The voice and laryngeal dysfunction in stroke: A report from the Neurolaryngology Subcommittee of the American Academy of Otolaryngology–Head and Neck Surgery

OBJECTIVE: Stroke is the third leading cause of death in the United States, behind heart disease and cancer. It affects as many as 5% of the population over 65 years old, and this number is growing annually due to the aging population. A significant portion of stroke patients that initially survive are faced with the risk of aspiration, as well as quality-of-life issues relating to impaired communication. The goal of this paper is to define the scope of practice in otolaryngology for these patients, and to review pertinent background literature. STUDY DESIGN: Consensus report and retrospective literature review. RESULTS: Otolaryngology involvement in these patients is critical to their rehabilitation, which often requires an interdisciplinary team of specialists. This committee presentation explores epidemiological data regarding the impact of stroke and its complications on hospitalizations. A pertinent review of neuroanatomy as it relates to laryngeal function is also discussed. State-of-the-art diagnostic and therapeutic procedures are presented. CONCLUSION: There is a well-defined set of diagnostic and therapeutic options for laryngeal dysfunction in the stroke patient. SIGNIFICANCE: Otolaryngologists play a critical role in the interdisciplinary rehabilitation team.     

Dysphagia in a Patient with Wegener's Granulomatosis: Case Report

Wegener's Granulomatosis is an autoimmune disease characterized by a rare form of systemic vasculitis which can result in damage to vital organs of the body by restricting blood flow to those organs. It affects various systems of the body including the central nervous system and cranial nerves. To our knowledge, there are no previous described cases of oropharyngeal dysphagia in these patients. This paper describes and discusses a case of oropharyngeal dysphagia in a patient with Wegener's Granulomatosis. Submitted March 3, 1999; accepted July 26, 2000 with revision     

Dysphagia and expiratory air flow

Expiratory air flow preserves the freedom of the upper airway from foodway contamination in patients with dysphagia. Valving the tracheostomy cannula, quad coughing, the Heimlich maneuver, the supraglottic swallow, and coupling to a ventilator each has a place among the measures used for treating aspiration.     

Dietary management of swallowing disorders

Two major concerns in the dietary management of the dysphagic patient are to maintain adequate nutrition and to ensure safety during oral feeding. Dysphagic patients require modifications of standard hospital diets. Kitchen or nursing staff must remove from standard diet trays solid foods and liquids that pose swallowing hazards. Training kitchen and nursing staff and removing food are time consuming. It is also hazardous if certain foods are served to dysphagic patients through error or lack of knowledge. In addition, there is risk of inadequate nutrition when food is removed from trays. This paper proposes a four-level diet plan for patients who have difficulty swallowing solids and liquids. These diets gradually advance for patients undergoing treatment to improve swallowing function. The proposed diets save time for kitchen and nursing staff, reduce the risk of aspiration among patients, and serve as models for families as they prepare for discharge and meal planning at home. Diet guidelines are based on recommendations of the American Dietetic Association.     

Comparison of Acute Toxicities in Two Primary Chemoradiation Regimens in the Treatment of Advanced Head and Neck Squamous Cell Carcinoma

Purpose

The optimal dosage and frequency of platinum-based chemoradiotherapy (CRT) regimen for treating advanced head and neck squamous cell carcinoma remains unresolved. This study aims to compare the toxicity and efficacy of weekly versus more dose-intensive cisplatin-based CRTs.

Methods

We reviewed 155 stage III/IV head and neck squamous cell carcinoma patients with no evidence of distant metastasis treated with one of two CRT regimens from 2000 to 2010 at Greater Baltimore Medical Center. Twice-daily radiation was provided as a split course over a 45-day period. Regimen A consisted of concomitant cisplatin (30?mg/m²/1?h) weekly for 6 cycles; regimen B consisted of concomitant cisplatin (12?mg/m²/1?h) and 5-fluorouracil (600?mg/m²/20?h) on days 1 through 5 and days 29 through 33. Main outcome measures included acute toxicities (myelosuppression, neurotoxicity, nephrotoxicity, gastrointestinal dysfunction), unplanned hospitalizations, and disease control at 12?months.

Results

Patients on regimen A were much less likely to experience ototoxicity due to their treatment (0% vs. 9.8%, P?=?0.04). They were more likely to experience thrombocytopenia acutely (46% vs. 26%, P?=?0.02), but the toxicity was not limiting (grade 1?C2). No significant differences exist in the incidence of other toxicities or unplanned hospitalizations. At 1?year, 97% of patients on A vs. 86% of patients on regimen B were free of disease (P?=?0.11).

Conclusions

With concurrent radiotherapy, low-dose, single-agent, weekly cisplatin is less likely than higher-dose daily cisplatin plus 5-fluorouracil provided at the beginning and end of treatment to be associated with ototoxicity. The preliminary data suggest at least equivalent efficacy, but longer follow-up is required.