Showing papers in "Dysphagia in 2015"

The Influence of Food Texture and Liquid Consistency Modification on Swallowing Physiology and Function: A Systematic Review

Abstract: Texture modification has become one of the most common forms of intervention for dysphagia, and is widely considered important for promoting safe and efficient swallowing. However, to date, there is no single convention with respect to the terminology used to describe levels of liquid thickening or food texture modification for clinical use. As a first step toward building a common taxonomy, a systematic review was undertaken to identify empirical evidence describing the impact of liquid consistency and food texture on swallowing behavior. A multi-engine search yielded 10,147 non-duplicate articles, which were screened for relevance. A team of ten international researchers collaborated to conduct full-text reviews for 488 of these articles, which met the study inclusion criteria. Of these, 36 articles were found to contain specific information comparing oral processing or swallowing behaviors for at least two liquid consistencies or food textures. Qualitative synthesis revealed two key trends with respect to the impact of thickening liquids on swallowing: thicker liquids reduce the risk of penetration–aspiration, but also increase the risk of post-swallow residue in the pharynx. The literature was insufficient to support the delineation of specific viscosity boundaries or other quantifiable material properties related to these clinical outcomes. With respect to food texture, the literature pointed to properties of hardness, cohesiveness, and slipperiness as being relevant both for physiological behaviors and bolus flow patterns. The literature suggests a need to classify food and fluid behavior in the context of the physiological processes involved in oral transport and flow initiation.

Decreased Tongue Pressure is Associated with Sarcopenia and Sarcopenic Dysphagia in the Elderly

Abstract: The aim of this study was to clarify the association between tongue pressure and factors related to sarcopenia such as aging, activities of daily living, nutritional state, and dysphagia. One-hundred-and-four patients without a history of treatment of stroke and without a diagnosis of neurodegenerative disease (36 men and 68 women), with a mean age of 84.1 ± 5.6 years, hospitalized from May 2013 to June 2013 were included in this study. Maximum voluntary tongue pressure against the palate (MTP) was measured by a device consisting of a disposable oral balloon probe. Nutritional and anthropometric parameters such as serum albumin concentration, Mini-Nutritional Assessment short form (MNA-SF), body mass index, arm muscle area (AMA), and others and presence of sarcopenia and dysphagia were analyzed to evaluate their relationships. Correlation analysis and univariate or multivariate analysis were performed. Simple correlation analysis showed that MTP correlated with Barthel index (BI), MNA-SF, serum albumin concentration, body mass index, and AMA. Univariate and multivariate analysis showed that sarcopenia, BI, MNA-SF, and age were the independent explanatory factors for decreased MTP, and the propensity score for dysphagia, including causes of primary or secondary sarcopenia, and the presence of sarcopenia were significantly associated with the presence of dysphagia. Decreased MTP and dysphagia were related to sarcopenia or the causes of sarcopenia in the studied population. Furthermore, the clinical condition of sarcopenic dysphagia may be partially interpreted as the presence of sarcopenia and causal factors for sarcopenia.

The Yale Pharyngeal Residue Severity Rating Scale: An Anatomically Defined and Image-Based Tool

Abstract: The Yale Pharyngeal Residue Severity Rating Scale was developed, standardized, and validated to provide reliable, anatomically defined, and image-based assessment of post-swallow pharyngeal residue severity as observed during fiberoptic endoscopic evaluation of swallowing (FEES). It is a five-point ordinal rating scale based on residue location (vallecula and pyriform sinus) and amount (none, trace, mild, moderate, and severe). Two expert judges reviewed a total of 261 FEES evaluations and selected a no residue exemplar and three exemplars each of trace, mild, moderate, and severe vallecula and pyriform sinus residue. Hard-copy color images of the no residue, 12 vallecula, and 12 pyriform sinus exemplars were randomized by residue location for hierarchical categorization by 20 raters with a mean of 8.3 years of experience (range 2–27 years) performing and interpreting FEES. Severity ratings for all images were performed by the same 20 raters, 2 weeks apart, and with the order of image presentations randomized. Intra-rater test–retest reliability, inter-rater reliability, and construct validity were determined by pooled multi-category multi-rater kappa statistics. Residue ratings were excellent for intra-rater reliability for vallecula (kappa = 0.957 ± 0.014) and pyriform sinus (kappa = 0.854 ± 0.021); very good to excellent for inter-rater reliability for vallecula (kappa = 0.868 ± 0.011) and pyriform sinus (kappa = 0.751 ± 0.011); and excellent for validity for vallecula (kappa = 0.951 ± 0.014) and pyriform sinus (kappa = 0.908 ± 0.017). Clinical uses include accurate classification of vallecula and pyriform sinus residue severity patterns as none, trace, mild, moderate, or severe for diagnostic purposes, determination of functional therapeutic change, and precise dissemination of shared information. Scientific uses include tracking outcome measures, demonstrating efficacy of interventions to reduce pharyngeal residue, investigating morbidity and mortality in relation to pharyngeal residue severity, and improving training and accuracy of FEES interpretation by students and clinicians. The Yale Pharyngeal Residue Severity Rating Scale is a reliable, validated, anatomically defined, and image-based tool to determine residue location and severity based on FEES.

The Relationship Between Pharyngeal Constriction and Post-swallow Residue

Abstract: Pharyngeal constriction has been proposed as a parameter that may distinguish functional from impaired swallows. We employed anatomically normalized pixel-based measures of pharyngeal area at maximum constriction, and the ratio of this measure to area at rest, and explored the association between these measures and post-swallow residue using the normalized residue ratio scale (NRRS). Videofluoroscopy data for 5 ml boluses of 22 % (w/v) liquid barium were analyzed from 20 healthy young adults and 40 patients with suspected neurogenic dysphagia. The frames of maximum pharyngeal constriction and post-swallow hyoid rest were extracted. Pixel-based measures of pharyngeal area were made using ImageJ and size-normalized using the squared C2–C4 vertebral distance as a reference scalar. Post-swallow residue and the areas of the vallecular and pyriform sinus spaces were measured on the hyoid rest frame to calculate the NRRSv and NRRSp. The dataset was divided into swallows with residue within or exceeding the upper confidence interval boundary seen in the healthy participants. Mixed model repeated measures ANOVAs were used to compare pharyngeal area (rest, constriction) and the pharyngeal constriction ratio, between individuals with and without residue. Measures of pharyngeal area at maximum constriction were significantly larger (i.e., less constricted, p = 0.000) in individuals with post-swallow residue in either the valleculae or the pyriform sinus. These results support the idea that interventions targeted toward improving pharyngeal constriction have the potential to be effective in reducing post-swallow residue.

Age-Related Changes in Pharyngeal Lumen Size: A Retrospective MRI Analysis

Abstract: Age-related loss of muscle bulk and strength (sarcopenia) is often cited as a potential mechanism underlying age-related changes in swallowing. Our goal was to explore this phenomenon in the pharynx, specifically, by measuring pharyngeal wall thickness and pharyngeal lumen area in a sample of young versus older women. MRI scans of the neck were retrospectively reviewed from 60 women equally stratified into three age groups (20s, 60s, 70+). Four de-identified slices were extracted per scan for randomized, blinded analysis: one mid-sagittal and three axial slices were selected at the anterior inferior border of C2 and C3, and at the pit of the vallecula. Pixel-based measures of pharyngeal wall thickness and pharyngeal lumen area were completed using ImageJ and then converted to metric units. Measures of pharyngeal wall thickness and pharyngeal lumen area were compared between age groups with one-way ANOVAs using Sidak adjustments for post-hoc pairwise comparisons. A significant main effect for age was observed across all variables whereby pharyngeal wall thickness decreased and pharyngeal lumen area increased with advancing age. Pairwise comparisons revealed significant differences between 20s versus 70+ for all variables and 20s versus 60s for all variables except those measured at C2. Effect sizes ranged from 0.54 to 1.34. Consistent with existing sacropenia literature, the pharyngeal muscles appear to atrophy with age and consequently, the size of the pharyngeal lumen increases.

Prophylactic Swallowing Exercises in Head and Neck Cancer Radiotherapy

Abstract: Many head and neck cancer (HNC) survivors experience reduced quality of life due to radiotherapy (RT)-related dysphagia. The aim of this prospective randomized trial was to evaluate the impact of prophylactic swallowing exercises on swallowing-related outcomes in HNC patients treated with curative RT. Patients treated with primary RT for HNC were candidates for this randomized protocol. Participants in the exercise group were instructed to perform swallowing exercises at home. Participants in the control group were given standard care. Patients were evaluated with modified barium swallow and several other secondary outcome measures at four and nine different time points, respectively. Data were analyzed according to intention-to-treat analyses. A total of 44 consecutive patients were included; 22 in each group. In general, there was no difference between the two groups regarding any of the dysphagia outcomes during and after treatment. Adherence to exercises was poor and dropouts due to especially fatigue were very frequent in both groups. Systematic swallowing exercises had no impact on swallowing outcomes within the first year after RT. Despite repeated supervised sessions, adherence to exercises was a major issue and dropouts were frequent in both the intervention and control group.

Effects of Tongue Strength Training and Detraining on Tongue Pressures in Healthy Adults

Abstract: This study examined the effect of tongue strengthening training and long-term detraining on tongue tip pressure, tongue base pressure, and tongue pressure during effortful swallowing. Ten young healthy volunteers (21-35 years) were participated in this study. Participants received 8-week tongue strengthening exercise 3 days a week with each session lasting 30 min. Measurement of tongue pressure and tongue strengthening exercise were administrated using Iowa Oral Performance Instrument (IOPI). Training intensity was applied at 60 and 80% of maximal tongue pressure for the first week and the remainder, respectively. Following completion of 8-week training, 28 weeks of detraining period was continued. Training increased tongue tip pressure, tongue base pressure, and tongue pressure during effortful swallowing above pre-training values (p < 0.05). After 28-week detraining, all tongue variables were significantly lower than after 8-week training (p < 0.05) but remained significantly higher than pre-training levels (p < 0.05). These findings demonstrate that high-intensity tongue strengthening exercise can improve tongue pressures. However, training effects were diminished gradually during detraining period. Thus, maintenance programs after strengthening exercise would be required for prolonging training effects.

The Effect of Prophylactic Percutaneous Endoscopic Gastrostomy (PEG) Tube Placement on Swallowing and Swallow-Related Outcomes in Patients Undergoing Radiotherapy for Head and Neck Cancer: A Systematic Review

Abstract: Patients undergoing radiotherapy for head and neck cancer (HNC) often experience malnutrition and dehydration during treatment. As a result, some centres place PEG tubes prophylactically (pPEG) to prevent these negative consequences. However, recent research has suggested that pPEG use may negatively affect swallowing physiology, function and/or quality of life, especially in the long term. The purpose of this study was to systematically review the literature on pPEG use in HNC patients undergoing radiotherapy and to determine its impact on swallowing-related outcomes. The following electronic databases were searched for all relevant primary research published through February 24, 2014: AMED, CINAHL, the Cochrane Library, Embase, Healthstar, Medline, and PsycINFO. Main search terms included HNC, radiotherapy, deglutition disorders, feeding tube(s), and prophylactic or elective. References for all accepted papers were hand searched to identify additional relevant research. Methodological quality was assessed using Cochrane’s Risk of Bias. At all levels, two blinded raters provided judgments. Discrepancies were resolved by consensus. The search retrieved 181 unique citations. Twenty studies met our inclusion criteria. Quality assessment revealed that all studies were at risk for bias due to non-randomized sampling and unreported or inadequate blinding. Ten studies demonstrated selection bias with significant baseline differences between pPEG patients and controls. Results regarding the frequency and severity of dysphagia and swallowing-related outcomes were varied and inconclusive. The impact of pPEG use on swallowing and swallowing-related outcomes remains unclear. Well-controlled, randomized trials are needed to determine if pPEG places patients at greater risk for developing long-term dysphagia.

Effectiveness of Non-invasive Brain Stimulation in Dysphagia Subsequent to Stroke: A Systemic Review and Meta-analysis

Abstract: The objective of this study is to assess the efficacy and safety of non-invasive brain stimulation (NIBS) in patients with dysphagia subsequent to stroke. A systematic search of the literature published by Medline (January 1, 1976 through June 21, 2013), EMBASE (January 1, 1985 through June 21, 2013), and the Cochrane Library (January 1, 1987 through June 21, 2013) was conducted for all relevant articles related to NIBS, dysphagia, and cerebrovascular disorders (CVD). Two reviewers (S.N.Y and S.B.P) independently evaluated the eligibility of retrieved data according to the selection criteria and assessed methodological quality of the studies using the ‘assessing risk of bias’ table recommended in the Cochrane Handbook for Systematic Reviews of Interventions (version 5.0.2). Six randomized controlled trials (59 intervention groups and 55 placebo groups) were identified as addressing the use of NIBS for dysphagia after CVD and were included in the meta-analysis. The function scale score improvement of dysphagia in patients treated with NIBS was statistically significant compared with that of patients who underwent sham stimulation (standardized mean difference = 1.08, 95 % confidence intervals = 0.29–1.88, p = 0.008; I 2 = 72 %). A subgroup analysis based on the type of intervention (three repetitive transcranial magnetic stimulation (rTMS) studies and three transcranial direct current stimulation (tDCS) studies) revealed a statistically significant beneficial effect of NIBS compared with sham stimulation in the rTMS group, but not in the tDCS group. When the results were examined based on intervention site (ipsilesional vs. contralesional site stimulation), no statistically significant difference was noted between two groups. No complications of NIBS were reported in this analysis.

Prevalence of oropharyngeal dysphagia in the Netherlands: a telephone survey

Abstract: Recent and specific data on the prevalence and/or incidence of oropharyngeal dysphagia in the general population are scarce. This study focuses on obtaining this data by means of a literature review and telephone survey. A literature review was performed to obtain data on the prevalence of dysphagia in the general population. Secondly, a quasi-random telephone survey using the functional health status questionnaire EAT-10 was conducted with the aim of establishing prevalence data on oropharyngeal dysphagia in the Netherlands. The literature review revealed six articles which met the inclusion criteria. The prevalence data on oropharyngeal dysphagia in the general population varied between 2.3 and 16 %. For the telephone survey, a total of 6,700 individuals were contacted by telephone, of which, 2,600 (39 %) participated in the study. Of the 2,600 participants, as many as 315 (12.1 %) were identified as having swallowing abnormalities and showed increased risk of oropharyngeal dysphagia with age. Prevalence data on oropharyngeal dysphagia in the Dutch general population were as high as 12.1 %. This data are in line with the retrieved prevalence data from the literature.

Safety and Efficacy of Oral Feeding in Infants with BPD on Nasal CPAP.

Abstract: Safety and efficacy of oral feeding was examined in infants with bronchopulmonary dysplasia (BPD) on nasal continuous positive airway pressure (NCPAP). We hypothesized that repetitive oral feeding enhances aero-digestive outcomes and reduces resource utilization. Data from infants with BPD (37–42 weeks post menstrual age) that were orally fed while on NCPAP (n = 26) were compared with those that were exclusively gavage fed on NCPAP (n = 27). Subject assignment was random and physician practice based. Specifically, we compared the differences in aero-digestive milestones, resource utilization, and safety metrics. Demographic characteristics such as gender distribution, gestational age, and birth weight, clinical characteristics such as frequency of intraventricular hemorrhage and patent ductus arteriosus needing surgical ligation were similar in both groups (p > 0.05). Characteristics of respiratory support and airway milestones were similar in both groups (p > 0.05). However, infants in NCPAP-oral fed group had earlier acquisition of full oral feeding milestone by 17 days (median) versus infants who were not orally fed during NCPAP (p 0.05). There were no tracheostomies in either group. There was no incidence of clinically significant aspiration pneumonia in infants during the period of the oral feeding while on NCPAP. Controlled introduction of oral feedings in infants with BPD during NCPAP is safe and may accelerate the acquisition of oral feeding milestones.

The Effect of Radiation Dose on Swallowing: Evaluation of Aspiration and Kinematics

Abstract: Radiation oncologists have focused on the pharyngeal constrictors as the primary muscles of concern for dysphagia. However, our prior investigations have demonstrated that radiation dose to the geniohyoid rather than the constrictor muscles was more closely related to penetration aspiration scores (PAS). We examined the relationship between (1) radiation dose and swallowing temporal kinematics, and (2) between PAS and swallowing kinematics in these patients. Videofluoroscopic swallowing studies of 41 patients following radiation therapy for oropharyngeal cancer were analyzed for thin liquid boluses. Timing measures included duration of laryngeal vestibule closure (DLVC), duration to maximum hyoid elevation (DTMHE), duration to cricopharyngeal opening (DTCPO), and pharyngeal transit time (PTT). PAS was extracted for each swallow and considered normal if ≤ 2. As minimum and mean dose to the geniohyoid increased, DTMHE, DTCPO, and PTT increased. Worse PA scores were most strongly correlated with radiation dose received by geniohyoid (r = 0.445, p < 0.0001). Mean DLVC varied according to PAS group (normal PAS mean = 0.67 s, abnormal PAS mean = 0.13 s; p < 0.001). Similarly, DTCPO was significantly different based upon PAS (normal PAS mean = 0.22 s, abnormal PAS mean = 0.37 s, p = 0.016). As PAS increased, DTPCO and PTT increased (r = 0.208, p = 0.04; r = 0.204, p = 0.043). A negative correlation was noted between PAS and DLVC (r = -0.375, p = 0.001). Higher doses of radiation to the geniohyoid muscles are associated with increased severity of dysphagia as measured through both kinematics and PAS. Consideration of dose to the geniohyoid should be considered when planning radiation.

A systematic review of self-reported swallowing assessments in progressive neurological disorders.

Abstract: Dysphagia experienced as a consequence of neurodegenerative disease can have severe consequences on a patient's health and well-being. Regular assessment of swallowing function can assist to achieve adequate nutrition and hydration. Here we review subjective swallowing assessments currently available are suitable for use in people with neurodegenerative disease. Measurement properties were reviewed for each tool and coverage of the World Health Organization's International Classification of Functioning, Disability and Health (WHO ICF) was considered. Assessments were identified following a review of the published literature Instruments were reviewed on the basis of reliability and validity, as well as administrative properties, such an interpretability, acceptability, and feasibility. Tools were also evaluated according to the WHO ICF framework. In total, 19 studies were identified for full-text review from 13,315 abstracts. Nine self-reported dysphagia assessment tools suitable for use in progressive neurological disorders were identified. The Swallowing Quality of Life Questionnaire (SWAL-QOL) yields the strongest combination of reliability (including internal consistency and test-retest reliability) and convergent validity while simultaneously covering all WHO ICF domains. Lengthy administration time was identified as a limitation of the SWAL-QOL. The review highlights a relative lack of well-validated self-report questionnaires in dysphagia for people with progressive neurological disease. Additional validation and evaluation of the clinical utility of the tools currently available is required to further promote an informed selection of available assessments.

Relationships Among Rheological, Sensory Texture, and Swallowing Pressure Measurements of Hydrocolloid-Thickened Fluids

Abstract: The objective of this study was to examine the relationships among three categories of measurements (rheological, sensory texture, and swallowing pressure) from fluids thickened to two different viscosities with 15 different hydrocolloids. Fluids at viscosities of 300 and 1500 cP (at 30 s−1) were targeted because these are the viscosities corresponding to the barium standards used in radiographic dysphagia diagnosis. Within the low viscosity (nectar) fluids (300 cP), the sensory properties thickness, stickiness, adhesiveness, mouth coating, and number of swallows were highly positively correlated with each other and highly positively correlated with the flow behavior index, n value (an indicator of shear-thinning behavior). Within the higher viscosity (thin honey) fluids (1500 cP), the sensory textures of adhesiveness, stickiness, mouth coating, and number of swallows correlated positively with rheological measures of n value. Swallowing pressures measured in the anterior oral cavity correlated negatively with the consistency coefficient k [shear stress/(shear rate)n]. Samples that were more shear thinning (lower n values, higher k values) were generally perceived as less thick, with less adhesive properties (stickiness, adhesiveness, mouthcoating, and number of swallows). This information can be useful for selecting thickeners for people with dysphagia. A desirable thickener for many dysphagic patients would be one that allowed for a safe swallow by being viscous enough to reduce airway penetration, yet pleasant to drink, having the minimal perceived thickness and mouthcoating associated with greater shear thinning.

Rotigotine Transdermal Patch Improves Swallowing in Dysphagic Patients with Parkinson's Disease.

Abstract: Abnormal swallowing, dysphagia, is a potentially fatal symptom in Parkinson's disease (PD) and is characterized by frequent silent aspiration, an unrecognized risk of suffocation and aspiration pneumonia. Several studies have reported that the injection of apomorphine, a dopamine agonist, alleviated dysphagia in some patients with PD. The effects of other antiparkinson medications against dysphagia remain controversial. Rotigotine is another dopamine agonist with non-oral administration, i.e., a transdermal patch. Its noninvasiveness seems to render this medicine even more suitable than apomorphine for dysphasic patients. However, no direct evidence has been reported. In the present retrospective open-label study, we for the first time objectively showed that rotigotine improved swallowing on videofluoroscopic examination in dysphagic patients with PD.

Swallowing Tablets and Capsules Increases the Risk of Penetration and Aspiration in Patients with Stroke-Induced Dysphagia

Abstract: We evaluated the prevalence of difficulties swallowing solid dosage forms in patients with stroke-induced dysphagia and whether swallowing tablets/capsules increases their risk of penetration and aspiration. Concurrently, we explored whether routinely performed assessment tests help identify patients at risk. Using video endoscopy, we evaluated how 52 patients swallowed four different placebos (round, oval, and oblong tablets and a capsule) with texture-modified water (TMW, pudding consistency) and milk and rated their swallowing performance according to the Penetration Aspiration Scale (PAS). Additionally, Daniels Test, Bogenhausener Dysphagiescore, Scandinavian Stroke Scale, Barthel Index, and Tinetti’s Mobility Test were conducted. A substantial proportion of the patients experienced severe difficulties swallowing solid oral dosage forms (TMW: 40.4 %, milk: 43.5 %). Compared to the administration of TMW/milk alone, the placebos increased the PAS values in the majority of the patients (TMW: median PAS from 1.5 to 2.0; milk: median PAS from 1.5 to 2.5, each p value <0.0001) and residue values were significantly higher (p < 0.05). Whereas video-endoscopic examination reliably identified patients with difficulties swallowing medication, neither patients’ self-evaluation nor one of the routinely performed bedside tests did. Therefore, before video-endoscopic evaluation, many drugs were modified unnecessarily and 20.8 % of these were crushed inadequately, although switching to another dosage form or drug would have been possible. Hence, safety and effectiveness of swallowing tablets and capsules should be evaluated routinely in video-endoscopic examinations, tablets/capsules should rather be provided with TMW than with milk, and the appropriateness of “non per os except medication” orders for dysphagic stroke patients should be questioned.

Videofluoroscopic Validation of a Translational Murine Model of Presbyphagia

Abstract: Presbyphagia affects approximately 40 % of otherwise healthy people over 60 years of age. Hence, it is a condition of primary aging rather than a consequence of primary disease. This distinction warrants systematic investigations to understand the causal mechanisms of aging versus disease specifically on the structure and function of the swallowing mechanism. Toward this goal, we have been studying healthy aging C57BL/6 mice (also called B6), the most popular laboratory rodent for biomedical research. The goal of this study was to validate this strain as a model of presbyphagia for translational research purposes. We tested two age groups of B6 mice: young (4–7 months; n = 16) and old (18–21 months; n = 11). Mice underwent a freely behaving videofluoroscopic swallow study (VFSS) protocol developed in our lab. VFSS videos (recorded at 30 frames per second) were analyzed frame-by-frame to quantify 15 swallow metrics. Six of the 15 swallow metrics were significantly different between young and old mice. Compared to young mice, old mice had significantly longer pharyngeal and esophageal transit times (p = 0.038 and p = 0.022, respectively), swallowed larger boluses (p = 0.032), and had a significantly higher percentage of ineffective primary esophageal swallows (p = 0.0405). In addition, lick rate was significantly slower for old mice, measured using tongue cycle rate (p = 0.0034) and jaw cycle rate (p = 0.0020). This study provides novel evidence that otherwise healthy aging B6 mice indeed develop age-related changes in swallow function resembling presbyphagia in humans. Specifically, aging B6 mice have a generally slow swallow that spans all stages of swallowing: oral, pharyngeal, and esophageal. The next step is to build upon this foundational work by exploring the responsible mechanisms of presbyphagia in B6 mice.

Videofluoroscopic Predictors of Penetration-Aspiration in Parkinson's Disease Patients.

Abstract: Parkinson’s disease (PD) patients show a high prevalence of swallowing disorders and tracheal aspiration of food. The videofluoroscopic study of swallowing (VFSS) allows clinicians to visualize the visuoperceptual and temporal parameters associated with swallowing disorders in an attempt to predict aspiration risk. However, this subject remains understudied in PD populations. Our aim was to identify the predictors of penetration–aspiration in PD patients using the VFSS. Consecutive patients were evaluated using VFSS with different consistencies and volumes of food. A speech-language pathologist measured the type of intra-oral bolus organization, loss of bolus control, bolus location at the initiation of the pharyngeal swallow, the presence of multiple swallows, piecemeal deglutition, bolus residue in the pharyngeal recesses and temporal measures. Scores ≥3 on the penetration–aspiration scale (PAS) indicated the occurrence of penetration–aspiration. Using logistic marginal regression, we found that residue in the vallecula, residue in the upper esophageal sphincter and piecemeal deglutition were associated with penetration–aspiration (odds ratio (OR) = 4.09, 2.87 and 3.83; P = 0.0040, 0.0071 and 0.0009, respectively). Penetration/aspiration occurred only with fluids (both of thin and thick consistency), and no significant differences were observed between fluid types or food volumes. The mechanisms underlying dysphagia and penetration/aspiration in PD patients and indications for further studies are discussed.

Penetration–Aspiration: Is Their Detection in FEES® Reliable Without Video Recording?

Abstract: Penetration-aspiration is known as the main finding in deglutition-disordered patients with implications for diagnostics and therapeutic management. Reliable detection of penetration-aspiration is given with fiberoptic endoscopic evaluation of swallowing (FEES(®)) as one of the gold standards in instrumental swallowing evaluation. The advice to implement video recording in FEES(®) to assure quality in identifying penetration-aspiration is often ignored, especially in bed-side settings. Thus, the aim of this study was to compare reliability and validity in detecting penetration-aspiration events with and without video recording. Eighty FEES(®) sequences, ten per severity grade of the Penetration-Aspiration Scale by Rosenbek et al., were rated by four blinded ENTs with two different methods. The first method simulated the evaluation without video recording (Method A), and the second one with video recording (Method B). Rating was performed twice per setting with 2 weeks in between and every time newly randomized. Intra- and inter-rater reliability as well as validity were analyzed for both evaluation methods. R-to-Z transformation was used to reveal the more reliable method and ordinal regression to determine potential rating influences. Method B demonstrated higher intra- and inter-rater reliability values than Method A and was revealed as more reliable in identifying penetration-aspiration according to r-to-Z transformation (Z = -2.92, p = .004). Ordinal regression detected a significant influence of the evaluation method choice on the rating results (p = .016). As Method B turned out to be more reliable than Method A in detecting penetration-aspiration, the presented study recommends the implementation of video recording in swallowing diagnostics.

Measuring outcomes for dysphagia: validity and reliability of the European Portuguese eating assessment Tool (P-EAT-10)

Abstract: The purpose of this study was to evaluate the validity and the reliability of the European Portuguese version of the EAT-10 (P-EAT-10). This research was conducted in three phases: (i) cultural and linguistic adaptation; (ii) feasibility and reliability test; and (iii) validity tests. The final sample was formed by a cohort of 520 subjects. The P-EAT-10 index was compared for socio-demographic and clinic variables. It was also compared for both dysphagic and non-dysphagic groups as well as for the results of the 3Oz wst. Lastly, the P-EAT-10 scores were correlated with the EuroQol Group Portuguese EQ-5D index. The Cronbach's α obtained for the P-EAT-10 scale was 0.952 and it remained excellent even if any item was deleted. The item-total and the intraclass correlation coefficients were very good. The P-EAT-10 mean of the non-dysphagic cohort was 0.56 and that of the dysphagic cohort was 14.26, the mean comparison between the 3Oz wst groups and the P-EAT-10 scores were significant. A significant higher perception of QoL was also found among the non-dysphagic subjects. P-EAT-10 is a valid and reliable measure that may be used to document dysphagia which makes it useful both for screening in clinical practice and in research.

Effects of Strengthening Exercises on Swallowing Musculature and Function in Senior Healthy Subjects: a Prospective Effectiveness and Feasibility Study

Abstract: Head and neck cancer (HNC) patients may develop dysphagia due to muscle atrophy and fibrosis following chemoradiotherapy. Strengthening of the swallowing muscles through therapeutic exercise is potentially effective for improving swallowing function. We hypothesize that a customized Swallow Exercise Aid (SEA), developed for isometric and isokinetic strengthening exercises (against resistance), can help to functionally strengthen the suprahyoid musculature, which in turn can improve swallowing function. An effectiveness/feasibility study was carried out with ten senior healthy volunteers, who performed exercises 3 times per day for 6 weeks. Exercises included chin tuck against resistance (CTAR), jaw opening against resistance (JOAR), and effortful swallow exercises with the SEA. Multidimensional assessment consisted of measurements of maximum chin tuck and jaw opening strength, maximum tongue strength/endurance, suprahyoid muscle volume, hyoid bone displacement, swallowing transport times, occurrence of laryngeal penetration/aspiration and/or contrast residue, maximum mouth opening, feasibility/compliance (questionnaires), and subjective swallowing complaints (SWAL-QOL). After 6-weeks exercise, mean chin tuck strength, jaw opening strength, anterior tongue strength, suprahyoid muscle volume, and maximum mouth opening significantly increased (p < .05). Feasibility and compliance (median 86 %, range 48-100 %) of the SEA exercises were good. This prospective effectiveness/feasibility study on the effects of CTAR/JOAR isometric and isokinetic strengthening exercises on swallowing musculature and function shows that senior healthy subjects are able to significantly increase swallowing muscle strength and volume after a 6-week training period. These positive results warrant further investigation of effectiveness and feasibility of these SEA exercises in HNC patients with dysphagia.

Alpha-Synuclein Pathology in Sensory Nerve Terminals of the Upper Aerodigestive Tract of Parkinson's Disease Patients.

Abstract: Dysphagia is common in Parkinson's disease (PD) and causes significant morbidity and mortality. PD dysphagia has usually been explained as dysfunction of central motor control, much like other motor symptoms that are characteristic of the disease. However, PD dysphagia does not correlate with severity of motor symptoms nor does it respond to motor therapies. It is known that PD patients have sensory deficits in the pharynx, and that impaired sensation may contribute to dysphagia. However, the underlying cause of the pharyngeal sensory deficits in PD is not known. We hypothesized that PD dysphagia with sensory deficits may be due to degeneration of the sensory nerve terminals in the upper aerodigestive tract (UAT). We have previously shown that Lewy-type synucleinopathy (LTS) is present in the main pharyngeal sensory nerves of PD patients, but not in controls. In this study, the sensory terminals in UAT mucosa were studied to discern the presence and distribution of LTS. Whole-mount specimens (tongue-pharynx-larynx-upper esophagus) were obtained from 10 deceased human subjects with clinically diagnosed and neuropathologically confirmed PD (five with dysphagia and five without) and four age-matched healthy controls. Samples were taken from six sites and immunostained for phosphorylated α-synuclein (PAS). The results showed the presence of PAS-immunoreactive (PAS-ir) axons in all the PD subjects and in none of the controls. Notably, PD patients with dysphagia had more PAS-ir axons in the regions that are critical for initiating the swallowing reflex. These findings suggest that Lewy pathology affects mucosal sensory axons in specific regions of the UAT and may be related to PD dysphagia.

Influence of the chin-down and chin-tuck maneuver on the swallowing kinematics of healthy adults

Abstract: The purpose of the study was to investigate the influence of the chin-tuck maneuver on the movements of swallowing-related structures in healthy subjects and formulate standard instructions for the maneuver. A total of 40 healthy volunteers (20 men and 20 women) swallowed 10 mL of diluted barium solution in a “normal and comfortable” position (NEUT), a comfortable chin-down position (DOWN), and a strict chin-tuck position (TUCK). Resting state anatomy and kinematic changes were analyzed and compared between postures. Although angles of anterior cervical flexion were comparable between DOWN (46.65 ± 9.69 degrees) and TUCK (43.27 ± 12.20), the chin-to-spine distance was significantly shorter in TUCK than in other positions. Only TUCK showed a significantly shorter anteroposterior diameter of the laryngeal inlet (TUCK vs. NEUT, 14.0 ± 4.3 vs. 16.3 ± 5.0 mm) and the oropharynx (18.8 ± 3.1 vs. 20.5 ± 2.8 mm) at rest. The maximal horizontal displacement of the hyoid bone was significantly less in TUCK (9.6 ± 3.0 mm) than in NEUT (12.6 ± 2.6 mm; p < 0.01) or DOWN (12.1 ± 3.0 mm; p < 0.01). TUCK facilitated movement of the epiglottic base upward (TUCK vs. NEUT, 15.8 ± 4.7 vs. 13.3 ± 4.5 mm; p < 0.01). In contrast, DOWN increased the horizontal excursion of the epiglottic base and reduced movement of the vocal cords. These results quantitatively elucidated the biomechanical influences of the chin-tuck maneuver including reduced horizontal movement of the hyoid bone, facilitation of vertical movement of the epiglottic base, and narrowing of the airway entrance. Comparing DOWN and TUCK, only TUCK induced significant changes in the airway entrance, hyoid movement, and epiglottic base retraction.

The Recline Exercise: Comparisons with the Head Lift Exercise in Healthy Adults

Abstract: The aim of this investigation was to examine the comparative effectiveness of the new Recline Exercise (RE) and the traditional Head Lift Exercise (Shaker Exercise) on submental muscle activity, tongue strength, and perceived exertion in 40 healthy young adults (mean age = 24.5 years, SD 2.6 years). Both groups participated in a 6-week exercise regimen. Outcome variables evaluated pre- and post-exercise included: duration and peak amplitude of submental muscle activity during swallowing measured via surface electromyography (sEMG); anterior and posterior isometric lingual pressures measured with the Iowa Oral Performance Instrument; and perceived exertion levels measured with the Borg category-ratio scale of perceived exertion. Results indicated no significant pre-post differences within or between groups in swallow duration and peak amplitude. In addition, the RE group demonstrated significant post-treatment increases in anterior and posterior tongue strength [p = 0.009; p < 0.001]; however, these increases were of small magnitude (d = 0.132; d = 0.319). Both groups showed marked improvements in perceived exertion levels [p < 0.001]. Our findings indicate that healthy young adults who perform the RE or the HLE do not have significant swallow duration or amplitude gains, most likely due to the reduced need for such gains in the healthy head/neck musculature for submaximal tasks. Furthermore, the significant lingual strength gains seen with the RE indicate that additional musculature is being engaged during its completion. These results are encouraging; however, future research in older adults and patients with dysphagia with examination of swallowing biomechanics is needed to determine its full potential as a rehabilitative regimen.

Electromagnetic Sensor-Guided Enteral Access Systems: A Literature Review

Abstract: Enteral feeding is the nutritional support of choice for acutely ill patients with functional gastrointestinal tracts who are unable to swallow. Several benefits including reduced mortality and length of hospital stay have been associated with early initiation of enteral feeding. However, misplacement of conventional nasoenteric tubes is relatively common and can result in complications including pneumothorax. In addition, the need to confirm the position by X-ray can delay the start of using the tube. Eliminating these delays can help patients start feeding, and minimise the adverse impact on initiating hydration and medication. The purpose of this review was to critically examine whether electromagnetic sensor-guided enteral access systems (EMS-EAS) can help overcome the challenges of conventional nasoenteric feeding tube placement and confirmation. The Royal Society of Medicine’s library performed two searches on Medline (1946–March 2014) and Embase (1947–March 2014) covering all papers on Cortrak or electromagnetic or magnetic guidance systems for feeding tubes in adults. Results from the literature search found an agreement between the radiographic and EMS-EAS confirmation of placement. EMS-EAS virtually eliminated the risk of misplacement and pneumothorax was not reported. In addition, studies showed a small decrease in the number of X-rays with EMS-EAS and a reduced average time to start feeding compared with blind placement. This review suggests that EMS-EAS reduces several complications associated with the misplacement of nasoenteric feeding tubes, and that there could be considerable improvements in mortality, morbidity, patient experience and cost if EMS-EAS is used instead of conventional methods.

The Effect of Bolus Consistency on Hyoid Velocity in Healthy Swallowing

Abstract: The aim of this study was to determine whether measures of hyoid velocity increase when swallowing liquids of thicker consistency at a constant volume. A gender-balanced sample of 20 healthy young participants (mean age 31.5) each swallowed 3 boluses of 5 ml volume in 3 consistencies (ultrathin, thin, and nectar-thick barium). Using frame-by-frame tracking of hyoid position, we identified the onset and peak of the hyoid movement and derived measures of velocity (i.e., distance in anatomically normalized units, i.e., % of the C2-4 vertebral distance, divided by duration in ms) for the X, Y, and XY movement directions. Peak hyoid velocity was also identified for each movement direction. Where significant differences were identified, the component measures of hyoid movement distance and duration were further explored to determine the strategies used to alter velocity. The results showed increased velocities and higher peak velocities with the nectar-thick stimuli compared to thin and ultrathin stimuli. This was achieved by a primary strategy of larger hyoid movement distances per unit of time when swallowing nectar-thick liquids. These results point to one mechanism by which thickened liquids may contribute to improved airway protection by facilitating more timely laryngeal vestibule closure.

The Physiologic Impact of Unilateral Recurrent Laryngeal Nerve (RLN) Lesion on Infant Oropharyngeal and Esophageal Performance

Abstract: Recurrent laryngeal nerve (RLN) injury in neonates, a complication of patent ductus arteriosus corrective surgery, leads to aspiration and swallowing complications. Severity of symptoms and prognosis for recovery are variable. We transected the RLN unilaterally in an infant mammalian animal model to characterize the degree and variability of dysphagia in a controlled experimental setting. We tested the hypotheses that (1) both airway protection and esophageal function would be compromised by lesion, (2) given our design, variability between multiple post-lesion trials would be minimal, and (3) variability among individuals would be minimal. Individuals' swallowing performance was assessed pre- and post-lesion using high speed VFSS. Aspiration was assessed using the Infant Mammalian Penetration-Aspiration Scale (IMPAS). Esophageal function was assessed using two measures devised for this study. Our results indicate that RLN lesion leads to increased frequency of aspiration, and increased esophageal dysfunction, with significant variation in these basic patterns at all levels. On average, aspiration worsened with time post-lesion. Within a single feeding sequence, the distribution of unsafe swallows varied. Individuals changed post-lesion either by increasing average IMPAS score, or by increasing variation in IMPAS score. Unilateral RLN transection resulted in dysphagia with both compromised airway protection and esophageal function. Despite consistent, experimentally controlled injury, significant variation in response to lesion remained. Aspiration following RLN lesion was due to more than unilateral vocal fold paralysis. We suggest that neurological variation underlies this pattern.

Electrophysiological Evaluation of Dysphagia in the Mild or Moderate Patients with Multiple Sclerosis: A Concept of Subclinical Dysphagia

Abstract: Swallowing mechanism and neurogenic dysphagia in MS have been rarely studied by electromyographical (EMG) methods. This study aims to evaluate the presence of subclinical dysphagia in patients with mild multiple sclerosis (MS) using electrophysiological methods. A prospective study of 51 patients with relapsing remitting multiple sclerosis and 18 age-matched healthy adults was investigated. We used electromyography to measure the activity of the submental muscles during swallowing. Electrophysiological recordings of patients were obtained during relapse, after relapse, and at any time in remission period. Clinical dysphagia was found in 12 % of MS patients, while electrophysiological swallowing abnormalities were encountered in 33 % of patients. Subclinical dysphagia was determined in 35 % of patients during an MS relapse, in 20 % of patients after a relapse, and in 25 % of all 51 patients in the remission period based on EMG findings. Duration of swallowing signal of submental muscles in all MS patients was found to be longer than in normal subjects (p = 0.001). During swallowing of 50 ml of sequential water, the compensatory respiratory cycles occurred more often in MS patients than normal subjects, especially during a relapse (p = 0.005). This is the first study investigating swallowing abnormalities and subclinical dysphagia from the electrophysiological aspect in MS patients with mild disability. The electrophysiological tests described in this study are useful to uncover subclinical dysphagia since they have the advantage of being rapid, easy to apply, non-invasive, and without risk for the patients.

The Effect of Bilateral Superior Laryngeal Nerve Lesion on Swallowing: A Novel Method to Quantitate Aspirated Volume and Pharyngeal Threshold in Videofluoroscopy

Abstract: The purpose was to determine the effect of bilateral superior laryngeal nerve (SLN) lesion on swallowing threshold volume and the occurrence of aspiration, using a novel measurement technique for videofluoroscopic swallowing studies (VFSS) in infant pigs. We used a novel radiographic phantom to assess volume of the milk containing barium from fluoroscopy. The custom made phantom was firstly calibrated by comparing image intensity of the phantom with known cylinder depths. Secondly, known volume pouches of milk in a pig cadaver were compared to volumes calculated with the phantom. Using these standards, we calculated the volume of milk in the valleculae, esophagus and larynx, for 205 feeding sequences from four infant pigs feeding before and after had bilateral SLN lesions. Swallow safety was assessed using the tested and validated IMPAS (Dysphagia 28(2):178–187, 2013). The log-linear correlation between image intensity values from the phantom filled with barium milk and the known phantom cylinder depths was strong (R 2 > 0.95), as was the calculated volumes of the barium milk pouches. The threshold volume of bolus in the valleculae during feeding was significantly larger after bilateral SLN lesion than in control swallows (p < 0.001). The IMPAS score increased in the lesioned swallows relative to the controls, indicating substantially impaired swallowing (p < 0.001). Bilateral SLN lesion dramatically increased the aspiration incidence and the threshold volume of bolus in valleculae. The use of this phantom permits quantification of the aspirated volume of fluid, allowing for more accurate 3D volume estimation from 2D X-ray in VFSS.

Swallowing problems at the end of the palliative phase: incidence and severity in 164 unsedated patients.

Abstract: Swallowing problems are reported to be a common finding in patients who receive palliative care. In existing literature, the incidence of swallowing problems is mostly described in small numbers of patients at the start of the palliative phase. As we hypothesized that the incidence of dysphagia might increase as the palliative phase progresses, this study describes the incidence of swallowing problems and related problems in 164 unsedated patients at the end of the palliative phase, defined by the last 72 h before their death. To determine the incidence of swallowing problems and related problems, questionnaires were completed bereaved by relatives and nursing staff. Our data shows that in the palliative phase the incidence of swallowing problems can be as high as 79 %. A significant correlation was found between swallowing problems and reduced psycho-social quality of life as assessed by nursing staff (ρ = −.284). Overall the nursing staff rated the incidence and severity of swallowing problems (and related problems like frequent coughing, loss of appetite, and problems with oral secretions) lower than the relatives. This study suggests that incidence of swallowing problems at the end of the palliative phase is high and that these difficulties may not only result in discomfort for patients, but also can raise concern for caregivers. More information and education on management of swallowing problems in palliative settings might be needed for both relatives and nursing staff. However, the data also suggest that any intervention should be proportional to the level of distress caused by the intervention.