Background and Purpose-Dysphagia can lead to pneumonia and subsequent death after acute stroke. However, no prospective study has demonstrated reduced pneumonia prevalence after implementation of a dysphagia screen. Methods-We performed a single-center prospective interrupted time series trial of a quality initiative to improve dysphagia screening. Subjects included all patients with ischemic or hemorrhagic stroke admitted to our institution over 42 months with a 31-month (n=1686) preintervention and an 11-month (n=648) postintervention period. The intervention consisted of a dysphagia protocol with a nurse-administered bedside dysphagia screen and a reflexive rapid clinical swallow evaluation by a speech pathologist. Results-The dysphagia initiative increased the percentage of patients with stroke screened from 39.3% to 74.2% (P<0.001).Furthermore, this initiative coincided with a drop in hospital-acquired pneumonia from 6.5% to 2.8% among patients with stroke (P<0.001). Patients admitted postinitiative had 57% lower odds of pneumonia, after controlling for multiple confounds (odds ratio=0.43; confidence interval, 0.255-0.711; P=0.0011). The best predictors of pneumonia were stroke type (P<0.0001), oral intake status (P<0.0001), dysphagia screening status (P=0.0037), and hospitalization before the beginning of the quality improvement initiative (P=0.0449). Conclusions-A quality improvement initiative using a nurse-administered bedside screen with rapid bedside swallow evaluation by a speech pathologist improves screening compliance and correlates with decreased prevalence of pneumonia among patients with stroke. (Stroke. 2013;44:3154-3160.)Key Words: cerebral hemorrhage ◼ dysphagia ◼ ischemic stroke ◼ pneumonia ◼ quality initiative ◼ screening ◼ subarachnoid hemorrhage

Background We validated the new European Organisation for Research and Treatment of Cancer Quality of Life Head and Neck Module (EORTC QLQ‐HN43). Methods We enrolled 812 patients with head and neck cancer from 18 countries. Group 1 completed the questionnaire before therapy, and 3 and 6 months later. In group 2 (survivors), we determined test–retest reliability using intraclass correlation coefficients (ICC). Internal consistency was assessed using Cronbach's Alpha, the scale structure with confirmatory factor analysis, and discriminant validity with known‐group comparisons. Results Cronbach's alpha was >0.70 in 10 of the 12 multi‐item scales. All standardized factor loadings exceeded 0.40. The ICC was >0.70 in all but two scales. Differences in scale scores between known‐groups were >10 points in 17 of the 19 scales. Sensitivity to change was found to be sufficient in 18 scales. Conclusions Evidence supports the reliability and validity of the EORTC QLQ‐HN43 as a measure of quality of life.

Objectives/Hypothesis Head and neck cancer pain is a prevalent problem, and the current opioid crisis has highlighted concerns raised in chronic pain management. This study assessed the characteristics of opioid use in patients undergoing treatment for oropharynx cancer and identified risk factors associated with chronic opioid use. Study Design Retrospective cohort study. Methods A study was conducted of 198 eligible patients who underwent radiotherapy as part of their treatment for oropharynx cancer at a single institution from 2012 to 2017. p16/human papillomavirus (HPV) status was determined by pathology report review. Opioid use was recorded. Statistical analysis was performed to assess risk factors for chronic opioid use and effect on overall survival. Results The average age was 62 years, and the mean follow‐up was 38 months. Eighty‐three percent of patients had stage III/IV disease, and 73% received chemoradiotherapy. Sixty‐nine percent were HPV/p16 positive. Fifty‐seven (29%) patients had preexisting chronic pain conditions. Chronic opioid use was observed in 53% of the patients. Age ≤ 62 years (P < .0001), history of depression (P = .0356), p16 negative status (P = .0097), opioid use at pretreatment visit (P = .0021), and presence of a preexisting chronic pain condition at time of diagnosis (P = .0181) were associated with chronic opioid use using univariate analysis. On multivariate analysis, T stage and anxiety/depression were associated with chronic opioid use. Overall survival was worse for patients who had chronic opioid use, but was not significant when recurrence was taken into consideration. Conclusions More than 50% of the patients treated for oropharynx squamous cell carcinoma in this cohort were chronic opioid users after treatment. Identifying patients at greatest risk for chronic opioid use prior to treatment may help with long‐term pain management in this patient population. Level of Evidence 4 Laryngoscope, 129:2087–2093, 2019

Purpose The aim of this study was to explore what methods should be used to determine the minimal important difference (MID) and minimal important change (MIC) in scores for the European Organisation for Research and Treatment of Cancer Head and Neck Cancer Module, the EORTC QLQ-HN43. Methods In an international multi-centre study, patients with head and neck cancer completed the EORTC QLQ-HN43 before the onset of treatment (t1), three months after baseline (t2), and six months after baseline (t3). The methods explored for determining the MID were: (1) group comparisons based on performance status; (2) 0.5 and 0.3 standard deviation and standard error of the mean. The methods examined for the MIC were patients' subjective change ratings and receiver-operating characteristics (ROC) curves, predictive modelling, standard deviation, and standard error of the mean. The EORTC QLQ-HN43 Swallowing scale was used to investigate these methods. Results From 28 hospitals in 18 countries, 503 patients participated. Correlations with the performance status were |r|< 0.4 in 17 out of 19 scales; hence, performance status was regarded as an unsuitable anchor. The ROC approach yielded an implausible MIC and was also discarded. The remaining approaches worked well and delivered MID values ranging from 10 to 14; the MIC for deterioration ranged from 8 to 16 and the MIC for improvement from − 3 to − 14. Conclusions For determining MIDs of the remaining scales of the EORTC QLQ-HN43, we will omit comparisons of groups based on the Karnofsky Performance Score. Other external anchors are needed instead. Distribution-based methods worked well and will be applied as a starting strategy for analyses. For the calculation of MICs, subjective change ratings, predictive modelling, and standard-deviation based approaches are suitable methods whereas ROC analyses seem to be inappropriate.

Background. Endoscopic dilation of postlaryngectomy strictures (PLS) is safe and effective; however, PLS are often refractory and require serial dilations. Long-term outcomes of dilation in patients with refractory PLS are not well reported. Materials and Methods. Seven patients with dysphagia and refractory PLS underwent serial endoscopic dilation therapy during a 4.5-year period. Dilation characteristics, technical success, clinical success, and diet advancement (as assessed by Diet/GT scale) were measured. Results. All strictures were complex, and there were no reported complications. The median number of dilations per patient was 12 (range 7 to 48). The average interval in between dilations was six weeks. Technical success was achieved in 6/7 patients, and clinical success was achieved in 2/7 patients. 6/7 patients had advancements in Diet/GT scores. Conclusions. Dilation of refractory PLS is safe and effective and frequently requires the use of a retrograde approach, fluoroscopic guidance, and/or lumen patency strings. Serial dilations are required to maintain luminal patency, relieve dysphagia, and advance oral diet. The definition of clinical success of dilation in these patients should avoid the use of a specific time interval between dilations to characterize success.

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Swallowing dysfunction remains a common problem after minimally invasive esophagectomy (MIE) with cervical anastomosis and can be readily identified. Silent aspiration likely contributes to pneumonia after MIE.

Background: Total laryngectomy (TL) is standard intervention for carcinoma of the head and neck or, in cases of non-functional larynx, as a result of disease or radiation exposure. Laryngeal extirpation serves as a unique human model of both recurrent and superior laryngeal nerve section and offers insight into motor and sensory aspects of cough: both volitional and in response to tussigenic stimuli. While motor changes in cough function are expected among those status post-TL due to postoperative reconstruction of the upper airway, motor cough parameters have not been well described and sensory aspects of cough are unknown in this population, which provides insight into a vagal denervation model in humans. Methods: Data were collected from three groups totaling 80 adults (39 male), including 25 healthy younger adults (HYA), 27 healthy older adults (HOA), and 28 adults post-TL. Cough was elicited both upon command and in response to nebulized capsaicin. Outcome measures included urge to cough and cough airflows. Results: Kruskal-Wallis test showed that two of the three groups differed significantly by urge to cough χ 2 (2, N = 244) = 8.974, p = 0.011. Post hoc analysis showed that post-TL subjects had reduced perceived urge to cough at all concentrations of capsaicin (p < 0.05). Cough airflows were significantly reduced for post-TL subjects compared to healthy controls in all metrics except post-peak phase integral (PPPI) for which HOA and TLs were comparable under both volitional and capsaicin-induced conditions. Conclusions: These findings support the hypothesis that both cough airflow and sensations are significantly reduced in post-TL subjects when compared with HOA. Interestingly, HOA and post-TL subjects have comparably reduced UTC and cough airflows when compared to HYA. The only metric of cough airflow for which these groups differ is the PPPI, which may be a compensatory adaptation for reduced cough airflows and/or sensation.