Prevalence of swallow, communication, voice and cognitive compromise following hospitalisation for COVID-19: the PHOSP-COVID analysis.

OBJECTIVE: Identify prevalence of self-reported swallow, communication, voice and cognitive compromise following hospitalisation for COVID-19. DESIGN: Multicentre prospective observational cohort study using questionnaire data at visit 1 (2-7 months post discharge) and visit 2 (10-14 months post discharge) from hospitalised patients in the UK. Lasso logistic regression analysis was undertaken to identify associations. SETTING: 64 UK acute hospital Trusts. PARTICIPANTS: Adults aged >18 years, discharged from an admissions unit or ward at a UK hospital with COVID-19. MAIN OUTCOME MEASURES: Self-reported swallow, communication, voice and cognitive compromise. RESULTS: Compromised swallowing post intensive care unit (post-ICU) admission was reported in 20% (188/955); 60% with swallow problems received invasive mechanical ventilation and were more likely to have undergone proning (p=0.039). Voice problems were reported in 34% (319/946) post-ICU admission who were more likely to have received invasive (p<0.001) or non-invasive ventilation (p=0.001) and to have been proned (p<0.001). Communication compromise was reported in 23% (527/2275) univariable analysis identified associations with younger age (p<0.001), female sex (p<0.001), social deprivation (p<0.001) and being a healthcare worker (p=0.010). Cognitive issues were reported by 70% (1598/2275), consistent at both visits, at visit 1 respondents were more likely to have higher baseline comorbidities and at visit 2 were associated with greater social deprivation (p<0.001). CONCLUSION: Swallow, communication, voice and cognitive problems were prevalent post hospitalisation for COVID-19, alongside whole system compromise including reduced mobility and overall health scores. Research and testing of rehabilitation interventions are required at pace to explore these issues.

Reconfiguration from emergency to urgent elective neurosurgery for glioblastoma patients improves length of stay, surgical adjunct use, and extent of resective surgery.

Background: Glioblastoma (GB) is the most common intrinsic brain cancer and is notorious for its aggressive nature. Despite widespread research and optimization of clinical management, the improvement in overall survival has been limited. The aim of this study was to characterize the impact of service reconfiguration on GB outcomes in a single centre. Methods: Patients with a histopathological confirmation of a diagnosis of GB between 01/01/2014 and 31/12/2019 were retrospectively identified. Demographic and tumour characteristics, survival, treatment (surgical and oncological), admission status, use of surgical adjunct (5-aminolevulinic acid, intra-operative neuro-monitoring), the length of stay, extent of resection, and surgical complications were recorded from the hospital databases. Results: From August 2018 the neurosurgical oncology service was reconfigured to manage high-grade tumours on an urgent outpatient basis by surgeons specializing in oncology. We demonstrate that these changes resulted in an increase in elective admissions, greater use of intra-operative adjuncts resulting in the improved extent of tumour resection, and a reduction in median length of stay and associated cost-savings. Conclusions: Optimizing neuro-oncology patient management through service reconfiguration resulted in increased use of intra-operative adjuncts, improved surgical outcomes, and reduced hospital costs. These changes also have the potential to improve survival and disease-free progression for patients with GB.

European Head and Neck Society recommendations for head and neck cancer survivorship care.

Survivors of head and neck cancer can experience long-term consequences of the cancer and subsequent treatments even after the cancer has resolved. Increasingly clinicians are aware of the social, psychological, financial, and emotional impacts of these cancers, in addition to the support required for the physical symptoms. This review provides recommendations on the long-term management and support required for survivors of head and neck cancer in the European healthcare setting.

Translating Dysphagia Evidence into Practice While Avoiding Pitfalls: Assessing Bias Risk in Tracheostomy Literature.

Critically ill patients who require a tracheostomy often have dysphagia. Widespread practice guidelines have yet to be developed regarding the acute assessment and management of dysphagia in patients with tracheostomy. In order for clinicians to base their practice on the best available evidence, they must first assess the applicable literature and determine its quality. To inform guideline development, our objective was to assess literature quality concerning swallowing following tracheostomy in acute stages of critical illness in adults. Our systematic literature search (published previously) included eight databases, nine gray literature repositories and citation chasing. Using inclusion criteria determined a priori, two reviewers, blinded to each other, conducted an eligibility review of identified citations. Patients with chronic tracheostomy and etiologies including head and/or neck cancer diagnoses were excluded. Four teams of two reviewers each, blinded to each other, assessed quality of included studies using a modified Cochrane Risk of Bias tool (RoB). Disagreements were resolved by consensus. Data were summarized descriptively according to study design and RoB domain. Of 6,396 identified citations, 74 studies met our inclusion criteria. Of those, 71 were observational and three were randomized controlled trials. Across all studies, the majority (> 75%) had low bias risk with: participant blinding, outcome reporting, and operationally defined outcomes. Areas requiring improvement included assessor and study personnel blinding. Prior to translating the literature into practice guidelines, we recommend attention to study quality limitations and its potential impact on study outcomes. For future work, we suggest an iterative approach to knowledge translation.

Laryngeal and soft palate valving in the harbour seal (Phoca vitulina).

Effective 'valving' in the upper aerodigestive tract (UAT) is essential to temporarily separate the digestive and respiratory pathways. Marine mammals are largely dedicated to feeding underwater, and in many cases swallowing prey whole. In seals, little work has been done to explore the anatomy and function of the UAT in the context of valving mechanisms that function to separate food and air pathways. Here we use videofluoroscopy, gross dissection, histology and computed tomography (CT) renderings to explore the anatomy of the larynx and soft palate in the harbour seal (Phoca vitulina), and generate models for how valving mechanisms in the head and neck may function during breathing, phonating, diving and swallowing. Harbour seals have an elevated larynx and the epiglottis may rise above the level of the soft palate, particularly in pups when sucking. In addition, the corniculate and arytenoid cartilages with associated muscles form most of the lateral margins of the laryngeal inlet and vestibule, and move independently to facilitate airway closure. The corniculate cartilages flex over the laryngeal inlet beneath the epiglottis to completely close the laryngeal vestibule and inlet. The vocal folds are thick and muscular and the medial margin of the folds contains a small vocal ligament. The soft palate has well-defined levator veli palatini muscles that probably function to elevate the palate and close the pharyngeal isthmus during feeding. Our results support the conclusion that harbour seals have evolved UAT valving mechanisms as adaptations to a marine environment that are not seen in terrestrial carnivores.

Patient advocacy in head and neck cancer: Realities, challenges and the role of the multi-disciplinary team.

This paper explores the concept of advocacy in head and neck cancer. We define inherent challenges in the development and success of advocacy within this context and offer ways to embed it within clinical practice. We outline what advocacy is, ways in which it may benefit people with head and neck cancer and the engagement required from healthcare professionals to facilitate advocacy to improve outcomes.

Investigating Swallowing and Tracheostomy Following Critical Illness: A Scoping Review.

OBJECTIVES: Tracheostomy and dysphagia often coexist during critical illness; however, given the patient's medical complexity, understanding the evidence to optimize swallowing assessment and intervention is challenging. The objective of this scoping review is to describe and explore the literature surrounding swallowing and tracheostomy in the acute care setting. DATA SOURCES: Eight electronic databases were searched from inception to May 2017 inclusive, using a search strategy designed by an information scientist. We conducted manual searching of 10 journals, nine gray literature repositories, and forward and backward citation chasing. STUDY SELECTION: Two blinded reviewers determined eligibility according to inclusion criteria: English-language studies reporting on swallowing or dysphagia in adults (≥ 17 yr old) who had undergone tracheostomy placement while in acute care. Patients with head and/or neck cancer diagnoses were excluded. DATA EXTRACTION: We extracted data using a form designed a priori and conducted descriptive analyses. DATA SYNTHESIS: We identified 6,396 citations, of which 725 articles were reviewed and 85 (N) met inclusion criteria. We stratified studies according to content domains with some featuring in multiple categories: dysphagia frequency (n = 38), swallowing physiology (n = 27), risk factors (n = 31), interventions (n = 21), and assessment comparisons (n = 12) and by patient etiology. Sample sizes (with tracheostomy) ranged from 10 to 3,320, and dysphagia frequency ranged from 11% to 93% in studies with consecutive sampling. Study design, sampling method, assessment methods, and interpretation approach varied significantly across studies. CONCLUSIONS: The evidence base surrounding this subject is diverse, complicated by heterogeneous patient selection methods, design, and reporting. We suggest ways the evidence base may be developed.

Late Dysphagia Following Radiotherapy After Nasopharyngeal Carcinoma: A Case Series.

Purpose Standard treatment for nasopharyngeal carcinoma (NPC) is radiation therapy (RT); however, long-term effects of RT frequently include significant swallowing impairments (dysphagia; Gaziano, 2002; Hui, Chan, & Le, 2018). Our objective was to describe swallowing physiology in consecutive outpatients with a history of NPC following RT using standardized methods. Understanding dysphagia characteristics in this patient population could ultimately inform rehabilitation strategies and improve patient outcomes. Method We conducted a retrospective, observational, descriptive study of consecutive outpatients undergoing videofluoroscopic swallowing (VFS) exams at our clinic, from 2009 to 2014. We included those with a diagnosis of NPC treated with RT. Those with other cancer diagnoses; previous tracheostomy; acute neurological injury; and progressive, degenerative neurological conditions were excluded. Two registered MBSImP clinicians, blinded to each other, reviewed and scored the VFS exams according to previously published methods (Martin-Harris et al., 2008). Following unblinding, a single reviewer collected demographic data from the electronic medical record. We reported overall impairment and MBSImP component scores descriptively. Results Of 158 outpatients undergoing VFS, 6 (N) met our inclusion criteria. The median time from completion of RT to outpatient VFS was 21.0 years. Patients reported a variety of dysphagia symptoms. All patients had high oral and pharyngeal residue scores (scores ≥ 2) and high impairment scores on components contributing to bolus transport and airway closure. Conclusions All patients presented with impairments in oral-pharyngeal bolus transport and airway protection. Our results identify specific swallowing impairments for this patient group highlighting possible latent RT effects on swallowing. This population would benefit from dysphagia rehabilitation and maintenance programs informed by multimodal diagnostic approaches.

The experiences of people who receive swallow therapy after surgical treatment of head and neck cancer.

OBJECTIVE: This research was initiated to explore the experiences and important elements of swallow therapy in patients after surgery for treatment of head and neck cancer (HNC). STUDY DESIGN: One-to-one, face-to-face interviews were conducted with patients with HNC 7 to 14 days after oral reconstructive surgery (free, pedicled, or bony flap). Analysis was conducted by using interpretive phenomenology. RESULTS: Analysis of interviews from 15 patients identified 2 overarching themes: "I never dreamt" and "They look at you, and they speak to you." There was no way for patients to be adequately prepared for the enormity of the surgery and its consequences; however, the way health care professionals interacted and communicated with the person, rather than the altered and disfigured self, was healing and therapeutic. CONCLUSIONS: There is a need for novel ways to prepare patients for HNC surgery and to support them in recovery, including ways to connect and help patients feel human again.

Liminality and head and neck cancer: core concepts and applications for clinical practice.

This article explores the concept of liminality and its potential application to understand the experience of being diagnosed and receiving treatment for head and neck cancer.The article describes how we identified liminality in people who had received surgical treatment of head and neck cancer and why it is important that the clinical team understand and consider liminality in their interventions, to improve outcomes. BACKGROUND: Head and neck cancer is a disease that may affect the way an individual looks and functions, specifically with regard to eating and drinking. This qualitative study identified the perceptions of people who had been diagnosed with head and neck cancer and had undergone surgical treatment, to develop our understanding of what happens to people beyond their physical recovery in hospital. METHODS: We carried out 1:1 face-to-face interviews with people in the acute phase of recovery following head and neck cancer surgery. We analysed and verified themes from the data, using an interpretive phenomenological methodology. RESULTS: The study identified a liminal phase which people described during their recovery from head and neck cancer surgery. Individuals described no longer being the people they were before surgery, but not yet the people they would be. We explored this concept and suggest ways in which the clinical team may identify and explore liminality post head and neck surgery. This information may help clinical teams to support people manage complex issues related to the sense of self, identity and recovery after head and neck cancer surgery.

Speech and swallowing outcomes following oral cavity reconstruction.

PURPOSE OF REVIEW: This review explores speech and swallowing outcomes following oral cavity reconstruction for treatment of head and neck cancer, with focus on articles published within 2015-2016. RECENT FINDINGS: There is limited recent evidence that explores functional outcomes following oral cavity surgery in the literature; therefore, an overview of the literature describing surgical interventions and their associated functional outcomes is timely. SUMMARY: We discuss the challenges associated with achieving adequate surgical margins, alongside optimal functional outcomes. The correlation between the size, site and type of reconstruction with speech and swallowing function are described, along with novel surgical and therapeutic interventions that may reduce treatment morbidity and have the potential to impact positively on quality of life.

Methadone and oedema in the palliative care setting: a case report and review of the literature.

INTRODUCTION: Methadone is a synthetic opioid which is being used with increased frequency in the palliative care setting for management of complex pain. There have been cases published reporting the development of oedema with methadone maintenance therapy but no cases on the association with methadone and peripheral oedema in the palliative care setting. As yet, the underlying mechanisms are unclear. CASE PRESENTATION: This case report describes a gentleman with ependymoma and difficult-to-control lower back pain and scrotal pain. This pain had failed to respond to other strong opioids. He was prescribed methadone and then subsequently developed bilateral peripheral oedema. CASE MANAGEMENT: Peripheral oedema resolved following cessation of methadone. CONCLUSIONS: This highlights an important potential adverse effect of methadone in a society of increased methadone prescription for pain control. The published literature to date is reviewed and possible underlying mechanisms explored.