Swallow Study Research Articles

Swallowing Kinematics in Rats Treated with Low Dose Chemotherapy Concurrently with Fractionated Radiation

Dysphagia is a common consequence of chemotherapy and radiation treatment for oropharyngeal cancer. Injury is thought to occur due to damage to the muscle and/or nerves. This can severely impair swallowing function, leading to serious negative outcomes such as aspiration related pneumonia or tube feeding placement to maintain nutrition. Currently, there are only strategies to prevent swallowing dysfunction; however, the development of chronic radiation associated dysphagia persists effecting ~25% of head and neck cancer survivors. Therefore, there is a need to study the mechanisms associated with radiation associated dysphagia to help guide new treatments to improve swallowing outcomes. The present study investigated the effects of concurrent chemoradiation on swallowing function. We tested the hypothesis that fractionated radiation with low doses of chemotherapy alters swallowing kinematics and bolus transit compared to radiation alone or normal controls. We monitored the functional extent of chemoradiation or radiation treatment using videofluoroscopy swallow study in self feeding rats (n=16) at four weeks post treatment. Twelve rats underwent 48Gy of fractionated radiation to the submental muscles using a clinical linear accelerator given in 12 fractions of 4Gy. Irradiated rats received either cisplatin 1mg/kg or saline IP once per week for four weeks during radiation treatment. Four rats received no treatment. During videofluoroscopy, thin liquids and puree consistencies mixed with 40% w/v barium sulfate were given ad libitum. The movement trajectories of the tongue, mandible, and hyoid bone were quantitatively tracked from video data. Changes in the speed of the jaw and hyoid during swallowing were observed between treated and control rats. No differences were observed in bolus flow parameters i.e. pharyngeal transit speed, inter‐swallow interval, and swallow frequency between treatment groups. The average size of the bolus in vallecula decreased by ~4% prior to initiating pharyngeal swallow with chemoradiated rats (p < 0.05). Results suggest that low doses of chemotherapy in conjunction with radiation appear to have minimal differences in swallowing kinematics compared to radiation alone. Higher doses of chemotherapy may be needed to induce similar abnormalities in swallowing as seen clinically.

Global Dysphagia Scale Detects Swallowing Disorder Following a Clinical Dose of Buprenorphine

Opioid use is associated with increased risk of chest infection due to opioid suppression of immune function, ventilation, cough, and secretion mobilization. Buprenorphine is a highly lipophilic, semi‐synthetic partial agonist of the mu opioid receptor. Intramuscular buprenorphine is commonly used for post‐operative analgesia at a dose range of 0.01‐0.04 mg/kg in the cat. While buprenorphine is considered to have a low side effect profile, its effects on the pharyngeal phase of swallow are unknown. We hypothesized that administration of opioid would result in clinically meaningful decline of pharyngeal swallow function. Experiments were performed on healthy adult cats (12 months old). Animals were administered intramuscular buprenorphine (0.015 mg/kg) q12 hours for 48 hours. One hour after the last dose was given, videofluoroscopic swallow studies were performed to evaluate the effects of the drug on swallow function. Animals were presented with 40% by volume barium sulfate in tuna water mixed to a thin consistency, and all animals ate voluntarily. Images were recorded in the lateral plane at 30 frames/second and compared to control feeding assessments using the Global Dysphagia Scale (GDS), a novel tool developed to rate swallow function in the cat. The GDS consists of an Airway Invasion Scale (AIS) and relevant components of the Modified Barium Swallow Impairment Profile (MBSImP), a standardized protocol for swallow assessment. The AIS is a 10‐point scale where scores of 0‐1 are normal, scores of 2‐4 indicate laryngeal penetration, and scores of 5‐9 indicate tracheobronchial aspiration. Four components of the MBSImP were included: Initiation of the pharyngeal swallow, pharyngeal stripping wave, pharyngoesophageal segment opening, and pharyngeal residue. The GDS rating was derived by adding the AIS and MBSImP sub‐totals. During control assessments mean GDS was 5.5 ± 1.3, and aspiration was not detected in any animal. On buprenorphine, mean GDS was 11.25 ± 4.2, and 50% of animals exhibited large volume tracheobronchial aspiration. In conclusion, after 48 hours on buprenorphine, airway protection during swallow failed without appreciable response in 50% of animals (no cough, throat clear, or cessation of eating). Our success in producing dysphagia (significant but varying by animal) with relatively small doses of opioid has potential implications for predicting aspiration pneumonia in post‐surgical clinical cases.

Deep Learning for Automatic Hyoid Tracking in Videofluoroscopic Swallow Studies.

The hyoid bone excursion is one of the most important gauges of larynx elevation in swallowing, contributing to airway protection and bolus passage into the esophagus. However, the implications of various parameters of hyoid bone excursion, such as the horizontal or vertical displacement and velocity, remain elusive and raise the need for a tool providing automatic kinematics analysis. Several conventional and deep learning-based models have been applied automatically to track the hyoid bone, but previous methods either require partial manual localization or do not transform the trajectory by anatomic axis. This work describes a convolutional neural network-based algorithm featuring fully automatic hyoid bone localization and tracking and spine axis determination. The algorithm automatically estimates the hyoid bone trajectory and calculates several physical quantities, including the average velocity and displacement in horizontal or vertical anatomic axis. The model was trained in a dataset of 365 videos of videofluoroscopic swallowing from 189 patients in a tertiary medical center and tested using 44 videos from 44 patients with different dysphagia etiologies. The algorithm showed high detection rates for the hyoid bone. The results showed excellent inter-rater reliability for hyoid bone detection, good-to-excellent inter-rater reliability for calculating the maximal displacement and the average velocity of the hyoid bone in horizontal or vertical directions, and moderate-to-good reliability in calculating the average velocity in horizontal direction. The proposed algorithm allows for complete automatic kinematic analysis of hyoid bone excursion, providing a versatile tool with high potential for clinical applications.

Stakeholder Perspectives on Radiation Use and Interdisciplinary Collaboration in Adult Modified Barium Swallow Studies.

The Modified Barium Swallow Study (MBSS) is a videofluoroscopic examination of the anatomy and physiology involved in swallowing. Like other fluoroscopic examinations, the MBSS uses ionizing radiation with related radiation risks. Thus, the procedures and protocols related to MBSSs must balance the benefit of the diagnostic information gained with the risk of radiation exposure. This requires complex decision-making for any given clinician but becomes complicated due to the interprofessional nature of conducting MBSSs, namely the direct involvement of both the speech-language pathologist and radiologist with indirect involvement of the medical physicist and the referring physician. This editorial provides the perspectives of the various stakeholder groups related to radiation use in adult MBSSs, identifies barriers to conducting MBSSs in an evidence-based manner, and suggests areas for improvement.

Radiation dose in barium swallow examinations: an Oxford tertiary care centre experience

To assess the radiation dose in standard barium swallow studies (BaSS) performed at a large tertiary referral centre, benchmarked against the national diagnostic reference level (NDRL), and to provide evidence to support reducing radiation dose through improving operator's training. In this retrospective observational study, 1,004 adult BaSS (M:F=411:593) were assessed. The radiation dose was first compared with NDRL, and then stratified by the operator's training level and compared using analysis of variance (ANOVA). The operators were categorised as radiology residents, advanced radiography practitioners, GI radiology fellows, and GI radiology consultants. Further comparative analysis is performed by comparing the test radiation dose when stratified based on the referrer's specialty, and whether they were performed for female patients of childbearing age. The findings show 68.2% of BaSS performed are within the NDRL and demonstrated statistically significant correlation (p<0.0001) between radiation dose and operator's training level, and for female patients of childbearing age (p<0.002) and the rest. The median dose was lower with more senior operators. There was no significant correlation between radiation dose and the referrer's specialty. The study presents evidence to support revisiting consultant-supervised BaSS training, in the interests of lowering the radiation exposure to patients and improving compliance with the NDRL.

Impact of Limb Phenotype on Tongue Denervation Atrophy, Dysphagia Penetrance, and Survival Time in a Mouse Model of ALS.

Current treatments for dysphagia in ALS do not target the underlying tongue weakness and denervation atrophy that is prevalent in spinal and bulbar ALS cases. To address this clinical gap, we studied the low copy number SOD1-G93A (LCN-SOD1) mouse model of ALS to quantify the impact of limb phenotype on tongue denervation atrophy, dysphagia penetrance, and survival time in preparation for future treatment-based studies. Two male LCN-SOD1 breeders and 125 offspring were followed for limb phenotype inheritance, of which 52 (30 LCN-SOD1 and 22 wild-type/WT, both sexes) underwent characterization of dysphagia penetrance (via videofluoroscopic swallow study; VFSS) and survival time at disease end-stage (15-20% body weight loss). From these, 16 mice (8/genotype) underwent postmortem histological analysis of the genioglossus for evidence of denervation atrophy. Results revealed that both breeders displayed a mixed (hindlimb and forelimb) ALS phenotype and sired equal proportions of hindlimb vs. mixed phenotype offspring. Dysphagia penetrance was complete for mixed (100%) versus incomplete for hindlimb (64%) phenotype mice; yet survival times were similar. Regardless of limb phenotype, LCN-SOD1 mice had significantly smaller genioglossus myofibers and more centralized myonuclei compared to WT mice (p < 0.05). These biomarkers of denervation atrophy were significantly correlated with VFSS metrics (lick and swallow rates, p < 0.05) but not survival time. In conclusion, both LCN-SOD1 phenotypes had significant tongue denervation atrophy, even hindlimb phenotype mice without dysphagia. This finding recapitulates human ALS, providing robust rationale for using this preclinical model to explore targeted treatments for tongue denervation atrophy and ensuing dysphagia.

Videofluoroscopy compared with clinical feeding evaluation in children with suspected aspiration.

AimVideofluoroscopy swallow studies (VFSS) are gold standard to diagnose aspiration in children but require resources and radiation compared with clinical feeding evaluation (CFE). We evaluated their added value for diagnosis, feeding management and clinical status.MethodsA retrospective single‐centre cross‐sectional study of children aged 0–18 years, with respiratory morbidity, referred for VFSS at a tertiary pediatric hospital.ResultsA total of 113 children, median age (range) 2.2 years (0.1–17.9), underwent VFSS. Diagnosis included chronic pulmonary aspiration (CPA), 87 (77%); neurological, 73 (64%); gastrointestinal, 73 (64%) and congenital heart disease, 42 (37%), not mutually exclusive. Forty‐six (41%) aspirated, 9 (8%) only overtly and 37 (33%) including silent aspirations. Those with CPA or cerebral palsy were more likely to have VFSS aspiration, OR 3.2 and 9.8 respectively.Feeding recommendations after VFSS differed significantly from those based on prior CFE, p < 0.001: The rate of exclusively orally fed children rose from 65% to 79%, p = 0.006; exclusively enterally fed children from 10% to 14%; p = 0.005. During the year after VFSS, there were significantly less antibiotic courses, total and respiratory admissions.ConclusionIn this population with high prevalence of clinically suspected CPA, VFSS altered feeding management compared with CFE and may have contributed to subsequent clinical improvement.

Correlation between Forced Vital Capacity and the Severity of Frailty-Induced Dysphagia.

Introduction: Frailty syndrome is a complex condition characterized by the gradual deterioration of an individual’s physical, mental, and social functions. Dysphagia is a dysfunction triggered by frailty. However, in patients with frailty syndrome, dysphagia is often undermined, and a proper evaluation is not performed. Therefore, we tried to identify the factors that can provide proper information regarding dysphagia in the frail population. Methods: Patients with dysphagia were divided into those with frailty-induced dysphagia and those with brain-lesion-induced dysphagia. Factors related to the participants’ pulmonary function test (PFT) results were evaluated. The severity of dysphagia was evaluated by determining modified videofluoroscopic dysphagia scale (mVDS) and penetration–aspiration scale (PAS) scores based on videofluoroscopic swallowing studies. Statistical analysis was performed to determine the correlation between PFT results and the parameters indicating dysphagia severity. Results: Multivariate logistic regression analysis revealed that forced vital capacity (FVC) was significantly correlated with mVDS scores in frailty-induced dysphagia (p < 0.05). However, no such significance was detected in brain-lesion-induced dysphagia (p ≥ 0.05). Conclusion: FVC was correlated with the severity of dysphagia (mVDS scores) in patients with frailty-induced dysphagia. Thus, serial FVC-based follow-up can be helpful for understanding patients’ dysphagia status. However, studies with a general population of patients with frailty-induced dysphagia are needed for definite generalization.

Developing a Protocol for Quantitative Analysis of Liquid Swallowing in Children.

Objective measures in videofluoroscopic swallow studies (VFSSs) can quantify swallow biomechanics. There are a wide array of validated measures studied in infants, children, and adults. There is a need for a pediatric VFSS protocol that consists of a small number of vital, time efficient, and clinically relevant measures. In this study, we aimed to establish a standard protocol for quantitative VFSS analysis in children. Protocol development began with a systematic literature review, which identified 22 quantitative and eight descriptive measures available in the literature. A pediatric VFSS database of 553 children was collected using a standardized VFSS protocol. Studies were evaluated using the 30 previously reported measures covering displacement and timing parameters as well as penetration-aspiration and residue. Measures were tested for rater reliability and internal consistency. Measures meeting acceptable values for protocol inclusion were included in the final protocol (Cronbach's alpha > .53). Interrater and intrarater reliability of 17 measures met acceptable reliability levels. During internal consistency testing, we removed six further measures based on Cronbach's alpha levels indicating that two or more measures were equivalent in measuring the same aspect of swallow biomechanics in children. A VFSS protocol of reliable, valid, and obtainable objective quantitative (n = 6) and descriptive measures (n = 3) with separate protocols for young infants (≤ 9 months) and older children was established. A standardized quantitative VFSS protocol for children has been developed to suit two age groups (≤ 9 and > 9 months old). Consistent VFSS administration and reporting support assessment over time and across disease groups. Future research should focus on how this information can be used by clinicians to produce individualized treatment plans for children with swallowing impairment.

Establishing diagnostic reference levels for pediatric fluoroscopic examinations in a tertiary hospital.

Diagnostic reference levels (DRLs) identify unusually high patient radiation exposures and are required for dose optimisation. DRLs for pediatric fluoroscopic examinations are not widely determined in Australia. Our objectives were to establish DRLs for pediatric fluoroscopic examinations in a South Australian tertiary hospital and compare these to previously published data and to explore relationships between patient dose area product (DAP), age and fluoroscopy times. Dose data from 365 pediatric patients undergoing 5 fluoroscopic examinations were retrospectively collected for a 3-year period commencing January 2018 to develop local DRLs. Relationships between DAP, age and fluoroscopy time were explored using scatterplots, Spearman's correlation, and regression analyses. Local DRLs were significantly lower than data published previously, possibly reflecting technological and procedural advancements. Each 1-year increase in patient age was associated with a 0.77 μGy·m2 increase in DAP for barium meal and follow-through studies (95% confidence interval [CI]=0.055, 1.48) (P=0.04), and a 1.37 μGy·m2 increase in DAP for barium swallow studies (95% CI=0.61, 2.12) (P<0.001). A low correlation was demonstrated between DAP and fluoroscopy time for micturating cystourethrography studies (r=0.35, 95% CI=0.15, 0.51, P<0.001) and barium meal and follow-through studies (r=0.37, 95% CI= -0.011, 0.65, P=0.05). Age and fluoroscopy time were not significantly related. This study provides updated Australian pediatric fluoroscopic DRLs, with the intention of promoting a national database for benchmarking pediatric doses. The local DRLs can be used for dose comparisons and optimisation between facilities.

Post-Treatment Evaluation of Swallowing Function Using Quantitative Videofluoroscopy in Head and Neck Patients Undergoing Immunoradiotherapy or Chemoradiotherapy

<h3>Purpose/Objective(s)</h3> To evaluate post-treatment swallowing function in head and neck squamous cell carcinoma (HNSCC) patients undergoing definitive chemoradiotherapy (CRT) vs. immunoradiotherapy (IRT) using quantitative videofluoroscopic swallow studies (qVFSS). <h3>Materials/Methods</h3> We conducted a cross-sectional study of 23 patients with previously untreated locoregionally advanced HNSCC using qVFSS 4-6 and/or 12-24 months after CRT or IRT. RT consisted of 70 Gy to the primary and 54-63 Gy to the neck in 35 fractions over 7 weeks. Systemic therapy consisted of concurrent cisplatin (N=14) or cetuximab (N=2) in the CRT group and concurrent + adjuvant pembrolizumab only in the IRT group. qVFSS studies were performed by a certified speech-language pathologist using C-arm fluoroscopy with standardized bolus protocol. Quantitative metrics (Pharyngeal Constriction Ratio (PCR), Total Pharyngeal Transit Time (TPT), Bolus Clearance Ratio (BCR), and Posterior Pharyngeal Wall Thickness (PPWT)) were calculated using Swallowtail® software (Belldev Medical LCC, Arlington Heights, IL), with raters blinded to treatment. Higher values of each metric indicate worse swallowing function. For patients undergoing multiple qVFSS, maximum values of each metric were used. Two sample <i>t</i> tests and Mann-Whitney U tests were used to compare metrics by treatment group. Paired <i>t</i> tests were used to compare pre vs. post-treatment qVFSS metrics. <h3>Results</h3> Two patients did not complete post-treatment qVFSS, leaving 21 for analysis (16 CRT, 5 IRT). Disease sites were: oropharynx-15, larynx-4, hypopharynx-1, unknown primary-1. Overall mean (SD) PCR, TPT, BCR, and PPWT were 0.15 (0.13), 0.96 (0.27), 14.4 (13.4), and 0.73 (0.24), respectively. Mean post-treatment PCR and BCR were significantly higher for patients receiving IRT vs. CRT (0.21 vs. 0.13, t test p<0.01 and 20.0 vs. 12.7, p=0.019, respectively) (<b>Table</b>). No significant differences were found in TPT or PPWT between groups (<b>Table</b>). Mean (SD) pre-treatment PCR, TPT, BCR, and PPWT were 0.18 (0.19), 0.91 (0.28), 11.6 (11.8), and 0.54 (0.16) respectively. No significant differences were observed comparing post- minus pre-treatment PCR (-0.042, p=0.36), TPT (+0.094, p=0.24), or BCR (+1.38, p=0.54); however, PPWT was significantly worse after treatment (+0.24, p=0.03). <h3>Conclusion</h3> Preliminary results indicate dysphagia is worse in patients treated with IRT; however, the analysis is limited by small sample and cross-sectional design. Future studies are needed to define effects of alternative treatments on dysphagia.

The Impact of Nasogastric Feeding Tube on Physiologic Swallow in Head and Neck Cancer Patients: A Multidisciplinary Clinical Trial

<h3>Purpose/Objective(s)</h3> Nasogastric feeding tubes (NGT) are ubiquitous within the head and neck (H&N) cancer patient population. NGT are often placed in post-surgical H&N cancer patients to allow for healing of suture lines in oral cavity and oropharyngeal free flap patients and are also used in transoral robotic surgery (TORS) patients. Despite their widespread use, the impact of NGT on the physiologic swallow of H&N cancer patients remains unknown. In the neurology literature, there is data demonstrating alterations in the functional swallow of elderly post-stroke patients with NGTs. This showed significant differences in pharyngeal transit time of an ingested barium bolus, with increased barium residue in the vallecula and pyriform sinus with the NGT in place, suggesting the NGT itself plays a role in altering physiologic swallow. The goals of the present study are twofold: 1: Determine the effects of an indwelling NGT on swallowing function in head and neck surgery patients. We hypothesize that the NGT will impair the physiologic swallow function resulting in a higher likelihood of laryngeal penetration and aspiration. 2: Determine the effect of an NGT on head and neck surgery patients perceived ability to swallow. We hypothesize that the presence of the NGT will negatively affect participants perception of their own ability to swallow. <h3>Materials/Methods</h3> This study was approved by our institutional review board (clinical trial VICC HN 2102). A multidisciplinary team involving H&N surgeons, speech language pathologists, and radiologists were critical in the development of this project. This is a crossover trial in which participants serve as their own control. Inclusion criteria include adult patients who underwent oral cavity or oropharyngeal cancer surgery including TORS and received an NGT as part of their standard of care. Exclusion criteria included altered mental status, need for long-term enteral feeding (i.e. NGT could not be safely removed to allow the patient to receive all nutrition via oral intake) and total or partial laryngectomy. Participants will complete two surveys about their subjective swallow, the Sydney Swallow Questionnaire and a 5-question supplemental survey utilizing a visual analog scale. They will undergo a video fluoroscopic swallow study (VFSS) with the NGT in place with thin and thick barium consistencies. The NGT is then removed and the two surveys and VFSS are repeated without the NGT in place. Objective measurements collected during the VFSS include oral, pharyngeal, and esophageal transit times and the penetration-aspiration scale scores. Ten of planned forty participants have been enrolled in the study. <h3>Results</h3> TBD <h3>Conclusion</h3> TBD

Cervical Vertebral Height Approximates Hyoid Displacement in Videofluoroscopic Images of Healthy Adults.

Clinicians and researchers commonly judge the completeness of hyoid displacement from videofluoroscopic swallow study (VFSS) videos. Judgments made during the clinical exam are often subjective, and post-examination analysis reduces the measure's immediate value. This study aimed to determine the validity and feasibility of a visual, anatomically scaled benchmark for judging complete hyoid displacement during a VFSS. The third and fourth cervical vertebral bodies (C3 and C4) lie at roughly the same vertical position as the hyoid body and are strongly correlated with patient height. We hypothesized that anterior and superior displacement of the hyoid bone would approximate the height of one C3 or C4 body during safe swallows. Trained raters marked points of interest on C3, C4, and the hyoid body on 1414 swallows of adult patients with suspected dysphagia (n = 195) and 50 swallows of age-matched healthy participants (n = 17), and rated Penetration Aspiration Scale scores. Results indicated that the mean displacements of the hyoid bone were greater than one C3 unit in the superior direction for all swallows from patient and healthy participants, though significantly and clinically greater in healthy participant swallows (p < .001, d > .8). The mean anterior and superior displacements from patient and healthy participant swallows were greater than one C4 unit. Results show preliminary evidence that use of the C3 and/or C4 anatomic scalars can add interpretive value to the immediate judgment of hyoid displacement during the conduct of a clinical VFSS examination.

Instrumental swallowing assessment in children

Children can present with a wide range of swallowing impairments. This may affect from neonates, infants,toddlers, young children to early teens. The most serious outcome of a severe swallowing impairment is gross aspiration leading to violation of airway and its consequences such as recurrent aspiration pneumonias, sepsis, poor weight gain, failure to thrive and long term developmentalsequel. Assessment of swallowing is done in children using perceptual clinical swallowing assessment by a speech and language therapist. This isa subjective assessment and may not clearly identify the defective phase of swallowing and may miss silent aspiration. Instrumental swallowing assessment is a method to identify swallowing impairment by objective evaluation of the entire swallowing process. This would identify the phase and quantify the severity of the impairment. It is mainly done in two ways. i.e. the Functional Endoscopic Evaluation of swallowing (FEES) and Video Fluoroscopic Swallow Study (VFSS). Both are valuable methods as they separately assess different phases of swallowing. The results are invaluable in further treatment of these children to overcome or mitigate their impairment. FEES involves inserting a fibro-optic pediatric laryngoscope in the child’s pharynx via the nose and simultaneous observation of swallowing mechanism while feeding orally. VFSS involves fluoroscopic viewing of the swallowing process while giving food mixed with a radio opaque substance. VFSS is further helpful in intra proceduralpositional maneuversand change in food consistencies to overcome the given impairment.

Conceptual Framework Behind the Development of a Level of Confidence Tool: The Pediatric Videofluoroscopic Swallow Study Value Scale.

The videofluoroscopic swallow study (VFSS) is the most commonly used instrumental procedure for evaluating swallowing in pediatric populations suspected of having dysphagia. Assessment and interpretation of a VFSS in pediatric populations is frequently challenged by testing-specific factors that can raise concerns regarding the representativeness of swallow events observed during testing compared to daily feeding/swallowing physiology. When VFSS findings do not represent typical swallowing patterns, treatment recommendations can result in suboptimal outcomes. To address this current challenge to pediatric VFSS interpretation and associated treatment recommendations, the pediatric VFSS Value Scale (pVFSS Value Scale) was developed within a tertiary regional pediatric medical center. This clinical focus article summarizes the initial scale development phases and resulting conceptual framework for rating clinical testing factors that influence a clinician's level of confidence regarding pediatric VFSS findings. Future goals for scientific evaluation and clinical utilization of this new rating scale are also reported. The pVFSS Value Scale was developed to assist clinicians with interpretation of pediatric VFSS assessment outcomes and to efficiently communicate factors influencing impressions and treatment recommendations with team members and caregivers. This clinical concept article summarizes potential uses of this tool to inform treatment planning as well as future clinical research to evaluate its psychometrics and clinical utility.

Finding relief for the self-conscious esophagus: laparoscopic anti-reflux surgery and the esophageal hypersensitivity and anxiety scale.

Measures of mood and effective coping strategies have notable correlations with quality of life and treatment responses. There is evidence that patients with previously diagnosed anxiety disorders have less improvement in patient-reported outcome measures (PROMs) after laparoscopic anti-reflux surgery (LARS) and that objective pathology does not correlate well with symptom severity. We were interested in investigating whether anxiety and hypervigilance, as measured preoperatively with the esophageal hypervigilance anxiety scale (EHAS), is associated with the improvement in GERD-specific PROMs and EHAS scores 6months after LARS. We performed a retrospective cohort study of 102 adult patients (31% men, average age 64) who underwent LARS. In the preoperative evaluation, baseline gastroesophageal reflux disease-health-related quality of life (GERD-HRQL), laryngopharyngeal reflux symptom index (LPR-RSI) and EHAS scores were collected in addition to the standard reflux workup, including endoscopy, manometry, barium swallow, and pH study. For all three surveys, a higher score represents worse symptom severity. At 6months postoperatively, 70 patients completed repeat GERD-HRQL, LPR-RSI, and EHAS surveys. We then analyzed for surgical and patient-related factors associated with improvement in the 6-month postoperative GERD-HRQL and LPR-RSI scores. There was a statistically significant decrease in the GERD-HRQL (25 vs. 2, p &lt; 0.001), LPR-RSI (17 vs. 3, p &lt; 0.001) and EHAS (34 vs. 15, p &lt; 0.001) 6months after LARS. On multivariable linear regression, a higher baseline EHAS score was independently associated with a greater improvement in GERD-HRQL (β 0.35, p &lt; 0.001) and LPR-RSI (β 0.19, p = 0.03) 6-months after LARS. Additionally, the degree of improvement in EHAS, GERD-HRQL, and LPR-RSI was not influenced by the type of LARS performed or by the severity of disease. These findings are consistent with literature suggesting that measures of psychoemotional health correlate better with symptom intensity than objective pathology. We found that patients with a higher EHAS score have greater symptom severity and lower quality of life at baseline. Novel findings to this study are that patients with a higher preoperative EHAS, a measure of psychoemotional health, actually benefitted more from surgery and not less, which has been the traditional view in the literature. Future studies are warranted to establish directionality and explore the role of preoperative cognitive behavioral therapy with LARS for patients with significant symptoms of hypervigilance and anxiety.

Effect of Intensive Oropharyngeal Training on Radiotherapy-Related Dysphagia in Nasopharyngeal Carcinoma Patients.

To evaluate the effect of intensive oropharyngeal functional training on swallowing in patients with dysphagia after radiotherapy for nasopharyngeal carcinoma. Fourteen patients with nasopharyngeal carcinomas and dysphagia after radiotherapy received intensive oropharyngeal training for two weeks. The Functional Oral Intake Scale (FOIS) and videofluoroscopic swallowing studies (VFSS) were used to evaluate swallowing function before and after intensive oropharyngeal training. Spatiotemporal parameters of the VFSS were analyzed using a digital image analysis system. After training, the FOIS, Rosenbek penetration-aspiration score, DIGEST, normalized residue ratio scale, and spatiotemporal parameters of VFSS were significantly improved (P < 0.05). This study indicated that intensive oropharyngeal training improves swallowing function after radiotherapy in patients with nasopharyngeal carcinoma.

Implementation of a speech and language therapy-led referring model for videofluoroscopic swallow studies: An evaluation of service outcomes.

Videofluoroscopic swallow studies (VFSS) are integral to diagnosing and supporting dysphagia management. However, in many countries, only doctors are authorized to complete medical imaging request forms, in accordance with radiation safety regulations. This can impact workflow and timely access to VFSS. Enhanced scope of practice (ESP) models of care exist, where speech and language therapists (SLTs) are authorized to complete VFSS request forms. However, formal evaluations of these ESP models are currently lacking. The primary aim of this study was to examine service outcomes regarding the safety and efficiency of SLTs completing VFSS request forms compared with the medical referring model (standard care). The secondary aim was to ascertain the impacts on SLTs' daily workflow and the utility of training for SLTs to complete VFSS requests. The study involved a mixed-method design. First, referrals completed using standard care versus those completed under the new SLT-led VFSS referring model were compared for efficiency (days to request completion, number of contacts between staff to complete requests and delay to VFSS appointments) and safety (compliance with radiation safety standards for requests, adverse events and change to dysphagia management to justify radiation exposure). Semi-structured interviews were then conducted with SLT referrers (n = 7) exploring the impacts of the model on daily workflow and the utility of training. VFSS inpatient requests were examined across a 3-month period (n = 61 requests) using the standard model, and for 6 months (n = 109 requests) following the introduction of SLT-led VFSS referring. Regarding efficiency, there was no significant difference between the two models, with most request forms taking less than or equal to 1 day to be completed. Adherence to radiation safety requirements was significantly greater in the SLT-led VFSS referring model compared with the standard model (p < 0.001) in relation to the overall requisite clinical information being documented on the request forms. No adverse events occurred and 100% of VFSSs led to changed dysphagia management. Interviews of VFSS referring SLTs revealed that completing requests was not complex or onerous, and that the training equipped them well to undertake the role. The SLT-led VFSS referring model was feasible for SLTs and resulted in satisfactory efficiency and greater adherence to radiation safety requirements for VFSS request forms than the standard model. Improved information on VFSS request forms provides clearer justification for the radiation procedure and helps optimize the diagnostic yield of VFSS. The evidence supports further widespread adoption of this model. What is already known on the subject Models of care permitting selected allied health professionals to refer patients for diagnostic radiology procedures have been established to achieve healthcare efficiencies. Evidence supports the safety and efficiency of physiotherapists referring to radiology. However, limited published outcome data exist regarding models of SLTs referring for radiology procedures, such as VFSS. What this paper adds to existing knowledge This study describes the implementation of a SLT-led VFSS inpatient referring model in a quaternary hospital and examines service outcomes. The findings reveal that VFSS request forms completed in the SLT-led referring model had greater adherence to radiation safety standards compared with the standard referring model. Efficiency was similar across both models and there were no adverse events. Completing VFSS requests did not disrupt daily workflow for SLTs and training was effective preparation for the role. What are the potential or actual clinical implications of this work? Results demonstrate that the SLT-led VFSS referral model can be safely and appropriately implemented in the inpatient setting. Improved quality of information documented on request forms by SLTs increases adherence with radiation safety standards, providing clearer justification for radiation assessments and potentially eliciting more targeted diagnostic information to inform dysphagia treatment planning. These findings may support other hospital services to establish this type of referring model.

The effects of different frequencies of repetitive transcranial magnetic stimulation (rTMS) on patients with swallowing disorders after cerebral infarction.

Swallowing disorders represent one of the most common complications after cerebral infarction. To study the effects of different frequencies of repetitive transcranial magnetic stimulation (rTMS) on swallowing disorders after cerebral infarction. Ninety patients with swallowing disorder after cerebral infarction were enrolled and randomly assigned to three groups: the 10 Hz frequency rTMS group (30 patients), the 5 Hz frequency rTMS group (30 patients), and the 1 Hz frequency rTMS group (30 patients); another 90 healthy persons without swallowing disorders were included as the control group. The Kubota's water-swallow test, the video fluoroscopic swallow study (VFSS), and the Electroencephalograph (EEG) were analyzed before and after treatment; the EEG of the control group was detected as the baseline. The Kubota's water-swallow test scores were significantly decreased while the scores of pharynx period and the aspiration degree of VFSS significantly increased in 10 Hz frequency rTMS group than before treatment (P≤0.05); the amplitudes of C3 of the EEG significantly increased in three frequency groups than before treatment (P≤0.05). 10 Hz frequency of rTMS is effective for the treatment of swallowing disorder after cerebral infarction, the excitement of C3 area maybe the therapeutic target of rTMS on swallowing disorder after cerebral infarction.

Using an Automated Speech Recognition Approach to Differentiate Between Normal and Aspirating Swallowing Sounds Recorded from Digital Cervical Auscultation in Children

Use of machine learning to accurately detect aspirating swallowing sounds in children is an evolving field. Previously reported classifiers for the detection of aspirating swallowing sounds in children have reported sensitivities between 79 and 89%. This study aimed to investigate the accuracy of using an automatic speaker recognition approach to differentiate between normal and aspirating swallowing sounds recorded from digital cervical auscultation in children. We analysed 106 normal swallows from 23 healthy children (median 13 months; 52.1% male) and 18 aspirating swallows from 18 children (median 10.5 months; 61.1% male) who underwent concurrent videofluoroscopic swallow studies with digital cervical auscultation. All swallowing sounds were on thin fluids. A support vector machine classifier with a polynomial kernel was trained on feature vectors that comprised the mean and standard deviation of spectral subband centroids extracted from each swallowing sound in the training set. The trained support vector machine was then used to classify swallowing sounds in the test set. We found high accuracy in the differentiation of aspirating and normal swallowing sounds with 98% overall accuracy. Sensitivity for the detection of aspiration and normal swallowing sounds were 89% and 100%, respectively. There were consistent differences in time, power spectral density and spectral subband centroid features between aspirating and normal swallowing sounds in children. This study provides preliminary research evidence that aspirating and normal swallowing sounds in children can be differentiated accurately using machine learning techniques.