Clinical Implementation of DIGEST as an Evidence-Based Practice Tool for Videofluoroscopy in Oncology: A Six-Year Single Institution Implementation Evaluation.

Clinical implementation of evidence-based practice (EBP) tools is a healthcare priority. The Dynamic Grade of Swallowing Toxicity (DIGEST) is an EBP tool developed in 2016 for videofluoroscopy in head and neck (H&N) oncology with clinical implementation as a goal. We sought to examine: (1) feasibility of clinical implementation of DIGEST in a national comprehensive cancer center, and (2) fidelity of DIGEST adoption in real-world practice. A retrospective implementation evaluation was conducted in accordance with the STARI framework. Electronic health record (EHR) databases were queried for all consecutive modified barium swallow (MBS) studies conducted at MD Anderson Cancer Center from 2016 to 2021. Implementation outcomes included: feasibility as measured by DIGEST reporting in EHR (as a marker of clinical use) and fidelity as measured by accuracy of DIGEST reporting relative to the decision-tree logic (penetration-aspiration scale [PAS], residue, and Safety [S] and Efficiency [E] grades). Contextual factors examined included year, setting, cancer type, MBS indication, and provider. 13,055 MBS were conducted by 29 providers in 7,842 unique patients across the lifespan in diverse oncology populations (69% M; age 1-96 years; 58% H&N cancer; 10% inpatient, 90% outpatient). DIGEST was reported in 12,137/13,088 exams over the 6-year implementation period representing 93% (95% CI: 93-94%) adoption in all exams and 99% (95% CI: 98-99%) of exams excluding the total laryngectomy population (n = 730). DIGEST reporting varied modestly by year, cancer type, and setting/provider (> 91% in all subgroups, p < 0.001). Accuracy of DIGEST reporting was high for overall DIGEST (incorrect SE profile 1.6%, 200/12,137), DIGEST-safety (incorrect PAS 0.4% 51/12,137) and DIGEST-efficiency (incorrect residue 1.2%, 148/12,137). Clinical implementation of DIGEST was feasible with high fidelity in a busy oncology practice across a large number of providers. Adoption of the tool across the lifespan in diverse cancer diagnoses may motivate validation beyond H&N oncology.

A custom device for managing recurrent tracheoesophageal voice prosthesis dislodgement and aspiration due to treatment refractory, severely enlarged puncture: A video case report.

We report the case of a laryngectomized patient with an enlarged tracheoesophageal puncture (TEP) that is refractory to standard treatments and culminating in life-threatening recurrent dislodgement and aspiration of custom fabricated dual extra-large flange voice prostheses (VP). The fabrication and use of a novel intraluminal prosthetic device to prevent dislodgement, lessen aspiration, and preserve TE voice is described. A custom device insetting a commercial VP into the posterior wall of a LaryTube (coined "inset-VP") was devised with the primary goal of eliminating chronic VP dislodgement and lessening aspiration while maintaining TE voice. Tools required to fabricate the device included a commercial laryngectomy tube, standard-flanged commercial indwelling voice prosthesis, felt-tip marker, 6 mm biopsy punch, and silk suture. After 7 months of using an inset-VP LaryTube device, the patient has experienced zero episodes of VP aspiration. Thin liquid aspiration control is equivalent or better than prior management with custom 24-30 mm dual collar prostheses. TEP voice is fluent and functional with device in place. Novel strategies are needed to manage the rare but devastating effects of a severely enlarged TEP. Solutions to manage symptoms need to be patient-specific, aligning with their anatomy, physiology, psychosocial needs, and goals. The inset-VP device described in this report may offer improved prosthetic retention in select patients with enlarged TE puncture and frequent VP dislodgements.

Intersection of Mental Health and Dysphonia: A Scoping Review.

OBJECTIVE: Previous research has indicated that voice disorders frequently co-occur with mental health disorders, which may influence voice treatment seeking behavior and effectiveness. Our goal is to characterize the existing literature on the relationship between voice disorders and mental health and to investigate nuances related to mental health and voice disorder diagnosis. DATA SOURCES: Ovid MEDLINE, ProQuest PsycINFO, and Web of Science. REVIEW METHODS: Using the PRISMA protocol, a scoping review was performed. Databases searched included: Ovid MEDLINE, ProQuest PsycINFO, and Web of Science. Our inclusion criteria were all adults seen in an outpatient setting for voice and mental health disorders, excluding those with a prior history of head and neck surgery, cancers, radiation, or developmental anomalies, and certain mental health disorders. Results were screened by two independent screeners for inclusion. Data were then extracted and analyzed to present key findings and characteristics. RESULTS: A total of 156 articles, with publication dates ranging from 1938 to 2021, were included in the analysis, with females and teachers being the most described population groups. The most frequently studied laryngeal disorders were dysphonia (n = 107, 68.6%), globus (n = 33, 21.2%), and dysphonia with globus (n = 16, 10.2%). The two most common mental health disorders found in the included studies were anxiety disorders (n = 123, 78.8%) and mood disorders (n = 111, 71.2%). The Voice Handicap Index was the most used tool to gather data on voice disorders (n = 36, 23.1%), while the Hospital Anxiety and Depression Scale was the most used tool to gather data on mental health disorders (n = 20, 12.8%). The populations studied within the included articles were predominately female and worked in educational occupations. Race and ethnicity was only reported for 10.2% of included articles (n = 16) and the most commonly studied race was White/Caucasian (n = 13, 8.3%). CONCLUSION: Our scoping review of the current literature on mental health and voice disorders reveals an intersection between the conditions. The current literature represents change over time in terms of terminology that recognizes the patient's individualized experience of mental health and laryngeal conditions. However, there is still a great deal of homogeneity in the studied patient populations in terms of race and gender, with patterns and gaps that require further investigation.

Clinical Validation of an Alternative Specimen Collection Kit for SARS-CoV-2 Testing at Fox Chase Cancer Center.

Background: Supply chain disruptions during the COVID-19 pandemic have affected the availability of components for specimen collection kits to detect SARS-CoV-2. Plastic injection molding offers a rapid and cheap method for mass production of swabs for upper respiratory tract sampling. Local production of virus transport medium increases flexibility to assemble sample collection kits if the medium provides appropriate stability for SARS-CoV-2 detection. Methods: A locally produced virus transport medium and a novel injection molded plastic swab were validated for SARS-CoV-2 detection by reverse-transcription quantitative polymerase chain reaction. Both components were compared to standard counterparts using viral reference material and representative patient samples. Results: Clinical testing showed no significant differences between molded and flocked swabs. Commercial and in-house virus transport media provided stable test results for over 40 days of specimen storage and showed no differences in test results using patient samples. Conclusions: This collection kit provides new supply chain options for SARS-CoV-2 testing.

Identification and management of late dysfunction in survivors of head and neck cancer: Implementation and outcomes of an interdisciplinary quality of life (IQOL) clinic.

BACKGROUND: Identifying and treating late dysfunction in survivors of head and neck cancer (HNC) is important; however, an effective way to do so is not established. METHODS: A quality improvement initiative altering our HNC survivorship clinic to include surveillance by rehabilitation providers was undertaken. The nature of dysfunction identified, along with the number and type of referrals to ancillary/support services were collected and compared to baseline. RESULTS: The baseline, single-provider, clinic evaluated 61 patients and referred 2 (3%) to ancillary/support services. Fifty-seven patients were evaluated in the interdisciplinary clinic, with 36 (63%) referred to at least one ancillary/support service for new/progressive dysfunction. Of 59 referrals made, 22 (37%) were for dysphagia, 17(29%) were for neck/shoulder dysfunction, and 28 (47%) were attended by the patient. CONCLUSION: Many HNC survivors exhibit late dysfunction appropriate for referral to ancillary/support services. A survivorship clinic including surveillance by rehabilitation specialists may optimize identification of dysfunction.

Patterns of Multidisciplinary Care of Head and Neck Squamous Cell Carcinoma in Medicare Patients.

Importance: Multidisciplinary care (MDC) yields proven benefits for patients with cancer, although it may be underused in the complex management of head and neck squamous cell carcinoma (HNSCC). Objective: To characterize the patterns of MDC in the treatment of HNSCC among elderly patients in the US. Design, Setting, and Participants: This nationwide, population-based, retrospective cohort study used Surveillance, Epidemiology, and End Results (SEER)-Medicare linked data from January 1, 1991, to December 31, 2011, to identify patients 66 years or older diagnosed with head and neck cancer and determine the dates of diagnosis, oncology consultations, treatment initiation, and speech therapy evaluation in addition to MDC completion. Multidisciplinary care was defined in a stage-dependent manner: localized disease necessitated consultations with radiation and surgical oncologists, and advanced-stage disease also included a medical oncology consultation, all before definitive treatment. Data were analyzed between December 2016 and September 2020. Main Outcomes and Measures: Rates of MDC across all subsites of head and neck cancer as measured by the presence of an evaluation for each oncologist on the MDC team and its effect on treatment initiation. Results: This cohort study assessed 28 293 patients with HNSCC (mean [SD] age, 75.1 [6.6] years; 67% male; 87% White) from the SEER-Medicare linked database. The HNSCC subsites included larynx (40%), oral cavity (30%), oropharynx (21%), hypopharynx (7%), and nasopharynx (2%). Overall, the practice of MDC significantly increased over time, from 24% in 1991 to 52% in 2011 (P < .001). For patients with localized (stage 0-II) tumors, 60% received care in the multidisciplinary setting, whereas 28% of those with advanced-stage disease did. A total of 18 181 patients (64%) were treated with initial definitive nonsurgical therapy across all stages. Regardless of stage and subsite, few patients (2%) underwent evaluation by a speech-language pathologist before definitive therapy. Multidisciplinary care prolonged the time to initiation of definitive treatment by 11 days for localized disease and 10 days for advanced disease. Conclusions and Relevance: This cohort study found that most elderly patients with localized HNSCC received MDC, whereas few patients with advanced-stage disease received such care, although a significant proportion received adjuvant therapy. Multidisciplinary care may prolong time to initiation of definitive treatment with an uncertain impact. Consultation with a speech-language pathologist before definitive therapy was rare.

Heat and moisture exchanger cassettes: Results of a quality/safety initiative to reduce postoperative mucus plugging after total laryngectomy.

BACKGROUND: Tracheal dryness is a concern after total laryngectomy due to the potential for mucus plugs (MP). This study compared heat and moisture exchanger (HME) cassettes to external tracheal humidification (ETH) surrounding MP events. METHODS: A retrospective comparative cohort study comparing outcomes before/after implementation of a patient safety initiative utilizing HME during post laryngectomy hospitalization. The number of MP events were compared with a pre-implementation control group using ETH. Patient characteristics were analyzed for correlation with MP. RESULTS: The rate of MP was significantly lower in the HME group than ETH (0.13 and 0.38 per 10 inpatient days, respectively, P = .02). The proportion of patients with one or more MP events was also significantly reduced in the HME group (50% ETH and 11% HME, P = .01). Method of humidification was the only significant variable associated with MP on logistic regression modeling (P = .008). CONCLUSIONS: HMEs were superior to ETH for prevention of MP.

Development of a Web-Based Supportive Care Program for Patients With Head and Neck Cancer.

Patients undergoing radiation treatment for head and neck cancer experience significant side-effects that can impact a wide range of daily activities. Patients often report receiving insufficient information during and after treatment, which could impede rehabilitation efforts; they may also encounter practical and logistical barriers to receipt of supportive care. Thus, we developed a web-based program, My Journey Ahead, to provide information and strategies for managing symptom-focused concerns, which may be easily accessed from the patient's home. The purpose of this study was to evaluate patient acceptability and satisfaction with the My Journey Ahead program. In Phase 1, five patients with head and neck squamous cell carcinoma (HNSCC) reviewed the web-based program and provided initial feedback, which informed program modifications. In Phase 2, 55 patients were recruited to evaluate the program. Patient assessments were obtained prior to and after use of the web-based program, and included measures of psychological distress, self-efficacy in coping with cancer-related issues, and satisfaction with the website. Among the 55 patients enrolled, 44 logged in and viewed the web-based program. Participants reported high levels of satisfaction with the information received, and indicated that the website was interesting and easy to use. Older age and higher levels of self-efficacy in coping were each associated with higher levels of satisfaction with the website. In summary, the web-based program was well-received by patients, the majority of whom found it to be informative and useful. An easy-to-use web-based program, particularly for older patients who may have difficulty locating reliable evidence-based information on the internet, may be helpful in addressing survivors' needs in symptom management and coping with cancer. CLINICAL TRIAL REGISTRATION: https://clinicaltrials.gov/, NCT02442336.

Dysphagia Screening for Pneumonia Prevention in a Cancer Hospital: Results of a Quality/Safety Initiative.

OBJECTIVE: Hospital-acquired aspiration pneumonia remains a rare but potentially devastating problem. The best means by which to prevent aspiration in a cancer hospital population has not been evaluated. The aim of this study was to evaluate the impact of dysphagia screening on aspiration pneumonia rates in an acute care oncology hospital. METHODS: A prospective single-institution quality improvement dysphagia screening protocol at a comprehensive cancer center. Effect of dysphagia screening implemented in 2016 on hospital-acquired aspiration pneumonia rates coded "aspiration pneumonitis due to food/vomitus" was compared with rates from 2014 to 2015 prior to implementation. Screening compliance, screening outcomes, patient demographics, and medical data were reviewed as part of a post hoc analysis. RESULTS: Of 12,392 admissions in 2014 to 2016, 97 patients developed aspiration pneumonia during their hospitalization. No significant change in aspiration pneumonia rate was seen during the dysphagia screening year when compared to prior years (baseline, 7.36; screening year, 8.78 per 1000 discharges; P = .33). Sixty-eight of the cases (66%) were associated with emesis/gastrointestinal obstruction or perioperative aspiration and only 15 (15%) with oropharyngeal dysphagia. Multivariate analysis found that patients admitted to gastrointestinal surgery had an aspiration risk equivalent to patients admitted to head and neck, thoracic, and pulmonary services (odds ratio, 0.65; P = .2). DISCUSSION: Nursing-initiated dysphagia screening did not decrease aspiration pneumonia rates. The causes of aspiration-associated pneumonia were heterogeneous. Aspiration of intestinal contents is a more common source of hospital-acquired pneumonia than oropharyngeal dysphagia.

Incidence and outcomes of radiation-induced late cranial neuropathy in 10-year survivors of head and neck cancer.

OBJECTIVES: To characterize the late cranial neuropathy among 10-year survivors of head and neck cancer treatment. MATERIALS AND METHODS: We retrospectively evaluated patients treated with curative-intent radiation for HNC between 1990 and 2005 at a single institution with systematic multidisciplinary follow-up ≥ 10 years. New findings of CNP were considered radiation-induced when examination, imaging and/or biopsy did not demonstrate a structural or malignant cause. Cox proportional hazards modeling was used for univariable analysis (UVA) and multivariable analysis (MVA) for time to CNP after completion of radiation. RESULTS: We identified 112 patients with no evidence of disease and follow-up ≥ 10 years (median 12.2). Sixteen (14%) patients developed at least one CNP. The median time to CNP was 7.7 years (range 0.6-10.6 years). Most common was CN XII deficit in eight patients (7%), followed by CN X deficit in seven patients (6%). Others included CN V deficit in three, and CN XI deficit in two. Eight of the thirteen patients with a CN X and/or CN XII deficit required a permanent gastrostomy tube. On UVA, site of primary disease, post-radiation neck dissection, chemotherapy, and radiation dose were significantly associated with increased risk of CNP. CONCLUSION: Iatrogenic CNP may develop years after head and neck cancer treatment and often leads to swallowing dysfunction. Long-term follow up is essential for these patients receiving head and neck radiation.

Understanding the role of speech language pathologists in managing dysphagia.

Collaboration between nurses and speech language pathologists is vital to the screening and management of dysphagia in acute care settings. This article examines each discipline's role in caring for patients with dysphagia.

Improved swallow outcomes after injection laryngoplasty in unilateral vocal fold immobility.

While the impact of injection laryngoplasty on voice outcomes in unilateral vocal fold immobility has been well characterized, there is a relative paucity of literature investigating its influence on swallow function and outcomes. We performed a retrospective chart review of patients presenting to an academic cancer center between January 2014 and January 2016 to evaluate the clinical impact of percutaneous injection laryngoplasty on reduction of aspiration risk, patient perception of swallowing, and recommended safe diet in patients with vocal fold immobility after head and neck and thoracic surgery. A consecutive sample of patients diagnosed with unilateral vocal fold immobility with patient- or clinician-identified abnormal swallow function who underwent bedside or in-office vocal fold injection was included in the study. Fiberoptic endoscopic evaluation of swallowing, Eating Assessment Tool-10 scores, Functional Oral Intake Scale scores, and patient perceptual assessment of swallow were evaluated pre- and postinjection. Twenty-one patients with new-onset unilateral vocal fold immobility who underwent injection laryngoplasty were evaluated. Median Eating Assessment Tool-10 and Functional Oral Intake Scale scores postinjection were significantly improved from preinjection. Patients who initially required restricted oral diets, or were nil per os, were able to advance their diet after injection laryngoplasty. Injection laryngoplasty is a safe and effective intervention for improvement of dysphagia in patients with unilateral vocal fold immobility. A single treatment may markedly reduce or eliminate risk of aspiration and potential sequelae.

Utility of Eating Assessment Tool-10 in Predicting Aspiration in Patients with Unilateral Vocal Fold Paralysis.

Objective Examine the incidence of penetration/aspiration in patients with unilateral vocal fold immobility and investigate the relationship with self-reported perception of dysphagia. Study Design Case series with chart review. Setting Academic cancer center. Subjects and Methods Adult patients with unilateral vocal fold immobility diagnosed between 2014 and 2016 were reviewed. Patients were stratified into an aspiration group and a nonaspiration group using objective findings on flexible endoscopic evaluation of swallowing, as scored using Rosenbek's Penetration Aspiration Scale. Objective findings were compared to patient perception of dysphagia. Bivariate linear correlation analysis was performed to evaluate correlation between Eating Assessment Tool-10 scores and presence of aspiration. Tests of diagnostic accuracy were calculated to investigate the predictive value of Eating Assessment Tool-10 scores >9 on aspiration risk. Results Of the 35 patients with new-onset unilateral vocal fold immobility were evaluated, 25.7% (9/35) demonstrated tracheal aspiration. Mean ± SD Eating Assessment Tool-10 scores were 19.2 ± 13.7 for aspirators and 7.0 ± 7.8 for nonaspirators ( P = .016). A statistically significant correlation was demonstrated between increasing Eating Assessment Tool-10 scores and Penetration Aspiration Scale scores ( r = 0.511, P = .002). Diagnostic accuracy analysis for aspiration risk in patients with an Eating Assessment Tool-10 score >9 revealed a sensitivity of 77.8% and a specificity of 73.1%. Conclusion Patient perception of swallowing difficulty may have utility in predicting aspiration risk. An EAT-10 of >9 in patients with unilateral vocal fold immobility may portend up to a 5 times greater risk of aspiration. Routine swallow testing to assess for penetration/aspiration may be indicated in patients with unilateral vocal fold immobility.

The Influence of Occupation on Self-perceived Vocal Problems in Patients With Voice Complaints.

OBJECTIVE: This study aimed to examine the relationships among patient occupation, laryngeal diagnosis, perceptual dysphonia severity, and patient-perceived voice impairment. METHODS: Adult patients presenting with a chief complaint of dysphonia over a 20-month period at a tertiary care, interdisciplinary voice center were included in this retrospective cohort study. Patients were categorized by profession: vocal performers, high occupational voice demand, low or no occupational voice demand, and retired. Associations between professional voice demand and clinician rating of dysphonia severity using the "Grade" score from the Grade, Roughness, Breathiness, Asthenia, and Strain scale and patient ratings of voice impairment using the Voice Handicap Index-10 (VHI-10) were tested using standard descriptive statistical methods. RESULTS: One hundred and sixty-three patients with a presenting complaint of dysphonia were evaluated. Significant associations were found on univariate and multivariable analysis among a patient's occupational voice demand, Grade, Roughness, Breathiness, Asthenia, and Strain grade, and VHI-10 score (P = 0.007 and P < 0.001, respectively). Patients subject to greater vocal demands as a result of their occupation had a greater perception of impairment, regardless of acoustic-perceptual severity, when compared with those with low or no occupational voice demand. Although voice diagnosis was significantly associated with VHI-10 score on univariate analysis, it failed to reach significance on multivariable analysis. Demographic measures such as gender and age also did not correlate with perceived vocal impairment. CONCLUSION: Patient-perception of voice impairment is influenced by occupational demand, independent of acoustic-perceptual dysphonia. Performers and people with high occupational voice needs demonstrate a unique sensitivity to subtle voice changes.

The Role of Occupational Voice Demand and Patient-Rated Impairment in Predicting Voice Therapy Adherence.

OBJECTIVE: Examine the relationship among the severity of patient-perceived voice impairment, perceptual dysphonia severity, occupational voice demand, and voice therapy adherence. Identify clinical predictors of increased risk for therapy nonadherence. METHODS: A retrospective cohort study of patients presenting with a chief complaint of persistent dysphonia at an interdisciplinary voice center was done. The Voice Handicap Index-10 (VHI-10) and the Voice-Related Quality of Life (V-RQOL) survey scores, clinician rating of dysphonia severity using the Grade score from the Grade, Roughness Breathiness, Asthenia, and Strain scale, occupational voice demand, and patient demographics were tested for associations with therapy adherence, defined as completion of the treatment plan. Classification and Regression Tree (CART) analysis was performed to establish thresholds for nonadherence risk. RESULTS: Of 166 patients evaluated, 111 were recommended for voice therapy. The therapy nonadherence rate was 56%. Occupational voice demand category, VHI-10, and V-RQOL scores were the only factors significantly correlated with therapy adherence (P < 0.0001, P = 0.018, and P = 0.008, respectively). CART analysis found that patients with low or no occupational voice demand are significantly more likely to be nonadherent with therapy than those with high occupational voice demand (P < 0.001). Furthermore, a VHI-10 score of ≤29 or a V-RQOL score of >40 is a significant cutoff point for predicting therapy nonadherence (P < 0.011 and P < 0.004, respectively). CONCLUSION: Occupational voice demand and patient perception of impairment are significantly and independently correlated with therapy adherence. A VHI-10 score of ≤9 or a V-RQOL score of >40 is a significant cutoff point for predicting nonadherence risk.

Maximizing Functional Outcomes in Head and Neck Cancer Survivors: Assessment and Rehabilitation.

With increases in survivorship for patients with head and neck cancer, attention is turning to quality-of-life issues for survivors. Care for these patients is multifaceted. Dysphagia and issues of voice/speech, airway obstruction, neck and shoulder dysfunction, lymphedema, and pain control are important to address. Rehabilitation interventions are patient-specific and aim to prevent, restore, compensate, and palliate symptoms and sequelae of treatment for optimal functioning. Central to providing comprehensive interdisciplinary care are the head and neck surgeon, laryngologist, and speech-language pathologist. Routine functional assessment, long-term follow-up, and regular communication and coordination among these specialists helps maximize quality of life in this challenging patient population.

Does Even Low-Grade Dysphonia Warrant Voice Center Referral?

OBJECTIVE: Data regarding the referral of dysphonic patients to specialty voice clinics are limited. The objective of this study is to examine the relationship between low perceptual dysphonia severity and subtle laryngeal findings to discern if this can help guide referral. STUDY DESIGN: This is a retrospective chart review. METHODS: The charts of 94 patients presenting with a primary complaint of hoarseness to a single laryngologist over a 1-year period at a tertiary care, interdisciplinary voice center were analyzed. Patients were stratified by clinician perceptual rating of dysphonia severity using the overall Grade score from the GRBAS (grade, roughness, breathiness, asthenia, strain) scale, and this was compared to their laryngeal findings on stroboscopy. RESULTS: Forty-one patients had a Grade score of 0 or 1, of whom 85% had relatively subtle findings on stroboscopy, including vocal fold paresis, muscle tension dysphonia, and spasmodic dysphonia. CONCLUSION: Patients with a primary complaint of hoarseness but absent or only mild perceptual dysphonia may have subtle or occult laryngeal findings that may be easily missed. These patients may benefit from early referral to a specialty voice center.

Inpatient injection laryngoplasty for vocal fold immobility: When is it really necessary?

PURPOSE: To compare pulmonary and swallow outcomes of injection laryngoplasty when performed in the acute versus subacute setting in head & neck and thoracic cancer patients presenting with new onset unilateral vocal fold immobility. MATERIALS AND METHODS: Case series with chart review at an academic cancer center over a 2year period. Based on swallow evaluation, patients diagnosed with vocal fold immobility were grouped into an unsafe swallow group, injected as inpatients, and a safe swallow group, for whom injection laryngoplasty was delayed to the outpatient setting or not performed. Rates of pneumonia, diet recommendations, and swallow outcomes were compared between groups. RESULTS: 24 patients with new-onset vocal fold immobility were evaluated. 7 underwent injection in the inpatient setting, 12 in the outpatient setting, and 5 did not undergo injection. There was no perceived difference in speech and swallow outcomes between the inpatient and outpatient injection groups. CONCLUSIONS: Injection laryngoplasty shows promise as an effective intervention for reducing aspiration risk and improving diet normalcy in patients with dysphagia as a result of unilateral vocal fold immobility. In patients determined to have a safe swallow, delay of injection laryngoplasty is not detrimental to swallow outcomes.

Treatment of Chronic Cough.

Objective Chronic cough remains a challenging condition, especially in cases where it persists despite comprehensive medical management. For these particular patients, there appears to be an emerging role for behavior modification therapy. We report a series of patients with refractory chronic cough to assess if there is any benefit of adding behavioral therapy to their treatment regimen. Study Design A case series with planned chart review of patients treated for chronic cough. Setting The review was performed with an outpatient electronic health record system at a tertiary care center. Subjects and Methods The charts of all patients treated for chronic cough by a single laryngologist over a 30-month period were analyzed. Patients' response to treatment and rate of cough improvement were assessed for those with refractory chronic cough who underwent behavior modification therapy. Results Thirty-eight patients with chronic cough were initially treated empirically for the most common causes of cough, of which 32% experienced improvement. Nineteen patients who did not significantly improve with medical management underwent behavior modification therapy with a speech-language pathologist. Of these patients, 84% experienced resolution or marked improvement of their symptoms. Conclusion Behavioral therapy may be underutilized in practice and could lead to improvement of otherwise recalcitrant cough.

Impact of baseline patient-reported dysphagia on acute gastrostomy placement in patients with head and neck squamous cell carcinoma undergoing definitive radiation.

BACKGROUND: Dysphagia-related symptoms in patients with head and neck cancer are common before treatment. We hypothesized greater self-reported baseline dysphagia would predict gastrostomy placement during primary radiation. METHODS: Swallowing-specific/general surveys (SwalQOL/EuroQOL) collected prospectively before definitive radiation were analyzed for associations with gastrostomy placement. Prophylactic gastrostomy was recommended at the discretion of a multidisciplinary team blinded to the surveys. RESULTS: Of 84 patients in the cohort, 42 patients (50%) received feeding tubes. Eleven patients (13%) who underwent prophylactic feeding tube placement reported the greatest pretreatment dysphagia, whereas those who avoided gastrostomies reported the least. Prophylactic gastrostomy was more strongly associated with patient-reported measures than other clinical criteria. Controlling for stage IV, T3 to T4 classification, smoking, chemotherapy, and pretreatment weight loss, baseline dysphagia remained an independent predictor of feeding tube placement (odds ratio [OR] = 0.12; 95% confidence interval [CI] = 0.05-0.55; p = .01). Patients without gastrostomies during treatment avoided persistent gastrostomy dependence. CONCLUSION: Baseline dysphagia-related symptoms before radiation are independent predictors of gastrostomy placement. © 2015 Wiley Periodicals, Inc. Head Neck 38: E1318-E1324, 2016.