xRead - Swallowing Disorders in the Adult Patient (October 2024)

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Coulter et al 2 20

7 Otolaryngology–Head and Neck Surgery Otolaryngology–Head and Neck Surgery, Vol. 168(1)

Sixty-seven percent of patients in the Buyukatalay et al 44 study and the single patient with dysphagia prior to surgery in the Baki et al 45 study improved after 6 months postoperatively while all patients continued to improve at 12 months. Dura tion of follow-up was variable, but when long-term follow-up was reported, the rates of recurrent dysphagia symptoms ranged from 0% to 18% with recurrence essentially isolated to reports of IL procedures that were not necessarily intended to provide long-term medialization. 35,39 While it can be assumed that the majority of subjects underwent some sort of dyspha gia therapy by a speech pathologist preceding and/or follow ing the medialization procedure, this was mentioned in just 1 study. 32 Dysphagia therapy has the potential to augment sur gical outcomes; therefore, this omission in the majority of studies examined here serves as a potential source of bias. Nine studies cited numeric outcomes before and after sur gery, as patient-reported outcome measures, objective radi ologic scores, or oral intake scores, and all but 2 studies 6,46 indicated improved mean or median outcomes after interven tion. Objective measures of swallowing, including those from VFS and FEES, were infrequently noted (eg, PAS), although patients who had preoperative aspiration based on VFS and/or FEES seemed to have high rates of improvement postopera tively. 17,25,35,36,47 Likewise, functional scales such as the Functional Outcome Swallowing Scale and FOIS were infre quently mentioned. The most common outcome measure was the EAT-10, which has excellent internal consistency, test retest reproducibility, and a strong correlation with aspiration events in patients with dysphagia. 48 The 4 studies using this outcome all noted improvement, with a reduction of 6 points, 44 4.5 points, 12 1point, 45 and 4.76 points. 41 Seven stud ies indicated improvement in dysphagia and/or aspiration as a percentage of the cohort without indication of a specific quan titative outcome measure. 19,23,25,31-33 In these studies, authors indicated that improvement was based on clinical assessment by the surgeon and/or speech pathologist after surgery at a defined interval, but specific methodology was not stipulated. Ten studies reported outcomes exclusively for UVFI related to recurrent nerve injury, most commonly from thor acic or anterior cervical surgery. Nine studies noted UVFI outcomes related to a variety of sources (central, high vagal, and idiopathic), although the recurrent nerve was typically the most common site of injury in those cohorts. Three relatively small studies 22,34,45 evaluated outcomes of high vagal or cen tral injuries only. Additionally, 3 studies 19,32,40 mentioned that patients with high vagal nerve, multiple cranial neuropathies, or central insults and UVFI had worse symptoms and outcomes after medialization procedures than those with recurrent laryn geal nerve injuries; however, this difference was not apparent by comparison of pooled outcomes among studies where, as stated previously, outcomes were generally positive for all. Though, this could have been a result of the relative rarity of high vagal and central causes in comparison with recurrent nerve injuries. Four studies did not specify the site of injury. While numerous studies investigating IL for dysphagia and/or aspiration in the acute setting have reported very good outcomes, the majority 14,36-38,47 did not document follow-up

9

7

10

intervention Notes MINORS

Immediately Retrospective study focused on swallowing outcomes

Retrospective study of arytenoid adduction

Retrospective study focused on swallowing outcomes

Follow-up after

all assessed at 3mo

mean 7mo

1mo POST,

outcomes, No. (%)

Dysphagia

68.5 LF Delayed NS 8 8/8 (100) overall success based on FILS; 6/8 improved after unilateral medialization laryngoplasty, 2/8

then improved after additional LF

Zuniga (2017) 41,c 21 RLN 65 IL Acute NS 21 Median FOIS improved 5 to 7; median EAT-10 improved 5 to 2; 9/ 21 diet modifications or NPO PRE (9/9 improved)

37 35/37 (95) improved at 3 mo POST Overall NS, but

Dysphagia, No. b

Reported

complication

major, 1 airway obstruction

Shi (2011) 33,c,d 37 RLN 44.5 LF Delayed Minor, 4 unspecified; Tateya (2010) 27,c 6 RLN, 1 central, 1 IDIO

Timing of

intervention

Mean

age, y Intervention

No. a and

injury

site of

Table 1. (continued)

Abbreviations: EAT-10, Eating Assessment Tool–10; FEES, functional endoscopic evaluation of swallowing; FILS, Food Intake Level Scale; FOIS, Functional Oral Intake Scale; FOSS, Functional Outcome Swallowing Scale; HVN, high vagal nerve; IDIO, idiopathic; IL, injection laryngoplasty; LF, laryngeal framework surgery; LR, laryngeal reinnervation; MINORS, Methodological Index for Nonrandomized Studies; NPO, nothing by mouth; NS, not specified; PAS, Penetration-Aspiration Scale; POST, postoperatively; PRE, preoperatively; RLN, recurrent laryngeal nerve; UNK, unknown; VFSS, videofluoroscopic swallow. a Total subjects in the cohort (whether or not they underwent a procedure or had dysphagia). b Subjects in each study who underwent a medialization procedure for UVFI with dysphagia and/or aspiration and PRE/POST dysphagia outcome data c Included in quantitative analysis of outcomes. d Included in quantitative analysis of complications.

Author (Year)