Objective and subjective evaluation of Velopharyngeal Dysfunction (VPD) following surgical repair of the cleft palate using the furlow palatoplasty - A new tool.

Velopharyngeal dysfunction (VPD) diagnosis and speech surgery outcomes are currently based solely on subjective evaluation criteria consisting of perceptual speech assessment and functional imaging. This study describes an objective and comparable method in VPD assessment and investigates the concurrence between the objective and subjective evaluations. The present study included 20 paediatric patients presenting with VPD after primary repair (intravelar veloplasty) of cleft palate. Our protocol was based on computerized analysis of voice parameters by means of an objective tool, spectrography integrated with Multi-Dimensional Voice Program (MDVP). The protocol also included perceptual evaluation by speech therapist and phoniatrician (consensus listening), and parents. This is a single surgeon, single centre experience and all patients underwent a secondary Furlow's palatoplasty. Assessments were performed pre- and postoperatively and upon completion of speech therapy. Results were compared using the two-tailed t student test for paired data. Statistical significance was set for p-values <0.05. Data analysis confirmed an improvement in velopharyngeal closure after surgery and speech therapy consistently with the results of perceptual evaluations. The results of the study confirmed the availability and reliability of an objective method for VPD evaluation based on the analysis of voice parameters with investigations that are simple and easily available in a hospital setting.

The role of the Sapienza GLObal Bedside Evaluation of Swallowing after Stroke (GLOBE-3S) in the prevention of stroke-associated pneumonia (SAP).

BACKGROUND AND PURPOSE: Stroke-associated pneumonia (SAP) affects 10 to 38% of patients in the acute phase of stroke. Stroke patients diagnosed with dysphagia have an 11-fold higher risk of developing SAP. Thus, identifying dysphagic patients through a highly accurate screening tool might be crucial in reducing the incidence of SAP. We present a case-control study designed to evaluate efficacy in reducing the risk of SAP between two swallowing screening tools, the classic water swallow test (WST) and a recently validated tool such as the GLOBE-3S (the Sapienza GLObal Bedside Evaluation of Swallowing after Stroke), which is a highly sensitive swallowing screening tool particularly accurate in detecting silent aspiration as well. METHODS: We analyzed the occurrence of dysphagia in 100 acute stroke patients distributed in two groups: half were screened with WST and the other half with GLOBE-3S. RESULTS: Dysphagia was diagnosed in 28 patients. The main result is that, among patients who passed the dysphagia screenings, none of those screened with the GLOBE-3S method developed pneumonia compared to 31.82% in the WST group. Discriminant function analysis (DFA) showed that NIH Stroke Scale (NIHSS) score and the dysphagia screening method (i.e., GLOBE-3S vs. WST) were the two main factors in the SAP's predicting model and the only significant ones per se. CONCLUSIONS: The new GLOBE-3S screening test can reduce the risk of SAP compared to WST.

Unilateral vocal fold paralysis post-thyroidectomy: does early intervention allow for better voice recovery?

OBJECTIVE: Thyroidectomy is the primary cause of unilateral vocal fold paralysis (UVFP). A delay in rehabilitation may cause dysfunctional phenomena and worsen dysphonia. The main aim is to investigate the impact of early Speech Therapy (ST) on voice recovery in UVFP post-thyroidectomy and propose an appropriate treatment schedule. PATIENTS AND METHODS: 93 patients with UVFP were analysed. 72 presented transient paralysis and 21 permanent ones. Individuals with permanent paralysis were retrospectively divided in two groups. Group A was composed of 11 patients (8 F, 3 M; mean age: 50.5 ± 8.6) who received ST within 8 weeks; Group B comprised 10 patients (7 F, 3 M; mean age: 57 ± 11.5) treated after more than 8 weeks. Videolaryngostroboscopy (VLS) was assessed and both objective and subjective voice parameters were collected. The non-parametric Wilcoxon test was applied to the sample. RESULTS: The resolution of supraglottic compensations was observed in 91% of cases in Group A, whereas in only 40% of cases in Group B. A functional glottal closure occurred in 73% of patients in group A, while it was completely absent in group B. Group A showed a statistically significant difference between the values of Jitter, NHR, TMF and VHI collected pre-ST compared to that collected after 1 year. Conversely, a statistically significant difference was found only for VHI values in group B. CONCLUSIONS: Early ST brings benefits to patients with permanent UVFP, both on voice recovery and on quality of life. A ST protocol should be applied both before and after thyroidectomy. The ST treatment should start early after surgery.

Sapienza Global Bedside Evaluation of Swallowing after Stroke: the GLOBE-3S study.

BACKGROUND AND PURPOSE: Dysphagia occurs in up to 50% of all patients with acute stroke. There is debate regarding which is the most effective screening tool in identifying aspiration in patients with acute stroke. We assessed the accuracy of the Sapienza Global Bedside Evaluation of Swallowing after Stroke (GLOBE-3S), which combines the Toronto Bedside Swallowing Screening Test (TOR-BSST©) with oxygen desaturation and laryngeal elevation measurement during swallowing. METHODS: We prospectively enrolled consecutive patients with stroke within 72 h of symptom onset. All patients with stroke firstly underwent a standard neurological examination, then the GLOBE-3S evaluation and finally the fiberoptic endoscopic evaluation of swallowing (FEES). Two different assessors, a neurologist and a speech pathologist, blind to both the clinical data and each other's evaluation, administered the GLOBE-3S and FEES examination. We assessed the accuracy of the GLOBE-3S in detecting post-stroke swallow impairment with aspiration using the FEES as the standard. RESULTS: We enrolled 50 patients with acute stroke, 28 of whom (56%) had swallowing impairment with aspiration at FEES evaluation. A total of 33 patients (66%) failed the GLOBE-3S evaluation. The GLOBE-3S reached a sensitivity of 100% and a specificity of 77.3% (negative predictive value, 100%; positive likelihood ratio, 4.34). The median time required for the GLOBE-3S to be performed was 297 s. CONCLUSIONS: GLOBE-3S is quick to perform at the bedside and can accurately identify aspiration in patients with acute stroke. By including the measurement of laryngeal elevation and monitoring of oxygen desaturation, it could represent a highly sensitive instrument to avoid the misdiagnosis of silent aspirators.

Late radiation-associated dysphagia in head and neck cancer patients: evidence, research and management.

In head and neck cancer (HNC) scenario, newer radiotherapy (RT) techniques, such as intensity modulated RT (IMRT), aim to reduce acute and late toxicity without impair tumor response and loco-regional control rates. However, late radiation-associated dysphagia (RAD) remains a major clinical problem and has gained a growing importance in the last few years, especially due to human papilloma virus (HPV)-related HNC favorable prognosis. The aim of this review was to provide clinical information about late RAD. The main anatomical structures involved in swallowing were described, in order to define potential organ at risk and available radiation-dose constraints in IMRT plan. Finally, possible rehabilitation strategies were proposed. This is expected to represent an opportunity for improved multidisciplinary management in HNC patients.

Long-term (12 to 18 months) functional voice assessment to detect voice alterations after thyroidectomy.

OBJECTIVES: Even when thyroidectomy preserves vocal cord motility it may leave patients with changes in voice quality. Although superior laryngeal nerve (LSN) damage after thyroidectomy manifests with aspecific symptoms, laryngoscopy discloses only slight morphological changes that are difficult to assess. We want to investigate the voice function in asymptomatic patients one year after thyroidectomy and to compare the obtained data against those of a healthy control group. PATIENTS AND METHODS: Thirty adult patients who had undergone thyroidectomy, all of them euphonic before and after the operation, were submitted to a complete voice assessment including voice self-evaluation tools, videolaryngostroboscopy and spectrographic analysis of voice. Primary outcome measures were differences between surgical patients and control group in terms of microperturbation of voice intensity and amplitude as measured by spectrographic analysis. RESULTS: In patients who had undergone thyroidectomy, acoustic parameters indicating amplitude microperturbations resulted slightly altered. All these values exceeded normal MDVP thresholds. Another interesting finding in our study sample concerns the lower F0 values we recorded in women patients after surgery than in healthy controls. Voice alterations may reflect prelaryngeal muscle scarring or fibrosis. Consider the possible alterations of vocal quality caused by scarring after surgery therefore strongly recommend surgery when the situation allows it, not to dissect the prelaryngeal muscles but only to spread apart. CONCLUSIONS: Our study conducted at least one year after thyroid surgery underlines that surgery-related slight voice deficits can persist over time. More refined phoniatric testing discloses voice alterations that normalize without specific rehabilitation therapy, therefore confirming that certain acoustic changes are clinically unimportant.

The Pooling-score (P-score): inter- and intra-rater reliability in endoscopic assessment of the severity of dysphagia.

This study evaluated the intra- and inter-rater reliability of the Pooling score (P-score) in clinical endoscopic evaluation of severity of swallowing disorder, considering excess residue in the pharynx and larynx. The score (minimum 4 - maximum 11) is obtained by the sum of the scores given to the site of the bolus, the amount and ability to control residue/bolus pooling, the latter assessed on the basis of cough, raclage, number of dry voluntary or reflex swallowing acts (< 2, 2-5, > 5). Four judges evaluated 30 short films of pharyngeal transit of 10 solid (1/4 of a cracker), 11 creamy (1 tablespoon of jam) and 9 liquid (1 tablespoon of 5 cc of water coloured with methlyene blue, 1 ml in 100 ml) boluses in 23 subjects (10 M/13 F, age from 31 to 76 yrs, mean age 58.56±11.76 years) with different pathologies. The films were randomly distributed on two CDs, which differed in terms of the sequence of the films, and were given to judges (after an explanatory session) at time 0, 24 hours later (time 1) and after 7 days (time 2). The inter- and intra-rater reliability of the P-score was calculated using the intra-class correlation coefficient (ICC; 3,k). The possibility that consistency of boluses could affect the scoring of the films was considered. The ICC for site, amount, management and the P-score total was found to be, respectively, 0.999, 0.997, 1.00 and 0.999. Clinical evaluation of a criterion of severity of a swallowing disorder remains a crucial point in the management of patients with pathologies that predispose to complications. The P-score, derived from static and dynamic parameters, yielded a very high correlation among the scores attributed by the four judges during observations carried out at different times. Bolus consistencies did not affect the outcome of the test: the analysis of variance, performed to verify if the scores attributed by the four judges to the parameters selected, might be influenced by the different consistencies of the boluses, was not significant. These initial data validate the clinical use of the P-score in the management of patients with deglutition disorders by a multidisciplinary team.

Morpho-functional patterns of physiologic oropharyngeal swallowing evaluated with dynamic fast MRI.

With the advent of dynamic fast MRI sequences the act of deglutition can be dynamically visualized in cine-mode. Twenty-three healthy volunteers were enrolled in this study to define the morpho-functional patterns of oral and pharyngeal deglutition using new dynamic MRI techniques. All subjects were previously submitted to video endoscopic assessment, to exclude swallowing abnormalities. As contrast material a combination of yogurt mixed with gadolinium-diethylene diamine pentaacetic acid was used. The protocol was divided into three parts: (a) preliminary assessment of the oral cavity, pharynx and laryngeal structures; (b) morphologic assessment of tongue, soft palate, pharynx, epiglottis and larynx-hyoid bone; (c) dynamic assessment of swallowing without administrating any contrast media and, in subsequent phase, by injecting 5 ml of yogurt-based contrast medium in the patient's mouth. The time resolution was 3-4 images/s. The MR protocol revealed to be effective in the evaluation of normal motility patterns of the structures involved in swallowing. Moreover, the evaluation of the bolus progression, slowdown or stagnation, was possible. On the contrary problems were encountered in calculating precisely the bolus progression time, because of the insufficient temporal resolution. However, more energy should be invested to optimize the spatial and temporal resolution of turbo-FLASH sequences, to obtain a better dynamic representation of a complex function such as deglutition.

Actinomycosis of submandibular gland: an unusual presentation.

An unusual presentation of oro-facial actinomycosis, mimicking the clinical appearance of a malignant lesion is reported. The patient, a 74-year-old female, presented with a right submandibular mass, which slowly grew in size over a period of about 2 months, and a modest dysphagia. A painless cervical mass was palpable over the submandibular region. The rhino-pharyngo-laryngeal region, explored by flexible fiberoptic examination, was normal. At ultrasonography, a 2x2 cm infiltrating dyshomogeneous mass, involving the right submandibular gland, was visible. No connection with adjacent organs was found. There was no associated cervical lymphoadenopathy. Ultrasound-guided fine-needle aspiration cytology, performed on lesion, revealed no evidence of malignancy. The presence of characteristic colonies of actinomyces infection was found. The patient was treated initially with tetracycline chloridrate 100 mg: 1 tablet every 12 hours for 7 weeks, but a repeat ultrasonography showed no resolution. A further fine-needle aspiration cytology showed no actinomyces infection in the specimen. The patient was treated with methylprednisolone, 20 mg every 24 hours, for 5 days. After steroid treatment, the patient has been well and, upon repeat ultrasonography, total resolution of the submandibular lesion was confirmed. In conclusion, the clinical presentation of cervicofacial actinomycosis is variable and may mimic a malignant lesion or chronic granulomatous infections. Diagnostic and therapeutic findings are discussed.

Transit time of swallowing after subtotal laryngectomy.

INTRODUCTION: The aim of subtotal laryngeal surgery (Cricohyoidopexy = CHP and Cricohyoidoepiglottopexy = CHEP) is to create a simplified but functional neolarynx. The neolarynx permits the passage of air, the closure of the airway, and ensures phonation through the vibration of the cricoid and arytenoid mucosa; furthermore, it allows the recovery of swallowing, optimizing the closure of the neoglottis with the movement of the remaining arytenoids. The aim of the present study was to evaluate, on a long-term basis, the efficiency of the swallowing function comparing swallowing times in CHEP and CHP with and without functional neck dissection (FND). MATERIALS AND METHODS: A radiological study was conducted on 48 patients selected from a group of 253, who underwent subtotal laryngectomies at the "G. Ferreri" Department of Otorhinolaryngology, Audiology and Phoniatrics of the University of Rome "La Sapienza". The selection of the 48 patients was carried out based on the following criteria: type of surgery, date of surgery (follow up of at least 12 months), patients who were not treated with radiotherapy before or after surgery, patients who were also examined with fibrolaryngoscopy and videofluoroscopy, patients not affected by motor deficits involving phonatory and swallowing regions (stroke, lesions of the central nervous system), negative follow up (no evidence of disease). The parameters for evaluating the functional recovery were the times the nasogastric tube and tracheotomy tube were kept in place. The functional recovery times of the groups thus formed were compared to one another Through videofluoroscopy the authors evaluated oral transit times (OTT) and pharyngeal transit times (PTT) as parameters of deglutition. RESULTS: The results consistently showed that swallowing time remains under one second as in individuals with normal swallowing functions. CONCLUSION: The study of deglutition times, conducted at least 12 months after surgery, does not show any substantial differences between CHEP and CHP with reference to pharyngeal transit and oral transit times.

Functional results of sub-total laryngectomy.

Sub-total laryngectomy (crico-hyoido-pexy and crico-hyoido-epiglotto-pexi), while achieving a radical oncological control results in a functional neolarynx efficacious in swallowing as well as in phonatory activities. 102 out of the 122 patients, treated with sub-total laryngectomy, underwent functional evaluations: the results appear to be extremely variable within each group. A better performance in crico-hyoido-epiglotto-pexi (CHEP) rather than in crico-hyoido-pexi (CHP) has been observed in these patients. However, a good life quality and social rehabilitation was assured to patients in both cases.

[Functional recovery in subtotal laryngectomies]. / Il recupero funzionale nelle laringectomie subtotali.

Subtotal laryngectomy, a valid treatment for carefully selected patients, is a safe oncologic procedure which preserves the cricoid-arytenoid unit creating a successful "neo-larynx" with valid phonatory and deglutition functions. At the E.N.T. Clinic of "La Sapienza" University of Rome from Jan. 1984 to Feb. 1992, 85 subjects underwent subtotal laryngectomy, 50 of which then underwent phoniatric examination. The remaining patients were not suitable candidates because of the trachealis cannula (14), or because they were lost at follow up (16). A total of 50 male subjects were examined. Twenty-eight underwent crico-hyoid-pexia, while 22 patients underwent crico-hyoid-epiglotto-pexia. Attention is drawn to the results which appear to be extremely variable with regard to each study group. We obtained better results with crico-hyoid-epiglotto-pexia than with crico-hyoid-pexia and we guaranteed a good social re-insertion in all cases.

[Rehabilitation of oro-pharyngeal dysphagia of neurogenic etiology using radiological examination: preliminary results]. / Riabilitazione della disfagia oro-faringeaad eziologia neurogena guidata dall'indagine radiologica: risultati preliminari.

Dysphagia is more frequently observed in patients with neurologic diseases (stroke, bulbar or pseudo-bulbar syndrome, amyotrophic lateral sclerosis, cranial trauma). Furthermore, the presence of this pathology is obviously more frequently noted in the light of the increase in the length of the human life span. It has become evident that alternative feeding procedures such as the nasogastric tube or gastrostomy may bring about complications and deprive patients of the oral phase of deglutition which plays a leading role in stimulating digestive functions. The Authors report a systematic research on the rehabilitation aspects of neurogenous dysphagia. All the patients studied underwent a neurological examination and oropharyngeal functional evaluation using echo-videorecording of the oral phase of deglutition and fluoro-videorecording of the pharyngeal phase. The data obtained allowed for the selection of five patients considered suitable for the rehabilitation program. One of them had a multi-infarct encephalopathy, two a spastic hemiplegia f.b.c., a fourth a cerebellar syndrome and the last a sequela of meningioma removal of the ponto-cerebellar angle with peripheral paralysis of the right VII, IX, X, XI cranial nerves. This last patient also underwent a crico-pharyngeal myotomy. Therapy consisted in making the patient sensitive to swallowing movements and in training them to assume a compensatory posture as well as functional rehabilitation of the organs involved in deglutition. The first datum emerging from the study is the lack of etiological homogeneity found in the cases treated with evident variability in different deglutition organ impairment, even though there was the common denominator of the dysphagia symptom. With regard to the results obtained, there was a complete resolution in one patient, while in the other four there was such an improvement as to allow the patients a safe autonomous oral assumption of food. The positive results obtained are not only linked to the recovery of damaged organs, but also to the development of compensatory strategies such as the choice of appropriate food consistency and the assumption of postures which protect the respiratory tract from aspiration and favor crico-pharyngeal relaxation.