Phoniatricians and otorhinolaryngologists approaching oropharyngeal dysphagia : an update on FEES

Purpose Oropharyngeal dysphagia (OD) is a common phenomenon in otorhinolaryngology and phoniatrics. As both sub-disciplines have a strong tradition and clinical experience in endoscopic assessment of the upper aerodigestive tract, the implementation of fiberoptic endoscopic evaluation of swallowing (FEES) was an almost self-evident evolution. This review aims to provide an update on FEES and the role of phoniatricians and otorhinolaryngologists using FEES in Europe. Methods A narrative review of the literature was performed by experts in the field of FEES both in the clinical context and in the field of scientific research. Results FEES is the first-choice OD assessment technique for both phoniatricians and otorhinolaryngologists. FEES is becoming increasingly popular because of its usefulness, safety, low costs, wide applicability, and feasibility in different clinical settings. FEES can be performed by health professionals of varying disciplines, once adequate knowledge and skills are acquired. FEES aims to determine OD nature and severity and can provide diagnostic information regarding the underlying etiology. The direct effect of therapeutic interventions can be evaluated using FEES, contributing to design the OD management plan. Standardization of FEES protocols and metrics is still lacking. Technological innovation regarding image resolution, frame rate frequency, endoscopic light source specifications, and endoscopic rotation range has contributed to an increased diagnostic accuracy. Conclusion The rising number of phoniatricians and otorhinolaryngologists performing FEES contributes to the early detection and treatment of OD in an aging European population. Nevertheless, a multidisciplinary approach together with other disciplines is crucial for the success of OD management.Peer reviewe

Identify. Quantify. Predict. Why immunologists should widely use molecular imaging for Coronavirus Disease 2019

Molecular imaging using PET/CT or PET/MRI has evolved from an experimental imaging modality at its inception in 1972 to an integral component of diagnostic procedures in oncology, and, to lesser extent, in cardiology and neurology, by successfully offerin

Electrophysiological correlates of the interplay between low-level visual features and emotional content during word reading

Schindler S, Schettino A, Pourtois G. Electrophysiological correlates of the interplay between low-level visual features and emotional content during word reading. Scientific Reports. 2018;8(1): 12228.Processing affectively charged visual stimuli typically results in increased amplitude of specific event-related potential (ERP) components. Low-level features similarly modulate electrophysiological responses, with amplitude changes proportional to variations in stimulus size and contrast. However, it remains unclear whether emotion-related amplifications during visual word processing are necessarily intertwined with changes in specific low-level features or, instead, may act independently. In this pre-registered electrophysiological study, we varied font size and contrast of neutral and negative words while participants were monitoring their semantic content. We examined ERP responses associated with early sensory and attentional processes as well as later stages of stimulus processing. Results showed amplitude modulations by low-level visual features early on following stimulus onset – i.e., P1 and N1 components –, while the LPP was independently modulated by these visual features. Independent effects of size and emotion were observed only at the level of the EPN. Here, larger EPN amplitudes for negative were observed only for small high contrast and large low contrast words. These results suggest that early increase in sensory processing at the EPN level for negative words is not automatic, but bound to specific combinations of low-level features, occurring presumably via attentional control processes

Myoinositol as a Safe and Alternative Approach in the Treatment of Infertile PCOS Women: A German Observational Study

The use of 2×2000 mg myoinositol + 2×200 μg folic acid per day is a safe and promising tool in the effective improvement of symptoms and infertility for patients with a polycystic ovary syndrome (PCOS). Using a questionnaire an observational study was performed under German gynecologists to collect data on ovulation and pregnancy rates in PCOS patients with infertility. In this observational study, 3602 infertile women used myoinositol and folic acid between 2 and 3 months in a dosage of 2×2000 mg myoinositol + 2×200 μg folic acid per day. In a subgroup of 32 patients, hormonal values for testosterone, free testosterone, and progesterone were analyzed before and after 12 weeks of treatment. The mean time of use was 10.2 weeks. During this time 70% of these women had a restored ovulation, and 545 pregnancies were obtained. This means a pregnancy rate of 15.1% of all the myoinositol and folic acid users. In 19 cases a concomitant medication with clomiphene or dexamethasone was used. One twin pregnancy was documented. Testosterone levels changed from 96.6 ng/ml to 43.3 ng/ml and progesterone from 2.1 ng/ml to 12.3 ng/ml (p<0.05) after 12 weeks of treatment. No relevant side effects were present among the patients. This study could show that a new treatment option for patients with a PCOS and infertility is available. The achieved pregnancy rates are at least in an equivalent or even superior range than those reported by the use of metformin

Position Statement of the Union of European Phoniatricians (UEP) : Fees and Phoniatricians' Role in Multidisciplinary and Multiprofessional Dysphagia Management Team

The need for multidisciplinary and multiprofessional management of dysphagia is constantly increasing and creating a major challenge for healthcare professionals and society, especially in terms of professional expertise and human resources. The distribution of tasks among the dysphagia team members, which includes phoniatricians, otolaryngologists, and speech-language therapists, is flexible and overlapping. For assessing dysphagia, the (fibreoptic) flexible endoscopic evaluation of swallowing (FEES), with or without videofluoroscopy, is a pivotal diagnostic tool. This position paper aims to illustrate the phoniatrician's role in performing a FEES, which is an indispensable component of the diagnostic workup of patients suffering from oropharyngeal dysphagia. It is based on the current collaborative expert view of the Swallowing Committee of the Union of European Phoniatricians and a literature review. A FEES is one of the core competences of phoniatricians due to their endoscopic expertise and experience in the field of dysphagia and diseases of the upper aerodigestive tract. Therefore, the phoniatrician is an important member of the dysphagia team, for the medical diagnostics of the aerodigestive tract and dysphagia as well as for FEES. Phoniatric competence is especially important for head and neck cancer patients, infants, and complex cases.Peer reviewe

Swallowing Safety and Eciency after Open Partial Horizontal Laryngectomy: A Videofluoroscopic Study

Dysphagia is common after an open partial horizontal laryngectomy (OPHL). The mechanisms causing lower airways' invasion and pharyngeal residue are unclear. The study aims to examine physio-pathological mechanisms affecting swallowing safety and efficiency after OPHL. Fifteen patients who underwent an OPHL type IIa with arytenoid resection were recruited. Videofluoroscopic examination of swallowing was performed. Ten spatial, temporal, and scalar parameters were analyzed. Swallowing safety and efficiency were assessed through the Dynamic Imaging Grade of Swallowing Toxicity (DIGEST) scale. Swallowing was considered unsafe or inefficient for a DIGEST safety or efficiency grade 2, respectively. Videofluoroscopic measurements were compared between safe vs. unsafe swallowers, and efficient vs. inefficient swallowers. Seven patients (46.7%) showed unsafe swallowing and 6 patients (40%) inefficient swallowing. Unsafe swallowers had worse laryngeal closure (p = 0.021). Inefficient swallowers presented a longer pharyngeal transit time (p = 0.008), a reduced pharyngoesophageal segment opening lateral (p = 0.008), and a worse tongue base retraction (p = 0.018 with solids and p = 0.049 with semisolids). In conclusion, swallowing safety was affected by incomplete laryngeal closure, while swallowing efficiency was affected by increased pharyngeal transit time, reduced upper esophageal sphincter opening, and incomplete tongue base retraction. The identified physio-pathological mechanisms could represent targets for rehabilitative and surgical approaches in patients with dysphagia after OPHL

Developing and Examining the Psychometrics of Single-word Quick Repetition Test for Speech Sound Production in Persian-speaking Children

Objectives: The present study aimed to develop and validate a quick repetition test using familiar and culture-based words for assessing Persian-speaking children with Speech Sound Disorders (SSDs). Methods: The study sample was divided into two groups, including 419 participants without any clinical signs of speech impairment and 36 cases with SSD. The psychometric properties of the single word quick repetition test, including reliability (inter-rater and test-retest reliability) and validity (construct, discriminant, convergent, clinical and concurrent validity) were examined. Moreover, the descriptive data for children without SSD were reported. Results: The obtained test-retest and inter-rater reliability data were satisfactory with Intraclass correlation coefficient (ICC): >0.7. There was a positive correlation between the results of the quick repetition test and phonetic test, indicating the scale's acceptable convergence validity. Using inflated beta-binomial regression, statistically significant improvement in test score was found with age (discriminant validity). Comparing the correct responses of the control and case groups (clinical validity) revealed a significant difference in responses between the study groups. Results of Bland–Altman plot suggested an acceptable agreement between quick repetition test and phonetic test (construct validity). Discussion: The Persian quick repetition test is a valid and reliable instrument facilitating the screening of speech sound abilities in 3-8-year-olds. Moreover, this test's conciseness makes it easily applicable in clinical practice and epidemiologic investigations. Establishing descriptive data from a large sample facilitated comparing children's speech ability to the speech development standards

Botulinum Toxin Is Effective in the Management of Neurogenic Dysphagia. Clinical-Electrophysiological Findings and Tips on Safety in Different Neurological Disorders

Background and Aims: Neurogenic dysphagia linked to failed relaxation of the upper esophageal sphincter (UES) can be treated by injecting botulinum toxin (BTX) into the cricopharyngeal (CP) muscle. We compared the effects of this treatment in different neurological disorders with dysphagia, to evaluate its efficacy over time including the response to a second injection. Materials and Methods: Sixty-seven patients with neurogenic dysphagia associated with incomplete or absent opening of the UES (24 with brainstem or hemispheric stroke, 21 with parkinsonian syndromes, 12 with multiple sclerosis, and 10 with spastic-dystonic syndromes secondary to post-traumatic encephalopathy) were treated with the injection of IncobotulinumtoxinA (dose 15–20 U) into the CP muscle under electromyographic guidance. The patients were assessed at baseline and after the first and second treatment through clinical evaluation and fiberoptic endoscopy of swallowing, while their dysphagia was quantified using the Dysphagia Outcome and Severity Scale (DOSS). An electrokinesiographic/electromyographic study of swallowing was performed at baseline. Results: Most patients responded to the first BTX treatment: 35 patients (52.2%) were classified as high responders (DOSS score increase >2 levels), while other 19 patients (28.4%) were low responders (DOSS score increase of ≤2 levels). The effect of the first treatment usually lasted longer than 4 months (67%), and in some cases up to a year. The treatment efficacy remained high also after the second injection: 31 patients (46.3%) qualified as high responders and other 22 patients (32.8%) showed a low response. Only in the parkinsonian syndromes group we observed a reduction in the percentage of high responders as compared with the first treatment. Side effects were mostly mild and reported in non-responders following the first injection. A severe side effect, consisting of ingestion pneumonia, was observed following the second BTX injection in two patients who had both been non-responders to the first. Non-responders were characterized electromyographically by higher values of the oropharyngeal interval. Conclusion: These findings confirm the effectiveness of IncobotulinumtoxinA injection in the treatment of neurogenic dysphagia due to hyperactivity and relaxation failure of the UES. Caution should be used as regards, the re-injection in non-responders to the first treatment

European Stroke Organization and European Society for Swallowing Disorders guideline for the diagnosis and treatment of post-stroke dysphagia

Post-stroke dysphagia (PSD) is present in more than 50% of acute stroke patients, increases the risk of complications, in particular aspiration pneumonia, malnutrition and dehydration, and is linked to poor outcome and mortality. The aim of this guideline is to assist all members of the multidisciplinary team in their management of patients with PSD. These guidelines were developed based on the European Stroke Organisation (ESO) standard operating procedure and followed the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach. An interdisciplinary working group identified 20 relevant questions, performed systematic reviews and meta-analyses of the literature, assessed the quality of the available evidence and wrote evidence-based recommendations. Expert opinion was provided if not enough evidence was available to provide recommendations based on the GRADE approach. We found moderate quality of evidence to recommend dysphagia screening in all stroke patients to prevent post-stroke pneumonia and to early mortality and low quality of evidence to suggest dysphagia assessment in stroke patients having been identified at being at risk of PSD. We found low to moderate quality of evidence for a variety of treatment options to improve swallowing physiology and swallowing safety. These options include dietary interventions, behavioural swallowing treatment including acupuncture, nutritional interventions, oral health care, different pharmacological agents and different types of neurostimulation treatment. Some of the studied interventions also had an impact on other clinical endpoints such as feedings status or pneumonia. Overall, further randomized trials are needed to improve the quality of evidence for the treatment of PSD

Probing the Nature of High Redshift Weak Emission Line Quasars: A Young Quasar with a Starburst Host Galaxy

We present the discovery of PSO J083.8371+11.8482, a weak emission line quasar with extreme star formation rate at $z=6.3401$. This quasar was selected from Pan-STARRS1, UHS, and unWISE photometric data. Gemini/GNIRS spectroscopy follow-up indicates a MgII-based black hole mass of $M_\mathrm{BH}=\left(2.0^{+0.7}_{-0.4}\right)\times10^9~M_\odot$ and an Eddington ratio of $L_\mathrm{bol}/L_\mathrm{Edd}=0.5^{+0.1}_{-0.2}$, in line with actively accreting supermassive black hole (SMBH) at $z\gtrsim6$. HST imaging sets strong constraint on lens-boosting, showing no relevant effect on the apparent emission. The quasar is also observed as a pure point-source with no additional emission component. The broad line region (BLR) emission is intrinsically weak and not likely caused by an intervening absorber. We found rest-frame equivalent widths of EW(Ly$\alpha$+NV) $=5.7\pm0.7$ Angstrom, EW(CIV) $\leq5.8$ Angstrom (3-sigma upper limit), and EW(MgII) $=8.7\pm0.7$ Angstrom. A small proximity zone size ($R_\mathrm{p}=1.2\pm0.4$ pMpc) indicates a lifetime of only $t_\mathrm{Q}=10^{3.4\pm0.7}$ years from the last quasar phase ignition. ALMA shows extended [CII] emission with a mild velocity gradient. The inferred far-infrared luminosity ($L_\mathrm{FIR}=(1.2\pm0.1)\times10^{13}\,L_\odot$) is one of the highest among all known quasar hosts at $z\gtrsim6$. Dust and [CII] emissions put a constraint on the star formation rate of SFR $=900-4900~M_\odot\,\mathrm{yr^{-1}}$, similar to that of hyper-luminous infrared galaxy. Considering the observed quasar lifetime and BLR formation timescale, the weak-line profile in the quasar spectrum is most likely caused by a BLR which is not yet fully formed rather than continuum boosting by gravitational lensing or a soft continuum due to super-Eddington accretion.Comment: 28 pages, 16 figures, 3 tables, accepted for publication in Ap