Normative Values of the Repetitive Saliva Swallow Test and Clinical Factors Affecting the Test Scores in Healthy Adults.

The Repetitive Saliva Swallow Test (RSST) is a screening test for oropharyngeal dysphagia during which the subject is asked to perform as many empty swallows as possible in 30 s. Previous validation studies found a cutoff value of 3 > swallows as pathological. The aims of this study were to establish the normative values of the RSST and to examine the effect of clinical factors on RSST scores in healthy adults. A cross-sectional study of 280 adults. An equal number of females and males were recruited for each decade of life, ages 20 to 90 years. Patients reporting swallowing difficulties, history of neurologic disorders, or head and neck surgery or radiation were excluded. Data collected included RSST scores, number and type of comorbidities, number of prescribed medications, body mass index, smoking habits, and self-assessment xerostomia questionnaire. The mean RSST score for the entire cohort was 7.01 ± 2.86. Males had a higher RSST score (7.6 ± 3.04 compared to 6.47 ± 2.56, p = 0.001). Age showed an inverse correlation with RSST scores (Pearson's Correlation Coefficient (PCC) = -0.463, p < 0.0001), as well as body mass index, BMI (PCC = -0.2, p < 0.0001), number of co-morbidities (PCC=-0.344, p < 0.0001) and number of prescribed medications (PCC= -0.425, p < 0.0001). Self-reported amount of saliva positively correlated (PCC = 1.05, p = 0.04) with RSST scores. A multivariate logistic regression analysis was performed. Age, sex, BMI, and number of prescribed medications were found as significant independent factors on RSST scores. RSST scores in healthy adults decline with age and are lower in females, individuals taking multiple medications and with higher BMI. Mean RSST for all age groups did not fall beneath the previously established pathological cut-off.

Evaluation of the Whiteout During Fiberoptic Endoscopic Evaluation of Swallowing and Examination of Its Correlation with Pharyngeal Residue and Aspiration.

To evaluate the whiteout duration (WOd) and intensity (WOi) during Fiberoptic Endoscopic Evaluation of Swallowing (FEES) and examine their correlation with each other and age, gender, bolus consistencies, residue, and aspiration. Retrospective review of 75 videorecorded FEES. The first swallow of each of the following were scored: "Empty" swallow, semisolids, solids, and liquids (International dysphagia diet standardization initiative (IDDSI) 4, 7, 0, respectively). Data scored for each swallow included WOd, WOi, Penetration and aspiration scale (PAS), Pharyngeal residue (Yale Pharyngeal Residue Severity Rating Scale, YPR-SRS), and saliva pooling (Murray Secretion scale, MSS). The highest PAS and YPR-SRS for each consistency during the entire examination were also collected. WOd was significantly longer for stronger WOi in IDDSI4 swallows (p = 0.019). WOi was weaker for IDDSI0 swallows compared to IDDSI7, IDDSI4, and empty swallows (p < 0.05). Patients with saliva pooling had significantly shorter WOd (0.81 ± 0.3 s for MSS = 0 vs. 0.62 ± 0.24 for MSS = 3, p = 0.04). Lower WOi was associated with higher mean age for IDDSI0 (mean ages of 73 ± 12, 64 ± 14, 73 ± 7, 59 ± 16 years for intensity levels 1-4 respectively, p = 0.019). Swallows with weaker WOi and longer WOd had significantly more aspirations in IDDSI7 (28.8% of PAS ≥ 6 for intensity 2 vs 0% for intensity 4, p = 0.003 and 0.77 ± 0.4 s for PAS 1-2 vs. 1.02 ± 0.08 for PAS 6-8, p = 0.049). WOi and WOd are significantly associated with each other. WOi may vary for different bolus consistencies and decreases with age. Longer WOd and weaker WOi are associated with penetration-aspiration. Shorter WOd is associated with saliva pooling.

Outcomes of abscess tonsillectomy in patients awaiting tonsillectomy: A comparison with interval tonsillectomy.

PURPOSE: Peritonsillar abscesses (PTA) occasionally occur in patients who have a concurrent history of recurrent tonsillitis or prior PTA episodes. These patients sometimes meet the indications for elective tonsillectomy even prior to the current PTA event. Abscess ("Quinsy") tonsillectomy (QT) could serve as definitive treatment in this specific subgroup, though it is not performed often. The purpose of this study was to compare the perioperative outcomes between immediate QT and tonsillectomy performed several days (delayed QT) or weeks (Interval tonsillectomy, IT) after incision and drainage (I&D) of the PTA in this specific subgroup. MATERIALS AND METHODS: A retrospective perioperative outcomes analysis of patients undergoing tonsillectomy (2002-2022) compared QT to delayed QT and IT in patients with PTA meeting AAO-HNS elective tonsillectomy criteria. RESULTS: 110 patients were included: 55 underwent IT, 36 underwent delayed QT, and 19 underwent immediate QT. Postoperative hemorrhage rates were 14.5 %, 11.1 %, and 5.3 % for IT, delayed QT, and immediate QT, respectively (P = 0.08). Mean hospitalization durations were 7.98, 6.92, and 5.37 days for IT, delayed QT, and immediate QT, respectively (P < 0.01). IT had a higher readmission rate due to pain compared to QT (14.5 % vs. 1.9 %, p = 0.032). CONCLUSION: Immediate QT in PTA patients eligible for elective tonsillectomy is associated with lower postoperative hemorrhage, shorter admission time, and potentially reduced postoperative pain compared to I&D and delayed or interval tonsillectomy. These findings suggest that immediate QT should be considered as a primary treatment in this subgroup of eligible patients.

In-office KTP laser treatment for laryngeal pathologies: 5-years outcomes.

INTRODUCTION: In the past two decades, laser systems were introduced into the office setting for laryngeal pathologies, offering the advantages of a shorter procedure and recovery. To date, long-term data on outcomes is limited. This study aims to evaluate the efficacy and safety of the office-based potassium-titanyl-phosphate (KTP) laser procedure for laryngeal pathologies. METHODS: A retrospective cohort of in-office KTP laser procedures for two main vocal folds lesions groups: (i) benign and pre-malignant; and (ii) intraepithelial lesions in a prior invasive cancer field between 2010 and 2020. Data were collected from electronic medical records, telephone interviews, and video documentation of the procedure, including treatment completion, disease control, and whether additional interventions were required. RESULTS: A total of 81 patients underwent 153 in-office KTP laser procedures for benign (36, 44.4%), pre-malignant (15, 18.5%), and lesions in a prior malignancy field (30, 37.1%) with a mean of 1.89 ± 1.81 procedures per patient. One hundred and thirty-eight (90.2%) procedures were well tolerated and completed successfully. During the 5-years of follow-up, 63% of the patients with previous malignancy were managed exclusively in the office. In the pre-malignant group, 76% required no additional type of intervention. Patients with papilloma required significantly more procedures per patient compared with other pathologies (3.6 ± 4 vs. 1.61 ± 1, p-value = 0.02). Surgery was required only in 18.2% of the papilloma patients. Three (1.9%) patients had short-term complications, all resolved within 6 months. Failure to complete the procedure was significantly associated with active smoking (p-value < 0.001) and, in most cases (90%), was related to patient intolerance. CONCLUSION: Office-based KTP laser laryngeal procedures have shown promising results for both benign and selected cases of lesions in a prior malignancy field with a high compliance and a very low complication rate, suggesting its use as an effective and safe treatment modality for selected patients.

A Novel Trans-Tracheostomal Retrograde Inhalation Technique Increases Subglottic Drug Deposition Compared to Traditional Trans-Oral Inhalation.

Subglottic stenosis represents a challenging clinical condition in otolaryngology. Although patients often experience improvement following endoscopic surgery, recurrence rates remain high. Pursuing measures to maintain surgical results and prevent recurrence is thus necessary. Steroids therapy is considered effective in preventing restenosis. Currently, however, the ability of trans-oral steroid inhalation to reach and affect the stenotic subglottic area in a tracheotomized patient is largely negligible. In the present study, we describe a novel trans-tracheostomal retrograde inhalation technique to increase corticosteroid deposition in the subglottic area. We detail our preliminary clinical outcomes in four patients treated with trans-tracheostomal corticosteroid inhalation via a metered dose inhaler (MDI) following surgery. Concurrently, we leverage computational fluid-particle dynamics (CFPD) simulations in an extra-thoracic 3D airway model to gain insight on possible advantages of such a technique over traditional trans-oral inhalation in augmenting aerosol deposition in the stenotic subglottic region. Our numerical simulations show that for an arbitrary inhaled dose (aerosols spanning 1-12 µm), the deposition (mass) fraction in the subglottis is over 30 times higher in the retrograde trans-tracheostomal technique compared to the trans-oral inhalation technique (3.63% vs. 0.11%). Importantly, while a major portion of inhaled aerosols (66.43%) in the trans-oral inhalation maneuver are transported distally past the trachea, the vast majority of aerosols (85.10%) exit through the mouth during trans-tracheostomal inhalation, thereby avoiding undesired deposition in the broader lungs. Overall, the proposed trans-tracheostomal retrograde inhalation technique increases aerosol deposition rates in the subglottis with minor lower-airway deposition compared to the trans-oral inhalation technique. This novel technique could play an important role in preventing restenosis of the subglottis.

Subglottic Mucosal Flap: Endoscopic Single-Stage Reconstruction for Anterior Glottic Stenosis.

OBJECTIVES/HYPOTHESIS: Anterior glottic stenosis (AGS) results from surgical intervention, carcinoma, papillomatosis, congenital, or idiopathic causes. It may be present as elastic web or fibrotic scar. It impairs vocal function and glottic airway. Reconstructive options include resection and placement of a keel or glottic web-based mucosal flaps to prevent restenosis. These methods may not be sufficient for reconstructing a thick anterior scar and may require multiple interventions. The aim of the study was to describe the anterior subglottic mucosal flap (ASGMF), a one-stage, keel-free technique for AGS repair. STUDY DESIGN: A retrospective cohort. METHODS: Patients with AGS were operated using the ASGMF between 2017 and 2020. The stenotic segment was excised, and then an ASGMF was developed. A unilateral oblique incision was performed to allow rotation and advancement of the flap toward the contralateral vocal fold. The flap was sutured to the mucosal edge of the vocal fold to create mucosal continuity and prevent restenosis. Vocal fold length ratio (VFLR), which is between the free part and the total vocal fold length, as well as stroboscopic measures, were calculated before and after surgery. RESULTS: Twelve patients were enrolled. Etiologies were iatrogenic, dysplasia, papillomatosis, carcinoma, and congenital. Average VFLR improved from 0.33 to 0.87 (P-value < .0001). Median amplitude and mucosal wave propagation improved from 12.3% and 9.5% to 28.6% and 22.7%, respectively (P-values = .0278, .0385). Phase symmetry improved from 24.5% to 60.9% (P-value = .0413). No complications were encountered. CONCLUSIONS: ASGMF for AGS is an effective surgical procedure, allowing for one stage, keel-free reconstruction of the anterior commissure. ASGMF can significantly elongate the free portion of the vocal folds and improve vibratory function. LEVEL OF EVIDENCE: 4 Laryngoscope, 132:612-618, 2022.

Effects of carbonation of liquids on penetration-aspiration and residue management.

OBJECTIVE: Carbonation as a sensory enhancement strategy for prevention of aspiration of thin liquids has not been thoroughly studied. The aim of our study was to examine the effect of carbonation on penetration-aspiration and pharyngeal residue in dysphagia patients using Fiber-Optic Endoscopic Evaluation of Swallowing (FEES) and to identify parameters associated with a response to carbonation. METHODS: A cross-sectional study of patients undergoing FEES in a dysphagia clinic. Patients were offered 100 cc of dyed water. Penetration-aspiration was scored using the penetration-aspiration scale (PAS). Residue was scored using the Yale Pharyngeal Residue Severity Rating Scale (YPR-SRS). Patients with a PAS ≥ 2 for water were subsequently offered 100 cc of carbonated water. PAS, YPR-SRS and residue clearance were compared between thin and carbonated liquids. Multivariate logistic regression analysis was used to identify predictors for good response to carbonation. RESULTS: 84 patients were enrolled, 77.4% males, with diverse dysphagia etiologies (58.3% neurogenic, 11.9% radiation-induced, 23.8% deconditioning-induced, and 6% neck surgery induced). Median PAS was 7 (IQR 4-8) for thin liquids and 4.5 (IQR 2-8) for carbonated liquids (P = 0.0001). YPR-SRS was reduced for carbonated compared to thin liquids in the vallecula (1.58 ± 0.83 vs 1.76 ± 0.93, P = 0.001) and piriform sinuses (1.5 ± 0.87 vs 1.67 ± 0.9, P = 0.002). 31 patients had improvement in PAS with carbonation. Deconditioning as a dysphagia etiology was found to predict good response to carbonation on multivariate logistic regression analysis. CONCLUSION: Carbonation may prevent aspiration and improve residue management for some patients with dysphagia for liquids. LEVEL OF EVIDENCE: IV.

Vocal Fold Fat Augmentation for Atrophy, Scarring, and Unilateral Paralysis: Long-term Functional Outcomes.

OBJECTIVE: There is a debate regarding the durability of fat implants. Our experience and recent publications suggest fat implantation may deliver a long-lasting improvement. This study aims to present the long-term outcomes for vocal fold fat augmentation using strict harvesting, preparing, and implantation protocols. STUDY DESIGN: A prospective cohort conducted between 2014 and 2020 (recruitment 2014-2017). SETTING: An academic tertiary referral center. SUBJECTS AND METHODS: Twenty-two patients with glottic insufficiency were enrolled: 11 had unilateral vocal fold paralysis (UVFP), and 11 had atrophy or scar. Harvested fat was injected unilaterally or bilaterally into multiple sites. Six of these patients also had simultaneous microlaryngoscopic removal of other benign glottic lesions. Outcome measurements included video stroboscopy; Grade, Roughness, Breathiness, Asthenia, Strain (GRBAS) score; Voice Handicap Index (VHI); and acoustic analysis, performed preoperatively, 3, 12, 24, and 36 months after surgery. RESULTS: Ten augmentations were unilateral and 12 bilateral. Comparing the preoperative and 36-month postoperative periods, the mean VHI score improved from 73.45 (±22.78) to 44.88 (±28.93), P = .001, and the mean GRBAS decreased from 8.64 (±3.89) to 2.82 (±2.3), P = .001; 24 months postoperatively, the mean fundamental frequency decreased from 163.88 Hz (±41.61) to 150.44 Hz (±41.47), P = .012. Stroboscopic analysis revealed statistically significant improvement in mucosal wave propagation, phase closure, and phase symmetry. Best results were achieved in the UVFP subgroup. Computed tomography scans demonstrated long-term viability of the implanted adipose tissue. CONCLUSION: Fat is an excellent source of autologous graft. With careful patient selection and proper surgical technique, fat is suitable for long-term correction of glottic insufficiency. Fat augmentation should be considered as a long-lasting or even permanent solution, rather than temporary.

Recurrent Respiratory Papillomatosis Office versus Operating Room: Systematic Review and Meta-Analysis.

OBJECTIVES: Recurrent respiratory papillomatosis can be treated in the office or operating room (OR). The choice of treatment is based on several factors, including patient and surgeon preference. However, there is little data to guide the decision-making. This study examines the available literature comparing operative treatment in-office versus OR. METHODS: A systematic review was performed following Preferred Reporting Items for Systematic Reviews guidelines. Of 2,864 articles identified, 78 were reviewed full-length and 18 were included. Outcomes of interest were recurrence and complication rates, number of procedures, time interval between procedures, and cost. RESULTS: Only one study compared outcomes of operative in-office to OR treatments. The weighted average complication rate for OR procedures was 0.02 (95% confidence interval [CI] 0.00-0.32), n = 8, and for office procedures, 0.17 (95% CI 0.08-0.33), n = 6. The weighted average time interval between OR procedures was 10.59 months (5.83, 15.35) and for office procedures 5.40 months (3.26-7.54), n = 1. The weighted average cost of OR procedures was $10,105.22 ($5,622.51-14,587.83), n = 2 versus $2,081.00 ($1,987.64-$2,174.36), n = 1 for office procedures. CONCLUSION: Only one study compares office to OR treatment. The overall data indicate no differences aside from cost and imply that office procedures may be more cost-effective than OR procedures. However, the heterogeneous data limits any strong comparison of outcomes between office and OR-based treatment of laryngeal papillomas. More studies to compare the two treatment settings are warranted.

Management of Iatrogenic Cervical Esophageal Perforations: A Narrative Review.

Importance: Esophageal perforations are difficult to diagnose and have a high mortality rate. Cervical esophageal perforations (CEPs) are the second most common anatomic type of esophageal perforations and are most often due to iatrogenic injury. They are often managed more conservatively than thoracic perforations. The current literature on CEPs is mostly observational, with a paucity of prospective controlled studies. In addition, there is scarce literature focusing specifically on iatrogenic CEPs (iCEPs) as an entity of their own. Observations: The existing studies on esophageal perforations address treatment by anatomic location and by cause, but few focus specifically on iCEPs. The cricopharynx is the most common site for injury in diagnostic endoscopy. The standard treatment is generally conservative management with drainage unless the perforation is greater than 2 cm, the diagnosis is delayed, or the patient shows signs of sepsis, which would prompt surgical intervention, most commonly in the form of primary repair via open or endoscopic approach. An open approach has been the mainstay of therapy; however, use of endoscopic clips, stents, and suturing is increasingly on the rise. Guideline recommendations on the optimal therapeutic approach for iCEPs are lacking. The most consistent recommendation in the literature is immediate and individualized treatment. Conclusions and Relevance: The management of iCEPs is controversial. There is a need for additional prospective studies comparing treatment options for iCEPs to establish a gold standard treatment and to assess for the expanding role of endoscopic interventions.

CO2 Laser Cordectomy Versus KTP Laser Tumor Ablation for Early Glottic Cancer: A Randomized Controlled Trial.

BACKGROUND AND OBJECTIVES: CO2 laser cordectomy has been the workhorse of laser surgery for early glottic squamous cell carcinoma (GSCC) since the early 1970s. During the last decades, potassium titanyl phosphate (KTP) laser surgery for early GSCC gained popularity, introducing the tumor ablation technique. Yet, there are no previous randomized controlled trials (RCT) that compare the oncologic and functional outcomes of KTP Laser ablation versus CO2 laser cordectomy for early GSCC. This study aims to compare by means of an RCT, CO2 laser cordectomy with KTP laser ablation for early GSCC, in terms of cure rates and vocal function. STUDY DESIGN/MATERIALS AND METHODS: A RCT conducted between 2013 and 2017. Patients with early GSCC were enrolled, and randomly assigned for either CO2 cordectomy or KTP-ablation surgery with curative intent. All CO2 cordectomies and most KTP-ablation procedures were performed under general anesthesia. Some KTP cases with residual disease were treated also under local anesthesia. Videostroboscopy measures, voice handicap index (VHI), GRBAS (a hoarseness scale for Grade, Roughness, Breathiness, Asthenia and Strain) score, and acoustic analyses were performed pre-operatively, 6 months and 3 years after surgery. RESULTS: Twenty-four patients, 12 in each group, were enrolled. Nine in each group had T1a carcinoma, the remaining had either carcinoma in situ or T1b. The average number of procedures was 1.67( ± 0.89) and 1.33( ± 0.89) for the KTP and CO2 groups, respectively. Although the tumor depth was comparable in both groups, patients in the KTP-ablation group underwent more superficial surgeries. Eleven (91.7%) procedures in the KTP group spared the vocal ligament, compared with 5 (41.7%) in the CO2 group, (P = 0.023). All patients were alive and disease-free after four years. On post-operative videostroboscopy, normal mucosal waves appeared in 5 (42%) of the KTP patients versus none (0%) of the CO2 (P = 0.02). The median post-operative non-vibrating portion was smaller in the KTP group (10%) compared with CO2 (50%), P = 0.043. Nevertheless, GRBAS and VHI scores improved comparably in both groups. CONCLUSIONS: KTP ablation technique offers similar curative outcome as CO2 cordectomy but may allow for better preservation of vocal fold's architecture and function. Yet, the clinical significance of these findings is unclear, since the subjective measures improved comparably for these two treatment modalities. Lasers Surg. Med. © 2019 Wiley Periodicals, Inc.

Development of the nasopharynx: A radiological study of children.

The relation between pharyngeal tonsil and the bony nasopharynx determines the nasopharyngeal airway patency. Despite its importance, an anatomical study utilizing advanced imaging has not been conducted. The aim of the study was to evaluate the pharyngeal tonsil and bony nasopharynx depth and their ratio (adenoid-nasopharyngeal ratio [ANR]) with relation to sex and age in the general pediatric population. After excluding reported history of adenoidectomy, acute upper airway illness, allergy, and poor quality, 200 randomly selected head computed tomographies (CTs) of children were evaluated. CTs were divided into five age groups (0-5, 5.1-8, 8.1-11, 11.1-14, and 14.1-17 years). For each CT scan, the pharyngeal tonsil, bony nasopharynx and ANR values were calculated. A significant difference was found in the bony nasopharynx and pharyngeal tonsil depth between the five age subgroups (P < 0.001). Both bony nasopharynx and pharyngeal tonsil depth significantly increased between the age groups of 0-5 years to 5.1-8 years (4.17 mm increase, P < 0.001 and 3.47 mm increase, P < 0.009, respectively). The pharyngeal tonsil depth gradually decreases following the age of 8 years. No difference was found between age groups beyond age of eight for both the pharyngeal tonsil tissue and the bony nasopharynx. The ANR has an upward trend in the age group of 5.1-8 years. No sexual predilection was found. The bony nasopharynx and the pharyngeal tonsil tissue both grow during childhood. Different growth rates result in the narrowest airway in the age group of 5.1-8 years (ANR peak). These growth curves should be taken under consideration when treating pediatric pharyngeal tonsil hypertrophy. Clin. Anat., 33:1019-1024, 2020. © 2019 Wiley Periodicals, Inc.

Outcome and survival following tracheostomy in patients ≥ 85 years old.

PURPOSE: To evaluate percutaneous dilatational tracheostomy in patients ≥ 85 years old: its complication rate and possible risk factors. In addition, to assess prognostic factors for short, intermediate and long term survival following the procedure. METHODS: A retrospective case-control study of 72 patients ≥ 85 years who received percutaneous dilatation tracheotomy (PTD), compared to a control group of younger patients (n = 182). Demographics, clinical and laboratory data were collected. Survival and risk for complications were analyzed. RESULTS: The study group's mean age was 89 ± 4. Twelve patients had complications, three (4.2%) were major. No significant difference was found in overall complication rates between the groups. Cerebrovascular disease with neurologic deficits and pre-procedure albumin levels were significantly associated with complications. Survival rates did not differ in 1 week and 1 month following procedure between study and control group. There was a significant difference in the 1-year survival rates between the patients ≥ 85 years and the control groups (18.1% vs. 34.4%, p = 0.01, respectively). Congestive heart failure, a frailty score > 0.27 and failure to wean from a cannula were associated with reduced 1-year survival. CONCLUSION: PTD is safe for patients ≥ 85 years. Complication risk factors and reduced survival should be discussed with patients and families before conducting tracheostomies. LEVEL OF EVIDENCE: 3b.

Association Between Laryngeal Sensation, Pre-swallow Secretions and Pharyngeal Residue on Fiberoptic Endoscopic Examination of Swallowing.

Reduced laryngeal sensation and accumulated pharyngeal secretions are known predictors of aspiration. Yet, their association with residue has not been fully explored. One Hundred and ten fiberoptic endoscopic examination of swallowing (FEES) examinations were retrospectively analyzed. Murray's secretion scale (MSS) for secretion stasis and laryngeal sensation were tested for association with residue severity (Yale pharyngeal residue severity rating scale, YPR-SRS) and the number of swallows required to clear the bolus. The bolus challenges of each consistency (liquid, purée and solid) with the highest PAS and YPR-SRS scores were analyzed. Impaired laryngeal sensation (ILS) and MSS were both independently significantly associated with higher YPR-SRS for all consistencies examined. Mean YPR-SRS for patients with both ILS and secretion stasis was respectively 2.4 ± 1.1, 2.5 ± 1.2, 2.4 ± 1.2 for liquid, purée and solids in the vallecula, and 2.9 ± 1.3, 2.3 ± 1.1, 2 ± 1 for pyriform sinuses residue compared to 1.8 ± 0.7, 1.6 ± 1, 1.6 ± 1 for vallecular residue and 1.8 ± 0.8, 1.4 ± 0.8, 1.3 ± 0.7 for pyriform sinus residue of patients with normal laryngeal sensation and no stasis (p < 0.05 for all except liquids in vallecula). The combined findings of both ILS and MSS ≥ 1 had a sensitivity of 25.9%, specificity of 94.2%, positive predictive value (PPV) of 83.3% and negative predictive value (NPV) of 53.3% for prediction of pharyngeal residue and a sensitivity of 58.3%, specificity of 88.8%, PPV of 39.9% and a NPV of 94.6% for prediction of aspiration. Both ILS and MSS were significantly associated with increased number of swallows required to clear a bolus. Abnormal laryngeal sensation and secretion stasis are associated with pharyngeal residue severity and reduced residue clearing on FEES.

Does the Hebrew Eating Assessment Tool-10 Correlate with Pharyngeal Residue, Penetration and Aspiration on Fiberoptic Endoscopic Examination of Swallowing?

The Eating Assessment Tool-10 (EAT-10) is a 10-item patient-reported outcome measure (PROM) for dysphagia patients. The objective of this study was to translate and validate the EAT-10Heb and to test for a correlation between its score and residue, penetration and aspiration on Fiberoptic Endoscopic Examination of Swallowing (FEES). 136 patients visiting two specialized dysphagia clinics and undergoing FEES between April 2015 and August 2017, filled the EAT-10Heb. 23 patients refilled the EAT-10Heb during a 2-week period following their first visit. FEES were scored for residue (1 point per consistency, maximum 3 points) and penetration and aspiration (1 point for penetration, 2 points for aspiration per consistency, maximum 6 points). 51 healthy volunteers also filled the EAT-10Heb. Internal consistency and test-retest reproducibility were examined for reliability testing. Validity was established by comparing EAT-10Heb scores of dysphagia patients to healthy controls. The EAT-10Heb score was then correlated with the FEES score. Internal consistency of the EAT-10Heb was high (Cronbach's alpha = 0.925) as was the test-retest reproducibility (Spearman's correlation coefficient = 0.82, p < 0.0001). The median EAT-10Heb score was significantly higher in the dysphagia group compared to healthy controls (13, IQR 7-22 points for dysphagia patients compared to 0, IQR 0-0 points for healthy controls, p < 0.0001). A weak correlation was found between the EAT-10Heb scores and the FEES score (Pearson's correlation coefficient = 0.376, p < 0.0001). While the EAT-10Heb was found to be a reliable and valid PROM, it only weakly correlates with the pathological findings on FEES examination.

Translation and Validation of the Dysphagia Handicap Index in Hebrew-Speaking Patients.

The Dysphagia Handicap Index (DHI) is a 25-item questionnaire assessing the physical, functional, and emotional aspects of dysphagia patients' quality of life (QoL). The study goal was to translate and validate the Hebrew-DHI. 148 patients undergoing fiberoptic endoscopic examination of swallowing (FEES) in two specialized dysphagia clinics between February and August 2017 filled the Hebrew-DHI and self-reported their dysphagia severity on a scale of 1-7. 21 patients refilled the DHI during a 2-week period following their first visit. FEES were scored for residue (1 point per consistency), penetration and aspiration (1 point for penetration, 2 points for aspiration, per consistency). 51 healthy volunteers also filled the DHI. Internal consistency and test-retest reproducibility were used for reliability testing. Validity was established by comparing DHI scores of dysphagia patients and healthy controls. Concurrent validity was established by correlating the DHI score with the FEES score. Internal consistency of the Hebrew-DHI was high (Cronbach's alpha = 0.96), as was the test-retest reproducibility (Spearman's correlation coefficient = 0.82, p < 0.001). The Hebrew-DHI's total score, and its three subscales (physical/functional/emotional) were significantly higher in dysphagia patients compared to those in healthy controls (median 38 pts, IQR 18-56 for dysphagia patients compared to 0, IQR 0-2 for healthy controls, p < 0.0001). A strong correlation was observed between the DHI score and the self-reported dysphagia severity measure (Spearman's correlation coefficient = 0.88, p < 0.0001). A moderate correlation was found between the DHI score and the FEES score (Pearson's correlation coefficient = 0.245, p = 0.003). The Hebrew-DHI is a reliable and valid questionnaire assessing dysphagia patients' QoL.

Correlation Between Pharyngeal Residue and Aspiration in Fiber-Optic Endoscopic Evaluation of Swallowing: An Observational Study.

OBJECTIVES: To examine the correlation between pharyngeal residue severity and clearance to penetration/aspiration on fiber-optic endoscopic examination of swallowing (FEES). DESIGN: Retrospective cohort. SETTING: Kaplan Medical Center dysphagia clinic. PARTICIPANTS: Patients (N=110) visiting a dysphagia clinic between 2014 and 2016 undergoing FEES. INTERVENTIONS: FEES were scored for penetration/aspiration with the Penetration Aspiration Scale (PAS), for residue severity using the Yale Pharyngeal Residue Severity Rating Scale (YPR-SRS). The numbers of swallows required to clear the pharynx were recorded. The first and the worst bolus challenges for each consistency (liquid, purée, solid) were analyzed. MAIN OUTCOME MEASURES: YPR-SRS and number of clearing swallows were correlated with the PAS of the same bolus challenge. RESULTS: The study population's mean age was 67±13.4 years; 54% were men (n=58). A significant correlation was found between the YPR-SRS and the PAS for all consistencies tested, in each anatomical site (vallecula or pyriform sinus) and for both the first and worst bolus challenges (P<.001 for all). The correlation of residue with aspiration was stronger when vallecula and pyriform sinuses scores were summated (Pearson product-moment correlation coefficient=0.573/0.631/0.446 for liquid/purée/solid for worst bolus challenge). Incorporating the number of clearing swallows to the YPR-SRS strengthened the correlation with PAS. CONCLUSIONS: Residue severity and clearance correlate with penetration/aspiration on FEES. The YPR-SRS can be applied to standardize description of residue in FEES and to aid in dysphagia evaluation.

Evaluation and Predictors for Nasogastric Tube Associated Pressure Ulcers in Critically Ill Patients.

BACKGROUND: Nasal device-related pressure ulcers are scarcely addressed in the literature. OBJECTIVES: To assess the prevalence and severity of cutaneous and mucosal nasogastric tube (NGT)-associated pressure ulcers (PU) in critically ill patients and to define predictors for their formation. METHODS: A single center observational study of intensive care unit patients with a NGT for more than 48 hours was conducted. Nasal skin was evaluated for PU. Ulcers were graded according to their depth. Consenting patients underwent a nasoendoscopic examination to evaluate intranasal mucosal injury. RESULTS: The study comprised 50 patients, 17 of whom underwent nasoendoscopic examination. Mean time of NGT presence in the nose was 11.3 ± 6.17 days. All patients had some degree of extranasal PU, 46% were low grade and 54% were high grade. Predictors for high grade extranasal PU compared to low grade PU were higher peak Sepsis-related Organ Failure Assessment (SOFA) scores (11.52 vs. 8.87, P = 0.009), higher peak C-reactive protein (CRP) levels (265.3 mg/L vs. 207.58, P = 0.008), and bacteremia (33.3% vs. 8.7%, P = 0.037). The columella was the anatomical site most commonly involved and the most severely affected. The number of intranasal findings and their severity were significantly higher in the nasal cavity containing the NGT compared to its contralateral counterpart (P = 0.039 for both). CONCLUSIONS: NGTs cause injury to nasal skin and mucosa in critically ill patients. Patients with bacteremia, high CRP, and high SOFA scores are at risk for severe ulcers, warranting special monitoring and preventive measures.

Bedside percutaneous dilatational tracheostomy in patients outside the ICU: a single-center experience.

PURPOSE: To assess the safety of medical-ward bedside percutaneous dilatational tracheostomy (GWB-PDT). MATERIALS AND METHODS: A retrospective study of all patients who underwent elective GWB-PDT between 2009 and 2015. A joint otolaryngology-ICU team performed all GWB-PDTs. The patients were followed until decannulation, discharge or death. Complications were divided into early (within 24 h) and late, and into minor and major. RESULTS: Two hundred and fifty six patients were included in the study. The mean age was 77.7 ±â€¯11.8 Medical history included cardiac comorbidities (42.6%) and cerebrovascular accidents (34.4%). Overall, 48 patients (18.9%) had 60 complications, of which 70% (42/60) were minor (13 early; 29 late complications). Fifteen patients (5.9%) had major complications. Eight patients had early major complications (loss of airway - two patients [0.8%], pneumothorax - two patients [0.8%], resuscitation - one patient [0.4%], and a single patient (0.4%) died within 24 h following PDT). Two additional patients (0.8%) underwent conversion to an open tracheostomy. Seven patients had late complications (airway complications in six patients [2.3%] and major bleeding in a single patient [0.4%]). Of the seven patients with late major complications, three had two major complications. Half of the complications occurred by POD 3. CONCLUSION: GWB-PDT is a feasible and safe solution for tracheostomies in general-ward ventilated patients.

Menstrual Cycle, Vocal Performance, and Laryngeal Vascular Appearance: An Observational Study on 17 Subjects.

OBJECTIVE: To assess the anatomical and functional features of the vocal folds during different phases of the female menstrual cycle. METHODS: An observational study of 17 healthy fertile female volunteers not using hormonal contraception was carried out. Each volunteer underwent two examinations: first, during the early days of the menstrual cycle when progesterone levels are low (p-depletion), and second, during premenstruation when progesterone levels are high (p-peak). The workup included blood hormone levels, Voice Handicap Index, acoustic analysis, rigid telescopy, stroboscopy, and narrow band imaging. The videos were evaluated by blinded observers. RESULTS: The participants' mean age was 31.7 ± 5.6 (range 23-43). Progesterone levels were 13- to 45-fold higher in p-peak relative to p-depletion. No significant differences were detected in Voice Handicap Index scores, stroboscopic reports, or acoustic analysis between p-peak and p-depletion examinations. Analyzing the rigid telescopy and narrow band imaging videos, the observers tended to estimate the different laryngeal subsites more vascularized during the p-peak examination. Moreover, this tendency was significantly correlated with blood progesterone levels during the p-depletion examinations; the lower the blood progesterone levels were during p-depletion, the higher the probability for the observers to estimate the p-peak examinations more vascularized (P value = 0.024). CONCLUSIONS: Alterations in laryngeal vascular characteristics are evident throughout the menstrual cycle and may suggest increased congestion during premenstrual days. Variations in progesterone levels during the menstrual cycle correlate with laryngeal vascular changes. Hormone-related alterations in vocal folds' vascularity may have a role in the variability of vocal performance in certain women.