Systematic approach to contextualize findings of flexible endoscopic evaluation of swallowing in neurogenic dysphagia- towards an integrated FEES report.

Flexible endoscopic evaluation of swallowing (FEES) is one of the most important methods for instrumental swallowing evaluation. The most challenging part of the examination consists in the interpretation of the various observations encountered during endoscopy and in the deduction of clinical consequences. This review proposes the framework for an integrated FEES-report that systematically moves from salient findings of FEES to more advanced domains such as dysphagia severity, phenotypes of swallowing impairment and pathomechanisms. Validated scales and scores are used to enhance the diagnostic yield. In the concluding part of the report, FEES-findings are put into the perspective of the clinical context. The potential etiology of dysphagia and conceivable differential diagnoses are considered, further diagnostic steps are proposed, treatment options are evaluated, and a timeframe for re-assessment is suggested. This framework is designed to be adaptable and open to continuous evolution. Additional items, such as novel FEES protocols, pathophysiological observations, advancements in disease-related knowledge, and new treatment options, can be easily incorporated. Moreover, there is potential for customizing this approach to report on FEES in structural dysphagia.

Pharyngeal Electrical Stimulation prior to extubation - Reduction of extubation failure rate in acute stroke patients?

PURPOSE: The aim of our study was to assess if PES before extubation can minimize the extubation failure risk in orally intubated, mechanically ventilated stroke patients at high risk of severe dysphagia. MATERIALS AND METHODS: Thirty-two ICU patients were prospectively enrolled in this study presenting with a high risk for dysphagia as defined by a DEFISS (Determine Extubation Failure In Severe Stroke) risk score and compared 1:1 to a retrospective matched patient control group. The prospective patient group received PES prior to extubation. Endpoints were need for reintubation, swallowing function as assessed with FEES, pneumonia incidence and length of stay after extubation. RESULTS: Post-extubation, the Fiberoptic Endoscopic Dysphagia Severity Score (FEDSS, 4.31 ± 1.53vs.5.03 ± 1.28;p = 0.047) and reintubation rate within 72 h (9.4vs.34.4%;p = 0.032) were significantly lower in the PES group than in the historical control group. Pulmonary infections after extubation were less common in PES-treated patients although this difference was not significant (37.5vs.59.4%;p = 0.133). Time from extubation to discharge was significantly shorter after PES compared with the control group (14.09 ± 11.58vs.26.59 ± 20.49 days;p = 0.003). CONCLUSIONS: In orally intubated and mechanically ventilated stroke patients at high risk of severe dysphagia, PES may improve swallowing function, reduce extubation failure risk and decrease time from extubation to discharge. Further research is required.

Dysphagia after stroke: research advances in treatment interventions.

After a stroke, most patients have dysphagia, which can lead to aspiration pneumonia, malnutrition, and adverse functional outcomes. Protective interventions aimed at reducing these complications remain the cornerstone of treatment. Dietary adjustments and oral hygiene help mitigate the risk of aspiration pneumonia, and nutritional supplementation, including tube feeding, might be needed to prevent malnutrition. Rehabilitative interventions aim to enhance swallowing function, with different behavioural strategies showing promise in small studies. Investigations have explored the use of pharmaceutical agents such as capsaicin and other Transient-Receptor-Potential-Vanilloid-1 (TRPV-1) sensory receptor agonists, which alter sensory perception in the pharynx. Neurostimulation techniques, such as transcranial direct current stimulation, repetitive transcranial magnetic stimulation, and pharyngeal electrical stimulation, might promote neuroplasticity within the sensorimotor swallowing network. Further advancements in the understanding of central and peripheral sensorimotor mechanisms in patients with dysphagia after a stroke, and during their recovery, will contribute to optimising treatment protocols.

Management of swallowing disorders in ICU patients - A multinational expert opinion.

BACKGROUND: Dysphagia is common in intensive care unit (ICU) patients, yet it remains underrecognized and often unmanaged despite being associated with life-threatening complications, prolonged ICU stays and hospitalization. PURPOSE: To propose an expert opinion for the diagnosis and management of dysphagia developed from evidence-based clinical recommendations and practitioner insights. METHODS: A multinational group of dysphagia and critical care experts conducted a literature review using a modified ACCORD methodology. Based on a fusion of the available evidence and the panel's clinical experience, an expert opinion on best practice management was developed. RESULTS: The panel recommends adopting clinical algorithms intended to promote standardized, high-quality care that triggers timely systematic dysphagia screening, assessment, and treatment of extubated and tracheostomized patients in the ICU. CONCLUSIONS: Given the lack of robust scientific evidence, two clinical management algorithms are proposed for use by multidisciplinary teams to improve early systematic detection and effective management of dysphagia in ICU patients. Additionally, emerging therapeutic options such as neurostimulation have the potential to improve the quality of ICU dysphagia care.

Validation of the DIGEST-FEES as a Global Outcome Measure for Pharyngeal Dysphagia in Parkinson's Disease.

Flexible Endoscopic Evaluation of Swallowing (FEES) is one of two diagnostic gold standards for pharyngeal dysphagia in Parkinson's disease (PD), however, validated global outcome measures at the patient level are widely lacking. The Dynamic Imaging Grade of Swallowing Toxicity for Flexible Endoscopic Evaluation of Swallowing (DIGEST-FEES) represents such an outcome measure but has been validated primarily for head and neck cancer collectives. The objective of this study was, therefore, to investigate the validity of the DIGEST-FEES in patients with PD. Content validity was evaluated with a modified Delphi expert survey. Subsequently, 66 FEES videos in PD patients were scored with the DIGEST-FEES. Criterion validity was determined using Spearman's correlation coefficient between the DIGEST-FEES and the Penetration-Aspiration Scale (PAS), the Yale-Residue-Rating-Scale, the Functional-Oral-Intake-Scale (FOIS), and the swallowing-related Unified-Parkinson-Disease-Rating-Scale (UPDRS) items. Inter-rater reliability was determined using 10 randomly selected FEES-videos examined by a second rater. As a result, the overall DIGEST-FEES-rating exhibited significant correlations with the Yale-Valleculae-Residue-Scale (r = 0.84; p < 0.001), the Yale-Pyriform-Sinus-Residue-Scale (r = 0.70; p < 0.001), the FOIS (r = - 0.55, p < 0.001), and the UPDRS-Swallowing-Item-Score (r = 0.42, p < 0.001). Further, the DIGEST-FEES-safety subscore correlated with the PAS (r = 0.63, p < 0.001). Inter-rater reliability was high for the overall DIGEST-FEES rating (quadratic weighted kappa of 0.82). Therefore, DIGEST-FEES is a valid and reliable score to evaluate overall pharyngeal dysphagia severity in PD. Nevertheless, the modified Delphi survey identified domains where DIGEST-FEES may need to be specifically adapted to PD or neurological collectives in the future.

The assessment of dysphagia after stroke: state of the art and future directions.

Dysphagia is a major complication following an acute stroke that affects the majority of patients. Clinically, dysphagia after stroke is associated with increased risk of aspiration pneumonia, malnutrition, mortality, and other adverse functional outcomes. Pathophysiologically, dysphagia after stroke is caused by disruption of an extensive cortical and subcortical swallowing network. The screening of patients for dysphagia after stroke should be provided as soon as possible, starting with simple water-swallowing tests at the bedside or more elaborate multi-consistency protocols. Subsequently, a more detailed examination, ideally with instrumental diagnostics such as flexible endoscopic evaluation of swallowing or video fluoroscopy is indicated in some patients. Emerging diagnostic procedures, technical innovations in assessment tools, and digitalisation will improve diagnostic accuracy in the future. Advances in the diagnosis of dysphagia after stroke will enable management based on individual patterns of dysfunction and predisposing risk factors for complications. Progess in dysphagia rehabilitation are essential to reduce mortality and improve patients' quality of life after a stroke.

Sarcopenic Dysphagia Revisited: A Cross-Sectional Study in Hospitalized Geriatric Patients.

Oropharyngeal dysphagia (OD) is a frequent finding in older patients with potentially lethal complications such as aspiration pneumonia, malnutrition, and dehydration. Recent studies describe sarcopenia as a causative factor for OD, which is occasionally referred to as "sarcopenic dysphagia" in the absence of a neurogenic etiology. In most of the previous studies on sarcopenic dysphagia, the diagnosis was based only on clinical assessment. In this study, flexible endoscopic evaluation of swallowing (FEES) was used as an objective method to evaluate the presence of OD, its association with sarcopenia, and the presence of pure sarcopenic dysphagia. In this retrospective cross-sectional study, 109 acute care geriatric hospital patients with suspected OD received FEES examination and bioimpedance analysis (BIA) in clinical routine. 95% of patients had at least one neurological disease, 70% fulfilled the criteria for sarcopenia, and 45% displayed moderate or severe OD. Although the prevalence of sarcopenia and OD was high, there was no significant association between OD and sarcopenia. Considering these results, both the association between sarcopenia and OD and pure sarcopenic dysphagia appear questionable. Further prospective studies are needed to elucidate if sarcopenia is merely an epiphenomenon of severe disease or whether it plays a causative role in the development of OD.

[Diagnostics and treatment of post-stroke dysphagia]. / Diagnostik und Therapie der Dysphagie nach einem Schlaganfall.

BACKGROUND: Post-stroke dysphagia is highly prevalent and leads to severe complications, such as aspiration pneumonia and malnutrition. Despite the high clinical relevance dysphagia management is heterogeneous and often inadequate. OBJECTIVE: The aim of this review article is to provide an overview of the diagnostic and treatment strategies for post-stroke dysphagia based on recent studies. MATERIAL AND METHODS: Narrative literature review. RESULTS: Dysphagia screening should be performed as early as possible in every stroke patient, e.g., with a simple water swallowing test or a multiconsistency protocol. Subsequently, flexible endoscopic evaluation of swallowing (FEES) is indicated in patients with abnormal screening results or existing risk factors for dysphagia. Dietary modifications, oral hygiene measures, and nutritional therapy can help reduce complications. Behavioral swallowing therapy or experimental therapies, such as neurostimulation procedures and pharmacological approaches aim to improve swallowing function and have shown promising results in studies. CONCLUSION: Timely management of dysphagia is necessary to reduce complications.

Costs of post-stroke dysphagia during acute hospitalization from a health-insurance perspective.

Purpose: Oropharyngeal dysphagia is a common and complication-prone symptom after stroke and is assumed to increase medical expenses. The purpose of this study was therefore to examine acute hospitalization costs associated with post-stroke dysphagia. Method: This retrospective study included patients with acute stroke who had been examined by Flexible Endoscopic Evaluation of Swallowing (FEES). Health insurance expenditures were determined for the patient cases according to the 2021 revenue criteria. Multiple linear regression was used to examine predictors of health insurance spending including age, sex, stroke severity, stroke characteristics, comorbidity, therapeutic interventions, duration of artificial ventilation, length of hospital stay, and severity of dysphagia, as assessed by the Fiberoptic Endoscopic Dysphagia Severity Scale (FEDSS), ranging from 1 (best) to 6 (worst). Findings: Six hundred seventy four patients (men/women: 367/307; mean age: 71.1 ± 12.8 years; mean National Institute of Health Stroke Scale: 11.2 ± 6.2; FEDSS 1/2/3/4/5/6: 113/73/144/119/124/101; mean health-insurance costs 11,521.5 ± 12,950.5€) were included in the analysis. Advanced age (p = 0.007; B = 57.6), catheter interventions (p < 0.001; B = 4105.6), tracheotomy (p = 0.006; B = 5195.2), duration of artificial ventilation (p < 0.001; B = 388.6), length of hospital stay (p < 0.001; B = 441.9), and severe dysphagia with an FEDSS of 6 (p = 0.004, B = 2554.3) were independent predictors of increased health insurance expenditures (p < 0.001, R-squared = adjusted-R-squared = 0.83). Discussion and conclusion: The results of this study show an association between severe dysphagia and health care costs for acute hospitalization from a health-insurance perspective. Therefore, therapies that target severe dysphagia with impaired secretion management may have the potential to reduce costs.

Relationship between post-stroke dysphagia and pharyngeal sensory impairment.

BACKGROUND: Post-stroke dysphagia (PSD) is common and can lead to serious complications. Pharyngeal sensory impairment is assumed to contribute to PSD. The aim of this study was to investigate the relationship between PSD and pharyngeal hypesthesia and to compare different assessment methods for pharyngeal sensation. METHODS: In this prospective observational study, fifty-seven stroke patients were examined in the acute stage of the disease using Flexible Endoscopic Evaluation of Swallowing (FEES). The Fiberoptic Endoscopic Dysphagia Severity Scale (FEDSS) and impaired secretion management according to the Murray-Secretion Scale were determined, as well as premature bolus spillage, pharyngeal residue and delayed or absent swallowing reflex. A multimodal sensory assessment was performed, including touch-technique and a previously established FEES-based swallowing provocation test with different volumes of liquid to determine the latency of swallowing response (FEES-LSR-Test). Predictors of FEDSS, Murray-Secretion Scale, premature bolus spillage, pharyngeal residue, and delayed or absent swallowing reflex were examined with ordinal logistic regression analyses. RESULTS: Sensory impairment using the touch-technique and the FEES-LSR-Test were independent predictors of higher FEDSS, Murray-Secretion Scale, and delayed or absent swallowing reflex. Decreased sensitivity according to the touch-technique correlated with the FEES-LSR-Test at 0.3 ml and 0.4 ml, but not at 0.2 ml and 0.5 ml trigger volumes. CONCLUSIONS: Pharyngeal hypesthesia is a crucial factor in the development of PSD, leading to impaired secretion management and delayed or absent swallowing reflex. It can be investigated using both the touch-technique and the FEES-LSR-Test. In the latter procedure, trigger volumes of 0.4 ml are particularly suitable.

Dysphagia for medication in Parkinson's disease.

Dysphagia is common in Parkinson's disease (PD) and is assumed to complicate medication intake. This study comprehensively investigates dysphagia for medication and its association with motor complications in PD. Based on a retrospective analysis, a two-dimensional and graduated classification of dysphagia for medication was introduced differentiating swallowing efficiency and swallowing safety. In a subsequent prospective study, sixty-six PD patients underwent flexible endoscopic evaluation of swallowing, which included the swallowing of 2 tablets and capsules of different sizes. Dysphagia for medication was present in nearly 70% of PD patients and predicted motor complications according to the MDS-UPDRS-part-IV in a linear regression model. Capsules tended to be swallowed more efficiently compared to tablets, irrespective of size. A score of ≥1 on the swallow-related-MDS-UPDRS-items can be considered an optimal cut-off to predict dysphagia for medication. Swallowing impairment for oral medication may predispose to motor complications.

Clinical determinants and neural correlates of presbyphagia in community-dwelling older adults.

Background: "Presbyphagia" refers to characteristic age-related changes in the complex neuromuscular swallowing mechanism. It has been hypothesized that cumulative impairments in multiple domains affect functional reserve of swallowing with age, but the multifactorial etiology and postulated compensatory strategies of the brain are incompletely understood. This study investigates presbyphagia and its neural correlates, focusing on the clinical determinants associated with adaptive neuroplasticity. Materials and methods: 64 subjects over 70 years of age free of typical diseases explaining dysphagia received comprehensive workup including flexible endoscopic evaluation of swallowing (FEES), magnetoencephalography (MEG) during swallowing and pharyngeal stimulation, volumetry of swallowing muscles, laboratory analyzes, and assessment of hand-grip-strength, nutritional status, frailty, olfaction, cognition and mental health. Neural MEG activation was compared between participants with and without presbyphagia in FEES, and associated clinical influencing factors were analyzed. Presbyphagia was defined as the presence of oropharyngeal swallowing alterations e.g., penetration, aspiration, pharyngeal residue pooling or premature bolus spillage into the piriform sinus and/or laryngeal vestibule. Results: 32 of 64 participants showed swallowing alterations, mainly characterized by pharyngeal residue, whereas the airway was rarely compromised. In the MEG analysis, participants with presbyphagia activated an increased cortical sensorimotor network during swallowing. As major clinical determinant, participants with swallowing alterations exhibited reduced pharyngeal sensation. Presbyphagia was an independent predictor of a reduced nutritional status in a linear regression model. Conclusions: Swallowing alterations frequently occur in otherwise healthy older adults and are associated with decreased nutritional status. Increased sensorimotor cortical activation may constitute a compensation attempt to uphold swallowing function due to sensory decline. Further studies are needed to clarify whether the swallowing alterations observed can be considered physiological per se or whether the concept of presbyphagia may need to be extended to a theory with a continuous transition between presbyphagia and dysphagia.

Comparison of Simultaneous Swallowing Endoscopy and Videofluoroscopy in Neurogenic Dysphagia.

OBJECTIVE: In the evaluation of oropharyngeal dysphagia, instrumental procedures, for example, flexible endoscopic evaluation of swallowing or videofluoroscopic swallowing study, are essential to improve diagnostic accuracy for salient findings such as penetration, aspiration, or pharyngeal residue. To date, it is unclear which of the 2 methods represents the diagnostic gold standard. The aim of this study, therefore, was to compare videofluoroscopy and swallowing endoscopy during a simultaneous swallowing examination in a large cohort of patients with oropharyngeal dysphagia. DESIGNS: Prospective observational study. SETTING AND PARTICIPANTS: In this study, 49 patients with oropharyngeal dysphagia (mean age 70.0 ± 10.8 years) were evaluated using simultaneous swallowing endoscopy and videofluoroscopy. Furthermore, the effect of narrow-band imaging in swallowing endoscopy on the assessment of penetration and aspiration was investigated in a subgroup of 19 patients. MEASURES: The Penetration-Aspiration Scale and the Yale Pharyngeal Residue Severity Rating Scale were rated independently based on both modalities. RESULTS: Both modalities showed a high correlation between penetration, aspiration, and pharyngeal residue. Causes for a higher score on the Penetration-Aspiration Scale in videofluoroscopy were intradeglutitive events that were not visible in swallowing endoscopy or false-positive events because of the loss of the lateral dimension in videofluoroscopy. A typical reason for a higher score on this scale in swallowing endoscopy was the better visualization of the anatomical structures. Narrow-band imaging in swallowing endoscopy resulted in a higher score on the Penetration-Aspiration Scale for liquids and semisolids in individual cases, although overall there was no statistically significant difference between scores using white light or narrow-band imaging. CONCLUSIONS AND IMPLICATIONS: Videofluoroscopy and swallowing endoscopy may equally be considered as a diagnostic gold standard for oropharyngeal dysphagia regarding penetration, aspiration, and pharyngeal residue. Narrow-band imaging may increase the sensitivity for penetration and aspiration in individual cases.

Detecting myositis as a cause of unexplained dysphagia: Proposal for a diagnostic algorithm.

BACKGROUND AND PURPOSE: Idiopathic inflammatory myopathy (IIM) can present with dysphagia as a leading or only symptom. In such cases, diagnostic evaluation may be difficult, especially if serological and electromyographical findings are unsuspicious. In this observational study we propose and evaluate a diagnostic algorithm to identify IIM as a cause of unexplained dysphagia. METHODS: Over a period of 4 years, patients with unexplained dysphagia were offered diagnostic evaluation according to a specific algorithm: The pattern of dysphagia was characterized by instrumental assessment (swallowing endoscopy, videofluoroscopy, high-resolution manometry). Patients with an IIM-compatible dysphagia pattern were subjected to further IIM-focused diagnostic procedures, including whole-body muscle magnetic resonance imaging, electromyography, creatine kinase blood level, IIM antibody panel and, as a final diagnostic step, muscle biopsy. Muscle biopsies were taken from affected muscles. In cases where no other muscles showed abnormalities, the cricopharyngeal muscle was targeted. RESULTS: Seventy-two patients presented with IIM-compatible dysphagia as a leading or only symptom. As a result of the specific diagnostic approach, 19 of these patients were diagnosed with IIM according to the European League Against Rheumatism (EULAR) criteria. Eighteen patients received immunomodulatory therapy as a result of the diagnosis. Of 10 patients with follow-up swallowing examination, dysphagia improved in three patients after therapy, while it remained at least stable in six patients. CONCLUSIONS: Idiopathic inflammatory myopathy constitutes a potentially treatable etiology in patients with unexplained dysphagia. The diagnostic algorithm presented in this study helps to identify patients with an IIM-compatible dysphagia pattern and to assign those patients for further IIM-focused diagnostic and therapeutic procedures.

Oropharyngeal Dysphagia and Impaired Motility of the Upper Gastrointestinal Tract-Is There a Clinical Link in Neurocritical Care?

Patients in the neurological ICU are at risk of suffering from disorders of the upper gastrointestinal tract. Oropharyngeal dysphagia (OD) can be caused by the underlying neurological disease and/or ICU treatment itself. The latter was also identified as a risk factor for gastrointestinal dysmotility. However, its association with OD and the impact of the neurological condition is unclear. Here, we investigated a possible link between OD and gastric residual volume (GRV) in patients in the neurological ICU. In this retrospective single-center study, patients with an episode of mechanical ventilation (MV) admitted to the neurological ICU due to an acute neurological disease or acute deterioration of a chronic neurological condition from 2011-2017 were included. The patients were submitted to an endoscopic swallowing evaluation within 72 h of the completion of MV. Their GRV was assessed daily. Patients with ≥1 d of GRV ≥500 mL were compared to all the other patients. Regression analysis was performed to identify the predictors of GRV ≥500 mL/d. With respect to GRV, the groups were compared depending on their FEES scores (0-3). A total of 976 patients were included in this study. A total of 35% demonstrated a GRV of ≥500 mL/d at least once. The significant predictors of relevant GRV were age, male gender, infratentorial or hemorrhagic stroke, prolonged MV and poor swallowing function. The patients with the poorest swallowing function presented a GRV of ≥500 mL/d significantly more often than the patients who scored the best. Conclusions: Our findings indicate an association between dysphagia severity and delayed gastric emptying in critically ill neurologic patients. This may partly be due to lesions in the swallowing and gastric network.

Standardized Endoscopic Swallowing Evaluation for Tracheostomy Decannulation in Critically Ill Neurologic Patients - a prospective evaluation.

BACKGROUND: Removal of a tracheostomy tube in critically ill neurologic patients is a critical issue during intensive care treatment, particularly due to severe dysphagia and insufficient airway protection. The "Standardized Endoscopic Evaluation for Tracheostomy Decannulation in Critically Ill Neurologic Patients" (SESETD) is an objective measure of readiness for decannulation. This protocol includes the stepwise evaluation of secretion management, spontaneous swallowing, and laryngeal sensitivity during fiberoptic endoscopic evaluation of swallowing (FEES). Here, we first evaluated safety and secondly effectiveness of the protocol and sought to identify predictors of decannulation success and decannulation failure. METHODS: A prospective observational study was conducted in the neurological intensive care unit at Münster University Hospital, Germany between January 2013 and December 2017. Three hundred and seventy-seven tracheostomized patients with an acute neurologic disease completely weaned from mechanical ventilation were included, all of whom were examined by FEES within 72 h from end of mechanical ventilation. Using regression analysis, predictors of successful decannulation, as well as decannulation failure were investigated. RESULTS: Two hundred and twenty-seven patients (60.2%) could be decannulated during their stay according to the protocol, 59 of whom within 24 h from the initial FEES after completed weaning. 3.5% of patients had to be recannulated due to severe dysphagia or related complications. Prolonged mechanical ventilation showed to be a significant predictor of decannulation failure. Lower age was identified to be a significant predictor of early decannulation after end of weaning. Transforming the binary SESETD into a 4-point scale helped predicting decannulation success in patients not immediately ready for decannulation after the end of respiratory weaning (optimal cutoff ≥1; sensitivity: 64%, specifity: 66%). CONCLUSIONS: The SESETD showed to be a safe and efficient tool to evaluate readiness for decannulation in our patient collective of critically ill neurologic patients.

Predictors, outcome and characteristics of oropharyngeal dysphagia in idiopathic inflammatory myopathy.

INTRODUCTION: Oropharyngeal dysphagia is a clinical hallmark of idiopathic inflammatory myopathy (IIM). This study investigated predictors, outcome, and characteristics of oropharyngeal dysphagia in patients with different types of IIM. METHODS: Flexible endoscopic evaluation of swallowing (FEES) videos of 71 IIM patients were retrospectively analyzed for bolus spillage, penetration, aspiration, and pharyngeal residue. Based on these findings, dysphagia severity was rated. Regression analyses were performed to investigate demographic and disease-specific predictors of dysphagia severity and pneumonia as outcome-relevant complications of dysphagia. A score was developed to rate the quality of the endoscopic white-out as a surrogate marker for pharyngeal muscle weakness with consecutive residue. RESULTS: Our analysis revealed no independent predictors of dysphagia severity. Dysphagia severity, however, was an independent predictor for pneumonia, which occurred in 24% of patients. Pharyngeal residue with risk of postdeglutitive aspiration was the most common dysphagia pattern. Attenuation of the endoscopic white-out was related to residue severity. DISCUSSION: Dysphagia in IIM assessed with FEES is associated with relevant complications, such as aspiration pneumonia, and must be considered independently of peripheral muscle weakness and disease duration. Swallowing impairment mainly presents with pharyngeal residue. The quality of the white-out may serve as a semi-quantitative surrogate marker for pharyngeal contractility.

Expiratory Muscle Strength Training for Therapy of Pharyngeal Dysphagia in Parkinson's Disease.

BACKGROUND: Pharyngeal dysphagia in Parkinson's disease (PD) is a common and clinically relevant symptom associated with poor nutrition intake, reduced quality of life, and aspiration pneumonia. Despite this, effective behavioral treatment approaches are rare. OBJECTIVE: The objective of this study was to verify if 4 week of expiratory muscle strength training can improve pharyngeal dysphagia in the short and long term and is able to induce neuroplastic changes in cortical swallowing processing. METHODS: In this double-blind, randomized, controlled trial, 50 patients with hypokinetic pharyngeal dysphagia, as confirmed by flexible endoscopic evaluation of swallowing, performed a 4-week expiratory muscle strength training. Twenty-five participants used a calibrated ("active") device, 25 used a sham handheld device. Swallowing function was evaluated directly before and after the training period, as well as after a period of 3 month using flexible endoscopic evaluation of swallowing. Swallowing-related cortical activation was measured in 22 participants (active:sham; 11:11) using whole-head magnetencephalography. RESULTS: The active group showed significant improvement in the flexible endoscopic evaluation of swallowing-based dysphagia score after 4 weeks and after 3 months, whereas in the sham group no significant changes from baseline were observed. Especially, clear reduction in pharyngeal residues was found. Regarding the cortical swallowing network before and after training, no statistically significant differences were found by magnetencephalography examination. CONCLUSIONS: Four-week expiratory muscle strength training significantly reduces overall dysphagia severity in PD patients, with a sustained effect after 3 months compared with sham training. This was mainly achieved by improving swallowing efficiency. The treatment effect is probably caused by peripheral mechanisms, as no changes in the cortical swallowing network were identified. © 2021 The Authors. Movement Disorders published by Wiley Periodicals LLC on behalf of International Parkinson and Movement Disorder Society.