Assessing Dysphagia in the Adult.

This article explores the landscape of dysphagia assessment in adults. Dysphagia, a complex condition affecting the lifespan and many health conditions, significantly compromises individuals' quality of life. Dysphagia is often underdiagnosed, emphasizing the need for comprehensive assessment methods to ensure timely and accurate intervention. It encompasses clinical history, physical examination, clinical and instrumental swallow evaluations. Procedures within each of these modalities are reviewed, highlighting strengths, limitations, and contribution toward a complete understanding of dysphagia, ultimately guiding effective intervention strategies for improved patient outcomes.

Post-extubation Assessment of Laryngeal Symptoms and Severity (PALSS) in the Intensive Care Unit: Protocol of a Prospective Cohort Study.

Aims: The Post-extubation Assessment of Laryngeal Symptoms and Severity (PALSS) study systematically evaluates patient symptoms related to endotracheal intubation with mechanical ventilation, assesses laryngeal injury and voice function after extubation, and develops a screening tool to identify patients with clinically important, post-extubation laryngeal injury. Design: Single-center, prospective observational cohort study conducted in 6 intensive care units (ICU). Methods: Patients ≥18 years old who are orally intubated and mechanically ventilated in an ICU and meet eligibility criteria will undergo flexible laryngoscopy, with a sample size goal of 300 completed laryngoscopies. Primary outcome measures include signs and symptoms of laryngeal injury, including voice symptoms and alterations in swallowing, measured using the Laryngeal Hypersensitivity Questionnaire-Acute and Voice Symptom Scale questionnaires respectively. Data will be collected within 72 hours post-extubation and at 7-day follow-up or hospital discharge (whichever occurs first). Data will be analyzed using descriptive statistics, regression models, and predictive modeling using machine learning. Discussion: The findings of this study will describe the clinical signs and symptoms of laryngeal injury post-extubation. Conclusion: The PALSS study will provide insights for future studies that explore laryngeal injuries using flexible laryngoscopy after endotracheal intubation. Implications for patient care: Identifying signs and symptoms of laryngeal injury after endotracheal intubation will facilitate the development of a screening tool that will assist in early identification of post-extubation laryngeal injury, and aid in decreasing short- and long-term complications of endotracheal intubation. Reporting Method: SPIRIT. Patient or Public Contribution: Patients were study participants; and family members provided informed consent when the patient lacked decision-making capacity.

Tracheostomy-related durable medical equipment: Insurance coverage, gaps, and barriers.

PURPOSE: Tracheostomy care is supply- and resource-intensive, and airway-related adverse events in community settings have high rates of readmission and mortality. Devices are often implicated in harm, but little is known about insurance coverage, gaps, and barriers to obtaining tracheostomy-related medically necessary durable medical equipment. We aimed to identify barriers patients may encounter in procuring tracheostomy-related durable medical equipment through insurance plan coverage. MATERIALS AND METHODS: Tracheostomy-related durable medical equipment provisions were evaluated across insurers, extracting data via structured telephone interviews and web-based searches. Each insurance company was contacted four times and queried iteratively regarding the range of coverage and co-pay policies. Outcome measures include call duration, consistency of explanation of benefits, and the number of transfers and disconnects. We also identified six qualitative themes from patient interviews. RESULTS: Tracheostomy-related durable medical equipment coverage was offered in some form by 98.1 % (53/54) of plans across 11 insurers studied. Co-pays or deductibles were required in 42.6 % (23/54). There was significant variability in out-of-pocket expenditures. Fixed co-pays ranged from $0-30, and floating co-pays ranged from 0 to 40 %. During phone interviews, mean call duration was 19 ± 10 min, with an average of 2 ± 1 transfers between agents. Repeated calls revealed high information variability (mean score 2.4 ± 1.5). Insurance sites proved challenging to navigate, scoring poorly on usability, literacy, and information quality. CONCLUSIONS: Several factors may limit access to potentially life-saving durable medical equipment for patients with tracheostomy. Barriers include out-of-pocket expenditures, lack of transparency on coverage, and low-quality information. Further research is necessary to evaluate patient outcomes.

Instrument adaptation and preliminary validation study of the Laryngeal Hypersensitivity Questionnaire used for assessment of laryngeal symptoms in patients with artificial airways.

BACKGROUND: The Newcastle Laryngeal Hypersensitivity Questionnaire (LHQ) was developed to measure abnormal laryngeal sensation and was originally validated in a patient sample from otolaryngologic and respiratory outpatient clinics. Modification is needed for patients who are mechanically ventilated via an endotracheal tube or a tracheostomy tube. OBJECTIVES: We sought to adapt and preliminarily validate a modified version of the LHQ appropriate for nurses and other clinicians to administer in acute hospital settings called the LHQ-Acute (LHQ-A). METHODS: Internal consistency and construct validity analyses using secondary data from patients at a tertiary teaching hospital who presented with symptoms of laryngeal irritability/hypersensitivity between September 2012 and October 2013 were performed. RESULTS: A total of 131 patients, most complaining of coughing and dysphonia, with a median age of 58 (interquartile range: 48, 66) years and 29 healthy participants with a median age of 62 (interquartile range: 50, 66) years were analysed. The original LHQ was reduced from 14 questions with responses on a 7-point scale to the LHQ-A containing 13 questions with responses on a 4-point scale. Correlations between items of the LHQ and LHQ-A were similar, and internal consistency was excellent and highly comparable, with Cronbach's alpha = 0.906 and 0.902, respectively. CONCLUSIONS: The LHQ-A, which has been adapted for nurses and other clinicians to administer to a critically ill patient population, demonstrated comparable reliability and validity to the original LHQ. Validation of the LHQ-A in independent patient populations from acute settings is necessary to better understand norms and changes during recovery from acute illness.

Kinematics of lateral tongue-pushing movement in coordination with masticatory jaw movement: An anteroposterior projection videofluorographic study.

OBJECTIVE: During the mastication of solid food, the tongue pushes the bolus laterally to place it onto occlusal surfaces as the jaw is opened. This movement is referred to as tongue-pushing (TP). TP has an important role in efficient chewing, but its kinematic mechanisms remain unclear. The present study quantified the kinematics of TP and its coordination with masticatory jaw movements. METHODS: Videofluorography (VFG) in anteroposterior projection was recorded while 14 healthy young adults ate 6 g each of cookies and meat. Small lead markers were glued to the tongue surface (left, right, and anterior) and buccal tooth surfaces (upper molars and lower canines). The position of the tongue and lower canine markers relative to the upper occlusal plane was quantified with Cartesian coordinates, using the right upper molar as the origin. Jaw motion during chewing was divided into TP and Non-TP cycles, based on the lateral movement of the food and tongue markers. The side of the jaw that compressed food particles was defined as the working side, while the other side was termed the balancing side. Horizontal and vertical displacements of tongue and jaw markers were compared between TP and Non-TP cycles, as well as between food types. RESULTS: The mediolateral displacement of all tongue markers was significantly larger in TP than in Non-TP cycles. Vertical displacement was also significantly greater in TP than in Non-TP cycles for the anterior and working side tongue markers. TP cycles occurred more frequently with meat-chewing than with cookie-chewing. CONCLUSION: TP is accomplished by rotation and lateral movements of the tongue surface on the working side and the anterior tongue blade, along with medial movement on the balancing side. These movements produce lateral shift and rotation of the tongue surface toward the working side in concert with jaw opening. Designing exercises to improve the strength of the lateral motion and rotation of the tongue body may be useful for individuals with impaired tongue function for eating and swallowing.

Symptom Assessment for Mechanically Ventilated Patients: Principles and Priorities: An Official American Thoracic Society Workshop Report.

Mechanically ventilated patients experience many adverse symptoms, such as anxiety, thirst, and dyspnea. However, these common symptoms are not included in practice guideline recommendations for routine assessment of mechanically ventilated patients. An American Thoracic Society-sponsored workshop with researchers and clinicians with expertise in critical care and symptom management was convened for a discussion of symptom assessment in mechanically ventilated patients. Members included nurses, physicians, a respiratory therapist, a speech-language pathologist, a critical care pharmacist, and a former intensive care unit patient. This report summarizes existing evidence and consensus among workshop participants regarding 1) symptoms that should be considered for routine assessment of adult patients receiving mechanical ventilation; 2) key symptom assessment principles; 3) strategies that support symptom assessment in nonvocal patients; and 4) areas for future clinical practice development and research. Systematic patient-centered assessment of multiple symptoms has great potential to minimize patient distress and improve the patient experience. A culture shift is necessary to promote ongoing holistic symptom assessment with valid and reliable instruments. This report represents our workgroup consensus on symptom assessment for mechanically ventilated patients. Future work should address how holistic, patient-centered symptom assessment can be embedded into clinical practice.

Sepsis, critical illness, communication, swallowing and Sustainable Development Goals 3, 4, 10.

PURPOSE: Sepsis is a major global health problem with an estimated 49 million cases globally each year causing as many as 11 million deaths. The primary objective of this commentary is to describe the impacts of sepsis and critical illness on communication and swallowing function, and to discuss management strategies considering the Sustainable Development Goals (SDGs). RESULT: Communication and swallowing disabilities can occur with sepsis and critical illness. A holistic framework to optimise function, recovery, and future research priorities across the lifespan can be developed through the SDGs. CONCLUSION: Communication and swallowing disabilities following critical illness associated with sepsis have global impacts. Early multidisciplinary engagement is key to optimising individuals' function. Collaborative research, education, and public awareness is urgently needed to increase equity in health outcomes across populations. This commentary paper supports progress towards good health and well-being (SDG 3), quality education (SDG 4) and reduced inequalities (SDG 10).

Current opinion of presentation of dysphagia and dysphonia in patients with coronavirus disease 2019.

PURPOSE OF REVIEW: Dysphagia and dysphonia are common presentations of both acute and long coronavirus disease 2019 (COVID-19). The majority of peer-reviewed publications in 2020 and early 2021 were expert guidance and consensus statements to support dysphagia management in multidisciplinary teams while protecting clinicians and patients from the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) virus. This review discusses dysphagia and dysphonia primary data published in 2021-2022, focusing on patient presentations, pathophysiology, and evidence for interventions. RECENT FINDINGS: Clinicians and researchers amassed knowledge of the cross-system presentation of dysphagia and dysphonia in patients with COVID-19, from severe disease requiring ICU stays to those with mild-to-moderate disease presenting to outpatient clinics. Pre-COVID-19 health status, hospitalization experience, presence of neurological symptoms, and impact of the virus to the upper aerodigestive and respiratory system need consideration in patient management. Long-term dysphagia and dysphonia manifested from COVID-19 require otolaryngologist and speech-language pathologist input. SUMMARY: Changes in immunity through population vaccination and variations in COVID-19 from SARS-CoV-2 mutations means prevalence data are challenging to interpret. However, there is no doubt of the presence of long-term dysphagia and dysphonia in our clinics. Long-term dysphagia and dysphonia are complex and a multidisciplinary team with a tailored approach for each patient is required.

Two dimensional computational model coupling myoarchitecture-based lingual tissue mechanics with liquid bolus flow during oropharyngeal swallowing.

Biomechanical relationships involving lingual myoanatomy, contractility, and bolus movement are fundamental properties of human swallowing. To portray the relationship between lingual deformation and bolus flow during swallowing, a weakly one-way solid-fluid finite element model (FEM) was derived employing an elemental mesh aligned to magnetic resonance diffusional tractography (Q-space MRI, QSI) of the human tongue, an arbitrary Lagrangian-Eulerian (ALE) formulation with remeshing to account for the effects of lingual surface (boundary) deformation, an implementation of patterned fiber shortening, and a computational visualization of liquid bolus flow. Representing lingual tissue deformation in terms of its 2D principal Lagrangian strain in the mid-sagittal plane, we demonstrated that the swallow sequence was characterized by initial superior-anterior expansion directed towards the hard palate, followed by sequential, radially directed, contractions of the genioglossus and verticalis to promote lingual rotation (lateral perspective) and propulsive displacement. We specifically assessed local bolus velocity as a function of viscosity (perfect slip conditions) and observed that a low viscosity bolus (5 cP) exhibited maximal displacement, surface spreading and local velocity compared to medium (110 cP, 300 cP) and high (525 cP) viscosity boluses. Analysis of local nodal velocity revealed that all bolus viscosities exhibited a bi-phasic progression, with the low viscosity bolus being the most heterogeneous and fragmented and the high viscosity bolus being the most homogenous and cohesive. Intraoral bolus cohesion was depicted in terms of the distributed velocity gradient, with higher gradients being associated with increased shear rate and bolus fragmentation. Lastly, we made a sensitivity analysis on tongue stiffness and contractility by varying the degree of extracellular matrix (ECM) stiffness through effects on the Mooney-Rivlin derived passive matrix and by varying maximum tetanized isometric stress, and observed that a graded increase of ECM stiffness was associated with reduced bolus spreading, posterior displacement, and surface velocity gradients, whereas a reduction of global contractility resulted in a graded reduction of obtainable accommodation volume, absent bolus spreading, and loss of posterior displacement. We portray a unidirectionally coupled solid-liquid FEM which associates myoarchitecture-based lingual deformation with intra-oral bolus flow, and deduce that local elevation of the velocity gradient correlates with bolus fragmentation, a precondition believed to be associated with aspiration vulnerability during oropharyngeal swallowing.

Does Medialization Improve Swallowing Function in Patients with Unilateral Vocal Fold Paralysis? A Systematic Review.

Glottal incompetence caused by unilateral vocal fold paralysis (UVFP) is a common cause of dysphagia and aspiration. Treatments targeted at reducing glottal incompetence by injection augmentation or medialization thyroplasty are well established at improving voice outcomes, but improvements in swallowing function are less clear. The objective of this systematic review was to determine the impact of vocal fold medialization on dysphagia outcomes. Six electronic bibliographic databases and one clinical trial registry were searched on 3/13/2020. Our patient population were adult patients with verified UVFP that underwent vocal fold medialization. We limited review to prospective studies that had formal dysphagia assessment both before and after medialization. Nine studies met selection criteria (7 prospective case series and 2 prospective cohort studies) totaling 157 patients. The most common etiology of UVFP was iatrogenic (74/157; 47%). The majority of patients underwent injection augmentation (92/157; 59%), and the remaining underwent medialization thyroplasty. A variety of methods were used to assess changes in dysphagia including patient-reported outcome measures, flexible endoscopic evaluation of swallowing, videofluoroscopic swallow study, and high-resolution manometry. 7/9 studies demonstrated clinically significant improvement in swallowing function following medialization; 4/9 studies demonstrated statistically significant improvement, and three studies did not show statistically significant improvement after intervention. Study participants and outcome measures evaluating swallowing function in this review were heterogeneous. Moreover, the reviewed studies are concerning for multiple risks of bias impacting their conclusions. Taken together, this systematic review demonstrates limited evidence that injection augmentation and medialization thyroplasty improve swallowing function and/or safety.

Dysphagia in Intensive Care Evaluation (DICE): An International Cross-Sectional Survey.

Dysphagia occurs commonly in the intensive care unit (ICU). Despite the clinical relevance, there is little worldwide research on prevention, assessment, evaluation, and/or treatment of dysphagia for ICU patients. We aimed to gain insight into this international knowledge gap. We conducted a multi-center, international online cross-sectional survey of adult ICUs. Local survey distribution champions were recruited through professional and personal networks. The survey was administered from November 2017 to June 2019 with three emails and a final telephone reminder. Responses were received from 746 ICUs (26 countries). In patients intubated > 48 h, 17% expected a > 50% chance that dysphagia would develop. This proportion increased to 43% in patients intubated > 7 days, and to 52% in tracheotomized patients. Speech-language pathologist (SLP) consultation was available in 66% of ICUs, only 4% reported a dedicated SLP. Although 66% considered a routine post-extubation dysphagia protocol important, most (67%) did not have a protocol. Few ICUs routinely assessed for dysphagia after 48 h of intubation (30%) or tracheostomy (41%). A large proportion (46%) used water swallow screening tests to determine aspiration, few (8%) used instrumental assessments (i.e., flexible endoscopic evaluation of swallowing). Swallowing exercises were used for dysphagia management by 30% of ICUs. There seems to be limited awareness among ICU practitioners that patients are at risk of dysphagia, particularly as ventilation persists, protocols, routine assessment, and instrumental assessments are generally not used. We recommend the development of a research agenda to increase the quality of evidence and ameliorate the implementation of evidence-based dysphagia protocols by dedicated SLPs.

An International Commentary on Dysphagia and Dysphonia During the COVID-19 Pandemic.

COVID-19 has had an impact globally with millions infected, high mortality, significant economic ramifications, travel restrictions, national lockdowns, overloaded healthcare systems, effects on healthcare workers' health and well-being, and large amounts of funding diverted into rapid vaccine development and implementation. Patients with COVID-19, especially those who become severely ill, have frequently developed dysphagia and dysphonia. Health professionals working in the field have needed to learn about this new disease while managing these patients with enhanced personal protective equipment. Emerging research suggests differences in the clinical symptoms and journey to recovery for patients with COVID-19 in comparison to other intensive care populations. New insights from outpatient clinics also suggest distinct presentations of dysphagia and dysphonia in people after COVID-19 who were not hospitalized or severely ill. This international expert panel provides commentary on the impact of the pandemic on speech pathologists and our current understanding of dysphagia and dysphonia in patients with COVID-19, from acute illness to long-term recovery. This narrative review provides a unique, comprehensive critical appraisal of published peer-reviewed primary data as well as emerging previously unpublished, original primary data from across the globe, including clinical symptoms, trajectory, and prognosis. We conclude with our international expert opinion on what we have learnt and where we need to go next as this pandemic continues across the globe.

Twenty-One for 2021: The Most Influential Papers in Laryngology Since 2000.

OBJECTIVES/HYPOTHESIS: To identify the most influential publications in laryngology since 2000. STUDY DESIGN: Modified Delphi process. METHODS: Samples of laryngologists drawn from editors of leading journals, organization officers, and thought leaders were invited to participate in a modified Delphi identification of influential laryngology papers. Influential was defined as follows: yielding meaningful practice changes, catalyzing further work as a foundation for an important topic, altering traditional views, or demonstrating durability over time. Quality and validity were not among the selection criteria. Each participant nominated 5 to 10 papers in Round 1. These nominations, augmented with papers from bibliometric analysis, were narrowed further in Round 2 as participants identified their top 20. The 40 papers with the most Round 2 votes were discussed by video conference and then subjected to Round 3 voting, with each participant again selecting their top 20 most influential papers. Final results were collated by the number of Round 3 votes. RESULTS: Sixteen of 18 invited laryngologists participated overall (all 16 in Rounds 1 and 3; 14 in Round 2). Twenty-one papers were identified as most influential. One paper appeared on all 16 Round 3 lists; three papers with eight (50%) votes each were lasted to make the list. Eleven of these 21 focused on voice; three each related to cancer, airway, and swallowing; and one encompassed all of these clinical areas. CONCLUSIONS: This list of 21 influential laryngology papers serves to focus further research, provides perspective on recent advances within the field, and is an educational resource for trainees and practicing physicians. LEVEL OF EVIDENCE: NA Laryngoscope, 132:406-412, 2022.

Speech-language pathology approaches to neurorehabilitation in acute care during COVID-19: Capitalizing on neuroplasticity.

Neurologic manifestations associated with a coronavirus disease 2019 (COVID-19) diagnosis are common and often occur in severe and critically ill patients. In these patients, the neurologic symptoms are confounded by critical care conditions, such as acute respiratory distress syndrome (ARDS). Patients with dual diagnoses of COVID-19 and neurologic changes such as myopathy, polyneuropathy, and stroke are likely at a higher risk of experiencing deficits with swallowing, communication, and/or cognition. Speech-language pathologists are an integral part of both the critical care and neurologic disorders multi-disciplinary teams, offering valuable contributions in the evaluation, treatment, and management of these areas. Patients in intensive care units (ICUs) who require mechanical ventilation often experience difficulty with communication and benefit from early speech-language pathology intervention to identify the most efficient communication methods with the medical team and caregivers. Moreover, patients with neurologic manifestations may present with cognitive-linguistic impairments such as aphasia, thereby increasing the need for communication-based interventions. Difficulties with voice and swallowing after extubation are common, often requiring frequent treatment sessions, possibly persisting beyond ICU discharge. After leaving the ICU, patients with COVID-19 often experience physical, cognitive, and mental health impairments collectively called post-intensive care syndrome. This is often a lengthy road as they progress toward full recovery, requiring continued speech-language pathology treatment after hospital discharge, capitalizing on the principles of neuroplasticity.

Addressing the post-acute sequelae of SARS-CoV-2 infection: a multidisciplinary model of care.

As of July 31, 2021, SARS-CoV-2 had infected almost 200 million people worldwide. The growing burden of survivorship is substantial in terms of the complexity of long-term health effects and the number of people affected. Persistent symptoms have been reported in patients with both mild and severe acute COVID-19, including those admitted to the intensive care unit (ICU). Early reports on the post-acute sequelae of SARS-CoV-2 infection (PASC) indicate that fatigue, dyspnoea, cough, headache, loss of taste or smell, and cognitive or mental health impairments are among the most common symptoms. These complex, multifactorial impairments across the domains of physical, cognitive, and mental health require a coordinated, multidisciplinary approach to management. Decades of research on the multifaceted needs of and models of care for patients with post-intensive care syndrome provide a framework for the development of PASC clinics to address the immediate needs of both hospitalised and non-hospitalised survivors of COVID-19. Such clinics could also provide a platform for rigorous research into the natural history of PASC and the potential benefits of therapeutic interventions.

COVID-19 survivorship: How otolaryngologist-head and neck surgeons can restore quality of life after critical illness.

Mortality from COVID-19 has obscured a subtler crisis - the swelling ranks of COVID-19 survivors. After critical illness, patients often suffer post-intensive care syndrome (PICS), which encompasses physical, cognitive, and/or mental health impairments that are often long-lasting barriers to resuming a meaningful life. Some deficits after COVID-19 critical illness will require otolaryngologic expertise for years after hospital discharge. There are roles for all subspecialties in preventing, diagnosing, or treating sequelae of COVID-19. Otolaryngologist leadership in multidisciplinary efforts ensures coordinated care. Timely tracheostomy, when indicated, may shorten the course of intensive care unit stay and thereby potentially reduce the impairments associated with PICS. Otolaryngologists can provide expertise in olfactory disorders; thrombotic sequelae of hearing loss and vertigo; and laryngotracheal injuries that impair speech, voice, swallowing, communication, and breathing. In the aftermath of severe COVID-19, otolaryngologists are poised to lead efforts in early identification and intervention for impairments affecting patients' quality of life.

Machine Learning in Laryngoscopy Analysis: A Proof of Concept Observational Study for the Identification of Post-Extubation Ulcerations and Granulomas.

OBJECTIVE: Computer-aided analysis of laryngoscopy images has potential to add objectivity to subjective evaluations. Automated classification of biomedical images is extremely challenging due to the precision required and the limited amount of annotated data available for training. Convolutional neural networks (CNNs) have the potential to improve image analysis and have demonstrated good performance in many settings. This study applied machine-learning technologies to laryngoscopy to determine the accuracy of computer recognition of known laryngeal lesions found in patients post-extubation. METHODS: This is a proof of concept study that used a convenience sample of transnasal, flexible, distal-chip laryngoscopy images from patients post-extubation in the intensive care unit. After manually annotating images at the pixel-level, we applied a CNN-based method for analysis of granulomas and ulcerations to test potential machine-learning approaches for laryngoscopy analysis. RESULTS: A total of 127 images from 25 patients were manually annotated for presence and shape of these lesions-100 for training, 27 for evaluating the system. There were 193 ulcerations (148 in the training set; 45 in the evaluation set) and 272 granulomas (208 in the training set; 64 in the evaluation set) identified. Time to annotate each image was approximately 3 minutes. Machine-based analysis demonstrated per-pixel sensitivity of 82.0% and 62.8% for granulomas and ulcerations respectively; specificity was 99.0% and 99.6%. CONCLUSION: This work demonstrates the feasibility of machine learning via CNN-based methods to add objectivity to laryngoscopy analysis, suggesting that CNN may aid in laryngoscopy analysis for other conditions in the future.