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PubMed1998

Acute and chronic changes in swallowing and quality of life following intraarterial chemoradiation for organ preservation in patients with advanced head and neck cancer.

BACKGROUND: Health-related quality of life (QOL) provides a measure of the patient's perception of his life after treatment. This study was undertaken to assess changes in QOL and swallowing in patients undergoing concurrent chemoradiotherapy (CR) for head and neck cancer. The assessment tools consisted of the Head and Neck Radiotherapy Questionnaire (HNRQ) and a swallowing questionnaire (SQ). METHODS: The HNRQ and SQ were administered to a group of CR patients prior to treatment (n = 58), after the last week of treatment (n = 37), and 6 months after treatment (n = 27). Weight change was monitored in treatment subjects. RESULTS: The results indicate that QOL and swallowing function decrease acutely during CR (p < .05) but improvement begins shortly after the treatment-related decline. At 6 months after CR, mean QOL exceeds pretreatment level. The oropharynx patients have the poorest outcome when compared with laryngeal and hypopharyngeal patients. A stronger correlation exists between swallowing and QOL at 6 months post-CR than during treatment (R = .52 versus R = .30). CONCLUSIONS: Quality of life and swallowing are compromised in advanced head and neck cancer patients prior to treatment. There was a further decrease in QOL and swallow function during CR. Organ-preservation programs in head and neck cancer result in improved QOL and swallowing 6 months after treatment. The degree of improvement is site-specific.

Acute Disease↗
PubMed1986

Swallowing and speech production in Parkinson's disease.

Videofluoroscopy was used to examine movement patterns during swallowing and speech production in 6 parkinsonian subjects and 6 age-matched controls. Motility patterns for liquid and semisolid swallows were documented. We performed temporospatial analyses of oropharyngeal structures, particularly the velum, which is prominently involved in both motor speech production and swallowing. Differences were found between groups and conditions. All of the parkinsonian subjects exhibited abnormal oropharyngeal movement patterns and timing during the volitional oral as well as the pharyngeal stage of swallowing; only 50% of these subjects admitted to any swallowing difficulty upon questioning. Two of the subjects with Parkinson's disease aspirated liquids. Duration of velar movement during speech production significantly differentiated the groups (p less than 0.01), reflecting reduced range of velar motion. Our findings suggest that rigidity and bradykinesia underlie the volitional speech abnormality as well as the disordered oral and pharyngeal stages of swallowing. Findings indicate that parkinsonian patients may be "silent aspirators" with decreased cough reflexes and lack of awareness of aspiration. The clinical value of videofluoroscopic monitoring of swallowing is that aspiration may be detected and managed early.

Adult↗
PubMedDate not supplied

Swallowing of bolus types by postsurgical head and neck cancer patients.

BACKGROUND: Clinically, head and neck cancer patients with anterior resections have better postoperative outcomes than do patients with posterior resections. METHODS: Videofluoroscopy was used to study the swallowing characteristics in postsurgery head and neck cancer patients and normal controls. Most patients received post-operative radiotherapy and chemotherapy, and no cancer recurrence was noted at the time of study, 4-8 months posttreatment. Bolus types included: 3 mL and 10 mL liquid barium, barium paste, and barium-coated cookie. Temporal measurements and a count of the number of swallows required to ingest each material were made from the videotaped data. Statistical analysis using an unbalanced univariate repeated measures ANOVA was performed. RESULTS: The major differences were found between bolus types, with few differences noted between surgical groups (anterior vs posterior resections) and normal controls. Patients took longer to ingest viscous material, accomplishing this by multiple piecemeal and clearing swallows. Coordination of mastication and swallowing of the cookie was different between normal and patient groups. CONCLUSIONS: Patients who are able to swallow reasonably well postoperatively maintain normal coordination and timing of swallowing activity and do not vary these parameters to compensate for structural inadequacy. Instead, repeated swallows are used.

Adult↗
PubMed2002

Sonographic examination of the oral phase of swallowing: bolus image enhancement.

PURPOSE: The purpose of this study was to evaluate the ability of 4 liquid boluses to enhance pixel brightness and the ease with which the boluses could be identified during the sonographic evaluation of oral swallowing in healthy young adults. METHODS: Ten healthy adult volunteers (5 men and 5 women), ranging in age from 21 to 31 years, underwent sonographic evaluation of the oral phase of swallowing while sitting in their usual feeding position. We compared the ability of the 4 following liquids to improve sonographic visualization of swallowing with that of water: a carbonated cola beverage, 5.0 ml of Thick-It in 120 ml of water, 2.5 ml of Thick-It in 120 ml of water, and 7.5 ml of confectioners' sugar in 120 ml of water. Water was used as a control. In each case, 5 ml of the liquid was introduced into the subject's oral cavity using a syringe, and the subject was instructed to swallow. Digitized still images and recorded video sequences of sonographic examinations of the swallowing were analyzed. The brightness of the bolus image on selected digitized video frames was measured digitally using Image Analyst software. Pixel brightness within selected regions of interest for each of the test liquids was statistically compared with that for water. Seven clinicians rated the visualization of each test liquid and water on paired sonographic videotape sequences. These ratings and the level of agreement between them were statistically tested. RESULTS: Only the carbonated cola beverage demonstrated statistically greater pixel brightness than that of water on digitized video frames (p = 0.01), whereas both cola (with a moderate inter-rater agreement, kappa = 0.50) and 5.0 ml Thick-It mixed with 120 ml of water (with a fair inter-rater agreement, kappa = 0.24) were significantly better visualized on sonographic video sequences. CONCLUSIONS: The digital still-frame analysis confirmed the clinicians' ratings of bolus visualization on real-time sonography, but dynamic sonography is more important than still frames in assessing sonographic swallow media because the dynamic images more closely parallel what is seen in clinical practice. Future investigations of sonographic contrast agents for use in the examination of the oral phase of swallowing should use both static digital (still-frame) and dynamic (real-time) assessment methods, as well as expert reviewers.

Adult↗
PubMed1997

Comparison of swallowing function in Parkinson's disease and progressive supranuclear palsy.

Dysphagia is common in both Parkinson's disease (PD) and progressive supranuclear palsy (PSP). Although it is believed to be more common in PSP, there are no controlled data and no comparison of swallowing function between these two disorders. Our aim was to assess dysphagia and swallow function in patients with PSP and PD. Seven patients with PSP were matched to seven patients with PD on the basis of disease duration. Self-rated dysphagia, movement disorder disability, modified barium swallow results, and abnormalities noted on manometry of the lower esophageal sphincter, esophageal body, upper esophageal sphincter, and pharynx were compared between the two groups. Neither severity nor duration of dysphagia differed between the two groups. Patients with PSP had a significantly greater degree of disability [median (range) Hoehn & Yahr score, 4 (3-5) vs. 2 (1-2); P < 0.002]. Manometric abnormalities were similar for the two groups. Oral-phase abnormalities on modified barium swallow were significantly more frequent in PSP (four patients with PSP vs. no patients with PD; p < 0.005). Pharyngeal abnormalities did not differ. Modified barium-swallow scores correlated well with self-reported dysphagia severity for patients with PSP (r = 0.93; p < 0.05) but not for those with PD (r = 0.42; p = NS). The frequency of abnormalities noted during the oral phase was significantly increased in PSP. It is hypothesized that the sensory information conveyed due to this may account for the better correlation between symptoms and swallowing abnormalities and the belief that swallowing problems are more common in PSP.

Barium↗
PubMed2005

Swallowing therapy--a prospective study on patients with neurogenic dysphagia due to unilateral paresis of the vagal nerve, Avellis' syndrome, Wallenberg's syndrome, posterior fossa tumours and cerebellar hemorrhage.

BACKGROUND: No studies exist dealing with the outcome of dysphagic patients with posterior fossa (IV. ventricle) tumours (PFT) or cerebellar hemorrhage (CH), and the outcome of patients with Wallenberg's syndrome (WS) after functional swallowing therapy (FST) has so far not been studied in detail. Patients and methods. 208 patients with neurogenic dysphagia (ND) who were consecutively admitted for functional swallowing therapy (FST) over a 3 year period to our hospital were examined clinically, by use of a videofluoroscopic swallowing study (VFSS) and/or fibreoptic evaluation of swallowing (FEES). The most frequent etiology was stroke (48%), followed by CNS tumours (13%). In the present study we defined three groups. Group 1 comprised 8 patients with PFT or CH. Group 2 consisted of 27 patients with WS, which was the leading cause among patients with non-hemispheric stroke. Since in WS a vagal nerve paresis due to affection of the Nucleus ambiguus occurs, 8 patients with Avellis' syndrome or unilateral paresis of the vagal nerve served as controls and were defined as group 3. Findings. In the three groups, functional feeding status showed significant improvement after FST comprising methods of restitution, compensation and adaptation, each of which were applied in more than 80% of patients. Outcome was, however, significantly worse in group 1 as compared to group 2 and in group 2 as compared to group 3. Dysfunction of the upper esophageal sphincter and reflex triggering were significantly more severely disturbed in groups 1 and 2 as compared to group 3. Group 1 showed significantly more severe disturbances of the oral phase as compared to groups 2 and 3. After FST, more than 50% (5/8) of group 1 and 30% (8/27) of WS patients (group 2) were dependent on tube feeding, whereas all patients of group 3 were full-oral feeders. Interpretation. This is the first study dealing with the outcome of dysphagic patients with PFT or CH. Based on our results it can be assumed that in these patients pressure is exerted on both dorsomedial central pattern generators (DMCPGs) for swallowing in a posterior-anterior direction. Due to the importance of the DMCPGs for swallowing, bilateral (and often MRI-invisible) lesions seem to be very harmful. For a better understanding of the pathomechanism responsible for ND in patients with PFT or CH, modern imaging methods such as proton magnetic resonance spectroscopy should be used for studying metabolic changes in the dorsal medulla in the future. Since the outcome of patients with WS with regard to dependence of tube feeding was not associated with the site or size of the lesion, it may due to the individual asymmetry of the swallowing-dominant forebrain hemisphere - depend on the side of the medullary infarction.

Adult↗
PubMed1994

Thermomechanical facilitation of swallowing evoked by electrical nerve stimulation in cats.

Application of a cold metal probe to the anterior faucial pillar has been reported to improve swallowing in some patients with dysphagia. Although a variety of stimuli contribute to the initiation of swallowing, the effects of a controlled, cold-thermal stimulus combined with mechanical stimulation have not been examined. It is known that simultaneous stimulation of the glossopharyngeal nerve (IX) and the superior laryngeal nerve may summate to facilitate swallowing in the cat. The goal of this study was to determine whether thermomechanical stimulation of the mucosa innervated by IX would interact with threshold electrical stimulation of the internal laryngeal nerve (ILN) to augment the swallowing response in cats. Four experimental conditions were tested over 24 trials in 4 pentobarbital-anesthetized cats. These included electrical stimulation of ILN, mechanical stimulation of the anterior faucial pillar with a thermode at ambient (room) temperature, concurrent ambient-mechanical and electrical stimulation, and concurrent cold-mechanical and electrical stimulation. Tissue was cooled to 8.9 degrees C during cold-mechanical-electrical stimulation and 25.3 degrees C during ambient-mechanical-electrical and ambient-mechanical alone stimulation. Ambient-mechanical stimulation alone did not produce swallowing. However, both forms of thermomechanical-electrical stimulation elicited a significantly greater number of swallows than did electrical stimulation alone. Therefore, mechanical stimulation with a thermode was capable of modifying the swallowing response in neurologically intact cats.(ABSTRACT TRUNCATED AT 250 WORDS)

Anesthesia↗
PubMed1996

Swallowing in hereditary sensory ataxia.

The oral, pharyngeal, and esophageal stages of swallowing were evaluated in 8 patients with recessively or dominantly inherited pure sensory ataxia. Six patients had swallowing difficulties: solid bolus obstruction, coughs during eating, and choking episodes. One patient had chronic bronchitis and another had recurrent pneumonia. The patients underwent a biphasic radiological barium swallow, including videofluoroscopy. No patient had a completely normal swallow. All had normal oral function, whereas pharyngeal function was abnormal in 6 patients. Esophageal function was abnormal in 6 patients. The swallowing dysfunction did not correlate with the severity of motor or sensory dysfunction in the limbs, nor with age or duration of ataxia. Our study shows that swallowing dysfunction is common in hereditary sensory ataxia. This dysfunction is likely to be due to involvement of the nucleus of the solitary tract in the brainstem. Despite some of the patients having suffered from choking episodes and others from bronchopulmonary complications, they did not spontaneously admit dysphagia. Swallowing should be evaluated thoroughly in patients with hereditary sensory ataxia since dysphagia in these patients might bring serious and potentially fatal complications.

Adult↗
PubMed1994

Viscosity effects on EMG activity in normal swallow.

This study investigated the effects of six consistencies on measures of swallow duration, muscle activity, and sound. Electromyographic (EMG) recordings of the submental and infrahyoid muscle complexes, and audio recordings of neck sounds were made while 5 normal subjects swallowed two foods in each of three consistency categories: liquid, thin paste, and thick paste. Total swallow duration, measured from EMG, increased significantly across consistency categories from liquids to thin pastes to thick pastes. Liquids and thin pastes were significantly different from thick pastes on all but one EMG measure. However, liquids and thin pastes failed to reach significance on any of the EMG measures. EMG activity in the submental muscles most often initiated the swallow whereas the infrahyoid muscle activity most frequently terminated the swallow. A sound spike occurred at relatively the same time in each swallow. Results are discussed in terms of systematic modulations of muscle activity during swallow.

Adult↗
PubMed1993

Oropharyngeal swallowing after stroke in the left basal ganglion/internal capsule.

One of the foci of Martin Donner's work was the neural control of swallowing. This present investigation continues that work by examining oropharyngeal swallowing in 8 patients identified with a single, small, left-basal ganglion/internal capsule infarction and 8 age-matched normal subjects. Stroke patients were assessed with a bedside clinical and radiographic swallowing assessment, and normal subjects received only the radiographic study. Results revealed disagreement between the bedside and radiographic assessments in one of the 8 stroke patients. Stroke and normal subjects differed significantly on some swallow measures on various bolus viscosities, but behaved the same as normal subjects on a number of measures. Differences in swallowing in the stroke subjects were not enough to prevent them from eating orally. The significant differences seen in the basal ganglia/internal capsule stroke subjects may result from damage to the sensorimotor pathways between the cortex and brainstem. These differences emphasize the importance of cortical input to the brainstem swallowing center in maintaining the systematic modulations characteristic of normal swallowing physiology.

Adult↗
PubMed1993

Volume accommodation during swallowing.

Bolus volume is an important modifier of the biomechanical events of the oropharyngeal swallow. The biomechanical events comprising a swallow can be divided into events associated with the reconfiguration of the pharynx into a swallow pathway and events associated with bolus transport from the oropharynx into the esophagus. Volume modification is achieved differently for the events of reconfiguration and propulsion. In the case of reconfiguration, a longer time is allocated to the process, as exemplified by sustained laryngeal elevation and hyoid excursion during larger volume swallows. On the other hand, in the case of bolus expulsion, volume accommodation is accomplished within the same period of time by utilizing increased vigor of expulsion. The result of deglutitive volume accommodation is a remarkably different fluoroscopic appearance of a small vs. a large volume swallow. The larger volume swallow seemingly takes longer and results in much more vigorous bolus expulsion than a small volume. However, this is more related to the bolus than the swallow.

Biomechanical Phenomena↗
PubMed1996

Swallowing and the duration of the hyoid movement in normal adults of different ages.

Normal swallows were examined using ultrasound imaging. Durational data of the hyoid movement were obtained from frame-by-frame analysis. The duration of the hyoid movement of three consecutive unstimulated (= dry) swallows was compared to that of stimulated (= wet) swallows in 120 subjects equally distributed among both sexes and four different age groups. Dry swallows proved to be longer than wet ones, and the duration of both types increased with age. The first dry swallow was invariably shorter than the third one; no such difference was noted with the wet swallows. With increasing age, the oral phase was more frequently accompanied by extra hyoid gestures, and the total number of swallows produced during a 10-second period was reduced in the elderly. These differences probably do not indicate pathology, but may be explained by changes in oral sensitivity, and subclinical oral-motor changes which occur in normal subjects with increasing age.

Adult↗
PubMed1998

Videofluorographic study of swallowing in Parkinson's disease.

We studied 16 patients with Parkinson's disease (PD) with dysphagia and 8 young and 7 elderly normal controls videofluorographically to evaluate the nature of swallowing disorders in PD patients. In 13 patients, abnormal findings in the oral phase were residue on the tongue or residue in the anterior and lateral sulci, repeated pumping tongue motion, uncontrolled bolus or premature loss of liquid, and piecemeal deglutition. Thirteen patients showed abnormal findings in the pharyngeal phase, including vallecular residue after swallow, residue in pyriform sinuses, and delayed onset of laryngeal elevation. Ten of these patients also showed abnormal findings in both the oral and pharyngeal phases. Aspiration was seen in 9 patients. The oral transit duration was significantly longer in the patients with and without aspiration than in the control subjects. The stage transition duration, pharyngeal transit duration, duration of the upper esophageal sphincter (UES) opening, and total swallow duration were significantly longer in the patients with and without aspiration than in the young controls, but were not longer than in the elderly controls. These durational changes in the pharyngeal phase of swallowing were similar to those in the elderly controls. The findings suggest that the disturbed motility in the oral phase of swallowing may be due to bradykinesia. Although PD patients with dysphagia evince a variety of swallowing abnormalities, the duration of pharyngeal swallowing may remain within the age-related range until the symptoms worsen.

Adult↗
PubMed1999

Outcomes of swallowing rehabilitation in chronic brainstem dysphagia: A retrospective evaluation.

This study examines the functional and physiologic outcomes of treatment in a group of 10 patients with chronic dysphagia subsequent to a single brainstem injury. All patients participated in a structured swallowing treatment program at a metropolitan teaching hospital. This program differs from more traditional swallowing treatment by the inclusion of surface electromyography biofeedback as a treatment modality and the completion of 10 hr of direct treatment in the first week of intervention. A retrospective analysis of medical records and patient questionnaires was used to gain information regarding medical history, site of lesion, prior interventions, and patient perception of swallowing recovery. Physiologic change in swallowing treatment, as measured by severity ratings of videofluoroscopic swallowing studies, was demonstrated in nine of 10 patients after 1 week or 10 sessions of treatment. Functional change was measured by diet level tolerance after 1 week of treatment, at 6 months, and again at 1 year posttreatment. Eight of the 10 patients were able to return to full oral intake with termination of gastrostomy tube feedings, whereas two demonstrated no long-term change in functional swallowing. Of the eight who returned to full oral intake, the average duration of tube feedings following treatment until discontinuation was 5.3 months, with a range of 1-12 months. Six patients who returned to oral intake maintained gains in swallowing function, and two patients returned to nonoral nutrition as the result of a new unrelated medical condition.

Adult↗
PubMed2005

[Dysphagia. Are swallowing sounds diagnostically useful?].

The origin and importance of swallowing sounds in dysphagia have been discussed in previous research. Those studies report a general similarity in the sound patterns of different swallowing actions. The current paper confirms this. In addition, the origin of swallowing sound patterns is examined more closely. Finally, we simultaneously analyzed the swallowing sounds of healthy voluntary subjects and patients with swallowing disorders using X-ray cinematography. Videoendoscopy was also done. As expected, we found a variety of sound sequences differing from those of healthy subjects. Patients with tracheal tubes or cannulae constitute a special group whose swallowing sounds give additional information about the act of swallowing.

Auscultation↗
PubMed2003

Swallowing disorders post orotracheal intubation in the elderly.

OBJECTIVES: The purpose of this study was to assess the prevalence and recovery time of swallowing dysfunction after prolonged endotracheal intubation in critically ill elderly patients compared to a younger cohort. DESIGN: This was a prospective, interventional, clinical study set in a medical intensive care unit in a university-affiliated hospital. SUBJECTS: The study involved 42 consecutive elderly patients (>/=65 years old) and 42 controls (<65 years) matched for severity of illness requiring endotracheal intubation for more than 48 h. INTERVENTIONS: A fiberoptic endoscopic evaluation of swallowing (FEES) was performed within 48 h post-extubation and on days 5, 9, and 14 for those with evidence of aspiration. RESULTS. Swallowing dysfunction was assessed by the detection of test material below the true vocal cords. Aspiration was documented in 52% of the elderly and 36% of the control group (P=0.2). No significant difference in the co-morbidity index and the length of mechanical ventilation was found between aspirators and non-aspirators. None of the control group had swallowing deficits after 2 weeks, while 13% of the elderly participants showed persistent impairment in the swallowing reflex. By multivariate analysis, the preadmission functional status was the only determinant of a slowly resolving swallowing deficit (hazard ratio 1.68; 95% confidence interval 1.26-3.97). No post-extubation aspiration pneumonia was identified in either group. CONCLUSIONS: Critically ill elderly patients exhibit delayed resolution of swallowing impairment post extubation. FEES should be considered for those with impaired preadmission functional status.

Aged↗
PubMed2000

Activity of respiratory laryngeal motoneurons during fictive coughing and swallowing.

Membrane potential changes and discharges from 28 laryngeal motoneurons were recorded intracellularly in the caudal nucleus ambiguus of decerebrate, paralyzed and ventilated cats. Electrical activities were recorded from 17 expiratory laryngeal motoneurons (ELMs) with maximal depolarizing membrane potential in early expiration, and from 11 inspiratory laryngeal motoneurons (ILMs) with maximal depolarizing membrane potential in inspiration. Activities during breathing were compared with those observed during fictive coughing and swallowing evoked by electrical stimulation of the superior laryngeal nerves. These non-respiratory behaviors were evidenced in paralyzed animals by characteristic discharge patterns of the phrenic, abdominal nerves and pharyngeal branch of the vagus nerve. We recorded the activity of 11 ELMs and 5 ILMs during coughing in which ELMs, but not ILMs, exhibited increased membrane depolarization and discharge frequencies. Membrane depolarization and discharge frequencies of all ELMs were also significantly increased during swallowing. In addition, membrane depolarization of most ELMs (15/17) was preceded by a short-lasting hyperpolarization due to chloride-dependent inhibitory mechanisms occurring at the onset of swallowing. Out of 10 ILMs tested during swallowing, 7 exhibited membrane depolarization, preceded in 5 cases by a short-lasting hyperpolarization. Discharge frequencies of ILMs were significantly reduced during swallowing. The same pattern of phasic activities of ILMs and ELMs was observed during coughing and breathing, suggesting the involvement of similar excitatory pathways in both behaviors. These results imply that the duration of activation and the discharge frequency of neurons of the central generator for breathing that drive laryngeal motoneurons are enhanced during coughing. During swallowing, in addition to central excitatory mechanisms, laryngeal motoneurons are subjected to an initial inhibition of unknown origin. This inhibition probably contributes to the temporal organization of the swallowing motor sequence.

Animals↗
PubMedDate not supplied

Videofluoroscopic evaluation of HIV/AIDS patients with swallowing dysfunction.

BACKGROUND: We investigated the association of abnormalities of the swallowing mechanism in the oral and pharyngeal phases of swallowing with symptoms of dysphagia and painful swallowing in patients with human immunodeficiency virus (HIV). METHODS: Seventeen patients, two with HIV and 15 with acquired immunodeficiency syndrome (AIDS), with symptoms of dysphagia or pain on swallowing for routine barium esophagograms were studied prospectively by videofluoroscopic examination of the oropharynx in addition to a routine biphasic esophagogram. The videofluoroscopic studies were performed in conjunction with a speech pathologist. RESULTS: All 17 patients demonstrated abnormalities in the oral, pharyngeal, or esophageal phase of swallowing. Eight patients aspirated, six of whom did not exhibit a cough reflex and were classified as silent aspirators. Seven of the eight patients who aspirated had chest radiographs consistent with aspiration pneumonia. CONCLUSION: A significant number of HIV-positive and AIDS patients with dysphagia or pain on swallowing have dysfunction of the swallowing mechanism and are at risk for aspiration.

Acquired Immunodeficiency Syndrome↗