Nicole Pizzorni

Dysphagia in head and neck cancer patients treated with radiotherapy and systemic therapies: Literature review and consensus.

BACKGROUND Head and neck cancer (HNC) and its therapy are associated with acute and late swallowing dysfunction. Consensus guidelines regarding evaluation and management are lacking. To address this gap, a multidisciplinary team of experts (oncologists, practitioners, deglutologists, etc.) met in Milan 17-18 February 2013 with the aim of reaching a consensus on the management of swallowing difficulties in HNC patients treated with radiotherapy with or without systemic therapies (such as chemotherapy and targeted agents). The consensus was focused particularly on those statements with limited evidence. The results of the literature review and the statements that obtained a consensus are reported and discussed in this paper. MATERIALS AND METHODS The Delphi Appropriateness Method was used for this consensus. External expert reviewers then evaluated the conclusions carefully according to their area of expertise. RESULTS This paper contains 6 clusters of statements about the management of swallowing problems in radio-treated HNC patients and a review of the recent literature on these topics. CONCLUSIONS Dysphagia assessment and its management are difficult and require a multi-team cooperation (ENT specialists, radiation and medical oncologists, deglutologists, etc.).

Swallowing, voice, and quality of life after supratracheal laryngectomy: Preliminary long-term results

The purpose of this study was to report preliminary long‐term outcomes after supratracheal laryngectomy (STL).

Functional outcomes after supracricoid laryngectomy: what do we not know and what do we need to know?

Supracricoid laryngectomies (SCLs) are conservative organ-sparing surgical techniques for the treatment of selected T2–T4 laryngeal carcinomas. Although these procedures allow preserving the larynx and its functions, in several countries SCLs are not adopted in oncological protocols. One of the possible reasons to account for this choice is the complexity of post-surgical in-hospital management and the variability in functional results. The aim of this review is to analyse the literature on functional results after SCLs as knowledge on functional results will help in focusing on what is needed in the future to reach more standardized post-surgical procedures and homogeneous outcomes. The analysis of the length of hospital stay, feeding-tube removal time and time to eventual tracheotomy decannulation showed a marked variability across authors and centres. Several factors may come into play, including health-system organizations in different countries. In most studies in-depth description of the criteria applied for discharge, tracheotomy tube removal and commencement of oral feeding were not reported. Moreover, the review on swallowing functional outcomes showed marked variability, as well as a lack of consensus on how to assess swallowing after SCLs. The analysis of voice functional outcomes also revealed a marked variability; surprisingly, the tools applied in the assessments were very often not adequate for substitution voice. Literature review showed that voice- and swallowing-related quality of life are often satisfactory but the variability among centres is still too large. Therefore, there is a need for clearer clinical recommendations on early post-surgical management, tracheal-cannula and feeding-tube removal criteria, voice- and swallowing-assessment protocol, rehabilitation need and timing.

Long-term functional results after open partial horizontal laryngectomy type IIa and type IIIa: A comparison study.

The purpose of this study was to compare long‐term swallowing, voice results, and quality of life (QOL) after open partial horizontal laryngectomy (OPHL) type IIa and type IIIa.

Neuromuscular Electrical Stimulation for Treatment-Refractory Chronic Dysphagia in Tube-Fed Patients : A Prospective Case Series

Objective: The aim of this study was to evaluate the role of neuromuscular electrical stimulation (NMES) in tube-fed patients with severe and chronic dysphagia refractory to traditional swallowing therapy (TT). Patients and Methods: A total of 11 consecutive dysphagic patients with tube-dependent nutrition and who had not responded to 6 months of TT were enrolled. Each patient received NMES for 30 min and TT for 30 min, twice a day, 5 days per week for 4 weeks. In order to evaluate the swallowing impairment, each patient underwent a fiberoptic endoscopic examination of swallowing immediately before the beginning of the treatment, after 2 weeks and after 4 weeks. Results: All enrolled patients managed to complete the swallowing treatment protocol for at least 2 weeks. After the 4-week treatment, 6 of 11 enrolled patients passed to a total oral diet with single or multiple consistencies despite specific food limitations or special preparation or compensation. Five patients, all affected by the most severe form of dysphagia, maintained tube-dependent nutrition. Conclusion: NMES as adjunctive treatment to TT may offer a new possibility for the management of tube-fed patients who are refractory to TT.

The Vocal Score Profile in Verdi's Characters

OBJECTIVES Selecting the appropriate repertoire for an opera singer may be crucial for both the prevention of voice disorders and the career progression. Here, we reviewed the score of 14 Verdis operas to gain the data for the creation of the vocal score profile of each role. MATERIALS AND METHODS Seven musicians were involved in the analysis process. Notes were counted and reported as absolute and relative frequency. Pitch measurements included pitch range, percentage of high-pitched notes, percentage of medium-pitched notes, percentage of low-pitched notes, high-pitched and low-pitched notes rate, percentage of the notes in the passaggio, identification of the prevalent octave, percentage of notes in the prevalent octave, and percentage of notes in a moderate range tessitura. The total phonation time was calculated for each character. RESULTS A heterogeneity among pitch and duration measurement was found among roles within the same voice type, leading to highly different vocal efforts required by the performer. CONCLUSIONS Data on 67 Verdi characters were gained, and the vocal demand of each role was discussed. Potentially, these results may support singers, singing teachers, and vocal coaches in the selection of the repertoire. The data may also assist clinicians in the conduction of counseling and during eventual voice therapy. Future studies must investigate the predictive value of the vocal score profile in appraising the risk of vocal injury.

Reliability and Validity of the Italian Version of the Protocol of Orofacial Myofunctional Evaluation with Scores (I-OMES)

Objective: To evaluate the reliability, validity, and responsiveness of the Italian OMES (I-OMES). Patients and Methods: The study consisted of 3 phases: (1) internal consistency and reliability, (2) validity, and (3) responsiveness analysis. The recruited population included 27 patients with orofacial myofunctional disorders (OMD) and 174 healthy volunteers. Forty-seven subjects, 18 healthy and all recruited patients with OMD were assessed for inter-rater and test-retest reliability analysis. I-OMES and Nordic Orofacial Test – Screening (NOT-S) scores of the patients were correlated for concurrent validity analysis. I-OMES scores from 27 patients with OMD and 27 age- and gender-matched healthy subjects were compared to investigate construct validity. I-OMES scores before and after successful swallowing rehabilitation in patients were compared for responsiveness analysis. Results: Adequate internal consistency (Cronbach α = 0.71) and strong inter-rater and test-retest reliability (intraclass coefficient correlation = 0.97 and 0.98, respectively) were found. I-OMES and NOT-S scores significantly and inversely correlated (r = –0.38). A statistical significance (p < 0.001) was found between the pathological group and the control group for the total I-OMES score. The mean I-OMES score improved from 90 (78–102) to 99 (89–103) after myofunctional rehabilitation (p < 0.001). Conclusion: The I-OMES is a reliable and valid tool to evaluate OMD.

Pathophysiology, Diagnosis, and Medical Management of Dysphagia

Swallowing is a complex physiologic process to transport saliva and nutrition from the oral cavity to the stomach, avoiding the threat of food or liquid entering the airway. Complex circuits in the brainstem and in supratentorial areas guarantee sequential and rhythmic patterns of motor neurons controlling the swallowing muscles. Dysphagia is the impairment of these mechanisms, leading to the reduction of swallowing safety with the risk of pulmonary complications and swallowing efficacy with the risk of malnutrition. Different mechanisms related to a wide range of clinical conditions may lead to swallowing safety and efficacy reduction. Appropriate management relies on identification of affected patients through screening programs and clinical and instrumental assessment. Medical management includes the treatment of the underlying diseases, avoidance of drugs that interfere with swallowing, botulinum toxin injection, and in selected cases surgery.

Social and Psychologic Impact of Dysphagia

Complications of oropharyngeal dysphagia include aspiration pneumonia, malnutrition, dehydration, and impact on psychosocial well-being. However, patients, caregivers, and clinicians perceive the importance of these complications differently, with patients addressing psychosocial sequelae as predominant. The chapter provides an overview of the psychological and social impact of dysphagia on patients and their caregivers. Embarrassment due to inability to eat and drink in a social acceptable way leads to social isolation. Diminished self-esteem, fear, anxiety, frustration, and depression may be experienced. Eating habits may be overturned, especially in case of more restricted diets and introduction of enteral feedings. Over time, patients find a range of coping strategies, which may be beneficial for some, while negative for others. Caregivers have to cope with changes of their role and responsibilities; in reaction to these, affective symptoms may arise. Implications for clinical practice are discussed, including a multidisciplinary and holistic assessment of the patient and the caregiver to be performed periodically, personalization of the counseling, skill-building programs, and interactions with other patients.

Speech and Language Pathologists’ Voice Use in Working Environments: A Field Study Using Ambulatory Phonation Monitoring

Objective: The aim of this study was to evaluate the speech and language pathologists’ (SLPs) voice production during a typical working day. Patients and Methods: A total of 28 SLPs, all females, were enrolled. According to the type of treated disease, the cohort of SLPs was divided into 4 groups (7 SLPs focused on the rehabilitation of dysphagic adult clients; 7 SLPs focused on the rehabilitation of deaf children; 7 SLPs focused on the rehabilitation of dysphonic adult clients; and 7 SLPs focused on the rehabilitation of aphasic adult clients). The voice production evaluation was performed using ambulatory phonation monitoring (APM). Results: Significant differences in the APM results were found between the 4 groups of SLPs. In particular, SLPs focusing on the treatment of dysphonic and deaf clients experienced a higher vocal load than SLPs focusing on the treatment of aphasic and dysphagic clients. Conclusion: SLPs may experience heavy vocal loads during working hours. In addition, it seems that some rehabilitation settings could be more vocally demanding than others.