Swallowing Strategies Research Articles

The Use of Pharyngeal High-Resolution (Impedance) Manometry in Patients With Head and Neck Cancer: A Scoping Review.

This scoping review aims to summarize and explore current literature on the usefulness and clinical implications of pharyngeal high-resolution (impedance) manometry (HRM/HRIM) in head and neck cancer (HNC) patients. Three online databases (MEDLINE, Embase, Scopus, and additionally Google Scholar) were searched until December 2023. Studies using pharyngeal HRM/HRIM to assess swallowing or voicing in HNC patients, written in any language and published in peer-reviewed journals, were considered eligible. Quality check was performed using the Quality Assessment Tool for Quantitative Studies from the Effective Public Healthcare Practice Project. Information about the study population and HRM/HRIM data (equipment, protocol, analysis, and outcomes) were extracted. Eight papers met the inclusion criteria, six utilizing HRM and two HRIM. The study design consisted of case-series (five) and case-control (three). The quality assessment indicated a weak global rating for seven papers and a moderate rating for one for the remaining study. Findings suggest that HNC patients with dysphagia suffer from reduced pressures in the pharynx and upper esophageal sphincter compared to healthy individuals, potentially influenced by tumor characteristics and treatment. Decreased pressures may indicate poor functioning of swallowing musculature and mechanism. Pharyngeal HRM/HRIM is sparsely used for swallowing assessment in HNC patients. However, wider use seems warranted, as it can offer valuable insights into swallowing biomechanics. This can help quantifying the degree and timing of pressures involved in swallowing (problems) and holds potential for clinical applications, such as earlier diagnosis of radiation-induced therapy or surgery complications. Additionally, it can be beneficial in evaluating therapeutic swallowing strategies.

Profiling of swallowing function in head and neck cancer patients prior to radiation therapy-Findings from a tertiary hospital in South India

PurposeHead and neck cancer (HNC) patients often face difficulties with swallowing, which can be due to the cancer itself or the treatment modalities like radiation therapy. The presentation of HNC can vary between developing and developed countries due to socioeconomic factors. The current study aimed to profile the swallowing function of HNC patients before starting radiation therapy in a tertiary hospital in India. MethodThis cross-sectional observational study examined patients with HNC who were scheduled for radiation therapy. The Functional Oral Intake Scale (FOIS) and Karnofsky Performance Status Scale were used to assess the patients’ swallowing status and functional abilities, respectively. The study also evaluated the relationship between swallowing function and clinical-demographic factors. ResultsOur assessment of 162 HNC patients found that the cancer site significantly affects swallowing. Although 92% of patients had an oral diet, 64% made dietary modifications. Patients with non-oral intake had either oral or pharyngeal cancer, and over 80% of oral cancer patients and 60% of those with pharyngeal cancer had already made changes to their diet. Patients with laryngeal cancer had a better oral intake, with 58% reporting no swallowing issues. ConclusionPatients with HNC scheduled for radiation therapy may experience varying degrees of swallowing difficulty. Early intervention and teaching of safe swallowing strategies are crucial to prepare for the potential worsening of swallowing difficulties resulting from the treatment. Advanced tumor stages and oral/pharyngeal cancers increase the risk of significant swallowing issues.

Clinical reasoning during dysphagia assessment and management in acute care: A longitudinal qualitative study.

Competent clinical reasoning forms the foundation for effective and efficient clinical swallowing examination (CSE) and consequent dysphagia management decisions. While the nature of initial CSEs has been evaluated, it remains unclear how new information gathered by speech-language therapists (SLTs) throughout a patient's acute-care journey is integrated into their initial clinical reasoning and management processes and used to review and revise initial management recommendations. To understand how SLTs' clinical reasoning and decision-making regarding dysphagia assessment and management evolve as patients transition through acute hospital care from referral to discharge. A longitudinal, qualitative approach was employed to gather information from two SLTs who managed six patients at a metropolitan acute-care hospital. A retrospective 'think-aloud' protocol was utilized to prompt SLTs regarding their clinical reasoning and decision-making processes during initial and subsequent CSEs and patient interactions. Three types of concept maps were created based on these interviews: a descriptive concept map, a reasoning map and a hypothesis map. All concept maps were evaluated regarding their overall structure, facts gathered, types of reasoning engaged in (inductive versus deductive), types of hypotheses generated, and the diagnosis and management recommendations made following initial CSE and during subsequent dysphagia management. Initial CSEs involved a rich process of fact-gathering, that was predominantly led by inductive reasoning (hypothesis generation) and some application of deductive reasoning (hypothesis testing), with the primary aims of determining the presence of dysphagia and identifying the safest diet and fluid recommendations. During follow-up assessments, SLTs engaged in increasingly more deductive testing of initial hypotheses, including fact-gathering aimed at determining the tolerance of current diet and fluid recommendations or the suitability for diet and/or fluid upgrade and less inductive reasoning. Consistent with this aim, SLTs' hypotheses were focused primarily on airway protection and medical status during the follow-up phase. Overall, both initial and follow-up swallowing assessments were targeted primarily at identifying suitable management recommendations, and less so on identifying and formulating diagnoses. None of the patients presented with adverse respiratory and/or swallowing outcomes during admission and following discharge from speech pathology. Swallowing assessment and management across the acute-care journey was observed as a high-quality, patient-centred process characterized by iterative cycles of inductive and deductive reasoning. This approach appears to maximize efficiency without compromising the quality of care. The outcomes of this research encourage further investigation and translation to tertiary and post-professional education contexts as a clear understanding of the processes involved in reaching diagnoses and management recommendations can inform career-long refinement of clinical skills. What is already known on the subject SLTs' clinical reasoning processes during initial CSE employ iterative cycles of inductive and deductive reasoning, reflecting a patient-centred assessment process. To date it is unknown how SLTs engage in clinical reasoning during follow-up assessments of swallowing function, how they assess the appropriateness of initial management recommendations and how this relates to patient outcomes. What this paper adds to the existing knowledge Our longitudinal evaluation of clinical reasoning and decision-making patterns related to swallowing management in acute care demonstrated that SLTs tailored their processes to each patient's presentation. There was an emphasis on monitoring the suitability of the initial management recommendations and the potential for upgrade of diet or compensatory swallowing strategies. The iterative cycles of inductive and deductive reasoning reflect efficient decision-making processes that maintain high-quality clinical care within the acute environment. What are the potential or actual clinical implications of this work? Employing efficient and high-quality clinical reasoning is a hallmark of good dysphagia practice in maximizing positive patient outcomes. Developing approaches to understanding and making explicit clinical reasoning processes of experienced clinicians may assist SLTs of all developmental stages to provide high standards of care.

Nurses' knowledge of patients´' swallowing ability

Background: oropharyngeal dysphagia is the result of a series of neuromuscular disorders that can impair swallowing. These alterations compromise adequate nutritional support and often endanger the safety of the person with dysphagia. The prevalence of dysphagia is known to increase with age, but it is still an underdiagnosed problem, which should be a concern for nurses. Objective: To identify nurses' knowledge of patients' swallowing ability in a Portuguese hospital. Methodology: Quantitative, descriptive-correlational, cross-sectional study using a non-probabilistic convenience sample of 62 nurses. The online survey includes sociodemographic/ professional indicators, an assessment of nurses' knowledge of swallowing ability, relevant data for dysphagia diagnosis and compensatory swallowing strategies. Results: 62 nurses were included, mostly female (80.6%), with an average age of 38.50 years, with a prevalence of those under 39 (53.2%), with a degree (71.0%) and who had been working in the profession for 14 years or less (54.8%), there was a higher percentage of men who had not had any training in dysphagia compared to women (66.7% vs. 52. 0%). The multiple linear regression showed as predictors of knowledge of swallowing ability: knowledge of relevant data to diagnose dysphagia, knowledge of compensatory strategies and inversely professional exercise (p<0.000). Conclusions: The higher the knowledge about compensatory swallowing strategies and the knowledge about the relevant data for diagnosing dysphagia, and the shorter the time spent in professional practice, the greater the nurses' knowledge about dysphagia. These results suggest the need of continuous education about dysphagia for more experienced professionals. What is the main contribution to evidence-based practice from this research? The article contributes to promote a a better Identification of nurses' knowledge about the signs of dysphagia and compensatory swallowing strategies in case of dysphagia.

Surface Electromyographic Activity of the Masseter Muscle During Regular and Effortful Saliva Swallows: A Preliminary Study.

Biofeedback is a critical component in motor learning of new, complex behaviors such as modifications to swallowing. Surface electromyography (sEMG) is a commonly employed biofeedback tool in swallowing management to assess muscle activity patterns, determine amplitude and duration of swallowing, and train swallowing strategies such as the effortful swallow (EFS) maneuver. The EFS can potentially change multiple physiological components of the swallowing process such as pressure generation and movement of biomechanical structures. The purposes of this study were to determine whether the masseter muscle could differentiate a normal swallow (NS) from an EFS and whether there was a relationship between perceived muscle effort used to swallow and objective measures of muscle activity. Twenty healthy young adults participated in this study. Masseter sEMG peak amplitude and duration were measured across five regular saliva swallows and five effortful saliva swallows. Additionally, participants rated their perceived swallowing effort using a visual analog scale (VAS). Two swallowing conditions, NSs and EFSs were compared with hierarchical models, and repeated measures correlation was used to determine the relationships between the VAS and sEMG peak amplitude. Participants produced swallows with greater masseter sEMG peak amplitude and duration during the EFS. Moreover, a positive correlation was identified between perceived swallowing effort and masseter sEMG peak amplitude. These findings support the potential use of the masseter muscle to differentiate NSs from EFSs and implement the VAS during therapy for tracking patients' performance, particularly in settings with limited access to sEMG.

1203 SUPPORTING SAFE SWALLOWING OF CARE HOME RESIDENTS WITH DYSPHAGIA: HOW DOES CARE COMPARE WITH GUIDANCE?

Abstract Introduction Dysphagia affects up to 70% of nursing home residents, causes significant morbidity and increased hospital admissions. Speech and language therapists (SLT) make recommendations to reduce the risk of aspiration and support safe eating and drinking but have limited capacity to offer ongoing guidance to care home staff. This study aimed to measure the mealtime experience of residents with dysphagia, how this compared with SLT advice and what factors influenced care. Methods The safety of nutrition/hydration care of residents with dysphagia in 2 care homes was observed using a structured tool capturing 12 elements of expected practice. Observed practice was compared to recommendations in SLT/care-plans. Interviews with staff aimed to understand factors that contributed to how dysphagia care was delivered. Results SLT recommendations for 18 residents with dysphagia were predominantly focused on food/fluid modification, other safe swallowing strategies were mentioned less frequently. 66 episodes of mealtime care for 11 residents were observed. Adherence to SLT/care-plan recommendations for food texture, posture and alertness of the resident was observed on 90% of occasions, but on less than 60% of occasions for alternating food and drink, prompting resident during feeding, ensuring swallow completed and throat/mouth clear. Compliance with recommended fluid thickness was 68%; thickening was frequently not aligned to required IDDSI level. Nutrition care was less safe when residents were fed in the dining room when multiple care staff were present. Interviews with 11 care home staff found care-plans were rarely consulted, care needs were communicated verbally during handover, and training was targeted at fluid modification but not at other safer swallowing strategies. Limited knowledge about causes of coughing whilst eating/drinking drove inappropriate SLT referrals. Conclusions A safe swallowing culture that addresses system and workforce issues in care homes would improve the experience of residents with dysphagia and reduce their risk of aspiration.

69-Year Old Man With Dysphagia and Nasal Regurgitation

69-Year Old Man With Dysphagia and Nasal Regurgitation

Fiberoptic Endoscopic Evaluation of Swallowing in Infants and Children: Protocol, Safety, and Clinical Efficacy: 25 Years of Experience.

The application of fiberoptic endoscopic evaluation of swallowing (FEES) in the pediatric dysphagia protocol requires specialized knowledge of pediatric conditions that result in dysphagia, recognition of normal and abnormal laryngopharyngeal anatomy and function across ages, and the ability to identify maturational changes in anatomy and function of the aerodigestive tract that pertain to airway protection and swallowing function. Over the past 25 years, we have performed over 7,000 collaborative Otolaryngology and Speech-Language Pathology FEES examinations in patients ranging from 2 days of age to young adults. During this time period, we have monitored the safety of the procedure, explored the feasibility and utility of FEES across conditions, compared and contrasted FEES to the videofluoroscopic evaluation of swallowing (VFSS), and developed specific pediatric FEES protocols with operational definitions for identification and interpretation of swallowing parameters. FEES has proved to be a safe procedure in patients across ages. There have been no significant adverse events. FEES is comparable to the VFSS in the assessment of events before and after the swallow. It provides unique information regarding laryngopharyngeal anatomy and function, airway protection integrity, sensory threshold, and secretion management ability, as well as pharyngeal swallowing dynamics and the efficacy of compensatory swallowing strategies. There are specific indications and contraindications for pediatric FEES, and unique components that characterize the pediatric FEES protocols across ages and conditions. FEES procedures performed jointly by an Otolaryngologist and Speech-Language pathologist offer a team approach to interpretation and management recommendations.

Using Spaced Retrieval With External Aids to Improve Use of Compensatory Strategies During Eating for Persons With Dementia.

This study was designed to determine whether spaced retrieval (SR), when paired with an external memory aid, is an effective technique to teach persons with dementia to use compensatory swallowing strategies. A secondary purpose was to learn whether speech-language pathologists naive to the study aims would judge posttraining sessions as improved, or safer, in comparison to baseline sessions, thereby validating the changes in behavior due to SR training to use external aids during meals. A multiple baseline design across behaviors was used to evaluate the effects of teaching compensatory swallowing behaviors (i.e., chin tuck, alternation of liquids and solids, lingual/finger sweep) to 5 nursing home residents diagnosed with dementia and coexisting dysphagia. SR training with the use of a visual aid was functionally related to improvements in 2-3 compensatory swallowing behaviors for each of the 5 participants. Study outcomes paired with social validation ratings demonstrated that persons with dementia could learn compensatory swallowing behaviors for perceived safety during intake. Because participants were eating in a quiet and controlled environment, generalization to the typical dining environment remains unknown, and further research is needed to investigate the long-term impact of this training protocol.

A Review of Dysphagia Presentation and Intervention Following Traumatic Spinal Injury: An Understudied Population.

Dysphagia is reported to be a common secondary complication for individuals with traumatic spinal injuries. Different etiologies of traumatic spinal injuries may lead to different profiles of swallowing impairment. We conducted a systematic review to determine the characteristics of dysphagia after traumatic spinal injury and to describe interventions currently used to improve swallowing function in this population. A comprehensive multiengine literature search identified 137 articles of which five were judged to be relevant. These underwent review for study quality, rating for level of evidence, and data extraction. The literature describing dysphagia after traumatic spinal injury was comprised predominantly of low-level evidence and single case reports. Aspiration, pharyngeal residue, and decreased/absent hyolaryngeal elevation were found to be common characteristics of dysphagia in this population. The most commonly used swallowing interventions included tube feeding, compensatory swallowing strategies, and steroids/antibiotics. Improvement in swallowing function following swallowing intervention was reported in all studies; however, there was no control for spontaneous recovery. The results demonstrate a need for high-quality research to profile the pathophysiology of dysphagia after traumatic spinal injury and controlled studies to demonstrate the efficacy of swallowing interventions in this population.

Outcomes of a pilot water protocol project in a rehabilitation setting.

There is considerable clinical interest in the risks and benefits of offering oral water intake, in the form of water protocols, to patients with thin-liquid dysphagia. We describe the design and implementation of a water protocol for patients in a rehabilitation setting with videofluoroscopically confirmed thin-liquid aspiration. The GF Strong Water Protocol (GFSWP) is an interdisciplinary initiative, with roles and accountabilities specified for different members of the interprofessional health-care team. Rules of the water protocol specify mode of water access (independent, supervised), the implementation of any safe swallowing strategies recommended on the basis of the patient’s videofluoroscopy, and procedures for evaluating and addressing oral care needs. Trial implementation of the water protocol in 15 participants showed that they remained free of adverse events, including pneumonia, over the course of an initial 14-day trial and continuing until discharge from the facility (range = 13–108 days). Seven participants were randomly assigned to a 14-day control phase in which they received standard care (without water access). Fluid intake measures taken after the oral water intake phase were increased (mean = 1,845 cc; 95% confidence interval: 1,520–2,169 cc) compared to those in the control phase (mean = 1,474 cc; 95% CI: 1,113–1,836 cc), with oral water intake measures comprising, on average, 563 cc (range = 238–888 cc) of the total post water trial fluid intake values. Fluid intake increased at least 10% of the calculated fluid requirements in 11/15 participants who received oral water access. These participants reported favorable quality-of-life outcomes, measured using the Swal-QOL. These findings support the implementation of the GFSWP, including its exclusion criteria, rules, and plans of care, for rehabilitation patients who aspirate thin liquids.

Stimulating Swallowing: Essential Central and Peripheral Nervous System Targets

Stimulating Swallowing: Essential Central and Peripheral Nervous System Targets

Duration and extent of dysphagia following pediatric airway reconstruction

Patients who undergo open airway reconstruction procedures are likely to experience some degree of post-operative dysphagia. This retrospective review describes the duration of post-operative dysphagia and the use of compensatory strategies in a group of 30 pediatric patients. A retrospective chart review of pediatric patients referred for post-operative swallowing assessment following airway reconstruction during a six-month period was completed. Age, sex, surgical procedure, stent type, co-morbid factors, duration of dysphagia, and use of compensatory dietary modifications and swallowing strategies was summarized and compared. Dysphagia was generally of short duration (1-5 days) in patients undergoing single stage procedures with anterior or anterior/posterior grafts. Duration of swallowing difficulty was increased in patients undergoing posterior grafts in combination with T tubes (10-14 days). The longest duration of difficulty (>2 weeks) occurred in patients who had anterior and posterior grafting with T tubes, combined with additional procedures such as vocal fold lateralization, epiglottic petiole repositioning, and/or arytenoidectomy. There was a greater likelihood of oral feeding difficulty post-operatively in patients presenting with pre-operative feeding issues such as oral aversion or specific texture refusal, and the pre-morbid need for supplemental tube feeding to supplement oral intake. Compensatory swallowing strategies were effective in decreasing aspiration associated with swallowing in oral feeders post-operatively, and in facilitating return to baseline swallowing skills. The duration of dysphagia overall was increased in patients undergoing anterior/posterior grafts in conjunction with in-dwelling T tubes, especially when combined with additional procedures. Compensatory strategies to assist with swallowing were found to be effective in the post-operative phase and included the use of a modified supraglottic swallowing sequence to assist with compensatory airway closure during swallowing in conjunction with diet modifications. Post-operative feeding difficulty occurred in patients with pre-existing feeding issues such as oral aversion and/or texture resistance regardless of reconstructive surgical procedure type.

Cough and Aspiration of Food and Liquids Due to Oral Pharyngeal Dysphagia

Oral pharyngeal dysphagia should be included in the differential diagnosis of patients with cough. Aspiration of food and liquid below the level of the true vocal folds observed on dynamic imaging studies i.e., videofluoroscopic (VSE) and endoscopic (FEES) evaluations of swallow, has been associated with pneumonia. Coughing while eating and drinking may indicate aspiration; however, aspiration may be clinically silent. Subjective patient, caregiver, and nurse reports of reflexive cough while eating are useful but limited in identifying patients who are at risk for aspiration. Objective measures of voluntary cough are under investigation to determine their capacity to predict the risk for aspiration and subsequent pneumonia. The treatment of dysphagic patients by a multidisciplinary team, including early evaluation by a speech-language pathologist, is associated with improved outcomes. Effective clinical interventions such as the use of compensatory swallowing strategies and the alteration of food consistencies should be based on the results of instrumental swallowing studies. Reflexive cough while eating and drinking is important for the detection of oral pharyngeal dysphagia and objective measure of voluntary cough may be a good screening tool for this condition.

Human Memory Systems: A Framework for Understanding Dementia

Human Memory Systems: A Framework for Understanding Dementia

P077 Swallowing Outcomes Following Supracricoid Partial Laryngectomy in the Setting of Adjuvant Therapy

Objective: To evaluate swallowing recovery following supracricoid partial laryngectomy. Design: Retrospective review. Setting: Major comprehensive cancer center. Patients: Twenty-seven patients treated with supracricoid partial laryngectomy for primary or recurrent larynx cancer. Intervention: Functional swallowing strategies, maneuvers, and therapies based on objective modified barium swallow (MBS) study results. Main Outcome Measures: Hospital recovery (length of stay, decannulation rates, complications), swallowing outcomes (physiology, symptoms), and nutritional results (time to oral intake, tube dependency, final diet). Results: Supracricoid partial laryngectomy included 1 arytenoid cartilage in 8 of 27 patients. The mean (SD) length of hospitalization was 8 days (9.23 days [median, 6 days; range, 3-53 days]) with a mean (SD) number of weeks to decannulation of 5 (8.23 weeks [median, 1 week; range, 1-30 weeks]). One patient required permanent tracheostomy. The most common complications were pneumonia and subcutaneous emphysema (7 [26%] of 27 complications). Pneumonia occurred more often in patients who had received radiation therapy (P=.02). Twenty-two patients had MBS studies. Initially, all patients aspirated thin liquids and 55% (12 of 22) aspirated pureed consistencies owing to neoglottic incompetency. Diet modifications alone did not alleviate aspiration; 64% (14 of 22) of patients needed to use swallowing strategies. The supraglottic swallow maneuver was most effective in reducing or eliminating aspiration. Eighty-one percent (22 of 27) of patients returned to complete oral intake with mean (SD) time to feeding tube removal of 10 weeks (8.33 weeks [median, 6 weeks; range, 1-29 weeks]); 7 of these patients used swallowing strategies. Nineteen percent of patients (5 of 27) remained partially (4 of 27) or fully (1 of 27) tube dependent. Arytenoid resection did not significantly affect hospital course or swallowing outcomes. Conclusion: Supracricoid partial laryngectomy initially produces severe swallowing dysfunction but most patients return to oral intake following targeted dysphagia intervention.

Cough and Aspiration of Food and Liquids Due to Oral-Pharyngeal Dysphagia: ACCP Evidence-Based Clinical Practice Guidelines

Cough may be an indicator of aspiration due to oral-pharyngeal dysphagia. Relevant literature was identified by searching the Communication Sciences and Disorders Dome, the Cumulative Index to Nursing and Allied Health Literature, the Educational Resource Information Center, Health & Psychosocial Instruments, the American Psychological Association, and the National Library of Medicine databases from 1965 to 2004 using the terms "deglutition," "aspiration," and "cough." Aspiration was observed on radiologic evaluation in over one third of acute stroke patients and in >40% of patients undergoing cervical spine surgery. Cough while eating may indicate aspiration, but aspiration may be clinically silent. Subjective patient and caregiver reports of cough while eating are useful in identifying patients who are at risk for aspiration. Objective measures of voluntary cough and tussigenic challenges to inhaled irritants are under investigation to determine their capacity to predict the risk for aspiration and subsequent pneumonia. The treatment of dysphagic patients by a multidisciplinary team, including early evaluation by a speech-language pathologist, is associated with improved outcomes. Effective clinical interventions such as the use of compensatory swallowing strategies and the alteration of food consistencies can be based on the results of instrumental swallowing studies. The efficacy of swallowing exercises and electrical muscle stimulation is under study. Surgical interventions may be considered in selected patients, but studies proving efficacy are generally lacking. Patients who are at risk for aspiration can be identified, and appropriate interventions can reduce its associated morbidity.

Objective assessment of swallowing dysfunction and aspiration after radiation concurrent with chemotherapy for head-and-neck cancer

Purpose: To objectively assess swallowing function after an intensive chemoradiation regimen for locally advanced head-and-neck cancer and to assess the clinical implications of swallowing dysfunction. Patients and Methods: Twenty-nine patients with nonresectable Stage IV head-and-neck cancer participated in a Phase I study of radiation, 70 Gy/7 weeks, concurrent with weekly gemcitabine. Because of a high rate of mucosal toxicity, reduced drug doses were delivered to subsequent patient groups: 300, 150, 50, and 10 mg/m 2/week. Twenty-six of these patients underwent prospective evaluation of swallowing function with videofluoroscopy and esophagogram. Studies were performed pretherapy, early post-therapy (1–3 months), and late post-therapy (6–12 months). Results: Complete tests were performed pretherapy in 22 patients, early post-therapy in 20, and late post-therapy in 13. Twenty-five patients had at least one post-therapy study. Post-therapy dysfunction was characterized by reduced inversion of the epiglottis, delayed swallow initiation and uncoordinated timing of the propulsion of the bolus, opening of the cricopharyngeal muscle, and closure of the larynx, all of which promoted aspiration during and after the swallow. In addition, reduced base-of-tongue retraction with reduced contact to the posterior pharyngeal wall and incomplete cricopharyngeal relaxation resulted in pooling in the pyriform sinuses and vallecula of residue, which was frequently aspirated after the swallow. Post-therapy aspirations were typically “silent,” eliciting no cough reflex, or the cough was delayed and noneffective in expelling the residue. Aspiration was observed in 3 patients (14%) in the pretherapy studies, in 13 (65%) in the early post-therapy studies, and in 8 (62%) in the late post-therapy studies (aspiration rates post-therapy vs. pretherapy: p = 0.0002). Six patients had pneumonia requiring hospitalization 1–14 months after therapy (median: 2.5 months), being the likely cause of death in 2 patients. Five cases of pneumonia occurred among 17 patients who had demonstrated aspiration in the post-therapy studies, compared with no cases of pneumonia among 8 patients who had not demonstrated aspiration ( p = 0.1). Of the 4 patients who had not undergone any post-therapy study, 1 developed pneumonia. Mucositis scores, prolonged tube feeding, presence of tracheostomy tube, and gemcitabine doses were not found to be related to aspiration or pneumonia risk. Conclusions: After intensive chemoradiotherapy, significant objective swallowing dysfunction is prevalent. It promotes aspiration, which may not elicit a cough reflex and may be associated with pneumonia. Aspiration pneumonia may be an underdocumented complication of chemoradiotherapy for head-and-neck cancer. Future studies should examine whether routine post-therapy videofluoroscopy and training aspirating patients in safe swallowing strategies can reduce this risk.

FEESST: a new bedside endoscopic test of the motor and sensory components of swallowing.

We here introduce an office or bedside method of evaluating both the motor and sensory components of swallowing, called fiberoptic endoscopic evaluation of swallowing with sensory testing (FEESST). FEESST combines the established endoscopic evaluation of swallowing with a technique that determines laryngopharyngeal (LP) sensory discrimination thresholds by endoscopically delivering air pulse stimuli to the mucosa innervated by the superior laryngeal nerve. Endoscopic assessment of LP sensory capacity followed by endoscopic visualization of deglutition was prospectively performed 148 times on 133 patients with dysphagia over an 8-month period. The patients had a variety of underlying diagnoses, with stroke and chronic neurologic disease predominating (n = 94). Subsequent to LP sensory testing, a complete dysphagia evaluation was conducted. Various food and liquid consistencies were dyed green, and attention was paid to their management throughout the pharyngeal stage of swallowing. Evidence of latent swallow initiation, pharyngeal pooling and/or residue, laryngeal penetration, laryngeal aspiration, and/or reflux was noted. Recommendations for therapeutic intervention were based on information obtained during the FEESST and often involved the employment of compensatory swallowing strategies, modification of the diet or its presentation, placement on non-oral feeding status, and/or referral to other related specialists. All patients successfully completed the examination. In 111 of the evaluations (75%), severe (>6.0 mm Hg air pulse pressure [APP]) unilateral or bilateral LP sensory deficits were found. With puree consistencies, 31% of evaluations with severe deficits, compared to 5% of evaluations with either normal sensitivity or moderate (4.0 to 6.0 mm Hg APP) LP sensory deficits, displayed aspiration (p < .001, chi2 test). With puree consistencies, 69% of evaluations with severe deficits, compared to 24% with normal or moderate deficits, displayed laryngeal penetration (p < .001, chi2 test). FEESST allows the clinician to obtain a comprehensive bedside assessment of swallowing that is performed as the initial swallowing evaluation for the patient with dysphagia.