MD Anderson Dysphagia Inventory Research Articles

Comparison of Functional Organ Preservation by Concomitant Boost Radiotherapy Versus Concurrent Chemoradiation in Locally Advanced Carcinoma of Larynx or Hypopharynx: A Prospective Randomized Study

Functional organ preservation is a major challenge in management of advanced laryngeal and hypopharyngeal carcinoma. Although ideal approach is a subject of much debate, radiotherapy with or without chemotherapy is most commonly used modality. This randomized study was conducted to compare functional organ preservation by chemoradiation (CRT) versus concomitant boost radiotherapy (CBRT). A total of 40 patients with advanced (stage III/stage IVa) laryngeal and hypopharyngeal cancer were randomized to receive either CRT (n = 20) to a dose of 66Gy in 33 fractions over 6.5weeks with concurrent cisplatin (100mg/m2 on days 1, 22 and 43) or CBRT (n = 20) to a dose of 67.5Gy in 40 fractions over 5weeks. Patients were assessed for organ preservation rate, toxicities, voice and swallowing functions utilizing Voice Related Quality of Life (VRQOL) and MD Anderson Dysphagia Inventory (MDADI) scores, respectively, for minimum follow up of 6months. Organ preservation rate (intact disease free larynx) at 6months post treatment was observed in 100% in CRT arm and 95% in CBRT arm. There was no significant difference in mucositis and dermatitis in two arms (p = 0.82 and 0.78, respectively). Dysphagia was observed more in CRT arm (n = 12 vs n = 6). Late toxicities grade 3 xerostomia, grade 2 dysguesia, were seen significantly more in CRT arm. There was no statistical difference between the two arms in terms of VRQOL (p = 0.55) and MDADI scores (p = 0.13). In CRT arm 13 patients complete response and in CBRT arm 12 patients had complete response. Accelerated fractionation with concomitant boost schedule is as effective as CRT in anatomical and functional preservation of larynx. The toxicities, voice and dysphagia related quality of life is comparable.

Effect of Induction Chemotherapy on Swallowing in Head and Neck Cancer Patients

Objective:To evaluate the effect of induction chemotherapy on swallowing and swallowing-related quality of life of patients with oropharyngeal, laryngeal and hypopharyngeal cancer.Study design:Prospective study of 33 patients with locally advanced tumors who were eligible for treatment with neoadjuvant chemotherapy followed by radiotherapy and concurrent chemotherapy. A multidimensional assessment of swallowing was performed using the following tools: (1) Clinical analysis, numerical scale for general pain and painful swallowing, American Speech and Hearing Association (ASHA) Functional Communication Measures (FCM) swallowing assessment scales, (2) assessment of Swallowing-Related Quality of Life (The MD Anderson Dysphagia Inventory - MDADI), and (3) swallowing videofluoroscopy.Results:There was a reduction in general pain scale (p=0.021), and quality of life (emotional, functional and physical) improved from average limitation (score of 61-80) to minimal limitation (81-100) after induction chemotherapy. According to the swallowing videofluoroscopy results, 26 (78.7%) of the patients had some degree of dysphagia pre-treatment, which decreased to 21 (63.6%) after induction.Conclusion:Our results suggest that induction chemotherapy improves numerous aspects of swallowing and has a positive impact on the quality of life of pre-chemoradiotherapy patients.

Patient-reported versus physiologic swallowing outcomes in patients with head and neck cancer after chemoradiation.

The primary objective of this project was to retrospectively investigate the relationship between patient-reported and physiologic swallowing measures after chemoradiation therapy for head neck cancer (HNC). Adult patients who underwent chemoradiation therapy for HNC and presented for videofluoroscopic swallow study were reviewed retrospectively. Surgically treated patients were excluded. Patient perception of swallowing-related outcomes was assessed via the MD Anderson Dysphagia Inventory (MDADI) on the same day that physiologic measures of swallow function were obtained. Using vidoefluoroscopic data, the Dynamic Imaging Grade of Swallowing Toxicity (DIGEST) scale yielded measures of safety (DIGEST-S: penetration/aspiration) and efficiency (DIGEST-E: residue). Statistical analysis for correlation coefficients was performed. Thirty patients met the inclusion criteria. The oropharynx was the most commonly affected site (70.0%), followed by the larynx (16.7%). The median radiation dose was 72 grays (Gy), and participants were assessed a mean of 4.6 (range 0-12) years following completion of treatment. There was no correlation between the MDADI and the DIGEST-E score (Pearson rho = -0.045, P = 0.812), DIGEST-S score (Pearson rho = 0.075, P = 0.695), or summary DIGEST grade (Pearson rho = 0.046, P = 0.810). MDADI scores did not change significantly with increasing time since radiation (P = 0.375), whereas the DIGEST-E scores, DIGEST-S score, and summary DIGEST grades worsened over time (P = 0.007, P = 0.002, and P = 0.0005, respectively). Assessment of swallowing physiology showed that function worsened after chemoradiation therapy, but this did not correlate with patient-reported quality-of-life measures. Reduced patient awareness of swallow dysfunction years after completion of chemoradiation has implications for management of dysphagia in the face of physiologic decline. 4 Laryngoscope, 129:2059-2064, 2019.

Prospective instrumental evaluation of swallowing, tongue function, and QOL measures following transoral robotic surgery alone without adjuvant therapy.

Transoral robotic surgery (TORS) has been utilized to deintensify treatment. No studies have measured swallow safety and efficiency, nor assessed the functional impact of TORS alone. This prospective cohort underwent baseline and 1-month postsurgery assessments including modified barium swallow evaluation, using the Dynamic Imaging Grade of Swallowing Toxicity (DIGEST) rating system, tongue range of motion assessment, the Performance Status Scale (PSS), and quality of life with the MD Anderson Dysphagia Inventory (MDADI). All DIGEST safety scores were 0 (normal) at both time points. DIGEST efficiency scores were mildly impaired in 2 of 10 patients postsurgery. PSS scores revealed all patients were on regular diets, were 100% understandable, and were eating in public at both time points. Tongue Range of Motion scores were 100 of 100 at both time points. MDADI scores were not significantly different across time points. Careful identification of patients can result in excellent outcomes following TORS. Future studies will examine longer follow-up of speech, swallowing, and tongue function in patients undergoing TORS surgery.

Translation and validation of the MD Anderson Dysphagia Inventory (MDADI) for Spanish-speaking patients.

The main objective of this study was to perform the adaptation and cultural translation and validation of the MD Anderson Dysphagia Inventory (MDADI) questionnaire for the Spanish language. A total of 69 patients were diagnosed with head and neck cancer treated with surgery; radiotherapy and chemoradiotherapy were included. MDADI was translated and a feasibility, internal consistency, test-retest reliability, and construct validity were assessed. The mean overall score of the MDADI was 51.9 (18-85). Internal consistency for total score was 0.908. The overall score of intraclass correlation coefficient was 0.98 and kappa coefficient scores were almost perfect (test-retest reliability). All domains of MDADI were significantly correlated with physical and mental domains of the SF-12. Construct validity was also evaluated with food texture measures, and with TNM classification. The translation and validation of the Spanish version of the MDADI was performed and can be considered an important patient-reported outcomes tool for dysphagia-related quality of life.

Radiation-induced late dysphagia after intensity-modulated radiotherapy in nasopharyngeal carcinoma patients: a dose-volume effect analysis

Dysphagia is a side effect of nasopharyngeal carcinoma chemo-radiotherapy (CRT) which greatly influences the quality of life of the patients. We analyzed late dysphagia in 134 patients with nasopharyngeal cancer undergoing radical radiotherapy (RT), and correlated these findings with dose–volume histogram (DVH) parameters of the swallowing organs at risk (SWOARs). DVH parameters of SWOARs were correlated with late dysphagia, and with RTOG/EORTC scale score and the M. D. Anderson dysphagia inventory (MDADI) score. The mean dose (Dmean) to the superior and inferior constrictor muscles (SCM and ICM) and age were associated with grade 2 late dysphagia. Receiver operating characteristic (ROC) curves showed that the threshold values for grade 2 late dysphagia were: Dmean to SCM ≥ 67 Gy, partial volume receiving specified dose of 60 Gy (V60) of SCM ≥ 95%, Dmean to ICM ≥ 47 Gy, and V50 of ICM ≥ 23%. The areas under the ROC curve were 0.681 (p = 0.02), 0.677 (p = 0.002), 0.71 (p < 0.001) and 0.726 (p < 0.001) respectively. Our study demonstrates a significant relationship between late dysphagia and the radiation doses delivered to the SCM and ICM. Our findings suggest that physicians should be cautious in reducing the RT dose to SWOARs in order to avoid severe dysphagia. Further prospective trials are necessary to recommend this as part of routine clinical practice.

Patient-Reported Outcome Measures of Long-Term Swallowing Function after Oropharyngeal Radiation Therapy: A Cross-Sectional Methods Comparison

Definitive radiation therapy (RT) plays an important role in the curative treatment of many patients with oropharyngeal cancer (OPC), but carries a risk of long-term toxicity including the development of severe dysphagia. Here we characterize the relationship of patient-reported outcomes (PRO) of swallowing to quality of life (QOL) and radiation dose in long-term OPC survivors following definitive RT. Patients with non-metastatic OPC treated with definitive RT at a single institution between January 2000 and April 2014 were examined. All patients completed the MD Anderson Symptom Inventory—Head and Neck (MDASI-HN), the MD Anderson Dysphagia Inventory (MDADI), and the EuroQol five dimension questionnaire (EQ-5D VAS) 12 months or more following end of RT in a cross-sectional survivorship survey. A single dysphagia question from MDASI-HN (designated MDASI-HN-S) was used. An MDASI-HN-S score ≥6 and composite MDADI score <60 were considered representative of moderate-severe swallowing dysfunction. The Bayesian information criteria (BIC) were used to test the predictive power of MDASI-HN-S and composite MDADI with QOL as measured by EQ-5D VAS. The modified Breiman recursive partitioning analysis (RPA) was used to identify an MDASI-HN-S cut off score for poor QOL. To assess validity of PRO cutpoints, the mean dose to candidate regions of interest (ROI) were compared in patients with and without moderate/severe dysphagia symptoms. A total of 714 patients met criteria for inclusion, with 91.9% treated with intensity modulated radiotherapy (IMRT) and a mean time from treatment of 6.7 years. Moderate/severe dysphagia was reported by 17% and 16% of respondents by MDASI-HN-S and composite MDADI, respectively. QOL as measured by EQ-5D VAS was lower in those with moderate/severe dysphagia per both MDASI-HN-S (63.4 vs 83.5, p<0.001) and composite MDADI scores (64.5 vs 83.2, p< 0.001). Although both inventories were predictive of QOL, the model including MDASI-HN-S was slightly more parsimonious for discrimination of EQ-5D VAS scores compared to composite MDADI (BIC of 6062 vs 6076). Recursive partitioning analysis showed that an MDASI-HN-S cutoff score of ≥6 correlated best with EQ-5D VAS decline (LogWorth 2.7, p<0.001). Among 320 patients with available DICOM-RT plans, a higher mean dose to the contralateral anterior digastric muscle, intrinsic tongue muscles, and larynx was associated with moderate-severe dysphagia by both MDASI-HN-S and composite MDADI (all p <0.05). In long-term survivors of OPC following definitive RT, the single item dysphagia MDASI-HN-S question performed as well as the 20-item MDADI for discrimination of patient-reported dysphagia and QOL. Dose-response relationships to candidate ROIs were similar for the two questionnaires.

Functional Burden Associated with Late Lower Cranial Neuropathy in Long-Term Oropharyngeal Cancer Survivors Treated with Definitive Radiation Therapy

Lower cranial neuropathy (LCNP) is a rare potentially disabling late toxicity induced by damage due to radiotherapy (RT) and other cancer therapies. The objective of this paper was to examine the impact of late LCNP on functional burden and swallowing related QOL. We hypothesized that OPC survivors with late LCNP would report significantly worse swallowing-related QOL scores. A total of 882 OPC survivors (median survival time: 7 years) who received definitive RT at an institution between January 2000 – December 2013 completed a cross-sectional survey (56% response rate) that included the MD Anderson Dysphagia Inventory (MDADI). The 19-item composite MDADI score representing overall swallowing-related QOL was the primary outcome and composite emotional, physical and functional subscale scores were secondary outcomes. Late LCNP events defined by onset >3-months after cancer therapy were abstracted from medical records. Multivariate models regressed MDADI scores on late LCNP status adjusting for clinical covariates. A total of 3.9% (n=34) of respondents (median survival time: 11.5 years) developed late LCNP. Among them, 50% were treated with RT and concurrent chemotherapy and 32%with RT only. They were treated with a higher total mean RT dose (LCNP: 69.5 vs. 68.2 Gy, p<0.001), 64% received IMRT-SF and 26% received 3D Conformal RT. Patients with late LCNP reported significantly worse mean composites scores (LCNP: 67.6 vs. no LCNP: 79.8, p<0.001). Late LCNP was independently associated with worse mean composite scores (β= -7.6, p=0.007, 95%CI: -13.1, -2.0) adjusting for age, survival time, sex, education, treatment modality, T-stage, subsite, RT type, solid food at baseline and smoking. Subscale scores that were most severe, in rank order of means, included physical (LCNP: 62.0 vs. no LCNP: 75.5, p<0.001), global (LCNP: 64.1 vs. no LCNP: 80.8, p<0.001), emotional (LCNP: 69.9 vs. no LCNP: 80.6, p<0.001) and functional scores (LCNP: 73.8 vs. no LCNP: 85.5, p<0.001). Late LCNP was independently associated with worse physical (β = - 8.8, p=0.008, 95%CI: - 15.23, -2.29), global (β = -10.6, p=0.01, 95%CI: -18.6, - 2.5), emotional (β = -6.1, p=0.035, 95%CI: -11.7, -4.2) and functional scores (β = -7.5, p=0.009, 95%CI: -13.0, -1.9) adjusting for age, survival time, sex, education, treatment modality, T-stage, subsite, RT type, solid food at baseline and smoking. In our large survey study, OPC survivors with late LCNP reported significantly poor swallowing related QOL and higher levels of functional impairment. Late LCNP may lead to profound deficits in swallowing, extended placement of feeding tubes, tracheostomy tubes, and refractory aspiration that can lead to pneumonia and diminished QOL. Further efforts are necessary to alleviate the functional burden associated with this disabling late effect of cancer treatment experienced by OPC survivors.

Objective and subjective hyposalivation after treatment for head and neck cancer: Long-term outcomes.

This study examined saliva weight over time and its association with diet and patient-rated swallowing, dry mouth, sticky saliva, and dysgeusia quality of life in head and neck cancer (HNCA) patients treated with surgery plus adjuvant chemoradiotherapy (CRT), or primary CRT. Prospective cohort study in an outpatient HNCA center setting. Patients were seen pretreatment, and 1, 3, 6, 12, 24, and 36 + months post-treatment. All had newly diagnosed oral, oropharynx, nasopharynx, larynx/hypopharynx cancer from 2010 to 2016 and were to undergo surgery + CRT or primary CRT. Stimulated saliva weight was assessed with the Saxon test. Diet, eating, dry mouth, and dysgeusia quality of life were assessed and correlated with saliva weight, treatment modality, and tumor site. Saliva weight decreased the most within the first 3 months across treatment groups, except for the surgery + CRT group, which continued to decline. Similar trends were seen by tumor site. Performance Status Scale (PSS) Normalcy of Diet and all quality-of-life scores declined following treatment. The European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Head and Neck-35 (EORTC QLQ-H&N35); Eating Assessment Tool (EAT-10); M. D. Anderson Dysphagia Inventory (MDADI) Composite, Global, and subdomain scores; and PSS Diet were significantly correlated with saliva weight. Saliva weight worsened post-treatment across groups and tumor site, with improvement by 36 + months. Saliva weight correlated with diet, eating quality of life and perception of dysgeusia across time points. Despite dose-sparing intensity-modulated radiation therapy, newer technologies are needed to preserve saliva production and maintain higher quality of life. 2b Laryngoscope, 128:2732-2739, 2018.

Impact of Head and Neck Cancer Treatment on Survivors' Mealtime Experience.

The objectives of the study were to develop a mealtime experience self-assessment questionnaire that was head and neck cancer (HNC) survivors-driven and based on the International Classification of Functioning, Disability and Health (ICF) framework, and to identify common mealtime issues reported by HNC survivors. Outcomes research. Mealtime issues reported by HNC survivors in prior research was synthesized and classified using the ICF framework to develop the content and structure of the Head and Neck Cancer Survivors' Assessment of Mealtimes (HNSAM). A total of 122 HNC survivors completed both HNSAM and M.D. Anderson Dysphagia Inventory (MDADI) to assess for concurrent validity, whereas 51% of participants completed a second HNSAM for test-retest reliability. The HNSAM scores were significantly correlated with the MDADI scores. Dysphagic participants (n = 45) had significantly higher HNSAM scores than the nondysphagic participants (n = 77). Principal component analysis revealed three factors that matched with the HNSAM subscales. Good internal consistency (Cronbach's α = 0.72-0.96) and test-retest reliability (intraclass correlation = 0.76-0.91) were found. Both dysphagic and nondysphagic participants reported difficulties with saliva-related issues and were not able to enjoy food/drinks that they previously enjoyed. HNC survivors experience mealtime changes after cancer treatment. These initial validity data support the potential for the HNSAM to help HNC survivors' identify changes to the mealtime experience. Validation of the English version of the tool is now required. 2c Laryngoscope, 129:1572-1578, 2019.

Changes in Patient-reported Swallow Function in the Long Term After Chemoradiotherapy for Oropharyngeal Carcinoma

AimsTo assess long-term patient-reported swallow function after chemoradiotherapy for oropharyngeal carcinoma and to evaluate the frequency of deterioration/improvement over years. Materials and methodsFifty-nine patients with oropharyngeal carcinoma treated with parotid-sparing intensity-modulated radiotherapy and concurrent chemotherapy between 2010 and 2012 had previously completed the MD Anderson Dysphagia Inventory (MDADI) at a median of 34 months (range 24–59) after treatment. An MDADI was posted to 55 alive and disease-free patients after a 30 month interval; 52/55 replies were received, a median of 64 months (range 52–88) after treatment; 27/52 (52%) had been managed with a prophylactic gastrostomy. A 10 point or greater change in the MDADI scores was defined as clinically significant. ResultsOverall, in the whole cohort, patient-reported swallow function showed a small absolute improvement in MDADI composite score on the second MDADI questionnaire (>5 years after treatment) compared with the first MDADI (>2 years after treatment); mean 68.0 (standard deviation 19.3) versus 64.0 (standard deviation 16.3), P = 0.021. Using the composite score, swallow function was stable over time in 29/52 (56%) patients; a clinically significant improvement in swallow function over time was noted in 17/52 (33%) patients; conversely 6/52 (12%) patients experienced a clinically significant deterioration with time. Abnormality of pre-treatment diet and a prophylactic gastrostomy correlated with an inferior MDADI composite score on the later questionnaire (P = 0.029 and P = 0.044, respectively). ConclusionsLong-term dysphagia is prevalent >5 years after treatment. Although long-term swallow function is stable in most patients, it is not static in a minority. On MDADI composite summary scores, 33% of patients experienced an improvement, whereas 12% deteriorated with time. Further investigation is needed to determine underlying mechanisms behind these divergent outcomes.

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

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. 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. 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. 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. 1b and 2b.

Prospective evaluation of patient reported swallow function with the Functional Assessment of Cancer Therapy (FACT), MD Anderson Dysphagia Inventory (MDADI) and the Sydney Swallow Questionnaire (SSQ) in head and neck cancer patients

ObjectivesThe Functional Assessment of Cancer Therapy (FACT) instrument is comprised of a group of related and overlapping quality of life (QoL) questionnaires including a core general form, head and neck cancer (HNC)-specific items, and an expert-selected index (FACT-HNSI). Understanding how these relate to more HNC-specific instruments such as the MD Anderson Dysphagia Inventory (MDADI) and Sydney Swallow Questionnaire (SSQ) is vital for guiding their use in clinical trials. Materials and methodsHNC patients concurrently completed MDADI, SSQ, and FACT questionnaires at radiation oncology clinic visits (2015–2016). Spearman correlation coefficients were calculated between each FACT instrument and MDADI or SSQ. Unsupervised k-means cluster analyses were performed to identify clusters of similar QoL responses. Principal component analysis (PCA) identified the degree of variability explained by each instrument. ResultsWe identified 631 instances (363 patients) where the questionnaires were completed concurrently. Correlations between the various FACT measures and SSQ or MDADI were all significant (p < 0.001), but FACT HNC-specific subscale and FACT-HNSI showed the strongest correlation with MDADI and SSQ. Clustering identified 3 distinct groups of responses when combining instruments either pairwise or three-way. PCA revealed that MDADI and FACT HNC-specific subscale provide similar and likely redundant information. ConclusionFACT HNC-subscale and FACT-HNSI may be preferable over other FACT measures for use in clinical trials where patient-reported swallow function is evaluated. MDADI and FACT provide similar insights into HNC patient QoL while SSQ provides additional, complementary information which could serve to better stratify patients into groups with high, medium, and low QoL outcomes.

Long term patient reported swallowing function following chemoradiotherapy for oropharyngeal carcinoma

Background and purposeLimited data are available to inform on long term swallowing outcomes following concurrent chemoradiotherapy for oropharyngeal carcinoma. The aims of this study are to determine long term patient-reported swallowing outcomes across two large UK centres in routine clinical practice and identify associated factors. Material and methodsAll patients treated for oropharyngeal squamous cell carcinoma with concurrent chemoradiotherapy, and irradiation of the bilateral neck, between 2011 and 2013 were identified. Those requiring therapeutic enteral feeding prior to treatment, or having subsequent disease relapse, were excluded from the study. Patients were sent postal invitations to complete the MD Anderson Dysphagia Inventory (MDADI), at least two years following completion of treatment. ResultsCompleted MDADI were received from 201/242 eligible patients (83%) at a median of 3.4 years (range 2–5) post treatment. Median composite MDADI score was 68.4. 64 (32%) had composite MDADI <60 classed as ‘poor’ function, 76 (38%) scores ≥60–<80 classed as adequate function, and 61 (31%) had scores ≥80 classed as optimal function. Patients with normal and abnormal pre-treatment diet had median composite MDADI scores of 70.5 versus 47.4 respectively. Patients who did not require enteral feeding during treatment and those who did had median composite MDADI scores of 76.3 versus 65.3 respectively. On multivariate analysis poorer performance status, abnormal pre-treatment diet, and use of enteral feeding during radiotherapy were all significantly associated with lower composite, global and subscale MDADI scores. ConclusionsPatient reported swallowing dysfunction remains common in the long term post-chemoradiotherapy. Impaired pre-treatment diet and use of enteral feeding during treatment are key factors associated with poorer swallowing outcomes.

HSS Dysphagia and Dysphonia Inventory (HSS-DDI) Following Anterior Cervical Fusion

Dysphagia and dysphonia are common complications after anterior cervical spine surgery; however, reported prevalences vary greatly due to a lack of reliable clinical standards for measuring postoperative swallowing and speech dysfunction. The Hospital for Special Surgery Dysphagia and Dysphonia Inventory (HSS-DDI) was developed as a patient-derived, patient-reported instrument to measure dysphagia and dysphonia more accurately after anterior cervical spine surgery than existing indices. This multiphase survey-development study implemented a mixed-methods approach. Phase 1 involved qualitative assessment of postoperative patient-reported swallowing or speaking deficiencies to assemble a draft survey. Phase 2 established test-retest reliability and finalized the 31-item HSS-DDI. Phase 3 compared the HSS-DDI with the Swallowing-Quality of Life (SWAL-QOL) questionnaire and the M.D. Anderson Dysphagia Inventory (MDADI) for validity and responsiveness. Phase 1, performed to formulate the draft survey, included 25 patients who were asked about speech and swallowing dysfunction after anterior cervical spine surgery involving at least 3 vertebral levels. Phase 2 included 49 patients who completed the draft survey twice. The mean scores (and standard deviation) for each administration of the HSS-DDI were 67 ± 24 and 75 ± 22, the Cronbach alpha coefficients were both 0.97, and the intraclass correlation coefficient was 0.80. The 31-item HSS-DDI was finalized with all but 2 items having weighted kappa values of ≥0.40. Phase 3 included 127 patients and established external validity, with most correlation coefficients between the HSS-DDI and the SWAL-QOL and MDADI ranging from 0.5 to 0.7. Internal validity was established by identifying worsening HSS-DDI scores with increases in the number of vertebral levels involved (p = 0.02) and in the Surgical Invasiveness Index (p = 0.006). HSS-DDI responsiveness ascertained by effect size (0.73) was better than that of the SWAL-QOL and MDADI. The average administration time for the HSS-DDI was 2 minutes and 25 seconds. The HSS-DDI is efficient, valid, and more responsive to change after anterior cervical spine surgery than existing surveys. The HSS-DDI fills a gap in postoperative assessment by providing a reliable, more clinically sensitive, patient and condition-specific evaluation of dysphagia and dysphonia prospectively and longitudinally.

Transoral Laser Microsurgery for Supraglottic Cancer.

Transoral laser microsurgery (TLM) is an accepted and effective treatment strategy for supraglottic carcinomas. Early supraglottic carcinoma has excellent outcomes independently of the treatment approach. The role of TLM for the treatment of locally advanced tumors is debated. Particularly, the functional outcomes after TLM have to be proven by functional assessment of large cohorts of patients. This study analyzes the oncologic and functional outcomes after TLM for supraglottic carcinomas. Ninety-one patients with pT1-pT4a supraglottic carcinomas treated between January 2002 and December 2012 were analyzed. Distribution of tumors (UICC 2010) was 11 patients with pT1, 31 patients with pT2, 36 patients with pT3, and 13 patients with pT4a tumors. Node status was positive in 40 (43.6%) patients; 61 (67.1%) patients had stage III or IVa disease. Local control and survival were estimated using the Kaplan-Meier method. For the assessment of functional outcomes, the MD Anderson Dysphagia Inventory (MDADI), the Voice Handicap Index-10 (VHI-10), and the performance status scale for head and neck cancer [Performance Status Scale for Head and Neck (PSS-HN)] were used. The median age was 62 years (range, 33-88 years). Fourteen (15.4%) patients developed a local or locoregional recurrence. The 5-year local control rate and 5-year ultimate local control rate were 72 and 92%, respectively. The 5-year overall survival rate was 63%. Twelve (13.2%) patients needed temporary tracheostomy. Sixty-eight (74.0%) patients had a nasogastric feeding tube post-operatively. At 1-year post-operative follow-up, only three patients were PEG dependent. The median VHI-10 score was 35, the median MDADI composite score was 80, and the median score of the domain "normalcy of diet" in the PSS-HN was 91. The oncologic outcomes are comparable to the results of open surgery for early and advanced supraglottic carcinomas. Functional swallowing outcome is superior to open surgery and to concomitant chemoradiation. Patients treated with TLM perceive low levels of voice- and swallowing-related quality of life impairment.

Comparison of long-term functional results between standard supracricoid laryngectomy and modified technique with sternohyoid muscle

IntroductionLaryngeal cancer is the most common cancer of the upper respiratory tract. The main methods of treatment included surgery (partial laryngectomy and total laryngectomy) and radiation therapy. Laryngeal dysfunction is seen after both treatment modalities. ObjectiveThe aim of the study is to compare postoperative functional results of the standard supracricoid partial laryngectomy technique and a modified supracricoid partial laryngectomy technique using the sternohyoid muscle. MethodsIn total, 29 male patients (average years 58.20±9.00 years; range 41–79 years) with laryngeal squamous cell carcinoma who underwent supra cricoid partial laryngectomy were included. The patients were divided into two groups in terms of the surgical techniques. In Group A, all patients underwent standard supracricoid partial laryngectomy technique between January 2007 and November 2011. In Group B, all patients underwent modified supracricoid partial laryngectomy between August 2010 and November 2011. Fiberoptic endoscopic evaluation of swallowing test, short version of the voice handicap index scores, and the MD Anderson dysphagia inventory, the time of oral feeding and the decanulation of the patients after surgery of each groups were compared. ResultsThe mean maximum phonation time was 8.68±4.21s in Group A and 15.24±6.16s in Group B (p>0.05). The S/Z (s/s) ratio was 1.23±0.35 in Group A and 1.08±0.26 in Group B (p>0.05); the voice handicap index averages were 9.86±4.77 in Group A and 12.42±12.54 in Group B (p>0.05); the fiberoptic endoscopic evaluation of swallowing test averages were calculated as 12.73±3.08 in Group A and 13.64±1.49 in Group B (p>0.05). In the MD Anderson dysphagia inventory, evaluation of swallowing, the emotional, physical, and functional scores were 29.21±4.11, 32.21±6.85, and 20.14±2.17 in the Group B, and 29.20±2.54, 32.4±4.79, and 19±1.92 in Group A, respectively. ConclusionAlthough there is no statistical difference in functional outcome comparisons, if rules are adhered to in preoperative patient selection, modified supracricoid partial laryngectomy can be applied safely and meaningful gains can be achieved in functional outcomes.

Two-Year Prospective Patient Reported Outcomes Related to Dysphagia After Intensity Modulated Proton Therapy for Oropharyngeal Cancer

Characterize longitudinal change in swallowing related quality of life during and after intensity modulated proton therapy (IMPT) for oropharyngeal cancer. The MD Anderson Dysphagia Inventory (MDADI) was administered prospectively at baseline, end of IMPT, and 10 weeks, and 6 , 12, and 24 months after IMPT as part of a prospective proton therapy registry. MDADI 19-item composite and subscale scores were plotted longitudinally. Pairwise tests were Bonferroni corrected for multiple comparisons (P<.003). Sixty-six patients with a mean age of 62 were included. Almost all had stage III/IV disease (96%) and 71% were treated with concurrent chemotherapy. A majority had T1-T2 primary tumors (80%); 84% had p16 positive disease and 41% were never smokers. Mean composite MDADI was 88.2±13.4 at baseline, dropping significantly to a nadir of 59.4±14.2 at end of IMPT (P<.001) with significant partial recovery by 10 weeks post-IMPT to 74.9±14.2 (P<.001) with stable average performance thereafter through 2 years (P>.003 compared to previous time point). Poor MDADI (score<60) were reported in 7%, 61%, 20%, and 13% of patients at baseline, end-IMPT, 10 weeks, and 2 years after IMPT, with 14% of patients showing persistently depressed MDADI Δ>20 at 2 years. Physical subscale performed lower than emotional or functional subscales at all points. Herein, we provide novel, prospective benchmark data suggesting potentially early recovery of perceived swallowing per MDADI after IMPT in OPC survivors. Expected performance patterns lend support to validity of MDADI after proton therapy.

Relationship between swallowing-related quality of life and fiberoptic endoscopic evaluation of swallowing in patients who underwent open partial horizontal laryngectomy.

Several studies have previously analyzed the relationship between QOL and signs of dysphagia in patients treated for head and neck cancer and have reported heterogeneous findings. To the best of our knowledge, no study has previously investigated this relationship among patients who underwent open partial horizontal laryngectomy (OPHL). The aim of the study is to determine if patient-reported swallowing-related QOL can discriminate between safe and unsafe swallowing in OPHL patients. 92 type I, type II, and type III OPHL patients at least 6months postoperatively were recruited. Fiberoptic endoscopic evaluation of swallowing (FEES) was conducted using liquids, semisolids, and solids. FEES recordings were assessed through the penetration-aspiration scale, the pooling score and the dysphagia outcome and severity scale. All patients completed the MD Anderson dysphagia inventory (MDADI). Kruskal-Wallis test and post-hoc Mann Whitney U test were performed to compare MDADI scores among different level of airway invasion, post-swallow pharyngeal residue's degree and overall dysphagia severity. ROC curves were generated to determine diagnostic accuracy of the MDADI. Statistically significant differences in MDADI scores were found between level of airway invasion with semisolids and solids, degree of pharyngeal residue with solids, and severity of dysphagia. MDADI showed significant diagnostic accuracy only in the detection of moderate/severe pharyngeal residue and severe dysphagia; however, sensitivity and specificity were low. Investigating patients' perception of swallowing impairment and swallowing-related QOL is not sufficient to discriminate safe and unsafe swallowing in OPHL patients.

Voice and swallowing outcomes following reoperative anterior cervical discectomy and fusion with a 2-team surgical approach.

OBJECTIVE Dysphagia and vocal cord palsy (VCP) are common complications after anterior cervical discectomy and fusion (ACDF). The reported incidence rates for dysphagia and VCP are variable. When videolaryngostroboscopy (VLS) is performed to assess vocal cord function after ACDF procedures, the incidence of VCP is reported to be as high as 22%. The incidence of dysphagia ranges widely, with estimates up to 71%. However, to the authors' knowledge, there are no prospective studies that demonstrate the rates of VCP and dysphagia for reoperative ACDF. This study aimed to investigate the incidence of voice and swallowing disturbances before and after reoperative ACDF using a 2-team operative approach with comprehensive pre- and postoperative assessment of swallowing, direct vocal cord visualization, and clinical neurosurgical outcomes. METHODS A convenience sample of sequential patients who were identified as requiring reoperative ACDF by the senior spinal neurosurgeon at the University of Alabama at Birmingham were enrolled in a prospective, nonrandomized study during the period from May 2010 until July 2014. Sixty-seven patients undergoing revision ACDF were enrolled using a 2-team approach with neurosurgery and otolaryngology. Dysphagia was assessed both preoperatively and postoperatively using the MD Anderson Dysphagia Inventory (MDADI) and fiberoptic endoscopic evaluation of swallowing (FEES), whereas VCP was assessed using direct visualization with VLS. RESULTS Five patients (7.5%) developed a new postoperative temporary VCP after reoperative ACDF. All of these cases resolved by 2 months postoperatively. There were no new instances of permanent VCP. Twenty-five patients had a new swallowing disturbance detected on FEES compared with their baseline assessment, with most being mild and requiring no intervention. Nearly 60% of patients showed a decrease in their postoperative MDADI scores, particularly within the physical subset. CONCLUSIONS A 2-team approach to reoperative ACDF was safe and effective, with no new cases of VCP on postoperative VLS. Dysphagia rates as assessed through the MDADI scale and FEES were consistent with other published reports.