Paul Carding

Patient-reported outcomes following parotid-sparing intensity-modulated radiotherapy for head and neck cancer. How important is dysphagia?

OBJECTIVESnSwallowing can be significantly affected during and following radiotherapy for head and neck cancer (HNC). The purpose of this study was to understand: (1) the trajectory of swallowing recovery following parotid-sparing intensity-modulated radiotherapy (IMRT) and (2) overall physical and social-emotional wellbeing and how patients prioritise swallowing following treatment.nnnMATERIALS AND METHODSnSixty-one HNC patients completed questionnaires as part of a prospective study exploring patient-reported swallowing outcomes following parotid-sparing IMRT. Participants were asked to complete the M.D. Anderson Dysphagia Inventory (MDADI) and University of Washington Quality of Life Questionnaire (UW-QoL) v.04 before treatment and 3, 6 and 12months after treatment. Given the rise in human papilloma virus (HPV) and associated oropharyngeal cancers, we completed a sub analysis of the data in those participants.nnnRESULTSnThere was a significant reduction in the MDADI composite scores 3months after completion of treatment. Improvements were observed by 12months, however, scores did not recover to baseline. The recovery in physical function was limited in comparison to social-emotional recovery at 12months. When oropharyngeal cancer scores were analysed, there was not a substantial difference to the whole group results. There was a shift in priorities following treatment. Swallowing was highlighted as a concern by 44% of HNC patients up to 12months after treatment with swallowing-related factors (saliva, taste and chewing) rated highly.nnnCONCLUSIONSnPatient reported swallowing outcomes were significantly affected from baseline to all follow-up time points and remained a priority concern at 12months following treatment. Overall social-emotional functioning does improve, suggesting that patients have the potential to adapt to their new normal following IMRT for HNC.

Head and neck cancer patients’ perceptions of swallowing following chemoradiotherapy

PurposeThe study aims to describe patients’ experiences of swallowing difficulties following (chemo)radiotherapy for head and neck cancer and to explore any changes over time.MethodsA purposive sample of patients with swallowing difficulties was selected at a range of time points, from 3 to 18xa0months following treatment. Ethnographic observations of 12 patients were conducted in their own homes, over a mealtime situation. Nine new patients were interviewed about changes to their eating and drinking from pre- to post-treatment. Thematic analysis was used to code and analyse the data.ResultsPatients’ reports of swallowing function were divided into four time zones: pre-treatment, during radiotherapy, early (0–3 months) and late (6–18 months) time points following treatment. The majority reported minimal problems at diagnosis, but marked impairment during and after radiotherapy, without a return to pre-treatment functioning. The focus was on severe physical side effects and changes to food preparation during radiotherapy and in the early phase of recovery. By 6xa0months, side effects began to subside, but swallowing was still difficult, leading to major changes to family life, socialisation and lifestyle.ConclusionsSwallowing problems after (chemo)radiotherapy are multi-faceted and highly individualised and restrict lives in the long term. Swallowing ability may improve in time, but does not appear to return to pre-treatment function. Further work is required to find ways of being able to best support patients living with this long-term condition.

Swallowing outcome measures in head and neck cancer--How do they compare?

OBJECTIVESnDysphagia is a common and debilitating side effect of chemoradiotherapy. Assessment is difficult; swallowing is multifactorial and studies choose from a range of dysphagia assessments. This study intended to investigate the relationship between swallowing assessments of dysphagia in a cohort of patients and to evaluate whether clinical swallowing measures can predict patient reported swallowing outcomes.nnnMATERIALS AND METHODSnOne hundred and seventy-three head and neck cancer patients from two teaching hospitals were recruited prospectively over 25 months. At three months follow-up patients were assessed using Rosenbecks Penetration-Aspiration Scale (PAS), The 100 ml Water Swallow Test (WST), The Performance Status Scale: Normalcy of Diet and the MD Anderson Dysphagia Inventory (MDADI).nnnRESULTSnThe highest correlation was observed between the MDADI and Normalcy of Diet (rho 0.68) and the lowest between the MDADI and the PAS (rho 0.34). Using multiple regression the PAS and WST accounted for 44% of the variance in the MDADI scores (R2 = 0.44, F = 37.8, p < 0.001). On stepwise regression, the model only retained the Normalcy of Diet scores (R2 = 0.42, F=107.9, p < 0.001). Separating the PAS into subgroups, those with no penetration or aspiration on the PAS scored significantly higher on the MDADI (p = <0.001).nnnCONCLUSIONnPatient reported swallowing outcomes were strongly aligned with diet restrictions but poorly aligned with clinical assessment. The WST, however, was more correlated than the PAS score, representing a more functional assessment. Clinical dysphagia, associated with significant morbidity, and patient reported dysphagia related to quality of life are not interchangeable and must be measured separately.

Injection laryngoplasty in the outpatient clinic under local anaesthetic: a case series of sixty‐eight patients

We aimed to assess self‐report and perceptual voice outcomes in patients undergoing local anaesthetic injection laryngoplasty in our outpatient clinic.

Vocal tract characteristics in Parkinson's disease.

Purpose of reviewVoice tremor is strongly linked to the Parkinsons disease speech–voice symptom complex. Little is known about the underlying anatomic source(s) of voice tremor when it occurs. We review recent literature addressing this issue. Additionally we report findings from a study we conducted employing rating of vocal tract structures viewed using nasolaryngoscopy during vocal and nonspeech tasks. Recent findingsIn Parkinsons disease, using laryngeal electromyography, tremor has not been identified in muscles in the vocal folds even when perceived auditorily. Preliminary findings using nasolaryngoscopy suggest that Parkinsons disease voice tremor is not associated with the vocal folds and may involve the palate, the global larynx, and the arytenoids. Tremor in the vertical larynx on /a/, and tremor in the arytenoid cartilages on /s/ differentiated patients with Parkinsons disease from neurologically healthy controls. Visual reliable detection of tremor when it is absent or borderline present, is challenging. SummaryParkinsons disease voice tremor is likely to be related to oscillatory movement in structures across the vocal tract rather than just the vocal folds. To progress clinical practice, more refined tools for the visual rating of tremor would be beneficial. How far voice tremor represents a functionally significant factor for speakers would also add to the literature.

Unilateral Vocal Fold Paralysis: A Systematic Review of Speech-Language Pathology Management

OBJECTIVESnDysphonia due to unilateral vocal fold paralysis (UVFP) can be characterized by hoarseness and weakness, resulting in a significant impact on patients activity and participation. Voice therapy provided by a speech-language pathologist is designed to maximize vocal function and improve quality of life. The purpose of this paper is to systematically review literature surrounding the effectiveness of speech-language pathology intervention for the management of UVFP in adults.nnnSTUDY DESIGNnThis is a systematic review.nnnMETHODSnElectronic databases were searched using a range of key terms including dysphonia, vocal fold paralysis, and speech-language pathology. Eligible articles were extracted and reviewed by the authors for risk of bias, methodology, treatment efficacy, and clinical outcomes.nnnRESULTSnOf the 3311 articles identified, 12 met the inclusion criteria: seven case series and five comparative studies. All 12 studies subjectively reported positive effects following the implementation of voice therapy for UVFP; however, the heterogeneity of participant characteristics, voice therapy, and voice outcome resulted in a low level of evidence.nnnCONCLUSIONSnThere is presently a lack of methodological rigor and clinical efficacy in the speech-language pathology management of dysphonia arising from UVFP in adults. Reasons for this reduced efficacy can be attributed to the following: (1) no standardized speech-language pathology intervention; (2) no consistency of assessment battery; (3) the variable etiology and clinical presentation of UVFP; and (4) inconsistent timing, frequency, and intensity of treatment. Further research is required to develop the evidence for the management of UVFP incorporating controlled treatment protocols and more rigorous clinical methodology.

Evaluating the efficacy of voice therapy for functional, organic and neurological voice disorders.

neurological voice disorders Carding, P.,* Bos-Clark, M., Fu, S., Gillivan-Murphy, P., Jones, S.M. &Walton, C.* *Speech Pathology, AustralianNational Catholic University, Brisbane, Qld, Australia Royal Devon and Exeter NHSTrust andUniversity of ST Mark and St John, Plymouth, UK Department of Audiology and Speech Pathology, MacKay Medical College, New Taipei City, Taiwan Mater Misericordiae University Hospital, Dublin, Ireland University Hospital of South Manchester, Manchester, UK

TOPPITS: Trial Of Proton Pump Inhibitors in Throat Symptoms. Study protocol for a randomised controlled trial

BackgroundPersistent throat symptoms and Extra Oesophageal Reflux (EOR) are among the commonest reasons for attendance at a secondary care throat or voice clinic. There is a growing trend to treat throat symptom patients with proton pump inhibitors (PPIs) to suppress stomach acid, but most controlled studies fail to demonstrate a significant benefit of PPI over placebo. In addition, patient views on PPI use vary widely.Methods/designA UK multi-centre, randomised, controlled trial for adults with persistent throat symptoms to compare the effectiveness of treatment with the proton pump inhibitor (PPI) lansoprazole versus placebo.The trial includes a six-month internal pilot, during which three sites will recruit 30 participants in total, to assess the practicality of the trial and assess the study procedures and willingness of the patient population to participate. If the pilot is successful, three additional sites will be opened to recruitment, and a further 302 participants recruited across the six main trial sites. Further trial sites may be opened, as necessary. The main trial will continue for a further 18 months. Participants will be followed up for 12 months from randomisation, throughout which both primary and secondary outcome data will be collected. The primary outcome is change in Reflux Symptom Index (RSI) score, the ‘area standard’ for this type of assessment, after 16 weeks (four months) of treatment. Secondary outcomes are RSI changes at 12 months after randomisation, Quality of Life assessment at four and 12 months, laryngeal mucosal changes, assessments of compliance and side effects, and patient-reported satisfaction.DiscussionTOPPITS is designed to evaluate the relative effectiveness of treatment with a proton pump inhibitor versus placebo in patients with persistent throat symptoms. This will provide valuable information to clinicians and GPs regarding the treatment and management of care for these patients, on changes in symptoms, and in Quality of Life, over time.Trial registrationISRCTN38578686. Registered 17 April 2014.

Swallowing performance and tube feeding status in patients treated with parotid-sparing intensity-modulated radiotherapy for head and neck cancer.

The purpose of this prospective study was to evaluate the swallowing performance of patients with head and neck cancer treated with parotid‐sparing intensity‐modulated radiotherapy (IMRT).

Does laryngeal reinnervation or type I thyroplasty give better voice results for patients with unilateral vocal fold paralysis (VOCALIST): study protocol for a feasibility randomised controlled trial

Introduction A functioning voice is essential for normal human communication. A good voice requires two moving vocal folds; if one fold is paralysed (unilateral vocal fold paralysis (UVFP)) people suffer from a breathy, weak voice that tires easily and is unable to function normally. UVFP can also result in choking and breathlessness. Current treatment for adults with UVFP is speech therapy to stimulate recovery of vocal fold (VF) motion or function and/or injection of the paralysed VF with a material to move it into a more favourable position for the functioning VF to close against. When these therapies are unsuccessful, or only provide temporary relief, surgery is offered. Two available surgical techniques are: (1) surgical medialisation; placing an implant near the paralysed VF to move it to the middle (thyroplasty) and/or repositioning the cartilage (arytenoid adduction) or (2) restoring the nerve supply to the VF (laryngeal reinnervation). Currently there is limited evidence to determine which surgery should be offered to adults with UVFP. Methods and analysis A feasibility study to test the practicality of running a multicentre, randomised clinical trial of surgery for UVFP, including: (1) a qualitative study to understand the recruitment process and how it operates in clinical centres and (2) a small randomised trial of 30 participants recruited at 3 UK sites comparing non-selective laryngeal reinnervation to type I thyroplasty. Participants will be followed up for 12 months. The primary outcome focuses on recruitment and retention, with secondary outcomes covering voice, swallowing and quality of life. Ethics and dissemination Ethical approval was received from National Research Ethics Service—Committee Bromley (reference 11/LO/0583). In addition to dissemination of results through presentation and publication of peer-reviewed articles, results will be shared with key clinician and patient groups required to develop the future large-scale randomised controlled trial. Trial registration number ISRCTN90201732; 16 December 2015.