Decreased Maximal Tongue Protrusion Length May Predict the Presence of Dysphagia in Stroke Patients

Objective To investigate the relationship between maximal tongue protrusion length (MTPL) and dysphagia in post-stroke patients.Methods Free tongue length (FTL) was measured using the quick tongue-tie assessment tool and MTPL was measured using a transparent plastic ruler in 47 post-stroke patients. The MTPL-to-FTL (RMF) ratio was calculated. Swallowing function in all patients was evaluated via videofluoroscopic swallowing study (VFSS), PenetrationAspiration Scale (PAS), Functional Oral Intake Scale (FOIS), and Videofluoroscopic Dysphagia Scale (VDS).Results The MTPL and RMF values were significantly higher in the non-aspirator group than in the aspirator group (MTPL, p=0.0049; RMF, p<0.001). MTPL and RMF showed significant correlations with PAS, FOIS and VDS scores. The cut-off value in RMF for the prediction of aspiration was 1.56, with a sensitivity of 84% and a specificity of 86%.Conclusion There is a relationship between MTPL and dysphagia in post-stroke patients. MTPL and RMF can be useful for detecting aspiration in post-stroke patients.

Swallowing muscle training for oropharyngeal dysphagia: A non-inferiority study of online versus face-to-face therapy

Introduction The purpose of this study is to show the non-inferiority of the telemedicine therapy versus face-to-face using the exercise therapy of oropharyngeal muscles in 183 patients treated consecutively from 2010 to 2020. Method We conducted a retrospective study comparing two dysphagia treatment groups: online versus face-to-face. Patients were distributed in a non-random way but according to patient's preferences. All patients followed the same pathway and were evaluated at the beginning and at the end of the study using the dysphagia outcome and severity scale and the functional oral intake scale. A non-inferiority analysis approximation was done with delta = 1 in both variables. Results Within a total of 183 patients, 114 (62.3%) used the online treatment and 69 (37.7%) the face-to-face one. The main cause of dysphagia was neurological in the total sample (60.7%) and within both groups. When we evaluate the clinical response, we find that both groups improved regardless of the type of therapy. The confidence interval of the difference between the beginning and the end of treatment did not reach the inferior limit of the delta defined, therefore supporting the no inferiority of online versus presential. Discussion This study shows the no inferiority of the online therapy versus the face-to-face one for the oropharyngeal training of the swallow muscles.

Change in Nutritional Status and Dysphagia after Resection of Head and Neck Cancer

Nutritional status is well-known to influence patient recovery after resection of head and neck cancer (HNC). The influence of preoperative nutritional status on dysphagia was assessed in patients who underwent surgical resection of HNC along with the assessment of nutritional status during the acute and subacute phases. Eighty-six patients underwent surgical resection and dysphagia assessments (repetitive saliva-swallowing test, water-swallowing test, and functional oral intake scale) and had their tongue pressure assessed five times (before surgery, after 1–2 weeks, and 1, 2, and 3 months after surgery). The nutritional status was assessed according to the body mass index, total protein, and albumin. The prognostic nutritional index was calculated from preoperative data, and the subjects were classified into three groups: Low-risk, Attention and High-risk groups. After surgery, the nutritional status index values were low, and the High-risk group showed significantly lower values in comparison to the other two groups. The water-swallowing test and functional oral intake scale findings were worse than they had been preoperatively until 2 months after surgery, and a significant correlation was noted between the postoperative nutritional status and the presence of dysphagia. The results indicated that the preoperative nutritional status of HNC patients influenced their ability to ingest/swallow, which in turn influenced their nutritional status after HNC resection.

Role of preoperative cervical alignment on postoperative dysphagia after occipitocervical fusion

Background: Dysphagia is one of the most serious complications of occipitocervical fusion (OCF). The previous studies have shown that postoperative cervical alignment, documented with occipito (O)-C2 angles, C2-C6 angles, and pharyngeal inlet angles (PIA), impacted the incidence of postoperative dysphagia in patients undergoing OCF. Here, we investigated the relationship of preoperative versus postoperative cervical alignment on the incidence of postoperative dysphagia after OCF. Methods: We retrospectively reviewed the clinical data/medical charts for 22 patients following OCF (2006– 2019). The O-C2 angles, C2-C6 angles, PIA, and narrowest pharyngeal airway spaces (nPAS) were assessed using plain lateral radiographs of the cervical spine before and after the surgery. The severity of dysphagia was assessed with the functional oral intake scale (FOIS) levels as documented in medical charts; based on this, patients were classified into the nondysphagia (FOIS: 7) versus dysphagia (FOIS: 1–6) groups. Results: Seven patients (35%) experienced dysphagia after OCF surgery. Preoperative PIA and nPAS were smaller in the dysphagia group. Spearman rank correlation showed a positive correlation between preoperative PIA and FOIS and between preoperative nPAS and FOIS. Conclusion: This study suggests that preoperative cervical alignment may best predict the incidence of postoperative dysphagia after OCF.

Change in Spontaneous Swallowing Frequency in HNC Patients Undergoing C/RT

Objective This study sought to evaluate the role and trajectory of spontaneous swallowing frequency (SFA) in patients with head and neck cancer (HNC) undergoing chemoradiotherapy (C/RT). Study Design. Prospective cohort. Setting University comprehensive cancer center. Methods A prospective cohort of 80 patients with HNC was followed from baseline to 3 months post-C/RT. Subjects were evaluated for performance on swallowing function, functional diet consumed, weight, swallowing frequency rate, perceived xerostomia, perceived pain, and mucositis. Relationships were evaluated using univariate correlations, t tests, and repeated-measures analysis of variance. The diagnostic accuracy of SFA to express dysphagia was calculated by area under the curve (AUROC) and displayed using receiver operator characteristic curves. Results In general, patients with HNC demonstrated a parabolic decline in most measures over the C/RT trajectory. SFA and perceived xerostomia did not show improved recovery by 3 months. SFA was related to swallow function, xerostomia, and functional diet consumed posttreatment and pain at 3 months. The ability of SFA to correctly identify clinical dysphagia (Mann Assessment of Swallowing–Cancer version [MASA-C]) and reduced oral intake (Functional Oral Intake Scale [FOIS]) at posttreatment was strong (AUROC MASA-C: 0.824 [95% CI, 0.63-1.00], P < .0018; AUROC FOIS: 0.96 [95% CI, 0.87-0.96], P < .0001). Conclusion This exploratory study suggests SFA may provide a useful method to identify dysphagia after HNC treatment. Furthermore, SFA may offer a simple, objective measure of swallowing function change in HNC over the C/RT trajectory.

Clinical effectiveness of the sequential 4-channel NMES compared with that of the conventional 2-channel NMES for the treatment of dysphagia in a prospective double-blind randomized controlled study

Background To date, conventional swallowing therapies and 2-channel neuromuscular electrical stimulation (NMES) are standard treatments for dysphagia. The precise mechanism of 2-channel NMES treatment has not been determined, and there are controversies regarding the efficacy of this therapy. The sequential 4-channel NMES was recently developed and its action is based on the normal contractile sequence of swallowing-related muscles. Objective To evaluate and compare the rehabilitative effectiveness of the sequential 4-channel NMES with that of conventional 2-channel NMES. Methods In this prospective randomized case–control study, 26 subjects with dysphagia were enrolled. All participants received 2- or 4-channel NMES for 2–3 weeks (minimal session: 7 times, treatment duration: 300–800 min). Twelve subjects in the 4-channel NMES group and eleven subjects in the 2-channel NMES group completed the intervention. Initial and follow-up evaluations were performed using the videofluoroscopic dysphagia scale (VDS), the penetration-aspiration scale (PAS), the MD Anderson dysphagia inventory (MDADI), the functional oral intake scale (FOIS), and the Likert scale. Results The sequential 4-channel NMES group experienced significant improvement in their VDS (oral, pharyngeal, and total), PAS, FOIS, and MDADI (emotional, functional, and physical subsets) scores, based on their pretreatment data. VDS (oral, pharyngeal, and total) and MDADI (emotional and physical subsets) scores, but not PAS and FOIS scores, significantly improved in the 2-channel NMES group posttreatment. When the two groups were directly compared, the 4-channel NMES group showed significant improvement in oral and total VDS scores. Conclusions The sequential 4-channel NMES, through its activation of the suprahyoid and thyrohyoid muscles, and other infrahyoid muscles mimicking physiological activation, may be a new effective treatment for dysphagia. Trial registration: clinicaltrial.gov, registration number: NCT03670498, registered 13 September 2018, https://clinicaltrials.gov/ct2/show/NCT03670498?term=NCT03670498&draw=2&rank=1.

Adaptation and Validation of the Dynamic Imaging Grade of Swallowing Toxicity for Flexible Endoscopic Evaluation of Swallowing: DIGEST-FEES

Purpose While flexible endoscopic evaluation of swallowing (FEES) is a common clinical procedure used in the head and neck cancer (HNC) population, extant outcome measures for FEES such as bolus-level penetration–aspiration and residue scores are not well suited as global patient-level endpoint measures of dysphagia severity in cooperative group trials or clinical outcomes research. The Dynamic Imaging Grade of Swallowing Toxicity (DIGEST) was initially developed and validated for use during videofluoroscopic evaluations as a way to grade safety, efficiency, and overall pharyngeal swallowing impairment. The purpose of this study was to adapt and validate DIGEST for use with FEES. Method A modified Delphi exercise was conducted for content validation, expert consensus, adaptation, and operationalization of DIGEST-FEES. Three blinded, expert raters then evaluated 100 de-identified post-HNC treatment FEES examinations. Intra- and interrater reliability were tested with quadratic weighted kappa. Criterion validity against the MD Anderson Dysphagia Inventory, Functional Oral Intake Scale, Secretion Severity Scale, and Yale Residue Rating Scale was assessed with Spearman correlation coefficients. Results Interrater reliability was almost perfect for overall DIGEST-FEES grade (κ w = 0.83) and safety grade (κ w = 0.86) and substantial for efficiency grade (κ w = 0.74). Intrarater reliability was excellent for all raters (0.9–0.91). Overall DIGEST-FEES grade correlated with MD Anderson Dysphagia Inventory ( r = −.43, p < .0001), Functional Oral Intake Scale ( r = −.43, p < .0001), Secretion Severity Scale ( r = .47, p < .0001), Yale Vallecular Residue ( r = .73, p < .0001), and Yale Pyriform Sinus Residue ( r = .65, p < .0001). Conclusion DIGEST-FEES is a valid and reliable scale to describe the severity of pharyngeal dysphagia in patients with HNC. Supplemental Material https://doi.org/10.23641/asha.14642787

Effect of Pretreatment Dysphagia on Postchemoradiation Swallowing Function in Head and Neck Cancer

Objectives Chemoradiation therapy (CRT) for head and neck cancer can have profound effects on swallowing function. Identification of risk factors for development of swallowing dysfunction after CRT may improve allocation of preventive strategies. The purpose of this study is to determine the association between pre-CRT dysphagia and post-CRT swallowing dysfunction. Study Design Retrospective cohort study. Setting Academic medical center. Methods Patients with head and neck cancer were evaluated before and 3 months after CRT. Dysphagia was assessed with the Eating Assessment Tool (EAT-10). Swallowing dysfunction was evaluated by a videofluoroscopic swallow study and the Penetration-Aspiration Scale and swallowing safety was evaluated by the Functional Oral Intake Scale. The association between pre-CRT EAT-10 scores and post-CRT swallowing dysfunction was evaluated. Results The mean ± SD post-CRT Functional Oral Intake Scale score was 6.5 ± 1.2 for individuals with a pre-CRT EAT-10 score <3 and 5.3 ± 1.9 for those with a pre-CRT EAT-10 score ≥3 ( P < .001). The mean post-CRT Penetration-Aspiration Scale score was 2.2 ± 1.5 for individuals with a pre-CRT EAT-10 score <3 and 3.8 ± 2.6 for those with a pre-CRT EAT-10 score ≥3 ( P < .001). After multivariate analysis adjusting for age, tumor subsite, T classification, and primary surgery, pre-CRT dysphagia (EAT-10 ≥3) was an independent predictor of post-CRT aspiration (odds ratio, 4.19 [95% CI, 1.08-16.20]; P = .04) and feeding tube dependence (odds ratio, 3.54 [95% CI, 1.01-12.33]; P = .04). Conclusion The presence of dysphagia before chemoradiation for head and neck cancer is an independent predictor of swallowing dysfunction after completion of therapy. These results may help target intervention toward preventing swallowing dysfunction in high-risk individuals.

Reassessment of Poststroke Dysphagia in Rehabilitation Facility Results in Reduction in Diet Restrictions

Background: Dysphagia assessment in postacute stroke patients can decrease the incidence of complications like malnutrition, dehydration, and aspiration pneumonia. It also helps to avoid unnecessary diet restrictions. The aim of this study is to verify if regular reassessment of dysphagia would change the diet management of postacute stroke patients in rehabilitation settings. Methods: This single-center retrospective study included 63 patients referred to an inpatient neurological rehabilitation center between 2018–2019. A standardized clinical swallowing evaluation and Fiberoptic Endoscopic Evaluation of Swallowing (FEES) were performed. Diet level according to Functional Oral Intake Scale (FOIS) was evaluated. As the primary endpoint, the FOIS values based on diagnostic procedures were assessed at hospital discharge, rehabilitation admission, and after FEES. Results: 19 women (30%) and 44 men (70%), with a mean age of 75 y (SD ± 10.08), were enrolled. The intergroup ANOVA revealed significant differences (p < 0.001) between dietary prescriptions in an acute care setting and following clinical and endoscopic reassessment in the rehabilitation center. Diet recommendations changed in 41 of 63 (65%) enrolled patients (p < 0.001). Conclusion: Instrumental diagnostic by FEES during the early convalescence period of stroke patients leads to clinically relevant changes to diet restrictions and lower rates of pneumonia. Our findings underline the need for regular and qualitative dysphagia diagnostics in stroke patients participating in neurological rehabilitation.