Sriramya Lapa

Importance: Dysphagia is frequently observed in patients with posterior fossa tumor (PFT). Surgery can cause either deterioration of or improvement in preexisting dysphagia. In this context, imaging findings might help in predicting postsurgical dysphagic outcomes. Objective: To identify radiological predictors for worsening or improvement in presurgical dysphagia, and for any new onset of postsurgical dysphagia, by analyzing the presurgical brain magnetic resonance imaging (pMRI). Setting: Tertiary referral hospital. Participants: Patients undergoing neurosurgical treatment for PFT. Intervention: Flexible endoscopic evaluation of swallowing, before and after surgery. Main Outcome Measures: pMRI findings (presence of affection of cranial nerves V, VII, IX, X, and XII, ventrocaudal pontine compression, olivary compression, hydrocephalus) associated with postsurgical dysphagia outcomes. Dysphagia severity was rated according to the Fiberoptic Endoscopic Dysphagia Severity Scale (FEDSS). Results: Forty-three patients (60.5% female, 51.5 ± 15.6 years) with PFT-surgery were included. Presurgical dysphagia rate increased from 72.1% (n = 31), with a median FEDSS of 1 (IQR 2 range 1-5), to 79.1% (n = 34). In 46.5% (n = 20) of the cases deterioration of presurgical dysphagia was observed with a median of 1 (IQR 3, range 1-6), while 8 subjects showed a new onset of dysphagia. In 23.3% (n = 10) of the patients, an improvement in presurgical dysphagia was observed. In 2 cases, dysphagia severity decreased from severe to mild. pMRI did not show a significant association with postsurgical dysphagic outcome. Conclusions: Morphological characteristics of the brain tumor prior to surgery are not associated with dysphagia outcome. Besides the small sample size limiting statistical analysis, one may postulate that pMRI findings alone might not suffice to predict dysphagia outcome in patients after PFT-surgery. Relevance: Our study provides insights into possible characteristics of the tumor in relation to dysphagia outcome. Future studies warrant a larger cohort, analysis of intraoperative factors, and findings from postsurgical MRI, to fully understand dysphagia outcome after PFT-surgery.

Objective: Seizures can cause transient neurological symptoms, such as hemiparesis and aphasia. However, temporary swallowing changes leading to postictal dysphagia have not been previously described. Therefore, this study evaluated the presence of swallowing disorders following seizure. In addition, dysphagia severity and duration of any recovery from dysphagic symptoms were investigated. Methods: The local clinical database of all fiberoptic endoscopic evaluation of swallowing (FEES) examinations performed from 2008 to 2019 was screened for patients diagnosed with seizures, but excluding patients with intensive care unit admission or intubation >24 h. Patient charts were evaluated to identify preexisting dysphagia or potential concurrent medical causes for dysphagia, including hyponatremia, increased intracranial pressure, sepsis, or other encephalopathies associated with infections, or other possible causes at the time of admission. Patients receiving >.5 defined daily doses of benzodiazepines or neuroleptics were also excluded. Age, sex, seizure semiology and etiology, comorbidities, concurrent pneumonia, and dysphagia course during hospitalization were evaluated as predictors of the occurrence of dysphagia or its potential duration. Results: We identified 41 patients with dysphagia following a seizure, without evidence of any concurrent cause of swallowing dysfunction. These patients all presented with focal structural epilepsy, they had a mean age of 79 +/- 11.3 years (range = 44-95 years), and 21 were women. The mean Elixhauser Comorbidity Score was 4.8. Hospital-acquired pneumonia was detected in 21 patients (51.2%). FEES diagnosed mild and severe dysphagia in 21 (51.2%) and 20 (48.8%) patients, respectively. Dysphagia improved significantly (p = .001) during hospitalization, persisting for an average of 3.9 days (median = 3 days, SD = 2.07 days, range = 1-8 days). Significance: Dysphagia is a potential transient neurological deficit following seizure. Our findings suggest that older patients, with focal structural epilepsy, are at risk for postictal dysphagia. Further studies are needed to ascertain the prevalence, complications, and predictors of postictal dysphagia. Dysphagia screening may improve early detection in patients with relevant risk factors, as well as reduce the occurrence of aspiration pneumonia.

Zusammenfassung Hintergrund Neurogene Dysphagien sind ein häufiges Symptom bei einer Vielzahl neurologischer Erkrankungen. Die Etablierung der flexiblen endoskopischen Evaluation des Schluckaktes (FEES) im Arbeitsfeld der Neurologie hat zu einer verbesserten Diagnostik und Therapie von Patienten mit Schluckstörungen geführt. Fragestellung Ziel dieses Reviews ist es, die Entwicklung der FEES-Untersuchung in der Neurologie darzustellen, ihren Mehrwert in der diagnostischen Einordnung neurogener Dysphagien zu erläutern sowie ihren Einfluss auf das Therapiemanagement bei dysphagischen Patienten zu beleuchten. Material und Methoden Narrativer Literaturreview Ergebnisse Die FEES-Untersuchung ist eine sichere und gut verträgliche Methode in der Diagnostik neurogener Dysphagien. Sie ermöglicht, den Schluckakt innerhalb des sehr heterogenen neurologischen Patientenkollektivs valide zu untersuchen. Dabei hat sie sich zu einem wichtigen Diagnostikum nicht nur in der Erfassung des Dysphagieschweregrads und des Aspirationsrisikos, sondern auch als verlässliche Methode zur ätiologischen Einordung dysphagischer Symptome entwickelt. Da die FEES ohne Strahlenexposition auskommt und mobil einsetzbar ist, ermöglicht sie neben der Untersuchung kritisch kranker Patienten („Bedside-Diagnostik“) auch die Beurteilung therapeutischer Maßnahmen. Schlussfolgerung Die systematische endoskopische Untersuchung des Schluckaktes ist als wichtige Funktionsdiagnostik im Bereich der Neurologie etabliert. Diese gilt es, noch weiterzuentwickeln, damit sie in gleichem Maße auch in den klinisch verwandten Fächern wie der Neurochirurgie, Neuroonkologie und Psychiatrie Anwendung findet.

Background: Dysphagia is a frequent symptom in acute ischemic stroke (AIS). Endovascular treatment (EVT) has become the standard of care for acute stroke secondary to large vessel occlusion. Although standardized guidelines for poststroke dysphagia (PSD) management exist, they do not account for this setting in which patients receive EVT under general anesthesia. Therefore, the aim of this study was to evaluate PSD prevalence and severity, as well as an appropriate time point for the PSD evaluation, in patients undergoing EVT under general anesthesia (GA).Methods: We prospectively included 54 AIS patients undergoing EVT under GA. Fiberoptic Endoscopic Evaluation of Swallowing (FEES) was performed within 24 h post-extubation in all patients. Patients presenting significant PSD received a second FEES-assessment to determine the course of dysphagia deficits over time. Dysphagia severity was rated according the Fiberoptic Dysphagia Severity Scale (FEDSS).Results: At first FEES (FEES 1) assessment, performed in the median 13 h (IQR 5–17) post-extubation, 49/54 patients (90.7%) with dysphagia were observed with a median FEDSS of 4 (IQR 3–6). Severe dysphagia requiring tube feeding was identified in 28/54 (51.9%) subjects, whereas in 21 (38.9%) patients early oral diet with certain food restrictions could be initiated. In the follow up FEES examination conducted in the median 72 h (IQR 70–97 h) after initial FEES 34/49 (69.4%) patients still presented PSD. Age (p = 0.030) and ventilation time (p = 0.035) were significantly associated with the presence of PSD at the second FEES evaluation. Significant improvement of dysphagia frequency (p = 0.006) and dysphagia severity (p = 0.001) could be detected between the first and second dysphagia assessment.Conclusions: PSD is a frequent finding both immediately within 24 h after extubation, as well as in the short-term course. In contrast to common clinical practice, to delay evaluation of swallowing for at least 24 h post-extubation, we recommend a timely assessment of swallowing function after extubation, as 50% of patients were safe to begin oral intake. Given the high amount of severe dysphagic symptoms, we strongly recommend application of instrumental swallowing diagnostics due to its higher sensitivity, when compared to clinical swallowing examination. Furthermore, advanced age, as well as prolonged intubation, were identified as significant predictors for delayed recovery of swallowing function.

Background and Purpose: Dysphagia is a common and severe symptom of acute stroke. Although intracerebral hemorrhages (ICHs) account for 10% to 15% of all strokes, the occurrence of dysphagia in this subtype of stroke has not been widely investigated. The aim of this study was to evaluate the overall frequency and associated lesion locations and clinical predictors of dysphagia in patients with acute ICH. Methods: Our analysis included 132 patients with acute ICH. Clinical swallowing assessment was performed within 48 hours after admission. All patients underwent computed tomography imaging. Voxel-based lesion-symptom mapping was performed to determine lesion sites associated with dysphagia. Results: Eighty-four patients (63.6%) were classified as dysphagic. Higher scores on the National Institutes of Health Stroke Scale, larger ICH volumes, and higher degree of disability were associated with dysphagia. Voxels showing a statistically significant association with dysphagia were mainly located in the right insular cortex, the right central operculum, as well as the basal ganglia, corona radiata, and the left thalamus and left internal capsule. In contrast to lobar regions, in subcortical deep brain areas also small lesion volumes (<10 mL) were associated with a substantial risk of dysphagia. Intraventricular ICH extension and midline shift as imaging findings indicating a space-occupying effect were not associated with dysphagia in multivariate analysis. Conclusions: Dysphagia is a frequent symptom in acute ICH. Distinct cortical and subcortical lesion sites are related to swallowing dysfunction and predictive for the development of dysphagia. Therefore, patients with ICH should be carefully evaluated for dysphagia independently from lesion size, in particular if deep brain regions are affected.

Background: While swallowing disorders are frequent sequela following posterior fossa tumor (PFT) surgery in children, data on dysphagia frequency, severity, and outcome in adults are lacking. The aim of this study was to investigate dysphagia before and after surgical removal of PFT. Additionally, we tried to identify clinical predictors for postsurgical swallowing disorders. Furthermore, this study explored the three-month outcome of dysphagic patients. Methods: In a cohort of patients undergoing PFT surgery, dysphagia was prospectively assessed pre- and postoperatively using fiberoptic endoscopic evaluation of swallowing. Patients with severe dysphagia at discharge were re-evaluated after three months. Additionally, clinical and imaging data were collected to identify predictors for post-surgical dysphagia. Results: We included 26 patients of whom 15 had pre-operative swallowing disorders. After surgery, worsening of pre-existing dysphagia could be noticed in 7 patients whereas improvement was observed in 2 and full recovery in 3 subjects. New-onset dysphagia after surgery occurred in a minority of 3 cases. Postoperatively, 47% of dysphagic patients required nasogastric tube feeding. Re-evaluation after three months of follow-up revealed that all dysphagic patients had returned to full oral intake. Conclusion: Dysphagia is a frequent finding in patients with PFT already before surgery. Surgical intervention can infer a deterioration of impaired swallowing function placing affected patients at temporary risk for aspiration. In contrast, surgery can also accomplish beneficial results resulting in both improvement and full recovery. Overall, our findings show the need of early dysphagia assessment to define the safest feeding route for the patient.

Objective: Deep brain stimulation (DBS) of the ventral intermediate nucleus (VIM) is a mainstay treatment for severe and drug‐refractory essential tremor (ET). Although stimulation‐induced dysarthria has been extensively described, possible impairment of swallowing has not been systematically investigated yet.Methods: Twelve patients with ET and bilateral VIM‐DBS with self‐reported dysphagia after VIM‐DBS were included. Swallowing function was assessed clinically and using by flexible endoscopic evaluation of swallowing in the stim‐ON and in the stim‐OFF condition. Presence, severity, and improvement of dysphagia were recorded.Results: During stim‐ON, the presence of dysphagia could be objectified in all patients, 42% showing mild, 42% moderate, and 16 % severe dysphagia. During stim‐OFF, all patients experienced a statistically significant improvement of swallowing function.Interpretation: VIM‐DBS may have an impact on swallowing physiology in ET‐patients. Further studies to elucidate the prevalence and underlying pathophysiological mechanisms are warranted.

At present, the flexible endoscopic evaluation of swallowing (FEES) is one of the most commonly used methods for the objective assessment of swallowing. This multicenter trial prospectively collected data on the safety of FEES and also assessed the impact of this procedure on clinical dysphagia management. Patients were recruited in 23 hospitals in Germany and Switzerland from September 2014 to May 2017. Patient characteristics, professional affiliation of the FEES examiners (physicians or speech and language therapists), side-effects and cardiorespiratory parameters, severity of dysphagia and clinical consequences of FEES were documented. 2401 patients, mean age 69.8 (14.6) years, 42.3% women, were included in the FEES-registry. The most common main diagnosis was stroke (61%), followed by Parkinson’s disease (6.5%). FEES was well tolerated by patients. Complications were reported in 2% of examinations, were all self-limited and resolved without sequelae and showed no correlation to the endoscopist’s previous experience. In more than 50% of investigations FEES led to changes of feeding strategies, in the majority of cases an upgrade of oral diet was possible. This study confirmed that FEES, even when performed by less experienced clinicians is a safe and well tolerated procedure and significantly impacts on the patients’ clinical course. Implementation of a FEES-service in different clinical settings may improve dysphagia care. ClinicalTrials.gov NCT03037762, registered January 31st 2017.

Background and Purpose—: Little is known about the frequency and the clinical characteristics of neurogenic dysphagia in pontine strokes. In this study, we sought to identify predictors for dysphagia in a cohort of patients with isolated pontine infarctions. Methods—: We included all patients admitted to our department between 2008 and 2014 having an acute (P P =0.004) and in the anterolateral vascular territory (78.6% versus 31.1%; P =0.002) occurred more often in the dysphagic group. In a multivariate model, age, infarct volume, and National Institutes of Health Stroke Scale value were independent predictors of dysphagia. Conclusions—: Dysphagia occurs frequently in patients with isolated pontine infarctions. Clinical and imaging predictors of dysphagia may help to provide optimal screening, to prevent complications and to improve long-term prognosis.

Neurogenic dysphagia is one of the most frequent and prognostically relevant neurological deficits in a variety of disorders, such as stroke, parkinsonism and advanced neuromuscular diseases. Flexible endoscopic evaluation of swallowing (FEES) is now probably the most frequently used tool for objective dysphagia assessment in Germany. It allows evaluation of the efficacy and safety of swallowing, determination of appropriate feeding strategies and assessment of the efficacy of different swallowing manoeuvres. The literature furthermore indicates that FEES is a safe and well-tolerated procedure. In spite of the huge demand for qualified dysphagia diagnostics in neurology, a systematic FEES education has not yet been established. The structured training curriculum presented in this article aims to close this gap and intends to enforce a robust and qualified FEES service. As management of neurogenic dysphagia is not confined to neurologists, this educational programme is applicable to other clinicians and speech–language therapists with expertise in dysphagia as well. The systematic education in carrying out FEES across a variety of different professions proposed by this curriculum will help to spread this instrumental approach and to improve dysphagia management.