Current approaches to instrumental assessment of swallowing in children.

PURPOSE OF THE REVIEW: This article reviews recent developments in the instrumental assessment of swallowing in children with a specific focus on research published between January 2017 and June 2018. RECENT FINDINGS: Instrumental swallowing assessments reported in the time period included: videofluoroscopic study of swallowing, digital cervical auscultation, dynamic ultrasound, high-resolution impedance manometry, nasal airflow thermistry and respiratory inductance plethysmography. Several studies were found exploring tools to objectively quantify videofluoroscopic study of swallowing data; swallowing from the mouth through to stomach was addressed including approaches to analysing mastication as well as evaluating oesophageal motility disorders. SUMMARY: Even though a vast range of instrumentation were studied, lack of clarity on clinical feasibility and objective measures that facilitate medical decision-making in practice mean further research is required to provide guidance on implementation. Promising novel approaches to aid the quantification of swallowing physiology from the mouth, pharynx and through to the oesophagus are emerging.

Swallowing function in advanced age.

PURPOSE OF REVIEW: To present current literature regarding swallowing function in advanced age, including healthy ageing, dysphagia and trends in multidisciplinary team service delivery. RECENT FINDINGS: Normative studies support swallowing efficiency but greater variability in healthy advanced age, through to 100 years old. Deviations from normative data and symptoms of dysphagia leading to aspiration or nutritional risk, imply swallowing disorder, rather than simply the ageing process. Quantitative and qualitative studies are emerging that promote management of swallow dysfunction for an ageing society, including innovative assessment, home treatment, swallowing exercise and optimized mealtimes. SUMMARY: Current literature on swallowing function in advanced age provides multidisciplinary perspectives and initiatives, with clear commitment to improving quality of life for older adults. The diversity of the older population and serious consequences of swallowing difficulties calls for routine screening tools for swallowing impairment and malnutrition risk. Representation of 'oldest old' in future normative studies is essential to guide swallowing management in adults over 85 years old.

IgG4-related disease in the head and neck.

PURPOSE OF REVIEW: To summarize current evidence regarding the pathophysiology, diagnostic criteria, and management of IgG4 disease in the head and neck. RECENT FINDINGS: The anti-CD20 antibody, rituximab is being used increasingly as a primary treatment modality in cases with a definitive diagnosis. Despite the favorable prognosis, it is now recognized that the incidence of cancer development within 3 years of diagnosis is higher than that of the general population. SUMMARY: IgG4-related disease is a sclerosing, chronic inflammatory disease, that is benign, and usually occurs in middle-aged to elderly individuals. Definitive diagnosis of IgG4-related disease requires radiological confirmation of enlargement of the affected organ, elevated serum IgG4 levels, and characteristic histopathological findings. Treatment is primarily with systemic corticosteroids or the monoclonal anti-CD20 antibody rituximab, surgical excision, or a combination of treatment modalities. Prognosis is good with complete remission in up to 90% of patients.

Physical and virtual modelling of the head and neck for surgical simulation and training.

PURPOSE OF REVIEW: Investigation and surgical manipulation of the larynx, pharynx, and oesophagus suffer from inherent challenges with access to the sites of interest. To reduce trauma and external scarring, visualization and minimally invasive interventions by the transnasal or transoral routes have become more prevalent. This article discusses engineering methods used to understand and overcome the mechanical constraints inside the airway and upper gastrointestinal tract, and examines the role that robotics and engineering are beginning to play in modelling of surgical interventions in this region. RECENT FINDINGS: Although robotic solutions to minimally invasive surgery of the airway and upper gastrointestinal tract already exist, there is still scope for increasing the breadth of their use. Physical and virtual models of these organs are used to investigate the capability and limitations of manual and robotic surgical interventions in this region. Understanding the tissue mechanics and tool capabilities is central to improving outcomes in the clinical setting. Both physical and virtual modelling modalities are used in training surgeons for both manual-assisted and robot-assisted surgeries. SUMMARY: Minimally invasive surgical interventions via the transnasal and the transoral route are strong candidates for overcoming access issues to the airway. They are likely to become more robotically driven as the demand for higher dexterity and accuracy increases for fine manipulation. Physical and virtual organ models are required to enable surgical training for these procedures.

Cricopharyngeal function or dysfunction: what's the deal?

PURPOSE OF REVIEW: The purpose of the review is to examine current research focused on upper oesophageal sphincter (UES) and cricopharyngeus muscle function, and how better understanding UES physiology will translate to improved management. RECENT FINDINGS: Although much is known about UES function, new information describing the dynamics of the UES and cricopharyngeus is being identified through manometry, combined fluoromanometry, and anatomic study. Response of the UES to injury, reflux, and surgical interventions is reported. Direct surgical treatment of cricopharyngeus noncompliance with or without diverticuli continues to show benefit and long-term results support a sustained improvement in three-quarters of patients. SUMMARY: UES and cricopharyngeus function is complex and dynamic. It is affected by internal signals such as posture and constitution of refluxate, aging, and interventions particularly radiation and surgery. Clear understanding of the triggers and responses of the UES will enable clinicians to choose the correct therapy for their dysphagic patients.

Management of oropharyngeal neurogenic dysphagia in adults.

PURPOSE OF REVIEW: This article reviews recent literature in the management of neurogenic oropharyngeal dysphagia (OPD) including assessment processes and treatments, with a specific focus on OPD as a result of stroke and Parkinson's disease. RECENT FINDINGS: A large number of high-quality systematic reviews were published that provide an excellent summary of current evidence across assessment and treatment of swallowing disorders. There is building interest and knowledge in technology in both the understanding and treatment of OPD including functional MRI, manometry, and noninvasive brain stimulation. SUMMARY: Neurologic disorders demonstrate a high prevalence of OPD resulting in significant decrement to health and healthcare costs. Novel technologies were reported in assessment and tracking of dysphagia as well as emerging innovative therapeutic options.

Treatment of aging vocal folds: surgical approaches.

PURPOSE OF REVIEW: Aging may affect the voice through either physiological or pathological changes. Globally society is aging and the working lifetime is extending. Increasing numbers of elderly will present with voice issues. This review examines current thinking regarding surgical treatment of the aging voice. RECENT FINDINGS: The mainstay of surgical treatment remains injection laryngoplasty and medialization thyroplasty. In-office injection laryngoplasty is increasingly common. Data suggest that patients with vocal fold atrophy do not achieve as much benefit from augmentation treatments as other causes of glottal incompetence. In addition the timing of injection laryngoplasty may influence the rate of subsequent medialization thyroplasty. Disease-specific treatments can provide some benefit to voice, such as deep brain stimulation in Parkinson's disease. Novel treatments including growth factor therapy are entering clinical practice and will provide new options for the clinician in future. SUMMARY: Voice disorders affect approximately 20% of the elderly population. Causes include neurologic, malignant, iatrogenic and benign vocal fold disorders. These should be ruled out before accepting dysphonia is age-related in nature. Treatment should be specific to recognized vocal disorders but may also address physiologic changes in the glottis. Injection laryngoplasty and thyroplasty remain effective options for treating glottal incompetence but novel therapies are showing promising results.

Chronic cough: an otorhinolaryngology perspective.

PURPOSE OF REVIEW: Cough lasting more than 8 weeks is a common presenting complaint to the otolaryngologist. Historically, chronic cough has been attributed to post-nasal drip, laryngopharyngeal reflux and cough-variant asthma. This study reviews chronic cough from the viewpoint of an otolaryngologist. RECENT FINDINGS: More recent studies suggest the influence of laryngeal neuropathy and its interplay with laryngopharyngeal reflux. There is limited evidence for post-nasal drip or cough-variant asthma causing chronic cough. SUMMARY: In this study, we review the evidence for cause of chronic cough, as well as up to date techniques for the otolaryngologist, including transnasal esophagoscopy, to assess the patient in clinic allowing accurate diagnosis. Treatment options for the otolaryngologist are discussed and the role of multidisciplinary input emphasized.

Respiratory manifestations of gastroesophageal reflux disease.

Gastroesophageal reflux disease (GERD) is highly associated with a range of respiratory symptoms, arising from a variety of etiologies. The following commentaries on respiratory manifestations of GERD address evidence for a role of a vagally mediated bronchoconstriction reflex in the development of asthma; the direct effects of airway obstruction on lower esophageal sphincter (LES) pressure and reflux episodes; the mechanisms by which reflux may play roles in chronic cough and airway stenosis; the limited efficacy of laparoscopic antireflux surgery (LARS) in improving GERD-related respiratory symptoms; the search for a marker for microaspiration and reflux-induced airway disease; and the potential of proton pump inhibitor (PPI) treatment for patients presenting with asthma and GERD.

Laryngopharyngeal reflux and GERD.

In patients with laryngopharygeal reflux (LPR), gastric contents exhibit retrograde flow into the upper aero-digestive tract, causing extraesophageal symptoms including chronic cough, hoarseness, indigestion, difficulty swallowing, globus pharyngis, and asthma. The following on laryngopharyngeal reflux includes commentaries on the use of patient-completed questionaires and anti-human pepsin antibodies and other non-invasive tests in diagnosis; the role of pepsin and acid in the etiologies of laryngeal cancers; and the application of proton pump inhibitor (PPI) therapy for the treatment of LPR.

Comparison of esophageal screen findings on videofluoroscopy with full esophagram results.

BACKGROUND: Videofluoroscopic swallowing studies do not routinely obtain images of the esophagus. We incorporated a single esophageal screening swallow into our videofluoroscopic swallowing study protocol. The purpose of this study was to compare findings from "esophageal screening" with the results of full esophagram. METHODS: Patients undergoing videofluoroscopic swallowing studies with an esophageal screen followed by full esophagram between January 1, 2009, and October 1, 2009, were retrospectively reviewed. Comparison of esophageal screening and esophagram results were undertaken, with esophagram used as the gold standard. RESULTS: Seventy-four patients underwent esophageal screening and esophagram. Sensitivity of esophageal screening is 63% (CI 50%-73%); specificity is 100% (CI 39%-100%). Positive and negative predictive values of esophageal screening were 100% and 13%, respectively. CONCLUSIONS: Esophageal screening identified 44/70 (63%) patients with esophageal disease. Esophageal screening is a simple tool that may guide further esophageal investigation. The sensitivity of esophageal screening is limited (63%). If clinical suspicion is high, formal esophagram should be considered.