Functional MRI during tongue strength tasks before and after partial glossectomy: Insights into the cortical activation of tongue motor function.

AIM: Because the tongue is a midline structure, studies on the neural correlates of lateralized tongue function are challenging and remain limited. Patients with tongue cancer who undergo unilateral partial glossectomy may be a unique cohort to study tongue-associated cortical activation, particularly regarding brain hemispheric lateralization. This longitudinal functional magnetic resonance imaging (fMRI) study investigated cortical activation changes for three tongue tasks before and after left-sided partial glossectomy in patients with squamous cell carcinoma of the tongue. METHODS: Seven patients with squamous cell carcinoma involving the left tongue who underwent fMRI before and 6 months after unilateral partial glossectomy were studied. Post-surgical changes in laterality index (LI) values for tongue-associated precentral and postcentral gyri fMRI activation were calculated for the dry swallow, tongue press, and saliva sucking tasks. Group analysis fMRI activation maps were generated for each of the three tasks. RESULTS: There were significant differences in changes in LI values post-surgery between the tongue press (p < 0.005; median: +0.24), saliva sucking (-0.10), and dry swallow tasks (-0.16). Decreased contralateral activation (change in LI ≥+0.20) was observed post-surgery during tongue press in six of seven patients, but only in two patients during saliva sucking and one patient during dry swallow (p < 0.05). There was also increased activation in the supplementary motor area following surgery. CONCLUSION: Post-surgical fMRI changes following left-sided partial glossectomy may suggest task-specific sensitivities to cortical activation changes following unilateral tongue deficits that may reflect the impacts of surgery and adaptive responses to tongue impairment.

Correction to: Volumetric Changes to the Pharynx in Healthy Aging: Consequence for Pharyngeal Swallow Mechanics and Function.

This erratum notifies the readers of the Dysphagia journal of an error in the original published version of this manuscript. In that manuscript, a previously available open source spreadsheet tool was used to calculate the position of the posterior laryngeal air column on lateral view videofluoroscopic images as a proxy for the bottom of the pharynx. We have subsequently been made aware of an error in the mathematical formula built into the spreadsheet, which resulted in a reversal of the results for the X and Y planes of measurement. This erratum provides corrections to the results and interpretations of the original manuscript.

Motor Learning, Neuroplasticity, and Strength and Skill Training: Moving From Compensation to Retraining in Behavioral Management of Dysphagia.

Purpose Learning a motor skill and regaining a motor skill after it is lost are key tenets to the field of speech-language pathology. Motor learning and relearning have many theoretical underpinnings that serve as a foundation for our clinical practice. This review article applies selective motor learning theories and principles to feeding and swallowing across the life span. Conclusion In reviewing these theoretical fundamentals, clinical exemplars surrounding the roles of strength, skill, experience, compensation, and retraining, and their influence on motor learning and plasticity in regard to swallowing/feeding skills throughout the life span are discussed.

Speech-Language Pathology Guidance for Tracheostomy During the COVID-19 Pandemic: An International Multidisciplinary Perspective.

Purpose As the COVID-19 pandemic has unfolded, there has been growing recognition of risks to frontline health care workers. When caring for patients with tracheostomy, speech-language pathologists have significant exposure to mucosal surfaces, secretions, and aerosols that may harbor the SARS-CoV-2 virus. This tutorial provides guidance on practices for safely performing patient evaluation and procedures, thereby reducing risk of infection. Method Data were collated through review of literature, guidelines, and consensus statements relating to COVID-19 and similar high-consequent infections, with a focus on mitigating risk of transmission to health care workers. Particular emphasis was placed on speech-language pathologists, nurses, and other allied health professionals. A multinational interdisciplinary team then analyzed findings, arriving at recommendations through consensus via electronic communications and video conference. Results Reports of transmission of infection to health care workers in the current COVID-19 pandemic and previous outbreaks substantiate the need for safe practices. Many procedures routinely performed by speech-language pathologists have a significant risk of infection due to aerosol generation. COVID-19 testing can inform level of protective equipment, and meticulous hygiene can stem spread of nosocomial infection. Modifications to standard clinical practice in tracheostomy are often required. Personal protective equipment, including either powered air-purifying respirator or N95 mask, gloves, goggles, and gown, are needed when performing aerosol-generating procedures in patients with known or suspected COVID-19 infection. Conclusions Speech-language pathologists are often called on to assist in the care of patients with tracheostomy and known or suspected COVID-19 infection. Appropriate care of these patients is predicated on maintaining the health and safety of the health care team. Careful adherence to best practices can significantly reduce risk of infectious transmission.

Effects of jaw exercise intervention timing on outcomes following oral and oropharyngeal cancer surgery: Pilot study.

BACKGROUND: Common in head and neck cancer patients, trismus can make speech and swallowing difficult and can compromise quality of life (QOL). Jaw range of motion exercise therapy may prevent or treat trismus in surgical patients. While the importance of these exercises is well-documented, there is little literature regarding the optimal timing of exercise initiation. METHODS: A prospective pilot study investigated the effects of early vs late jaw exercise intervention on postoperative jaw opening and QOL measures, which were examined descriptively. RESULTS: Timing of exercise intervention was not found to significantly impact the measured outcomes. However, provisional, descriptive findings showed that jaw opening was significantly associated with multiple QOL measures, with greater jaw opening associated with improved QOL. For certain QOL measures, this positive association was stronger at earlier time points than at later time points. CONCLUSIONS: The exploratory findings of this pilot study support further research into possible benefits of early jaw exercise intervention.

The impact of time after radiation treatment on dysphagia in patients with head and neck cancer enrolled in a swallowing therapy program.

BACKGROUND: Swallowing dysfunction after radiotherapy (RT) for head and neck cancer can be devastating. A randomized control trial compared swallow exercises versus exercise plus neuromuscular electrical stimulation therapy and found no overall difference in outcomes. METHODS: Quality of life (QOL), diet, and swallowing variables collected at discrete intervals on 117 patients were reanalyzed to test the hypothesis that shorter time between the completion of radiotherapy and beginning of the swallowing therapy program yielded improved outcomes. RESULTS: At baseline, subjects < 1 year post radiation had significantly better function than subjects >2 years post RT in several measures. Over the therapy program, the early group showed significant improvement in diet and QOL. Swallowing physiologic variables showed no difference between groups. CONCLUSION: Beginning a swallowing therapy program within 1 year of completion of radiotherapy demonstrates more consistent improvement in QOL and diet performance compared to later periods.

Volumetric Changes to the Pharynx in Healthy Aging: Consequence for Pharyngeal Swallow Mechanics and Function.

Pharyngeal lumen volume is prone to increase as a consequence of pharyngeal muscle atrophy in aging. Yet, the impact of this on swallowing mechanics and function is poorly understood. We examined the relationship between pharyngeal volume and pharyngeal swallowing mechanics and function in a sample of healthy community-dwelling seniors. Data were collected from 44 healthy seniors (21 male, mean age = 76.9, SD = 7.1). Each participant swallowed 9 boluses of barium (3 × 5 ml thin, 3 × 20 ml thin, 3 × 5 ml nectar). Pharyngeal shortening, pharyngeal constriction, pyriform sinus and vallecular residue were quantified from lateral view videofluorosopic swallowing studies. Pharyngeal lumen volume was captured during an oral breathing task with acoustic pharyngometry. In addition, within-participant measures of strength and anthropometrics were collected. Four linear mixed effects regression models were run to study the relationship between pharyngeal volume and pharyngeal constriction, pharyngeal shortening, pyriform sinus residue, and vallecular residue while controlling for bolus condition, age, sex, and posterior tongue strength. Increasing pharyngeal lumen volume was significantly related to worse constriction and vallecular residue. In general, larger and thicker boluses resulted in worse pharyngeal constriction and residue. Pharyngeal shortening was only significantly related to posterior tongue strength. Our work establishes the utility of acoustic pharyngometry to monitor pharyngeal lumen volume. Increasing pharyngeal lumen volume appears to impact both pharyngeal swallowing mechanics and function in a sample of healthy, functional seniors.

Prospective instrumental evaluation of swallowing, tongue function, and QOL measures following transoral robotic surgery alone without adjuvant therapy.

BACKGROUND: Transoral robotic surgery (TORS) has been utilized to deintensify treatment. No studies have measured swallow safety and efficiency, nor assessed the functional impact of TORS alone. METHODS: This prospective cohort underwent baseline and 1-month postsurgery assessments including modified barium swallow evaluation, using the Dynamic Imaging Grade of Swallowing Toxicity (DIGEST) rating system, tongue range of motion assessment, the Performance Status Scale (PSS), and quality of life with the MD Anderson Dysphagia Inventory (MDADI). RESULTS: All DIGEST safety scores were 0 (normal) at both time points. DIGEST efficiency scores were mildly impaired in 2 of 10 patients postsurgery. PSS scores revealed all patients were on regular diets, were 100% understandable, and were eating in public at both time points. Tongue Range of Motion scores were 100 of 100 at both time points. MDADI scores were not significantly different across time points. CONCLUSIONS: Careful identification of patients can result in excellent outcomes following TORS. Future studies will examine longer follow-up of speech, swallowing, and tongue function in patients undergoing TORS surgery.

Objective and subjective hyposalivation after treatment for head and neck cancer: Long-term outcomes.

OBJECTIVES/HYPOTHESIS: This study examined saliva weight over time and its association with diet and patient-rated swallowing, dry mouth, sticky saliva, and dysgeusia quality of life in head and neck cancer (HNCA) patients treated with surgery plus adjuvant chemoradiotherapy (CRT), or primary CRT. STUDY DESIGN: Prospective cohort study in an outpatient HNCA center setting. METHODS: Patients were seen pretreatment, and 1, 3, 6, 12, 24, and 36 + months post-treatment. All had newly diagnosed oral, oropharynx, nasopharynx, larynx/hypopharynx cancer from 2010 to 2016 and were to undergo surgery + CRT or primary CRT. Stimulated saliva weight was assessed with the Saxon test. Diet, eating, dry mouth, and dysgeusia quality of life were assessed and correlated with saliva weight, treatment modality, and tumor site. RESULTS: Saliva weight decreased the most within the first 3 months across treatment groups, except for the surgery + CRT group, which continued to decline. Similar trends were seen by tumor site. Performance Status Scale (PSS) Normalcy of Diet and all quality-of-life scores declined following treatment. The European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Head and Neck-35 (EORTC QLQ-H&N35); Eating Assessment Tool (EAT-10); M. D. Anderson Dysphagia Inventory (MDADI) Composite, Global, and subdomain scores; and PSS Diet were significantly correlated with saliva weight. CONCLUSIONS: Saliva weight worsened post-treatment across groups and tumor site, with improvement by 36 + months. Saliva weight correlated with diet, eating quality of life and perception of dysgeusia across time points. Despite dose-sparing intensity-modulated radiation therapy, newer technologies are needed to preserve saliva production and maintain higher quality of life. LEVEL OF EVIDENCE: 2b Laryngoscope, 128:2732-2739, 2018.

Swallow Event Sequencing: Comparing Healthy Older and Younger Adults.

Previous research has established that a great deal of variation exists in the temporal sequence of swallowing events for healthy adults. Yet, the impact of aging on swallow event sequence is not well understood. Kendall et al. (Dysphagia 18(2):85-91, 2003) suggested there are 4 obligatory paired-event sequences in swallowing. We directly compared adherence to these sequences, as well as event latencies, and quantified the percentage of unique sequences in two samples of healthy adults: young (< 45) and old (> 65). The 8 swallowing events that contribute to the sequences were reliably identified from videofluoroscopy in a sample of 23 healthy seniors (10 male, mean age 74.7) and 20 healthy young adults (10 male, mean age 31.5) with no evidence of penetration-aspiration or post-swallow residue. Chi-square analyses compared the proportions of obligatory pairs and unique sequences by age group. Compared to the older subjects, younger subjects had significantly lower adherence to two obligatory sequences: Upper Esophageal Sphincter (UES) opening occurs before (or simultaneous with) the bolus arriving at the UES and UES maximum distention occurs before maximum pharyngeal constriction. The associated latencies were significantly different between age groups as well. Further, significantly fewer unique swallow sequences were observed in the older group (61%) compared with the young (82%) (χ2 = 31.8; p < 0.001). Our findings suggest that paired swallow event sequences may not be robust across the age continuum and that variation in swallow sequences appears to decrease with aging. These findings provide normative references for comparisons to older individuals with dysphagia.

Alterations to Swallowing Physiology as the Result of Effortful Swallowing in Healthy Seniors.

A significant proportion of healthy seniors report difficulty swallowing, thought to result from age-related decline in muscle bulk/function. Effortful Swallowing (ES) is used both as a compensatory maneuver to improve pharyngeal propulsion/clearance and has been proposed as an exercise to improve pharyngeal strength. This study sought to quantify the immediate kinematic, temporal, and functional changes during an ES maneuver to quantify its exercise potential to combat age-related changes in swallowing. Videofluoroscopy data were collected from 44 healthy seniors (21 male) over 65 years old (mean = 76.9, SD = 7.1). Each participant swallowed six 5 ml boluses of Varibar nectar-thick liquids: three with regular effort and three using ES. Individual swallows (n = 260) were measured on pharyngeal constriction, pharyngeal shortening, laryngeal closure duration, hyoid movement duration, UES opening duration, stage transition duration, pharyngeal transit time, pharyngeal response duration, Normalized Residue Ratio Scale (NRRS), and the Penetration-Aspiration Scale (PAS). Non-parametric Wilcoxon Rank Sum for repeated measures tested the effect of ES on each outcome. Exact p-values were calculated based on permutation methods, individual p values < 0.008 was deemed to be significant. The ES maneuver significantly prolonged all temporal variables. While we found no significant differences for pharyngeal constriction, significantly less (i.e., worse) pharyngeal shortening was observed in ES condition compared with regular effort swallows. Further, significantly worse pyriform sinus residue (NRRSv) was observed in the ES condition. No differences between ES and regular effort swallows were noted for pharyngeal constriction, NRRSv or PAS. We speculate that these negative manifestations of worse kinematics (less pharyngeal shortening) and function (increase in NRRSp) may be the result of forced volitional manipulation of swallowing in the ES condition in an otherwise normal elderly swallow.

Total lower lip and chin reconstruction with radial forearm free flap: A novel approach.

BACKGROUND: The management of large chin and lower lip defects is challenging due to this facial subunit's tremendous functional and aesthetic importance. Specific methods for total lower lip and mentum reconstruction are not well chronicled. Aesthetic and functional goals of this reconstruction include restoration of oral competence by maintaining lower lip height, vermilion reestablishment, color-matched skin introduction to the chin, sensation restoration, and ideally restoration of dynamic activity to the lower lip. METHODS: Literature review performed. RESULTS: Presentation of novel, two-stage technique for lower lip and chin reconstruction with a submental flap and a radial forearm free flap, suspension of the lower lip and chin with a tensor fascia lata graft, and vermilion reconstruction with a buccal mucosal flap. CONCLUSIONS: This procedure meets all goals of total lower lip reconstruction with the exception of the introduction of dynamic tissue and represents a novel solution to a challenging reconstructive problem.

Prophylactic Swallow Therapy for Patients with Head and Neck Cancer Undergoing Chemoradiotherapy: A Randomized Trial.

Evidence supporting prophylactic swallow exercises for patients with head and neck cancer (HNC) has not been universally demonstrated. This RCT examined diet level, feeding tube use, swallow function, and quality of life (QOL) of patients undergoing chemoradiotherapy who performed prophylactic swallowing exercises. Sixty HNC patients were randomized into exercise versus control groups. Swallowing, oromotor, toxicity, and QOL data were recorded (baseline, 3, 6, 12, 24 months). Physiological swallow function was examined at baseline and 3 months. Swallow exercises were completed twice daily. Oral intake at 3 months was 10% better in the exercise group, which was not statistically significant (p = 0.49). Significant (p < 0.05) differences in secondary outcomes including oromotor function, pharyngeal impairment, oral pharyngeal swallow efficiency, and incisal opening were noted at early time points (3-6 months) in the exercise group. Possible positive early improvements in swallow function are associated with swallowing exercises, although these improvements are not significant longer term.

Dynamic Imaging Grade of Swallowing Toxicity (DIGEST): Scale development and validation.

BACKGROUND: The National Cancer Institute's Common Terminology Criteria for Adverse Events (CTCAE) is the universal framework for toxicity reporting in oncology trials. The objective of this study was to develop a CTCAE-compatible modified barium swallow (MBS) grade for the purpose of grading pharyngeal dysphagia as a toxicity endpoint in cooperative-group organ-preservation trials for head and neck cancer (HNC). It was hypothesized that a 5-point, CTCAE-compatible MBS grade (Dynamic Imaging Grade of Swallowing Toxicity [DIGEST]) based on the interaction of pharyngeal residue and laryngeal penetration/aspiration ratings would be feasible and psychometrically sound. METHODS: A modified Delphi exercise was conducted for content validation, expert consensus, and operationalization of DIGEST criteria. Two blinded raters scored 100 MBSs conducted before or after surgical or nonsurgical organ preservation. Intrarater and interrater reliability was tested with weighted κ values. Criterion validity against oropharyngeal swallow efficiency (OPSE), the Modified Barium Swallow Impairment Profile (MBSImP™©), the MD Anderson Dysphagia Inventory (MDADI), and the Performance Status Scale for Head and Neck Cancer Patients (PSS-HN) was assessed with a 1-way analysis of variance and post hoc pairwise comparisons between DIGEST grades. RESULTS: Intrarater reliability was excellent (weighted κ = 0.82-0.84) with substantial to almost perfect agreement between raters (weighted κ = 0.67-0.81). DIGEST significantly discriminated levels of pharyngeal pathophysiology (MBSImP™©: r = 0.77; P < .0001), swallow efficiency (OPSE: r = -0.56; P < .0001), perceived dysphagia (MDADI: r = -0.41; P < .0001), and oral intake (PSS-HN diet: r = -0.49; P < .0001). CONCLUSIONS: With the development of DIGEST, the MBS rating has been adapted to the CTCAE nomenclature of ordinal toxicity grading used in oncology trials. DIGEST offers a psychometrically sound measure for HNC clinical trials and investigations of toxicity profiles, dose responses, and predictive modeling. Cancer 2017;62-70. © 2016 American Cancer Society.

Impact of Compliance on Dysphagia Rehabilitation in Head and Neck Cancer Patients: Results from a Multi-center Clinical Trial.

A 5-year, 16-site, randomized controlled trial enrolled 170 HNC survivors into active (estim + swallow exercise) or control (sham estim + swallowing exercise) arms. Primary analyses showed that estim did not enhance swallowing exercises. This secondary analysis determined if/how patient compliance impacted outcomes. A home program, performed 2 times/day, 6 days/week, for 12 weeks included stretches and 60 swallows paired with real or sham estim. Regular clinic visits ensured proper exercise execution, and detailed therapy checklists tracked patient compliance which was defined by mean number of sessions performed per week (0-12 times) over the 12-week intervention period. "Compliant" was defined as performing 10-12 sessions/week. Outcomes were changes in PAS, HNCI, PSS, OPSE, and hyoid excursion. ANCOVA analyses determined if outcomes differed between real/sham and compliant/noncompliant groups after 12 weeks of therapy. Of the 170 patients enrolled, 153 patients had compliance data. The mean number of sessions performed was 8.57/week (median = 10.25). Fifty-four percent of patients (n = 83) were considered "compliant." After 12 weeks of therapy, compliant patients in the sham estim group realized significantly better PAS scores than compliant patients in the active estim group (p = 0.0074). When pooling all patients together, there were no significant differences in outcomes between compliant and non-compliant patients. The addition of estim to swallowing exercises resulted in worse swallowing outcomes than exercises alone, which was more pronounced in compliant patients. Since neither compliant nor non-compliant patients benefitted from swallowing exercises, the proper dose and/or efficacy of swallowing exercises must also be questioned in this patient population.

Staged laryngeal reconstruction with a prefabricated flap for radiation recurrent glottic carcinoma.

OBJECTIVES/HYPOTHESIS: Although salvage total laryngectomy remains the definitive approach to recurrent/persistent glottic cancer following failed radiation therapy for favorable early-stage disease, it comes at the price of a permanent laryngostome and an impact on quality of life. We describe a three-stage method of laryngeal reconstruction for salvage partial laryngectomy to address the unique challenges of operating on radiation recurrent/persistent cancer. STUDY DESIGN: This was a single-surgeon retrospective case series of patients who underwent a three-stage laryngeal reconstruction for salvage partial laryngectomy. METHODS: We performed a comprehensive review of the clinical, pathologic, and radiologic files of all patients who underwent a three-stage laryngeal reconstruction for salvage partial laryngectomy. RESULTS: Seven male patients underwent a three-stage laryngeal reconstruction following open partial salvage laryngectomy. The average follow-up time since salvage surgery was 55 months. All patients were without evidence of recurrence and demonstrated satisfactory functional outcomes. CONCLUSION: Staged reconstruction provides a more controlled assessment of wound healing and valuable pathologic information regarding the specific disease virulence and adequacy of the margins. LEVEL OF EVIDENCE: 4. Laryngoscope, 126:1061-1070, 2016.

Efficacy of electrical stimulation and exercise for dysphagia in patients with head and neck cancer: A randomized clinical trial.

BACKGROUND: Neuromuscular electrical stimulation (NMES) is a highly sought after but poorly studied treatment for dysphagia among patients with head and neck cancer with dysphagia. This study investigated the efficacy of NMES in this patient population. METHODS: In this double-blinded, randomized controlled trial, 170 patients with head and neck cancer experiencing posttreatment dysphagia were randomized into active NMES + swallow exercise versus sham NMES + swallow exercise groups. Outcomes after a 12-week program included changes in fluoroscopy measures, diet, and quality of life. RESULTS: After the 12-week program, the active NMES group had significantly worse Penetration Aspiration Scale scores than the sham group. Both groups reported significantly better diet and quality of life. No other measures were significant. CONCLUSION: NMES did not add benefit to traditional swallow exercises. Unfortunately, swallow exercises were not effective by themselves either. For patients with head and neck cancer with moderate to severe dysphagia caused by radiation therapy, current behavioral therapies are of limited help in reversing long-term dysphagia. © 2015 Wiley Periodicals, Head Neck 38: E1221-E1231, 2016.

Reconstruction of expanding tracheoesophageal fistulae in post-radiation therapy patients who undergo total laryngectomy with a bipaddled radial forearm free flap: Report of 8 cases.

BACKGROUND: Our surgical approach describes a bipaddled radial forearm free flap (RFFF) for closure of chronic tracheoesophageal fistulae (TEF) in patients who underwent total laryngectomy. The desired functional results were achieved. METHODS: Eight patients underwent the procedure. The surgical approach includes exposure and resection of the fistula tract, and a bipaddled RFFF transfer. Key surgical maneuvers include: circumferential dissection and mobilization of the trachea; partial sternal resection in select cases; inset of flap's distal paddle into the anterior esophageal wall; and inset of the proximal skin paddle to the posterior tracheal wall and cervical skin. RESULTS: Successful reconstruction of all 8 cases was done to restore a normal diet and a widely patent tracheal opening. One patient developed a delayed esophageal stricture, which was successfully managed with home dilation. CONCLUSION: Several TEF treatment approaches have been reported. Our 87.5% esophageal lumen preservation success rate, reestablishment of adequate airway, and uncomplicated postoperative courses demonstrates the reliability of this surgical approach. © 2015 Wiley Periodicals, Inc. Head Neck 38: E172-E178, 2016.

A survey of variables used by speech-language pathologists to assess function and predict functional recovery in oral cancer patients.

Oromotor and clinical swallow assessments are routinely performed by speech-language pathologists (SLPs) who see head and neck cancer (HNC) patients. However, the tools used to assess some of these variables vary. SLPs routinely identify and quantify abnormal functioning in order to rehabilitate the patient. However, function in terms of tongue range of motion (ROM) is typically described using a subjective severity rating scale. The primary objective of this study was to gain insight via survey into what variables SLPs consider important in assessing and documenting function after HNC treatment. A second objective was to seek feedback regarding a scale designed by the authors for assessing tongue ROM for this cohort of patients. This survey also was developed to elucidate salient factors that might have an impact on the prognosis for speech and swallow outcomes. Of the 1,816 SLPs who were sent the survey, 292 responded who work with HNC patients. Results revealed that although 95 % of SLPs assess tongue strength, only 13 % use instrumental methods. Although 98 % assess tongue ROM, 88 % estimate ROM based on clinical assessment. The majority of respondents agreed with the utility of the proposed tongue ROM rating scale. Several variables were identified by respondents as having an impact on overall prognosis for speech and swallow functioning. Tracking progress and change in function with treatment can be accomplished only with measurable assessment techniques. Furthermore, a consistent measuring system can benefit patients with other diagnoses that affect lingual mobility and strength.