Research Archive Content

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Basic Science

Authors: 

Konradi, Jürgen, Dr.
Zajber, Milla
Betz, Ulrich, Dr.
Drees, Philipp, Dr.
Gerken, Annika, Dr.
Meine, Hans, Dr.

Full Citation:

Konradi J, Zajber M, Betz U, Drees P, Gerken A, Meine H. AI-Based Detection of Aspiration for Video-Endoscopy with Visual Aids in Meaningful Frames to Interpret the Model Outcome. Sensors (Basel). 2022 Dec 4;22(23):9468. doi: 10.3390/s22239468. PMID: 36502169; PMCID: PMC9736280.

Abstract: 

Disorders of swallowing often lead to pneumonia when material enters the airways (aspiration). Flexible Endoscopic Evaluation of Swallowing (FEES) plays a key role in the diagnostics of aspiration but is prone to human errors. An AI-based tool could facilitate this process. Recent non-endoscopic/non-radiologic attempts to detect aspiration using machine-learning approaches have led to unsatisfying accuracy and show black-box characteristics. Hence, for clinical users it is difficult to trust in these model decisions. Our aim is to introduce an explainable artificial intelligence (XAI) approach to detect aspiration in FEES. Our approach is to teach the AI about the relevant anatomical structures, such as the vocal cords and the glottis, based on 92 annotated FEES videos. Simultaneously, it is trained to detect boluses that pass the glottis and become aspirated. During testing, the AI successfully recognized the glottis and the vocal cords but could not yet achieve satisfying aspiration detection quality. While detection performance must be optimized, our architecture results in a final model that explains its assessment by locating meaningful frames with relevant aspiration events and by highlighting suspected boluses. In contrast to comparable AI tools, our framework is verifiable and interpretable and, therefore, accountable for clinical users.

Why you should read this article:

This study is the first approach to automatically recognize glottis and vocal chords as well as to automatically detect aspirations in FEES videos by an AI. Although there is room for improvement regarding aspiration detection, the promising results show that an explainable AI could support dysphagia diagnostics.

How to access this article:

https://www.mdpi.com/1424-8220/22/23/9468 

Esophageal Dysphagia

Authors: 

A Gillman, C Kenny, M Hayes, M Walshe, JV Reynolds, J Regan

Full Citation:

Gillman, A., Kenny, C., Hayes, M., Walshe, M., Reynolds, J. V., & Regan, J. (2024). Nature, severity, and impact of chronic oropharyngeal dysphagia following curative resection for esophageal cancer: a cross-sectional study. Diseases of the Esophagus, doae003.

Abstract: 

Chronic oropharyngeal dysphagia (COD) and aspiration after esophageal cancer surgery may have clinical significance; however, it is a rarely studied topic. In a prospective cross-sectional observational study we comprehensively evaluated the nature, severity, and impact of COD, its predictors, and the impact of the surgical approach and site of anastomosis. Forty participants were recruited via purposive sampling from the (Irish) National Center between November 2021 and August 2022. Swallow evaluations included videofluoroscopy [Dynamic Imaging Grade of Swallowing Toxicity v2 (DIGESTv2), MBS Impairment Profile, Penetration-Aspiration Scale)]. Functional Oral Intake Scale (FOIS) identified oral intake status. The patient reported outcome measures of swallowing, and Quality of Life (QL) included EAT-10 and MD Anderson Dysphagia Inventory (MDADI). Fourteen (35%) participants presented with COD on DIGESTv2 and 10% had uncleared penetration/aspiration. Avoidance or modification of diet on FOIS was observed in 17 (42.5%). FOIS was associated with pharyngeal dysphagia (OR = 4.05, P = 0.046). Median (range) EAT-10 and MDADI Composite results were 3(0–30) and 77.9(60–92.6), respectively. Aspiration rates significantly differed across surgical groups (P = 0.029); only patients undergoing transhiatal surgery aspirated. Survivors of esophageal cancer surgery may have COD that is undiagnosed, potentially impacting swallow-related QL. Given the small number of aspirators, further research is required to determine whether aspiration risk is associated with surgical approach. A FOIS score below 7 may be a clinically useful prompt for the MDT to refer for evaluation of COD following curative intent surgery. These data present findings that may guide preventive and rehabilitative strategies toward optimizing survivorship.

How to access this article:

https://doi.org/10.1093/dote/doae003

Geriatrics

Authors: 

Bendix Labeit, Paul Muhle, Jonas von Itter, Janna Slavik, Andreas Wollbrink, Peter Sporns, Thilo Rusche, Tobias Ruck, Anna Hüsing-Kabar, Reinhold Gellner, Joachim Gross, Rainer Wirth, Inga Claus, Tobias Warnecke, Rainer Dziewas, Sonja Suntrup-Krueger

Abstract: 

Background: "Presbyphagia" refers to characteristic age-related changes in the complex neuromuscular swallowing mechanism. It has been hypothesized that cumulative impairments in multiple domains affect functional reserve of swallowing with age, but the multifactorial etiology and postulated compensatory strategies of the brain are incompletely understood. This study investigates presbyphagia and its neural correlates, focusing on the clinical determinants associated with adaptive neuroplasticity.

Materials and methods: 64 subjects over 70 years of age free of typical diseases explaining dysphagia received comprehensive workup including flexible endoscopic evaluation of swallowing (FEES), magnetoencephalography (MEG) during swallowing and pharyngeal stimulation, volumetry of swallowing muscles, laboratory analyzes, and assessment of hand-grip-strength, nutritional status, frailty, olfaction, cognition and mental health. Neural MEG activation was compared between participants with and without presbyphagia in FEES, and associated clinical influencing factors were analyzed. Presbyphagia was defined as the presence of oropharyngeal swallowing alterations e.g., penetration, aspiration, pharyngeal residue pooling or premature bolus spillage into the piriform sinus and/or laryngeal vestibule.

Results: 32 of 64 participants showed swallowing alterations, mainly characterized by pharyngeal residue, whereas the airway was rarely compromised. In the MEG analysis, participants with presbyphagia activated an increased cortical sensorimotor network during swallowing. As major clinical determinant, participants with swallowing alterations exhibited reduced pharyngeal sensation. Presbyphagia was an independent predictor of a reduced nutritional status in a linear regression model.

Conclusions: Swallowing alterations frequently occur in otherwise healthy older adults and are associated with decreased nutritional status. Increased sensorimotor cortical activation may constitute a compensation attempt to uphold swallowing function due to sensory decline. Further studies are needed to clarify whether the swallowing alterations observed can be considered physiological per se or whether the concept of presbyphagia may need to be extended to a theory with a continuous transition between presbyphagia and dysphagia.

Why you should read this article:

In this article, we provide a analysis of age-related swallowing abnormalities (presbyphagia). We thoroughly examine various clinical and biological determinants. Additionally, we investigate the neuronal compensation mechanisms within the swallowing network as a consequence of presbyphagia. Moreover, we engage in a discussion regarding the presbyphagia model as a whole.

How to access this article:

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9366332/

Authors: 

Bendix Labeit, Sigrid Ahring, Maik Boehmer, Peter Sporns, Sonja Sauer, Inga Claus, Malte Roderigo, Sonja Suntrup-Krueger, Rainer Dziewas, Tobias Warnecke, Paul Muhle

Abstract: 

Objective: In the evaluation of oropharyngeal dysphagia, instrumental procedures, for example, flexible endoscopic evaluation of swallowing or videofluoroscopic swallowing study, are essential to improve diagnostic accuracy for salient findings such as penetration, aspiration, or pharyngeal residue. To date, it is unclear which of the 2 methods represents the diagnostic gold standard. The aim of this study, therefore, was to compare videofluoroscopy and swallowing endoscopy during a simultaneous swallowing examination in a large cohort of patients with oropharyngeal dysphagia.

Designs: Prospective observational study.

Setting and participants: In this study, 49 patients with oropharyngeal dysphagia (mean age 70.0 ± 10.8 years) were evaluated using simultaneous swallowing endoscopy and videofluoroscopy. Furthermore, the effect of narrow-band imaging in swallowing endoscopy on the assessment of penetration and aspiration was investigated in a subgroup of 19 patients.

Measures: The Penetration-Aspiration Scale and the Yale Pharyngeal Residue Severity Rating Scale were rated independently based on both modalities.

Results: Both modalities showed a high correlation between penetration, aspiration, and pharyngeal residue. Causes for a higher score on the Penetration-Aspiration Scale in videofluoroscopy were intradeglutitive events that were not visible in swallowing endoscopy or false-positive events because of the loss of the lateral dimension in videofluoroscopy. A typical reason for a higher score on this scale in swallowing endoscopy was the better visualization of the anatomical structures. Narrow-band imaging in swallowing endoscopy resulted in a higher score on the Penetration-Aspiration Scale for liquids and semisolids in individual cases, although overall there was no statistically significant difference between scores using white light or narrow-band imaging.

Conclusions and implications: Videofluoroscopy and swallowing endoscopy may equally be considered as a diagnostic gold standard for oropharyngeal dysphagia regarding penetration, aspiration, and pharyngeal residue. Narrow-band imaging may increase the sensitivity for penetration and aspiration in individual cases.

Why you should read this article:

This study conducted a simultaneous investigation comparing FEES and VFSS, providing valuable insights on diagnostic parameters for significant dysphagia pathologies. Furthermore, it sheds light on the underlying reasons for disparities in diagnostics. For anyone with an interest in instrumental swallowing diagnostics, this article holds particular relevance.

How to access this article:

https://www.sciencedirect.com/science/article/pii/S1525861021008628?via%3Dihub

Head-and-Neck Cancer

Authors: 

Hanne Massonet
Ann Goeleven
Leen Van den Steen
Alice Vergauwen
Margot Baudelet
Gilles Van Haesendonck
Olivier Vanderveken
Heleen Bollen
Lisette van der Molen
Fréderic Duprez
Peter Tomassen
Sandra Nuyts
Gwen Van Nuffelen

Abstract: 

Background: Chronic radiation-associated dysphagia (C-RAD) is considered to be one of the most severe functional impairments in head and neck cancer survivors treated with radiation (RT) or chemoradiation (CRT). Given the major impact of these late toxicities on patients’ health and quality of life, there is a strong need for evidence-based dysphagia management. Although studies report the benefit of strengthening exercises, transference of changes in muscle strength to changes in swallowing function often remains limited. Therefore, combining isolated strengthening exercises with functional training in patients with C-RAD may lead to greater functional gains.

- Methods: This 3-arm multicenter randomized trial aims to compare the efficacy and possible detraining effects of mere strengthening exercises (group 1) with a combination of strengthening exercises and functional swallowing therapy (group 2) and non-invasive brain stimulation added to that combination (group 3) in 105 patients with C-RAD. Patients will be evaluated before and during therapy and 4 weeks after the last therapy session by means of swallowing-related and strength measures and quality of life questionnaires.

- Discussion: Overall, this innovative RCT is expected to provide new insights into the rehabilitation of C-RAD to optimize post-treatment swallowing function.

How to access this article:

https://trialsjournal.biomedcentral.com/articles/10.1186/s13063-022-06832-6https://doi.org/10.1016/j.jcrc.2023.154447

Authors: 

Rhona Brady, Laura McSharry, Susan Lawson, Julie Regan

Full Citation:

Brady, R., McSharry, L., Lawson, S., & Regan, J. (2022). The impact of dysphagia prehabilitation on swallowing outcomes post‐chemoradiation therapy in head and neck cancer: a systematic review. European Journal of Cancer Care, 31(3), e13549

Abstract: 

Introducation: This study aimed to summarise research findings on dysphagia prehabilitation initiated before chemoradiation therapy (C)RT in head and neck cancer (HNC) including its impact on three swallowrelated outcomes at distinct time points.

Methods: A comprehensive search was completed in PubMed, Embase, Web of Science and CINAHL. Inclusion criteria were studies of adults with HNC with an exercise-based prehabilitation programme beginning before (C)RT. Methodological quality was rated using the Downs and Black checklist. The Template for Intervention Descriptions and Replication (TIDieR) checklist was used to evaluate how well studies were reported.

Results: Eight studies (three randomised control trials) involving 295 adults with HNC were included. The largest participant group (63%) were Stage III/IV head and neck squamous cell carcinoma (HNSCC). Prehabilitation was completed independently at home (100%) and typically began 2 weeks before CRT (75%). Studies evaluated the impact of dysphagia prehabilitation across functional (n = 6), quality of life (n = 5) and physiological (n = 4) domains. Prehabilitation significantly altered physiological (25%), functional (66%) and quality of life (50%) outcomes. Fifty per cent of studies included long-term (>1 year) outcomes. 1Quality of included studies ranged from poor (25%) to good (38%). Six (75%) studies reported sufficient details of exercise programmes.

Conclusion: Limited evidence supports exercise-based dysphagia prehabilitation before (C)RT to improve swallowrelated outcomes, and long-term benefits remain unclear. Further high-quality research using core outcome sets is required.

How to access this article:

https://doi.org/10.1111/ecc.13549

Intensive Care

Authors: 

Likar, Rudolf
Aroyo, Ilia
Bangert, Katrin
Degen, Björn
Dziewas, Rainer
Galvan, Oliver
Trapl Grundschober, Michaela
Köstenberger, Markus
Muhle, Paul
Schefold, Joerg C.
Zuercher, Patrick

Abstract: 

Background: Dysphagia is common in intensive care unit (ICU) patients, yet it remains underrecognized and often unmanaged despite being associated with life-threatening complications, prolonged ICU stays and hospitalization.

Purpose: To propose an expert opinion for the diagnosis and management of dysphagia developed from evidence-based clinical recommendations and practitioner insights.

Methods: A multinational group of dysphagia and critical care experts conducted a literature review using a modified ACCORD methodology. Based on a fusion of the available evidence and the panel's clinical experience, an expert opinion on best practice management was developed.

Results: The panel recommends adopting clinical algorithms intended to promote standardized, high-quality care that triggers timely systematic dysphagia screening, assessment, and treatment of extubated and tracheostomized patients in the ICU.

Conclusions: Given the lack of robust scientific evidence, two clinical management algorithms are proposed for use by multidisciplinary teams to improve early systematic detection and effective management of dysphagia in
ICU patients. Additionally, emerging therapeutic options such as neurostimulation have the potential to improve the quality of ICU dysphagia care.

Why you should read this article:

Swallowing disorders often occur in the course of acute illnesses and dysphagia is often difficult to recognize during intensive care treatment.
The consequences of dysphagia can be serious, from pneumonia to the need for intubation, prolonged hospital stays, and the need for prolonged rehabilitative care.
In this work, as part of an expert opinion, a concept is presented for the structured management of dysphagia in the intensive care unit, from evidence-based recommendations to practical applications.

How to access this article:

https://doi.org/10.1016/j.jcrc.2023.154447

Authors: 

Julie Regan, Margaret Walshe, Sarah Lavan, Eanna Horan, Patricia Gillivan Murphy, Anne Healy, Caoimhe Langan, Karen Malherbe, Breda Flynn Murphy, Maria Cremin, Denise Hilton, Jenni Cavaliere, Alice Whyte

Full Citation:

Regan, J., Walshe, M., Lavan, S., Horan, E., Gillivan Murphy, P., Healy, A., ... & Whyte, A. (2021). Post‐extubation dysphagia and dysphonia amongst adults with COVID‐19 in the Republic of Ireland: a prospective multi‐site observational cohort study. Clinical Otolaryngology, 46(6), 1290-1299.

Abstract: 

Objectives: This study aims to (i) investigate post-extubation dysphagia and dysphonia amongst adults intubated with SARS-COV-2 (COVID-19) and referred to speech and language therapy (SLT) in acute hospitals across the Republic of Ireland (ROI) between March and June 2020; (ii) identify variables predictive of post-extubation oral intake status and dysphonia and (iii) establish SLT rehabilitation needs and services provided to this cohort.

Design: A multi-site prospective observational cohort study.

Participants: One hundred adults with confirmed COVID-19 who were intubated across eleven acute hospital sites in ROI and who were referred to SLT services between March and June 2020 inclusive.

Main Outcome Measures: 1 Oral intake status, level of diet modification and perceptual voice quality.

Results: Based on initial SLT assessment, 90% required altered oral intake and 59% required tube feeding with 36% not allowed oral intake. Age (OR 1.064; 95% CI 1.018–1.112), proning (OR 3.671; 95% CI 1.128–11.943) and pre-existing respiratory disease (OR 5.863; 95% CI 1.521–11.599) were predictors of oral intake status post-extubation. Two-thirds (66%) presented with dysphonia post-extubation. Intubation injury (OR 10.471; 95% CI 1.060–103.466) and pre-existing respiratory disease (OR 24.196; 95% CI 1.609–363.78) were predictors of post-extubation voice quality. Thirty-seven per cent required dysphagia intervention postextubation, whereas 20% needed intervention for voice. Dysphagia and dysphonia persisted in 27% and 37% cases, respectively, at hospital discharge.

Discussion: Post-extubation dysphagia and dysphonia were prevalent amongst adults with COVID-19 across the ROI. Predictors included iatrogenic factors and underlying respiratory disease. Prompt evaluation and intervention is needed to minimise complications and inform rehabilitation planning.

Why you should read this article:

Post-extubation dysphagia and dysphonia are multifactorial and can lead to prolonged ICU stay, prolonged tube feeding, aspiration pneumonia and increased morbidity and mortality. In this multi-site prospective cohort study across eleven acute hospitals, 90% of adults required an altered oral diet post-extubation and 36% were not allowed oral intake based on SLT evaluation. Sixty-six per cent presented with post-extubation dysphonia. Age, proning and pre-existing respiratory disease were predictors of post-extubation oral intake status, whereas intubation injury and pre-existing respiratory disease were predictors of post-extubation dysphonia. Over a third (37%) required dysphagia intervention post-extubation, whereas 20% needed intervention for voice. Dysphagia and dysphonia persisted in 27% and 37% cases, respectively, at hospital discharge, indicating that speech and language therapists should be included in outpatient multidisciplinary COVID clinics in the community.

How to access this article:

https://doi.org/10.1111/coa.13832

 

Neurology

Authors: 

Bendix Labeit, Emilia Michou, Shaheen Hamdy, Michaela Trapl-Grundschober, Sonja Suntrup-Krueger, Paul Muhle, Philip M Bath, Rainer Dziewas

Abstract: 

Dysphagia is a major complication following an acute stroke that affects the majority of patients. Clinically, dysphagia after stroke is associated with increased risk of aspiration pneumonia, malnutrition, mortality, and other adverse functional outcomes. Pathophysiologically, dysphagia after stroke is caused by disruption of an extensive cortical and subcortical swallowing network. The screening of patients for dysphagia after stroke should be provided as soon as possible, starting with simple water-swallowing tests at the bedside or more elaborate multi-consistency protocols. Subsequently, a more detailed examination, ideally with instrumental diagnostics such as flexible endoscopic evaluation of swallowing or video fluoroscopy is indicated in some patients. Emerging diagnostic procedures, technical innovations in assessment tools, and digitalisation will improve diagnostic accuracy in the future. Advances in the diagnosis of dysphagia after stroke will enable management based on individual patterns of dysfunction and predisposing risk factors for complications. Progess in dysphagia rehabilitation are essential to reduce mortality and improve patients' quality of life after a stroke.

Why you should read this article:

This review paper comprehensively discusses the pathophysiology and diagnostic aspects of post-stroke dysphagia. In addition to providing insights into the current state of knowledge, the paper offers specific recommendations for clinical practice and outlines future directions in the field.

How to access this article:

This article is not open access.

Please email benlabeit@gmail.com to request the original article.

Authors: 

Bendix Labeit, Almut Kremer, Paul Muhle, Inga Claus, Tobias Warnecke, Rainer Dziewas, Sonja Suntrup-Krueger

Abstract: 

Purpose: Oropharyngeal dysphagia is a common and complication-prone symptom after stroke and is assumed to increase medical expenses. The purpose of this study was therefore to examine acute hospitalization costs associated with post-stroke dysphagia.

Method: This retrospective study included patients with acute stroke who had been examined by Flexible Endoscopic Evaluation of Swallowing (FEES). Health insurance expenditures were determined for the patient cases according to the 2021 revenue criteria. Multiple linear regression was used to examine predictors of health insurance spending including age, sex, stroke severity, stroke characteristics, comorbidity, therapeutic interventions, duration of artificial ventilation, length of hospital stay, and severity of dysphagia, as assessed by the Fiberoptic Endoscopic Dysphagia Severity Scale (FEDSS), ranging from 1 (best) to 6 (worst).

Findings: Six hundred seventy four patients (men/women: 367/307; mean age: 71.1 ± 12.8 years; mean National Institute of Health Stroke Scale: 11.2 ± 6.2; FEDSS 1/2/3/4/5/6: 113/73/144/119/124/101; mean health-insurance costs 11,521.5 ± 12,950.5€) were included in the analysis. Advanced age (p = 0.007; B = 57.6), catheter interventions (p < 0.001; B = 4105.6), tracheotomy (p = 0.006; B = 5195.2), duration of artificial ventilation (p < 0.001; B = 388.6), length of hospital stay (p < 0.001; B = 441.9), and severe dysphagia with an FEDSS of 6 (p = 0.004, B = 2554.3) were independent predictors of increased health insurance expenditures (p < 0.001, R-squared = adjusted-R-squared = 0.83).

Discussion and conclusion: The results of this study show an association between severe dysphagia and health care costs for acute hospitalization from a health-insurance perspective. Therefore, therapies that target severe dysphagia with impaired secretion management may have the potential to reduce costs.

Why you should read this article:

This article offers a comprehensive analysis of the cost structures associated with post-stroke dysphagia for health insurance providers. It highlights specific dysphagia-related findings that are linked to additional costs, allowing for insights into potential cost-saving measures.

How to access this article:

https://journals.sagepub.com/doi/full/10.1177/23969873221147740?rfr_dat=cr_pub++0pubmed&url_ver=Z39.88-2003&rfr_id=ori%3Arid%3Acrossref.org

Authors: 

Bendix Labeit, Anne Jung, Sigrid Ahring, Stephan Oelenberg, Paul Muhle, Malte Roderigo, Fiona Wenninger, Jonas von Itter, Inga Claus, Tobias Warnecke, Rainer Dziewas, Sonja Suntrup-Krueger

Abstract: 

Background: Post-stroke dysphagia (PSD) is common and can lead to serious complications. Pharyngeal sensory impairment is assumed to contribute to PSD. The aim of this study was to investigate the relationship between PSD and pharyngeal hypesthesia and to compare different assessment methods for pharyngeal sensation.

Methods: In this prospective observational study, fifty-seven stroke patients were examined in the acute stage of the disease using Flexible Endoscopic Evaluation of Swallowing (FEES). The Fiberoptic Endoscopic Dysphagia Severity Scale (FEDSS) and impaired secretion management according to the Murray-Secretion Scale were determined, as well as premature bolus spillage, pharyngeal residue and delayed or absent swallowing reflex. A multimodal sensory assessment was performed, including touch-technique and a previously established FEES-based swallowing provocation test with different volumes of liquid to determine the latency of swallowing response (FEES-LSR-Test). Predictors of FEDSS, Murray-Secretion Scale, premature bolus spillage, pharyngeal residue, and delayed or absent swallowing reflex were examined with ordinal logistic regression analyses.

Results: Sensory impairment using the touch-technique and the FEES-LSR-Test were independent predictors of higher FEDSS, Murray-Secretion Scale, and delayed or absent swallowing reflex. Decreased sensitivity according to the touch-technique correlated with the FEES-LSR-Test at 0.3 ml and 0.4 ml, but not at 0.2 ml and 0.5 ml trigger volumes.

Conclusions: Pharyngeal hypesthesia is a crucial factor in the development of PSD, leading to impaired secretion management and delayed or absent swallowing reflex. It can be investigated using both the touch-technique and the FEES-LSR-Test. In the latter procedure, trigger volumes of 0.4 ml are particularly suitable.

Why you should read this article:

This article explores the connection between pharyngeal sensory impairment and post-stroke dysphagia, as well as various dysphagia findings.

How to access this article:

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9933330/

Authors: 

Bendix Labeit, Elijahu Berkovich, Inga Claus, Malte Roderigo, Anna-Lena Schwake, Dvora Izgelov, Dorit Mimrod, Sigrid Ahring, Stephan Oelenberg, Paul Muhle, Verena Zentsch, Fiona Wenninger, Sonja Suntrup-Krueger, Rainer Dziewas, Tobias Warnecke

Abstract: 

Dysphagia is common in Parkinson's disease (PD) and is assumed to complicate medication intake. This study comprehensively investigates dysphagia for medication and its association with motor complications in PD. Based on a retrospective analysis, a two-dimensional and graduated classification of dysphagia for medication was introduced differentiating swallowing efficiency and swallowing safety. In a subsequent prospective study, sixty-six PD patients underwent flexible endoscopic evaluation of swallowing, which included the swallowing of 2 tablets and capsules of different sizes. Dysphagia for medication was present in nearly 70% of PD patients and predicted motor complications according to the MDS-UPDRS-part-IV in a linear regression model. Capsules tended to be swallowed more efficiently compared to tablets, irrespective of size. A score of ≥1 on the swallow-related-MDS-UPDRS-items can be considered an optimal cut-off to predict dysphagia for medication. Swallowing impairment for oral medication may predispose to motor complications.

This article delves into the phenomenon of medication dysphagia. It introduces a two-dimensional classification of medication dysphagia and investigates the connection between medication dysphagia and motor complications in patients with Parkinson's disease.

Why you should read this article:

This article delves into the phenomenon of medication dysphagia. It introduces a two-dimensional classification of medication dysphagia and investigates the connection between medication dysphagia and motor complications in patients with Parkinson's disease.

How to access this article:

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9653428/

Authors: 

Bendix Labeit, Paul Muhle, Jonas von Itter, Janna Slavik, Andreas Wollbrink, Peter Sporns, Thilo Rusche, Tobias Ruck, Anna Hüsing-Kabar, Reinhold Gellner, Joachim Gross, Rainer Wirth, Inga Claus, Tobias Warnecke, Rainer Dziewas, Sonja Suntrup-Krueger

Abstract:

Background: "Presbyphagia" refers to characteristic age-related changes in the complex neuromuscular swallowing mechanism. It has been hypothesized that cumulative impairments in multiple domains affect functional reserve of swallowing with age, but the multifactorial etiology and postulated compensatory strategies of the brain are incompletely understood. This study investigates presbyphagia and its neural correlates, focusing on the clinical determinants associated with adaptive neuroplasticity.

Materials and methods: 64 subjects over 70 years of age free of typical diseases explaining dysphagia received comprehensive workup including flexible endoscopic evaluation of swallowing (FEES), magnetoencephalography (MEG) during swallowing and pharyngeal stimulation, volumetry of swallowing muscles, laboratory analyzes, and assessment of hand-grip-strength, nutritional status, frailty, olfaction, cognition and mental health. Neural MEG activation was compared between participants with and without presbyphagia in FEES, and associated clinical influencing factors were analyzed. Presbyphagia was defined as the presence of oropharyngeal swallowing alterations e.g., penetration, aspiration, pharyngeal residue pooling or premature bolus spillage into the piriform sinus and/or laryngeal vestibule.

Results: 32 of 64 participants showed swallowing alterations, mainly characterized by pharyngeal residue, whereas the airway was rarely compromised. In the MEG analysis, participants with presbyphagia activated an increased cortical sensorimotor network during swallowing. As major clinical determinant, participants with swallowing alterations exhibited reduced pharyngeal sensation. Presbyphagia was an independent predictor of a reduced nutritional status in a linear regression model.

Conclusions: Swallowing alterations frequently occur in otherwise healthy older adults and are associated with decreased nutritional status. Increased sensorimotor cortical activation may constitute a compensation attempt to uphold swallowing function due to sensory decline. Further studies are needed to clarify whether the swallowing alterations observed can be considered physiological per se or whether the concept of presbyphagia may need to be extended to a theory with a continuous transition between presbyphagia and dysphagia.

Why you should read this article:

In this article, we provide a analysis of age-related swallowing abnormalities (presbyphagia). We thoroughly examine various clinical and biological determinants. Additionally, we investigate the neuronal compensation mechanisms within the swallowing network as a consequence of presbyphagia. Moreover, we engage in a discussion regarding the presbyphagia model as a whole.

How to access this article:

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9366332/ 

Authors: 

Bendix Labeit, Thalia Grond, Achim G Beule, Maik Boehmer, Christian Thomas, Paul Muhle, Inga Claus, Malte Roderigo, Claudia Rudack, Heinz Wiendl, Rainer Dziewas, Tobias Warnecke, Sonja Suntrup-Krueger

Abstract: 

Background and purpose: Idiopathic inflammatory myopathy (IIM) can present with dysphagia as a leading or only symptom. In such cases, diagnostic evaluation may be difficult, especially if serological and electromyographical findings are unsuspicious. In this observational study we propose and evaluate a diagnostic algorithm to identify IIM as a cause of unexplained dysphagia.

Methods: Over a period of 4 years, patients with unexplained dysphagia were offered diagnostic evaluation according to a specific algorithm: The pattern of dysphagia was characterized by instrumental assessment (swallowing endoscopy, videofluoroscopy, high-resolution manometry). Patients with an IIM-compatible dysphagia pattern were subjected to further IIM-focused diagnostic procedures, including whole-body muscle magnetic resonance imaging, electromyography, creatine kinase blood level, IIM antibody panel and, as a final diagnostic step, muscle biopsy. Muscle biopsies were taken from affected muscles. In cases where no other muscles showed abnormalities, the cricopharyngeal muscle was targeted.

Results: Seventy-two patients presented with IIM-compatible dysphagia as a leading or only symptom. As a result of the specific diagnostic approach, 19 of these patients were diagnosed with IIM according to the European League Against Rheumatism (EULAR) criteria. Eighteen patients received immunomodulatory therapy as a result of the diagnosis. Of 10 patients with follow-up swallowing examination, dysphagia improved in three patients after therapy, while it remained at least stable in six patients.

Conclusions: Idiopathic inflammatory myopathy constitutes a potentially treatable etiology in patients with unexplained dysphagia. The diagnostic algorithm presented in this study helps to identify patients with an IIM-compatible dysphagia pattern and to assign those patients for further IIM-focused diagnostic and therapeutic procedures.

Why you should read this article:

Are you struggeling with the challenges involved in diagnostic work-up in patients with unclear dysphagia? This article introduces a diagnostic algorithm that can assist in identifying myositis as an underlying condition. Utilizing this algorithm may help you pinpoint this potentially treatable ailment in your patients.

How to access this article:

https://onlinelibrary.wiley.com/doi/10.1111/ene.15202

Authors: 

Marc Pawlitzki, Sigrid Ahring, Leoni Rolfes, Rainer Dziewas, Tobias Warnecke, Sonja Suntrup-Krueger, Heinz Wiendl, Luisa Klotz, Sven G Meuth, Bendix Labeit

Abstract: 

Background and purpose: Neuromyelitis optica spectrum disorder (NMOSD) and myelin oligodendrocyte glycoprotein antibody disease (MOGAD) are demyelinating disorders that typically affect the optic nerves and the spinal cord. However, recent studies have demonstrated various forms of brain involvement indicating encephalitic syndromes, which consequently are included in the diagnostic criteria for both. Swallowing is processed in a distributed brain network and is therefore disturbed in many neurological diseases. The aim of this study was to investigate the occurrence of oropharyngeal dysphagia in NMOSD and MOGAD using flexible endoscopic evaluation of swallowing (FEES) as a surrogate parameter of brain involvement.

Methods: Thirteen patients with NMOSD and MOGAD (mean age 54.2 ± 18.6 years, six men) who received FEES during clinical routine were retrospectively reviewed. Their extent of oropharyngeal dysphagia was rated using an ordinal dysphagia severity scale. FEES results were compared to a control group of healthy individuals. Dysphagia severity was correlated with the presence of clinical and radiological signs of brain involvement, the Expanded Disability Status Scale (EDSS) and the occurrence of pneumonia.

Results: Oropharyngeal dysphagia was present in 8/13 patients, including six patients without other clinical indication of brain involvement. Clinical or subclinical swallowing impairment was significantly more severe in patients with NMOSD and MOGAD compared to the healthy individuals (p = 0.009) and correlated with clinical signs of brain involvement (p = 0.038), higher EDSS (p = 0.006) and pneumonia (p = 0.038).

Conclusion: Oropharyngeal dysphagia can occur in NMOSD and MOGAD and might be associated with pneumonia and disability. FEES may help to detect subclinical brain involvement.

Why you should read this article:

Delve into the intriguing realm of dysphagia in demyelinating disorders, such as Neuromyelitis Optica Spectrum Disorder (NMOSD) and Myelin Oligodendrocyte Glycoprotein Antibody Disease (MOGAD), with this study. While traditionally affecting optic nerves and spinal cords, emerging research reveals brain involvement in these conditions, adding a new dimension to their diagnostic criteria. This investigation employs FEES to explore oropharyngeal dysphagia as a potential marker of brain engagement.

How to access this article:

https://onlinelibrary.wiley.com/doi/10.1111/ene.14691

Authors: 

Bendix Labeit, Ksenia Perlova, Marc Pawlitzki, Tobias Ruck, Paul Muhle, Inga Claus, Sonja Suntrup-Krueger, Heinz Wiendl, Rainer Dziewas, Tobias Warnecke

Abstract: 

Introduction: Oropharyngeal dysphagia is a clinical hallmark of idiopathic inflammatory myopathy (IIM). This study investigated predictors, outcome, and characteristics of oropharyngeal dysphagia in patients with different types of IIM.

Methods: Flexible endoscopic evaluation of swallowing (FEES) videos of 71 IIM patients were retrospectively analyzed for bolus spillage, penetration, aspiration, and pharyngeal residue. Based on these findings, dysphagia severity was rated. Regression analyses were performed to investigate demographic and disease-specific predictors of dysphagia severity and pneumonia as outcome-relevant complications of dysphagia. A score was developed to rate the quality of the endoscopic white-out as a surrogate marker for pharyngeal muscle weakness with consecutive residue.

Results: Our analysis revealed no independent predictors of dysphagia severity. Dysphagia severity, however, was an independent predictor for pneumonia, which occurred in 24% of patients. Pharyngeal residue with risk of postdeglutitive aspiration was the most common dysphagia pattern. Attenuation of the endoscopic white-out was related to residue severity.

Discussion: Dysphagia in IIM assessed with FEES is associated with relevant complications, such as aspiration pneumonia, and must be considered independently of peripheral muscle weakness and disease duration. Swallowing impairment mainly presents with pharyngeal residue. The quality of the white-out may serve as a semi-quantitative surrogate marker for pharyngeal contractility.

Why you should read this article:

Discover the essential insights into oropharyngeal dysphagia in idiopathic inflammatory myopathy (IIM) with this study. By analyzing FEES videos from 71 IIM patients, the authors uncover predictors, outcomes, and characteristics of dysphagia in various IIM types. This research underscores the significant impact of dysphagia severity on complications like pneumonia, highlighting the importance of early intervention. With pharyngeal residue as a primary dysphagia pattern and the innovative use of endoscopic white-out quality as a surrogate marker for pharyngeal muscle weakness, this article provides valuable insights for clinicians and researchers in the field of dysphagia and IIM.

How to access this article:

https://onlinelibrary.wiley.com/doi/10.1002/mus.27225

Authors: 

Tobias Warnecke*, Bendix Labeit*, Jens Schroeder, Alexander Reckels, Sigrid Ahring, Sriramya Lapa, Inga Claus, Paul Muhle, Sonja Suntrup-Krueger, Rainer Dziewas

Abstract: 

Objective: Introduction and validation of a phenotypic classification of neurogenic dysphagia based on flexible endoscopic evaluation of swallowing (FEES).

Methods: A systematic literature review was conducted, searching MEDLINE from inception to May 2020 for FEES findings in neurologic diseases of interest. Based on a retrospective analysis of FEES videos in neurologic diseases and considering the results from the review, a classification of neurogenic dysphagia was developed distinguishing different phenotypes. The classification was validated using 1,012 randomly selected FEES videos of patients with various neurologic disorders. Chi-square tests were used to compare the distribution of dysphagia phenotypes between the underlying neurologic disorders.

Results: A total of 159 articles were identified, of which 59 were included in the qualitative synthesis. Seven dysphagia phenotypes were identified: (1) "premature bolus spillage" and (2) "delayed swallowing reflex" occurred mainly in stroke, (3) "predominance of residue in the valleculae" was most common in Parkinson disease, (4) "predominance of residue in the piriform sinus" occurred only in myositis, motoneuron disease, and brainstem stroke, (5) "pharyngolaryngeal movement disorder" was found in atypical Parkinsonian syndromes and stroke, (6) "fatigable swallowing weakness" was common in myasthenia gravis, and (7) "complex disorder" with a heterogeneous dysphagia pattern was the leading mechanism in amyotrophic lateral sclerosis. The interrater reliability showed a strong agreement (kappa = 0.84).

Conclusion: Neurogenic dysphagia is not a symptom, but a multietiologic syndrome with different phenotypic patterns depending on the underlying disease. Dysphagia phenotypes can facilitate differential diagnosis in patients with dysphagia of unclear etiology.

Why you should read this article:

Discover a novel approach to understanding neurogenic dysphagia with this study: By introducing and validating a phenotypic classification of neurogenic dysphagia based on FEES, this research paves the way for a more refined diagnosis and tailored treatment.

How to access this article:

https://n.neurology.org/content/96/6/e876.long

Authors: 

Bendix Labeit, Inga Claus, Paul Muhle, Liesa Regner, Sonja Suntrup-Krueger, Rainer Dziewas, Tobias Warnecke

Abstract: 

Background: Dysphagia frequently occurs in patients with Parkinson's disease (PD) and is associated with severe complications. However, the underlying pathology is poorly understood at present. This study investigated the effect of cognitive and motor dual-task interference on oropharyngeal swallowing in PD.

Methods: Thirty PD patients (23 men, mean age 65.90 ± 9.32 years, mean Hoehn and Yahr stage 2.62 ± 0.81, mean UPDRS 18.00 ± 7.18) were examined using flexible endoscopic evaluation of swallowing (FEES). FEES was performed during three paradigms: at baseline without interference, during a cognitive dual-task, and during a motor dual-task. Oropharyngeal swallowing function was rated using a score which was validated to detect changes in PD related dysphagia. The three paradigms were compared using a two-way-repetitive-measures-ANOVA and a post-hoc-analysis.

Results: Mean swallowing score in baseline FEES was 10.67 ± 5.89. It significantly increased (worsened) to 15.97 ± 7.62 (p < 0.001) in the motor dual-task and to 14.55 ± 7.49 (p < 0.001) in the cognitive dual-task. Premature bolus spillage and pharyngeal residue both significantly increased during both of the dual-task conditions whereas penetration/aspiration events did not change.

Conclusion: Oropharyngeal swallowing in patients with PD is not purely reflexive but requires mental capacity. Additional allocation of attentional resources in the central control of swallowing seems to be an effective compensatory mechanism in PD-related dysphagia: The proposed dual-task protocol may be useful to challenge swallowing functional reserve. Conversely, as a therapeutic strategy, it could be beneficial to focus attention on swallowing and to avoid dual-task situations.

Why you should read this article:

Dive into the intricate relationship between cognitive and motor functions in Parkinson's disease-related dysphagia with this pioneering study. Swallowing, a seemingly automatic process, is revealed to be influenced by cognitive demands in Parkinson's disease patients. The study, conducted using FEES, uncovers the impact of cognitive and motor dual-task interference on oropharyngeal swallowing.

How to access this article:

https://onlinelibrary.wiley.com/doi/10.1111/ene.14603

Authors: 

Bendix Labeit, Marc Pawlitzki, Tobias Ruck, Paul Muhle, Inga Claus, Sonja Suntrup-Krueger, Tobias Warnecke, Sven G Meuth, Heinz Wiendl, Rainer Dziewas

Abstract: 

1) Background: Dysphagia is a clinical hallmark and part of the current American College of Rheumatology/European League Against Rheumatism (ACR/EULAR) diagnostic criteria for idiopathic inflammatory myopathy (IIM). However, the data on dysphagia in IIM are heterogenous and partly conflicting. The aim of this study was to conduct a systematic review on epidemiology, pathophysiology, outcome and therapy and a meta-analysis on the prevalence of dysphagia in IIM. (2) Methods: Medline was systematically searched for all relevant articles. A random effect model was chosen to estimate the pooled prevalence of dysphagia in the overall cohort of patients with IIM and in different subgroups. (3) Results: 234 studies were included in the review and 116 (10,382 subjects) in the meta-analysis. Dysphagia can occur as initial or sole symptom. The overall pooled prevalence estimate in IIM was 36% and with 56% particularly high in inclusion body myositis. The prevalence estimate was significantly higher in patients with cancer-associated myositis and with NXP2 autoantibodies. Dysphagia is caused by inflammatory involvement of the swallowing muscles, which can lead to reduced pharyngeal contractility, cricopharyngeal dysfunction, reduced laryngeal elevation and hypomotility of the esophagus. Swallowing disorders not only impair the quality of life but can lead to serious complications such as aspiration pneumonia, thus increasing mortality. Beneficial treatment approaches reported include immunomodulatory therapy, the treatment of associated malignant diseases or interventional procedures targeting the cricopharyngeal muscle such as myotomy, dilatation or botulinum toxin injections. (4) Conclusion: Dysphagia should be included as a therapeutic target, especially in the outlined high-risk groups.

Why you should read this article:

Discover the comprehensive insights provided by this systematic review and meta-analysis, delving into the intricate relationship between dysphagia and idiopathic inflammatory myopathy (IIM). Dysphagia, now a part of the diagnostic criteria for IIM, is investigated in terms of epidemiology, pathophysiology, outcome, and therapy.

This study synthesizes data from 234 articles and 116 meta-analyzed studies, encompassing a vast cohort of IIM patients. Therapeutically, it emphasizes the importance of considering dysphagia as a therapeutic target, especially for high-risk groups. Don't miss this opportunity to gain a deeper understanding of the complex interplay between IIM and dysphagia.

How to access this article:

https://www.mdpi.com/2077-0383/9/7/2150

Authors: 

Bendix Labeit, Inga Claus, Paul Muhle, Sriramya Lapa, Sonja Suntrup-Krueger, Rainer Dziewas, Nani Osada, Tobias Warnecke

Abstract: 

Introduction: The pathophysiology of dysphagia in Parkinson's disease (PD) is heterogeneous and poorly understood at present. This study investigated the phenotypes, prevalence and pathophysiology of oropharyngeal freezing (OPF) in PD and its relation to dysphagia.

Methods: In a prospective study, 50 PD patients were systematically screened for OPF using flexible endoscopic evaluation of swallowing (FEES). In addition, FEES-videos of 50 patients with post-stroke dysphagia and 50 healthy subjects were retrospectively evaluated as control groups. In PD patients freezing was assessed with the "freezing of gait (FoG) questionnaire" and the relationship between OPF and FoG was analyzed.

Results: In analogy to FoG, signs for OPF presented as either temporarily missing or delayed swallowing reflex in combination with freezing associated movement abnormalities e.g. festination, trembling, or akinesia. Seventeen PD patients (34%) showed considerable signs for OPF (15 cases of festination, 3 cases of trembling, 3 cases of akinesia). In the patients with post-stroke dysphagia, OPF was detected in 2 patients (4%). The healthy subjects showed no signs for OPF. The distribution of OPF differed significantly between the investigated groups (p < 0.01). PD patients with signs for OPF scored significantly higher in the FoG-questionnaire (12.69 ± 6.37) compared to patients without OPF (7.29 ± 5.17; p < 0.01).

Conclusion: Swallowing in PD patients can be impaired by OPF. We suggest that OPF and FoG share common pathophysiologic mechanisms based on their association and similar semiologies.

Why you should read this article:

Dive into the intricate relationship between cognitive and motor functions in Parkinson's disease-related dysphagia with this pioneering study. Swallowing, a seemingly automatic process, is revealed to be influenced by cognitive demands in Parkinson's disease patients. The study, conducted using FEES, uncovers the impact of cognitive and motor dual-task interference on oropharyngeal swallowing.

How to access this article:

This article is not open access. Please email benlabeit@gmail.com to request the original article.

Authors: 

Bendix Labeit, Inga Claus, Paul Muhle, Sonja Suntrup-Krueger, Rainer Dziewas, Tobias Warnecke

Abstract: 

Background. Pharyngeal dysphagia is a common symptom of Parkinson’s disease (PD) leading to severe complications. PD-related pharyngeal dysphagia (PDrPD) may significantly improve in up to half of patients following acute oral levodopa challenge. Objective. The aim of this study was to investigate the effects of levodopa-carbidopa intestinal gel (LCIG) on PDrPD. Methods. Forty-five PD patients under LCIG treatment were available for retrospective analysis. In all patients with PDrPD who underwent flexible endoscopic evaluation of swallowing (FEES) in the clinical “on-state” both before and after implementation of LCIG treatment, FEES videos were systematically reassessed. PDrPD was characterized using a PD-specific FEES score evaluating premature bolus spillage, penetration/aspiration, and pharyngeal residue. Further, the duration of white-out was assessed, as a parameter for pharyngeal bradykinesia. Results. Eleven patients with PDrPD (mean age 74.6 ± 4.4 years; mean Hoehn and Yahr stage 3.8 ± 0.6) received FEES both before and after the onset of LCIG treatment. The mean swallowing score improved from 14.9 ± 7.3 to 13.0 ± 6.9 after implementation of LCIG; however, this difference was not significant (). Premature bolus spillage decreased significantly () from 5.4 ± 1.1 to 3.6 ± 1.0, and white-out duration decreased significantly () from 984 ± 228 ms to 699 ± 131 ms after implementation of LCIG. Conclusions. LCIG may affect PDrPD and reduce premature bolus spillage and pharyngeal bradykinesia. Future studies with larger sample sizes are required to follow-up on these pilot results and identify which factors predict a good response of PDrPD to LCIG treatment.

Why you should read this article:

Delve into the realm of Parkinson's disease-related pharyngeal dysphagia and its potential improvement with levodopa-carbidopa intestinal gel treatment in this enlightening study.

How to access this article:

https://www.hindawi.com/journals/pd/2020/4260501/

Authors: 

Bendix Labeit, Paul Muhle, Mao Ogawa, Inga Claus, Thomas Marian, Sonja Suntrup-Krueger, Tobias Warnecke, Jens Burchard Schroeder, Rainer Dziewas

Abstract: 

Background: Intact pharyngeal sensation is essential for a physiological swallowing process, and conversely, pharyngeal hypesthesia can cause dysphagia. This study introduces and validates a diagnostic test to quantify pharyngeal hypesthesia.

Methods: A total of 20 healthy volunteers were included in a prospective study. Flexible endoscopic evaluation of swallowing (FEES) and a sensory test were performed both before and after pharyngeal local anesthesia. To test pharyngeal sensation, a small tube was positioned transnasally in the upper third of the oropharynx with contact to the lateral pharyngeal wall. Increasing volumes of blue-dyed water were injected through the tube, and the latency of swallowing response (LSR) was determined by two independent raters from the endoscopic video recording. Three trials were performed for each administered volume starting with 0.1 mL and increased by 0.1 mL up to 0.5 mL.

Key results: The average LSR without anesthesia was 2.24 ± 0.80 s at 0.1 mL, 1.79 ± 0.84 s at 0.2 mL, 1.29 ± 0.62 s at 0.3 mL, 1.17 ± 0.41 s at 0.4 mL, and 1.19 ± 0.52 s at 0.5 mL. With anesthesia applied, the average LSR was 2.65 ± 0.62 s at 0.1 mL, 2.64 ± 0.49 s at 0.2 mL, 2.44 ± 0.65 s at 0.3 mL, 2.10 ± 0.80 s at 0.4 mL, and 2.18 ± 0.85 s at 0.5 mL. LSR was significantly longer following anesthesia at 0.2 mL (t = -3.82; P = .001), 0.3 mL (t = -4.65; P < .000), 0.4 mL (t = -5.77; P < .000), and 0.5 mL (t = -3.49; P = .005).

Conclusion and inferences: Pharyngeal hypesthesia can be quantified with sensory testing using LSR. Suitable volumes to distinguish between normal and impaired pharyngeal sensation are 0.2 mL, 0.3 mL, 0.4 mL and 0.5 mL. Experimentally induced pharyngeal anesthesia represents a valid model of sensory dysphagia.

Why you should read this article:

Discover a novel method for quantifying pharyngeal hypesthesia and its implications in dysphagia diagnosis. This prospective study, involving 20 healthy volunteers, introduces and validates a diagnostic test to assess pharyngeal sensation.

How to access this article:

https://onlinelibrary.wiley.com/doi/10.1111/nmo.13690

Authors: 

Bendix Labeit, Hannah Mueller, Paul Muhle, Inga Claus, Tobias Warnecke, Rainer Dziewas, Sonja Suntrup-Krueger

Abstract: 

Background: For the early detection of post-stroke dysphagia (PSD), valid screening parameters are crucial as part of a step-wise diagnostic procedure. This study examines the role of the National Institute of Health Stroke Scale (NIH-SS) as a potential low-threshold screening parameter.

Methods: During a ten-year period, 687 newly admitted patients at University Hospital Muenster were included in a retrospective analysis, if they had ischemic or haemorrhagic stroke confirmed by neuroimaging and had received NIH-SS scoring and endoscopic swallowing evaluation upon admission. The NIH-SS score was correlated with dysphagia severity as measured by the validated 6-point fiberoptic endoscopic dysphagia severity score (FEDSS), and the ideal cut-off score to predict PSD, defined as FEDSS > 1, was calculated. Supra- and infratentorial strokes were analysed separately due to their differing role in the pathophysiology of neurogenic dysphagia.

Results: NIH-SS and dysphagia severity show a significant positive correlation in the whole study population (R2 = 0.745) as well as in both analysed subgroups (R2 = 0.494 for supra- and R2 = 0.646 for infratentorial strokes, p < 0.0005, respectively). For supratentorial strokes, the ideal NIH-SS cut-off is > 9 (sensitivity 68.3%, specificity 61.5%, positive predictive value 89.7%, negative predictive value 28.4%). For infratentorial strokes, a lower ideal cut-off > 5 was calculated (sensitivity 67.4%, specificity 85.0%, positive predictive value 95.1%, negative predictive value 37.8%).

Conclusions: NIH-SS may be used as an adjunct to predict dysphagia in acute stroke patients with moderate sensitivity and specificity. Differentiation between supra- and infratentorial regions is essential not to miss dysphagia in infratentorial stroke.

Why you should read this article:

Explore the potential of the National Institute of Health Stroke Scale as a valuable screening parameter for the early detection of post-stroke dysphagia in a comprehensive ten-year retrospective analysis with 687 patients.

How to access this article:

This article is not open access. Please email benlabeit@gmail.com to request the original article.

Authors: 

Bendix Labeit, Sriramya Lapa, Paul Muhle, Sonja Suntrup-Krueger, Inga Claus, Florin Gandor, Sigrid Ahring, Stephan Oelenberg, Rainer Dziewas, Tobias Warnecke

Abstract: 

Flexible Endoscopic Evaluation of Swallowing (FEES) is one of two diagnostic gold standards for pharyngeal dysphagia in Parkinson's disease (PD), however, validated global outcome measures at the patient level are widely lacking. The Dynamic Imaging Grade of Swallowing Toxicity for Flexible Endoscopic Evaluation of Swallowing (DIGEST-FEES) represents such an outcome measure but has been validated primarily for head and neck cancer collectives. The objective of this study was, therefore, to investigate the validity of the DIGEST-FEES in patients with PD. Content validity was evaluated with a modified Delphi expert survey. Subsequently, 66 FEES videos in PD patients were scored with the DIGEST-FEES. Criterion validity was determined using Spearman's correlation coefficient between the DIGEST-FEES and the Penetration-Aspiration Scale (PAS), the Yale-Residue-Rating-Scale, the Functional-Oral-Intake-Scale (FOIS), and the swallowing-related Unified-Parkinson-Disease-Rating-Scale (UPDRS) items. Inter-rater reliability was determined using 10 randomly selected FEES-videos examined by a second rater. As a result, the overall DIGEST-FEES-rating exhibited significant correlations with the Yale-Valleculae-Residue-Scale (r = 0.84; p < 0.001), the Yale-Pyriform-Sinus-Residue-Scale (r = 0.70; p < 0.001), the FOIS (r = - 0.55, p < 0.001), and the UPDRS-Swallowing-Item-Score (r = 0.42, p < 0.001). Further, the DIGEST-FEES-safety subscore correlated with the PAS (r = 0.63, p < 0.001). Inter-rater reliability was high for the overall DIGEST-FEES rating (quadratic weighted kappa of 0.82). Therefore, DIGEST-FEES is a valid and reliable score to evaluate overall pharyngeal dysphagia severity in PD. Nevertheless, the modified Delphi survey identified domains where DIGEST-FEES may need to be specifically adapted to PD or neurological collectives in the future.

Why you should read this article:

This is the first validation study for the DIGEST-FEES, a patient based dysphagia severity classification, for Parkinson's disease

How to access this article:

https://link.springer.com/article/10.1007/s00455-023-10650-6 

Authors: 

Labeit, Bendix, MD Michou, Emilia, PhD Trapl-Grundschober, Emilia, PhD Suntrup-Krueger, Sonja, MD Muhle, Paul, MD Bath, Philip, MD Dziewas, Rainer MD

Full Citation:

Lancet Neurol 2024; 23: 418–28

Abstract: 

After a stroke, most patients have dysphagia, which can lead to aspiration pneumonia, malnutrition, and adverse functional outcomes. Protective interventions aimed at reducing these complications remain the cornerstone of treatment. Dietary adjustments and oral hygiene help mitigate the risk of aspiration pneumonia, and nutritional supplementation, including tube feeding, might be needed to prevent malnutrition. Rehabilitative interventions aim to enhance swallowing function, with different behavioural strategies showing promise in small studies. Investigations have explored the use of pharmaceutical agents such as capsaicin and other TransientReceptor-Potential-Vanilloid-1 (TRPV-1) sensory receptor agonists, which alter sensory perception in the pharynx. Neurostimulation techniques, such as transcranial direct current stimulation, repetitive transcranial magnetic stimulation, and pharyngeal electrical stimulation, might promote neuroplasticity within the sensorimotor swallowing network. Further advancements in the understanding of central and peripheral sensorimotor mechanisms in patients with dysphagia after a stroke, and during their recovery, will contribute to optimising treatment protocols.

Why you should read this article:

This manuscript provides an up-to-date summary of the different treatment modalities of post-stroke dysphagia. Protective and restorative treatment options are differentiated, and their indications are discussed with regards to the different time windows after stroke.

How to access this article:

This article is not open access.

Please email benlabeit@gmail.com to request the original article.

Authors: 

Dziewas, Rainer Warnecke, Tobias Labeit, Bendix Claus, Inga Muhle, Paul Oelenberg, Stephan Ahring, Sigrid Wüller, Christina Jung, Anne von Itter, Jonas Suntrup-Krueger, Sonja

Full Citation:

Neurol Res Pract 2024 May 9;6(1):26. doi: 10.1186/s42466024-00321-8

Abstract: 

Flexible endoscopic evaluation of swallowing (FEES) is one of the most important methods for instrumental swallowing evaluation. The most challenging part of the examination consists in the interpretation of the various observations encountered during endoscopy and in the deduction of clinical consequences. This review proposes the framework for an integrated FEES-report that systematically moves from salient findings of FEES to more advanced domains such as dysphagia severity, phenotypes of swallowing impairment and pathomechanisms. Validated scales and scores are used to enhance the diagnostic yield. In the concluding part of the report, FEES-findings are put into the perspective of the clinical context. The potential etiology of dysphagia and conceivable differential diagnoses are considered, further diagnostic steps are proposed, treatment options are evaluated, and a timeframe for reassessment is suggested. This framework is designed to be adaptable and open to continuous evolution. Additional items, such as novel FEES protocols, pathophysiological observations, advancements in disease-related knowledge, and new treatment options, can be easily incorporated. Moreover, there is potential for customizing this approach to report on FEES in structural dysphagia.

Why you should read this article:

This article provides a twelve-step structure to prepare a comprehensive FEES-report, which closely refers to the clinical context and includes precise recommendations for further diagnostic and therapeutic interventions.

How to access this article:

This article is open access and may be found here: DOI: 10.1186/s42466-024-00321-8

Authors: 

Bülent Alyanak, Fatih Bağcıer, Serkan Kablanoğlu

Full Citation:

Alyanak B, Bağcıer F, Kablanoğlu S. Treatment of Post-stroke Dysphagia With Interferential Current: Three Case Reports and a Review of the Literature. Cureus. 2024;16(2):e54806. Published 2024 Feb 24. doi:10.7759/cureus.54806

Abstract: 

Stroke is damage to the central nervous system due to vascular pathology. Stroke causes many complications. One of the most important of these complications is dysphagia. Dysphagia is a major cause of morbidity and mortality. In recent years, the benefits of using interferential current (IFC) stimulation in the treatment of dysphagia due to various etiologies have been demonstrated. However, there are significant gaps in the literature regarding patient populations, treatment procedures, and evaluation of treatment response. Here, we report the treatment of three cases of dysphagia after ischemic stroke with IFC stimulation and review the current literature. The patients had no previous treatment for dysphagia and were using only compensatory methods. This case report highlights the benefit of IFC stimulation in the treatment of post-stroke dysphagia both clinically and videofluoroscopically. It should be kept in mind that IFC stimulation may be an important alternative in the treatment of post-stroke dysphagia.

Why you should read this article:

Interferential flow has emerged as a new treatment modality for dysphagia. Although various benefits have been described, the number of methodologically sound studies is small and has not been applied to all patient populations. This article demonstrates the benefits of interferential flow in the most common post-stroke dysphagia using videofluoroscopy. There are no studies evaluating the effects of videofluoroscopic interferential flow in patients with post-stroke dysphagia. Therefore, we hope that this article can give clinicians an idea and pave the way for new studies.

How to access this article:

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10894016/

Rehabilitation

Authors: 

Julie Regan

Full Citation:

Regan, J. (2020). Impact of sensory stimulation on pharyngoesophageal swallowing biomechanics in adults with dysphagia: a high-resolution manometry study. Dysphagia, 35(5), 825-833.

Abstract: 

Evidence supporting sensory stimulation of swallowing is based mostly on videofluoroscopy and provides little insight into changes to swallowing physiology. In this study, the impact of sensory stimulation on pharyngo-esophageal swallowing biomechanics was investigated in adults with dysphagia using pharyngeal high-resolution manometry. Fifteen adults (8 males; 45–86 years) with mixed etiology dysphagia were consecutively recruited over a three-month period. PHRM equipment with a 4.2 mm pressure catheter was used. The protocol included duplicate 10 ml neutral, sour, cold, and carbonated liquid swallows in randomized order. Semi-automated analysis was completed using an online portal (www.swallowgateway.com). Data from 98/120 swallows were analyzed. During the pharyngeal phase, mean pharyngeal contractile integral (PhCI) increased significantly with cold (p = 0.03), sour (p = 0.00), and carbonation (p = 0.02). Mean velopharyngeal contractile integral (VCI) (p = 0.01) and mesopharyngeal contractile integral (MCI) (p = 0.04) both increased significantly with carbonation. Mean hypopharyngeal contractile integral (HPCI) was not significantly altered by sensory stimulation. Regarding UES opening, UES relaxation time (UESRT) increased significantly with cold (p = 0.032), carbonation (p = 0.032), and sour (p = 0.027). Extent of UES opening as measured by IRP reduced significantly with cold stimulation (9.34 to 5.17 mmHg) (p = 0.032). No significant changes were observed to UES basal pressure or UES peak pressure with sensory stimulation. Sensory stimulation induced biomechanical changes to pharyngeal contraction vigor, UES relaxation time and extent of UES opening during swallowing in adults with dysphagia. This study contributes evidence to support sensory stimulation as a dysphagia intervention. Further combined pressure impedance studies in homogeneous clinical populations are ongoing.

How to access this article:

https://link.springer.com/article/10.1007/s00455-019-10088-9

Authors: 

J Regan, M Walshe, Nathalie Rommel, Jan Tack, BP McMahon

Full Citation:

Regan, J., Walshe, M., Rommel, N., Tack, J., & McMahon, B. P. (2013). New measures of upper esophageal sphincter distensibility and opening patterns during swallowing in healthy subjects using EndoFLIP®. Neurogastroenterology & Motility, 25(1), e25-e34.

Abstract: 

Background: This paper aims to measure upper esophageal sphincter (UES) distensibility and extent and duration of UES opening during swallowing in healthy subjects using EndoFLIP®.

Methods: Fourteen healthy subjects (20–50 years) were recruited. An EndoFLIP® probe was passed trans-orally and the probe balloon was positioned across the UES. Two 20-mL ramp distensions were completed and UES cross-sectional area (CSA) and intra-balloon pressure (IBP) were evaluated. At 12-mL balloon volume, subjects completed dry, 5- and 10-mL liquid swallows and extent (mm) and duration (s) of UES opening and minimum IBP (mmHg) were analyzed across swallows.

Key Results: Thirteen subjects completed the study protocol. A significant change in UES CSA (P < .001) and IBP (P < .000) was observed during 20-mL distension. UES CSA increased up to 10-mL distension (P < .001), from which point IBP raised significantly (P = 0.004). There were significant changes in UES diameter (mm) (P < .000) and minimum IBP (mmHg) (P < .000) during swallowing events. Resting UES diameter (4.9 mm; IQR 0.02) and minimum IBP (18.8 mmHg; IQR 2.64) changed significantly during dry (9.6 mm; IQR 1.3: P < .001) (3.6 mmHg; IQR 4.1: P = 0.002); 5 mL (8.61 mm; IQR 2.7: P < .001) (4.8 mmHg; IQR 5.7: P < .001) and 10-mL swallows (8.3 mm; IQR 1.6: P < 0.001) (3 mmHg; 4.6: P < .001). Median duration of UES opening was 0.5 s across dry and liquid swallows (P = 0.91). Color contour plots of EndoFLIP® data capture novel information regarding pharyngo-esophageal events during swallowing. 1

Conclusions & Inferences: Authors obtained three different types of quantitative data (CSA, IBP, and timing) regarding UES distensibility and UES opening patterns during swallowing in healthy adults using only one device (EndoFLIP®). This new measure of swallowing offers fresh information regarding UES dynamics which may ultimately improve patient care.

How to access this article:

This article is not open access. 

Please contact juregan@tcd.ie for how to access.

Authors: 

N Heslin, J Regan

Full Citation:

Heslin, N., & Regan, J. (2022). Effect of effortful swallow on pharyngeal pressures during swallowing in adults with dysphagia: a pharyngeal high-resolution manometry study. International Journal of Speech-Language Pathology, 24(2), 190-199.

Abstract: 

Purpose: Evidence base to support the use of the effortful swallow in clinical populations with dysphagia is currently lacking. This study aims to quantify the effects of effortful swallowing on pharyngeal swallowing biomechanics in adults with dysphagia using pharyngeal high-resolution manometry (PHRM).

Method: ManoScan HRM equipment with a 4.2 mm pressure catheter was used. Participants completed duplicate 10ml baseline and 10ml effortful liquid (IDDSI Level 0) swallows in randomised order. PHRM data were analysed using a semi-automated online platform (www.swallowgateway.com).

Result: Fifteen adults (8 males; range 45-86 years) with mixed aetiology dysphagia (Functional Oral Intake Scale Level 2–5) were included. Median pharyngeal contractile (156.81 mmHg cm s; IQR 80.62) increased significantly (213.50 mmHg cm s; IQR 117.2) during effortful swallowing. Significant increases were also observed in velopharyngeal pressure, mesopharyngeal pressure, hypopharyngeal pressure and upper oesophageal sphincter (UOS) relaxation duration. UOS integrated relaxation pressure (IRP) was not significantly altered with effortful swallowing.

Conclusion: Effortful swallowing induced significant biomechanical changes to swallow in adults with dysphagia. Increases in global pharyngeal rigour, tongue base pressure and UOS opening duration were captured by PHRM during effortful swallowing. Further investigation in larger homogeneous clinical populations is needed to verify the physiological effects of this frequently employed intervention.

How to access this article:

https://doi.org/10.1080/17549507.2021.1975817

Respiration

Authors: 

Julie Regan, Susan Lawson & Vânia De Aguiar

Full Citation:

Regan, J., Lawson, S., & De Aguiar, V. (2017). The Eating Assessment Tool-10 predicts aspiration in adults with stable chronic obstructive pulmonary disease. Dysphagia, 32, 714720.

Abstract: 

Adults with COPD frequently present with dysphagia, which often leads to clinical complications and hospital admissions. This study investigates the ability of the Eating Assessment Tool (EAT-10) to predict aspiration during objective dysphagia evaluation in adults with stable COPD. Thirty adults (20 male, 10 female; mean age = 69.07 ± 16.82) with stable COPD attended an outpatient dysphagia clinic for a fiberoptic endoscopic evaluation of swallowing (FEES) in an acute teaching hospital (January 2015November 2016). During evaluations, individuals completed an EAT-10 rating scale followed immediately by a standardised FEES exam. Aspiration status during FEES was rated using the penetration–aspiration scale by clinicians blinded to EAT-10 scores. Data were retrospectively analysed. Significant differences in mean EAT-10 scores were found between aspirators (16.3; SEM = 2.165) and non-aspirators (7.3; SEM = 1.009) (p = 0.000). The EAT-10 predicted aspiration with a high level of accuracy (AUC = 0.88). An EAT-10 cut-off value of >9 presented a sensitivity of 91.67, specificity of 77.78 with positive and negative likelihood ratios of 4.12 and 0.11, respectively. Positive and negative predictive values were 73.30 and 93.30, respectively. Diagnostic odds ratio was 38.50 (p < 0.01, CI 3.75–395.42). EAT-10 is a quick, easy to administer tool, which can accurately predict the presence of aspiration in adults with COPD. The scale can also very accurately exclude the absence of aspiration, helping clinicians to determine the need for onward referral for a comprehensive dysphagia evaluation. This may ultimately reduce clinical complications and hospital admissions resulting from dysphagia in this clinical population.

How to access this article:

https://link.springer.com/article/10.1007/s00455-017-9822-2 

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