Surgical Treatment of Acquired Velopharyngeal Insufficiency in Adults With Dysphagia and Dysphonia.

OBJECTIVES: Velopharyngeal insufficiency (VPI) is a form of velopharyngeal dysfunction caused by abnormal or insufficient anatomy. This process is known to be associated with dysphagia and dysphonia but surgical interventions for these complex patients have not been well studied. The current study characterized a small cohort of adult patients with acquired VPI, dysphonia, and dysphagia, as well as associated surgical interventions. METHODS: A retrospective descriptive case series of 22 (N = 22) adult patients over a 6-year period with acquired VPI and varying degrees of dysphagia and dysphonia was described from a multi-disciplinary voice and swallowing clinic. Perceptual assessment, nasopharyngoscopy, fluoroscopic swallowing assessment, and patient reported outcomes were reviewed to characterize the cohort. RESULTS: VPI etiologies included: stroke (n = 4), head and neck cancer (n = 5), brainstem lesions (n = 5), trauma (n = 5), and other/unknown (n = 3). All 22 patients underwent nasopharyngoscopy and were categorized as having unilateral (n = 13), central (n = 4), or no (n = 5) velopharyngeal deficits. Seventeen patients (77.2%) underwent modified barium swallow studies, revealing that soft palate elevation scored least impaired among patients with no VPI, and most impaired among patients with unilateral VPI deficits. All 22 patients underwent some form of surgical intervention for VPI, with 14 (63.6%) of those patients requiring additional surgical revision. CONCLUSION: This series is one of the first to the authors' knowledge to characterize a cohort of individuals with VPI, dysphagia, and dysphonia and associated surgical interventions.

Chest wall kinematics during speech breathing in tracheoesophageal speakers.

OBJECTIVES: The purpose of the present study was to determine how tracheoesophageal (TE) speakers manipulate the chest wall (rib cage and abdomen) to speak and how respiratory compromise (chronic obstructive pulmonary disease; COPD) and task variables influence those behaviors. METHODS: The chest wall movements of 11 male TE speakers (5 with COPD and 6 without COPD) were measured during tidal breathing, spontaneous speech, and reading. Repeated-measures multivariate analyses were used to compare breathing behaviors across speech tasks and by respiratory health. Additional repeated-measures multivariate analyses and 1-way analyses of variance were conducted on temporal, aerodynamic, and linguistic measures. RESULTS: There was a significant main effect of task and a significant interaction effect of COPD and task on chest wall movements. Rib cage movements varied by task, whereas abdominal movements were as predicted. There was a significant difference in utterance length by task. There were no main effects of COPD on the chest wall and no significant group differences in utterance length, aerodynamic measures, or intelligibility. The TE speakers were generally accurate in inspiring at appropriate linguistic boundaries. CONCLUSIONS: The results suggest that there is robust control for speech breathing following laryngectomy, but that there is also increased effort within the chest wall. Implications for future research considerations are discussed.

Lung volumes used during speech breathing in tracheoesophageal speakers.

OBJECTIVES: The purpose of this study was to determine how tracheoesophageal (TE) speakers manipulate lung volumes to meet speech demands and how respiratory compromise (chronic obstructive pulmonary disease [COPD]) and task variables influence these behaviors. METHODS: The lung volumes of 9 male TE speakers (4 with COPD, 5 without) during tidal breathing, spontaneous speech, and reading were investigated. Repeated-measures multivariate analyses of variance were used to compare lung volumes and utterance length across speech tasks and by respiratory health. A one-way analysis of variance was used to compare aerodynamic measures and intelligibility by COPD diagnosis. RESULTS: There was a significant main effect of task and a significant interaction effect of COPD and task on lung volumes at initiation and termination of speech. The TE speakers terminated speech exclusively below the resting expiratory level (REL) in both speech tasks because of elevated RELs, which are often present after laryngectomy. There were no main effects of COPD on any lung volume measures and no significant group differences in utterance length, aerodynamic measures, or intelligibility. CONCLUSIONS: Intelligibility and aerodynamic measures were not influenced by lung volumes and were comparable to findings of previous research. Speaking past the REL might be a compensation to optimize expiratory control for speech in a compromised system and a marker for the increased effort often anecdotally described by TE speakers.

Relation of mucous membrane alterations to oral intake during the first year after treatment for head and neck cancer.

BACKGROUND: Acute oral mucositis is associated with pain and impaired swallowing. Little information is available on the effects of chronic mucositis on swallowing. METHODS: Sixty patients treated for cancer of the head and neck were examined during the first year after their cancer treatment. Oral mucosa was rated with the Oral Mucositis Assessment Scale. Stimulated whole-mouth saliva, oral pain rating, percent of oral intake, and 2 subscales of the Performance Status Scale for Head and Neck (PSS-HN) cancer were also collected. RESULTS: Mucositis scores and pain ratings decreased over time while functional measures of eating improved over time. Reduction in chronic mucositis was correlated with improved oral intake and diet. CONCLUSION: Lack of association with pain was attributed to the absence of ulcerations. Continued impairment of oral intake during the first year posttreatment may be related to oral mucosal changes and other factors.

Establishing validity of the Consensus Auditory-Perceptual Evaluation of Voice (CAPE-V).

PURPOSE: The Consensus Auditory-Perceptual Evaluation of Voice (CAPE-V) was developed to provide a protocol and form for clinicians to use when assessing the voice quality of adults with voice disorders (Kempster, Gerratt, Verdolini Abbott, Barkmeier-Kramer, & Hillman, 2009). This study examined the reliability and the empirical validity of the CAPE-V when used by experienced voice clinicians judging normal and disordered voices. METHOD: The validity of the CAPE-V was examined in 2 ways. First, we compared judgments made by 21 raters of 22 normal and 37 disordered voices using the CAPE-V and the GRBAS (grade, roughness, breathiness, asthenia, strain; see Hirano, 1981) scales. Second, we compared our raters' judgments of overall severity to a priori consensus judgments of severity for the 59 voices. RESULTS: Intrarater reliability coefficients for the CAPE-V ranged from .82 for breathiness to .35 for strain; interrater reliability ranged from .76 for overall severity to .28 for pitch. CONCLUSIONS: Although both CAPE-V and GRBAS reliability coefficients varied across raters and parameters, this study reports slightly improved rater reliability using the CAPE-V to make perceptual judgments of voice quality in comparison to the GRBAS scale. The results provide evidence for the empirical (concurrent) validity of the CAPE-V.

What information do clinicians use in recommending oral versus nonoral feeding in oropharyngeal dysphagic patients?

There is little evidence regarding the type(s) of information clinicians use to make the recommendation for oral or nonoral feeding in patients with oropharyngeal dysphagia. This study represents a first step toward identifying data used by clinicians to make this recommendation and how clinical experience may affect the recommendation. Thirteen variables were considered critical in making the oral vs. nonoral decision by the 23 clinicians working in dysphagia. These variables were then used by the clinicians to independently recommend oral vs. nonoral feeding or partial oral with nonoral feeding for the 20 anonymous patients whose modified barium swallows were sent on a videotape to each clinician. Clinicians also received data on the 13 variables for each patient. Results of clinician agreement on the recommendation of full oral and nonoral only were quite high, as measured by Kappa statistics. In an analysis of which of the 13 criteria clinicians used in making their recommendations, amount of aspiration was the criterion with the highest frequency. Recommendations for use of postures and maneuvers and the effect of clinician experience on these choices were also analyzed.

Reliability of speech-language pathologist and otolaryngologist ratings of laryngeal signs of reflux in an asymptomatic population using the reflux finding score.

OBJECTIVE: To determine inter- and intrajudge agreement in rating signs of laryngopharyngeal reflux (LPR) under "ideal" conditions: Experienced coworkers in a practice devoted to voice-disordered patients, raters trained in the items on a standardized scale, raters from both speech-language pathology (SLP) and otolaryngology, and raters of asymptomatic participants. STUDY DESIGN: Prospective study using a scale to rate videolaryngoscopic examinations. METHODS: Two SLPs and two otolaryngologists used the Reflux Finding Scale (RFS) to independently rate videotapes of endoscopic examinations for 30 participants asymptomatic of reflux. RESULTS: Thirteen (43%) were assigned a total score >7, indicative of LPR, by at least one rater. Intraclass correlation coefficients showed a significant lack of agreement in total scores provided by the otolaryngologists and by all raters combined. One otolaryngologist and the two SLPs demonstrated good interrater agreement in total scores. McNamar's statistic and Poisson regression modeling showed differences in rater agreement for many individual items. Repeated ratings of four participants showed no significant differences, indicating good intrarater reliability. CONCLUSIONS: Level of rater agreement regarding the presence and the severity of physical findings attributed to LPR within and between otolaryngologists and SLPs differed. Given the role each profession plays in the diagnosis and treatment of LPR and related voice disturbances, higher levels of interprofessional agreement are desired. Results support the need for greater consensus among professionals regarding the discreet features of physical findings associated with LPR, a fuller understanding of normal variants, and greater emphasis on interrater reliability when rating physical findings.

Paradoxical Vocal-Cord Dysfunction: Management in Athletes.

OBJECTIVE: To describe a treatment strategy for paradoxical vocal-cord dysfunction (PVCD) as it applies to an athletic population. BACKGROUND: Paradoxical vocal-cord dysfunction has been identified as a cause of dyspnea and stridor in athletes. The basic element of PVCD is an inappropriate closure of the vocal cords during respiration, resulting in airway obstruction. This condition is familiar to speech-language pathologists and otolaryngologists yet remains poorly understood in the sports medicine community. Treatment strategies are even less understood. A therapeutic exercise program designed to promote diaphragmatic breathing may allow an athlete to gain control during episodes of dyspnea. Elimination of contributing or concomitant conditions is critical to resolution of the condition. DESCRIPTION: The treatment of PVCD requires an understanding of the pathoanatomy of the condition. The focus of the exercise program is on relaxation of the larynx and conscious activation of the diaphragm and abdominal muscles during respiration. The athlete must have a sense of laryngeal control while performing the exercises. In addition, the patient and practitioner must realize the amount of neuromuscular reeducation required to change breathing patterns. CLINICAL ADVANTAGES: This therapy may allow the athlete to gain control over episodic dyspnea, participate in athletic activities with fewer complications, and, perhaps, reduce or eliminate medications prescribed to treat suspected bronchospasm.