Showing papers in "Dysphagia in 1992"

Coordination of mastication and swallowing.

Abstract: The coordination of mastication, oral transport, and swallowing was examined during intake of solids and liquids in four normal subjects. Videofluorography (VFG) and electromyography (EMG) were recorded simultaneously while subjects consumed barium-impregnated foods. Intramuscular electrodes were inserted in the masseter, suprahyoid, and infrahyoid muscles. Ninety-four swallows were analyzed frame-by-frame for timing of bolus transport, swallowing, and phases of the masticatory gape cycle. Barium entered the pharynx a mean of 1.1 s (range −0.3 to 6.4 s) before swallow onset. This interval varied significantly among foods and was shortest for liquids. A bolus of food reached the valleculae prior to swallow onset in 37% of sequences, but most of the food was in the oral cavity at the onset of swallowing. Nearly all swallows started during the intercuspal (minimum gape) phase of the masticatory cycle. Selected sequences were analyzed further by computer, using an analog-to-digital convertor (for EMG) and frame grabber (for VFG). When subjects chewed solid food, there were loosely linked cycles of jaw and hyoid motion. A preswallow bolus of chewed food was transported from the oral cavity to the oropharynx by protraction (movement forward and upward) of the tongue and hyoid bone. The tongue compressed the food against the palate and squeezed a portion into the pharynx one or more cycles prior to swallowing. This protraction was produced by contraction of the geniohyoid and anterior digastric muscles, and occurred during the intercuspal (minimum gape) and opening phases of the masticatory cycle. The mechanism of preswallow transport was highly similar to the oral phase of swallowing. Alternation of jaw adductor and abductor activity during mastication provided a framework for integration of chewing, transport, and swallowing.

Aspiration after stroke: lesion analysis by brain MRI.

Abstract: Aspiration is a common problem following stroke, resulting in feeding difficulties and aspiration pneumonia. Despite past studies using clinical assessments and computed tomographic (CT) scans of the head, the correlation of stroke location with aspiration remains unclear. Since brain magnetic resonance imaging is more sensitive than CT for many stroke types, we have correlated MRI lesions with aspiration in patients who have sustained a stroke. We selected patients with acute stroke who underwent brain MRI and a swallowing evaluation. Aspiration was present in 21 of 38 patients (55%). Patients with just small vessel infarcts had a significantly lower occurrence of aspiration (3 of 14, 21%) compared to those with both large- and small-vessel infarcts (15 of 20, 75%, p = 0.002). Multivariate analysis of several specific brain areas failed to identify a significant association between stroke location and the occurrence of aspiration. These findings suggest that patients who have experienced stroke should be individually evaluated for swallowing dysfunction regardless of stroke location or size, since even small-vessel strokes can be associated with aspiration in greater than 20% of cases.

Dysphagi in Huntington's disease: A 16-year retrospective

Abstract: Degenerative diseases of the basal ganglia are commonly complicated by dysphagia. In 35 patients with Huntington's disease (HD), a hereditary neurodegenerative basal ganglia disease characterized by chorea, dementia, and emotional changes, an extensive battery of clinical and radiologic procedures helped to identify numerous abnormalities of deglutition. The results permitted the classification of our patients with HD into hyperkinetic (HD-h) or rigid-bradykinetic (HD-rb) groups. Although the two groups share multiple abnormalities, statistically significant intergroup differences were observed. Clincial assessmen of the HD-h cohort (30 patients) demonstrated rapid lingual chorea, swallow incoordination repetitive swallows, prolonged laryngeal elevation, inability to stop respiration and frequent eructations. In the HD-rb group (five patients), frequently observed abnormalities included mandibular rigidity, slow lingual chorea, coughing on foods, and choking on liquids. Videofluoroscopic swallowing studies (VFSS) using a variety of barium-impregnated, foods and liquids confirmed the abnormalities noted on the clinical assessment. Respiratory and laryngeal chorea, pharyngeal space retention, and aspiration were also identified. Numerous compensatory techniques introduced during videofluoroscopy benefited all patients.

Nutritional considerations for the pureed diet texture in dysphagic elderly.

Abstract: In long-term care facilities little attention is given to the nutritional density, flavor, and presentation of the pureed diet texture. Use of the food processor to puree food offers opportunities for the development of pureed meals that are flavorful and appealing. This article presents guidelines that foodservice departments can use to transform their traditional pureed meals into “cuisine puree”.

Can protein-calorie malnutrition cause dysphagia?

Abstract: Nutrient deprivation has previously been shown to cause alterations in muscle and nerve function. Although an effect has never been studied in the neuromusculature of deglutition, the authors argue that an effect is likely. The proposed result is an increase in swallowing impairment in dysphagic individuals and associated risk of aspiration. Research studying the relationship between malnutrition and dysphagia is needed to verify clinical significance. Until controlled studies are completed, the authors suggest alternative alimentation in repleting severely malnourished dysphagic patients prior to attempting oral diet. A review of nutritional status indices is included to aid in identifying dysphagic patients at nutritional risk. Early identification of nutritional compromise and intervention can prevent malnutrition and its deleterious effects.

Sounds of swallowing following total laryngectomy

Abstract: Accelerometer transduced sounds of swallowing in total laryngectomees did not show acoustical differences for liquid vs paste swallows, as are found in normals. Compared with normal swallows, tongue propulsion of the bolus in laryngectomee swallows occurred closer in time to a distinctive spectral change associated with bolus flow into the esophagus. Interpretation stressed the lack of mechanical traction from laryngeal elevation contributing to pharyngoesophageal sphincter opening, and the increased role of tongue propulsion in laryngectomee swallows.

Viscosity measurements of barium sulfate mixtures for use in motility studies of the pharynx and esophagus.

Abstract: Detailed viscosity measurements have been made of barium sulfate mixtures over a wide range of viscosities for use in radiography of the esophagus, stomach, and duodenum. A new methodology was developed for more accurate estimation of viscosity in non-Newtonian fluids in conventional cylinder-type viscometers. As base cases, the variation of viscosity with shear rate was measured for standard commercial mixes of e.z.hd (250% w/v) and a diluted mixture of liquid e.z.paque (40% w/v). These suspensions are strongly shear thinning at low shear rates. Above about 3s-1 the viscosity is nearly constant, but relatively low. To increase the viscosity of the barium sulfate mixture, Knott's strawberry syrup was mixed to different proportions with e.z.hd powder. In this way viscosity was systematically increased to values 130,000 times that of water. For these mixtures the variation of viscosity with temperature, and the change in mixture density with powder-syrup ratio are documented. From least-square fits through the data, simple mathematical formulas are derived for approximate calculation of viscosity as a function of mixture ratio and temperature. These empirical formulas should be useful in the design of "test kits" for systematic study for pharyngeal and esophageal motility, and clinical analysis of motility disorders as they relate to bolus consistency.

Periventricular white matter changes and oropharyngeal swallowing in normal individuals

Abstract: Cranial magnetic resonance imaging (MRI) has revealed patchy periventricular white matter lesions or “unidentified bright objects” (UBOs) in otherwise neurologically intact individuals. Quantitative videofluoroscopic swallowing evaluations and cranial MRI examinations were studied in 49 neurologically normal volunteers (ages 43 to 79 years). Total swallowing duration (TSD) and its subcomponents of oral transit duration (OTD), stage transition duration (STD), and pharyngeal response duration were measured for liquid and semisolid swallows. MRIs were graded from 0, or no UBOs, to 3, or multiple and confluent lesions. The effect of the presence of UBOs on swallowing durational measures and risk factors was analyzed with age differences accounted for statistically (AN-COVA). TSD and OTD for semisolids were significantly differentiated by MRI score (P<0.009 andP<0.047, respectively). That is, a demonstrable effect was found for an increased number of UBOs on duration of oropharyngeal swallowing in normal individuals.

Food intake by maneuver; an extreme compensation for impaired swallowing.

Abstract: We report two young patients able to exist on exclusively oral intake despite an absent pharyngeal swallow response. Videofluoroscopic swallowing studies showed that both patients used a sequence of devised maneuvers rather than a coordinated pharyngeal swallow to move the bolus, protect the airway, and open the upper esophageal sphincter during bolus ingestion. We conclude that it is possible for young, highly motivated individuals to maintain oral intake despite ablation of neurologic elements crucial for the normal swallow response.

Swallowing problems after excision of tumors of the skull base: diagnosis and management in 12 patients.

Abstract: Acute-onset dysphagia can be a debilitating complication of operative intervention in skull base surgery. A retrospective study performed at Baptist Hospital investigated the oropharyngeal deficits, compensatory swallow techniques, and diet modifications of 12 patients who had undergone excision of skull base tumors. Oropharyngeal dysfunction, reduced laryngeal elevation, and copious pharyngeal retention were the most prominent swallowing deficits. Aspiration occurred in 75% of the patients studied. The most frequently employed compensatory swallow techniques were head turns to the affected side, supraglottic swallow, double swallows, alternating liquids and solids, carbonated beverage swallows, and small bolus size. Approximately 2 weeks following skull base surgery, 58% of the patients were able to tolerate oral intake with the aid of compensatory swallow techniques and diet modifications. Only 1 patient in this group remained unable to tolerate food by mouth. This paper focuses on identification of the disordered components of the swallow and the therapeutic management techniques characteristic of the patient who has undergone excision of a skull base tumor.

Impact of the diagnostic procedure on outcome measures of swallowing rehabilitation in head and neck cancer patients.

Abstract: This study was designed to determine whether swallow rehabilitation outcomes were affected by the type of evaluation procedure utilized by the clinician. The two evaluation techniques compared were the bedside examination and videofluoroscopy (the modified barium swallow). Ten institutions participated in this study, enrolling a total of 103 partial laryngectomized patients, 21 in the bedside arm and 82 in the videofluoroscopy arm. Data on recovery of oral intake were collected weekly. All patients received an X-ray study of swallow at 3 months after the operation. Mean time to oral intake of food was significantly lower in patients assessed with bedside examination. Overall swallow measures of transit times and swallow efficiencies after 3 months revealed significantly better function in the videofluoroscopy group. Results are discussed in terms of the visibility of swallow physiology with the two assessment techniques, the accuracy of therapy planning with the bedside examination versus videofluoroscopy and the ability of head and neck cancer patients to tolerate some aspiration without developing aspiration pneumonia.

Clinical and demographic data in 75 patients with near-fatal choking episodes.

Abstract: The clinical background and circumstances of 75 patients who had survived a near-fatal choking episode, i.e., had undergone a Heimlich maneuver, oropharyngeal suctioning, or intubation, is reported. Sixty had choked on a solid bolus (often of a complex texture like sandwiches and chicken soup). Four patients had choked on mashed banana. In 30 patients neurologic disease (such as cerebrovascular disease, Parkinson disease, or dementia) was present. Choking occurred during breakfast (16 patients), lunch (21), dinner (26), and snacks (12). Twenty-five choked at home, 18 in nursing homes, 14 in hospitals, nine in restaurants, and nine in drinking establishments. Twelve were being fed at the time of choking. Fifty-eight of the individuals had oral, pharyngeal, or esophageal abnormalities on radiographic examination that could explain the choking episode. Fourteen patients who were able to vocalize during the choking episode had probably suffered from esophageal impaction. Our study indicates that elderly individuals and those with neurogenic dysphagia are at risk for choking. Dysphagia diet (semisolids) may actually contribute to the risk in these patients. Young adults may also be at risk during episodes of consumption of alcohol and snacks.

Oral diseases in HIV-1 infection

Abstract: HIV-associated oral lesions have been reported since the beginning of the AIDS epidemic, be they fungal, viral, bacterial, neoplastic, or non-specific in origin. The most common lesions are oral candidiasis (OC; noted in several forms) and oral hairy leukoplakia (OHL). OC appears to be directly related to levels of immunosuppression while OHL, a newly described lesion, is associated with the Epstein-Barr virus. Although prevalence data for all types of oral lesions are scarce, this review identifies and describes those reported most often. Lesions associated with HIV may appear on most oral mucosal surfaces and may differ from those seen on other body areas. The role of saliva in reducing the potential for transmission of the HIV virus appears to be significant. Physicians and dentists should cooperate in the management of the HIV patient who has oral disease.

Aging and the esophagus: common pathologic conditions and their effect upon swallowing in the geriatric population.

Abstract: Dysphagia in the elderly is most often oropharyngeal or hypopharyngeal in location and neuropathologic in etiology. Aging itself, although causing demonstrable structural and functional changes in the esophagus, does not cause any clinically relevant esophageal dysphagia. A variety of pathologic conditions seen in the geriatric population affect the esophagus and can alter esophageal function, resulting in symptomatic dysphagia. Accurate diagnosis requires a thorough evaluation performed in an unhurried fashion, often with the assistance of ancillary personnel. Treatment of these esophageal disorders is multidisciplinary and may involve dietary manipulations, the administration of medications, therapeutic endoscopic procedures, and occasionally surgery.

Scintigraphic detection of salivary aspiration: Description of a new diagnostic technique and case reports

Abstract: Pneumonia is the feared consequence of persistent aspiration of saliva. Although some persons with impaired protection of the laryngeal airway are thought to be at risk, it is not known with certainty which factors are important. Some patients receive tracheostomies to enhance airway safety, often without clear evidence of aspiration of oropharyngeal secretions. A simple, readily available technique is described by which oral secretions are scintigraphically labeled with technetium-99m sulfur colloid via slow intraoral infusion. Subsequent sequential chest imaging with a gamma camera allows detection and tracking of the aspirated material. Three persons are described in whom this technique was used. Inone, the scintigraphic analysis was instrumental in implicating infected saliva as the likely source of recurrent pulmonary infections. Although the method is useful in detecting aspiration of saliva in high risk persons, more study is needed to equate the degree of aspiration visualized with the risk of pulmonary disease.

Foreign body entrapment in the esophagus of healthy subjects--a manometric and scintigraphic study.

Abstract: Foreign body entrapment and mucosal injury caused by oral medications are increasingly reported to occur in the upper esophagus in apparently normal subjects. We performed esophageal manometry in 40 normal volunteers to determine whether a unique motility pattern in the upper third of the esophagus predisposes to entrapment of foreign bodies at this site; 18 normal volunteers also had transit scintigraphy of a gelatine capsule filled with a radionuclide. The esophageal body was divided into five consecutive segments starting proximally, with each segment corresponding to 20% of the total length. Amplitude, slope, and velocity of the esophageal contraction were markedly decreased in the second segment compared with the other segments. Entrapment and dissolution of a gelatine capsule occurred in 39% of volunteers in the proximal eosphagus correlating to the second segment, i.e., the segment with the lowest amplitude, slope, and velocity of esophageal contractions. The observation that wet swallows have greater amplitudes (P<0.01) and steeper slopes (P<0.05) than dry swallows explains why the occurrence of pill entrapment was reduced when taken with sufficient water. However, even with a water chaser of 120 mL, pill entrapment occurred at the second segment of the esophagus in 1 of 18 volunteers. The observed motility pattern in the proximal eosphagus provides a better explanation for the entrapment of foreign bodies at this site than compression of the esophagus by the left main stem bronchus, aortic arch, or left atrium as suggested by other investigators.

Dysphagia in cerebral palsy: a comparative study of the Exeter Dysphagia Assessment Technique and a multidisciplinary assessment.

Abstract: Eighteen children with cerebral palsy in a special school, most of whom had feeding difficulties, were studied to compare the diagnostic value of the Exeter Dysphagia Assessment Technique (EDAT) with an exhaustive clinical assessment undertaken by a multidisciplinary team experienced in the diagnosis and treatment of dysphagia of neurological origin. Four feeding skills were assessed by each method independently, viz. anticipation, intraoral sensory perception, oral-motor efficiency, and pharyngeal triggering. Comparison of the two sets of results showed agreement in at least 78% of the assessed skills. The possible reasons for the few discrepancies are discussed. The noninvasive EDAT equipment was easy to use with the children, who had a range of type and severity of cerebral palsy. The test was undertaken in their familiar surroundings and took 15 to 20 min per child. Interpretation of the results showed that EDAT provided a rapid, reliable diagnostic aid which assisted in the assessment of the degree of feeding impairment within each of the four feeding skills tested.

Swallowing in torticollis before and after rhizotomy.

Abstract: To determine risk factors for dysphagia after ventral rhizotomy, videofluoroscopic barium swallowing examinations were done on 41 spasmodic torticollis patients before and after surgery. Radiologic abnormalities were present in 68.3% of the patients before surgery, but these were only mildly abnormal in the majority. After surgery 95.1% showed radiologic abnormalities which were moderate or severe in one-third of the patients. Swallowing abnormalities correlated significantly with duration of torticollis and subjective complaints of swallowing difficulty both before and after surgery, but not with age, sex, or type of torticollis. The major acute postoperative finding was aggravation of preexisting pharyngeal dysfunction. Follow-up from about half of our original sample showed that gradual improvement occurred from 4 to 24 weeks after surgery by subjective report. We review the innervation of intrinsic and extrinsic pharyngeal musculature, and suggest that C1-3 rhizotomies and selective sectioning of the spinal accessory nerve are responsible for aggravation of pharyngeal swallowing dysfunction in the acute postsurgical period.

Laryngologic aspects of bolus asphyxiation-bolus death.

Abstract: Among 12,982 forensic autopsies, 78 cases of cafe coronary due to bolus impaction in the larynx (bolus death) were observed from 1947 to 1988. In all cases bolus material occluded the entry to the larynx; only once was a signular occlusion of the glottis observed. The bolus frequently extended into the mouth, trachea, and bronchial tree or esophagus. In all cases small amounts of aspirated material were observed in the deeper parts of the bronchial tree. The most commonly observed bolus was not masticated meat or a meat product. In adults and the elderly the bolus was often too large to pass the physiological narrowings of the hypopharynx. It was commonly lodged above the arytenoid cartilages. Forty-five of the bolus events were observed by bystanders. In 43 of the victims vital reactions were observed by bystanders or at the autopsy. This justifies the hope that many lives could have been saved had the right diagnosis and immediate therapy been initiated. The first step should be manual extraction or use of the Heimlich maneuver; in cases of failure of both attempts, immediate tracheotomy followed by hospitalization and bronchial lavage are indicated.

Multiple swallows and piecemeal deglutition; Observations from normal adults and patients with head and neck cancer

Abstract: The incidence of multiple swallows for liquid and paste, and the time delay between multiple swallows, was determined from videofluoroscopic records of modified barium swallow tests. In a comparison of liquid and paste, the overall incidence of multiple swallows did not differ, for either patients with head and neck cancer or normal controls. However, for liquid swallows the incidence in patients with cancer was abnormally high, predominantly in patients with pharyngeal cancer.

Oral dysfunction following Nissen fundoplication.

Abstract: In this case report we describe a child with mild neurologic impairment who developed debilitating gagging and retching, and severe oralmotor dysfunction following Nissen fundoplication and gastrostomy tube placement. All oral intake ceased after the operation. Evaluation for postoperative dumping syndrome was negative, and the child's symptoms failed to improve despite numerous medical and surgical measures. However, immediately following reversal of the Nissen fundoplication, the child's gagging and retching ceased, and his oral-motor function began to improve. This is a previously undescribed complication of Nissen fundoplication, a surgical procedure commonly employed in children with neurologic impairment.

Scintigraphic quantification of pharyngeal retention following deglutition

Abstract: A procedure is described for quantifying the amount of bolus material retained in the pharynx after completion of a swallow, using radionuclide swallow techniques. Data are derived from scintigraphic time-activity curves. The procedure takes into consideration the differential attenuation of radioactivity through various regions in the body, and expresses the result as a percentage of the total radioactivity in the ingested bolus. Illustrative examples are provided for swallows by normal individuals and patients with head and neck cancer.

Ethical dilemmas in dysphagia management and the right to a natural death.

Abstract: Speech pathologists are at the forefront in dealing with the consequences of life-saving measures and the technological advances that promote surival. Many ethical dilemmas exist in the area of dysphagia management and these are often emphasized in the nursing home environment. A client's autonomy and ability to make informed decisions will invariably determine the role of the speech pathologist in making decisions or facilitating debate regarding eating and feeding status.

Esophageal motor disorders in patients evaluated for dysphagia and/or noncardiac chest pain

Abstract: During the period January, 1983-October, 1990, 429 subjects were referred for functional evaluation of dysphagia and/or noncardiac chest pain. Of these, 304 (70.8%) were shown to have some kind of esophageal motor abnormality. The most frequent motor abnormality of the esophagus was represented by nonspecific motor disorders (31%), followed by achalasia (13%), whereas the other dysfunctions accounted for a smaller percentage. In particular, diffuse esophageal spasm was shown to be quite rare. It is concluded that esophageal manometry may provide a high diagnostic yield in patients presenting with dysphagia and/or noncardiac chest pain.

Utilization of Nasogastric feeding tubes in a group of chronically Ill, Elderly patients in a community hospital

Abstract: Physician practice patterns and attitudes about the use of nasogastric (NG) feeding tubes in a group of elderly patients with severe chronic illness were explored in a community-based teaching hospital in Rochester, NY, using a physician questionnaire and a chart review. The physician questionnaire showed considerable divergence in beliefs about whether this treatment is extraordinary (42%), ordinary (21%), or comfort oriented (37%). Physicians who believed it was extraordinary treatment said they would recommend it less often than those who believed it to be ordinary or comfort oriented in the abstract scenario of a chronically ill, elderly patient who was not maintaining adequate nutrition. Most physician-respondents believed that the patient's wishes should guide the decision. Independently, Medical records were retrospectively reviewed for all patients admitted to the hospital in the previous year who had an NG feeding tube placed, who were over the age of 70 years, and who had primary diagnoses of cerebrovascular accident, organic brain syndrome, or metastatic cancer. Contrary to the questionnaire responses, oral or written consent was documented in only 2 of 51 insertions of NG tubes. Of the 7 charts where a surrogate gave consent, only one expressed consideration of the patient's actual wishes. The clinical reasoning leading to the decision documented in the chart emphasized biomedical concerns much more than the patient's quality of life (8∶1 ratio). Sixty-four percent (35/55) of patients in the study group died in the hospital, including 90% (19/21) of those who were to be treated with a comfort orientation. In only 2 of 55 patients was medical improvement cited as the reason for discontinuing use of the NG feeding tube. Restraints were used in 53% of the patients to keep the tube in. Recommendations are made that emphasize the need for active patient and family participation in the decision to use an NG feeding tube, requiring a balanced presentation of potential benefits, burdens, and limitations in patients with severe irreversible illnesses.

Velar activity and timing of eustachian tube function in swallowing.

Abstract: Velar motion for dry and liquid swallows was investigated. as well as velar activity in speech, based on X-ray microbeam pellet tracking data. Electromyographic recordings for tensor and levator veli palatini were obtained simultaneously. Velar pellet trajectories for swallowing were more complex than for speech, since there was a highvelocity anterior component in swallowing. For some swallows this anterior component was integrated with velar elevation (especially in liquid swallows), but in other cases initial velar elevation occurred considerably earlier (chiefly in dry swallows). The burst of tensor and levator veli palatini activity characteristic of swallowing was associated with the anterior component of velar pellet motion, but not consistently with velar elevation per se. The conventional view on timing of tensor veli palatini contraction in a swallow, which governs Eustachian tube opening, is that this is associated with velar closure. The X-ray microbeam data suggest rather that Eustachian tube ventilation is more closely associated in time to the onset of pharyngeal peristalsis, which may or may not coincide with initial velar elevation.

Meeting the oral health needs of institutionalized elderly.

Abstract: Numerous impairments cause suffering to the institutionalized elderly person. The medically compromised or severely demented patient, especially one with swallowing difficulties, presents a challenge to the dental practitioner. This paper summarizes typical geriatric dental problems that caregivers in a long-term care (LTC) facility should find recognizable. It also describes palliative and preventive treatment modalities that help improve the quality of life for such institutionalized patients.

Perendoscopic pneumatic dilatation in achalasia: assessment of outcome using esophageal scintigraphy.

Abstract: Sixteen patients (nine male) underwent perendoscopic pneumatic dilatation for achalasia. The Witzel dilator was chosen as it allows placement of the balloon under endoscopic vision. Its efficacy was assessed using esophageal scintigraphy. Symptom score and esophageal transit values at 100 s and after a drink of water all improved significantly (P less than or equal to 0.014) after dilatation and there was a significant correlation between the improved symptom score and the change in transit values after 100 s (r = 0.586, P = 0.017). At follow-up at 8 (3-16) months [mean (range)], 15 of 16 patients (94%) are symptom free. The Witzel dilator is effective in the treatment of achalasia. Esophageal scintigraphy offers a quantitative assessment of esophageal function, helping the clinical investigator evaluate new forms of therapy.

Systematic desensitization of oral hypersensitivity in a patient with a closed head injury.

Abstract: A 36-year-old man who had sustained a closed head injury displayed extreme fear of being stimulated in the oral cavity, of being presented with foods, and of swallowing. The patient's fear increased his muscle tone and hypersensitivity in the facial and oral area, thereby preventing assessment of his dysphagia. We describe the use of systematic desensitization to alleviate the patient's fear thus allowing successful completion of a videofluoroscopic barium swallow examination.