Characteristics of Dysphagia in Severe Traumatic Brain Injury Patients: A Comparison With Stroke Patients

OBJECTIVE: To compare the swallowing characteristics of dysphagic patients with traumatic brain injury (TBI) with those of dysphagic stroke patients. METHODS: Forty-one patients with TBI were selected from medical records (between December 2004 to March 2013) and matched to patients with stroke (n=41) based on age, sex, and disease duration. Patients' swallowing characteristics were analyzed retrospectively using a videofluoroscopic swallowing study (VFSS) and compared between both groups. Following thorough review of medical records, patients who had a history of diseases that could affect swallowing function at the time of the study were excluded. Dysphagia characteristics and severity were evaluated using the American Speech-Language-Hearing Association National Outcome Measurement System swallowing scale, clinical dysphagia scale, and the videofluoroscopic dysphagia scale. RESULTS: There was a significant difference in radiological lesion location (p=0.024) between the two groups. The most common VFSS finding was aspiration or penetration, followed by decreased laryngeal elevation and reduced epiglottis inversion. Swallowing function, VFSS findings, or quantified dysphagia severity showed no significant differences between the groups. In a subgroup analysis of TBI patients, the incidence of tube feeding was higher in patients with surgical intervention than in those without (p=0.011). CONCLUSION: The swallowing characteristics of dysphagic patients after TBI were comparable to those of dysphagic stroke patients. Common VFSS findings comprised aspiration or penetration, decreased laryngeal elevation, and reduced epiglottis inversion. Patients who underwent surgical intervention after TBI were at high risk of tube feeding requirement.

Change of Swallowing in Patients With Head and Neck Cancer After Concurrent Chemoradiotherapy

OBJECTIVE: To evaluate the functional characteristics of swallowing and to analyze the parameters of dysphagia in head and neck cancer patients after concurrent chemoradiotherapy (CCRT). METHODS: The medical records of 32 patients with head and neck cancer who were referred for a videofluoroscopic swallowing study from January 2012 to May 2015 were retrospectively reviewed. The patients were allocated by duration after starting CCRT into early phase (1 month after radiation therapy) groups. We measured the modified penetration aspiration scale (MPAS) and American Speech-Language-Hearing Association National Outcome Measurement System swallowing scale (ASHA-NOMS). The oral transit time (OTT), pharyngeal delay time (PDT), and pharyngeal transit time (PTT) were recorded to assess the swallowing physiology. RESULTS: Among 32 cases, 18 cases (56%) were of the early phase. In both groups, the most common tumor site was the hypopharynx (43.75%) with a histologic type of squamous cell carcinoma (75%). PTT was significantly longer in the late phase (p=0.03). With all types of boluses, except for soup, both phases showed a statistically significant difference in MPAS results. The mean ASHA-NOMS level for the early phase was 5.83±0.78 and that for the late phase was 3.79±1.80, with statistical significance (p=0.01). The PTT and ASHA-NOMS level showed a statistically significant correlation (correlation coefficient=–0.52, p=0.02). However, it showed no relationship with the MPAS results. CONCLUSION: The results of our study suggest that in the late phase that after CCRT, the OTT, PDT, and PTT were longer than in the early phase and the PTT prolongation was statistically significant. Therefore, swallowing therapy targeting the pharyngeal phase is recommended after CCRT.

Effects of Cervical Kyphosis on Recovery From Dysphagia After Stroke

OBJECTIVE: To determine the effects of cervical kyphosis on the recovery of swallowing function in subacute stroke patients. METHODS: Baseline and 1-month follow-up videofluoroscopic swallowing studies (VFSSs) of 51 stroke patients were retrospectively analyzed. The patients were divided into the cervical kyphosis (Cobb's angle <20°, n=27) and control (n=24) groups. The penetration-aspiration scale (PAS), American Speech-Language-Hearing Association National Outcomes Measurement System swallowing scale (ASHA NOMS), and videofluoroscopic dysphagia scale (VDS) were used to determine the severity of dysphagia. Finally, the prevalence of abnormal VFSS findings was compared between the two groups. RESULTS: There were no significant differences in baseline PAS, ASHA NOMS, and VDS scores between the two groups. However, the follow-up VDS scores in the cervical kyphosis group were significantly higher than those in the control group (p=0.04), and a follow-up study showed a tendency towards worse ASHA NOMS scores (p=0.07) in the cervical kyphosis group. In addition, the cervical kyphosis group had a higher occurrence of pharyngeal wall coating in both baseline and follow-up studies, as well as increased aspiration in follow-up studies (p<0.05). CONCLUSION: This study showed that stroke patients who had cervical kyphosis at the time of stroke might have impaired recovery from dysphagia after stroke.

A Systematic Approach to Find a Professional Audiology Clinic: Patient-Based Information

This brief communication introduced a systematic way to find a professional audiology clinic developed for patients and professionals by the American Academy of Audiology, American Speech-Language-Hearing Association, and Healthy Hearing. Patients can access each organization's website to find professionals and/or clinics based on criteria such as location, hours, special areas, types of service, reviews and rating by previous patients, and kinds of insurance accepted. Such a system may protect the patients from information overload, guarantee accurate information, and help them find themselves professional audiologists who can assist them. We expect professional organizations to adopt this system as soon as possible and link hearing-impaired patients with professional audiologists in Korea.

Habilidade de ordenação temporal e nível de especificidade nos diferentes testes tonais / Temporal ordering ability and level of specificity at different pure tone tests

RESUMO Objetivo: Avaliar a habilidade de ordenação temporal com diferentes testes, verificar a especificidade desses testes e comparar o resultado com o grau de facilidade/dificuldade relatado pelos sujeitos. Métodos: Os indivíduos realizaram avaliação audiológica básica e Teste Dicótico de Dígitos, para triagem do processamento auditivo, e foram submetidos ao Teste Padrão de Frequência (TPF) e ao Teste Padrão de Duração (TPD), nas versões de Taborga-Lizarro, Musiek e Auditec®, para avaliar a habilidade de Ordenação Temporal. Após, foi apresentada a Escala Visual Analógica (EVA), para que os sujeitos identificassem a dificuldade de cada teste. Resultados: Foram avaliados 33 sujeitos, 29 do gênero feminino e quatro do gênero masculino, com idade entre 17 e 27 anos. Houve maior número de indivíduos que atingiram valores normais no teste Auditec® e de Taborga-Lizarro, para o TPD e TPF. No teste de Musiek, houve um número de sujeitos com resultados normais muito próximos aos de sujeitos com alteração de processamento. Na distribuição do teste mais difícil, houve significância estatística para o teste de Musiek. Quanto à especificidade dos testes, o Auditec® mostrou-se melhor, porém, a análise foi realizada apenas em TPF. Conclusão: Embora os indivíduos não tenham apresentado alteração e queixa de processamento auditivo, houve diferença nos resultados dos testes de ordenação temporal. Quanto ao grau de dificuldade relatado para o teste de Musiek, verificou-se que houve influência deste fator nos resultados dos testes. Na análise de especificidade dos testes, pôde-se observar melhores resultados para o teste Auditec®.

ABSTRACT Purpose: Evaluate temporal ordering ability with different tests, verify the specificity of these tests and compare the result with the level of easiness/difficulty reported by the subjects. Methods: The subjects carried out basic audiological evaluation and Dichotic Digit Test, for auditory processing screening, and they also underwent Frequency Pattern Test (FPT) and Duration Pattern Test (TPD), in the versions of Taborga-Lizarro, Musiek and Auditec®, in order to evaluate the temporal ordering ability. Afterwards, the Visual Analogue Scale (VAS) was presented, so that the subjects could identify the difficulty of each test. Results: A total of 33 subjects were evaluated, being 29 women and four men, aged from 17 to 27 years. There were a higher number of individuals who have reached normal levels in Auditec® test and in Taborga-Lizarro test, for FPT and TPD. In the Musiek test, there were some subjects with normal results very close to the ones observed on subjects with processing disorders. In the distribution of the most difficult test, there was a statistical significance for the Musiek test. In terms of the specificity of the test, Auditec® proved to be better. However, the analysis was performed only on TPD. Conclusion: Although the subjects did not present change and auditory processing complaints, we found difference in the results of temporal ordering tests. In relation to the reported difficulty for Musiek test, we verified that there was influence of this factor on the test results. In the analysis for specificity tests, better results for the Auditec® test could be observed.

Comparison of Swallowing Functions Between Brain Tumor and Stroke Patients

OBJECTIVE: To compare the swallowing functions according to the lesion locations between brain tumor and stroke patients. METHODS: Forty brain tumor patients and the same number of age-, lesion-, and functional status-matching stroke patients were enrolled in this study. Before beginning the swallowing therapy, swallowing function was evaluated in all subjects by videofluoroscopic swallowing study. Brain lesions were classified as either supratentorial or in-fratentorial. We evaluated the following: the American Speech-Language-Hearing Association (ASHA) National Outcome Measurement System (NOMS) swallowing scale, clinical dysphagia scale, functional dysphagia scale (FDS), penetration-aspiration scale (PAS), oral transit time, pharyngeal transit time, the presence of vallecular pouch residue, pyriform sinus residue, laryngopharyngeal incoordination, premature spillage, a decreased swal-lowing reflex, pneumonia, and the feeding method at discharge. RESULTS: The incidence of dysphagia was similar in brain tumor and stroke patients. There were no differences in the results of the various swallowing scales and other parameters between the two groups. When compared brain tumor patients with supratentorial lesions, brain tumor patients with infratentorial lesions showed higher propor-tion of dysphagia (p=0.01), residue (p<0.01), FDS (p<0.01), PAS (p<0.01), and lower ASHA NOMS (p=0.02) at initial evaluation. However, there was no significant difference for the swallowing functions between benign and malig-nant brain tumor patients. CONCLUSION: Swallowing function of brain tumor patients was not different from that of stroke patients according to matching age, location of lesion, and functional status. Similar to the stroke patients, brain tumor patients with infratentorial lesions present poor swallowing functions. However, the type of brain tumor as malignancy does not influence swallowing functions.

The Effectiveness of Oro-Esophageal Tube Feeding with Dysphagia after Brainstem Stroke

OBJECTIVE: To investigate whether intermittent oro-esophageal (OE) tube feeding could improve swallowing function in brainstem stroke patients. METHOD: 23 patients suffering from dysphagia after acute brainstem stroke were enrolled in this study. All patients used nasogastric tubes for feeding. In a prospective, single blinded, randomized case control study conducted between January 2007 and April 2009, 11 patients were randomized to the study group who were fed with OE tube and received traditional swallowing treatment, and 12 patients were randomized to the control group who were fed with nasogastric tube and received traditional swallowing treatment. The effects of each treatment were assessed using functional dysphagia scale (FDS), penetration-aspiration scale (PAS), and American Speech-Language-Hearing Association National Outcome Measurement System (ASHA NOMS). RESULTS: The pretreatment evaluation showed no significant difference between the two groups for all parameters. After treatment, FDS, ASHA NOMS improved in both groups (p<0.05). But, PAS score improved only in the study group (p<0.05). In comparison between two groups, FDS, PAS and ASHA NOMS scores showed significant improvement in study groups (p<0.05) than control groups. CONCLUSION: OE tube can be a possible substitute for nasogastric tube in patients suffering from dysphagia after brainstem stroke. And it suggests that OE tube feeding may be used to facilitate recovery of swallowing function.

Electrical Stimulation of the Suprahyoid Muscles in Brain-injured Patients with Dysphagia: A Pilot Study

OBJECTIVE: To investigate the therapeutic effects of repetitive electrical stimulation of the suprahyoid muscles in brain-injured patients with dysphagia. METHOD: Twenty-eight brain-injured patients who showed reduced laryngeal elevation and supraglottic penetration or subglottic aspiration during a videofluoroscopic swallowing study (VFSS) were selected. The patients received either conventional dysphagia management (CDM) or CDM with repetitive electrical stimulation of the suprahyoid muscles (ESSM) for 4 weeks. The videofluoroscopic dysphagia scale (VDS) using the VFSS and American Speech-Language-Hearing Association National Outcome Measurement System (ASHA NOMS) swallowing scale (ASHA level) was used to determine swallowing function before and after treatment. RESULTS: VDS scores decreased from 29.8 to 17.9 in the ESSM group, and from 29.2 to 16.6 in the CDM group. However, there was no significant difference between the groups (p=0.796). Six patients (85.7%) in the ESSM group and 14 patients (66.7%) in the CDM group showed improvement according to the ASHA level with no significant difference between the ESSM and CDM groups (p=0.633). CONCLUSION: Although repetitive neuromuscular electrical stimulation of the suprahyoid muscles did not further improve the swallowing function of dysphagia patients with reduced laryngeal elevation, more patients in the ESSM group showed improvement in the ASHA level than those in the CDM group. Further studies with concurrent controls and a larger sample group are required to fully establish the effects of repetitive neuromuscular electrical stimulation of the suprahyoid muscles in dysphagia patients.

Clinical Factors Associated with Severity of Post-stroke Dysphagia

OBJECTIVE: To describe factors associated with the severity of post-stroke dysphagia. METHODS: We reviewed retrospectively medical records of patients having dysphagia following stroke in Seoul National University hospital from April 2002 through Dec 2009. A total of 578 patients (male and female, 331 and 247) were included. The following parameters were recorded and analyzed: patient's sex, age, type of stroke, onset of dysphagia, location of lesion and the American Speech-Language-Hearing Association National Outcome Measurement System Swallowing Scale (ASHA NOMS). Using Binary logistic regression and multiple regression analysis, the relationship between dysphagia severity and other factors were analyzed. RESULTS: Their average duration between onset of stroke and the date of videofluoroscopic swallowing study (VFSS) was 32.3 +/- 18.4 days. Patients with hemorrhagic stroke (172 patients, ASHA 4.06 +/- 1.98) showed poorer swallowing function than those with ischemic stroke (406 patients, ASHA 4.49 +/- 2.02, p=0.013). Binary logistic regression analysis showed that patients who had longer duration from onset to the first study, hemorrhagic stroke, bilateral lesion and older age were at higher risk for dysphagia requiring non-oral supplements (p=0.031, 0.039, 0.042, and 0.043, respectively). Multiple regression analysis revealed that longer duration from onset to study, older age and hemorrhagic stroke were associated with the lower ASHA NOMS (p=0.006, 0.009 and 0.021, respectively). Bilateral lesion, sex, history of previous stroke and involvement of the brainstem, however, were not significant factors. CONCLUSION: Hemorrhagic stroke, longer duration from stroke onset to the initial evaluation, and older age were identified as associated factors with the poorer swallowing function after stroke. Further prospective studies will be required to evaluate the prognostic value of these characteristics.

Validation of Clinical Dysphagia Scale: Based on Videofluoroscopic Swallowing Study

OBJECTIVE: Dysphagia is one of the important determinants of the prognosis for various diseases. Clinical dysphagia scale (CDS) was developed to screen dysphagia after stroke. We aimed to reevaluate this scale with comparison to the videofluoroscopic swallowing study (VFSS) findings. METHOD: Retrospective chart reviews were completed on 677 dysphagic patients undergoing the VFSS from July 2000 to January 2004. CDS was evaluated by a physiatrist before the VFSS. Functional dysphagia scale, new VFSS scale, and American Speech-Language-Hearing Association National Outcome Measurement System swallowing scale (ASHA NOMS scale) were evaluated based on the VFSS. The correlations between CDS and these VFSS scales were studied. In 118 patients, followed up for more than 6 months, the initial CDS were analysed with the follow-up VFSS findings. RESULTS: CDS was correlated with the VFSS findings and also correlated in disease groups other than stroke (p<0.05). CDS was different significantly between the aspiration, penetration, and normal group classified on the simultaneous VFSS but not on the VFSS after more than 6 months (p= 0.102). CONCLUSION: We confirmed that CDS was a quantitative clinical tool responding the VFSS findings well and was adoptable to any dysphagic patients irrespective of the causal disorders.