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Changes in tongue pressure and dysphagia at oral cancer patients by palatal augmentation prosthesis

Changes in tongue pressure and dysphagia at oral cancer patients by palatal augmentation prosthesis INTRODUCTIONTongue movement plays a pertinent role in swallowing. It is crucial in both maintaining the bolus as a cohesive unit through its manipulation during mastication, and propelling the bolus out of the oral cavity and through the pharynx. Tongue pressure against the hard palate is the most significant oral pressure in the propulsion of the bolus from the oral cavity and into the pharynx.1,2 Tongue contact with the alveolar ridge and central groove exhibited centripetal and subsequent centrifugal motion that created an oropharyngeal propulsive chamber in conjunction with the pharyngeal walls.3 Higher tongue pressure decreases oral residue. Tongue pressure contributed to the propulsion of the food bolus from the oral cavity into the pharynx in the elderly.4 Tongue pressure is an indicator of other swallowing‐related muscles. Tongue‐pressure resistance training improves tongue pressure and PAS score.5 The older adult had lower tongue strength generally took longer to eat a meal and ate less than those with higher tongue strength.6 Tongue pressure has been reported to be a good predictor of the presence of dysphagia, is associated with aspiration.7 The palatal augmentation prosthesis (PAP) is an intraoral prosthesis used in the treatment of dysphagia (Figure 1). It allows reshaping of the hard palate to improve contact between tongue and palate during swallowing because of impaired tongue mobility. Several studies have been reported regarding PAP insertion for oral cancer patients who have undergone glossectomy.8 However, the detailed mechanism with which PAP improves bolus propulsion and pharyngeal function in oral cancer patients remain unknown. The Videofluoroscopic Dysphagia Scale (VDS) can predict the long‐term prognosis of dysphagia patients.9 It consists of 14 items, with a total of 100 points, representing oral and pharyngeal functions that can be observed by videofluoroscopic (VF) evaluation. This study aims to examine the effect of PAP on oral cancer, using tongue pressure and VDS to understand the components of swallow efficiency that PAP impacts.1FIGUREPalatal augmentation prosthesis (PAP). (A) PAP (tongue side), (B) PAP (hard plate side), (C) Without PAP, (D) With PAPMATERIALS AND METHODSPatient selectionA retrospective case series was conducted in accordance with the Helsinki Declaration and was approved by the Tohoku University Hospital Institutional Review Board (IRB) (Reference number: 2014‐1‐274). All patients have received treatment, including surgery, radiation therapy, or chemotherapy, for advanced head and neck cancer (HNC).A multidisplinary team is in charge of dysphagia cases in our hospital. This team is part of our hospital's Swallowing Centre, that was established through the collaboration between our medical and dental departments. From our database, we extracted information of the patients who had previously received HNC surgery as well as prosthetic treatment between March 2016 and March 2020. Among them, 15 patients (10 males and 5 female subjects aged 29–82 years; median 65.5 ± 12.1 years) were provided PAPs by prosthodontists.Assessment of tongue pressureTongue pressure was measured as the maximum voluntary tongue pressure against the palate using a commercial device (JMS tongue pressure measuring instrument, JMS, Hiroshima, Japan)10 with or without PAP on the same day as the VDS. The instrument was calibrated to 0.0 kPa after applying pressure (19.6 ± 1.0 kPa) to balloon outside the oral cavity. Patients were placed in a sitting position, then asked to place the balloon in their mouth and hold the plastic pipe at the midpoint of their central incisors with their lips closed. The participants were instructed to compress a small balloon, attached to the probe's tip, between the tongue and the hard palate's anterior part for 7 s with maximum voluntary effort. The pressures were measured three times, and the average value was recorded.Assessment of VDSThe patients were directed to swallow 3 and 5 ml of diluted barium. Subsequently, identical tests were repeated using foods such as yogurt, puddings, rice porridge, and rice with standardized viscosity and quality. The reference diet was pudding. All study procedures were recorded on AVI files (30 frames/s). After all patients finished the VFSS study, the video recordings were collected, and each file was given a random number. These files were then copied to 10 DVDs, with each DVD containing all video recordings in a different randomized order. These DVDs were sent to an interpreter for analysis. Two physiatrists analyzed the AVI files. Conclusions were drawn by consensus.VDS consists of the oral phase and the pharyngeal phase (Table 1) based on VF results. The VF data was randomized, and blinded evaluation of data was conducted by three experienced otolaryngologists.1TABLEThe items of the videofluoroscopic dysphagia scale (VDS)ParameterCoded valueScoreParameterCoded valueScoreLip closureIntact04Triggering of pharyngeal swallowingNormal04.5Inadequate2Delayed4.5None4Vallecular residueNone06Bolus formationIntact06<10%2Inadequate310%–50%4None6>50%6MasticationIntact08Laryngeal elevationNormal09Inadequate4Impaired9None8Pyriform sinus residueNone013.5ApraxiaNone04.5<10%4.5Mild1.510%–50%9Moderate3>50%13.5Severe4.5Coating on the pharyngeal wallNo09Tongue to palate contactIntact010Yes9Inadequate5Pharyngeal transit time≤1.0 s06None10>1.0 s6Premature bolus lossNone04.5AspirationNone012<10%1.5Supraglottic penetration610%–50%3Subglottic aspiration12>50%4.5Pharyngeal phase60Oral transit time≤1.5 s03>1.5 s3Oral phase40Total100STATISTICAL ANALYSISWilcoxon signed‐rank test was performed using the statistical software SPSS version 27 (IBM, Chicago, IL). Differences with a corrected p‐value of less than .05 were considered significant.RESULTPatients' characteristicsA total of 15 patients (10 men and 5 women) were included in this study, with an age range of 29–82 (median 65.4 ± 11.7) years (Table 2). Their baseline characteristics are shown in Table 1. All patients had oral cancer, in which tongue cancer was the most common with 12 incident patients. The seventh edition of UICC (Union for International Cancer Control) TNM classification was applied. Since 13 of 15 were cases with advanced cancer, most had received surgery with free flap reconstruction, except for two cases with marginal mandibulectomy and with partial glossectomy. Eight cases had undergone total or subtotal glossectomy. Resection of the mandible affected mastication, dribbling of food from the oral cavity, and delayed oral transit.11 So we used PAP at segmental mandibulectomy cases. Fourteen patients received neck dissection (11 bilateral and 3 unilateral). No patients had a radiation history before the surgical treatment, while five patients received adjuvant (chemo)radiation therapy postoperatively. Only one patient, who had received surgery with free flap reconstruction for tongue cancer, received chemoradiotherapy for hypopharyngeal cancer after 3 years. No other patients had another duplicated cancer in the head and neck region. The period between the surgical treatment and the prosthetic treatment was varied across patients (from 6 months to 11 years). Since the VF evaluation is performed after the PAP adjustment is completed, the period before and after wearing varies depending on the case (from 0 months to 11 months).2TABLEThe patients' characteristics (First VF means the period from primary treatment to swallowing center consultation. Span means the period from primary assessment to palatal augmentation prosthesis assessment)SexAgePrimaryTMNStageSurgical fieldNeck dissectionFree flap reconstructionChemoradiation therapyFirst VFSpanM29TongueT3N1M0IIISubtotal glossectomyBilateralYN3 m0.5M35TongueT3N0M0IIISubtotal glossectomyBilateralYN1 m5F56Lower gingivaT4aN0M0IVaSegmental mandibulectomyBilateralYN1 m11F61TongueT4aN0M0IVaTotal glossectomyBilateralYN4 m8F62Floor of mouthT4aN0M0IVaSegmental mandibulectomyRightYN3 m4F64TongueT3N0M0IIITotal glossectomyBilateralYY1 m1F65TongueT1N0M0ISubtotal glossectomyBilateralYN4 m8M66TongueT3N1M0IVaSubtotal glossectomyBilateralYY8 y 7 m5M67TongueT3N0M0IIISubtotal glossectomyBilateralYN9 y 5 m0M69Floor of mouthT1N2cM0IVaMarginal mandibulectomyBilateralNY1 y3M70TongueT4aN0M0IVaSubtotal glossectomy and segmental mandibulectomyBilateralYY1 m2M74TongueT2N1M0IVaHemiglossectomyRightYY7 m1M78TongueT2N0M0IIPartial glossectomyBilateralYY21y5M82TongueT2N1M0IIIPartial glossectomyLeftNN3 m6M82TongueT3N0M0IIIHemiglossectomyRightYN23y4The tongue pressureTongue pressure was increased in 13 cases (Figure 2). Two cases decrease tongue pressure. They were cases in which outpatient adjustment was not possible and cases in which dentures were incompatible due to the appearance of new swaying teeth. After intervention with PAP, the tongue pressure was 12.3 ± 6.7 kPa, which was significantly increased compared to without PAP (6.6 ± 5.6 kPa) (p = .017).2FIGUREThe tongue pressure without (left) and with (right) palatal augmentation prosthesis (PAP) n = 15VDS scoreThe cases with improved tongue pressure (13 patients expected two patients which decrease tongue pressure) were investigated through the VDS score (Table 3). Ten patients (76.9%) had improved in their total VDS score although three patients did not improve. The total mean VDS score was 46.7 ± 19.2 and 40.1 ± 21.4 in the without and with PAP groups, respectively, which was significantly improved (p = .045). The mean VDS score of the oral phase also significantly improved in the PAP group (21.0 ± 6.3) as compared to the without PAP group (16.5 ± 7.5) (p = .015). In contrast, there was no significant difference between the two groups in the pharyngeal phase (p = .388). Significant differences were found in each category, such as tongue to palate contact (p = .010) and pyriform sinus residue (p = .018) (Figure 3). The CRT group had a higher VDS score without PAP. CRT does not seem to affect the improvement of VDS by PAP (Table 4). The unilateral neck dissection group tended to improve VDS by PAP (Table 5).3TABLEThe videofluoroscopic dysphagia scale (VDS) score before and after the interventionBefore interventionAfter interventionpLip closure0.3 ± 0.80.1 ± 0.2.180Bolus formation3.8 ± 1.33.1 ± 1.5.053Mastication5.2 ± 1.44.3 ± 2.0.058Apraxia2.1 ± 0.91.8 ± 0.9.605Tongue to palate contact5.8 ± 2.33.9 ± 2.6.010*Premature bolus loss1.4 ± 1.41.4 ± 1.6.944Oral transit time2.4 ± 0.81.9 ± 0.9.096Triggering of pharyngeal swallowing2.8 ± 0.82.9 ± 1.4.660Vallecular residue1.9 ± 1.42.2 ± 1.4.131Laryngeal elevation6.6 ± 2.75.5 ± 3.3.196Pyriform sinus residue4.4 ± 4.22.6 ± 2.9.018*Coating on the pharyngeal wall4.5 ± 4.34.3 ± 4.1.577Pharyngeal transit time2.5 ± 2.62.8 ± 2.3.317Aspiration3.0 ± 3.93.6 ± 4.2.858Oral phase21.0 ± 6.316.5 ± 7.5.015*Pharyngeal phase25.6 ± 15.223.6 ± 17.6.388Total46.7 ± 19.240.1 ± 21.4.045*Note: Asterisk indicated p < .05. n = 13.3FIGUREpharyngeal residue without (left) and with (right) palatal augmentation prosthesis (PAP)4TABLEThe videofluoroscopic dysphagia scale (VDS) score before and after the intervention with or without CRTCRT +CRT −Before interventionAfter interventionBefore interventionAfter interventionLip closure0.1 ± 0.30.4 ± 1.10.0 ± 0.00.3 ± 0.7Bolus formation4.0 ± 1.74.0 ± 1.72.8 ± 1.33.6 ± 1.1Mastication4.9 ± 1.85.3 ± 1.74.1 ± 1.85.0 ± 1.1Apraxia1.8 ± 1.02.6 ± 0.71.9 ± 0.81.7 ± 0.8Tongue to palate contact5.0 ± 3.25.3 ± 3.13.9 ± 2.25.4 ± 2.3Premature bolus loss2.7 ± 1.51.9 ± 1.40.9 ± 1.11.4 ± 1.5Oral transit time2.2 ± 1.22.3 ± 0.81.9 ± 0.62.3 ± 0.9Triggering of pharyngeal swallowing3.8 ± 0.83.3 ± 1.12.5 ± 1.32.5 ± 0.6Vallecular residue3.1 ± 1.23.1 ± 1.01.9 ± 1.31.2 ± 0.9Laryngeal elevation8.0 ± 1.57.3 ± 2.04.3 ± 3.45.8 ± 2.6Pyriform sinus residue4.6 ± 2.85.5 ± 4.11.2 ± 2.52.5 ± 3.8Coating on the pharyngeal wall6.5 ± 2.37.0 ± 2.43.0 ± 4.02.3 ± 3.9Pharyngeal transit time4.8 ± 1.83.7 ± 2.31.8 ± 1.61.6 ± 2.2Aspiration4.2 ± 5.15.3 ± 4.33.3 ± 3.92.4 ± 3.0Oral phase20.7 ± 8.721.9 ± 7.815.5 ± 5.819.7 ± 5.5Pharyngeal phase35.0 ± 11.935.1 ± 9.918.0 ± 15.018.4 ± 11.8Total55.7 ± 13.757.0 ± 15.133.5 ± 18.938.1 ± 14.85TABLEThe videofluoroscopic dysphagia scale (VDS) score before and after the intervention unilateral or bilateral neck dissectionUnilateral neck dissectionBilateral neck dissectionBefore interventionAfter interventionBefore interventionAfter interventionLip closure0.0 ± 0.00.2 ± 0.30.1 ± 0.20.4 ± 1.0Bolus formation3.3 ± 1.92.8 ± 1.03.3 ± 1.54.1 ± 1.3Mastication3.3 ± 1.75.3 ± 0.04.8 ± 1.75.1 ± 1.6Apraxia1.8 ± 1.01.5 ± 0.71.9 ± 0.92.3 ± 0.8Tongue to palate contact4.6 ± 2.53.3 ± 1.94.2 ± 2.76.1 ± 2.4Premature bolus loss1.8 ± 1.31.4 ± 1.11.6 ± 1.71.7 ± 1.6Oral transit time1.8 ± 1.01.5 ± 1.02.1 ± 0.82.6 ± 0.5Triggering of pharyngeal swallowing3.0 ± 1.22.6 ± 0.83.0 ± 1.32.9 ± 1.0Vallecular residue3.2 ± 1.82.2 ± 1.12.1 ± 1.21.9 ± 1.5Laryngeal elevation6.0 ± 4.25.3 ± 2.95.7 ± 3.16.8 ± 2.3Pyriform sinus residue3.8 ± 4.33.8 ± 4.72.1 ± 2.63.7 ± 4.0Coating on the pharyngeal wall3.8 ± 4.51.5 ± 1.74.6 ± 3.65.2 ± 4.3Pharyngeal transit time3.0 ± 2.62.0 ± 1.63.0 ± 2.22.5 ± 2.7Aspiration2.5 ± 3.03.0 ± 1.24.1 ± 4.73.8 ± 4.3Oral phase16.4 ± 7.716.0 ± 3.418.0 ± 7.522.3 ± 6.4Pharyngeal phase25.2 ± 18.920.3 ± 12.124.6 ± 15.826.8 ± 14.3Total41.6 ± 23.936.3 ± 13.942.7 ± 19.749.0 ± 17.7DISCUSSIONSwallowing function is one of the major concerns in survivors of head and neck cancer.12 Dysphagia has been described as the most critical problem affecting the quality of life.13 We showed the effect of PAP on oral cancer using tongue pressure and VDS.In this study, PAP improved tongue pressure and tongue to palate contact. Tongue pressure was a predictive factor for decreased oral and pharyngeal food residue, and it has been used for quantitative evaluation of oropharyngeal swallowing function.4 In addition, tongue pressure is associated with masticatory performance.14 The estimated weighted mean tongue pressure in healthy subjects using JMS is 39.3 ± 0.92 kPa and 30.3 ± 0.42 kPa in individuals under 60 years old and above 60 years old, respectively.15 In our study, 8 of 15 cases had undergone total or subtotal glossectomy. Tongue pressure without PAP was 6.6 ± 5.6 kPa, which was similar to the previous report; its value is 15.3% ± 5.6% decreased compared to before subtotal glossectomy.16 Palmer et al. reported that tongue pressure was positively correlated with suprahyoid muscle activities.17 Tongue pressure with PAP was significantly increased compared to without PAP. The wearing of PAP did not lead to a full recovery in tongue pressure compared with the normal population. However, the VDS score of the oral phase and the pyriform sinus residue were significantly improved with the PAP. It may be necessary to investigate not only the pressure, but also the timing, duration, and locations of the contacts between tongue and palate during the propulsion of a bolus from the oral cavity to the pharynx.18The VDS scale using VF was developed to assess dysphagia's severity.19 This scale was originally created to quantify the severity of dysphagia of stroke patients,20 but there were also statistically significant correlations for other health conditions such as spinal cord injury, peripheral neuropathy, neurodegenerative disease, traumatic brain injury, brain tumor, poor general medical condition, and local structural lesions involving the head and neck.21 Moreover, the VDS allows clinicians to understand and explain dysphagia and delineate dysphagia's aggravation and improvement in detail as the scale consists of 14 items, including the oral and pharyngeal phases. In our study, total VDS score improved by 76.9% in the patients whose tongue pressure had improved. Weber et al. reported that 27.8% of patients did not improve in swallowing function with the PAP.22 These results suggest that PAP alone may not contribute to improved swallowing function in some patients. Hence, it is essential to combine PAP with other approaches, such as swallowing function training.23Our study revealed that pyriform sinus residue was significantly improved after wearing PAP. Meyer et al. reported that only worsening oral and pharyngeal residue correlated considerably with the deteriorating quality of life of head and neck cancer survivors.12 They stated that oral and pharyngeal residue had an independent effect on patients' diet, willingness to eat in public, and ability to participate in social gatherings. The results of our study corroborate with findings from a previous study that showed that oral residue was reduced from 90% to 25% and pharyngeal residue from 25% to 10%.24 Increased pharyngeal pressure may have affected the reduction of the pyriform sinus residue. In the rat model, peaks of thyrohyoid electromyography bursts and oropharynx pressure were decreased following bilateral hypoglossal nerve transection, but significantly increased and were longer after covering the hard and soft palates with acrylic material.25Furthermore, PAP may accelerate the laryngeal elevation in the upward direction with the upper esophageal sphincter (UES) opening. Intrabolus pressures are associated with relaxation of the upper esophageal sphincter.26 Posterior pharyngeal wall advancement increased to compensate for swallowing function among individuals with reduced tongue muscle strength.27 It is possible that the tongue pressure by PAP and the compensatory action of the pharynx increased the pharyngeal pressure and assisted in the dilatation of UES. Further studies are needed in order to evaluate pharyngeal pressure using manometry or other pressure measurements.LimitationThere are a few limitations in this study that deserve mention. First, the timing of VF before and after PAP placement is different for each patient. Other factors, such as swallowing rehabilitation, may influence the outcome. Second, our study is a retrospective study with a small number of patients. Further prospective studies involving more patients are needed. Divide into a group that creates PAP before oral cancer surgery and a group that does not use it and compares the swallowing function after surgery.CONCLUSIONThe wearing of PAP can improve tongue pressure and tongue to palate contact, and show improvement in pyriform sinus residue. These results suggest a possible effect on the pharyngeal phase while wearing PAP.ACKNOWLEDGEMENTSThis work was supported by The Clinical Research Promotion Program for Young Investigators of Tohoku University Hospital.CONFLICT OF INTERESTThe authors declare no financial relationships or conflict of interest.AUTHORS' CONTRIBUTIONSAll authors had full access to the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Conceptualization, K.K., S.K., K.S.; Data Curation, I.K., T.H., T.K., J.O., R.Is.; Project Administration, I.K., R.Ik., J.S., A.H.‐K., J.O., A.O., N.Sh., K.K., S.K., K.S., Y.K.; Methodology, N.S., R.T.; Investigation, T.H., N.S., R.T., T.K., A.H.‐K.; Formal Analysis, T.H., R.Ik., J.S., R.Is.; Resources, A.O.; Writing ‐ Original Draft, R.Ik.; Writing ‐ Review & Editing, T.H., R.Ik., J.S., A.H.‐K., R.Is., N.Sh.; Visualization, I.K., R.Ik., R.T., J.O., R.Is.; Supervision, R.Ik., J.S., A.H.‐K., J.O., A.O., N.Sh., K.K., S.K., K.S., Y.K.; Funding Acquisition, Y.K.ETHICS STATEMENTThis study was approved by the Tohoku University Hospital Institutional Review Board (IRB protocol number: 2014‐1‐274). Consent was obtained from patients.DATA AVAILABILITY STATEMENTThe data that support the findings of this study are available from the corresponding author upon reasonable request.REFERENCESKonaka K, Kondo J, Hirota N, et al. Relationship between tongue pressure and dysphagia in stroke patients. Eur Neurol. 2010;64(2):101‐107.Clark HM, Henson PA, Barber WD, Stierwalt JA, Sherrill M. Relationships among subjective and objective measures of tongue strength and oral phase swallowing impairments. Am J Speech Lang Pathol. 2003;12(1):40‐50.Peter JK, Shezhang L, Jerilyn AL, Gulchin AE, Frank F. Deglutitive tongue action: volume accommodation and bolus propulsion. Gastroenterology. 1993;104:152‐162.Ono T, Takahiro O, Isami K, et al. Influence of bite force and tongue pressure on oro‐pharyngeal residue in the elderly. Gerodontology. 2007;24:143‐150.Chizuru N, Koji H, Haruka T, Kenichiro K, Ariya C, et al. Tongue‐pressure resistance training improves tongue and suprahyoid muscle functions simultaneously. Clin Interv Aging. 2019;14:601‐608.Ashwini MN, Catriona MS, Heather K. The effect of tongue strength on meal consumption in long term care. Clin Nutr. 2016;35:1078‐1083.Butler SG, Stuart A, Leng X, et al. The relationship of aspiration status with tongue and handgrip strength in healthy older adults. J Gerontol A Biol Sci Med Sci. 2011;66(4):452‐458.Marunick M, Tselios N. The efficacy of palatal augmentation prostheses for speech and swallowing in patients undergoing glossectomy: a review of the literature. J Prosthet Dent. 2004;91(1):67‐74.Stoeckli SJ, Huisman TA, Seifert B, Martin‐Harris BJ. Interrater reliability of videofluoroscopic swallow evaluation. Dysphagia. 2003;18(1):53‐57.Maeda K, Akagi J. Decreased tongue pressure is associated with sarcopenia and sarcopenic dysphagia in the elderly. Dysphagia. 2015;30(1):80‐87.Mansi J, Mansi K. Swallowing skills and aspiration risk following treatment of head and neck cancers. Indian J Surg Oncol. 2019;10:402‐405.Meyer TK, Pisegna JM, Krisciunas GP, Pauloski BR, Langmore SE. Residue influences quality of life independently of penetration and aspiration in head and neck cancer survivors. Laryngoscope. 2017;127(7):1615‐1621.Platteaux N, Dirix P, Dejaeger E, Nuyts S. Dysphagia in head and neck cancer patients treated with chemoradiotherapy. Dysphagia. 2010;25(2):139‐152.Takahashi M, Koide K, Arakawa I, Mizuhashi F. Association between perioral muscle pressure and masticatory performance. J Oral Rehabil. 2013;40(12):909‐915.Arakawa I, Igarashi K, Imamura Y, Muller F, Abou‐Ayash S, Schimmel M. Variability in tongue pressure among elderly and young healthy cohorts: a systematic review and meta‐analysis. J Oral Rehabil. 2021;48(4):430‐448.Hamahata A, Beppu T, Shirakura S, et al. Tongue pressure in patients with tongue cancer resection and reconstruction. Auris Nasus Larynx. 2014;41(6):563‐567.Palmer PM, Jaffe DM, McCulloch TM, Finnegan EM, Van Daele DJ, Luschei ES. Quantitative contributions of the muscles of the tongue, floor‐of‐mouth, jaw, and velum to tongue‐to‐palate pressure generation. J Speech Lang Hear Res. 2008;51(4):828‐835.Li Q, Minagi Y, Ono T, et al. The biomechanical coordination during oropharyngeal swallowing: an evaluation with a non‐invasive sensing system. Sci Rep. 2017;7(1):15165.Khedr EM, Abo‐Elfetoh N, Rothwell JC. Treatment of post‐stroke dysphagia with repetitive transcranial magnetic stimulation. Acta Neurol Scand. 2009;119(3):155‐161.Han TR, Paik NJ, Park JW, Kwon BS. The prediction of persistent dysphagia beyond six months after stroke. Dysphagia. 2008;23(1):59‐64.Kim J, Oh BM, Kim JY, Lee GJ, Lee SA, Han TR. Validation of the videofluoroscopic dysphagia scale in various etiologies. Dysphagia. 2014;29(4):438‐443.Weber RS, Ohlms L, Bowman J, Jacob R, Goepfert H. Functional results after total or near total glossectomy with laryngeal preservation. Arch Otolaryngol Head Neck Surg. 1991;117(5):512‐515.Kato K, Ikeda R, Suzuki J, et al. Questionnaire survey on nurses and speech therapists regarding dysphagia rehabilitation in Japan. Auris Nasus Larynx. 2020;48:241‐247.Davis JW, Lazarus C, Logemann J, Hurst PS. Effect of a maxillary glossectomy prosthesis on articulation and swallowing. J Prosthet Dent. 1987;57(6):715‐719.Tsujimura T, Suzuki T, Yoshihara M, et al. Involvement of hypoglossal and recurrent laryngeal nerves on swallowing pressure. J Appl Physiol. 2018;124(5):1148‐1154.Charles C, Corinne AJ, Michael JH, Taher IO, Timothy MM. Modulation of upper esophageal sphincter (UES) relaxation and opening during volume swallowing. Dysphagia. 2017;32(2):216‐224.Keigo N, Takeshi K, Taishi M, Yuri Y, Fumiyo T. Tongue muscle strength affects posterior pharyngeal wall advancement during swallowing: a cross‐sectional study of outpatients with dysphagia. J Oral Rehabil. 2021;48:169‐175. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Cancer Reports Wiley

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© 2022 Wiley Periodicals LLC.
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Abstract

INTRODUCTIONTongue movement plays a pertinent role in swallowing. It is crucial in both maintaining the bolus as a cohesive unit through its manipulation during mastication, and propelling the bolus out of the oral cavity and through the pharynx. Tongue pressure against the hard palate is the most significant oral pressure in the propulsion of the bolus from the oral cavity and into the pharynx.1,2 Tongue contact with the alveolar ridge and central groove exhibited centripetal and subsequent centrifugal motion that created an oropharyngeal propulsive chamber in conjunction with the pharyngeal walls.3 Higher tongue pressure decreases oral residue. Tongue pressure contributed to the propulsion of the food bolus from the oral cavity into the pharynx in the elderly.4 Tongue pressure is an indicator of other swallowing‐related muscles. Tongue‐pressure resistance training improves tongue pressure and PAS score.5 The older adult had lower tongue strength generally took longer to eat a meal and ate less than those with higher tongue strength.6 Tongue pressure has been reported to be a good predictor of the presence of dysphagia, is associated with aspiration.7 The palatal augmentation prosthesis (PAP) is an intraoral prosthesis used in the treatment of dysphagia (Figure 1). It allows reshaping of the hard palate to improve contact between tongue and palate during swallowing because of impaired tongue mobility. Several studies have been reported regarding PAP insertion for oral cancer patients who have undergone glossectomy.8 However, the detailed mechanism with which PAP improves bolus propulsion and pharyngeal function in oral cancer patients remain unknown. The Videofluoroscopic Dysphagia Scale (VDS) can predict the long‐term prognosis of dysphagia patients.9 It consists of 14 items, with a total of 100 points, representing oral and pharyngeal functions that can be observed by videofluoroscopic (VF) evaluation. This study aims to examine the effect of PAP on oral cancer, using tongue pressure and VDS to understand the components of swallow efficiency that PAP impacts.1FIGUREPalatal augmentation prosthesis (PAP). (A) PAP (tongue side), (B) PAP (hard plate side), (C) Without PAP, (D) With PAPMATERIALS AND METHODSPatient selectionA retrospective case series was conducted in accordance with the Helsinki Declaration and was approved by the Tohoku University Hospital Institutional Review Board (IRB) (Reference number: 2014‐1‐274). All patients have received treatment, including surgery, radiation therapy, or chemotherapy, for advanced head and neck cancer (HNC).A multidisplinary team is in charge of dysphagia cases in our hospital. This team is part of our hospital's Swallowing Centre, that was established through the collaboration between our medical and dental departments. From our database, we extracted information of the patients who had previously received HNC surgery as well as prosthetic treatment between March 2016 and March 2020. Among them, 15 patients (10 males and 5 female subjects aged 29–82 years; median 65.5 ± 12.1 years) were provided PAPs by prosthodontists.Assessment of tongue pressureTongue pressure was measured as the maximum voluntary tongue pressure against the palate using a commercial device (JMS tongue pressure measuring instrument, JMS, Hiroshima, Japan)10 with or without PAP on the same day as the VDS. The instrument was calibrated to 0.0 kPa after applying pressure (19.6 ± 1.0 kPa) to balloon outside the oral cavity. Patients were placed in a sitting position, then asked to place the balloon in their mouth and hold the plastic pipe at the midpoint of their central incisors with their lips closed. The participants were instructed to compress a small balloon, attached to the probe's tip, between the tongue and the hard palate's anterior part for 7 s with maximum voluntary effort. The pressures were measured three times, and the average value was recorded.Assessment of VDSThe patients were directed to swallow 3 and 5 ml of diluted barium. Subsequently, identical tests were repeated using foods such as yogurt, puddings, rice porridge, and rice with standardized viscosity and quality. The reference diet was pudding. All study procedures were recorded on AVI files (30 frames/s). After all patients finished the VFSS study, the video recordings were collected, and each file was given a random number. These files were then copied to 10 DVDs, with each DVD containing all video recordings in a different randomized order. These DVDs were sent to an interpreter for analysis. Two physiatrists analyzed the AVI files. Conclusions were drawn by consensus.VDS consists of the oral phase and the pharyngeal phase (Table 1) based on VF results. The VF data was randomized, and blinded evaluation of data was conducted by three experienced otolaryngologists.1TABLEThe items of the videofluoroscopic dysphagia scale (VDS)ParameterCoded valueScoreParameterCoded valueScoreLip closureIntact04Triggering of pharyngeal swallowingNormal04.5Inadequate2Delayed4.5None4Vallecular residueNone06Bolus formationIntact06<10%2Inadequate310%–50%4None6>50%6MasticationIntact08Laryngeal elevationNormal09Inadequate4Impaired9None8Pyriform sinus residueNone013.5ApraxiaNone04.5<10%4.5Mild1.510%–50%9Moderate3>50%13.5Severe4.5Coating on the pharyngeal wallNo09Tongue to palate contactIntact010Yes9Inadequate5Pharyngeal transit time≤1.0 s06None10>1.0 s6Premature bolus lossNone04.5AspirationNone012<10%1.5Supraglottic penetration610%–50%3Subglottic aspiration12>50%4.5Pharyngeal phase60Oral transit time≤1.5 s03>1.5 s3Oral phase40Total100STATISTICAL ANALYSISWilcoxon signed‐rank test was performed using the statistical software SPSS version 27 (IBM, Chicago, IL). Differences with a corrected p‐value of less than .05 were considered significant.RESULTPatients' characteristicsA total of 15 patients (10 men and 5 women) were included in this study, with an age range of 29–82 (median 65.4 ± 11.7) years (Table 2). Their baseline characteristics are shown in Table 1. All patients had oral cancer, in which tongue cancer was the most common with 12 incident patients. The seventh edition of UICC (Union for International Cancer Control) TNM classification was applied. Since 13 of 15 were cases with advanced cancer, most had received surgery with free flap reconstruction, except for two cases with marginal mandibulectomy and with partial glossectomy. Eight cases had undergone total or subtotal glossectomy. Resection of the mandible affected mastication, dribbling of food from the oral cavity, and delayed oral transit.11 So we used PAP at segmental mandibulectomy cases. Fourteen patients received neck dissection (11 bilateral and 3 unilateral). No patients had a radiation history before the surgical treatment, while five patients received adjuvant (chemo)radiation therapy postoperatively. Only one patient, who had received surgery with free flap reconstruction for tongue cancer, received chemoradiotherapy for hypopharyngeal cancer after 3 years. No other patients had another duplicated cancer in the head and neck region. The period between the surgical treatment and the prosthetic treatment was varied across patients (from 6 months to 11 years). Since the VF evaluation is performed after the PAP adjustment is completed, the period before and after wearing varies depending on the case (from 0 months to 11 months).2TABLEThe patients' characteristics (First VF means the period from primary treatment to swallowing center consultation. Span means the period from primary assessment to palatal augmentation prosthesis assessment)SexAgePrimaryTMNStageSurgical fieldNeck dissectionFree flap reconstructionChemoradiation therapyFirst VFSpanM29TongueT3N1M0IIISubtotal glossectomyBilateralYN3 m0.5M35TongueT3N0M0IIISubtotal glossectomyBilateralYN1 m5F56Lower gingivaT4aN0M0IVaSegmental mandibulectomyBilateralYN1 m11F61TongueT4aN0M0IVaTotal glossectomyBilateralYN4 m8F62Floor of mouthT4aN0M0IVaSegmental mandibulectomyRightYN3 m4F64TongueT3N0M0IIITotal glossectomyBilateralYY1 m1F65TongueT1N0M0ISubtotal glossectomyBilateralYN4 m8M66TongueT3N1M0IVaSubtotal glossectomyBilateralYY8 y 7 m5M67TongueT3N0M0IIISubtotal glossectomyBilateralYN9 y 5 m0M69Floor of mouthT1N2cM0IVaMarginal mandibulectomyBilateralNY1 y3M70TongueT4aN0M0IVaSubtotal glossectomy and segmental mandibulectomyBilateralYY1 m2M74TongueT2N1M0IVaHemiglossectomyRightYY7 m1M78TongueT2N0M0IIPartial glossectomyBilateralYY21y5M82TongueT2N1M0IIIPartial glossectomyLeftNN3 m6M82TongueT3N0M0IIIHemiglossectomyRightYN23y4The tongue pressureTongue pressure was increased in 13 cases (Figure 2). Two cases decrease tongue pressure. They were cases in which outpatient adjustment was not possible and cases in which dentures were incompatible due to the appearance of new swaying teeth. After intervention with PAP, the tongue pressure was 12.3 ± 6.7 kPa, which was significantly increased compared to without PAP (6.6 ± 5.6 kPa) (p = .017).2FIGUREThe tongue pressure without (left) and with (right) palatal augmentation prosthesis (PAP) n = 15VDS scoreThe cases with improved tongue pressure (13 patients expected two patients which decrease tongue pressure) were investigated through the VDS score (Table 3). Ten patients (76.9%) had improved in their total VDS score although three patients did not improve. The total mean VDS score was 46.7 ± 19.2 and 40.1 ± 21.4 in the without and with PAP groups, respectively, which was significantly improved (p = .045). The mean VDS score of the oral phase also significantly improved in the PAP group (21.0 ± 6.3) as compared to the without PAP group (16.5 ± 7.5) (p = .015). In contrast, there was no significant difference between the two groups in the pharyngeal phase (p = .388). Significant differences were found in each category, such as tongue to palate contact (p = .010) and pyriform sinus residue (p = .018) (Figure 3). The CRT group had a higher VDS score without PAP. CRT does not seem to affect the improvement of VDS by PAP (Table 4). The unilateral neck dissection group tended to improve VDS by PAP (Table 5).3TABLEThe videofluoroscopic dysphagia scale (VDS) score before and after the interventionBefore interventionAfter interventionpLip closure0.3 ± 0.80.1 ± 0.2.180Bolus formation3.8 ± 1.33.1 ± 1.5.053Mastication5.2 ± 1.44.3 ± 2.0.058Apraxia2.1 ± 0.91.8 ± 0.9.605Tongue to palate contact5.8 ± 2.33.9 ± 2.6.010*Premature bolus loss1.4 ± 1.41.4 ± 1.6.944Oral transit time2.4 ± 0.81.9 ± 0.9.096Triggering of pharyngeal swallowing2.8 ± 0.82.9 ± 1.4.660Vallecular residue1.9 ± 1.42.2 ± 1.4.131Laryngeal elevation6.6 ± 2.75.5 ± 3.3.196Pyriform sinus residue4.4 ± 4.22.6 ± 2.9.018*Coating on the pharyngeal wall4.5 ± 4.34.3 ± 4.1.577Pharyngeal transit time2.5 ± 2.62.8 ± 2.3.317Aspiration3.0 ± 3.93.6 ± 4.2.858Oral phase21.0 ± 6.316.5 ± 7.5.015*Pharyngeal phase25.6 ± 15.223.6 ± 17.6.388Total46.7 ± 19.240.1 ± 21.4.045*Note: Asterisk indicated p < .05. n = 13.3FIGUREpharyngeal residue without (left) and with (right) palatal augmentation prosthesis (PAP)4TABLEThe videofluoroscopic dysphagia scale (VDS) score before and after the intervention with or without CRTCRT +CRT −Before interventionAfter interventionBefore interventionAfter interventionLip closure0.1 ± 0.30.4 ± 1.10.0 ± 0.00.3 ± 0.7Bolus formation4.0 ± 1.74.0 ± 1.72.8 ± 1.33.6 ± 1.1Mastication4.9 ± 1.85.3 ± 1.74.1 ± 1.85.0 ± 1.1Apraxia1.8 ± 1.02.6 ± 0.71.9 ± 0.81.7 ± 0.8Tongue to palate contact5.0 ± 3.25.3 ± 3.13.9 ± 2.25.4 ± 2.3Premature bolus loss2.7 ± 1.51.9 ± 1.40.9 ± 1.11.4 ± 1.5Oral transit time2.2 ± 1.22.3 ± 0.81.9 ± 0.62.3 ± 0.9Triggering of pharyngeal swallowing3.8 ± 0.83.3 ± 1.12.5 ± 1.32.5 ± 0.6Vallecular residue3.1 ± 1.23.1 ± 1.01.9 ± 1.31.2 ± 0.9Laryngeal elevation8.0 ± 1.57.3 ± 2.04.3 ± 3.45.8 ± 2.6Pyriform sinus residue4.6 ± 2.85.5 ± 4.11.2 ± 2.52.5 ± 3.8Coating on the pharyngeal wall6.5 ± 2.37.0 ± 2.43.0 ± 4.02.3 ± 3.9Pharyngeal transit time4.8 ± 1.83.7 ± 2.31.8 ± 1.61.6 ± 2.2Aspiration4.2 ± 5.15.3 ± 4.33.3 ± 3.92.4 ± 3.0Oral phase20.7 ± 8.721.9 ± 7.815.5 ± 5.819.7 ± 5.5Pharyngeal phase35.0 ± 11.935.1 ± 9.918.0 ± 15.018.4 ± 11.8Total55.7 ± 13.757.0 ± 15.133.5 ± 18.938.1 ± 14.85TABLEThe videofluoroscopic dysphagia scale (VDS) score before and after the intervention unilateral or bilateral neck dissectionUnilateral neck dissectionBilateral neck dissectionBefore interventionAfter interventionBefore interventionAfter interventionLip closure0.0 ± 0.00.2 ± 0.30.1 ± 0.20.4 ± 1.0Bolus formation3.3 ± 1.92.8 ± 1.03.3 ± 1.54.1 ± 1.3Mastication3.3 ± 1.75.3 ± 0.04.8 ± 1.75.1 ± 1.6Apraxia1.8 ± 1.01.5 ± 0.71.9 ± 0.92.3 ± 0.8Tongue to palate contact4.6 ± 2.53.3 ± 1.94.2 ± 2.76.1 ± 2.4Premature bolus loss1.8 ± 1.31.4 ± 1.11.6 ± 1.71.7 ± 1.6Oral transit time1.8 ± 1.01.5 ± 1.02.1 ± 0.82.6 ± 0.5Triggering of pharyngeal swallowing3.0 ± 1.22.6 ± 0.83.0 ± 1.32.9 ± 1.0Vallecular residue3.2 ± 1.82.2 ± 1.12.1 ± 1.21.9 ± 1.5Laryngeal elevation6.0 ± 4.25.3 ± 2.95.7 ± 3.16.8 ± 2.3Pyriform sinus residue3.8 ± 4.33.8 ± 4.72.1 ± 2.63.7 ± 4.0Coating on the pharyngeal wall3.8 ± 4.51.5 ± 1.74.6 ± 3.65.2 ± 4.3Pharyngeal transit time3.0 ± 2.62.0 ± 1.63.0 ± 2.22.5 ± 2.7Aspiration2.5 ± 3.03.0 ± 1.24.1 ± 4.73.8 ± 4.3Oral phase16.4 ± 7.716.0 ± 3.418.0 ± 7.522.3 ± 6.4Pharyngeal phase25.2 ± 18.920.3 ± 12.124.6 ± 15.826.8 ± 14.3Total41.6 ± 23.936.3 ± 13.942.7 ± 19.749.0 ± 17.7DISCUSSIONSwallowing function is one of the major concerns in survivors of head and neck cancer.12 Dysphagia has been described as the most critical problem affecting the quality of life.13 We showed the effect of PAP on oral cancer using tongue pressure and VDS.In this study, PAP improved tongue pressure and tongue to palate contact. Tongue pressure was a predictive factor for decreased oral and pharyngeal food residue, and it has been used for quantitative evaluation of oropharyngeal swallowing function.4 In addition, tongue pressure is associated with masticatory performance.14 The estimated weighted mean tongue pressure in healthy subjects using JMS is 39.3 ± 0.92 kPa and 30.3 ± 0.42 kPa in individuals under 60 years old and above 60 years old, respectively.15 In our study, 8 of 15 cases had undergone total or subtotal glossectomy. Tongue pressure without PAP was 6.6 ± 5.6 kPa, which was similar to the previous report; its value is 15.3% ± 5.6% decreased compared to before subtotal glossectomy.16 Palmer et al. reported that tongue pressure was positively correlated with suprahyoid muscle activities.17 Tongue pressure with PAP was significantly increased compared to without PAP. The wearing of PAP did not lead to a full recovery in tongue pressure compared with the normal population. However, the VDS score of the oral phase and the pyriform sinus residue were significantly improved with the PAP. It may be necessary to investigate not only the pressure, but also the timing, duration, and locations of the contacts between tongue and palate during the propulsion of a bolus from the oral cavity to the pharynx.18The VDS scale using VF was developed to assess dysphagia's severity.19 This scale was originally created to quantify the severity of dysphagia of stroke patients,20 but there were also statistically significant correlations for other health conditions such as spinal cord injury, peripheral neuropathy, neurodegenerative disease, traumatic brain injury, brain tumor, poor general medical condition, and local structural lesions involving the head and neck.21 Moreover, the VDS allows clinicians to understand and explain dysphagia and delineate dysphagia's aggravation and improvement in detail as the scale consists of 14 items, including the oral and pharyngeal phases. In our study, total VDS score improved by 76.9% in the patients whose tongue pressure had improved. Weber et al. reported that 27.8% of patients did not improve in swallowing function with the PAP.22 These results suggest that PAP alone may not contribute to improved swallowing function in some patients. Hence, it is essential to combine PAP with other approaches, such as swallowing function training.23Our study revealed that pyriform sinus residue was significantly improved after wearing PAP. Meyer et al. reported that only worsening oral and pharyngeal residue correlated considerably with the deteriorating quality of life of head and neck cancer survivors.12 They stated that oral and pharyngeal residue had an independent effect on patients' diet, willingness to eat in public, and ability to participate in social gatherings. The results of our study corroborate with findings from a previous study that showed that oral residue was reduced from 90% to 25% and pharyngeal residue from 25% to 10%.24 Increased pharyngeal pressure may have affected the reduction of the pyriform sinus residue. In the rat model, peaks of thyrohyoid electromyography bursts and oropharynx pressure were decreased following bilateral hypoglossal nerve transection, but significantly increased and were longer after covering the hard and soft palates with acrylic material.25Furthermore, PAP may accelerate the laryngeal elevation in the upward direction with the upper esophageal sphincter (UES) opening. Intrabolus pressures are associated with relaxation of the upper esophageal sphincter.26 Posterior pharyngeal wall advancement increased to compensate for swallowing function among individuals with reduced tongue muscle strength.27 It is possible that the tongue pressure by PAP and the compensatory action of the pharynx increased the pharyngeal pressure and assisted in the dilatation of UES. Further studies are needed in order to evaluate pharyngeal pressure using manometry or other pressure measurements.LimitationThere are a few limitations in this study that deserve mention. First, the timing of VF before and after PAP placement is different for each patient. Other factors, such as swallowing rehabilitation, may influence the outcome. Second, our study is a retrospective study with a small number of patients. Further prospective studies involving more patients are needed. Divide into a group that creates PAP before oral cancer surgery and a group that does not use it and compares the swallowing function after surgery.CONCLUSIONThe wearing of PAP can improve tongue pressure and tongue to palate contact, and show improvement in pyriform sinus residue. These results suggest a possible effect on the pharyngeal phase while wearing PAP.ACKNOWLEDGEMENTSThis work was supported by The Clinical Research Promotion Program for Young Investigators of Tohoku University Hospital.CONFLICT OF INTERESTThe authors declare no financial relationships or conflict of interest.AUTHORS' CONTRIBUTIONSAll authors had full access to the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Conceptualization, K.K., S.K., K.S.; Data Curation, I.K., T.H., T.K., J.O., R.Is.; Project Administration, I.K., R.Ik., J.S., A.H.‐K., J.O., A.O., N.Sh., K.K., S.K., K.S., Y.K.; Methodology, N.S., R.T.; Investigation, T.H., N.S., R.T., T.K., A.H.‐K.; Formal Analysis, T.H., R.Ik., J.S., R.Is.; Resources, A.O.; Writing ‐ Original Draft, R.Ik.; Writing ‐ Review & Editing, T.H., R.Ik., J.S., A.H.‐K., R.Is., N.Sh.; Visualization, I.K., R.Ik., R.T., J.O., R.Is.; Supervision, R.Ik., J.S., A.H.‐K., J.O., A.O., N.Sh., K.K., S.K., K.S., Y.K.; Funding Acquisition, Y.K.ETHICS STATEMENTThis study was approved by the Tohoku University Hospital Institutional Review Board (IRB protocol number: 2014‐1‐274). Consent was obtained from patients.DATA AVAILABILITY STATEMENTThe data that support the findings of this study are available from the corresponding author upon reasonable request.REFERENCESKonaka K, Kondo J, Hirota N, et al. Relationship between tongue pressure and dysphagia in stroke patients. 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Journal

Cancer ReportsWiley

Published: Jul 1, 2022

Keywords: dysphagia; oral cancer; palatal augmentation prosthesis; swallowing; videofluoroscopic dysphagia scale

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