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Rainer Wirth,1,2 Rainer Dziewas,3 Anne Marie Beck,4 Pere Clavé,5 Shaheen Hamdy,6 Hans Juergen Heppner,7,8 Susan Langmore,9 Andreas Herbert Leischker,10 Rosemary Martino,11 Petra Pluschinski,12 Alexander Rösler,13 Reza Shaker,14 Tobias Warnecke,3 Cornel Christian Sieber,2,15 Dorothee Volkert2 1Department for Internal Medicine and Geriatrics, St Marien-Hospital Borken, Borken, Germany; 2Institute for Biomedicine of Aging, Friedrich-Alexander-Universität Erlangen-Nürnberg, Nürnberg, Germany; 3Department of Neurology, University Hospital Münster, Münster, Germany; 4Department of Nutrition and Health, Faculty of Health and Technology, Metropolitan University College, Copenhagen, Denmark; 5Centro de Investigación Biomédica en Red de enfermadades Hepáticas y Digestivas (CIBERehd), Hospital de Mataró, Universitat Autònoma de Barcelona, Mataró, Spain; 6Centre for Gastrointestinal Sciences, Institute of Inflammation and Repair, University of Manchester, Salford Royal Hospital, Salford, UK; 7Department of Geriatrics, Witten- Herdecke University, 8Helios Clinic Schwelm, Schwelm, Germany; 9Department of Speech, Language and Hearing Sciences, Boston University School of Medicine, Boston, MA, USA; 10Department of Geriatrics, Alexianer Hospital Krefeld, Krefeld, Germany; 11Department of Speech-Language Pathology, University of Toronto, Toronto, Canada; 12Department of Phoniatrics and Pediatric Audiology, University of Marburg, Marburg, Germany; 13Department of Geriatrics, Marien Hospital Hamburg, Hamburg, Germany; 14Division of Gastroenterology and Hepatology, Medical College of Wisconsin, Milwaukee, WI, USA; 15Department of General Internal Medicine and Geriatrics, St John of God Hospital Regensburg, Regensburg, Germany Abstract: Oropharyngeal dysphagia (OD) is a highly prevalent and growing condition in the older population. Although OD may cause very severe complications, it is often not detected, explored, and treated. Older patients are frequently unaware of their swallowing dysfunction which is one of the reasons why the consequences of OD, ie, aspiration, dehydration, and malnutrition, are regularly not attributed to dysphagia. Older patients are particularly vulnerable to dysphagia because multiple age-related changes increase the risk of dysphagia. Physicians in charge of older patients should be aware that malnutrition, dehydration, and pneumonia are frequently caused by (unrecognized) dysphagia. The diagnosis is particularly difficult in the case of silent aspiration. In addition to numerous screening tools, videofluoroscopy was the traditional gold standard of diagnosing OD. Recently, the fiberoptic endoscopic evaluation of swallowing is increasingly utilized because it has several advantages. Besides making a diagnosis, fiberoptic endoscopic evaluation of swallowing is applied to evaluate the effectiveness of therapeutic maneuvers and texture modification of food and liquids. In addition to swallowing training and nutritional interventions, newer rehabilitation approaches of stimulation techniques are showing promise and may significantly impact future treatment strategies. Keywords: aspiration, dehydration, dysphagia, geriatric, malnutrition, older

Background and purpose: Diagnosis of pharyngeal dysphagia caused by myasthenia gravis (MG) based on clinical examination alone is often challenging. Flexible endoscopic evaluation of swallowing (FEES) combined with Tensilon (edrophonium) application, referred to as the FEES‐Tensilon test, was developed to improve diagnostic accuracy and to detect the main symptoms of pharyngeal dysphagia in MG. Here we investigated inter‐ and intra‐rater reliability of the FEES‐Tensilon test and analyzed the main endoscopic findings. Methods: Four experienced raters reviewed a total of 20 FEES‐Tensilon test videos in randomized order. Residue severity was graded at four different pharyngeal spaces before and after Tensilon administration. All interpretations were performed twice per rater, 4 weeks apart (a total of 160 scorings). Intra‐rater test–retest reliability and inter‐rater reliability levels were calculated. Results: The most frequent FEES findings in patients with MG before Tensilon application were prominent residues of semi‐solids spread all over the hypopharynx in varying locations. The reliability level of the interpretation of the FEES‐Tensilon test was excellent regardless of the rater's profession or years of experience with FEES. All four raters showed high inter‐ and intra‐reliability levels in interpreting the FEES‐Tensilon test based on residue clearance (kappa = 0.922, 0.981). The degree of residue normalization in the vallecular space after Tensilon application showed the highest inter‐ and intra‐rater reliability level (kappa = 0.863, 0.957) followed by the epiglottis (kappa = 0.813, 0.946) and pyriform sinuses (kappa = 0.836, 0.929). Conclusion: Interpretation of the FEES‐Tensilon test based on residue severity and degree of Tensilon clearance, especially in the vallecular space, is consistent and reliable. [ABSTRACT FROM AUTHOR]

Background and purpose Dysphagia is a well-known complication of acute stroke. Given the complexity of cerebral swallowing control it is still difficult to predict which patients are likely to develop swallowing dysfunction based on their neuroimaging. In Part 2 of a comprehensive voxel-based imaging study, whether the location of a stroke lesion can be correlated with further dysfunctional swallowing patterns, pulmonary protective reflexes and pneumonia was evaluated. Methods In all, 200 acute stroke cases were investigated applying flexible endoscopic evaluation of swallowing within 96 h from admission. Lesions were mapped using patients' computed tomography/magnetic resonance images and these were registered to a standard space. The percentage of lesioned volume of 137 anatomically defined brain regions was determined on a voxel basis ( FSL5.0). Region-specific odds ratios ( ORs) were calculated with respect to the presence of oropharyngeal residue, delayed swallow response, insufficient cough reflex and occurrence of pneumonia during hospital stay. Colour-coded lesion location maps of brain regions with significant ORs were created ( P < 0.05). Results Lesion maps for residue and impaired swallow response depicted parietal-temporal areas of the right hemisphere. Limbic structures in the right hemisphere and sensory regions on the left were associated with cough reflex disturbance. There was no overlap of lesion maps for impaired swallow response and insufficient cough reflex or pneumonia, but substantial overlap between the last two conditions. Conclusions This study gives new insights on the cortical representation of single components of swallowing and airway protection behaviours. The lesion model may help to risk-stratify patients for dysphagia and pneumonia based on their brain scan. [ABSTRACT FROM AUTHOR]

Background and purpose Although early identification of patients at risk for dysphagia is crucial in acute stroke care, predicting whether a particular patient is likely to have swallowing problems based on the brain scan is difficult because a comprehensive model of swallowing control is missing. In this study whether stroke location is associated with dysphagia incidence, severity and the occurrence of penetration or aspiration was systematically evaluated relying on a voxel-based imaging analysis approach. Methods Two hundred acute stroke patients were investigated applying fiberoptic endoscopic evaluation of swallowing within 96 h from admission. Lesion masks were obtained from each patient's brain scan and registered to standard space. The percentage of lesioned volume of 137 atlas-based brain regions was determined in each case. Region-specific odds ratios were afterwards calculated with respect to presence of dysphagia, its severity and occurrence of penetration or aspiration. Results In all, 165 patients were diagnosed with dysphagia, 80 of whom had severe swallow impairment. For each investigated item there were significant differences of regional percentage infarction in distinct brain areas between affected patients and those who did not present with that specific dysfunction. In particular, right hemispheric lesions of the pre- and post-central gyri, opercular region, supramarginal gyrus and respective subcortical white matter tracts were related to dysphagia, with post-central lesions being especially associated with severe swallowing impairment. Conclusions Distinct brain lesion locations are related to the incidence, severity and pattern of swallowing dysfunction. [ABSTRACT FROM AUTHOR]