Rehabilitation Program for Prosthetic Tracheojejunal Voice Production and Swallowing Function Following Circumferential Pharyngolaryngectomy and Neopharyngeal Reconstruction with a Jejunal Free Flap

The case of a 68-year-old woman with postoperative speech and swallowing problems following a circumferential pharyngolaryngectomy and neopharyngeal reconstruction with a jejunal free flap is presented. The primary tumor was an extended papillary thyroid carcinoma (pT4N0M0). For vocal restoration, an indwelling Provox® 1 voice prosthesis was inserted secondarily. The patient received speech and swallowing therapy, including digital maneuvers at the level of the proximal (cervical) part of the jejunal graft to improve speech and swallowing function. Pre- and/ or post-treatment data on speech and swallowing function were gathered using the following assessment methods: esophageal insufflation test, Voice Handicap Index (VHI), videofluoroscopy of phonation (VFSph), digital high-speed endoscopy of jejunal vibration during voice production, fiber-optic endoscopic evaluation of swallowing (FEES), and videofluoroscopy of swallowing (VFSs). This case clearly demonstrates that even after extensive laryngopharyngectomy with jejunal free flap reconstruction, a tailored rehabilitation program can improve both voice and swallowing function, and that these results clearly can be objectified/visualized, underlining the validity of this approach

Swallowing in Parkinson Patients versus Healthy Controls: Reliability of Measurements in Videofluoroscopy

Objective. To determine and describe the pathophysiological aspects of oropharyngeal swallowing in patients with Parkinson's disease more accurately, a pilot study of qualitative as well as quantitative parameters of swallowing was performed using videofluoroscopy (VFS). Methods. Ten patients with a diagnosis of idiopathic Parkinson's disease having dysphagic complaints and ten healthy age- and gender-matched control subjects underwent a standardized videofluoroscopic swallowing protocol. Information on the swallowing function was derived from temporal, spatial, and descriptive visuoperceptual parameters. Intra- and interrater reliability was calculated. Results. No significant differences were found between Parkinson patients and healthy control subjects for the majority of the reliable variables. Conclusions. It was concluded that swallowing function seemed to be preserved in the early stages of Parkinson's disease. Furthermore, the reliability of many quantitative as well as qualitative swallowing parameters proved insufficient, raising questions about the interpretation of study outcomes in videofluoroscopy

Quality of Life in Oncological Patients with Oropharyngeal Dysphagia: Validity and Reliability of the Dutch Version of the MD Anderson Dysphagia Inventory and the Deglutition Handicap Index

Quality of life is an important outcome measurement in objectifying the current health status or therapy effects in patients with oropharyngeal dysphagia. In this study, the validity and reliability of the Dutch version of the Deglutition Handicap Index (DHI) and the MD Anderson Dysphagia Inventory (MDADI) have been determined for oncological patients with oropharyngeal dysphagia. At Maastricht University Medical Center, 76 consecutive patients were selected and asked to fill in three questionnaires on quality of life related to oropharyngeal dysphagia (the SWAL-QOL, the MDADI, and the DHI) as well as a simple one-item visual analog Dysphagia Severity Scale. None of the quality-of-life questionnaires showed any floor or ceiling effect. The test-retest reliability of the MDADI and the Dysphagia Severity Scale proved to be good. The test-retest reliability of the DHI could not be determined because of insufficient data, but the intraclass correlation coefficients were rather high. The internal consistency proved to be good. However, confirmatory factor analysis could not distinguish the underlying constructs as defined by the subscales per questionnaire. When assessing criterion validity, both the MDADI and the DHI showed satisfactory associations with the SWAL-QOL (reference or gold standard) after having removed the less relevant subscales of the SWAL-QOL. In conclusion, when assessing the validity and reliability of the Dutch version of the DHI or the MDADI, not all psychometric properties have been adequately met. In general, because of difficulties in the interpretation of study results when using questionnaires lacking sufficient psychometric quality, it is recommended that researchers strive to use questionnaires with the most optimal psychometric properties

The effects of neuromuscular electrical stimulation for dysphagia in opercular syndrome: a case study

A 76-year-old man with opercular syndrome characterized by complete bilateral loss of voluntary control of facial, lingual, pharyngeal and masticatory muscles is presented with focus on the severe dysphagia. Three years earlier the patient had experienced two strokes resulting in opercular syndrome with severe dysphagia. Despite initial logopedic dysphagia treatment, swallowing did not improve. A new treatment for dysphagia, consisting of neuromuscular electrical stimulation was applied on the patient. He returned to oral feeding. Clinical and treatment observations are reported

FEES protocol derived estimates of sensitivity: aspiration in dysphagia patients

Aspiration is a common phenomenon in patients with oropharyngeal dysphagia. It can be studied using fiberoptic endoscopic evaluation of swallowing (FEES). FEES is well known and widely used in the diagnosis and treatment of swallowing disorders. However, various protocols exist, and there is no consensus on the examination protocol. The objective of this prospective study was to determine the FEES protocol derived estimates of sensitivity (Se') to detection of aspiration in dysphagic patients. The study estimated the probability of aspiration as a function of the number of swallow trials in dysphagic patients using FEES. The derived sensitivity was calculated based on presence or absence of aspiration in a ten-swallow trial protocol as arbitrary 'gold standard'. Eighty-four persons were included, comprising two patient populations with oropharyngeal dysphagia. Dysphagia in one group was due to head and neck cancer and possible oncological treatment effects on swallowing; in the other it was a result of neurological disease. All patients underwent a standardized FEES examination using ten swallows of thin liquid followed by ten swallows of thick liquid, all in boluses of 10 cc each. FEES recordings were rated for aspiration by an expert panel blinded to patients' identity and clinical history. Descriptive statistics, Kaplan–Meier survival analysis techniques, and Log Rank/Mantel–Cox tests were used. In both patient populations the aspiration risk was underestimated when using a limited number (three or four) of swallow trials. The oncology and neurology patients differed significantly in the number of swallow trials required to determine aspiration for thin liquids (median values 2 and 7 respectively, P = 0.006). FEES protocols using a limited number of swallow trials can underestimate the aspiration risk in both oncological and neurological patients suffering from oropharyngeal dysphagia, especially when using boluses with a thin liquid consistency

The effect of surface electrical stimulation on swallowing in dysphagic Parkinson patients

Surface electrical stimulation has been applied on a large scale to treat oropharyngeal dysphagia. Patients suffering from oropharyngeal dysphagia in the presence of Parkinson’s disease have been treated with surface electrical stimulation. Because of controversial reports on this treatment, a pilot study was set up. This study describes the effects of a single session of surface electrical stimulation using different electrode positions in ten patients with idiopathic Parkinson’s disease (median Hoehn and Yahr score: II) and oropharyngeal dysphagia compared to ten age- and gender-matched healthy control subjects during videofluoroscopy of swallowing. Three different electrode positions were applied in random order per subject. For each electrode position, the electrical current was respectively turned “on” and “off” in random order. Temporal, spatial, and visuoperceptual variables were scored by experienced raters who were blinded to the group, electrode position, and status (on/off) of the electrical current. Interrater and interrater reliabilities were calculated. Only a few significant effects of a single session of surface electrical stimulation using different electrode positions in dysphagic Parkinson patients could be observed in this study. Furthermore, significant results for temporal and spatial variables were found regardless of the status of the electrical current in both groups suggesting placebo effects. Following adjustment for electrical current status as well as electrode positions (both not significant, P > 0.05) in the statistical model, significant group differences between Parkinson patients and healthy control subjects emerged. Further studies are necessary to evaluate the potential therapeutic effect and mechanism of electrical stimulation in dysphagic patients with Parkinson’s disease

Observers' Agreement on Measurements in Fiberoptic Endoscopic Evaluation of Swallowing

This study analyzed the effect that dysphagia etiology, different observers, and bolus consistency might have on the level of agreement for measurements in FEES images reached by independent versus consensus panel rating. Sixty patients were included and divided into two groups according to dysphagia etiology: neurological or head and neck oncological. All patients underwent standardized FEES examination using thin and thick liquid consistencies. Two observers scored the same exams, first independently and then in a consensus panel. Four ordinal FEES variables were analyzed. Statistical analysis was performed using a linear weighted kappa coefficient and Bayesian multilevel model. Intra- and interobserver agreement on FEES measurements ranged from 0.76 to 0.93 and from 0.61 to 0.88, respectively. Dysphagia etiology did not influence observers’ agreement level. However, bolus consistency resulted in decreased interobserver agreement for all measured FEES variables during thin liquid swallows. When rating on the consensus panel, the observers deviated considerably from the scores they had previously given on the independent rating task. Observer agreement on measurements in FEES exams was influenced by bolus consistency, not by dysphagia etiology. Therefore, observer agreement on FEES measurements should be analyzed by taking bolus consistency into account, as it might affect the interpretation of the outcome. Identifying factors that might influence agreement levels could lead to better understanding of the rating process and assist in developing a more precise measurement scale that would ensure higher levels of observer agreement for measurements in FEES exams

Swallow-related quality of life and oropharyngeal dysphagia in myotonic dystrophy

Purpose: This study describes swallow-related quality of life (SWAL-QOL) in patients with myotonic dystrophy type 1 (DM1) and investigates its association with swallowing function and disease severity. Methods: A SWAL-QOL questionnaire was completed by 75 DM1 patients and 25 healthy control subjects. The severity of the disease was evaluated using the muscular impairment rating scale (MIRS). Twenty-eight DM1 patients underwent a videofluroscopic swallowing examination (VFS). Spearman’s correlation coefficient was used to measure the direction and strength of associations. Results: The SWAL-QOL median scores were significantly lower for the DM1 group than for the healthy control group. The scores for the majority of the SWAL-QOL domains were lower in patients with proximal muscular weakness (MIRS 4 and 5). Postswallow vallecular pooling and piecemeal deglutition were the most impaired VFS outcome variables. Conclusion: Our results suggest that a multidimensional swallowing assessment is recommended for DM1 patients as SWAL-QOL and VFS measure different aspects of the swallowing function, thus providing complementary information