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BackgroundThe aim of this systematic review was to determine whether introduction of oral feeding for infants and children receiving nasal continuous positive airway pressure (nCPAP) or high flow nasal cannula (HFNC) respiratory support facilitates achievement of full oral feeding without adverse effects, compared to no oral feeding (NPO; nil per oral) on CPAP or HFNC.MethodsA protocol was lodged with the PROSPERO International Prospective Register of Systematic Reviews. We searched Medline, Embase, CINAHL, CENTRAL and AustHealth from database inception to 10th June 2020. Study population included children (preterm to ResultsThe search retrieved 1684 studies following duplicate removal. Title and abstract screening identified 70 studies for full text screening and of these, 16 were included in the review for data extraction. Methods of non-invasive ventilation (NIV) included nCPAP (n = 6), nCPAP and HFNC (n = 5) and HFNC (n = 5). A metanalysis was not possible as respiratory modes and cohorts were not comparable. Eleven studies reported on adverse events. Oral feeding safety was predominantly based on retrospective data from chart entries and clinical signs, with only one study using an instrumental swallow evaluation (VFSS) to determine aspiration status.ConclusionsFindings are insufficient to conclude whether commencing oral feeding whilst on nCPAP or HFNC facilitates transition to full oral feeding without adverse effects, including oropharyngeal aspiration. Further research is required to determine the safety and efficacy of oral feeding on CPAP and HFNC for infants and children.Trial registrationPROSPERO registration number: CRD42016039325.

Purpose The purpose of this study was to examine (a) the agreement between allied health assistants (AHAs) and speech-language pathologists (SLPs) when completing dysphagia screening for low-risk referrals and at-risk patients under a delegation model and (b) the operational impact of this delegation model. Method All AHAs worked in the adult acute inpatient settings across three hospitals and completed training and competency evaluation prior to conducting independent screening. Screening (pass/fail) was based on results from pre-screening exclusionary questions in combination with a water swallow test and the Eating Assessment Tool. To examine the agreement of AHAs' decision making with SLPs, AHAs ( n = 7) and SLPs ( n = 8) conducted an independent, simultaneous dysphagia screening on 51 adult inpatients classified as low-risk/at-risk referrals. To examine operational impact, AHAs independently completed screening on 48 low-risk/at-risk patients, with subsequent clinical swallow evaluation conducted by an SLP with patients who failed screening. Results Exact agreement between AHAs and SLPs on overall pass/fail screening criteria for the first 51 patients was 100%. Exact agreement for the two tools was 100% for the Eating Assessment Tool and 96% for the water swallow test. In the operational impact phase ( n = 48), 58% of patients failed AHA screening, with only 10% false positives on subjective SLP assessment and nil identified false negatives. Conclusion AHAs demonstrated the ability to reliably conduct dysphagia screening on a cohort of low-risk patients, with a low rate of false negatives. Data support high level of agreement and positive operational impact of using trained AHAs to perform dysphagia screening in low-risk patients.

Purpose This clinical focus article considers the roles of the clinical swallow examination (CSE) as a clinically meaningful assessment method used in both adult and pediatric populations. Method This clinical focus article explores the utility of the CSE across the life span. Specifically, components, reliability, standardized assessments, and limitations of the CSE within the adult and pediatric populations are highlighted. Conclusions The CSE remains a crucial assessment tool for the speech-language pathologist. The experienced clinician can make important judgments regarding patient safety and function. If the CSE is conducted mindfully and methodically, findings can help chart the course of care for individuals needing additional assessment and possibly intervention.

Objectives To evaluate the impact of early inpatient bedside injection laryngoplasty (IL) in hospitalized patients with iatrogenic unilateral vocal fold immobility (UVFI). Study design Retrospective cohort study. Methods A retrospective review of hospitalized patients with iatrogenic UVFI undergoing IL between September 2013 and June 2017 was performed. Patients had a swallow evaluation by a speech-language pathologist and bedside IL. Evaluated outcomes included swallow scores, return to diet, secondary events/procedures, and hospital length of stay. Outcomes related to etiology of UVFI were also examined. Results The cohort consisted of 90 patients (61% male, 52% after cardiac/cardiothoracic surgery). Seventy-seven percent of all patients who could improve had increased swallow scores after IL. The lowest number (40%) from the subgroup of patients with high vagal injuries as the cause of UVFI obtained improvement in swallow scores, whereas 87% of those in the cardiac surgery group improved. There were more bronchoscopies and reintubations in patients before IL than after IL. Conclusion Hospitalized patients with UVFI are at increased risk of morbidity and mortality due to dysphagia. We advocate for early swallow evaluation and intervention with IL if there is dysphagia and risk of aspiration. Coordination of care between interdisciplinary teams is paramount to a successful inpatient IL program. Level of evidence 2b Laryngoscope, 131:115-120, 2021.

Objective To investigate dysphagia in patients recovering from SARS-CoV-2 admitted to acute inpatient rehabilitation by summarizing clinical swallow evaluation and videofluoroscopic swallow study findings. Design Retrospective cohort study Setting Urban inpatient rehabilitation hospital Participants First forty inpatient admissions with SARS-CoV-2 who participated in a videofluoroscopic swallow study Interventions None Main Outcome Measures Patient characteristics upon admission (duration of intubation, tracheostomy status, comorbidities, VFSS completion at previous level of care); admission International Dysphagia Diet level (IDDSI); Mann Assessment of Swallowing Ability (MASA), Functional Oral Intake Scale (FOIS), dysphagia severity rating; Penetration Aspiration Scale (PAS) rated during VFSS; and IDDSI level recommended following completion of VFSS. Results 20% of patients had been evaluated by videofluoroscopy in acute care. 19/37 (51.%) individuals were upgraded to IDDSI level 7 regular diet with level 0 thin liquids and achieved a FOIS of 7 after the completion of the VFSS. Five individuals (13%) received a diet downgrade or remained on the same diet recommendations from their admission. Total numerical score (TNS) of less than 170 on the Mann Assessment of Swallow Ability (MASA) predicted presence of aspiration in 54% (7/13) of patients. 56% (15/27) of the sample had a TNS less than 170 but did not demonstrate any instances of aspiration. The odds of patients having a PAS greater than or equal to 3 increased by approximately 15% (OR=1.15, 95% CI: 1.03, 1.27, p=0.013). Thus, with each additional day of intubation during acute care stay, there was an 15% greater likelihood of having airway invasion. Conclusions Instrumental swallow evaluations are imperative to diagnose and treat dysphagia in the post COVID population. Because of the heterogeneity of this population, high incidence of prolonged intubation, and limitations of the clinical swallowing evaluation, instrumental assessments need to be performed on a more consistent basis as infection prevention protocols evolve.

Objectives/hypothesis Determine surgical and swallowing outcomes after surgery for type III laryngotracheoesophageal cleft (LTEC). Study design Case series with chart review. Methods Chart review was performed on patients with type III LTEC between 2000 and 2019. Demographics, surgical outcomes, and swallowing outcomes were collected and analyzed. Results Thirty-three patients met inclusion criteria (28 open and 5 endoscopic repairs). Mean age was 3.4 years for the open group and 0.9 years for the endoscopic group. Seventeen (51.5%) patients had a syndromic diagnosis, most commonly Opitz syndrome and Trisomy 21. Mean follow-up was 33.6 months. Thirteen (39.4%) patients had a previous repair attempt prior to repair at our institution. Twenty-four (70.6%) patients had a tracheostomy prior to or at the time of surgical repair and 13 (38.2%) remain tracheostomy-dependent. Nine patients (27.3%) required a revision cleft repair and four (12.1%) required two revisions. Thirty-one patients had an intact repair at last follow-up (93.9). Two patients died outside the hospital over a year after surgery. Preoperatively 13 of 17 patients with swallowing evaluations aspirated. After repair, 11 of 20 patients were deemed safe for all consistencies and seven were safe for thickened. Endoscopic approaches were performed during the last 2 years of the study and had significantly lower operative time (354.4 minutes vs. 171.5 minutes). Conclusions Endoscopic and open approaches are effective for treatment of type III LTEC with 27.3% requiring revision and 93.9% of repairs intact at last follow-up. Overall swallowing outcomes were good in patients who underwent postoperative instrumental swallow evaluation. Level of evidence IV Laryngoscope, 2021.

IntroductionDysphagia affects several children in USA and around the globe. Videofluoroscopic Swallow Study (VFSS) and Fiberoptic Endoscopic Evaluation of Swallowing (FEES) are the most objective studies to define swallowing function. The presence of tracheal aspiration during VFSS or FEES in children with dysphagia is associated with an increased risk of aspiration pneumonia. However, the association of laryngeal penetration with aspiration pneumonia remains unclear. This systematic review aims to assess the risk of aspiration pneumonia in children with dysphagia with laryngeal penetration on VFSS/FEES and compare it with children with tracheal aspiration and children with neither tracheal aspiration nor laryngeal penetration.Methods and analysisThis study will be a systematic review and meta-analysis. Systematic electronic searches will be conducted on PubMed, EMBASE, Web of Science, CINHAL, Scopus, Cochrane CENTRAL, LILACS and WHO Global Index Medicus. We will include studies published through 6 October 2021. Primary outcome will be the incidence of aspiration pneumonia. Secondary outcomes will be incidence of hospitalisation, paediatric intensive care unit admission, enteral tube requirement, growth, symptoms improvement and mortality. The Cochrane Risk of Bias In Non-Randomised Studies of Interventions tool will be used to assess the risk of bias. Meta-analysis will be used to pool the studies. We will pool dichotomous outcomes to obtain an odd ratio (OR) and report with 95% CI. Continuous outcomes will be pooled to obtain mean difference and reported with 95% CI. Overall grade of evidence will be assessed using Grading of Recommendations Assessment, Development and Evaluation (GRADE) criteria, and findings will be presented in a summary of findings table.Ethics and disseminationThis study is a systematic review without contact with patients. Therefore, IRB approval is not required. Authors consent to publishing this review. Data will be kept for review by editors and peer reviewers. Data will be available to general public on request.PROSPERO registration numberCRD42020222145.

Anterior cervical discectomy and fusion (ACDF) is a commonly performed procedure for cervical spine pathologies, with excellent arthrodesis and symptom resolution. Post-operative dysphagia is a significant concern for patients undergoing this procedure because it can significantly affect their quality of life. Studies have shown that the incidence of post-operative dysphagia increases with an increase in the number of levels performed. A retrospective chart review was performed by interrogating our procedure log system and the key words “anterior cervical discectomy and fusion” was inserted in to the search bar. All patients with a four level ACDF were selected. Chart review was performed for their speech evaluation immediate after surgery and three months post operatively. A total of 28 patients were identified for the study. Speech evaluation records were available for 21 of the 28 patients. Two of the patients had posterior instrumentation and were eliminated. There were 11 females and 8 males, average age was 62 (range 47–73), and all the patients had a C3–C7 ACDF. 2 out of the 19 (11%) patients had dysphagia diagnosed via barium swallow evaluation immediately after surgery, which persisted for 3 months. Both patients diagnosed with dysphagia were females. The Two patients were 72 and 73 years old. The incidence of post-operative dysphagia in patients undergoing 4 levels ACDF at our institution was found to be lower than the current literature quotes. Age and gender were more predictive of developing dysphagia in this study.

Introduction: Initial research has been conducted to determine the diagnostic accuracy of the pitch glide during the clinical swallow evaluation to identify aspiration in adults after stroke. Findings suggest that reduced pitch glide can predict aspiration in patients with dysphagia after stroke. This study aimed to identify the diagnostic accuracy of the pitch glide in detecting aspiration, pharyngeal residue and hyo­laryngeal excursion during swallowing in adults with respiratory diseases. Material and Methods: 17 adults (9 males and 8 females) with dysphagia who had a background of respiratory diseases (chronic obstructive pulmonary disease = 11; lower respiratory tract infection = 6) were consecutively recruited in an acute hospital setting. Participants completed two pitch glide tasks (/a/ and /i/) immediately before a videofluoroscopic swallowing study (VFSS). Pitch glide recordings were analysed by blinded researchers both acoustically (Praat software) to obtain maximum F0, pitch range and auditory-perceptually using a binary scale (“normal” or “abnormal”). Clinicians blinded to pitch glide ratings rated 5 mL, 10 mL and a sip of liquid swallows during VFSS using the Penetration-Aspiration Scale, Bolus Residue Scale and hyolaryngeal component of the MBS Measurement Tool for Swallow Impairment. Receiver operating characteristic curve, Pearson correlations and independent sample t tests were used to address the research questions. Results: Maximum F0 of sound /a/ had high sensitivity and specificity in identifying aspiration on 10 mL of liquids during VFSS. Both pitch glides (/a/ and /i/) had moderate sensitivity and specificity in predicting aspiration on a sip of liquids. However, auditory-perceptual measures of pitch glide had weak accuracy in identifying people who were aspirating during VFSS. Finally, all pitch glide measures (acoustic and auditory-perceptual) had low accuracy in predicting pharyngeal residue and hyolaryngeal excursion. Conclusion: Based on this initial pilot study, acoustic pitch glide of sound /a/ is an accurate way to predict aspiration on 10 mL of liquids in patients with respiratory diseases. Based on findings from this study, both auditory-perceptual and acoustic analyses of pitch glide could not identify residue and hyolaryngeal excursion.

Background Gaucher disease type 2 (GD2) is defined by acute neurological decline, failure to thrive, and early demise. Currently, there is no clear standard for evaluating, staging, and counseling regarding neurological decline in GD2. Due to the high prevalence of progressive dysphagia secondary to acute neurological involvement, we aimed to identify key components of swallow function which could serve as markers of disease progression in GD2. Methods A post-hoc analysis of modified barium swallow studies was performed. Six parameters of swallowing were scored in a retrospective chart review of eleven infants with GD2. Mixed effects regression, principal component analysis (PCA), and a transition analysis were used to evaluate swallow function and model disease progression. Results All patients exhibited impaired swallow function. There was no association between any of the swallow parameters and age, indicating non-linear disease progression. PCA and transition analysis identified five parameters capturing multiple dimensions of swallowing which defined two distinct disease states. Conclusion A five-parameter swallow evaluation was sufficient to identify distinct states of GD2 and model prospective outcomes. This multi-dimensional evaluation could be a useful efficacy parameter for future therapeutic trials in GD2 and other neurodegenerative disorders of infancy.

Background Dysphagia following extubation is common in intensive care unit (ICU) patients. Diagnosing postextubation dysphagia allows identification of patients who are at highest risk for aspiration and its associated adverse outcomes. Older adults are at an increased risk of postextubation dysphagia and its complications due to multiple comorbidities, a higher baseline risk of dysphagia, and increased risk of pneumonia. Objectives We aimed to investigate the association between postextubation dysphagia and 1-year mortality in older patients. Secondary outcomes included ICU and hospital lengths of stay, ICU readmission, and place of discharge. Methods We performed a retrospective cohort study from January 1 to December 31, 2013. ICU patients, aged 65 years and older, who were successfully extubated and underwent a formal swallow evaluation by a speech and language pathologist (SLP) were included. Dysphagia was graded using a seven-point scale, and those with at least mild-moderate dysphagia were labeled as having clinically significant dysphagia. Results Of 1075 patients who were screened, 359 were survivors, aged 65 years and older; and of these survivors, 111 had a swallow evaluation performed by an SLP after liberation from mechanical ventilation. Mean age was 73.8 years (SD = 7.0 years), and 41.4% had clinically significant dysphagia. In a multivariable regression model, there was no significant association between dysphagia and 1-year mortality. Furthermore, there was no statistically significant difference in ICU or hospital length of stay, ICU readmission, or place of discharge of those with clinically significant dysphagia compared to those without. Conclusions Among mechanically ventilated ICU patients, aged 65 years and older, who underwent a swallow evaluation following extubation, dysphagia was not associated with mortality, ICU and hospital lengths of stay, ICU readmission, and place of discharge. Given conflicting evidence in the literature, larger prospective studies are needed to clarify whether postextubation dysphagia is associated with worse outcomes in older patients admitted to the ICU. J Am Geriatr Soc 67:1895-1901, 2019.

OBJECTIVES/HYPOTHESIS Infants who undergo congenital heart surgery are at risk of developing vocal fold motion impairment (VFMI) and swallowing difficulties. This study aims to describe the dysphagia in this population and explore the associations between surgical complexity and vocal fold mobility with dysphagia and airway protection. STUDY DESIGN Retrospective chart review. METHODS This is a retrospective chart review of infants (age

Background: This study explored the available literature on the phenomenon of clinical reasoning and described its influence on the clinical swallow evaluation. By exploring the relationship between clinical reasoning and the clinical swallow evaluation, it is possible to modernise the approach to dysphagia assessment. Objectives: This study aimed to contextualise the available literature on clinical reasoning and the CSE to low-middle income contexts through the use of a scoping review and expert consultation. Method: A scoping review was performed based on the PRISMA-ScR framework. The data was analysed using thematic analysis. Articles were considered if they discussed the clinical swallow evaluation and clinical reasoning, and were published in the last 49 years. Results: Through rigorous electronic and manual searching, 12 articles were identified. This review made an argument for the value of clinical reasoning within the clinical swallow evaluation. The results of the study revealed three core themes related to the acquisition, variability and positive impact of clinical reasoning in the clinical swallow evaluation. Conclusion: The results of this review showed that the clinical swallow evaluation is a complex process with significant levels of variability usually linked to the impact of context. This demonstrates that in order to deliver effective and relevant services, despite challenging conditions, healthcare practitioners must depend on clinical reasoning to make appropriate modifications to the assessment process that considers these salient factors.

Introduction Dysphagia occurs in up to 50% of patients with acute stroke symptoms, resulting in increased aspiration pneumonia rates and mortality. The purpose of this study was to validate a health system's dysphagia (swallow) screening tool used since 2007 on all patients with suspected stroke symptoms. Annual rates of aspiration pneumonia for ischemic stroke patients have ranged from 2% to 3% since 2007. Methods From August 17, 2015 through September 30, 2015, a bedside dysphagia screening was prospectively performed by 2 nurses who were blinded to all patients age 18 years or older admitted through the emergency department with suspected stroke symptoms at 21 Joint Commission accredited primary stroke centers in an integrated health system. The tool consists of 3 parts: pertinent history, focused physical examination, and progressive testing from ice chips to 90 mL of water. A speech language pathologist blinded to the nurse's screening results performed a formal swallow evaluation on the same patient. Results The end study population was 379 patients. Interrater reliability between 2 nurses of the dysphagia screening was excellent at 93.7% agreement (Ƙ = 0.83). When the dysphagia screenings were compared with the gold standard speech language pathologist professional swallow evaluation, the tool demonstrated both high sensitivity (86.4%; 95% confidence interval = 73.3-93.6) and high negative predictive value (93.8%; 95% confidence interval = 87.2-97.1). Conclusion This tool is highly reliable and valid. The dysphagia screening tool requires minimal training and is easily administered in a timely manner.

Objectives In pediatric patients undergoing endoscopic laryngeal cleft repair, immediate postoperative dysphagia is not well-characterized. This study examined whether worsened dysphagia is present in the immediate postoperative period as detected by clinical swallow evaluation, and evaluated how this relates to postoperative change in presenting symptoms and findings on swallow studies. Methods A retrospective cohort was conducted at a tertiary academic medical center, evaluating all pediatric patients who underwent endoscopic laryngeal cleft repair by a single surgeon from October 2014 through December 2018. All patients underwent instrumental swallow evaluation preoperatively and clinical swallow evaluation within 24 h following surgery. Results Thirty-nine patients met inclusion criteria. Based on clinical swallow evaluation performed within 24 h after surgery, 4 patients (10%) were recommended to thicken their diet from preoperative baseline; all others were unchanged. All patients were admitted to the PICU for observation; 34 (87%) discharged on postoperative day 1. Thirty-seven patients attended 6-week follow-up, with 2 (5%) requiring thicker diet since discharge; all others were stable or improved. Prevalence of recurrent respiratory infections, subjective dysphagia, chronic cough, and wheezing significantly decreased after surgery. No statistically significant change occurred in prevalence of aspiration or penetration on instrumental swallow studies postoperatively. Conclusion Endoscopic laryngeal cleft repair is well-tolerated in pediatric patients, and most do not have obviously worsened dysphagia at immediate postoperative evaluation. Improvement in symptoms postoperatively may be a more useful indicator of surgical outcomes beyond instrumental swallow studies alone. The relative stability of these patients provides further evidence that they can likely be managed on the floor or as outpatients rather than in the ICU postoperatively.

Introduction Slide tracheoplasty is now considered gold standard treatment for long segment congenital tracheal stenosis. Outcomes are typically focused upon airway patency. Dysphagia is often reported in children undergoing cardiothoracic surgery, but not specifically after slide tracheoplasty. This study was carried out to describe the nature and prevalence of dysphagia following slide tracheoplasty for long segment congenital tracheal stenosis. Methods Retrospective case note review was conducted on a series of patients who underwent swallow evaluation following slide tracheoplasty between 2006 and 2014. A clinical swallow assessment was carried out by a Speech and Language Therapist with videofluoroscopic evaluation of swallowing where indicated. Logistic regression assessed the impact of gender, feeding history, weight, tracheal diameter, stenting and co-morbidities on the likelihood of having post-operative dysphagia. Results 43 out of 83 slide tracheoplasty patients underwent swallow evaluation. Dysphagia was identified in 30 (70%) of 43 patients. Videofluoroscopy was undertaken in 22 of these patients. All patients who had a videofluoroscopy presented with altered swallow physiology. Aspiration risk was confirmed in 15 patients with frank aspiration seen in 9. Pre-operative history of dysphagia was present in 9 patients. There were two cases of vocal fold palsy. The presence of a stent was the strongest predictor of post-operative dysphagia with an odds ratio of 10.6 (95% CI 1.2–92.8). Conclusions This study documents a high prevalence of post-operative dysphagia in a pediatric population following slide tracheoplasty. In most cases there was no history suggestive of dysphagia pre-operatively. Swallowing needs to be assessed after slide tracheoplasty and longitudinal studies are required.

Purpose To compare pulmonary and swallow outcomes of injection laryngoplasty when performed in the acute versus subacute setting in head & neck and thoracic cancer patients presenting with new onset unilateral vocal fold immobility. Materials and methods Case series with chart review at an academic cancer center over a 2 year period. Based on swallow evaluation, patients diagnosed with vocal fold immobility were grouped into an unsafe swallow group, injected as inpatients, and a safe swallow group, for whom injection laryngoplasty was delayed to the outpatient setting or not performed. Rates of pneumonia, diet recommendations, and swallow outcomes were compared between groups. Results 24 patients with new-onset vocal fold immobility were evaluated. 7 underwent injection in the inpatient setting, 12 in the outpatient setting, and 5 did not undergo injection. There was no perceived difference in speech and swallow outcomes between the inpatient and outpatient injection groups. Conclusions Injection laryngoplasty shows promise as an effective intervention for reducing aspiration risk and improving diet normalcy in patients with dysphagia as a result of unilateral vocal fold immobility. In patients determined to have a safe swallow, delay of injection laryngoplasty is not detrimental to swallow outcomes.

The cricopharyngeus muscle along with cervical esophageal musculature and the inferior pharyngeal constrictors make up the upper esophageal sphincter (UES). This complex controls anterograde and retrograde flow between the pharynx and esophagus to prevent aspiration of esophageal contents, prevent aerophagia, aid deglutition, and permit belching and vomiting. As the cricopharyngeal muscle resides in the transition zone between the inferior constrictors and cervical esophageal musculature and actively contributes to all UES functions, dysfunction can significantly impair deglutition. Cricopharyngeal dysfunction may result from aberrant neural input, fibrosis, or hypertonicity. Clinical manifestations range from a globus sensation to dysphagia and/or aspiration. Diagnostic tools include a clinical swallow evaluation, functional endoscopic evaluation of swallow, videofluoroscopy, manometry, and/or electromyography. Current evidence suggests that videofluoroscopy and manometry are most useful in directing treatment for the patient’s symptoms. Treatment of cricopharyngeal dysfunction ranges from swallow therapy in select cases to botulinum toxin injection, passive or active dilation, or open or endoscopic surgical myotomy. While few randomized controlled trials exist comparing treatment modalities, patient factors such as risks associated with general anesthesia and surgeon and patient goals can help direct a treatment plan.

Objectives: To identify and describe the types and time course of dysphagia following cervical spinal cord injury (SCI). Methods: This was a prospective cohort study conducted in an SCI inpatient rehabilitation unit. Seventy-six individuals with SCI were enrolled. Inclusion criteria were age 18 years or older, admitted into SCI inpatient rehabilitation unit, and medically stable for participation in bedside swallow evaluation (BSE) and videofluoroscopic swallow study (VFSS). All participants first underwent a BSE, of whom 33 completed a VFSS. A follow-up BSE was conducted on individuals who tested positive on the initial BSE and continued to show signs of dysphagia. Diagnosis and type of dysphagia as well risk factors were collected. Results: Twenty-three out of 76 individuals with cervical SCI were diagnosed with dysphagia using the BSE. All participants with positive BSE and VFSS had pharyngeal dysfunction. For participants with a positive initial BSE and persisting dysphagia ( n = 14), a follow-up BSE demonstrated resolution within 34 days. Risk factors associated with dysphagia were older age, nasogastric tube, invasive mechanical ventilation, tracheostomy, and pneumonia. Posterior spinal surgery was associated with a decreased risk of dysphagia. Conclusion: Dysphagia was present in 30% of individuals based on the initial BSE. All individuals with dysphagia demonstrated pharyngeal phase dysfunction on the VFSS. No participants experiencing dysphagia were missed on the BSE as confirmed by VFSS. In the subset of individuals who received a follow-up BSE, the time course of resolution of dysphagia was at most 34 days from initial BSE.

The clinical swallow evaluation, or bedside swallow evaluation, provides swallow specialists with the foundation for identification and management of swallowing disorders. The process of completing a clinical swallow evaluation allows for hypothesis generation and testing regarding etiology of and interventions for dysphagia and helps the clinician to determine what kinds of additional data need to be obtained. For pediatric patients in particular, data obtained during clinical evaluation will streamline diagnosis and treatment, guide decision-making during instrumental assessments, and help to establish the positive rapport that is essential for effective intervention in pediatric patients with dysphagia.

Context Dysphagia is usually associated with malignancies of the head, neck, and upper gastrointestinal tract but also occurs in those with tumors outside anatomic swallow regions. It can lead to aspiration pneumonia, malnutrition, reduced quality of life, and psychosocial distress. No studies have yet reliably described dysphagia prevalence in those with malignancies outside anatomic swallow regions. Objective The objective of this study was to establish the prevalence and predictors of dysphagia in adults with solid malignancies outside the head, neck, and upper gastrointestinal tract. Methods A cross-sectional, observational study using consecutive sampling was conducted. There were 385 participants (mean age 66 ± 12 years) with 21 different primary cancer sites from two acute hospitals and one hospice. Locoregional disease was present in 33%, metastatic in 67%. Dysphagia was screened by empirical questionnaire and confirmed through swallow evaluation. Demographic and clinical predictors were determined by univariate and multivariate binary regression. Results Dysphagia occurred in 19% of those with malignancies outside anatomic swallow regions. Prevalence was 30% in palliative care and 32% in hospice care. Dysphagia was most strongly associated with cough, nausea, and worse performance status. It was also associated with lower quality of life and nutritional difficulties. Conclusion Dysphagia was common and usually undiagnosed before study participation. It occurred at all disease stages but coincided with functional decline. It may therefore represent a cancer frailty marker. Oncology and palliative care services should routinely screen for this symptom. Timely dysphagia identification and management may improve patient well-being and prevent adverse effects like aspiration pneumonia and weight loss.

Objectives Static Endoscopic Evaluation of Swallowing (SEES) has been demonstrated to have a strong correlation with the Videofluoroscopic Swallow Study (VFSS) in adults. In children, Fiberoptic Endoscopic Evaluations of Swallow (FEES) are frequently performed to avoid repeated VFSS; however, a subset of the population does not tolerate FEES. The purpose of this study was to evaluate the utility of a modified SEES in children. Methods Charts of 50 consecutive patients who underwent FEES evaluations were reviewed. Patients age 3 months to 12 years undergoing SEES, FEES, and VFSS were extracted. We compared a binary assessment of outcome on SEES versus VFSS as the diagnostic standard to report characteristics, including sensitivity, specificity, and positive and negative predicted value. Results A total of 36 patients met all inclusion criteria (mean age 2.8 years). Using the VFSS as the diagnostic standard, residue seen on SEES had a sensitivity of 80.0%, specificity of 85.7%, a positive predictive value of 88.9%, and a negative predictive value of 75.0% for predicting deep penetration or aspiration. Conclusion SEES may be helpful for developing an initial diagnostic impression and may serve as a platform for patient and caregiver counseling. In children who are unable to cooperate with FEES, SEES may provide clinical insight in predicting an abnormal swallow study; however, a normal SEES was less reliable in predicting a safe swallow on subsequent VFSS in this patient population. Level of evidence 4 Laryngoscope, 130:1590-1594, 2020.

BACKGROUND Per-oral endoscopic myotomy (POEM) has become the preferred alternative treatment to standard Heller myotomy for patients with esophageal achalasia, in Latin American countries. The aim of our study was to evaluate the efficacy and safety of a POEM in the management of achalasia with and without Chagas disease in patients receiving POEM. METHODS Patients who underwent POEM from tertiary centers in Latin America were included in a dedicated registry. Countries included Brazil, Colombia, Ecuador, Mexico, Nicaragua, and Venezuela. Patients enrolled needed to have a preoperative manometry and swallow contrast study confirming achalasia. Clinical success was defined as significant improvement in Eckardt score after therapy. RESULTS POEM was technically successful in 81/89 (91%) patients (mean age, 44 y). There was a significant decrease in preprocedure and postprocedure Eckardt score from 8.7 (range, 3 to 12) to 2.15 (0 to 10) (P

Background: Cervical spine fractures occur in 2.6% to 4.7% of trauma patients aged 65 years or older. Mortality rates in this population ranges from 19% to 24%. A few studies have specifically looked at dysphagia in elderly patients with cervical spine injury. Aims: The aim of this study is to evaluate dysphagia, disposition, and mortality in elderly patients with cervical spine injury. Settings and Design: Retrospective review at an the American College of Surgeons-verified level 1 trauma center. Methods: Patients 65 years or older with cervical spine fracture, either isolated or in association with other minor injuries were included in the study. Data included demographics, injury details, neurologic deficits, dysphagia evaluation and treatment, hospitalization details, and outcomes. Statistical Analysis: Categorical and continuous data were analyzed using Chi-square analysis and one-way analysis of variance, respectively. Results: Of 136 patients in this study, 2 (1.5%) had a sensory deficit alone, 4 (2.9%) had a motor deficit alone, and 4 (2.9%) had a combined sensory and motor deficit. Nearly one-third of patients (n = 43, 31.6%) underwent formal swallow evaluation, and 4 (2.9%) had a nasogastric tube or Dobhoff tube placed for enteral nutrition, whereas eight others (5.9%) had a gastrostomy tube or percutaneous endoscopic gastrostomy tube placed. Most patients were discharged to a skilled nursing unit (n = 50, 36.8%), or to home or home with home health (n = 48, 35.3%). Seven patients (5.1%) died in the hospital, and eight more (5.9%) were transferred to hospice. Conclusion: Cervical spine injury in the elderly patient can lead to significant consequences, including dysphagia and need for skilled nursing care at discharge.

Objective To determine the effect of expiratory muscle strength training (EMST) on both cough and swallow function in stroke patients. Design Prospective pre-post intervention trial with 1 participant group. Setting Two outpatient rehabilitation clinics. Participants Adults (N=14) with a history of ischemic stroke in the preceding 3 to 24 months. Intervention EMST. The training program was completed at home and consisted of 25 repetitions per day, 5 days per week, for 5 weeks. Main Outcome Measures Baseline and posttraining measures were maximum expiratory pressure, voluntary cough airflows, reflex cough challenge to 200μmol/L of capsaicin, sensory perception of urge to cough, and fluoroscopic swallow evaluation. Repeated measures and 1-way analyses of variance were used to determine significant differences pre- and posttraining. Results Maximum expiratory pressure increased in all participants by an average of 30cmH2O posttraining. At baseline, all participants demonstrated a blunted reflex cough response to 200μmol/L of capsaicin. After 5 weeks of training, measures of urge to cough and cough effectiveness increased for reflex cough; however, voluntary cough effectiveness did not increase. Swallow function was minimally impaired at baseline, and there were no significant changes in the measures of swallow function posttraining. Conclusions EMST improves expiratory muscle strength, reflex cough strength, and urge to cough. Voluntary cough and swallow measures were not significantly different posttraining. It may be that stroke patients benefit from the training for upregulation of reflex cough and thus improved airway protection.

United States census data project dramatic increases in the geriatric population ageing demographics by 2060 with concomitant health-care consequences. The purpose of this replication and continuation study was to collect new 2014 demographic data relative to ageing, swallow evaluation referral rates, and oral feeding status in geriatric-hospitalized patients for comparison with published data from 2000 to 2007. This was a planned data acquisition study of consecutive hospitalized patients referred for swallow assessments. Swallow evaluation referral rates for 2014 were described according to inpatient discharges, age range 60-105 years grouped by decade, gender, admitting diagnostic category, results of swallow evaluations, and oral feeding status. Determination of aspiration risk status was made with the Yale Swallow Protocol and diagnosis of dysphagia made with fiberoptic endoscopic evaluation of swallowing (FEES). There were 1348 referrals and 961 patients ≥60 years of age participated. Overall swallow evaluation referral rates increased an average of 63 % between the comparison years 2007 and 2014 with consistent increases corresponding to the decades, i.e., 60-69 (46 %), 70-79 (68 %), 80-89 (53 %), and 90+ (222 %). A total of 75 % of participants resumed oral alimentation and oral medications. Swallow evaluation referral rates increased by 63 % for 60-90+ year-old acute care geriatric-hospitalized participants despite only a 23 % increase in inpatient discharges for the years 2007 versus 2014. This corroborated previously reported increases for individual years from 2000 to 2007. For timely, safe, and successful initiation of oral alimentation, it is important to perform a reliable swallow screen for aspiration risk assessment with the Yale Swallow Protocol and, if failed, instrumental testing with FEES. More dysphagia specialists are needed through 2060 and beyond due to projections of continued population ageing resulting in ever increasing referral rates for swallow assessments.

Purpose: To determine the relationship between air pulse vs. touch laryngeal adductor reflex (LAR) tests and the clinical sensory findings of fiberoptic endoscopic evaluations of swallowing.Method: A retrospective review was conducted for 43 patients with dysphagia due to stroke that underwent fiberoptic endoscopic evaluation of swallowing with sensory testing (FEESST). Each patient received LAR testing using air pulse or touch methodologies. Clinically, responsiveness to pharyngeal residue and responsiveness to penetration or aspiration were analysed.Result: The sensitivity, specificity, positive and negative predictive values for both LAR test groups indicate that LAR testing did not effectively predict sensory function during the clinical swallow evaluation. Across both LAR groups, specificity values were higher than sensitivity values. In fact, the specificity values for the light touch LAR test group were extremely high, but the negative predictive values did not support those findings. Sensitivity and positive predictive values were low for both groups.Conclusion: Although LAR testing provides valuable information regarding laryngeal sensory discrimination, the results of the current study suggest that a clinical evaluation of swallowing is critical for effectively assessing the way in which patients utilise sensory information during swallowing.

Postoperative dysphagia leads to aspiration pneumonia, prolonged hospital stay, and is associated with increased mortality. A simple and sensitive screening test to identify patients requiring objective dysphagia evaluation is presently lacking. In this study, we evaluated the efficacy of a novel targeted swallow screen evaluation. This was a prospective trial involving all adult patients who underwent elective cardiac surgery with cardiopulmonary bypass at our institution over an 8-week period. Within 24 hours of extubation and before the initiation of oral intake, all postsurgical patients were evaluated using the targeted swallow screen. A fiberoptic endoscopic evaluation of swallowing was requested for failed screenings. During the study, 50 postcardiac surgery patients were screened. Fifteen (30%) failed the targeted swallow screen, and ten of the fifteen (66%) failed the subsequent fiberoptic endoscopic evaluation of swallowing exam and were confirmed to have dysphagia. The screening test had 100 per cent sensitivity for detecting dysphagia in our patient population, and a specificity of 87.5 per cent. The overall incidence of dysphagia was 20 per cent. We have shown that a targeted swallow evaluation can efficiently screen patients during the postcardiac surgery period. Furthermore, we have shown that the true incidence of dysphagia after cardiac surgery is significantly higher than previously recognized in literature.

Background Previous reports have documented the efficacy of an early switch from intravenous to oral antimicrobials in community-acquired pneumonia, but not aspiration pneumonia. Therefore, we assessed the feasibility and efficacy of these newly developed criteria for community-acquired pneumonia in patients with aspiration pneumonia. Methods This prospective observational study included consecutive patients admitted with aspiration pneumonia over a 10-month period at St. Luke's International Hospital; we excluded patients that required intensive care. The criteria for an early switch were stability of vital signs (temperature≤38°C; respiratory rate≤24breaths/min; pulse rate≤100beats/min for >24h) and a successful swallow evaluation (repetitive saliva swallowing test score≥2; modified water swallowing test score≥4). Our primary endpoint was successful completion of antimicrobial treatment 30 days after the switch, without reversion to intravenous antimicrobials. Our anticipated success rate was set as 60–75%, based on a previous study. Results Of the 70 patients admitted with aspiration pneumonia, 32 (45.7%) were excluded, and 38 (54.3%) met the inclusion criteria. Of these 38 patients, 29 (76.3%) met the switch criteria. The median duration of hospital stay for the included patients was 16 (5–30) days and 30 (12–68) days, respectively ( P =0.03). Among patients who met the switch criteria, 26 (89.7%) completed oral treatment successfully while 3 (10.3%) reverted to intravenous antimicrobials. Conclusions Approximately 75% of patients met the switch criteria; of these, nearly 90% underwent safe conversion to oral therapy. These results demonstrate the efficacy and feasibility of our switch criteria.

Nutritional issues are not a part of normal aging but are present in 5%–30% of community-dwelling independent older adults, and up to 77% of older adults in long-term-care settings. The consequences of nutritional issues in older adults include disability, morbidity, mortality, reduced quality of life, and increased healthcare costs. Body mass index, weight loss, and questionnaires such as the Mini-Nutritional Assessment are useful for identifying older adults with malnutrition. A stepwise, interdisciplinary approach to malnutrition ensures that the contributing dietary, functional, dental, medication, mood, cognitive, and swallowing factors are appropriately treated. Medication reduction is frequently safer and more effective than the addition of an appetite stimulant when anorexia is contributing to malnutrition. Swallowing issues including dysphagia are more common in older adults with a history of stroke, traumatic brain injury, pneumonia, Parkinson's disease, and dementia. Dysphagia can result in a diminished quality of life, aspiration pneumonia, chronic lung disease, malnutrition, dehydration, hospitalization, and death. In older adults swallowing may be slower in all phases and result in pooling in the pharynx but is not considered a disorder. Evaluation and management of dysphagia is optimized with interprofessional collaborative practice including speech-language pathologists, physicians, nurses, dieticians, and others. Screening swallowing helps to identify individuals who require a comprehensive swallow assessment including a clinical swallow evaluation and instrumental swallow examinations, such as a videofluoroscopic swallow study (also known as modified barium swallow study) or a fiberoptic endoscopic evaluation of swallow. Treatment of swallowing problems includes education, compensatory strategies, and rehabilitative approaches, harnessing the principles of neuroplasticity to exercise swallow functions and improve swallow physiology. Healthcare professionals need to work as a team to systematically identify and treat factors contributing to malnutrition, weight loss, and dysphagia, to improve the quality of life of older adults. In this chapter, we will present a systematic approach to nutritional issues in older adults to help the interdisciplinary team care for these fragile patients.

Evaluating the swallowing function of the patient with head and neck cancer (HNC) is an important part of the management process and should be completed on all patients. The ability to swallow is an integral part of our existence and impacts the quality of life as well as nutrition and hydration. Proper nutrition is critical for wound healing and to provide the body with energy as the patient goes through the treatment process.

Stroke is the leading cause of serious adult long-term disability in the United States with the estimated cost of $33 billion dollars annually.1,2 Dysphagia, or impaired swallowing, is a common complication of acute stroke with an incidence that ranges from 37% to 78%.3 Dysphagia is associated with aspiration, pneumonia, and malnutrition and remains challenging to identify at the bedside. It has been estimated that approximately half of all aspiration caused by dysphagia goes unrecognized.3 With the aging of adults in the United States, there is a critical need to focus on the early detection of dysphagia symptoms in hospitalized patients who experienced a stroke, accompanied by the initiation of a validated dysphagia screening protocol (DSP).4 This article will provide an update of the most commonly used DSPs and will provide guidance in the selection of a DSP for use in nursing. Nurses, on the forefront of stroke care delivery, maintain a key role in early identification of patients with dysphagia. Although the Joint Commission no longer requires dysphagia screening rates be reported for stroke center certification, the Joint Commission encourages consistent monitoring for dysphagia and use of evidence-based DSPs.5 Recommendations from the American Heart Association declare that a swallow evaluation should be performed in the first 24 hours after stroke.6 Physician order sets should include a swallow assessment with nutrition and swallow evaluation before oral intake. Patients who cannot swallow should have a nasogastric tube placed or endoscopic gastrostomy tube depending on severity. Patients should be kept NPO (nil per os or nothing by mouth) with intravenous normal saline running at a rate …

Review question/objective The objective of this systematic review is to synthesise the best available evidence on the diagnostic test accuracy (sensitivity and specificity) of Clinical Swallow Assessment (CSA) compared with Video Fluoroscopic Swallow Study (VFSS) in diagnosing oropharyngeal aspiration in children and adults with dysphagia. In this review, VFSS will be the 'Gold Standard' or, reference test and CSA will be the index test. VFSS is the radiographic assessment of swallow function usually performed by a Speech Pathologist and Radiologist. CSA is defined as a non-invasive, non-instrumental assessment of swallow function. It is usually performed by a Speech Pathologist and includes a thorough case history and assessment of oro-motor function. For example, tongue, jaw movement, cough reflex and review of swallow function with a range of food and fluids. A rating is usually provided to describe the level of function and likely presence or absence of aspiration. Based on the CSA findings the Speech Pathologist recommends specific diet and fluid modifications, feeding techniques and positioning techniques to enable safe oral feeding. Inclusion criteria Types of participants Studies will be considered in this review if they include: infants, children or adults with dysphagia. The following definitions will be used within this review: - infant will be defined as < 36 months; - children will be defined as 36 months – 18 years; - adults will be defined as 18 years and over; - dysphagia will be defined as 'a swallowing disorder' 6. The definition uses 36 months as the cut off between infants and children as this is the stage when the infant transitions from sucking patterns used for bottle feeding and early solids and begins to chew solids, self feed and drink from a range of cups consistent with an older child 4. There will be no exclusion of studies based on age or gender. Studies will be excluded that include the population of head and neck cancer (HNC) patients, patients with a tracheostomy in situ and patients with craniofacial anomalies. The primary treatment for HNC patients includes surgery and radiotherapy . Radiotherapy can have a specific impact on swallowing , not necessarily seen in other populations and surgical resections can result in predictable swallowing difficulties . Patients with a tracheostomy in situ and patients with craniofacial anomalies also have known anatomical changes that have a specific impact on swallow function. The clinician undertaking the clinical swallow assessment has access to any anatomical changes following surgery. This is different to other populations whereby information regarding specific neurological and anatomical information is not necessarily available. Focus of the review The focus of this review will be on diagnostic test accuracy (sensitivity and specificity) of Clinical Swallow Assessment (CSA) compared with Video Fluoroscopic Swallow Study (VFSS) in diagnosing oropharyngeal aspiration in children and adults with dysphagia. In this review, VFSS will be the 'Gold Standard' or, reference test and CSA will be the index test. The terms VFSS and Modified Barium Swallow (MBS) refer to the same study. Although this review will use the term VFSS defined as the radiographic assessment of the oral and pharyngeal swallow, MBS studies will also be included. The terms Clinical Swallow Assessment and Bedside Swallow Evaluation also refer to the same diagnostic tool . Clinical Swallow Assessment (CSA) will be used within this review, defined as the non-instrumental, non-radiologic assessment of swallow function by a Speech Pathologist, however studies of Bedside Swallow Evaluation will also be included. Studies that do not use CSA as the index test or do not use VFSS as the reference test will be excluded. In addition, studies of effectiveness, experience or comparison of treatment interventions will be excluded. The diagnostic test accuracy of CSA and VFSS will be compared using: sensitivity and specificity. Where possible, positive and negative predictive values will also be analysed and reported. Sensitivity of a diagnostic test is defined as 'the ability of the test to identify correctly those who have the disease'34. Specificity of a diagnostic test is defined as 'the ability of the test to identify correctly those who do not have the disease' Positive predictive value is defined as the proportion of patients who test positive and actually have the disease in question . Negative predictive value is defined as the proportion of patients who test negative and actually do not have the disease in question .

The treatment of achalasia is dependent on evaluation of esophageal function of patients with this progressive disorder. This begins with an evaluation of its symptoms and their severity. The Eckardt scale is the most widely used, though it has limitations. Timed barium swallow evaluation provides a simple inexpensive means to evaluate esophageal emptying across a non-relaxing lower esophageal sphincter, before and after therapy. High resolution esophageal manometry has improved our ability to assess both esophageal body and sphincteric function. It has allowed identification of manometric phenotypes, which help prognosticate response to therapy. Esophageal impedance measurements of liquid swallows and esophageal emptying are a new and promising advance. Endoscopic ultrasound can measure esophageal muscle thickness, but has an adjunctive role mainly aimed at excluding structural abnormalities, such as malignancy causing secondary achalasia.

Sumarry Introduction: Spinocerebellar ataxia (SCA) is a degenerative disease that can cause loss of coordination of voluntary muscle movement such as that required for swallowing. Aims: The purposes of this cross-sectional and comparative case study were: (1) to assess the severity of dysphagia through a videofluoroscopic swallow study, and (2) to compare differences in frequency, intensity, and duration of sound waves produced during swallowing in normal and SCA patients by using sonar Doppler. Method: During swallow evaluation using videofluoroscopy, a sonar Doppler transducer was placed on the right side of the neck, at the lateral edge of the trachea, just below the cricoid cartilage to capture the sounds of swallowing in 30 SCA patients and 30 controls. Result: The prevalence in the dynamic evaluation of swallowing videofluoroscopy was by changes in the oral phase of swallowing. The analysis of variance of the averages found in each variable - frequency, intensity and duration of swallowing - shows there was a significant correlation when compared to the healthy individual curve. Conclusion: The study demonstrates the prevalence of oral dysphagia observed in dynamic videofluoroscopic swallow evaluation. In patients with SCA, the mean initial frequency (IF), initial intensity (II), and final intensity (FI) were higher and the time (T) and peak frequency (PF) were lower, demonstrating a pattern of cricopharyngeal opening very close to that found in normal populations.

Purpose: The purpose of this study was to determine if a significant difference in labial strength exists between healthy controls, individuals who had experienced a stroke with no deficits, individuals who had experiencd a stroke and dysarthria, and in- dividuals who had experienced a stroke with dysar- thria and dysphagia. Method: Four groups participated in the study: a control group of healthy adults and 3 experimental groups of patients with a diagnosis of stroke. The experimental groups were characterized according to the following features: labial weakness only, dysar- thria, and dysarthria and dysphagia. All participants performed an oral motor evaluation, diadochoki- netic rates, clinical swallow evaluation, and bilateral measurements of labial strength using the Iowa Oral Performance Instrument (IOPI; Iowa Oral Performance Instrument Medical, 2010). Results: Significant differences in labial strength were S peech production and deglutition are complicated acts requiring precise, se- quenced movements involving the cen- tral nervous system, peripheral nervous system, and muscles. Recent clinical research on articulation and the oral preparatory and oral phases of the swallow has focused on the role of the tongue in speech pro- duction and deglutition (Goozee, Murdoch, & The- odoros, 2001; Neel & Palmer, 2012; Steele, Bailey, Molfenter, Yeates, & Grace-Martin, 2010; Stierwalt &

Objectives (1) To determine factors associated with physical therapy (PT) or occupational therapy (OT) evaluation and speech or swallow therapy evaluation in hospitalized children with traumatic brain injury (TBI); (2) to describe when during the hospital stay the initial therapy evaluations typically occur; and (3) to quantify any between-hospital variation in therapy evaluation. Design Retrospective cohort study. Setting Children's hospitals participating in the Pediatric Health Information System database (January 2001–June 2011). Participants Children (age Interventions Not applicable. Main Outcome Measures PT or OT evaluation and speech or swallow therapy evaluation. A propensity score was calculated to allow comparison of expected with observed rates of therapy evaluations by the hospital. Results The median hospital length of stay was 5 days (interquartile range, 3–10d). Overall, 8748 (41%) of 21,399 children received either a PT or OT evaluation, and 5490 (26%) out of 21,399 children received either a speech or swallow evaluation. Older children and those with higher energy injury mechanisms, more severe injuries, extremity fractures, more treatment with neuromuscular blocking agents or pentobarbital, and admission to a hospital with an American College of Surgeons Level I pediatric trauma designation were more likely to receive therapy evaluations. The median time until the first therapy evaluation was 5 (PT or OT) and 7 days (speech or swallow). Expected hospital evaluation rates were 25% to 54% (PT or OT) and 16% to 35% (speech or swallow), while observed hospital evaluation rates were 11% to 74% (PT or OT) and 4% to 55% (speech or swallow). Conclusions There is wide between-hospital variation in provision of rehabilitation therapies for children with TBI. Evidence-based criteria for initiation of routine therapy evaluations after TBI are needed.

Objective: To identify the presenting features of a laryngeal cleft in children. To compare rigid and flexible endoscopic methods available for identifying laryngeal cleft and determine their utility. Methods: The charts of all patients diagnosed with laryngeal cleft in a tertiary care institution between 2009 and 2010 were evaluated retrospectively for age, gender, comorbidity, presenting features, and results of bedside swallow evaluation. Findings on flexible and direct laryngoscopy, both performed under general anesthesia, were compared. Results: Eleven patients had a diagnosis of laryngeal cleft, confirmed by direct laryngoscopy. Nine of eleven had signs of aspiration on modified barium swallow study (MBSS). Of the eight subjects who underwent flexible laryngoscopy by a pulmonologist, a deep interarytenoid groove was only reported in four cases. In all eleven cases, the arytenoids could be physically separated during direct laryngoscopy, allowing for definitive diagnosis of the cleft and identification of its type and severity. Conclusion: Video swallow studies and flexible laryngoscopy may raise suspicion or even diagnose a laryngeal cleft, however, a laryngeal cleft must be confirmed by direct laryngscopy in which the interarytenoid space is palpated. Furthermore, a patient in whom symptoms persist but no laryngeal cleft is identified on flexible examination should have a direct laryngoscopy to rule out a cleft.

Objective Unilateral vocal fold immobility (UVFI) results in deficits in phonatory, respiratory, and swallow function of the pediatric patient. Little is known about long-term functional swallow outcomes. Methods Medical records of children diagnosed with UVFI between 2005 and 2014 at a tertiary children's hospital were retrospectively reviewed. Etiology, laryngoscopy findings, and swallow status at diagnosis and follow-up were recorded. Swallow outcomes were compared by etiology using Fisher's exact test. McNemar's test was used to identify correlations between return of mobility and swallow recovery. Rates of pneumonia were compared with initial swallow evaluation results using a two-tailed t -test. Results Eighty-eight patients with UVFI were identified and 73 patients (47% female, mean age 14.4 months, standard deviation (SD) 26.7 months) had complete medical records. Mean follow up time was 52.7 months (SD 36.8 months). Etiologies included cardiothoracic surgery (68.5%), idiopathic (12.3%), prolonged intubation (11.0%), central nervous system (CNS) abnormality (5.5%), and non-cardiac iatrogenic injury to the recurrent laryngeal nerve (2.7%). Forty-seven patients underwent a follow up laryngoscopy, and recovery of vocal fold (VF) mobility was documented in 42.6% (20/47). At diagnosis, 31.5% fed orally, compared with 79.5% at follow-up. Direct correlation between recovery of VF mobility and swallow recovery was not demonstrated. Cardiac etiologies demonstrated higher rates of swallow recovery than CNS abnormalities (p = 0.0393). Twenty-five children aspirated on initial modified barium swallow (MBS) and 10 children developed pneumonias at some point during the follow up period. There was no significant difference in rates of pneumonia in patients with and without aspiration on MBS. Conclusion Recovery of swallow in children with UVFI does not directly parallel return of VF mobility. Long-term swallow outcome is favorable in this population. Initial MBS does not indicate ultimate swallow outcome.

Symptoms of infantile gastroesophageal reflux disease (GERD) may overlap with oropharyngeal dysphagia, but the evaluation and treatment of these conditions vary greatly. In this investigation, the incidence of oropharyngeal dysphagia in infants with GERD-like symptoms is determined.A retrospective chart review was performed on infants referred to a pediatric gastroenterology clinic for GERD-like symptoms. A feeding screen was performed in all infants. Standardized bedside swallow evaluation and modified barium swallow (MBS) studies were then performed when clinically indicated. A similarly aged cohort of normal participants also underwent a standard bedside swallow evaluation for group comparison.Study population included 67 infants. A swallow evaluation was recommended in 39 of 67 infants with abnormalities noted in all. Swallowing abnormalities were more frequent and clustered in infants with GERD-like symptoms vs controls. MBS was abnormal in 16 of 17 qualifying infants. Characteristics of at-risk infants included extreme prematurity, developmental delay, or symptoms refractory to antireflux medications.Oropharyngeal dysphagia is prominent in infants with GERD-like symptoms.

Background:Breastfeeding assessment in the hospital to determine adequacy of feeds remains controversial. Swallow evaluation is integral to current assessment tools, but the literature is not clear about whether the number of swallows is an accurate indicator of breast milk intake in early postpartum.Objectives:To determine the reliability and validity of swallows as a measure of breast milk intake in the first days of a newborn’s life.Methods:Thirty mother-baby dyads were observed at one breastfeeding; pre- and postfeed weights were done, bedside audible swallows were counted, and feeds were videotaped for independent rating. Milk intake was determined from weight change, adjusted for insensible water loss.Results:Number of swallows was significantly and positively correlated with breast milk intake ( r = .71). Number of swallows alone, however, accounted for only 50.8% ( R2= .508) of the variation in milk intake. Infant age was the best predictor of milk intake (βage= .56 vs βNo. swallows= .36), accounting for 68% of the variation in milk intake when combined with swallows. The majority of infants took in 10 g or less of breast milk (77%); length of feeds was variable. In-room (at bedside) lactation consultant (LC) and video rater LC swallow counts were significantly and positively correlated ( r = .93; P < .01). However, the 2 lactation consultant swallow numbers include clinically important discrepancies in a Bland-Altman analysis.Conclusions:Number of swallows was not supported as a reliable or valid indicator of milk intake and adequacy of a feed in the first few days of life.

Objective To assess the accuracy of bedside swallow evaluation (BSE) compared with videofluorosopic swallow study (VFSS) in diagnosing dysphagia in individuals with tetraplegia due to spinal cord injury (SCI). Design A prospective diagnostic accuracy study according to STAndards for the Reporting of Diagnostic accuracy studies (STARD) criteria. Setting A county hospital with acute inpatient SCI unit. Patients Thirty-nine subjects with SCI and tetraplegia were enrolled. All of the subjects underwent BSE, and 26 subjects completed the VFSS. Methods Individuals with SCI underwent a BSE followed by a VFSS within 72 hours of the BSE. The subjects were diagnosed as having dysphagia if they had positive findings in either BSE or VFSS. Main Outcome Measures Sensitivity, specificity, and positive and negative predictive values were calculated by using VFSS as the criterion standard. Results Fifteen subjects (38%) were diagnosed as having dysphagia based on the BSE results. Among the subjects who completed the VFSS, 11 were diagnosed with dysphagia (42%) and 4 were diagnosed with aspiration (10%). Of the 26 subjects who completed both BSE and VFSS, only 1 subject was diagnosed differently compared with BSE (3.8%). Different diet recommendations were made in 4 cases after VFSS versus BSE. Different liquid recommendations were made in 8 cases after VFSS versus BSE. Sensitivity of BSE was 100% (95% confidence interval [CI], 71.5%-100%), specificity was 93.3% (95% CI, 68.1%-99.8%). A positive predictive value of BSE was 91.7% (95% CI, 61.5%-100%), and the negative predictive value was 100% (95% CI, 76.8%-100%). Conclusions Dysphagia is present in approximately 38% of individuals with acute tetraplegia. Because only one of the 21 subjects was diagnosed differently based on VFSS, we believe that BSE is an appropriate screening tool for dysphagia for individuals with cervical SCI. However, VFSS provided additional information on diet and liquid recommendations, so there appears to be an important clinical role for the VFSS.

Dysphagia occurs in a significant number of individuals with spinal cord injury (SCI) presenting to acute care and inpatient rehabilitation. This prospective study has found dysphagia in nearly 40% of individuals with tetraplegia. Tracheostomy, mechanical ventilation, nasogastric tube, and age are significant risk factors. The detrimental complications of dysphagia in SCI can cause significant morbidity and delays in rehabilitation. Thus, early and accurate diagnosis of dysphagia is imperative to reduce the risk of developing life-threatening complications. Incidence and risk factors of dysphagia and the use of the bedside swallow evaluation (BSE) and videofluoroscopy swallow study (VFSS) to diagnose dysphagia are presented. The often underappreciated role of respiratory therapists, including assist cough, high tidal volume ventilation, and the use of Passy-Muir valve, in the care of individuals with SCI who have dysphagia is discussed. Improved secretion management and respiratory stabilization enable the individuals with dysphagia to be evaluated sooner and safely by a speech pathologist. Early evaluation and intervention could improve upon morbidity and delayed rehabilitation, thus improving overall clinical outcomes.

Objective To evaluate early postoperative swallowing function in otherwise typically-developing children following supraglottoplasty. Methods Retrospective chart review case series. Results Of 37 children identified as having undergone supraglottoplasty for severe laryngomalacia at our institution between January 2007 and October 2011, 24 were identified as otherwise typically developing with no indications/signs of swallowing problems pre-operatively and eligible for inclusion in this study. Twenty-two children underwent bilateral supraglottoplasty and 2 children underwent unilateral supraglottoplasty using the CO 2 laser or the laryngeal skimmer microdebrider in combination with cold steel technique, based on the discretion of four Pediatric Otolaryngologists. Seventeen children were seen post-operatively for a clinical swallow evaluation. Six children were found to have swallowing dysfunction. Four of the six children showed variable symptoms, signs, or findings concerning for aspiration with oral feeding. Three of six underwent video fluoroscopic swallow study (VFSS). All 6 children responded to dietary modifications, positioning alterations, and anti-reflux medications. All showed improvement by their 4-week post-operative follow-up visit. The median age of the 24 patients at the time of surgery was 3 months, with a range from 2 weeks to 4 years. The median age of the patients found to have transient post-operative swallowing dysfunction was 1.5 months, with a range of 2 weeks to 4 months. There was no association between post-operative swallowing dysfunction and the surgical technique employed. Conclusions Supraglottoplasty in otherwise typically developing children carries a risk of transient swallowing dysfunction with a low risk of persistent dysfunction. Most patients can be assessed post-operatively via clinical swallow evaluation without requiring an instrumental swallow study.

Objective This article illustrates our operative technique for pharyngostomy tube placement and describes our clinical experience with pharyngostomy use for gastric conduit decompression after esophagectomy. Methods We retrospectively reviewed patients undergoing pharyngostomy tube placement for gastric conduit decompression after esophagectomy from January 2008 to August 2009. Patients were included if they had a pharyngostomy tube placed at esophagectomy (prophylactic placement) or as a means of decompression after postesophagectomy anastomotic leak (therapeutic placement). We collected operative and clinical data and performed a descriptive statistical analysis. Results We placed 25 pharyngostomy tubes for gastric conduit decompression after esophagectomy. Eleven were placed prophylactically (44%); the remaining 14 were placed therapeutically (56%) after anastomotic leak. Prophylactic pharyngostomy tubes remained in place a median of 8 days (range 4–17 days), whereas therapeutic pharyngostomy tubes were left in place a median of 15 days (range 7–125 days). There were 4 infectious complications (16%) unrelated to length of pharyngostomy use: 2 cases of cellulitis (resolved with antibiotics, tube remaining in place) and 2 superficial abscesses after tube removal requiring bedside debridement. Seventy-two percent of patients underwent swallow evaluation; 22% of these patients had radiographic evidence of aspiration. Conclusions Pharyngostomy tube placement for gastric conduit decompression after esophagectomy is simple, and tubes can stay in place for prolonged periods. Our experience suggests that pharyngostomy tubes are a safe alternative to nasogastric drainage.

Objetivo: avaliar a sensibilidade e a especificidade do protocolo Volume-Viscosity Swallow Test (V-VST) para detectar a presença de disfagia em pacientes com doença pulmonar obstrutiva crônica (DPOC) em relação à videofluoroscopia. Método: estudo transversal, descritivo, analítico, com amostra de conveniência de indivíduos de ambos os sexos, ingressantes no Programa Multiprofissional de Reabilitação Pulmonar. Os participantes realizaram avaliação fonoaudiológica clínica da deglutição através do protocolo V-VST e avaliação instrumental pela videofluoroscopia da deglutição, sendo através dos resultados dessas calculado o valor de sensibilidade e especificidade do V-VST. Resultados: foram avaliados 29 sujeitos com média de idade de 63,9±8,6 anos (intervalo de 40 a 78 anos), a maioria do gênero masculino (51,7%). A avaliação segundo o protocolo V-VST demonstrou que a maioria dos participantes tinha deglutição sem alterações (55,2%). A análise do V-VST apresentou baixa sensibilidade (39,10%) e baixa especificidade (33,30%) em relação à videofluoroscopia com valor preditivo positivo de 69,20%. Conclusão: A aplicação do protocolo V-VST para avaliação clínica da deglutição apresentou baixa sensibilidade e especificidade em relação à videofluoroscopia para identificar a presença de disfagia em sujeitos com DPOC.

Background High-resolution manometry (HRM) utilizes software tools to diagnose esophageal motor disorders. Performance of these software metrics could be affected by averaging and by software characteristics of different manufacturers. Methods High-resolution manometry studies on 86 patients referred for antireflux surgery (61.6 ± 1.4 year, 70% F) and 20 healthy controls (27.9 ± 0.7 year, 45% F) were first subject to standard analysis (Medtronic, Duluth, GA, USA). Coordinates for each of 10 test swallows were exported and averaged to generate a composite swallow. The swallows and averaged composites were imported as ASCII file format into Manoview (Medtronic) and Medical Measurement Systems database reporter (MMS, Dover, NH, USA), and analyses repeated. Comparisons were made between standard and composite swallow interpretations. Key Results Correlation between the two systems was high for mean distal contractile integral (DCI, r2 ≥ 0.9) but lower for integrated relaxation pressure (IRP, r2 = 0.7). Excluding achalasia, six patients with outflow obstruction (mean IRP 23.2 ± 2.1 with 10-swallow average) were identified by both systems. An additional nine patients (10.5%) were identified as outflow obstruction (15 mmHg threshold) with MMS 10-swallow and four with MMS composite swallow evaluation; only one was confirmed. Ineffective esophageal motility was diagnosed by 10-swallow evaluation in 19 (22.1%) with Manoview, and 20 (23.3%) with MMS. On Manoview composite, 17 had DCI

Objective: The objective of this study was to describe improvements in pediatric swallowing after gastroesophageal reflux treatment. Study Design: The authors conducted a retrospective database and chart review at two tertiary care children's hospitals. Participants: Patients (21 males, 7 females) ranged in age from 1 to 32 months. All patients had clinical evidence of gastroesophageal reflux disease (GERD) as well as evidence of dysphagia with aspiration (laryngeal vestibule and/or trachea) or hypopharyngeal pooling on flexible endoscopic evaluation of swallowing and sensation testing (FEESST) or videofluoroscopic swallow study (VSS). Intervention: Each child underwent either medical or surgical intervention for control of their GERD. Outcome Measures: Outcome measures were change in laryngopharyngeal sensation and swallowing function with repeat swallow evaluation after GERD treatment. Results: A significant improvement in both swallow function and sensory testing was demonstrated after GERD treatment. Conclusions: GERD may result in decreased laryngopharyngeal sensitivity, which may contribute to pediatric swallowing dysfunction. Control of GERD may improve swallow function. These findings have important clinical implications that need further study.

This study was designed to examine the effect of diet variables, namely: bolus volume and consistency on the biomechanical measures of swallowing in stroke patients for better management of their oro-pharyngeal (O-P) dysphagia. Fifty patients with chronic and acute strokes were selected for the study. All patients were evaluated through an especially designed diagnostic protocol. Each subject was asked to swallow different bolus consistencies (thin and thick liquids; semisolid and solid) in different volumes (3, 5 and 10 ml). The biomechanical measures that were analysed from videofluoroscopic assessment of the patients include the following: (A) degree of impairment of the structural movement and bolus flow; (B) temporal measures of swallowing; (C) percent of O-P residue and percentage of the bolus penetrated/aspirated; (D) penetration/aspiration (P/A) scale; and (E) O-P Swallow Efficiency (OPSE) Score. The results demonstrated that the pharynx adapts itself to the increasing bolus volumes even in an impaired pharyngeal function. However, larger bolus volumes in both thin and thick liquids resulted in an increase in percentage of bolus P/A and higher P/A scale. The results also demonstrated that both thin and thick liquid consistencies were unsafe regarding the airway P/A and might better be avoided in the early stages of restoration of oral feeding in stroke patients. While on the other hand, semisolid consistency was the safest swallowed consistency in both patient groups. Presentation of calibrated bolus sizes and various consistencies should be an integral part of the swallow evaluation protocol. These evaluations will aid in choosing an appropriate nutritional option for patients with O-P dysphagia.

The past two decades have brought an enormous widening of interest in and knowledge about swallowing disorders. The most frequently used technique for swallow evaluation is X-ray videofluoroscopy. Most interventions are based on this examination. Only a few studies assessing interobserver reliability of videofluoroscopy have been published. The aim of our study was to assess the interobserver reliability of videofluoroscopy for swallow evaluation. Fifty-one consecutive dysphagic patients referred for videofluoroscopy were entered into the study regardless of their underlying disorder. The first swallow (5 ml of a semisolid radio-opague contrast media) of each patient was assessed in the lateral projection by 9 independent, experienced observers from different international swallow centers. All studies were evaluated according to a standardized protocol sheet and the interobserver reliability was calculated. The interobserver reliabilities assessed as kappa coefficient for parameters of the oral and pharyngeal phase, for the temporal occurrence of penetration/aspiration, and for the location of bolus residue ranged from 0.01 to 0.56. High reliability with an intraclass coefficient of 0.80 was achieved only with the well defined penetration/aspiration score. Our study underlines the need for exact definitions of the parameters assessed by videofluoroscopy, in order to raise interobserver reliability. To date, only aspiration is evaluated with high reliability by videofluoroscopy, whereas the reliability of all other parameters of oropharyngeal swallow is poor.