Feasibility study of the Nox-T3 device to detect swallowing and respiration pattern in neurologically impaired patients in the acute phase.

Dysphagia is a frequent complication in neurologically impaired patients, which can lead to aspiration pneumonia and thus prolonged hospitalization or even death. It is essential therefore, to detect and assess dysphagia early for best patient care. Fiberoptic endoscopic and Videofluoroscopy evaluation of swallowing are the gold standard exams in swallowing studies but neither are perfectly suitable for patients with disorders of consciousness (DOC). In this study, we aimed to find the sensitivity and specificity of the Nox-T3 sleep monitor for detection of swallowing. A combination of submental and peri-laryngeal surface electromyography, nasal cannulas and respiratory inductance plethysmography belts connected to Nox-T 3 allows recording swallowing events and their coordination with breathing, providing time-coordinated patterns of muscular and respiratory activity. We compared Nox-T3 swallowing capture to manual swallowing detection on fourteen DOC patients. The Nox-T3 method identified swallow events with a sensitivity of 95% and a specificity of 99%. In addition, Nox-T3 has qualitative contributions, such as visualization of the swallowing apnea in the respiratory cycle which provide additional information on the swallowing act that is useful to clinicians in the management and rehabilitation of the patient. These results suggest that Nox-T3 could be used for swallowing detection in DOC patients and support its continued clinical use for swallowing disorder investigation.

Discrimination and Risky Sexual Behavior, Substance Use, and Suicidality among Transgender Individuals.

Transgender identities are becoming increasingly common in the United States, and existing research provides ample evidence that risky sexual behaviors, substance use, and suicidality are prevalent experiences among transgender persons. Yet, prior research provides little insight into understanding the specific mechanisms that may promote deviant outcomes among transgender persons. Drawing from an aspect of general strain theory, the goal of this study is to examine the extent to which transwomen and transmen vary in risky sexual behaviors, substance use, and suicidality, and to explore the degree to which discrimination - as a source of strain - plays a role within this process. An analysis of data from transgender individuals from the Virginia Transgender Health Initiative Study (THIS) demonstrates that transwomen and transmen significantly diverge in self-reported risky sexual behaviors, substance use, and suicidality. Greater discrimination based on transgender identity relates to significantly increased odds of suicidality and elevated levels of substance use, but does not relate to risky sexual behavior. Overall, effects of discrimination on each outcome are similar for both transwomen and transmen.

[COVID-related ENT affections: acute management and issues of rehabilitation strategy]. / Atteintes ORL liées au Covid : prise en charge aiguë et enjeux de la stratégie rééducative.

The ENT specialist manages patients with SARS-CoV-2 infection in the acute phase as well as in the long-term sequelae. Acute management includes evaluation of patients with prolonged orotracheal intubation, surgical tracheostomies and monitoring of their weaning as well as airway assessment. Long-term sequelae include olfactory disorders, upper airway damage, laryngeal damage and their functional consequences : dyspnea, dysphonia and dysphagia. ENT symptoms after SARS-CoV-2 infection have an impact on patients' morbidity and quality of life. We created an ENT Task Force at the CHUV to better organize medical management. This article summarizes the main points.

Le spécialiste ORL prend en charge les patients avec infection due au SARS-CoV-2, en aigu mais aussi dans le cadre des séquelles à long terme. La prise en charge aiguë comprend l'évaluation des patients avec intubation orotrachéale prolongée, la réalisation de trachéotomies et le suivi de leur sevrage ainsi qu'un bilan des voies aériennes. Les séquelles à long terme comprennent les troubles olfactifs et du goût, les lésions des voies aériennes supérieures, les atteintes laryngées et leurs conséquences fonctionnelles : dyspnée, dysphonie et dysphagie. Les symptômes ORL liés au SARS-CoV-2 ont un impact sur la morbidité et la qualité de vie des patients. Une Task Force ORL a été créée au sein du CHUV pour mieux coordonner la prise en charge. Cet article en résume les principaux axes.

[Physiopathology and treatment of cough: an etiological approach]. / Physiopathologie et traitement de la toux†: approche étiologique.

Chronic cough is a common symptom in the consultation of any general practitioner. It may be idiopathic or reflect a chronic disease. However, cough can become excessive, occurring in response to stimuli that do not usually cause this symptom. This entity is called Cough hypersensitivity syndrome (CHS). Its treatment involves the use of neuromodulator substances that specifically target this hypersensitivity, while maintaining intact the cough reflex, essential for protecting the airways. This review aims to present the current knowledge about the pathophysiology of chronic cough, the initial diagnostic approach that this symptom requires and cough treatments either available or in development.

La toux chronique est un symptôme fréquent dans la consultation de tout médecin généraliste. Elle peut être idiopathique ou refléter une maladie chronique. La toux peut aussi devenir excessive, survenant en réponse à des stimuli qui n'occasionnent pas de toux à l'état normal. Cette entité est désignée comme syndrome d'hypersensibilité à la toux. Son traitement implique l'utilisation de substances neuromodulatrices qui ciblent spécifiquement cette hypersensibilité, tout en maintenant intact le réflexe de toux, essentiel à la protection des voies aériennes. Cet article vise à présenter les connaissances actuelles sur la physiopathologie de la toux chronique, la démarche diagnostique initiale que ce symptôme nécessite et les traitements antitussifs disponibles ou en développement.

Predictive Factors of Swallowing Disorders and Bronchopneumonia in Acute Ischemic Stroke.

BACKGROUND: In stroke patients, early complications such as swallowing disorders (SD) and bronchopneumonia (BP) are frequent and may worsen outcome. The aim of this study was to evaluate the prevalence of SD in acute ischemic stroke (AIS) and the risk of BP, as well as to identify factors associated with these conditions. METHODS: We retrospectively studied all AISs over a 12-month period in a single-center registry. We determined the frequency of SD in the first 7 days and of BP over the entire hospital stay. Associations of SD and BP with patient characteristics, stroke features, dental status, and presence of a feeding tube were analyzed in multivariate analyses. RESULTS: In the 340 consecutive patients, the overall frequency of SD and BP was 23.8% and 11.5%, respectively. The multivariate analyses showed significant associations of SD with NIHSS scores >4, involvement of the medulla oblongata and wearing a dental prosthesis (area under the receiver-operator curve (AUC) of 76%). BP was significantly associated with NIHSS scores >4, male sex, bilateral cerebral lesions, the presence of SD, and the use of an enteral feeding tube (AUC 84%). In unadjusted analysis, unfavorable 12-month outcome and mortality were increased in the presence of SD. CONCLUSION: In AIS, SD and BP are associated with stroke severity and localization and wearing a dental prosthesis increases the risk of SD. Given that patients with SD have an increased risk of poor outcome and mortality, high-risk patients warrant early interventions, including more randomized trials.

[Salivary management in amyotrophic lateral sclerosis]. / Prise en charge des troubles salivaires dans la sclérose latérale amyotrophique.

80 % of patients suffering from amyotrophic lateral sclerosis present bulbar involvement and 50 % have salivary symptoms, which are often poorly managed. They present either with drooling or thick secretions. This elevates the risk of bronchoaspiration leading to pneumonia, second cause of death in this population. It is hence paramount to treat, while enhancing the patient's quality of life. The first line of treatment is a salivary drying agent such as an atropine-based medication. These treatments have a low adverse effect rate, are reversible and easy to dose. Management of thick secretions is possible with mucolytics. Taking into account the severity of the bulbar involvement, the second line of treatment, once controversial, is salivary gland injections of botulinium toxin.

Lors d'une sclérose latérale amyotrophique, 80 % des patients vont développer une atteinte bulbaire et 50 % une gêne salivaire sévère liée à leur trouble de la déglutition. La salive peut être subjectivement trop abondante ou trop visqueuse. Des bronchoaspirations salivaires et alimentaires répétées sont la deuxième cause de mortalité chez ces patients. Améliorer la gêne salivaire est donc primordial pour leur qualité de vie ainsi que pour la mortalité. Les médicaments prescrits en première intention sont les asséchants salivaires atropiniques. Des mucolytiques permettent de fluidifier les sécrétions visqueuses. Des injections de toxine botulique dans les glandes salivaires, parfois controversées, sont prescrites en deuxième intention, en tenant compte de la sévérité de l'atteinte bulbaire.

Transoral robotic-assisted supracricoid partial laryngectomy with cricohyoidoepiglottopexy: Procedure development and outcomes of initial cases.

BACKGROUND: We report on the feasibility and functional outcome of transoral robotic (TORS) supracricoid partial laryngectomy (SCPL) with cricohyoidoepiglottopexy (CHEP). METHODS: Cadaveric studies and functional outcome at 3 years using the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC-QLQ-H&N35), the Functional Outcome Swallowing Scale (FOSS), the Performance Status Scale for Head and Neck Cancer (PSS-HN), computerized voice analysis, and videotape recordings. Data were compared with a historical cohort of open CHEPs/cricohyoidopexies (CHPs). RESULTS: The EORTC-QLQ-H&N35 scores, FOSS scores, and PSS-HN scores at 3 years of 2 operated patients were 46 and 43, 2 and 1, and 75 of 100 (eating in public) and 100 of 100 (normalcy of diet), respectively. The mean fundamental frequency, jitter, shimmer, noise-to-harmonic ratio (NHR), and maximum phonation time (MPT) were 85 HZ and 81 Hz, 8.52% and 6.39%, 28.2% and 13.5%, 0.61 and 0.71, 19 seconds and 15 seconds, respectively. CONCLUSION: Functional outcome data suggest that the procedure is feasible and safe.

Bamboo Nodes of Vocal Folds: A Description of 10 Cases and Review of the Literature.

OBJECTIVE: Bamboo nodes are vocal fold lesions, mostly associated with autoimmune diseases. PATIENTS AND METHODS: This is a retrospective clinical study including 10 patients with bamboo nodes. Data were collected regarding associated autoimmune disorder and type of treatment. A systematic review of the literature was conducted. RESULTS: All patients were women, with hoarseness as the most frequent symptom. There was in most cases an associated autoimmune disease: 3 patients with systemic lupus erythematosus; 3 with rheumatoid arthritis; 1 with Sjögren syndrome; 1 with Hashimoto disease; and 1 with mixed connective tissue disease. Four patients were treated with speech therapy, 3 with oral steroids, 1 with speech therapy and oral steroids combined, 1 with oral steroids and laryngeal steroid injections, and 1 had oral steroids, surgery, and speech therapy. Speech therapy was the first-line treatment. CONCLUSION: Bamboo nodes should be looked for in every patient with a diagnosis of autoimmune disease complaining of dysphonia.

Recurrent laryngeal nerve injury after thyroid and parathyroid surgery: Incidence and postoperative evolution assessment.

Recurrent laryngeal nerve (RLN) injury is a feared complication after thyroid and parathyroid surgery. It induces important postoperative morbidity. The present study aimed to assess the incidence of transient/permanent postoperative RLN injuries after thyroid and parathyroid surgery in the present cohort, to observe the timing of recovery, and to identify risk factors for permanent RLN injury after thyroidectomy.All consecutive patients operated on at our institution for thyroid and parathyroid pathologies from 2005 to 2013 were reviewed for vocal cord paresis. Vocal cord paresis was defined based on postoperative fiberoptic laryngoscopy. Demographics, intraoperative details, and postoperative outcomes were collected. Treatment types were assessed, and recovery times collected. Patients with vocal cord paresis on preoperative fiberoptic laryngoscopy were excluded from the analysis.The cohort included 451 thyroidectomies (756 nerves at risk) and 197 parathyroidectomies (276 nerves at risk). There were 63 postoperative vocal cord pareses after thyroidectomy and 13 after parathyroidectomy. Sixty-nine were transient (10.6%) and 7 permanent (1.1%). The main performed treatment was speech therapy in 51% (39/76) of the patients. Median recovery time after transient injuries was 8 weeks. In the group with vocal cord paresis, risk factors for permanent injuries after thyroidectomy were previous thyroidectomy and intraoperative RLN injury on univariate analysis. On multivariate analysis, only intraoperative RLN injury remained significant.Most of the patients with transient postoperative RLN injury recovered normal vocal cord mobility within 6 months. The most common performed treatment was in this cohort speech therapy. Permanent RLN injuries remained rare (1.1%).

Clinical and biochemical responses after Gamma Knife surgery for a dopamine-secreting paraganglioma: case report.

INTRODUCTION: The efficacy of Gamma Knife surgery (GKS) in local tumor control of non-secreting paragangliomas (PGLs) has been fully described by previous studies. However, with regard to secreting PGL, only one previous case report exists advocating its efficacy at a biological level. CASE REPORT: The aims of this study were: 1) to evaluate the safety/efficacy of GKS in a dopamine-secreting PGL; 2) to investigate whether the biological concentrations of free methoxytyramine could be used as a marker of treatment efficacy during the follow-up. We describe the case of a 62-year-old man diagnosed with left PGL. He initially underwent complete surgical excision. Thirty months after, he developed recurrent biological and neuroradiological disease; the most sensitive biomarker for monitoring the disease, concentration of plasma free methoxytyramine, started to increase. GKS was performed at a maximal marginal dose of 16 Gy. During the following 30 months, concentration of free methoxytyramine gradually decreased from 0.14 nmol/l (2*URL) before GKS to 0.09 nmol/l, 6 months after GKS and 0.07 nmol/l at the last follow-up after GKS (1.1*URL), confirming the efficacy of the treatment. Additionally, at 30 months there was approximately 36.6% shrinkage from the initial target volume. CONCLUSION: The GKS treatment was safe and effective, this being confirmed clinically, neuroradiologically and biologically. The case illustrates the importance of laboratory tests taking into account methoxytyramine when analyzing biological samples to assess the biochemical activity of a PGL. In addition, the identification of methoxytyramine as a unique positive biomarker could designate it for the monitoring of tumor relapse after treatments, including Gamma Knife surgery.

[Common benign lesions of the vocal fold : diagnostic criteria and management]. / Lésions bénignes courantes des cordes vocales : critères diagnostiques et prise en charge.

The vocal cord or vocal fold is a remarkable structure, capable to support significant physical constraints. When the voice malmenage becomes chronic, it may appear an organic alteration causing nodules, polyps or Reinke edema even a lesion of the posterior glottis, the granuloma. These lesions are benign but lead to dysphonia that can be invalidating. Treatment can be a speech therapy with correction of breath and posture and, in some cases, a surgical treatment. In this article, we describe these common lesions with their histological characteristics and pathophysiological hypotheses which lead to their appearance and treatment.

La corde vocale ou pli vocal est une structure remarquable, capable de supporter d'importantes contraintes physiques. Pourtant, lorsque le malmenage vocal devient chronique, il peut apparaître une altération organique entraînant des nodules, des polypes ou un œdème de l'espace de Reinke, voire une lésion de la glotte postérieure, le granulome. Ces lésions entraînent une dysphonie pouvant être invalidante. Le traitement peut être une prise en charge logopédique avec correction du souffle, réduction des tensions cervicales, changement de la posture, ainsi qu'un traitement chirurgical dans certains cas. Dans cet article, nous décrivons ces lésions courantes, leurs caractéristiques histologiques ainsi que les hypothèses physiopathologiques présidant à leur apparition et à leur traitement.

Rhinopharyngeal autologous fat injection for treatment of velopharyngeal insufficiency in patients with cleft palate.

Patients with cleft palate are prone to velopharyngeal insufficiency. In minor cases or when hypernasal speech does not resolve after velopharyngoplasty, an augmentation pharyngoplasty with autologous fat can be proposed. The aim of the present study is to evaluate the short-term (within 2 months) and long-term efficiency (during the 24 months following the procedure) of our procedure in the setting of velopharyngeal insufficiency related to a cleft palate. Twenty-two patients with cleft palate related velopharyngeal insufficiency were included in this retrospective study. All patients were operated following the same technique, in the same institution. The pre- and postoperative evaluations included a nasometry, a subjective evaluation using the Borel-Maisonny score, and a nasofibroscopy to assess the degree of velopharyngeal closure. Scores of Borel-Maisonny and nasometry were compared before, shortly after the procedure (within 2 months) and long term after the procedure (within 24 months). Forty-one procedures in 22 patients with a cleft palate performed in our institution between October 2004 and January 2012 were included in the study. Nine patients had a previous velopharyngoplasty with persistent rhinolalia despite intensive speech therapy. In 14 patients the procedure was repeated because of recurrent hypernasal speech after the first injection. The average number of procedures per patient was 1.8. Postoperative nasometry and Borel-Maisonny scores were statistically significantly improved and remained stable until the end of the follow-up (median 42 months postoperative) in most patients. Complications were rare and minor. Autologous fat injection is a simple procedure for treatment of minor velopharyngeal insufficiencies in patients with cleft palate, with good long-term results and few complications.

Acute neurorehabilitation: does a neurosensory and coordinated interdisciplinary programme reduce tracheostomy weaning time and weaning failure?

BACKGROUND/PURPOSE: A new coordinated interdisciplinary unit was created in the acute section of the department of clinical neurosciences, the Acute NeuroRehabilitation (NRA) unit. The objective was to evaluate the impact of the unit and its neurosensory programme on the management of tracheostomy patients in terms of reduction in the average time taken for weaning, weaning success rate and therapeutic efficiency. METHODS: This 49-month retrospective study compares 2 groups of tracheostomy patients before (n = 34) and after (n = 46) NRA intervention. The outcome measures evaluate the benefits of the NRA unit intervention (time to decannulation, weaning and complication rates) and the benefits of the coordination (time to registration in a rehabilitation centre and rate of non-compliance with standards of care). RESULTS: Weaning failure rate was reduced from 27.3% to 9.1%, no complications or recannulations were observed in the post-intervention group after weaning and time to decannulation following admission to our unit decreased from 19.13 to 12.75 days. The rate of non-compliance with patient standards of care was significantly reduced from 45% to 30% (Mann-Whitney p = 0.003). DISCUSSION/CONCLUSIONS: This interdisciplinary weaning programme helped to reduce weaning time and weaning failure, without increased complications, in the sample studied. Coordination improved the efficiency of the interdisciplinary team in the multiplicity and complexity of the different treatments.

Treatment of velopharyngeal insufficiency by autologous fat injection.

Velopharyngeal insufficiency (VPI) is a structural or functional trouble, which causes hypernasal speech. Velopharyngeal flaps, speech therapy and augmentation pharyngoplasty, using different implants, have all been used to address this trouble. We hereby present our results following rhinopharyngeal autologous fat injection in 18 patients with mild velopharyngeal insufficiency (12 soft palate clefts, 4 functional VPI, 2 myopathy). 28 injections were carried out between 2004 and 2007. The degree of hypernasal speech was evaluated pre- and postoperatively by a speech therapist and an ENT specialist and quantified by an acoustic nasometry (Kay Elemetrics). All patients were exhaustively treated with preoperative speech therapy (average, 8 years). The mean value of the nasalance score was 37% preoperatively and 23% postoperatively (p = 0.015). The hypernasality was reduced postoperatively in all patients (1-3 degrees of the Borel-Maisonny score). There were no major complications, two minor complications (one hematoma, one cervical pain). The autologous fat injection is a simple, safe, minimally invasive procedure. It proves to be efficient in cases of mild velopharyngeal insufficiency or after a suboptimal velopharyngoplasty.

[Unilateral laryngeal paralysis]. / Paralysies laryngées unilatérales.

Investigations, diagnosis and treatment of laryngeal paralysis depend upon history taking and examination of phonation, swallowing and of the pharyngo-larynx. In unilateral paralysis, the main symptom is dysphonia. Dysphagia lasting more than 10 days may indicate a proximal vagus nerve lesion. Voice and swallowing therapy may be undertaken. If this remains insufficient after one month, a temporary or definitive vocal fold medialisation may be considered. Paralysis is considered to be definitive if lasting for more than 12 months. A minimal of one-year follow-up is indicated in case of idiopathic paralysis.