An Unusual Case of Contralateral Hypoglossal and Recurrent Laryngeal Nerve Palsies Following Endotracheal Intubation.

We present an unusual case of a 62-year-old male presenting with contralateral hypoglossal and recurrent laryngeal nerve palsies following endotracheal intubation for emergency cardiac surgery. Postoperative, the patient was referred to Speech and Language Therapy due to concerns regarding the safety of his swallow. Oromotor assessment revealed left-sided tongue weakness and aphonia. Flexible endoscopic evaluation of swallowing (FEES) revealed a right vocal cord palsy and severe oropharyngeal dysphagia. There were no other focal neurological signs. An MRI head did not demonstrate a medial medullary stroke or other intracranial lesion. CT neck showed no abnormality identified in relation to the course of the right vagus nerve or recurrent laryngeal nerve at the skull base or through the neck respectively. The patient required a gastrostomy for nutrition and hydration. He continued to be assessed at several month intervals over the course of a year using FEES to obtain a range of voice, secretion and swallowing outcome measures. The patient commenced intensive dysphagia therapy targeting pharyngeal drive, hyolaryngeal excursion and laryngeal sensation. Swallow manoeuvres were trialled during FEES and a head-turn to the side of the vocal cord palsy during deglutition reduced aspiration risk which expedited return to oral intake. The patient had partial recovery over twelve months. Hypoglossal nerve palsy completely resolved. The right vocal cord remained paralysed however the left vocal cord compensated enabling the patient to produce a normal voice. The patient was able to take thin fluids and regular diet and the gastrostomy was removed.

Which Provider Specialties are Performing Diagnostic Procedures for Dysphagia in the United States?

OBJECTIVE: Care of patients with dysphagia occurs at the intersection of several different medical specialties. Otolaryngologists are uniquely equipped to diagnose dysphagia given their specialized training, yet the extent to which otolaryngologists perform diagnostic procedures for dysphagia is unknown. The objective of this study was to characterize the specialty-level variation among providers performing diagnostic assessments for dysphagia. METHODS: We performed a retrospective, cross-sectional analysis of dysphagia care utilization among Medicare beneficiaries from 2013 to 2021 using the CMS Physician & Other Practitioners by Provider and Service dataset. American Association of Medical Colleges (AAMC) data reports were used to determine the total number of providers per specialty. For each procedure and specialty, the percentage of providers performing >10 procedures annually and the average annual number of procedures per performing provider (non-radiology) were calculated. RESULTS: We analyzed nine common dysphagia diagnostic procedures, including manometry, 24-h pH testing, flexible endoscopic evaluation of swallowing (FEES), and modified barium swallow study (MBSS). Mean 3.7 (SD 1.4) otolaryngologists (0.04% of practicing) performed manometry testing annually, compared to 493 (69.3) gastroenterologists (3.3%). Less than 1% of practicing otolaryngologists (37.8 (8.0) (0.04%)) and gastroenterologists (51.6 (8.4), 0.35%) performed 24-h pH testing annually. FEES testing was most commonly performed by otolaryngologists; however, only 48 (6.3) providers (0.51% of practicing) performed these procedures annually. For MBSS, fewer otolaryngologists (5.2 (1.0), 0.05%) perform these assessments than other medical specialties. Each otolaryngologist performed 110.7 (52.5) studies annually, compared to 200.1 (68.0) per gastroenterologist. CONCLUSION: Otolaryngologists represent a small fraction of providers performing dysphagia-related diagnostic procedures despite a unique training within our specialty to comprehensively diagnose and manage this condition. LEVEL OF EVIDENCE: 3 Laryngoscope, 134:3698-3705, 2024.

Risk of dysphagia in a population of infants born preterm: characteristic risk factors in a tertiary NICU

Abstract Objective: To examine the prevalence and characteristics of dysphagia and suck-swallow-breath incoordination as phenotypes of oral feeding difficulties. Method: A cross-sectional study with secondary data collected consecutively over 2 years from October 2020 to October 2022 to measure the prevalence of swallowing and oral feeding difficulty in preterm infants using Flexible endoscopic evaluation of swallowing examination at the tertiary Integrated Dysphagia Clinic. Results: The prevalence of swallowing disorders was 25 % and the prevalence of suck-swallow-breath incoordination was 62.5 %. The significant risk factor that may show a possible correlation with oral feeding difficulty was mature post-menstrual age (p = 0.006) and longer length of stay (p = 0.004). The dominant percentage of upper airway abnormality and disorder were retropalatal collapse (40 %), laryngomalacia (42.5 %), paradoxical vocal cord movement (12.5 %), and gastroesophageal reflux disease (60 %). The dominant characteristic of oral motor examination and flexible endoscopic evaluation of swallowing examination was inadequate non-nutritive sucking (45 %), inadequate postural tone (35 %), and inadequate nutritive sucking (65 %). Conclusion: Dysphagia in preterm infants is mostly observed in those with mature post-menstrual age, longer length of stay, and the presence of gastroesophageal reflux disease with inadequate non-nutritive sucking and nutritive sucking abilities. Suck-swallow-breath incoordination is primarily observed in those with immature post-menstrual age, a higher prevalence of cardiopulmonary comorbidity, and a higher prevalence of upper airway pathologies (laryngomalacia, paradoxical vocal cord movement) with inadequate nutritive sucking ability.

Safety-related outcomes for patients with a tracheostomy and the use of flexible endoscopic evaluation of swallowing (FEES) for assessment and management of swallowing: A systematic review.

PURPOSE: The purpose of this systematic review was to examine safety-related outcomes for patients with tracheostomy after flexible endoscopic evaluation of swallowing (FEES) to assess and manage their swallow, when compared to other non-instrumental swallow assessments such as clinical swallowing examination (CSE) and/or a modified Evans blue dye test (MEBDT). METHOD: Three databases were searched for articles referring to safety-related outcome data for adults with a tracheostomy, who underwent FEES and CSE and/or MEBDT. Articles were screened using predefined inclusion/exclusion criteria. RESULT: The search strategy identified 2097 articles; following abstract and full-text screening, seven were included for review. The summary of evidence found low to very low certainty that FEES was associated with improved outcomes across swallow safety, physiological outcomes, tracheostomy cannulation duration, functional outcomes, and detection of upper airway pathologies. CONCLUSION: This systematic review demonstrated low to very low certainty evidence from seven heterogeneous studies with low sample sizes that incorporating FEES may be associated with improved safety-related outcomes. There is less evidence supporting the accuracy of other swallow assessments conducted at the point of care (i.e. CSE and MEBDT). Future research requires studies with larger sample sizes and routine reporting of safety-related outcomes with use of FEES.

Improvement in swallowing safety after injection laryngoplasty in patients with unilateral vocal paralysis complicated with aspiration.

BACKGROUND: The benefit of injection laryngoplasty (IL) on voice for unilateral vocal fold paralysis (UVFP) is supported increasingly in literatures, yet less is known for swallowing. Also, prevalence of patient-reported dysphagia is substantially higher than instrumental studies. This prospective study focused on swallowing outcomes, with predetermined flexible endoscopic evaluation of swallowing (FEES) protocol that simulates daily life situation. METHODS: Adult patients with UVFP and aspiration receiving IL were recruited. Voice outcome measurements, as well as swallowing outcomes including Eating Assessment Tool (EAT-10) and FEES, which challenged patients with different fluid volumes: 10 mL, 20 mL, and 90 mL cup sipping were evaluated. RESULTS: Significant improvements were demonstrated in all voice outcomes. Significant changes were also presented inEAT-10 (P < 0.01). Pre-operatively, penetration-aspiration scale (PAS) was 1.5 ± 1.3, 1.9 ± 1.7 and 2.3 ± 1.8 for 10 mL, 20 mL and 90 mL serial sipping, and improved to 1.1 ± 0.3, 1.1 ± 0.4 and 1.4 ± 0.7 post-operatively (P < 0.01). Safe swallowing (PAS ≤ 2) was achieved in all, except for one patient, who presented with a post-injection PAS of 4 (material enters the airway, contacts the vocal folds, and is ejected from the airway) on 90 mL cup sipping, whose pre-injection PAS was 7 (residue in trachea). CONCLUSION: Maintaining swallowing function suitable for social environment is important. Our results demonstrated the feasibility of the predetermined FEES protocol, and positive effects of IL on both voice and swallowing outcomes.

Effectiveness of FEES with artificial intelligence-assisted computer-aided diagnosis.

OBJECTIVES: FEES is a standard procedure for diagnosing dysphagia. However, appropriate evaluation of FEES findings is difficult for inexperienced evaluators. Recent progress in deep learning has highlighted the use of artificial intelligence-assisted computer-aided diagnosis (AI-assisted CAD) in medical applications. We investigated the detection accuracy of FEES findings evaluated by inexperienced evaluators with and without the use of CAD. METHODS: The algorithm for FEES-CAD was developed using 25,630 expert-annotated images. A total of 45 inexperienced evaluators from three groups of people (resident doctors, nurses, and medical students), evaluated 32 FEES videos from 32 patients. To confirm the effectiveness of FEES-CAD, first, 32 FEES videos were evaluated without the use of CAD. Second, one half was evaluated with, and one half without, the use of CAD. The detection accuracy of the FEES findings was investigated, and the evaluation results obtained with CAD were statistically compared with those obtained without CAD. RESULTS: In the first FEES evaluation, the total detection accuracy was 82.2 %. In the second evaluation, the total detection accuracy with CAD was 84.3 %, and that without CAD was 81.7 %. The detection accuracies by the resident doctors, nurses, and medical students with CAD were 90.1 %, 82.6 %, and 79.4 %, respectively, and those without CAD were 83.7 %, 80.9 % and 80.1 %, respectively. In the resident doctors, the detection accuracy was significantly better when CAD was used for evaluation, compared with the non-CAD evaluations. CONCLUSION: The present study demonstrated the effectiveness of FEES-CAD in improving the detection accuracy of resident doctors, however, the differences were small.

Risk of dysphagia in a population of infants born pre-term: characteristic risk factors in a tertiary NICU.

OBJECTIVE: To examine the prevalence and characteristics of dysphagia and suck-swallow-breath incoordination as phenotypes of oral feeding difficulties. METHOD: A cross-sectional study with secondary data collected consecutively over 2 years from October 2020 to October 2022 to measure the prevalence of swallowing and oral feeding difficulty in preterm infants using Flexible endoscopic evaluation of swallowing examination at the tertiary Integrated Dysphagia Clinic. RESULTS: The prevalence of swallowing disorders was 25 % and the prevalence of suck-swallow-breath incoordination was 62.5 %. The significant risk factor that may show a possible correlation with oral feeding difficulty was mature post-menstrual age (p = 0.006) and longer length of stay (p = 0.004). The dominant percentage of upper airway abnormality and disorder were retropalatal collapse (40 %), laryngomalacia (42.5 %), paradoxical vocal cord movement (12.5 %), and gastroesophageal reflux disease (60 %). The dominant characteristic of oral motor examination and flexible endoscopic evaluation of swallowing examination was inadequate non-nutritive sucking (45 %), inadequate postural tone (35 %), and inadequate nutritive sucking (65 %). CONCLUSION: Dysphagia in preterm infants is mostly observed in those with mature post-menstrual age, longer length of stay, and the presence of gastroesophageal reflux disease with inadequate non-nutritive sucking and nutritive sucking abilities. Suck-swallow-breath incoordination is primarily observed in those with immature post-menstrual age, a higher prevalence of cardiopulmonary comorbidity, and a higher prevalence of upper airway pathologies (laryngomalacia, paradoxical vocal cord movement) with inadequate nutritive sucking ability.

Diagnostic accuracy of the 'Dysphagia Screening Tool for Geriatric Patients' (DSTG) compared to Flexible Endoscopic Evaluation of Swallowing (FEES) for assessing dysphagia in hospitalized geriatric patients - a diagnostic study.

BACKGROUND: Oropharyngeal dysphagia is highly prevalent among hospitalized geriatric patients. The screening instruments used to date have been evaluated primarily in stroke patients. This diagnostic study aimed to validate a new screening instrument for oropharyngeal dysphagia, the 'Dysphagia Screening Tool for Geriatric Patients' (DSTG), as compared to one of the gold standards, flexible endoscopic evaluation of swallowing (FEES). MATERIALS AND METHODS: Geriatric inpatients admitted to five geriatric hospitals in Germany were consecutively evaluated using both DSTG and FEES in random order and by different evaluators blinded to the results of the other evaluation. In the FEES examination, a score of more than 3 on Rosenbek's Penetration Aspiration Scale was considered evidence of clinically relevant oropharyngeal dysphagia. Sensitivity, specificity and further measures of test performance were calculated for DSTG. RESULTS: The 53 volunteers recruited were on average 85 years of age, 56.6% were women. Twenty patients (37.7%) were diagnosed with dysphagia using FEES. Of these, 12 were screened as positive on DSTG. Of the 33 FEES negative patients, 4 tested positive on DSTG. The following test parameters were calculated for DSTG: sensitivity: 0.60, 95% confidence interval [0.39 ; 0.78], specificity 0.88 [0.73 ; 0.95], positive predictive value 0.75 [0.51 ; 0.90], negative predictive value 0.78 [0.63 ; 0.89], positive likelihood ratio 4.95 [1.85 ; 13.27], negative likelihood ratio 0.46 [0.26 ; 0.79]. In a receiver-operator characteristic (ROC) curve analysis, the area under the curve (AUC) was 0.77 [0.62 ; 0.91]. No adverse events occurred. CONCLUSION: The DSTG appears to be a valid instrument for screening of oropharyngeal dysphagia in geriatric inpatients.

Confidence, Accuracy, and Reliability of Penetration-Aspiration Scale Ratings on Flexible Endoscopic Evaluations of Swallowing by Speech Pathologists.

This study investigated rater confidence when rating airway invasion with the penetration-aspiration scale (PAS) on flexible endoscopic evaluations of swallowing (FEES), raters' accuracy against a referent-standard, inter-rater reliability, and potential associations between clinician confidence, experience, and accuracy. Thirty-one clinicians who use FEES in their daily practice were asked to judge airway invasion with the PAS and to rate their confidence that their score was correct (0-100) for 40 video clips, five in each of the 8 PAS categories. We found that raters were most confident in rating PAS 1, 7, and 8. The average confidence score across all videos was 76/100. Confidence did not have a significant relationship with accuracy against the referent-standard. Accuracy was highest for PAS 1 (92%), followed by PAS 8 (80%), PAS 7 (77%), and PAS 4 (72%). Accuracy was below 60% for PAS 2, 3, 5, and 6, the lowest being for PAS 3 (49%). Mean accuracy for all ratings, compared to referent-standard ratings, was highest for the intermediate group (71%), followed by expert (68%) and novice (65%). In general, we found that certain PAS scores tend to be rated more accurately, and that participating SLPs had varied confidence in PAS ratings on FEES. Potential reasons for these findings as well as suggested next steps are discussed.

Effect of COVID-19 on the incidence of postintubation laryngeal lesions.

Background: Critically ill patients intubated in the intensive care unit experience prolonged intubation leading to increased frequency of laryngeal injuries. This study aimed to demonstrate a suspected increase in vocal fold injury in patients who were intubated with COVID-19 as compared with patients intubated for other reasons. Methods: A retrospective review of medical records was performed to identify patients examined using flexible endoscopic evaluation of swallowing exams. The study included 25 patients with COVID-19 and 27 without COVID-19 at Baylor Scott & White Medical Center in Temple, Texas. Various injuries were evaluated, ranging from granulation tissue to vocal cord paralysis. Severe lesions were those causing clinically significant airway obstruction or requiring operative intervention. The incidence of laryngeal injury in patients intubated for COVID-19 was then compared with that of patients intubated for other reasons. Results: The increased presence of severe injury in COVID-positive patients appeared clinically significant but was not statistically significant (P = 0.06). Interestingly, patients who received pronation therapy had 4.6 times the odds of more severe injury compared with patients who did not (P = 0.009). Conclusion: Lower thresholds for performing flexible laryngoscopy on postintubated patients who are proned may allow for earlier intervention and reduce morbidity in an already at-risk population.

Successful Continuation of Oral Intake in a Dysphagic and Tetraplegic Patient With Alternate Right and Left Complete Lateral Decubitus Positions in Rehabilitation.

Cervical spinal cord injury can result in dysphagia and tetraplegia. Dysphagia therapy can be required to avoid aspiration pneumonia during oral intake for persons with cervical spinal cord injury. Complete lateral decubitus position may be a specific position for safe swallowing. However, the literature on dysphagia therapy in complete lateral decubitus position for persons with tetraplegia and dysphagia is limited. We present the case of a 76-year-old man with dysphagia and tetraplegia secondary to cervical cord injury. As the patient wished for oral intake, swallowing training in an elevated position of the head at 60° was already initiated. Two days after admission, aspiration pneumonia occurred. As the spasticity increased continuously, the patient could not comfortably undertake swallowing training in an elevated head position of 60°. The flexible endoscopic evaluation of swallowing (FEES) was performed for the patient. The patient did not swallow water or jelly safely in an elevated head position. However, the patient swallowed jelly safely in the right complete lateral decubitus position. Two months after the initiation of oral intake in the right complete lateral decubitus position, the second FEES revealed that the patient swallowed jelly and food in the form of paste safely in the left complete lateral decubitus position. To relieve the pain of the right shoulder induced by continuous right complete lateral decubitus position, the patient retained oral intake in the left or right complete lateral decubitus position alternately for six months without recurrent aspiration pneumonia. Right and left complete lateral decubitus positions when alternately performed in swallowing training can be useful and safe for a patient with dysphagia and tetraplegia secondary to cervical spinal cord injury.

Pharyngeal Squeeze Maneuver During Endoscopy-What Does it Tell Us?

OBJECTIVES: Diminished pharyngeal constriction is a common biomechanical deficit associated with dysphagia and holds strong predictive value for aspiration. Pharyngeal squeeze manoeuvre (PSM) was previously validated for evaluating pharyngeal constriction on endoscopy. However, PSM is not routinely used in laryngology clinics or flexible endoscopic evaluation of swallowing (FEES) protocols worldwide. This study explored PSM in the acute care setting and its relationship with swallowing safety and efficiency, other swallowing biomechanical functions, and clinical outcomes. METHODS: This prospective observational study consented 222 consecutive inpatients of mixed aetiology who were receiving FEES as part of their standard care. Established FEES protocols were performed including assessment of secretion accumulation, urge-to-clear ratings, laryngeal motor, and sensory functional tests, PSM, as well as aspiration, and residue during oral trials. Swallow frequency and cough peak flow were also collected as well as clinical outcomes at discharge. RESULTS: PSM was impaired in 46% of the patients. Accumulated secretions, penetration-aspiration, and post-swallow residue were frequent and correlated with abnormal PSM (p < 0.05). PSM was reliable and agreed with pharyngeal constriction ratio on videofluoroscopy in all 15 patients who had both assessments within 72 h. Abnormal PSM correlated with vocal cord immobility, reduced peak cough flow, and reduced swallow frequency (p < 0.05). Abnormal PSM predicted restricted diet on hospital discharge with an odds ratio of 10.38. CONCLUSIONS: PSM is a quick and simple addition to an endoscopic evaluation and has the potential to predict likelihood of impaired swallow safety and efficiency as well as clinical outcomes. LEVEL OF EVIDENCE: 3 Laryngoscope, 133:3429-3435, 2023.

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

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

Physical Properties of Meals that are Suitable for Patients after Surgery to Treat Oral Cavity Cancers.

OBJECTIVES: To determine proper characteristics of food which would be safe and satisfactory for swallowing in oral cavity cancer patients undergoing surgery and to create a recipe that provides adequate nutrients, energy, good taste, and can be easily made at home. MATERIALS AND METHODS: Patients who were enrolled in this study underwent oral cancer surgery in the Department of Otorhinolaryngology, Faculty of Medicine Siriraj Hospital from September 2017 to July 2018. This experimental research was conducted postoperatively before receiving chemoradiation. Each type of food was prepared by the researchers to have a combination of two physical properties, which were 3 different consistencies (liquid, nectar-like, and honey-like) and 2 different temperatures (room temperature (25ºC) and cold temperature (4ºC)). Each patient had to swallow six different types of prepared food by random sequences. Flexible endoscopic evaluation of swallowing (FEES) was used to evaluate objective swallowing function by 3 parameters, including premature oropharyngeal spillage, laryngeal penetration or aspiration, and post-swallow retaining residues. Satisfaction measurement was evaluated with visual analog scale (VAS). RESULTS: There were 42 postoperative oral cavity cancer patients enrolled in this study. Subjects consisted of 23 males (54.8%) and 19 females (45.2%) with the mean age of 62 ± 13 years.  Most patients had oral tongue carcinoma (64.3 %). FEES revealed nectar at room temperature was the safest with score of 0.83 ± 0.82 (possible score of 0-3, with 0 was best). However, patients significantly preferred liquid at room temperature more than other kinds of food (VAS taste = 8.26 ± 1.52 and VAS easy swallowing = 8.05 ± 1.74). When evaluating specifically in patients with oral tongue cancer, FEES scores, VAS taste, and VAS easy swallowing showed similar results the liquid at room temperature was the best. CONCLUSIONS: We suggested that the nectar-like thickened food at room temperature was determined to be the most proper food characteristic for oral cancer patients undergoing surgery in order to prevent aspiration. However, patients' satisfaction analysis suggested that they preferred other type of food. The physician should advise patients of the proper kind of food for safe swallowing and avoidance of serious complication especially aspiration pneumonia.

Will levels of experience of examiners affect the diet provided for patients with swallowing impairment?

OBJECTIVE: Flexible endoscopic evaluation of swallowing (FEES) is widely performed to determine the safety of oral intake. However, evaluation results can vary among examiners depending on their experience. To analyze the impact of such differences, we investigated the diet provided for patients with swallowing impairment evaluated by experienced and inexperienced examiners. METHODS: We included 20 subjects with swallowing impairment. They underwent FEES twice, once by an experienced examiner (EE) and once by an inexperienced examiner (IE), in random order. The second FEES was generally performed within one month of the first FEES. The diet provided by the EE (EE results) and by the IE (IE results) during and after FEES was investigated and statistically compared. Respiratory and oral intake conditions at each time of FEES were also investigated and the results were included in the corresponding EE or IE results. RESULTS: The median interval between FEES was 13.5 days. There was no significant difference between the EE and IE results regarding swallowing impairment-related conditions, such as amount of sputum suctioned, oral intake status, or prevalence of fever after FEES. However, there was a significant difference in the texture-modified diet provided after FEES: A close-to-normal diet was provided by the EE compared to the diet provided by the IE. CONCLUSION: This study demonstrated a difference in the provided diet for patients with swallowing impairment between the examiners with different levels of experience. Our results suggest that EEs may be able to safely recommend patients with swallowing impairment have a close-to-normal diet.

Flexible endoscopic evaluation of swallowing in children with type 1 spinal muscular atrophy.

PURPOSE: This study aimed to report on implementing flexible endoscopic evaluation of swallowing (FEES) in infants and toddlers with type 1 spinal muscular atrophy (SMA). In addition, a comparison of FEES results and clinical scores was carried out. METHODS: A prospective pilot study was conducted including ten symptomatic children with SMA type 1 (two SMN2 copies). They started treatment with one of the three currently approved therapies for SMA at a median age of 3.8 months (range 0.7-8.9). FEES was performed according to a standard protocol using Penetration-Aspiration Scale (PAS) and Murray Secretion Scale as a primary outcome. The Children's Hospital of Philadelphia Infant Test of Neuromuscular Disorders (CHOP-INTEND) for motor function, Neuromuscular Disease Swallowing Status Scale (NdSSS), Oral and Swallowing Abilities Tool (OrSAT), and single clinical swallowing-related parameters were also assessed. RESULTS: Distinct swallowing disorders were already evident in eight children at inclusion. The most common findings from FEES were pharyngeal secretion pooling, penetration, and aspiration of saliva and food as well as delayed initiation of swallowing. Despite an average increase in motor function, no comparable improvement was found in swallowing function. None of the surveyed clinical scores showed a significant dependence on PAS in a mixed linear model. CONCLUSIONS: Valuable information regarding the status of dysphagia can be gathered endoscopically, particularly concerning secretion management and when oral intake is limited. Currently available clinical tools for children with type 1 may represent a change in nutritional status but are not yet mature enough to conclude swallowing ability. Further development is still required.

Prehabilitation of dysphagia in the therapy of head and neck cancer- a systematic review of the literature and evidence evaluation.

Background: Prehabilitation is becoming increasingly important in oncology because of the significant survival benefits that the reduction of malnutrition provide. Specifically, tumor- and therapy-related dysphagia leads to malnutrition in more than half of head and neck tumor patients. Studies describe the positive effects of an early onset of swallow-specific prehabilitation on the protection of the swallowing function. This paper intents to evaluate the existing evidence on the efficacy of preventive forms of swallowing therapy. Methods: A systematic literature search was performed in February 2022 in the Cochrane Library, MEDLINE via PubMed, and ClinicalTrials.gov databases for randomized controlled trials investigating preventive swallowing therapy in head and neck tumor patients. This Procedure complies with the PRISMA statement. The RCTs were evaluated by using the PEDro Scale and the Cochrane Risk of Bias tool RoB2. Results: Five randomized-controlled trials with 423 participants were identified. Four Studies showed moderate to high quality in the PEDro analysis, one showed less. The risk of bias was high in all studies because there was no possibility for blinding and there were high dropout rates. Heterogeneity in interventions, measurement instruments, measurement time points, and outcomes limits a general statement about which swallowing exercises are suitable for the prevention of dysphagia in head and neck tumor patients. Evidence is provided for short-term effects (≤24 months) on functional aspects of swallowing and quality of life. Overall, a decreasing adherence over time was observed in the intervention groups. Discussion: Initial studies describe swallowing-specific prehabilitation programs in head and neck tumor patients as effective, at least in the short term, whereas long-term effects need to be further investigated. At the current time the evidence base for clear recommendations does not appear to be sufficiently high and studies share a high risk of bias. Further well-designed research, especially considering the conditions in the national health care system, is needed. Other: There was no funding and no registration.

Dysphagia Management in Children: Implementation and Perspectives of Flexible Endoscopic Evaluation of Swallowing (FEES).

Dysphagia is any impairment of swallowing that compromises the safety, efficiency, or adequacy of nutritional or liquid intake. It is common in children, especially in some clinical populations, and may result in failure to thrive and respiratory problems due to pulmonary aspiration. Swallowing disorders have a severe impact on children's health, growth, and development, and on the quality of life of the child and family. Clinical evaluation cannot validly predict aspiration, which is mostly silent. A team management approach is advocated, including instrumental swallowing assessments. FEES has been proven to be safe and valid and is increasingly used in children of all ages. It allows the identification of structural abnormalities, assessment of the child's diet with real-life food and liquids while the child holds the optimal or preferred position, examination during breastfeeding, and assessment of fatigue and treatment strategies. FEES is carried out following a protocol that comprises three parts: the evaluation of the anatomical and physiological parameters of swallowing, testing of food and liquids of a range of different consistencies, and evaluation of treatment methods. Pediatric FEES involves adaptations for infants, and special considerations about readiness for nutritive trials and the infant's ability to sustain a coordinated feeding pattern. Varying consistencies and volumes of food or liquids are tried. Care of the dysphagic child involves team work. FEES, as a part of the assessment and management of dysphagia, enables the evaluation of the safety, efficiency, and adequacy of oral food and liquid intake. Future perspectives include standardized training in clinical FEES protocols to ensure clinical competency of the pediatric FESS team members and the development and validation of standardized examination and interpretation protocols for pediatric FEES.

Conformity between modified Swallowing Outcome After Laryngectomy questionnaire and Flexible Endoscopic Evaluation of Swallowing in laryngeal carcinoma patients after total laryngectomy.

Background: One of the impacts in anatomic laryngeal and phariyngeal changes after total laryngectomy (TL) is oropharyngeal dysphagia (OPD). The detection of neopharyngeal residue as a sign of OPD can be performed by videofluoroscopy (VFS) and flexible endoscopic evaluation of swallowing (FEES). The availability of these tools in rural areas is still limited, thus the treatment of OPD is not maximal. There is a need for a more practical tool, including the modified swallowing outcomes after laryngectomy (SOAL) questionnaire. Methods: This was an analytic observational diagnostic study with a cross-sectional approach. Samples were obtained in Otorhinolaryngology Oncology Clinic and Outpatient Clinic of Dr. Soetomo General Academic Hospital, Surabaya, Indonesia, who filled SOAL modified questionnaire followed by FEES. Samples were obtained within 3 months from 10 May to 10 August 2021. The number of samples obtained through simple random sampling was 16 post-TL patients from a total population of 17 patients who met the inclusion and exclusion criteria. The conformity test between modified SOAL questionnaire and FEES was analyzed using McNemar comparison test and Kappa association test. Results: McNemar test showed no significant difference between both assessment tools (p > 0.05), and the Kappa test showed an association between both tools (p < 0.05). The results of this study stated that there was conformity between modified SOAL questionnaire and FEES in patients after TL in all types of food bolus had Kappa score of >0.81, showing a reliable association between these tools. Kappa test also showed that out of all three types of boluses, the soft bolus had the highest conformity with a Kappa score of 0.875, followed by thick bolus with 0.839, and watery bolus with 0.818. Conclusion: There was a conformity between the results of the modified SOAL questionnaire and FEES in head and neck surgery patients after TL.

Effects of Carbonated Thickened Drinks on Pharyngeal Swallowing with a Flexible Endoscopic Evaluation of Swallowing in Older Patients with Oropharyngeal Dysphagia.

This study aimed to determine the efficacy of carbonated and sweetened drinks added to thickened liquids, which are routinely used for patients with dysphagia to improve dysphagia. Patients swallowed thin liquid (Thin), thickened liquid (Thick), carbonated thin drink (C-Thin), and carbonated thickened drink (C-Thick) in random order. Penetration and/or aspiration were scored using the Penetration−Aspiration Scale (PAS). The residue was scored using the Yale Pharyngeal Residue Severity Rating Scale (YPR-SRS). Swallowing reflex initiation was scored using the Hyodo score. The subjective difficulty of swallowing was scored on a face scale. We analyzed 13 patients with a mean age of 79.6 ± 9.6 years. PAS was significantly lower in the C-Thick group than the Thin group (p < 0.05). Swallowing reflex initiation was significantly different between the Thin and Thick (p < 0.01) groups; moreover, post hoc analysis revealed that it was significantly lower in the C-Thick group than the Thin group (p < 0.01). The subjective difficulty of swallowing in the C-Thick was significantly lower than the Thick group (p < 0.05). C-Thick was easier to swallow than Thick and may improve penetration and/or aspiration in older patients with dysphagia with complex diseases.