Risk Factors For Dysphagia Research Articles

Long-term follow-up of protective effects on salivary and swallowing structures and improvement of late xerostomia and dysphagia by level IIb optimisation in clinical target volume of nasopharyngeal carcinoma.

This study aimed to assess the long-term effect of level IIb clinical target volume (CTV) optimisation on survival, xerostomia, and dysphagia in patients with nasopharyngeal carcinoma (NPC). Clinical data of 415 patients with NPC treated with intensity-modulated radiotherapy between December 2014 and October 2018 were retrospectively analysed. The patients were categorised into modified and comparison groups. Late xerostomia and dysphagia were evaluated using Radiation Therapy Oncology Group/European Organisation for Research and Treatment of Cancer scoring. Survival analysis was performed using the Kaplan-Meier method. Differences in late toxicity and dose parameters between both groups were compared. Prognostic factors for survival and late toxicity were assessed using regression analyses. Patients in the modified group developed late xerostomia and dysphagia less frequently than those in the comparison group did (P < 0.001). The mean dose (Dmean) and V26 of parotid glands; Dmean and V39 of submandibular glands; and Dmean of sublingual glands, oral cavity, larynx, and superior, middle, and lower pharyngeal constrictor muscles were lower in the modified group than those in the comparison group (all P < 0.001). Both groups had no significant differences in overall, local recurrence-free, distant metastasis-free, or progression-free survival. The Dmean of the parotid and sublingual glands was a risk factor for xerostomia. The Dmean of the parotid and sublingual glands and middle pharyngeal constrictor muscle was a risk factor for dysphagia. Level IIb optimisation in NPC patients who meet certain criteria specially the exclusion of positive retropharyngeal nodes treated with intensity-modulated radiotherapy has the potential to better protect the salivary and swallowing structures, decreasing the development of late radiation-induced xerostomia and dysphagia while maintaining long-term survival.

Study on predictive models for swallowing risk in patients with AECOPD.

Dysphagia is considered a complication in patients with acute exacerbation of chronic obstructive pulmonary disease (AECOPD). However, AECOPD may have risk factors for dysphagia. Through a cross-sectional study, which included 100 patients with AECOPD. General information, Pulmonary function, COPD assessment test (CAT) and modified Medical Research Council (mMRC) were collected by questionnaire. The questionnaires were administered by uniform-trained investigators using standard and neutral language, and swallowing risk was assessed by using a water swallow test (WST) on the day of patient admission. Among the 100 included patients, 50(50%) were at risk of swallowing. Multivariate analysis using logistic regression analysis showed that age ≥ 74 years old, mMRC ≥ level 2, hospitalization days ≥ 7 days and the use of BIPAP assisted ventilation were important influencing factors for swallowing risk in patients with AECOPD. Patients with AECOPD are at risk for dysphagia, assessing age, mMRC, hospitalization days and the use of BIPAP assisted ventilation can be used to screen for swallowing risk, thus contributing to the implementation of early prevention measures.

Post-extubation dysphagia in pediatric trauma patients: a single-center case-series study

We aimed to investigate whether ventilator support time influences the occurrence of dysphagia in pediatric trauma patients. This case-series study was conducted in a single pediatric emergency and critical care center from April 2012 to March 2022. Trauma patients aged < 16 years who underwent tracheal intubation were divided into two groups based on the occurrence of dysphagia within 72 h after extubation, and their data were analyzed. Tracheal intubation was performed in 75 pediatric trauma patients, and 53 of them were included in the analysis. A total of 22 patients had post-extubation dysphagia and head trauma. The dysphagia group tended to have more severe head injuries (Abbreviated Injury Scale (AIS) 4 [4–5] vs. 4 [0–4]; p < 0.05), a longer ventilator support time (7 days [4–11] vs. 1 day [1–2.5]; p < 0.05), and a longer length of hospital stay (27 days [18.0–40.3] vs. 11 days [10.0–21.0]; p < 0.05). Severe head trauma and a long duration of tracheal intubation may be risk factors for dysphagia in pediatric trauma patients. Therefore, early recognition of these risk factors could assist in treatment planning for speech-language pathologist intervention and nutritional routes of administration.

Risk factors for dysphagia in patients with acute and chronic ischemic stroke: A retrospective cohort study

BackgroundDysphagia is a common and clinically significant complication of ischemic stroke. The prevalence and risk factors for dysphagia may vary at different stages following an ischemic stroke. MethodsThis study included patients with acute and chronic ischemic stroke who were treated at the Department of Rehabilitation, First Affiliated Hospital, Zhejiang University School of Medicine from 2019 to 2022. Various demographic, clinical, and laboratory parameters were collected, and statistical analyses were performed to investigate their association with dysphagia. ResultsAmong the 399 ischemic stroke patients included in the study, 165 (41.4 %) experienced dysphagia, with 72 (38.7 %) in the acute phase and 93 (43.7 %) in the chronic phase. Univariate analysis revealed significant associations (p < 0.05) between dysphagia and factors such as pulmonary infection, aphasia, NIHSS score, ADL score, NLR score, lower extremity Brunnstrom's stages, and sit-to-stand balance. Multiple logistic regression analysis, after adjusting for confounding factors, identified the ADL score as an independent predictor of dysphagia. These findings were consistent across three time-windows: the acute phase, the chronic phase, and 180 days after stroke onset. Additionally, the lymphocyte count and pulmonary infection were identified as potential independent indicators. ConclusionsThis study investigated the prevalence and risk factors for dysphagia in ischemic stroke patients at different time-windows. A low ADL score (<40) may serve as a valuable and reliable predictor for poststroke dysphagia in clinical settings.

Integrated Swallowing, Nutrition and Medication Management in Care Homes using Telehealth

Pressures from the pandemic have increased waiting times and highlighted the disjointed community services, particularly for vulnerable care home residents significantly affected by Covid-19 (Nawaz and Tulunay-Ugur, 2018). Currently, nearly half a million people live in care homes in the UK. Up to 50% of these residents suffer from swallowing difficulties that can potentially exacerbate symptoms of malnutrition, dehydration, aspiration pneumonia, non-adherence to medication and unwarranted hospital admission ( Chen et al., 2020; Munson, 2022). Digital technologies for swallowing difficulties are effective in improving clinical outcomes for residents in care homes as it has the potential to provide multidisciplinary integrated care to individuals with complex health needs (Pownall et al., 2019).&#x0D; The project has three aims (1) to provide multidisciplinary training to care home staff to manage risks while health services are recovering after the pandemic, (2) co-design with an efficient integrated clinical pathway with multiple stakeholders, (3) to provide multidisciplinary integrated swallowing, nutrition and medication management to care home residents.&#x0D; The training process includes an understanding of learners' needs and expectations, the development of immersive training modules, and the provision of hybrid training sessions. To improve the efficiency of care, this project also co-designed an integrated clinical pathway with the stakeholders. Process pathways were created with all the stakeholders to ensure these are both efficient and fit for purpose. The expected length of time was negotiated during the pathway development, as well as roles and accountability. This project used video conferencing to conduct integrated multidisciplinary care to care home residents. Care home staff are with the residents, while clinicians are based in the hospital clinics. Patient families are also invited to attend and participate in the holistic anticipatory care plans.&#x0D; The project developed a single point of access with one referral to access the three professionals responsible for providing holistic care for residents with swallowing, nutrition and medication issues. Training assessment showed improved competency and confidence. Care home staff felt involved as they communicated the frustration of making multiple referrals, coordinating and attending separate waiting lists and appointments from each profession. The integrated video consultations by the multidisciplinary team were able to improve individual experiences, maximise clinical outcomes, reduce cost, and provide equity of care for marginalised community groups while ensuring staff wellbeing. &#x0D; The project showed the potential of providing remote integrated swallowing, nutrition and medication management to care home residents to enrich community resources and build capacity to meet increasing demands.&#x0D; Chen, S. et al. (2020) "Prevalence and risk factors of dysphagia among nursing home residents in eastern China: a cross-sectional study", BMC Geriatrics. BMC Geriatrics, 20(1), pp. 1–11. doi: 10.1186/s12877-020-01752-z.&#x0D; Munson, S. (2022) ""Care home stats: number of settings, population &amp; workforce"", Carehome.co.uk. Available at: https://www.carehome.co.uk/advice/care-home-stats-number-of-settings-population-workforce.&#x0D; Nawaz, S. and Tulunay-Ugur, O. E. (2018) "Dysphagia in the older patient", Otolaryngologic Clinics of North America. Elsevier, 51(4), pp. 769–777.&#x0D; Pownall, S. et al. (2019) "The development of a digital dysphagia guide with care homes: Co-production and evaluation of a nutrition support tool", Geriatrics (Switzerland), 4(3). doi: 10.3390/geriatrics4030048.&#x0D; &#x0D;

Prevalence and risk factors for dysphagia in older adults after thyroid and parathyroid surgery

BackgroundWe aimed to determine the prevalence and risk factors for dysphagia in adults 65 years and older before and after thyroidectomy or parathyroidectomy. MethodsWe performed a longitudinal prospective cohort study of older adults undergoing initial thyroidectomy or parathyroidectomy. We administered the Dysphagia Handicap Index questionnaire preoperatively and 1, 3, and 6 months postoperatively. We compared preoperative and postoperative total and domain-specific scores using paired t tests and identified risk factors for worse postoperative scores using multivariable logistic regression. ResultsOf the 175 patients evaluated, the mean age was 71.1 years (range = 65–94), 73.7% were female, 40.6% underwent thyroidectomy, 57% underwent bilateral procedures, and 21.1% had malignant diagnoses. Preoperative swallowing dysfunction was reported by 77.7%, with the prevalence 22.4% greater in frail than robust patients (P = .013). Compared to preoperative scores, 43.4% and 49.1% had worse scores at 3 and 6 months postoperatively. Mean functional domain scores increased by 62.3% at 3 months postoperatively (P = .007). Preoperative swallowing dysfunction was associated with a 3.07-fold increased likelihood of worse functional scores at 3 months. Whereas frailty was associated with preoperative dysphagia, there was no association between worse postoperative score and age, sex, race, frailty, body mass index, smoking status, gastroesophageal reflux disease, comorbidity index, malignancy, surgical extent, or type of surgery. ConclusionAdults 65 years and older commonly report swallowing impairment preoperatively, which is associated with a 3.07-fold increased likelihood of worsened dysphagia after thyroid and parathyroid surgery that may persist up to 6 months postoperatively.

Second free jejunum transfer after flap loss does not affect oral intake: A retrospective case-control study

Free jejunum transfer is one of the standard procedures for restoring oral intake after total pharyngo-laryngo-esophagectomy. Flap loss leading to a second free jejunum transfer rarely occurs. This study investigated the impact of a second free jejunum transfer on post-operative oral intake. A retrospective review was conducted on patients who underwent a first free jejunum transfer between July 1998 and December 2019. A total of 367 patients were included in the study. Among them, 17 patients who underwent a second free jejunum transfer because necrosis constituted the second free jejunum transfer group, whereas 350 patients who did not require a second free jejunum transfer formed the first free jejunum transfer group. The incidence of dysphagia requiring tube feeding and post-operative complications was compared between the two groups. Moreover, risk factors for dysphagia and complications were estimated. There were no statistically significant differences in the incidence of dysphagia post-operation between the two groups. A second free jejunum transfer was a statistically significant factor for complications at 2- and 6-months post-operation; however, there were no significant differences in complication rates at the 12-month follow-up. Furthermore, there were no significant differences in the incidence of severe complications between the two groups. Although a second free jejunum transfer increases early complications, it is not associated with major complications and does not negatively impact oral intake. These findings support the conclusion that free jejunum transfer is safe and helps maintain post-operative quality of life.

Predictive Factors for Dysphagia After Anterior Cervical Spine Surgery: A Prospective Multicenter Study

To identify the incidence and predictors of postoperative dysphagia in patients who undergo anterior cervical spine surgery (ACSS) by utilizing the Eating Assessment Tool (EAT-10). A multicenter prospective study was undertaken at three hospitals to evaluate patients undergoing ACSS between January 2021 and January 2023. Included patients were aged 18-80years and were undergoing primary or revision ACSS. Dysphagia was assessed using the validated EAT-10 questionnaire. Patients with dysphagia were included in the observation group, and those without dysphagia were included in the control group. Of the 343 patients enrolled, 50 patients (14.6%) had EAT-10 scores of 3 or more at the 6-month follow-up. In the univariate analysis, patients with dysphagia at 7days had a longer operative time, were current smokers, had involvement of vertebral bodies at C4 and above, and underwent intraoperative neurophysiological monitoring. Patients with dysphagia at 6months had involvement of vertebral bodies at C4 and above and underwent intraoperative neurophysiological monitoring. In the multivariate analysis to determine associations with prolonged dysphagia, only the involvement of vertebral bodies at C4 and above (odds ratio 3.883, 95% confidence interval 1.847-8.165, P=0.001) and intraoperative neurophysiological monitoring (odds ratio 0.273, 95% confidence interval 0.080-0.931, P=0.038) remained significant. Dysphagia is common after ACSS, affecting more than 67.5% of patients at 7days postoperatively, but over time, the incidence of dysphagia gradually decreases. Involvement of the vertebral bodies at C4 and above is a risk factor for dysphagia after ACSS, and intraoperative neurophysiological monitoring is a protective factor.

Prevalence and clinical predictors of dysphagia after heart transplantation.

Dysphagia is a common complication after heart transplantation (HTPL), but few studies exist on dysphagia after HTPL, and the prevalence is unknown. The objective of our current study was to establish the prevalence and risk factors for dysphagia after HTPL and to classify its characteristics through Videofluoroscopic Swallowing Studies (VFSS). The recipients of HTPL carried out at a single center from January 2011 to November 2019 were assessed retrospectively. Dysphagia was evaluated by a bedside swallowing exam and VFSS to evaluate for evidence of aspiration. The duration of ventilator and preoperative extracorporeal membrane oxygenation (ECMO) support, intensive care unit, hospital stay, the progress of oral feeding after surgery, the presence of a tracheostomy, and vocal cord palsy were analyzed. On the third and seventh days following surgery, we looked at the relationship between risk factors and oral feeding progress, respectively. Additionally, we contrasted these risk variables with the no penetration/aspiration (PA) group and the PA group on VFSS. Among the study cohort of 421 patients, 222 (52.7%) patients had access to oral feeding on the third day of surgery. The number of patients who underwent VFSS due to clinically suspected dysphagia was 96 (22.8%). Of these, 54 (56.2%) had aspiration or penetration (PA group), while 42 (43.8%) had no abnormal findings (No-PA group). In the multivariable regression model, preoperative ECMO support, vocal cord abnormalities, tracheostomy, and emergent need for HTPL were identified as independent risk variables for oral feeding progress on postoperative days (PODs) 3 and 7. Among these factors, preoperative ECMO support had the highest odds ratio (OR) at PODs 3 (OR: 4.73, CI: 1.997, 11.203, p<.001) and 7 (OR: 5.143, CI: 2.294, 11.53, p<.001). We identified the prevalence and potential risk factors for postoperative dysphagia in this retrospective analysis of 421 heart transplant recipients. The pathophysiology of postoperative dysphagia was multifactorial, and it was more common than the incidence after general cardiothoracic surgery.

Incidence and Risk Factors for Dysphagia Following Cerebellar Stroke: a Retrospective Cohort Study

The cerebellum is known to play a supportive role in swallowing-related functions; however, wide discrepancies about the incidence rate of swallowing disorders following cerebellar strokes exist within the literature. This study aimed to investigate the incidence rate of dysphagia and the factors which may affect the presence of dysphagia and clinical recovery in individuals diagnosed with cerebellar stroke. A retrospective chart audit of 1651 post-stroke patients (1049 males and 602 females) admitted with a cerebellar stroke to a comprehensive tertiary hospital in China was conducted. Data on demographics, medical, along with swallowing function assessment were collected. Differences between dysphagic and non-dysphagic groups were evaluated using t-tests and Pearson’s chi-square test. Univariate logistic regression analysis was performed to establish factors associated with the presence of dysphagia. A total of 11.45% of participants were identified with dysphagia during inpatient admission. Individuals with mixed types of stroke, multiple lesions in the cerebellum, and ages older than 85 years old were more likely to develop dysphagia. Moreover, the prognosis of dysphagia following a cerebellar stroke was associated with lesions in different parts of the cerebellum. The cumulative recovery rates from the best to worse were the right hemisphere group, the cerebellum vermis or peduncle group, and both the hemisphere group and the left hemisphere group, respectively.

Dysphagia is closely related to frailty in mild-to-moderate Alzheimer’s disease

IntroductionPhysical phenotype and the cumulative deficit model are two well-known concepts of frailty. One of the main components of frailty is loss of muscle mass and function, which may also include swallowing muscles, therefore is a risk factor for dysphagia. Since dysphagia is seen starting from the early stages of Alzheimer’s Disease (AD), in this study we aimed to reveal the relationship between frailty and dysphagia and dysphagia-related quality of life through Swallow Quality of Life (SwalQoL) tool in patients with AD and compare them with cognitively intact older adults.MethodsComprehensive geriatric assessment, dysphagia evaluation by Eating-Assessment Tool (EAT-10) and SwalQoL questionnaire, and frailty assessment via FRAIL and Clinical Frailty Scale (CFS) were performed on all 101 participants of the study. Thirty-five patients were cognitively intact, 36 patients were diagnosed with mild AD, and 30 patients were diagnosed with moderate AD.ResultsSex distribution was similar between the groups, however, there was a statistically significant age difference. The prevalence of frailty increased according to both frailty indexes as the cognitive status deteriorated. All parameters of SwalQoL except fear and sleep parameters deteriorated as cognitive status impaired. In quantile regression of the total score of the SwalQoL questionnaire and multivariable logistic regression of EAT-10, frailty, as defined by CFS and FRAIL, was associated with dysphagia and poor quality of life regardless of age, presence of dementia, as well as nutritional status.ConclusionSwallowing difficulties in AD negatively affects the quality of life, and it is closely related to frailty in mild-to-moderate AD.

Lower SMI is a risk factor for dysphagia in Japanese hospitalized patients with osteoporotic vertebral and hip fracture: A retrospective study

ObjectivesMany patients with osteoporotic fragile fracture often suffer from dysphagia that results in malnutrition, further deterioration of physical strength, and rehabilitation difficulties. This study aims to investigate the risk factors for dysphagia in hospitalized patients with osteoporotic vertebral and/or hip fractures. MethodsBetween January 2020 and December 2021, 569 inpatients were managed for osteoporotic vertebral or hip fractures. Of these, 503 patients were analyzed and 66 were excluded as the required data could not be obtained or dysphagia with causative diseases such as cerebrovascular disease. The patients were divided into 2 groups: patients with dysphagia (P-group) and patients without dysphagia (N-group). We investigated gender, fracture site, age, systemic skeletal muscle mass index (SMI), bone mineral density (BMD), and body mass index (BMI) in early stage of hospitalization and studied their relationship with dysphagia. ResultsThere were no significant differences in gender and fracture site between the 2 groups. A significant difference was observed in age, SMI, BMD, and BMI (P < 0.01). We performed a logistic regression analysis with the P-group as the objective variable and age, SMI, BMD, and BMI as explanatory variables. We divided objective groups into all patients, patients with vertebral fracture, patients with hip fracture, men, and women. SMI was an independent risk factor in all groups. ConclusionsLower SMI was a risk factor for dysphagia in hospitalized patients with osteoporotic vertebral and hip fractures. We carefully observed swallowing function of patients with decreased SMI to maintain the nutritional status and prevent rehabilitation difficulties.

Comment on “prevalence and risk factors of dysphagia in patients with multiple sclerosis”

We read the recent interesting article entitled “Prevalence and Risk Factors of Dysphagia in Patients with Multiple Sclerosis,” published in Dysphagia on February 2021. We believe the discussion part of this study could have provided further and more precise interpretations regarding its results. Thus, we would also like to comment our inferences in accordance with its results to highlight some essential points.

Risk factors of dysphagia in patients with ischemic stroke: A meta-analysis and systematic review.

BackgroundDysphagia is a common yet serious complication in stroke patients. We aimed to conduct a meta-analysis and systematic review to evaluate the risk factors of dysphagia in patients with ischemic stroke, to provide insights to the clinical treatment and nursing care of dysphagia.MethodsWe searched PubMed, Embase, Cochrane Library, Web of Science, China National Knowledge Infrastructure (CNKI) and Wanfang Database, China Biomedical Literature Database (CBM) for studies on dysphagia in patients with ischemic stroke up to January 31, 2022. The quality of the literature was evaluated using the Newcastle-Ottawa scale. Meta-analysis was performed using RevMan 5.3 software.ResultsA total of 10 studies involving 4637 ischemic stroke patients were included, 1183(25.51%) patients had dysphagia after stroke. The synthesized outcomes showed that elder age (SMD = 0.42, 95%CI:0.34–0.50), hypertension (OR = 1.96, 95%CI:1.48–2.61), diabetes (OR = 1.83, 95%CI:1.47–2.28), brainstem stroke (OR = 2.12, 95%CI:1.45–3.09) were associated with dysphagia in patients with ischemic stroke (all P<0.05). There was no significant difference in the gender between dysphagia and no dysphagia patients (OR = 1.07, 95%CI:0.91–1.27, P = 0.40). Egger regression tests indicated there were no significant publication biases in the synthesized outcomes (all P>0.05).ConclusionsElder age, hypertension, diabetes and brainstem stroke are associated with the development of dysphagia in patients with ischemic stroke. Attention should be paid to the assessment and early intervention of those risk factors for dysphagia to improve the prognosis of stroke patients.

DYSPHAGIA FOLLOWING ANTERIOR CERVICAL SPINE SURGERY: A TWO YEAR PROSPECTIVE STUDY

Introduction: Incidence of dysphagia following anterior cervical spine surgery is not uncommon, in studies it has ranged from 2% to 60%. Most studies in have been done in a retrospective manner which have doubtful conclusions. We have followed up 212 case of anterior cervical spine surgery for two years and documented the risk factors in patients developing dysphagia in the follow-up period. Aims &amp; objectives: To nd the incidence and risk factor for dysphagia in anterior cervical spine surgery. Materials &amp; method: st It's a prospective study where patients under went operation in our institute in the year from 1 january2018 st st to 31 December 2019. We have completed our follow up in 31 December 2021. Results: Proportion analysis (chi-square or a Fisher Exact Test), prevalence ratios, and 95% condence intervals were used for data analysis. Female gender(p &lt;0.03), revision surgeries (p &lt;0.01) and more than 3 level surgeries( p&lt;0.03) seems to be some important risk factors. Conclusion: study concluded that female gender, revision surgeries and surgery done in ≥ 3 cervical levels are at risk for dysphagia.

Jaw-Opening Force as a Useful Index for Dysphagia: A Cross-Sectional and Multi-Institutional Study

Introduction: Jaw-opening force (JOF) can be a potential screening tool for dysphagia. However, confounding variables such as comorbidities or physical and oral functions that are associated with the physiology of swallowing have not previously been examined. Adjusting for these variables could reveal the relationship between JOF and dysphagia and indicate whether JOF is an independent factor associated with dysphagia. We therefore aimed to assess the efficacy of using JOF for dysphagia screening in this multi-institutional study. Methods: Community-dwelling older adults over the age of 65 years (N = 403) who visited the university dental hospitals and participated in health surveys (mean age ± standard deviation, 77.1 ± 7.0 years; range, 65–96 years) between November 2018 and January 2020 were included in this study. The JOFs of all participants were measured. The measured JOF was compared with the presence of dysphagia, which was defined using the Functional Oral Intake Scale and the Eating Assessment Tool-10. Results: Multiple logistic regression analysis revealed that the presence of dysphagia was independently associated with JOF, calf circumference, and dependence after adjusting for age and sex. Discussion/Conclusion: Decreased JOF can be a risk factor for dysphagia in older adults.

A risk prediction model for dysphagia in older patients: a single-center prospective study

Surveys based on western populations have identified many risk factors for dysphagia in older people, but the potential risk factors consistent with the demographic characteristics of older, hospitalized Chinese patients require further study. This single-center prospective study aimed to determine the incidence of dysphagia in western China, and to develop and validate a model to predict the risk of dysphagia among older patients. A total of 343 inpatients (aged ≥ 65 years without dysphagia and cognitive impairment) were included. A score ≥ 2 on the Eating Assessment Tool-10 was defined as dysphagia. After a six-month follow-up, 70 (20.4%) patients were found to have dysphagia. The final model included age, wearing dentures, activities of daily living, cerebral vascular disease, coronary heart disease, and malignancy. The developed model has high predictive accuracy and can be easily implemented in daily practice.

Risk Factors of Dysphagia after Anterior Decompression and Fusion Surgery for Degenerative Cervical Spine

Risk Factors of Dysphagia after Anterior Decompression and Fusion Surgery for Degenerative Cervical Spine

Transoral videolaryngoscopic surgery for laryngeal and hypopharyngeal cancer―Technical updates and long-term results

Abstract Objective Transoral videolaryngoscopic surgery (TOVS) was developed as a non-robotic procedure for en bloc laryngo-hypopharyngeal cancer resection. Straight devices had been used for this procedure, however, some cases had difficulty to reach the lesions especially in hypopharyngeal area. To overcome this problem, technical updates to facilitate transoral manipulation were developed and long term oncological and functional results were analyzed. Methods Surgical indications were Tis, T1, T2 and selected T3 cases. In advanced T3 or T4 lesions, neoadjuvant chemotherapy was performed before surgery. Radiation failure cases (rT1 and rT2) were also indicated for TOVS. Resectable nodal involvement can be managed by combination of neck dissection. Ninety hypopharyngeal and 25 supraglottic cancer cases were retrospectively reviewed for survival analyses. In fresh hypopharyngeal cancer, 51 Stage 0–II disease and 32 Stage III-IV disease were included. In supraglottic cancer, 11 Stage I–II disease and 9 Stage III-IV disease were included. Twelve radiation failure cases were analyzed separately. As new devices, malleable forceps and malleable suction coagulator were introduced to reach the whole laryngo-hypopharynx. New curved blades for the FKWO retractor were developed and these were applied for difficult hypopharyngeal exposure cases by conventional blades. Swallowing functional outcome and risk factors for postoperative dysphagia were evaluated by univariate analysis. Results The 5-year overall survival, disease-specific survival and larynx preservation rate of fresh hypopharyngeal cancer cases were 83.2%, 94.3% and 94.6%, respectively. Those of supraglottic cancer cases were 80%, 95% and 94.7%, respectively. Those of salvage cases were 87.5%, 87.5% and 82.5%, respectively. Those of T3 and T4 hypopharyngeal cancer treated by neoadjuvant chemotherapy with TOVS were 75.0%, 82.5% and 100% respectively. Surgical complication included bleeding (2.6%) and emergency tracheostomy (3.4%). Oral intake was maintained in 94.8% cases. By univariate analysis, patient’s age (especially 80 years of age or older), larger resected area, arytenoid resection and tracheostomy were regarded as risk factors for postoperative dysphagia. Among 31 recent cases, 5 cases had difficulty in exposing hypopharyngeal lesions by conventional blades. These exposure problems were solved by curved blades. Conclusion Using malleable devices and new curved blades for the FKWO retractor, exposure problems in the hypopharynx could be solved and TOVS could be applied in more cases. Although oncological outcomes and functional outcomes were good, patients with risk factors for dysphagia should be carefully indicated.

PILL-INDUCED PNEUMONITIS PRECIPITATING GROSS HEMOPTYSIS BY ASPIRATED ANTICOAGULANT MEDICATION

TOPIC: Signs and Symptoms of Chest Diseases TYPE: Medical Student/Resident Case Reports INTRODUCTION: Pill pneumonitis (PP) is described as pulmonary inflammation and fibrosis secondary to the aspiration of pills. Those having dysphagia are at the highest risk for aspiration include neurologic impairment, anatomic deformity, and oropharyngeal dysfunction. The epidemiology of this condition is ill-defined to date given the scarcity of its diagnosis. Herein, we present a unique case of pill pneumonitis secondary to anticoagulant aspiration leading to gross hemoptysis. CASE PRESENTATION: A 26-year-old male, with a 2-year remote history of MVA complicated by right upper extremity DVT on Rivaroxaban, presented with a two-day history of gross hemoptysis with concurrent cough and dyspnea. PMH is otherwise unremarkable. The patient recalled choking a few days prior on his medications. Upon presentation, he had stable vital signs and a physical exam remarkable for mild left-sided rales.Laboratory workup demonstrated no leukocytosis and no significant change in hemoglobin. CT angiogram demonstrated peribronchial patchy consolidation with scattered ground-glass opacities; With reactive mediastinal and hilar lymphadenopathy. The patient was admitted for evaluation of new-onset hemoptysis and a subsequent bronchoscopy discerned diffuse patchy erythematous friable mucosa with foreign body particulates, most notably in the left mainstem bronchus. Otherwise, all accompanying testing was unyielding included infectious and autoimmune panels and tissue biopsies. The patient's Rivaroxaban was discontinued and the Ultrasound of the upper extremity showed no evidence of DVT. He received a course of steroids and antibiotics. The patient's gross hemoptysis resolved by the second day of hospitalization. DISCUSSION: PP is a serious complication to FBA and the acute onset of cough, wheezing, and dyspnea should raise suspicion in patients without other suggestive causes. These include pneumonia, congestive heart failure, or trauma. This case is noteworthy due to the patient's aspiration of an anticoagulant leading to an acute onset of pill pneumonitis with significant gross hemoptysis. A high degree of suspicion is needed to initiate early and aggressive diagnostic and interventional treatment, and the threshold of suspicion should be lowered in patients with a greater risk of aspiration. Our patent did not have risk factors for dysphagia, however, unnecessary use of anticoagulant therapy led to the acute progression of this patient's clinical presentation. Furthermore, management of pill pneumonitis is based on early and aggressive bronchoalveolar lavage and foreign body removal, which has shown to reduce disease progression and reverse inflammatory changes. CONCLUSIONS: This case describes a novel cause of PP, as no previous case describes aspiration of anticoagulant medication and emphasizes the importance of early diagnosis and proper anticoagulant use as a means of preventing unforeseen complications. REFERENCE #1: Hill, S. N., Main, A. N., & Fuggle, W. J. (1988). Covert inhalation of tablet causing fatal pneumonia. Postgraduate Medical Journal, 64(747), 66-67. doi:10.1136/pgmj.64.747.66 REFERENCE #2: Hu, X., Lee, J. S., Pianosi, P. T., & Ryu, J. H. (2015). Aspiration-related pulmonary syndromes. Chest, 147(3), 815-823. doi:10.1378/chest.14-1049 REFERENCE #3: Lee, P., Culver, D. A., Farver, C., & Mehta, A. C. (2002). Syndrome of iron pill aspiration. Chest, 121(4), 1355-1357. doi:10.1378/chest.121.4.1355 DISCLOSURES: No relevant relationships by Connor Kerndt, source=Web Response no disclosure on file for Shahid Mohammed; No relevant relationships by Mitchelle Zolotarevsky, source=Web Response