Head and Neck Virtual Coach: A Randomized Control Trial of Mobile Health as an Adjunct to Swallowing Therapy During Head and Neck Radiation.

Dysphagia is a common consequence of head and neck radiation and may be mitigated by performance of swallowing exercises during radiation treatment. Given historically poor adherence to such exercise protocols, we created a mobile health application, HNC Virtual Coach as an adjunct to standard clinical care. This randomized control trial investigated the impact of HNC Virtual Coach on adherence as well as swallowing outcomes by comparing those using the mobile app to those receiving only standard clinical care and paper logs. Both treatment groups were provided with the same exercise protocol as well as the same baseline educational information. Outcome measures included adherence rates, physiologic measures obtained during a Modified Barium Swallow Study (PAS, MBS-ImP, DIGEST), patient-reported outcomes (MDADI), diet levels (FOIS, PSS-HN), and quality of information received (INFO-25). Patients using the HNC Virtual Coach tended to have better adherence to treatment recommendations during radiation therapy. Increased adherence was associated with better patient-reported quality of life, but not physiologic function 2-3 months following completion of radiation. Results suggest that a mobile health application may provide benefit for some patients undergoing head and neck radiation.

Practice patterns in transoral robotic surgery: results of an American head and neck society survey.

To understand perioperative practices for transoral robotic surgery (TORS) among academic medical centers. An electronic cross-sectional survey was distributed to fellows and program directors participating in 49 American Head and Neck Society fellowships. Operative decisions, medical and swallowing management, and disposition planning were assessed. Thirty-eight responses were collected (77.6%). Twenty-three centers (60.5%) performed > 25 cases annually with the remainder performing fewer. The da Vinci Si was the most commonly used platform (n = 28, 73.7%). A majority of institutions advocated tailored resection to adequate margins (n = 27, 71.1%) over fixed subunit-based resection (n = 11, 28.9%). Most surgeons (n = 29, 76.3%) performed neck dissection concurrent with TORS, and 89.5% (n = 34) routinely ligated external carotid artery branches. A minority of institutions (n = 17, 45.9%) endorsed a standardized TORS care pathway. Antibiotic choices and duration varied, the most common choice being ampicillin/sulbactam (n = 21, 55.3%), and the most common duration being 24 h or less (n = 22, 57.9%). Multimodal analgesia was used at 36 centers (94.7%), steroids at 31 centers (81.6%), and pharmacologic venous thromboembolic prophylaxis at 29 centers (76.3%). Nasogastric feeding tubes were placed during surgery at 20 institutions (54.1%). Speech-language pathologists routinely performed postoperative swallow evaluations at 29 (78.4%) sites. Practice patterns are variable among institutions performing TORS. While certain surgical and postoperative practices were quite common, many institutions reported no standard TORS care pathway. Further understanding of the impact of individual practices on outcomes is necessary to develop evidence-based perioperative protocols for TORS.

Feeding Tube Placement Following Transoral Robotic Surgery for Oropharyngeal Squamous Cell Carcinoma.

OBJECTIVE: To identify factors that may predict the need for feeding tubes in patients undergoing transoral robotic surgery (TORS) in the perioperative setting. STUDY DESIGN: Retrospective chart review. SETTING: Academic tertiary center. METHODS: A retrospective series of patients undergoing TORS for oropharyngeal squamous cell carcinoma (OPSCC) was identified between October 2016 and November 2019 at a single tertiary academic center. Patient data were gathered, such as frailty information, tumor characteristics, and treatment, including need for adjuvant therapy. Multiple logistic regression was performed to identify factors associated with feeding tube placement following TORS. RESULTS: A total of 138 patients were included in the study. The mean age was 60.2 years (range, 37-88 years) and 81.9% were male. Overall 82.9% of patients had human papilloma virus-associated tumors, while 28.3% were current or former smokers with a smoking history ≥10 pack-years. Eleven patients (8.0%) had a nasogastric or gastrostomy tube placed at some point during their treatment. Five patients (3.6%) had feeding tubes placed perioperatively (<4 weeks after TORS), of which 3 were nasogastric tubes. Six patients (4.3%) had feeding tubes placed in the periadjuvant treatment setting for multifactorial reasons; 5 of which were gastrostomy tubes. Only 1 patient (0.7%) was gastrostomy dependent 1 year after surgery. Multiple logistic regression did not demonstrate any significant predictive variables affecting perioperative feeding tube placement following TORS for OPSCC. CONCLUSIONS: Feeding tubes are seldom required after TORS for early-stage OPSCC. With appropriate multidisciplinary planning and care, patients may reliably avoid the need for feeding tube placement following TORS for OPSCC.

COVID-19: reflections on providing dysphagia care in a Boston hospital.

PURPOSE OF REVIEW: Coronavirus Disease-19, (COVID-19) has challenged the customary practice of speech language pathologists (SLPs) in the acute care hospital arena, particularly in patients with swallowing disorders. RECENT FINDINGS: In this article, we present themes that emerged from qualitative interviews in which 15 SLPs in a tertiary academic medical center in Boston share their clinical experience caring for over 500 patients with COVID-19: triumphs, concerns, and fears. SUMMARY: The broad themes addressed include adapting to practice laced with fear and uncertainty about safety for themselves and their decision making, coming to terms with disparate and unpredictable clinical presentation, teamwork and collaboration and relationships with their patients despite physical and language barriers.

Prediction of Speech, Swallowing, and Quality of Life in Oral Cavity Cancer Patients: A Pilot Study.

OBJECTIVES/HYPOTHESIS: To investigate the impact of specific treatment-related variables on functional and quality of life outcomes in oral cavity cancer (OCC) patients. STUDY DESIGN: Retrospective Cohort. METHODS: Patients with primary OCC at least 6 months after resection and adjuvant therapy were included. Patients completed surveys including the Speech Handicap Index (SHI), M.D. Anderson Dysphagia Inventory (MDADI), and Functional Assessment of Cancer Therapy-Head and Neck (FACT-HN). Performance Status Scale (PSS) and tongue mobility scale were completed to allow provider-rated assessment of speech and tongue mobility, respectively. Additional details regarding treatment were also collected. These data were used to generate a predictive model using linear regression. RESULTS: Fifty-three patients with oral tongue and/or floor of mouth (FOM) resection were included in our study. In multivariable analysis, greater postoperative tongue range of motion (ROM) and time since treatment improved SHI. Flap reconstruction and greater postoperative tongue ROM increased MDADI and PSS (eating and speech). A larger volume of resected tissue was inversely correlated with PSS (diet and speech). Tumor site was an important predictor of PSS (all sections). There were no statistically significant predictors of FACT-HN. CONCLUSIONS: In this pilot study, we propose a battery of tools to assess function in OCC patients treated with surgery. Using the battery of tools we propose, our results show that a surgical endpoint that preserves tongue mobility and employs flap reconstruction resulted in better outcomes, whereas those with greater volume of tissue resected and FOM involvement resulted in poorer outcomes. Larger prospective studies are needed to validate our findings. LEVEL OF EVIDENCE: 3 Laryngoscope, 131:2497-2504, 2021.

Risk Factors for Laryngectomy for Dysfunctional Larynx After Organ Preservation Protocols: A Case-Control Analysis.

OBJECTIVE: (1) To identify factors associated with severe dysfunctional larynx leading to total laryngectomy after curative treatment of head and neck squamous cell carcinoma and (2) to describe swallowing and voice outcomes. STUDY DESIGN: Retrospective single-institution case-control study. SETTING: Tertiary care referral center. METHODS: A 10-year chart review was performed for patients who had previously undergone radiation or chemoradiation for head and neck mucosal squamous cell carcinoma and planned to undergo total laryngectomy for dysfunctional larynx, as well as a control group of matched patients. Controls were patients who had undergone radiation or chemoradiation for mucosal squamous cell carcinoma but did not have severe dysfunction warranting laryngectomy; these were matched to cases by tumor subsite, T stage, and time from last treatment to video swallow study. Main outcomes assessed were postoperative diet, alaryngeal voice, pharyngeal dilations, and complications. RESULTS: Twenty-six patients were scheduled for laryngectomy for dysfunctional larynx, of which 23 underwent surgery. Originally treated tumor subsites included the larynx, oropharynx, hypopharynx, oral cavity, and a tumor of unknown origin. The median time from end of cancer treatment to laryngectomy was 11.5 years. All cases were feeding tube or tracheostomy dependent or both prior to laryngectomy. As compared with matched controls, cases were significantly less likely to have undergone IMRT (intensity-modified radiotherapy) and more likely to have pulmonary comorbidities. Eighty-nine percent of cases with follow-up achieved functional alaryngeal voice, and all were able to have oral intake. CONCLUSION: Non-IMRT approaches and pulmonary comorbidities are associated with laryngectomy for dysfunction after radiation or chemoradiation.

Atlas-Based Tongue Muscle Correlation Analysis From Tagged and High-Resolution Magnetic Resonance Imaging.

Purpose Intrinsic and extrinsic tongue muscles in healthy and diseased populations vary both in their intra- and intersubject behaviors during speech. Identifying coordination patterns among various tongue muscles can provide insights into speech motor control and help in developing new therapeutic and rehabilitative strategies. Method We present a method to analyze multisubject tongue muscle correlation using motion patterns in speech sound production. Motion of muscles is captured using tagged magnetic resonance imaging and computed using a phase-based deformation extraction algorithm. After being assembled in a common atlas space, motions from multiple subjects are extracted at each individual muscle location based on a manually labeled mask using high-resolution magnetic resonance imaging and a vocal tract atlas. Motion correlation between each muscle pair is computed within each labeled region. The analysis is performed on a population of 16 control subjects and 3 post-partial glossectomy patients. Results The floor-of-mouth (FOM) muscles show reduced correlation comparing to the internal tongue muscles. Patients present a higher amount of overall correlation between all muscles and exercise en bloc movements. Conclusions Correlation matrices in the atlas space show the coordination of tongue muscles in speech sound production. The FOM muscles are weakly correlated with the internal tongue muscles. Patients tend to use FOM muscles more than controls to compensate for their postsurgery function loss.

Differentiating post-cancer from healthy tongue muscle coordination patterns during speech using deep learning.

The ability to differentiate post-cancer from healthy tongue muscle coordination patterns is necessary for the advancement of speech motor control theories and for the development of therapeutic and rehabilitative strategies. A deep learning approach is presented to classify two groups using muscle coordination patterns from magnetic resonance imaging (MRI). The proposed method uses tagged-MRI to track the tongue's internal tissue points and atlas-driven non-negative matrix factorization to reduce the dimensionality of the deformation fields. A convolutional neural network is applied to the classification task yielding an accuracy of 96.90%, offering the potential to the development of therapeutic or rehabilitative strategies in speech-related disorders.

Assessing functional outcomes in head and neck surgical oncology.

BACKGROUND: A reliable method of measuring functional outcomes is essential to inform treatment decisions in head and neck cancer. METHODS: Members of the American Head and Neck Society were surveyed regarding their use of functional outcome assessment tools. Qualitative statistical analysis was performed to identify major tools used and to clarify obstacles to functional outcome assessment. A comprehensive literature review was performed to identify available tools. RESULTS: A total of 142 surgeons were surveyed. 44.12% of respondents use at least 1 tool to assess functional outcomes. The most frequently used tools were modified barium swallow, MD Anderson Dysphagia Inventory, and functional endoscopic evaluation of swallow (FEES). 72.65% of respondents reported barriers to assessment, most frequently a lack of support to administer the tests or to collect, apply or analyze the results. Review of the literature revealed 173 available tools. CONCLUSIONS: Although a wide variety of validated tools are available in the literature to assess functional outcomes after head and neck surgery, major obstacles to their use persist. The lack of a standard measure that is practical and transferable continues to impair research progression in this field.

Patient-reported versus physiologic swallowing outcomes in patients with head and neck cancer after chemoradiation.

OBJECTIVE: The primary objective of this project was to retrospectively investigate the relationship between patient-reported and physiologic swallowing measures after chemoradiation therapy for head neck cancer (HNC). METHODS: Adult patients who underwent chemoradiation therapy for HNC and presented for videofluoroscopic swallow study were reviewed retrospectively. Surgically treated patients were excluded. Patient perception of swallowing-related outcomes was assessed via the MD Anderson Dysphagia Inventory (MDADI) on the same day that physiologic measures of swallow function were obtained. Using vidoefluoroscopic data, the Dynamic Imaging Grade of Swallowing Toxicity (DIGEST) scale yielded measures of safety (DIGEST-S: penetration/aspiration) and efficiency (DIGEST-E: residue). Statistical analysis for correlation coefficients was performed. RESULTS: Thirty patients met the inclusion criteria. The oropharynx was the most commonly affected site (70.0%), followed by the larynx (16.7%). The median radiation dose was 72 grays (Gy), and participants were assessed a mean of 4.6 (range 0-12) years following completion of treatment. There was no correlation between the MDADI and the DIGEST-E score (Pearson rho = -0.045, P = 0.812), DIGEST-S score (Pearson rho = 0.075, P = 0.695), or summary DIGEST grade (Pearson rho = 0.046, P = 0.810). MDADI scores did not change significantly with increasing time since radiation (P = 0.375), whereas the DIGEST-E scores, DIGEST-S score, and summary DIGEST grades worsened over time (P = 0.007, P = 0.002, and P = 0.0005, respectively). CONCLUSION: Assessment of swallowing physiology showed that function worsened after chemoradiation therapy, but this did not correlate with patient-reported quality-of-life measures. Reduced patient awareness of swallow dysfunction years after completion of chemoradiation has implications for management of dysphagia in the face of physiologic decline. LEVEL OF EVIDENCE: 4 Laryngoscope, 129:2059-2064, 2019.

State of the art: Rehabilitation of speech and swallowing after total laryngectomy.

Despite the development and expansion of non-surgical organ preservation therapy, total laryngectomy continues to be the optimal therapy for far-advanced local disease and the only curative option for radiotherapy failures not amenable to partial laryngeal procedures. Laryngectomy, however, remains a life-altering operation with profound effects on swallowing and speech. In the nearly 150 years since the first total laryngectomy was performed, few ablative aspects have changed, but reconstructive techniques have undergone radical evolution. This review will trace the origins of laryngeal rehabilitation for voice and swallowing, the current state of the art with attention to pre-treatment considerations and post-operative management, current surgical management techniques, and the future of functional laryngeal reconstruction.

Managing the late effects of chemoradiation on swallowing: bolstering the beginning, minding the middle, and cocreating the end.

PURPOSE OF REVIEW: Late dysphagia has a profound impact on quality of life in patients treated with chemoradiation therapy for advanced head and neck cancer and the number of survivors is growing. Traditional treatment methods are not uniformly successful in reducing the swallow impairment in these patients. RECENT FINDINGS: Manifestations of late dysphagia are complex and do not follow a uniform trajectory. Patient's experience of eating and engagement in treatment is critical given the complex, variable nature of late dysphagia. Novel swallow treatment methods target respiratory function including coordination and strength as well as patient adherence. SUMMARY: Head and neck cancer survivors deserve routine and fastidious surveillance beyond the 5-year survival point with respect to swallow function if the enormous biopsychosocial burden of late dysphagia is to be addressed.

Human papilloma virus-related oropharyngeal cancer: opportunities and challenges in dysphagia management.

PURPOSE OF REVIEW: Human papilloma virus (HPV) has emerged as the most common cause of oropharyngeal cancer (OPC) compared with traditional causes of excess alcohol and tobacco use. In this article, we will discuss HPV-related OPC and the challenges and opportunities presented in dysphagia management relative to efforts to de-escalate treatment and improve outcomes. RECENT FINDINGS: It is becoming increasingly apparent that patients with HPV-positive disease appear to respond favourably to chemoradiation. Targeted chemoradiation is associated with severe early and late toxicities related to swallow function. Research is in progress to ascertain the benefit of treatment de-escalation with a particular focus on swallowing outcomes. Patients are younger and, with the improved outcomes reported in the literature, surviving longer with the consequences of their treatment. Given the changing demographic of this patient group, there are a number of opportunities to optimize swallowing outcomes, and this should be underpinned by detailed swallowing evaluation and counselling prior to treatment. A number of strategies have been suggested to improve swallowing outcomes; however, persisting and late-onset swallowing effects continue to be a risk. Transoral surgery is evolving as an option for the treatment of HPV-positive disease; however, more studies are required to understand functional outcomes. SUMMARY: Clinical trials are now underway to ascertain the effectiveness of tailored treatments for HPV-positive OPC with a focus on swallowing outcomes. It is encouraging that studies are now including detailed, multidimensional swallowing evaluation. Until such time as longitudinal data are available, patients should be treated by speech-language pathologists based on existing radiation treatment protocols and in the knowledge that patients may experience significant late swallowing difficulties.

Intensity-modulated versus conventional radiation therapy for oropharyngeal carcinoma: long-term dysphagia and tumor control outcomes.

BACKGROUND: The purpose of this study was to determine the relative clinical benefits of intensity-modulated radiation therapy (IMRT) versus conventional radiotherapy (CRT) in the treatment of patients with oropharyngeal carcinoma. METHODS: We compared tumor control and toxicity outcomes in 132 patients with stage III to IVA/B oropharyngeal carcinoma treated with definitive chemoradiation in the human papillomavirus (HPV) era. RESULTS: Patients treated with IMRT had lower rates of xerostomia (p = .01) and shorter duration of gastrostomy-tube dependence (p < .0001), but increased risk of cervical esophageal stricture (p = .03). The overall rates of late dysphagia were not different between the 2 groups (p = .40). In multivariate analysis, IMRT was a significant predictor of decreased disease-specific mortality (hazard ratio [HR] = 0.24; p = .03) after adjustment for T-category and active smoking. After adjustment for T classification, IMRT use was associated with a trend toward a significant decrease in locoregional failure (HR = 0.17; p = .08). CONCLUSION: The incidence of late dysphagia is similar in IMRT and CRT, but the mechanism of dysphagia is different.

Clinical factors predicting for prolonged enteral supplementation in patients with oropharyngeal cancer treated with chemoradiation.

OBJECTIVES: The purpose of this study is to determine the pre-treatment clinical factors associated with prolonged enteral feeding in patients with oropharyngeal cancer treated with chemoradiation. MATERIALS AND METHODS: One hundred and nine patients with stage III-IVB oropharyngeal carcinoma treated with definitive chemoradiation were analyzed. Feeding tube usage was defined as the duration of active usage for nutritional purposes. RESULTS: Median follow-up was 4.4 years and median feeding tube usage was 2.5 months. On multivariate analysis, increasing duration of feeding tube usage was associated with narcotic use before treatment (p = 0.04), living alone at the time of treatment (p = 0.04), and larger pre-treatment decrease in body-mass index (p = 0.01). Prolonged feeding tube usage was associated with decreased overall survival (p = 0.06) and disease-free survival (p = 0.02) in univariate analysis. CONCLUSIONS: By identifying patients at risk for prolonged feeding tube usage, aggressive measures can be attempted to prevent feeding tube dependence.

Pharyngoesophageal stricture after treatment for head and neck cancer.

BACKGROUND: The purpose of this study was to report the risk of pharyngoesophageal stricture after treatment for head and neck cancer. METHODS: Human studies on radiation therapy with or without chemotherapy for head and neck cancer published in peer-reviewed journals with assessment of pharyngoesophageal stricture with barium swallow or endoscopy were included. RESULTS: A total of 4727 patients from 26 studies treated between 1989 and 2008 were eligible for analysis. The reported overall risk of stricture was 7.2%. The risks of pharyngoesophageal stricture in both conventional and intensity-modulated radiation therapy (IMRT) studies were 5.7% and 16.7%, respectively (p < .001). Use of concurrent (p < .001) and taxane (p = .01) chemotherapy was associated with the IMRT technique. Prospective studies reported a 3.3-fold increased risk of stricture compared with that of retrospective studies (odds ratio: 3.3; 95% confidence interval: 2.3-4.8; p < .001). CONCLUSIONS: Pharyngoesophageal stricture after IMRT and chemotherapy treatment for head and neck cancer is not uncommon. Videofluoroscopic swallow study should be performed prospectively to evaluate swallowing function.