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The Charleston Swallowing Conference at Northwestern University is a clinical multidisciplinary conference designed for dysphagia clinicians who practice across all care settings and treat individuals of all ages. This special issue of the American Journal of Speech-Language Pathology contains selected articles from the July 2018 conference dedicated to innovation and implementation of dysphagia practice. The collection of articles includes clinical best practices, new patient-centered assessment and treatment discoveries, re-examination and application of current practices across the age spectrum, and the role of novel technology and data science initiatives. Clinicians and researchers will gain practical, tangible, and directly translatable information toward advanced skill sets in swallowing assessment and treatment.

Background Fluid thickening is a well-established management strategy for oropharyngeal dysphagia (OD). However, the effects of thickening agents on the physiology of impaired swallow responses are not fully understood, and there is no agreement on the degree of bolus thickening. Aim To review the literature and to produce a white paper of the European Society for Swallowing Disorders (ESSD) describing the evidence in the literature on the effect that bolus modification has upon the physiology, efficacy and safety of swallowing in adults with OD. Methods A systematic search was performed using the electronic Pubmed and Embase databases. Articles in English available up to July 2015 were considered. The inclusion criteria swallowing studies on adults over 18 years of age; healthy people or patients with oropharyngeal dysphagia; bolus modification; effects of bolus modification on swallow safety (penetration/aspiration) and efficacy; and/or physiology and original articles written in English. The exclusion criteria consisted of oesophageal dysphagia and conference abstracts or presentations. The quality of the selected papers and the level of research evidence were assessed by standard quality assessments. Results At the end of the selection process, 33 articles were considered. The quality of all included studies was assessed using systematic, reproducible, and quantitative tools (Kmet and NHMRC) concluding that all the selected articles reached a valid level of evidence. The literature search gathered data from various sources, ranging from double-blind randomised control trials to systematic reviews focused on changes occurring in swallowing physiology caused by thickened fluids. Main results suggest that increasing bolus viscosity (a) results in increased safety of swallowing, (b) also results in increased amounts of oral and/or pharyngeal residue which may result in post-swallow airway invasion, (c) impacts the physiology with increased lingual pressure patterns, no major changes in impaired airway protection mechanisms, and controversial effects on oral and pharyngeal transit time, hyoid displacements, onset of UOS opening and bolus velocity—with several articles suggesting the therapeutic effect of thickeners is also due to intrinsic bolus properties, (d) reduces palatability of thickened fluids and (e) correlates with increased risk of dehydration and decreased quality of life although the severity of dysphagia may be an confounding factor. Conclusions The ESSD concludes that there is evidence for increasing viscosity to reduce the risk of airway invasion and that it is a valid management strategy for OD. However, new thickening agents should be developed to avoid the negative effects of increasing viscosity on residue, palatability, and treatment compliance. New randomised controlled trials should establish the optimal viscosity level for each phenotype of dysphagic patients and descriptors, terminology and viscosity measurements must be standardised. This white paper is the first step towards the development of a clinical guideline on bolus modification for patients with oropharyngeal dysphagia.

Fluid thickening is a well-established management strategy for oropharyngeal dysphagia (OD). However, the effects of thickening agents on the physiology of impaired swallow responses are not fully understood, and there is no agreement on the degree of bolus thickening.To review the literature and to produce a white paper of the European Society for Swallowing Disorders (ESSD) describing the evidence in the literature on the effect that bolus modification has upon the physiology, efficacy and safety of swallowing in adults with OD.A systematic search was performed using the electronic Pubmed and Embase databases. Articles in English available up to July 2015 were considered. The inclusion criteria swallowing studies on adults over 18 years of age; healthy people or patients with oropharyngeal dysphagia; bolus modification; effects of bolus modification on swallow safety (penetration/aspiration) and efficacy; and/or physiology and original articles written in English. The exclusion criteria consisted of oesophageal dysphagia and conference abstracts or presentations. The quality of the selected papers and the level of research evidence were assessed by standard quality assessments.At the end of the selection process, 33 articles were considered. The quality of all included studies was assessed using systematic, reproducible, and quantitative tools (Kmet and NHMRC) concluding that all the selected articles reached a valid level of evidence. The literature search gathered data from various sources, ranging from double-blind randomised control trials to systematic reviews focused on changes occurring in swallowing physiology caused by thickened fluids. Main results suggest that increasing bolus viscosity (a) results in increased safety of swallowing, (b) also results in increased amounts of oral and/or pharyngeal residue which may result in post-swallow airway invasion, (c) impacts the physiology with increased lingual pressure patterns, no major changes in impaired airway protection mechanisms, and controversial effects on oral and pharyngeal transit time, hyoid displacements, onset of UOS opening and bolus velocity-with several articles suggesting the therapeutic effect of thickeners is also due to intrinsic bolus properties, (d) reduces palatability of thickened fluids and (e) correlates with increased risk of dehydration and decreased quality of life although the severity of dysphagia may be an confounding factor.The ESSD concludes that there is evidence for increasing viscosity to reduce the risk of airway invasion and that it is a valid management strategy for OD. However, new thickening agents should be developed to avoid the negative effects of increasing viscosity on residue, palatability, and treatment compliance. New randomised controlled trials should establish the optimal viscosity level for each phenotype of dysphagic patients and descriptors, terminology and viscosity measurements must be standardised. This white paper is the first step towards the development of a clinical guideline on bolus modification for patients with oropharyngeal dysphagia.

Purpose Our objectives were to (a) identify oral and pharyngeal physiologic swallowing impairment severity classes based on latent class analyses (LCAs) of the Modified Barium Swallow Impairment Profile (MBSImP) swallow task scores and (b) quantify the probability of severity class membership given composite MBSImP oral total (OT) and pharyngeal total (PT) scores. Method MBSImP scores were collected from a patient database of 319 consecutive modified barium swallow studies. Because of missing swallow task scores, LCA was performed using 25 multiply imputed data sets. Results LCA revealed a three-class structure for both oral and pharyngeal models. We identified OT and PT score intervals to assign subjects to oral and pharyngeal impairment latent severity classes, respectively, with high probability (probability of class membership ≥ 0.9 given OT or PT scores within specified ranges) and high confidence (95% credible interval [CI] widths ≤ 0.24 for all total scores within specified ranges). OT scores ranging from 0 to 10 and from 14 to 18 yielded assignments in Oral Latent Classes 1 and 2, respectively, while OT = 22 was assigned to Oral Latent Class 3. PT scores ranging from 0 to 13 and from 18 to 24 yielded assignments in Pharyngeal Latent Classes 1 and 2, respectively, while PT = 26 was assigned to Pharyngeal Latent Class 3. Conclusions LCA of MBSImP task-level data revealed significant underlying oral and pharyngeal ordinal class structures representing increasingly severe gradations of physiologic swallow impairment. Clinically meaningful OT and PT score ranges were derived facilitating latent class assignment. Supplemental Material https://doi.org/10.23641/asha.12315677

Background Preliminary studies have shown that respiratory–swallow training (RST) is a successful treatment for oropharyngeal head and neck cancer patients with refractory dysphagia. Refining the RST protocol with automated analysis software to provide real-time performance feedback has the potential to improve accessibility, reproducibility, and translation to diverse clinical settings. Method An automated software program for data acquisition and analysis developed to detect swallows, determine respiratory phase, calculate lung volume at the onset of the swallow, and provide real-time performance feedback was tested for feasibility in a small cohort of healthy adults. Outcome Measures Percent difference in swallow detection and accuracy of real-time performance feedback of respiratory phase and lung volume at swallowing onset between the automated software and the manual gold standard method were determined. Results The automated software program accurately detected the onset of the swallow on 91% of the swallows completed during the training trials. Feedback of respiratory phase and lung volume was accurate on 94% of the trials in which the swallow was accurately detected. Conclusions This novel, automated, and real-time RST software successfully detected the onset of the swallow, respiratory phase, and lung volume at swallow onset and provided appropriate real-time performance feedback with a high degree of accuracy in healthy adults. The software has the potential to improve the accessibility, efficiency, and translation of RST to diverse patient populations.

Purpose Swallowing is a complex process, mediated by a broad bilateral neural network that spans from the brainstem to subcortical and cortical brain structures. Although the cortex's role in swallowing was historically neglected, we now understand, especially through clinical observations and research of patients with stroke, that it substantially contributes to swallowing control. Neuroimaging techniques (e.g., magnetic resonance imaging) have helped significantly to elucidate the role of cortical and subcortical brain areas, in general, and the importance of specific areas in swallowing control in healthy individuals and patients with stroke. We will review recent discoveries in cortical and subcortical neuroimaging research studies and their generalizability across patients to discuss their potential implications and translation to dysphagia diagnosis and treatment in clinical practice. Conclusions Stroke lesion locations have been identified that are commonly associated across patients with the occurrence and recovery of dysphagia, suggesting that clinical brain scans provide useful information for improving the diagnosis and treatment of patients with stroke. However, individual differences in brain structure and function limit the generalizability of these relationships and emphasize that the extent of the motor and sensory pathology in swallowing, and how the patient recovers, also depends on a patient's individual brain constitution. The involvement of the damaged brain tissue in swallowing control before the stroke and the health of the residual, undamaged brain tissue are crucial factors that can differ between individuals.

High-resolution cervical auscultation (HRCA) is an evolving clinical method for noninvasive screening of dysphagia that relies on data science, machine learning, and wearable sensors to investigate the characteristics of disordered swallowing function in people with dysphagia. HRCA has shown promising results in categorizing normal and disordered swallowing (i.e., screening) independent of human input, identifying a variety of swallowing physiological events as accurately as trained human judges. The system has been developed through a collaboration of data scientists, computer–electrical engineers, and speech-language pathologists. Its potential to automate dysphagia screening and contribute to evaluation lies in its noninvasive nature (wearable electronic sensors) and its growing ability to accurately replicate human judgments of swallowing data typically formed on the basis of videofluoroscopic imaging data. Potential contributions of HRCA when videofluoroscopic swallowing study may be unavailable, undesired, or not feasible for many patients in various settings are discussed, along with the development and capabilities of HRCA. The use of technological advances and wearable devices can extend the dysphagia clinician's reach and reinforce top-of-license practice for patients with swallowing disorders.

Contains fulltext : 225337.pdf (Publisher’s version ) (Closed access) Malignant dysphagia is the most common symptom in advanced oesogastric cancers patients. Relief of dysphagia allows quality of life improvement, nutritional replenishment and potentially improves prognosis. Chemotherapy alone is effective and should be prioritised in patients with metastatic disease a good performance status, and its impact on dysphagia should be determined before further interventions are planned. Regarding local treatments, the insertion of a covered self-expandable metallic stent is the most commonly used alternative, as it allows for the rapid relief of severe dysphagia. Although several randomised trials have highlighted the role of oesophageal brachytherapy, this technique is often not easily accessible. Contemporary trials are ongoing to better define the role of external radiation therapy. While awaiting these results, external radiation therapy can be considered as a second-best option for patients with a life-expectancy > 3 months. It is important to offer nutritional support and to integrate quality of life measures in the palliative management of dysphagia. This multidisciplinary international position paper aims to propose a decision-making process and highlight randomised trials for the management of malignant dysphagia in metastatic oesogastric cancer patients.

Purpose People with amyotrophic lateral sclerosis frequently experience bulbar impairment and dysarthria that may restrict their ability to take part in everyday communication situations. The aim of this study is to examine selected variables that may contribute to restrictions in communicative participation. Method Community-dwelling participants with amyotrophic lateral sclerosis ( N = 70) who reported communication changes but continued to use natural speech completed a survey, including the Communicative Participation Item Bank, demographics (age, sex, living situation, employment status, education, and time since diagnosis), and self- reported symptom-related variables (physical activity, emotional problems, fatigue, pain, speech severity, speech usage, and cognitive and communication skills). To identify predictors of restrictions in communicative participation, these variables were entered into a backward stepwise multiple linear regression analysis. Results Three variables (speech severity, swallowing severity, and speech usage) were included in the final model and accounted for 55% of the variability. Conclusions Better speech and swallowing skills and higher speech usage are associated with better communicative participation in this sample. Thus, when making clinical decisions regarding intervention, clinicians should continue their efforts to target speech and swallow abilities, while recognizing other variables that have the potential of restricting communicative participation.

Background: Due to the high post-stroke frequency of dysphagia, dysarthria, and aphasia, we developed comprehensive neuroanatomical, clinical, and demographic models to predict their presence after acute ischemic stroke. Methods: The sample included 160 randomly selected first-ever stroke patients with confirmed infarction on magnetic resonance imaging from 1 tertiary stroke center. We documented acute lesions within 12 neuroanatomical regions and their associated volumes. Further, we identified concomitant chronic brain disease, including atrophy, white matter hyperintensities, and covert strokes. We developed predictive models using logistic regression with odds ratios (OR) and their 95% confidence intervals (95% CI) including demographic, clinical, and acute and chronic neuroanatomical factors. Results: Predictors of dysphagia included medullary (OR 6.2, 95% CI 1.5–25.8), insular (OR 4.8, 95% CI 2.0–11.8), and pontine (OR 3.6, 95% CI 1.2–10.1) lesions, followed by brain atrophy (OR 3.0, 95% CI 1.04–8.6), internal capsular lesions (OR 2.9, 95% CI 1.2–6.6), and increasing age (OR 1.4, 95% CI 1.1–1.8). Predictors of dysarthria included pontine (OR 7.8, 95% CI 2.7–22.9), insular (OR 4.5, 95% CI 1.8–11.4), and internal capsular (OR 3.6, 95% CI 1.6–7.9) lesions. Predictors of aphasia included left hemisphere insular (OR 34.4, 95% CI 4.2–283.4), thalamic (OR 6.2, 95% CI 1.6–24.4), and cortical middle cerebral artery (OR 4.7, 95% CI 1.5–14.2) lesions. Conclusion: Predicting outcomes following acute stroke is important for treatment decisions. Determining the risk of major post-stroke impairments requires consideration of factors beyond lesion localization. Accordingly, we demonstrated interactions between localized and global brain function for dysphagia and elucidated common lesion locations across 3 debilitating impairments.

Background: A patency capsule (PC) can help predict capsule endoscope (CE) retention; however, PC tolerability is unknown in children. We retrospectively evaluated PC tolerability in school-aged children. Methods: Sixty-one patients (median age, 12.9 years; range 7.4-17.3 years) who underwent PC examination were analyzed for occurrence and determinants of ingestion difficulty and relationships between ingestion of the 2 capsules. We defined ingestion difficulty as taking 30 min or more, or failure, to ingest the PC. Results: Thirty-nine patients (64%) successfully ingested the PC without ingestion difficulty. The other 22 had ingestion difficulty and were significantly younger (11.7 ± 2.2 vs. 13.0 ± 1.8 years; p = 0.04) and shorter (143.3 ± 14.0 vs. 154.6 ± 12.5 cm; p = 0.003) than those without ingestion difficulty. Multivariate analysis showed that the most significant factor for predicting PC ingestion difficulty was height (cutoff value, 152 cm). Time to ingest the CE was significantly shorter than that for PC ingestion (8 ± 32 vs. 20 ± 58 min; p = 0.01). All patients indicated that ingestion of the CE was easier because of its smooth surface compared with the PC. Conclusions: PC ingestion is not guaranteed in school-aged children. PC ingestion ability should be evaluated by considering the child's height and lack of experience ingesting capsules prior to PC examination.

Background Tongue pressure is an effective index of swallowing function, and it decreases with aging and disease progression. Previous research has shown beneficial effects of swallowing exercises combined with myofunctional tongue-strengthening therapy on tongue function. Tongue exercises delivered through mobile health (mHealth) technologies have the potential to advance health care in the digital age to be more efficient for people with limited resources, especially older adults. Objective The purpose of this study is to explore the immediate and long-term maintenance effects of an 8-week home-based mHealth app intervention with biweekly (ie, every 2 weeks) human mediation aimed at improving the swallowing tongue pressure in older adults. Methods We developed an mHealth app intervention that was used for 8 weeks (3 times/day, 5 days/week, for a total of 120 sessions) by 11 community-dwelling older adults (10 women; mean age 75.7 years) who complained of swallowing difficulties. The app included a swallowing monitoring and intervention protocol with 3 therapy maneuvers: effortful prolonged swallowing, effortful pitch glide, and effortful tongue rotation. The 8-week intervention was mediated by biweekly face-to-face meetings to monitor each participant’s progress and ability to implement the training sessions according to the given protocol. Preintervention and postintervention isometric and swallowing tongue pressures were measured using the Iowa Oral Performance Instrument. We also investigated the maintenance effects of the intervention on swallowing tongue pressure at 12 weeks postintervention. Results Of the 11 participants, 8 adhered to the home-based 8-week app therapy program with the optimal intervention dosage. At the main trial end point (ie, 8 weeks) of the intervention program, the participants demonstrated a significant increase in swallowing tongue pressure (median 17.5 kPa before the intervention and 26.5 kPa after the intervention; P=.046). However, long-term maintenance effects of the training program on swallowing tongue pressure at 12 weeks postintervention were not observed. Conclusions Swallowing tongue pressure is known to be closely related to dysphagia symptoms. This is the first study to demonstrate the effectiveness of the combined methods of effortful prolonged swallowing, effortful pitch glide, and effortful tongue rotation using mobile app training accompanied by biweekly human mediation in improving swallowing tongue pressure in older adults. The mHealth app is a promising platform that can be used to deliver effective and convenient therapeutic service to vulnerable older adults. To investigate the therapeutic efficacy with a larger sample size and observe the long-term effects of the intervention program, further studies are warranted. International Registered Report Identifier (IRRID) RR2-10.2196/19585

Background Swallowing difficulties (ie, dysphagia) are common among older adults, with a 13% to 54% prevalence. Adequate interventions to improve the swallowing function of older adults would reduce morbidity and enhance health-related quality of life outcomes. Mobile health (mHealth) apps may help alleviate dysphagia symptoms by providing programs that maximize the intensity and frequency of training without requiring high costs or regular clinic visits. Objective The aim of this pilot study was to assess the usability of swallowing training apps by quantitatively and qualitatively evaluating older adults’ self-reported data, taking into consideration their educational levels and exposure to mobile technology. We conducted surveys and brief interviews while the participants used a swallowing intervention app we developed. We subsequently identified and resolved individual-specific usability issues to improve future implementation of the app protocol for older persons with swallowing difficulties. Methods A total of 11 participants (10 women, 91%; mean age 75.7 years, SD 3.93) from two district-run senior welfare centers took part in this study. The participants were divided into a high-potential group and a low-potential group based on their total number of years of education and smart device usage. To investigate the usability of the app twice (ie, in the second week of the intervention and the postintervention stage), we used mixed methods consisting of both quantitative approaches, namely the System Usability Scale (SUS) and modified Computer Self-Efficacy Scale (mCSES) surveys, and qualitative approaches (ie, interviews). Results The quantitative results of the SUS and mCSES surveys revealed that the high-potential group was more inclined to adopt and learn new technology than the low-potential group. Specifically, within the high-potential group, a Wilcoxon signed-rank test indicated that the postintervention mCSES scores (median 65.50) were significantly higher than those in the second week of intervention (median 54.00; z=–2.023, P=.04). Additionally, the usability scores in the low-potential group were within the “marginal acceptability” range even after completion of an 8-week intervention program. Qualitative analyses via semi-structured interviews yielded promising outcomes regarding app acceptability, training program utilization, emotional responses, and learning experience. Conclusions To the best of the authors’ knowledge, this usability and feasibility study is the first report of a swallowing training app designed to improve the swallowing function of older adults. Future research should consider several issues, such as user characteristics, pretraining education, and the intensity and innate characteristics of the intervention program.

Background: Dysphagia is a frequent and dangerous complication of acute stroke. Apart from a well-timed oropharyngeal muscular contraction pattern, sensory feedback is of utmost importance for safe and efficient swallowing. In the present study, we therefore analyzed the relation between pharyngolaryngeal sensory deficits and post-stroke dysphagia (PSD) severity in a cohort of acute stroke patients with middle cerebral artery (MCA) infarction. Methods: Eighty-four first-ever MCA stroke patients (41 left, 43 right) were included in this trial. In all patients, fiberoptic endoscopic evaluation of swallowing (FEES) was performed according to a standardized protocol within 96 h after stroke onset. PSD was classified according to the 6-point fiberoptic endoscopic dysphagia severity scale. Pharyngolaryngeal sensation was semi-quantitatively evaluated by a FEES-based touch technique. Results: PSD severity was closely related to the pharyngolaryngeal sensory deficit. With regards to lateralization of the sensory deficit, there was a slight but significant preponderance of sensory loss contralateral to the side of stroke. Apart from that, right hemispheric stroke patients were found to present with a more severe PSD. Conclusions: This study provides evidence that an intact sensory feedback is of utmost importance to perform nonimpaired swallowing and highlights the key role of disturbed pharyngeal and laryngeal afferents in the pathophysiology of PSD.

Introduction: Acute intoxications with corrosive substances can cause severe chemical injuries of the upper gastrointestinal tract, most often located in the mouth, pharynx, esophagus, stomach and duodenum. If a patient survives the acute phase of intoxication, regenerative response may result in esophageal and/or gastric stenosis, and increased risk of esophageal and gastric cancer. Such intoxication may be fatal due to perforation or tracheal necrosis. Enteral nutrition is a nutritional method when nutritional substances are administered through specially designed tubing placed through the nose or percutaneously, directly into the GIT. Aim: The aim of this study is to describe the methods of artificial nutrition in patients with acute corrosive intoxications and the importance of nutritional support in the treatment of these intoxications. Discussion: Nutrition in the treatment of acute corrosive intoxications is one of the most important therapeutic processes that largely contribute to faster recovery of the post-corrosive injuries of upper GIT, stabilization of biologic, immunologic and metabolic parameters, and reduction of length of stay in hospital Aim of the treatment of acute corrosive intoxications is to prevent perforation and progressive fibrosis, and esophageal and gastric stenosis. There are different and often conflicting positions, on the conservative treatment of acute corrosive intoxications in adults. Such treatment mainly consists of anti-secretory treatment, antibiotics and intensive hyper-alimentation, aiming to prevent late post-corrosive intoxications. Conclusion: It is considered that nutritional support plays a major role in maintenance of metabolic processes and prevention of severe metabolic complications that could additionally aggravate the condition and impair the treatment. Key words: corrosive poisonings, deglutition, deglutition disorders, nutritional therapy, enteral nutrition, parenteral nutrition

To demonstrate CT findings in patients with chronic aspiration compared with a control group without aspiration, as detected by the videofluoroscopic swallowing study (VFSS).This retrospective, observational study included patients with and without diagnoses of aspiration confirmed by VFSS, who underwent CT examination of the lungs between 2010 and 2014. Two radiologists blinded to the presence of aspiration reviewed the images to detect the presence of any abnormality. Consensus was reached with a third radiologist. CT pulmonary findings (bronchial thickening, bronchiolectasis, centrilobular nodules, ground-glass opacities, atelectasis, consolidation and air trapping) were compared between the groups using the χ(2) test, with a significance level of 0.05.A total of 56 patients (28 patients with diagnoses of aspiration; 52% male, mean age 65 ± 15 years) were included in the study. Patients with aspiration were more likely to than those in the control group to demonstrate atelectasis, centrilobular nodules, bronchiolectasis, consolidation and ground-glass opacities (all p 0.05), with a significant predilection for the lower lobes (p 0.001). Bronchial wall thickening and air trapping did not differ between groups.Atelectasis, centrilobular nodules, bronchiolectasis, consolidation and ground-glass opacities occurred more frequently in patients with aspiration than in those without aspiration, with a pronounced tendency for distribution in the lower lobes.CT findings of aspiration are very important, as pulmonary symptoms may be the first manifestation of this disorder. Knowledge of these findings is essential to enable the early diagnosis of aspiration disorders and prevent lung damage.

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.

Background The Test of Masticating and Swallowing Solids (TOMASS) is an international standardized swallowing assessment tool. However, its psychometric characteristics have not been analysed in patients with dysphagia. Aims To analyse TOMASS's (1) inter- and intra-rater reliability in a clinical population of patients with dysphagia, (2) known-group validity, (3) concurrent validity and (4) correlation with meal duration. Methods & procedures Two age- and gender-matched groups of 39 participants each were recruited: A group of patients with dysphagia and a control group with no history of dysphagia. The TOMASS was carried out in both populations, video-recorded and scored offline by two speech and language therapists (SLT 1 and SLT 2) (inter-rater reliability) and twice by the same SLT (intra-rater reliability). In the clinical group, the TOMASS was carried out three times: (1) to verify understanding of the required tasks, (2) performed concurrently during fibreoptic endoscopic evaluation of swallowing (FEES) to assess validity and (3) during clinical assessment to assess reliability. TOMASS under endoscopic control was recorded and the number of white-out events was counted to compare with the number of observed swallows per cracker during standard TOMASS as a measure of concurrent validity. As additional measures of TOMASS validity, oral dental status, classified as 'functional' or 'partially functional', and duration of a standard meal were assessed by an SLT (SLT 1 or SLT 2), and then correlated with TOMASS. Outcome & results TOMASS's inter- and intra-rater reliability were high (intraclass correlation coefficient (ICC) > 0.95) in both the clinical and the control groups. The number of masticatory cycles (p = 0.020), swallows (p = 0.013) and total time (p = 0.003) of TOMASS were significantly lower in the control group than in the clinical group. Patients with 'partially functional' oral dental status showed a significantly higher number of masticatory cycles per cracker and a longer duration of ingestion than patients with a 'functional' one. Concurrent validity suggested a substantial agreement between TOMASS and FEES in defining the number of swallows per cracker. The mean difference of the two measures was -0.02 (95% confidence interval (CI) = -1.7 to 1.2). Meal duration significantly correlated with the 'number of swallows per cracker' (r = 0.49; p = 0.002) and 'total time' (r = 0.41; p = 0.011). Conclusions & implications Preliminary psychometric analysis of TOMASS in a clinical sample of outpatients with dysphagia suggests that it is a reliable and valid (specifically related to the number of swallows per cracker) tool. TOMASS's application in clinical practice to quantitatively measure solid bolus ingestion is recommended. What this paper adds What is already known on the subject The Test of Masticating and Swallowing Solids (TOMASS) is an international standardized swallowing assessment tool to evaluate oral preparation and oral phase of solids. The TOMASS' reliability and validity were tested on healthy subjects and normative data were gained. What this paper adds to existing knowledge The study provides the first data on the validity and reliability of the TOMASS in a clinical population. The TOMASS was proved to be a reliable and valid tool also in patients with dysphagia and to distinguish between patients with dysphagia and healthy subjects. What are the potential or actual clinical implications of this work? The use of the TOMASS in clinical practice is recommended as a valid and reliable tool to quantitatively measure the ingestion of solid in patients with dysphagia.

A 32-year-old female with a history of bipolar disorder and schizophrenia was transported to our tertiary-care hospital after swallowing a large toilet paper holder bracket. Removal of the large foreign body required coordination between anesthesiology, otolaryngology, and trauma surgery. A tracheostomy airway was established, and the object was removed transorally. The object was found to be a toilet paper holder bracket measuring 7.5 cm × 5.4 cm × 5.4 cm with a 2.6 cm screw protruding from the end. A review of articles describing the removal of foreign bodies from the upper aerodigestive tract found our object to be the largest foreign body ingestion described in literature. One report suggested that 18% of adult patients with foreign body ingestions had primary neuropsychiatric disorders. Our patient’s psychiatric disorder was a major underlying factor leading to the ingestion, with our patient reporting hallucinations instructing her to ingest household objects.

Aspiration pneumonia is a life-threatening disease for the elderly. To prevent its risk, regular swallowing assessment is necessary; however, current screening tools for swallow assessment are not widely available and medical experts are insufficient. As a portable assessment tool, we have been developing a smartphone-based realtime monitoring device (GOKURI) which can evaluate swallowing ability based on swallow sounds. For better detection accuracy of the system, we integrated a deep learning model which was developed based on the swallowing anatomy. In this paper, we provide a detailed analysis to see how the swallow sounds detected by the deep learning-based monitor correspond to the actual swallow activities. Also, as an example of practical application of the system, we analyzed the changes of the swallow abilities over time by recording swallow sounds twice for the same participants at a nursing home. To minimize the risk of aspiration pneumonia, caregivers need to understand the disability levels of the patient’s swallows so that safe feeding assistance can be provided. The result of this paper implies the possibility of using GOKURI as a daily swallowing monitor with minimum interventions.

To perform a systematic review of studies reporting swallow-associated outcomes in patients who received surgery for head and neck cancer (HNC), informed by an anatomic and physiologic framework of pharyngeal phase of swallowing (Pearson's dual-sling model).PUBMED and Google Scholar databases were searched for peer-reviewed papers published between 1990 and 2019 using relevant MeSH terms. Exclusion criteria were 1) discussions comparing reconstruction techniques, 2) case-report/series (n 10), 3) perspective articles, 4) papers comparing objective instrumental methods of swallowing evaluation, 5) animal/cadaver studies, 6) no instrumental or validated swallow assessment tools used, 7) papers that discuss/include radiotherapy treatment, 8) systematic reviews, 9) papers that discuss swallow training or rehabilitation methods. Two investigators reviewed papers meeting inclusion/exclusions criteria. Muscles resected, anatomic resection site, swallow outcomes, and patient treatment variables were collected.A total of 115,020 peer-reviewed papers were identified. 74 papers were relevant to this review, 18 met inclusion and exclusion criteria, and none discussed surgical impact on the pharyngeal phase of swallowing using Pearson's dual-sling model. Most papers discussed the effect of tongue-base, supraglottic, or regional anatomic resection. Post-surgical resection Follow-up times ranged from 1 to 13 months. 67% of studies used objective instrumental swallow studies; 22% used patient reported outcome measures. Follow up time since surgical resection, time to feeding tube removal, feeding tube present/absent, aspiration severity were used to define dysphagia endpoints.To date, no surgical HNC studies have used the dual-sling mechanism to guide study design, and dysphagia assessment has been inconsistent. To counsel patients on the effects of surgery on pharyngeal phase of swallow function, specialists need physiologically grounded research that correlates muscles resected with consistent measures of swallow function.

Background: A clinical swallow examination (CSE) provides integral information that informs the diagnostic decision-making process within dysphagia management. However, multiple studies have highlighted a high degree of reported variability within the CSE process. It has been hypothesized that such variability may be the result of the clinical reasoning process rather than poor practices. Aims: To elucidate the nature of expert, speech–language therapists’ (SLTs) clinical reasoning during an initial bedside assessment of patients referred for suspected dysphagia in the acute care environment. Methods & Procedures: An exploratory ‘observation of practice’ qualitative methodology was used to achieve the aim. Four expert SLTs, from two clinical services, completed CSEs with 10 new referrals for suspected dysphagia. All assessments were video-recorded, and within 30 min of completing the CSE, a video-stimulated ‘think aloud’ semi-structured interview was conducted in which the SLT was prompted to articulate their clinical reasoning at each stage of the CSE. Three types of concept maps were generated based on this video and interview content: a descriptive concept map, a reasoning map and a hypothesis map. Patterns that consistently characterized the assessment process were identified, including the overall structure; types of reasoning (inductive versus deductive), facts (i.e., clinical information) drawn upon; and outcomes of the process (diagnosis and recommendations). Interview content was examined to identify types of expert reasoning strategies using during the CSE. Outcomes & Results: SLTs’ approach to clinical assessment followed a consistent structure, with data gathered pre-bedside, during the patient interview and direct assessment before a management recommendation was made. Within this structure, SLTs engaged in an iterative approach with inductive hypothesis-generating and deductive hypothesis-testing, with each decision-making pathway individually tailored and informed by patient-specific facts collected during the assessment. Clinical assessment was primarily geared towards management of an initial acute presentation with less focus on formulating a diagnostic statement. Conclusions & Implications: Variability in reported dysphagia practice is likely the result of a patient-centred assessment process characterized by iterative cycles of fact-gathering in order to generate and test clinical hypotheses. This has implications for the development of novel assessment tools, as well as professional development and education of novice SLTs. What this paper adds What is already known on the subject CSE practices are reportedly variable, which has led to calls for more stringent, standardized assessment tools. Emerging evidence suggests that this variation is non-random, but may arise from clinical reasoning processes. What this paper adds to existing knowledge We directly observed expert SLTs conducting CSEs and identified patterns in practice that were consistent across all CSEs evaluated. These patterns were consistent in structure, whereas the content of the assessment items varied and was tailored to individual patient presentation. Overall, expert SLTs engaged in balanced cycles of inductive hypothesis generation and deductive hypothesis-testing, a hallmark of good clinical assessment and practice. What are the potential or actual clinical implications of this work? Ensuring quality CSE requires a more nuanced approach that considers the role of clinical reasoning in SLTs’ decision-making and the potential unintended negative consequences of standardized assessment tools.

Sensory enhancement techniques, like other compensatory strategies, aim to reduce dysphagia symptoms. The use of carbonated liquids has been proposed as a possible sensory technique, however to date, there is limited information of its efficacy or guidance for clinical implementation. A narrative synthesis was completed to determine the quality and strength of the evidence base for use of carbonation as a compensatory strategy in dysphagia rehabilitation.From 101 articles initially identified, 14 articles met the study criteria. Eleven papers described the effects of carbonation on swallowing in healthy participants whereas three described the impact of carbonation in dysphagic populations. A narrative synthesis of papers was undertaken given the diversity of identified studies.Synthesis of findings was challenging given the exploratory phase of most research activity with diverse populations described and extensive differences in research methodologies. There is currently weak, but potentially positive evidence to support using carbonation as a compensatory technique in dysphagia rehabilitation.Despite future potential, existing evidence fails to provide clear direction for the clinical implementation of carbonation. Validation of carbonation use with the dysphagic population requires further research with consistent, controlled methodologies, and larger cohorts of participants to inform potential for dysphagia rehabilitation. Implications for Rehabilitation The use of carbonated liquids has been proposed as a possible sensory enhancement technique which may facilitate changes to swallow physiology. However to date, there is limited information to direct clinical implementation. This paper provides a narrative synthesis of existing knowledge and highlights possible limitations of findings reported. Research to date has used disparate research methodologies in varied populations making synthesis of current findings challenging.

Swallowing is a complex process that involves sequential voluntary and involuntary muscle contractions. Malfunctioning of swallowing related muscles could lead to dysphagia. However, there is a lack of standardized and non-invasive methods that support and improve the diagnosis and ambulatory care. This paper presents a classification scheme of two swallowing phases (oral and pharyngeal) based on signals of surface electromyography (sEMG). Eight acquisition channels recorded the EMG activity of 47 healthy subjects while they swallowed water, yogurt and saliva. Every signal was processed, segmented and labeled with background activity, oral or pharyngeal classes. Nine time domain and four frequency domain features were extracted from the segments, assessed individually and then compared in groups according to a correlation analysis. A support vector machine (SVM) with radial basis function kernel and a feedforward artificial neural network (ANN) with one hidden layer were used as classifiers. Different hyperparameters of the SVM and number of hidden neurons of the ANN were assessed for the proposed scheme. The recognition accuracy of SVM (92,03%) was higher than ANN's (90,26%). Time domain features were found to have better capability of representation than their frequency domain counterpart. Nevertheless, expanding the feature space improved the performance of the classifiers. Experimental results show that proposed sEMG-based method can correctly distinguish between oral and pharyngeal swallowing phases and can be used for assessment of continuous swallowing tasks. This paper extends previous reported findings to small muscles with low signal-to-noise ratio and high crosstalk acquired in multichannel systems.

Dysphagia is one of the most important treatment-related side effects in head and neck cancer (HNC), as it can lead to severe life-threating complications such as aspiration pneumonia and malnutrition. Intensity-modulated radiotherapy (IMRT) could reduce swallowing dysfunction by producing a concave dose distribution and reducing doses to the swallowing-related organs at risk (SWOARs). The aim of this study was to review the current literature in order to compare swallowing outcomes between IMRT and three-dimensional conformal radiotherapy (3DCRT). A search was conducted in the PubMed and Embase databases to identify studies on swallowing outcomes, both clinically and/or instrumentally assessed, after 3DCRT and IMRT. Dysphagia-specific quality of life and objective instrumental data are summarized and discussed. A total of 262 papers were retrieved from the searched databases. An additional 23 papers were retrieved by hand-searching the reference lists. Ultimately, 22 papers were identified which discussed swallowing outcomes after 3DCRT and IMRT for HNC. No outcomes from randomized trials were identified. Despite several methodological limitations, reports from the current literature seem to suggest better swallowing outcomes with IMRT compared to 3DCRT. Further improvements are likely to result from the increased use of IMRT plans optimized for SWOAR sparing.

In order to study the rehabilitation of dysphagia after stroke, this paper uses tomographic imaging technology and repeated transcranial magnetic stimulation rTMS therapy to verify the effect of this treatment method on the rehabilitation of dysphagia after stroke. In this study, the method of systematic review and meta-analysis are used to comprehensively collect the current published literature on the application of repeated transcranial magnetic stimulation in post-stroke dysphagia, and to quantitatively synthesize and qualitatively analyze the data and opinions. This article aims to explore the therapeutic effect and mechanism of repeated transcranial magnetic stimulation in the treatment of dysphagia after stroke, and to evaluate its effectiveness, so as to better guide the application of repetitive transcranial magnetic stimulation in the rehabilitation of dysphagia after stroke. The evaluation methods of rTMS for the clinical efficacy of PAS, FDS, VDS, DOSS, DD, and BI in patients with dysphagia after stroke are consistent. The influencing factors of rTMS on the swallowing function impairment of stroke include the choice of stimulation frequency, stimulation site, and stimulation time. Low-frequency stimulation of the contralateral hemisphere and high-frequency stimulation of the affected brain can reduce the excitability of the contralateral brain and enhance the excitability of the affected brain. The stimulation site is mainly in the pharyngeal cortex. Experiments show that rTMS can improve swallowing dysfunction after stroke within 2 weeks, and rTMS has no obvious side effects on swallowing dysfunction in patients with cerebral infarction.

Communication and swallowing are highly complex sensorimotor events that are tightly linked to respiration and vital to health and well-being. The tongue is a complex organ, often described as a muscular hydrostat, that is crucial for maintaining airway patency, preparing and safely transporting food/liquid, and rapidly changing position and shape for speech. As with any complex behavior, tongue function can be compromised with aging, diseases/conditions, trauma, or as a pharmacologic side effect. As such, modeling lingual function and dysfunction for basic and translational research is paramount; understanding how the nervous system controls tongue function for complex behavior is foundational to this work. Non-invasive access to tongue tissues and kinematics during awake behavior has been historically challenging, creating a critical need to measure tongue function in model systems. Germane to this field of study are the instruments and assays of licking/lapping and drinking, including tongue force and timing measures, many of which were designed or modified by Dr. Stephen C. Fowler. The focus of this paper is to review some of the important contributions of measuring tongue behaviors in awake rats and mice and how these have been modified by other researchers to advance translational science.

Texture-modified foods (TMF) is a common intervention for improving swallowing safety and efficiency for people with dysphagia. Non-standardized texture classification (NSTC) of foods is used worldwide. However, as this study documents, it can introduce a lack of clarity and confusion over definitions that can potentially harm patients' safety. The International Dysphagia Diet Standardisation Initiative (IDDSI) framework offers international terminology and standardized methods for texture testing that can address this issue AIMS: To document differences between NSTC and standardized texture classification (STC) of the IDDSI, to document changes in the STC in the 30 min following meal delivery, and to explore the relationship between food intake and texture level.In this observational study, data were collected from 24 long-term care departments during five meals served to 624 residents, including at least one breakfast, lunch and dinner. To document differences between NSTC and STC, all NSTC food textures used in the LTC facilities were reclassified to match the IDDSI texture level at the time food left the kitchen (n = 1276). To document time-related changes in texture, the STC texture as food left the kitchen was compared with texture 30 min later (n = 1276). Finally, to explore the relationship between texture and consumption, estimates were made of single-item food consumption (n = 3820) using a subjective evaluation of consumption percentage OUTCOMESRESULTS: A total of 1276 food items were classified over the course of five meal services (with at least one each from breakfast, lunch and dinner). Statistically significant differences in NSTC and STC texture levels were found that revealed that residents were consuming food that was more difficult to eat than intended by the TMF prescription. In addition, significant changes in food texture were found over time, with texture levels significantly increasing 30 min after food left the kitchen. Finally, greater consumption was found for softer textures in comparison with regular foods; moreover, food consumption was greatest during breakfast and lowest during lunch.Residents requiring TMF received harder textures than intended which required complex swallowing ability, thus introducing a choking risk. Using the STC as proposed by the IDDSI could improve patient safety, oral intake and nutritional status. Time-related changes should also be considered in circumstances where patients do not consume food soon after service. Lastly, reduced food consumption during lunch might negatively impact overall nutrient intake, particularly in cultures where lunch is the main meal of the day.What is already known on the subject Despite widespread agreement on the importance of STC, institutional care providers widely use NSTC. The IDDSI framework offers international terminology and standardized methods for texture testing. The clinical importance of using STC is not well understood. What this paper adds to existing knowledge This study found that residents who required texture-modified foods were eating food textures that were more challenging to swallow than intended. Differences were found in food texture between when it left the kitchen compared with texture 30 min later. Pureed texture had greater consumption than regular textured food. Food consumption was found to be the highest during breakfast, and reduced during lunch, which might negatively impact overall nutrient intake. What are the potential or actual clinical implications of this work? Accurate food texture prescription is the first step towards increasing patients' safety. However, food preparation and handling are also very important steps, not to be disregarded. Time-related changes in food texture are remarkable and should be considered in circumstances where patients do not consume food soon after service, as these can compromise patients' safety.

The use of ultrasound as an adjunct to clinical swallowing evaluation provides quantitative physiological and morphological data. As a low-risk procedure, ultrasound imaging can be performed outside of a medical setting. This is particularly important for patients living in rural areas with restricted access to a hospital. Technical advances have produced pocket-sized ultrasound technology that is more affordable, and therefore within the fiscal reach of most allied health services.To explore the validity and reliability of pocket-sized ultrasound technology in dysphagia assessment.Data were acquired from 43 patients with dysphagia using the Clarius ultrasound device. Ultrasound and videofluoroscopic measures of hyoid and laryngeal displacement during liquid and puree swallowing were collected concurrently to quantify correlation and agreement between identical measures derived from the two instruments. Reliability of ultrasound was assessed for measures of hyoid and laryngeal displacement, tongue thickness, and size of the submental muscles in eight patients. Reliability was evaluated for the entire process of data acquisition including scanning and online measurement using an iPad in a clinical setting and for offline measurement on a computer screen to explore environmental influences on reliability.Results revealed poor correlation between the measures of interest across instruments. Reliability of the entire process of data acquisition in a clinical setting was insufficient while reliability was more promising for offline measurements.The clinical use of pocket-sized ultrasound devices, such as the Clarius system, for swallowing evaluation is not indicated at this time. Enhanced validity and reliability of the entire process of data acquisition are needed prior to clinical translation of such technology.What is already known on the subject The use of ultrasound allows for radiation-free, non-invasive swallowing assessment. Some data suggest that ultrasound is valid and reliable in the evaluation of swallowing using standard-sized equipment. Insufficient validity and reliability have been reported for pocket-sized ultrasound technology in the assessment of healthy swallowing. What this paper adds to existing knowledge This research is the first to provide validity and reliability data of the pocket-sized Clarius technology in the evaluation of swallowing in patients with dysphagia. Insufficient validity and reliability of online data acquisition in a clinical environment were found. Reliability for offline measurement was more promising. What are the potential or actual clinical implications of this work? The clinical use of pocket-sized ultrasound devices, such as the Clarius system, for swallowing assessment is not indicated at this time.

The present paper investigates a portable eustachian-tube-function testing device by sonotubometry based on pure-tone sound transmission via the eustachian tube (ET). The measured results obtained by the proposed method were validated through comparison with the existing testing technique based on broadband sound inspection. The measurement results for the ET opening time (Topen) and the sound pressure difference in the ear canal between open and closed ETs (ΔL) obtained using pure-tone sounds with tonal frequency components of 7.0 and 9.5 kHz generally agreed with the results obtained by the existing technique with broadband testing sound.

Voice reconstruction is possible, with an ileo-colon free flap, using the ileo-cecal valve as a new vocal cord. The voice carried by the ileal segment might have a ‘wet’ and coarse quality, even though still preferred by the patient over a pneumatic artificial larynx. Hence, secondary revisions may be needed, to shorten the ileum segment in the neck and to increase voice quality. Differently from classic fascio-cutaneous free flaps, the ileo-colon flap never integrates with the recipient site and continues to rely on the vascular pedicle for viability. During any subsequent revision, any injury to the pedicle causes irreversible ischaemia of the intestinal segment. This paper aims to present details about the surgical technique for voice tube shortening, without compromising its vascular supply. The mainstays of a safe surgical revision are the anti-mesenteric approach to the ileum segment and the division from the mesentery from inside to outside the intestinal wall. We developed our technique after our experience with 191 ileo-colic flaps for voice reconstruction. Adopting these refinements, no necroses ever occurred.

Patients with neurodegenerative diseases are at an increased risk of dysphagia and aspiration pneumonia. In this study, we examined whether ingestion of capsaicin prior to swallowing changes the temporal dynamics of swallowing in such patients. In a crossover, randomized controlled trial, 29 patients with neurodegenerative diseases were given a soluble wafer containing 1.5 μg capsaicin or an identical placebo 20 min prior to testing. For evaluation with video fluoroscopy (VF), patients consumed a barium-containing liquid plus thickening material. The durations of the latency, elevating and recovery periods of the hyoid were assessed from VF. Overall, no significant differences were observed in the duration of each period between capsaicin and placebo treatments. However, reductions in the latency and elevating periods were positively correlated with baseline durations. In subgroup analyses, that correlation was observed in patents with amyotrophic lateral sclerosis (ALS) but not in patients with Parkinson’s disease. The consumption of wafer paper containing capsaicin before the intake of food may be effective in patients with dysphagia related with certain neurodegenerative diseases, particularly ALS patients. Further studies will be needed to validate this finding.

Unlike appendicular motor symptoms, such as bradykinesia and rigidity, in Parkinson's disease (PD), which have already been reported to respond well to deep brain stimulation (DBS), there is limited literature on the effects of DBS on swallowing function in patients with PD. The field lacks consensus as there are conflicting reports among existing studies regarding whether swallowing function improves or declines following DBS implantation. This narrative review aims to summarize and analyze the studies published on the effect of DBS on swallowing function in patients with PD. We collated studies published up to February 2020 using a comprehensive electronic database search of PubMed, SCOPUS, EMBASE, and the Cochrane Library. Two reviewers independently assessed the studies using strict inclusion and exclusion criteria. The primary literature search yielded 529 relevant papers. After reading their titles and abstracts and assessing their eligibility based on the full-text, we finally included and reviewed 14 publications. Nine of these studies reported positive effects of DBS on swallowing function and four studies showed no significant positive results. The remaining study showed decreased swallowing function after unilateral subthalamic nucleus-DBS surgery. In conclusion, we found that DBS has the potential to improve swallowing function in patients with PD. However, high-quality evidence is lacking. To clearly elucidate the effect of DBS on swallowing function in patients with PD, high-quality randomized controlled trials should be conducted in the future.

Swallowing and swallowing disorders have garnered continuing interest over the past several decades. Electroencephalography (EEG) is an inexpensive and non-invasive procedure with very high temporal resolution which enables analysis of short and fast swallowing events, as well as an analysis of the organizational and behavioral aspects of cortical motor preparation, swallowing execution and swallowing regulation. EEG is a powerful technique which can be used alone or in combination with other techniques for monitoring swallowing, detection of swallowing motor imagery for diagnostic or biofeedback purposes, or to modulate and measure the effects of swallowing rehabilitation. This paper provides a review of the existing literature which has deployed EEG in the investigation of oropharyngeal swallowing, smell, taste and texture related to swallowing, cortical pre-motor activation in swallowing, and swallowing motor imagery detection. Furthermore, this paper provides a brief review of the different modalities of brain imaging techniques used to study swallowing brain activities, as well as the EEG components of interest for studies on swallowing and on swallowing motor imagery. Lastly, this paper provides directions for future swallowing investigations using EEG.

Medical teams are frequently faced with challenging clinical scenarios when their patients exhibit reduced intake of food and drink. Speech-language pathologists, who serve as oropharyngeal swallowing specialists in medical settings, are frequently the first to be summoned with the referral, 'Poor PO intake. Please evaluate and treat.' As our practices have illuminated, many differentials other than oropharyngeal dysphagia are often at play.Changes to taste, salivary supply/dry mouth, hunger drive, and psychosocial circumstances will significantly impact intake per os - each scenario to be explored further in this paper. Consequences to diminished nutrition and hydration include medical complications, lengthier hospital stays, and diminished quality of life.In this review, two medical speech-language pathologists detail more common alternative diagnoses that explain reduced intake by mouth amongst adults with acute and chronic diseases. Ultimately, a multidisciplinary approach should be considered when evaluating such patients to ensure a comprehensive and effective care plan.

Introduction and objectives The objective of this paper was to show our experience and considerations when quantifying hyoid bone displacement and to observe its correlation with the qualitative scales that evaluate dysphagia. Methods Hyoid displacement was assessed using the method described by Molfenter and Steele’s group in 2014 in a series of 14 patients affected by oropharyngeal dysphagia. The degree of dysphagia was also qualitatively assessed with the Rosenbek Penetration and Aspiration Scale (PAS) of 1996 and with the Functional Oral Intake Scale (FOIS) of Crary of 2005. All assessments were done before and after treatment. Results All patients increased their hyoid bone total displacement after the treatment. These variations were highly correlated with the variations in the PAS scale with aspiration or penetration. However, the variations of hyoid bone displacement did not correlate with the FOIS scale. Conclusions The improvement in total hyoid bone displacement is a clinical indicator of improved aspiration of patients suffering dysphagia. However, the improvement of this displacement is not related to the oral intake tolerance of the patients.

Purpose: Representatives of the American Board of Swallowing and Swallowing Disorders (AB-SSD) and American Speech-Language-Hearing Association (ASHA) Special Interest Group (SIG) 13: Swallowing and Swallowing Disorders (Dysphagia) developed this tutorial to identify and recommend best practice guidelines for speech-language pathologists who conduct and interpret fiberoptic endoscopic evaluation of swallowing (FEES) procedures in adults. This document also includes proposed training needs and methods for achieving competency. Expert opinion is provided regarding indications for performing the FEES exam, potential contraindications, adverse effects and safety, equipment and personal protection, the exam protocol, interpretation and documentation of findings, and training requirements to perform and interpret the exam. Conclusions: This tutorial by the AB-SSD and SIG 13 represents the first update about the FEES procedure since ASHA's position paper and technical report published in 2004. Creation of this document by members of the AB-SSD and SIG 13 is intended to guide professionals who are training for or practicing FEES in the adult population toward established best practices and the highest standards of care.

Cervical auscultation has been used clinically as an augmentative procedure for swallow examination. Despite its frequent use for screening and preliminary assessment of swallowing, the usefulness of cervical auscultation is controversial due to a lack of sufficient research, particularly in quantifying swallowing sounds.To document the acoustic characteristics of normal swallowing sound associated with swallowing bolus of different consistencies among younger healthy adults.A total of 30 healthy young adult participants swallowed 5 ml thickened liquids of four different consistencies (slightly thick, mildly thick, moderately thick and extremely thick) prepared using a starch-based commercial thickener, and the corresponding swallowing sounds were recorded using a wireless accelerometric stethoscope. An array of acoustic measures including duration of swallowing sound (DSS), duration to peak intensity (DPI), frequency at peak intensity (FPI), peak intensity (PI), average intensity (AI), and difference between peak and average intensity (DPAI) values associated with the swallowing signals were obtained.In general, increased durational measures of the swallowing sounds were associated with an increase in bolus consistency. Intensity measures including PI, AI and DPAI were found to be stable across different consistencies. The change in FPI did not appear to be particularly meaningful due to its high variability. In addition, no significant differences were observed between men and women.Swallow sounds associated with different bolus consistencies could be quantified and used to differentiate consistencies. The present findings could serve as a reference for future swallowing research of normal and dysphagic population.What is already known on the subject Cervical auscultation using traditional stethoscope has been used as part of an informal clinical swallow examination by practitioners. Validity of cervical auscultation is controversial, possibly due to the lack of normative data on swallow sounds. What this paper adds to existing knowledge The present study explored the possibility of using wireless accelerometric stethoscopy for cervical auscultation for dysphagia screening. Acoustic profiles of swallow sounds associated with boluses of different consistencies in healthy individuals were examined. What are the potential or actual clinical implications of this work? Findings contribute to our knowledge about the acoustic characteristics of swallow sounds of boluses of different consistencies in healthy young individuals. The study provides normative clinical data on cervical auscultation using wireless accelerometric stethoscope for normal swallow.

Vocal fold scarring is the cause of severe dysphonia and represents a therapeutic challenge; dysphagia can also be present in case of soft tissue defect due to previous oncological surgery. The ideal surgical solution should concurrently provide vocal fold augmentation and re-establishment of tissue elasticity. Nanofat technique has given so far promising results in remodeling skin scars and improving tissue pliability. The present paper describes for the first time the use of nanofat injected into the vocal fold cover for pliability restoration, combined with traditional microfat for vocal fold augmentation. Seven patients (aged 23-77 years) affected by severe dysphonia, related to extensive vocal fold scarring (3 of them were also affected by dysphagia for liquid consistencies), underwent a single procedure of concurrent microfat and nanofat vocal fold injection under direct microlaryngoscopy in general anesthesia. Results were evaluated by objective outcome measures and auto evaluation performed by questionnaires concerning the phonatory and swallowing efficiency. The voice quality and the perceived swallowing capability of all patients improved after surgery and are stable at follow-up (4-8 months). The reported preliminary data show that nanofat, due to its regenerative potential related to adipose-derived stem cells and growth factors, can be a promising adjunct to traditional fat augmentation to improve elasticity of the delicate multilayered structure of the vocal fold and to enhance its vibratory capabilities. Further experience on a wider number of patients and long-term follow-up are necessary to confirm the validity of this technique.

The vocal folds (VFs) are a pair of muscles in the larynx that play a critical role in breathing, swallowing, and speaking. VF function can be adversely affected by various medical conditions including head or neck injuries, stroke, tumor, and neurological disorders. In this paper, we propose a deep learning system for automated detection of laryngeal adductor reflex (LAR) events in laryngeal endoscopy videos to enable objective, quantitative analysis of VF function. The proposed deep learning system incorporates our novel orthogonal region selection network and temporal context. This network learns to directly map its input to a VF open/close state without first segmenting or tracking the VF region. This one-step approach drastically reduces manual annotation needs from labor-intensive segmentation masks or VF motion tracks to frame-level class labels. The proposed spatio-temporal network with an orthogonal region selection subnetwork allows integration of local image features, global image features, and VF state information in time for robust LAR event detection. The proposed network is evaluated against several network variations that incorporate temporal context and is shown to lead to better performance. The experimental results show promising performance for automated, objective, and quantitative analysis of LAR events from laryngeal endoscopy videos with over 90% and 99% F1 scores for LAR and non-LAR frames respectively.

Background Dysphagia is highly prevalent condition in older adults living in nursing homes. There is also evidence indicating that aspiration is one of the major health risks for these older adults, which is more likely to result in respiratory infections, aspiration pneumonia and sudden bolus death. Evidence syntheses have demonstrated the effectiveness of interventions for prevention of aspiration among hospitalized older people. The aim of this scoping review is to describe the current spread of interventions to prevent or reduce aspiration in older adults with dysphagia with a specific focus on those who reside in nursing homes. Methods The Joanna Briggs Institute methods and PRISMA-ScR guidelines were used to inform this review. MEDLINE, CINAHL, EMBASE, Cochrane Library, Joanna Briggs Institute EBP Database and Web of Science were searched for related articles from 2010 to 2020 as well as Chinese databases (CNKI, WANFANG DATA and VIP) and databases for unpublished material. A three-step search strategy was utilized, including the use of citation software to manage search results and de-duplication, abstract review and full-text review by two reviewers. Details of included studies were then extracted using a prepared data extraction tool. The resulting map was displayed in tabular form along with a narrative summary. Results Although 637 articles were located, 19 papers were included in the final analysis. Interventions to prevent aspiration in older adults with dysphagia living in nursing homes included: more bedside evaluation, modification of dietary, creating an appropriate environment for swallowing, providing appropriate feeding assistance, appropriate posture or maneuver for swallowing, appropriate rehabilitation program, medication treatment, and stimulation treatment. Conclusion Nursing homes, particularly those in developing countries, require more support for staff training and necessary equipment. Professional interventions provided by speech and language therapists are still limited in the setting of nursing homes. Modification of dietary was the most frequently used intervention to prevent or reduce aspiration. Multi-disciplinary interventions had the best results for aspiration management, but for many nursing homes, access to such teams is limited. Nursing home residents respond well to person-centered interventions that have a comprehensive consideration of their degree of aspiration risk, health condition, individual feelings and cognitive state.

Objective Methylene blue (MB) is frequently administered during fiberoptic endoscopic evaluation of swallowing (FEES) to enhance visualization of pharyngeal bolus transit. However, the safety of MB is being questioned since serious adverse events (AEs) such as hemodynamic instability, hemolysis, and serotonin syndrome were reported. The aim of this study is a systematic analysis of the literature to obtain an evidence-based overview of AEs due to oral administration of MB and to determine its safety as a food dye during swallowing assessment. Methods A systematic literature search was carried out in PubMed, Embase, and Cochrane Library. Two reviewers independently selected articles describing oral administration of MB as a main diagnostic/therapeutic intervention, dosage, and AEs. Expert opinions, conference papers, sample size < 10, and animal studies were excluded. Level of evidence of the included studies was determined. Results A total of 2264 unduplicated articles were obtained. Seventeen studies met the inclusion criteria with 100% agreement between the two reviewers. Among these, twelve studies were randomized controlled trials. In a pooled population of 1902 patients receiving oral MB, three serious AEs were reported related to MB. Non-serious AEs showed a dose-related trend and were usually mild and self-limiting. A meta-analysis could not be performed as studies were methodologically too heterogeneous. Conclusion Serious AEs due to oral administration of MB are rare (n = 3, 0.16%). MB-related non-serious AEs are mild, self-limiting, and show a dose-related trend. These findings indicate that it is safe to use small amounts of MB as a food dye during swallowing examinations.

Intragastric balloons (IGBs), by occupying the stomach space and prolonging satiety, is a promising method to treat obesity and consequently improves its associated comorbidities, e.g. coronary heart disease, diabetes, and cancer. However, existing IGBs are often tethered with tubes for gas or liquid delivery or require endoscopic assistance for device delivery or removal, which are usually uncomfortable, costly, and may cause complications. This paper presents a novel tetherless, magnetically actuated capsule (EndoPil) which can deploy an IGB inside the stomach after being swallowed and being activated by an external magnet. The external magnet attracts a small magnet inside the EndoPil to open a valve, triggering the chemical reaction of citric acid and potassium bicarbonate to produce carbon dioxide gas, which inflates a biocompatible balloon (around 120 mL). A prototype, 13 mm in diameter and 35 mm in length, was developed. Simulations and bench-top tests were conducted to test the force capability of the magnetic actuation mechanism, the required force to activate the valve, and the repeatability of balloon inflation. Experiments on animal and human were successfully conducted to demonstrate the safety and feasibility of inflating a balloon inside the stomach by an external magnet. Nanyang Technological University The study is funded by the Gastroenterology Research Fund in Singapore (NUS WBS No. R-172-000-004-720) and the Startup Grant from Nanyang Technological University, Singapore (NTU WBS No. M4081419).

Swallowing, deglutition, is realized by highly coordinated activities of many nerves and muscles, but it is hard to observe directly due to intracorporal movement, and there is a limitation to the number of muscles that can be percutaneously measured. In addition, since there are few studies on the mechanical analysis of the swallowing movement, the detailed muscle activity pattern during swallowing has not yet been clarified. To tackle this problem from the viewpoint of biomechanics, we have been developing the musculoskeletal model of swallowing which can estimate the activities of swallowing-related muscles based on the movements of hyoid bone and thyroid cartilage. In this paper, we analyzed the activities of swallowing-related muscles under two different bolus conditions: bolus of water and nectar thickened liquid to investigate the effect of physical property of bolus in the activities of swallowing-related muscles.

In this paper, we introduce the development of a new sensing device for measuring the pace, time, order, and intake of meal consumption for the elderly in a nursing home. The developed device is a portable sensor sheet which is suitable for use in nursing homes because it is designed not to disturb meal consumption and can be used conveniently. We first describe the measurement method of food intake using the proposed device such as the pace, time, order of meal. Finally, we report an experiment that we conducted about eating behavior in the nursing home while using the proposed device together with a sensing device for swallowing activities.

BACKGROUND: Swallowing is a motor process with several discordances and a very difficult neurophysiological study. Maybe that is the reason for the scarcity of papers about it. OBJECTIVE: It is to describe the chewing neural control and oral bolus qualification. A review the cranial nerves involved with swallowing and their relationship with the brainstem, cerebellum, base nuclei and cortex was made. METHODS: From the reviewed literature including personal researches and new observations, a consistent and necessary revision of concepts was made, not rarely conflicting. RESULTS AND CONCLUSION: Five different possibilities of the swallowing oral phase are described: nutritional voluntary, primary cortical, semiautomatic, subsequent gulps, and spontaneous. In relation to the neural control of the swallowing pharyngeal phase, the stimulus that triggers the pharyngeal phase is not the pharyngeal contact produced by the bolus passage, but the pharyngeal pressure distension, with or without contents. In nutritional swallowing, food and pressure are transferred, but in the primary cortical oral phase, only pressure is transferred, and the pharyngeal response is similar. The pharyngeal phase incorporates, as its functional part, the oral phase dynamics already in course. The pharyngeal phase starts by action of the pharyngeal plexus, composed of the glossopharyngeal (IX), vagus (X) and accessory (XI) nerves, with involvement of the trigeminal (V), facial (VII), glossopharyngeal (IX) and the hypoglossal (XII) nerves. The cervical plexus (C1, C2) and the hypoglossal nerve on each side form the ansa cervicalis, from where a pathway of cervical origin goes to the geniohyoid muscle, which acts in the elevation of the hyoid-laryngeal complex. We also appraise the neural control of the swallowing esophageal phase. Besides other hypotheses, we consider that it is possible that the longitudinal and circular muscular layers of the esophagus display, respectively, long-pitch and short-pitch spiral fibers. This morphology, associated with the concept of energy preservation, allows us to admit that the contraction of the longitudinal layer, by having a long-pitch spiral arrangement, would be able to widen the esophagus, diminishing the resistance to the flow, probably also by opening of the gastroesophageal transition. In this way, the circular layer, with its short-pitch spiral fibers, would propel the food downwards by sequential contraction. RESUMO CONTEXTO: A deglutição é um processo motor com muitas discordâncias e de difícil estudo quanto a sua neurofisiologia. Talvez por essa razão sejam tão raros os artigos sobre esse tema. OBJETIVO - Descrever o controle neural da mastigação e a qualificação do bolo que se obtém durante a fase oral. Revisar os nervos cranianos envolvidos com a deglutição e suas relações com o tronco cerebral, cerebelo, núcleos de base e córtex. MÉTODOS: Revisão da literatura com inclusão de trabalhos pessoais e novas observações buscando dar consistência a necessária revisão dos conceitos, muitas vezes conflitantes. RESULTADOS E CONCLUSÃO: Em relação a fase oral da deglutição consideramos o controle neural em cinco distintas possibilidades. Fase oral nutricional voluntária, fase oral cortical voluntária primaria, fase oral semiautomática, fase oral em goles subsequentes e fase oral espontânea. Em relação ao controle neural da fase faríngea da deglutição, pode-se observar que o estímulo que dispara a fase faríngea não é o toque produzido pela passagem do bolo, mas sim a distensão pressórica, tenha ou não conteúdo em passagem. Na deglutição nutricional, alimento e pressão são transferidos, mas na fase oral da deglutição primária cortical somente pressão é transferida e temos resposta faríngea similar a nutricional. A fase faríngea incorpora como parte de sua dinâmica as atividades orais já em curso. A fase faríngea se inicia por ação do plexo faríngeo composto pelos nervos glossofaríngeo (IX), vago (X), e acessório (XI), com envolvimento do trigêmeo (V), do facial (VII), glossofaríngeo (IX) e hipoglosso (XII). O plexo cervical (C1, C2), e o nervo hipoglosso, a cada lado, formam a alça cervical de onde, com origem cervical, um ramo segue para o músculo gênio-hioide, um músculo que atua na dinâmica de elevação do complexo hiolaríngeo. Foi também considerado o controle neural da fase esofágica da deglutição. Além de outras hipóteses foi considerado que é possível que a camadas musculares consideradas como longitudinal e circular para o esôfago sejam a longitudinal composta por fibras espirais de passo longo e a circular por fibras espirais de passo curto. Essa morfologia associada ao conceito de preservação de energia, nos permite admitir que a contração da camada longitudinal por seu arranjo espiral seja capaz de alargar o esôfago diminuindo sua resistência ao fluxo e provavelmente e também abrindo a transição esofagogástrica. Desse modo a camada circular, espiral de passo curto, pode propelir o bolo por constrição sequencial de cranial para caudal.

Objectives The purpose of this paper is to report the technique and outcomes of the use of gastro-omental free flap reconstruction in glossectomy defects. Materials and Methods This is a prospective case series of 9 patients of tongue squamous cell carcinoma, who underwent either subtotal or partial glossectomy and reconstruction with gastro–omental free flap. The flap anatomy, surgical technique and the outcomes including the swallowing and speech are presented. Results Five patients underwent partial glossectomy and 4 had sub-total glossectomy. The median age was 43 years; and the median follow up was 11.4 months. Laparoscopic harvest was done in 8 patients. There was one flap loss. Seven patients underwent postoperative radiotherapy. Functional evaluation was done in 5 patients who were disease free. Four could tolerate soft diet orally, one patient was on liquid to pureed diet. Speech was intelligible in 4. None of the patients had any complications related to laparotomy or laparoscopy. Conclusion Gastro-omental flap provided a secretory mucosal surface and was beneficial in the saliva depleted patients post radiotherapy. The laparoscopic harvest of this flap has minimized donor site morbidity. One patient had a flap loss. Two patients reported superficial ulcerations on the surface, one of them had to undergo surgical debulking to correct it while the other healed with conservative measures. Speech and swallowing outcomes of the reconstructed tongue was good, especially in patients with partial glossectomy. The reconstructed gastric mucosal flaps tolerated the adjuvant radiation well.

International audience; Objectives: This systematic literature review aims to summarize the existing scientific evidence about the association between a reduced salivary function and food consumption in elderly people.Methods: A validated search strategy in two databases (PubMed and ISI Web of Knowledge) was carried out and retrieved papers together with their reference lists were screened by two independent reviewers. The quality of the included studies was critically appraised via the Quality Assessment Criteria for Evaluating Primary Research Papers.Results: From the originally identified studies (n=391), only 15 articles (all cross-sectional studies) met the pre-fixed inclusion/exclusion criteria. The methodological quality of the included studies was in general good, although only 3 from 15 obtained the maximum score. The control of confounding factors was the quality variable more poorly rated in the selected studies. Salivary hypofunction was associated with a decrease of the objective chewing and swallowing abilities and taste perception. Moreover, most of the selected studies showed a relationship between salivary hypofunction and food consumption (in terms of appetite loss, unbalanced dietary intake and malnutrition), although no causality could be established.Conclusions: This study highlights the fact that salivary hypofunction definition and measurements are different across the studies. Therefore, future research efforts should focus on establishing a gold standard to define and identify salivary hypofunction throughout life and on performing longitudinal studies controlling for confounding factors to establish causality

Disorders of swallowing are poorly characterized but quite common in schizophrenia. They are a source of considerable morbidity and mortality in this population, generally as a result of either acute asphyxia from airway obstruction or more insidious aspiration and pneumonia. The death rate from acute asphyxia may be as high as one hundred times that of the general population. Most swallowing disorders in schizophrenia seem to fall into one of two categories, changes in eating and swallowing due to the illness itself and changes related to psychotropic medications. Behavioral changes related to the illness are poorly understood and often involve eating too quickly or taking inappropriately large boluses of food. Iatrogenic problems are mostly related to drug-induced extrapyramidal side effects, including drug-induced parkinsonism, dystonia, and tardive dyskinesia, but may also include xerostomia, sialorrhea, and changes related to sedation. This paper will provide an overview of common swallowing problems encountered in patients with schizophrenia, their pathophysiology, and management. While there is a scarcity of quality evidence in the literature, a thorough history and examination will generally elucidate the predominant problem or problems, often leading to effective management strategies.

The question whether an injury was sustained during life or not is one of the most important subjects in forensic medicine. Therefore, vital reactions have been a main research topic in forensic medicine for a long period and many renowned forensic pathologists have devoted important papers to this field. The research area ranges from macroscopically visible organ reactions, over tissue alterations (enzyme histochemistry, later on immunohistochemistry with a wide range of enzymes and other analytes, molecular pathology) to biochemical responses to injury. Especially in the field of immunohistochemistry and molecular pathology much progress has been achieved in the last years (e.g. heat-shock-proteins or positive aquaporine3-staining in mechanical skin trauma). Furthermore, 20 years after its implementation postmortem imaging also contributes to the detection and visualization of vital signs. The aim of the present review is to provide an update on forensically relevant vital signs/vital reactions. Systemic vital reactions especially of the circulatory and respiratory system as well as local vital reactions will be addressed. Vital reactions of different organ systems will be discussed in detail regarding pathogenesis and possible postmortem evolution. Current research on immunohistochemically detectable vital reactions (heat-shock-protein expression, aquaporine3-staining in mechanical trauma of the skin) will be addressed as well as biochemical vital reactions (agonochemical stress reaction, myoglobine in electrocution death, hypoxanthine as marker of hypoxia).