Faculty Bibliography

Introduction: Edema is a frequent clinical observation after chemoradiation treatment (CRT) for oral/oropharyngeal cancer (O/OP Ca). Our aims were to reliably quantify edema from video fluoroscopy (VF) at 3 time points (baseline 1-month (mo) and 4-mo post CRT) and to explore the relationship between edema and (a) patient-reported outcomes (EAT-10) and (b) functional impairment on VF (Dynamic Imaging Grade of Swallowing Toxicity DIGEST).
Material(s) and Method(s): 15 patients (7 M; age 38-76) with O/OP Ca received radiotherapy (70 Gy 7 weeks) and 3 weekly doses of cisplatin. VF was completed pre-CRT 1-mo and 4-mo post-CRT. Edema was captured by measuring posterior pharyngeal wall (PPW) thickness and pharyngeal area (PA) at rest. EAT-10 surveys were completed on the day of VF. DIGEST scores were rated according to published protocols. Mixed model repeated measures ANOVAs were run for each edema measure (PPW PA) to test for the effect of TIME EAT-10 and DIGEST while controlling for age and sex.
Result(s): For PPW we found a main effect of TIME but not EAT-10 or DIGEST (Table 1). Post-hoc comparisons revealed a significant worsening from mean at baseline (4.1 mm) to 4-mo post CRT (6.0 mm) but not at 1-mo post CRT (5.4 mm). For PA we found a main effect of TIME and of DIGEST grade (Table 2). Mean PA was significantly smaller at 1-mo post CRT (527 mm2) compared with baseline (716 mm2) but not different from 4-mo post CRT (652 mm2). Mean PA was significantly greater for grade 2 (751 mm2) compared with grade 0 (442 mm2) contrary to the hypothesized direction.
Conclusion(s): The data confirm that post-CRT edema can be quantified on 2D lateral VF. Patient reported outcomes (EAT-10) were not independently predictive of edema. Surprisingly worse DIGEST grades were associated with increased pharyngeal area at rest perhaps reflecting impairment associated with pharyngeal atrophy not edema. Future work should monitor patients' edema and swallow function over a longer time period and at a greater frequency

Previous research has established that a great deal of variation exists in the temporal sequence of swallowing events for healthy adults. Yet, the impact of aging on swallow event sequence is not well understood. Kendall et al. (Dysphagia 18(2):85-91, 2003) suggested there are 4 obligatory paired-event sequences in swallowing. We directly compared adherence to these sequences, as well as event latencies, and quantified the percentage of unique sequences in two samples of healthy adults: young (< 45) and old (> 65). The 8 swallowing events that contribute to the sequences were reliably identified from videofluoroscopy in a sample of 23 healthy seniors (10 male, mean age 74.7) and 20 healthy young adults (10 male, mean age 31.5) with no evidence of penetration-aspiration or post-swallow residue. Chi-square analyses compared the proportions of obligatory pairs and unique sequences by age group. Compared to the older subjects, younger subjects had significantly lower adherence to two obligatory sequences: Upper Esophageal Sphincter (UES) opening occurs before (or simultaneous with) the bolus arriving at the UES and UES maximum distention occurs before maximum pharyngeal constriction. The associated latencies were significantly different between age groups as well. Further, significantly fewer unique swallow sequences were observed in the older group (61%) compared with the young (82%) (χ²â€‰= 31.8; p < 0.001). Our findings suggest that paired swallow event sequences may not be robust across the age continuum and that variation in swallow sequences appears to decrease with aging. These findings provide normative references for comparisons to older individuals with dysphagia.

Objectives/UNASSIGNED:Edema is a frequent clinical observation following chemoradiation treatment (CRT) of oral/oropharyngeal cancer and is thought to contribute to post-CRT swallowing impairment. Our aims were to reliably quantify pharyngeal edema pre- and post-CRT from videofluoroscopic (VF) swallowing studies and to explore the relationship between edema and swallowing impairment. Swallowing impairment was captured using patient-reported swallowing outcomes (EAT-10) and with VF confirmation of impairment (DIGEST). Methods/UNASSIGNED:40 patients (24 M, age 38-76) with oral/oropharyngeal cancer received radiotherapy (70 Gy, 7 weeks) and 3 weekly doses of cisplatin. VF and EAT-10 were completed pre- and 1-month post-CRT. Edema was captured by measuring posterior pharyngeal wall (PPW) thickness, vallecular space, and pharyngeal area (PA) on a single post-swallow rest frame. Wilcoxon sign rank tests and paired t-tests evaluated within-subject changes in impairment and edema respectively. A linear mixed effect regression model explored the influence of time, patient-reported outcomes, and functional impairment on measures of edema. Results/UNASSIGNED:Swallowing function (EAT-10 and DIGEST) was significantly worse post-CRT. PPW thickness (but not vallecular space and pharyngeal area) was significantly worse post-CRT. PPW thickness was only significantly influenced by time (pre- vs. post-CRT) but not by measures of swallow function. Conclusion/UNASSIGNED:Our findings establish the use of PPW thickness as a reliable measure of acute edema in post-CRT treatment. In this small, retrospective sample, edema was not significantly correlated with either patient-reported or measured swallow function. Prospective longitudinal work, examining the relationship between objective measures of edema, patient perception of impairment, and swallow function and biomechanics is warranted. Level of Evidence/UNASSIGNED:4.

Purpose/UNASSIGNED:It has been widely reported that a proportion of healthy, community-dwelling seniors will develop dysphagia in the absence of a known neurological, neuromuscular, or structural cause. Our objective was to test whether various feasible, noninvasive measures of swallowing could differentiate safe versus unsafe and efficient versus inefficient swallowing on videofluoroscopy (VF) in a sample of healthy seniors. Method/UNASSIGNED:VFs from 44 (21 male, 23 female) healthy community-dwelling seniors (> 65 years old) were compared with a series of feasible, noninvasive swallowing metrics: maximal tongue strength (anterior and posterior), hand grip strength, pharyngeal volume, age, body mass index, 3-oz water swallow challenge, the 10-item Eating Assessment Tool questionnaire, and the Frailty Index. The VF protocol included 9 liquid barium boluses (3 × 5 ml thin, 3 × 20 ml thin, and 3 × 5 ml nectar). Each swallow was rated (randomized and blind) for safety using the Penetration-Aspiration Scale score and for efficiency using the Normalized Residue Ratio Scale (NRRS). Participants were deemed "unsafe" if they had any single Penetration-Aspiration Scale scores ≥ 3 and "inefficient" if they had any NRRS valleculae score > 0.082 or NRRS pyriform sinus score > 0.067. Univariate analyses of variance were run for each continuous swallowing measure by swallowing safety and swallowing efficiency status. Pearson's chi-square analyses were used to compare binary outcomes by swallow safety and efficiency status. Bonferroni corrections were applied to control for multiple comparisons. Results/UNASSIGNED:None of the swallowing measures significantly differentiated safe from unsafe swallows. Although several variables trended to distinguishing efficient from inefficient swallows (age, 10-item Eating Assessment Tool, 3-oz water swallow challenge), only one variable, pharyngeal volume, was significantly different between efficient and inefficient swallows (p = .002). Conclusion/UNASSIGNED:Our findings support the notion that larger pharyngeal volumes (measured using acoustic pharyngometry) are associated with worse swallowing efficiency, a finding we attribute to atrophy of the pharyngeal musculature in healthy aging.

A significant proportion of healthy seniors report difficulty swallowing, thought to result from age-related decline in muscle bulk/function. Effortful Swallowing (ES) is used both as a compensatory maneuver to improve pharyngeal propulsion/clearance and has been proposed as an exercise to improve pharyngeal strength. This study sought to quantify the immediate kinematic, temporal, and functional changes during an ES maneuver to quantify its exercise potential to combat age-related changes in swallowing. Videofluoroscopy data were collected from 44 healthy seniors (21 male) over 65 years old (mean = 76.9, SD = 7.1). Each participant swallowed six 5 ml boluses of Varibar nectar-thick liquids: three with regular effort and three using ES. Individual swallows (n = 260) were measured on pharyngeal constriction, pharyngeal shortening, laryngeal closure duration, hyoid movement duration, UES opening duration, stage transition duration, pharyngeal transit time, pharyngeal response duration, Normalized Residue Ratio Scale (NRRS), and the Penetration-Aspiration Scale (PAS). Non-parametric Wilcoxon Rank Sum for repeated measures tested the effect of ES on each outcome. Exact p-values were calculated based on permutation methods, individual p values < 0.008 was deemed to be significant. The ES maneuver significantly prolonged all temporal variables. While we found no significant differences for pharyngeal constriction, significantly less (i.e., worse) pharyngeal shortening was observed in ES condition compared with regular effort swallows. Further, significantly worse pyriform sinus residue (NRRSv) was observed in the ES condition. No differences between ES and regular effort swallows were noted for pharyngeal constriction, NRRSv or PAS. We speculate that these negative manifestations of worse kinematics (less pharyngeal shortening) and function (increase in NRRSp) may be the result of forced volitional manipulation of swallowing in the ES condition in an otherwise normal elderly swallow.

Purpose: The purpose of this study was to explore the impact of anterior cervical discectomy and fusion (ACDF) with anterior instrumentation on swallowing function and physiology as measured on videofluoroscopic swallowing studies. Method: We retrospectively analyzed both functional measures (penetration-aspiration, residue) and physiological/anatomical measures (hyoid excursion, posterior pharyngeal wall thickness) in a series of 17 patients (8 men, 9 women, mean age 54 years). These measures were extracted from calibrated 5-ml boluses of thin radio-opaque liquids on both pre-ACDF and post-ACDF videofluoroscopies, thus controlling for individual variation and protocol variation. Results: After ACDF surgery, we found significant within-subject worsening of Penetration-Aspiration Scale (Rosenbek, Robbins, Roecker, Coyle, & Wood, 1996) scores, vallecular (but not piriform sinus) residue, superior (but not anterior) hyoid excursion, and posterior pharyngeal wall thickness. Results are discussed in the context of previous literature. Conclusions: ACDF surgery can affect both physiological/anatomical and functional measures of swallowing. Future research should expand to other biomechanical and temporal variables, as well as greater bolus volumes and a wider array of viscosities and textures.

Purpose: Edema is a frequent clinical observation after chemoradiation treatment (XRT) for oral/oropharyngeal cancer (O/OP Ca). Our aim is to quantify within-subject measures of edema from pre- and post-XRT videofluoroscopy (VF) and to explore the relationship between edema and aspiration. Method(s): Fourty patients (24 male; ages 38-76) diagnosed with O/OP Ca received radiotherapy (70 Gy, 7 weeks) and 3 weekly doses of cisplatin. VF was completed pre- and again 4 weeks post-XRT. 3 pixel-based measures captured edema from a post-swallow rest frame of a 5 ml thin liquid bolus: posterior pharyngeal wall (PPW) thickness, pharyngeal area (PA) and vallecular space (VS). Worst PAS scores categorized subjects as unsafe (>=3) or safe (<=2). Repeated measures ANOVAs were used to explore the relationship between the edema measure (pre- vs post-XRT) and swallow safety (safe vs unsafe). Result(s): The proportion of patients with unsafe swallows increased from 8/40 pre-XRT to 14/40 post-XRT, though this was not significant (p = 0.2). A significant main effect was confirmed in reduced PA post-XRT [F = 29.9, p = 0.00] and a trending increase was observed for PPW [F = 3.2, p = 0.08]. However, no significant differences between unsafe vs safe groups were found for any edema variables. Conclusions (Including Clinical Relevance): The data confirm that post-XRT edema can be quantified on VF by measuring PPW thickness and PA. A significant worsening in edema measures in individuals with unsafe compared with safe swallows was not detected. The data was limited by a low proportion of post-XRT aspirators. Future analyses will examine the relationship between edema and residue

Acoustic Pharyngometry (APh) is a method for quantifying oropharyngeal tract configuration using sound wave reflection and is commonly used in diagnostics and research of sleep apnea. The standard preset output of APh (minimal cross-sectional area) has been established as reliable. However, by conducting post-processing measures on specific breathing tasks, APh data can also reveal oral length, oral volume, pharyngeal length, and pharyngeal volume. Given that these measures may have utility in dysphagia research, the reliability of these measures is unknown and is the focus of the current study. Ten young healthy female volunteers completed two sessions of APh data collection to obtain measures of oral length, oral volume, pharyngeal length, and pharyngeal volume 1 week apart. Two-way mixed intraclass correlation coefficients were calculated to establish intra-rater reliability, inter-rater reliability, and test-retest reliability. Results revealed excellent levels of agreement within and across raters for all oropharyngeal tract parameters. Levels of test-retest agreement for oral length and oral volume indicated these parameters are appropriate for monitoring change within an individual. All parameters were deemed to have acceptable test-retest values as outcome measures in group-level analysis.

The aim of this study was to determine whether measures of hyoid velocity increase when swallowing liquids of thicker consistency at a constant volume. A gender-balanced sample of 20 healthy young participants (mean age 31.5) each swallowed 3 boluses of 5 ml volume in 3 consistencies (ultrathin, thin, and nectar-thick barium). Using frame-by-frame tracking of hyoid position, we identified the onset and peak of the hyoid movement and derived measures of velocity (i.e., distance in anatomically normalized units, i.e., % of the C2-4 vertebral distance, divided by duration in ms) for the X, Y, and XY movement directions. Peak hyoid velocity was also identified for each movement direction. Where significant differences were identified, the component measures of hyoid movement distance and duration were further explored to determine the strategies used to alter velocity. The results showed increased velocities and higher peak velocities with the nectar-thick stimuli compared to thin and ultrathin stimuli. This was achieved by a primary strategy of larger hyoid movement distances per unit of time when swallowing nectar-thick liquids. These results point to one mechanism by which thickened liquids may contribute to improved airway protection by facilitating more timely laryngeal vestibule closure.