Fiberoptic endoscopic evaluation of swallowing (FEES) in pediatrics: A systematic review.

OBJECTIVES: The systematic review aimed to provide an overview of the state-of-art regarding the use of fiberoptic endoscopic evaluation of swallowing (FEES) in pediatrics, specifically investigating FEES feasibility, safety, diagnostic accuracy, and protocols. METHODS: Four electronic databases were searched for original studies on the pediatric population that instrumentally assessed swallowing function using FEES. A hand-search of the references of included studies was performed. Data on the population, feasibility of endoscope insertion and bolus trials, adverse events, sensitivity and specificity, and FEES equipment and protocol were extracted. The quality of the studies was assessed using the checklists of the Johanna Briggs Institute. Selection of the studies, data extraction, and quality appraisal were conducted by two independent researchers. RESULTS: Eighty-two reports from 81 studies were included. The mean overall quality of the studies was 80 % (17-100 %). The feasibility of endoscope insertion was high (89%-100 %), while the feasibility of bolus trials varied from 40 % to 100 %. Adverse events were excessive crying (8 studies), irritability or agitation (4 studies), transitory oxygen desaturations (3 studies, 1.2-6.7 % of the patients), epistaxis (3 studies, 0.8-3.3 % of the patients), increased heart rate (1 study, 1 patient), vomiting (1 study, 1 patient), hypertonia (1 study), and hypersalivation (1 study). No major complications were reported. Using VFSS as the reference standard, FEES was generally found to be less sensitive (25-94 %) but more specific (75-100 %) for aspiration, whereas the reverse was true for penetration (sensitivity 76-100 %, specificity 44-83 %). FEES protocols were highly heterogeneous with poor reporting. CONCLUSION: FEES is a safe, accurate, and generally feasible examination in the pediatric population with suspected dysphagia. However, a consensus on the best FEES protocol for clinical practice and research is currently lacking.

Pharyngeal Residue Scoring in Fiberoptic Endoscopic Evaluation of Swallowing: Reliability Comparison and Applicability Among Different Scales.

Several scales to assess pharyngeal residue in Fiberoptic Endoscopic Evaluation of Swallowing (FEES) are currently available. The study aimed to compare the reliability and the applicability in real clinical practice among four rating scales: the Pooling Score (P-SCORE), the Boston Residue and Clearance Scale (BRACS), the Yale Pharyngeal Residue Severity Rating Scale (YPRSRS), and the Residue Ordinal Rating Scale (RORS). Twenty-five FEES videos were evaluated four times, once for each scale, by four speech and language pathologists. To test intra-rater reliability, the same raters re-assessed the videos two weeks apart. To test the applicability, raters recorded the time required to complete each assessment and the perceived difficulty/ease on a visual-analog scale (VAS). The intra-rater and the inter-rater reliability were calculated with Cohen's weighted Kappa and the Fleiss weighted Kappa, respectively. Time and perceived difficulty/ease scores were compared. The intra-rater reliability analysis showed almost perfect agreement for YPRSRS (k = 0.91) and RORS (k = 0.83) and substantial agreement for P-SCORE (k = 0.76) and BRACS (k = 0.74). Pairwise comparison showed no significant differences among the scales. The inter-rater reliability for the YPRSRS (k = 0.78) was significantly higher than P-SCORE (k = 0.52, p < 0.001), BRACS (k = 0.56, p < 0.001), and RORS (k = 0.65, p = 0.005). The BRACS required the longest time (p < 0.001) and was perceived as the most difficult scale (p < 0.001). The RORS was perceived as the easiest scale (p < 0.05). In conclusion, the YPRSRS showed the highest reliability, while raters perceived the RORS as the easiest to score. These results will allow clinicians to consciously choose which scale to use in clinical practice.

The Test of Masticating and Swallowing Solids (TOMASS): Reliability and validity in patients with dysphagia.

BACKGROUND: The Test of Masticating and Swallowing Solids (TOMASS) is an international standardized swallowing assessment tool. However, its psychometric characteristics have not been analysed in patients with dysphagia. AIMS: To analyse TOMASS's (1) inter- and intra-rater reliability in a clinical population of patients with dysphagia, (2) known-group validity, (3) concurrent validity and (4) correlation with meal duration. METHODS & PROCEDURES: Two age- and gender-matched groups of 39 participants each were recruited: A group of patients with dysphagia and a control group with no history of dysphagia. The TOMASS was carried out in both populations, video-recorded and scored offline by two speech and language therapists (SLT 1 and SLT 2) (inter-rater reliability) and twice by the same SLT (intra-rater reliability). In the clinical group, the TOMASS was carried out three times: (1) to verify understanding of the required tasks, (2) performed concurrently during fibreoptic endoscopic evaluation of swallowing (FEES) to assess validity and (3) during clinical assessment to assess reliability. TOMASS under endoscopic control was recorded and the number of white-out events was counted to compare with the number of observed swallows per cracker during standard TOMASS as a measure of concurrent validity. As additional measures of TOMASS validity, oral dental status, classified as 'functional' or 'partially functional', and duration of a standard meal were assessed by an SLT (SLT 1 or SLT 2), and then correlated with TOMASS. OUTCOME & RESULTS: TOMASS's inter- and intra-rater reliability were high (intraclass correlation coefficient (ICC) > 0.95) in both the clinical and the control groups. The number of masticatory cycles (p = 0.020), swallows (p = 0.013) and total time (p = 0.003) of TOMASS were significantly lower in the control group than in the clinical group. Patients with 'partially functional' oral dental status showed a significantly higher number of masticatory cycles per cracker and a longer duration of ingestion than patients with a 'functional' one. Concurrent validity suggested a substantial agreement between TOMASS and FEES in defining the number of swallows per cracker. The mean difference of the two measures was -0.02 (95% confidence interval (CI) = -1.7 to 1.2). Meal duration significantly correlated with the 'number of swallows per cracker' (r = 0.49; p = 0.002) and 'total time' (r = 0.41; p = 0.011). CONCLUSIONS & IMPLICATIONS: Preliminary psychometric analysis of TOMASS in a clinical sample of outpatients with dysphagia suggests that it is a reliable and valid (specifically related to the number of swallows per cracker) tool. TOMASS's application in clinical practice to quantitatively measure solid bolus ingestion is recommended. What this paper adds What is already known on the subject The Test of Masticating and Swallowing Solids (TOMASS) is an international standardized swallowing assessment tool to evaluate oral preparation and oral phase of solids. The TOMASS' reliability and validity were tested on healthy subjects and normative data were gained. What this paper adds to existing knowledge The study provides the first data on the validity and reliability of the TOMASS in a clinical population. The TOMASS was proved to be a reliable and valid tool also in patients with dysphagia and to distinguish between patients with dysphagia and healthy subjects. What are the potential or actual clinical implications of this work? The use of the TOMASS in clinical practice is recommended as a valid and reliable tool to quantitatively measure the ingestion of solid in patients with dysphagia.

Psychometric properties of the Italian version of the Speech Handicap Index.

OBJECTIVE: Speech impairment is common in patients affected by head and neck cancer and impact on quality of life. Therefore, specific instruments are required for its evaluation. The aim of this study is to evaluate the psychometric properties of the Italian Speech Handicap Index. METHODS: Data were obtained from 50 patients and 75 asymptomatic subjects. The study consisted of five phases: (1) item generation, (2) internal consistency and reliability analysis, (3) normative data generation, (4) validity analysis, performed by comparing the Italian Speech Handicap Index scores obtained in patients and asymptomatic subjects, and by correlating its scores with the results of the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Head and Neck Module, and (5) cut-off value. RESULTS: Internal consistency was good (Cronbach α = 0.9) and the test-retest reliability was strong. A significant difference in Italian Speech Handicap Index total score between patients and asymptomatic subjects was found. Moderate correlations between the two questionnaires were observed. A cut-off value of 14.5 demonstrated a sensitivity of 96% and a specificity of 100%. CONCLUSION: The Italian Speech Handicap Index is a reliable and valid clinical tool. Its application in everyday practice and outcome research is recommended.IMPLICATIONS FOR REHABILITATIONRehabilitation of speech in head and neck cancer patients is frequently needed, especially after surgical treatment.Speech impairment represents one of the most essential factors influencing the quality of life in head and neck cancer patients.The evaluation of the speech impairment should be performed using dedicated assessment tools.

Impact of Oral Myofunctional Therapy on Orofacial Myofunctional Status and Tongue Strength in Patients with Tongue Thrust.

INTRODUCTION: Tongue thrust is a frequent clinical condition characterized by abnormal patterns of movements and altered tongue posture on the mouth floor. It might contribute to determining alterations in the maxillofacial morphology and in the development of malocclusion. Several therapeutic options are available for treatment. In particular, the orofacial myofunctional therapy (OMT) is frequently adopted even if only few studies have analyzed its efficacy using validated instruments and no information is available regarding the effect of dentition on the results obtained with OMT. OBJECTIVE: To evaluate the effect of OMT through a validated instrument and explore the role of dentition on its efficacy. METHODS: A total of 22 consecutive patients with tongue thrust were enrolled. According to the presence of mixed or complete dentition, the cohort of patients was divided into 2 groups. Each patient underwent OMT according to the Garliner method (10 weekly sessions of 45 min each in hospital and daily exercises at home). The efficacy of OMT was evaluated using the Orofacial Myofunctional Evaluation with Scores (OMES), a validated protocol developed for the assessment of orofacial myofunctional disorders, and the Iowa Oral Performance Instrument (IOPI) to measure the peak isometric pressure exerted by the anterior and posterior part of the tongue. Both OMES and IOPI were administered before and at the end of the treatment. RESULTS: A significant improvement in the OMES scores was demonstrated after OMT. No significant differences between the patients with intermediate and mixed dentition obtained in both the pre- and post-treatment conditions were demonstrated in the OMES scores. Similarly, a significant increase in the peak isometric tongue pressure in both the anterior and posterior parts of the tongue was demonstrated after OMT in the groups. No differences between the two groups in both the pre- and post-treatment conditions were demonstrated in the IOPI scores. CONCLUSIONS: OMT improves orofacial motricity and tongue strength in patients with tongue thrust regardless of the type of dentition.

The Mealtime Assessment Scale (MAS): Part 2 - Preliminary Psychometric Analysis.

AIMS: The Mealtime Assessment Scale (MAS) was developed to assess swallowing safety and efficacy during the meal. The study aims to perform a preliminary validation of MAS by investigating internal consistency, inter-rater agreement, concurrent and known-group validity, and responsiveness. METHODS: MAS was tested on 100 persons without dysphagia (group 1) and 100 persons with dysphagia (group 2). Fifty subjects were simultaneously evaluated at mealtime using MAS by two independent clinicians to test inter-rater agreement. For concurrent validity, MAS was correlated with the Mann Assessment of Swallowing Ability (MASA) and American Speech-Language-Hearing Association National Outcomes Measurement System (ASHA NOMS) swallowing scale. MAS scores of groups 1 and 2 were compared for known-group validity. Responsiveness was tested reassessing 36 patients from group 2 after diet improvement. RESULTS: Internal consistency and responsiveness were established for efficacy but not for safety. For inter-rater agreement, an average deviation index <0.66 was found for all items. MAS showed strong correlations with MASA and ASHA NOMS. MAS scores were significantly different between groups 1 and 2. CONCLUSION: Preliminary evidence of the validity and reliability of MAS was established, except for the internal consistency and the responsiveness of the safety subscale. Further studies need to complete the validation process.

An articulatory-based disyllabic and trisyllabic Non-Word Repetition test: reliability and validity in Italian 3- to 7-year-old children.

The contribution of the phonological working memory to the Non-Word Repetition (NWR) task is well established, but growing evidence also suggests a valuable underlying role of oro-motor abilities. Assuming that NWR involves output implementation mediated by the speech motor system, the study aimed to develop a novel Italian NWR task of disyllabic and trisyllabic items. The task, for the first time, was composed using each Italian speech sound. The study also aimed to investigate the reliability proprieties of the task (test-retest, intra-rater, inter-rater), internal consistency, concurrent and construct validity, and to collect normative data for pre-school children. An observational cross-sectional study was conducted and 375 Italian-speaking typically developing children aged 3.0-6.11 years were assessed with the novel test. Two raters assessed inter-rater reliability in a random sub-sample; test-retest reliability was examined through a repeated administration of the task two weeks apart; intra-rater reliability was investigated by two evaluations of the same audio-recordings. To evaluate concurrent validity children were also assessed through a pre-existing NWR test, and to estimate construct validity, scores from children of different age groups were compared. Results indicated excellent test-retest, intra-rater, inter-rater reliability agreement, high internal consistency and good concurrent validity. Normative data suggested that successful performance on NWR increases with age and declines with an increase in stimuli length. Despite the low working memory load in the disyllabic and trisyllabic items, a saturation of the task was not observed for any age group. The novel NWR test is a reliable and valid instrument, and it can be applied in clinical practice to assess how the child retains, plans and articulates a phonological and motor programme of unknown verbal material.

Functional fat injection under local anesthesia to treat severe postsurgical dysphagia, case report.

BACKGROUND: In this study, we present the first application of functional fat injection performed under local anesthesia in the treatment of severe dysphagia secondary to head and neck cancer surgery. METHODS: Functional fat injection was performed using a transcervical approach. Control of injection depth and site was performed through a transnasal flexible endoscope. The effect of surgery was evaluated through videofluoroscopy (VFS), Fiberendoscopic Evaluation of Swallowing (FEES), Functional Oral Intake Scale (FOIS), and Eating Assessment Tool-10 (EAT-10). RESULTS: Before the functional fat injection, the patient was dependent on permanent tube feeding; the VFS and FEES revealed a severe impairment of swallowing abilities. The EAT-10 scored 26. Twelve months after surgery, the patient was on oral diet, the VFS demonstrated mild to moderate dysphagia, the FEES demonstrated aspiration only with liquids and the EAT-10 improved. CONCLUSION: Functional fat injection under local anesthesia could be useful in the treatment of chronic dysphagia in selected patients.

Normative and validation data of an articulation test for Italian-speaking children.

OBJECTIVES: As a standardized instrument to assess speech sound development in Italian-speaking children is currently lacking, norms used to diagnose speech sound disorders (SSD) are mainly based on studies including English-speaking participants. This application may result in misidentification of SSD due to linguistic differences. The aims of the study were to establish normative data on speech sound development of Italian-speaking children and to evaluate psychometric properties of Rossi's articulation test, the picture-naming test selected to assess speech sound development. METHODS: A cross-sectional study including 694 normally-developing Italian-speaking children aged from 3 to 7 years was conducted. Children were administered Rossi's articulation test, and percentages of speech sound correct production were calculated. To evaluate inter-rater reliability of the test, audio-recordings of 50 children were scored by an additional examiner. The same rater scored the audio-recordings of 50 children twice with an interval of at least 1 week. To evaluate test-retest reliability, 144 participants were re-tested after 1-3 weeks by the same assessor. Scores were compared through Intraclass Correlation Coefficient (ICC). To assess construct validity, the developmental progression of total scores across age groups was verified by the estimation of the reference range for the test, using a regression procedure. RESULTS: Almost all Italian children in the sample produced vowels and approximants correctly. Singleton consonants were acquired before consonant clusters. Ages of acquisition of each consonant were presented: plosives and nasals were early mastered by Italian children, while dental affricates, alveolar fricatives and the palatal lateral were the latest acquired segments. All ICCs were superior to 0.9 (reliability). A statistically significant improvement in test score with age was found (construct validity). CONCLUSIONS: The paper provides normative data for speech sound development of Italian-speaking children; preliminary psychometric analysis of Rossi's articulation test revealed satisfactory reliability and construct validity. Clinicians are recommended to use Rossi's articulation test to assess speech sound development in Italian children.

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.

The Relationship between Socioeconomic Status and Narrative Abilities in a Group of Italian Normally Developing Children.

OBJECTIVE: Only limited and conflicting information is available regarding the relationship between socioeconomic status (SES) and narrative abilities. Besides, the role fathers' SES plays in the development of their children's narrative abilities has never been investigated. The aim of this study was to analyze the relationship between fathers' and mothers' SES and narrative abilities of their children assessed with the Italian version of the Bus Story Test (I-BST). SUBJECTS AND METHODS: A total of 505 normally developing Italian children were enrolled in the study. Information regarding parents' educational level and employment was collected for each child. Narrative abilities were evaluated using the I-BST. The relationships between parents' employment, educational level, and I-BST scores were analyzed by univariate and multivariate regression analysis. RESULTS: In univariate analysis, both fathers' and mothers' education and employment were associated with most I-BST subscale scores, especially when higher educational and employment levels were contrasted with the lowest educational and employment levels. In multiple regression analysis, significant associations were found only between the fathers' working status and educational level and I-BST subscale scores. CONCLUSIONS: Parental education and employment might impact narrative abilities of children. When both fathers' and mothers' SES variables are considered together, only fathers' education and working status seemed to be associated with I-BST scores.

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.

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.