Eosinophilic Esophagitis: Clinical Pearls for Primary Care Providers and Gastroenterologists.

Eosinophilic esophagitis (EoE) is a chronic and progressive immune-mediated esophageal disorder. Given its increasing incidence, it is now a leading cause of dysphagia and food impaction in the United States. Eosinophilic esophagitis is most common in adult White men and has a high concurrence rate with other atopic conditions like allergic rhinitis, bronchial asthma, and eczema. The initial presentation includes symptoms of esophageal dysfunction, classically solid-food dysphagia. Without treatment, inflammation can progress to fibrosis with the formation of strictures, leading to complications such as food impaction. It is a clinicopathologic disease requiring compatible clinical symptoms and histologic evidence of eosinophil-predominant inflammation of the esophageal epithelium with more than 15 eosinophils per high-power field. The mainstay of management includes the 3 d's (diet, drugs, dilation): dietary modifications to eliminate trigger food groups; medications including proton pump inhibitors, swallowed topical glucocorticoids, and dupilumab; and esophageal dilation to manage strictures. Various elimination diets have been found to be effective, including 1-food, 2-food, 4-food, and 6-food elimination diets. Dupilumab, a humanized monoclonal antibody that regulates interleukin 4 and 13 signaling pathways, has shown promising results in clinical trials and was approved by the Food and Drug Administration in 2022 for use in EoE. Symptom alleviation, although important, is not the sole end point of treatment in EoE as persistent inflammation, even in the absence of symptoms, can lead to esophageal fibrosis and stricture formation over time. The chronic nature and high recurrence rates of EoE warrant maintenance therapy in patients with EoE after initial remission is achieved.

Clinical Evaluation of the Adult with Eosinophilic Esophagitis.

Adult patients with eosinophilic esophagitis (EoE) typically present with a history of dysphagia for solids, sometimes with additional reflux-like pain and a history of prior food impactions. In contrast to these alarming symptoms, the general appearance and physical examination of adult patients with EoE is in line with apparently healthy individuals. Therefore, the diagnosis is based on a history of solid-food dysphagia and eosinophilic tissue infiltration. Importantly, the increasing prevalence of EoE variants, that is, typical EoE symptoms in the absence of a relevant eosinophilia, and several studies with eosinophil-targeting drugs, call the pathogenic role of eosinophils into question.

Recognition and Management of Feeding Dysfunction in the Pediatric Patient with Eosinophilic Esophagitis.

Feeding is a complex skill requiring coordination of multiple body systems. Multiple factors are considered in feeding dysfunction in pediatric patients with eosinophilic gastrointestinal disorders, including overall development, nutritional status, mealtime behaviors, and medical comorbidities. Symptoms of feeding dysfunction vary by age, with maladaptive learned feeding behaviors spanning all age ranges. Knowledge of the normal acquisition of feeding skills is critical to interpret the impact of the disease and plan appropriate intervention. Assessment and treatment from a feeding and swallowing disorders specialist can dramatically impact successful outcomes in nutrition, growth, mealtime dynamics and ultimatly quality of life for children and their caregivers in home and social settings.

Dysphagia lusoria caused by aberrant right subclavian artery associated with truncus bicaroticus in an 8-month-old girl. Case report and review of literature.

Dysphagia lusoria is a rare pediatric condition caused by extrinsic compression of the esophagus by an abnormal subclavian artery. The most common congenital abnormality in aortic arch development is an aberrant right subclavian artery. The retroesophageal right subclavian artery is typically symptomatic in 10-33% of cases. The patient, an 8-month-old girl with a history of early dysphagia and stridor, was diagnosed with an abnormal right subclavian artery. She was admitted to the pneumology service multiple times due to stridor, vomiting, and failure to thrive. During hospitalization at the gastroenterology service, a barium swallow and an upper digestive endoscopy indicated an abnormal right subclavian artery, which was confirmed by an Angiography CT scan. She underwent surgery at the age of sixteen months. All symptoms are resolved following surgical intervention, and the patient is still asymptomatic and in good clinical condition 12 months later. Every physician should be aware of abnormal right subclavian arteries and their clinical symptoms in children and adults in order to recognize and diagnose them early. Only an early evaluation may reduce complications such as delayed physical growth, dysphagia, and recurrent respiratory infections.

Nurses' practices in stroke-related dysphagia in low- and middle-income countries.

BACKGROUND:  Nurses are often required to perform dysphagia screening prior to oral intake by people following stroke. Previous studies report limited knowledge of nurses in identifying symptoms of post-stroke dysphagia. OBJECTIVE:  To explore existing literature regarding nurses' practices and knowledge in the identification and management of post-stroke oropharyngeal dysphagia (OPD) in low- and middle income countries (LMICs). METHOD:  A scoping review was conducted according to the PRISMA-ScR guidelines. Studies were retrieved from PubMed, Scopus, EBSCOhost (CINAHL and Health source: Nursing and Academic edition), Web of Science Core collection, and Cochrane libraries. No time frame was applied, and all included studies were screened according to predefined eligibility criteria. RESULTS:  Eight studies were included from 1 792 initial hits. Studies described nursing practices in acute care pertaining to identification and management of stroke-related dysphagia in LMICs. Increased knowledge was reported in nurses who had greater clinical experience in managing patients with dysphagia. Needs for training relating to dysphagia management and opportunities for interprofessional collaboration with speech-language therapists (SLTs) were identified. Contextual barriers specific to LMICs impacting on optimal nursing management of dysphagia included heavy workloads, staff-shortages and time constraints.Conclusion and contribution: Eight studies described nurses' practices and identified needs for the improvement of nurses' dysphagia care in LMICs. This scoping review highlighted the urgency for further research in dysphagia management that provides creative, contextually relevant solutions for improved protocols and training of health care professionals. Findings may be valuable for the multidisciplinary team involved in post-stroke dysphagia care.

Swallowing and feeding of young children on high-flow oxygen therapy.

BACKGROUND:  Oral feeding practices of young patients on high-flow oxygen (HFO2) have been controversial. Limited literature exists on this topic, but new studies suggest introducing oral feeds. OBJECTIVE:  This study aims to describe the changes in swallowing and feeding of a group of young children on HFO2. METHOD:  Twelve participants (mean age 34.17 months [s.d. = 3.97]) on HFO2 were assessed clinically at the bedside using the Schedule of Oral Motor Assessment. Assessments were conducted twice to determine the change in characteristics: upon approval from the managing doctor when respiratory stability on HFO2 was achieved and for a second time on the last day of receiving HFO2 (mean 2.6 days apart). Patients received standard in-patient care and speech therapy intervention. RESULTS:  Most participants displayed typical oral motor function at initial and final assessments for liquid, puree and semi-solid consistencies. Purees and soft solid consistencies were introduced to most participants (n = 11, 91.7%). Solids and chewables were challenging for all participants during both assessments. Half of the participants displayed gagging and a wet vocal quality with thin liquids at the initial assessment only. CONCLUSION:  This small-scale study found that HFO2 should not preclude oral diets, but in this sample, small amounts of oral feeding could be introduced with caution, in an individualised manner, and with a collaborative multidisciplinary approach. Further research is essential.Contribution: Partial oral feeding of specific consistencies was possible during the assessment of young paediatric in-patients on HFO2. Monitoring of individual patient characteristics and risk factors by a specialist feeding team is essential.

Head and neck cancer patients treated with concomitant chemoradiotherapy involving the oral cavity and oropharynx: is another choice possible than prophylactic gastrostomy?

PURPOSE OF REVIEW: Recent recommendations on cachexia highlight, in head and neck cancers, the heterogeneity of studies, focusing on weight loss and sequelae including swallowing disorders. The current national guidelines emphasize that, in cases of concurrent chemoradiotherapy (cCRT) involving the oral cavity and oropharynx, prophylactic gastrostomy placement should be carried out systematically. We review why this technique is particularly relevant in this specific location for the feasibility of cCRT. RECENT FINDINGS: A randomized trial is underway on swallowing disorders and the quality of life of patients after prophylactic vs. reactive gastrostomy in advanced oropharyngeal cancer patients treated with CRT. Concurrently, recent literature reviews emphasize the importance of the cumulative dose of chemotherapy for local control and survival. In cases of cCRT involving the oral cavity or the oropharynx, nutritional support could have a beneficial or detrimental impact on chemotherapy. SUMMARY: Specifically for patients treated with cCRT involving the oral cavity and oropharynx, prophylactic gastrostomy would be able to fulfill the three objectives of local control, survival, and quality of life, minimizing complications related to nutritional support. Studies need to be more homogeneous. In clinical practice, nutrition should primarily assist in carrying out cancer treatment when survival is the main goal.

[Right aortic arch with mirror image branching : a rare cause of dysphagia]. / L'image du mois. Arc aortique droit avec image en miroir : une cause rare de dysphagie.

We report the case of a 36-year-old female whose dysphagia revealed a congenital anomaly of the thoracic aorta: the right aortic arch with mirror image branching. This is a rare embryonic developmental anomaly where the aorta wraps around the right bronchus and the supra-aortic trunks emerge from the arch in the opposite order to normal. Most of the patients are asymptomatic unless there is a significant compression of mediastinal structures. Major compression of the esophagus or trachea, aneurysmal disease, dissection of the thoracic aorta, or the presence of a Kommerell diverticulum larger than 2 cm may require a surgical repair. There is no standard treatment and it must be adapted to the clinical presentation and the anatomic configuration of each patient. Our patient did not receive any treatment for her condition.

Nous rapportons le cas d'une patiente de 36 ans dont le tableau de dysphagie a permis de mettre en évidence une anomalie congénitale de l'aorte thoracique : l'arc aortique droit avec image en miroir. Il s'agit d'une anomalie de développement embryonnaire rare où l'aorte s'enroule autour de la bronche souche droite et où les troncs supra-aortiques émergent de la crosse dans l'ordre inverse et opposé à la normale. La grande majorité des patients est asymptomatique, à moins qu'il existe une compression des structures médiastinales. Une compression majeure de l'oesophage ou de la trachée, une maladie anévrismale, une dissection de l'aorte thoracique ou la présence d'un diverticule de Kommerell de plus de 2 cm peuvent justifier une sanction chirurgicale. Il n'y a pas de traitement standard et celui-ci doit être adapté à la présentation clinique et à la configuration anatomique du patient. Notre patiente n'a bénéficié d'aucun traitement pour son affection.

X-ray-guided self-expandable metal stent (SEMS) implantation in oesophageal malignancy as an alternative treatment.

<b><br>Indroduction:</b> Significant dysphagia, aspiration pneumonia, and impossible oral nutrition in patients with unresectable or recurrent gastroesophageal malignancy or bronchial cancer invading the oesophagus with a tracheoesophageal fistula lead to cachexia. Dehiscence of the esophago-jejunal or gastroesophageal anastomosis may cause severe oesophageal haemorrhage. We believe that X-ray-guided oesophageal stent implantation (SEMS) is an alternative palliative method for microjejunostomy or full parenteral nutrition.</br> <b><br>Aim:</b> The aim of this paper was to assess the safety and efficacy of a novel X-ray-guided oesophageal stent implantation technique.</br> <b><br>Materials and methods:</b> This retrospective analysis included 54 patients (35 men and 19 women) treated for malignant dysphagia, gastroesophageal/gastrointestinal anastomotic fistula or bronchoesophageal fistula in two Surgical Units between 2010 and 2019, using a modified intravascular approach to oesophageal stent implantation.</br> <b><br>Results:</b> The presented modified intravascular method of oesophageal stent implantation was successfully performed in all described patients requiring oral nutrition restoration immediately following oesophageal stent implantation. Two patients with oesophageal anastomotic dehiscence died on postoperative days 7 and 9 due to circulatory and respiratory failure. One patient was reimplanted due to a recurrent fistula. Two patients with ruptured thoracic aneurysm and thoracic stent graft implantation due to oesophageal haemorrhage, who were implanted with an oesophageal stent, died on postoperative days 4 and 14.</br> <b><br>Conclusions:</b> The modified intravascular X-ray-guided SEMS technique may be a palliative treatment for patients with unresectable oesophageal malignancies.</br>.

The effect of behavioral therapy on dysphagia of acute ischemic stroke patients feeding with a nasogastric tube.

This prospective observational study aimed to assess the impact of behavioral therapy on dysphagia in patients with acute ischemic stroke undergoing nasogastric tube feeding. The study was conducted between June 2020 and May 2022 at the Neurological Center of Bach Mai Hospital, Vietnam, with a sample size of 230 patients divided into two groups: a normal and a behavioral therapy group. The normal therapy group received routine care and treatment based on standard protocols, while the behavioral therapy group underwent daily swallowing exercises for approximately 60 minutes. The Gugging Swallowing Screen (GUSS) was utilized to screen individuals with dysphagia, and the difference-in-differences (DID) method was adopted to estimate the effect of behavioral therapy on dysphagia patients. The study concluded that behavioral therapy improved dysphagia in patients with acute ischemic stroke undergoing nasogastric tube feeding. This study highlights the potential of behavioral therapy as an effective intervention for dysphagia rehabilitation in stroke patients.

[Gastrointestinal symptoms and problems in children cared by pediatric palliative care teams. Observational study]. / Síntomas y problemas gastrointestinales en niños asistidos por equipos de cuidados paliativos pediátricos. Estudio observacional.

Gastrointestinal symptoms and problems (GI- SP) frequently cause discomfort and suffering in pediatric patients with life-threatening and/or life-limiting illnesses (LTI/LLI). Pediatric palliative care (PPC) professionals should be aware of them and perform a comprehensive approach. OBJECTIVE: To determine the prevalence of GI- SP in patients treated in PPC units and to describe the pharmacological and non-pharmacological measures prescribed. PATIENTS AND METHOD: Observational, prospective, multicenter, prospective study in patients with LTI/LLI, seen by PPC teams in Uruguay. The variables analyzed included age, sex, origin, type of LTI/LLI, presence of mucositis, vomiting, swallowing disorders, abdominal pain, constipation, diarrhea, digestive bleeding, problems with digestive prosthesis, and prescribed pharmacological and non-pharmacological treatment. RESULTS: 10 out of 16 PPC teams participated. 96 out of 436 patients seen presented GI- SP (22%). Median age was 4.2 years (1 month-18 years). LTI/LLI: 65% neurological and 7% oncological. The 96 patients had 114 consultations; 50% had 2 or more GI- SP per consultation. GI- SP observed: swallowing disorders (57%), constipation (53%), nausea and/or vomiting (24%), gastrostomy problems (17%), abdominal pain (10%), digestive bleeding (3%), and diarrhea (2%). There were variable prescriptions of pharmacological and non-pharmacological measures; only 50% of those with swallowing disorder received speech and hearing therapy. CONCLUSIONS: GI- SP motivated consultations in all PPC settings, frequently due to 2 or more GI- SP. Swallowing disorders and gastrostomy complications are frequent but not very visible problems in PPC. According to the comprehensive approach, pharmacological and non-pharmacological measures were implemented.

Clinical outcomes before and after videofluoroscopic swallow study in children 24 months of age or younger.

OBJECTIVE: To evaluate the combined impact of videofluoroscopic swallow study (VFSS) and therapeutic feeding and swallowing interventions on clinical outcomes in children with oropharyngeal dysphagia (OPD). METHODS: This was an uncontrolled longitudinal analytical study in which OPD patients were evaluated before and after VFSS. Children ≤ 24 months of age diagnosed with OPD in a clinical setting and undergoing VFSS for investigation and management of OPD were included in the study. The study participants received therapeutic feeding and swallowing interventions after having undergone VFSS, being followed at an outpatient clinic for pediatric dysphagia in order to monitor feeding and swallowing difficulties. Respiratory and feeding outcomes were compared before and after VFSS. RESULTS: Penetration/aspiration events were observed in 61% of the VFSSs (n = 72), and therapeutic feeding and swallowing interventions were recommended for 97% of the study participants. After the VFSS, there was a reduction in the odds of receiving antibiotic therapy (OR = 0.007) and in the duration of antibiotic therapy (p = 0.014), as well as in the odds of being admitted to hospital (p = 0.024) and in the length of hospital stay (p = 0.025). A combination of oral and enteral feeding became more common than oral or enteral feeding alone (p = 0.002). CONCLUSIONS: A high proportion of participants exhibited penetration/aspiration on VFSS. Therapeutic feeding and swallowing interventions following a VFSS appear to be associated with reduced respiratory morbidity in this population.

[Dysphagia as the main symptom in anterior cervical spine osteophytes (Forestier disease and cervical spondylosis deformans). Case reports and literature review]. / Disfagiya kak osnovnoi simptom pri perednikh osteofitakh sheinogo otdela pozvonochnika (bolezn' Forest'e i tservikal'nyi deformiruyushchii spondilez): obzor literatury i analiz klinicheskikh sluchaev.

Anterior cervical osteophytes are a fairly common X-ray finding in people over 50 years old. Incidence of dysphagia in patients with anterior osteophytes varies from 1% in those aged 40-60 years to 10.6% in patients over 60 years old. The most common causes of anterior cervical hyperosteophytosis causing dysphagia are cervical spondylosis deformans and Forestier disease. We present 2 clinical cases of spondylogenic dysphagia in cervical spondylosis deformans and Forestier disease. The review is devoted to the causes and diagnostic methods for dysphagia caused by anterior cervical osteophytes, as well as surgical options for this pathology. CONCLUSION: Microsurgical resection of anterior osteophytes is an effective method for dysphagia after ineffective therapy for 3 months. Microsurgical osteophytectomy provides stable regression of dysphagia with low recurrence rate.

Dysphagia as a primary manifestation of basilar impression: A case report.

Secondary basilar invagination or basilar impression is an anomaly at the craniovertebral junction where the odontoid process prolapses into the foramen magnum with the risk of compressing adjacent structures and obstructing the proper flow of cerebrospinal fluid (CSF). The incidence is less than 1% in the general population and occurs mainly in the first three decades of life when it is associated with malformations of the neuroaxis. In older age, the main aetiologies are diseases that alter bone mineral density. The clinical course is usually progressive and the most common symptoms are asthenia, cervical pain and restricted movement, but also dysphonia, dyspnoea and dysphagia. It is a progressive disease which, if left untreated, can cause severe neurological damage and death. We report the case of a 79-year-old woman with osteoporosis and progressive dysphagia leading to severe malnutrition, which conditioned the decision not to intervene due to the high perioperative risk.

Prediction of dysphagia aspiration through machine learning-based analysis of patients' postprandial voices.

BACKGROUND: Conventional diagnostic methods for dysphagia have limitations such as long wait times, radiation risks, and restricted evaluation. Therefore, voice-based diagnostic and monitoring technologies are required to overcome these limitations. Based on our hypothesis regarding the impact of weakened muscle strength and the presence of aspiration on vocal characteristics, this single-center, prospective study aimed to develop a machine-learning algorithm for predicting dysphagia status (normal, and aspiration) by analyzing postprandial voice limiting intake to 3 cc. METHODS: Conducted from September 2021 to February 2023 at Seoul National University Bundang Hospital, this single center, prospective cohort study included 198 participants aged 40 or older, with 128 without suspected dysphagia and 70 with dysphagia-aspiration. Voice data from participants were collected and used to develop dysphagia prediction models using the Multi-Layer Perceptron (MLP) with MobileNet V3. Male-only, female-only, and combined models were constructed using 10-fold cross-validation. Through the inference process, we established a model capable of probabilistically categorizing a new patient's voice as either normal or indicating the possibility of aspiration. RESULTS: The pre-trained models (mn40_as and mn30_as) exhibited superior performance compared to the non-pre-trained models (mn4.0 and mn3.0). Overall, the best-performing model, mn30_as, which is a pre-trained model, demonstrated an average AUC across 10 folds as follows: combined model 0.8361 (95% CI 0.7667-0.9056; max 0.9541), male model 0.8010 (95% CI 0.6589-0.9432; max 1.000), and female model 0.7572 (95% CI 0.6578-0.8567; max 0.9779). However, for the female model, a slightly higher result was observed with the mn4.0, which scored 0.7679 (95% CI 0.6426-0.8931; max 0.9722). Additionally, the other models (pre-trained; mn40_as, non-pre-trained; mn4.0 and mn3.0) also achieved performance above 0.7 in most cases, and the highest fold-level performance for most models was approximately around 0.9. The 'mn' in model names refers to MobileNet and the following number indicates the 'width_mult' parameter. CONCLUSIONS: In this study, we used mel-spectrogram analysis and a MobileNetV3 model for predicting dysphagia aspiration. Our research highlights voice analysis potential in dysphagia screening, diagnosis, and monitoring, aiming for non-invasive safer, and more effective interventions. TRIAL REGISTRATION: This study was approved by the IRB (No. B-2109-707-303) and registered on clinicaltrials.gov (ID: NCT05149976).

Diagnostic value of water swallow test for dysphagia in patients with head and neck cancer: A systematic review and meta-analysis.

The diagnostic efficacy of the water swallow test (WST) is relatively robust for patients with neurogenic dysphagia; however, its diagnostic performance in identifying dysphagia among patients with HNC varies across studies. Our study aims to assess the diagnostic value of the WST for detecting dysphagia in patients with HNC. Systematic retrieval of studies on the use of WST for screening dysphagia in patients with HNC from databases up to August 1, 2023. Quality assessment of the included studies was performed using the Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2) tool. Calculate the pooled sensitivity, specificity, positive likelihood ratio (LR), negative LR, diagnostic odds ratio (DOR), and area under the receiver operating characteristic curve (AUC) to evaluate the screening ability of WST for dysphagia. A total of seven articles, encompassing eight study groups, were included, involving the analysis of 691 patients. The meta-analysis results demonstrate that the WST has a combined sensitivity, specificity, positive LR, negative LR, DOR, and AUC for diagnosing dysphagia in patients with HNC of 0.82 (95% CI [0.64, 0.92]), 0.79 (95% CI [0.70, 0.86]), 4.00 (95% CI [2.51, 6.36]), 0.22 (95% CI [0.10, 0.50]), 17.94 (95% CI [5.56, 57.92]), and 0.86 (95% CI [0.83, 0.89]), respectively. Significant heterogeneity was observed among the included studies. Meta-regression analysis showed that the pooled sensitivity of tumor sites and treatment was closely related, while the pooled specificity of treatment and version was closely related. The subgroup analysis showed that the WST's pooled sensitivity for diagnosing dysphagia in patients with nasopharyngeal cancer was 0.40 (95% CI [0.26, 0.56]), with an AUC of 0.50, lower than in other HNC sites. The WST performed better in surgical patients than in those undergoing radiotherapy (RT) or chemoradiotherapy (CRT), with lower sensitivity, specificity, and AUC values of 0.49 (95% CI [0.36, 0.61]), 0.66 (95% CI [0.59, 0.72]), and 0.64, respectively, for RT or CRT patients. The modified WST version showed different specificity values of 0.82 (95% CI [0.75, 0.87]), compared to the regular version of 0.68 (95% CI [0.61, 0.74]). Additionally, Deek's test indicated the absence of publication bias in this study (p = 0.32). The WST demonstrates favorable sensitivity and specificity in detecting dysphagia among patients with HNC. However, the diagnostic value may vary depending on factors such as tumor sites, treatment, and the specific version of the WST used.

Functional Laryngectomy and Quality of Life in Survivors of Head and Neck Cancer With Intractable Aspiration.

Importance: Late effects of head and neck cancer (HNC) treatment include profound dysphagia, chronic aspiration, and death. Functional laryngectomy (FL) can improve patient survival and quality of life (QoL); however, removing a failing larynx for a noncancer reason is a difficult decision. Data regarding the ability of FL to improve self-perceptions of voice, swallowing, and QOL in survivors of HNC with intractable aspiration are inconclusive. Objective: To investigate the association of FL with changes in self-reported perceptions of voice, swallowing, oral intake, QoL, and mood in survivors of HNC experiencing profound dysphagia and intractable aspiration. Design, Settings, and Participants: This cohort study was conducted at a single academic institution and included survivors of HNC with profound swallowing dysfunction and intractable aspiration who underwent FL from July 2016 through March 2022. Of the initial 22 patients enrolled, 2 patients (15%) died of aspiration pneumonia before receiving FL. Data analyses were performed from July 2016 through March 2023. Main Outcomes and Measures: Self-reported measures of voice using the VHI (30-item Voice Handicap Index), swallowing using the EAT-10 (10-item Eating Assessment Tool), functional oral intake scale using the FOIS (Functional Oral Intake Scale), and quality of life using the FACT-H&N (Functional Assessment of Cancer Therapy-Head & Neck) were assessed before FL and at 1, 3, and 6 months after FL. Mood states were evaluated using the POMS (Profile of Mood States, second edition), before FL and at 6 months after FL. Results: The study analyses included 20 patients (mean [SD] age, 72.4 (7.0) years; 19 [95%] males and 1 [5%] female) who underwent FL and had complete data across all time points. Among these, 12 patients (60%) had received chemoradiation for oropharyngeal, 7 (35%) for laryngeal, or 1 (5%) for nasopharyngeal cancer. The mean (SD) time from completion of oncologic treatment to FL was 15.5 (5.5) years. Mean (SD) score on the EAT-10 improved from 33.2 (7.4) to 23.1 (10.8) at 1 month; 12.1 (9.1) at 3 months; and 8.3 (7.4) at 6 months, with a large effect size (η2 = 0.72; 95% CI, 0.54-0.80). Mean (SD) score on the FOIS improved from 2.0 (1.5) to 2.9 (1.7) at 1 month; 4.8 (2.5) at 3 months; and 5.2 (1.7) at 6 months, with a large effect size (η2 = 0.6; 95% CI, 0.38-0.71). Improvement in oral intake was achieved in 19 patients (95%), and feeding tubes were removed in 10 of 16 patients (63%) who were feeding tube-dependent; 6 patients (27%) continued to require supplemental tube feedings. Mean (SD) score on the VHI improved from 63.6 (34.0) to 86.9 (33.7) at 1 month; 71.3 (36.1) at 3 months; and 39.7 (26.9) at 6 months, with a large effect size (η2 = 0.42; 95% CI, 0.19-0.56). Seventeen patients (85%) were able to use a tracheoesophageal voice prosthesis for alaryngeal communication. Mean (SD) score on the FACT-H&N improved from 86.2 (17.8) to 93.6 (18.4) at 1 month; 109.0 (18.4) at 3 months; and 121.0 (16.8) at 6 months, with a large effect size (η2 = 0.64; 95% CI, 0.42-0.74). Mean (SD) score on the POMS improved from 58.9 (13.2) at baseline to 44.5 (9.9) at 6 months, with a large effect size (Cohen d = 1.04; 95% CI, 0.48-1.57). None of the patients experienced major complications of FL; 1 patient (5%) had a postoperative pharyngocutaneous fistula. Conclusions and Relevance: The findings of this cohort study indicate that FL was associated with marked improvements in self-perception of voice and swallowing, functional oral intake, QoL, and mood state among survivors of HNC. These findings can serve as a framework for FL counseling among HNC survivors experiencing profound dysphagia and intractable aspiration.

Therapeutic approach to dysphagia in post-COVID patients in a rehabilitation unit: a descriptive longitudinal study.

BACKGROUND: A high rate of hospitalized patients for COVID-19 had dysphagia, frequently underdiagnosed, and not treated, inducing a prolonged dysphagia with protracted recovery. Specific treatments and protocols have not been well described yet. AIM: Given the potential benefits of respiratory muscle training (IEMT) and neuromuscular stimulation (NMES) in dysphagia treatment, this study aimed to assess the feasibility of the protocol used for treating dysphagia in patients who experienced prolonged hospitalization for COVID-19. DESIGN: Observational, descriptive, prospective study. SETTING: Department of Physical Medicine and Rehabilitation of a tertiary University hospital. POPULATION: Fifty-eight COVID-19 patients were admitted for intensive rehabilitation (March 2020 to October 2021) were prospectively studied. METHODS: Dysphagia was diagnosed using videofluoroscopy and treated with a 3-week protocol adapted from neuromuscular stimulation (NMES) in a motor threshold and inspiratory/expiratory muscle strength training (IEMST), five sets of five repetitions three times daily for 3 weeks. Feasibility was assessed with adherence, outcomes achieved, and occurrence of adverse/unexpected events. Respiratory function (peak cough flow, maximal inspiratory/expiratory pressures) and swallow function (Penetration-Aspiration Scale and Bolus Residue Scale measured by videofluoroscopy) were recorded descriptive statistics, Student's t test for numerical data, and Wilcoxon Test for ordinal variables were applied. SPPSS vs28 and STATA version 15.1 (StataCorp, College Station, TX, USA) were used for statistical analysis. P values 0.05 were considered significant. RESULTS: Dysphagia was highly prevalent in severe COVID-19 patients (86.6%); all respiratory and swallow parameters improved after a 3-week intervention and 12 of 18 patients dependent on tube feeding resumed a normal diet (66.7%; McNemar P=0.03), and 84.09% attended a no restriction diet at discharge. Adherence to treatment was 85%. No significant adverse events were detected. CONCLUSIONS: We conclude that a structured swallowing-exercise training intervention based on IEMT and NMES is feasible and safe in prolonged hospitalization post-COVID patients. CLINICAL REHABILITATION IMPACT: To describe rehabilitation protocols used to treat dysphagia in post-COVID patients will help us to optimize the available techniques in each center and to induce a faster recovery avoiding potential complications.