Oral Dysfunction in Patients With Head and Neck Cancer: A Systematic Review.

BACKGROUND: Head and neck cancers (HNCs) and their treatment may cause oral function impairment. PURPOSE: This study was designed to identify oral dysfunction in patients receiving treatment for HNCs using a systematic review. METHODS: The PubMed, Embase, and CINAHL databases were searched for studies on oral function impairment in patients receiving treatment for HNCs published between January 2014 and May 2019. Only descriptive, correlational, and interventional quantitative studies that included patients receiving treatment for HNCs who presented with oral dysfunction, were published in English during the aforementioned time frame, and were accessible in full-text versions were selected. RESULTS: Twenty-eight studies (13 cross-sectional, two longitudinal, 12 randomized controlled trial, and one retrospective chart review) fulfilled the inclusion criteria. Oral mucositis, dysphagia, xerostomia, trismus, and chewing and speech problems were the most common oral dysfunctions. Age, cancer stage, tumor location, treatment modalities, treatment status, treatment dose, and pretreatment oral function were factors associated with oral dysfunction. Although individual interventions were shown to improve oral dysfunction, the related evidence was inconclusive. CONCLUSIONS/IMPLICATIONS FOR PRACTICE: Primary HNCs and their treatment significantly deteriorate oral function. A holistic and interdisciplinary approach may maximize oral function.

Clinical side effects after oral administration of palm oil and Alchornea cordifolia decoction in a child.

Alchornea cordifolia is known to be a plant with a variety of medicinal properties and is quoted by many traditional healers to treat a variety of medicinal problems in the Democratic Republic of Congo. However, very little is known about its potential toxicity. We report the case of a 9-year-old boy referred for assessment of suspected bronchial troubles without a history of atopic disease or drug allergy who developed dyspnea, dysphagia, asthenia and lingual ulcers within 30 minutes after nasal and oral administration of decoction of palm oil associated with A. cordifolia leaves in water. In the present report, adverse effects of A. cordifolia therapy may be related to the mixtures of active compounds that they contain and can cause the symptoms observed in our patient. These findings call for caution in the use of A. cordifolia especially in children.

[Laryngeal dystonia: novel forms of therapeutic administration of botulinum toxin by direct routes]. / Distonia laringea: nuevas formas de administracion terapeutica de toxina botulinica por via directa.

AIM: To describe our experience in the treatment of laryngeal dystonia (in abduction and adduction), with special emphasis given to the technical aspects (approach procedure, dosage and type of botulinum toxin type A used), as well as treatment response and possible side effects. PATIENTS AND METHODS: We conducted a cross-sectional descriptive study of a sample of patients with laryngeal dystonia treated by means of transoral administration of onabotulinumtoxinA or incobotulinumtoxinA over a period of 10 years (2007-2017). Data collected include demographic and clinical variables, treatment response (based on a self-rating scale), the duration of treatment and the appearance of side effects. SAMPLE SIZE: 15 patients (11 women; mean age: 44.06 years) with laryngeal dystonia (mean time since onset of 40 months; 12 patients with dystonia in adduction) and 174 administrations (92% incobotulinumtoxinA; average dosage of 5 U in each vocal cord). The procedure took an average of 11.7 minutes to perform. Response was good in 31% of the procedures and very good in 57.5%. Side effects were recorded in 14.4% of the procedures, although always mild and transitory, with a predominance of dysphagia and dysphonia. CONCLUSION: In our experience, transoral administration of botulinum toxin type A to treat laryngeal dystonia has proved to be a simple, quick, effective and safe technique.

TITLE: Distonia laringea: nuevas formas de administracion terapeutica de toxina botulinica por via directa.Objetivo. Describir nuestra experiencia en el tratamiento de la distonia laringea (en abduccion y aduccion), destacando los aspectos tecnicos (procedimiento de abordaje, dosis y tipo de toxina botulinica de tipo A utilizada), asi como la respuesta al tratamiento y los posibles efectos adversos. Pacientes y metodos. Estudio descriptivo transversal de una muestra de pacientes con distonia laringea tratados mediante administracion transoral de onabotulinumtoxina o incobotulinumtoxina A durante un periodo de 10 años (2007-2017). Se recogen las variables demograficas y clinicas, la respuesta al tratamiento (a partir de una escala de autoevaluacion), la duracion de este y la aparicion de efectos adversos. Resultados. Tamaño muestral: 15 pacientes (11 mujeres; edad media: 44,06 años) con distonia laringea (tiempo medio de evolucion de 40 meses; 12 pacientes con distonia en aduccion) y 174 administraciones (92% incobotulinumtoxina A; dosis media de 5 U en cada cuerda vocal). La duracion media del procedimiento fue de 11,7 minutos. La respuesta fue notable en el 31% de los procedimientos y alta en el 57,5%. Se registraron efectos adversos en el 14,4% de los procedimientos, siempre de caracter leve y transitorio, con predominio de la disfagia y la disfonia. Conclusion. En nuestra experiencia, la administracion transoral de toxina botulinica de tipo A como tratamiento de la distonia laringea ha demostrado ser una tecnica sencilla, rapida, eficaz y segura.

Dysphagia and Speech-Language Pathology Involvement Following Chemical Ingestion Injury: A Review of 44 Cases Admitted to a Quaternary Australian Hospital (2008-2012).

PURPOSE: This study aimed to explore the clinical characteristics of an adult chemical ingestion population and examine the course of return to oral intake post injury and speech-language pathologist (SLP) involvement during the initial acute-care admission. METHOD: A retrospective chart review of adults admitted to a quaternary hospital for the treatment of an acute chemical ingestion injury between 2008 and 2012 was conducted. RESULTS: Forty-four adults (23 men, 21 women) were identified as receiving treatment for ingestion injury, of whom 18 (40.91%) required altered oral intake. Of those requiring altered oral intake, 50% were referred to SLPs. Individuals requiring altered oral intake were significantly (p < .05) older, more likely to be men, and present with more severe injuries requiring longer ICU and hospital admissions following intentional chemical ingestions than those who were able to commence a normal oral diet without any alteration or nonoral supplementation. By discharge, 15.91% (n = 7) of the total cohort had not resumed normal oral intake. CONCLUSIONS: Return to oral intake post chemical ingestion injury can be protracted and complex. Referrals to SLPs were limited. These data may aid prognostic insight as well as provide (a) collateral information to assist discharge planning and follow-up and (b) background for evaluating the potential for SLP involvement.

Persistent Dysphagia After Induction Chemotherapy in Patients with Esophageal Adenocarcinoma Predicts Poor Post-Operative Outcomes.

PURPOSE: Preoperative therapy is frequently employed in the management of esophageal adenocarcinoma. However, many patients are found to have advanced pathologic stage and have poor outcomes. A prognostic factor which identifies this patient population before surgery would be desirable, as alternative treatment strategies may be warranted. METHODS: Between 2/08 and 1/12, 60 evaluable patients with locally advanced esophageal adenocarcinoma enrolled in single-arm phase II trial of induction chemotherapy, surgery, and post-operative adjuvant chemo-radiotherapy (CRT). A clinical stage of T3, N1, or M1a (AJCC 6th) was required for eligibility. Induction chemotherapy with epirubicin 50 mg/m2 d1, oxaliplatin 130 mg/m2 d1, and fluorouracil 200 mg/m2/day continuous infusion for 3 weeks, was given every 21 days for 3 cycles and was followed by surgical resection. Adjuvant CRT consisted of 50-55 Gy @ 1.8-2.0 Gy/day and 2 cycles of cisplatin (20 mg/m2/day) and fluorouracil (1000 mg/m2/day) given as 96-h infusions during weeks 1 and 4 of radiotherapy. Dysphagia was assessed at baseline and after induction chemotherapy. RESULTS: Persistent dysphagia was associated with worse distant metastatic control [HR 3.48 (1.43-8.43), p = 0.006], recurrence free survival [HR 3.04 (1.34-6.92), p = 0.008], and overall survival [HR 3.31 (1.43-7.66), p = 0.005]. Persistent dysphagia was associated with more advanced pathologic T descriptor (pT) (p = 0.048) and N descriptor (pN) (p = 0.002), a greater median number of involved lymph nodes (3 v 1, p = 0.003), and greater residual tumor viability (p = 0.05). No patients with persistent dysphagia had pT0-T2 or pN0 disease. CONCLUSIONS: Persistent dysphagia after induction chemotherapy is associated with more advanced pathologic stage and inferior outcomes.

Utilizing Cerebral Perfusion Scan and Diffusion-tensor MR Imaging to Evaluate the Effect of Hyperbaric Oxygen Therapy in Carbon Monoxide-induced Delayed Neuropsychiatric Seqeulae- A Case Report and Literature Review.

PURPOSE: Detection of regional cerebral blood flow (rCBF) and/or brain magnetic resonance imaging (MRI) has been used to investigate functional defect of brain caused by carbon monoxide (CO) poisoning. In this report, we attempted to demonstrate the correlation of changes in brain singlephoton emission computed tomography (SPECT) and diffusion-tensor MR image (DTI) with functional improvement of severe delayed neuropsychiatric sequelae (DNS) after CO intoxication during the treatment of hyperbaric oxygen therapy (HBOT). CASE REPORT: The patient had normal activities of daily life after he recovered from acute CO poisoning. One month later, he presented symptoms of declined cognitive functioning, aphasia, apraxia, dysphagia, muscle rigidity, urine and fecal incontinence. After one course of HBOT, these symptoms improved significantly and the patient could regain most of his previous functioning. The patient's improvement was evidenced by increased rCBF in Brodmann areas 7, 8, 11 and 40, as well as higher mean fractional anisotropy (FA) value of DTI. CONCLUSION: Although the efficacy of HBOT in DNS patients is still needed to be evaluated in large clinical study, these data suggest that HBOT may be the choice to improve DNS efficiently and shorten the duration of suffering with favorable outcome.

Botulinum toxin A for children with salivary control problems.

OBJECTIVE: The aim of this study was to review the response of children who have received botulinum toxin A (BtA) injections for saliva control in our institution. METHODS: Retrospective case series of children attending a saliva control clinic in a paediatric tertiary referral hospital. Children were identified from the saliva control database, which has been in place since its creation in 2006. Prior to receiving BtA all the children in the study had previously undertaken a 3-month trial of pharmacological therapy, with no effect. All BtA injections were performed freehand to the parotid and submandibular glands. The background diagnosis, comorbidities for the child, age at presentation, dose of BtA, the response, and any complications were recorded. RESULTS: 97 children were identified and 175 BtA doses were given (median per child: 1, mean: 1.9). 59 (61%) were male. The age range was between 2 months and 18 years (mean 8.6 years, median 8.8 years). The dose injected varied between 0.52 units/kg and 21.28 unit/kg (mean 5 units/kg, median 4.2 units/kg). These were performed using local anaesthetic on 131 (75%) occasions. The remainder were performed under general anaesthetic. Responses to BtA were classed as effective 109 (62%), partially effective 14 (8%) or not effective 50 (29%). The response duration was between 0.25 and 18 months (mean 4 months). Complications were seen following 22 injections (10.9%). Data modelled using binary logistic regression found that male gender and children with cerebral palsy are statistically predicted to have a better response to BtA. CONCLUSION: Botulinum A injected under local anaesthetic is a safe, effective treatment for children with sialorrhoea. Ultrasound guidance is not necessary as long as anatomical landmarks are used for placement. The main adverse effect that can result is dysphagia, which is of concern in children that can swallow independently prior to injection. Male sex and cerebral palsy are statistically independent positive predictive factors for successful outcome of BtA injections for sialorrhoea, however this does not preclude other children from receiving or benefitting from it. Children that respond well to BtA initially, are likely to respond well in the future.

Toxicity data for preoperative concurrent chemoradiotherapy with oxaliplatin and continuous infusion 5-fluorouracil for locally advanced esophageal cancer.

The purpose of this retrospective analysis was to characterize the feasibility and tolerability of oxaliplatin/5-fluorouracil (5-FU) given concurrently with radiotherapy for patients with locally advanced esophageal cancer. Between July 2005 and March 2009, 15 patients with clinical stage T3/T4 and/or N1/M1a lower esophageal or gastroesophageal junction adenocarcinoma were treated with preoperative chemoradiotherapy using oxaliplatin every 2 weeks and continuous infusion 5-FU. The main treatment-related toxicities were oral mucositis and dysphagia. During the first 2 weeks of treatment, 20% of patients presented with grade 1-2 oral mucositis, and one patient developed grade 1 dysphagia. In weeks 3-4, 53% of the patients experienced grade 1-2 mucositis, and 40% experienced grade 1-2 dysphagia. One patient only experienced grade 3 mucositis in week 4. Three patients (20%) had grade 3-4 dysphagia in weeks 3-4 and were continued on intravenous fluids and pain medications. During the last 2 weeks of chemoradiotherapy, 53% of patients reported grade 1-2 oral mucositis, mostly grade 1 and 73% of patients experienced grade 1-2 dysphagia and 26% patients experienced grade 3-4 dysphagia. Other toxicities included fatigue, nausea, neuropathy, and diarrhea. Only one patient experienced > 10% weight loss. The whole group was treated with aggressive supportive care during radiotherapy. Five (33%) patients achieved a pathological complete response. No patients developed locoregional failure. Sixty percent of the patients developed distant metastases and the 2-year disease-free survival was 53%. The median survival was 3.2 years with the 2-year overall survival of 73%. Preoperative oxaliplatin/5-FU-based chemoradiotherapy for locally advanced esophageal cancer is feasible, but associated with substantial gastrointestinal toxicity. A careful attention to nutrition and hydration throughout the course of therapy is required.

Aluminium phosphide-induced esophageal stricture palliation with polyflex stent.

A 21-year-old woman developed midesophageal stricture two weeks after ingestion of aluminium phosphide (AlP) tablets. Aluminium phosphide is a lethal protoplasmic toxin and is also the most common cause of suicidal poisoning in northern India. Upper gastrointestinal endoscopy (UGIE) showed a tight esophageal stricture 29 cm from the incisors with a circumferential ulcer. Dilatation up to 17 mm was done using Savary-Gilliard dilators. She had repeated dilatations three times at nearly two-week intervals. In view of the resistant stricture, a silicone Polyflex stent was placed across the stricture and removed after 3 months; there was no recurrence of stricture even after three months of follow-up. Patients with recurrent esophageal stricture and those with fistula may benefit from silicone expandable stents.

Pica and the elephant's ear.

This is a case report of an otherwise healthy 2-year-old boy with a history of pica, associated with iron deficiency anemia. This boy was referred to our department for a neurologic evaluation because of an acute episode of sialorrhea, difficulty in speaking, dysphagia, and repeated swallowing movements. An uncertain episode of a brief-duration still gaze was also reported. In addition, the history revealed that the child had earlier ingested a leaf from a poisonous houseplant called Colocasia esculenta, also known as "elephant's ear." The habit of pica subsided after treatment with iron supplements. A 9-month follow-up period was uneventful. Neurologic manifestations can accompany accidental intoxications of some non-nutrient substances. Thus, pica must be suspected in children with acute behavior alterations.

Ecbalium elaterium (squirting cucumber)--remedy or poison?

BACKGROUND: Ecbalium elaterium is a plant endemic to the Mediterranean basin. Its roots and cucumber-shaped fruit have been used in folk medicine since antiquity. The alleged uses of the fruit juice are as a potent cathartic, analgesic, and antiinflammatory agent. Cucurbitacin B, a triterpene derivative is the active antiinflammatory principal. PATIENTS: We present a series of 13 patients who were exposed to the juice of Ecbalium elaterium in its natural form. In 3 patients, exposure was intranasal for the treatment of sinusitis or liver cirrhosis. In 3 other cases, children ingested the fruit unwittingly. In 6 patients, exposure was ocular and, in one, dermal. Within minutes of exposure, the patients exhibited irritation of mucous membranes at various degrees of severity manifested as edema of pharynx, dyspnea, drooling, dysphagia, vomiting, conjunctivitis, corneal edema, and erosion, depending on the route of the exposure. Recovery began within several to 24 hours after administration of oxygen, steroids, antihistamines, and beta-2-agonists. Ocular exposures responded to topical steroid and antibiotic eyedrops within a few days. The toddler with the dermal exposure remained asymptomatic. CONCLUSION: Exposure to the juice of Ecbalium elaterium, mainly in its undiluted form, may cause irritation of mucous membranes, supposedly of inflammatory nature. Patients exposed orally or intranasally should be closely followed for upper airway obstruction. Patients exposed ocularly should have their eyes promptly irrigated to prevent corneal and conjunctival injury.

Induction chemotherapy followed by concurrent chemotherapy and high-dose radiotherapy for locally advanced squamous cell carcinoma of the upper-thoracic and midthoracic esophagus.

The purpose of this study was to evaluate the efficacy and toxicity of an induction chemotherapy schedule followed by high-dose radiotherapy and concurrent chemotherapy for locally advanced squamous cell carcinomas of the upper and midthoracic esophagus. Patients were treated with three courses of fluorouracil, leucovorin, etoposide, and cisplatin-containing induction chemotherapy followed by high-dose external beam radiotherapy to 65 Gy in 6 weeks for T4 and obstructing T3 tumors. Transversable T3 tumors received 60 Gy in 6 weeks by external radiotherapy, followed by two high-dose-rate esophageal brachytherapy fractions of 4 Gy in 5-mm tissue depth. Concurrent to radiotherapy, cisplatin and etoposide were given. Long-term survival of 22 patients was 41% and 31% at 2 and 3 years, respectively, with a median follow-up of 39 months. The probability of locoregional tumor recurrence was 60% at 3 years for all patients and 30% for those with a partial or complete response to induction chemotherapy. Acute toxicity of this schedule was moderate. Long-term survivors had a good swallowing function. This schedule offers a considerable chance of long-term survival for patients with locally advanced squamous cell carcinomas of the upper and midthoracic esophagus. Local in-field recurrences are the main risk after definitive radiochemotherapy. Dose escalation of radiotherapy is possible because of the observed low late toxicity.

[Legionella pneumonia caused by aspiration of hot spring water after sarin exposure].

A 72-year-old man was exposed to the sarin gas attack in a Tokyo subway on March 20 th, 1995. After exposure, he noticed eye discomfort, chest tightness, headache and weakness of the lower limbs and oropharyngeal muscles. Despite these symptoms, he visited a hot spring on the same day with his family. On March 25 th, his muscle weakness progressed, and a low grade fever appeared. His muscle weakness disappeared 8 days after exposure to sarin, but respiratory failure rapidly developed, necessitating artificial ventilation within four day after hospitalization on March 28th. Chemotherapy with erythromycin, imipenem/cilastatin, and steroid pulse therapy was begu. PCR and culture of sputum collected by bronchofiberscopy were positive for Legionella pneumophila, serogroup I. His respiratory state improved, but subsequent infection with Pseudomonous aeruginosa. Enterobacter cloacae, and Candida tropicalis/glabrata caused his death 71 days after admission. Oropharyngeal muscle weakness caused by sarin-mediated cholinesterase inhibition was strongly suspected as the cause of hot spring water aspiration. Transbronchial lung biopsy revealed organizing pneumonia with fibrosis. Bronchoscopic findings included redness, edema and fragility of all visible areas of the airway, which was thought to be due to bronchitis caused by Legionellosis.

Experiences with a new ergoline (CF 25-397) in parkinsonism.

Studies on rats with unilateral nigral lesions suggest that a new ergoline, CF 25-397, is a dopaminergic agonist that might improve parkinsonism. CF 25-397 induces less stereotyped behavior than other dopaminergic agents in rats, and might therefore cause less dyskinesia than levodopa in man. We investigated the clinical actions of CF 25-397 in nine patients. During treatment, severe deterioration resulted in hypokinesia and rigidity; five patients showed marked dysphagia and dysphonia. There was statistically significant deterioration in four timed tests. Mild improvement, not statistically significant, was noted in tremor. These results indicate that clinical implication of the response to potential therapeutic agents in rodent models of parkinsonism must be interpreted with caution.

Complications of "slow-K" therapy.

(1) The failure of ;Slow-K' tablets to disintegrate prevents rapid release but allows them to be trapped by their bulk in the intestine.(2) Two cases are reported. In the first the tablet was trapped in a caecal diverticulum and the patient developed an abcess. In the second, abdominal pain developed which subsided when ;Slow-K' was stopped. Later ;Slow-K' was again started and the patient developed dysphagia.(3) The possibility of abdominal complications with this treatment should be remembered.(4) Effervescent KC1 preparations may replace ;Slow-K' but KC1 supplementation may be necessary only in cardiac disease.