Lynn M. Acton

Fiberoptic endoscopic evaluation of swallowing (FEES) with and without blue-dyed food.

The purpose of this prospective study was to determine if fiberoptic endoscopic evaluation of swallowing (FEES) maintains high intra- and interrater reliability in detecting pharyngeal dysphagia and aspiration without the addition of FD&C Blue No. 1 to food. Twenty consecutive adults referred for a swallow evaluation participated. Nine subjects received blue-dyed food and 11 subjects received regular nondyed food, i.e., yellow pudding and white skim milk. Four variables were rated: (1) the stage transition characterized by depth of bolus flow to at least the vallecula prior to the pharyngeal swallow; (2) evidence of bolus retention in the vallecula or pyriform sinuses after the pharyngeal swallow; (3) laryngeal penetration defined as material in the laryngeal vestibule but not passing below the level of the true vocal folds either before or after the pharyngeal swallow; and (4) tracheal aspiration defined as material below the level of the true vocal folds either before or after the pharyngeal swallow. Three speech–language pathologists experienced in interpreting FEES results independently and blindly reviewed the digitized videotape three times. Intrarater agreements for the four variables with blue-dyed and non-blue-dyed food trials were 100% and monochrome trials ranged from 95% to 100%. Average kappa values for interrater reliability ranged from moderate to excellent agreement (0.61–1.00) for all viewing conditions. Kappa values for blue-dyed trials versus monochrome trials were 0.83 and for non-blue-dyed trials versus monochrome trials were 0.88, indicative of excellent reliability under both viewing conditions. FEES maintains both high intra- and interrater reliability in detecting the critical features of pharyngeal dysphagia and aspiration using either blue-dyed or non-blue-dyed foods. The endoscopist, therefore, can be assured of reliable FEES results using regular, non-dyed food trials.

Success of Recommending Oral Diets in Acute Stroke Patients Based on Passing a 90-cc Water Swallow Challenge Protocol

Abstract Purpose: This study investigated the success of recommending specific oral diets following an acute stroke based on passing a 90-cc water swallow challenge protocol. Method: The study was a single group consecutively referred case series design. The study took place in a large, urban, tertiary care teaching hospital and involved 75 acute adult stroke inpatients in a 90-cc water swallow challenge. The volume (in cc) of liquid ingested, percent of meal eaten, and specific diet recommendations made 12 to 24 hours after passing a 90-cc water swallow challenge were accessed electronically from routine oral intake information entered by nursing staff on each participant’s daily flow sheets. Nurses were blinded to the study’s purpose. Results: All 75 participants were drinking thin liquids and eating food successfully 12 to 24 hours after passing a 90-cc water swallow challenge. The mean volume of liquid ingested was 385.4 cc and percent of diet eaten ranged from 10% to 100%. Flow sheets indicated that specific diet recommendations were followed with 100% accuracy. Conclusions: Successfully recommending specific oral diets to acute stroke patients based on passing a 90-cc water swallow challenge protocol was supported. A 90-cc challenge is an easily administered, highly reliable, cost-effective, and validated clinical assessment that can be used by a variety of qualified health care professionals to identify aspiration risk. When a 90-cc challenge protocol is passed, specific diet recommendations can be made safely and confidently without the need for further objective dysphagia testing.

Voice restoration with the advantage tracheoesophageal voice prosthesis.

OBJECTIVES: To determine whether the Blom-Singer indwelling Advantage tracheoesophageal voice prosthesis (TEP) extends prosthesis life span significantly in patients with documented premature device failure due to fungal colonization. STUDY DESIGN AND SETTING: Data were collected in a prospective manner on a total of 42 standard indwelling TEP users who exhibited early device failure, that is, between 2 weeks and 6 months, due to fungal colonization of the flap valve despite appropriate use of oral antifungal agents. There were 29 men and 13 women, whose ages ranged from 36 years 10 months to 86 years 8 months. METHODS: Baseline data were derived from the average number of days 3 previous standard indwelling prostheses functioned before leaking. An Advantage indwelling TEP was placed after the third change, oral antifungal agents stopped, and routine care implemented, that is, flush and brush the device in situ twice each day. Each participant was assigned to 1 of 3 groups. Group 1 had device failure equal to or less than 2 months (n = 12). Group 2 had device failure between 2 and 4 months (n = 19). Group 3 had device failure between 4 and 6 months (n = 11). RESULTS: Groups 1 and 2 exhibited significantly longer device life span, that is, 77 and 82 days, respectively (P < 0.01), and group 3 exhibited device life span that was longer but not significantly so, that is, 12 days (P > 0.05), after the change from standard to Advantage TEP. Individual data indicated that the majority of participants, that is, 32 of 42 (76.2%), experienced longer device life span after changing to the Advantage prosthesis. Specifically, 9 of 12 (75.0%) users in group 1, 17 of 19 (89.5%) users in group 2, and 6 of 11 (54.5%) users in group 3 exhibited longer device life span. The combination of using an Advantage TEP, discontinuing oral antifungal agents, and reducing the number of both TEP changes and clinic visits resulted in overall cost benefits for both the user and the health care system. The cost benefit for group 1 was

Safe initiation of oral diets in hospitalized patients based on passing a 3-ounce (90 cc) water swallow challenge protocol

520.00; group 2,

Comparison of the Glottic Closure Reflex in Traditional “Open” versus Endoscopic Laser Supraglottic Laryngectomy

393.00; and group 3,

Investigation of tracheoesophageal voice prosthesis leakage patterns: patient's self-report versus clinician's confirmation.

204.25. CONCLUSIONS: The Advantage TEP extended device life span significantly for standard indwelling device users with documented premature device failure due to fungal colonization, reduced costs associated with tracheoesophageal voice restoration rehabilitation, and enhanced user satisfaction by eliminating use of oral antifungal agents and reducing clinic visits. SIGNIFICANCE: Use of an Advantage indwelling voice prosthesis is warranted from both cost and user satisfaction perspectives when early and repeated device failure occurs as a result of fungal colonization.

Effect of orogastric tubes on aspiration status and recommendations for oral feeding.

BACKGROUND Safe and timely oral alimentation is crucial for optimum patient care. OBJECTIVE To determine the short-term success of recommending specific oral diets, including drinking thin liquids, to acute care hospitalized patients at risk for dysphagia based on passing a 3-ounce water swallow challenge protocol. DESIGN Prospective single group consecutively referred case series. SETTING Large, urban, tertiary care, teaching hospital. PARTICIPANTS 1000 hospitalized patients. INTERVENTION 3-ounce (90 cc) water swallow challenge protocol. MEASUREMENTS Specific diet recommendations and volume (in cc) of liquid ingested at the next days meal 12-24 h after passing a 3-ounce challenge protocol were accessed electronically from oral intake information entered on each participants daily care logs. Eating and drinking success, clinically evident aspiration events and compliance with ordering the recommended diet were recorded. Care providers were blinded to the studys purpose. RESULTS Of 1000 patients, 907 met the inclusion criteria of stable medical, surgical or neurological conditions 12-24 h after passing a 3-ounce water swallow challenge protocol. All 907 were both eating and drinking thin liquids successfully and without overt signs of dysphagia. Median volume of liquid ingested was 340 cc [interquartile range (IQR), 240-460]. Specific diet recommendations were followed with 100% accuracy. CONCLUSION A 3-ounce water swallow challenge protocol successfully identified patients who can be safely advanced to an oral diet without subsequent identification of overt signs of aspiration within 12-24 h of testing. Importantly, when a clinical 3-ounce challenge protocol administered by a trained provider is passed, specific diet recommendations, including drinking thin liquids, can be made safely and without the need for additional instrumental dysphagia testing.

Laryngeal physiology and voice acoustics are maintained after minimally invasive parathyroidectomy.

Objectives: Cancer of the supraglottic larynx may be surgically treated with either traditional “open” supraglottic laryngectomy (OSL) or endoscopic laser supraglottic laryngectomy (ELSL). Pharyngeal dysphagia is a well-documented consequence of traditional OSL from which near-normal swallowing characteristically recovers 14 to 40 days after surgery. Conversely, ELSL results in the resumption of serviceable swallowing within 2 to 7 days after surgery. Methods: A prospective assessment of the glottic closure reflex in 6 consecutive patients who had ELSL was performed by fiberoptic endoscopic evaluation of swallowing with sensory testing. Results: All 6 patients with ELSL demonstrated an intact glottic closure reflex both before surgery and 48 to 72 hours after surgery. In contrast, 7 of 8 historical control patients who had OSL demonstrated a persistent absence of the glottic closure reflex 3 weeks to 12 years later. Conclusions: Although a number of clinical factors influence swallowing recovery, one important factor separating our patient groups was the preservation of the glottic closure reflex in patients who underwent endoscopic laser resection. Because the loss of the glottic closure response persists for years after traditional OSL, it is concluded that the sensory field deficit caused by superior laryngeal nerve section is largely not recoverable; however, compensatory mechanisms remain important in serviceable recovery, even if delayed after operation. Indeed, preservation of the glottic closure response appears to enhance swallowing recovery when equivalent compensatory mechanisms are used.

Hands-Free Speech in Glottic Stenosis Patients

This study investigated the patients self‐report and clinicians confirmation of tracheoesophageal voice prosthesis leakage patterns (through or around) with or without the cough reflex and whether prosthesis diameter affected the leakage route.

Voice Disorders in Actors

Objective. To investigate the effects, if any, of the presence of an orogastric tube on incidence of aspiration and oral diet recommendations. Study Design. Case series with planned data collection. Setting. Large, urban, tertiary care teaching hospital. Subjects and Methods. Referred sample of 10 consecutively enrolled inpatients (2 pediatric, aged 17 days and 3 months, respectively; and 8 adults, mean age 63 years). An orogastric tube was present for the first videofluoroscopic swallowing study or fiberoptic endoscopic evaluation of swallowing and then removed for the second swallow study. Results. There were no significant differences (P = 1.0) for both overall incidence of aspiration and aspiration by food consistency (liquid or puree) dependent on orogastric tube presence. All 9 participants recommended for an oral diet ate successfully. Conclusions. An orogastric tube did not affect incidence of aspiration. A videofluoroscopic or endoscopic evaluation of swallowing can be performed with an orogastric tube present, and there is no contraindication to keeping an orogastric tube in place to supplement oral alimentation until prandial nutrition is adequate.