Brenda Villegas

Evaluation of Swallow Function After Tongue Cancer Treatment Using Real-Time Magnetic Resonance Imaging: A Pilot Study

IMPORTANCE Magnetic resonance imaging (MRI) has the advantage of imaging swallow function at any anatomical level without changing the position of patient, which can provide detailed information than modified barium swallow, by far the gold standard of swallow evaluation. OBJECTIVE To investigate the use of real-time MRI in the evaluation of swallow function of patients with tongue cancer. DESIGN, SETTING, AND PARTICIPANTS Real-time MRI experiments were performed on a Signa Excite HD 1.5-T scanner (GE Healthcare), with gradients capable of 40-mT/m (milli-Tesla per meter) amplitudes and 150-mT/m/ms (mT/m per millisecond) slew rates. The sequence used was spiral fast gradient echo sequence. Four men with base of tongue or oral tongue squamous cell carcinoma and 3 age-matched healthy men with normal swallowing participated in the experiment. INTERVENTIONS Real-time MRI of the midsagittal plane was collected during swallowing. Coronal planes between the oral tongue and base of tongue and through the middle of the larynx were collected from 1 of the patients. MAIN OUTCOMES AND MEASURES Oral transit time, pharyngeal transit time, submental muscle length change, and the distance change between the hyoid bone and anterior boundary of the thyroid cartilage were measured frame by frame during swallowing. RESULTS All the measurable oral transit and pharyngeal transit times of the patients with cancer were significantly longer than the ones of the healthy participants. The changes in submental muscle length and the distance between the hyoid bone and thyroid cartilage happened in concert for all 60 normal swallows; however, the pattern differed for each patient with cancer. To our knowledge, the coronal view of the tongue and larynx revealed information that has not been previously reported. CONCLUSIONS AND RELEVANCE This study has demonstrated the potential of real-time MRI to reveal critical information beyond the capacity of traditional videofluoroscopy. Further investigation is needed to fully consider the technique, procedure, and standard scope of applying MRI to evaluate swallow function of patients with cancer in research and clinic practice.

Safety of Microstimulator During Radiation Therapy - A Preliminary Study on Head and Neck Cancer Patients

Objectives: To determine the safety and performance of miniature neuromuscular stimulator called MicroStimulator (MS) during radiation therapy (RT) of head and neck cancer (HNC). Study Design: Pilot study Methods: Four patients who underwent modified radical neck dissection for HNC received MS implants. The implant was placed 2-3 mm above and parallel to the hypoglossal nerve. All patients had tracheotomy and gastric tubes placed during surgery. Stimulation thresholds were obtained in three patients and electrical exercise programs were initiated in two patients. One patient completed the study, started RT and stimulation of the MS 3-4 weeks after surgery. The implant was energized and controlled by a radio frequency magnetic field from an external coil placed near the implant. Patients underwent stimulation of the MS one hour per day using intermittent trains of stimuli generating fused, maximal contractions. Results: No postoperative or implant specific complication was noted. All patients required and tolerated stimulation without pain or discomfort. Visible contraction of muscles of swallowing was noted in both patients during stimulation indicating that MS remained functional during RT. All patients used the device at home and maintained their oral feeding and weight. None had aspiration pneumonia. Conclusions: MS appears to be a safe device for stimulation of swallowing muscles during MS for HNC. Implant performance is not affected by RT. It effectively stimulates the nerves to induce robust contraction of muscles of swallowing and laryngeal elevation. High patient compliance was achieved with this implant.

Device Life of Two Generations of Provox Voice Prostheses

Background: Tracheoesophageal voice prostheses are invaluable for speech rehabilitation in patients who have received total laryngectomy, but device failure impedes communication and creates psychosocial and financial burdens. This study compares the Provox 2 and Provox Vega voice prostheses on the parameter of device life. Methods: This was a retrospective observational study of 21 patients with 181 device replacements at an academic tertiary care medical center. Disparity in device life and factors that may influence device life were analyzed. Results: The mean device life for Provox 2, at 115.6 days (SE = 5.8), was longer than for Provox Vega, at 65.1 days (SE = 7.5) (P < .001). Conclusions: Device longevity was greater for Provox 2 over Provox Vega. These results will facilitate the design of prospective studies to assess reasons for variations in device life between patients and device types.

Solitary Fibrous Tumor of the Postcricoid Region: A Case Report and Literature Review

Solitary fibrous tumor (SFT) is a rare mesenchymal neoplasm that can present essentially anywhere in the body. Presentations in the hypopharynx are extremely rare with only two previous cases reported. We report the first case of postcricoid SFT occurring in a 58-year-old male requiring a microsuspension laryngoscopy excision following an unsuccessful transoral robotic attempt. The excision was uneventful, and the patient is currently without recurrence. Current management strategies of the hypopharyngeal SFT, the unique differential diagnosis, and challenges in surgical approaches in the postcricoid region are discussed.

Laryngeal Elevation Velocity and Aspiration in Acute Ischemic Stroke Patients.

Objectives Aspiration after stroke has been associated with aspiration pneumonia, which contributes to increased mortality of stroke. Laryngeal elevation is a core mechanism for protection from aspiration. Few studies have explored the predictive value of laryngeal elevation velocity for aspiration after stroke. This study aimed to explore the ability of laryngeal elevation velocity to predict aspiration in patients with acute ischemic stroke. Methods This was a prospective cohort study that included consecutive acute ischemic stroke patients treated at a teaching hospital during a 10-month period. Patients underwent magnetic resonance imaging (MRI) to confirm the diagnosis of acute ischemic stroke. Patients who were at risk of aspiration and could swallow 5 ml of diluted barium (40%, w/v) for a videofluoroscopic swallowing (VFS) study were included. The association between abnormal indices in the oral and pharyngeal phase of the VFS study and aspiration was examined using univariate analyses. These indices included the lip closure, tongue movement and control, laryngeal elevation velocity and range, the latency of pharyngeal swallowing, pharyngeal transit time (PTT), abnormal epiglottis tilt, residual barium in the pharynx, and the duration of upper esophageal sphincter (UES) opening. The laryngeal elevation velocity (%/s) was calculated as the range of laryngeal elevation (%) from the resting position to the maximum superior position or to the position where the laryngeal vestibule is fully closed divided by the corresponding duration of laryngeal elevation. The range of laryngeal elevation (%) was the percentage calculated as the distance between the resting laryngeal position and the maximum superior excursion position or position where the laryngeal vestibule is fully closed divided by the distance between the resting laryngeal position and the lowest edge of the mandible. A logistic regression analysis was used to determine the predictive value for aspiration secondary to reduced laryngeal elevation velocity after adjusting for the effects of other indices. Intrarater and interrater reliability were calculated using Pearson’s correlation coefficients. Results Data from 89 patients were analyzed. This cohort included 71 males and 18 females with a mean age of 59.31±11.46 years. The mean time from stroke onset to the VFS study was 3 days (1–7). Twenty one (23%) patients aspirated while swallowing 5 ml of diluted barium (40%, w/v). Aspiration was associated with age, the velocity (%/s) of laryngeal elevation and duration, delayed pharyngeal phase, pharyngeal transit time, abnormal epiglottic tilt, and invalid laryngeal elevation before true swallowing, and duration of upper esophageal sphincter (UES) opening. After adjusting for the effects of the indices mentioned above, logistic regression analysis revealed that a reduced of laryngeal elevation velocity before vestibule closure was predictive of aspiration independently (OR, 0.993; 95% CI, 0.987–1.000). Discussions Reduced laryngeal elevation velocity for laryngeal elevated to position where laryngeal vestibule is fully closed was an independent predictor of aspiration in patients with acute ischemic stroke. This may be related to a decreased contraction velocity of the muscles involved in hyolaryngeal elevation. Therapeutic methods aimed at improving laryngeal elevation velocity may decrease aspiration events and pneumonias after stroke.

ABCLOVE: Voice therapy outcomes for patients with head and neck cancer

Dysphonia related to head and neck cancer is unique, and demands treatment tailored to its unique pathology. Activate exercises, breathing, counseling, laryngeal manipulation, oral resonance, vocal exercises, and elimination of habits (ABCLOVE) is an 8‐week multimodality voice therapy program addressing vocal rehabilitation specifically for patients with head and neck cancer.

Effects of Resonance Voice Therapy on Hormone-Related Vocal Disorders in Professional Singers: A Pilot Study

Background: Menstruation-related hormonal alteration can be detrimental to the professional singing voice of women. Resonance Voice Therapy (RVT) has been proven to improve vocal production. However, no research to date has been conducted examining the subjective, acoustic, and stroboscopic effects of RVT on professional female singers having premenstrual or postmenopausal voice disorders. Aim: The aim of this study is to compare the vocal effects of RVT with a control cervical-thoracic intervention in healthy female singers during the premenstrual phase as well as in postmenopausal singers and to evaluate which intervention will allow singers to improve vocal performance regardless of changes in hormonal status. Design: A randomized study was designed for this research. The research subjects were 20 professional female singers from the Southern California area, USA, with 10 premenstrual subjects in one group and 10 postmenopausal subjects in the other group. Among each group, 5 subjects were randomly selected to receive RVT and the remaining subjects received cervical-thoracic–focused exercises. The therapies consisted of 1 month of daily 15-minute sessions. For premenstrual subjects, voice data were collected at days 25 to 27 of the premenstrual phase during a scheduled initial voice evaluation. Follow-up data were collected during the same phase of the menstrual cycle (days 25-27) after 1 month of exercises. For postmenopausal subjects, voice data were collected at an initial voice evaluation with follow-up after 1 month of the assigned voice treatment. Outcomes were assessed with the singer’s voice handicap index (VHI), laryngeal videostroboscopic examination, maximum phonation time (MPT), relative average perturbation (RAP), and pitch range before and following completion of therapies. Alleviation or deterioration percentages were used for statistical analysis. Student t test was used for statistical comparison between therapies. Results: The RVT decreased singer’s VHI for both premenstrual and postmenopausal subjects by an average of 67%, compared with 7.8% for the cervical-thoracic therapy. The RVT also effectively decreased RAP by an average of 57% when combining the premenstrual and postmenopausal groups. The RVT increased MPT and pitch range among both premenstrual and postmenopausal subjects. The stroboscopic examination did not detect any significant differences between the 2 interventions. Conclusions: The RVT is effective for professional female singers with hormone-related premenstrual and postmenopausal vocal changes. The RVT is suggested as one of the therapeutic approaches for vocal abnormalities in such a population. A larger cohort may be needed for future research. Level of Evidence: 1b

Comprehensive Rehabilitation of Oral Cancer

The management of oral cancer necessarily involves not only therapy directed toward improving survival but also rehabilitation of the patient with the goals of improving quality of life and preserving the patient’s dignity. Surgical resection, radiation therapy, and chemotherapy create substantial morbidity and deformity. Treatment of this region therefore has tremendous consequences for irreplaceable functions: mastication, deglutition, verbal communication, respiration, and facial expression. Moreover, cancer creates extensive psychosocial and financial burden for the patient, their families, and the society in general. The focus on quality of life as it pertains to rehabilitation is critical to understanding the oral cancer patient. This chapter is dedicated to the discussion of oral cancer rehabilitation, with an emphasis on functional considerations in order to achieve maximum conservation of activity and quality of life.