Not just dyspnoea: swallowing as a concern for adults with laryngotracheal stenosis undergoing airway reconstruction

Acquired laryngotracheal stenosis (LTS) is a rare condition causing dyspnea and stridor. Patients often require multiple surgical procedures with no guarantee of a definitive outcome. Difficulty swallowing is a recognised problem associated with LTS and the reconstructive surgeries required to manage the condition. The breathlessness patient’s experience impacts on swallowing, and the vulnerable structures of the larynx are implicated during complex surgeries. This leads to dysphagia post-surgery, with some patients experiencing more chronic symptoms depending on the biomechanical impact of the surgery, or a pre-existing dysphagia. Despite this there is limited observational research about the dysphagia associated with LTS, with no exploration of the patient experience. Our aim was to investigate patient experience of living with LTS focussing on dysphagia in order to guide clinical practice. A qualitative study was completed using focus groups and semi-structured interviews with 24 patients who have had reconstructive surgery for LTS. Thematic analysis was used to identify three over-arching themes: The Physical Journey, The Emotional Journey and The Medical Journey. Key sub-themes included the importance of self-management and control, presence of symptoms, benefits of therapy, living with a life-long condition, fear and anxiety, autonomy, medicalisation of normal processes and the dichotomy between staff expertise and complacency. Swallowing was connected to all themes. The results are reviewed with consideration of the wider literature of lived experience particularly in relation to other chronic conditions and those that carry a high symptom burden such as head and neck cancer. Future clinical and research recommendations have been made. Akin to other clinical groups, adults with LTS are keen that management of their swallowing is person-centred and holistic

A Practitioner’s Guide to Performing a Holistic Evaluation of Technology-Enhanced Learning in Medical Education

Technology-enhanced learning (TEL) is now a common mode of educational delivery within medical education. Despite this upsurge, there remains a paucity in comprehensive evaluation of TEL efficacy. In order to make meaningful and evidence-informed decisions on ‘how’ and ‘when’ to utilise technology within a course, ‘useful knowledge’ is required to support faculty in these decision-making processes. In this monograph, a series of pragmatic and achievable approaches for conducting a holistic evaluation of a TEL resource intervention are detailed. These suggestions are based on an established TEL evaluation framework, as well as the author’s own experience and that of the broader literature. The approaches cover development of an appropriate research question that is based on the availability of existing TEL resources alongside the peer-reviewed literature; the development of an appropriate team as well as recommendations for navigating ethical approval; conducting small-scale quantitative and qualitative measure; and performing a large-scale mixed methods assessment to understand the holistic impact of the TEL resource

Voice and swallowing outcomes for adults undergoing reconstructive surgery for laryngotracheal stenosis

Purpose of review Adult laryngotracheal stenosis is a rare, multifactorial condition which carries a significant physical and psychosocial burden. Surgical approaches have developed in recent years, however, voice and swallowing function can be affected prior to treatment, in the immediate postoperative phase, and as an ongoing consequence of the condition and surgical intervention. In this study we discuss: the nature of the problem; surgical interventions to address airway disorders; optimal patterns of care to maximize voice and swallowing outcomes. Recent findings Studies in this field are limited and focused on surgical outcomes and airway status with voice and swallowing a secondary consideration. Retrospective studies of swallowing have focused on factors such as the duration of dysphagia symptoms following airway surgery and made comparisons between type of surgery, use of stent, and length of swallowing problems. The literature suggests that patients are likely to return to their preoperative diet. There has been a focus on voice outcomes following cricotracheal resection which results in a postoperative decrease in the fundamental frequency. However, study comparisons are limited by the use of inconsistent outcome measures (for both voice and swallowing) which are often not validated, with heterogeneous groups and varying surgical techniques. Summary The limited literature suggests that swallowing function is more likely to recover to presurgical status than voice function. Further prospective studies incorporating consistent instrumental, clinician, and patient-reported outcome measurement are required to understand the nature and extent of dysphagia and dysphonia resulting from this condition and its treatment

Laryngeal sarcoidosis and swallowing: what do we know about dysphagia assessment and management in this population?

Introduction Sarcoidosis is a chronic granulomatous disease of unknown aetiology and laryngeal involvement is seen in a small percentage of cases. Dysphagia is a common but under-reported symptom. Little is known about how dysphagia typically presents or is managed in the context of this fluctuating disease. We present our case series using an SLT-led model of assessment and management. Methods A literature search was conducted for any articles that reported both laryngeal sarcoidosis and dysphagia. We then analysed a case series of laryngeal sarcoidosis patients treated at Charing Cross Hospital. We report on multidimensional swallowing evaluation and rehabilitative interventions. Results Seventeen papers report both laryngeal sarcoidosis and dysphagia, with only one paper giving details on the nature of the dysphagia and the treatment provided. In our case series (n = 7), patients presented with FOIS Scores ranging from 5 to 7 pre-operatively (median = 6). Aspiration (median PAS Score = 6 and Range = 3–8) and pharyngeal residue were common. Sensory issues were also prevalent with most unaware of the extent of their difficulties. Management interventions included safe swallowing advice, compensatory strategies, exercises and close surveillance given their potential for repeated surgical interventions. Conclusion Laryngeal sarcoidosis is a rare condition. Dysphagia is under-reported and our experience highlights the need for specialist dysphagia intervention. Further research is required to understand dysphagia management requirements in the context of this fluctuating disease process

Utility of ultrasound in the assessment of swallowing and laryngeal function: a rapid review and critical appraisal of the literature

Background Ultrasound (US) is not widely used as part of the speech and language therapy (SLT) clinical toolkit. The COVID‐19 pandemic has intensified interest in US as an alternative to SLT instrumental tools such as the videofluoroscopic swallowing study (VFSS), fibreoptic endoscopic evaluation of swallowing (FEES) and endoscopic evaluation of the larynx (EEL) as a non‐invasive, non‐aerosol‐generating procedure that can be delivered at the bedside to assess swallowing and/or laryngeal function. To establish the appropriacy of routine US use, and in response to a national professional body request for a position statement, a group of expert SLTs conducted a rapid review of the literature. Aim To explore critically the clinical utility of US as an assessment tool for swallowing and laryngeal function in adults. Methods & Procedures A rapid review of four databases was completed to identify articles using US to assess swallowing and/or laryngeal function in adults compared with reference tests (VFSS/FEES/EEL/validated outcome measure). Screening was completed according to predefined inclusion/exclusion criteria and 10% of abstracts were rescreened to assess reliability. Data were extracted from full texts using a predeveloped form. The QUADAS‐2 tool was used for quality ratings. Information from included studies was summarized using narrative synthesis and visual illustration. Outcomes & Results Ten papers used US to assess swallowing, and 13 to assess laryngeal function. All were peer‐reviewed primary studies across a range of clinical populations and with a wide geographical spread. Four papers had an overall low risk of bias, but the remaining 19 had at least one domain where risk of bias was judged as high or unclear. Applicability concerns were identified in all papers. The papers that used US to assess swallowing varied widely in terms of the anatomical structures assessed and methodology employed. The papers assessing laryngeal function were more homogenous in their methodology. Sensitivity and specificity data were provided for 12 of the laryngeal function papers with ranges of 64.3–100% and 48.5–100%, respectively. Conclusions & Implications There is burgeoning evidence to support the use of US as an adjunct to SLT clinical assessment of swallowing and laryngeal function. However, the current literature does not support its use as a tool in isolation. Further research is required to establish reliability in US assessment as well as clear SLT‐driven protocols and training

Pedagogical Perspectives on the Use of Technology within Medical Curricula : Moving Away from Norm Driven Implementation

There is often an expectation that any educational institution worth its salt will be at the forefront of technological advances. An often unchallenged and somewhat romanticised viewpoint persists that, in all cases, technology is best. What is not always openly discussed is the evidence base and pedagogy behind the use of technology, visualisation and traditional approaches of teaching within the fields of medical and anatomy education curricula. There are many advantages to using technology within the learning environment but, often, it is possible to achieve the same outcomes through the use of many other non-technological instructional modalities. The frequent shortcoming when institutions use technology is that there is a lack of integration across the curriculum, a failure to map to the blueprint, little attempt to include technology in the feedback cycle and assessment, and insufficient time and resource allocation for educators developing resources. Without careful implementation and integration, it can appear that institutions are throwing the latest developments at students without due care and consideration to the evidence-base and without the necessary institutional support for staff and resource development. This is not the fault of educators; the competing demands on staff time and institutional drive to climb the ranking tables means that technology is often perceived as the quick fix