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Purpose: To develop a European White Paper document on oropharyngeal dysphagia (OD) in head and neck cancer (HNC). There are wide variations in the management of OD associated with HNC across Europe. Methods: Experts in the management of specific aspects of OD in HNC across Europe were delegated by their professional medical and multidisciplinary societies to contribute to this document. Evidence is based on systematic reviews, consensus-based position statements, and expert opinion. Results: Twenty-four sections on HNC-specific OD topics. Conclusion: This European White Paper summarizes current best practice on management of OD in HNC, providing recommendations to support patients and health professionals. The body of literature and its level of evidence on diagnostics and treatment for OD in HNC remain poor. This is in the context of an expected increase in the prevalence of OD due to HNC in the near future. Contributing factors to increased prevalence include aging of our European population (including HNC patients) and an increase in human papillomavirus (HPV) related cancer, despite the introduction of HPV vaccination in various countries. We recommend timely implementation of OD screening in HNC patients while emphasizing the need for robust scientific research on the treatment of OD in HNC. Meanwhile, its management remains a challenge for European professional associations and policymakers. [ABSTRACT FROM AUTHOR]

Background: Most people with stroke exhibit a variety of impairments that need to be addressed by a multidisciplinary team. Communication and swallowing disorders are common and should be screened very early. To guarantee a patient‐centred approach, all patients, even those with speech and language disorders, must be actively engaged in the healthcare process. Effective communication is essential to success in many of the needed interventions. However, healthcare professionals often do not receive formal training in communicating with these patients, thus increasing the risk of preventable adverse events. Aims: To describe the design, implementation and evaluation of a post‐acute stroke multidisciplinary team training using patient actors in a simulation approach. Methods & Procedures: A 2‐day course focused on the transdisciplinary knowledge related to communication and swallowing that all members of the multidisciplinary stroke team should acquire was implemented. A case‐based learning methodology used simulation and resorting to patients' actors. Learning outcomes were evaluated by comparing the results obtained in two knowledge tests, one for each topic, which participants performed before and after each day course. Reaction to the training was gathered concerning the content, teacher quality and course organization. The follow‐up was performed 6 months later to assess training skills transfer to the workplace environment. Outcomes & Results: All the participants considered that the programme objectives were relevant or truly relevant and revealed that the programme's dynamic, rhythm and scenarios set were excellent. After the end of the programme, both communication and swallowing knowledge increased. Most participants had the opportunity to employ the acquired training skills in their work environment. The main barriers identified to implementing these skills were the 'need for additional training', the 'lack of time' or 'the lack of opportunities'. Conclusions & Implications: Simulation is a central method to increase and improve health professionals' skills when intervening with stroke patients. Using simulation with patient actors allows flexibility and diversification of clinical situations under analysis, which can provide a multiplier effect of reflection and learning. The implemented training achieved its objectives. WHAT THIS PAPER ADDS: What is already known on this subject: Simulation in the training of health professionals is increasingly used as a good practice, allowing the recreation of scenarios identical to those in the context of professional practice. This strategy is used not only in initial training but also for the development of advanced skills. What this study adds to the existing knowledge: This study reports the use of simulation using actor patients for the development of transdisciplinary skills in the topics of communication and swallowing in people with stroke What are the clinical and practical implications of this work?: The study demonstrates that in a short period of training, the use of simulation with actor patients favours the development of transdisciplinary skills in the topics of communication and swallowing in people with stroke. At the same time, the skills developed are transferable to professional practice. [ABSTRACT FROM AUTHOR]

Background: : Dysphagia is prevalent in subjects with Parkinson's disease (PD). Swallowing intervention to improve or maintain swallowing function is of major importance as dysphagia may considerably impact physical and psycho‐social health. Aims: : A mixed methods systematic review was conducted to summarize and appraise literature reporting (1) effects of behavioural interventions for swallowing in individuals with PD; and (2) participants' perspectives of swallowing interventions. Methods & Procedures: : Electronic databases were searched systematically in July 2020 for articles published between 2014 and 2020. In addition, studies published between 2000 and 2014 were identified non‐systematically through previous reviews. Peer‐reviewed quantitative and qualitative research in English or German documenting behavioural interventions for swallowing in individuals with a diagnosis of PD was eligible for inclusion. Participants at all disease stages were included. Behavioural interventions included rehabilitative and compensatory strategies. Studies reporting swallowing outcomes with and without a comparative group were included. For each study, the National Health and Medical Research Council level of evidence was defined. Included studies were critically appraised using the Standard Quality Assessment Criteria for Evaluating Primary Research Papers from a Variety of Fields. An integrated synthesis was performed after separate analysis of effect data and data reflecting participants' experiences. This review was conducted based on published JBI methodology and the guideline from the Preferred Reporting Items for Systematic Reviews and Meta‐Analysis system was followed. Main Contribution: : A total of 33 studies published in English met the inclusion criteria. Thirty‐one studies reported quantitative data, one was qualitative and one was mixed methods. Intervention effects on swallowing function, swallowing safety and swallowing‐related quality of life were reported for various treatment approaches. Three studies explored how participants perceived the intervention. Overriding themes including subjects' views regarding treatment schedules and levels of effort or comfort associated with the intervention were identified across these studies. Combining evidence of intervention effects and subjects' experiences was possible for one rehabilitative and one compensatory intervention. Conclusions & Implications: : Beneficial effects of swallowing interventions have been reported; however, most experiments were case studies of variable methodological quality. Randomized‐controlled trials with robust methodology to explore treatment effects in larger samples is needed to guide clinical practice. Research reporting subjects' views is scarce. More studies exploring how individuals perceive behavioural interventions for swallowing are necessary to inform clinical decision‐making. WHAT THIS PAPER ADDS: What is already known on the subject: Dysphagia is common in individuals with PD. Swallowing intervention is of major importance as dysphagia may negatively affect physical and psycho‐social health of subjects with PD. What this study adds: Beneficial effects of behavioural interventions for swallowing, including rehabilitative and compensatory strategies, have been reported; however, available data are mostly based on case studies of variable quality. Data on how participants perceive specific behavioural interventions are lacking. Based on the available data, integration of efficacy data and individuals' experiences is limited. What are the clinical implications of this work?: Given the current evidence of intervention effects and individuals' views on behavioural treatment strategies, interventions implemented into clinical practice require careful evaluation on a case‐by‐case basis. More high‐quality research is needed to examine interventions' short‐ and long‐term effects in larger samples to guide clinical practice. In addition to studies evaluating intervention effects, research exploring participants' experiences with interventions is required as a foundation for clinical decision‐making. [ABSTRACT FROM AUTHOR]

Background: Post‐COVID Syndrome (also known as Long COVID) refers to the multi‐system condition affecting individuals following COVID‐19 infection. This can include speech and language therapy (SLT) needs, including voice, swallowing, communication and upper airway difficulties. There is limited published literature in this clinical area of practice, particularly for those receiving input from community SLT services. Aims: To describe and compare demand, typical SLT presentation and service delivery across two National Health Service (NHS) Long COVID multidisciplinary services. Independent retrospective service evaluation was completed for each service. Descriptive statistics were produced and compared across services. This service evaluation followed The Strengthening the Reporting of Observation Studies in Epidemiology guidelines for cohort studies. Outcomes & Results: The findings indicated similarities across the two services in SLT service need and demand, clinical presentations and intervention approaches provided within Long COVID services. There were specific differences in the service provision and delivery of intervention in cognitive communication and upper airways subspecialities. Conclusions & Implications: This study highlights the clinical complexities of SLT needs in individuals with Long COVID and the importance for an appropriately skilled and supported workforce within effective multidisciplinary teams. We call for consensus on SLT practices and a consistent and standardized approach to evaluation for SLT needs in Long COVID. WHAT THIS PAPER ADDS: What is already known on this subject: SLT needs, including voice, swallowing, communication and upper airway difficulties, are present in individuals presenting with Long COVID, both in those who were or were not hospitalized. SLTs are seeing such individuals in a variety of settings, including community services and Long COVID multidisciplinary teams. There is minimal evidence of the clinical presentations and interventions provided to individuals with SLT needs compared across Long COVID services. What this study adds to existing knowledge: This study compares two NHS Long COVID services providing a SLT service pathway. It highlights the similarities and differences in service demand and capacity, patient presentation, and SLT intervention to make suggestions for future practice consideration and priority evaluation. Expert consensus among SLT clinicians is a priority to ensure clinicians are delivering consistent and equitable care for patients, while new evidence and data emerge. A consistent and standardized approach to data collection and outcome measures is essential to ensure future research captures the impact and value of SLT input with individuals with Long COVID. What are the clinical implications of this work?: The complexities and multifactorial SLT needs of individual with Long COVID call for appropriate SLT staffing provision, skill and training to fulfil the needs of this population. Speech and language therapists should be integrated with multidisciplinary Long COVID services to provide holistic care for patients and to support the professionals working with individuals with post‐COVID voice, swallowing, communication and upper airway symptoms. [ABSTRACT FROM AUTHOR]

Background: Studies suggest swallow intervention programmes that incorporate visual biofeedback and motor programming principles can improve swallowing and quality of life for people with idiopathic Parkinson's disease (IPD) and dysphagia. Few studies have examined outcomes using instrumentation. Aims: Using fibreoptic endoscopic examination of swallowing (FEES), this study examines the effectiveness of a neurorehabilitation intervention involving biofeedback via surface electromyography (sEMG) to improve swallowing in people with IPD, and to explore the feasibility of the intervention approach. Methods & Procedures: We recruited 12 participants with IPD and dysphagia. A total of 10 completed the study. Intervention was delivered for 1 h per day, 5 days per week, for 4 weeks (20 h). Swallowing tasks using sEMG biofeedback incorporated principles of motor learning and neuroplasticity. Instrumental and non‐instrumental assessment, including quality‐of‐life measures carried out at four different time points (two pre‐treatment and two post‐treatment). The final assessment was at 3 months post‐intervention. Outcome & Results: Statistically significant improvement (p < 0.05) in oral intake methods (95% confidence interval (CI) = 4.70–5.50) and in pharyngeal residue from saliva (95% CI = 2.14–3.15) and solids (95% CI = 2.4–3.5) post‐intervention were confirmed using FEES with improvements at 3 months. The intervention protocol was well tolerated. Participants reported positive change in saliva control and duration of mealtimes as well as unanticipated improvements in voice and cognitive attention. Conclusions & Implications: An intensive neurorehabilitation with biofeedback shows positive effects in improving swallow function in IPD. This protocol is feasible with amendments to inform a larger clinical trial. What this paper adds: What is already known on the subject: Biofeedback has positive effects on increasing swallowing function and quality of life in people with IPD and dysphagia. sEMG is the most common method used to deliver swallowing biofeedback in this population. The quality of the evidence on the intervention, based on findings from a recent systematic review, is low. Included studies in this review were heterogeneous in terms of type and frequency of biofeedback, study design and outcome measures. The majority of outcome measures were subjective and higher quality studies to examine the efficacy of biofeedback using sEMG are needed. What this study adds: Recognizing the limitations of earlier studies, this within‐subject feasibility study examined the efficacy and effectiveness of an intensive biofeedback intervention using sEMG in a sample of people with dysphagia and IPD. Valid and reliable outcome measures were used and repeated after a 3‐month period. The feasibility of the methodological approach was also tested and a qualitative component was included in the study. Positive findings were evident. Qualitative information added new perspectives and provided direction for new outcomes to be included in future studies. This study helps to inform further research trials as well as clinical practice. Clinical implications of this study: This intensive intervention using principles of neuroplasticity and motor programming with sEMG biofeedback led not only to positive swallowing outcomes but also to unexpected benefits such as improved voice production and general attention skills. No adverse events were reported. Improvement in function was retained at 3 months post‐intervention. Despite the small sample size, participants described the benefits of the treatment, and enjoyed sEMG biofeedback tasks, especially using an sEMG game mode. This suggests that intensive biofeedback not only improved swallowing but also was acceptable to these participants. This intensive protocol has merit and is worth considering further in clinical practice. [ABSTRACT FROM AUTHOR]

Background: Speech and language therapists and nurses need to work together to keep patients with swallowing difficulties safe throughout their acute stroke admission. Speech and language therapists make recommendations for safe swallowing following assessment and nurses put recommendations into practice and monitor how patients cope. There has been little research into the everyday realities of ongoing swallow safety management by these two disciplines. Patient safety research in other fields of healthcare indicates that safety can be enhanced through understanding the cultural context in which risk decisions are made. Aims: To generate new understanding for how speech and language therapists (SLTs) and nurses share information for ongoing management of swallows safety on stroke units. Methods & Procedures: An ethnographic methodology involving 40 weeks of fieldwork on three stroke wards in England between 2015 and 2017. Fieldwork observation (357 h) and interviews with 43 members of SLT and nursing staff. Observational and interview data were analysed iteratively using techniques from the constant comparative method to create a thematically organized explanation. Outcomes & Results: An explanation for how disciplinary differences in time and space influenced how SLT and nursing staff shared information for ongoing management of swallow safety, based around three themes: (1) SLTs and nurses were aligned in concern for swallow safety across all information‐sharing routes; however, (2) ambiguity was introduced by the need for the information contained in swallowing recommendations to travel across time, creating dilemmas for nurses. Patients could improve or deteriorate after recommendations were made and nurses had competing demands on their time. Ambiguity had consequences for (3) critical incident reporting and relationships. SLTs experienced dilemmas over how to act when recommendations were not followed. Conclusions & Implications: This study provides new understanding for patient safety dilemmas associated with the enactment and oversight of swallowing recommendations in context, on stroke wards. Findings can support SLTs and nurses to explore together how information for ongoing dysphagia management can be safely implemented within ward realities and kept up to date. This could include considering nursing capacity to act when SLTs are not there, mealtime staffing and SLT 7‐day working. Together they can review their understanding of risk and preferred local and formal routes for learning from it. What this paper adds: What is already known on the subject: It is known that information to keep swallowing safe is shared through swallowing recommendations, which are understood to involve a balance of risks between optimizing the safety of the swallow mechanism and maintaining physiological and emotional health. There is increasing appreciation from patient safety research, of the importance of understanding the context in which hospital staff make decisions about risk and patient safety. What this paper adds to existing knowledge: The paper provides new empirical understanding for the complexities of risk management associated with SLT and nursing interactions and roles with respect to ongoing swallow safety. What are the potential or actual clinical implications of this work?: Findings can underpin SLT and nurse discussion about how swallow safety could be improved in their own settings. [ABSTRACT FROM AUTHOR]

Background: Digital cervical auscultation (CA) has been proposed since the 1950s for screening aspiration among patients with dysphagia. Researchers have investigated the 'external' effects such as bolus viscosity, volume, and head and neck positions. However, the influences of standardized liquid viscosity and food texture on swallowing sounds have not been fully understood due to lacking uniform standardization of bolus preparation. Furthermore, a paucity of the literature recommends proper viscous liquids and foods to start swallowing training or monitor the swallowing progress during the continuum of disease based on acoustic signals. Aims: To investigate the effects of eight‐level liquids and foods on swallowing sound features based on the International Dysphagia Diet Standardisation Initiative (IDDSI). Methods & Procedures: We collected swallowing sounds from 30 healthy participants ranging in age from 19 to 60 years and who were self‐reporting no history of swallowing disorders. Each participant swallowed liquids and foods regarding different consistency or texture with their head–trunk in a neutral position. Outcomes & Results: Features of swallowing acoustic signals and the IDDSI flow test as well as food test confirmed the level 3 moderately thick (MO3) was more suitable to categorize into liquids and the level 4 extremely thick (EX4) was more corresponded to the properties of food bolus. We found significant differences in duration of acoustic signals across different liquids and foods except between swallowing level 0 thin liquid and level 1 slightly thick liquid, as well as EX4 and level 5 minced and moist. Our results also demonstrated liquid viscosity significantly impacted the peak intensity of swallowing sounds. Conclusions & Implications: As an initial exploration of digital CA across eight levels of different liquids and foods according to the IDDSI, we established the baseline findings for future comparisons with other study populations or other various consistent liquids/foods. Although both MO3 and EX4 can be considered as liquid or food boluses with high thickness, MO3 might be suitable as the 'start liquid' for patients with dysphagia; however, the decision still needs to be confirmed by the healthcare provider based on patients' safety and the area of deficit. We also concluded there are influences of varied fluid consistency and food texture on swallowing sounds. Furthermore, future investigations should explore whether changing viscosity levels could either continuously or discretely disturb the swallowing acoustic signals. What this paper adds: What is already known on the subject: Previous studies have found that the 'external' effects such as bolus viscosity, volume, and head and neck positions. Due to lacking uniform standardization of bolus preparation, there is limited information about the influences of standardized liquid viscosity and food texture on swallowing sounds. What this paper adds to the existing knowledge: As an initial exploration, we utilized digital CA with a large sample of viscous liquids and different textures of foods based on the IDDSI to investigate the swallowing sounds. What are the potential or actual clinical implications of this work?: This study confirms that the effects of various fluid consistency and food texture on swallowing acoustic signals. However, the findings of this study support the need for further research relating to changing viscosity could either continuously or discretely disturb the swallowing acoustic signals. [ABSTRACT FROM AUTHOR]

Background: Quantitative measures can increase precision in describing swallowing function, improve interrater and test–retest reliability, and advance clinical decision‐making. The Test of Mastication and Swallowing Solids (TOMASS) and the Timed Water Swallow Test (TWST) are functional tests for swallowing that provide quantitative results. Aims: To explore the relationship between TOMASS and TWST; evaluate test–retest and interrater reliability; explore age and gender effects; and gather normative data. Methods & Procedures: Healthy community dwelling participants (n = 298, ≥ 20 years old) were recruited. Of those, 126 were included in the reliability study. Participants completed the TWST and TOMASS. Outcomes & Results: Associations between TWST and TOMASS measures were found using Pearson's correlation coefficient. Age was positively associated with an increase in the number of bites (n = 292, r = 0.15, p = 0.009), masticatory cycles (n = 291, r = 0.33, p < 0.0001) and duration (n = 292, r = 0.32, p < 0.0001) for the TOMASS. For the TWST, age was positively associated with an increase in duration (n = 296, r = 0.23, p < 0.0001), and negatively associated with volume (n = 296, r = −0.205, p < 0.0001), and swallowing capacity (n = 296, r = −0.24, p < 0.0001). Females required more bites, masticatory cycles, swallows and longer time than males in TOMASS. In TWST, females required more swallows, longer time, and had lower volume per swallow and reduced swallowing capacity than males. Intraclass correlation coefficient (ICC) revealed good test–retest reliability and moderate to excellent interrater reliability. Conclusions & Implications: This study provides support for the validity of the TOMASS and TWST. Reduced efficiency in one of the tests might indicate a need to evaluate performance in the other. Extended chewing time and increased number of masticatory cycles might be compensatory behaviours for reduced oral processing abilities that are motor, sensory and/or mechanical. WHAT THIS PAPER ADDS: The TOMASS and TWST are functional tests of swallowing that provide quantitative results. They are easy to incorporate as part of the clinical evaluation of swallowing due to low cost and quick administration. Age and gender effects were found for the TWST and TOMASS, but they were only tested on relative measures rather than absolute measures. Different types of crackers used for TOMASS led to differences in performance and in normative values. What is already known on the subject: Associations between performance during TWST and TOMASS were found: time, number of swallows and time per swallow were correlated, meaning that need for more time and more swallows is reflected in both drinking and chewing. The study provides further support for age and gender effects in TWST and TOMASS, on both relative and also on absolute measures, which were not investigated previously. Longer durations in TOMASS and TWST with an increase in age, are likely to be the result of compensatory behaviours to allow safe swallowing. Normative data for a country‐specific cracker are presented (Israel). What are the potential or actual clinical implications of this work?: Reduced efficiency in one of the tests might indicate a need to evaluate performance in the other. Establishing country specific norms for commonly available crackers is necessary, since crackers size and ingredients, such as fat content and moisture, influence chewing and swallowing. There is a balancing act between safety and efficiency in older adults' swallowing behaviour. Reducing pace in eating and drinking probably supports safer swallowing. [ABSTRACT FROM AUTHOR]

Background: Dysphagia is a highly prevalent condition and affects a wide range of cohorts. A common compensatory strategy to manage dysphagia is diet modification. However, this technique is often associated with poor patient quality of life and adverse long‐term effects. Carbonated liquids have shown promise as an alternative compensatory strategy for the management of dysphagia. Aims: To examine the effect of genetic taste status and intensity of carbonation on swallowing and palatability in a healthy young adult population. To examine the palatability of carbonated liquids over time. Methods & Procedures: A total of 35 healthy young adults were recruited for this prospective, quantitative cohort study. They each drank 150 ml of still water (SW), lightly carbonated water (LCW) and highly carbonated water (HCW). Swallow function, palatability and genetic taste status were assessed using the timed water swallow test, the hedonic general labelled magnitude scale and participant ratings of the bitterness of propylthiouracil strips, respectively. Participants were divided into groups of supertasters, moderate tasters and non‐tasters. Outcomes & Results: A significant difference was found between SW and HCW on three tests of swallow function. Average time per swallow increased (p = 0.03), average swallow velocity decreased (p = 0.001) and average volume per swallow decreased (p = 0.017) on HCW compared with SW. HCW had a greater impact on swallow function than LCW. A significant mean difference in palatability ratings was found across intensity levels of carbonated fluids (p = 0.002), specifically between SW and HCW (p = 0.001). HCW was less palatable than SW. The palatability of carbonated liquids, investigated within a subgroup of five participants, did not decrease after a 24‐h period during which participants only drank carbonated liquids (p = 0.102). A significant difference was found between supertasters' (n = 9) (mean = 13.33) and non‐tasters' (n = 20) (mean = –24.5) palatability ratings of HCW (p = 0.03). Despite differences in swallow function between SW and HCW, no differences were detected between supertasters' and non‐tasters' swallow function on SW, LCW or HCW. Conclusions & Implications: Carbonated liquids have the ability to alter swallow function in a healthy young adult population; however, liquids must be highly carbonated in order to have an effect. Additionally, highly carbonated liquids are less palatable than SW, but the palatability of carbonated liquids does not decrease over time. Furthermore, supertasters find HCW more palatable than non‐tasters. These findings suggest that carbonated liquids alter swallowing in a healthy population. Further research in a clinical population is needed to better understand the potential role of sensory stimulation as a dysphagia intervention. What this paper adds: What is already known on the subject: Several studies have found that carbonated liquids have the ability to alter swallow function in both healthy and clinical populations. However, there is a lack of evidence around the optimum intensity of CO2 in carbonated liquids and the palatability of carbonated liquids as well as the palatability of carbonated fluids over time. What this paper adds to existing knowledge: The findings from this study suggest that carbonated liquids can alter swallow function in a healthy young adult population, but liquids must be highly carbonated in order to have an effect. HCW is less palatable than SW, but the palatability of carbonated liquids does not decrease over time. Additionally, supertasters find HCW more palatable than non‐supertasters (non‐tasters). What are the potential or actual clinical implications of this work?: The findings from this study suggest that carbonated liquids may be suitable for use as a sensory stimulation technique for people with dysphagia, as their palatability does not decrease over time; however, further research in a clinical population is needed in order to determine this. Additionally, intensity of stimulus is an important factor to consider during dysphagia evaluation to identify what intensity is required to optimize swallowing. [ABSTRACT FROM AUTHOR]

In this paper, a new approach for predicting the swallowing behavior of dysphagia was developed by a simulation of the pharyngeal area through a novel two-phase finite volume model. The physical properties of a bolus (surface tension, density, and viscosity), and the tongue driving pressure, which can affect the bolus transmission in the pharynx, were implemented in the proposed model to ameliorate the swallowing scenario simulation. Furthermore, the paper deals with the effect of cress seed gum (CSG) and xanthan gum (XG), as thickeners, at different concentration levels on the developed model for the swallowing behavior. The tongue pressure was assumed as a linear distribution with bolus axial-radial motion couplings. All samples containing the thickeners exhibited a typical shear-thinning behavior. The non-Newtonian fluids were demonstrated that these fluids are relatively safer and more effective than Newtonian fluids to swallow for patients with dysphagia by decreasing swallowing flow rate. Moreover, the results of pressure-inlet and flow rate diagrams confirmed that non-Newtonian fluids might lead to swallowing amelioration as well as aspiration risk reduction with increasing the thickeners’ concentration. The presented computational fluid dynamic (CFD) method showed that the proposed model could provide a practical procedure for classifying dysphagia products to ameliorate the swallowing scenario simulation. [ABSTRACT FROM AUTHOR]

Background: The potential for using ultrasound by speech and language therapists (SLTs) as an adjunct clinical tool to assess swallowing function has received increased attention during the COVID‐19 pandemic, with a recent review highlighting the need for further research on normative data, objective measurement, elicitation protocol and training. The dynamic movement of the hyoid, visible in ultrasound, is crucial in facilitating bolus transition and protection of the airway during a swallow and has shown promise as a biomarker of swallowing function. Aims: To examine the kinematics of the hyoid during a swallow using ultrasound imaging and to relate the patterns to the different stages of a normal swallow. To evaluate the accuracy and robustness of two different automatic hyoid tracking methods relative to manual hyoid position estimation. Methods & Procedures: Ultrasound data recorded from 15 healthy participants swallowing a 10 ml water bolus delivered by cup or spoon were analysed. The movement of the hyoid was tracked using manually marked frame‐to‐frame positions, automated hyoid shadow tracking and deep neural net (DNN) tracking. Hyoid displacement along the horizontal image axis (HxD) was charted throughout a swallow, and the maximum horizontal displacement (HxD max) and maximum hyoid velocity (HxV max) along the same axis were automatically calculated. Outcomes & Results: The HxD and HxV of 10 ml swallows are similar to values reported in the literature. The trajectory of the hyoid movement and its location at significant swallow event time points showed increased hyoid displacement towards the peak of the swallow. Using an interclass correlation coefficient, HxD max and HxV max values derived from the DNN tracker and shadow tracker are shown to be in high agreement and moderate agreement, respectively, when compared with values derived from manual tracking. Conclusions & Implications: The similarity of the hyoid tracking results using ultrasound to previous reports based on different instrumental tools supports the possibility of using hyoid movement as a measure of swallowing function in ultrasound. The use of machine learning to automatically track the hyoid movement potentially provides a reliable and efficient way to quantify swallowing function. These findings contribute towards improving the clinical utility of ultrasound as a swallowing assessment tool. Further research on both normative and clinical populations is needed to validate hyoid movement metrics as a means of differentiating normal and abnormal swallows and to verify the reliability of automatic tracking. WHAT THIS PAPER ADDS: What is already known on this subject: There is growing interest in the use of ultrasound as an adjunct tool for assessing swallowing function. However, there is currently insufficient knowledge about the patterning and timing of lingual and hyoid movement in a typical swallow. We know that movement of the hyoid plays an essential role in bolus transition and airway protection. However, manual tracking of hyoid movement is time‐consuming and restricts the extent of large‐scale normative studies. What this study adds: We show that hyoid movement can be tracked automatically, providing measurable continuous positional data. Measurements derived from this objective data are comparable with similar measures previously reported using videofluoroscopy and of the two automatic trackers assessed, the DNN approach demonstrates better robustness and higher agreement with manually derived measures. Using this kinematic data, hyoid movement can be related to different stages of swallowing. Clinical implications of this study: This study contributes towards our understanding of the kinematics of a typical swallow by evaluating an automated hyoid tracking method, paving the way for future studies of typical and disordered swallow. The challenges of image acquisition highlight issues to be considered when establishing clinical protocols. The application of machine learning enhances the utility of ultrasound swallowing assessment by reducing the labour required and permitting a wider range of hyoid measurements. Further research in normative and clinical populations is facilitated by automatic data extraction allowing the validity of prospective hyoid measures in differentiating different types of swallows to be rigorously assessed. [ABSTRACT FROM AUTHOR]

Despite continued surgical advancements in the field of cardiothoracic transplantation, post-operative complications remain a burden for the patient and the multidisciplinary team. Lesser-known complications including swallowing disorders (dysphagia), and voice disorders (dysphonia), are now being reported. Such disorders are known to be associated with increased morbidity and mortality in other medical populations, however their etiology amongst the heart and lung transplant populations has received little attention in the literature. This paper explores the potential mechanisms of oropharyngeal dysphagia and dysphonia following transplantation and discusses optimal modalities of diagnostic evaluation and management. A greater understanding of the implications of swallowing and laryngeal dysfunction in the heart and lung transplant populations is important to expedite early diagnosis and management in order to optimize patient outcomes, minimize allograft injury and improve quality of life. [ABSTRACT FROM AUTHOR]

Saliva exerts multiple functions in relation to the initial digestive processes taking place in the upper parts of the gastrointestinal tract. Ingestion of food and beverages, in turn, is a strong stimulus for secretion of saliva with a differential composition depending on the neuronal stimulation pattern. This review paper provides insight into the mechanisms by which saliva acts in relation to taste, mastication, bolus formation, enzymatic digestion and swallowing. Also, the protective functions of saliva including maintenance of dental and mucosal integrity will be discussed as they indirectly influence the digestive process. The final part of this study focuses on the implications of xerostomia and salivary gland dysfunction on gastrointestinal functions. [ABSTRACT FROM AUTHOR]

Purpose: Treatment in intensive care units (ICUs) often results in swallowing dysfunction. Recent longitudinal studies have described the recovery of critically ill people, but we are not aware of studies of the recovery of swallowing function in patients with ICU-acquired muscle weakness. This paper aims to describe the time course of regaining water swallowing function in patients with ICU-acquired weakness in the post-acute phase and to describe the risks of regaining water swallowing function and the risk factors involved. Methods: This cohort study included patients with ICU-acquired muscle weakness in our post-acute department, who were unable to swallow. We monitored the process of regaining water swallowing function using the 3-ounce water swallowing test. Results: We included 108 patients with ICU-acquired muscle weakness. Water swallowing function was regained after a median of 12 days (interquartile range =17) from inclusion in the study and after a median of 59 days (interquartile range= 36) from the onset of the primary illness. Our multivariate Cox Proportional Hazard model yielded two main risk factors for regaining water swallowing function: the number of medical tubes such as catheters at admission to the post-acute department (adjusted hazard ratio [HR] = 1.282; 95% confidence interval [CI]: 1.099-1.495) and the time until weaning from the respirator in days (adjusted HR =1.02 per day; 95%CI: 0.998 to 1.008). Conclusion: We describe a time course for regaining water swallowing function based on daily tests in the post-acute phase of critically ill patients. Risk factors associated with regaining water swallowing function in rehabilitation are the number of medical tubes and the duration of weaning from the respirator. Implications for rehabilitation: Little guidance is available for the management of swallowing dysfunction in the rehabilitation of critically ill patients with intensive-care-units acquired muscle weakness. There is a time dependent pattern of recovery from swallowing dysfunction with daily water swallowing tests in the post-acute phase of critically ill patients. Daily water swallowing tests can be used to test swallowing dysfunction in the post-acute phase of critically ill patients The amount of medical tubes and the duration of weaning from respirator are associated risk factors for recovery of swallowing dysfunction. [ABSTRACT FROM AUTHOR]

The paper reviews human mastication, focusing on its age-related changes. The first part describes mastication adaptation in young healthy individuals. Adaptation to obtain a food bolus ready to be swallowed relies on variations in number of cycles, muscle strength and volume of emitted saliva. As a result, the food bolus displays granulometric and rheological properties, the values of which are maintained within the adaptive range of deglutition. The second part concerns healthy ageing. Some mastication parameters are slightly modified by age, but ageing itself does not impair mastication, as the adaptation possibilities remain operant. The third part reports on very aged subjects, who display frequent systemic or local diseases. Local and/or general diseases such as tooth loss, salivary defect, or motor impairment are then indistinguishably superimposed on the effects of very old age. The resulting impaired function increases the risk of aspiration and choking. Lastly, the consequences for eating behaviour and nutrition are evoked. [ABSTRACT FROM AUTHOR]

Purpose:Duchenne muscular dystrophy (DMD) is a rapidly progressive neuromuscular disorder causing weakness of the skeletal, respiratory, cardiac and oropharyngeal muscles with up to one third of young men reporting difficulty swallowing (dysphagia). Recent studies on dysphagia in DMD clarify the pathophysiology of swallowing disorders and offer new tools for its assessment but little guidance is available for its management. This paper aims to provide a step-by-step algorithm to facilitate clinical decisions regarding dysphagia management in this patient population. Methods:This algorithm is based on 30 years of clinical experience with DMD in a specialised Centre for Neuromuscular Disorders (Inkendaal Rehabilitation Hospital, Belgium) and is supported by literature where available. Results:Dysphagia can worsen the condition of ageing patients with DMD. Apart from the difficulties of chewing and oral fragmentation of the food bolus, dysphagia is rather a consequence of an impairment in the pharyngeal phase of swallowing. By contrast with central neurologic disorders, dysphagia in DMD accompanies solid rather than liquid intake. Symptoms of dysphagia may not be clinically evident; however laryngeal food penetration, accumulation of food residue in the pharynx and/or true laryngeal food aspiration may occur. The prevalence of these issues in DMD is likely underestimated. Conclusions: There is little guidance available for clinicians to manage dysphagia and improve feeding for young men with DMD. This report aims to provide a clinical algorithm to facilitate the diagnosis of dysphagia, to identify the symptoms and to propose practical recommendations to treat dysphagia in the adult DMD population.Implications for RehabilitationLittle guidance is available for the management of dysphagia in Duchenne dystrophy.Food can penetrate the vestibule, accumulate as residue or cause aspiration.We propose recommendations and an algorithm to guide management of dysphagia.Penetration/residue accumulation: prohibit solid food and promote intake of fluids.Aspiration: if cough augmentation techniques are ineffective, consider tracheostomy. [ABSTRACT FROM AUTHOR]

Purpose: Altered fractionation radiotherapy with concomitant boost (AFRT-CB) may be considered an alternative treatment for patients not appropriate for chemoradiation (CRT). As functional outcomes following AFRT-CB have been minimally reported, this exploratory paper describes the outcomes of patients managed with AFRT-CB or CRT at 6 months post-treatment. Methods: Using a cross-sectional analysis design, functional outcomes of 14 AFRT-CB and 17 CRT patients with T1-T3 oropharyngeal cancers were explored at 6 months post-treatment. Clinical and instrumental swallow assessments, weight and nutritional status, and the functional impact of treatment were examined. Results: Inferior outcomes were observed for the CRT patients on the RBHOMS ( p = 0.03) which was reflected in diet and fluid restrictions with 18% of the CRT group requiring modified fluids and diets. Although a trend ( p = 0.07) was noted for increased lingual deficits and aspiration risk for fluids in the CRT group, no other significant differences were observed. Both groups experienced an average of 10 kg weight loss and reported reduced general and swallowing-related function. Conclusions: These preliminary data suggest functional outcomes following AFRT-CB and CRT were largely comparable at 6 months post-treatment. Treatment intensification in any form may contribute to impaired function which requires multidimensional intervention. Larger cohort investigations with systematic methodology are needed to further examine these initial findings. [ABSTRACT FROM AUTHOR]

Our understanding of etiology of obesity and overweight is incomplete due to lack of objective and accurate methods for monitoring of ingestive behavior (MIB) in the free-living population. Our research has shown that frequency of swallowing may serve as a predictor for detecting food intake, differentiating liquids and solids, and estimating ingested mass. This paper proposes and compares two methods of acoustical swallowing detection from sounds contaminated by motion artifacts, speech, and external noise. Methods based on mel-scale Fourier spectrum, wavelet packets, and support vector machines are studied considering the effects of epoch size, level of decomposition, and lagging on classification accuracy. The methodology was tested on a large dataset (64.5 h with a total of 9966 swallows) collected from 20 human subjects with various degrees of adiposity. Average weighted epoch-recognition accuracy for intravisit individual models was 96.8%, which resulted in 84.7% average weighted accuracy in detection of swallowing events. These results suggest high efficiency of the proposed methodology in separation of swallowing sounds from artifacts that originate from respiration, intrinsic speech, head movements, food ingestion, and ambient noise. The recognition accuracy was not related to body mass index, suggesting that the methodology is suitable for obese individuals. [ABSTRACT FROM AUTHOR]

Because of its distinct advantage in radiation-free soft tissue imaging, ultrasonography has been widely used to study lingual, pharyngeal, hyoid, laryngeal, and even esophageal action during swallowing in individuals of all ages. Qualitative ultrasonographic observations have made considerable contributions to our understanding of deglutition. Quantitative ultrasonographic swallowing research has also grown by leaps and bounds over the years with advances in imaging technologies and analytical methodologies. As a technical primer for new investigators, this paper reviews the modern methods for quantitative analysis in ultrasonographic swallowing research. The intended outcome is a basic understanding of the application of ultrasonography with various analysis options to the quantitative study of the deglutitive action of selected upper aerodigestive structures. Though proven useful for swallowing research, ultrasonography has inherent limitations and methodological issues. Future technological advancement and sophisticated image processing and analysis algorithms will resolve some of these issues. [ABSTRACT FROM AUTHOR]

Summary Modelling flavour release from foods in the mouth requires detailed knowledge of the mastication process. In this paper we show how the distribution of chewing and swallowing time intervals as well as the sphericity changes on chewing and swallowing all conform accurately to a Pearson Type IV probability distribution. We show how these distributions, measured by electromyography for each panellist, can be used to generate simulated individual mastication patterns for use in flavour release calculations. [ABSTRACT FROM AUTHOR]

Diabetes, a metabolic disorder due to high blood glycemic index in the human body. The glycemic index varies in the human of improper diet and eating pattern such as junk foods, variation in the quantity of food, swallowing of food without chewing and stress. However, the diagnose of increase or decrease in the glycemic index is a challenging task. Similarly, the regulation of glycemic index without regular exercise is a major problem in day to day life. In this paper, we propose a novel SCS method to regulate glycemic index without exercise through changing the eating method. The proposed SCS eating method consists of Size of the food, Chewing style and Swallow time (SCS) of the food to regulate glycemic index. Furthermore, the proposed SCS method evaluate and validate through the acoustic signal acquired and processed with deep learning algorithm to analyze the chewing pattern of food to formulate a standard procedure for eating style and to reduce the glycemic level. The validation of diabetes done by measurement of blood glycemic through AccuChek Instant S Glucometer. Furthermore, the SCS method of eating style from 50 diabetes persons reduces the blood glucose level drastically by 85% after following the proposed method of eating style. [ABSTRACT FROM AUTHOR]

Background This paper aims to measure upper esophageal sphincter (UES) distensibility and extent and duration of UES opening during swallowing in healthy subjects using EndoFLIP®. Methods Fourteen healthy subjects (20-50 years) were recruited. An EndoFLIP® probe was passed trans-orally and the probe balloon was positioned across the UES. Two 20-mL ramp distensions were completed and UES cross-sectional area (CSA) and intra-balloon pressure (IBP) were evaluated. At 12-mL balloon volume, subjects completed dry, 5- and 10-mL liquid swallows and extent (mm) and duration (s) of UES opening and minimum IBP (mmHg) were analyzed across swallows. Key Results Thirteen subjects completed the study protocol. A significant change in UES CSA ( P < .001) and IBP ( P < .000) was observed during 20-mL distension. UES CSA increased up to 10-mL distension ( P < .001), from which point IBP raised significantly ( P = 0.004). There were significant changes in UES diameter (mm) ( P < .000) and minimum IBP (mmHg) ( P < .000) during swallowing events. Resting UES diameter (4.9 mm; IQR 0.02) and minimum IBP (18.8 mmHg; IQR 2.64) changed significantly during dry (9.6 mm; IQR 1.3: P < .001) (3.6 mmHg; IQR 4.1: P = 0.002); 5 mL (8.61 mm; IQR 2.7: P < .001) (4.8 mmHg; IQR 5.7: P < .001) and 10-mL swallows (8.3 mm; IQR 1.6: P < 0.001) (3 mmHg; 4.6: P < .001). Median duration of UES opening was 0.5 s across dry and liquid swallows ( P = 0.91). Color contour plots of EndoFLIP® data capture novel information regarding pharyngo-esophageal events during swallowing. Conclusions & Inferences Authors obtained three different types of quantitative data (CSA, IBP, and timing) regarding UES distensibility and UES opening patterns during swallowing in healthy adults using only one device (EndoFLIP®). This new measure of swallowing offers fresh information regarding UES dynamics which may ultimately improve patient care. [ABSTRACT FROM AUTHOR]