Purpose NCI’s Common Terminology Criteria for Adverse Events (CTCAE) is the universal framework for toxicity reporting in oncology trials. We sought to develop a CTCAE-compatible modified barium swallow (MBS) grade for the purpose of grading pharyngeal dysphagia as a toxicity endpoint in cooperative group organ preservation trials for head and neck cancer (HNC). We hypothesized that a 5-point CTCAE-compatible MBS grade (“DIGEST”) based on the interaction of pharyngeal residue and laryngeal penetration/aspiration ratings is feasible and psychometrically sound. Methods A modified Delphi exercise was conducted for content validation, expert consensus, and operationalization of DIGEST criteria. Two blinded raters scored 100 MBS conducted before or after surgical or non-surgical organ preservation. Intra- and inter-rater reliability were tested by weighted Kappa. Criterion validity against OPSE, MBSImP™©, MDADI, and PSS-HN was assessed with one-way ANOVA and post hoc pairwise comparisons between DIGEST grades. Results Intra-rater reliability was excellent (weighted Kappa=0.82–0.84) with substantial to almost perfect agreement between raters (weighted Kappa=0.67–0.81). DIGEST significantly discriminated levels of pharyngeal pathophysiology (MBSImP™©: r=0.77, p<0.0001), swallow efficiency (OPSE: r=−0.56, p<0.0001), perceived dysphagia (MDADI: r=−0.41, p<0.0001), and oral intake (PSS-HN diet: r=−0.49, p<0.0001). Conclusions With the development of DIGEST, we have adapted MBS rating to the CTCAE nomenclature of ordinal toxicity grading used in oncology trials. DIGEST offers a psychometrically sound measure for HNC clinical trials and investigations of toxicity profiles, dose-response, and predictive modeling.

Head and neck cancer patients with tracheostomies and laryngectomies, as well as their healthcare providers, face unique challenges in the context of the current COVID-19 pandemic. This document consolidates best available evidence to date and presents recommendations to minimize the risks of aerosolization and SARS-CoV-2 exposures in both the inpatient and outpatient settings. The cornerstones of these recommendations include the use of closed-circuit ventilation whenever possible, cuffed tracheostomy tubes, judicious use of heat moisture exchange units, appropriate personal protective equipment for providers and patients, meticulous hand hygiene, and minimal manipulation of tracheostomy tubes.

The global pandemic of 2019 novel coronavirus disease (COVID-19) has tremendously altered routine medical service provision and imposed unprecedented challenges to the health care system. This impacts patients with dysphagia complications caused by head and neck cancers. As this pandemic of COVID-19 may last longer than severe acute respiratory syndrome (SARS) in 2003, a practical workflow for managing dysphagia is crucial to ensure a safe and efficient practice to patients and health care personnel. This document provides clinical practice guidelines based on available evidence to date to balance the risks of SARS-CoV-2 exposure with the risks associated with dysphagia. Critical considerations include reserving instrumental assessments for urgent cases only, optimizing the noninstrumental swallowing evaluation, appropriate use of personal protective equipment (PPE), and use of telehealth when appropriate. Despite significant limitations in clinical service provision during the pandemic of COVID-19, a safe and reasonable dysphagia care pathway can still be implemented with modifications of setup and application of newer technologies. K E Y

There is a high incidence of depressive symptoms in HNCA patients at 1 year following definitive therapy, which is independent of primary treatment modality and is associated with poorer global QOL and MDADI scores. Although depression and swallowing function are highly correlated, depression has a greater effect on QOL than swallowing scores, suggesting that early identification and aggressive treatment of patients with depressive symptoms is warranted to maximize post-treatment QOL.

The aim of this study was to examine the impact of gabapentin (neurontin) on swallowing and feeding tube use during chemoradiation (CRT) for oropharyngeal squamous cell carcinoma (OPSCC), and physiologic swallowing outcomes following completion of treatment. A total of 23 patients treated for OPSCC with concurrent CRT and prophylactically treated for pain using gabapentin were assessed. Historical controls were matched for T stage and primary site of disease. Timing of PEG use and removal were recorded. Video fluoroscopic swallowing studies were completed post-treatment to assess physiologic outcomes as well as penetration-aspiration scores (PAS). Functional oral intake scale (FOIS) scores were determined at the time of swallowing evaluation to assess diet level. Patients treated with gabapentin began using their PEG tubes later (3.7 vs. 2.29 weeks; P = 0.013) and had their PEG tubes removed earlier (7.29 vs. 32.56 weeks; P = 0.039) than the historical controls. A number of physiologic parameters were found to be less impacted in the gabapentin group, including oral bolus control (P = 0.01), epiglottic tilt (P = 0.0007), laryngeal elevation (P = 0.0017), and pharyngeal constriction (P = 0.002). PAS scores were significantly lower in the group treated with gabapentin (1.89 vs. 4; P = 0.0052). Patients receiving gabapentin had more advanced diet levels at the time of the initial swallowing study as evidenced by their FOIS scores (5.4 vs. 3.21; P = 0.0003). We conclude that patients using gabapentin for pain management during CRT appears to do well maintaining swallow function during treatment and have favorable post-treatment physiologic swallowing outcomes. Prospective evaluation is warranted.

Postoperative pneumonia is associated with increased mortality, complications, length of hospitalization, and hospital-related costs in HNCA surgical patients. Variables associated with an increased risk of pneumonia are inherent comorbidities in HNCA and known risk factors for VAP, making this a high-risk group for this never event. Caution must be used in the institution of reforms that threaten to inadequately reimburse the provision of care to this vulnerable population. Aggressive preoperative identification and treatment of underlying pulmonary disease, weight loss, and dysphagia may reduce morbidity and mortality.

Dysphonia and dysphagia are common complications of anterior cervical discectomy (ACD). We sought to determine the relationship between dysphagia and in-hospital mortality, complications, speech therapy/dysphagia training, length of hospitalization, and costs associated with ACD. Discharge data from the Nationwide Inpatient Sample for 1,649,871 patients who underwent ACD of fewer than four vertebrae for benign acquired disease between 2001 and 2010 were analyzed using cross-tabulations and multivariate regression modeling. Dysphagia was reported in 32,922 cases (2.0 %). Speech therapy/dysphagia training was reported in less than 0.1 % of all cases and in only 0.2 % of patients with dysphagia. Dysphagia was significantly associated with age ≥65 years (OR = 1.5 [95 % CI 1.4-1.7], P < 0.001), advanced comorbidity (OR = 2.3 [2.0-2.6], P < 0.001), revision surgery (OR = 2.7 [2.3-3.1], P < 0.001), disc prosthesis placement (OR = 1.5 [1.0-2.0], P = 0.029), and vocal cord paralysis (OR = 11.6 [8.3-16.1], P < 0.001). Dysphagia was a significant predictor of aspiration pneumonia (OR = 8.6 [6.7-10.9], P < 0.001), tracheostomy (OR = 2.3 [1.6-3.3], P < 0.001), gastrostomy (OR = 30.9 [25.3-37.8], P < 0.001), and speech therapy/dysphagia training (OR = 32.0 [15.4-66.4], P < 0.001). Aspiration pneumonia was significantly associated with in-hospital mortality (OR = 15.9 [11.0-23.1], P < 0.001). Dysphagia, vocal cord paralysis, and aspiration pneumonia were significant predictors of increased length of hospitalization and hospital-related costs, with aspiration pneumonia having the single largest impact on length of hospitalization and costs. Dysphagia is significantly associated with increased morbidity, length of hospitalization, and hospital-related costs in ACD patients. Despite the known risk of dysphagia in ACD patients and an established role for the speech-language pathologist in dysphagia management, speech-language pathology intervention appears underutilized in this population.

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