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.

A Biomechanical Study of Hyoid Bone and Laryngeal Movements During Swallowing Comparing the Blom Low Profile Voice Inner Cannula and Passy-Muir One Way Tracheotomy Tube Speaking Valves.

The aim of this prospective, consecutive, cohort study was to investigate the biomechanical effects, if any, of the Blom low profile voice inner cannula and Passy-Muir one-way tracheotomy tube speaking valves on movement of the hyoid bone and larynx during swallowing. Ten adult patients (8 male, 2 female) with an age range of 61-89 years (mean 71 years) participated. Criteria for inclusion were ≥18 years of age, English speaking, and ability to tolerate both changing to a Blom tracheotomy tube and placement of a one-way tracheotomy tube speaking valve with a fully deflated tracheotomy tube cuff. Digitized videofluoroscopic swallow studies were performed at 30 frames/s and with each patient seated upright in the lateral plane. A total of 18 swallows (three each with 5 cc bolus volumes of single contrast barium and puree + barium × 3 conditions) were analyzed for each participant. Variables evaluated included larynx-to-hyoid bone excursion (mm), maximum hyoid bone displacement (mm), and aspiration status under three randomized conditions: 1. Tracheotomy tube open with no inner cannula; 2. Tracheotomy tube with Blom valve; and 3. Tracheotomy tube with Passy-Muir valve. Blinded reliability testing with a Pearson product moment correlation was performed on 20 % of the data. Intra- and inter-rater reliability for combined measurements of larynx-to-hyoid bone excursion and maximum hyoid bone displacement was r = 0.98. Intra- and inter-rater reliability for aspiration status was 100 %. No significant differences (p > 0.05) were found for larynx-to-hyoid bone excursion and maximum hyoid bone displacement during swallowing based upon an open tracheotomy tube, Blom valve, or Passy-Muir valve. Aspiration status was identical for all three randomized conditions. The presence of a one-way tracheotomy tube speaking valve did not significantly alter two important components of normal pharyngeal swallow biomechanics, i.e., hyoid bone and laryngeal movements. Aspiration status was similarly unaffected by valve use. Clinicians should be aware that the data do not support placement of a one-way tracheotomy tube speaking valve to reduce prandial aspiration.

Ketorolac after free tissue transfer: a comparative effectiveness study.

OBJECTIVE: We sought to compare postoperative pain and complications in patients undergoing free tissue transfer for reconstruction of head and neck defects with and without ketorolac. METHODS: In this retrospective cohort study, we identified patients who underwent head and neck free tissue transfer procedures at the University of Iowa between July 2010 and December 2012. A subset of patients received ketorolac as an anti-platelet agent. Main outcome measures include postoperative analgesic use, pain scores, and bleeding complications. RESULTS: We identified 138 free tissue transfers, with 42 procedures in the ketorolac cohort. In the first 7 postoperative days, patients in the ketorolac and non-ketorolac cohorts received equivalent narcotic doses (morphine equivalents, 48.9 mg/day vs 46.6 mg/day, P = .72). The ketorolac group reported higher mean pain scores (3.1 vs 2.4, P = .004). Ketorolac use was not associated with need for transfusion (P = .86) or number of days with neck drains (P = .79). CONCLUSION: Ketorolac did not demonstrate a significant analgesic effect in this group of patients in terms of pain scores and opioid requirements. However, there also was no evidence to suggest a higher likelihood of bleeding complications. Ketorolac may be safely used as an anti-platelet agent, with narcotic requirements unchanged.

Arytenoid repositioning device.

OBJECTIVES: We report development of a device and technique to manage laryngeal paralysis through minimal-access arytenoid adduction (for unilateral paralysis) and arytenoid abduction (for bilateral paralysis). METHODS: A human cadaver study coupled with directed engineering was used to develop instrumentation designed to secure the muscular process of the arytenoid into favorable adducted or abducted positions. Digital video, photography, and 3-dimensional computed tomographic (CT) imaging of cadaveric larynges were done to evaluate the surgical technique. RESULTS: Testing of prototypes identified the ideal implant to be a 0.36-mm wire with a distal spring-wound coil placed through a trocar via a small drill hole in the anterior thyroid cartilage. An endoscopic view of transilluminated light through the pyriform sinus mucosa identified the tip location of the trocar adjacent to the muscular process of the arytenoid cartilage. Placement of the device through the trocar permitted rotation to engage the muscular process and/or adjacent soft tissue with the distal coil. Implant fixation to the thyroid cartilage positioned the vocal cord into either adduction or abduction. Three-dimensional CT imaging coupled with review of the video documentation established the feasibility of this technique. CONCLUSIONS: We confirm the feasibility of minimal-access arytenoid adduction and abduction through development of a new technique and device.

Disease Endotypes Predict the Severity of Mucous Membrane Pemphigoid.

Mucous membrane pemphigoid is an autoimmune disease with variable clinical presentation and multiple autoantigens. To determine whether disease endotypes could be identified on the basis of the pattern of serum reactivity, the clinical and diagnostic information of 70 patients with mucous membrane pemphigoid was collected, and reactivity to dermal or epidermal antigens, using indirect immunofluorescence, and specific reactivity to bullous pemphigoid (BP) autoantigens BP180 and BP230, collagen VII, and laminin 332 were evaluated. Most patients had lesions at multiple mucosae, with the most prevalent being oropharyngeal (mouth, gingiva, pharynx; 98.6%), followed by ocular (38.6%), nasal (32.9%), genital or anal (31.4%), laryngeal (20%), and esophageal (2.9%) sites and skin (45.7%). Autoantigen profiling identified BP180 (71%) as the most common autoantigen, followed by laminin 332 (21.7%), collagen VII (13%), and BP230 IgG (11.6%). Reactivity to dermal antigens predicted a more severe disease characterized by a higher number of total sites involved, especially high-risk sites, and a decreased response to rituximab. In most cases, identification of dermal indirect immunofluorescence reactivity is an accurate predictor of disease course; however, confirmation of laminin 332 reactivity is important, with dermal indirect immunofluorescence positivity because of an increased risk of solid tumors. In addition, the ocular mucosae should be monitored in patients with IgA on direct immunofluorescence.

Management of Zenker's diverticulum in the endoscopic age: current practice patterns.

OBJECTIVES: Zenker's diverticulum (ZD) is a common source of dysphagia with a well-established surgical treatment history. Variations may exist between practitioners in the preoperative, intraoperative, and postoperative management of patients with ZD because of recent evolutions in surgical approach toward an endoscopic technique. METHODS: An online survey instrument was prepared and forwarded to the membership of the American Broncho-Esophagological Association (ABEA) to ascertain the current practice patterns of its members regarding numerous care parameters for patients with ZD. RESULTS: Data on preoperative evaluation, operative care, postoperative management, and recalled incidence of complications, including mediastinitis, were evaluated. Subgroup analysis demonstrated significant differences in multiple care parameters for those surgeons who predominantly perform endoscopic operations (more than 80% willingness to perform endoscopic operations) compared to those who occasionally perform endoscopic operations (less than 80%), including average case number, advancement of oral intake, hospital discharge, use of antibiotics, and views on the efficacy of endoscopic surgical techniques. These changes were noted despite similar times since graduation from training for the two groups. CONCLUSIONS: These data present a contemporary snapshot of clinical care patterns of the ABEA membership for patients with ZD and suggest differences in care patterns for surgeons with a higher enthusiasm for endoscopic techniques and larger case volumes.

Post-operative Complication Rate Comparison Between Airway Surgery and Upper Airway Stimulation Using NSQIP and ADHERE.

OBJECTIVE: Postoperative complication rates were compared between obstructive sleep apnea surgery (OSAS) and hypoglossal nerve upper airway stimulation (UAS). STUDY DESIGN: Cohort. SETTING: Multi-institutional international databases. METHODS: OSAS data were collected from the NSQIP database (2014; American College of Surgeons National Surgery Quality Improvement Program). UAS data were obtained from the ADHERE registry (Adherence and Outcome of Upper Airway Stimulation for OSA International Registry; 2016-December 2019). ADHERE comorbidities and complications were categorized to match NSQIP definitions. A chi-square test was used for proportion P values. RESULTS: There were 1623 UAS procedures in ADHERE and 310 in NSQIP. The UAS group was older than the OSAS group (mean ± SD, 60 ± 11 vs 42 ± 13 years) but similarly male (75% vs 77%) and overweight (body mass index, 29 ± 4 vs 29 ± 3 kg/m2). There was a higher proportion of hypertension, diabetes, and heart disease in the UAS cohort. Palatopharyngoplasty was the most common surgical procedure (71%), followed by tonsillectomy (25%). UAS operative time was longer (132 ± 47 vs 54 ± 33 minutes). Postoperative length of stay was not normally distributed, as 71% of UAS stays were <1 day as opposed to 40% of OSA stays (P < .0001). Thirty-day return to the operating room related to the procedure was 0.1% for UAS and 4.8% for OSAS (P < .0001). Surgical site infections were 0.13% for UAS and 0.9% for OSAS (P = .046). CONCLUSION: The UAS cohort was older and more likely to have comorbid hypertension, diabetes, and heart disease. Despite baseline differences, the postoperative complication rate was lower with UAS than with OSAS.

Epiglottis is not essential for successful swallowing in humans.

Controversy has continued for well over 100 years regarding the role of the epiglottis in deglutition. We describe the effect of isolated epiglottectomy on swallowing success in a case series of 3 adult human subjects with isolated epiglottectomy due to trauma, surgery, or cancerous erosion. The patients were 42, 51, and 70 years of age, and swallowing was analyzed objectively with videofluoroscopy. All subjects exhibited successful swallowing with all food types: thin liquid, puree, and solid food. Specifically, the patient with traumatic epiglottectomy exhibited rapid swallowing success, the patient with surgical epiglottectomy exhibited a short period of dysphagia due to postoperative edema, followed by swallowing success, and the patient with epiglottectomy due to cancerous erosion of the entire epiglottis exhibited long-term adaptation, with successful swallowing maintained. We conclude that the epiglottis is not essential for successful swallowing in humans, because individuals can readily adapt to isolated epiglottectomy and avoid tracheal aspiration.

Computer-assisted assessment of hyoid bone motion from videofluoroscopic swallow studies.

Videofluoroscopic examination of swallowing remains the standard for evaluation of patients with swallowing complaints. Although attempts have been made to objectify aspects of the study, findings from the study are largely subjective and reliant on clinician training and judgment leading to considerable inter-rater variability. We describe a computerized image analysis program designed to objectify one component of the swallow study, the movement of the hyoid bone. Hyoid motion has been shown to be different in dysphagic versus non-dysphagic patients. Reduced hyoid elevation is also considered a risk factor for aspiration; however, there has not been much work done on actually quantifying hyoid motion and associating it with other aspects of the swallow study. The clinician is prompted to define the hyoid bone in a calibration frame, and the system then tracks that region of interest throughout the rest of the study. This system shows strong correlations with manual analysis and can account for head position changes during the study. While the hyoid bone was reported on in this study, other regions of interest within the image field could also be tracked using this technique. A more quantitative analysis such as this has the opportunity to improve the inter-rater reliability of the test and therefore lead to more consistent findings from swallow studies.

Esophageal Manometry, pH Testing, Endoscopy, and Videofluoroscopy in Patients With Globus Sensation.

OBJECTIVES/HYPOTHESIS: Combine techniques commonly employed in the clinical workup of patients with isolated globus sensation to identify the most common pharyngoesophageal abnormality. The primary aim was to retrospectively review high-resolution manometry, pH probe testing, contrast videofluoroscopy, and endoscopy studies in patients with a primary complaint of globus sensation. The specific hypothesis was esophageal high-resolution manometry identifies the most significant proportion of abnormalities compared to all other modalities. STUDY DESIGN: Retrospective cohort study. METHODS: An inclusive retrospective chart review was performed for patients evaluated between 2009 and 2016 with the primary complaint of globus sensation. Age at testing, self-identified gender, associated diagnoses, and results from each modality were collected. Descriptive statistics and pairwise comparisons were performed as well as sensitivity and specificity calculations. RESULTS: One hundred seventy-two patients met inclusion criteria. The cohort had an age range of 22.7 to 88.5 years and was predominantly female. Esophageal manometry identified abnormalities in 62.8% of patients, and pH testing identified abnormal acidification in approximately 20%. The esophagram identified abnormalities in 24% of patients, and esophagogastroduodenoscopy identified abnormalities in 22%. Modified barium swallows were normal in 93% of patients. Measures of sensitivity and specificity of other modalities were poor compared to esophageal manometry and pH testing. CONCLUSIONS: Patients with isolated globus sensation have evidence of esophageal dysmotility and laryngopharyngeal and gastroesophageal reflux disease in high proportions. Esophageal high-resolution manometry testing identifies the greatest proportion of abnormalities of the investigated modalities. LEVEL OF EVIDENCE: 4 Laryngoscope, 130:2120-2125, 2020.

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.

Evaluation of open approach and injection laryngoplasty in revision thyroplasty procedures.

INTRODUCTION: Vocal outcomes after medialization laryngoplasty are variable and may change over time. A revision procedure via open approach or an injection laryngoplasty may be necessary to improve vocal outcomes. METHODS: A retrospective chart review was performed. RESULTS: Twenty-nine subjects were identified and stratified into group 1A (n = 9) if the allograft was repositioned/replaced, group 1B (n = 4) if the allograft was removed, and group 2 (n = 16) if an injection laryngoplasty was performed. Statistically significant differences were found between all data prerevision to postrevision (P < or = 0.05) for group 1A and group 2 when multiple paired-sample t tests were calculated for patient-reported voice severity ratings and voice impact ratings as well as clinician-reported voice ratings of grade, roughness, and breathiness. Results of group 2 were often temporary, with 10 of 16 (62.5%) subjects receiving multiple injections. CONCLUSION: Both open revision laryngoplasty and injection laryngoplasty are successful at providing improved vocal outcomes. Results are often temporary after injection laryngoplasty and often require multiple procedures.

Quantitative contributions of the muscles of the tongue, floor-of-mouth, jaw, and velum to tongue-to-palate pressure generation.

PURPOSE: The purpose of this investigation was to evaluate the relationship between tongue-to-palate pressure and the electromyography (EMG) measured from the mylohyoid, anterior belly of the digastric, geniohyoid, medial pterygoid, velum, genioglossus, and intrinsic tongue muscles. Methods Seven healthy adults performed tongue-to-palate pressure tasks at known percentages of their maximum pressure while intramuscular EMG was recorded from the muscles stated above. Multiple regression analysis was performed. RESULTS: Predictors of pressure included the posterior fibers of the genioglossus, mylohyoid, anterior belly of digastric, medial pterygoid, and intrinsic tongue. CONCLUSIONS: Increasing tongue-to-palate pressure coincides with increased muscle activity. Activation of the floor-of-mouth, tongue, and jaw closing muscles increased tongue-to-palate pressure. These findings support the use of a tongue-press exercise to strengthen floor-of-mouth muscles, tongue, and jaw-closing muscles.

Nf2 Mutation in Schwann Cells Delays Functional Neural Recovery Following Injury.

Merlin is the protein product of the NF2 tumor suppressor gene. Germline NF2 mutation leads to neurofibromatosis type 2 (NF2), characterized by multiple intracranial and spinal schwannomas. Patients with NF2 also frequently develop peripheral neuropathies. While the role of merlin in SC neoplasia is well established, its role in SC homeostasis is less defined. Here we explore the role of merlin in SC responses to nerve injury and their ability to support axon regeneration. We performed sciatic nerve crush in wild-type (WT) and in P0SchΔ39-121 transgenic mice that express a dominant negative Nf2 isoform in SCs. Recovery of nerve function was assessed by measuring mean contact paw area on a pressure pad 7, 21, 60, and 90 days following nerve injury and by nerve conduction assays at 90 days following injury. After 90 days, the nerves were harvested and axon regeneration was quantified stereologically. Myelin ultrastructure was analyzed by electron microscopy. Functional studies showed delayed nerve regeneration in Nf2 mutant mice compared to the WT mice. Delayed neural recovery correlated with a reduced density of regenerated axons and increased endoneurial space in mutants compared to WT mice. Nevertheless, functional and nerve conduction measures ultimately recovered to similar levels in WT and Nf2 mutant mice, while there was a small (∼17%) reduction in the percent of regenerated axons in the Nf2 mutant mice. The data suggest that merlin function in SCs regulates neural ultrastructure and facilitates neural regeneration, in addition to its role in SC neoplasia.

Celecoxib Versus Placebo in Tonsillectomy: A Prospective, Randomized, Double-Blind Placebo-Controlled Trial.

OBJECTIVES: Celecoxib is a cyclooxygenase-2-specific inhibitor indicated to treat acute pain and pain secondary to osteoarthritis and rheumatoid arthritis. Surgical models of acute pain have demonstrated superior pain relief to placebo. The objective of this study was to test the safety and efficacy of celecoxib for pain relief after tonsillectomy compared to placebo. METHODS: Adult subjects were randomized to 200 mg celecoxib versus placebo with a loading dose the night before surgery then twice daily for 10 days. Subjects were instructed to supplement the study drug with hydrocodone/acetaminophen liquid or acetaminophen for pain as needed. Subjects completed a daily diary regarding their pain, nausea, vomiting, diet, and activity. RESULTS: Seventeen subjects enrolled. Intraoperative blood loss was similar between groups, and no subject had postoperative bleeding. Three patients returned to the emergency department for treatment, and 2 patients could not complete the diaries, all in the placebo group. Subjects in the placebo group required statistically significant (P < .05) higher doses of narcotic and acetaminophen to control pain. Pain and diet rating scores were slightly better in the celecoxib group compared to placebo. CONCLUSIONS: In this small cohort, celecoxib reduced postoperative narcotic and acetaminophen requirements compared to placebo without complications.

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.

Conservative management of stapler failure in Zenker's endoscopic diverticulotomy.

The endoscopic stapler has achieved widespread use in the management of Zenker's diverticulum owing to its ease of use and safety. However, complications associated with its use can and do occur. This study details the treatment course of 2 patients who underwent an endoscopic stapler approach to their Zenker's diverticulum complicated by the stapler's not sealing the mucosal edges. Although the patients' hospital stays were extended as a result, they suffered no long-term morbidity as a result of the complication.

Timing of glottic closure during swallowing: a combined electromyographic and endoscopic analysis.

OBJECTIVES: We performed a case series to enhance our understanding of the coupling between neuromuscular events and glottic closure. METHODS: We performed combined flexible video laryngoscopy and electromyography in 4 healthy human subjects. Hooked-wire electrodes were placed in the superior pharyngeal constrictor, longitudinal pharyngeal, cricopharyngeus, thyroarytenoid, genioglossus, suprahyoid, and posterior cricoarytenoid muscles. A flexible endoscope tip was positioned in the oropharyngeal-hypopharyngeal region. The subjects performed multiple trials each of 10-mL normal and super-supraglottic liquid swallows. RESULTS: Arytenoid movement consistently preceded full glottic closure and was associated with cessation of activity of the posterior cricoarytenoid muscle. In 89% of normal swallows, the glottis was partially open in the video frame before bolus passage. The maximum amount of thyroarytenoid electromyographic activity occurred during endoscopic whiteout. When subjects executed a super-supraglottic swallow, early thyroarytenoid activity coincided with arytenoid contact. CONCLUSIONS: The initial medialization of the arytenoids is due to a decrease in motor tone of the posterior cricoarytenoid muscle. Full glottic closure typically occurs late in the process of swallowing, with activation of the thyroarytenoid muscle. Shifting of arytenoid medialization and glottic closure earlier in the super-supraglottic swallow indicates that glottic closure is under significant voluntary control.