Determining the Impact of Thickened Liquids on Swallowing in Patients Undergoing Irradiation for Oropharynx Cancer.

The current standard for the treatment of oropharynx cancers is radiation therapy. However, patients are frequently left with dysphagia characterized by penetration-aspiration (impaired safety) and residue (impaired efficiency). Although thickened liquids are commonly used to manage dysphagia, we lack evidence to guide the modification of liquids for clinical benefit in the head and neck cancer population. The objective of this study was to assess the impact of slightly and mildly thick liquids on penetration-aspiration and residue in 12 patients with oropharyngeal cancer who displayed penetration-aspiration on thin liquid within 3 to 6 months after completion of radiotherapy. Significantly fewer instances of penetration-aspiration were seen with slightly and mildly thick liquids as compared with thin (P < .05). No differences were found across stimuli in the frequency of residue. Patients with oropharyngeal cancers who present with post-radiation therapy dysphagia involving penetration-aspiration on thin liquids may benefit from slightly and mildly thick liquids without risk of worse residue.

Validation of Articulatory Rate and Imprecision Judgments in Speech of Individuals With Amyotrophic Lateral Sclerosis.

Purpose Perceptual judgments of articulatory function are commonly used by speech-language pathologists to evaluate articulatory performance in individuals with amyotrophic lateral sclerosis (ALS). The goal of this study was to evaluate the psychometric properties (e.g., reliability, validity) of these perceptual measures to inform their application as part of a comprehensive bulbar assessment tool in ALS. Method Preexisting data from 51 individuals with ALS were obtained from a larger longitudinal study. Five independent raters provided perceptual judgments of articulatory rate and imprecision in a sentence task. Inter- and intrarater reliability of these judgments were assessed. Perceptual ratings were correlated with an acoustic measure of articulatory rate, in syllables per second, obtained from passage-reading recordings. Both perceptual and acoustic measures were correlated with gold-standard kinematic tongue and jaw movement measures, recorded from sentences using electromagnetic articulography. Results The results revealed good inter- and intrarater reliability of perceptual judgments of articulatory function. Strong correlations were observed between perceptual ratings of articulatory rate and imprecision and acoustic measures of articulatory rate and kinematic measures of tongue speed. Conclusions These findings support the clinical application of perceptual judgments of articulatory function as valid and reliable measures of underlying articulatory changes in bulbar ALS. Additional research is needed to understand the responsiveness of these measures to clinical changes in articulatory function in ALS.

Mechanisms of Impaired Swallowing on Thin Liquids Following Radiation Treatment for Oropharyngeal Cancer.

Purpose Dysphagia is one of the most debilitating chronic symptoms experienced by patients who undergo radiation treatment for head and neck cancer. Despite the high prevalence of dysphagia in patients with head and neck cancer, we lack understanding of the specific changes in swallowing physiology that arise in the short-term following radiation therapy and how these changes impact the key functions of swallowing safety and efficiency. This study sought to identify pathophysiological mechanisms underlying impairments in swallowing safety and efficiency on thin liquids following (chemo)radiation for oropharyngeal cancer. Method Videofluoroscopic swallowing studies were completed in 12 male patients within 6 months following completion of (chemo)radiation and in 12 healthy male controls. To compare swallowing function and physiology between groups, we analyzed three discrete sips of 20% w/v thin liquid barium per participant. The videofluoroscopic swallowing study recordings were rated for swallowing safety, efficiency, timing parameters, and pixel-based measures of structural area or movement. Results The oropharyngeal cancer cohort displayed significantly higher frequencies of penetration-aspiration, incomplete laryngeal vestibule closure, prolonged time-to-laryngeal vestibule closure, and poor pharyngeal constriction. Incomplete or delayed laryngeal vestibule closure was associated with airway invasion, while poor pharyngeal constriction was associated with pharyngeal residue. Conclusions This study highlights the primary mechanisms behind impaired safety and efficiency of the swallow in patients following (chemo)radiation for oropharyngeal cancer.

Measurement of Pharyngeal Residue From Lateral View Videofluoroscopic Images.

Purpose The field lacks consensus about preferred metrics for capturing pharyngeal residue on videofluoroscopy. We explored four different methods, namely, the visuoperceptual Eisenhuber scale and three pixel-based methods: (a) residue area divided by vallecular or pyriform sinus spatial housing ("%-Full"), (b) the Normalized Residue Ratio Scale, and (c) residue area divided by a cervical spine scalar (%(C2-4)2). Method This study involved retrospective analysis of an existing data set of videofluoroscopies performed in 305 adults referred on the basis of suspected dysphagia, who swallowed 15 boluses each (six thin and three each of mildly, moderately, and extremely thick 20% w/v barium). The rest frame at the end of the initial swallow of each bolus was identified. Duplicate measures of pharyngeal residue were made independently by trained raters; interrater reliability was calculated prior to discrepancy resolution. Frequency distributions and descriptive statistics were calculated for all measures. Kendall's τb tests explored associations between Eisenhuber scale scores and pixel-based measures, that is, %-Full and %(C2-4)2. Cross-tabulations compared Eisenhuber scale scores to 25% increments of the %-Full measure. Spearman rank correlations evaluated relationships between the %-Full and %(C2-4)2 measures. Results Complete data were available for 3,545 boluses: 37% displayed pharyngeal residue (thin, 36%; mildly thick, 41%; moderately thick, 35%; extremely thick, 34%). Eisenhuber scale scores showed modest positive associations with pixel-based measures but inaccurately estimated residue severity when compared to %-Full measures with errors in 20.6% of vallecular ratings and 14.2% of pyriform sinus ratings. Strong correlations (p < .001) were seen between the %-Full and %(C2-4)2 measures, but the %-Full measures showed inflation when spatial housing area was small. Conclusions Generally good correspondence was seen across different methods of measuring pharyngeal residue. Pixel-based measurement using an anatomical reference scalar, for example, (C2-4)2 is recommended for valid, reliable, and precise measurement.

A Cross-Sectional, Quantitative Videofluoroscopic Analysis of Swallowing Physiology and Function in Individuals With Amyotrophic Lateral Sclerosis.

Purpose To date, research characterizing swallowing changes in individuals with amyotrophic lateral sclerosis (ALS) has primarily relied on subjective descriptions. Thus, the degree to which swallowing physiology is altered in ALS, and relationships between such alterations and swallow safety and/or efficiency are not well characterized. This study provides a quantitative representation of swallow physiology, safety, and efficiency in a sample of individuals with ALS, to estimate the degree of difference in comparison to published healthy reference data and identify parameters that pose risk to swallow safety and efficiency. Secondary analyses explored the therapeutic effect of thickened liquids on swallowing safety and efficiency. Method Nineteen adults with a diagnosis of probable-definite ALS (El-Escorial Criteria-Revised) underwent a videofluoroscopic swallowing study, involving up to 15 sips of barium liquid (20% w/v), ranging in thickness from thin to extremely thick. Blinded frame-by-frame videofluoroscopy analysis yielded the following measures: Penetration-Aspiration Scale, number of swallows per bolus, amount of pharyngeal residue, degree of laryngeal vestibule closure (LVC), time-to-LVC, duration of LVC (LVCdur), pharyngeal area at maximum constriction, diameter of upper esophageal sphincter opening, and duration of UES opening (UESOdur). Measures of swallow physiology obtained from thin liquid trials were compared against published healthy reference data using unpaired t tests, chi-squared tests, and Cohen's d effect sizes (adjusted p < .008). Preliminary relationships between parameters of swallowing physiology, safety, and efficiency were explored using nonparametric Cochrane's Q, Friedman's test, and generalized estimating equations (p < .05). Results Compared to healthy reference data, this sample of individuals with ALS displayed a higher proportion of swallows with partial or incomplete LVC (24% vs. < 1%), increased time-to-LVC (d = 1.09), reduced UESwidth (d = 0.59), enlarged pharyngeal area at maximum constriction, prolonged LVCdur (d = 0.64), and prolonged UESOdur (d = 1.34). Unsafe swallowing (i.e., PAS ≥ 3) occurred more frequently when LVC was partial/incomplete or time-to-LVC was prolonged. Pharyngeal residue was associated with larger pharyngeal areas at maximum constriction. Unsafe swallowing occurred less frequently with extremely thick liquids, compared to thin liquids. No significant differences in pharyngeal residue were observed based on liquid thickness. Conclusions Quantitative videofluoroscopic measurements revealed moderate-to-large differences in swallow physiology between this sample of individuals with ALS and healthy reference data. Increased time-to-LVC, noncomplete LVC, and enlarged pharyngeal area at maximum constriction were associated with impaired swallow safety or efficiency. Thickened liquids may mitigate the risk of acute episodes of aspiration in individuals with ALS. Further work is needed to corroborate these preliminary findings and explore how swallowing profiles evolve throughout disease progression.

Reference Values for Healthy Swallowing Across the Range From Thin to Extremely Thick Liquids.

Purpose Thickened liquids are frequently used as an intervention for dysphagia, but gaps persist in our understanding of variations in swallowing behavior based on incremental thickening of liquids. The goal of this study was to establish reference values for measures of bolus flow and swallowing physiology in healthy adults across the continuum from thin to extremely thick liquids. Method A sex-balanced sample of 38 healthy adults underwent videofluoroscopy and swallowed 20% weight-to-volume concentration barium prepared in thin and slightly, mildly, moderately, and extremely thick consistencies using a xanthan gum thickener. Participants took comfortable sips and swallowed without a cue; sip volume was measured based on presip and postsip cup weights. A standard operating procedure (the ASPEKT method: Analysis of Swallowing Physiology: Events, Kinematics and Timing) was used to analyze videofluoroscopy recordings. Results The results clarify that, for thin liquid sips (10-14 ml), a single swallow without clearing swallows is typical and is characterized by complete laryngeal vestibule closure, complete pharyngeal constriction, and minimal postswallow residue. Aspiration was not seen, and penetration was extremely rare. Bolus position at swallow onset was variable, extending as low as the pyriform sinuses in 37% of cases. With thicker liquids, no changes in event sequencing, laryngeal vestibule closure, pharyngeal constriction, or postswallow residue were seen. The odds of penetration were significantly reduced. A longer timing interval until onset of the hyoid burst movement was seen, with an associated higher bolus position at swallow onset. Other timing measures remained unaffected by changes in bolus consistency. Conclusion The results include new reference data for swallowing in healthy adults across the range from thin to extremely thick liquids.

Modulation of Tongue Pressure According to Liquid Flow Properties in Healthy Swallowing.

Purpose During swallowing, the tongue generates the primary propulsive forces that transport material through the oral cavity toward the pharynx. Previous literature suggests that higher tongue pressure amplitudes are generated for extremely thick liquids compared with thin liquids. The purpose of this study was to collect detailed information about the modulation of tongue pressure amplitude and timing across the range from thin to moderately thick liquids. Method Tongue pressure patterns were measured in 38 healthy adults (aged under 60 years) during swallowing with 4 levels of progressively thicker liquid consistency (International Dysphagia Diet Standardisation Initiative, Levels 0 = thin, 1 = slightly thick, 2 = mildly thick, and 3 = moderately thick). Stimuli with matching gravity flow (measured using the International Dysphagia Diet Standardisation Initiative Flow Test; Cichero et al., 2017 ; Hanson, 2016 ) were prepared both with/without barium (20% weight per volume concentration) and thickened with starch and xanthan gum thickeners. Results After controlling for variations in sip volume, thicker liquids were found to elicit significantly higher amplitudes of peak tongue pressure and a pattern of higher (i.e., steeper) pressure rise and decay slopes (change in pressure per unit time). Explorations across stimuli with similar flow but prepared with different thickeners and with/without barium revealed very few differences in tongue pressure, with the exception of significantly higher pressure amplitudes and rise slopes for nonbarium, starch-thickened slightly and mildly thick liquids. Conclusions There was no evidence that the addition of barium led to systematic differences in tongue pressure parameters across liquids with closely matched gravity flow. Additionally, no significant differences in tongue pressure parameters were found across thickening agents. Supplemental Material https://doi.org/10.23641/asha.7616537.

Reduced pharyngeal constriction is associated with impaired swallowing efficiency in Amyotrophic Lateral Sclerosis (ALS).

BACKGROUND: Swallowing inefficiency is a prevalent but understudied problem in individuals with Amyotrophic Lateral Sclerosis (ALS). Although reduced pharyngeal constriction has been identified as a mechanism contributing to swallowing inefficiency following stroke, this relationship has not been empirically tested in the ALS population. This study sought to characterize profiles of swallowing efficiency in a sample of ALS patients and investigate relationships between pharyngeal constriction and swallowing efficiency. METHODS: Twenty-six adults with ALS underwent videofluoroscopic swallowing studies, involving 3 mL-thin, 20 mL-thin, and 3 mL-pudding boluses. Full-length recordings were segmented into bolus clips and randomized for analysis. We recorded the total number of swallows per bolus and obtained normalized pixel-based measures of pharyngeal constriction area and post-swallow residue in the vallecular and pyriform sinuses. Linear mixed models with Spearman's correlations were used to determine relationships between pharyngeal constriction and swallowing efficiency, with added factors of bolus volume and thickness. KEY RESULTS: Individuals with ALS demonstrated reduced pharyngeal constriction and increased vallecular and pyriform sinus residue, compared to norms. Reduced pharyngeal constriction had a significant effect on the presence of vallecular and pyriform sinus residue as well as the number of swallows per bolus. Increased bolus thickness was associated with increased vallecular residue, while increased bolus volume was associated with reduced pharyngeal constriction. Results were significant at P < 0.05. CONCLUSIONS & INFERENCES: Our results suggest that reduced pharyngeal constriction is a significant physiological parameter related to swallow inefficiency in ALS. Future work is needed to corroborate these preliminary results and investigate factors to mitigate such impairments.

A Preliminary Videofluoroscopic Investigation of Swallowing Physiology and Function in Individuals with Oculopharyngeal Muscular Dystrophy (OPMD).

Dysphagia is one of the primary symptoms experienced by individuals with Oculopharyngeal Muscular Dystrophy (OPMD). However, we lack understanding of the discrete changes in swallowing physiology that are seen in OPMD, and the resulting relationship to impairments of swallowing safety and efficiency. This study sought to describe the pathophysiology of dysphagia in a small sample of patients with OPMD using a videofluoroscopy examination (VFSS) involving 3 × 5 mL boluses of thin liquid barium (22% w/v). The aim of this study is to extend what is known about the pathophysiology of dysphagia in OPMD, by quantifying changes in swallow timing, kinematics, safety, and efficiency, measured from VFSS. This study is a secondary analysis of baseline VFSS collected from 11 adults (4 male), aged 48-62 (mean 57) enrolled in an industry-sponsored phase 2 therapeutic drug trial. Blinded raters scored the VFSS recordings for safety [Penetration-Aspiration Scale (PAS)], efficiency [Normalized Residue Ratio Scale (NRRS)], timing [Pharyngeal Transit Time (PTT), Swallow Reaction Time (SRT), Laryngeal Vestibule Closure Reaction Time (LVCrt), Upper Esophageal Sphincter Opening Duration (UESD)], and kinematics (hyoid movement, pharyngeal constriction, UES opening width). Impairment thresholds from existing literature were defined to characterize swallowing physiology and function. Further, Fisher's Exact tests and Pearson's correlations were used to conduct a preliminary exploration of associations between swallowing physiology (e.g., kinematics, timing) and function (i.e., safety, efficiency). Compared to published norms, we identified significant differences in the degree of maximum pharyngeal constriction, hyoid movement distance and speed, as well as degree and timeliness of airway closure. Unsafe swallowing (PAS ≥ 3) was seen in only 3/11 patients. By contrast, clinically significant residue (i.e., NRRS scores ≥ 0.09 vallecular; ≥ 0.2 pyriform) was seen in 7/11 patients. Fisher's Exact tests revealed associations between prolonged SRT, PTT, and unsafe swallowing. Weak associations were also identified between post-swallow residue and poor pharyngeal constriction during the swallow. Detailed analysis of swallowing physiology in this series of adults with OPMD aligns with impaired muscular function (e.g., reduced pharyngeal constriction, incomplete laryngeal vestibule closure) associated with the disease, and primary functional challenges with swallow efficiency. Further work is needed to explore a greater range of food and liquid textures, and to identify additional physiological mechanisms underlying swallowing impairment in OPMD.

Effects of Tongue Strength Training on Mealtime Function in Long-Term Care.

PURPOSE: The primary aim of this study was to determine the feasibility and effectiveness of an 8-week tongue-strengthening intervention protocol for seniors with mild to moderately severe cognitive impairment in the long-term care setting. Outcome measures of interest included tongue strength, mealtime duration, and food intake. METHOD: In this pre-post group study of treatment outcomes, data were collected from 7 adults (aged 84-99 years). Participants were observed across a series of mealtimes to determine mealtime duration and intake before and after 16 treatment sessions. During therapy, participants performed isometric strength exercises and tongue pressure accuracy tasks using the Iowa Oral Performance Instrument (model number 2.1, IOPI Medical). Differences in tongue strength as a function of treatment were explored between the first 3 and final 3 sessions using univariate repeated-measures analysis of variance. Single-subject methods were used to explore baseline and posttreatment data for measures of mealtime function. RESULTS: Anterior and posterior tongue strength increased significantly with therapy. There were no changes in mealtime function. CONCLUSIONS: This study shows proof of concept that some older adults with cognitive impairment are able to participate in a tongue-strengthening intervention and achieve improvements in tongue strength. Failure to find evidence of associated changes of mealtime function suggests that mealtime measures may not be directly sensitive to changes in tongue strength.

Trends in Research Literature Describing Dysphagia in Motor Neuron Diseases (MND): A Scoping Review.

Dysphagia in motor neuron diseases (MNDs) is highly complex, affecting all stages of swallowing and leading to impaired swallowing safety and efficiency. In order to explore the degree to which research is capturing the symptom of dysphagia in MND, we conducted a scoping review of the existing literature. The primary aims of this review were to identify common themes within the literature on dysphagia in MND, explore patterns and trends in research focus, and identify if any imbalances exist between the research themes related to dysphagia description and management. A comprehensive search strategy yielded 1690 unique articles for review. Following relevance screening, a total of 157 articles were included in the synthesis. Relevant data and keywords were extracted from each article and grouped into themes. Frequency estimates were calculated for each theme to identify trends across research literature. Swallowing impairment in MNDs is described in a variety of ways across current research. The most commonly reported theme was Aspiration/Penetration, mentioned in 73.2% of all included articles; a significant imbalance was identified between reports of swallowing safety and efficiency (p = 0.008). The most frequently reported theme related to dysphagia management was Enteral Nutrition, and very few studies have reported on the efficacy of Rehabilitation/Compensatory recommendations. It is suggested that researchers and clinicians remain mindful of imbalances and gaps in research, and aim to characterize dysphagia in MNDs in a comprehensive manner. Further research investigating discrete, measureable changes in swallowing pathophysiology would be beneficial to delineate the key factors contributing to impaired swallowing safety and efficiency.

A Review of Dysphagia Presentation and Intervention Following Traumatic Spinal Injury: An Understudied Population.

Dysphagia is reported to be a common secondary complication for individuals with traumatic spinal injuries. Different etiologies of traumatic spinal injuries may lead to different profiles of swallowing impairment. We conducted a systematic review to determine the characteristics of dysphagia after traumatic spinal injury and to describe interventions currently used to improve swallowing function in this population. A comprehensive multiengine literature search identified 137 articles of which five were judged to be relevant. These underwent review for study quality, rating for level of evidence, and data extraction. The literature describing dysphagia after traumatic spinal injury was comprised predominantly of low-level evidence and single case reports. Aspiration, pharyngeal residue, and decreased/absent hyolaryngeal elevation were found to be common characteristics of dysphagia in this population. The most commonly used swallowing interventions included tube feeding, compensatory swallowing strategies, and steroids/antibiotics. Improvement in swallowing function following swallowing intervention was reported in all studies; however, there was no control for spontaneous recovery. The results demonstrate a need for high-quality research to profile the pathophysiology of dysphagia after traumatic spinal injury and controlled studies to demonstrate the efficacy of swallowing interventions in this population.