Rehabilitation of neurogenic dysphagia with percutaneous endoscopic gastrostomy.

Neurogenic oropharyngeal dysphagia is common in nursing home populations, and the risk of aspiration is sufficient to indicate the need for percutaneous endoscopid gastrostomy (PEG) feedings. Although intake provided through the PEG may meet the nutritional and hydration requirements for this group of patients, the risk of complication, e.g., aspiration of reflux, skin breakdown at the site of insertion, potential for infection, digestive difficulties, higher risk of rehospitalization, pneumonia, prolonged nursing home stay, and greater morbidity than for those without PEG tubes, may compromise the gains accrued from the ease of feeding. In an attempt to reduce these complications and return individuals to per orum (PO) diets, a program was developed to treat the dysphagia. Sixteen male nursing home patients were enrolled in a treatment program based on videofluoroscopic examination. Interventions included combinations of dietary consistency modifications, compensatory techniques, and direct swallow retraining. Results indicated such an approach reintroduced successful oral feeding in all patients, improved dietary consistency, resulted in a mean weight gain of 5.1 pounds, yielded a mean albumin increase of 0.5 g/dl, and allowed PEG tubes to be removed in 10 of the 16 patients. As a result of intervention, these findings suggest significant benefits in both quality of life issues and health care savings for this neurogenically based population.

Recovery of postoperative swallowing in patients undergoing partial laryngectomy.

This study assessed the achievement of postoperative swallowing in patients undergoing partial laryngectomy surgery. Oropharyngeal swallow efficiency was used to predict time to achievement of outcome. Fifty-five patients were followed for up to 1 year in two hemilaryngectomy and four supraglottic laryngectomy groups. Within 10 days of healing, a videofluoroscopic evaluation enabled the measurement of swallowing efficiency. Times to achievement of oral intake, removal of feeding tube, preoperative diet, and normal swallow were analyzed using actuarial curves. Patients with hemilaryngectomies achieved swallowing rehabilitation sooner than patients with nonextended supraglottic laryngectomies (p < .05) who, in turn, achieved swallowing function sooner than did patients undergoing supraglottic laryngectomies with tongue base resection (p < .05). Median time to attainment of preoperative diet in these three groups was 28 days, 91 days, and > 335 days, respectively. Higher early postoperative oropharyngeal swallow efficiency was related to earlier achievement of oral food intake and of preoperative diet (p < .05). Results show that the time course for swallowing rehabilitation covers an extended postoperative period. In some surgical groups, functional swallowing and eating may be achieved within 3 months of surgery while for other types, significant impairment remains up to 9 months postoperatively Early radiographic assessments of swallowing function are useful in predicting the time to swallow recovery. Recovery of swallowing ability may be delayed in patients who have not achieved oral intake before radiotherapy is started.

Impact of the diagnostic procedure on outcome measures of swallowing rehabilitation in head and neck cancer patients.

This study was designed to determine whether swallow rehabilitation outcomes were affected by the type of evaluation procedure utilized by the clinician. The two evaluation techniques compared were the bedside examination and videofluoroscopy (the modified barium swallow). Ten institutions participated in this study, enrolling a total of 103 partial laryngectomized patients, 21 in the bedside arm and 82 in the videofluoroscopy arm. Data on recovery of oral intake were collected weekly. All patients received an X-ray study of swallow at 3 months after the operation. Mean time to oral intake of food was significantly lower in patients assessed with bedside examination. Overall swallow measures of transit times and swallow efficiencies after 3 months revealed significantly better function in the videofluoroscopy group. Results are discussed in terms of the visibility of swallow physiology with the two assessment techniques, the accuracy of therapy planning with the bedside examination versus videofluoroscopy and the ability of head and neck cancer patients to tolerate some aspiration without developing aspiration pneumonia.

Home treatment for aphasic patients by trained nonprofessionals.

Thirty-seven aphasic men received 8-10 hr of individual treatment each week for 12 weeks from a home therapist (wife, friend, relative) who was trained and directed by a speech pathologist. Treatment was followed by 12 weeks of no treatment. Patients were evaluated at entry and at 6, 12, 18, and 24 weeks after entry with a battery of speech and language measures. The group made substantial progress on all measures during the 12 weeks of treatment and ceased to progress when treatment was discontinued. Progress for the home treatment patients did not differ significantly from that of patients who received 12 weeks of individual treatment from speech pathologists or from that of patients for whom treatment was deferred for 12 weeks. Patient selection, training of the home therapists, and other methodological aspects are described to assist speech pathologists in making decisions about the use of trained volunteers in aphasia treatment.

Comparison of clinic, home, and deferred language treatment for aphasia. A Veterans Administration Cooperative Study.

Aphasic patients who met stringent selection criteria were assigned randomly to three groups: clinic treatment by a speech pathologist for 12 weeks, followed by 12 weeks of no treatment; home treatment by a trained volunteer for 12 weeks, followed by 12 weeks of no treatment; or deferred treatment for 12 weeks, followed by 12 weeks of treatment by a speech pathologist. At 12 weeks after entry, language measures indicated that the clinic-treatment patients made significantly more improvement than did the deferred-treatment patients, and improvement in home-treatment patients did not differ significantly from either clinic- or deferred-treatment patients. At 24 weeks after entry, after deferred-treatment patients had received clinic treatment, there were no significant differences among the groups. These results suggest that clinic treatment for aphasia is efficacious, and delaying treatment for 12 weeks does not compromise ultimate improvement.

Speech and swallow following Staffieri voice restoration procedure.

The Loyola University and Hines Veterans Administration Surgical Service completed the Staffieri procedure to construct a pharyngoesophageal flap at the time of total laryngectomy in 12 patients. Following surgery, 11 patients produced speech that was highly intelligible. Ultimately, seven continued to rely on this method of speech as their primary means of communication. Voice quality was judged to be rough, strained, wet, and breathy in a majority of patients. Aspiration of liquids was evident in 11 of 12. Four underwent revisions to reduce the size of the fistula and to correct swallowing problems.