https://journal.chestnet.org/article/S0012-3692(15)36028-1/pdf

Aspiration pneumonia and dysphagia in the elderly.

https://gut.bmj.com/content/gutjnl/45/suppl_2/II31.full.pdf

Functional esophageal disorders.

A 53-year-old man, who is otherwise healthy and has a 20-year history of occasional heartburn, reports having had worsening heartburn for the past 12 months, with daily symptoms that disturb his sleep. He reports having had no dysphagia, gastrointestinal bleeding, or weight loss and in fact has recently gained 20 lb (9 kg). What would you advise regarding his evaluation and treatment?

https://www.nejm.org/doi/pdf/10.1056/NEJMcp0804684

Gastroesophageal Reflux Disease

https://www.gastrojournal.org/article/0016-5085(92)90013-O/pdf

Oropharyngeal swallowing in normal adults of different ages.

Purpose To identify the anatomic structures whose damage or malfunction cause late dysphagia and aspiration after intensive chemotherapy and radiotherapy (RT) for head-and-neck cancer, and to explore whether they can be spared by intensity-modulated RT (IMRT) without compromising target RT. Methods and materials A total of 26 patients receiving RT concurrent with gemcitabine, a regimen associated with a high rate of late dysphagia and aspiration, underwent prospective evaluation of swallowing with videofluoroscopy (VF), direct endoscopy, and CT. To assess whether the VF abnormalities were regimen specific, they were compared with the VF findings of 6 patients presenting with dysphagia after RT concurrent with high-dose intra-arterial cisplatin. The anatomic structures whose malfunction was likely to cause each of the VF abnormalities common to both regimens were determined by literature review. Pre- and posttherapy CT scans were reviewed for evidence of posttherapy damage to each of these structures, and those demonstrating posttherapy changes were deemed dysphagia/aspiration-related structures (DARS). Standard three-dimensional (3D) RT, standard IMRT (stIMRT), and dysphagia-optimized IMRT (doIMRT) plans in which sparing of the DARS was included in the optimization cost function, were produced for each of 20 consecutive patients with advanced head-and-neck cancer. Results The posttherapy VF abnormalities common to both regimens included weakness of the posterior motion of the base of tongue, prolonged pharyngeal transit time, lack of coordination between the swallowing phases, reduced elevation of the larynx, and reduced laryngeal closure and epiglottic inversion, contributing to a high rate of aspiration. The anatomic structures whose malfunction was the likely cause of each of these abnormalities, and that also demonstrated anatomic changes after RT concurrent with gemcitabine doses associated with dysphagia and aspiration, were the pharyngeal constrictor muscles (median thickness near midline 2.5 mm before therapy vs. 7 mm after therapy; p = 0.001), the supraglottic larynx (median thickness, 2 mm before therapy vs. 4 mm after therapy; p Conclusions The structures whose damage may cause dysphagia and aspiration after intensive chemotherapy and RT are the pharyngeal constrictors and the glottic and supraglottic larynx. Compared with 3D-RT, moderate sparing of these structures was achieved by stIMRT, and an additional benefit, whose extent varied among the patients, was gained by doIMRT, without compromising target doses. Clinical validation is required to determine whether the dosimetric gains are translated into clinical ones.

Dysphagia and aspiration after chemoradiotherapy for head-and-neck cancer: Which anatomic structures are affected and can they be spared by IMRT?

https://www.gastrojournal.org/article/0016-5085(89)90391-0/pdf

Upper esophageal sphincter opening and modulation during swallowing.

Swallows of 4 bolus volumes (1, 5, 10, 20 ml) were examined in three groups of subjects: 6 subjects 20-29 years of age, 12 subjects 30-59 years of age, and 6 subjects 60-79 years of age. A simultaneous manometric and videofluoroscopic data collection protocol permitted measurement of bolus transit, temporal aspects of the oropharyngeal swallow, and pharyngeal peristalsis. Statistically significant effects of increasing bolus volume were oral transit of the bolus head (decreased) and duration of cricopharyngeal opening (increased). Five measures were significantly changed with increasing age: duration of pharyngeal swallow delay (increased), duration of pharyngeal swallow response (decreased), duration of cricopharyngeal opening (decreased), peristaltic amplitude (decreased), and peristaltic velocity (decreased).

Preliminary observations on the effects of age on oropharyngeal deglutition.

Proximal esophageal pH-metry in patients with 'reflux laryngitis'.

An evaluation was done of 325 consecutive patients who underwent esophageal manometry to investigate the relationship between solid food dysphagia and peristaltic dysfunction in gastroesophageal reflux disease. All patients with dysphagia were endoscoped to evaluate for mechanical obstruction. Manometry was done focusing on the incidence of peristaltic dysfunction (failed peristaltic sequences or sequences characterized by foci of hypotensive peristalsis). The major finding was that the severity of manometrically demonstrated peristaltic dysfunction in reflux patients correlated with the prevalence of dysphagia. After excluding patients with esophageal rings or strictures from the analysis, the overall prevalence of dysphagia was 39% among the 157 reflux patients. Within this group, 29% of patients with minimal peristaltic dysfunction experienced dysphagia compared to 78% of patients with severe peristaltic dysfunction. We conclude that peristaltic dysfunction should be considered along with mechanical obstruction as a potential cause of dysphagia in patients with gastroesophageal reflux disease.

P. Jacob

Papers

Upper esophageal sphincter opening and modulation during swallowing.

Preliminary observations on the effects of age on oropharyngeal deglutition.

Proximal esophageal pH-metry in patients with 'reflux laryngitis'.

Peristaltic dysfunction associated with nonobstructive dysphagia in reflux disease.

Radiation-induced esophageal injury: a spectrum from esophagitis to cancer.