Showing papers in "Dysphagia in 2006"

Generation of the central masticatory pattern and its modification by sensory feedback.

Abstract: Mammalian mastication results from the interaction of an intrinsic rhythmical neural pattern and sensory feedback generated by the interaction of the effecter system (muscles, bones, joints, teeth, soft tissues) with food. The main variables that explain variation in the pattern of human mastication are the subjects themselves, their age, the type of food being eaten, and time during a sequence of movements. The intrinsic pattern of mastication is generated by a central pattern generator (CPG) located in the pons and medulla. The output of the CPG is modified by inputs that descend from higher centers of the brain and by feedback from sensory receptors. Intraoral touch receptors, muscle spindles in the jaw-closing muscles, and specialized mechanoreceptors in the periodontal ligament have especially powerful effects on movement parameters.

Measures of Tongue Function Related to Normal Swallowing

Abstract: The availability of objective measures of tongue function presents a possible supplement to the clinical dysphagia evaluation. The purpose of this study was to improve our understanding of normal tongue physiology during swallowing and maximum isometric tasks, establish a preliminary database of tongue function variables, and determine if differences existed among the variables as a function of age, gender, or varied bolus consistency. Ninety subjects, divided into age and gender groups, participated in tasks that determined maximum isometric tongue pressure, mean tongue pressure during swallowing, and percentage of maximum isometric pressure used during swallowing. Descriptive statistics, correlations, and analyses of variance were computed to analyze the data. Results indicated that males had significantly higher maximum isometric pressures than females, and the youngest group had significantly higher maximum pressures than the oldest group. Mean swallowing pressures and percentage of maximum isometric pressures used during swallowing differed as a function of bolus type but did not differ as a function of age or gender. In addition, maximum isometric pressures were correlated with mean swallowing pressures, and mean swallowing pressures and percentage of maximum isometric pressures used during swallowing were correlated between consistencies.

Decreased Tongue Pressure Reflects Symptom of Dysphagia

Abstract: The tongue plays a key role in oropharyngeal swallowing. It has been reported that maximum isometric tongue pressure decreases with age. The risk for dysphagia resulting from low tongue strength remains unclear. This study was designed to reveal the relationship between tongue pressure and clinical signs of dysphagic tongue movement and cough and to demonstrate the clinical value of tongue pressure measurement in the evaluation of swallowing function. One hundred forty-five institutionalized elderly in five nursing homes participated. Evaluation of physical activity with self-standing up capability and mental condition with Mini Mental Status Examination (MMSE) were recorded. Maximum tongue pressure was determined using a newly developed tongue pressure measurement device. Voluntary tongue movement and signs of dysphagic cough at mealtime were inspected and evaluated by one clinically experienced dentist and speech therapist. The relationship between level of tongue pressure and incidence of cough was evaluated using logistic regression analysis with physical and mental conditions as covariates. Tongue pressure as measured by the newly developed device was significantly related to the voluntary tongue movement and incidence of cough (p < 0.05). The results of this study suggest that tongue pressure measurement reflects clinical signs of dysphagic tongue movement and cough and that measurement of tongue pressure is useful for the bedside evaluation of swallowing.

The challenge of mastication: preparing a bolus suitable for deglutition.

Abstract: The main function of mastication is to transform a solid food into a bolus that can be swallowed safely. The bolus characteristics such as particles size or cohesiveness, are continuously sensed during mastication and they are important in initiating deglutition. This study examined the following question: What is the condition of the bolus just before swallowing? Ten subjects with normal dentition aged 37.5 +/- 3.7 years were asked to chew without swallowing six different foods (three nuts and three vegetables) while the number of cycles and the duration of the sequence were recorded. The particle size distribution shown by the expectorated food bolus just before swallowing was examined by image analysis. The results showed that, for a given food, the sizes of the bolus particles just before swallowing were comparable in all subjects. However, the number of cycles and duration of the sequence varied between subjects. Taken together these data strongly suggest that the granularity of the bolus before swallowing has to reach a predetermined state which is obtained by using an individual chewing strategy. This suggests that the bolus structure reflects a key factor for homeostasis and explains the large interindividual variability of the mastication physiologic parameters.

The effect of taste and palatability on lingual swallowing pressure.

Abstract: There is evidence that a strong, unpalatable, sour bolus improves swallowing in neurogenic dysphagia. It is not known whether other tastes may alter swallowing physiology. This study investigated the effect of moderate versus high taste concentrations (sweet, sour, salty, bitter) and barium taste samples on lingual swallowing pressure in ten healthy young adults, using a three-bulb lingual pressure array secured to the hard palate. Palatability of the samples was analyzed using the nine-point hedonic scale. Results showed that moderate sucrose, high salt, and high citric acid elicited significantly higher lingual swallowing pressures compared with the pressures generated by water. Pressures in the anterior bulb were significantly higher than those recorded from the middle or posterior bulb. There was no significant effect of palatability on lingual swallowing pressures. High salt and citric acid are known to elicit chemesthesis mediated by the trigeminal nerve. These results suggest that chemesthesis may play a crucial role in swallowing physiology. If true, dysphagia diet recommendations that include trigeminal irritants such as carbonation may be beneficial to individuals with dysphagia. However, before this recommendation more research is needed to examine how food properties and their perception affect swallowing in individuals with and without dysphagia.

Clinical Validity of the SWAL-QOL and SWAL-CARE Outcome Tools with Respect to Bolus Flow Measures

Abstract: The aim of this study was to quantify the association between a dysphagia-specific quality of life (SWAL-QOL) and quality of care (SWAL-CARE) questionnaire and four measures of bolus flow. Three hundred eighty-six people with oropharyngeal dysphagia completed a videofluoroscopic examination of their swallowing structure and physiology. They also completed the SWAL-QOL and SWAL-CARE surveys. Measures of bolus flow patterns for each swallow were analyzed from videofluoroscopic recordings and correlated with the SWAL-QOL and SWAL-CARE scale scores. The SWAL-QOL and SWAL-CARE scales were modestly related to the four measures of the bolus flow. The SWAL-QOL and SWAL-CARE were most related to measures of oral transit duration and total swallow duration. The SWAL-QOL and SWAL-CARE scales were least related to pharyngeal transit duration. Results were stronger for semisolid trials than for liquid trials. Results were generally weak for the Penetration Aspiration Scale. For all of the significant relationships, the greater the bolus flow severity, the worse the quality of life. The observed modest correlations suggest that patient-centered quality-of-life measures and clinician-driven bolus flow measures provide distinct yet complementary information about oropharyngeal dysphagia. Both sets of measures should be used in dysphagia effectiveness and outcomes research.

Evaluating oral stimulation as a treatment for dysphagia after stroke

Abstract: Deglutitive aspiration is common after stroke and can have devastating consequences. While the application of oral sensory stimulation as a treatment for dysphagia remains controversial, data from our laboratory have suggested that it may increase corticobulbar excitability, which in previous work was correlated with swallowing recovery after stroke. Our study assessed the effects of oral stimulation at the faucial pillar on measures of swallowing and aspiration in patients with dysphagic stroke. Swallowing was assessed before and 60 min after 0.2-Hz electrical or sham stimulation in 16 stroke patients (12 male, mean age = 73 +/- 12 years). Swallowing measures included laryngeal closure (initiation and duration) and pharyngeal transit time, taken from digitally acquired videofluoroscopy. Aspiration severity was assessed using a validated penetration-aspiration scale. Preintervention, the initiation of laryngeal closure, was delayed in both groups, occurring 0.66 +/- 0.17 s after the bolus arrived at the hypopharynx. The larynx was closed for 0.79 +/- 0.07 s and pharyngeal transit time was 0.94 +/- 0.06 s. Baseline swallowing measures and aspiration severity were similar between groups (stimulation: 24.9 +/- 3.01; sham: 24.9 +/- 3.3, p = 0.2). Compared with baseline, no change was observed in the speed of laryngeal elevation, pharyngeal transit time, or aspiration severity within subjects or between groups for either active or sham stimulation. Our study found no evidence for functional change in swallow physiology after faucial pillar stimulation in dysphagic stroke. Therefore, with the parameters used in this study, oral stimulation does not offer an effective treatment for poststroke patients.

Effects of Neuromuscular Electrical Stimulation on Submental Muscle Activity

Abstract: Neuromuscular electrical stimulation (NMES) therapy has been proposed as a treatment option for pharyngeal dysphagia. However, little is known about the effects, if any, that NMES has on specific biomechanical aspects of the pharyngeal swallow. The purpose of this study was to determine if two weeks of NMES applied to the submental muscles increased myoelectric activity. Ten age- and gender-matched subjects participated, and eight completed the protocol. Treatment was delivered using an AB or BA design. No treatment was given during the A condition. Subjects received ten 1-h NMES treatments during the B condition. Results indicated that seven of eight subjects exhibited no significant gains in myoelectric activity of the submental muscles following NMES. Therefore, the benefit of NMES to the submental muscles with the goal of improving the pharyngeal swallow is not supported. Additional research investigating duration of treatment as well as frequency and amplitude modulation of NMES is needed to determine if, how, and why NMES applied to the submental muscles affects the biomechanical aspects of both the normal and disordered pharyngeal swallow.

Evaluating oral stimulation in the treatment of dysphagia after stroke

Abstract: Deglutitive aspiration is common after stroke and can have devastating consequences. While the application of oral sensory stimulation as a treatment for dysphagia remains controversial, data from our laboratory have suggested that it may increase corticobulbar excitability, which in previous work was correlated with swallowing recovery after stroke. Our study assessed the effects of oral stimulation at the faucial pillar on measures of swallowing and aspiration in patients with dysphagic stroke. Swallowing was assessed before and 60 min after 0.2-Hz electrical or sham stimulation in 16 stroke patients (12 male, mean age = 73 +/- 12 years). Swallowing measures included laryngeal closure (initiation and duration) and pharyngeal transit time, taken from digitally acquired videofluoroscopy. Aspiration severity was assessed using a validated penetration-aspiration scale. Preintervention, the initiation of laryngeal closure, was delayed in both groups, occurring 0.66 +/- 0.17 s after the bolus arrived at the hypopharynx. The larynx was closed for 0.79 +/- 0.07 s and pharyngeal transit time was 0.94 +/- 0.06 s. Baseline swallowing measures and aspiration severity were similar between groups (stimulation: 24.9 +/- 3.01; sham: 24.9 +/- 3.3, p = 0.2). Compared with baseline, no change was observed in the speed of laryngeal elevation, pharyngeal transit time, or aspiration severity within subjects or between groups for either active or sham stimulation. Our study found no evidence for functional change in swallow physiology after faucial pillar stimulation in dysphagic stroke. Therefore, with the parameters used in this study, oral stimulation does not offer an effective treatment for poststroke patients.

Swallowing lateralization: the effects of modified dual-task interference.

Abstract: A modified dual-task paradigm was designed to learn whether swallowing functions are selectively mediated by the left or right hemisphere. Healthy right-handed men (N = 38) were studied using videofluoroscopy to examine continuous straw drinking at baseline and with three interference conditions (silent word repetition, line orientation, finger tapping). Results indicate that activation of both right and left hemispheres can interfere with some swallowing behaviors. Findings suggest possibly different roles of the two hemispheres in the mediation of swallowing and support the notion that specific components of swallowing may be preferentially mediated by the left versus the right hemisphere.

Sound Component Duration of Healthy Human Pharyngoesophageal Swallowing: A Gender Comparison Study

Abstract: Cervical auscultation is a noninvasive technique for studying swallowing that was first used in the 1960s. The aim of our study was to use the numeric acoustic recording technique for analyzing swallowing sound signals in healthy subjects while they ingested a defined volume and consistency of a specific substance. Twenty males and ten females were included in the study and given 10 ml of a barium suspension to swallow. A microphone was placed on the skin overlying the lateral border of the trachea, directly under the inferior border of the cricoid, and connected to a computer. For each sound recording, the total duration of the sound (td), the number (n) of sound components (SC), the duration of each SC (c1, c2, c3,...), and the intervals (i1, i2,...) between the SCs were measured. For all the recordings, the mean durations of acoustic parameters (TDm, C1m, C2m, C3m, I1m, I2m) were calculated and compared by using Student's t test. In the 20 male subjects, the mean acoustic parameters were calculated (MTDm, MC1m, MC2m, MC3m, MI1m, MI2m) and compared with the mean acoustic parameters (FTDm, FC1m, FC2m, FC3m, FI1m, FI2m) in the ten females by using a Wilcoxon nonparametric statistical test. We were able to interpret 80% of the recordings. The TDm was 710 +/- 28 ms. Three main SCs were detected: C1m = 100 +/- 56, C2m = 150 +/- 90, C3m = 80 +/- 54 ms; I1m = 100 +/- 66, I2m = 190 +/- 120 ms. No significant difference in these parameters was observed with respect to gender. This study enabled us to decompose the swallowing sounds into three main SCs and to quantify their normal durations. These results should prove useful for the assessment of sound variations in pathologic conditions.

Prevalence of Dysphagia in Acute and Community Mental Health Settings

Abstract: The incidence of dysphagia in the population with mental health disorders may be higher as a result of a number of factors including the nature of the psychiatric disorder, effects of psychiatric medications, co-occurring neurologic conditions, and institutionalization and behavioral changes associated with the mental illness. This study aimed to determine the prevalence of dysphagia among adults with mental health disorders (MHDs) who attend acute and community mental health settings. Sixty attenders at a local area psychiatric service were assessed using a simple swallowing screening test. Subjects presented with a variety of mental health disorders and were attending an acute inpatient unit, day hospital, or long-term care setting. Thirty-two percent of those assessed demonstrated overt signs of oropharyngeal dysphagia. There was an increased prevalence in the inpatient unit (35%); the lowest prevalence of dysphagia was in those attending the day hospitals (27%). Thirty-one percent of those attending long-term care settings also had dysphagic symptoms. Twenty-three percent of individuals with schizophrenia in the total group had oropharyngeal dysphagia; this figure rose to 31% in the inpatient unit. Twenty-seven percent of individuals with bipolar affective disorder (BPAD) demonstrated overt signs of oropharyngeal dysphagia. Each of these individuals with BPAD was in an inpatient setting. The results of this study provide evidence to suggest that there is an increased incidence of dysphagia in those with mental health disorders. Of particular interest is the marked proportion (approximately one third) of those attending acute and long-term care settings with dysphagia. Possible contributing factors are discussed.

Influences of thermal and gustatory characteristics on sensory and motor aspects of swallowing.

Abstract: Two sets of experiments were conducted to examine the effects of two sensory modalities, temperature and taste, of foods on perceptual and motor aspects of swallowing in 20 young, healthy subjects (10 subjects for each experiment). A tasteless and odorless thickening agent was the basic testing material. The first experiment compared the swallowing of foods at four temperatures ranging from 5°C to 50°C. Food at 50°C was more acceptable for swallowing than at 5°C, 20°C, or 35°C. The suprahyoid muscles were less active during swallowing food at 50°C compared with swallowing food at the other three temperatures. The second experiment compared foods with the five basic taste qualities (sweetness, saltiness, sourness, bitterness, and umami) with a tasteless food (dissolved in distilled water) to examine the influence of gustatory sensation. The sweet and tasteless foods were somewhat more acceptable for swallowing than the sour and bitter foods. However, none of the foods differentially altered the motor parameters of swallowing. Interactive influences of temperature and gustatory sensations of foods on swallowing are discussed.

Hyoid-bolus transit latencies in normal swallow.

Abstract: Pharyngeal swallow delay is frequently found in dysphagic patients and is thought to be a factor in a range of swallowing problems, including aspiration. Implicit in notions of swallow "delay" is a temporal interval between two events that is longer than normal. However, there appears to be little agreement about which referent events should be considered in determining delay. A number of pharyngeal bolus transit points and various pharyngeal gestures have been used in delays determined from fluoroscopic evidence, and other referents have been used in electromyographic and manometric studies of swallow. In this study latencies between the first movement of the hyoid and several pharyngeal bolus transit points were calculated from fluoroscopic swallow studies in normal nondysphagic adults. Means and standard deviations of these latencies are provided for a 3-cc and a 20-cc bolus and for both nonelderly and elderly adults. The data may be a useful resource for relating the specific latencies investigated to concepts of pharyngeal swallow delay, in particular, when assessing videofluoroscopic studies using a similar protocol.

Dysphagia and hoarseness associated with painless aortic dissection: a rare case of cardiovocal syndrome.

Abstract: Cardiovocal syndrome (Ortner's syndrome) is characterized by left recurrent laryngeal nerve palsy due to cardiovascular disease, but in rare cases it can also be caused by aortic dissection. An 81-year-old man with hypertension was admitted to the hospital with aspiration pneumonia. He had been developing progressive dysphagia and hoarseness for several months before admission. A videofluoroscopic swallowing study showed supraglottic penetration with barium paste and liquid. Laryngoscopy and electromyography revealed left vocal cord palsy caused by left recurrent laryngeal neuropathy, and a contrast-enhanced chest CT revealed dissection of the aortic arch.

Cine Magnetic Resonance Imaging with Single-Shot Fast Spin Echo for Evaluation of Dysphagia and Aspiration

Abstract: The aim of this study was to determine the feasibility of and interest in evaluation of swallowing using dynamic magnetic resonance imaging (cine-MRI) in patients with dysphagia and aspiration caused by an abnormal pharyngeal phase of swallow. A cohort of six patients previously treated for head and neck cancer with persistent dysphagia and/or aspiration were evaluated an average of 47 months after treatment. The morphology and mobility of the oral, oropharyngeal, and laryngeal structures were analyzed using cine-MRI using single-shot fast spin echo technology. The qualitative observations were compared with a clinical fiberoptic swallowing evaluation. Swallowing physiology was analyzable for dry (saliva) swallow in all patients. MRI was well-tolerated by all six patients and no clinical aspiration occurred during the MRI. In five of six cases, further information on the cause of dysphagia was obtained using cine-MRI compared with the clinical evaluation alone. In the remaining case, cine-MRI confirmed the clinical evaluation. Cine-MRI using the dry swallow technique is feasible and without risk in patients with clinical aspiration. Cine-MRI is complementary to clinical evaluation of swallowing in patients with an abnormal pharyngeal phase of swallowing resulting from treatment of cancer.

Esophageal diverticula: pathogenesis, clinical aspects, and natural history.

Abstract: It has been gradually accepted that esophageal diverticula result from esophageal motor disorders rather than from primary anatomic abnormalities. Twenty-seven patients with these diverticula were evaluated with respect to pathogenesis, clinical aspects, diagnostic tests, therapy, and natural history for a mean of 27 months of followup. Thirteen diverticula were midesophageal, 11 were situated in the distal third of the esophagus, and 3 were in both regions. Esophageal dysmotility was observed in 85% of patients. Specific esophageal motor disorders were more frequent in association with diverticula of the distal third than in midesophageal diverticula, suggesting that they result from a pulsion mechanism. Traction was the possible mechanism in 27% of midesophageal diverticula. Endoscopic esophagitis was seen in one patient and abnormal acid reflux in 25% of the cases, mainly in patients with distal diverticula. Distal diverticula presented with more severe symptoms than did midesophageal diverticula, and 27% of those required surgical treatment. Patients with midesophageal diverticula seem to have a better prognosis than those with more distal disease.

Correlation of Glottal Closure Using Concurrent Ultrasonography and Nasolaryngoscopy in Children: A Novel Approach to Evaluate Glottal Status

Abstract: Objectives Endoscopic procedures to assess aerodigestive symptoms by evaluating glottal motion are not practical in neonates because of small nares, respiratory difficulties, or additional stress. Our objective was to determine the temporal correlation between concurrent nasolaryngoscopy (NLS) and ultrasonography (USG) evaluation of glottal motion.

Swallowing Function Outcomes Following Nonsurgical Therapy for Advanced-Stage Laryngeal Carcinoma

Abstract: The purposes of this study were to (1) evaluate swallowing function using both subjective and objective measures in patients treated nonsurgically for stages III and IV laryngeal squamous cell carcinoma, (2) assess the effect of time from treatment completion on swallowing function, and (3) assess sequelae associated with modality of treatment. To achieve these objectives, a retrospective study of 14 patients was conducted. Fiberoptic endoscopic evaluation of swallowing (FEES) was performed and evaluated by three independent judges for seven functional criteria: standing secretions, valleculae spillage, valleculae residue, postcricoid residue, laryngeal penetration, aspiration, and cough. Patient interviews were performed to establish patient perception of swallowing and his/her current posttreatment diet. Results revealed that each patient exhibited swallowing abnormalities in at least one of the seven objective functional categories studied. Ten patients suffered from variable degrees of dysphagia, ranging from mild to severe, on all measures. No significant differences were noted between those patients with less than or greater than 12 months posttreatment. Common treatment sequelae included PEG tube placement for nutritional supplementation, tracheostomy placement for airway security and/or pulmonary toilet, repeated episodes of aspiration pneumonia requiring hospital admission, and radiation-induced oropharyngeal stricture. Further studies using subjective and objective swallowing function measures for patients treated with alternative chemoradiation regimens versus surgery (with or without adjuvant therapies) for advanced stage laryngeal cancer are needed.

Comparison of two methods for measuring tongue pressure during swallowing in people with head and neck cancer

Abstract: Reliable measurement tools are essential to achieve rigor in dysphagia research. In order for tongue pressure to be measured accurately in the head and neck cancer population, where change in function needs to be captured over time, a reliable tool is required. Assessing the reliability of tools that are used in swallowing evaluation has been a neglected area of dysphagia research. This article evaluates and compares the reliability of two variants of the Kay Swallowing Workstation (KSW) three-bulb silicon tongue pressure array (hand-held and fixed-position) when used to capture oral tongue pressures in two groups of participants diagnosed with head and neck cancer who had not yet commenced cancer treatment. Tongue pressure data and videofluoroscopic images were collected and recorded simultaneously onto the KSW while participants swallowed set quantities of liquid and pudding boluses. Peak amplitude tongue pressures were extracted and used in analyses. Systematic and nonsystematic variability were examined using analysis of variance and intraclass correlation coefficients, respectively. The fixed-position array demonstrated better reliability than did the hand-held method. This should be further investigated with a larger participant sample.

Update on clinical trials in Dysphagia.

Abstract: Randomized clinical trials (RCTs) are often known as the gold standard in treatment efficacy studies. This article defines the characteristics of RCTs and the factors that investigators must consider in designing clinical trials in dysphagia. Design issues unique to behavioral treatments often used in dysphagia are discussed. Ongoing RCTs in dysphagia are described including studies of (1) the effectiveness of the Shaker exercise versus standardized treatment in patients with severe dysphagia resulting from stroke or treatment for head and neck cancer who have been nonoral for at least three months; (2) the comparative effects of nectar- and honey-thickened liquids versus chin tuck posture and in patients with dementia or Parkinson's disease with or without dementia who aspirate on thin liquids; and (3) the comparative effects of muscle exercise versus sensory postural therapy for dysphagia resulting from treatment for head and neck cancer. Issues in generalizing from the results of clinical trials are also described.

A questionnaire study to assess long-term outcome in patients with abnormal esophageal manometry.

Abstract: Patients with unexplained chest pain or dysphagia are often referred for esophageal manometric studies to further investigate their symptoms. Four main manometric abnormalities have been described: achalasia, diffuse esophageal spasm, “nutcracker” (hypercontracting) esophagus, and hypocontracting esophagus. With the exception of achalasia, treatments are of limited benefit and the natural history of these conditions is largely unknown. We sent questionnaires to patients who were investigated at least three years before our study began. They repeated a DeMeester symptom questionnaire that they had completed at the time of their initial study. Questionnaires were sent to 137 patients with diffuse esophageal spasm, “nutcracker” (hypercontracting) esophagus, or hypocontracting esophagus. We also sent questionnaires to 57 patients with dysphagia or chest pain who had had normal esophageal manometry and pH studies. These patients acted as symptomatic controls. Responses were compared using the Wilcoxon signed ranks test. Seventy-two (53%) patients with diffuse esophageal spasm, “nutcracker” esophagus, or hypocontracting esophagus replied. An additional 8 (6%) patients died. Symptom scores in all three conditions had improved significantly over time (p ≤ 0.01 for each condition, Wilcoxon signed ranks test). Patients with dysphagia or chest pain but normal esophageal studies had not improved. The significance of diffuse esophageal spasm, “nutcracker” esophagus, and hypocontracting esophagus found at esophageal manometry remains uncertain. Although treatment is often ineffective, these conditions typically run a benign course. Patients can be reassured that their symptoms are likely to improve with time.

Laterality of swallowing in healthy subjects by AP projection using videofluoroscopy.

Abstract: Although anteroposterior projections in videofluoroscopic examination of swallowing (VF) provide clinically important information, the laterality of swallowing in healthy subjects has not been examined fully to date. One hundred sixty-seven healthy volunteers were prospectively studied. The subjects were asked to swallow 5 ml of barium solution three times while X-ray images were taken that showed the pathway of the solution from the pharynx into the esophagus to assess the laterality of swallowing. We classified patterns of swallowing into three types according to passage in the pharyngoesophageal segment as indicated by width: RD (right-side-dominant flow), LD (left-side-dominant flow), and NL (no laterality in flow). Fifty-eight percent of the subjects were classified as NL, 35% as LD, and 7% as RD. The ratio of types in women was NL:LD:RD = 7:2:1. There were no significant differences among the groups according to age. Although classifications in young men (age = 20–30 years) tended to be the same as in women regardless of age, ratios of LD tended to increase with age; 71% of elderly adults (age = 51–75 years) were classified as LD. These results demonstrate laterality in normal swallowing and will be helpful in determining treatment strategies for the patients with dysphagia.

An Unusual Cause of Mechanical Dysphagia: An Agglomerate of Calculi in a Tonsillar Residue

Abstract: We report the case of a 68-year-old man affected by severe oropharyngeal dysphagia for solid food, who had undergone tonsillectomy when he was 22 years old. Videolaryngoscopy revealed a smooth-surfaced, elongated overgrowth on the left lateral pharyngeal wall that protruded toward the left pyriform fossa and impeded the transit of solid boli. A computed tomography scan showed that the solid content of the lesion was markedly inhomogeneous and denser than the surrounding soft tissues. The mass was removed by means of direct pharyngoscopy under general anesthesia. It was found that it arose from the inferior pole of the left tonsillar fossa and had a central cavity filled with caseum and multiple calculi. Histopathologic examination showed that its soft tissue component consisted of lymphoid tonsillar tissue. The operation totally resolved the swallowing disturbance. This case report highlights that tonsilloliths in a tonsillar residue should be considered in the differential diagnosis of mechanical oropharyngeal dysphagia, even in tonsillectomized patients.

Leakage of Fluid in Different Types of Tracheal Tubes

Abstract: The aim of this study was to evaluate leakage of liquids, i.e., water and saliva, past low-pressure cuffs of tracheostomy tubes. Three different types of tracheostomy tubes, TRACOE® vario (TRACOE Medical GmbH, Germany), Rusch Ultra-Tracheoflex® (Rusch GmbH, Germany), and Portex Blue Line Ultra™ (Smiths Medical, UK) were tested in isolated pig tracheas. Sixty samples (10 tubes each of 7- and 8-mm inner diameter of each type) were used. Four different experiments were devised: type 1 (water and artificial ventilation), type 2 (water and no artificial ventilation), type 3 (saliva and artificial ventilation), and type 4 (saliva and no artificial ventilation). Six milliliters of water or artificial saliva were infused over the cuff and the volume of fluid that leaked past the cuff was measured after 5, 10, and 15 min. Intracuff pressure was also measured three times. The saliva experiments resulted in less leakage than the water experiments. Leakage after treatment with water or artificial saliva is higher without artificial ventilation than with ventilation. The amount of leakage among the tubes with respect to manufacturer showed statistically significant results. However, there were no differences among tracheostomy tubes with respect to internal diameter.

Reproducibility of swallowing over time in healthy elderly adults.

Abstract: The purpose of this study was to evaluate the reproducibility of aspects of swallowing assessed over time by the Exeter Dysphagia Assessment Technique. Fourteen healthy elderly adults were assessed during the morning on four consecutive days. During day 1, the assessment was repeated ten times. During days 2, 3, and 4 the assessment was carried out once and at the same time of the day. This allowed the reproducibility of the data to be examined between sessions and between days. The results show that the reproducibility of data between sessions was moderate to very good for all of the items evaluated (median kappas = 0.56–0.82, ICCs = 0.7–0.8). Between-day reproducibility was also moderate to very good for nine of the variables measured (median kappas = 0.58–0.96, ICCs = 0.53–0.84) and poor for one (ICC = 0.15). We conclude that the majority of variables examined by the Exeter Dysphagia Assessment Technique are reliable when swallowing is assessed repeatedly and on different days.

Change in levator veli palatini muscle activity in relation to swallowing volume during the transition from the oral phase to pharyngeal phase.

Abstract: The aim of this study was to examine whether the levator veli palatini (LVP) muscle might be involved in the regulation of velopharyngeal function during the transition between the oral and pharyngeal phases during swallowing, and to examine whether LVP muscle activity could be regulated in relation to the volume of swallowing. Eight normal adults participated in this study. Smoothed EMG signals of the LVP muscle were collected. At the same time, palatoglossus muscle activity was also monitored. Each subject swallowed water at five different volumes: 12.5%, 25%, 50%, 100%, and 150 (or 200) % of the optimum volume for swallowing, which was individually determined for each subject. LVP muscle activity was positively correlated with changes in swallowing volume. The LVP muscle was involved in the regulation of swallowing during the transition from the oral to pharyngeal phases.

Is the anatomical protrusion on the posterior hypopharyngeal wall associated with cadavers of only the elderly

Abstract: Cricopharyngeal bars are commonly seen on a barium swallow radiologic examination and represent the failure of the cricopharyngeus to relax. Traditionally, the bars have been considered as functional or physiologic protrusions. Recently, anatomical cricopharyngeal protrusion has been found in about 30% of cadavers of the elderly, suggesting that such a structural change may become a physical barrier that affects the normal deglutition in a living person. This suggests that such a radiographic finding should be carefully considered when interpreting radiologic and manometrical examinations and managing dysphagia of the elderly. However, the finding of the anatomical cricopharyngeal protrusion was based on the observation of cadavers of the elderly (mean age = 77 years). The aim of this study was to further investigate whether such an anatomical cricopharyngeal protrusion exists in cadavers of other ages. Using the dissection method, we examined 63 human cadavers that were divided into three age groups: young adult (6 females and 10 males, age = 16–24 years old), adult (8 females and 23 males, age = 25–64 years old), and early elderly (5 females and 11 males, age = 65–69 years old). We found that 57 of the 63 cadavers had a smooth mucosal surface on the posterior hypopharyngeal and upper esophageal wall. A slightly thickened posterior muscular wall was observed at the cricoid level in six cadavers (five from the adult group and one from the early elderly group), but its boundary was not clearly identified. Taking the previous reports together, our results suggest that an anatomical cricopharyngeal protrusion is closely associated with the aging process.

Surface Electromyography in Preoperative Evaluation and Postoperative Monitoring of Zenker’s Diverticulum

Abstract: Patients with Zenker’s diverticulum (ZD) underwent surface electromyography (sEMG) evaluation to determine sEMG patterns specific for ZD. Group 1 comprised patients with proven long-standing ZD that refused surgical treatment (n = 11, age mean = 55.7 years). Group 2 comprised surgically operated on patients with ZD (n = 6, age mean = 61 years). The timing, amplitude, and graphic patterns of activity of the masseter, submental, and laryngeal strap muscles were examined during voluntary single water swallows (“normal”), single swallows of excessive amounts of water (20 ml, “stress test”), and continuous drinking of 100 cc of water. The muscle activity in pharyngeal and initial esophageal stages of swallowing was measured, and graphic records were evaluated in relation to timing and voltage. The data were compared with the previously established normative database. The main sEMG patterns of ZD are (1) duration of swallowing and drinking is longer than normal (p < 0.05), (2) electric amplitude of laryngeal strap muscles during swallowing activity is higher than normal (p < 0.05), and (3) regurgitation peaks immediately after swallow followed by secondary swallow of the regurgitated portion of a bolus as seen at the sEMG records are specific graphic patterns for the ZD. Zenker’s diverticulum has its own specific sEMG patterns. Surface EMG, being an important screening method for patients with dysphagia, is a valuable additional diagnostic tool for ZD. Because it is noninvasive and nonradiographic, it can be used for monitoring of long-standing cases of the disease as well as monitoring of postsurgical recovery.

Prevention of hypopharyngeal stenosis with silastic sheeting following transoral resection.

Abstract: Hypopharyngeal stenosis following transoral laser microresection (TLM) of hypopharyngeal carcinomas is a rare but devastating complication. Early oral intake and insertion of a nasogastric feeding tube have been thought to prevent stenosis after surgery. However, though rare, severe dysphagia can be caused by hypopharyngeal stenosis following TLM despite preventive efforts. We suggest a new way to prevent hypopharyngeal stenosis by using silastic sheeting with a feeding tube. This stent was inserted in three patients who underwent extensive TLM of hypopharyngeal carcinomas. This technique will help in the treatment and prevention of hypopharyngeal stenosis following TLM in selected patients with wide or circumferential hypopharyngeal tumors.