Platelet Rich plasma injection of the vocal folds in benign vocal pathologies.

PURPOSE: There are few options for treatment of dysphonia secondary to vocal pathology related to lamina propria scar, atrophy, sulcus, or inflammatory disorders. Platelet rich plasma (PRP) may provide anti-inflammatory and regenerative properties seen with other tissue engineering therapies without the risks associated with these treatments. We evaluated vocal fold (VF) injection of PRP for feasibility, phonatory effects, patient satisfaction and durability. METHODS: Patients with dysphonia secondary to vocal fold scar, atrophy, sulcus and inflammatory lesions were included. PRP injections were administered in office, to bilateral vocal folds. Patients were followed up at 1 week, 1 month, 3 months and 6 months to assess outcomes (GRBAS scale, maximum phonation time, vocal fatigue index (VFI), voice handicap index (VHI-10) and stroboscopy). RESULTS: 75 intracordal PRP injections were administered to 48 patients. All injections were completed, and no adverse reactions were experienced. Improvements in VHI-10 scores at 1,3,6 months were seen (mean VHI 21.73 at baseline, 15.62 at six months, p < 0.001). 72.3% rated improvement at 7 or above on Likert scale. 95.7% of patients would consider a future PRP injection. Secondary outcomes VFI, MPT, and GRBAS also demonstrated significant improvements over time. Patients receiving a single PRP injection (n = 26) still demonstrated significant VHI-10 improvements at 1,3 and 6 months. CONCLUSIONS: VF office PRP injections are feasible and safe and can provide phonatory benefit and reduce vocal effort in benign VF disorders. A single PRP injection is sufficient to provide sustained benefit in some cases. LEVEL OF EVIDENCE: Level III: prospective cohort study.

'It's very values driven': A qualitative systematic review of the meaning of compassion according to healthcare professionals.

AIMS AND OBJECTIVES: To explore the meaning ascribed to the concept of compassion by healthcare professionals. BACKGROUND: Compassion is universally regarded as the foundation of healthcare, a core value of healthcare organisations, and essential to the provision of quality care. Despite increasing research on compassion in healthcare, how healthcare professionals understand compassion remains unclear. DESIGN: A systematic review of qualitative studies was conducted and is reported following PRISMA guidelines. METHOD: Medline, Emcare, PsychINFO and CINAHL were searched to November 2021 for qualitative studies in English that explored healthcare professionals' understandings of compassion. Included studies were appraised for quality before data were extracted and thematically analysed. FINDINGS: Seventeen papers met the inclusion criteria. An overarching theme, 'It's very values driven' underpins the four main themes identified: (1) 'It's about people and working with them': Compassion as being human, (2) 'There is this feeling': Compassion as being present, (3) 'If I don't understand them, I won't be able to help': Compassion as understanding, (4) 'Wanting to help in some way': Compassion as action. CONCLUSIONS: Healthcare professional participants reported compassion as motivated by values and inherent to humanistic healthcare practice. The meanings healthcare professions described were varied and contextual. Qualitative research should further explore healthcare practitioners' experiences of compassion as part of their practice to inform health professions education, policy, and practice. RELEVANCE TO CLINICAL PRACTICE: To practice with compassion, healthcare professionals require supportive and humanistic organisations that honour each person's humanity and encourage people to be human and compassionate to each other as well as to patients, their families and/or carers. Healthcare professionals need to reflect on what compassion means to them, how it is situated within their unique practice context, and how compassion can enhance clinical practice. NO PATIENT OR PUBLIC CONTRIBUTION: This systematic review had no patient or public contribution.

Impact of Quantitative Videofluoroscopic Swallowing Measures on Clinical Interpretation and Recommendations by Speech-Language Pathologists.

Quantitative measures are available for adult videofluoroscopic swallow study (VFSS) analysis but are yet to be seen routinely in clinical practice. This study explores agreement between traditional observational analysis and quantitative analysis, and the impact of analytical approaches on subsequent diagnosis and recommendations. One hundred adults referred for VFSSs with swallowing concerns were administered a standardised VFSS protocol. All VFSSs were analysed using three approaches: (1) a traditional observational analysis typically used by treating speech-language pathologists (SLPs), (2) quantitative analysis by two independent raters, and (3) binary subjective analysis by 11 independent raters. Three metrics were focussed on; pharyngeal constriction (PC), hyoid displacement (Hmax) and pharyngoesophageal segment opening (PESmax). All raters were blinded to others' ratings. Treating SLPs using traditional observational analysis were provided with no instructions. Quantitative analysis used published Leonard and Kendall digital displacement measures. Binary subjective analysis involved rating each VFSS as normal versus impaired for the three metrics above. Treating SLPs using traditional observational analysis and quantitative analysis raters independently provided diagnostics and treatment plans. PC, Hmax and PESmax achieved fair agreement (Kappa = 0.33-0.36) between binary subjective analysis compared to substantial agreement (ICC = 0.77-0.94) for quantitative analysis. Reports of impairment were significantly lower in the traditional observational and binary subjective analyses compared with studies rated using the quantitative analysis (p < 0.05). Consequently, this resulted in significantly less rehabilitation recommendations when traditional observational analysis was used in comparison to the quantitative analysis. Quantitative measures to analyse VFSSs can be used in clinical practice producing increased inter-rater agreement and supporting more targeted rehabilitation recommendations than using a traditional observational VFSS analysis alone.

Variability in Swallowing Biomechanics in Infants with Feeding Difficulties: A Videofluoroscopic Analysis.

Clinicians performing feeding evaluations in infants often report swallow variability or inconsistency as concerning. However, little is known about whether this represents pathological incoordination or normal physiologic variance in a developing child. Our retrospective study explored quantitative videofluoroscopic measures in 50 bottle-fed infants (0-9 months) referred with feeding concerns. Our research questions were as follows: Is it possible to assess swallow to swallow variability in an infant with feeding concerns, is there variability in pharyngeal timing and displacement in infants referred for videofluoroscopy, and is variability associated with aspiration risk? Measures were taken from a mid-feed, 20-s loop recorded at 30 frames per second. Each swallow within the 20-s loop (n = 349 swallows) was analysed using quantitative digital measures of timing, displacement and coordination (Swallowtail™). Two blinded raters measured all swallows with strong inter-rater reliability (ICC .78). Swallow frequency, suck-swallow ratio, residue and aspiration were also rated. Variability in timing and displacement was identified across all infants but did not correlate with aspiration (p > .05). Sixteen infants (32%) aspirated. Across the cohort, swallow frequency varied from 1 to 15 within the 20-s loops; suck-swallow ratios varied from 1:1 to 6:1. Within-infant variability in suck-swallow ratios was associated with higher penetration-aspiration scores (p < .001). In conclusion, pharyngeal timing and displacement variability is present in infants referred with feeding difficulties but does not correlate with aspiration. Suck-swallow ratio variability, however, is an important risk factor for aspiration that can be observed at bedside without radiation. These objective measures provide insight into infant swallowing biomechanics and deserve further exploration for their clinical applicability.

Dysphagia Care Across the Continuum: A Multidisciplinary Dysphagia Research Society Taskforce Report of Service-Delivery During the COVID-19 Global Pandemic.

At the time of writing this paper, there are over 11 million reported cases of COVID-19 worldwide. Health professionals involved in dysphagia care are impacted by the COVID-19 pandemic in their day-to-day practices. Otolaryngologists, gastroenterologists, rehabilitation specialists, and speech-language pathologists are subject to virus exposure due to their proximity to the aerodigestive tract and reliance on aerosol-generating procedures in swallow assessments and interventions. Across the globe, professional societies and specialty associations are issuing recommendations about which procedures to use, when to use them, and how to reduce the risk of COVID-19 transmission during their use. Balancing safety for self, patients, and the public while maintaining adequate evidence-based dysphagia practices has become a significant challenge. This paper provides current evidence on COVID-19 transmission during commonly used dysphagia practices and provides recommendations for protection while conducting these procedures. The paper summarizes current understanding of dysphagia in patients with COVID-19 and draws on evidence for dysphagia interventions that can be provided without in-person consults and close proximity procedures including dysphagia screening and telehealth.

Predicting penetration-aspiration through quantitative swallow measures of children: a videofluoroscopic study.

PURPOSE: Quantitative measures have improved the reliability and accuracy in interpretation and reporting of videofluoroscopy (VFSS). Associations between quantitative VFSS measures and swallow safety in children are not widely reported. The ability to predict aspiration in children, even if not observed during brief VFSS, will improve diagnostic reporting and potentially reduce the need for extended radiation time. The aims of this study were to determine associations between quantitative fluoroscopic swallow measures and penetration-aspiration and to predict likelihood of penetration-aspiration. METHODS: We selected videofluoroscopic data of 553 children from a pediatric hospital database for this single-center retrospective observational study. A standard protocol of VFSS administration was used and data were recorded at 30 frames-per-second. A set of quantitative and descriptive swallow measures was obtained using a specialized software with satisfactory inter-rater and intra-rater reliability. Binomial logistic regression with backward likelihood ratio was conducted, while controlling for age, gender, and etiology. RESULTS: We found bolus clearance ratio (BCR), pharyngeal constriction ratio (PCR), duration to hyoid maximal elevation (Hdur), and total pharyngeal transit time (TPT) to be predictive of penetration-aspiration in children. PCR was the most predictive of penetration-aspiration in children (61.5%). Risk of aspiration was more than 100 times, when BCR = ≥ 0.1, TPT = ≥ 2 s, Hdur = > 1 s or PCR = ≥ 0.2 (p < 0.05 for all measures). CONCLUSION: The results confirm the potential of objective quantitative swallow measures in predicting the risk of aspiration in children with dysphagia. These parameters provide predictive measures of aspiration risk that are clinically useful in identifying children of concern, even if no aspiration is observed during VFSS.

Twenty years of quantitative instrumental measures of swallowing in children: a systematic review.

Early identification and intervention has shown better health outcomes for children with dysphagia. Instrumental swallowing assessments are vital and have been a focus of dysphagia research in the last two decades. This systematic review explores published quantitative instrumental measures of swallowing in children. Five subject-related databases were searched to identify original scientific articles published in English, using instrumental quantitative measures of swallowing to study swallowing/feeding mechanism in children since 1998. Two thousand two hundred and two articles were found from the initial database search and 36 were included in the final qualitative synthesis following PRISMA guidelines. Selected studies showed great diversity in target population, phase/s of swallowing studied, instrumentation used (n = 10) and quantitative measures reported (n = 144). Videofluoroscopy and manometry have been studied most repeatedly. With less frequency, a variety of other instruments has been used to describe suck-swallow patterns and swallowing-related respiration. High-resolution manometry shows the greatest increase in publications with validated, reliable quantitative measures of pharyngeal and oesophageal pressures and timing. More recently, quantification of videofluoroscopy analysis has been a focus.Conclusion: A diverse range of quantitative measures of swallowing is available for children in the literature. However, further reliability and validity testing is needed. Opportunities for clinical application of these quantitative manometric and videofluoroscopic measures are restricted by limited normative comparisons and vast variability in published measures.What is known?• Instrumental swallowing assessments are reliable and accurate in diagnosing swallowing difficulties in children.• However, subjective interpretation of observational findings often questions the optimal use of instrumentation.What is new?• High-resolution manometry has shown promising progress with the development of quantitative objective swallow measures for children. While attempts to quantify video-fluoroscopic measures have been increased in the recent past.• A vast variety of instruments has been used to obtain quantitative and/or objective swallow measures of children, yet clinical application is still in progress.

What is a normal pharynx? A videofluoroscopic study of anatomy in older adults.

PURPOSE: Structural and functional pharyngeal changes occur with age. How these affect swallowing in healthy older adults is not well defined. This study presents quantitative pharyngeal anatomic features in healthy adults using videofluoroscopic study of swallowing (VFSS). This will help our understanding of the normal changes in swallowing that occur with age and illustrate what may constitute normal variation compared with abnormal swallow function. METHODS: 138 mixed gender adults with no history of dysphagia were recruited and underwent a standardized VFSS protocol. Parameters including age, BMI, and gender were correlated with the presence of a cricopharyngeal bar, spinal changes and pharyngeal wall thickness at rest. RESULTS: 46% of participants had notable spinal changes. 8% of participants demonstrated cricopharyngeal bars and 12% of subjects revealed osteophytes. Age positively correlated with the presence of a cricopharyngeal bar (rs = 0.281, p < 0.001) and presence of osteophytes (rs = 0.334, p < 0.001). The incidence of cricopharyngeal bars in adults over 70 years old was 16%. CONCLUSIONS: A significant number of healthy adults with no swallowing complaints have variant pharyngeal anatomic findings such as cervical vertebral osteophytes and cricopharyngeal bars. This must be taken into account when assessing patients with dysphagia complaints to avoid misattribution of symptoms to these potentially asymptomatic variants. This ensures correct recommendations are made regarding management including diet modification, compensatory strategies, and surgical intervention.

Measuring Competency Development in Objective Evaluation of Videofluoroscopic Swallowing Studies.

Clinical interpretation of videofluoroscopic swallow study (VFSS) has often been criticized for its poor objectivity and inter-rater agreement. In order to address this, objective VFSS measures have been developed, reported and demonstrated to be valid and reliable. However, widespread clinical implementation is lacking. Reasons cited include lack of training and excessive time taken to perform measures. This study investigated competency development in selected standardized objective VFSS measures among speech-language pathologists (SLPs) naive to quantitative measurement. Six novice (no VFSS experience) and four experienced (2-10 years of VFSS experience) SLPs participated in 4 h of training in how to perform selected objective VFSS measures including pharyngeal constriction ratio, maximum pharyngoesophageal opening, pharyngoesophageal opening duration, airway closure duration and total pharyngeal transit time. Each week for eight weeks, participants were asked to independently measure and report three VFSS of patients affected by stroke. By week 8, all SLPs, irrespective of prior experience level, were able to achieve 80% accuracy in measures in comparison to the consensus of three expert clinicians. SLPs' mean time for completion reduced from 50 min in week 1-25 min in week 8. Inter-rater agreement for measures improved across the eight-week period (range ICC = -31.05 to .60 in week 1 to ICC = .71 to .98 in week 8). There was high agreement in location of impairment and consequent management recommendations by week 8. In conclusion, SLPs can reliably learn and incorporate objective VFSS measures within a reasonable time frame. Level of experience has limited influence on the learning curve.

Application and Verification of Quantitative Objective Videofluoroscopic Swallowing Measures in a Pediatric Population with Dysphagia.

OBJECTIVE: To investigate the feasibility of obtaining and utilizing objective measures of timing and displacement from videofluoroscopy performed in pediatrics. STUDY DESIGN: Children (n = 121; mean age 38 months, range 9 days-21 years, SD 4 years) referred for videofluoroscopy were recruited. All underwent a standardized protocol including a mid-feed 20-second loop recorded at 25 frames per second. Videos were analyzed using objective digital measures of timing and displacement. Radiation dose was recorded. RESULTS: Quantitative measures were obtained in all children. Maximum opening of the pharyngoesophageal segment and timing measures were correlated with increasing age. Values were congruent with validated adult data. Mean radiation time was 1.58 minutes (range 0.15-3.47, SD 0.66), and mean radiation dose was 30.16 cGycm2 (range 6.5-85 SD 15.17). Radiation dose (P = .21) and radiation time (P = .72) were not significantly different using the increased frame rate compared with an age-matched cohort (n =100) prior to protocol change. CONCLUSIONS: Objective quantitative measures of swallowing measurements can be obtained successfully from pediatric videofluoroscopy performed at high frame rates, without increasing radiation dose. Measures are biologically consistent, reproducible, demonstrate internal cross-correlation, and mirror adult data. These measures have potential to support targeted management and objective monitoring of change by pediatric feeding teams in the future.

Home-based oral health program for adults with intellectual disabilities: An intervention study.

BACKGROUND: Poor oral health is common in adults with intellectual disabilities leading to risk of mouth and lung infections. Yet, little is known about the benefits of preventative oral health programs. OBJECTIVE/HYPOTHESIS: This prospective longitudinal experimental mixed methods study evaluated the efficacy of an oral health program aimed at improving knowledge and behaviours in adults with intellectual disabilities living in supported housing. METHODS: A 90-min training session was provided to residents and their staff at 12 houses (56 residents; 67 staff). Follow-up training sessions (at 1 week, 1,2,3 months) were tailored to the learning abilities, behavioural/physical challenges, and independence of residents. Outcome measures were collected pre, 1, 2 and 3 months (n = 36): dental exam, plaque index, gingival signs, tongue coating index and behavioural rating scale. At 3 months, support workers (n = 10) and residents (n = 19) were interviewed. Residents' interviews were supported by Talking Mats®. RESULTS: Most residents (94%) required support for oral cares; with 63% fully dependant on their support workers. 24 (63%) residents had significantly improved plaque scores at 3 months (p < .001). Resident interviews were restricted by communication competency but supported interviews indicated positive responses to 3-sided toothbrush 91%, interdental brush/flosser 60%, and mouthwash 100%. Support worker interviews revealed perceived health and social benefits including fresher breath and benefits of routines. CONCLUSIONS: Oral health programs for adults with intellectual disabilities living in supported housing are well received by staff and residents, leading to changes in oral care routines and measurable changes in oral health.

Surgical Outcomes in Zenker Diverticula: A Multicenter, Prospective, Longitudinal Study.

OBJECTIVE: To compare improvement in patient-reported outcomes (PROM) in persons undergoing endoscopic and open surgical management of Zenker diverticula (ZD). METHODOLOGY: Prospective, multicenter cohort study of all individuals enrolled in the Prospective OUtcomes of Cricopharyngeus Hypertonicity (POUCH) Collaborative who underwent surgery for ZD. Patient survey, radiography reports, and the 10-item Eating Assessment Tool (EAT-10) pre- and post-procedure were abstracted from a REDCap database, which summarized means, medians, percentages, and frequencies of. Outcome based on operative intervention (endoscopic vs. open) was compared using t-test, Wilcoxon rank sum test or chi-square test, as appropriate. RESULTS: One hundred and forty-seven persons were prospectively followed. The mean age (SD) of the cohort was 68.7 (11.0). Overall, 66% of patients reported 100% improvement in EAT-10; 81% of patients had greater than 75% improvement; and 88% had greater than 50% improvement. Endoscopic was used for n = 109 patients, and open surgical intervention was used for n = 38. The median [interquartile range, IQR] EAT-10 percent improvement for endoscopic treatment was 93.3% [72, 100], and open was 100% [92.3, 100] (p = 0.05). The incidence of intraoperative complications was 3.7% for endoscopic and 7.9% for open surgical management. The median [IQR] in follow-up was 86 and 97.5 days, respectively. CONCLUSION: Both endoscopic and open surgical management of ZD provide significant improvement in patient-reported outcomes. The data suggest that open diverticulectomy may provide a modest advantage in symptomatic improvement compared to endoscopic management. The data suggest that the postoperative complication rate is higher in the open surgical group. LEVEL OF EVIDENCE: 3 Laryngoscope, 134:97-102, 2024.

Postoperative Care of Zenker Diverticula: Contemporary Perspective from the Prospective OUtcomes Cricopharyngeaus Hypertonicity (POUCH) Collaborative.

OBJECTIVES: The aim of the study was to identify trends in postoperative management of persons undergoing surgery for Zenker diverticula (ZD) by evaluating length of stay (LOS), diet on discharge, and imaging with or without surgical complication. METHODS: Prospectively enrolled adult patients with cricopharyngeal muscle dysfunction with diverticula undergoing surgery from August 1, 2017 to February 1, 2023 were included. Data were extracted from a multi-institutional REDCap database, summarizing means, medians, percentages, and frequencies. Fisher's exact or chi squared analyses were utilized, as appropriate, to compare subsets of data. Descriptive analysis assessed differences in clinical course and the relationship to postoperative management. RESULTS: There were 298 patients with a mean (standard deviation) age of 71.8 (11.2) years and 60% male. Endoscopic surgery was performed in 79.5% (237/298) of patients versus 20.5% (61/298) open surgery. Sixty patients (20.1%) received postoperative imaging, with four leaks identified. Complications were identified in 9.4% of cases (n = 29 complications in 28 patients), more commonly in open surgery. Most (81.2%) patients were discharged within 23 h. About half of patients (49%) were discharged from the hospital on a pureed/liquid diet; 36% had been advanced to a soft diet. In patients without complications, LOS was significantly longer following open cases (p = 0.002); postoperative diet was not different between open and endoscopic (p = 0.26). CONCLUSIONS: Overall, most patients are discharged within 23 h without imaging. However, LOS was affected by surgical approach. Postoperative complications are different in endoscopic versus open surgery. Complications with either approach were associated with prolonged LOS, need for imaging, and diet restriction. LEVEL OF EVIDENCE: Level III Laryngoscope, 134:2678-2683, 2024.

Surgical Nonresponders in Zenker Diverticulum and Lower Esophageal Pathology (POUCH Collaborative).

OBJECTIVE: To identify characteristics of patients who have poor improvement in symptoms following surgical management of Zenker Diverticulum (ZD). METHODS: Prospective, multicenter cohort study of all individuals enrolled in the Prospective OUtcomes of Cricopharyngeus Hypertonicity (POUCH) Collaborative who underwent surgical repair of ZD between August 2017 and January 2024. Patient demographics, esophagrams, and the 10-item Eating Assessment Tool (EAT-10) pre- and post-procedure were obtained from a REDCap database. t-tests, Wilcoxon rank sum tests, Chi-square or Fisher's exact tests were used to compare the characteristics. Patients with <50% improvement in their EAT-10 scores were deemed surgical nonresponders (SNRs). Those with ≥50% improvement in their EAT-10 scores were deemed surgical responders (SRs). RESULTS: A total of 184 patients were prospectively followed after undergoing either open or endoscopic surgical management. Twenty-two patients (12%) were deemed SNRs. Preoperative presence of a hiatal hernia was statistically significant characteristic between the SNRs (63.6%) and SRs (32.1%) (p = 0.004). Size of the ZD and history of previous ZD surgery was not a significant characteristic. The length of stay and complication rate were not statistically different between the groups. CONCLUSION: Coexistent esophageal pathology may lead to poor symptomatic improvement following ZD surgery. Preoperative workup of other esophageal disorders is recommended to detect likely SNRs. For SNRs, further esophageal workup may be necessary to evaluate for other esophageal causes related to poor symptomatic improvement following ZD surgery. LEVEL OF EVIDENCE: Level 3 Laryngoscope, 2024.

Bolus Clearance Ratio Elevated in Patients With Neurogenic Dysphagia Compared With Healthy Adults: A Measure of Pharyngeal Efficiency.

PURPOSE: Postswallow pharyngeal residue is a risk factor for aspiration, implies swallowing inefficiency, and increases the work of eating. The Bolus Clearance Ratio (BCR) is a derived metric that relates quantities of bolus material observed in the pharynx at two different points: before and after a swallow. The ratio provides a percentage estimate of bolus clearance. In healthy adults, mean BCR is < .05; that is, less than 5% of an ingested bolus is retained in the pharynx. The aim of this study was to compare BCR measures from patients referred for videofluoroscopic swallow studies with concerns related to stroke (n = 100) or other neurological conditions (n = 131, including Parkinson's disease and dementia) with BCRs for 139 healthy adults across the age range. METHOD: BCR for a 20 ml of thin liquid barium bolus was measured. Additional metrics included age, penetration-aspiration scale (PAS) score, and quantitative measures of timing and displacement. Correlations were explored between BCR and pharyngeal constriction ratio (PCR), pharyngoesophageal segment opening (PESmax), maximum hyoid displacement (HMax), and total pharyngeal transit time (TPT). RESULTS: BCR values for patients with stroke (Mdn = 9%, interquartile range [IQR]: 19%, range: 0%-73%) and other neurological conditions (Mdn = 9%, IQR: 16%, range: 0%-96%) were significantly higher than in healthy norms (Mdn = 2%, IQR: 4%, range: 0%-16%, p < .001). BCR was significantly correlated with age (R s = .23, p < .01), TPT (R s = .20, p < .01), PCR (R s = .55, p < .01), PESmax (R s = -.17, p < .01), HMax (R s = -.16, p < .01), and PAS (R s = .38, p < .01). CONCLUSIONS: BCR was elevated in patients with neurogenic dysphagia in comparison with healthy norms and was significantly associated with increased aspiration severity (i.e., PAS). BCR was also correlated with pharyngeal timing and displacement parameters, with the strongest correlation with pharyngeal constriction-a measure of pharyngeal strength. The BCR offers clinicians a simple, quantitative measure of bolus residue and, therefore, pharyngeal efficiency and may be used to assess change in patients over time and with treatment.

Killian Jamieson Diverticulum, the Great Mimicker: A Case Series and Contemporary Review.

OBJECTIVE: To assess barium esophagram (BAS) as a diagnostic marker for patients with Killian Jamieson diverticula (KJD). METHODS: Prospective, multicenter cohort study of individuals enrolled in the Prospective OUtcomes of Cricopharyngeus Hypertonicity (POUCH) Collaborative. Patient demographics, comorbidities, radiographic imaging reports, laryngoscopy findings, patient-reported outcome measures (PROM), and operative reporting were abstracted from a REDCap database and summarized using means, medians, percentages, frequencies. Paired t-tests and Wilcoxon Signed Rank test were used to test pre- to post-operative differences in RSI, EAT-10, and VHI-10 scores. Diagnostic test evaluation including sensitivity, specificity, positive, and negative predictive value with 95% confidence intervals were calculated comparing BAS findings to operative report. RESULTS: A total of 287 persons were enrolled; 13 (4%) patients were identified with confirmed KJD on operative reports. 100% underwent open transcervical excision. BAS has a 46.2% (95% confidence interval [CI]: 23.2, 70.9) sensitivity and 97.8% (95% CI: 95.3, 99.0) specificity in detecting a KJD and 50% (95% CI: 25.4, 74.6) positive predictive value but 97.4% (95%CI: 94.8, 98.7) negative predictive value. Preoperatively, patients reported mean (SD) RSI and EAT-10 of 19.4 (9) and 8.3 (7.5) accordingly. Postoperatively, patients reported mean (SD) RSI and EAT-10 as 5.4 (6.2) and 2.3 (3.3). Both changes in RSI and EAT-10 were statistically significant (p = 0.008, p = 0.03). CONCLUSION: KJD are rare and represent <5% of hypopharyngeal diverticula undergoing surgical intervention. Open transcervical surgery significantly improves symptoms of dysphagia. BAS has high specificity but low sensitivity in detecting KJD. LEVEL OF EVIDENCE: 4 Laryngoscope, 133:2110-2115, 2023.

Cricopharyngeus Muscle Dysfunction and Hypopharyngeal Diverticula (e.g., Zenker): A Multicenter Study.

OBJECTIVE: To describe demographics and imaging and compare findings and symptoms at presentation in a large cohort of persons with cricopharyngeus muscle dysfunction (CPMD) with and without hypopharyngeal diverticula. METHODOLOGY: Prospective, multicenter cohort study of all individuals enrolled in the Prospective OUtcomes of Cricopharyngeal Hypertonicity (POUCH) Collaborative. Patient survey, comorbidities, radiography, laryngoscopy findings, and patient-reported outcome measures (e.g., Eating Assessment Tool [EAT-10]) data were abstracted from a REDCap database and summarized using means, medians, percentages, and frequencies. Diagnostic categories were compared using analysis of variance. RESULTS: A total of 250 persons were included. The mean age (standard deviation [SD]) of the cohort was 69.0 (11.2). Forty-two percent identified as female. Zenker diverticula (ZD) was diagnosed in 85.2%, 9.2% with CPMD without diverticula, 4.4% with a Killian Jamieson diverticula (KJD), and 1.2% traction-type diverticula. There were no differences between diagnostic categories in regard to age, gender, and duration of symptoms (p = 0.25, 0.19, 0.45). The mean (SD) EAT-10 score for each group was 17.1 (10.1) for ZD, 20.2 (9.3) for CPMD, and 10.3 (9.4) for KJD. Patients with isolated CPMD had significantly greater EAT-10 scores compared to the other diagnostic groups (p = 0.03). CONCLUSION: ZD is the most common, followed by CPMD without diverticula, KJD, and traction-type. Patients with isolated obstructing CPMD may be more symptomatic than persons with ZD or KJD. LEVEL OF EVIDENCE: 4 Laryngoscope, 133:1349-1355, 2023.

Mixed methods evaluation research for a mental health screening and referral clinical pathway.

RATIONALE: This study is an exemplar of mixed method evaluation research for development of a clinical pathway. AIM: To develop and evaluate an evidence-based, feasible mental health screening and referral clinical pathway for Department of Veterans' Affairs-funded community nursing care of war veterans and war widows in the Australian context. METHODS: Mixed methods were applied to formulate and clinically evaluate an appropriate pathway. The pathway was applied at urban and rural sites for the nursing care of 97 war veteran and war widow clients. Evaluative data were collected from clients, their informal carers, community nurses, and general practitioners. Chart auditing and pre-post measures were undertaken. Collaboration occurred with an interdisciplinary design team. RESULTS: The final modified six-page pathway includes use of validated screening tools (Kessler Psychological Distress Scale [K10]) and Alcohol Use Disorder Identification Test, appropriate referral information, directions for support and health-promoting education, and evidence-based guidelines. IMPLICATIONS FOR PRACTICE: The clinical pathway is a useful, tested, evidence-based guide for generalist community nurses to identify and suitably respond to common mental healthcare needs of war veterans and war widows. The pathway provides outcomes acceptable to clients and their carers, nurses and doctors. CONCLUSIONS: This study provides an evaluated clinical pathway for generalist community nurses to screen for mental health difficulties, make appropriate referrals as required and to support war veteran and war widow clients. However, the study also shows how research can be used to develop and evaluate practical, evidence-based clinical pathways.

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

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

Automated Assessment of Glottal Dysfunction Through Unified Acoustic Voice Analysis.

This paper uses the recent glottal flow model for iterative adaptive inverse filtering to analyze recordings from dysfunctional speakers, namely those with larynx-related impairment such as laryngectomy. The analytical model allows extraction of the voice source spectrum, described by a compact set of parameters. This single model is used to visualize and better understand speech production characteristics across impaired and nonimpaired voices. The analysis reveals some discriminative aspects of the source model which map to a physiological class description of those impairments. Furthermore, being based on analysis of source parameters only, it is complementary to any existing techniques of vocal-tract or phonetic analysis. The results indicate the potential for future automated speech reconstruction systems that adapt to the method of reconstruction required, as well as being useful for mainstream speech systems, such as ASR, in which front-end analysis can direct back-end models to suit characteristics of impaired speech.