xRead - Swallowing Disorders in the Adult Patient (October 2024)
10976817, 2023, 1, Downloaded from https://aao-hnsfjournals.onlinelibrary.wiley.com/doi/10.1177/01945998211072832 by University Of Miami Libraries, Wiley Online Library on [01/07/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
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2 Coulter et al
Otolaryngology–Head and Neck Surgery
to 69% of those with UVFI have symptomatic dysphagia 4,5 while 20% to 50% have aspiration. 5 Management options for patients with UVFI and dysphagia generally consist of diet modification, dysphagia therapy, compensatory swallowing strategies, and sometimes surgical procedures to assist with glottic closure. Generally, the first step in decreasing aspiration risk is rheologic modification of the diet. Thicker consistencies have a much slower flow rate and cause an increase in pharyngeal pressures to facilitate upper esophageal sphincter relaxation. 6,7 Dysphagia therapy is also typically initiated simultaneously to improve swallow ing efficiency and reduce residue; however, these strategies are sometimes limited by patient cooperation. 8,9 When these measures are initiated in those with UVFI and dysphagia, suc cess rates as high as 73% have been reported. 9 Surgical options are typically considered only when these nonsurgical treatment strategies have failed to provide sufficient benefit. Impaired vocal fold closure weakens the creation of a physical barrier between the hypopharynx and trachea and reduces the ability to generate sufficient subglottic air pres sure. 10 Decreased sensation and pharyngeal weakness associ ated with central and high vagal nerve causes of UFVI can also significantly contribute to dysphagia and aspiration symptoms. 10-12 More severe dysphagia has been correlated with acute-onset UVFI, central causes, and impairment of upper esophageal sphincter relaxation. 5,13 However, while vocal fold closure may not be the only cause or potentially even the primary driver of symptoms in all individuals with UVFI-associated dysphagia, it is likely the most straightfor ward ‘‘target’’ to address surgically and is often the first type of procedure considered when conservative measures have been exhausted. Surgical options to improve glottal closure include injec tion laryngoplasty (IL), laryngeal framework (LF) surgery (medialization laryngoplasty with or without arytenoid adduc tion), and laryngeal reinnervation (LR). These surgical options are commonly employed for improvement of voice, but all of them can be performed to improve swallowing symptoms associated with impaired glottal closure due to UVFI as well. 7,10,12,14-27 While these surgical options are typi cally performed to address dysphagia and aspiration associ ated with UVFI and successful outcomes are generally reported in published studies, available data mainly consist of uncontrolled observational studies of relatively low quality. One systematic review recently investigated IL in the acute setting for aspiration, 28 but no published study has systemati cally evaluated the body of evidence available on all mediali zation procedures in regard to dysphagia outcomes (inclusive of aspiration). Therefore, in this systematic review and meta analysis, the objective is to examine and summarize the effect of vocal fold medialization procedures on outcomes of patients with dysphagia and UVFI. Additionally, we intend to stratify data by type of intervention and provide a summary of complications associated with these procedures.
Methods The current study was executed in accordance with the PRISMA statement (Preferred Reporting Items for Systematic Reviews and Meta-analyses). 29 This study was granted exemption by the Naval Medical Center–San Diego Institu tional Review Board. Search Strategy A comprehensive search strategy was applied in Ovid MED LINE, Embase, Web of Science, and CENTRAL (Cochrane Central Register of Controlled Trials) by a research librarian. The search was run from database inception to October 20, 2021. The following search terms were used: vocal fold paralysis, vocal fold immobility, glottic incompetence, unilat eral, deglutition disorders, dysphagia, aspiration, and swal lowing. Controlled vocabularies (MeSH terms and Emtree) were retrieved and applied in our search. The PRISMA approach for systematic reviews was followed in reporting the steps for including studies. The full list of references was screened for potentially relevant articles. Study Selection and Eligibility Criteria Two independent authors reviewed the identified studies and evaluated the titles and abstracts to locate potentially relevant articles. The full texts of the relevant articles were then evalu ated for eligibility. In case of a disagreement, a consensus was reached through a discussion among all authors. Studies were of any design, including case series, and reported on patients . 18 years of age with UVFI who underwent surgical inter vention to address glottic insufficiency and had pre- and postoperative swallowing data of any outcome related to swallowing, aspiration, and/or oral feeding status, with follow-up of any duration. Exclusion criteria were diagnoses other than unilateral vocal fold paralysis, interventions other than vocal fold augmentation/medialization procedures, pri mary or secondary outcomes not related to swallowing and/or aspiration, and full texts not available in English. Studies that comprised patients with unilateral and bilateral vocal fold immobility were included if the outcomes for those with uni lateral immobility could be extracted separately. Only the largest cohort meeting inclusion/exclusion criteria was included when studies from the same institution with overlap ping cohorts were encountered, if they could not clearly be separated. The PRISMA flow diagram is shown in Figure1 . Data Extraction The articles meeting inclusion and exclusion criteria were read in full, and the authors extracted data using a data extrac tion form. The form contained the author, year of publication, number of subjects, mean age, surgical intervention, minor and major complications, and dysphagia outcomes. Minor complications were those judged to be temporary or requiring minor intervention (ie, postoperative oxygen requirement or
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