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Swallowing after free-flap reconstruction in patients with oral and pharyngeal cancer.

Swallowing and intraoral sensation outcome were investigated prospectively after microvascular free-flap reconstruction. Forty-one patients with a large oral or oropharyngeal carcinoma underwent free-flap surgery usually combined with radiotherapy. The patients completed modified barium swallow, self-rating of swallowing, and 2-point moving discrimination preoperatively and at four time points during the 12-month follow-up period, and a plain chest X-ray one year after operation. Swallowing was impaired with respect to an objective and subjective measure after therapy. Rates for nonsilent and silent aspiration increased during the follow-up. Intraoral sensation deteriorated. Swallowing outcome was not related to sensation. One year after surgery, 86% of the patients ate regular masticated or soft food. Microvascular transfers offer a reasonable option for oral reconstruction. This study does not support the need for sensate flaps. Swallowing problems should be routinely sought and patients rehabilitated during a sufficiently long follow-up with videofluorography regardless of the patient's perception of swallowing.

Adult↗

Impact of swallowing therapy on aspiration rate following treatment for locally advanced head and neck cancer.

This study examines the efficacy of swallowing therapy in cancer-free patients who developed aspiration following treatment for locally advanced head and neck cancer. The records of 41 patients who underwent swallowing therapy for aspiration were reviewed. All patients were cancer free at a median follow-up of 25 months (6-150 months). Their treatment were respectively chemoradiation (24), and postoperative radiation (17). All patients had two or more modified barium swallow (MBS). Dysphagia severity was graded from 1 to 7. Dysphagia grade was compared before and following swallowing therapy. Before swallowing therapy, there were 16 grade 5 (trace aspiration), and 25 grade 6-7 (severe aspiration). In the chemoradiation group, there were nine grade 5, five grade 6, and 10 grade 7. Corresponding numbers for the postoperative group were: seven grade 5, seven grade 6, and three grade 7. Following swallowing therapy, there were six grade 3, seven grade 4, 10 grade 5, six grade 6, and 12 grade 7. In the chemoradiation group, there were four grade 3, three grade 4, four grade 5, five grade 6, and eight grade 7. In the postoperative group, there were two grade 3, four grade 4, six grade 5, one grade 6, and four grade 7. Overall, 13 patients (32%) had improvement of their dysphagia severity. Seven of them were in the chemoradiation group (29%), and six (35%) were in the postoperative group. Among 25 patients who presented with grade 6-7 aspiration, only nine (36%) improved to grade 5 or less. Four of them (27%) were in the chemoradiation group, and five (29%) were in the postoperative group. Swallowing therapy is effective to improve dysphagia severity and reduce the need for tube feedings. However, a significant number of patients still suffered from chronic severe aspiration. New strategies must be devised to improve their outcome.

Adult↗

Physiologic model of oropharyngeal swallowing revisited.

OBJECTIVE: The purposes of this investigation were to determine whether the temporal onsets of swallow events segment into oral and pharyngeal phases, to test the interdependence of temporal onsets of swallow events, and to determine the influence of age on total swallow duration. STUDY DESIGN AND SETTING: The onsets of swallowing and respiratory measures were studied in 76 healthy normal individuals. RESULTS: Confirmatory factor analysis revealed a 2-factor solution but did not support the hypothesized 2-phase structure (ie, oral and pharyngeal). Two of the onsets, apnea onset and apnea offset, formed a single factor that explained 12.6% of the variation among the 11 onset times. The other 9 onsets formed a second factor that explained 66.4% of the variation. Age accounted for modest variation in total swallow duration. CONCLUSIONS: The two factors, oropharyngeal and respiratory, explained 79% of the variation among the 11 onset times. SIGNIFICANCE: This finding speaks to the overlap between the initiation of oral and pharyngeal components of swallowing in adults and highlights the artificiality of separating the swallowing continuum into isolated phases.

Adult↗

Brainstem viscerotopic organization of afferents and efferents involved in the control of swallowing.

Cholera toxin horseradish peroxidase (CT-HRP), a sensitive antegrade and retrograde tracer, is effective at labeling swallowing motoneurons and their dendritic fields within the nucleus ambiguus (NA), nucleus of the solitary tract (NTS), dorsal motor nucleus of the vagus nerve, and hypoglossal nucleus. Using this tracer to label motoneurons within the NTS demonstrates that palatal, pharyngeal, and laryngeal afferents overlap considerably within the interstitial and intermediate subnuclei. These afferents have a pattern of distribution within the NTS similar to the labeling observed after application of the same tracer to the superior laryngeal nerve. Esophageal afferents, however, terminate entirely within the central (NTScen) subnucleus and do not overlap their distribution with palatal, pharyngeal, or laryngeal afferents. Within the nodose ganglion (NG), sensory neurons projecting to the soft palate and pharynx are located superiorly, and those projecting to the esophagus and stomach are located inferiorly, an organization that indicates rostrocaudal positioning along the alimentary tract. Sensory neurons within the NG and NTS contain, among others, the major excitatory and inhibitory amino acid neurotransmitters glutamate (Glu) and gamma-aminobutyric-acid (GABA). Both Glu and GABA help to coordinate esophageal peristalsis. Using pseudorabies virus as a transsynaptic tracer demonstrates the role of GABA and Glu as mediators of synaptic transmission within the swallowing central pattern generator, a fact further supported by the presence of specific receptors for each neurotransmitter within the NTScen. Anatomic studies using CT-HRP have been effective in revealing the total extent of extranuclear dendritic projections and the organization of dendrites within the confines of a nucleus; further studies have produced the following data. Motoneurons innervating the soft palate, pharynx, larynx, and cervical esophagus have extensive dendrites that extend into the adjacent reticular formation with a distinct pattern for each muscle group. Motoneurons of the musculature active during the buccopharyngeal phase of swallowing (soft palate, pharynx, cricothyroid, and cervical esophagus) have extensive dendritic arborizations that terminate within the adjacent reticular formation of the NA. Swallowing premotor neurons located in the reticular formation surrounding the NA are active during the buccopharyngeal phase of swallowing. These data provide an anatomic basis for interaction of swallowing motoneurons with premotor neurons located in this area. Motoneurons innervating all levels of the esophagus are confined to the compact formation (NAc), whereas those motoneurons projecting to the pharynx and cricothyroid muscle are located in the semicompact formation (NAsc). The intrinsic laryngeal muscles were represented within the loose formation (NAI) and the heart within the external formation. In contrast, the dendrites of motoneurons projecting to the thoracic and subdiaphragmatic esophagus are confined to the NAc. Both the NAsc and NAc have extensive longitudinal bundling of dendrites within the confines of the nucleus, resulting in the formation of a rostrocaudal dendritic plexus where dendrites crisscross between bundles. Intranuclear bundling of dendrites is evident in the soft palate, pharynx, and esophagus and is lacking only for the cricothyroid muscle. Moreover, ventrolateral- and dorsomedial-oriented dendritic bundles are present within the NAsc. In contrast to the longitudinal dendritic bundles, the ventrolateral- and dorsomedial-oriented dendritic bundles exit the NAsc and penetrate the adjacent reticular formation. The extensive bundling of motoneuronal dendrites within the NA supports the hypothesis that these structures serve as networks for the generation of complex motor activities, such as swallowing.

Brain Stem↗

Sour taste stimulation facilitates reflex swallowing from the pharynx and larynx in the rat.

Chemical stimulation of the pharynx and larynx is effective in eliciting reflex swallowing. A sour taste bolus facilitates the onset of swallowing in patients with neurogenic dysphagia, but the mechanism of the facilitation has not been clarified. We investigated the effect of sour solutions on the elicitation of reflex swallowing in anesthetized rats. The main ducts of salivary glands were ligated to avoid the effect of saliva. A small amount of water, sour solutions, and other taste solutions were applied to the mucosa of the pharyngolaryngeal region. Acetic acid and citric acid, which provide a sour taste, had a stronger effect on evoking reflex swallowing as compared with other taste solutions. The effectiveness of these acids increased with increasing concentrations. We also examined the contribution of the superior laryngeal nerve (SLN) and the pharyngeal branch of the glossopharyngeal nerve (GPNph) to reflex swallowing. Acetic acid was greatly effective in evoking swallowing in both the region innervated by the SLN and the GPNph. On the other hand, water was effective in the SLN region but only slightly effective in the GPNph region. The results indicate that stimulation of the pharyngolaryngeal region with sour solutions facilitates reflex swallowing, suggesting that the facilitation may be due to increases of sensory inputs via the SLN and GPNph.

Acetic Acid↗

Role of the modified barium swallow in management of patients with dysphagia.

The modified barium swallow is a radiographic (videofluoroscopic) procedure designed to define the anatomy and physiology of the patient's oropharyngeal swallow and examine the effectiveness of selected rehabilitation strategies designed to eliminate aspiration or excess oral or pharyngeal residue (the symptoms of the patient's dysphagia). Rehabilitation strategies introduced during the modified barium swallow after the patient's oropharyngeal anatomy and physiology have been defined include (1) postural changes to redirect food flow and change pharyngeal dimensions, (2) sensory enhancement techniques, and (3) swallow maneuvers. Combining the modified barium swallow with a follow-up swallowing rehabilitation plan can decrease the cost and time for rehabilitation of patients with dysphagia. In some cases the patient can begin safe oral intake immediately after the modified barium swallow, and therapy may not be needed if consistent spontaneous recovery is anticipated.

Administration, Oral↗

Neuroimaging evidence for cortical involvement in the preparation and in the act of swallowing.

This study employed whole head magnetoencephalography and synthetic aperture magnetometry to investigate the cortical topography of the preparation and the execution of volitional and reflexive water swallowing and of a simple tongue movement. Concerning movement execution, activation of the mid-lateral primary sensorimotor cortex was strongly lateralized to the left during volitional water swallowing, less strongly lateralized to the left during reflexive water swallowing, and not lateralized at all during tongue movement. In contrast, the preparation for both volitional water swallowing and tongue movement showed a bilateral activation of the primary sensorimotor cortex. No activation was seen prior to reflexive water swallowing. Activation of the left insula and frontal operculum was observed only during both the preparation and the execution of volitional water swallowing. These new findings suggest a left hemispheric dominance for the cortical control of swallowing in humans.

Adult↗

Air swallowing in Rett syndrome.

The possible causes of excessive swallowing of air leading to bloating, which is common in Rett syndrome (RS), were investigated during feeding and at rest. Seven individuals with RS aged between 4 and 33 years (three with air bloat) underwent feeding videoflouroscopy and concurrent respiration monitoring. The results were compared with a randomly selected group of 11 individuals, aged between 2 and 16 years, with quadriplegic cerebral palsy and feeding problems, some of whom had mild air bloat. All individuals from both groups had isolated pharyngeal swallows and several mouth breathed; this may account for some air swallowing but not the severe air bloat characteristic of RS. Thirty-three individuals with RS aged between 3 and 44 years were monitored for nasal respiration, chest movements, swallowing, and vocal cord position at rest (between feeding). Twenty had air bloat, 17 of whom swallowed air during breath-holding in the same way, and three gulped air during hyperventilation. Of the 13 without air bloat, eight did not have recurrent breath-holding and five did, but without concurrent air swallowing. Several methods for reducing air swallowing in apnoea were investigated. The most successful was a dummy with an air leak, but this was poorly tolerated and could only be used for short periods of time. Apnoeas and air bloat are often worse when individuals are distressed and may in some individuals be reduced by anxiolytic medications.

Adolescent↗

The relationship between the 'superior constrictor swallow', clicking of the ears and ear disease.

A normal modified type of swallow is described, the function of which is to open the pharyngotympanic tube. It is associated with clicking of the ears. The tensor veli palatini, the levator palatini and the superior constrictor muscles appear to be the muscles involved, as it can occur without swallowing or movement of the tongue, or speaking. This modified swallow has been called the 'superior constrictor swallow', and it is demonstrated by productions of typical frames from a cine film. Sniffing, yawning and normal swallowing can occur with or without opening of the pharyngotympanic tubes, but this normal modified swallow (SCS) must be initiated to produce opening of the tubes. The change in middle-ear pressures with clicking is well shown with tympanometry. Modified swallow, largely involving the inferior constrictor muscle, may also occur.

Deglutition↗

Dynamics of swallowing-induced cardiac chronotropic responses in healthy subjects.

Simultaneous recording of ECG and swallowing movements in healthy humans (n=23, age 20-57 years) showed that each swallow is accompanied by transient tachycardia with initial abrupt and pronounced heart rate increase. These rapid changes in heart rate (evaluation by maximum increment of heart rate over two successive heartbeats, Delta HR(2bt)) are typical of vagal chronotropic responses. The amplitude of tachycardia induced by a single swallow was significantly higher in the supine position (13.1 +/- 5.6 bpm) compared to the standing position (8.5 +/- 3.8 bpm; p<0.0001). Chronotropic responses to a series of three or more successive swallows consisted of two phases, the initial abrupt acceleration and subsequent slower growth of heart rate. In the standing position, the portion of the first rapid phase significantly decreased, while the portion of the slower phase increased compared to the supine position. The amplitude of tachycardia induced by a single swallow and parameter Delta HR(2bt) can serve as indices of the strength of parasympathetic modulation of the heart. By contrast, further slow increase in the heart rate determined by summation of responses to a series of successive swallows can result from not only inhibition of the parasympathetic influences, but also enhancement of sympathetic activity during swallowing.

Adult↗

Cortical control mechanisms in volitional swallowing: the Bereitschaftspotential.

OBJECTIVE: This research sought to identify a well-defined pre-motor potential, the Bereitschaftspotential (BP), as a manifestation of cortical contribution to the pre-motor planning of volitional swallowing. METHODS: EEG data were collected from 20 research participants during volitional execution of swallowing and finger movement tasks. A5 second pre-movement epoch for each task was triggered on EMG identification of movement onset. A grand average for each task representing approximately 2400 trials across all research participants was derived to compare and contrast morphological features of the derived waveform. RESULTS: Volitional pharyngeal swallowing and finger movement generated similar waveform characteristics of duration and slope; however, statistically significant differences were identified in polarity and in amplitude at four points both early and late in the epoch. Additionally, swallowing produced a pre-motor waveform with a rapid declination of EEG activity in the final 500 msec prior to movement onset. CONCLUSIONS: This study demonstrates activation of the supplementary motor cortex preceding the onset of volitional swallowing. However, unlike purely voluntary movements, the volitional pharyngeal swallowing task, as assessed with this methodology, does not appear to recruit the primary motor cortex. Thus engagement of the swallowing response appears to rely on indirect parallel pathways between extrapyramidal cortical motor planning regions and lower motor neurons.

Adolescent↗

Mechanism of sequential swallowing during straw drinking in healthy young and older adults.

Recent research has revealed differences between isolated and sequential swallowing in healthy young adults; however, the influence of normal aging on sequential swallowing has not been studied. Thus, the purpose of this investigation was to examine the effects of normal aging on deglutition during sequential straw drinking. Videofluoroscopic samples of two 10-s straw drinking trials were obtained for 20 healthy young men (age 29 +/- 3 years) and 18 healthy older men (age 69 +/- 7 years). Hyolaryngeal complex (HLC) movement patterns, leading edge of the bolus location at swallow onset, and occurrences of airway invasion were determined. Two HLC patterns were identified: (a). HLC lowering with the epiglottis returned to upright between swallows and (b). partially maintained HLC elevation with the epiglottis inverted between swallows. The bolus was frequently in the hypopharynx at swallow onset. Strong associations were identified between age and HLC pattern, age and leading edge of the bolus location, and HLC pattern and leading edge location. Laryngeal penetration was uncommon overall; however, it occurred more frequently in the older adults than in the young adults. A significant relation was identified between age and the average Penetration-Aspiration Scale score. Laryngeal penetration was associated with both HLC movement patterns and hypopharyngeal bolus location, particularly in older adults. Results indicate that subtle age-related differences are evident in healthy young and older adults with sequential straw drinking. These data suggest that specific inherent swallowing patterns may increase the risk of laryngeal penetration with normal aging.

Adult↗

Mechanisms of recovery of swallow after supraglottic laryngectomy.

This study examines oropharyngeal swallow disorders and measures of pharyngeal and laryngeal movement during deglutition from videofluorographic studies of oropharyngeal swallow in 9 patients who had undergone supraglottic laryngectomy and 9 age-matched normal subjects. The swallows of surgical patients were examined at 2 weeks and 3 months postoperatively. Two critical factors in recovery of swallowing were identified: (a) airway closure at the laryngeal entrance, that is, the space between the arytenoid cartilage and the base of the tongue, and (b) the movement of the tongue base to make complete contact with the posterior pharyngeal wall. When patients achieved these two functions, they returned to normal swallowing. The duration of tongue base contact to the posterior pharyngeal wall and extent of anterior movement of the arytenoid increased significantly from 2 weeks to 3 months in the surgical patients. At 2 weeks postsurgery, patients who had undergone supraglottic laryngectomy exhibited significantly shorter airway closure and tongue base to pharyngeal wall contact, reduced laryngeal elevation, increased width of cricopharyngeal (CP) opening, and later onset of airway closure and tongue base movement than normal subjects. These significant differences remained at 3 months postoperatively, although swallow measures were moving toward normal in the patients who had undergone supraglottic laryngectomy. Comparison of patients not eating at 2 weeks with patients at the time of first eating revealed significantly longer duration of tongue base contact to the pharyngeal wall, longer duration of airway closure, and greater movement of the arytenoid in patients who were eating. Results indicate that the focus of swallowing therapy after supraglottic laryngectomy should be on improvement of posterior movement of the tongue base and anterior tilting of the arytenoid to close the airway entrance and improve bolus propulsion (in the case of the tongue base).

Barium Sulfate↗

Effects of a sour bolus on oropharyngeal swallowing measures in patients with neurogenic dysphagia.

This study examines the effects of a sour bolus (50% lemon juice, 50% barium liquid) on pharyngeal swallow measures in two groups of patients with neurogenic dysphagia. Group 1 consisted of 19 patients who had suffered at least one stroke. Group 2 consisted of 8 patients with dysphagia related to other neurogenic etiologies. All patients were selected because they exhibited delays in the onset of the oral swallow and delays in triggering the pharyngeal swallow on boluses of 1 ml and 3 ml liquid barium during videofluoroscopy. Results showed significant improvement in oral onset of the swallow in both groups of patients and a significant reduction in pharyngeal swallow delay in Group 1 patients and in frequency of aspiration in Group 2 patients with the sour as compared to the non-sour boluses. Other selected swallow measures in both subject groups also improved with the sour bolus. Volume effects were present but not as consistently as in prior studies. Implications for swallow therapy are discussed.

Adult↗

Swallowing and tongue function following treatment for oral and oropharyngeal cancer.

This study examined tongue function and its relation to swallowing in 13 subjects with oral or oropharyngeal cancer treated with primary radiotherapy +/- chemotherapy and 13 age- and sex-matched control subjects. Measures of swallowing and tongue function were obtained using videofluoroscopy, pretreatment and 2 months posttreatment. Maximum isometric strength and endurance at 50% of maximum strength were obtained with the Iowa Oral Performance Instrument (IOPI). Control subjects were tested once. All subjects with head and neck cancer were evaluated pretreatment and 2 months posttreatment. No significant differences were found for the tongue function measures pre- and 2 months posttreatment in the group with head and neck cancer. Significantly higher tongue strength was observed in the control than in the group with head and neck cancer both pre- and posttreatment. No significant differences were found for the 2 groups for tongue endurance measures. Significant correlations of tongue strength and endurance and some swallow measures were found pre- and posttreatment for the group with head and neck cancer and for the control group. These correlations included oral and pharyngeal temporal swallow measures and oropharyngeal swallow efficiency. Pretreatment differences between the 2 groups in tongue strength were likely related to tumor bulk, pain, and soreness. Two-month posttreatment differences were likely related to radiation +/- chemotherapy changes to the oral and pharyngeal mucosa. This study provides support for the hypothesis that tongue strength plays a role in oropharyngeal swallowing, particularly related to the oral phase of the swallow.

Adult↗

Swallowing rehabilitation after oro-pharyngeal resection for squamous cell carcinoma.

The resection of even relatively small tumours that involve the base of tongue can lead to problems with swallowing. Free tissue transfer has improved the functional results and reduced the complications of head and neck surgery. The outcome after ablative operations depends on the site and extent of the resection, and in cases where the tongue base is involved, swallowing can be severely impaired. Aspiration in a patient with swallowing difficulties is of particular concern, however, there is a range of techniques that can be introduced during videofluoroscopy to reduce or eliminate aspiration. It is during the rehabilitation phase that procedures and techniques to improve swallowing and prevent aspiration should be incorporated. The efficacy of adaptive manoeuvres needs further evaluation, and in this study we aim to assess the effectiveness of compensatory procedures and therapy techniques (chin tuck and supraglottic swallow) in eliminating aspiration. We report on a study of the swallow function of 13 patients following surgical resection of the oropharynx including the base of tongue. Postoperative assessment by videofluoroscopy was carried out at 2 weeks, 1 month, 3 months, and 6 months according to a standard protocol. Subjects were analysed in two groups depending on the degree of resection of the tongue base resection (less than 1/4,1/4 or more).Patients' swallowing disorders were related to the extent of the resection and the consistency of the bolus. Those with involvement of a quarter of the tongue base or more generally had greater impairment, and radiotherapy tended to exacerbate these problems. Compensatory procedures and therapy techniques were effective in 50% of patients who aspirated, and tended to be more effective between the one month and 6 month follow-up in patients with smaller resections.

Aged↗

[Cinematographic functional diagnosis of swallowing after plastic reconstruction of large tumor defects of the mouth cavity and pharynx].

BACKGROUND: Reestablishing good swallowing function after resection and reconstruction of head and neck tumors is very important for our patients' well-being. Today many different surgical concepts for reconstruction after tumor surgery are in common use. It is necessary to establish a good diagnostic procedure for postoperative assessment of the swallowing function. High-speed cineradiography at a minimum of 50 frames per second is well established for evaluating swallowing problems in head and neck patients. METHODS: Thirty-six patients divided into three groups were examined using high speed cineradiography after surgical treatment of pharyngeal and oral cavity cancer. Group 1 (n = 12) included patients with a subtotal or total tongue resection and reconstruction with infrahyoid myofascial flap and jejunal flap; Group II (n = 8), patients with total resection of the oropharynx soft palate and velum and reconstruction with a free radial forearm flap; Group III (n = 15), patients with total laryngopharyngektomy and reconstruction with jejunal flap and siphon and with or without repair of the digastric muscle. RESULTS: Group I: All patients with tongue reconstruction were able to swallow normally from the oral cavity into the pharynx. All patients had normal bolus propulsion because of a good tongue volume and tongue motility. There was only one case of aspiration after total glossectomy with the larynx left in place. All patients could swallow with the head and neck in a normal position. Group II: All patients with reconstruction of the soft palate and velum were able to initiate proper bolus propulsion without nasal regurgitation or rhinolalia aperta. Only one patients suffered from chronic aspiration after hemiresection of the oropharynx and hypopharynx. Group III: All patients with pharynx reconstruction had no problems with bolus transfer through the reconstructed pharynx. Aspiration into the reconstructed pharynx was a major problem for those patients without repair of the digastric muscle (5/8 = 63%). Better results were observed in the patients who underwent repair of the digastric muscle. There was only one case (13%) of aspiration. CONCLUSIONS: By using high-speed cineradiography it is possible to make a detailed description of the swallowing function after extensive surgical treatment of pharyngeal and oral cavity cancer. We think that high-speed cineradiography is a very sensitive diagnostic procedure capable of detecting all functional aspects of swallowing. High-speed cineradiography should be one of the standard diagnostic studies performed surgery of the oral cavity and pharynx.

Adult↗

Swallowing dysfunction related to snoring: a videoradiographic study.

Biopsy studies of the soft palatal and oropharyngeal tissues in habitual snorers and patients suffering from obstructive sleep apnoea have shown signs of neurogenic lesions. These lesions might affect the pharyngeal swallowing function, which is dependent on adequate sensitivity. The objective of the present study was to test the hypothesis that snoring is associated with aberrant pharyngeal swallowing function. Forty-one consecutive patients without dysphagia, seeking medical attention because of heavy snoring and various degrees of daytime sleepiness, were prospectively selected. Fifteen non-snoring volunteers without dysphagia served as controls. Patients and volunteers were videoradiographically examined in lateral and posteroanterior views during the oral and pharyngeal phases of swallowing. The hypothesis was verified. Snoring patients demonstrated deviant pharyngeal swallowing function seven times more frequently than did the non-snoring volunteers. Deviant pharyngeal swallowing function was observed in 22 (54%) of the snorers compared with 1 (7%) of the non-snoring volunteers. Impaired bolus control with premature leakage of bolus into the pharynx and a delayed evocation of the swallowing reflex was the most common finding, followed by bolus residual in the pharynx and laryngeal penetration. The conclusion was that snoring is associated with subclinical pharyngeal swallowing dysfunction.

Adult↗