Swallowing Function Research Articles

Prevalence, recovery, and factors associated with dysphagia in an older critically ill trauma cohort: A cross-sectional study

BackgroundPatients admitted to the intensive care unit (ICU) following trauma often have multiple injuries, which can lead to disordered swallowing, dysphagia. The prevalence of dysphagia in trauma populations ranges between 4.2% and 86%; however, clinical and associated longitudinal health outcomes and patient-reported quality of life are unknown. ObjectivesThe objective of this study was to compare hospital and clinical outcomes for older critically ill trauma patients diagnosed with and without dysphagia up to 12 months after hospital admission. Secondary outcomes include characteristics of dysphagia assessment and recovery during indexed hospital admission. MethodsPost hoc analysis of an observational study. All patients were recruited from a tertiary ICU trauma unit, all were aged above 50 years, with an expected ICU length of stay of >24 h. Criteria of dysphagia diagnosis were determined via presence of International Classification of Diseases (ICD-10) code (R13). Hospital, clinical, and health-reported quality-of-life data were collected. ResultsNinety-eight patients were included with 79 (81%) being male, overall median injury severity scale: 21.5 (interquartile range: 14–29); 38 (38.8%) with spinal injury, 37 (37.8%) with multitrauma excluding head injury, and 23 (23.5%) with multitrauma including head injury. Prevalence of dysphagia was 29%, with patients diagnosed with dysphagia more likely to have required invasive mechanical ventilation (odds ratio [OR]: 4.0, 95% confidence interval [CI]: 1.25–12.78), for an increased duration (OR: 2.6, 95% CI: 0.27–4.92) and required longer ICU admission (OR: 2.98, 95% CI: 0.28–5.69). Recovery of swallow function was protracted beyond the indexed hospital admission, with only 18% of those diagnosed with dysphagia returning to a normal, unrestricted, oral diet by hospital discharge. At 6 and 12 months, functional disabilities were reported across the cohort with no significant differences between groups. ConclusionsIn older critically ill trauma patients, dysphagia is common. Use and duration of invasive mechanical ventilation and increased ICU length of stay for survivors were significantly increased for those with dysphagia. Management of swallowing is required across the continuum of care commencing in and beyond ICU to optimise recovery and outcomes.

Perioperative change trajectories and predictors of swallowing function and swallowing-related quality of life in patients with oral cancer: a longitudinal observational study

ObjectiveTo determine change trajectories and predictors of swallowing function and swallowing-related quality of life (QoL) in perioperative patients with oral cancer.DesignLongitudinal observational study.SettingA tertiary cancer hospital in Hunan Province, China.ParticipantsPatients...

Predictive value of intraoperative vagus nerve corticobulbar motor evoked potentials to assess the risk of dysphagia in fourth ventricle surgery.

Dysphagia is a significant complication in fourth ventricle surgery. Corticobulbar motor evoked potentials (CB-MEPs) of the lower cranial nerves may provide real-time information possibly correlating with postoperative swallowing dysfunction, and the vagus nerves may prove ideal for this purpose. However, the literature is heterogeneous, non-systematic, and inconclusive on this topic. The object of this retrospective study was to evaluate the correlation between CB-MEPs of the vagus nerve and postoperative worsening or new-onset swallowing deficits in intraaxial fourth ventricle surgery. In 21 consecutive patients undergoing surgery for fourth ventricle intraaxial tumors between February 2018 and October 2022, endotracheal tubes with two applied electrodes contacting the vocal cords were used to record vagus nerve MEPs including values at baseline, the end of surgery, and the minimum value during the operation. From the mean value of right and left vagus nerve MEP amplitudes, the minimum-to-baseline amplitude ratio (MBR) and final-to-baseline amplitude ratio (FBR) were calculated. These indexes were correlated with postoperative swallowing function. Given their clinical significance, receiver operating characteristic curves were obtained to evaluate the performance of these indexes in predicting postoperative swallowing function. The area under the curve (AUC) was 0.850 (p < 0.001) and the best cutoff for FBR was 67.55% for the worsening of swallowing in the postoperative period. The AUC was 0.750 (p = 0.026) and the best cutoff was 46.37% in MBR for the absence of a swallowing disorder at the late follow-up. This study confirmed that vagus nerve MEPs are reliable predictors of postoperative swallowing function in fourth ventricle surgery and can be feasibly used as an intraoperative monitoring technique.

Timing and Outcomes of Percutaneous Endoscopic Gastrostomy After Ischemic Stroke.

Guidelines recommend using percutaneous endoscopic gastrostomy (PEG) for dysphagia after 2 weeks of stroke onset. We aimed to study the impact of PEG timing on outcomes in patients with ischemic stroke. In this retrospective study of patients with ischemic stroke and PEG between 2014 and 2019, early PEG was defined as PEG tube placed within 14 days of stroke and late PEG after 14 days. Outcomes of 30-day mortality, PEG-related complications, and functional swallow recovery were compared between early and late PEG. Logistic regression model assessed factors associated with PEG timing. The median time of PEG tube placement after stroke was 10.9 days. Of the 161 included patients, 60.9% had early PEG, and its associated patient factors were nursing facility discharge (adjusted odds ratio (OR): 3.4, confidence interval (CI): 1.48 - 7.82) and infection (OR: 0.32, CI: 0.139 - 0.178). Late PEG had 3.27 times greater odds of swallowing recovery, but mortality and complications were not significantly different between early and late PEG. Skilled nursing facility disposition and lack of infection were predictors of early PEG, constituting the majority of PEG placed for ischemic stroke-related dysphagia. Although better odds of swallowing recovery were seen with late PEG, likely implicating better patient selection, overall, the timing of PEG tube placement did not impact short-term mortality and complications.

An Evaluation of Psychometric Properties of EAT-10: A Malayalam Version.

The Eating Assessment Tool (EAT-10) is a 10-item self-administered questionnaire that assesses the severity of dysphagia symptoms, the impact of dysphagia on quality of life and treatment efficacy. EAT-10 has been adapted into several languages, including Malayalam. However, the information on the psychometric properties of EAT-10 MALAYALAM is not known. Therefore, the study aimed to evaluate the psychometric properties of the EAT-10 MALAYALAM. EAT-10 MALAYALAM questionnaire was administered to two groups of native Malayalam-speaking participants. Group 1 consisted of a total of 110 participants (76 males and 34 females) with a mean age of 52.9 ± 13.5years diagnosed with oropharyngeal dysphagia. Group 2 consisted of 110 age and gender-matched healthy participants with normal swallow function and no history and symptoms of swallowing disorders. The test-retest reliability was assessed using Spearman's rank correlation coefficient between the test and the retest scores; internal consistency was assessed using Cronbach's alpha, and Known groups validity was evaluated by comparing the EAT-10 MALAYALAM scores between the participants of both groups. The results of Spearman's correlation coefficient showed 0.99, indicating that the EAT-10-MALAYALAM has excellent test-retest reliability. The Cronbach's alpha was 0.94, indicating strong internal consistency. Mann-Whitney U test showed significant differences in the scores of EAT-10-MALAYALAM between the participants of both groups. Therefore, it was inferred that EAT-10-MALAYALAM had good known groups validity. The EAT-10-MALAYALAM is a valid and reliable tool for screening Malayalam-speaking dysphagia patients.

Imaging swallowing function and the mechanisms driving dysphagia in inclusion body myositis.

Sporadic inclusion body myositis (IBM) is a progressive condition which commonly affects patients aged above 40. IBM does not respond to immunosuppression and no proven treatments are available. Up to 80% of patients develop some degree of swallowing impairment during the disease course. Dysphagia is a source of marked morbidity in IBM and predisposes patients to life-threatening complications such as aspiration pneumonia. The pathophysiology behind dysphagia in IBM is not fully understood. Evidence from imaging demonstrates that impaired swallowing is predominantly underpinned by oropharyngeal deficits. Changes in cricopharyngeal physiology is thought to be an important factor influencing dysphagia in IBM. However, it is unclear whether this is secondary to structural changes within the cricopharyngeus itself or driven by impairment of the muscles promoting pharyngeal clearance. The approach to dysphagia in IBM patients is limited by a lack of validated instruments to reliably assess swallowing function and an absence of effective therapeutic interventions derived from controlled trials targeting dysphagia. Imaging modalities such as the video fluoroscopic swallowing study (VFSS) are commonly used to evaluate dysphagia in IBM. Whilst VFSS is a commonly used technique in clinical practice; cumulative radiation exposure with repeated testing can be a limitation. Alternative imaging techniques could be developed further as outcome measures for assessing swallowing.In this review, we provide an overview of imaging techniques used to assess swallowing and the insight provided from such investigations into the mechanisms behind dysphagia in IBM. We suggest future directions for evaluation and outcome measurement of dysphagia in this population.

Prevalence of Voice and Swallow Problems in Individuals Living with Sickle Cell Disease

Introduction: Sickle Cell Disease (SCD) is an inherited blood disorder with profound implications on a wide variety of tissue types (Kavanagh et al., 2022). As many as 37% of patients with SCD experience silent cerebral infarction by age 14 (DeBaun et al., 2012). Neurological insults can increase risk for voice and swallow disorders which compromise physical health and diminish quality of life for many individuals (Aronson &amp; Bless, 2009). In fact, voice disorders (dysphonia) affect 6% of adults (Roy et al., 2005), and swallowing difficulties (dysphagia) impact as many as 16% (Adkins et al., 2020). Since both phonation and deglutition require the coordination of multiple muscles and nerves (Kendall, 2008), diseases such as SCD may be associated with elevated risk for dysphonia and dysphagia. Unfortunately, the frequency of these symptoms in individuals with SCD has rarely been considered. This study examined the prevalence and nature of dysphonia and dysphagia in individuals with SCD. Methods: Adults (age &amp;gt;18) diagnosed with SCD were surveyed regarding the presence of voice and swallow complaints, symptomology, voice-use patterns, voice and swallow-related quality of life, demographic information, and medical history. Additionally, participants completed the Voice Handicap Index-10 (VHI-10), Eating Assessment Tool (EAT-10), and Reflux Severity Index (RSI). To enable comparisons with previous epidemiological studies of voice and swallow disorder prevalence, survey questions were adapted from previously published investigations (Roy et al., 2004, 2005). Participants were recruited from an outpatient hematology clinic during routine visits and completed the survey online using Redcap. Univariate and multivariate analyses were used to identify dysphonia and dysphagia risk. Results: Twenty-four patients have completed this study (males=16, females=8; mean age=35.2 years; genotype: SS=8, S/β thalassemia zero=3, SC=6, S/β thalassemia plus=7) with recruitment ongoing. Forty-five percent of patients reported a voice complaint within the last 4 years with symptoms lasting longer than 4 weeks in all cases (Table 1). Sixty-six percent of patients presented with VHI scores indicating a voice problem. Dysphonia was described as episodic, with 83.3% of cases becoming more severe during sickle cell crises. Voice problems resulted in exclusion from social activities (37.5%), missed days of work (12.5%), inability to perform daily tasks (12.5%), inability to sing (27.2%), and difficulty performing one's occupation (12.5%). Individuals who vaped were 8% more likely to report dysphonia ( p=.04), and those who drank more than 3 alcoholic beverages a week were 25% more likely to report dysphonia ( p=.03). Patients with dysphonia presented with significantly more severe VHI scores ( p=.019, dysphonia=15.1, normophonic=10.0) and RSI scores ( p=.036, dysphonia=10.5, normophonic=6.8) than those with no voice complaint. No voice use pattern predicted voice disorder risk. One third of participants reported a swallow complaint, with 75% of cases occurring within the last 2 years (Table 1). Forty-one percent of patients presented with EAT-10 scores indicating dysphagia. Swallowing problems were evident with meats (8.3%), bread-like consistencies (20.8%), pills (29.2%), and thin liquids (4.2%). Dysphagia symptoms were episodic in 87.5% of cases, becoming more severe during sickle cell crisis in 37.5% of cases. Patients with dysphagia symptoms presented with significantly more severe EAT-10 scores than those without swallow symptoms ( p&amp;lt;.001, dysphagia group=6.12, no dysphagia=2.06). No patients reported seeing a medical professional for dysphonia or dysphagia symptoms. Conclusions: Dysphonia and dysphagia were markedly elevated in patients with SCD when compared with the general population. Although these symptoms diminished quality of life, no patient had received treatment or even evaluation of these symptoms. Given the medical complexity of patients with SCD, diagnostic overshadowing might have precluded thorough workups of symptoms. This is unfortunate as impairments in voice and swallow function greatly impact quality of life and, in some cases, can be life-threatening. If the current findings are confirmed by future large-scale studies, individuals with SCD may benefit from proactive systematic monitoring and treatment of the subsystems responsible for voice and swallow.

Association between oral condition and subjective psychological well-being among older adults attending a university hospital dental clinic: A cross-sectional study.

Positive psychological well-being has a favorable impact on survival rates in both healthy and unhealthy populations. Oral health is also associated with psychological well-being, is multidimensional in nature, and includes physical, psychological, emotional, and social domains that are integral to overall health and well-being. This study aimed to identify the associations between individual and environmental characteristics, oral condition and nutritional status in relation to subjective well-being among older adults using the Wilson and Cleary conceptual model. The participants were older adults (age ≥ 60 years) attending a university hospital. Subjective well-being was assessed using the World Health Organization-5 Well-Being Index, oral condition was assessed based on the number of bacteria in the tongue coating, oral wettability, tongue pressure, occlusal force, oral diadochokinesis, and masticatory ability, and subjective swallowing function was assessed using the Eating Assessment Tool, number of remaining teeth, and number of functional teeth. In addition, factors related to well-being, including social networks, life-space mobility, nutritional status, smoking history, drinking history, and medical history were assessed. In the analysis, structural equation modeling was used to investigate the association between oral condition and subjective well-being. Confirmatory factor analysis revealed oral condition as a latent variable, including tongue pressure, oral diadochokinesis /pa/, /ta/, /ka/, occlusal force, masticatory ability, subjective swallowing function, and number of functional teeth. Structural Equation Modeling revealed that oral condition was positively correlated with nutritional status, and nutritional status was positively correlated with the World Health Organization-5 Well-Being Index. These findings suggest that oral condition may influence subjective well-being via nutritional status or social environmental factors.

Advantages of instant forms of antibiotics in the treatment of lower respiratory tract infections

Antibacterial drugs are the basis of pathogenetic therapy of most infectious diseases, including lower respiratory tract infections, which continue to occupy a leading place in the structure of morbidity and mortality from infectious diseases worldwide. At the same time, the continuing steady growth of antibiotic resistance of microorganisms, the problem of creating and developing new antibacterial drugs for use in outpatient practice determines the degree of importance of optimizing the dosage regimen of this group of drugs. According to domestic and foreign clinical recommendations, the drugs of choice for the treatment of lower respiratory tract infections in outpatient practice are aminopenicillins and inhibitor-protected penicillins. In the literature review of domestic and foreign studies, the advantages of instant forms of antibacterial drugs in the pharmacotherapy of lower respiratory tract infections are considered in detail and systematized. These include higher bioavailability of the drug, which provides an appropriate level of pharmacodynamic and clinical efficacy, a more favorable safety profile, ease of use in children and elderly patients, as well as in patients with impaired swallowing function, pharmacoeconomical advantages. Thus, the use of dispersible forms of antibacterial drugs in outpatient practice in the treatment of lower respiratory tract infections makes it possible to increase the effectiveness of pharmacotherapy, improve patient tolerance and adherence to treatment, which is especially important when taking medications independently, reduce treatment costs, which in combination helps to curb the development of antibiotic resistance.

Evaluating the effectiveness of video-game based swallowing function training in patients with dysphagia: study protocol for a randomized controlled trial

BackgroundDysphagia can lead to serious complications such as aspiration and aspiration pneumonia, timely and effective rehabilitation training can improve the swallowing function of patients. However, the conventional rehabilitation training methods used in clinical settings have shortcomings such as poor adherence of patients. We present the study design of a randomized controlled trial that evaluated whether video-game based swallowing rehabilitation training can effectively improve swallowing in patients with dysphagia and whether it has additional benefits compared with conventional training methods to improve swallowing function and training compliance among patients with dysphagia.MethodsA randomized controlled trial with 4 weeks of intervention and 4 weeks of follow-up will be conducted in a rehabilitation center in Beijing, China. We will enroll 78 patients aged 18–80 years with dysphagia. Participants will be randomly assigned to the experimental group (video-game based swallowing function training) and the control group (conventional swallowing function training). All participants will receive 30 min of training per day, 5 times per week, for a total of 4 weeks. The primary outcome is swallowing function. Secondary outcomes include patients' quality of life, training compliance, and training satisfaction. Outcomes are assessed at baseline (pre-treatment), 4 weeks of treatment (post-treatment), and 8 weeks (follow-up), and the assessor is not aware of the participants’ grouping.DiscussionThe protocol describes a new rehabilitation training method for dysphagia, which involves participant eligibility recruitment, recruitment strategies, and data analysis plan. The results of the study will inform the rehabilitation training and clinical care management of swallowing function in patients with dysphagia.Trial registrationClinicalTrials.gov, NCT05978700. Registered on 28 July 2023.

Swallowing Rehabilitation: Tracing the Evolution of Assessment and Intervention Approaches for Dysphagia over 30 Years.

Dysphagia or difficulty in swallowing is a common condition affecting millions worldwide. It can occur due to structural problems, neurological disorders, cancer treatment, aging, etc. Swallowing rehabilitation aims to help patients regain safe and efficient swallowing function through compensatory strategies and exercises. This literature review examines the recent advancements in swallowing rehabilitation techniques over the past three decades, with a focus on innovations in diagnostics, personalized medicine, and patient care.

Longitudinal Analysis of Dysphagia and Factors Related to Postoperative Pneumonia in Patients Undergoing Esophagectomy for Esophageal Cancer

AbstractFew studies have quantified longitudinal changes in swallowing in patients undergoing esophagectomy for esophageal cancer. This study longitudinally analyzed the changes in the Modified Barium Swallow Study Impairment Profile (MBSImP™) scores, swallowing kinematic measurements, and swallowing-related symptoms in patients undergoing esophagectomy. We also examined the association between identified swallowing impairment and aspiration pneumonia after surgery. We included consecutive patients who underwent esophagectomy and completed laryngoscopy and videofluoroscopy before, two weeks, and three months after surgery. We analyzed physiological impairments using the MBSImP. We also assessed the swallowing kinematics on a 5 mL thickened liquid bolus at three time points. Vocal fold mobility was assessed using a laryngoscope. Repeated measures were statistically examined for longitudinal changes in swallowing function. The association between the significant changes identified after esophagectomy and aspiration pneumonia was tested. Twenty-nine patients were included in this study. Preoperative swallowing function was intact in all participants. The timing of swallowing initiation and opening of the pharyngoesophageal segment remained unchanged after surgery. Tongue base retraction and pharyngeal constriction ratio worsened two weeks after surgery but returned to baseline levels three months after surgery. Three months after surgery, hyoid displacement and vocal fold immobility did not fully recover. Aspiration pneumonia occurred in nine patients after surgery and was associated with postoperative MBSImP pharyngeal residue scores. Decreased hyoid displacement and vocal fold immobility were observed postoperatively and persisted for a long time. The postoperative pharyngeal residue was associated with pneumonia and thus should be appropriately managed after surgery.

Evaluation of oral medications in the geriatric medical care ward based on the Guidelines for Appropriate Use of Medications for the Elderly (2018), and an analysis of the number of oral medicines in relation to the nutritional route and activities of daily living (ADL) categories

This study aimed to evaluate the use of potentially inappropriate medications (PIMs) and to examine the number of oral medicines based on the swallowing function and activities of daily living (ADL) categories in a geriatric medical care ward. A prospective investigation of oral medication use of 124 consecutive patients (male, n=58; female, n=66) admitted to a geriatric medical care ward was conducted from November 2019 to October 2020. Nutritional routes and ADL categories were quantitatively assessed, and the respective medication quantities were subjected to a statistical analysis. The average number of oral medications was 5.8 at acute care admission, 4.4 upon transfer to the geriatric medical care ward and 4.8 at discharge. Approximately 30% of oral medications were classified as PIMs, including antithrombotic agents, diuretics, antidiabetic drugs, magnesium oxide, sleep and anxiolytic medications, and antipsychotic drugs. Magnesium oxide, antipsychotic drugs, sleep and anxiolytic medications were frequently discontinued during the patient's stay at the geriatric medical care ward. The proportion of PIMs significantly decreased from 35.1% at admission, to 28.8% at ward transfer, and 24.3% at discharge (P<0.01). The number of oral medicines at discharge varied based on the nutritional route, with averages of 5.5 for oral intake, 3.6 for enteral nutrition, and 0.7 for venous nutrition. It also varied based on ADL categories, with averages of 6.0 for ADL 1, 5.8 for ADL 2, and 3.8 for ADL 3. The use of PIMs decreased in the geriatric medical care ward. A reduced swallowing function and lower ADL were associated with a decrease in the quantity of oral medicines.

Swallowing Function After Epiglottopexy in Children.

Epiglottopexy has been an increasingly utilized intervention in children with epiglottic prolapse and airway obstruction. Given the role of the epiglottis in protecting the airway during swallowing and the potential effect of repositioning the epiglottis on the passage of the bolus, we aimed to compare swallowing outcomes before and after epiglottopexy in children. A retrospective cohort study. Tertiary care children's hospital. Data were extracted from charts of children who underwent epiglottopexy and had a subsequent instrumental swallowing evaluation between January 2018 and September 2022. A total of 93 patients underwent epiglottopexy. Of these, 38 patients met inclusion requirements. The mean age at surgery was 41 ± 47 months. Most patients (n = 37, 97.4%) had significant comorbidities such as secondary airway lesions (n = 33, 91.7%), a genetic or syndromic disorder (n = 25, 69.4%), and dysphagia (n = 29, 76.3%). All patients had a concurrent procedure at the time of epiglottopexy with supraglottoplasty (n = 24, 63.2%) and lingual tonsillectomy (n = 16, 42.1%) being the most common. No changes in initiation or patterns of swallowing were noted postoperatively. A total of 7 (18.4%) patients had worsening swallow function: 2 had new-onset dysphagia, and 5 had worsening pre-existing dysphagia. Liquid or food textures penetrated remained unchanged or improved in most cases. No risk factors for worsening dysphagia were identified in our cohort. Children with medical comorbidities undergoing epiglottopexy with additional airway interventions may experience new or worsening dysphagia. However, the procedure is generally safe without notable patterned changes in the swallowing mechanism.

Postoperative Swallowing Function in Patients with Deep Neck Infection

Introduction: Early detection of dysphagia risk, initiating rehabilitation, and resumption of appropriate diet based on swallowing function is important during deep neck infection (DNI) control. This study aimed to evaluate the extent of cervical abscess development, particularly in the deep neck space, and its relationship to postoperative swallowing function. Methods: A retrospective chart review was performed for all DNI cases treated between April 2015 and April 2021. Deep neck spaces were divided into categories based on computed tomography findings. Functional Oral Intake Scale (FOIS) scores of 4 or higher was defined as normal or slight swallowing disorder and 3 or lower as dysphagia. Results: Seventeen cases were included in the analysis. Based on FOIS, 14 cases were classified into the dysphagia group at 2 weeks after surgery, 11 cases at 4 weeks, and 8 cases at 8 weeks. There was no significant difference between the location of the abscess and dysphagia at 2 weeks after surgery. Patients with anterior cervical space abscess significantly increased dysphagia 4 weeks (p = 0.018) and 8 weeks (p = 0.036) after surgery. Conclusion: Abscess formation in the anterior cervical space may be associated with prolonged dysphagia after treatment due to inflammation and scarring of the muscles associated with swallowing.

Impact of Salvage Surgery on Health-Related Quality of Life in Oral Squamous Cell Carcinoma: A Prospective Multi-Center Study.

Patients with recurrent oral squamous cell carcinoma (OSCC) have limited treatment options. Salvage surgery offers potential curative therapy. The need for extensive ablative surgery together with microvascular reconstruction implies invasive and painful treatment with questionable functional outcome. To address the impact of salvage surgery on the health-related quality of life (HRQoL) of patients suffering from recurrent OSCC, a multi-center prospective analysis was initiated. Patients with recurrent OSCC from 2015 to 2022 at two German cancer centers were included. Interdisciplinary tumor board decisions determined surgery as the only curative treatment modality. HRQoL, was assessed via a EORTC questionnaire (European Organization for Research and Treatment of Cancer-EORTC: QLQ-C30 and QLQ-H&N35) in dependence of the recurrent tumor stage. Patients completed the questionnaires once before surgery (baseline) and then every 3 months during follow-up or up to the end of treatment. In total, 55 patients were included. The mean follow-up period was 26.7 ± 19.3 months. Global health status showed superior mean scores after 12 months (60.83 ± 22.58) compared to baseline (53.33 ± 26.41) in stage 1 and 2 recurrent tumors. In advanced recurrent tumors' mean scores for global health showed only minor positive differences after 12 months (55.13 ± 22.7) compared to baseline (53.2 ± 25.58). In terms of the mouth pain, mean scores were lower after salvage surgery in small recurrent tumors after 12 months (20.37 ± 17.73) compared to baseline (41.67 ± 33.07; Wilcoxon two-sample signed-rank test p = 0.028). In advanced recurrent tumors, a significant reduction in mean scores was detected 3 months after salvage surgery (29.7 ± 22.94) compared to baseline (47.76 ± 25.77; Wilcoxon two-sample signed-rank test p = 0.003). Up to 12 months, swallowing function was evaluated inferior compared to baseline independent of tumor stage (Mean score recurrent stage I/II: 12-months 48.15 ± 27.57, baseline 28.7 ± 22.87; stage III/IV: 12-months 49.36.42 ± 27.53; baseline 30.13 ± 26.25). Improved HRQoL could be obtained in advanced recurrent OSCC after salvage surgery despite reduced swallowing function. In small recurrent tumors, overall, HRQoL was superior to baseline. Salvage surgery positively affected pain burden. For advanced recurrent tumors, important pain relieve could be observed as soon as 3 months after surgery.

Prophylactic vs. Reactive Gastrostomy Tube Placement in Patients Treated with Radiotherapy for Head and Neck Cancer

Radiotherapy (RT) for head and neck cancer (HNC) can cause acute toxicities resulting in weight loss warranting alterative enteral access. Some institutions favor prophylactic gastrostomy tube (GT) placement to prevent malnutrition at the forefront, while others choose to reactively place tubes if nutritional deficits arise. Though prophylactic GT placement may limit on-treatment weight loss, this approach may result in unneeded GT placement and may potentially impact long-term swallowing function. Patients with HNC treated with CRT from 2018-2021 were reviewed. GT placement prior to CRT (prophylactic [ppx] tube) was performed at the discretion of the treating radiation oncologist. The remainder of patients were treated with reactive (rx) GT placement in the event of on-treatment weight loss approaching 10-15%. Patient, disease and treatment factors were abstracted from the medical record. Primary endpoints were placement of GT in the rx group, weight change at the end of RT, and time to tube removal. In total, 278 patients were identified; 35 GT-dependent patients and 22 patients with nasal cavity/paranasal sinus cancers were excluded, yielding 221 for analysis. Baseline factors associated with GT group included age, ECOG, baseline swallowing function, primary site, T and N stage, stage group, and treatment year. Treatment factors associated with GT group were: neck target (bilateral v. unilateral/none), concurrent chemotherapy, and total dose. Of the 118 patients in the rx group, 14 (12%) required rx GT placement during or within 30 days of CRT. RT completion rates were similar between groups (95-96%, p = 1). GT was removed at last follow-up in 57% of patients in both groups (p = 1). Percent on-treatment weight loss was -8.9% (SD 6.7) and -7.2% (SD 6.1) for the ppx and rx groups, respectively (p = 0.04). Median Kaplan-Meier estimate of time to GT removal was 7.7 months (95% CI 6.0-11.3) and did not differ between groups (log-rank p = 0.87). Factors associated with the placement of rx GT include: concurrent chemotherapy (yes 20% vs. No 0%, p.0007) and baseline FOIS (5 or less 40% vs. 6 or more 9%, p = 0.02). T stage, N stage, overall stage, postoperative RT, degree of neck irradiation were not associated. Reactive gastrostomy tube placement in patients treated with chemoradiotherapy for head and neck cancer patients is feasible and results in low rates of gastrostomy tube placement. There are no observed differences in on-treatment weight loss between patients treated using a prophylactic versus reactive approach. No differences in time to gastrostomy tube removal were observed.

Reducing the Risk of Post-RT Aspiration by Sparing Specific Aspiration Related Organs at Risk

Radiotherapy (RT)-induced aspiration is a serious and potentially life-threatening side effect. We identified functional swallowing units (FSUs), musculature involved in larynx elevation and tongue base retraction (R&O 2019; 130:62). FSUs were strongly related to aspiration. We developed a prediction model with baseline aspiration status and dose in FSUs as factors which performed well in predicting videofluoroscopy assessed RT-induced aspiration, at 6 months. FSUs are not yet recognized as Swallowing Organs at Risk (SWOARs) in daily practice and in treatment plan optimization. In the current study, we aimed to apply the aspiration prediction model in RT treatment plan optimization to actively spare the FSUs and establish the potential to reduce the risk of late RT-induced aspiration. The planning study included 30 HNC patients treated with definitive radiotherapy. We optimized VMAT plans directly on logistic regression models (R&O 2021; 162:85), including normal tissue complication probability (NTCP) models for xerostomia, dysphagia and aspiration, and logistic models for target volume coverage and overall plan quality. Automated plans were created with and without using the NTCP-model for aspiration, i.e., with and without specific sparing of the previously identified FSU, including musculature associated with aspiration. The FSU sparing plans were created with and without assuming baseline aspiration. All NTCP models were weighted equally during optimization. The NTCP of toxicities including salivary, swallowing and speech problems, pain and general symptoms were evaluated for each plan. All plans complied with all treatment planning quality criteria and were successful in limiting the risk of xerostomia and dysphagia. Plans optimized using the NTCP model for aspiration significantly reduced the risk of late aspiration (p < 0.001) and in all 30 patients. The optimizer of the planning system increased its efforts to spare the FSUs even more when baseline aspiration was assumed. Therefore, the aspiration risk reduction was greatest in these plans (average risk was reduced from 73.9 to 60.6%, versus from 37.8 to 29.5% in plans assuming no aspiration at baseline). Aspiration risk reduction by sparing FSUs did not reduce overall plan quality. A slight redistribution of dose was seen as a result of FSU sparing. The largest observed NTCP increase was 0.6% for moderate-to-severe xerostomia. FSU sparing unintentionally reduced the average NTCP of moderate-to-severe hoarseness and speech problems with 2.1% and 1.2%, respectively. Sparing all specific aspiration related organs at risk, including FSUs, during RT has the potential to significantly reduce the risk of RT-induced aspiration, especially in patients with pre-existing baseline aspiration. With automatic planning, FSUs sparing does not increase complexity of the treatment planning process and does not compromise treatment plan quality.

Conformal 3D computed tomography planned endoluminal brachytherapy for the local control of esophageal cancer

PurposeTo outline the toxicity, tolerability, and efficacy of a 3D conformal computed tomography planned endoluminal brachytherapy (ELBT) treatment for esophageal adenocarcinoma (OAC) or squamous cell carcinoma (OSCC). Methods and MaterialsA retrospective single-center analysis of toxicity, tolerability, and outcomes for 65 consecutive patients with OAC/OSCC who received 6–8Gy in one fraction or 12–16Gy in two fractions of high-dose-rate ELBT as salvage postchemoradiotherapy (n = 7 and n = 14 respectively), or as a boost to external beam radiotherapy (n = 14 and n = 30, respectively). ResultsMedian overall survival from the first brachytherapy application was 7.4 (IQR 5.0–14.7) months for the boost cohort and 9.2 (IQR 5.8–20.1) months for the salvage cohort. In a univariate analysis, use of a higher, fractionated dose of radiotherapy was associated with longer overall survival. At least one-third (33%; n = 7) of the salvage cohort and 28% (n = 12) of the boost cohort exhibited a local recurrence prior to death. Overall, 66.7% of the salvage and 56.8% of the boost cohort experienced odynophagia. Swallow function stabilized or improved early after treatment, with only 11.6% of the boost and 14.3% of the salvage cohort demonstrating a long-term decline in dysphagia score. Conclusions3D conformal planned ELBT is safe and tolerable. Most patients exhibit an early and sustained stabilization or improvement in their swallow function and greater survival is seen with higher brachytherapy doses. Further research is required to determine the place of brachytherapy in the management of esophageal cancer, particularly when planned using contemporary conformal approaches.

Videofluoroscopic analysis of the laryngeal movement of older adults in swallowing.

Even without diseases that cause dysphagia, physiological swallowing function declines with age, increasing the risk of aspiration. This study analyzed age-related changes in laryngeal movement in older adults. The study population consisted of 10 volunteers in their 80s and six in their 20s. A videofluoroscopic study of 3 and 10mL barium swallows was performed laterally using a digital fluorographic. The recorded images were retrieved to a personal computer and analyzed frame-by-frame using video analysis software. The movement of the larynx during swallowing, barium's pharyngeal transit time (PTT), and laryngeal elevation delay time (LEDT) were analyzed. Results were compared between the 20s and 80s age groups using statistical analyses. The PTT was shorter in the 20s than in the 80s age group. The PTT was significantly longer in the 80s group than in the 20s for both 3 and 10mL barium swallows. LEDT in the 80s was statistically significantly longer than that in the 20s for the 10ml barium. No statistically significant differences were found; however, there was a tendency for the 80s group to have more types of laryngeal movement velocity peaks. In this study, LEDT was prolonged in the 80s with 10ml barium swallowing than in the 20s. Two peak patterns of laryngeal elevation during swallowing were observed. The velocity peaks showed a two-peak pattern when the patients were in their 80s and when the barium volume was tested at 10mL. Our results suggest that aging's effect on swallowing relates to laryngeal elevation.