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

This White Paper by the European Society for Swallowing Disorders (ESSD) reports on the current state of screening and non-instrumental assessment for dysphagia in adults. An overview is provided on the measures that are available, and how to select screening tools and assessments. Emphasis is placed on different types of screening, patient-reported measures, assessment of anatomy and physiology of the swallowing act, and clinical swallowing evaluation. Many screening and non-instrumental assessments are available for evaluating dysphagia in adults; however, their use may not be warranted due to poor diagnostic performance or lacking robust psychometric properties. This white paper provides recommendations on how to select best evidence-based screening tools and non-instrumental assessments for use in clinical practice targeting different constructs, target populations and respondents, based on criteria for diagnostic performance, psychometric properties (reliability, validity, and responsiveness), and feasibility. In addition, gaps in research that need to be addressed in future studies are discussed. The following recommendations are made: (1) discontinue the use of non-validated dysphagia screening tools and assessments; (2) implement screening using tools that have optimal diagnostic performance in selected populations that are at risk of dysphagia, such as stroke patients, frail older persons, patients with progressive neurological diseases, persons with cerebral palsy, and patients with head and neck cancer; (3) implement measures that demonstrate robust psychometric properties; and (4) provide quality training in dysphagia screening and assessment to all clinicians involved in the care and management of persons with dysphagia.

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.

Background: Dysphagia is one of the most dangerous symptoms of acute stroke. Various screening tools have been suggested for the early detection of this condition. In spite of conflicting results, measurement of oxygen saturation (SpO2) during clinical swallowing assessment is still recommended by different national guidelines as a screening tool with a decline in SpO2 ≥2% usually being regarded as a marker of aspiration. This paper assesses the sensitivity of SpO2 measurements for the evaluation of aspiration risk in acute stroke patients. Methods: Fifty acute stroke patients with moderate to severe dysphagia were included in this study. In all patients, fiberoptic endoscopic evaluation of swallowing (FEES) was performed according to a standardised protocol. Blinded to the results of FEES, SpO2 was monitored simultaneously. The degree of desaturation during/after swallows with aspiration was compared to the degree of desaturation during/after swallows without aspiration in a swallow-to-swallow analysis of each patient. To minimise potential confounders, every patient served as their control. Results: In each subject, a swallow with and a swallow without aspiration were analysed. Overall, aspiration seen in FEES was related to a minor decline in SpO2 (mean SpO2 without aspiration 95.54 ± 2.7% vs. mean SpO2 with aspiration 95.28 ± 2.7%). However, a significant desaturation ≥2% occurred only in 5 patients during/after aspiration. There was no correlation between aspiration/dysphagia severity or the amount of aspirated material and SpO2 levels. Conclusions: According to this study, measurement of oxygen desaturation is not a suitable screening tool for the detection of aspiration in stroke patients.

Background: Oropharyngeal dysphagia (OD) and malnutrition are highly prevalent in older patients that are discharged from general hospitals (47% and 30%, respectively). Aims: To develop a nutritional plan for these patients involving a triple adaptation of their traditional diet: (a) rheological adaptation (texture and viscosity) for safe deglutition, (b) nutritional adaptation (water, calories, and proteins), and (c) organoleptic adaptation to improve compliance. Methods: Two fluid viscosities (250 and 800 mPa·s) were selected according to previous studies on optimal viscosities in older patients. The British Dietetic Association food texture classification based on common clinical practice selected two food textures (thick purée and fork-mashable. Two levels of calorie protein enrichment were selected according to previous studies using the Mini Nutritional Assessment (MNA®). Results: The daily caloric-protein and hydric needs were established at 1750 kcal, 70 g protein, and 1750 mL water in patients with MNA® ≥ 17; and, 2037 kcal, 90 g protein, and 2000 mL water/day in malnourished patients. Sixteen weekly menus (296 recipes) were developed while using two textures, two levels of viscosity, two nutritional phenotypes (normal/at-risk vs. malnourished), and two seasons of the year (spring/summer-autumn/winter) based on Mediterranean cuisine. Conclusion: This concept paper demonstrates that traditional Mediterranean cooking can be adapted to meet the rheological, nutritional, and hydration needs of older patients with OD. The recipes that we have developed meet the needs of patients with varying degrees of OD and malnutrition are reproducible in patient’s homes and they could have a major impact on the clinical outcomes of these patients.

Purpose The modified barium swallow study (MBSS) is a widely used videofluoroscopic evaluation of the functional anatomy and physiology of swallowing that permits visualization of bolus flow throughout the upper aerodigestive tract in real time. The information gained from the examination is critical for identifying and distinguishing the type and severity of swallowing impairment, determining the safety of oral intake, testing the effect of evidence-based frontline interventions, and formulating oral intake recommendations and treatment planning. The goal of this review article is to provide the state of the science and best practices related to MBSS. Method State of the science and best practices for MBSS are reviewed from the perspectives of speech-language pathologists (SLPs) and radiologists who clinically practice and conduct research in this area. Current quandaries and emerging clinical and research trends are also considered. Results This document provides an overview of the MBSS and standards for conducting, interpreting, and reporting the exam; the SLPs' and radiologist's perspectives on standardization of the exam; radiation exposure; technical parameters for recording and reviewing the exam; the importance of an interdisciplinary approach with engaged radiologists and SLPs; and special considerations for examinations in children. Conclusions The MBSS is the primary swallowing examination that permits visualization of bolus flow and swallowing movement throughout the upper aerodigestive tract in real time. The clinical validity of the study has been established when conducted using reproducible and validated protocols and metrics applied according to best practices to provide accurate and reliable information necessary to direct treatment planning and limit radiation exposure. Standards and quandaries discussed in this review article, as well as references, provide a basis for understanding the current best practices for MBSS.

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.

Key points Despite evidence that the human cerebellum has an important role in swallowing neurophysiology, the effects of cerebellar stimulation on swallowing in the disrupted brain have not been explored.In this study, for the first time, the application of cerebellar neurostimulation is characterized in a human model of disrupted swallowing (using a cortical virtual lesion).It is demonstrated that cerebellar stimulation can reverse the suppressed activity in the cortical swallowing system and restore swallowing function in a challenging behavioural task, suggesting the findings may have important therapeutic implications. Abstract Repetitive transcranial magnetic stimulation (rTMS) can alter neuronal activity within the brain with therapeutic potential. Low frequency stimulation to the ‘dominant’ cortical swallowing projection induces a ‘virtual‐lesion’ transiently suppressing cortical excitability and disrupting swallowing behaviour. Here, we compared the ability of ipsi‐lesional, contra‐lesional and sham cerebellar rTMS to reverse the effects of a ‘virtual‐lesion’ in health. Two groups of healthy participants (n = 15/group) were intubated with pharyngeal catheters. Baseline pharyngeal motor evoked potentials (PMEPs) and swallowing performance (reaction task) were measured. Participants received 10 min of 1 Hz rTMS to the pharyngeal motor cortex which elicited the largest PMEPs to suppress cortical activity and disrupt swallowing behaviour. Over six visits, participants were randomized to receive 250 pulses of 10 Hz cerebellar rTMS to the ipsi‐lesional side, contra‐lesional side or sham while assessing PMEP amplitude or swallowing performance for an hour afterwards. Compared to sham, active cerebellar rTMS, whether administered ipsi‐lesionally (P = 0.011) or contra‐lesionally (P = 0.005), reversed the inhibitory effects of the cortical ‘virtual‐lesion’ on PMEPs and swallowing accuracy (ipsi‐lesional, P, Key points Despite evidence that the human cerebellum has an important role in swallowing neurophysiology, the effects of cerebellar stimulation on swallowing in the disrupted brain have not been explored.In this study, for the first time, the application of cerebellar neurostimulation is characterized in a human model of disrupted swallowing (using a cortical virtual lesion).It is demonstrated that cerebellar stimulation can reverse the suppressed activity in the cortical swallowing system and restore swallowing function in a challenging behavioural task, suggesting the findings may have important therapeutic implications.

Objectives: this prospective, cluster randomised, controlled trial investigated the effect of oral neuromuscular training among older people in intermediate care with impaired swallowing. Methods: older people (≥65 years) with swallowing dysfunction were cluster randomised according to care units for 5 weeks of neuromuscular training of the orofacial and pharyngeal muscles or usual care. The primary endpoint was the change in swallowing rate (assessed with a timed water swallow test) from baseline to the end-of-treatment and 6 months post-treatment. The secondary endpoints were changes in signs of aspiration during the water swallow test, and swallowing-related quality of life (QOL). An intention-to-treat principle was followed, and mixed-effects models were used for data analysis with the clustered study design as a random factor. Results: in total, 385 participants from 36 intermediate care units were screened, and 116 participants were randomly assigned to oral neuromuscular training (intervention; n = 49) or usual care (controls; n = 67). At the end of treatment, the geometric mean of the swallowing rate in the intervention group had significantly improved 60% more than that of controls (P = 0.007). At 6 months post-treatment, the swallowing rate of the intervention group remained significantly better (P = 0.031). Signs of aspiration also significantly reduced in the intervention group compared with controls (P = 0.01). No significant between-group differences were found for swallowing-related QOL. Conclusions: oral neuromuscular training is a new promising swallowing rehabilitation method among older people in intermediate care with impaired swallowing. Trial registration: ClinicalTrials.gov: NCT02825927. Originally included in thesis in manuscript form.

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.

The aim of this study was to evaluate the clinical effectiveness of covered Niti-S stent placement under multidetector CT and fluoroscopy guidance for the palliation of dysphagia in patients with cervical esophageal cancer. Under radiological imaging guidance using axial and sagittal CT scans, and fluoroscopy, Niti-S esophageal stents were placed in ten consecutive patients with complete obstruction caused by cervical esophageal cancer (9 men and 1 woman; age range = 54–79 years; mean age = 68.1 years) between February 2010 and December 2011. The procedure time and technical success rate were evaluated. Swallowing improvement was assessed by the following items: ability to eat and/or swallow (graded as follows: 3 = ability to eat normal diet, 2 = ability to eat semisolids, 1 = ability to swallow liquids, 0 = complete obstruction). Procedural and post-procedural complications were also evaluated. Survival (mean ± SD) was examined. The mean (±SD) procedure time was 40 ± 19 min (range = 21–69 min). Stent placement was technically successful in all patients; inadequate stent deployment did not occur in any case. Ability to eat and/or swallow was improved and scored 2.4 (score 3 in 5 cases, score 2 in 4 cases, score 1 in 1 case, and score 0 in no case) after stent placement. No major or post-procedural complications were encountered. The mean survival time was 131 ± 77 days (range = 31–259 days). Niti-S stents appeared to be a safe and effective device for the palliation of dysphagia caused by advanced cervical esophageal cancer. Multidetector CT and fluoroscopy image guidance helped the operators accurately place the stents in the cervical esophagus.

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

OBJECTIVE: To explore the potential of volumetric-modulated arc therapy (VMAT) to reduce the risk of swallowing problems after curative chemoradiotherapy. METHODS: 20 patients with head and neck cancer who previously underwent radiotherapy were selected. Radiotherapy was prescribed according to simultaneous integrated boost technique with all targets irradiated simultaneously over 30 daily fractions. Doses of 70.5 (67.5), 60.0 and 55.5 Gy were prescribed to primary tumour, high-risk nodal regions and low-risk nodal regions, respectively. Pharyngeal constrictor muscles (PCM) and glottic and supraglottic larynx (SGL) were considered organs at risk related to swallowing dysfunction (SW-OARs). Upper pharyngeal constrictor muscles (uPCM), middle pharyngeal constrictor muscles (mPCM) and lower pharyngeal constrictor muscles (lPCM) part of PCM were also outlined separately. Clinical standard plans (standard-VMAT) and plans aiming to spare SW-OARs (swallowing dysfunction-VMAT) were also created. Normal tissue complication probabilities (NTCP) for physician-rated swallowing dysfunction were calculated using a recently predictive model developed by Christianen et al. RESULTS: Planning with two strategies demonstrated comparable planning target volume coverage and no differences in sparing of parotid glands and other non-swallowing organs at risk. SW-VMAT plans provided mean dose reduction for uPCM and SGL by 3.9 and 4.5 Gy, respectively. NTCP values for Radiation Therapy Oncology Group grade 2-4 swallowing dysfunction was decreased by 9.2%. Dose reductions with SW-VMAT depended on tumour location and overlap with SW-OARs. CONCLUSION: VMAT plans aiming at sparing swallowing structures are feasible, providing a significant reduction in NTCP swallowing dysfunction with respect to conventional VMAT. ADVANCES IN KNOWLEDGE: Dysphagia is today considered one of the dose-limiting toxicities of chemoradiotherapy. The dose sparing of swallowing structures represents a major challenge in radiotherapy. VMAT is a complex new technology having the potential to significantly reduce the risk of dysphagia after curative chemoradiotherapy.

High-resolution manometry (HRM) with esophageal pressure topography (EPT) allowed for the establishment of an objective quantitative measurement of esophagogastric junction (EGJ) relaxation, the integrated relaxation pressure (IRP). This study assessed whether or not a novel 3D-HRM assembly could improve on this measurement. Twenty-five normal subjects were studied with both a standard HRM assembly and a novel hybrid assembly (3D-HRM), including a 9.0 cm 3D-HRM segment composed of 96 radially dispersed independent pressure sensors. The standard IRP was computed using each assembly and compared with a novel paradigm, the 3D-IRP, an analysis premised on finding the axial maximum and radial minimum pressure at each sensor ring along the sleeve segment. Fourteen additional subjects underwent barium swallows with 3D-HRM and concurrent videofluoroscopy to compare the electronic sleeve (eSleeve) paradigm (circumferential average) to the 3D eSleeve paradigm (radial minimum) as a predictor of transphincteric flow. The 3D-IRP was significantly less than all other calculations of IRP with the upper limit of normal being 12 mmHg vs. 17 mmHg for the standard IRP. The sensitivity (0.78) and the specificity (0.88) of the 3D-eSleeve were also better than the standard eSleeve (0.55 and 0.85, respectively) for predicting flow permissive time verified fluoroscopically. The 3D-IRP and 3D-eSleeve calculated using the radial pressure minimum lowered the normative range of EGJ relaxation (upper limit of normal 12 mmHg) and yielded intraluminal pressure gradients that better correlated with bolus flow than did analysis paradigms based on circumferentially averaged pressure.

The brain renin-angiotensin system (RAS) plays an important role in hydromineral and neuroendocrine balance. Although previous studies showed that exogenous angiotensin (Ang) II increased dipsogenic and vasopressin responses in near-term fetuses, little is known about the functional development of fetal endogenous brain RAS in the regulation of body fluid homeostasis. To determine the functional development of the central angiotensin-converting enzyme (ACE) in utero, we investigated the electrocortical (ECoG) activity, swallowing activity, oxytocin (OT) release, and c-fos expression in response to intracerebroventricular Ang I administration in the near-term fetal lamb. Ang I did not change fetal low-voltage (LV) and high-voltage (HV) ECoG temporal distributions, but increased fetal swallowing activity during LV ECoG (1.0 ± 0.1 to 3.5 ± 0.4 swallows/min). Additionally, Ang I evoked an increase in c-fos-immunoreactivity in putative dipsogenic centers, including the supraoptic and paraventricular nuclei of the hypothalamus, accompanied by an increase in fetal plasma OT levels. The expression of c-fos was demonstrated in OT neurons in the hypothalamus. The Ang I-mediated increase in fetal swallowing and plasma OT was inhibited by captopril. These results demonstrate the functional development of the fetal brain ACE system in the last trimester of gestation, which plays an important role in the RAS-mediated dipsogenic response and OT release in the regulation of body fluid homeostasis.

This systematic review explores studies using biomechanical analysis of hyoid bone displacement in videofluoroscopy of swallowing as a spatial outcome parameter to evaluate intervention effects. Two authors independently carried out the literature search using the electronic databases Embase, PubMed, and Cochrane Library. Differences in their search findings were settled by discussion. The search was limited to publications in the English, German, French, Spanish, or Dutch language. MeSH terms were used, supplemented by free-text words to identify the most recent publications. In addition, reference lists were searched by hand. Only studies using videofluoroscopy to evaluate the biomechanical effects of swallowing interventions in dysphagic subjects were included in the review. While the body of literature on measuring hyoid bone displacement in videofluoroscopy has grown, only 12 studies met the inclusion criteria. Several of the 12 studies had methodological shortcomings. In general, the conclusions could not be compared across the studies because of their heterogeneous designs and outcome measures. Overall, several intervention effect studies reported significant results. In particular, bolus modification and swallowing maneuvers showed a greater range of hyoid bone displacement. In light of this review, further research on hyoid bone displacement as a spatial variable in well-defined patient populations using well-defined videofluoroscopic protocols to measure intervention effects is recommended.

Swallowing-related activity was examined in respiratory (n = 60) and non-respiratory (n = 82) neurons that were located in and around the nucleus of the solitary tract (NTS) in decerebrated, neuromuscularly blocked and artificially ventilated rats. Neurons that were orthodromically activated by electrical stimulation of the superior laryngeal nerve (SLN) were identified, and fictive swallowing was evoked by SLN stimulation. The pharyngeal phase of swallowing was monitored by hypoglossal nerve activity. Two types of non-respiratory neurons with swallowing-related bursts were identified: ‘early’ swallowing neurons (n = 24) fired during periods of hypoglossal bursts, and ‘late’ swallowing neurons (n = 8) fired after the end of hypoglossal bursts. The remaining non-respiratory neurons were either suppressed (n = 21) or showed no change in activity (n = 29) during swallowing. On the other hand, respiratory neurons with SLN inputs included 56 inspiratory and four expiratory neurons. Inspiratory neurons were classified into two major types: a group of neurons discharged simultaneously with hypoglossal bursts (type 1 neurons, n = 19), while others were silent during bursts but were active during inter-hypoglossal bursts when swallowing was provoked repetitively (type 2 neurons, n = 34). Three of the expiratory neurons fired during hypoglossal bursts. Many of the swallowing-related non-respiratory neurons and the majority of the inspiratory neurons received presumed monosynaptic inputs from the SLN. Details of the distribution and firing patterns of these NTS neurons, which have been revealed for the first time in a fictive swallowing preparation in the rat, suggest their participation in the initiation, pattern formation and mutual inhibition between swallowing and respiration.

OBJECTIVE—To characterise swallowing function in patients with cervical dystonia with botulinum toxin treatment failure, before and after selective peripheral denervation surgery. METHODS—Twelve patients with cervical dystonia had a thorough examination including standardised assessment for cervical dystonia, scoring of subjective dysphagia, and videofluoroscopic swallow. Videofluoroscopy was scored by consensus opinion between a speech and language therapist and an independent blinded radiologist using a validated scoring system. RESULTS—Seven patients with cervical dystonia experienced no subjective dysphagia either before or after surgery, although in all these patients there was objective videofluoroscopic evidence of underlying mild to moderate oropharyngeal dysphagia preoperatively and postoperatively. The most common finding was delayed initiation of swallow. Three other patients, also without subjective dysphagia before surgery, developed postoperative dysphagia. In these patients, videofluoroscopy showed a delayed swallow reflex before surgery, which was worse postoperatively in two. The remaining two patients had mild subjective dysphagia before surgery that improved postoperatively in one and deteriorated in the other. In the first, videofluoroscopy was normal preoperatively and postoperatively, and in the second, oral bolus preparation was moderately abnormal preoperatively and swallow initiation was delayed postoperatively. Mean subjective dysphagia scores did not change significantly. Apart from a significant improvement of tongue base retraction, videofluoroscopic scores were not significantly different after surgery. Postoperatively there was significant improvement of overall cervical dystonia severity and abnormal head rotation in the group as a whole. There was no correlation between age, duration of symptoms of cervical dystonia, preoperative or postoperative cervical dystonia severity, subjective dysphagia scores, or videofluoroscopic scores. However, in the five patients with persisting anterior sagittal head shift as part of the torticollis, tongue base retraction was less likely to improve after surgery compared with those without head shift. CONCLUSION—Surgical denervation of dystonic neck muscles, leading to improved neck posture, can also improve tongue base retraction, which is a key component of normal bolus propagation. However, delayed swallow initiation, a common feature in patients with cervical dystonia, can be further compromised by surgery, leading to subjective dysphagia. In general, selective peripheral denervation seems to be a safe procedure with no major compromise of swallowing function.

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 and purpose: Transient lower oesophageal sphincter relaxations (TLESRs) are the main mechanism underlying gastro-oesophageal reflux and are a potential pharmacological treatment target. We evaluated the effect of the CB1/CB2 receptor agonist Δ9-tetrahydrocannabinol (Δ9-THC) on TLESRs in dogs. Based on these findings, the effect of Δ9-THC was studied in healthy volunteers. Experimental approach: In dogs, manometry was used to evaluate the effect of Δ9-THC in the presence and absence of the CB1 receptor antagonist SR141716A on TLESRs induced by gastric distension. Secondly, the effect of 10 and 20 mg Δ9-THC was studied in 18 healthy volunteers in a placebo-controlled study. Manometry was performed before and for 3 h after meal ingestion on three occasions. Key results: In dogs, Δ9-THC dose-dependently inhibited TLESRs and reduced acid reflux rate. SR141716A significantly reversed the effects of Δ9-THC on TLESRs. Similarly, in healthy volunteers, Δ9-THC significantly reduced the number of TLESRs and caused a non-significant reduction of acid reflux episodes in the first postprandial hour. In addition, lower oesophageal sphincter pressure and swallowing were significantly reduced by Δ9-THC. After intake of 20 mg, half of the subjects experienced nausea and vomiting leading to premature termination of the study. Other side-effects were hypotension, tachycardia and central effects. Conclusions and implications: Δ9-THC significantly inhibited the increase in meal-induced TLESRs and reduced spontaneous swallowing in both dogs and humans. In humans, Δ9-THC significantly reduced basal lower oesophageal sphincter pressure. These findings confirm previous observations in dogs and indicate that cannabinoid receptors are also involved in the triggering of TLESRs in humans.