Alterations in Swallowing Six Weeks After Primary Anterior Cervical Discectomy and Fusion (ACDF).

This aim of this study is to characterize the nature and pathophysiology of dysphagia after ACDF surgery by precisely and comprehensively capturing within-subject changes on videofluoroscopy between preoperative and postoperative time points. 21 adults undergoing planned primary ACDF procedures were prospectively recruited and enrolled. Participants underwent standardized preoperative and six-week postoperative videofluoroscopic swallow studies. Videos were blindly rated using the Penetration-Aspiration Scale (PAS) and analysis of total pharyngeal residue (%C2-42), swallowing timing, kinematics, and anatomic change was completed. Linear mixed-effects modeling was used to explore the relationships between possible predictor variables and functional outcomes of interest that changed across timepoints. There was no change in PAS scores across timepoints. Total pharyngeal residue (%C2-C42) was increased postoperatively (p < 0.001). Our statistical model revealed significant main effects for timepoint (p = 0.002), maximum pharyngeal constriction area (MPCAN) (p < 0.001), and maximum thickness of posterior pharyngeal (PPWTMAX) (p = 0.004) on the expression of total pharyngeal residue. There were significant two-way interactions for timepoint and MPCAN (p = 0.028), timepoint and PPWTMAX (p = 0.005), and MPCAN and PPWTMAX (p = 0.010). Unsurprisingly, we found a significant three-way interaction between these three predictors (p = 0.027). Our findings suggest that in planned ACDF procedures without known complications, swallowing efficiency is more likely to be impaired than airway protection six weeks after surgery. The manifestation of impaired swallowing efficiency at this timepoint appears to be driven by a complex relationship between reduced pharyngeal constriction and increased prevertebral edema.

A scoping review of the methods used to capture dysphagia after anterior cervical discectomy and fusion: the need for a paradigm shift.

OBJECTIVE: Dysphagia is the most commonly reported complication of annterior cervical discectomy and fusion (ACDF) surgery. However, the incidence of dysphagia post-ACDF varies widely-partly attributable to differing outcome measures used to capture dysphagia. Our objective was to conduct a scoping review of the literature to quantify which dysphagia outcome measures have been employed post-ACDF and examine trends by study design, year, and location. METHODS: After removing duplicates, 2396 abstracts were screened for inclusion. A total of 480 studies were eligible for full-text review. After applying exclusion criteria, data was extracted from 280 studies. We extracted the dysphagia outcome measure(s), study design (prospective vs retrospective), year, and location (country). Approximately 10% of studies were repeated for intra-rater agreement. RESULTS: In total, 317 dysphagia outcome measures were reported in 280 studies (primarily retrospective-63%). The largest proportion of outcome measures were categorized as "unvalidated patient-reported outcome measures" (46%), largely driven by use of the popular Bazaz scale. The next most common categories were "insufficient detail" and "validated patient-reported outcome measures" (both 16%) followed by "chart review/database" (13%) and instrumental assessment (7%). Studies examining dysphagia post-ACDF steadily increased over the years and the use of validated measures increased in the past 10 years. CONCLUSIONS: This scoping review of the literature highlights that nearly half of the ACDF dysphagia literature relies on unvalidated patient-reported outcome measures. The current understanding of the mechanism, timeline, and presentation of dysphagia post-ACDF are likely limited due to the metrics that are most commonly reported in the literature.

Swallow Event Sequencing: Comparing Healthy Older and Younger Adults.

Previous research has established that a great deal of variation exists in the temporal sequence of swallowing events for healthy adults. Yet, the impact of aging on swallow event sequence is not well understood. Kendall et al. (Dysphagia 18(2):85-91, 2003) suggested there are 4 obligatory paired-event sequences in swallowing. We directly compared adherence to these sequences, as well as event latencies, and quantified the percentage of unique sequences in two samples of healthy adults: young (< 45) and old (> 65). The 8 swallowing events that contribute to the sequences were reliably identified from videofluoroscopy in a sample of 23 healthy seniors (10 male, mean age 74.7) and 20 healthy young adults (10 male, mean age 31.5) with no evidence of penetration-aspiration or post-swallow residue. Chi-square analyses compared the proportions of obligatory pairs and unique sequences by age group. Compared to the older subjects, younger subjects had significantly lower adherence to two obligatory sequences: Upper Esophageal Sphincter (UES) opening occurs before (or simultaneous with) the bolus arriving at the UES and UES maximum distention occurs before maximum pharyngeal constriction. The associated latencies were significantly different between age groups as well. Further, significantly fewer unique swallow sequences were observed in the older group (61%) compared with the young (82%) (χ2 = 31.8; p < 0.001). Our findings suggest that paired swallow event sequences may not be robust across the age continuum and that variation in swallow sequences appears to decrease with aging. These findings provide normative references for comparisons to older individuals with dysphagia.

Quantifying Pharyngeal Residue Across the Adult Life Span: Normative Values by Age, Gender, and Swallow Task.

PURPOSE: We quantified pharyngeal residue using pixel-based methods in a normative data set, while examining influences of age, gender, and swallow task. METHOD: One hundred ninety-five healthy participants underwent a videofluoroscopic swallow study following the Modified Barium Swallow Impairment Profile (MBSImP) protocol. ImageJ was used to compute Normalized Residue Ratio Scale and the Analysis of Swallowing Physiology: Events, Kinematics and Timing (ASPEKT) pharyngeal residue measures. Reliability was established. Descriptive statistics were performed for all residue measures. Inferential statistics were performed using ASPEKT total scores (i.e., %C2-42). Logistic regression models explored predictors of residue versus no residue. Generalized linear mixed models explored predictors of nonzero residue. Spearman rho explored relationships between ASPEKT total residue scores and MBSImP Component 16 (Pharyngeal Residue) scores. RESULTS: Majority of swallows (1,165/1,528; 76.2%) had residue scores of zero. Residue presence (%C2-42 > 0) was influenced by age (more in older [F = 9.908, p = .002]), gender (more in males [F = 18.70, p < .001]), viscosity (more in pudding, nectar, and honey [F = 25.30, p < .001]), and volume (more for cup sip [F = 37.430, p < .001]). When residue was present (363/1,528 = 23.8%), amounts were low (M = 1% of C2-42, SD = 2.4), and only increasing age was associated with increased residue (F = 9.008, p = .007) when controlling for gender and swallow task. Increasing residue was incremental (0.01% of C2-42 per year). As ASPEKT total residue values increased, MBSImP Component 16 scores also increased. CONCLUSIONS: Pharyngeal residue amounts were very low in healthy adults. Residue presence can be influenced by age, gender, and swallow task. However, when present, the amount of pharyngeal residue was only associated with increasing age. SUPPLEMENTAL MATERIAL: https://doi.org/10.23641/asha.21957221.

An intensive swallowing exercise protocol for improving swallowing physiology in older adults with radiographically confirmed dysphagia.

PURPOSE: The aim of this study was to investigate improvements in swallowing function and physiology in a series of healthy older adults with radiographically confirmed dysphagia, following completion of an exercise-based swallowing intervention. PATIENTS AND METHODS: Nine otherwise healthy older adults (six females, mean age =75.3, SD =5.3) had confirmed impairments in swallowing safety and/or efficiency on a modified barium swallow study. Each participant completed an 8-week swallowing treatment protocol including effortful swallows, Mendelsohn maneuvers, tongue-hold swallows, supraglottic swallows, Shaker exercises and effortful pitch glides. Treatment sessions were conducted once per week with additional daily home practice. Penetration-Aspiration Scale and the Modified Barium Swallowing Impairment Profile (MBSImP) were scored in a blind and randomized fashion to examine changes to swallowing function and physiology from baseline to post-treatment. RESULTS: There were significant improvements in swallowing physiology as represented by improved oral and pharyngeal composite scores of the MBSImP. Specific components to demonstrate statistical improvement included initiation of the pharyngeal swallow, laryngeal elevation and pharyngeal residue. There was a nonsignificant reduction in median PAS scores. CONCLUSION: Swallowing physiology can be improved using this standardized high-intensity exercise protocol in healthy adults with evidence of dysphagia. Future research is needed to examine the individual potential of each exercise in isolation and to determine ideal dose and frequency. Studies on various etiological groups are warranted.

Physiological Compensation for Advanced Bolus Location at Swallow Onset: A Retrospective Analysis in Healthy Seniors.

Purpose Previous work has established that advanced bolus location at swallow onset (BLSO) alone is not correlated with an increased swallowing safety risk in healthy seniors. The primary goal of this retrospective study was to examine whether healthy seniors systematically alter their laryngeal vestibule closure reaction time (LVCrt) to maintain a safe swallow in the context of advanced BLSO. The secondary goal was to determine if longer LVCrt distinguished Penetration-Aspiration Scale (PAS; Rosenbek, Robbins, Roecker, Coyle, & Wood, 1996) scores of 1 versus 2. Method Videofluoroscopy studies from 43 healthy seniors (21 men, 22 women; M age = 76.7 years, SD = 7.2) were analyzed. LVCrt was calculated for 3 × 5 ml and 3 × 20 ml thin liquid barium boluses per participant. PAS and BLSO (Modified Barium Swallow Impairment Profile Component 6) were scored for all swallows. Reliability (intraclass correlation coefficient > .75) was established on all measures. A linear mixed-effects regression was run to examine the effect of PAS and BLSO on LVCrt while controlling for bolus volume and repeated swallow trial. Results There was a main effect of BLSO (F = 4.6, p = .004) and PAS (F = 29.3, p < .001) on LVCrt. Post hoc pairwise comparisons revealed that LVCrt was significantly faster in BLSO scores of 3 (pyriforms) compared to scores of both 0 (posterior angle of the ramus) and 1 (valleculae). Significantly prolonged LVCrt was observed in PAS scores of 2 in comparison to 1. No significant main effects of bolus volume or trial, or interactions, were observed. Conclusions Our findings suggest that healthy seniors compensate for advanced BLSO by increasing their LVCrt. Furthermore, faster LVCrt was shown to distinguish PAS scores of 1 versus 2. Additional work should explore the relationship between LVCrt, BLSO, and PAS scores in dysphagic populations, specifically those with known sensory impairments.

Analysis of pharyngeal edema post-chemoradiation for head and neck cancer: Impact on swallow function.

OBJECTIVES: Edema is a frequent clinical observation following chemoradiation treatment (CRT) of oral/oropharyngeal cancer and is thought to contribute to post-CRT swallowing impairment. Our aims were to reliably quantify pharyngeal edema pre- and post-CRT from videofluoroscopic (VF) swallowing studies and to explore the relationship between edema and swallowing impairment. Swallowing impairment was captured using patient-reported swallowing outcomes (EAT-10) and with VF confirmation of impairment (DIGEST). METHODS: 40 patients (24 M, age 38-76) with oral/oropharyngeal cancer received radiotherapy (70 Gy, 7 weeks) and 3 weekly doses of cisplatin. VF and EAT-10 were completed pre- and 1-month post-CRT. Edema was captured by measuring posterior pharyngeal wall (PPW) thickness, vallecular space, and pharyngeal area (PA) on a single post-swallow rest frame. Wilcoxon sign rank tests and paired t-tests evaluated within-subject changes in impairment and edema respectively. A linear mixed effect regression model explored the influence of time, patient-reported outcomes, and functional impairment on measures of edema. RESULTS: Swallowing function (EAT-10 and DIGEST) was significantly worse post-CRT. PPW thickness (but not vallecular space and pharyngeal area) was significantly worse post-CRT. PPW thickness was only significantly influenced by time (pre- vs. post-CRT) but not by measures of swallow function. CONCLUSION: Our findings establish the use of PPW thickness as a reliable measure of acute edema in post-CRT treatment. In this small, retrospective sample, edema was not significantly correlated with either patient-reported or measured swallow function. Prospective longitudinal work, examining the relationship between objective measures of edema, patient perception of impairment, and swallow function and biomechanics is warranted. LEVEL OF EVIDENCE: 4.