Knowledge Infrastructure, WANFANG DATA, VIP citation databases, and Chinese BioMedical Literature Database for randomized controlled trials (published between January 1, 2000, and January 23, 2023, without language restrictions) comparing the TTE group to the control group (non-TTE group). We assessed the risk of bias using Cochrane risk of bias assessment tool. Our primary end points were operation duration, the number of patients with postoperative dysphagia, and Visual Analog Scale (VAS) for laryngopharyngeal pain. We used a fixed-effects model to assess the pooled data.

RESULTS

Of the 823 identified studies, 5 were eligible and included in our analysis (N = 542 participants). Compared with the control group, TTE reduced the incidence of postoperative dysphagia (relative risk = 0.41, 95% confidence interval [CI]: 0.28, 0.61, P < 0.05) and operation duration (weighted mean difference = -10.24, 95% CI: -14.48, -6.00, P < 0.05). However, no significant difference was observed in postoperative VAS between the 2 groups (weighted mean difference = -0.11, 95% CI: -0.23, 0.11, P = 0.08 > 0.05).

CONCLUSIONS

TTE can effectively reduce operation duration and postoperative dysphagia. However, it does not result in a significant difference in postoperative VAS.

Preservation of superior laryngeal nerve in transoral surgery: A technology to enhance the recovery of swallowing function after surgery of hypopharyngeal carcinoma

OBJECTIVES

We intended to preserve the internal branch of superior laryngeal nerve in transoral surgery of hypopharyngeal squamous cell carcinoma and observe swallowing function recovery.

METHODS

26 patients with hypopharyngeal squamous cell carcinoma underwent transoral surgery with the preservation of internal branch of superior laryngeal nerve. Sensation in the pharyngolaryngeal mucosa was tested by flexible laryngoscope and swallow function was evaluated by water swallow test and MD Anderson Dysphagia Inventory questionnaire after surgery.

RESULTS

Surgeries were successfully performed in all patients. The internal branch of superior laryngeal nerve were preserved in all patients. Testing of mucosa sensation revealed the presence of the cough reflex in most patients. The water swallow test showed that 12 cases (46.15%) on the 1st day, 23 cases (88.46%) on the 7th day and 25 cases (96.15%) on the 14th day after operation had normal swallowing function. The mean score of MD Anderson Dysphagia Inventory was 98 on the 14th day after operation. All patients achieved an oral soft diet at a median of 3 days (range, 2-6 days), full normal oral diet at a median of 5.5 days (range, 4-10 days) and removal of the nasogastric tube at a median of 6 days (range, 5-11 days). During the two-year follow-up, 3 patients recured, 1 patient died of lung metastasis.

CONCLUSIONS

Preserving of the internal branch of superior laryngeal nerve in transoral surgery is feasible, and it can help to achieve a satisfactory recovery of the swallowing function after surgery of hypopharyngeal squamous cell carcinoma.

Routine Prophylactic Percutaneous Endoscopic Gastrostomy in Head and Neck Cancers with Bilateral Neck Irradiation: A Regional Cancer Experience in New Zealand

INTRODUCTION

Patients with head and neck cancer (HNC) are particularly susceptible to dysphagia and malnutrition. Prophylactic percutaneous endoscopic gastrostomy (PEG) placement is a method used to manage these issues, but practices vary among institutions. At Midcentral District Health Board, patients receiving radiotherapy to the primary and bilateral neck regions routinely undergo prophylactic PEG placement. This study aimed to review the nutritional and PEG-related outcomes of these patients.

METHODS

Records of 49 patients were retrospectively reviewed. Their demographics, tumour and treatment characteristics were recorded. We evaluated patient weight loss, non-elective hospitalisation, treatment interruption rates, PEG-related complications, usage, dependency rates and late dysphagia rates.

RESULTS

Oropharyngeal cancers were the most common primary site (61.2%), and 83.7% of patients received primary chemoradiotherapy. Mean weight loss at treatment completion was 5.6% ± 4.3 (4.6 kg ± 3.9). The rate of non-elective hospitalisations was 26.5%, and only 2% of patients had treatment interruptions. Peristomal infection was the most frequent PEG complication (20.4%). No PEG-related mortality was reported. Median duration of PEG dependency was 97 days (14-388 days). Two patients remained permanently dependent at 3 years due to grade 3 dysphagia, and six patients experienced grade ≥2 late dysphagia.

CONCLUSION

Our study showed that prophylactic PEG tube placement was relatively safe, with a high utilisation rate and low long-term dependence on PEG tubes after treatment completion. However, complications related to their use should be addressed through a multidisciplinary approach, with careful assessment by clinicians. The weight loss and hospitalisation rates observed were consistent with earlier studies that utilised prophylactic PEG tubes.

Zero-profile anchored spacer versus conventional plate-cage construct in bilevel anterior cervical discectomy and fusion: a systematic review and meta-analysis

BACKGROUND

Zero-profile anchored spacers (ZAS) and plate-cage constructs (PCC) are currently employed when performing anterior cervical discectomy and fusion (ACDF). Nevertheless, the efficacy and safety of both devices in bilevel ACDF remain controversial. The goal of our meta-analysis is to assess the overall long-term efficacy and security among ZAS and PCC in bilevel ACDF.

METHODS

A search of four electronic databases was conducted to identify researches that compared ZAS with PCC for bilevel ACDF. Stata MP 17.0 software was used for this meta-analysis.

RESULTS

Nine researches with a total of 580 patients were involved. In comparison to PCC, ZAS significantly reduced intraoperative bleeding and postoperative dysphagia rates. No significant differences were found concerning operation time, JOA score, NDI score, cervical Cobb angle, fusion rates, the incidence of adjacent segmental degeneration (ASD) and implant sinking rates at last follow-up.

CONCLUSION

Compared to PCC, ZAS achieved similar efficacy and security in bilevel ACDF with respect to operative time, JOA score, NDI score, cervical Cobb angle, fusion rates, implant sinking rates and ASD rates at final follow-up. It is worth noting that ZAS offered considerable benefits over conventional PCC for the reduction of intraoperative bleeding and postoperative dysphagia. Therefore, for patients requiring bilevel ACDF, ZAS seems superior to PCC. Given the limitations of our study, larger prospective randomised controlled trials are needed to establish reliable proof to consolidate our conclusions.

Adhering to Eat and Exercise Status During Radiotherapy for Oropharyngeal Cancer for Prevention and Mitigation of Radiotherapy-Associated Dysphagia

Importance

Previously published work reported independent benefit of maintenance of oral intake (eat) and swallowing exercise adherence (exercise) during radiotherapy (RT) on diet and functional outcomes. The current study seeks to validate the authors' previously published findings in a large contemporary cohort of patients with oropharynx cancer (OPC) and address limitations of the prior retrospective study using prospective, validated outcome measures.

Objective

To examine the longitudinal association of oral intake and swallowing exercise using validated, clinician-graded and patient-reported outcomes.

Design, Setting, and Participants

Secondary analysis of a prospective OPC registry including patients who underwent primary RT/chemoradiotherapy (CRT) or primary transoral robotic surgery plus RT/CRT for OPC at a single-institution comprehensive cancer center.

Exposures

Adherence to speech pathology swallowing intervention during RT coded as (1) eat: oral intake at end of RT (nothing by mouth [NPO]; partial oral intake [PO], with feeding tube [FT] supplement; full PO); and (2) exercise: swallowing exercise adherence (nonadherent vs partial/full adherence).

Main Outcomes and Measures

Feeding tube and diet (Performance Status Scale for Head and Neck Cancer) patient-reported swallowing-related quality of life (MD Anderson Dysphagia Inventory; MDADI) and clinician-graded dysphagia severity grade (videofluoroscopic Dynamic Imaging Grade of Swallowing Toxicity; DIGEST) were collected at baseline, 3 to 6 months, and 18 to 24 months post-RT.

Results

A total of 595 patients (mean [SD] age, 65 [10] years; 532 [89%] male) who underwent primary RT (111 of 595 [19%]), CRT (434 of 595 [73%]), or primary transoral robotic surgery plus RT/CRT (50 of 595 [8%]) were included in this cohort study. At the end of RT, 55 (9%) patients were NPO, 115 (19%) were partial PO, 425 (71%) were full PO, and 340 (57%) reported exercise adherence. After multivariate adjustment, subacute return to solid diet and FT were independently associated with oral intake (odds ratio [OR], 2.0; 95% CI, 1.0-4.1; OR, 0.1; 95% CI, 0.0-0.2, respectively) and exercise (OR, 2.9; 95% CI, 1.9-4.5; OR, 0.3; 95% CI, 0.1-0.5, respectively). Subacute MDADI (β = 6.5; 95% CI, 1.8-11.2), FT duration (days; β = -123.4; 95% CI, -148.5 to -98.4), and less severe dysphagia per DIGEST (OR, 0.6; 95% CI, 0.3-1.0) were independently associated with oral intake, while exercise was independently associated with less severe laryngeal penetration/aspiration per DIGEST-safety (OR, 0.7; 95% CI, 0.4-1.0). DIGEST grade associations with oral intake were not preserved long-term; however, exercise was associated with a higher likelihood of solid diet intake and better swallow safety per DIGEST.

Conclusions and Relevance

The findings of this cohort study extend the authors' previously published findings that oral intake and swallowing exercise during RT are associated with favorable functional outcomes, now demonstrated with broader domains of function using validated measures. Patterns of benefit differed in this study. Specifically, better subacute recovery of swallow-related quality of life and less severe dysphagia were found among patients who maintained oral intake independent of exercise adherence, and shorter FT utilization and better long-term diet and swallowing safety were found among those who exercised independent of oral intake.

Feasibility of Mobile and Sensor Technology for Remote Monitoring in Cancer Care and Prevention

Objectives. Remote monitoring (RM) of health-related outcomes may optimize cancer care and prevention outside of clinic settings. CYCORE is a software-based system for collection and analyses of sensor and mobile data. We evaluated CYCORE's feasibility in studies assessing: (1) physical functioning in colorectal cancer (CRC) patients; (2) swallowing exercise adherence in head and neck cancer (HNC) patients during radiation therapy; and (3) tobacco use in cancer survivors post-tobacco treatment (TTP). Methods. Participants completed RM: for CRC, blood pressure, activity, GPS; for HNC, video of swallowing exercises; for TTP, expired carbon monoxide. Patient-reported outcomes were assessed daily. Results. For CRC, HNC and TTP, respectively, 50, 37, and 50 participants achieved 96%, 84%, 96% completion rates. Also, 91-100% rated ease and self-efficacy as highly favorable, 72-100% gave equivalent ratings for overall satisfaction, 72-93% had low/no data privacy concerns. Conclusion. RM was highly feasible and acceptable for patients across diverse use cases.

Effectiveness of Water Jelly Ingestion for Both Rehabilitation and Prevention of Aspiration Pneumonia in Elderly Patients With Moderate to Severe Dysphagia

BACKGROUND AND AIMS

We evaluated the effectiveness of water jelly ingestion for both rehabilitation and the prevention of aspiration pneumonia in a retrospective analysis of elderly patients with moderate to severe dysphagia.

PATIENTS AND METHODS

Study 1: consecutive patients with borderline ingestion in an endoscopic swallowing evaluation were enrolled (n=36, 18 men and 18 women: mean age 82±9 y) and categorized into a group with water jelly (50 to 100 mL) ingestion training 3×/day or an untrained control group. Their food intake levels were then compared using a Food Intake Level Scale. Study 2: consecutive patients who were hospitalized because of aspiration pneumonia were enrolled (n=64, 35 men and 29 women: mean age 81±9 y) and categorized into a group with cyclic ingestion of water jelly immediately after each meal or a control group. The incidence of aspiration pneumonia that was newly developed during hospitalization was compared between the groups.

RESULTS

In study 1, 36 patients with a Hyodo-Komagane score of 8 were enrolled. Three of the 12 (25%) patients who underwent water jelly ingestion training were able to eat a pureed diet (level 5, 2 patients; level 6, 1 patient) while none of the 24 patients (0%) who did not undergo this training were able to eat any form of diet (levels 5 and 6, no patients) (P=0.011). In study 2, 64 patients were enrolled. No newly developed aspiration pneumonia was observed in the 34 patients (0%) who received cyclic water jelly ingestion, whereas 17% (5/30) of patients not receiving water jelly after meals newly developed aspiration pneumonia during hospitalization (P=0.031).

CONCLUSIONS

Water jelly ingestion was effective for both rehabilitation and the prevention of aspiration pneumonia in elderly patients with moderate to severe dysphagia.

Effects of Carbonation on Swallowing: Systematic Review and Meta-Analysis

OBJECTIVES

The effectiveness of the use of carbonation in preventing penetration/aspiration or enhancing swallowing function in adults remains unclear. This systematic review aimed to evaluate the effectiveness of carbonation on improving swallowing function in adult subjects.

METHODS

Literature published before March 2021 was inspected using MEDLINE, CINAHL, Web of Science Core Collection, The Cochrane Library, Cochrane Central Register of Controlled Trials, and Ichushi-web databases. We searched for intervention studies or randomized control trials considering the effects of carbonated liquids on swallowing function. The risk of bias was assessed using the Cochrane tool for assessing the risk of bias for randomized controlled trials and the Risk of Bias Assessment Tool for Nonrandomized Studies.

RESULTS

The systematic review identified 19 studies with a total of 586 participants. The effects of carbonation on swallowing function are diverse. Overall, most studies showed that carbonation promotes swallowing function compared to other liquids. Five studies were included in the quantitative synthesis. Meta-analysis showed that carbonated liquids prevent aspiration (risk difference [RD] -0.27%, 95% confidence interval [CI] -0.44 to -0.10; I²  = 0%; number needed to treat 3.8, 95% CI 2.2 to 15.0; moderate quality of evidence) when compared to noncarbonated thin liquids. Carbonated liquids also increased the duration of swallowing apnea than did noncarbonated liquids (standardized mean difference 0.25 (mean difference 0.36 seconds), 95% CI 0.03 to 0.47; I²  = 0%; low quality of evidence).

CONCLUSIONS

Carbonation had favorable effects on swallowing function. Further in-depth studies are needed to clarify the benefits of carbonation.

LEVEL OF EVIDENCE

NA Laryngoscope, 2022.

Dysphagia, Fear of Choking and Preventive Measures in Patients with Huntington's Disease: The Perspectives of Patients and Caregivers in Long-Term Care

OBJECTIVES

To explore the prevalence of dysphagia and fear of choking in patients with Huntington's disease (HD) as well as preventive measures, both those applied and those not included in managing dysphagia. Also, to investigate related problems encountered by their formal and informal caregivers.

DESIGN

A multi-center observational cross-sectional study.

SETTING AND PARTICIPANTS

158 HD patients, recruited from six Dutch nursing homes specialized in HD, and their formal and informal caregivers.

MEASUREMENTS

Patients were assessed by means of questionnaires enquiring about dysphagia, fear of choking and measures to manage dysphagia. Also, questionnaires were administered about awareness of dysphagia symptoms, cognition and anxiety. Because we expected individuals with greater care dependency to have a higher severity of dysphagia, we distinguished between a care-independent and a care-dependent group of HD patients.

RESULTS

In the total group, 90.5% of HD patients had one or more dysphagia symptoms. The prevalence of FoC in HD patients and the formal and informal caregivers' fears about choking in HD patients was 45.7%, 19.0% and 59.5%, respectively, for care-independent patients and 58.7%, 50.1% and 77.5% for care-dependent patients. The score on the Huntington's Disease Dysphagia Scale was a predictor for fear of FoC in care-independent patients. Speech-language therapy, supervision during eating and drinking and adaptation of food and drink consistency were the most frequently applied measures to manage dysphagia, a combination was used in most HD patients.

CONCLUSIONS

In HD patients, the prevalence of dysphagia is high and fear of choking is common among both patients and caregivers. A more severe degree of dysphagia is a predictor of FoC in care-independent HD patients. A combination of measures was used to manage dysphagia in most HD patients.

The PRO-ACTIVE trial protocol: a randomized study comparing the effectiveness of PROphylACTic swallow InterVEntion for patients receiving radiotherapy for head and neck cancer

BACKGROUND

Swallowing therapy is commonly provided as a treatment to lessen the risk or severity of dysphagia secondary to radiotherapy (RT) for head and neck cancer (HNC); however, best practice is not yet established. This trial will compare the effectiveness of prophylactic (high and low intensity) versus reactive interventions for swallowing in patients with HNC undergoing RT.

METHODS

This multi-site, international randomized clinical trial (RCT) will include 952 adult patients receiving radiotherapy for HNC and who are at high risk for post-RT dysphagia. Participants will be randomized to receive one of three interventions for swallowing during RT: RE-ACTIVE, started promptly if/when dysphagia is identified; PRO-ACTIVE EAT, low intensity prophylactic intervention started before RT commences; or, PRO-ACTIVE EAT+EXERCISE, high intensity prophylactic intervention also started before RT commences. We hypothesize that the PRO-ACTIVE therapies are more effective than late RE-ACTIVE therapy; and, that the more intensive PRO-ACTIVE (EAT + EXERCISE) is superior to the low intensive PRO-ACTIVE (EAT). The primary endpoint of effectiveness is duration of feeding tube dependency one year post radiation therapy, selected as a pragmatic outcome valued equally by diverse stakeholders (e.g., patients, caregivers and clinicians). Secondary outcomes will include objective measures of swallow physiology and function, pneumonia and weight loss, along with various patient-reported swallowing-related outcomes, such as quality of life, symptom burden, and self-efficacy.

DISCUSSION

Dysphagia is a common and potentially life-threatening chronic toxicity of radiotherapy, and a priority issue for HNC survivors. Yet, the optimal timing and intensity of swallowing therapy provided by a speech-language pathologist is not known. With no clearly preferred strategy, current practice is fraught with substantial variation. The pragmatic PRO-ACTIVE trial aims to specifically address the decisional dilemma of when swallowing therapy should begin (i.e., before or after a swallowing problem develops). The critical impact of this dilemma is heightened by the growing number of young HNC patients in healthcare systems that need to allocate resources most effectively. The results of the PRO-ACTIVE trial will address the global uncertainty regarding best practice for dysphagia management in HNC patients receiving radiotherapy.

TRIAL REGISTRATION

The protocol is registered with the US Patient Centered Outcomes Research Institute, and the PRO-ACTIVE trial was prospectively registered at ClinicalTrials.gov , under the identifier NCT03455608 ; First posted: Mar 6, 2018; Last verified: Jun 17, 2021. Protocol Version: 1.3 (January 27, 2020).

Does Local Steroid Reduce Dysphagia After Cervical Disc Replacement? A Prospective, Randomized, Placebo-controlled, Double-blinded Study

STUDY DESIGN

A prospective, randomized, placebo-controlled, double-blinded study.

OBJECTIVE

To examine the effect of intraoperatively administered local Depo-Medrol on the incidence and severity of postoperative dysphagia in patients undergoing cervical disk replacement (CDR) surgery.

SUMMARY OF BACKGROUND DATA

Dysphagia is often reported as an adverse event after anterior cervical surgeries. One method for reducing the incidence of postoperative dysphagia in patients undergoing anterior cervical discectomy and fusion surgeries is the intraoperative application of topical corticosteroids to the retroesophageal space. There have been no studies examining the effect of local steroids on dysphagia after CDR surgery.

MATERIALS AND METHODS

Seventy-three patients underwent CDR surgery by a single surgeon at a single institution. A 1 cm ×3 cm ×3 mm gel foam collagen sponge was saturated by the nurse with either saline (1 cc) or Depo-Medrol (40 mg/1 cc) based on randomization protocol. The sponge was placed ventral to the cervical disk implant in the retroesophageal space. Study follow-up occurred on postoperative day 1, 4, 7, 14 and postoperative month 1, 2, and 3. Dysphagia outcomes were classified using the Bazaz Dysphagia Score and Eating Assessment Tool 10.

RESULTS

The steroid group, compared with the control group, had significantly reduced incidence of dysphagia (50% vs. 75%; P=0.0427) and severe dysphagia (12% vs. 36% Bazaz score, P=0.0253; 18% vs. 42% Eating Assessment Tool 10, P=0.0378) at POD4. There was no significant long-term difference in rates of dysphagia between the control and the steroid group.

CONCLUSIONS

This study provides level 1 evidence that the use of intraoperative locally administered Depo-Medrol significantly reduces the incidence and severity of dysphagia within the first week after CDR surgery. The use of local steroid may provide patients undergoing CDR surgery with a more pleasant early recovery experience with respect to dysphagia.

Prevention and management of acute esophageal toxicity during concomitant chemoradiotherapy for locally advanced lung cancer

BACKGROUND

Standard treatment for locally advanced non-small cell lung cancer (LA-NSCLC) is concomitant chemoradiotherapy. The survival benefit of combined treatment is partially counterbalanced by an increased rate of acute esophageal toxicity. Several pharmaceutical products are available for prevention and management of esophagitis, including Faringel Plus.

AIM

To assess the incidence and the grade, identify the correlations with clinical, dosimetric, and therapeutic variables, and analyse the role of Faringel Plus as a pharmaceutical preventive measure against acute esophageal toxicity.

METHODS

Patients with LA-NSCLC treated with concomitant radiochemotherapy were retrospectively reviewed. Acute esophagitis and dysphagia were graded according to Common Terminology Criteria for Adverse Events version 5.0. Clinical, dosimetric, and therapeutic correlations were investigated using χ² test.

RESULTS

Among the 23 analysed patients, 18 (78.3%) and 1 (4.3%) developed G2 and G3 esophagitis, respectively; G1-2 dysphagia were reported in 11 cases (47.8%). No statistically significant correlation between the variables considered and acute esophageal toxicity was identified. In the group of patients who received Faringel Plus as preventive treatment (10 subjects, 43.5%), dysphagia presentation time was significantly longer (p = 0.038); esophagitis onset time was longer and symptoms duration was shorter. Faringel Plus allowed a reduction in the use of analgesic drugs.

CONCLUSIONS

Acute mild esophageal toxicity was confirmed to be a common side effect in this setting. No clinical-dosimetric parameter has been demonstrated to be effective in predicting acute esophageal toxicity. The use of Faringel Plus appears effective as a therapeutic and prophylactic tool to manage acute esophageal toxicity.

Additional fundophrenicopexia, after Nissen fundoplication, reduces postoperative dysphagia and re-operation rate in the long-term follow up

Background

Various technical modifications of Nissen fundoplication (NF) that aim to improve patients’ outcomes have been discussed. This study aims to evaluate the effect of division of the short gastric vessels (SGV) and the addition of a standardized fundophrenicopexia on the postoperative outcome after NF.

Methods

283 consecutive patients with GERD treated with NF were divided into four groups following consecutive time periods: with division of the SGV and without fundophrenicopexia (group A), with division of the SGV and with fundophrenicopexia (group B), without division of the SGV and with fundophrenicopexia (group C) and without division of the SGV and without fundophrenicopexia (group D). Postoperative contrast swallow, dysphagia scoring, GEDR-HRQL and proton pump inhibitor intake were evaluated. A comparative analysis of patients with division of the SGV and those without (161 A + B vs. 122 C + D), and patients with fundophrenicopexia and those without (78 A vs. 83 B and 49 C vs. 73 D) was performed.

Results

Fundophrenicopexia reduced postoperative dysphagia rates (0 group C vs. 5 group D, p = 0.021) in patients where the SGV were preserved and reoperation rates (1 group B vs. 7 group A, p = 0.017) in patients where the SGV were divided. There was no significant difference in the postoperative rates of heartburn relief, dysphagia, gas bloating syndrome, interventions, re-fundoplication and the GERD-HRQL score between groups A + B and C + D, respectively.

Conclusion

Standardized additional fundophrenicopexia in patients undergoing Nissen fundoplication significantly reduces postoperative dysphagia in patients without division of the SGV and reoperation rates in patients with division of the SGV. Division of the SGV has no influence on the postoperative outcome of NF.

Local Retropharyngeal Space Anesthetic for Dysphagia Reduction after Anterior Cervical Discectomy and Fusion Surgery: A Single-Center, Prospective, Randomized, Double-Blinded, Placebo-Controlled Clinical Trial

OBJECTIVE

The main objective of this study was to analyze the ability of local anesthetic instillation into the retropharyngeal space to reduce dysphagia symptoms and occurrence rates in patients undergoing anterior cervical discectomy and fusion (ACDF) procedures.

METHODS

A single-center, prospective, randomized, double-blinded, and placebo-controlled clinical study was performed. We enrolled patients undergoing one- or two-level ACDF procedures for cervical degenerative disc disease with disc herniation, radiculopathy and/or myelopathy symptoms. The patients were randomly assigned (1:1 ratio) to receive either 0.5% bupivacaine hydrochloride or 0.9% NaCl solution.

RESULTS

Forty-three (74%) and 41 (77%) of patients reported dysphagia symptoms at the time of discharge in the investigational and control groups, respectively. There were no statistically significant differences in duration of dysphagia symptoms, Swallowing-Quality of Life (SWAL-QOL) survey or pain scores between the investigational and control patient groups at any of the follow-up time points. Controlling for independent variables, only younger age significantly predicted dysphagia symptoms at discharge, 2-week, and 3-month follow-ups (P ≤ 0.03; R ≥ -0.038; OR 0.96, 95% CI 0.93-0.99. Female sex was associated with lower SWAL-QOL scores at discharge (P = 0.046; R = 0.87; OR 2.38, 95% CI 1.02-5.56). A total of 8 (13.8%) and 6 (11.3%) patients in the investigational and control groups, respectively, were referred to a specialist or underwent speech therapy for their dysphagia symptoms. There were no adverse reactions to the study drug observed.

CONCLUSIONS

Local retropharyngeal space anesthetic instillation did not reduce dysphagia symptoms or occurrence rates in patients undergoing anterior discectomy and fusion surgeries.

Pharmacological considerations in antipsychotic drug selection for prevention of drug-induced dysphagia

Antipsychotic drugs have the ability to induce dysphagia. The aim of this study was to determine the association between the receptor affinity of antipsychotic drugs and the time-to-onset of dysphagia, and to identify factors that prevent antipsychotic drug-induced dysphagia. We used the receptor affinity of 13 antipsychotic drugs for which data were reported in an in vitro test using human receptors, extracted time-to-onset dysphagia from the Japan Adverse Drug Event Report database, and used data from 46 patients to evaluate the correlation between receptor affinity and time-to-onset of dysphagia. We found a negative correlation between D₂ receptor affinity and time-to-onset of dysphagia (r = -0.4572, p = 0.0016), and a positive correlation between H₁, M₁, and M₃ receptor affinity and time-to-onset of dysphagia (r = 0.5006, p = 0.0006; r = 0.4130, p = 0.0059; and r = 0.4149, p = 0.0057, respectively). Antipsychotic drugs with a strong D₂ receptor-blocking action may accelerate the onset of dysphagia, whereas a strong H₁, M₁, and M₃ receptor-blocking action may delay the onset of dysphagia. The current study revealed the relationship between the receptor affinity of antipsychotic drugs and the time-to-onset of dysphagia, which should aid in the selection of antipsychotic drugs, while preventing dysphagia.

Effectiveness of Online Training and Supervisor Feedback on Safe Eating and Drinking Practices for Individuals With Developmental Disabilities

Dysphagia is common in individuals with developmental disabilities. Little research exists on the impact of trainings aimed at improving Direct Care Staff's (DCS) use of safe eating and drinking practices. This article presents two studies using pre-and postexperimental design, evaluating online training to improve DCSs' knowledge and ability to identify nonadherence to diet orders. A pilot study (n = 18) informed improvements to the intervention. The follow-up study (n = 64) compared those receiving training with those receiving training plus supervisor feedback. There was no significant difference between groups after training. Both groups increased in knowledge and identification of nonadherence to diet orders. Online training may be an effective tool for training DCS in safe eating and drinking practices.

Development and Predictors of Sarcopenic Dysphagia during Hospitalization of Older Adults

The study aimed to investigate the impact of sarcopenia and sarcopenia-related conditions on the development of swallowing disorders during hospitalization. Older adult inpatients (n = 8768) without swallowing disorders in the premorbid period were studied. Sarcopenia-related conditions were evaluated in terms of nutritional status, physical status, and ambulatory conditions as well as hand-grip strength and muscle mass assessed by calf circumference. Development of swallowing disorders was defined based on food texture at discharge from the hospital. The patients’ mean age was 76.1 ± 6.9 years. A total of 374 (4.3%) patients developed swallowing disorders during hospitalization. They were older, with poorer nutritional status, and had more decline of physical performance than those without swallowing disorders. Performance Status score (odds ratio (OR) = 1.28 (1.12–1.46) p < 0.001), ambulatory dependency (OR = 1.72 (1.09–2.71), p = 0.020), malnutrition score (OR = 0.92 (0.87–0.97), p = 0.002), insufficient nutritional intake (OR = 2.33 (1.60–3.40), p < 0.001), and length of stay (OR = 1.01 (1.00–1.01), p = 0.001) were independent contributing factors for swallowing disorder development in the multivariate analysis. The presence of possible sarcopenia was also a contributor to swallowing disorder development. In conclusion, swallowing disorders could develop in patients with possible sarcopenia and sarcopenia-related conditions during hospitalization. Clinicians should be aware of this risk and provide appropriate interventions to prevent sarcopenic dysphagia.

The Effects of Perioperative Corticosteroids on Dysphagia Following Surgical Procedures Involving the Anterior Cervical Spine: A Prospective, Randomized, Controlled, Double-Blinded Clinical Trial

BACKGROUND

Dysphagia is one of the most common complications of surgical procedures in the anterior cervical spine, and can persist up to 2 years postoperatively. Corticosteroids are relatively safe and inexpensive for treating various inflammatory conditions. Perioperative corticosteroid administration for anterior cervical spine procedures may effectively minimize postoperative dysphagia, potentially leading to better outcomes, decreased readmission rates, and improved patient satisfaction. The purpose of this study was to determine the efficacy of perioperative corticosteroids in decreasing the severity and duration of dysphagia following single-level and multilevel anterior cervical spine procedures.

METHODS

Seventy-four patients undergoing elective anterior cervical surgical procedures for degenerative conditions were recruited. Patients with prior cervical procedures; with a diagnosis of fracture, malignancy, or infection; or requiring combined anterior-posterior procedures were excluded. Patients were randomized to perioperative intravenous dexamethasone or saline solution. Doses were administered before incision and at 8 and 16 hours postoperatively. Investigators and patients were blinded to the treatment throughout the study. Dysphagia outcomes were assessed with use of the Bazaz dysphagia scale and the Dysphagia Short Questionnaire (DSQ) at 1 day, 2 days, 1 week, 2 weeks, 1 month, 3 months, 6 months, and 12 months postoperatively. Statistical analysis was performed comparing means and standard deviations; significance was set at p < 0.05. Clinical outcomes were measured with use of the Quality of Life-12 and Neck Disability Index.

RESULTS

Sixty-four patients were included in the analysis. There were 49 anterior cervical discectomies and fusions, 8 corpectomies, 1 hybrid procedure (corpectomy and adjacent discectomy), and 6 single-level arthroplasties. Patients who received corticosteroids had significantly better dysphagia scores on both the Bazaz scale and DSQ at most time points up to 6 months postoperatively (p < 0.05). On subgroup analysis, patients with multilevel (≥2-level) fusion benefited significantly from corticosteroids on both scales, whereas those with single-level procedures did not. There were no short-term wound complications or infections, and length of stay and fusion rates were comparable.

CONCLUSIONS

Perioperative administration of corticosteroids can reduce dysphagia symptoms following multilevel anterior cervical procedures. Benefit was noted immediately and up to 6 months postoperatively. There was no significant effect on short-term wound-healing, infection rates, length of stay, or fusion rates.

LEVEL OF EVIDENCE

Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Tongue strengthening exercise is effective in improving the oropharyngeal muscles associated with swallowing in community-dwelling older adults in South Korea: A randomized trial

BACKGROUND

Tongue strengthening exercise (TSE) is a remedial method for the training of swallowing-related muscles in the oropharyngeal phase. However, clinical evidence of its effectiveness is insufficient.

METHODS

To investigate the effect of TSE on the oropharyngeal muscles associated with swallowing in older adults, in this study, 40 elder adults living in the community were recruited and assigned to 2 groups. The experimental group performed a TSE with a 1-repetition maximum resistance level of 70%. The exercise was divided into an isometric and isotonic part. The control group did not perform an exercise. We measured the muscle strength and thickness of the tongue and suprahyoid muscles using an Iowa Oral Performance Instrument and ultrasonography.

RESULTS

The experimental group showed a statistically significant increase in tongue muscle strength and thickness in the oral phase (P = .001 and <.001, respectively). In the pharyngeal phase, the experimental group showed a statistically significant increase in the mylohyoid and digastric muscles (suprahyoid muscles) (P = .045 and .019, respectively). The control group showed no statistically significant changes.

CONCLUSION

TSE is effective in increasing the strength and thickness of the oropharyngeal muscles of elder adults and is recommended for those who are vulnerable to swallowing difficulties.

Motor Imagery Practice and Increased Tongue Strength: A Case Series Feasibility Report

Purpose The aim of the study was to determine the effects of a 6-week progressive resistance tongue exercise protocol in mental practice form on tongue strength. Investigation begins in typically aging adults, a population susceptible to reduced tongue strength and dysphagia secondary to age-related changes in the swallowing mechanism. It was hypothesized that typically aging adults who perform a 6-week progressive resistance tongue exercise protocol in mental practice form would increase tongue strength. Method A prospective, case series intervention study was used. Six healthy women aged 53-78 years completed a 6-week mental practice tongue resistance exercise program utilizing motor imagery to imagine completion of tongue exercises. The main outcome was mean isometric maximum tongue pressures (tongue strength), which were collected at baseline and Weeks 2, 4, and 6 using the Iowa Oral Performance Instrument ( IOPI Medical, 2013 ). Results By Week 6 of the study, all participants had significantly increased their tongue strength compared to baseline. Conclusions The findings indicate that mental practice using motor imagery for tongue exercise may improve tongue strength in healthy individuals at risk for dysphagia and may thus represent a promising direction warranting further investigation in typically aging individuals and patients with dysphagia and decreased tongue strength.

Clinical Significance of Esophageal Outflow Resistance Imposed by a Nissen Fundoplication

BACKGROUND

Attention has been focused on the amplitude of esophageal body contraction to avoid persistent dysphagia after a Nissen fundoplication. The current recommended level is a contraction amplitude in the distal third of esophagus above the fifth percentile. We hypothesized that a more physiologic approach is to measure outflow resistance imposed by a fundoplication, which needs to be overcome by the esophageal contraction amplitude.

STUDY DESIGN

The esophageal outflow resistance, as reflected by the intra-bolus pressure (iBP) measured 5 cm above the lower esophageal sphincter (LES), was measured in 53 normal subjects and 37 reflux patients with normal esophageal contraction amplitude, before and after a standardized Nissen fundoplication. All were free of postoperative dysphagia. A test population of 100 patients who had a Nissen fundoplication was used to validate the threshold of outflow resistance to avoid persistent postoperative dysphagia.

RESULTS

The mean (SD) amplitude of the iBP in normal subjects was 6.8 (3.7) mmHg and in patients before fundoplication was 3.6 (7.0) mmHg (p = 0.003). After Nissen fundoplication, the mean (SD) amplitude of the iBP increased to 12.0 (3.2) mmHg (p < 0.0001 vs normal subjects or preoperative values). The 95th percentile value for iBP after a Nissen fundoplication was 20.0 mmHg and was exceeded by esophageal contraction in all patients in the validation population, and 97% of these patients were free of persistent postoperative dysphagia at a median 50-month follow-up.

CONCLUSIONS

Nissen fundoplication increases the outflow resistance of the esophagus and should be constructed to avoid an iBP > 20 mmHg. Patients whose distal third esophageal contraction amplitude is >20 mmHg have a minimal risk of dysphagia after a tension-free Nissen fundoplication.

An Algorithmic Approach to Nutritional Difficulties in People With Developmental Disabilities

With the increasing survival rate of people with developmental disabilities into adulthood and later life, nutritional support and feeding of these individuals frequently becomes a critical problem which must be addressed by their caregivers and healthcare providers. Problems surrounding mealtimes include difficulty with the mechanisms of feeding as well as medical complications including aspiration and gastrointestinal dysmotility. No comprehensive guidelines exist to aid caregivers and healthcare providers regarding the issues in feeding and nutrition in this population. We offer an algorithmic approach to the nutrition-related problems of aspiration, laborious meals and mealtime refusal, choosing the best route for tube feeding, and when to return patients with developmental disabilities back to oral feeding.

Understanding the role of speech language pathologists in managing dysphagia

Collaboration between nurses and speech language pathologists is vital to the screening and management of dysphagia in acute care settings. This article examines each discipline's role in caring for patients with dysphagia.

The Use of Rigiflex Pneumatic Balloon Dilator during Laparoscopic Heller's Myotomy in Patients with Achalasia: A Novel Technical Method and Its Surgical Outcomes

Pneumatic balloon dilatation (BD) and laparoscopic Heller's myotomy (LHM) are usually preferred treatment options for relieving dysphagia symptoms in achalasia. The aim of the present study was to describe a new technical method for a safe and effective LHM. Endoscopic BD tube (Rigiflex 30-mm pneumatic balloon) is simultaneously insufflated and desufflated in the esophagus during LHM to assess myotomy in 50 consecutive patients. Dysphagia symptoms were determined using Eckardt's score. Three esophageal mucosal perforations occurred during surgery, which was primary repaired. The preoperative Eckardt score improved significantly from 4.54 ± 1.85 to 0.54 ± 0.73 (P < 0.001) at the first postoperative annual follow-up. The use of endoscopic BD tube during LHM is an easy and valuable method that allows to assess whether the dissection of muscular fibers in the myotomy area is appropriate or not.

Maintaining endotracheal tube cuff pressure at 20 mmHg during anterior cervical spine surgery to prevent dysphagia: a double-blind randomized controlled trial

PURPOSE

Anterior cervical spine surgery is associated with postoperative dysphagia, sore throat and dysphonia. It is unclear, whether this is caused by increased endotracheal tube (ETT) cuff pressure after retractor placement. This study aims to assess the effect of ETT cuff pressure adjustment on postoperative dysphagia, sore throat and dysphonia.

METHODS

In this, single-centre, observer and patient-blinded randomized controlled trial patients treated with anterior cervical spine surgery were randomized to adjustment of the ETT cuff pressure to 20 mmHg after placement of the retractor versus no adjustment. Primary outcome was the incidence and severity of postoperative dysphagia. Secondary outcomes were sore throat and dysphonia. Outcomes were evaluated on day one and 2 months after the operation.

RESULTS

Of 177 enrolled patients, 162 patients (92.5%) could be evaluated. The incidence of dysphagia was 75.9% on day one and 34.6% 2 months after surgery. Dysphagia in the intervention and control group was present in 77.8% versus 74.1% of patients on day one (odds ratio (OR) 1.2, 95% confidence interval (CI) (0.6-2.5)) and 28.4% versus 40.7% of patients after 2 months (OR 0.6, 95% CI 0.3-1.1), respectively. Severity of dysphagia, sore throat and dysphonia was similar in both groups.

CONCLUSIONS

Anterior cervical spine surgery is accompanied by a high incidence of postoperative dysphagia, lasting until at least 2 months after surgery in over a third of our patients. Adjusting ETT cuff pressure to 20 mmHg after retractor placement, as compared to controls, did not lower the risk for both short- and long-term dysphagia. Netherlands National Trial Registry Number: NTR 3542. These slides can be retrieved under electronic supplementary material.

Comparison between zero-profile spacer and plate with cage in the treatment of single level cervical spondylosis

BACKGROUND

Retrospective study of 68 patients of symptomatic cervical spondylosis who were treated by anterior cervical discectomy and fusion (ACDF).

OBJECTIVE

The purpose of this study was to compare the clinical and radiological outcomes of patients with single level cervical spondylosis using either zero-profile spacer (group A) or anterior cervical plate and cage (group B).

METHODS

Clinical and radiological data of 68 patients undergoing ACDF from C3-C7 were collected retrospectively. There were 35 patients with a mean age of 54.05 years who received treatment by zero-profile implant. A total of 33 patients with a mean age of 52.09 years underwent fusion by traditional plate with cage. Group A and group B were followed up for an average of 23.68 months and 24.39 months, respectively. Age, blood loss, and operation time were assessed. The clinical outcomes were evaluated by JOA and VAS score before and after surgery. In addition, incidence of dysphagia was recorded. The Cobb angle (from C2 to C7) change was measured on the lateral cervical spine radiographs.

RESULTS

There was no significant difference in terms of operation time and blood loss between two groups. The postoperative JOA significantly increased and the VAS decreased correspondently in both groups. The postoperative Cobb angle increased and showed statistical difference compared with preoperative Cobb angle in both groups. There was no significant difference between group A and group B in achieving clinical symptoms and radiograph improvement according to postoperative JOA, VAS and Cobb angle comparison. The incidence of postoperative dysphagia was lower in the group A than group B.

CONCLUSIONS

Our study suggests that the application of zero-p spacer can achieve similar clinical and radiological improvement compared with traditional plate and cage. Meanwhile, zero-p is superior to plate and cage with a lower incidence of postoperative dysphagia.

Analysis of dysphagia in advanced-stage head-and-neck cancer patients: impact on quality of life and development of a preventive swallowing treatment

OBJECTIVES

Swallowing and voice dysfunctions are common side effects following head-and-neck squamous-cell carcinoma (HNSCC) treatment. Our aim was to analyze the relationships between quality of life, swallowing, and phonatory problems in patients with an advanced-stage HNSCC and to prospectively evaluate the effects of a prophylactic swallowing program.

METHODS

First, we retrospectively studied 60 advanced HNSCC patients treated with exclusive or adjuvant radiotherapy/chemoradiotherapy (RT/CRT). Subjects were classified according to general and clinical-therapeutic features. Outcome measures included EORTC QLQ-C30, EORTC QLQ-H&N35, Dysphagia Handicap Index (DHI), M.D.Anderson Dysphagia Inventory (MDADI), and Voice Handicap Index (VHI). Then, we conducted a prospective evaluation of a prophylactic swallowing counselling in 12 consecutive advanced-stage HNSCC patients by a two-arm case-control analysis. These patients were treated with exclusive or adjuvant RT/CRT.

RESULTS

71% of the retrospective population studied reported swallowing dysfunction as a major side effect. No differences were detected in the severity of dysphagia or dysphonia according to type of treatment or staging of the primary tumour, while hypopharyngeal and laryngeal cancer patients showed significantly better swallowing ability and better QoL compared to oral cavity and oropharyngeal localisation (p < 0.05). In addition, a relevant correlation between swallowing and voice problems emerged (p < 0.05). In the prospective part, while no statistical correlation was evident before the start of RT/CRT in the experimental group compared to the control one, the former showed better performances at MDADI (p = 0.006) and DHI (p = 0.002) test 3 months after its end.

CONCLUSION

Dysphagia is both an acute-and-long-term side effect which greatly affects QoL of HNSCC patients undergoing multimodality treatment. Our data show that a prophylactic swallowing program could actually produce a beneficial effect on patients' outcomes.

LEVEL OF EVIDENCE

1b and 2b.

Changes in Swallowing and Cough Functions Among Stroke Patients Before and After Tracheostomy Decannulation

We investigated the functional changes in swallowing and voluntary coughing before and after tracheostomy decannulation among stroke patients who had undergone a tracheostomy. We also compared these functions between stroke patients who underwent tracheostomy tube removal and those who did not within 6 months of their stroke. Seventy-seven stroke patients who had undergone a tracheostomy were enrolled. All patients were evaluated by videofluoroscopic swallowing studies and a peak flow meter through the oral cavity serially until 6 months after their stroke. During the intensive rehabilitation period, if a patient satisfied the criteria for tracheostomy tube removal, the tube was removed. The patients were divided into the 'decannulated' group and the 'non-decannulated' group according to their tracheostomy tube removal status. In the decannulated group, swallowing function did not change before and after tracheostomy decannulation; however, cough function was significantly improved after decannulation. Although both groups exhibited functional improvement in swallowing and coughing over time, the improvement in the decannulated group was more significant than the improvement in the non-decannulated group. Our results revealed that stroke patients who had better functional improvement in swallowing and coughing were more likely to be potential candidates for tracheostomy decannulation. Stroke patients who recovered from neurogenic dysphagia, they were no longer affected by the mechanical effect of the tracheostomy tube on swallowing function. This study suggests that if patients show improvement in swallowing and coughing after their stroke, a multidisciplinary approach to tracheostomy decannulation would be needed to achieve better rehabilitation outcomes.

Heller Myotomy: To Wrap or Not to Wrap?

Heller myotomy (HM) is widely recognized as the most effective treatment of achalasia. Although effective in improving dysphagia symptoms, HM is associated with reflux. Over a five-year period, 63 laparoscopic HM were performed. Patients underwent myotomy alone or HM plus reconstitution of the angle of His without any fundoplication, anterior, or posterior partial fundoplication. Two postoperative outcomes were examined: dysphagia and reflux. Twenty-two patients received no fundoplication (34.9%). Forty-one (65.1%) antireflux procedures were performed, including 21 reconstitutions of the angle of His (33.3%), nine (14.3%) anterior fundoplications, and 11 (17.5%) posterior fundoplications. All patients demonstrated preoperative dysphagia. Postoperative dysphagia was present in 23 of 63 (36.5%). Of these, 13 (56.5%) patients had an antireflux procedure, whereas 28 of 40 who had an antireflux procedure (70%) had no postoperative dysphagia (P = 0.28). Thirty-nine of 62 (62.9%) had symptomatic esophageal reflux preoperatively, and postoperative reflux was reported in 22 of 63 (34.9%). Reflux was present in 72.7 per cent of patients who had an antireflux procedure versus 61 per cent of those without the addition of an antireflux procedure (P = 0.415). However, HM independently improved reflux status regardless of whether an antireflux procedure was performed using the exact McNemar's test (P = 0.0014). Although the performance of an antireflux procedure did not appear to alter the reflux status after HM for achalasia, neither was it associated with postoperative dysphagia. More importantly, HM was independently associated with an improvement of reflux symptoms regardless of the type of antireflux procedure performed or whether one was used or not.

Swallowing Exercises: Will They Really Help Head and Neck Cancer Patients?

Purpose: The work was a comparative study, the aim of which is to evaluate the impact of swallowing exercises on swallowing problems among head and neck cancer patients (HNCPs) after CRT. Methods: The sample of 60 HNCPs was equally divided into control and study groups. The investigators met all patients 3 times (before, during and after CRT); swallowing ability was assessed using the Sydney Swallowing Questionnaire (SSQ). The University of Texas, MD Anderson Cancer Center Swallowing Exercise Protocol was explained and demonstrated by the investigators to the study group. All tools used were translated into Arabic. Data analyses were carried out using the statistical package for social sciences (SPSS), program version 20. Results: Most of the patients from both groups experienced mild dysphagia during the 1st visit. By the 3rd visit, severe dysphagia (to thin and thick liquids, and soft and hard food) was higher in the control group (73.3%) compared to the study group (26.7%). By the third visit there was statistically significant difference between both groups in swallowing thin liquids (p = 0.01), as well as thick liquids (p = 0.01). At the 1st visit, there was no significant difference regarding swallowing soft food (p = 0.24), hard food (p = 0.17), dry food (p = 0.89) and swallowing Saliva (p = 0.28). While by the 3rd visit, there was significant difference between control and study groups in all parameters. Conclusions: Adequate prevention and treatment of dysphagia, with use of swallowing programs, is essential to plan a complete therapeutic programme.

Effect of perioperative oral care on prevention of postoperative pneumonia associated with esophageal cancer surgery: A multicenter case-control study with propensity score matching analysis

The aim of this study was to investigate the effectiveness of oral care in prevention of postoperative pneumonia associated with esophageal cancer surgery.Postoperative pneumonia is a severe adverse event associated with esophageal cancer surgery. It is thought to be caused by aspiration of oropharyngeal fluid containing pathogens. However, the relationship between oral health status and postoperative pneumonia has not been well investigated.This study included 539 patients with esophageal cancer undergoing surgery at 1 of 7 university hospitals. While 306 patients received perioperative oral care, 233 did not. Various clinical factors as well as occurrence of postoperative pneumonia were retrospectively evaluated. Propensity-score matching was performed to minimize selection biases associated with comparison of retrospective data between the oral care and control groups. Factors related to postoperative pneumonia were analyzed by logistic regression analysis.Of the original 539 patients, 103 (19.1%) experienced postoperative pneumonia. The results of multivariate analysis of the 420 propensity score-matched patients revealed longer operation time, postoperative dysphagia, and lack of oral care intervention to be significantly correlated with postoperative pneumonia.The present findings demonstrate that perioperative oral care can reduce the risk of postoperative pneumonia in patients undergoing esophageal cancer surgery.

Artificial Nutrition and Hydration in People With Late-Stage Dementia

The progressive nature of dementia marks this disease as a terminal illness in the advanced stage, and palliative care rather than curative treatment is indicated. The use of feeding tubes to deliver artificial nutrition and hydration at end of life is often part of the plan of care for people with dementia. Current evidence, however, suggests that tube feeding in advanced dementia is not beneficial and the burdens of the procedure and the feedings themselves outweigh any benefits. Evidence also reveals that healthcare providers may lack evidence-based knowledge about artificial nutrition and hydration to adequately inform families and surrogate decision makers. This article examines the evidence regarding use of artificial nutrition and hydration for patients with end-stage dementia and offers implications for home care clinicians.

DARS: a phase III randomised multicentre study of dysphagia- optimised intensity- modulated radiotherapy (Do-IMRT) versus standard intensity- modulated radiotherapy (S-IMRT) in head and neck cancer

BACKGROUND

Persistent dysphagia following primary chemoradiation (CRT) for head and neck cancers can have a devastating impact on patients' quality of life. Single arm studies have shown that the dosimetric sparing of critical swallowing structures such as the pharyngeal constrictor muscle and supraglottic larynx can translate to better functional outcomes. However, there are no current randomised studies to confirm the benefits of such swallow sparing strategies. The aim of Dysphagia/Aspiration at risk structures (DARS) trial is to determine whether reducing the dose to the pharyngeal constrictors with dysphagia-optimised intensity- modulated radiotherapy (Do-IMRT) will lead to an improvement in long- term swallowing function without having any detrimental impact on disease-specific survival outcomes.

METHODS/DESIGN

The DARS trial (CRUK/14/014) is a phase III multicentre randomised controlled trial (RCT) for patients undergoing primary (chemo) radiotherapy for T1-4, N0-3, M0 pharyngeal cancers. Patients will be randomised (1:1 ratio) to either standard IMRT (S-IMRT) or Do-IMRT. Radiotherapy doses will be the same in both groups; however in patients allocated to Do-IMRT, irradiation of the pharyngeal musculature will be reduced by delivering IMRT identifying the pharyngeal muscles as organs at risk. The primary endpoint of the trial is the difference in the mean MD Anderson Dysphagia Inventory (MDADI) composite score, a patient-reported outcome, measured at 12 months post radiotherapy. Secondary endpoints include prospective and longitudinal evaluation of swallow outcomes incorporating a range of subjective and objective assessments, quality of life measures, loco-regional control and overall survival. Patients and speech and language therapists (SLTs) will both be blinded to treatment allocation arm to minimise outcome-reporting bias.

DISCUSSION

DARS is the first RCT investigating the effect of swallow sparing strategies on improving long-term swallowing outcomes in pharyngeal cancers. An integral part of the study is the multidimensional approach to swallowing assessment, providing robust data for the standardisation of future swallow outcome measures. A translational sub- study, which may lead to the development of future predictive and prognostic biomarkers, is also planned.

TRIAL REGISTRATION

This study is registered with the International Standard Randomised Controlled Trial register, ISRCTN25458988 (04/01/2016).

Multivariable normal tissue complication probability model-based treatment plan optimization for grade 2-4 dysphagia and tube feeding dependence in head and neck radiotherapy

BACKGROUND AND PURPOSE

Radiotherapy of the head and neck is challenged by the relatively large number of organs-at-risk close to the tumor. Biologically-oriented objective functions (OF) could optimally distribute the dose among the organs-at-risk. We aimed to explore OFs based on multivariable normal tissue complication probability (NTCP) models for grade 2-4 dysphagia (DYS) and tube feeding dependence (TFD).

MATERIALS AND METHODS

One hundred head and neck cancer patients were studied. Additional to the clinical plan, two more plans (an OF_DYS and OF_TFD-plan) were optimized per patient. The NTCP models included up to four dose-volume parameters and other non-dosimetric factors. A fully automatic plan optimization framework was used to optimize the OF_NTCP-based plans.

RESULTS

All OF_NTCP-based plans were reviewed and classified as clinically acceptable. On average, the Δdose and ΔNTCP were small comparing the OF_DYS-plan, OF_TFD-plan, and clinical plan. For 5% of patients NTCP_TFD reduced >5% using OF_TFD-based planning compared to the OF_DYS-plans.

CONCLUSIONS

Plan optimization using NTCP_DYS- and NTCP_TFD-based objective functions resulted in clinically acceptable plans. For patients with considerable risk factors of TFD, the OF_TFD steered the optimizer to dose distributions which directly led to slightly lower predicted NTCP_TFD values as compared to the other studied plans.

Using Spaced Retrieval With External Aids to Improve Use of Compensatory Strategies During Eating for Persons With Dementia

PURPOSE

This study was designed to determine whether spaced retrieval (SR), when paired with an external memory aid, is an effective technique to teach persons with dementia to use compensatory swallowing strategies. A secondary purpose was to learn whether speech-language pathologists naive to the study aims would judge posttraining sessions as improved, or safer, in comparison to baseline sessions, thereby validating the changes in behavior due to SR training to use external aids during meals.

METHOD

A multiple baseline design across behaviors was used to evaluate the effects of teaching compensatory swallowing behaviors (i.e., chin tuck, alternation of liquids and solids, lingual/finger sweep) to 5 nursing home residents diagnosed with dementia and coexisting dysphagia.

RESULTS

SR training with the use of a visual aid was functionally related to improvements in 2-3 compensatory swallowing behaviors for each of the 5 participants.

CONCLUSIONS

Study outcomes paired with social validation ratings demonstrated that persons with dementia could learn compensatory swallowing behaviors for perceived safety during intake. Because participants were eating in a quiet and controlled environment, generalization to the typical dining environment remains unknown, and further research is needed to investigate the long-term impact of this training protocol.

Cortical Adaptation following Partial Glossectomy with Primary Closure: Implications for Reconstruction of the Oral Tongue

Objectives:

The considerable variability in functional outcomes for speech and swallowing with different reconstruction techniques following partial glossectomy may reflect the ability of patients to adapt to altered tongue structure. The purpose of this study was to determine mechanisms of cortical adaptation in swallowing to partial glossectomy reconstructed with primary closure.

Methods:

Four patients treated with partial glossectomy and primary closure underwent functional magnetic resonance imaging at a mean of 6 months after operation, and the data were compared to those from 8 healthy controls.

Results:

Statistically significant increases in activity occurred predominately in the parietal cortices and the cerebellum. The volume of the resection was most highly correlated with activity in the premotor and parietal cortices and cerebellum.

Conclusions:

The adaptive changes in the cortex following partial glossectomy with primary closure reflect adaptation to the biomechanics of tongue movement during swallowing, and not altered sensation in the tongue.

[Preventing swallowing disorders in neurological patients]

Swallowing disorders in neurological rehabilitation are common and important as they can have harmful consequences. A multi-disciplinary hospital team was created to study ways of preventing their occurrence. This article presents the areas to focus on and the main orientations of patient management.

Study protocol for a randomized controlled trial: tongue strengthening exercises in head and neck cancer patients, does exercise load matter?

BACKGROUND

Reduced tongue strength is an important factor contributing to early and late dysphagia in head and neck cancer patients previously treated with chemoradiotherapy. The evidence is growing that tongue strengthening exercises can improve tongue strength and swallowing function in both healthy and dysphagic subjects. However, little is known about the impact of specific features of an exercise protocol for tongue strength on the actual outcome (strength or swallowing function). Previous research originating in the fields of sports medicine and physical rehabilitation shows that the degree of exercise load is an influential factor for increasing muscle strength in the limb skeletal muscles. Since the tongue is considered a muscular hydrostat, it remains to be proven whether the same concepts will apply.

METHODS/DESIGN

This ongoing randomized controlled trial in chemoradiotherapy-treated patients with head and neck cancer investigates the effect of three tongue strengthening exercise protocols, with different degrees of exercise load, on tongue strength and swallowing. At enrollment, 51 patients whose dysphagia is primarily related to reduced tongue strength are randomly assigned to a training schedule of 60, 80, or 100% of their maximal tongue strength. Patients are treated three times a week for 8 weeks, executing 120 repetitions of the assigned exercise once per training day. Exercise load is progressively adjusted every 2 weeks. Patients are evaluated before, during and after treatment by means of tongue strength measurements, fiber-optic endoscopic evaluation of swallowing and quality-of-life questionnaires.

DISCUSSION

This randomized controlled trial is the first to systematically investigate the effect of different exercise loads in tongue strengthening exercise protocols. The results will allow the development of more efficacious protocols.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN14447678.

[Preoperative evaluation of surgery for intractable aspiration based on the prognostic nutritional index]

Because there is no absolute indicator of the nutritional status and prognosis in patients with severe aspiration problems, it is quite difficult to arrive at a true long-time prognosis. By performing surgery for intractable aspiration on such patients, both the prognosis and QOL of the patients could be expected to improve. In our department, we have experienced patients dying within 6 months after surgery. In these cases, the patient's preoperative nutritional status was not good. Therefore, we consider that, when we adopt this procedure, there should be some indicators we should use which could have an effect on the prognosis of such nutritionally-challenged patients. In patients who underwent surgery for intractable aspiration; we examined the relationship between their survival and the prognostic nutritional index (PNI) which is an indicator of the risk of complications such as post-operative events in the surgical field. We investigated the relationship between the prognosis and the postoperative indicators of each of the following: WBC, CRP, serum albumin level, and PNI. Out of a total of 31 cases, the average O-PNI of eight cases in which death occurred was 29.45, and the average of six cases in which death occurred within 6 months after surgery was 28.26. The average O-PNI of the survivors was 36.01. A significant association was noted between the early postoperative deaths and some of the four indicators namely that serum albumin level and O-PNI. Based on the ROC curve, the O-PNI offered higher precision than the albumin level. The cut-off value of the O-PNI value for early postoperative mortality rate was 32. The early postoperative mortality rate was 44.4% in patients with less than 32 O-PNI in the preoperative examination, but if it were O-PNI 32 or more, the early postoperative mortality rate was 9.1%, significantly lower. Therefore, O-PNI could be useful as one of the prognostic evaluation factors in the case of preoperative surgery for intractable aspiration. Based on the O-PNI score, it was possible to evaluate the survival benefit associated with this operative procedure. We showed a treatment algorithm based on the preoperative O-PNI value. We believe there is a necessity to develop preoperative effective nutritional therapy as a future issue.

Meta-Analysis Comparing Zero-Profile Spacer and Anterior Plate in Anterior Cervical Fusion

Background

Anterior plate fusion is an effective procedure for the treatment of cervical spinal diseases but is accompanied by a high incidence of postoperative dysphagia. A zero profile (Zero-P) spacer is increasingly being used to reduce postoperative dysphagia and other potential complications associated with surgical intervention. Studies comparing the Zero-P spacer and anterior plate have reported conflicting results.

Methodology

A meta-analysis was conducted to compare the safety, efficacy, radiological outcomes and complications associated with the use of a Zero-P spacer versus an anterior plate in anterior cervical spine fusion for the treatment of cervical spinal disease. We comprehensively searched PubMed, Embase, the Cochrane Library and other databases and performed a meta-analysis of all randomized controlled trials (RCTs) and prospective or retrospective comparative studies assessing the two techniques.

Results

Ten studies enrolling 719 cervical spondylosis patients were included. The pooled data showed significant differences in the operation time [SMD = –0.58 (95% CI = −0.77 to 0.40, p < 0.01)] and blood loss [SMD = −0.40, 95% CI (−0.59 to –0.21), p < 0.01] between the two groups. Compared to the anterior plate group, the Zero-P group exhibited a significantly improved JOA score and reduced NDI and VAS. However, anterior plate fusion had greater postoperative segmental and cervical Cobb’s angles than the Zero-P group at the last follow-up. The fusion rate in the two groups was similar. More importantly, the Zero-P group had a lower incidence of earlier and later postoperative dysphagia.

Conclusions

Compared to anterior plate fusion, Zero-P is a safer and effective procedure, with a similar fusion rate and lower incidence of earlier and later postoperative dysphagia. However, the results of this meta-analysis should be accepted with caution due to the limitations of the study. Further evaluation and large-sample RCTs are required to confirm and update the results of this study.

Utilizing Cerebral Perfusion Scan and Diffusion-tensor MR Imaging to Evaluate the Effect of Hyperbaric Oxygen Therapy in Carbon Monoxide-induced Delayed Neuropsychiatric Seqeulae- A Case Report and Literature Review

PURPOSE

Detection of regional cerebral blood flow (rCBF) and/or brain magnetic resonance imaging (MRI) has been used to investigate functional defect of brain caused by carbon monoxide (CO) poisoning. In this report, we attempted to demonstrate the correlation of changes in brain singlephoton emission computed tomography (SPECT) and diffusion-tensor MR image (DTI) with functional improvement of severe delayed neuropsychiatric sequelae (DNS) after CO intoxication during the treatment of hyperbaric oxygen therapy (HBOT).

CASE REPORT

The patient had normal activities of daily life after he recovered from acute CO poisoning. One month later, he presented symptoms of declined cognitive functioning, aphasia, apraxia, dysphagia, muscle rigidity, urine and fecal incontinence. After one course of HBOT, these symptoms improved significantly and the patient could regain most of his previous functioning. The patient's improvement was evidenced by increased rCBF in Brodmann areas 7, 8, 11 and 40, as well as higher mean fractional anisotropy (FA) value of DTI.

CONCLUSION

Although the efficacy of HBOT in DNS patients is still needed to be evaluated in large clinical study, these data suggest that HBOT may be the choice to improve DNS efficiently and shorten the duration of suffering with favorable outcome.