Sunnybrook Facial Grading System reliability in subacute stroke patients.

BACKGROUND: A lack of evidence on the reliability limits the utility of the Sunnybrook Facial Grading System (SFGS) in individuals affected by stroke both in clinical and research settings. AIM: To examine the test-retest reliability and the inter-rater reliability of the SFGS in patients affected by subacute stroke. DESIGN: A repeated-assessments design (fifteen days apart) was used to examine the test-retest reliability of the SFGS. SETTING: Inpatient Rehabilitation Unit. POPULATION: Thirty-two inpatients with subacute stroke. METHODS: Thirty-two inpatients with subacute stroke participated in the test-retest reliability study. All patients were video recorded in sitting position and uncovered face for about two minutes, in static position to evaluate symmetry at rest, then assessing symmetry of voluntary movement and synkinesis. For the inter-rater reliability, fifteen experts in neurorehabilitation were selected as raters. The facial function was assessed using the Italian version of the SFGS was used as grading system on a recorded video of each patient. The inter-rater reliability was carried out through the ICC, Intraclass Correlation Coefficient, while the intra-rater reliability was assessed comparing for each rater the scores evaluated at T0 and T1 using Wilcoxon signed-rank test. RESULTS: Evaluations at T0 and T1 showed a significant correlation with a total ICC (T0+T1) of 0.901 (95% CI: 0.852-0.942; P<0.001). The ICC of T0 scores is 0.914 (95% CI: 0.869-0.950; P<0.001), while the ICC of T1 scores is 0.886 (95% CI: 0.829-0.995; P<0.001). The scores of the "voluntary movement symmetry" area is correlated with ICC of 0.916 (95% CI: 0.835-0.958; P<0.001). The scores of the "resting symmetry" area show correlation with ICC of 0.567 (95% CI: 0.277-0.762; P<0.001). The area of "synkinesis" shows a lower correlation with ICC of 0.175 (95% CI: -0.180-0.489; P<0.001). The scores attributed to the patients in the two different moments of observation resulted not significantly different from 12 out of 15 raters. CONCLUSIONS: The SFGS resulted reliable in its overall score to assess the facial palsy also in patients affected by stroke. CLINICAL REHABILITATION IMPACT: The findings of this study provide empirical evidence of reliable properties of the SFGS for assessing central facial palsy in patients with stroke.

A stimulus for eating. The use of neuromuscular transcutaneous electrical stimulation in patients affected by severe dysphagia after subacute stroke: A pilot randomized controlled trial.

BACKGROUND: Oropharyngeal dysphagia is a common problem in subacute stroke patients leading to aspiration pneumonia and malnutrition. Non-invasive neuromuscular electrical stimulation (NMES) coupled with traditional therapy could be best treatment option for patients with post-stroke dysphagia, however results are still inconclusive and more studies are requested. OBJECTIVE: The aim of the study was to investigate the effect of laryngopharyngeal neuromuscular electrical stimulation on dysphagia caused by stroke. METHODS: Thirty-three patients affected by subacute stroke and dysphagia participated in this study. The subjects were divided into NMES plus traditional dysphagia training (n = 17) and traditional dysphagia training alone in a time matched condition (n = 16). Both groups were treated 5 days/week for 8 weeks. All patients were evaluated before and after the treatment. The study was designed as a single blind randomized controlled trial. Primary outcomes were considered the status of swallowing function according to the Functional Oral Intake Scale (FOIS), the instrumental Fiberoptic Endoscopic Examination of Swallowing examination, the Penetration Aspiration Scale and the Pooling score and the presence of oropharyngeal secretion. Secondary outcomes were the type of diet taken by mouth; the need for postural compensations and the duration of the dysphagia training. RESULTS: A functional improvement was observed in both groups but treatment group showed a significant improvement for primary outcome with the exception of the pooling Score (p = 0.015, p = 0.203; p = 0.003; p = 0.048 respectively) and for secondary outcome p <0.005. The results confirm that laryngopharyngeal neuromuscular electrical stimulation in post-stroke patients with dysphonia improve outcome of the training. CONCLUSIONS: Laryngopharyngeal neuromuscular electrical stimulation may be considered as an additional and effective treatment option for dysphagia after stroke.

Effect of Radiofrequency Thermal Ablation Treatment on Nasal Ciliary Motility: A Study with Phase-Contrast Microscopy.

OBJECTIVE: To investigate the efficacy of nasal ciliary motility after radiofrequency ablation treatment in patients with isolated inferior turbinate hypertrophy and to clarify how long until normal ciliary function is restored. STUDY DESIGN: Prospective, single-group, pretest-posttest design. SETTING: Academic tertiary care medical center. SUBJECTS AND METHODS: This study involved 34 adult patients affected by nasal obstruction due to inferior turbinate hypertrophy who underwent radiofrequency ablation treatment between June and December 2014. Diagnosis was assessed according to clinical history, nasal endoscopy, and active anterior rhinomanometry. Cytologic samples were collected by nasal scraping before surgery and 1, 2, and 3 months after surgery. Ciliary motility was evaluated by nasal cytology with phase-contrast microscopy. Functional aspects of nasal mucosa were studied, with a focus on 3 parameters: (1) nasal mucociliary clearance, assessed by saccharin nasal transit time test; (2) percentage of ciliated cell motility, measured as the ratio between cells with motility and cells without motility; and (3) efficacy of ciliary motility, measured as the ratio between cells with valid motility and cells with hypovalid motility. RESULTS: Ciliary motility and ciliary efficacy showed a significant reduction after 1 and 2 months from surgery, returning to normal values within 3 months. No significant changes in saccharin nasal transit time were recorded during the follow-up. CONCLUSIONS: The outcomes of this study suggest that radiofrequency ablation treatment causes ciliary motility changes of nasal mucosa that are completely restored after at least 3 months after surgery. These cytologic abnormalities do not affect nasal functionality.

Cytologic and functional alterations of nasal mucosa in smokers: temporary or permanent damage?

OBJECTIVE: Tobacco smoke is a significant risk factor for respiratory diseases. The purpose of this study is to analyze the cytologic and functional features of nasal mucosa in smokers, nonsmokers, and ex-smokers to evaluate if nasal alterations in smokers are permanent or reversible conditions after smoking cessation. STUDY DESIGN: Case series with planned data collection. SETTING: University medical center. SUBJECTS AND METHODS: Ninety healthy volunteers recruited from the staff of Alfredo Fiorini Hospital, Sapienza University of Rome, were enrolled in this prospective study from October to November 2013. We divided the cases according to smoking habits (smokers, nonsmokers, ex-smokers). Each group was composed of 30 subjects. Cytologic features of nasal mucosa and effectiveness of nasal mucociliary clearance were studied, focusing on 4 parameters: (1) nasal mucociliary clearance, assessed by saccharin nasal transit time; (2) ratio between the number of ciliated cells and goblet cells, analyzed by microscopic observation of cytologic specimens of nasal mucosa that had undergone May Grunwald Giemsa staining; (3) evaluation of ciliary motility; and (4) time of ciliary movement of ciliated cells analyzed by phase-contrast microscopy. RESULTS: All parameters were significantly reduced in the smokers compared to the nonsmokers. There were no statistically significant differences between the nonsmoker and ex-smoker groups. CONCLUSION: Cigarette smoking causes cytologic modifications of nasal mucosa that influence the effectiveness of mucociliary clearance. Our preliminary study suggests that these changes are not permanent and that nasal mucosa of ex-smokers recovers normal cytologic and functional features.

Swallowing ability and chronic aspiration after supracricoid partial laryngectomy.

OBJECTIVE: Sporadic episodes of aspiration may occur after supracricoid partial laryngectomy. To prevent risks of pulmonary consequences, a limitation of oral intake of food or a "nothing by mouth" regimen has been suggested. The objective of this study was to evaluate the long-term swallowing and pulmonary status of patients after supracricoid partial laryngectomy. STUDY DESIGN: Case series with chart review. SETTING: Tertiary University Hospital Policlinico "Umberto I" and Santa Lucia Foundation, Rome, Italy. SUBJECTS AND METHODS: The swallowing status of a selected group of 116 patients who recovered functional deglutition after supracricoid partial laryngectomy was analyzed during follow-up consultation. Swallowing evaluation included clinical observation, fiberoptic endoscopic evaluation of swallowing, and a videofluoroscopy. When aspiration was confirmed by videofluoroscopy, a high-resolution computed tomography (CT) of the chest was performed in order to assess the radiological manifestations of aspiration. A group of 45 patients with chronic obstructive pulmonary disease and normal deglutition was used as a control. RESULTS: Seventy-nine patients out of 116 showed a fiberoptic endoscopic evaluation of swallowing suggestive for aspiration; only 45 patients had aspiration confirmed by videofluoroscopy. No significant differences in radiological findings were noted in the patients affected by postoperative chronic aspiration compared to the control group. CONCLUSION: Patients with functional deglutition after supracricoid partial laryngectomy show a mild and well-tolerated degree of chronic aspiration and do not require a limitation of oral intake of food.

Supracricoid partial laryngectomy in the treatment of laryngeal cancer: univariate and multivariate analysis of prognostic factors.

OBJECTIVES: To evaluate the oncological results of supracricoid partial laryngectomy as a treatment for selected glottic and supraglottic cancer in a large series of patients who had undergone uniform treatment over a 16-year period and to determine the different prognostic factors that may influence local control and survival. DESIGN: Retrospective clinical study. SETTING: Academic tertiary referral medical center. PATIENTS: The study population comprised 253 consecutive patients (234 men and 19 women) with glottic and supraglottic squamous cell carcinoma. The mean age was 58 years for men and 59.2 years for women. INTERVENTION: Supracricoid partial laryngectomy: 180 patients had undergone cricohyoidopexy and 73 had undergone cricohyoidoepiglottopexy. MAIN OUTCOME MEASURES: Local control and overall survival. Potential prognostic factors for local control and survival were evaluated with univariate and multivariate models. RESULTS: The 3-, 5-, 10-, and 16-year overall survival rates in this group of 253 patients were 85.8%, 79.1%, 57.6%, and 57.6%, respectively. With regard to local control, univariate and multivariate analyses showed that a positive resection margin was the only important predictor of local control and that a dysplastic lesion at the margin of resection is just as aggressive as the presence of invasive carcinoma. When considering the prognostic factors influencing survival, univariate analysis showed that the tumor category, lymph node category, tumor stage, and recurrence all had a significant influence on the survival rate. Multivariate analysis showed that the most important predictor of survival was recurrence. CONCLUSIONS: Supracricoid partial laryngectomy is a valid choice in the treatment of selected glottic and supraglottic cancer while maintaining laryngeal functions and achieving a high rate of local control. T category, N category, tumor stage, positive resection margins, and recurrence are the most important predictors of oncological outcome.

Prognostic value of resection margins in supracricoid laryngectomy.

OBJECTIVES: The objective was to assess the prognostic value of surgical margin involvement in patients treated for squamous cell carcinoma of the larynx. STUDY DESIGN: Retrospective study. METHODS: A review was made of 253 patients treated with supracricoid laryngectomy between 1984 and 2001. A histopathological study on the surgical resection margins was performed in all cases. The incidence of local recurrence was correlated with the histological features of resection margins. RESULTS: Forty patients (15.8%) were identified as having positive margins: 29 had invasive carcinoma and 11 had dysplastic lesions. The remaining 213 patients (84.2%) had negative margins. Subsequent follow-up showed that 19 of 253 patients developed local recurrence and 3 patients developed regional recurrence. Nine of these patients had positive resection margins (six with invasive carcinoma and three with dysplastic lesions), and 10 had negative resection margins. Overall survival at 3 years was significantly higher for patients without recurrence than for patients with local or regional failure (89.9% vs. 45.5% [P <.05]). CONCLUSION: According to results of the study, patients with positive resection margins developed local recurrence more frequently than those with clear resection margins (P <.05).

Recurrent malignant schwannoma of the parapharyngeal space in neurofibromatosis type 1.

Malignant schwannoma is an aggressive tumor that carries a poor prognosis despite wide excision, chemotherapy, and radiotherapy. Malignant schwannoma of the parapharyngeal space is an uncommon finding; to our knowledge, only four cases have been described in the literature during the past 30 years, and only one of them involved a patient who had clinical evidence of neurofibromatosis type 1. In this article, we describe a new case of malignant schwannoma of the parapharyngeal space in a patient who had clinical evidence of neurofibromatosis type 1. Following resection of the tumor and a total parotidectomy, the diagnosis was made on the basis of histology and immunohistochemistry. The patient underwent postoperative chemotherapy with carboplatin and UP16. However, 5 months following surgery, the tumor recurred and metastasized. The patient was then placed on a different polychemotherapeutic regimen, which was made up of 3 g/m2 of ifosfamide, 1.5 mg/m2 of vincristine, and 1.5 mg/m2 of doxorubicin (IVA2 protocol). The IVA2 regimen slowed tumor growth, but 13 months after the initiation of therapy, the patient died of neoplastic cachexia. Although chemotherapy is generally ineffective in most cases of malignant schwannoma, we did experience some positive results with the IVA2 protocol. Therefore, we recommend that this combination be considered as a first-line adjuvant therapy following surgery or as a first-line therapy for patients with inoperable tumors.

CO2 laser cordectomy for early-stage glottic carcinoma: a long-term follow-up of 156 cases.

OBJECTIVES: To define when laser resection of early-stage glottic carcinoma is indicated and to compare the results obtained by laser surgery with other therapeutic options. STUDY DESIGN: Retrospective study of 151 patients treated from April 1982 to June 1996 in the Department of Otorhinolaryngology at "La Sapienza" University. We provide analysis of indications, techniques, and oncologic results of this study. METHODS: Glottic tumors were treated with type III, type IV, and type Va cordectomies according to the classification of endoscopic cordectomies proposed by the European Laryngological Society in 2000. RESULTS: The results are summarized as follows: all patients with carcinoma in situ Tis are free of disease with local control rate at 3 years of 100%; 2 died of other causes without evidence of local recurrence with an overall survival rate at 3 years of 83.2%. Of the 117 patients with stage T1a cancer, 110 are free of disease at 3 years with local control rate of 94%; 4 patients died of other causes without evidence of local recurrence with an overall survival rate of 96.5%. Of the 22 patients with stage T1b cancer, 20 are free of disease at 3 years with a local control rate of 91%; 1 patient died of other causes without evidence of local recurrence with an overall survival rate at 3 years of 95.4%. CONCLUSIONS: According to our experience, we can conclude that endoscopic laser surgery is an efficacious and cost-effective treatment for early stage glottic cancer.