Association of Tongue Strength and Maximum Incisal Opening with Oral Intake in Persons with Head and Neck Cancer Treated with Radiotherapy: A Retrospective Study.

Persons treated with radiotherapy (RT) for cancer of the head and neck (HNC) may experience limited oral intake at treatment completion. The purpose of this retrospective study was to examine the contributions of tongue strength and maximum incisal opening (MIO) to oral intake in a cohort of veterans treated for HNC. Medical records of veterans diagnosed with HNC treated with RT who were seen by the Speech Pathology Service prior to and throughout treatment per usual care were reviewed for this study; eighty-two records met the inclusion criteria for analysis. Tongue strength in kPa, MIO in mm, feeding tube status at completion of RT, and food and liquid consistencies consumed at completion of RT were among the data abstracted from the records. Most veterans (67%) did not have a feeding tube present at the completion of RT and reported drinking thin liquids (84.2%) at treatment completion. Eighteen percent reported including all food consistencies in their diet at the end of treatment. Both MIO and tongue strength decreased after treatment. Greater tongue strength during RT and larger MIO at the completion of RT were predictive of improved functional outcomes for oral intake at the end of treatment. This study provides evidence of the importance of increasing tongue strength and MIO during treatment with RT, and supports an important focus for intervention by speech-language pathologists.

Ultrasonography as Biofeedback to Increase Muscle Activation During the Mendelsohn Maneuver in Healthy Adults.

The Mendelsohn Maneuver (MM) is a therapeutic strategy that targets reduced laryngeal elevation. Both clinicians and clients identify the MM as one of the more difficult interventions to teach and learn. The purpose of this study was to examine the effect of applying real-time ultrasound as visual feedback in teaching the MM to healthy adults. Twenty-four healthy adults were randomized to two-parallel groups. The standard care group (control group) received verbal instruction, verbal reinforcement, and tactile cueing while practicing the maneuver. The experimental group received the same instruction with additional real-time ultrasound as visual biofeedback. Participants completed a single session which consisted of baseline assessment, training, and post-training assessment. Outcomes were submental surface electromyography (sEMG) signal duration, maximum amplitude, and area under the curve. Statistical analysis revealed that training with feedback significantly increased submental sEMG activity during the MM; however, the addition of ultrasound as biofeedback did not significantly increase muscle activation when performing the MM over verbal instruction with verbal/tactile feedback alone. Both groups demonstrated significantly greater muscle activity measured by sEMG when applying the MM. Although the current study did not indicate that adding ultrasound biofeedback was superior to traditional training alone in teaching healthy adults to perform the MM, it does support the clinical use of biofeedback tools for learning swallowing maneuvers. Ultrasound may be a biofeedback option for people with language deficits or differences to learn a swallowing maneuver. Further studies are required to determine the clinical application of ultrasound as biofeedback on people with dysphagia.

Using Ultrasound to Document the Effects of Expiratory Muscle Strength Training (EMST) on the Geniohyoid Muscle.

Expiratory muscle strength training (EMST) is an exercise program designed to strengthen the muscles of expiration by increasing expiratory load during breathing exercises using either resistive or pressure threshold devices. Previous research has shown that EMST may increase submental suprahyoid muscle activity as measured with surface electromyography. The impact of EMST on submental muscles is of interest to those who treat dysphagia. The purpose of this study was to determine whether the cross-sectional area of the geniohyoid muscle changes as observed with ultrasound during a 5-week EMST program performed at 75% of maximum expiratory strength using the EMST150 device in healthy adults. Ten healthy adults participated in the 5-week program. Maximum expiratory pressure (MEP) and cross-sectional area of the geniohyoid muscle were measured weekly. Geniohyoid cross-sectional area was measured from ultrasound images recorded in the coronal plane. Repeated Measures ANOVA was used to determine whether there were significant changes among the dependent variables over the study period. Both MEP and geniohyoid area increased significantly in response to a 5-week program of EMST. EMST in healthy adults is effective at strengthening the geniohyoid muscle as reflected by significantly increased cross-sectional area measured with B-mode ultrasound. This is the first study to document weekly change in muscle morphology as a result of EMST. Increasing geniohyoid muscle mass and consequent strength through a program of EMST may be beneficial for persons with pharyngeal stage dysphagia resulting from reduced hyolaryngeal elevation, reduced laryngeal closure, or reduced UES opening.

Swallowing Patterns in the HNC Population: Timing of Penetration-Aspiration Events and Residue.

OBJECTIVE: This study described swallowing patterns in a large head/neck cancer (HNC) cohort. STUDY DESIGN: In a retrospective review of data from a randomized controlled trial, we studied timing of penetration events as they related to aspiration and oral/pharyngeal residue. SETTING: Retrospective review of a multicenter randomized controlled trial. SUBJECTS AND METHODS: In total, 168 patients who were >3 months postradiation received baseline modified barium swallow evaluations. Retrospective analyses of data from these exams were studied, including Penetration-Aspiration Scale (PAS) scores and timing of these events (before, during, or after the swallow), as well as percentage of oral and pharyngeal residue. RESULTS: Aspiration occurred more frequently after than before or during the swallow (P < .05). There were significantly more events of penetration that led to aspiration after the swallow (n = 260) when compared to events before (n = 6) or after (n = 81) the swallow. There was more pharyngeal (16%-25%) than oral residue (5%-20%). Weak correlations were found between thin liquid, nectar-thick liquid, pudding residue, and PAS scores, with varying significance (pharyngeal residue/PAS rs: .26*, .35*, .07*; oral residue/PAS rs: .21*, .16, .3; *P < .05). CONCLUSION: The predominant pattern for this sample of postradiation patients with HNC with dysphagia was aspiration that occurred after the swallow, rather than before or during the swallow. The aspiration was directly caused by penetration events that occurred during the swallow, resulting in aspiration as the airway reopened. Patients demonstrated more pharyngeal residue than oral residue, but a weak relationship was found between residue and penetration/aspiration events. These results guide clinicians in targeting appropriate swallowing interventions.

Dose-volume relationship for laryngeal substructures and aspiration in patients with locally advanced head-and-neck cancer.

BACKGROUND: Literature has shown a significant relationship between radiation dose to the larynx and swallowing disorders. We prospectively studied the dose-volume relationship for larynx substructures and aspiration. METHODS: Forty nine patients with stage III/IV head-and-neck (H&N) squamous cell carcinoma were prospectively enrolled in this IRB-approved, federally funded study. All patients received IMRT-based chemoradiation therapy (CRT) and were scheduled for videofluorography (VFG) prior to CRT and at 3, 6, 9, 12, and 24 months post-CRT. Twelve laryngeal substructures were contoured in each patient: thyroid cartilage, cricoid cartilage, total epiglottis, suprahyoid epiglottis, infrahyoid epiglottis, total larynx, supraglottic larynx, subglottic larynx, glottic larynx, arytenoids, aryepiglottic (AE) folds, and glossoepiglottic fold. After exclusions, 29 patients were included in the final analysis. Incidence of aspiration at 1 year following CRT was correlated with dose-volume data to laryngeal substructures using logistic regression. RESULTS: The median age was 54 years with 79% being non-smokers. Tumor sites included oropharynx (22), unknown primary (6), and hypopharynx (1). One year following CRT, 10/29 (34%) showed aspiration on VFG. Dose to the AE folds showed the highest correlation with aspiration at 12 months and was significant on multivariate analysis (p = 0.025). A mean dose cutpoint of 6500 cGy or higher to the AE folds was associated with an increased risk of aspiration at 1 year [positive likelihood ratio (+LR) 2.81, positive predictive value (PPV) 60%, negative predictive value (NPV) 92.9%, relative risk (RR) 8.4]. CONCLUSIONS: In this analysis, mean dose to the AE folds was associated with an increased risk of aspiration at 1 year. However, these are hypothesis-generating data that require further research and validation in a larger patient subset.

The impact of time after radiation treatment on dysphagia in patients with head and neck cancer enrolled in a swallowing therapy program.

BACKGROUND: Swallowing dysfunction after radiotherapy (RT) for head and neck cancer can be devastating. A randomized control trial compared swallow exercises versus exercise plus neuromuscular electrical stimulation therapy and found no overall difference in outcomes. METHODS: Quality of life (QOL), diet, and swallowing variables collected at discrete intervals on 117 patients were reanalyzed to test the hypothesis that shorter time between the completion of radiotherapy and beginning of the swallowing therapy program yielded improved outcomes. RESULTS: At baseline, subjects < 1 year post radiation had significantly better function than subjects >2 years post RT in several measures. Over the therapy program, the early group showed significant improvement in diet and QOL. Swallowing physiologic variables showed no difference between groups. CONCLUSION: Beginning a swallowing therapy program within 1 year of completion of radiotherapy demonstrates more consistent improvement in QOL and diet performance compared to later periods.

Impact of Compliance on Dysphagia Rehabilitation in Head and Neck Cancer Patients: Results from a Multi-center Clinical Trial.

A 5-year, 16-site, randomized controlled trial enrolled 170 HNC survivors into active (estim + swallow exercise) or control (sham estim + swallowing exercise) arms. Primary analyses showed that estim did not enhance swallowing exercises. This secondary analysis determined if/how patient compliance impacted outcomes. A home program, performed 2 times/day, 6 days/week, for 12 weeks included stretches and 60 swallows paired with real or sham estim. Regular clinic visits ensured proper exercise execution, and detailed therapy checklists tracked patient compliance which was defined by mean number of sessions performed per week (0-12 times) over the 12-week intervention period. "Compliant" was defined as performing 10-12 sessions/week. Outcomes were changes in PAS, HNCI, PSS, OPSE, and hyoid excursion. ANCOVA analyses determined if outcomes differed between real/sham and compliant/noncompliant groups after 12 weeks of therapy. Of the 170 patients enrolled, 153 patients had compliance data. The mean number of sessions performed was 8.57/week (median = 10.25). Fifty-four percent of patients (n = 83) were considered "compliant." After 12 weeks of therapy, compliant patients in the sham estim group realized significantly better PAS scores than compliant patients in the active estim group (p = 0.0074). When pooling all patients together, there were no significant differences in outcomes between compliant and non-compliant patients. The addition of estim to swallowing exercises resulted in worse swallowing outcomes than exercises alone, which was more pronounced in compliant patients. Since neither compliant nor non-compliant patients benefitted from swallowing exercises, the proper dose and/or efficacy of swallowing exercises must also be questioned in this patient population.

Residue influences quality of life independently of penetration and aspiration in head and neck cancer survivors.

OBJECTIVES/HYPOTHESIS: Dysphagia is one of the most significant side effects of the treatment of head and neck cancer. Residue and aspiration are two indicators of dysphagia, but aspiration is historically the only indicator of interest, because it may impact health outcomes. Clinicians have anecdotally used residue as another marker of swallowing dysfunction, but it is understudied. This project investigated the impact of aspiration versus residue on function and quality of life (QoL) in these patients. STUDY DESIGN: Observational study. METHODS: A total of 168 head and neck cancer survivors with moderate to severe dysphagia were enrolled in a randomized clinical trial comparing two swallow therapy interventions. Data at time of entry were used for the current study. A modified barium swallow study was done to compute Penetration-Aspiration Scale (PAS) scores, percentage oral residue, and percentage pharyngeal residue with three bolus consistencies (5 mL thin, nectar, and pudding). The Performance Status Scale (PSS) and the Head Neck Cancer Inventory (HNCI) questionnaires were administered. Data were analyzed to determine associations between aspiration and residue estimates with function and QoL scores. RESULTS: Worsening aspiration and residue estimates were all correlated with decreased scores on the PSS functional scales (r = -0.190 to -0.324, P ≤ .031). However, only increasing residue estimates were significantly related to decreased patient-perceived QoL on the HNCI (r = -.178 to -.194, P < .046). This effect was more pronounced with oral versus pharyngeal residue. CONCLUSIONS: In this group of head and neck cancer survivors, penetration/aspiration and residue show independent effects. PAS affects functional status only, but residue affects both functional status and QoL. This study supports that residue should be considered a primary measurement of swallowing function and be a target for identification, treatment, and evaluation of swallowing. LEVEL OF EVIDENCE: 2c. Laryngoscope, 127:1615-1621, 2017.

Orosensory contributions to dysphagia: a link between perception of sweet and sour taste and pharyngeal delay time.

Pharyngeal delay is a significant swallowing disorder often resulting in aspiration. It is suspected that pharyngeal delay originates from sensory impairment, but a direct demonstration of a link between oral sensation and pharyngeal delay is lacking. In this study involving six patients with complaints of dysphagia, taste sensation of the oral tongue was measured and subsequently related to swallowing kinematics. It was found that a response bias for sour taste was significantly correlated with pharyngeal delay time on paste, highlighting oral sensory contributions to swallow motor dysfunctions. Investigating the precise nature of such a link between oral sensation and dysphagia would constitute a basis for understanding the disorder. The results of this study highlight oral sensory contributions to pharyngeal swallow events and provide impetus to examine this link in larger samples of dysphagic patients.

Efficacy of electrical stimulation and exercise for dysphagia in patients with head and neck cancer: A randomized clinical trial.

BACKGROUND: Neuromuscular electrical stimulation (NMES) is a highly sought after but poorly studied treatment for dysphagia among patients with head and neck cancer with dysphagia. This study investigated the efficacy of NMES in this patient population. METHODS: In this double-blinded, randomized controlled trial, 170 patients with head and neck cancer experiencing posttreatment dysphagia were randomized into active NMES + swallow exercise versus sham NMES + swallow exercise groups. Outcomes after a 12-week program included changes in fluoroscopy measures, diet, and quality of life. RESULTS: After the 12-week program, the active NMES group had significantly worse Penetration Aspiration Scale scores than the sham group. Both groups reported significantly better diet and quality of life. No other measures were significant. CONCLUSION: NMES did not add benefit to traditional swallow exercises. Unfortunately, swallow exercises were not effective by themselves either. For patients with head and neck cancer with moderate to severe dysphagia caused by radiation therapy, current behavioral therapies are of limited help in reversing long-term dysphagia. © 2015 Wiley Periodicals, Head Neck 38: E1221-E1231, 2016.

Effect of induction chemotherapy on swallow physiology and saliva production in patients with head and neck cancer: a pilot study.

BACKGROUND: No objective data are available to assess the potential damage induction chemotherapy alone contributes to swallowing physiology and salivary production in patients with locally and regionally confined head and neck cancer. METHODS: Thirteen patients with head and neck cancer were evaluated preinduction and postinduction chemotherapy. Assessment included: (1) percentage of nutrition taken orally and food consistencies in diet; (2) videofluorographic swallow evaluation; (3) whole mouth saliva collection; (4) quality-of-life questionnaire; and (5) pain and oral mucositis scores. RESULTS: All patients were able to consume most foods and took 100% of their nutrition orally both preinduction and postinduction chemotherapy. Although a number of swallow measures worsened, no statistically significant differences were observed in diet, quality of life measures, pain, or saliva weight, or in most temporal swallow measures. Pharyngeal residue decreased significantly after chemotherapy. CONCLUSION: Induction chemotherapy alone did not significantly negatively alter swallowing physiology and salivary secretion, although the trend was toward worsening in function.

Comparison of swallowing function after intensity-modulated radiation therapy and conventional radiotherapy for head and neck cancer.

BACKGROUND: Intensity-modulated radiotherapy (IMRT) is hoped to protect structures important for swallow function. We compared posttreatment swallow function in 7 pairs of patients with head and neck cancer treated with either IMRT or conventional radiotherapy (RT). METHODS: Patients were matched on tumor characteristics. Swallowing function was evaluated with the modified barium swallow procedure pretreatment and at 3 and 6 months postcancer treatment completion. Swallows were analyzed for bolus transit times, bolus residues, laryngeal closure (LAC) duration, cricopharyngeal opening (CPO) duration, and oropharyngeal swallow efficiency (OPSE). Data were analyzed using multifactor repeated measures analysis of variance and adjusted for baseline function. RESULTS: Main effect of radiation type was significant for all measures on at least 1 bolus type. Patients treated with IMRT demonstrated shorter bolus transit times, less oral and pharyngeal residue, longer LAC, and larger OPSE. CONCLUSION: Patients treated with IMRT demonstrated faster, more efficient swallows, and greater airway protection.

Effects of enhanced bolus flavors on oropharyngeal swallow in patients treated for head and neck cancer.

BACKGROUND: Treatment for head and neck cancer can reduce peripheral sensory input and impair oropharyngeal swallow. This study examined the effect of enhanced bolus flavor on liquid swallows in these patients. METHODS: Fifty-one patients treated for head and neck cancer with chemoradiation or surgery and 64 healthy adult control subjects served as subjects. All were randomized to receive sour, sweet, or salty bolus flavor. Patients were evaluated at 7-10 days, 1 month, and 3 months after completion of tumor treatment. Control subjects received 1 assessment. RESULTS: All bolus flavors affected oropharyngeal swallow; sour flavor significantly shortened pharyngeal transit time across all evaluations. CONCLUSIONS: Sour flavor influenced the swallow of patients treated for head and neck cancer, as well as that of control subjects in a manner similar to those with neurologic impairment observed in an earlier study. Sour flavor may improve the speed of pharyngeal transit regardless of whether a patient has suffered peripheral or central sensory damage.

Verbal communication for the ventilator-dependent patient requiring an inflated tracheotomy tube cuff: A prospective, multicenter study on the Blom tracheotomy tube with speech inner cannula.

BACKGROUND: The purpose of this study was to present our findings on the impact of the Blom tracheotomy tube with speech inner cannula on voice production abilities and speech intelligibility scores of ventilator-dependent patients requiring a fully inflated tracheotomy tube cuff. METHODS: Prospective single group case-series design permitted consecutive accrual of 23 adult inpatients from acute care and rehabilitation settings. Maximum ambient room noise, voice intensity, phonation duration of vowel /a/, and speech intelligibility scores were determined over 3 sessions. RESULTS: All participants achieved audible voicing with the Blom tracheotomy tube. Voice intensity was significantly greater than ambient room noise by >10 dB SPL (p = .003). Speech intelligibility scores improved significantly from 80% to 85% (p = .03). Phonation duration averaged from 3.30 to 3.45 seconds. There were no significant changes in oxygen saturation (p > .05), and no significant complications occurred. CONCLUSION: The Blom tracheotomy tube with speech inner cannula permitted individuals requiring mechanical ventilation with a fully inflated tracheotomy tube cuff to produce excellent speech intelligibility for verbal communication. © 2012 Wiley Periodicals, Inc. Head Neck, 2013.

Relation of mucous membrane alterations to oral intake during the first year after treatment for head and neck cancer.

BACKGROUND: Acute oral mucositis is associated with pain and impaired swallowing. Little information is available on the effects of chronic mucositis on swallowing. METHODS: Sixty patients treated for cancer of the head and neck were examined during the first year after their cancer treatment. Oral mucosa was rated with the Oral Mucositis Assessment Scale. Stimulated whole-mouth saliva, oral pain rating, percent of oral intake, and 2 subscales of the Performance Status Scale for Head and Neck (PSS-HN) cancer were also collected. RESULTS: Mucositis scores and pain ratings decreased over time while functional measures of eating improved over time. Reduction in chronic mucositis was correlated with improved oral intake and diet. CONCLUSION: Lack of association with pain was attributed to the absence of ulcerations. Continued impairment of oral intake during the first year posttreatment may be related to oral mucosal changes and other factors.

A randomized study comparing the Shaker exercise with traditional therapy: a preliminary study.

Seven institutions participated in this small clinical trial that included 19 patients who exhibited oropharyngeal dysphagia on videofluorography (VFG) involving the upper esophageal sphincter (UES) and who had a 3-month history of aspiration. All patients were randomized to either traditional swallowing therapy or the Shaker exercise for 6 weeks. Each patient received a modified barium swallow pre- and post-therapy, including two swallows each of 3 ml and 5 ml liquid barium and 3 ml barium pudding. Each videofluorographic study was sent to a central laboratory and digitized in order to measure hyoid and larynx movement as well as UES opening. Fourteen patients received both pre-and post-therapy VFG studies. There was significantly less aspiration post-therapy in patients in the Shaker group. Residue in the various oral and pharyngeal locations did not differ between the groups. With traditional therapy, there were several significant increases from pre- to post-therapy, including superior laryngeal movement and superior hyoid movement on 3-ml pudding swallows and anterior laryngeal movement on 3-ml liquid boluses, indicating significant improvement in swallowing physiology. After both types of therapy there is a significant increase in UES opening width on 3-ml paste swallows.

Relationship between manometric and videofluoroscopic measures of swallow function in healthy adults and patients treated for head and neck cancer with various modalities.

Pharyngeal manometry complements the modified barium swallow with videofluoroscopy (VFS) in diagnosing pressure-related causes of dysphagia. When manometric analysis is not feasible, it would be ideal if pressure information about the swallow could be inferred accurately from the VFS evaluation. Swallowing function was examined using VFS and concurrent manometry in 18 subjects (11 head and neck patients treated with various modalities and 7 healthy adults). Nonparametric univariate and multivariate analyses revealed significant relationships between manometric and fluoroscopic variables. Increases in pressure wave amplitude were significantly correlated with increased duration of tongue base to pharyngeal wall contact, reduced bolus transit times, and oropharyngeal residue. Pharyngeal residue was the most important VFS variable in reflecting pharyngeal pressure measurements. Certain VFS measures were significantly correlated with measures of pressure assessed with manometry. Further research is needed before observations and measures from VFS alone may be deemed sufficient for determining pressure-generation difficulties during the swallow in patients who are unable or unwilling to submit to manometric testing.

Augmentation of deglutitive thyrohyoid muscle shortening by the Shaker Exercise.

Earlier studies of the effect of 6 weeks of the Shaker Exercise have shown significant increase in UES opening and anterior excursion of larynx and hyoid during swallowing in patients with upper esophageal sphincter (UES) dysfunction, resulting in elimination of aspiration and resumption of oral intake. This effect is attributed to strengthening of the suprahyoid muscles, as evidenced by comparison of electromyographic changes in muscle fatigue before and after completion of the exercise regime. The effect of this exercise on thyrohyoid muscle shortening is unknown. Therefore the aim of this study was to determine the effect of the exercise on thyrohyoid muscle shortening. We studied 11 dysphagic patients with UES dysfunction. Six were randomized to traditional swallowing therapy and five to the Shaker Exercise. Videofluoroscopy was used to measure deglutitive thyrohyoid shortening before and after completion of assigned therapy regimen. Maximum thyrohyoid muscle shortening occurred at close temporal proximity to the time of maximal thyroid cartilage excursion. The percent change in thyrohyoid distance from initiation of deglutition to maximal anterior/superior hyoid excursion showed no statistically significant difference between the two groups prior to either therapy (p = 0.54). In contrast, after completion of therapy, the percent change in thyrohyoid distance in the Shaker Exercise group was significantly greater compared to the traditional therapy (p = 0.034). The Shaker Exercise augments the thyrohyoid muscle shortening in addition to strengthening the suprahyoid muscles. The combination of increased thyrohyoid shortening and suprahyoid strengthening contributes to the Shaker Exercise outcome of deglutitive UES opening augmentation.

The Feasibility of Establishing Agreement Between Laboratories for Measures of Oropharyngeal Structural Movements.

Kinematic analysis, also commonly referred to as biomechanical analysis, of the swallow is used to measure movement of oropharyngeal structures over time. Two laboratory directors who have used kinematic analysis in their research collaborated to determine the feasibility of establishing agreement between two separate laboratories on measures of structural movements of the swallow. This report describes the process that was followed toward the goal of establishing measurement agreement. Under the direction of the laboratory directors, one research technician from each laboratory participated in a process that included initial meetings, training sessions, and pre- and post-training evaluation of reproducibility.Because agreement on initial measures of structural movement demonstrated weak correlation on some measures, the research technicians trained together for approximately 6 hours. After training, statistical analyses indicated that (a) most Pearson correlations for measures of structural movements were greater than 0.80 and were highly statistically significant; (b) most percentages of absolute deviation were under 25%; and (c) most concordance coefficients were above .70. These statistics indicate that the two laboratories were able to increase their level of agreement in measuring selected structural movements of the swallow after a brief amount of training.Factors affecting measurement agreement include image quality, establishment of rules for measuring, and the opportunity for regular discussions among research assistants and investigators from both laboratories.

Rehabilitation of dysphagia following head and neck cancer.

Patients who have cancers of the oral cavity, pharynx, or larynx may be treated with surgery, radiotherapy, chemotherapy, or a combination of these modalities. Each treatment type may have a negative impact on posttreatment swallowing function; these effects are presented in this article. A number of rehabilitative procedures are available to the clinician to reduce or eliminate swallowing disorders in patients treated for cancer of the head and neck. The various procedures-including postures, maneuvers, modifications to bolus volume and viscosity, range-of-motion exercises, and strengthening exercises-and their efficacy in patients treated for head and neck cancer are discussed.