Penetration-aspiration Scores Research Articles

Examining the effect of intensive individual swallowing exercise therapy protocol on swallowing physiology in geriatric patients hospitalized in the thoracic diseases service with a complaint of major swallowing dysfunction with multiple prognoses

Objectives: The study aimed to compare the effectiveness of short-term (one month) and long-term (three months) individual swallowing therapy programs in the geriatric individuals diagnosed with dysphagia by instrumental evaluation. Patients and methods: Hospital records of 31 patients (16 females, 15 males; mean age: 66.8±16.4 years; range, 66 to 83 years) were prospectively examined between April 1, 2019, and September 30, 2022. Fiberoptic endoscopic swallowing study recordings were made at the beginning of the study. The recordings were scanned and examined, and individuals with observed problems in swallowing safety and efficacy, having the same severity of dysphagia, were identified. Patients were randomly assigned to long-term (51.2%; n=16; 8 males, 8 females) and short-term (48.8%; n=15; 7 males, 8 females) therapy groups. During fiberoptic endoscopy, patients were given food of different consistencies (thin liquid, honey, nectar, pudding, and solid consistency) according to the International Dysphagia Diet Standardization Initiative protocol, and they were evaluated before therapy and one week, one month, and three months after therapy using the penetration-aspiration scale and the Yale Pharyngeal Residue Severity Scale-Vallecula/Pyriform Sinus. Functional Oral Intake Scale and Turkish Eating Assessment Tool-10 (T-EAT-10) results were compared between the groups. An exercise-based individual swallowing therapy program of one and three months was applied to short-term and long-term therapy groups, respectively. Results: When the post-therapy penetration aspiration scores and pharyngeal residual severity scores of individuals receiving long-term and short-term therapy were compared, a higher score was found in the group receiving shortterm therapy than the long-term group, and a significant difference was found (p<0.001). Pharyngeal phase abnormalities were detected in 27 (88.4%) patients, whereas laryngeal penetration/aspiration status was found in 23 (75.3%) patients, and both variables were found to be significantly higher in the short-term group (p=0.015 and p=0.014, respectively). The T-EAT-10 scores obtained before therapy in the long-term therapy group were significantly higher than T-EAT-10 scores obtained at the third month after therapy (p=0.004, p<0.001, and p<0.05, respectively). Silent aspiration of thin liquid, nectar, and solid consistency was experienced in 78% of patients before therapy. Conclusion: Long-term swallowing therapy program appears to be more effective than short-term in geriatric individuals with dysphagia.

Longitudinal changes of swallowing safety and efficiency in infants with spinal muscular atrophy who received disease modifying therapies.

Dysphagia is a common feature of the natural history of patients with spinal muscular atrophy (SMA). Literature regarding swallowing safety and efficiency is scarce in patients with SMA, particularlyin the era of newborn screening programs and disease-modifying therapies. To describe the longitudinal changes of swallowing safety and efficiency in children with SMA who received one or more disease modifying therapies METHODS: Case series of patients with SMA followed at the University of Florida from 1 May 2019 to 31 December 2022 who had two or more videofluoroscopy swallowing studies (VFSS), with the first being within 30 days of their first treatment. Data extracted from the electronic health record included: neuromotor outcomes, VFSS penetration aspiration scores (PAS), presence of abrnormal oral or pharyngeal residue, clinical history, and timing of disease-modifying therapies administration. Seven subjects were included (five male); three were diagnosed via newborn screen. Median age at diagnosis was 10 days (range: 4-250). Median age at initial VFSS was 29 days (range: 9-246), and age at the last VFSS was 26.1 months (range: 18.2-36.2). All subjects received onasemnogene-abeparvovec (OA); four received additional therapies. PAS at diagnosis was abnormal in four subjects. Six subjects required feeding modifications after VFSS results. Of these, three had silent aspiration (PAS 8) and three of them improved after treatment. Swallowing safety and efficiency can be impaired in patients with SMA despite early treatment. Larger, prospective studies are needed to define optimal timiing of longitudinal instrumental evaluations.

Effect of acupuncture for dysphagia after stroke based on fiberoptic endoscopic swallowing function evaluation

To observe the effect of acupuncture combined with regular treatment and swallowing function training on pharyngeal motor, sensory function and penetration-aspiration function in patients with dysphagia after stroke. A total of 60 patients with dysphagia after stroke were randomly divided into a control group and an observation group, 30 patients in each group. Both groups were treated with conventional treatment and swallowing function training; in addition, the observation group was treated with acupuncture at Lianquan (CV 23), Fengfu (GV 16), Yifeng (TE 17). All the treatments were given once a day, 5 days a week, for totally 4 weeks. In the two groups, the pharyngeal motor and sensory function, penetration-aspiration scores were evaluated by fiberoptic endoscopic evaluation of swallowing (FEES), and the Kubota water swallowing test scores were assessed before and after treatment, and the clinical effects were compared. After treatment, the pharyngeal motor and sensory function in the two groups were all higher than those before treatment (P<0.05), and those in the observation group were better than the control group (P<0.05). After treatment, the penetration-aspiration scores and Kubota water swallowing test scores in the two groups were all lower than those before treatment (P<0.05), and those in the observation group were lower than the control group (P<0.05). The total effective rate was 93.3% (28/30) in the observation group, which was better than 73.3% (22/30) in the control group (P<0.05). Acupuncture combined with regular treatment and swallowing training could improve the pharyngeal motor and sensory function, and penetration-aspiration scores in patients with dysphagia after stroke.

A feasibility pilot study of the effects of neurostimulation on swallowing function in Parkinson's Disease [version 2; peer review: 1 approved, 3 approved with reservations, 1 not approved

IntroductionDysphagia often occurs during Parkinson’s disease (PD) and can have severe consequences. Recently, neuromodulatory techniques have been used to treat neurogenic dysphagia. Here we aimed to compare the neurophysiological and swallowing effects of three different types of neurostimulation, 5 Hertz (Hz) repetitive transcranial magnetic stimulation (rTMS), 1 Hz rTMS and pharyngeal electrical stimulation (PES) in patients with PD.Method12 PD patients with dysphagia were randomised to receive either 5 Hz rTMS, 1 Hz rTMS, or PES. In a cross-over design, patients were assigned to one intervention and received both real and sham stimulation. Patients received a baseline videofluoroscopic (VFS) assessment of their swallowing, enabling penetration aspiration scores (PAS) to be calculated for: thin fluids, paste, solids and cup drinking. Swallowing timing measurements were also performed on thin fluid swallows only. They then had baseline recordings of motor evoked potentials (MEPs) from both pharyngeal and (as a control) abductor pollicis brevis (APB) cortical areas using single-pulse TMS. Subsequently, the intervention was administered and post interventional TMS recordings were taken at 0 and 30 minutes followed by a repeat VFS within 60 minutes of intervention.ResultsAll interventions were well tolerated. Due to lower than expected recruitment, statistical analysis of the data was not undertaken. However, with respect to PAS swallowing timings and MEP amplitudes, there was small but visible difference in the outcomes between active and sham.ConclusionPES, 5 Hz rTMS and 1 Hz rTMS are tolerable interventions in PD related dysphagia. Due to small patient numbers no definitive conclusions could be drawn from the data with respect to individual interventions improving swallowing function and comparative effectiveness between interventions. Larger future studies are needed to further explore the efficacy of these neuromodulatory treatments in Parkinson’s Disease associated dysphagia.

Variability in Swallowing Biomechanics in Infants with Feeding Difficulties: A Videofluoroscopic Analysis

Clinicians performing feeding evaluations in infants often report swallow variability or inconsistency as concerning. However, little is known about whether this represents pathological incoordination or normal physiologic variance in a developing child. Our retrospective study explored quantitative videofluoroscopic measures in 50 bottle-fed infants (0–9 months) referred with feeding concerns. Our research questions were as follows: Is it possible to assess swallow to swallow variability in an infant with feeding concerns, is there variability in pharyngeal timing and displacement in infants referred for videofluoroscopy, and is variability associated with aspiration risk? Measures were taken from a mid-feed, 20-s loop recorded at 30 frames per second. Each swallow within the 20-s loop (n = 349 swallows) was analysed using quantitative digital measures of timing, displacement and coordination (Swallowtail™). Two blinded raters measured all swallows with strong inter-rater reliability (ICC .78). Swallow frequency, suck-swallow ratio, residue and aspiration were also rated. Variability in timing and displacement was identified across all infants but did not correlate with aspiration (p > .05). Sixteen infants (32%) aspirated. Across the cohort, swallow frequency varied from 1 to 15 within the 20-s loops; suck-swallow ratios varied from 1:1 to 6:1. Within-infant variability in suck-swallow ratios was associated with higher penetration-aspiration scores (p < .001). In conclusion, pharyngeal timing and displacement variability is present in infants referred with feeding difficulties but does not correlate with aspiration. Suck-swallow ratio variability, however, is an important risk factor for aspiration that can be observed at bedside without radiation. These objective measures provide insight into infant swallowing biomechanics and deserve further exploration for their clinical applicability.

Breathing-swallow dysfunction in COPD: How silent aspiration may be contributing to exacerbations.

Breathing-swallow dysfunction in COPD: How silent aspiration may be contributing to exacerbations.

A feasibility pilot study of the effects of neurostimulation on dysphagia recovery in Parkinson’s Disease

Introduction: Dysphagia often occurs during Parkinson’s disease (PD) and can have severe consequences. Recently, neuromodulatory techniques have been used to treat neurogenic dysphagia. Here we aimed to compare the neurophysiological and swallowing effects of three different types of neurostimulation, 5 Hertz (Hz) repetitive transcranial magnetic stimulation (rTMS), 1 Hz rTMS and pharyngeal electrical stimulation (PES). Method: 12 PD patients with dysphagia were randomised to receive either 5 Hz rTMS, 1 Hz rTMS, or PES. In a cross-over design, patients were assigned to one intervention and received both real and sham stimulation. Patients received a baseline videofluoroscopic (VFS) assessment of their swallowing, enabling penetration aspiration scores (PAs) to be calculated for: thin fluids, paste, solids and cup drinking. Swallowing timing measurements were also performed on thin fluid swallows only. They then had baseline recordings of motor evoked potentials (MEPs) from both pharyngeal and (as a control) abductor pollicis brevis (APB) cortical areas using single-pulse TMS. Subsequently, the intervention was administered and post interventional TMS recordings were taken at 0 and 30 minutes followed by a repeat VFS within 60 minutes of intervention. Results: All interventions were well tolerated. Due to lower than expected recruitment, statistical analysis of the data was not undertaken. However, with respect to PAs swallowing timings and MEP amplitudes, there was visual separation in a positive direction between active and sham groups for all interventions. Conclusion: PES, 5 Hz rTMS and 1 Hz rTMS are tolerable interventions in PD related dysphagia. Due to small patient numbers no definitive conclusions could be drawn from the data with respect to individual interventions improving swallowing function and comparative effectiveness between interventions. Larger future studies are needed to further explore the efficacy of these neuromodulatory treatments in Parkinson’s Disease associated dysphagia.

A generalized equation approach for hyoid bone displacement and penetration\u2013aspiration scale analysis

Swallowing physiology includes numerous biomechanical events including displacement of the hyoid bone, which is a crucial component of airway protection and opening of the proximal esophagus. The objective of this study was to evaluate the potential relations between the trajectory of hyoid bone movement and the risk of airway penetration and aspiration during a videofluoroscopic swallowing study. Two hundred sixty-five patients were involved in this study, producing a total of 1433 swallows of various volumes consisting of thin liquid, nectar-thick liquid, and solids during a fluoroscopic exam. The anterior and posterior landmarks of the body of the hyoid bone were manually marked in each frame of each fluoroscopic video. Generalized estimation equations were applied to evaluate the relationship between penetration–aspiration scores and mathematical features extracted from the hyoid bone trajectories, while also considering the influence of other independent variables such as age, bolus volume, and viscosity. Our results indicated that penetration–aspiration scores showed a significant relation to age. The maximum anterior (horizontal) displacement of the anterior hyoid bone landmark was significantly associated with the penetration–aspiration scores. Differences in the displacement of the hyoid bone are useful observations in airway protection.Article highlightsIn this work, the potential relations between the trajectory of hyoid bone movement and the risk of airway penetration and aspiration during a videofluoroscopic swallowing study were evaluated.We extracted features from the hyoid bone trajectories and applied generalized estimation equations to investigate their relationship to penetration–aspiration scales.The results showed that the maximum anterior (horizontal) displacement of the anterior hyoid bone landmark was significantly associated with the penetration–aspiration scales.

Early fiberoptic endoscopic evaluation of swallow in transoral robotic surgery: Description of swallow function and recovery in the acute postoperative period for oropharyngeal squamous cell carcinoma.

Transoral robotic surgery (TORS) is a minimally invasive approach for the treatment of oropharyngeal cancer. The effects on swallowing and speech need to be comprehensively evaluated to understand the associated morbidity. A prospective cohort of 21 patients was recruited to undergo pre-TORS and post-TORS swallowing and communication assessment. Fiberoptic endoscopic evaluation of swallowing (FEES) was used in the first postoperative week. Sixteen participants (76.2%) had penetration-aspiration scores ≥3 or higher, seven (33.3%) aspirated on thin liquids, three (14.3%) did so silently. Prolonged recovery trajectory occurred for the majority of the cohort, particularly if TORS was followed by adjuvant radiotherapy. Swallowing and communication scores were significantly worse in base of tongue primary tumors and with advanced age. Early FEES demonstrates a significant decline in swallowing function, including increased secretion load, pharyngeal residue, laryngeal penetration, and aspiration. Silent aspiration occurred in 14% and thus highlights the necessity for instrumental assessment to ascertain aspiration risk.

Dose and Volume De-Escalation for Human Papillomavirus–Positive Oropharyngeal Cancer is Associated with Favorable Posttreatment Functional Outcomes

To report functional outcomes for patients with human papillomavirus-positive oropharyngeal cancer treated on a phase 2 protocol of risk- and induction chemotherapy response-adapted dose and volume de-escalated radiation therapy (RT)/chemoradiation (CRT). Patients were stratified as low risk (LR) or high risk (HR) according to T/N-stage and smoking history. Induction chemotherapy was followed by radiographic response assessment. LR patients with ≥50% response received 50 Gy RT (RT50), whereas LR patients with 30% to 50% response or HR patients with ≥50% response received 45 Gy CRT (CRT45). All other patients received 75 Gy CRT (CRT75) with RT limited to the first echelon of uninvolved nodes. Pre- and post-RT/CRT modified barium swallow studies were performed. Percutaneous endoscopic gastrostomy (PEG) tube placement, body mass index (BMI), and narcotic use were recorded. Statistical comparisons used linear or logistic regression, the Mann-Whitney U test, the χ2 test, or Fisher's exact test as appropriate. Twenty-eight LR and 34 HR patients were enrolled; 49 completed RT50/CRT45 and 11 completed CRT75. PEG-tube dependency at the end of RT/CRT and 3 months post-RT/CRT significantly differed according to risk and treatment groups (all P < .05). Treatment intensity was independently associated with 3-month PEG status while adjusting for risk group (P = .002). The CRT75 group had a median -8.42% change from baseline BMI at 1 year post-RT/CRT versus -2.54% for the RT50/CRT45 group (P = .01). At the end of RT/CRT, CRT75 patients were less likely to tolerate a normal diet, more likely to have swallowing performance status scale scores ≥4, more likely to have Rosenbek's penetration-aspiration scores ≥7, more likely to have developed trismus, and more likely to require narcotics >2 months (all P < .05). Induction chemotherapy followed by risk- and response-adapted dose and volume de-escalated RT/CRT is associated with clinically meaningful functional outcomes including (1) improved swallowing function, (2) higher BMI, and (3) shorter narcotic use for patients receiving de-escalation.

Effects of the Passy-Muir speaking valve on tracheotomized patients′ swallowing function after brain damage

Objective To investigate the effect of a Passy-Muir speaking valve (PMV) on the biomechanics of swallowing and on aspiration among persons tracheotomized after brain damage. Methods Twenty tracheotomized patients with aspiration after brain injury were selected and randomly divided into a non-PMV intervention group and a PMV intervention group, each of 10. Both groups were given routine swallowing training, while the PMV intervention group was additionally provided with a PMV and trained to use it. The treatment ended when the tracheal tube was removed or after 2 weeks. High-resolution manometry and videofluoroscopy were used to evaluate the maximum pressure in the velopharynx (VP-Max), the maximum post-deglutitive upper esophageal sphincter (UES) pressure (UES-Max) and Rosenbek penetration aspiration (PAS) scores for both groups before and after the treatment. Results Before the treatment there was no significant difference between the two groups in terms of average VP-Max, UES-Max or PAS score. After the treatment, the average VP-Max and UES-Max had increased significantly in both groups, and the average PAS score of the PMV intervention group had decreased significantly. There was a significant positive correlation between the increases in VP-Max and the decrease in PAS scores. Conclusion Inserting a PMV can improve velopharynx contraction and post-deglutitive UES among persons tracheotomized after a brain injury. The increase in maximum velopharynx pressure is positively correlated with decreases in aspiration. Key words: Tracheotomy; Aspiration; Passy-Muir speaking valve; Swallowing

Esophageal Transit Times Vary with Underlying Comorbid Disease.

Little is known about esophageal transit times (ETT) in relation to underlying comorbid disease or aspiration risk. Our study evaluated liquid ETT in patients relative to underlying comorbid disease and compared this with ETT in healthy adults. We examined whether prolonged ETT was associated with swallow risk. Prospective observational study. Radiology department. Patients included those referred to speech pathology for a videofluoroscopic study of swallowing (VFSS) within a tertiary hospital. A total of 617 patients (49% female; mean ± SD age, 77 ± 15 years) and 139 healthy adults (56% female; age, 59 ± 22 years) were included. All patients underwent a standardized VFSS with esophageal screening. Patients were categorized by chief underlying disorder: previous stroke (n = 207), other neurologic condition (n = 188), respiratory conditions (n = 91), or gastroenterology conditions (n = 131). All VFSSs were analyzed with objective measures. ETT and penetration-aspiration scores were compared between groups. Advancing age was significantly associated with increased ETT (P < .05). When controlling for age, mean 20-mL ETT remained significantly different across groups: healthy adults, 11 seconds; stroke, 17 seconds; other neurologic condition, 15 seconds; gastroenterology, 14 seconds; and respiratory, 9 seconds (P < .001). One-third of patients aspirated; no healthy adults aspirated. Increasing ETT was associated with aspiration events (P < .001). Liquid ETTs differ among patients with different underlying primary diagnoses. Patients following stroke show significantly prolonged ETT and increased risk of aspiration. Prolonged ETT may influence symptom complaint and warrants consideration.

Dose and Volume De-Escalation for HPV-Positive Oropharyngeal Cancer is Associated with Favorable Post-Treatment Functional Outcomes

To report functional outcomes for patients with HPV+ oropharyngeal cancer treated on a phase II protocol of risk- and induction chemotherapy response-adapted dose and volume de-escalated radiation (RT)/chemoradiation (CRT). Patients were stratified as low-risk (LR) or high-risk (HR) according to T/N-stage and smoking history. Induction chemotherapy was followed by radiographic response assessment. LR patients with ≥50% response received 50Gy RT (RT50) whereas LR patients with 30-50% response or HR patients with ≥50% response received 45Gy CRT (CRT45). All other patients received 75Gy CRT (CRT75) with RT limited to the first echelon of uninvolved nodes. Pre- and post-RT/CRT oropharyngeal motility studies were performed. Percutaneous endoscopic gastrostomy (PEG) tube placement, body mass indices (BMI), and narcotic use were recorded. Statistical comparisons used logistic regression, the Mann-Whitney U test, the chi square test, or Fisher’s exact test as appropriate. Twenty-eight LR and 34 HR patients were enrolled, and 49 completed RT50/CRT45 while 11 completed CRT75. PEG-tube dependency at the end of RT/CRT and 3 months post-RT/CRT significantly differed according to risk- and treatment groups (all p<0.05, see table). Treatment intensity independently associated with 3-month PEG status while adjusting for risk group (p=0.002). The CRT75 group had a median -8.42% change from baseline BMI one year post-RT/CRT vs. -2.54% for the RT50/CRT45 group (p=0.01). At the end of RT/CRT, CRT75 patients were less likely to tolerate a normal diet, more likely to have Swallowing Performance Status Scale (SPS) scores ≥4 corresponding to at least mild-moderate dysphagia, more likely to have Rosenbek’s penetration-aspiration scores ≥6, more likely to have developed trismus, and more likely to require narcotics >2 months (all p<0.05, see table). Induction chemotherapy followed by risk- and response-adapted dose and volume de-escalated RT/CRT is associated with clinically meaningful functional outcomes including (1) improved swallowing function, (2) higher BMI, and (3) lower narcotic use for patients receiving de-escalation.Abstract 2959; Table 1Post-RT/CRT Swallowing Outcomes by Risk- and Treatment Group*Low RiskHigh RiskP-valueRT50/CRT45CRT75P-valueNo. (%)No. (%)No. (%)No. (%)PEG-Tube DependenceEnd of RT/CRT2 (7)16 (50)0.00059 (18)9 (82)0.00013-months post-RT/CRT1 (4)11 (34)0.0035 (10)7 (64)0.0005Regular Diet/Thin Liquids19 (86)20 (74)0.4835 (88)4 (44)0.01SPS Score ≥46 (27)8 (31)0.798 (21)6 (67)0.01Rosenbek’s Penetration-Aspiration Scale ≥64 (18)7 (27)0.515 (13)6 (67)0.002Developed Trismus2 (11)3 (15)1.002 (6)3 (43)0.03Narcotic Use > 2 Months13 (48)17 (59)0.4323 (48)7 (88)0.04***Denominator for percentages includes patients with available data for each outcome**One-sided Fisher's exact test Open table in a new tab

Effect of Expiratory Muscle Strength Training on Swallowing and Cough Functions in Patients With Neurological Diseases: A Meta-analysis.

The aim of this review was to evaluate and summarize the results of published studies exploring the effects of expiratory muscle strength training on swallowing and cough functions in patients with neurological diseases. The study used Embase, PubMed, and the Cochrane Library as data sources. Randomized controlled trials or pretest/posttest studies of adults with neurological diseases were included. The data included basic population characteristics, penetration-aspiration scores, peak expiratory flow rate, cough volume acceleration, and maximum expiratory pressure. Ten studies were included in this meta-analysis. Compared with the control groups, expiratory muscle strength training in patients with neurological diseases significantly reduced the penetration-aspiration scores (risk ratio = -0.94, 95% confidence interval = 1.27 to -0.61, P < 0.01) but did not increase the voluntary cough peak expiratory flow rate (risk ratio = 0.57, 95% confidence interval = 0.62 to 1.77, P = 0.35), cough volume acceleration (risk ratio = 33.87, 95% confidence interval = 57.11 to 124.85, P = 0.47), or maximum expiratory pressure (risk ratio = 14.78, 95% confidence interval = 16.98 to 46.54, P = 0.36). Expiratory muscle strength training might improve swallowing function in patients with neurological diseases. However, conclusive evidence supporting the use of this approach in isolation for improving cough function is unavailable. Additional multicenter, randomized clinical trials performed using reliable and valid cough function outcome measures are required to explore the effects of expiratory muscle strength training on cough function.

Predictors of Percutaneous Endoscopic Gastrostomy Placement in Acute Ischemic Stroke

Background: Dysphagia is a common complication of stroke and can have a lasting impact on morbidity and mortality; yet there are no standards to guide dysphagia management in stroke patients. We assessed predictors of percutaneous endoscopic gastrostomy (PEG) placement in an ischemic stroke cohort and sought to determine the utility of an objective scale in predicting PEG placement in a high-risk sub-set. Methods: Consecutive cases of ischemic stroke were retrospectively, identified and demographic and clinical variables were collected. Penetration-Aspiration (PAS) scores (1-2 normal; 3-5 penetration; 6-8 aspiration) were calculated for patients undergoing Fiberoptic Endoscopic Evaluation of Swallowing (FEES) or Modified Barium Swallowing Studies (MBSS). Multiple logistic regression analysis was used to assess predictors of PEG placement. Results: Among 724 patients, 131 underwent PEG placement. In univariate analysis of the overall cohort, sex, age, insured payer status, arrival National Institute of Health Stroke Scale (NIHSS), NIHSS level of consciousness severity, NIHSS dysarthria severity, diabetes mellitus, and prior International Conference for Harmonization (ICH) were all significantly associated with PEG placement. Among 197 high-risk patients undergoing FEES or MBSS, the multivariate logistic regression analysis showed that PAS scores 6-8 versus 1-2 (odds ratio [OR] 13.2; 95% confidence interval [CI] 4.58, 38.2), PAS score 3-5 versus 1.2 (OR 33.8; 95% CI 11.6, 98.3), Hispanic race (OR, 5.73; 95% CI 1.82, 18.0), male sex (OR, 2.59; 95% CI 1.05, 6.34), and arrival NIHSS (OR, 1.11; 95% CI 1.05, 1.18) were associated with PEG placement. Conclusions: Use of an objective dysphagia scale simplified the prediction model among acute ischemic stroke patients undergoing instrumental assessments of dysphagia with FEES or MBSS. Male sex and Hispanic race were also significantly associated with PEG placement in this analysis. These findings support the need for rigorously designed prospective studies to assess biological and social factors that influence PEG placement and to determine, how to best evaluate and manage patients with dysphagia.

Abstract WP305: Predictors of Early Improvement of Swallow Function in Acute Ischemic Stroke Patients With Severe Dysphagia

Introduction: Dysphagia is a common complication of stroke that often improves with time. Percutaneous endoscopic gastrostomy (PEG) tubes are used to bridge patients with dysphagia until oral feeding is safe. We sought to evaluate factors associated with early improvement in swallow for patients in whom PEG tube was deferred after an initial failed instrumental assessment of swallow (IAS) study. Methods: Consecutive cases of AIS were identified from our inpatient registry (6/14- 4/15). We included patients who failed an initial IAS with Fiberoptic Endoscopic Evaluation of Swallowing or Modified Barium Swallow Study. Speech language pathologists (SLP) calculated Penetration-Aspiration (PEN-ASP) scores (1-2 normal; 3-5 penetration; 6-8 aspiration) based on performance on IAS. Recovery of swallow was defined as improvement in the PEN-ASP category with thin or nectar-thickened liquids. Univariate analyses and multiple logistic regression were used to assess predictors of improvement in swallow with demographic data, medical history, stroke etiology, and NIHSS as independent variables. Results: Among 104 patients who failed an IAS an average of 5.5 days after hospital admission, PEG was deferred in 60 pending repeat IAS. Younger patients (62.9±13.1 vs 69.3±14.2) and those with lower NIHSS (median 10.5; IQR 5,15 vs median 13.5; IQR 8.0, 20) were more often referred for second IAS (p &lt; 0.05). Improvement in swallow function was seen in 45% of patients on a 2 nd IAS performed an average of 3.9 days after the initial study. Race, but not stroke etiology, stroke severity, stroke location or other clinical factors, was associated with recovery of swallow. The odds (adjusted) of improving on a subsequent evaluation in African Americans (AA) were 5.91 (95% CI: 1.56, 22.40 ) times higher than the odds for Whites. Conclusion: Our study shows that AA race is associated with early improvement in swallow function for reasons that are unclear. There was no association with age, stroke severity, or stroke etiology. Further analysis of factors associated with recovery of swallow is necessary in order to avoid PEG placement in patients with rapid recovery. A follow-up IAS 3-4 days after an initial study should be considered in select patients before PEG placement.

Repetitive Transcranial Magnetic Stimulation for Post-stroke Dysphagia: a Meta-analysis

Background. Dysphagia is common among post-stroke patients, causing disability due to malnutrition and pneumonia. Repetitive transcranial magnetic stimulation (rTMS) is a novel treatment modality to address this complication. Objective. The study aimed to compare real versus sham rTMS in treating post-stroke dysphagia. Methods. PubMed, Ovid, ClinicalKey, Herdin, and Google Scholar databases were searched from their earliest record to 31 July 2015 for randomized controlled trials that used rTMS to treat post-stroke dysphagia. The Jadad scale was used to assess the quality of the studies. The weighted mean difference (WMD) between baseline and post-treatment mean for Penetration Aspiration Scores (PAS) measured in the experimental and control groups were extracted for subsequent meta-analyses. Results. Three studies were analyzed. The WMD in PAS score between rTMS and control using liquid bolus two weeks after treatment in two good quality studies was -1.14 (95% confidence interval (CI) = -1.80 – -0.48, P = 0.001, I2 = 0.0%), and after four weeks was -1.83 (CI = -3.22 – -0.44, P = 0.010, I2 = 0.0%). Conclusion. Treatment of post-stroke dysphagia with rTMS improved PAS on subgroup analyses of studies using liquid bolus after two weeks, and between real and sham treatment after four weeks.

One-Year Swallowing Outcomes in Patients Treated with Prophylactic Gabapentin During Radiation-Based Treatment for Oropharyngeal Cancer.

Recent investigations by our study team have demonstrated patients using gabapentin for pain management during chemoradiotherapy (CRT) do well maintaining swallowing during treatment with less need for narcotic pain medication, PEG dependence, weight loss, and short-term swallowing morbidity. The purpose of this investigation was to characterize the long-term swallowing function of these patients 1-year following treatment. Sequential patients receiving CRT for oropharyngeal cancer and concurrent gabapentin were evaluated 1-year following treatment for swallowing outcomes. Functional Oral Intake Scores (FOIS) were utilized to assess diet level. The MD Anderson Dysphagia Inventory (MDADI) was chosen to evaluate patient perception of swallowing function. Videofluoroscopic swallowing studies were completed approximately 1 year after treatment to assess physiologic outcomes as well as Penetration Aspiration Scores (PAS). Data from 26 consecutive participants were available for analysis. The majority of patients had advanced stage disease (Stage 3-4). No patients had a PEG tube 1-year following treatment, and the mean FOIS score was 6.83. Pharyngeal deficits were infrequent with reduced pharyngeal constriction and prominence/early closure of cricopharyngeus predominating. Mean PAS score was 1.5, indicating that the majority of patients had either no laryngeal penetration/aspiration, or transient penetration that was fully cleared. Mean MDADI score was 85.52, indicating that, in general, patients perceived their swallowing to be minimally impaired. Patients receiving gabapentin pain management as part of a comprehensive dysphagia prevention protocol during CRT have excellent long-term swallowing outcomes as reflected in diet levels, physiologic functioning, and patient-perceived quality of life.

Abstract 91: An Objective Screening Tool Predicts Surgical Feeding Tube Placement in Acute Ischemic Stroke Patients

Introduction: Dysphagia is a common post-stroke complication, yet there are no standard tools to guide recommendations for placement of percutaneous endoscopic gastrostomy (PEG) tube. Prior prediction models in acute ischemic stroke (AIS) have had inconsistent findings and have not included objective swallowing assessments. We hypothesized that inclusion of an aspiration-based score would simplify the prediction model and be a strong independent predictor of PEG placement among patients referred for instrumental assessment of swallowing (IAS) after failed bedside swallow. Methods: Consecutive cases of AIS were identified from our inpatient registry (6/14- 4/15). Patients transferred to hospice or dying within 3 days of hospitalization were excluded. NIHSS and sub-items, medical history, and demographic data were included in the full model and subgroup analysis which included patients undergoing IAS. Univariate and multiple logistic regression were used to assess predictors of PEG placement. Penetration-Aspiration (PEN-ASP) scores (1-2 normal; 3-5, penetration, 6-8, aspiration) calculated using Fiberoptic Endoscopic Evaluation of Swallowing and Modified Barium Swallow Studies were included in the model for subgroup analysis. Results: Among 731 AIS patients, 17.9% (131) of patients received a PEG and 200 patients received IAS (39.5 % PEG). In the full model, arrival GCS and NIHSS, NIHSS level of consciousness score, and prior Diabetes Mellitus and ICH (p &lt; 0.05). Among patients receiving IAS, arrival NIHSS, PEN-ASP score, and race (Hispanic v White) was associated with PEG placement. Conclusions: This study represents the largest cohort of AIS patients undergoing PEG placement and IAS. We demonstrated that the PEN-ASP score helps to predict PEG placement in AIS. Race also emerged as a predictor, and in future studies, we will examine patient and provider-level factors to explain this association.

Altered pharyngeal structure and dynamics among patients with cervical kyphosis.

Deformities of the anterior cervical spine are an established cause of dysphagia. Whereas osteophytes and spinal fusion hardware have been reported to alter bolus flow and contribute to swallowing dysfunction, the relationship between abnormal spine curvature and swallowing dysfunction is not established. The purpose of this investigation was to evaluate the association between cervical kyphosis and objective measures of swallowing dysfunction on videofluoroscopy. Case-control study of patients presenting to tertiary dysphagia center. All videofluoroscopic swallow studies (VFSS) performed at our institution, between August 1, 2014, and August 1, 2015, were retrospectively reviewed to identify patients with abnormal cervical kyphosis, according to Cobb and Jackson angle measurements. Patients with kyphosis were age- and gender-matched to persons without kyphosis. VFSS and demographic parameters were collected and compared between groups. Thirty-six patients with cervical kyphosis exceeding two standard deviations (SD) beyond established age-specific normal ranges were identified. The mean age of the entire cohort was 61.6 (SD ±19.1) years. Mean pharyngeal area was 3.34 cm2 greater in kyphosis patients compared to controls (95% confidence interval [CI]: 0.47-5.21 cm2 ; P = .0007). This was associated with increased hypopharyngeal transit time (0.57 seconds, 95% CI: 0.045-1.09 seconds, P = .034), and higher prevalence of penetration (P = .014). There was no significant difference in the pharyngeal constriction ratio (PCR), a surrogate measure of pharyngeal strength (P = .83). Patients with cervical spine kyphosis have a significantly dilated pharynx (P = .0007), elongated hypopharyngeal transit time (P = .034), and worsened penetration aspiration scores (P = .021). Absence of a difference in PCR suggests adequate compensation as a group. 3b. Laryngoscope, 127:1832-1837, 2017.