Professor Paul Carding

Background: The unprecedented rapid re-deployment of healthcare workers from different care pathways into newly created and fluid COVID-19 teams provides a unique opportunity to examine the interaction of many of the established non-technical factors for successful delivery of clinical care and teamwork in healthcare settings. This research paper therefore aims to address these gaps by qualitatively exploring the impact of COVID work throughout the pandemic on permanent and deployed personnel's experiences, their ability to effectively work together, and the effect of social dynamics (e.g., cohesion, social support) on teamwork and mental health.  Methods: Seventy-five interviews were conducted across the UK between March and December 2021 during wave 2 and 3 of COVID-19 with 75 healthcare workers who were either permanent staff on Intensive Care/High Dependency Units used as COVID wards, had been rapidly deployed to such a ward, or had managed such wards. Work Life Balance was measured using the WLB Scale. Interview transcripts were qualitatively coded and thematic codes were compared using network graph modelling.Results: Using thematic network analysis, four overarching thematic clusters were found, (1) Teamwork, (2) Organizational Support & Management, (3) Cohesion & Social Support, and (4) Psychological Strain. The study has three main findings. First, the importance of social factors for teamwork and mental health, whereby team identity may influence perceptions of preparedness, collaboration and communication, and impact on the collective appraisal of stressful events and work stressors. Secondly, it demonstrates the positive and negative impact of professional roles and skills on the development of teamwork and team identity. The study identifies the more pronounced negative impact of COVID work on deployed personnel's workload, mental health, and career intentions, exacerbated by reduced levels of social support during, and after, their deployment. Conclusions: The analysis was able to highlight the interactive and interdependent role of social dynamics on teamwork, suggesting that besides technical skills and preparedness, group membership and perception of professional category may play a bigger role for teamwork than previously stated. It also highlights the potentially protective impact of team-membership on participants experience of their pandemic work, especially considering the length of the recent pandemic.

Purpose. This research investigates the relative effectiveness of independent online and blended learning approaches for novice analysts’ development of videofluoroscopic swallowing study (VFSS) analytical skills. The secondary aims were to explore the impact of training on decision-making and to describe learners’ perspectives of training outcomes. Method. Undergraduate speech-language pathology students (n = 74) who had completed the dysphagia academic curriculum in an undergraduate speech-language pathology program were recruited for a randomised control trial. The ability to identify swallowing impairments in adults was compared pre- and post-training across three conditions: independent online (n = 23), peer-supported (n = 23), and expert-facilitated training (n = 28). The training comprised online VFSS training and practice with a commercially available digital video disc (DVD). Result. The three training approaches were equal in improving novice analysts’ identification of impairments on VFSS. Participants’ analysis improved pre- to post-training (p =

Background.
Perceptual, cognitive and previous clinical experience may influence a novice Videofluoroscopic Swallowing Study (VFSS) analyst's trajectory towards competency. Understanding these factors may allow trainees to be better prepared for VFSS training and may allow training to be developed to accommodate differences between trainees.

Aims. 
This study explored a range of factors previously suggested in the literature as influencing the development of novice analysts’ VFSS skills. We hypothesised that knowledge of swallow anatomy and physiology, visual perceptual skills, self-efficacy and interest, and prior clinical exposure would all influence VFSS novice analysts’ skill development.

Methods & Procedures. 
Participants were undergraduate speech pathology students recruited from an Australian university, who had completed the required theoretical units in dysphagia. Data assessing the factors of interest were collected—the participants identified anatomical structures on a still radiographic image, completed a physiology questionnaire, completed subsections of the Developmental Test of Visual Processing—Adults, self-reported the number of dysphagia cases they managed on placement, and self-rated their confidence and interest. Data for 64 participants relating to the factors of interest were compared with their ability to accurately identify swallowing impairments following 15 h of VFSS analytical training, using correlation and regression analysis.

Outcomes & Results. 
Success in VFSS analytical training was best predicted by clinical exposure to dysphagia cases and the ability to identify anatomical landmarks on still radiographic images.

Conclusions & Implications. 
Novice analysts vary in the acquisition of beginner-level VFSS analytical skill. Our findings suggest that speech pathologists who are new to VFSS may benefit from clinical exposure to dysphagia cases, sound foundational knowledge of anatomy relevant to swallowing and the ability to see the anatomical landmarks on still radiographic images. Further research is required to equip VFSS trainers and trainees for training, to understand differences between learners during skill development.

Background: Pre- and post-operative voice therapy may improve voice and quality-of-life outcomes for patients undergoing phonosurgery to remove benign vocal fold lesions (BVFLs). However, what constitutes voice therapy in this population is poorly described, resulting in a poor evidence base, lack of clinical guidelines and unwarranted variation in management. In order to develop the evidence base, a robust, iterative process of intervention development work should precede feasibility testing and effectiveness studies.

Methods & procedures: Guidance for developing complex interventions, drawing on evidence, theory and modelling, was used to inform the development of a pre- and post-operative voice therapy intervention entitled 'PaPOV'. Data from four sources of evidence were synthesized using a published triangulation protocol. Data from a systematic review, national survey of current practice, expert interview study, and patient and public involvement conversations were used to populate a triangulation matrix, outlining components of a PaPOV. Data were coded to reflect areas of agreement, dissonance and silence with each component of the intervention. Based on this evidence, an assessment of convergence for each intervention component could be made.

Outcomes & results: In total, 61 components of the PaPOV intervention were explored. Of these, 27 were categorized as having stability of consensus according to a priori criteria. A total of 34 failed to meet the criteria. This was more frequently due to silence (27) rather than dissonance (seven) in the data. By evidencing areas of agreement and stability of consensus across data sources, the validity of individual findings has been enhanced. Furthermore, the study has exposed specific areas of the intervention that lack consensus and require exploration through further intervention development studies.

Conclusions & implications: This systematic triangulation process has contributed to the development of a PaPOV intervention for patients with BVFLs. Exploration of specific components relating to the intervention will allow outstanding questions to be answered in preparation for feasibility testing.

The rapid increase of acute and intensive care capacities in hospitals needed during the response to COVID-19 created an urgent demand for skilled healthcare staff across the globe. To upscale capacity, many hospitals chose to increase their teams in these departments with rapidly re-deployed inter-professional healthcare personnel, many of whom had no prior experience of working in a high-risk environment and were neither prepared nor trained for work on such wards. This systematic review of reviews examines the current evidence base for successful teamwork in rapidly deployed interprofessional teams in intensive and acute care settings, by assessing systematic reviews of empirical studies to inform future deployments and support of rapidly formed clinical teams. This study identified 18 systematic reviews for further analysis. Utilising an integrative narrative synthesis process supported by thematic coding and graphical network analysis, 13 themes were found to dominate the literature on teams and teamwork in inter-professional and inter-disciplinary teams. This approach was chosen to make the selection process more transparent and enable the thematic clusters in the reviewed papers to be presented visually and codifying four factors that structure the literature on inter-professional teams (i.e., team-internal procedures and dynamics, communicative processes, organisational and team extrinsic influences on teams, and lastly patient and staff outcomes). Practically, the findings suggest that managers and team leaders in fluid and ad-hoc inter-professional healthcare teams in an intensive care environment need to pay attention to reducing pre-existing occupational identities and power-dynamics by emphasizing skill mix, establishing combined workspaces and break areas, clarifying roles and responsibilities, facilitating formal information exchange and developing informal opportunities for communication. The results may guide the further analysis of factors that affect the performance of inter-professional teams in emergency and crisis deployment.

Background: Evidence across a range of musically trained, hearing disordered and voice disordered populations present conflicting results regarding the relationship between pitch discrimination (PD) and voice quality. PD characteristics of female speakers with and without a musical training background and no self-reported voice disorder, and the relationship between PD and voice quality in this particular population, have not been investigated.

Aims: To evaluate PD characteristics in a cohort of female participants without a self-reported voice disorder and the relationship between PD and acoustic voice measures.

Method: One hundred fourteen female participants were studied, all of whom self-reported as being non-voice disordered. All completed the Newcastle Assessment of Pitch Discrimination which involved a two-tone PD task. Their voices were recorded producing standardized vocal tasks. Voice samples were acoustically analyzed for frequency-domain measures (fundamental frequency and its standard deviation, and harmonics-to-noise ratio) and spectral-domain measures (cepstral peak prominence and the Cepstral/Spectral Index of Dysphonia). Data were analyzed for the whole cohort and for musical and non-musical training backgrounds.

Results: In the whole cohort, there were no significant correlations between PD and acoustic voice measures. PD accuracy in musically trained speakers was better than in non-trained speakers and correlated with fundamental frequency standard deviation in prolonged vowel tasks. Vocalists demonstrated superior PD accuracy and fundamental frequency standard deviation in prolonged vowels compared to instrumentalists but did not show significant correlations between PD and acoustic measures. The Newcastle Assessment of Pitch Discrimination was a reliable tool, showing moderate-good prediction value in differentiating musical background.

Conclusions: There was little evidence of a relationship between PD and acoustic measures of voice quality, regardless of musical training background and superior PD accuracy among the musically trained. These data do not support ideas concerning the co-development of perception and action among individuals identified as having voice quality measures within normal ranges. Numerous measures of voice quality, including measures sensitive to pitch, did not distinguish across musically and non-musically trained individuals, despite individual differences in pitch discrimination.

Purpose
To synthesise the available evidence relating to best practice in training videofluoroscopy and barium swallow analysts.

Method
The review was conducted according to the PRISMA statement and registered in PROSPERO (CRD42017053744). Data were extracted from nine databases. Studies were included if they described training approaches for clinicians or students of any profession learning to interpret videofluoroscopic (VFSS) or barium swallow studies and were written in English. The methods were heterogeneous and a metanalysis was not possible; a narrative review is presented.

Result
Sixteen studies were eligible, including those designed to evaluate the influence of training as well as those that described training as part of validating an assessment tool or method. The quality of the studies was assessed with the Hawker scale and assigned an NHMRC rating. While the evidence was low quality (NHMRC level IV), training consistently improved the accuracy and reliability of clinicians and students conducting VFSS. No studies reported the outcome of training for barium swallow analysis. There was significant variability in the dose, method, and setting of training.

Conclusion
To elucidate best practice in VFSS analysis to ensure training is cost effective and results in accurate diagnosticians requires further research

Background. Persistent throat symptoms, such as throat clearing, globus sensation, voice change and catarrh are extremely common. On very limited evidence, they are increasingly attributed to “laryngopharyngeal reflux (LPR)” and treated with proton pump inhibitors (PPIs) in primary and secondary care. Methods. A double blind placebo controlled UK multicentre phase III trial randomly allocated adults with persistent throat symptoms 1:1 to either 30 mg of Lansoprazole or matched placebo twice daily for 16 weeks, stratified by centre and symptom severity. The primary outcome was patient-reported symptomatic response, measured by the total Reflux Symptom Index (RSI) score at the end of therapy. Secondary outcomes included safety, further symptoms and quality of life measures at 12-months. Results. 346 participants were randomised from 8 UK centres: mean (sd) age 52 (13), 196 (57%) female, 162 (47%) severe symptoms, balanced across randomised groups. Mean RSI scores (95% CI) were similar at baseline- Lansoprazole: 22.0 (20.4, 23.6), placebo: 21.7 (20.5, 23.0). Improvements (reduction in score) were observed in both groups at 16-weeks: Lansoprazole: 17.4 (15.5, 19.4), placebo: 15.6 (13.8, 17.3) (p=0.096 adjusted by site, severity). There was no statistically significant difference between randomised groups.  No significant differences were observed in the secondary outcome measures. Conclusions. TOPPITS is the largest, definitive trial to assess PPI effectiveness for persistent throat symptoms. It found no advantage of Lansoprazole over placebo in a range of outcomes. The near routine use of PPIs for throat symptoms should be discontinued. 

Aims and objectives: To review interventions and strategies designed to progress UK clinical academic career pathways in nursing and identify barriers and facilitators to aid wider implementation.

Background: For over a decade, the UK political agenda has promoted the entry of nurses into clinical academic roles. Partnerships between the National Health Service and academia are known to increase nursing recruitment, retention and quality of care. However, there remains a lack of nurses working in these partnership roles.

Design: A systematised review was conducted. An electronic database search was carried out in PubMed, CINAHL, the British Nursing Database, and PsychInfo for articles published between Sept 2006 to June 2020. A narrative approach to data synthesis was used and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed.

Results: Ten papers were included in the review. The authors reported a range of programmes, pathways and toolkits. Pathway outcome measures included numbers of nurses recruited onto clinical academic programmes, clinical academic programmes completed, nursing research outputs, impact on clinical practice and impact on nursing recruitment. Barriers and facilitators to pathway development included funding, clinical and research time constraints, infrastructure, strong and strategic clinical-academic leadership and effective partnership working. The quality of the included studies was mixed; more high quality, evidence-based programmes need to be developed and rigorously evaluated. 

Conclusions: The findings can inform nursing clinical academic research pathway development internationally, by identifying key drivers for success. Sustained and cohesive implementation of clinical academic research pathways is lacking across the UK.

Objective. To assess the use of proton pump inhibitors (PPIs) to treat persistent throat symptoms.

Design. Pragmatic, double blind, placebo controlled, randomised trial.

Setting. Eight ear, nose, and throat outpatient clinics, United Kingdom.

Participants. 346 patients aged 18 years or older with persistent throat symptoms who were randomised according to recruiting centre and baseline severity of symptoms (mild or severe): 172 to lansoprazole and 174 to placebo.

Intervention. Random blinded allocation (1:1) to either 30 mg lansoprazole twice daily or matched placebo twice daily for 16 weeks.

Main outcome measures. Primary outcome was symptomatic response at 16 weeks measured using the total reflux symptom index (RSI) score. Secondary outcomes included symptom response at 12 months, quality of life, and throat appearances.

Results. Of 1427 patients initially screened for eligibility, 346 were recruited. The mean age of the study sample was 52.2 (SD 13.7) years, 196 (57%) were women, and 162 (47%) had severe symptoms at presentation; these characteristics were balanced across treatment arms. The primary analysis was performed on 220 patients who completed the primary outcome measure within a window of 14-20 weeks. Mean RSI scores were similar between treatment arms at baseline: lansoprazole 22.0 (95% confidence interval 20.4 to 23.6) and placebo 21.7 (20.5 to 23.0). Improvements (reduction in RSI score) were observed in both groups—score at 16 weeks: lansoprazole 17.4 (15.5 to19.4) and placebo 15.6 (13.8 to 17.3). No statistically significant difference was found between the treatment arms: estimated difference 1.9 points (95% confidence interval −0.3 to 4.2 points; P=0.096) adjusted for site and baseline symptom severity. Lansoprazole showed no benefits over placebo for any secondary outcome measure, including RSI scores at 12 months: lansoprazole 16.0 (13.6 to 18.4) and placebo 13.6 (11.7 to 15.5): estimated difference 2.4 points (−0.6 to 5.4 points).

Conclusions. No evidence was found of benefit from PPI treatment in patients with persistent throat symptoms. RSI scores were similar between the lansoprazole and placebo groups after 16 weeks of treatment and at the 12 month follow-up.

Objective. To assess the use of proton pump inhibitors (PPIs) to treat persistent throat symptoms.

Design. Pragmatic, double blind, placebo controlled, randomised trial.

Setting. Eight ear, nose, and throat outpatient clinics, United Kingdom.

Participants. 346 patients aged 18 years or older with persistent throat symptoms who were randomised according to recruiting centre and baseline severity of symptoms (mild or severe): 172 to lansoprazole and 174 to placebo.

Intervention. Random blinded allocation (1:1) to either 30 mg lansoprazole twice daily or matched placebo twice daily for 16 weeks.

Main outcome measures. Primary outcome was symptomatic response at 16 weeks measured using the total reflux symptom index (RSI) score. Secondary outcomes included symptom response at 12 months, quality of life, and throat appearances.

Results. Of 1427 patients initially screened for eligibility, 346 were recruited. The mean age of the study sample was 52.2 (SD 13.7) years, 196 (57%) were women, and 162 (47%) had severe symptoms at presentation; these characteristics were balanced across treatment arms. The primary analysis was performed on 220 patients who completed the primary outcome measure within a window of 14-20 weeks. Mean RSI scores were similar between treatment arms at baseline: lansoprazole 22.0 (95% confidence interval 20.4 to 23.6) and placebo 21.7 (20.5 to 23.0). Improvements (reduction in RSI score) were observed in both groups—score at 16 weeks: lansoprazole 17.4 (15.5 to19.4) and placebo 15.6 (13.8 to 17.3). No statistically significant difference was found between the treatment arms: estimated difference 1.9 points (95% confidence interval −0.3 to 4.2 points; P=0.096) adjusted for site and baseline symptom severity. Lansoprazole showed no benefits over placebo for any secondary outcome measure, including RSI scores at 12 months: lansoprazole 16.0 (13.6 to 18.4) and placebo 13.6 (11.7 to 15.5): estimated difference 2.4 points (−0.6 to 5.4 points).

Conclusions. No evidence was found of benefit from PPI treatment in patients with persistent throat symptoms. RSI scores were similar between the lansoprazole and placebo groups after 16 weeks of treatment and at the 12 month follow-up.

Objectives
(1) To describe factors influencing the content, timing, and intensity of pre- and postoperative voice therapy for patients undergoing phonosurgery for benign vocal fold lesions. (2) To understand experts’ rationale for decisions made. (3) To critically analyze factors influencing intervention in relation to the wider literature in order to contribute to the development of a complex intervention.

Design
Qualitative interview study.

Setting
Multidisciplinary voice clinics in England.

Participants
Ten expert voice therapists with a mean of 22 years experience.

Main outcome measures
Participants were asked to describe factors influencing their current practice and views on optimum treatment for patients undergoing phonosurgery for benign vocal fold lesions. Data were analyzed using the Framework Method of thematic analysis.

Results
Factors influencing intervention related to four key themes. Pathophysiological, Patient, Therapist, and Service factors influenced the content, timing, and duration of the voice therapy provided. Consensus on core elements included delivering indirect and direct therapy preoperatively to manage underlying causative factors and address patient expectations. Postoperative intervention focused on indirect therapy to facilitate wound healing and direct therapy to improve vibratory characteristics of the vocal fold. Elements of therapy were highly individualized within participants according to the four themes above, but similarity between participants on broad parameters of intervention was high.

Conclusions
Expert voice therapists use direct and indirect methods pre- and postoperatively to treat patients with benign vocal fold lesions. Optimizing wound healing and mobilization of the epithelium postoperatively are concerns for expert voice therapists which distinguish postoperative patients from other dysphonic patients. This study provides an insight into the factors influencing clinician's intervention provision which can contribute to the development of an optimal pre- and postoperative voice therapy intervention. Further research to refine and test the effectiveness of an intervention is now required.

Background.
The COVID‐19 pandemic and the UK government's subsequent coronavirus action plan have fundamentally impacted on every aspect of healthcare. One area that is severely affected is ear, nose and throat (ENT)/laryngology where speech and language therapists (SLTs) engage in a diverse range of practice with patients with a range of conditions, including voice disorders, airway problems, and head and neck cancers (HNCs). A large majority of these patients are in high‐risk categories, and many specialized clinical practices are vulnerable. In addition, workforce and research issues are challenged in both the immediate context and the future.

Aims.
To discuss the threats and opportunities from the COVID‐19 pandemic for SLTs in ENT/laryngology with specific reference to clinical practice, workforce and research leadership.

Methods & Procedures.
The relevant sections of the World Health Organisation's (WHO) health systems building blocks framework (2007) were used to structure the study. Expert agreement was determined by an iterative process of multiple‐group discussions, the use of all recent relevant policy documentation, and other literature and shared documentation/writing. The final paper was verified and agreed by all authors.

Main Contribution.
The main threats to ENT/laryngology SLT clinical services include increased patient complexity related to COVID‐19 voice and airway problems, delayed HNC diagnosis, reduced access to instrumental procedures and inequitable care provision. The main clinical opportunities include the potential for new modes of service delivery and collaborations, and harnessing SLT expertise in non‐instrumental assessment. There are several workforce issues, including redeployment (and impact on current services), training implications and psychological impact on staff. Workforce opportunities exist for service innovation and potential extended ENT/SLT practice roles. Research is threatened by a reduction in immediate funding calls and high competition. Current research is affected by very limited access to participants and the ability to conduct face‐to‐face and instrumental assessments. However, research opportunities may result in greater collaboration, and changes in service delivery necessitate robust investigation and evaluation. A new national set of research priorities is likely to emerge.

Conclusions & Implications.
The immediate impact of the pandemic has resulted in major disruption to all aspects of clinical delivery, workforce and research for ENT/laryngology SLT. It is unclear when any of these areas will resume operations and whether permanent changes to clinical practice, professional remits and research priorities will follow. However, significant opportunity exists in the post‐COVID era to re‐evaluate current practice, embrace opportunities and evaluate new ways of working.

Background. The COVID‐19 pandemic and the UK government's subsequent coronavirus action plan have fundamentally impacted on every aspect of healthcare. One area that is severely affected is ear, nose and throat (ENT)/laryngology where speech and language therapists (SLTs) engage in a diverse range of practice with patients with a range of conditions, including voice disorders, airway problems, and head and neck cancers (HNCs). A large majority of these patients are in high‐risk categories, and many specialized clinical practices are vulnerable. In addition, workforce and research issues are challenged in both the immediate context and the future.

Aims. To discuss the threats and opportunities from the COVID‐19 pandemic for SLTs in ENT/laryngology with specific reference to clinical practice, workforce and research leadership.

Methods & Procedures. The relevant sections of the World Health Organisation's (WHO) health systems building blocks framework (2007) were used to structure the study. Expert agreement was determined by an iterative process of multiple‐group discussions, the use of all recent relevant policy documentation, and other literature and shared documentation/writing. The final paper was verified and agreed by all authors.

Main Contribution. The main threats to ENT/laryngology SLT clinical services include increased patient complexity related to COVID‐19 voice and airway problems, delayed HNC diagnosis, reduced access to instrumental procedures and inequitable care provision. The main clinical opportunities include the potential for new modes of service delivery and collaborations, and harnessing SLT expertise in non‐instrumental assessment. There are several workforce issues, including redeployment (and impact on current services), training implications and psychological impact on staff. Workforce opportunities exist for service innovation and potential extended ENT/SLT practice roles. Research is threatened by a reduction in immediate funding calls and high competition. Current research is affected by very limited access to participants and the ability to conduct face‐to‐face and instrumental assessments. However, research opportunities may result in greater collaboration, and changes in service delivery necessitate robust investigation and evaluation. A new national set of research priorities is likely to emerge.

Conclusions & Implications. The immediate impact of the pandemic has resulted in major disruption to all aspects of clinical delivery, workforce and research for ENT/laryngology SLT. It is unclear when any of these areas will resume operations and whether permanent changes to clinical practice, professional remits and research priorities will follow. However, significant opportunity exists in the post‐COVID era to re‐evaluate current practice, embrace opportunities and evaluate new ways of working.

Background.
The COVID‐19 pandemic and the UK government's subsequent coronavirus action plan have fundamentally impacted on every aspect of healthcare. One area that is severely affected is ear, nose and throat (ENT)/laryngology where speech and language therapists (SLTs) engage in a diverse range of practice with patients with a range of conditions, including voice disorders, airway problems, and head and neck cancers (HNCs). A large majority of these patients are in high‐risk categories, and many specialized clinical practices are vulnerable. In addition, workforce and research issues are challenged in both the immediate context and the future.

Aims.
To discuss the threats and opportunities from the COVID‐19 pandemic for SLTs in ENT/laryngology with specific reference to clinical practice, workforce and research leadership.

Methods & Procedures.
The relevant sections of the World Health Organisation's (WHO) health systems building blocks framework (2007) were used to structure the study. Expert agreement was determined by an iterative process of multiple‐group discussions, the use of all recent relevant policy documentation, and other literature and shared documentation/writing. The final paper was verified and agreed by all authors.

Main Contribution.
The main threats to ENT/laryngology SLT clinical services include increased patient complexity related to COVID‐19 voice and airway problems, delayed HNC diagnosis, reduced access to instrumental procedures and inequitable care provision. The main clinical opportunities include the potential for new modes of service delivery and collaborations, and harnessing SLT expertise in non‐instrumental assessment. There are several workforce issues, including redeployment (and impact on current services), training implications and psychological impact on staff. Workforce opportunities exist for service innovation and potential extended ENT/SLT practice roles. Research is threatened by a reduction in immediate funding calls and high competition. Current research is affected by very limited access to participants and the ability to conduct face‐to‐face and instrumental assessments. However, research opportunities may result in greater collaboration, and changes in service delivery necessitate robust investigation and evaluation. A new national set of research priorities is likely to emerge.

Conclusions & Implications.
The immediate impact of the pandemic has resulted in major disruption to all aspects of clinical delivery, workforce and research for ENT/laryngology SLT. It is unclear when any of these areas will resume operations and whether permanent changes to clinical practice, professional remits and research priorities will follow. However, significant opportunity exists in the post‐COVID era to re‐evaluate current practice, embrace opportunities and evaluate new ways of working.

Purpose. In the absence of evidence-based guidelines, this study sought to understand current speech-language pathologists’ (SLPs) practice when treating drooling in children with a neurodisability.

Method. Descriptive research using cross-sectional survey methodology. Online survey methods were used to obtain specific information on Australian SLPs’ self-reported assessment and treatment practices relative to working with children with neurodisability who drool. Questions focussed on level of expertise, treatment approaches and barriers to evidence-based practice (EBP) in this area. Participants were sourced through three targeted associations/organisations. Data were analysed using descriptive and non-parametric statistics.

Result. Participants were Australian SLPs who had recent experience working with children with neurodisability who drool (n = 68). They favoured informal rather than formal methods for assessment. Preferred treatment techniques included behavioural intervention methods (46–53%) and modifying positioning (43.3%). Client suitability dominated reasoning regarding treatment selection (60%) with 57% of SLPs reporting EBP barriers.

Conclusion. Drooling was perceived to be a complex practice area for which SLPs desire additional education. Despite availability, valid and reliable assessments of drooling were not commonly used. Clinicians have limited evidence to support their practice: further research is needed to establish evidence-based treatments for drooling.

Speech and voice changes are a central feature of the symptom complex of people with Parkinson’s disease (pwPD). Speaking is a social activity involving the pwPD, family, and the wider communicative context. Sensory-motor, cognitive-linguistic, and affective changes in Parkinson’s disease (PD) combine to alter communication, impacting on psycho-social quality-of-life, leading to risks of social withdrawal and increased depression and anxiety. The underlying pathophysiology of speech, voice, and communication difficulties in pwPD is multi-factorial and complex. Sensory-motor changes in the respiratory, phonatory, and articulatory subsystems, underscaling of effort, and central processing problems are further affected by broader cognitive-linguistic difficulties, and non-speech motor deficits. Many studies show that, when pwPD are asked to rate their own voice and how it functions in everyday situations, they show increased voice-related disability and negative impact relative to healthy controls. Voice treatment is integral to improving communication in pwPD. Studies show positive benefits from the perspective of pwPD and carers. Treatment approaches vary from one-to-one to group interventions, a singular focus on increasing loudness to more general voice exercises, and choral singing. The nature and underlying pathophysiology of speech, voice, and communication changes in pwPD are reviewed before exploring the effects of voice treatment programs and pwPD and carer perceptions of their effect. Larger scale, better powered, controlled trials of intervention for voice and speech that measure clinically and socially relevant outcomes are finally underway. Future research should also focus on issues of treatment compliance, practicality (for service delivery and use), and long-term follow-up outcomes. The role of carers in longer-term maintenance represents a further important area of exploration.

Speech and voice changes are a central feature of the symptom complex of people with Parkinson’s disease (pwPD). Speaking is a social activity involving the pwPD, family, and the wider communicative context. Sensory-motor, cognitive-linguistic, and affective changes in Parkinson’s disease (PD) combine to alter communication, impacting on psycho-social quality-of-life, leading to risks of social withdrawal and increased depression and anxiety. The underlying pathophysiology of speech, voice, and communication difficulties in pwPD is multi-factorial and complex. Sensory-motor changes in the respiratory, phonatory, and articulatory subsystems, underscaling of effort, and central processing problems are further affected by broader cognitive-linguistic difficulties, and non-speech motor deficits. Many studies show that, when pwPD are asked to rate their own voice and how it functions in everyday situations, they show increased voice-related disability and negative impact relative to healthy controls. Voice treatment is integral to improving communication in pwPD. Studies show positive benefits from the perspective of pwPD and carers. Treatment approaches vary from one-to-one to group interventions, a singular focus on increasing loudness to more general voice exercises, and choral singing. The nature and underlying pathophysiology of speech, voice, and communication changes in pwPD are reviewed before exploring the effects of voice treatment programs and pwPD and carer perceptions of their effect. Larger scale, better powered, controlled trials of intervention for voice and speech that measure clinically and socially relevant outcomes are finally underway. Future research should also focus on issues of treatment compliance, practicality (for service delivery and use), and long-term follow-up outcomes. The role of carers in longer-term maintenance represents a further important area of exploration.

Speech and voice changes are a central feature of the symptom complex of people with Parkinson’s disease (pwPD). Speaking is a social activity involving the pwPD, family, and the wider communicative context. Sensory-motor, cognitive-linguistic, and affective changes in Parkinson’s disease (PD) combine to alter communication, impacting on psycho-social quality-of-life, leading to risks of social withdrawal and increased depression and anxiety. The underlying pathophysiology of speech, voice, and communication difficulties in pwPD is multi-factorial and complex. Sensory-motor changes in the respiratory, phonatory, and articulatory subsystems, underscaling of effort, and central processing problems are further affected by broader cognitive-linguistic difficulties, and non-speech motor deficits. Many studies show that, when pwPD are asked to rate their own voice and how it functions in everyday situations, they show increased voice-related disability and negative impact relative to healthy controls. Voice treatment is integral to improving communication in pwPD. Studies show positive benefits from the perspective of pwPD and carers. Treatment approaches vary from one-to-one to group interventions, a singular focus on increasing loudness to more general voice exercises, and choral singing. The nature and underlying pathophysiology of speech, voice, and communication changes in pwPD are reviewed before exploring the effects of voice treatment programs and pwPD and carer perceptions of their effect. Larger scale, better powered, controlled trials of intervention for voice and speech that measure clinically and socially relevant outcomes are finally underway. Future research should also focus on issues of treatment compliance, practicality (for service delivery and use), and long-term follow-up outcomes. The role of carers in longer-term maintenance represents a further important area of exploration.

Vocal fold nodules present the voice clinic team with a number of clinical dilemmas which are not as simple as previously thought. The definition, aetiology, prevalence and diagnosis are all poorly understood. Furthermore, treatment evidence for both behavioural and surgical approaches is weak. This paper reviews the published evidence pertaining to all of these aspects. Specific areas of uncertainty that remain include poorly defined nomenclature, the natural history of paediatric vocal nodules, the establishment of criteria to measure successful treatment, optimal configuration of speech therapy regimens and the rationale for surgical intervention. The authors suggest the development of evidence‐based guidelines for UK practice.

Objectives. Unilateral vocal fold paralysis (UVFP) typically results in marked changes in voice quality and performance and has a significant impact on quality of life. Treatment approaches generally aim to restore glottal closure for phonation and improve vocal function. There are a wide range of voice outcome measures that are available to measure the treatment effect. Careful selection of voice outcome measures is required to ensure that they are adequate for purpose and are psychometrically sound to detect the treatment effect. This article aims to critically evaluate the literature for voice outcome measures that are used for patients with UVFP. Study Design. Systematic review. Methods. Nine databases were searched for UVFP treatment studies published since 2003 (n = 2,484 articles). These articles and their references were screened using inclusion/exclusion criteria, including population characteristics, treatment, voice outcomes, and study findings. Data from the included articles was extracted and appraised with respect to multidimensionality, timing, selection rationale, validity, reliability, and responsiveness to change of the voice outcome measures. Results. A total of 29 studies met the inclusion criteria for the systematic review. These studies showed considerable variability in the rationale, selection, and application of voice outcome measures for reporting the treatment effect for patients with UVFP. Conclusion. There is currently a significant disparity in the selection and use of voice outcome measures for patients with UVFP. A set of principles around selection rationale, validity, reliability, and responsiveness to change is proposed to enhance the judicious selection of voice outcome measures for this patient group.

Purpose. Patients with throat cancer at later stages often undergo total laryngectomy, a procedure that removes the larynx (voice box) and directly impacts the patient’s ability to produce natural voice and communication. This narrative review aimed to explore how changes to communication following laryngectomy may impact quality of life (QoL) for patients. Methods. Literature searches were conducted using CINAHL, MEDLINE and PsychInfo databases for studies published between 2007 and 2018. The search terms (and derivatives) of laryngectomy AND communication AND quality of life were used. A synthesis and appraisal of the studies was conducted. Results. Twelve studies met the inclusion criteria and were included in this review. The two main themes identified relating to changes in communication and impact on QoL were changes in communication competency (immediate changes and communication option used) and adaptation to change (e.g. self-related factors and relationships with others). Regardless of the type of communication option used, participants in all studies reported negative changes in their communication competency and QoL post-laryngectomy. Voice-related factors and aesthetics of the communication option used were noted to influence self-ratings of QoL for the participants, rather than how well others understood them. Participants using tracheoesophageal speech (TES) consistently showed the highest self-reported QoL across the majority of studies. A model incorporating the findings from this review has been proposed which outlines how changes in communication post-laryngectomy may lead to an impact on QoL. Here, the factors of changes in communication competency, self-perception and social engagement impact each other and are also influenced by adaptation to change. Conclusion. This review has highlighted the complex nature of changes faced by patients following laryngectomy in relation to communication and QoL. The model linking communication changes to QoL may become a useful tool for researchers and clinicians in supporting the management of patients post-laryngectomy.

Purpose. Patients with throat cancer at later stages often undergo total laryngectomy, a procedure that removes the larynx (voice box) and directly impacts the patient’s ability to produce natural voice and communication. This narrative review aimed to explore how changes to communication following laryngectomy may impact quality of life (QoL) for patients. Methods. Literature searches were conducted using CINAHL, MEDLINE and PsychInfo databases for studies published between 2007 and 2018. The search terms (and derivatives) of laryngectomy AND communication AND quality of life were used. A synthesis and appraisal of the studies was conducted. Results. Twelve studies met the inclusion criteria and were included in this review. The two main themes identified relating to changes in communication and impact on QoL were changes in communication competency (immediate changes and communication option used) and adaptation to change (e.g. self-related factors and relationships with others). Regardless of the type of communication option used, participants in all studies reported negative changes in their communication competency and QoL post-laryngectomy. Voice-related factors and aesthetics of the communication option used were noted to influence self-ratings of QoL for the participants, rather than how well others understood them. Participants using tracheoesophageal speech (TES) consistently showed the highest self-reported QoL across the majority of studies. A model incorporating the findings from this review has been proposed which outlines how changes in communication post-laryngectomy may lead to an impact on QoL. Here, the factors of changes in communication competency, self-perception and social engagement impact each other and are also influenced by adaptation to change. Conclusion. This review has highlighted the complex nature of changes faced by patients following laryngectomy in relation to communication and QoL. The model linking communication changes to QoL may become a useful tool for researchers and clinicians in supporting the management of patients post-laryngectomy.

Aim. To review the evidence for behavioural interventions to reduce drooling in children with neurodisability. Method. A detailed search in eight databases sought studies that: (1) included participants aged 0 to 18 years with neurodisability and drooling; (2) provided behavioural interventions targeting drooling or a drooling‐related behaviour; and (3) used experimental designs. Two reviewers extracted data from full‐text papers independently. Results were tabulated for comparison. The Risk of Bias assessment in N‐of‐1 Trials scale for single case experimental designs (SCEDs) and the Cochrane risk of bias assessment tool for randomized controlled trials (RCTs) were applied. Results. Of an initial yield of 763, seven SCEDs and one RCT were included. Behavioural interventions included the use of reinforcement, prompting, self‐management, instruction, extinction, overcorrection, and fading. Each assessed body functions or structures’ outcomes (drooling frequency and severity); three included activity outcomes (mouth drying, head control, eye contact, and vocalizations) and none assessed participation or quality of life. While each study reported positive effects of intervention, risk of bias was high. Interpretation. Low‐level evidence suggests behavioural interventions may be useful for treatment of drooling in children with neurodisability. Well‐designed intervention studies are urgently needed to determine effectiveness. What this paper adds. 1. Behavioural interventions used to treat drooling included reinforcement, prompting, self‐management, extinction, overcorrection, instruction, and fading. 2. Interventions targeted body structures and function‐level outcomes and activity‐level outcomes. 3. Low‐level evidence supports the use of behavioural intervention to treat drooling.

Perceptual assessment of tracheoesophageal voice quality following total laryngectomy with surgical voice restoration is essential to investigate functional outcomes in relation to surgical procedure and rehabilitation regimes. There is no current tool with established reliability and validity to fulfill this purpose. This study describes the development of a set of new perceptual scales, in relation to core validity and reliability issues. These were investigated using voice stimuli from 55 voice prosthesis speakers and evaluated by 22 judges—12 speech and language therapists (SLTs), 10 Ear, Nose, and Throat surgeons—classified into experienced or not at assessing voice. SLT judges rated more parameters reliably than Ear, Nose, and Throat raters, and SLTs with specialist experience in laryngectomy and laryngeal voice attained the most parameters at an acceptable level of agreement. These scales are ready for clinical use, with the most optimal assessors being expert SLTs. Future studies are needed to ascertain precisely how reliability may relate to training, experience, voice stimuli type, and scale format.

Background. Voice tremor associated with Parkinson disease (PD) has not been characterized. Its relationship with voice disability and disease variables is unknown. Objectives. This study aimed to evaluate voice tremor in people with PD (pwPD) and a matched control group using acoustic analysis, and to examine correlations with voice disability and disease variables. Methods. Acoustic voice tremor analysis was completed on 30 pwPD and 28 age-gender matched controls. Voice disability (Voice Handicap Index), and disease variables of disease duration, Activities of Daily Living (Unified Parkinson's Disease Rating Scale [UPDRS II]), and motor symptoms related to PD (UPDRS III) were examined for relationship with voice tremor measures. Results. Voice tremor was detected acoustically in pwPD and controls with similar frequency. PwPD had a statistically significantly higher rate of amplitude tremor (Hz) than controls (P = 0.001). Rate of amplitude tremor was negatively and significantly correlated with UPDRS III total score (rho −0.509). For pwPD, the magnitude and periodicity of acoustic tremor was higher than for controls without statistical significance. The magnitude of frequency tremor (Mftr%) was positively and significantly correlated with disease duration (rho 0.463). PwPD had higher Voice Handicap Index total, functional, emotional, and physical subscale scores than matched controls (P 

Objective. The objective of this prospective study is to report on long-term swallowing outcomes in a group of head and neck cancer patients following (chemo) radiotherapy treatment, assess for changes over time and identify any predictor variables of outcome. Materials and methods. 42 survivors were assessed on four swallowing measures and followed up from pre-treatment to six years post 3D (chemo) radiotherapy. Measures included a swallowing specific QOL questionnaire, penetration-aspiration scale, dietary restrictions and a timed water swallow test. Results. At six years, 71% reported swallowing difficulties on the questionnaire. One fifth of patients had aspiration, with a raised risk of chest infection. Seven percent required a laryngectomy for a dysfunctional larynx. Despite this, half the group reported having a normal diet. There was variation in the pattern of change between one and six years. A significant deterioration was only observed in the timed water swallow test (p 

Children with speech sound disorders benefit from feedback about the accuracy of sounds they make. Home practice can reinforce feedback received from speech pathologists. Games in mobile device applications could encourage home practice, but those currently available are of limited value because they are unlikely to elaborate “Correct”/”Incorrect” feedback with information that can assist in improving the accuracy of the sound. This protocol proposes a “Wizard of Oz” experiment that aims to provide evidence for the provision of effective multimedia feedback for speech sound development. Children with two common speech sound disorders will play a game on a mobile device and make speech sounds when prompted by the game. A human “Wizard” will provide feedback on the accuracy of the sound but the children will perceive the feedback as coming from the game. Groups of 30 young children will be randomly allocated to one of five conditions: four types of feedback and a control which does not play the game. The results of this experiment will inform not only speech sound therapy, but also other types of language learning, both in general, and in multimedia applications. This experiment is a cost-effective precursor to the development of a mobile application that employs pedagogically and clinically sound processes for speech development in young children.

Purpose of review: Unilateral vocal fold paralysis (UVFP) is a common cause of neurogenic dysphonia resulting in glottal insufficiency. To restore glottal sufficiency and reduce the presenting dysphonia, treatment involving either surgical intervention, voice therapy or a combination of the two is typically provided. Currently, there is no consensus for the most effective voice treatment for UVFP. This results in an inability to compare current studies, and a lack of treatment effectiveness for the management of UVFP. This study aims to review the most recent literature for the management of dysphonia due to UVFP to establish the current evidence base for voice treatment options. Recent findings: There was found to be a lack of consistency in the rationale, selection and timing of the surgical intervention and/or voice therapy being provided for patients with UVFP. Summary: Further consensus is required for the rationale and selection of voice treatment prescriptions for the management of UVFP in order to improve treatment effectiveness and voice outcomes in patients with UVFP. 

Background: Medically unexplained loss or alteration of voice—functional dysphonia—is the commonest presentation to speech and language therapists (SLTs). Besides the impact on personal and work life, functional dysphonia is also associated with increased levels of anxiety and depression and poor general health. Voice therapy delivered by SLTs improves voice but not these associated symptoms. The aims of this research were the systematic development of a complex intervention to improve the treatment of functional dysphonia, and the trialling of this intervention for feasibility and acceptability to SLTs and patients in a randomised pilot study Methods: A theoretical model of medically unexplained symptoms (MUS) was elaborated through literature review and synthesis. This was initially applied as an assessment format in a series of patient interviews. Data from this stage and a small consecutive cohort study were used to design and refine a brief cognitive behavioural therapy (CBT) training intervention for a SLT. This was then implemented in an external pilot patient randomised trial where one SLT delivered standard voice therapy or voice therapy plus CBT to 74 patients. The primary outcomes were of the acceptability of the intervention to patients and the SLT, and the feasibility of changing the SLT’s clinical practice through a brief training. This was measured through monitoring treatment flow and through structured analysis of the content of intervention for treatment fidelity and inter-treatment contamination. Results: As measured by treatment flow, the intervention was as acceptable as standard voice therapy to patients. Analysis of treatment content showed that the SLT was able to conduct a complex CBT formulation and deliver novel treatment strategies for fatigue, sleep, anxiety and depression in the majority of patients. On pre-post measures of voice and quality of life, patients in both treatment arms improved. Conclusion: These interventions were acceptable to patients. Emotional and psychosocial issues presented routinely in the study patient group and CBT techniques were used, deliberately and inadvertently, in both treatment arms. This CBT “contamination” of the voice therapy only arm reflects the chief limitation of the study: one therapist delivered both treatments.

Background. Voice tremor associated with Parkinson disease (PD) has not been characterized. Its relationship with voice disability and disease variables is unknown. Objectives. This study aimed to evaluate voice tremor in people with PD (pwPD) and a matched control group using acoustic analysis, and to examine correlations with voice disability and disease variables. Methods. Acoustic voice tremor analysis was completed on 30 pwPD and 28 age-gender matched controls. Voice disability (Voice Handicap Index), and disease variables of disease duration, Activities of Daily Living (Unified Parkinson's Disease Rating Scale [UPDRS II]), and motor symptoms related to PD (UPDRS III) were examined for relationship with voice tremor measures. Results. Voice tremor was detected acoustically in pwPD and controls with similar frequency. PwPD had a statistically significantly higher rate of amplitude tremor (Hz) than controls (P = 0.001). Rate of amplitude tremor was negatively and significantly correlated with UPDRS III total score (rho −0.509). For pwPD, the magnitude and periodicity of acoustic tremor was higher than for controls without statistical significance. The magnitude of frequency tremor (Mftr%) was positively and significantly correlated with disease duration (rho 0.463). PwPD had higher Voice Handicap Index total, functional, emotional, and physical subscale scores than matched controls (P 

Introduction. A functioning voice is essential for normal human communication. A good voice requires two moving vocal folds; if one fold is paralysed (unilateral vocal fold paralysis (UVFP)) people suffer from a breathy, weak voice that tires easily and is unable to function normally. UVFP can also result in choking and breathlessness. Current treatment for adults with UVFP is speech therapy to stimulate recovery of vocal fold (VF) motion or function and/or injection of the paralysed VF with a material to move it into a more favourable position for the functioning VF to close against. When these therapies are unsuccessful, or only provide temporary relief, surgery is offered. Two available surgical techniques are: (1) surgical medialisation; placing an implant near the paralysed VF to move it to the middle (thyroplasty) and/or repositioning the cartilage (arytenoid adduction) or (2) restoring the nerve supply to the VF (laryngeal reinnervation). Currently there is limited evidence to determine which surgery should be offered to adults with UVFP. Methods and analysis. A feasibility study to test the practicality of running a multicentre, randomised clinical trial of surgery for UVFP, including: (1) a qualitative study to understand the recruitment process and how it operates in clinical centres and (2) a small randomised trial of 30 participants recruited at 3 UK sites comparing non-selective laryngeal reinnervation to type I thyroplasty. Participants will be followed up for 12 months. The primary outcome focuses on recruitment and retention, with secondary outcomes covering voice, swallowing and quality of life.

Objectives. Dysphonia due to unilateral vocal fold paralysis (UVFP) can be characterized by hoarseness and weakness, resulting in a significant impact on patients' activity and participation. Voice therapy provided by a speech-language pathologist is designed to maximize vocal function and improve quality of life. The purpose of this paper is to systematically review literature surrounding the effectiveness of speech-language pathology intervention for the management of UVFP in adults. Study Design. This is a systematic review. Methods. Electronic databases were searched using a range of key terms including dysphonia, vocal fold paralysis, and speech-language pathology. Eligible articles were extracted and reviewed by the authors for risk of bias, methodology, treatment efficacy, and clinical outcomes. Results. Of the 3311 articles identified, 12 met the inclusion criteria: seven case series and five comparative studies. All 12 studies subjectively reported positive effects following the implementation of voice therapy for UVFP; however, the heterogeneity of participant characteristics, voice therapy, and voice outcome resulted in a low level of evidence. Conclusions. There is presently a lack of methodological rigor and clinical efficacy in the speech-language pathology management of dysphonia arising from UVFP in adults. Reasons for this reduced efficacy can be attributed to the following: (1) no standardized speech-language pathology intervention; (2) no consistency of assessment battery; (3) the variable etiology and clinical presentation of UVFP; and (4) inconsistent timing, frequency, and intensity of treatment. Further research is required to develop the evidence for the management of UVFP incorporating controlled treatment protocols and more rigorous clinical methodology.

Purpose of review.Voice tremor is strongly linked to the Parkinson's disease speech–voice symptom complex. Little is known about the underlying anatomic source(s) of voice tremor when it occurs. We review recent literature addressing this issue. Additionally we report findings from a study we conducted employing rating of vocal tract structures viewed using nasolaryngoscopy during vocal and nonspeech tasks. Recent findings. In Parkinson's disease, using laryngeal electromyography, tremor has not been identified in muscles in the vocal folds even when perceived auditorily. Preliminary findings using nasolaryngoscopy suggest that Parkinson's disease voice tremor is not associated with the vocal folds and may involve the palate, the global larynx, and the arytenoids. Tremor in the vertical larynx on /a/, and tremor in the arytenoid cartilages on /s/ differentiated patients with Parkinson's disease from neurologically healthy controls. Visual reliable detection of tremor when it is absent or borderline present, is challenging. Summary. Parkinson's disease voice tremor is likely to be related to oscillatory movement in structures across the vocal tract rather than just the vocal folds. To progress clinical practice, more refined tools for the visual rating of tremor would be beneficial. How far voice tremor represents a functionally significant factor for speakers would also add to the literature.

Background. Persistent throat symptoms and Extra Oesophageal Reflux (EOR) are among the commonest reasons for attendance at a secondary care throat or voice clinic. There is a growing trend to treat throat symptom patients with proton pump inhibitors (PPIs) to suppress stomach acid, but most controlled studies fail to demonstrate a significant benefit of PPI over placebo. In addition, patient views on PPI use vary widely. Methods/design. A UK multi-centre, randomised, controlled trial for adults with persistent throat symptoms to compare the effectiveness of treatment with the proton pump inhibitor (PPI) lansoprazole versus placebo. The trial includes a six-month internal pilot, during which three sites will recruit 30 participants in total, to assess the practicality of the trial and assess the study procedures and willingness of the patient population to participate. If the pilot is successful, three additional sites will be opened to recruitment, and a further 302 participants recruited across the six main trial sites. Further trial sites may be opened, as necessary. The main trial will continue for a further 18 months. Participants will be followed up for 12 months from randomisation, throughout which both primary and secondary outcome data will be collected. The primary outcome is change in Reflux Symptom Index (RSI) score, the ‘area standard’ for this type of assessment, after 16 weeks (four months) of treatment. Secondary outcomes are RSI changes at 12 months after randomisation, Quality of Life assessment at four and 12 months, laryngeal mucosal changes, assessments of compliance and side effects, and patient-reported satisfaction. Discussion. TOPPITS is designed to evaluate the relative effectiveness of treatment with a proton pump inhibitor versus placebo in patients with persistent throat symptoms. This will provide valuable information to clinicians and GPs regarding the treatment and management of care for these patients, on changes in symptoms, and in Quality of Life, over time. 

Background. The purpose of this prospective study was to evaluate the swallowing performance of patients with head and neck cancer treated with parotid‐sparing intensity‐modulated radiotherapy (IMRT). Methods. Sixty‐two patients were recruited. Data were collected before and up to 12 months after treatment. Measures included the Performance Status Scale for head and neck cancer (PSS‐HN Normalcy of Diet and Eating in Public subscales), tube feeding status, and 100 mL water swallow test (WST) volume and capacity scores. Results. There was a significant reduction in PSS‐HN and WST scores from baseline to 3 months (p 

Objectives. Dysphagia is a common and debilitating side effect of chemoradiotherapy. Assessment is difficult; swallowing is multifactorial and studies choose from a range of dysphagia assessments. This study intended to investigate the relationship between swallowing assessments of dysphagia in a cohort of patients and to evaluate whether clinical swallowing measures can predict patient reported swallowing outcomes. Materials and methods. One hundred and seventy-three head and neck cancer patients from two teaching hospitals were recruited prospectively over 25 months. At three months follow-up patients were assessed using Rosenbeck’s Penetration–Aspiration Scale (PAS), The 100 ml Water Swallow Test (WST), The Performance Status Scale: Normalcy of Diet and the MD Anderson Dysphagia Inventory (MDADI). Results. The highest correlation was observed between the MDADI and Normalcy of Diet (rho 0.68) and the lowest between the MDADI and the PAS (rho 0.34). Using multiple regression the PAS and WST accounted for 44% of the variance in the MDADI scores (R2 = 0.44, F = 37.8, p

Purpose of review. Advanced lung cancer can cause changes to swallowing and communication function. Direct tumour invasion, dyspnoea and deconditioning can all impact on swallowing function and communication. Cancer treatment, if administered, may cause or compound symptoms. In this study, the nature of swallowing and communication difficulties in patients with advanced lung cancer will be discussed, and management options including medical management, speech and language therapy (SLT) intervention, and surgical interventions will be considered. Recent findings. Advanced lung cancer can result in voice and swallowing difficulties, which can increase symptom burden and significantly impact on quality of life (QOL). There is a growing evidence base to support the use of injection laryngoplasty under local anaesthetic to offer immediate improvement in voice, swallowing and overall QOL. Summary. There is limited literature on the nature and extent of voice and swallowing impairment in patients with lung cancer. Well designed studies with robust and sensitive multidimensional dysphagia and dysphonia assessments are required. Outcome studies examining interventions with clearly defined treatment goals are required. These studies should include both functional and patient-reported outcome measures to develop the evidence base and to ensure that interventions are both timely and appropriate.

Purpose. The study aims to describe patients’ experiences of swallowing difficulties following (chemo)radiotherapy for head and neck cancer and to explore any changes over time. Methods. A purposive sample of patients with swallowing difficulties was selected at a range of time points, from 3 to 18 months following treatment. Ethnographic observations of 12 patients were conducted in their own homes, over a mealtime situation. Nine new patients were interviewed about changes to their eating and drinking from pre- to post-treatment. Thematic analysis was used to code and analyse the data. Results. Patients’ reports of swallowing function were divided into four time zones: pre-treatment, during radiotherapy, early (0–3 months) and late (6–18 months) time points following treatment. The majority reported minimal problems at diagnosis, but marked impairment during and after radiotherapy, without a return to pre-treatment functioning. The focus was on severe physical side effects and changes to food preparation during radiotherapy and in the early phase of recovery. By 6 months, side effects began to subside, but swallowing was still difficult, leading to major changes to family life, socialisation and lifestyle. Conclusions. Swallowing problems after (chemo)radiotherapy are multi-faceted and highly individualised and restrict lives in the long term. Swallowing ability may improve in time, but does not appear to return to pre-treatment function. Further work is required to find ways of being able to best support patients living with this long-term condition.

Objectives: Swallowing can be significantly affected during and following radiotherapy for head and neck cancer (HNC). The purpose of this study was to understand: (1) the trajectory of swallowing recovery following parotid-sparing intensity-modulated radiotherapy (IMRT) and (2) overall physical and social-emotional wellbeing and how patients prioritise swallowing following treatment. Materials and methods: Sixty-one HNC patients completed questionnaires as part of a prospective study exploring patient-reported swallowing outcomes following parotid-sparing IMRT. Participants were asked to complete the M.D. Anderson Dysphagia Inventory (MDADI) and University of Washington Quality of Life Questionnaire (UW-QoL) v.04 before treatment and 3, 6 and 12 months after treatment. Given the rise in human papilloma virus (HPV) and associated oropharyngeal cancers, we completed a sub analysis of the data in those participants. Results: There was a significant reduction in the MDADI composite scores 3 months after completion of treatment. Improvements were observed by 12 months, however, scores did not recover to baseline. The recovery in physical function was limited in comparison to social-emotional recovery at 12 months. When oropharyngeal cancer scores were analysed, there was not a substantial difference to the whole group results. There was a shift in priorities following treatment. Swallowing was highlighted as a concern by 44% of HNC patients up to 12 months after treatment with swallowing-related factors (saliva, taste and chewing) rated highly. Conclusions: Patient reported swallowing outcomes were significantly affected from baseline to all follow-up time points and remained a priority concern at 12 months following treatment. Overall social-emotional functioning does improve, suggesting that patients have the potential to adapt to their “new normal” following IMRT for HNC.

Objectives. We aimed to assess self‐report and perceptual voice outcomes in patients undergoing local anaesthetic injection laryngoplasty in our outpatient clinic. Design. Prospective case series. Setting. Department of Otolaryngology‐Head and Neck Surgery, Freeman Hospital, Newcastle‐upon‐Tyne, UK. Participants. Sixty‐eight patients underwent local anaesthetic injection laryngoplasty in the outpatient clinic over the 2‐year study period. Main outcome measure. Voice Performance Questionnaire (patient‐rated), and perceptual voice analysis (observer‐rated) Grade, Roughness, Breathiness, Aesthenia and Strain scores were recorded before and 2 weeks after injection laryngoplasty. Results. Fifty‐seven patients had sufficient pre‐ and post‐procedure data to be included in the analysis. These included 32 men and 25 women, age range 26–97 years. Of the remaining patients, they were excluded due to failed procedure (n = 3), too unwell to proceed (n = 1), died before follow‐up was complete (n = 3) and incomplete data (n = 4). The median Voice Performance Questionnaire score improved from 42 to 21; (P

Background. This prospective study evaluated swallowing outcomes prechemoradiotherapy (pre‐CRT) up to 1 year post‐CRT, in a substantial cohort of patients with head and neck cancer and explored factors predicting outcome. Methods. One hundred twelve patients were assessed pretreatment and at 3, 6, and 12 months posttreatment using a questionnaire, endoscopic assessment, water swallow test, and diet score. Results. Seventy‐one patients were retained, the majority had oropharyngeal (53%) or hypopharyngeal cancer (20%). A marked deterioration occurred between pretreatment and 3 months posttreatment (p ≤ .01). Significant improvement between 3 and 12 months was found on 2 swallowing measures, but not self reported. Three of the 4 pretreatment assessments predicted outcomes at 1 year. Conclusion. CRT results in a marked deterioration on different paradigms of swallowing measurements. Improvement occurs on some clinical measures, but limited change is observed in patients' perceptions. Pretreatment measures are important indicators of long‐term dysphagia. Swallowing recovery is complex, taking different courses between clinical tests and perspectives.

Objectives. A diagnosis of head and neck cancer (HNC) is a profound event for patients and family members who play a crucial role in their care. Eating and drinking difficulties affect patients' quality of life (QOL), but the impact on the carers' QOL has not been explored. This preliminary mixed method study reports on carer QOL over time and investigates the relationship with dysphagia. Methods. Two hundred and eight HNC patients referred for (chemo)radiotherapy were asked to identify a carer and complete a health‐related QOL and a swallowing QOL questionnaire at pre‐treatment, 3 and 12 months post‐treatment. Carers were given the Caregiver QOL‐Cancer (CQOL‐C) questionnaire at the same time points. A purposive sample of patient and carer dyads was observed over mealtimes and interviewed. Results. Seventy per cent of carers returned a questionnaire at least once. There was no change in CQOL‐C scores between pre‐treatment and 3  months, but a significant improvement was found between 3 and 12 months post‐treatment (p = 0.012). Patient‐reported outcomes accounted for 52% of variance in carer QOL measurements (R2 = 0.52, p 

Background. The voice impact of treatment for nonlaryngeal head and neck primary sites remains unknown. Methods. We conducted a prospective study of a consecutive sample of patients undergoing chemoradiation for nonlaryngeal head and neck cancer. The Voice Symptom Scale (VoiSS) was completed, and voice recordings were made at 3 time‐points. Results. Of 42 recruited patients, 34 completed the measures before and in the early posttreatment phase (mean 16.5 weeks), while 21 patients were assessed at the final time‐point (mean, 20.4 months). VoiSS scores showed statistically significant progressive deterioration in the total score (p = .02) and impairment subscale (p

Aims. Perceptual rating of voice quality is a key component in the comprehensive assessment of voice, but there are practical difficulties in making reliable measurements. We have developed the Newcastle Audio Ranking (NeAR) test, a new referential system for the rating of voice parameters. In this article, we present our first results using NeAR. Methods. We asked five experts and 11 naive raters to assess 15 male and 15 female voices using the NeAR test. We assessed: validity with respect to the GRBAS scale; interrater reliability; sensitivity to subtle voice differences; and the performance of expert versus naïve raters. Results. There was a uniformly excellent agreement with GRBAS (r=0.87) and interrater agreement (intraclass correlation coefficient=0.86). Considering each GRBAS grade of voice separately, there was still good interrater agreement in NeAR, implying it has good sensitivity to subtle changes. All these results were equally true for expert and naive raters. Conclusion. The NeAR test is a promising new tool in the assessment of voice disorders.

We undertook a service evaluation to establish how oropharyngeal dysphagia is managed in head and neck cancer patients receiving radiotherapy in the United Kingdom. A web-based survey including 23 open and closed questions was distributed to Speech and Language Therapy (SLT) teams via a national network of Royal College of Speech and Language Therapists (RCSLT) special interest groups with members involved in head and neck cancer care. Forty-six teams responded to the survey and 89% completed the questionnaire fully. Fifty percent (n = 21/42) of the SLT teams reported routinely seeing patients prior to commencing radiotherapy. Baseline oromotor assessment (85.7% (n = 36/42)), clinical dysphagia assessment (90.5% (n = 38/42)) and information provision on the potential treatment effects on swallowing (97.6% (n = 41/42)) and communication ability (85.7% (n = 36/42)) were the most common components of initial evaluation. In keeping with expert opinion and emerging evidence, prophylactic swallowing exercises were administered by 71.4% (n = 30/42) of teams targeting specific aspects of swallowing, although the nature, intensity and duration of programmes varied. A range of measures are used to monitor progress during treatment. Our survey highlighted that resource limitations affect service provision with some teams managing the consequences of treatment rather than proactive multidisciplinary intervention prior to and during treatment. Cancer- and treatment-related dysphagia can impact significantly on a broad range of outcomes following radiotherapy. There is variability in dysphagia service provision to patients before, during and following treatment. Comprehensive evaluation of swallowing function prior to treatment and proactive management can yield benefits for patients, inform multidisciplinary case management and support those involved in clinical trials to accurately determine treatment effects.