Jacqui Allen

Prevalence of penetration and aspiration on videofluoroscopy in normal individuals without dysphagia

Objective: To determine the prevalence of penetration and aspiration on videofluoroscopic swallow studies (VFSS) in normal individuals without dysphagia. Study Design: Case series with planned data collection. Setting: A tertiary urban university hospital. Subjects and Methods: Normal adult volunteers without dysphagia, neurological disease, or previous surgery underwent VFSS. Studies were recorded and then reviewed for evidence of penetration or aspiration. The degree of penetration was assessed with the penetration-aspiration scale (PAS). The effect of age, bolus size, and consistency was evaluated. Results: A total of 149 VFSS (596 swallows) were reviewed. The mean age of the cohort was 57 years (±19 years); 56 percent were female. Only one (0.6%) individual aspirated on VFSS. Seventeen (11.4%) individuals demonstrated penetration. The mean PAS for the entire cohort was 1.17 (±0.66). Prevalence of penetration by swallow was 2.85 percent (17/596). Prevalence of penetration was 9.3 percent in elderly individuals aged >65 years and 14.3 percent in adults aged <65 years (P = 0.49). Prevalence of penetration on a liquid bolus was 3.4 percent (15/447) and on paste was 1.3 percent (2/149) (P > 0.05). Prevalence of penetration for a bolus <30 cc was 2.34 percent (7/298) and for a bolus >30 cc was 5.4 percent (8/149) (P > 0.05). Conclusion: Aspiration on VFSS is not a normal finding. Penetration is present in 11.4 percent of normal adults and is more common with a liquid bolus.

Cause of vocal fold scar.

Purpose of reviewThe prolonged debilitation, loss of income, and decrement in quality of life caused by vocal fold scar is exacerbated by our inability to successfully treat this difficult problem. As technology focuses on developing innovative treatments, we need to fully appreciate and understand the mechanisms giving rise to glottal scar, on both a macroscopic and microscopic level. This review examines recent literature pertaining to the gross and molecular mechanisms which give rise to vocal fold scar. Recent findingsMechanisms of vocal fold scar production have been examined in both macroscopic and microscopic detail. Trauma and injury involving any aspect of the lamina propria, particularly the deeper layers, may result in epithelial tethering and scar formation. At the molecular level, early inflammatory cytokines activate and recruit fibroblasts which then drive the fibrotic cascade. Transforming growth factor-β enhances fibrosis and is balanced by tissue matrix metalloproteinases and hepatocyte growth factor activity. Molecular signaling offers novel opportunities to intervene in scar formation. SummaryNew work investigating the cause of vocal fold scar identifies complex molecular processes leading to fibrosis in the lamina propria. Improved mechanistic understanding offers insight into prevention strategies and possible targets for antifibrotic therapies that may help prevent or treat this debilitating condition.

Effect of cricopharyngeus muscle surgery on the pharynx.

Cricopharyngeus muscle dysfunction (CPD) ranges from asymptomatic cricopharyngeal bar (CPB) to Zenkers diverticulum. Previous work suggests that CPD can result in dilation and weakening of the pharynx above the obstruction. The purpose of this investigation was to evaluate the ability of surgery on the cricopharyngeus muscle to improve pharyngeal area and strength.

Comparison of esophageal screen findings on videofluoroscopy with full esophagram results

Videofluoroscopic swallowing studies do not routinely obtain images of the esophagus. We incorporated a single esophageal screening swallow into our videofluoroscopic swallowing study protocol. The purpose of this study was to compare findings from “esophageal screening” with the results of full esophagram.

Botulinum toxin in the treatment of vocal fold nodules.

Purpose of reviewPromising new techniques in the management of vocal fold nodules have been developed in the past 2 years. Simultaneously, the therapeutic use of botulinum toxin has rapidly expanded. This review explores the use of botulinum toxin in treatment of vocal nodules and summarizes current therapeutic concepts. Recent findingsNew microsurgical instruments and techniques, refinements in laser technology, radiosurgical excision and steroid intralesional injections are all promising new techniques in the management of vocal nodules. Botulinum toxin-induced ‘voice rest’ is a new technique we have employed in patients with recalcitrant nodules. Successful resolution of nodules is possible with this technique, without the risk of vocal fold scarring inherent in dissection/excision techniques. Botulinum toxin usage is exponentially increasing, and large-scale, long-term studies demonstrate its safety profile. SummaryTargeted vocal fold temporary paralysis induced by botulinum toxin injection is a new, well tolerated and efficacious treatment in patients with persistent vocal fold nodules.

Treatment of aging vocal folds: surgical approaches.

Purpose of reviewAging may affect the voice through either physiological or pathological changes. Globally society is aging and the working lifetime is extending. Increasing numbers of elderly will present with voice issues. This review examines current thinking regarding surgical treatment of the aging voice. Recent findingsThe mainstay of surgical treatment remains injection laryngoplasty and medialization thyroplasty. In-office injection laryngoplasty is increasingly common. Data suggest that patients with vocal fold atrophy do not achieve as much benefit from augmentation treatments as other causes of glottal incompetence. In addition the timing of injection laryngoplasty may influence the rate of subsequent medialization thyroplasty. Disease-specific treatments can provide some benefit to voice, such as deep brain stimulation in Parkinsons disease. Novel treatments including growth factor therapy are entering clinical practice and will provide new options for the clinician in future. SummaryVoice disorders affect approximately 20% of the elderly population. Causes include neurologic, malignant, iatrogenic and benign vocal fold disorders. These should be ruled out before accepting dysphonia is age-related in nature. Treatment should be specific to recognized vocal disorders but may also address physiologic changes in the glottis. Injection laryngoplasty and thyroplasty remain effective options for treating glottal incompetence but novel therapies are showing promising results.

Cricopharyngeal function or dysfunction: what's the deal?

Purpose of reviewThe purpose of the review is to examine current research focused on upper oesophageal sphincter (UES) and cricopharyngeus muscle function, and how better understanding UES physiology will translate to improved management. Recent findingsAlthough much is known about UES function, new information describing the dynamics of the UES and cricopharyngeus is being identified through manometry, combined fluoromanometry, and anatomic study. Response of the UES to injury, reflux, and surgical interventions is reported. Direct surgical treatment of cricopharyngeus noncompliance with or without diverticuli continues to show benefit and long-term results support a sustained improvement in three-quarters of patients. SummaryUES and cricopharyngeus function is complex and dynamic. It is affected by internal signals such as posture and constitution of refluxate, aging, and interventions particularly radiation and surgery. Clear understanding of the triggers and responses of the UES will enable clinicians to choose the correct therapy for their dysphagic patients.

Management of oropharyngeal neurogenic dysphagia in adults.

Purpose of reviewThis article reviews recent literature in the management of neurogenic oropharyngeal dysphagia (OPD) including assessment processes and treatments, with a specific focus on OPD as a result of stroke and Parkinsons disease. Recent findingsA large number of high-quality systematic reviews were published that provide an excellent summary of current evidence across assessment and treatment of swallowing disorders. There is building interest and knowledge in technology in both the understanding and treatment of OPD including functional MRI, manometry, and noninvasive brain stimulation. SummaryNeurologic disorders demonstrate a high prevalence of OPD resulting in significant decrement to health and healthcare costs. Novel technologies were reported in assessment and tracking of dysphagia as well as emerging innovative therapeutic options.

Physical and virtual modelling of the head and neck for surgical simulation and training.

Purpose of reviewInvestigation and surgical manipulation of the larynx, pharynx, and oesophagus suffer from inherent challenges with access to the sites of interest. To reduce trauma and external scarring, visualization and minimally invasive interventions by the transnasal or transoral routes have become more prevalent. This article discusses engineering methods used to understand and overcome the mechanical constraints inside the airway and upper gastrointestinal tract, and examines the role that robotics and engineering are beginning to play in modelling of surgical interventions in this region. Recent findingsAlthough robotic solutions to minimally invasive surgery of the airway and upper gastrointestinal tract already exist, there is still scope for increasing the breadth of their use. Physical and virtual models of these organs are used to investigate the capability and limitations of manual and robotic surgical interventions in this region. Understanding the tissue mechanics and tool capabilities is central to improving outcomes in the clinical setting. Both physical and virtual modelling modalities are used in training surgeons for both manual-assisted and robot-assisted surgeries. SummaryMinimally invasive surgical interventions via the transnasal and the transoral route are strong candidates for overcoming access issues to the airway. They are likely to become more robotically driven as the demand for higher dexterity and accuracy increases for fine manipulation. Physical and virtual organ models are required to enable surgical training for these procedures.

You are only as old as you sound.

DOI:10.1097/MOO.0000000000000106 It is well recognized that the global population continues to age significantly and that with this changing demographic comes a new set of challenges in managing chronic disorders and agerelated changes. Improved health in persons over 65 years of age means that many remain within the workforce for longer, and the need for consistent vocal function becomes crucial. Vocal issues are estimated to affect between 12 and 35% of those aged greater than 65 years [1]. Elderly will comprise almost a third of the United States population by 2030 [1]. This issue of Current Opinion in Otolaryngology focuses on two aspects of voice: the changes inherent with aging and how we might identify and deal with them and what other tools we should be using to more completely assess vocal function. Age-related laryngeal change has been documented at both a functional and a microscopic level, although there is still debate over what represents senescent change versus accumulated insults that alter vocal dynamics. In some ways, this is a moot point when it comes to surgical treatment given that many of the methods currently used for reconstruction of voice are mechanical and gross in nature. But is this part of the problem? Our incomplete understanding of physiology and pathophysiology of voice limits our ability to target and develop feasible treatments. We need to know what occurs in health and in disease. We need to know and understand more of the subtleties of glottic function, including molecular pathways, and how regions aside from the true vocal folds also affect voice production. Only then can we begin to hypothesize new approaches for assessment, intervention and management. Underpinning any detection of abnormality is the ability to reference a ‘normal’. Currently semantic differences are common among laryngologists in discussing the prevalence and cause of agerelated phonatory change. This highlights the gap in our knowledge and limits collaboration. We need to speak the same language and utilize similar diagnostic paradigms so that like can be compared with like. Reconciliation of terminology and diagnostic criteria and identification of aging phenomena whether they cause perceptual changes or not, are required. More clearly focused prospective research is needed to identify benefits of therapy and