Effects of carbonation of liquids on penetration-aspiration and residue management.

OBJECTIVE: Carbonation as a sensory enhancement strategy for prevention of aspiration of thin liquids has not been thoroughly studied. The aim of our study was to examine the effect of carbonation on penetration-aspiration and pharyngeal residue in dysphagia patients using Fiber-Optic Endoscopic Evaluation of Swallowing (FEES) and to identify parameters associated with a response to carbonation. METHODS: A cross-sectional study of patients undergoing FEES in a dysphagia clinic. Patients were offered 100 cc of dyed water. Penetration-aspiration was scored using the penetration-aspiration scale (PAS). Residue was scored using the Yale Pharyngeal Residue Severity Rating Scale (YPR-SRS). Patients with a PAS ≥ 2 for water were subsequently offered 100 cc of carbonated water. PAS, YPR-SRS and residue clearance were compared between thin and carbonated liquids. Multivariate logistic regression analysis was used to identify predictors for good response to carbonation. RESULTS: 84 patients were enrolled, 77.4% males, with diverse dysphagia etiologies (58.3% neurogenic, 11.9% radiation-induced, 23.8% deconditioning-induced, and 6% neck surgery induced). Median PAS was 7 (IQR 4-8) for thin liquids and 4.5 (IQR 2-8) for carbonated liquids (P = 0.0001). YPR-SRS was reduced for carbonated compared to thin liquids in the vallecula (1.58 ± 0.83 vs 1.76 ± 0.93, P = 0.001) and piriform sinuses (1.5 ± 0.87 vs 1.67 ± 0.9, P = 0.002). 31 patients had improvement in PAS with carbonation. Deconditioning as a dysphagia etiology was found to predict good response to carbonation on multivariate logistic regression analysis. CONCLUSION: Carbonation may prevent aspiration and improve residue management for some patients with dysphagia for liquids. LEVEL OF EVIDENCE: IV.

Human Nasal Turbinate Tissues in Organ Culture as a Model for Human Cytomegalovirus Infection at the Mucosal Entry Site.

The initial events of viral infection at the primary mucosal entry site following horizontal person-to-person transmission have remained ill defined. Our limited understanding is further underscored by the absence of animal models in the case of human-restricted viruses, such as human cytomegalovirus (HCMV), a leading cause of congenital infection and a major pathogen in immunocompromised individuals. Here, we established a novel ex vivo model of HCMV infection in native human nasal turbinate tissues. Nasal turbinate tissue viability and physiological functionality were preserved for at least 7 days in culture. We found that nasal mucosal tissues were susceptible to HCMV infection, with predominant infection of ciliated respiratory epithelial cells. A limited viral spread was demonstrated, involving mainly stromal and vascular endothelial cells within the tissue. Importantly, functional antiviral and proleukocyte chemotactic signaling pathways were significantly upregulated in the nasal mucosa in response to infection. Conversely, HCMV downregulated the expression of nasal epithelial cell-related genes. We further revealed tissue-specific innate immune response patterns to HCMV, comparing infected human nasal mucosal and placental tissues, representing the viral entry and the maternal-to-fetal transmission sites, respectively. Taken together, our studies provide insights into the earliest stages of HCMV infection. Studies in this model could help evaluate new interventions against the horizontal transmission of HCMV.IMPORTANCE HCMV is a ubiquitous human pathogen causing neurodevelopmental disabilities in congenitally infected children and severe disease in immunocompromised patients. The earliest stages of HCMV infection in the human host have remained elusive in the absence of a model for the viral entry site. Here, we describe the establishment and use of a novel nasal turbinate organ culture to study the initial steps of viral infection and the consequent innate immune responses within the natural complexity and the full cellular repertoire of human nasal mucosal tissues. This model can be applied to examine new antiviral interventions against the horizontal transmission of HCMV and potentially that of other viruses.

Does the Hebrew Eating Assessment Tool-10 Correlate with Pharyngeal Residue, Penetration and Aspiration on Fiberoptic Endoscopic Examination of Swallowing?

The Eating Assessment Tool-10 (EAT-10) is a 10-item patient-reported outcome measure (PROM) for dysphagia patients. The objective of this study was to translate and validate the EAT-10Heb and to test for a correlation between its score and residue, penetration and aspiration on Fiberoptic Endoscopic Examination of Swallowing (FEES). 136 patients visiting two specialized dysphagia clinics and undergoing FEES between April 2015 and August 2017, filled the EAT-10Heb. 23 patients refilled the EAT-10Heb during a 2-week period following their first visit. FEES were scored for residue (1 point per consistency, maximum 3 points) and penetration and aspiration (1 point for penetration, 2 points for aspiration per consistency, maximum 6 points). 51 healthy volunteers also filled the EAT-10Heb. Internal consistency and test-retest reproducibility were examined for reliability testing. Validity was established by comparing EAT-10Heb scores of dysphagia patients to healthy controls. The EAT-10Heb score was then correlated with the FEES score. Internal consistency of the EAT-10Heb was high (Cronbach's alpha = 0.925) as was the test-retest reproducibility (Spearman's correlation coefficient = 0.82, p < 0.0001). The median EAT-10Heb score was significantly higher in the dysphagia group compared to healthy controls (13, IQR 7-22 points for dysphagia patients compared to 0, IQR 0-0 points for healthy controls, p < 0.0001). A weak correlation was found between the EAT-10Heb scores and the FEES score (Pearson's correlation coefficient = 0.376, p < 0.0001). While the EAT-10Heb was found to be a reliable and valid PROM, it only weakly correlates with the pathological findings on FEES examination.

Translation and Validation of the Dysphagia Handicap Index in Hebrew-Speaking Patients.

The Dysphagia Handicap Index (DHI) is a 25-item questionnaire assessing the physical, functional, and emotional aspects of dysphagia patients' quality of life (QoL). The study goal was to translate and validate the Hebrew-DHI. 148 patients undergoing fiberoptic endoscopic examination of swallowing (FEES) in two specialized dysphagia clinics between February and August 2017 filled the Hebrew-DHI and self-reported their dysphagia severity on a scale of 1-7. 21 patients refilled the DHI during a 2-week period following their first visit. FEES were scored for residue (1 point per consistency), penetration and aspiration (1 point for penetration, 2 points for aspiration, per consistency). 51 healthy volunteers also filled the DHI. Internal consistency and test-retest reproducibility were used for reliability testing. Validity was established by comparing DHI scores of dysphagia patients and healthy controls. Concurrent validity was established by correlating the DHI score with the FEES score. Internal consistency of the Hebrew-DHI was high (Cronbach's alpha = 0.96), as was the test-retest reproducibility (Spearman's correlation coefficient = 0.82, p < 0.001). The Hebrew-DHI's total score, and its three subscales (physical/functional/emotional) were significantly higher in dysphagia patients compared to those in healthy controls (median 38 pts, IQR 18-56 for dysphagia patients compared to 0, IQR 0-2 for healthy controls, p < 0.0001). A strong correlation was observed between the DHI score and the self-reported dysphagia severity measure (Spearman's correlation coefficient = 0.88, p < 0.0001). A moderate correlation was found between the DHI score and the FEES score (Pearson's correlation coefficient = 0.245, p = 0.003). The Hebrew-DHI is a reliable and valid questionnaire assessing dysphagia patients' QoL.

Type I-II laryngeal cleft: clinical course and outcome.

BACKGROUND: Laryngeal cleft (LC) is a rare congenital anomaly manifesting in a variety of symptoms, including swallowing disorders and aspirations, dyspnea, stridor and hoarseness. The mild forms (types I-II) may be underdiagnosed, leading to protracted symptomatology and morbidity. OBJECTIVES: To evaluate the diagnostic process, clinical course, management and outcome in children with type I-II laryngeal clefts. METHODS: We conducted a retrospective case analysis for the years 2005-2012 in a tertiary referral center. RESULTS: Seven children were reviewed: five boys and two girls ranging in age from birth to 5 years. The most common presenting symptoms were cough, aspirations and pneumonia. Evaluation procedures included fiber-optic laryngoscopy (FOL), direct laryngoscopy (DL) and videofluoroscopy. Other pathologies were seen in three children. Six children underwent successful endoscopic surgery and one child was treated conservatively. The postoperative clinical course was uneventful in most of the cases. CONCLUSIONS: Types I-II LC should be considered in the differential diagnosis of children presenting with protracted cough and aspirations. DL is crucial for establishing the diagnosis. Endoscopic surgery is safe and should be applied promptly when conservative measures fail.

Steroid-based treatments for patients with total sudden sensorineural hearing loss.

CONCLUSIONS: In patients with total sudden sensorineural hearing loss (SSNHL), oral prednisone (OP) alone or intratympanic dexamethasone (ITD) alone have comparable results. The addition of salvage ITD following OP does not seem to add over either single modality treatment. OBJECTIVES: To study the effect of steroid-based treatments in patients with total SSNHL. METHODS: The medical charts of 59 patients with total loss of hearing, defined as pure tone thresholds in the profound range (> 90 dB) with an unobtainable speech reception threshold (SRT) that were treated with OP (n = 20), ITD (n = 13), or OP followed by salvage ITD (n = 26) were analyzed. Response to treatment was evaluated by means of pure tone thresholds, SRT, and speech discrimination score (SDS), immediately after treatment and on a follow-up visit. RESULTS: Forty-nine patients (83%) responded to treatment, with mean significant improvements of 36, 34, 31, and 25 dB at 500, 1000, 2000, and 4000 Hz, respectively. The mean improvement in SRT was 33 dB, and SDS improved by 32%. There were no differences in improvement in pure tone thresholds and SRT among the three treatment groups. The late effect of OP was similar to the effect of salvage ITD.

Cricopharyngeal achalasia in children: surgical and medical treatment.

BACKGROUND: Cricopharyngeal achalasia (CA) is a rare cause of dysphagia in children presenting with non-specific symptoms such as choking, food regurgitation, nasal reflux, coughing, recurrent pneumonia, cyanosis, and failure to thrive. It results from failure of relaxation of the upper esophageal sphincter (UES) and may appea reither as an isolated lesion or in conjunction with other pathologies. Recognition and early diagnosis of this condition may minimize morbidity in children. OBJECTIVES: To evaluate the clinical course of four children with cricopharyngeal achalasia presenting to our clinic. METHODS: We conducted a 5 year retrospective chart review in a tertiary referral center. RESULTS: Four children were diagnosed with primary cricopharyngeal achalasia between 2006 and 2010. Diagnosis was established by videofluoroscopy and all underwent uneventful cricopharyngeal myotomy. Three children recovered completely and one child showed partial improvement. For residual UES spasm in a partially improved patient, botulinum toxin was injected into the UES which led to further improvement. Dysphagia recurred in one child who was successfully treated with botulinum toxin injection. CONCLUSIONS: Cricopharyngeal myotomy is a safe procedure in infants and young children. Botulinum toxin injection of the UES was found to be effective in refractory cases.

Hearing loss in bullous myringitis.

OBJECTIVE: To evaluate the incidence of sensorineural and mixed hearing loss in patients with bullous myringitis. METHODS: Prospective observational study was conducted in a tertiary care medical center.Patients diagnosed as having bullous myringitis in our medical center between 2007 and 2009, underwent pure-tone audiometry upon presentation and were treated according to physicians' preferences RESULTS: Bullous myringitis was diagnosed in 43 patients (16 males, 27 females) with a mean age of 30.9 years (range 15-92). Thirty-six (83.7%) had unilateral infection (24 right, 12 left), and 7 (16.3%) had bilateral involvement. The most common type of hearing loss was mixed, detected in 24 patients (55.8%) and involving 27 of the 50 affected ears (54%). Seven patients (16.3%) had a conductive hearing loss, involving 9 ears (18%). Three patients (6.9%) presented with sensorineural hearing loss involving 5 ears (10%). The mean air-bone gap was 20.6±8.8dB. Down-slope audiometry was noted in 68.7% of the affected ears, followed by a U-shaped curve (25%). The sensorineural component mainly involved the high frequencies and the hearing loss ranged from slight to severe. CONCLUSION: The results of the present study demonstrate a high incidence of mixed or sensorineural hearing loss in bullous myringitis patients, and emphasize the need for routine early audiometric evaluation and appropriate follow up for individuals diagnosed as having bullous myringitis.

Cochlear implantation in elderly patients: surgical and audiological outcome.

BACKGROUND: Deteriorated hearing affects speech perception and speech production, and negatively impacts on social interaction, employment, income, and, as a result, the quality of life of the elderly population. Lack of satisfaction with conventional hearing aids motivated part of them to turn to more sophisticated cochlear device systems. OBJECTIVE: To investigate the outcome of cochlear implantation (CI) among elderly cochlear implant recipients. METHODS: The medical records of 20 postlingual patients aged >65 years at the time of CI, who were followed up for a period of at least 12 months were retrospectively reviewed for age at the time of CI, the cause and duration of deafness, hearing aid experience, comorbidities, complications of the procedure and audiological outcome. Pre- and post-CI speech perception performance was tested using a battery of speech perception tests. RESULTS: In addition to bilateral severe to profound hearing loss, all 20 patients had some comorbidities and 13 had more than 2 pathologies that are associated with hearing impairment. Major complications such as facial nerve paralysis and foreign body reaction were rare (n = 2). Minor complications such as disequilibrium (n = 5) and wound problems (n = 5) resolved spontaneously or were successfully managed conservatively. There were no complications associated with general anesthesia used during the CI procedure. Statistical analysis using the Wilcoxon Signed Rank Test showed significant differences (p < 0.01) between the pre- and postspeech perception categories. No significant correlations were found between the background data: unaided thresholds, aided thresholds, duration of profound deafness, duration of hearing aid use prior to CI, speech perception before CI and speech perception performance after CI using Pearson correlations. CONCLUSION: CI was found to be associated with significant hearing benefit in elderly candidates. However, every CI candidate must be informed about possible complications associated with the procedure, especially related to the vestibular system. At the same time, it should be made clear that life-threatening conditions are rare and that the surgery is usually safe.

Outcome of tracheostomy in patients over 85 years old (oldest-old patients).

OBJECTIVE: To investigate morbidity, complication rate, and mortality in oldest-old patients who undergo tracheostomy. STUDY DESIGN: Historical cohort study. SUBJECT AND METHODS: The medical records for 64 patients (>85 years) who underwent standard or percutaneous tracheostomy between 2001 and 2005 in a tertiary care hospital were reviewed for in-hospital and out-of-hospital mortality, complications, and decannulation rate. RESULTS: Twenty-eight (43.8%) patients were discharged from the hospital and all remained tracheotomized at that time. Postoperative mortality had not been related to the procedure itself and the mortality rate reached 75 percent within the first three postoperative months and 93.8 percent within the first year post-tracheostomy. The post-tracheostomy course was complicated in three (4.7%) patients. There was no significant correlation between the length of hospital stay or survival and demographic parameters, pneumonia as the reason for mechanical ventilation, or performance of surgery before tracheostomy. CONCLUSION: Tracheostomy is a safe surgical procedure in the oldest-old patients. The high rate of the postoperative mortality is not related to the procedure itself. The possibility of permanent stoma should be considered and discussed with the patients and their families during the preoperative counseling.

Taste changes in patients who underwent cochlear implantation by the nonmastoidectomy approach.

OBJECTIVES: To describe taste changes following a nonmastoidectomy approach to cochlear implantation (CI). STUDY DESIGN: Retrospective. METHOD: Ninety-four adult patients (63 females) who underwent CI using the suprameatal approach (SMA) were studied. They responded to a questionnaire on post-CI taste changes, duration of these changes and their influence on eating habits, weight and quality of life. RESULTS: Fourteen patients (14.9%, all females) reported taste dysfunction (13 ranked as being mild). In 1 patient, the symptoms lasted >24 months, and dysgeusia was counted as permanent in this case. One patient changed her eating habits: she now prefers vegetarian food. The patients with early (<1 month) recovery of taste function were younger than those with delayed recovery. CONCLUSIONS: The SMA is a favorable technique for the preservation of taste sensation in CI patients. Manipulation on the chorda tympani nerve during the SMA did not much disturb the patients' eating habits and their quality of life.