Dysphagia after chemo-radiation for nasopharyngeal cancer: A scoping review

ObjectiveNasopharyngeal cancer (NPC) has distinct characteristics regarding its global prevalence, initial presentation, management and patient outcomes compared to other subtypes of head and neck cancer (HNC). The mainstay of NPC treatment is chemo-radiation (C/RT) and while dysphagia is a known early and late toxicity of C/RT treatment, the nature of dysphagia post NPC treatment has had limited investigation. The objective of this review is to summarise the existing evidence regarding dysphagia following NPC to inform the future research agenda for this population. Dysphagia incidence, characteristic deficits observed across the phases of swallowing, efficacy of current dysphagia interventions, and effect on quality of life will be explored.Data sourcesDatabases including MEDLINE, CINAHL, Embase, Scopus and Web of Science were included.MethodsA scoping review was conducted according to PRISMA-ScR guidelines. Two independent reviewers screened selected full text articles.ResultsOf the initial 2495 articles found, 28 articles were included. Reports of penetration and aspiration varied widely (0%–91.6%), with high rates of silent aspiration identified in 2 studies (42%, 66%). Oral, pharyngeal and upper esophageal phase impairments were reported. Of these, upper esophageal stasis and multiple pharyngeal stage deficits were most prevalent. The pharyngeal constrictors were found to have a significant dose–effect relationship and shielding to the anterior neck field was effective to preserve swallowing function. Six treatment studies were identified with limited evidence supporting the use of neuromuscular electrical stimulation, dilatation and swallowing exercises. Quality of life was adversely affected.ConclusionsDysphagia is a prevalent early and late problem post NPC treatment, with impairments across all phases of the swallow. Studies on preventing dysphagia and treatment efficacy remain limited. More systematic study of the nature of dysphagia and the efficacy of treatment in this population is warranted.     

Outcome comparison of two methods of pharyngeal cavity reconstruction in uvulopalatopharyngoplasty

Conclusions: The efficacy of uvulopalatopharyngoplasty (UPPP) can be achieved without application of an apposition suture of the palatopharyngeal arch and the palatoglossal arch. Objective: To compare the outcomes of two different methods of pharyngeal cavity reconstruction in UPPP. Methods: Forty-eight patients with obstructive sleep apnoea syndrome (OSAS) underwent UPPP (uvula-preserving). A classical pharyngeal cavity reconstruction was performed in 24 patients in group one, with plastic suture of the inferior nasopharynx and exposure of the tonsillar fossa in 24 patients in group two. The parameters evaluated were the subjective symptom score, the Epworth Sleepiness Scale (ESS), and polysomnography result. The mean operating times and complications of the post-operative pharyngeal cavity were investigated. Results: No significant difference was observed in surgical success (p?=?0.54), subjective syndromes (snoring, sleep apnoea, morning headache, daytime sleepiness) (p?=?0.16, 0.36, 0.79 and 0.52), ESS (p?=?0.41), apnoea-hypopnoea index (AHI) (p?=?0.32), and minimum SaO₂ (p?=?0.13) between the two groups. In group one, the mean operating time was 54.72?±?6.52?min, 11 suture dehiscence (45.8%), and five scar hypertrophy of the pharyngeal wall (20.8%) were observed post-operatively; while in group two was 38.78?±?5.75?min, no suture dehiscence resulting from suture cutting of tissue, three scar hypertrophy were observed (12.5%).     

Fiberoptic endoscopy evaluation of swallowing in patients with amyotrophic lateral sclerosis

Amyotrophic lateral sclerosis (ALS) is a progressive degenerative motor neuron disease that adversely affects the muscles responsible for swallowing.ObjectiveTo assess the oral preparatory, oral transit and pharyngeal phases of swallowing in ALS patients through endoscopic evaluation.MethodThis cross-sectional historical cohort study included ALS patients submitted to endoscopic examination. Eleven patients (six males and five females; mean age of 61.7 years) were enrolled in the study from january to december of 2011.ResultsAll patients had alterations in phases of the swallowing process, but only 72.7% complained of dysphagia. The oral preparatory phase was altered in 63.6% of the subjects; the oral transit and pharyngeal phases were altered in all studied individuals, regardless of food consistency. Laryngeal penetration or tracheal aspiration were seen in 90.9% of the patients during the pharyngeal phase while they were swallowing fluids.ConclusionEven in the absence of complaints, dysphagia is a frequent comorbidity in ALS patients. The oral transit and pharyngeal phases were the most frequently affected. Laryngeal penetration or tracheal aspiration occurred more frequently during the pharyngeal phase while patients were swallowing fluids.     

Prediction and risk of dysphagia after uvulopalatopharyngoplasty and uvulopalatoplasty

Objective—To test the hypothesis that preoperative asymptomatic pharyngeal swallowing dysfunction predisposes for the development of symptoms of dysphagia after uvulopalatopharyngoplasty (UPPP) and uvulopalatoplasty (UPP).

Material and Methods—A total of 42 patients who snored were scheduled to undergo UPPP (n=20) or UPP (n=22). UPP was performed using either a CO₂ laser or a conventional steel scalpel. Preoperatively and 1 year postoperatively all patients were examined videoradiographically to assess pharyngeal swallowing function. They also completed a questionnaire pre- and postoperatively concerning their snoring problems and swallowing function as well as the outcome of surgery.

Results—Preoperatively, 7 (17%) patients reported dysphagia. Pharyngeal swallowing dysfunction was demonstrated in 6/7 patients with preoperative dysphagia while pharyngeal swallowing dysfunction was evident preoperatively in 18/35 non-dysphagic patients. Of the 35 patients without preoperative dysphagia, 10 (29%) developed dysphagia after surgery. There was no significant risk of development of postoperative dysphagia for patients with compared to patients without preoperative pharyngeal swallowing dysfunction. Only one of the seven patients with preoperative dysphagia experienced worsening of the problem. A total of 93% of the patients reported a decrease in snoring and 95% reported a decrease in daytime sleepiness.

Conclusions—Preoperative pharyngeal swallowing dysfunction was not proven to predict the development of dysphagia after UPPP or UPP. The surgical method did not influence the frequency of postoperatively acquired dysphagia. The results do not indicate that patients with preoperative dysphagia should be excluded from treatment with UPPP or UPP.     

Different types of dysphagia alleviated by the chin-down position

ObjectiveRetrospective videofluoroscopic swallowing study (VFSS) evaluations of pharyngeal swallowing were used to evaluate the types of dysphagia alleviated by the chin-down maneuver.Materials and methodsThe study population consisted of 64 patients who underwent VFSS evaluations during neutral and chin-down maneuvers presenting specifically penetration or aspiration. The assessment of the VFSS movie clips of each maneuver was performed using parameters of the Modified Barium Swallow Impairment Profile (MBSImP) and the presence and degree of airway invasion(PDAI) by three blinded raters in the following five subcategorized groups, 1. patietns presenting penetration or aspiration during swallow 2. after swallow, patients of 3. head and neck, 4. digestive and 5. neuromuscular disorders, respectively. The scores registered for the two maneuvers were statistically compared. Additionally, we examined statistically which factors had the impact on the improvement of the PDAI using fisher's exact test.ResultsCompared with the neutral position, PDAI, pharyngeal constriction, anterior hyoid movement, pharyngeal constriction, laryngeal elevation, laryngeal closure, upper esophageal sphincter opening, initiation of the pharyngeal swallow, and pharyngeal clearance in pyriform sinus were significantly (p < 0.01–0.05) improved with the chin-down maneuver. In a subcategory comparison with group 1, 3 and 4, the PDAI improved significantly (p < 0.01) with the chin-down maneuver, in which laryngeal elevation and laryngeal closure had statistically the impact (p < 0.01–0.05) on improvement of PDAI.ConclusionThe chin-down maneuver was most effective in improving swallow function when the impairment included penetration and aspiration during swallow caused by inadequate laryngeal elevation and laryngeal closure     

Evaluation of chronological changes in videofluorographic findings after transoral videolaryngoscopic surgery to reveal mechanism of dysphagia

ObjectivesTransoral surgery preserves good swallowing function in most cases, however, postoperative dysphagia sometimes leads to fatal complication such as aspiration pneumonia. We investigated the chronological changes in swallowing function have not been revealed relationship with dysphagia. The primary aim of this study was to reveal the mechanism of dysphagia following transoral surgery by analyzing chronological videofluorography (VF) findings. Moreover, the secondary aim of this study was to evaluate the relationship between mechanism of dysphagia and risk factors of patients to clarify the risk for dysphagia lead to prevention of postoperative complications.Methods22 patients who underwent transoral videolaryngoscopic surgery (TOVS) for either supraglottic or hypopharyngeal cancer were evaluated swallowing function. We performed VF during the preoperative, postoperative acute, and stable phases and investigated the chronological changes in the VF findings. The following parameters were evaluated by VF: horizontal distance of laryngeal movement, vertical distance of laryngeal elevation, laryngeal elevation delay time (LEDT), Bolus Residue Scale (BRS) scores, and Penetration Aspiration Scale (PAS) scores. Additionally, we evaluated risk factors for postoperative aspiration by investigating relationships between preoperative VF parameters, age of patients, history of radiation therapy, resection area, tumor (T) stage, postoperative Numeric Rating Scale (NRS), and PAS and BRS scores.ResultsThe median time at which oral feeding was resumed in this study was 9 (2–200) days. The patients who had postoperative acute PAS scores of 4 and above exhibited delays in resuming oral ingestion after surgery. TOVS did not impair laryngeal elevation and LEDT; however, the BRS and PAS scores temporarily worsened in the acute phase compared to the preoperative scores. These scores almost recovered to their preoperative states in the stable phase, and both the BRS and PAS scores worsened and recovered concurrently. Patients who exhibited poor vertical distance in laryngeal elevation as observed via preoperative VF or who had histories of radiation therapy had worse PAS scores in postoperative acute phase VF. Patients with broad resection areas had worse BRS scores in postoperative acute phase VF.ConclusionTOVS didn't impair the function of laryngeal elevation and elicitation of the swallowing reflex whereas pharyngeal bolus clearance, laryngeal penetration, and aspiration temporarily deteriorated concurrently but eventually almost recovered to their baseline values.Patients with histories of radiotherapy, poor laryngeal elevation, and broad resection areas are at the risk of postoperative dysphagia after TOVS. Patients with these risk factors need appropriate evaluation before resuming postoperative oral intake.     

Correlating muscle resection with functional swallow outcomes: An anatomic framework informed systematic review of the literature

ObjectiveTo perform a systematic review of studies reporting swallow-associated outcomes in patients who received surgery for head and neck cancer (HNC), informed by an anatomic and physiologic framework of pharyngeal phase of swallowing (Pearson's dual-sling model).MethodsPUBMED and Google Scholar databases were searched for peer-reviewed papers published between 1990 and 2019 using relevant MeSH terms. Exclusion criteria were 1) discussions comparing reconstruction techniques, 2) case-report/series (n < 10), 3) perspective articles, 4) papers comparing objective instrumental methods of swallowing evaluation, 5) animal/cadaver studies, 6) no instrumental or validated swallow assessment tools used, 7) papers that discuss/include radiotherapy treatment, 8) systematic reviews, 9) papers that discuss swallow training or rehabilitation methods. Two investigators reviewed papers meeting inclusion/exclusions criteria. Muscles resected, anatomic resection site, swallow outcomes, and patient treatment variables were collected.ResultsA total of 115,020 peer-reviewed papers were identified. 74 papers were relevant to this review, 18 met inclusion and exclusion criteria, and none discussed surgical impact on the pharyngeal phase of swallowing using Pearson's dual-sling model. Most papers discussed the effect of tongue-base, supraglottic, or regional anatomic resection. Post-surgical resection Follow-up times ranged from 1 to 13 months. 67% of studies used objective instrumental swallow studies; 22% used patient reported outcome measures. Follow up time since surgical resection, time to feeding tube removal, feeding tube present/absent, aspiration severity were used to define dysphagia endpoints.ConclusionsTo date, no surgical HNC studies have used the dual-sling mechanism to guide study design, and dysphagia assessment has been inconsistent. To counsel patients on the effects of surgery on pharyngeal phase of swallow function, specialists need physiologically grounded research that correlates muscles resected with consistent measures of swallow function.     

Role of videoendoscopy in assessment of pharyngeal function in oropharyngeal dysphagia: Comparison with videofluoroscopy and manometry

Objective: The purpose of the current report is to evaluate the ability of videoendoscopic swallowing study in assessing pharyngeal propulsion and aspiration episodes when compared with videofluoroscopy and manometry. Study Design: Prospective study. Methods: Thirty-four patients with oropharyngeal dysphagia underwent videoendoscopy of swallowing to assess pharyngeal propulsion as pathologic or non-pathologic, and aspiration. These features were compared with those found on manometry and videofluoroscopy, which were considered as the reference examinations. Sensitivity, specificity, and positive and negative predictive values of videoendoscopy were estimated, with their 95% confidence intervals. Results: A total agreement between videoendoscopy and videofluoroscopy was found in 76.4% of cases for pharyngeal propulsion and in 82.3% for aspiration. This rate for pharyngeal propulsion reached 82.3% between videoendoscopy and manometry. Moreover, in 24 cases (70.5%) in which videofluoroscopy and manometry agreed for pharyngeal propulsion, 22 were assessed similarly through fiberoscopy. When using fluoroscopy and manometry as reference examinations, videoendoscopy detected nearly 90% (95% confidence interval [CI] = 0.80, 1.0) of impaired pharyngeal propulsion. Concerning aspiration, 70% (95% CI = 0.54, 0.85) of events detected by videoendoscopy were also observed on videofluoroscopy. Sensitivity, specificity, and positive and negative predictive values of videoendoscopy reached a higher rate (90% to 92.8%) when agreement was found between fluoroscopy and manometry. Conclusions: Videoendoscopy is an examination that can be used to detect inexpensively pharyngeal propulsion disorders and aspiration episodes. Laryngoscope, 108:1712–1716, 1998     

Radiopaque contrast dye in nasopharynx reaches the middle ear during swallowing and/or yawning

Conclusion

Contrast dye in the nasopharynx reaches the middle ear during swallowing and yawning in normal adults. This suggests that displacement of bacteria in nasopharyngeal secretion to the middle ear may occur frequently during sleep.

Objective

The middle ear is sterile under normal conditions. The purpose of this study was to examine by means of CT whether radiopaque contrast dye in the nasopharynx would reflux into the middle ear of normal adults during swallowing and/or yawning.

Material and methods

Six normal adult volunteers were studied. Contrast dye was kept at the orifices of the Eustachian tube during swallowing and/or yawning by placing volunteers in either a head-down or lateral decubitus position. Reflux was determined by the presence of contrast dye in the middle ear on CT scanning of the temporal bone.

Results

Two of the three volunteers in each group (four out of six in total) had contrast material detected in one or both middle ear cavities.     

Swallowing after non-surgical treatment (radiation therapy / radiochemotherapy protocol) of laryngeal cancer

Radiation therapy and radiochemotherapy protocols can cause swallowing difficulties.Aim: To evaluate swallowing in patients undergoing radiation therapy and radiochemotherapy protocol only for the treatment of laryngeal tumors.Methods: A prospective study of 20 patients, with a mean age of 62 years, at the end of oncological therapy. Six patients (30%) underwent radiation therapy, and 14 patients (70%) underwent combined therapy. The mean time between treatment and an evaluation of swallowing was 8.5 months. Videofluoroscopy was done to assess the preparatory, oral and pharyngeal phases of swallowing.Results: All patients had only an oral diet. Normal swallowing was present in only 25% of patients. The swallowing videofluoroscopic examination identified the following changes: bolus formation (85%), bolus ejection (60%), oral cavity stasis (55%), changes in the onset of the pharyngeal phase (100%), decreased laryngeal elevation (65%), and hypopharyngeal stasis (80%). Laryngeal penetration was observed in 25% of the cases; 40% presented tracheal aspiration. The grade of penetration/ aspiration was mild in 60% of cases. Aspiration was silent in 35% of patients. Although 75% of patients had dysphagia, only 25% complained of swallowing difficulties.Conclusion: Patients with laryngeal cancer that underwent radiation therapy/combined treatment can present changes in all swallowing phases, or may be asymptomatic.     

An oral pharyngeal scope for objective oropharyngeal examination: a new device for oropharyngeal study

Objective: There has been little progress in examination of the oropharynx with a light source such as electric light, a penlight, or a forehead mirror over the past 100 years. It is therefore necessary to develop methods to display and record oropharyngeal observations.

Method: Since the aim of this study was to assess the safeness to use from the perspective of physicians, medical staffs, patients, and patients’ families and usefulness of pharyngeal scope, the number of devices was limited, the number of patients was not set based on hypothetical statistical tests.

Results: A total of 150 volunteers were enrolled in this study. Among them, 96 underwent examination alone and the remaining 28 underwent treatment procedures. The study was done without any complications in all 150 cases. Most (91.3%) physicians hoped to continue using the new device if available. When comparing the use of the device for observation alone and for treatment procedures, there was no significant difference for evaluation items (p?>?.05) except convenience factor which received a significantly different (p?=?.0154) evaluation from physicians for observation alone and for treatment procedures. A positive evaluation was received about examination, recording/display and explanation from the patients and patients’ families.

Conclusions: Our new device received positive evaluations by who underwent examination of the oral cavity and pharynx, recording of the results, and treatment procedures.     

Low-phase angle in body composition measurements correlates with prolonged hospital stay in head and neck cancer patients

Background: Bioelectrical impedance analysis (BIA) is a method for estimating body composition. Clinically the most important parameter is the phase angle (PA), which decreases with progressing malnutrition and is highly predictive for impaired survival and mortality.

Aim: To evaluate the association of low PA with the complication rate and length of hospital stay.

Material and methods: A cohort of 61 head and neck cancer (HNC) patients underwent BIA prior to surgical treatment. Information on patient and tumour characteristics, treatment, and surgical complications were gathered from hospital records and correlated with BIA results.

Results: The median PA was 4.5 (range, 2.7–6.5), and, in 67% of the patients, it was lower than reference values. Low PA was associated with longer hospital stay (p?=?.002) in the whole cohort and in the patient group with radical neck dissections it correlated with a higher surgical complication rate (p?=?.014), but not with Clavien–Dindo scoring for surgical complications.

Conclusions and significance: BIA is a feasible instrument for analysing body composition that reflects nutritional status in cancer patients. Our results show that HNC patients have a low PA at diagnosis. Low PA is associated with a long hospital stay and an increase in the complication rate. BIA can be of clinical value in preoperative risk evaluation.     

Clinical characteristics of subglottic cancer: emphasis on therapeutic management strategies for stage II subglottic cancer*

Abstract

Background: Subglottic cancer (SGC) is extremely rare, as most laryngeal cancers are localized to the glottic region. Accordingly, the clinical characteristics of SGC have not been well characterized.

Objectives: In the current study, SGCs were clinically evaluated, and the outcomes of radiotherapy (RT) in patients with stage II SGC were assessed.

Materials and Methods: Medical data derived from 11 patients with SGC, who were treated at our hospital between 1995 and 2019, were retrospectively reviewed.

Results: In our department SGC accounted for 3.9% of the 280 laryngeal cancer patients treated during the study period. At the time of SGC diagnosis, 9 (81.8%) had stage II cancer, 1 had stage III cancer, and 1 had stage IV cancer. Stage II SGC patients treated with concurrent chemoradiotherapy (CCRT) showed a significantly higher local control rate (p?=?.026) and laryngeal dysfunction free rate (p?=?.026) than those treated with RT alone. Salvage surgery, performed in 4 patients whose disease was not locally controlled with CCRT/RT, was successful in 3 patients.

Conclusion: As a treatment strategy for stage II SGC, CCRT is an acceptable initial treatment for laryngeal function and preservation while salvage surgery is effective for recurrence after CCRT/RT treatment.     

Association between head and neck cancer and sexually transmitted diseases: a Danish nationwide,case-control study

Abstract

Background: An association between sexually transmitted diseases (STDs) and occurrence of head and neck cancer (HNC) is proposed.

Aims/objectives: We aimed to determine the association between selected STDs (syphilis, gonorrhoea, HIV) and HNC.

Materials and methods: Patients diagnosed with HNC in Denmark between 1978 and 2014 identified through the Danish Cancer Registry were included. Patients were age- and sex-matched in a 1:10 ratio with general population controls. Uni- and multivariate analyses were performed using the Cox regression model to assess the correlation between STD and HNC.

Results: A total of 39,405 HNC patients (63% men; 63.0 years at HNC diagnosis) and 393,238 controls were included. STD in HNC patients was 0.27%, vs. 0.11% in controls. Patients with cancer of the upper airways had a significantly higher prevalence of an STD prior to the HNC compared to controls. Most HNC patients with a prior STD (64.1%) developed the HNC within five years after the STD diagnosis.

Conclusions: Although the studied STDs are rare, patients with cancer of the upper aerodigestive tract more commonly had a previous diagnosis of STD compared to controls. The study promotes the hypothesis that a causal link exists between STD and HNC.     

Reduction of post-operative pain after tonsillectomy by a local mucosal flap – a prospective,randomized, controlled clinical trial on 100 adult patients

Abstract

Background: Tonsillectomy is one of the most frequent operations in otorhinolaryngology being associated with intense post-operative pain and an impairment of swallowing and speech.

Aims: To determine whether wound sealing with a local mucosal flap can improve patient rehabilitation.

Materials and methods: The study was designed as a prospective, randomized, monocentric, controlled clinical trial including 100 patients. Patients were operated on using either conventional extracapsular tonsillectomy (n?=?50) or a modified technique with a local mucosal flap prepared from the posterior surface of the tonsil (n?=?50). Number of requested pain medications, local oedema, patient-reported pain level, post-operative haemorrhage, impairment of speech, swallowing and general condition were assessed. The study was registered at the German Clinical Trials Register.

Results: The mucosal flap technique significantly reduced post-operative pain [2.94 (intervention group) vs. 4.61 (control group) in an numerical analogue scale, p?<?.001] and the number of pain medications [6 (intervention group) vs. 1 (control group), p?<?.001].

Conclusions: Wound sealing with a local mucosal flap can reduce post-operative pain in tonsillectomy patients and is recommended whenever anatomically feasible.

Significance: This new tonsillectomy technique can help to reduce post-operative pain and thereby improve the patients’ post-operative rehabilitation.     

Oral neuromuscular training relieves hernia-related dysphagia and GERD symptoms as effectively in obese as in non-obese patients

Abstract

Background: Many physicians insist patients lose weight before their hiatal hernia (HH) condition and related symptoms including intermittent esophageal dysphagia (IED) and gastroesophageal reflux disease (GERD) can be treated, but it is not proven that body mass index (BMI) has an impact on exercise-based treatment of HH-related symptoms.

Aims/Objectives: To investigate whether BMI has significance on IQoro® neuromuscular training (IQNT) effectiveness in treating HH-related symptoms.

Material and Methods: Eighty-six patients with sliding HH and enduring IED and GERD symptoms, despite proton pump inhibitor medication, were consecutively referred for 6 months’ IQNT comprising 11/2?minutes daily. They were grouped by BMI which was recorded before and after IQNT, as were their symptoms of IED, reflux, heartburn, chest pain, globus sensation, non-productive cough, hoarseness, and misdirected swallowing. They were also assessed on food swallowing ability, water swallowing capacity and lip force both before and after treatment.

Results: After IQNT, all BMI groups showed significant improvement (p?<?.001) of all assessments’ and symptoms; and heartburn, cough and misdirected swallowing were significantly more reduced in the severely obese.

Conclusions and significance: IQNT can treat HH-related IED and GERD symptoms as successfully in moderately or severely obese patients as in those with normal bodyweight.     

Blowing time ratio and high-resolution manometry to evaluate swallowing function of patients with oral and oropharyngeal cancer

ObjectiveThe blowing time ratio, which is the ratio of the blowing time when the nostrils are open and closed, is significantly correlated with velopharyngeal pressure, not only during speech but also during swallowing. This study aimed to further evaluate the usefulness of the blowing time ratio as a screening tool to evaluate the swallowing pressure of patients treated for oral and oropharyngeal cancers using high-resolution manometery (HRM).MethodsTen patients treated for oral or oropharyngeal cancer were recruited for this study. Swallowing pressures at the velopharynx, oropharynx, and upper esophageal sphincter (UES) were measured using HRM. Their correlations with the blowing time ratio were analyzed.ResultsThe blowing time ratio was significantly correlated with the swallowing pressures of the oropharynx (CC = 0.815, p = 0.004) and the velopharynx (CC = 0.657, p = 0.039), but not of the UES.ConclusionsThe present results further support our previous finding that the blowing time ratio is a useful screening tool to evaluate velopharyngeal and oropharyngeal swallowing pressures in patients treated for oral and oropharyngeal cancer.     

Videofluoroscopic evaluation of mastication and swallowing in individuals with TMD

To study mastication and swallowing disorders in patients with temporomandibular disorders (TMD).Objective: To investigate mastication and swallowing disorders in patients with severe TMD referred to surgery.Materials and Methods: Clinical and experimental study involving ten individuals with TMD submitted to deglutition videofluoroscopy. These patients did not have posterior teeth, mastication pain and food replacement in favor of pasty consistence food. The assessment of the oral and pharyngeal phases approached the following aspects: side of onset and preferential side for chewing, premature escape, remains of food residues in the oral cavity or in the pharyngeal recesses, number of necessary swallowing efforts, laryngeal penetration and/or tracheal aspiration.Results: During mastication and the oral phase we observed tongue compensatory movements upon chewing (n = 7; 70%), premature escape (n = 4; 40%), food remains in the cavity after swallowing (n = 5; 50%) and an excessive number of deglutition efforts (n = 5; 50%). On the pharyngeal phase we observed food remains in the valleculae (n = 6; 60%), in the pyriform sinuses (n = 4; 40%); laryngeal penetration (n = 1; 10%) and tracheal aspiration (n = 4; 40%).Conclusion: TMD patients may have alterations in their chewing and swallowing patterns, with laryngeal penetration and/or tracheal aspiration. The study indicates the need for a multidisciplinary assessment because of dysphagia in TMD patients.     

The relationship between hyoid and laryngeal displacement and swallowing impairment

Clin. Otolaryngol. 2011, 36 , 30–36 Objectives: Reduced range of hyoid and laryngeal movement is thought to contribute to aspiration risk and pharyngeal residues in dysphagia. Our aim was to determine the extent to which movements of the hyoid and larynx are correlated in the superior and anterior directions in swallowing, and whether movement range is predictive of penetration–aspiration or pharyngeal residue. Design: Prospective, single‐blind study of penetration–aspiration and pharyngeal residue with objective frame‐by‐frame measures of hyoid and laryngeal excursion from videofluoroscopy. Setting: Tertiary hospital and rehabilitation teaching hospital. Participants: Twenty‐eight participants referred for videofluoroscopy: 13 women, aged 57–77; 15 men, aged 54–70. Individuals with known neurodegenerative diseases or prior surgery to the neck were excluded. Each swallowed three boluses of 40% w/v thin liquid barium suspension. Outcomes: Two speech‐language pathologists independently rated penetration–aspiration, vallecular and pyriform sinus residue. Cervical spine length, hyoid and laryngeal displacement were traced frame‐by‐frame. Predictive power was calculated. Results: Cervical spine length was significantly greater in men. Hyoid displacement ranged from 34–63% of the C2–4 distance. Arytenoid displacement ranged from 18–66%, with significantly smaller anterior displacement in men. Positive hyoid–laryngeal movement correlations in both axes were the most common pattern observed. Participants with reduced displacement ranges (≤first quartile) and with abnormal correlation patterns were more likely to display penetration–aspiration. Those with reduced anterior hyoid displacement and abnormal correlation patterns had a greater risk of post‐swallow pharyngeal residues. Conclusions: It is difficult for clinicians to make on‐line appraisals of the extent to which hyoid and laryngeal movement may be contributing to functional swallowing consequences during videofluoroscopy. This study suggests that it is most important for clinicians to discern whether reduced anterior displacement of these structures is contributing to a patient’s swallowing impairment. Measures of structural displacement in thin liquid swallowing should be corrected for variations in participant height. Reductions in anterior hyoid and laryngeal movement below the first‐quartile boundaries are statistically associated with increased risk for penetration–aspiration and post‐swallow residues.     

Voice and swallowing after total laryngectomy

Background: Voice and swallowing problems are often seen in patients with advanced larynx cancer, after total laryngectomy (TL) and chemo/radiotherapy.

The aim of this study was to determine the occurrence of voice and swallowing problems in patients who have been laryngectomised and investigate if these symptoms were related to age, time after TL, radiotherapy and TNM-classification. In addition, we studied how often the patients changed their voice prostheses and the need of therapeutic interventions after TL.

Methods: Forty-five patients were included in the study and completed the Swedish version of the Sydney Swallow Questionnaire and the Voice Handicap Index-T.

Results: Swallowing problems were reported by 89% of the patients and moderate-to-severe voice handicap was reported by 66%. Most of the subjects who had dysphagia also presented voice problems (r_s?=?0.67 p?≤?.01). Additional therapeutic interventions to manage problems with voice and/or swallowing after TL were required in 62% of the patients.

Conclusions: Swallowing and voice problems after TL are common. Thus, the preoperative information and assessment of these functions, as well as the treatment and the post-operative rehabilitation should be evaluated and optimised to provide better functional results after treatment of advanced larynx cancer.