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PubMed1996

Echo-planar magnetic resonance imaging of deglutitive vocal fold closure: normal and pathologic patterns of displacement.

Abnormalities of vocal fold closure during deglutition predispose to aspiration due to impairment of airway protection. Conventional assessment of deglutitive vocal fold motion with laryngoscopy does not permit visualization through a complete adduction-abduction cycle. We determined spatiotemporal patterns of deglutitive vocal fold adduction through echo-planar magnetic resonance imaging in 15 normal volunteers and 6 patients with vocal fold paralysis. In normal volunteers, deglutitive vocal fold adduction was synchronized with laryngeal elevation, with complete vocal fold closure at the apex. Patients with unilateral vocal fold paralysis demonstrated reduced elevation and medial movement of the involved vocal fold. At maximal laryngeal elevation the uninvolved vocal fold attained a position superior to the paralyzed fold, resulting in level differences and an interglottic gap. Patients with bilateral vocal fold paralysis demonstrated reduced elevation and medial movement of both vocal folds. These findings indicate that normal and abnormal patterns of vocal fold displacement can be distinguished noninvasively through the use of echo-planar imaging.

Adult↗

PubMed1972

Normal deglutitive responses of the human lower oesophageal sphincter.

The responses to deglutition of the lower oesophageal high pressure zone were studied in 13 healthy subjects. The recording assembly included three perfused pressure recording catheters, whose recording orifices were at the same axial level, and a more distally situated pH electrode. Relaxation and contraction progressed in a sequential fashion along the length of the high pressure zone. At the time of maximum relaxation, a small pressure gradient, which was greatest at a point approximately 1 cm distal to the pressure inversion point, was maintained between stomach and oesophagus. The frequency of post-deglutitive contractions in the high pressure zone, which were observed to occur distal to the pressure inversion point in all subjects, steadily increased as the recording assembly was withdrawn proximally. The amplitude of such contractions was greater in the high pressure zone than in the distal oesophagus. There was a significant correlation between maximum resting pressure and amplitude of contractions within the high pressure zone. The proper assessment of the function of the high pressure zone should include consideration of the spatiotemporal relationships of pressure events within the lower oesophagus and the high pressure zone, in addition to measurements of their absolute dimensions. The pH electrode measurements, performed after the intragastric instillation of at least 150 ml of 0.1 N HCl, showed transient falls in the pH of the distal high pressure zone after deglutition in all subjects. These pH responses decreased in frequency as the pH electrode was withdrawn proximally, and did not occur in the non-sphincteric oesophagus. It would appear therefore that although gastroesophageal competence is retained during swallowing, the mucosal lining of the greater part of the high pressure zone is briefly exposed to gastric contents for a few seconds after deglutition.

Adult↗

PubMed1996

Piecemeal deglutition and dysphagia limit in normal subjects and in patients with swallowing disorders.

OBJECTIVE: Before the advanced evaluation of deglutition and selection of a treatment method, objective screening methods are necessary for patients with dysphagia. In this study a new electroclinical test was established to evaluate patients with dysphagia. METHODS: This test is based on determining piecemeal deglutition; which is a physiological phenomenon occurring when a bolus of a large volume is divided into two or more parts which are swallowed successively. The combined electrophysiological and mechanical method used to record laryngeal movements detected by a piezoelectric transducer, and activities of the related submental integrated EMG (SM-EMG)-and sometimes the cricopharyngeal muscle of the upper oesophageal sphincter (CP-EMG)-were performed during swallowing. Thirty normal subjects and 66 patients with overt dysphagia of neurogenic origin were investigated after detailed clinical evaluation. Twenty patients with a potential risk of dysphagia, but who were normal clinically at the time of investigation, were also evaluated to determine the specificity of the test. All subjects were instructed to swallow doses of water, gradually increasing in quantity from 1 ml to 20 ml, and any recurrence of the signals related to swallowing within the eight seconds was accepted as a sign of dysphagia limit. RESULTS: In normal subjects as well as in the patients without dysphagia, piecemeal deglutition was never seen with less than 20 ml water. This volume was therefore accepted as the lower limit of piecemeal deglutition. In patients with dysphagia, dysphagia limits were significantly lower than those of normal subjects. CONCLUSION: The method is a highly specific and sensitive test for the objective evaluation of oropharyngeal dysphagia even in patients with suspected dysphagia of neurogenic origin. It can also be safely and simply applied in any EMG laboratory.

Adult↗

PubMed2003

Deglutitive inhibition affects both esophageal peristaltic amplitude and shortening.

Deglutitive inhibition attenuates ongoing esophageal contractions if swallows are separated by short time intervals. This study aimed to determine whether esophageal shortening, mediated by longitudinal muscle, was similarly affected. Eight healthy subjects with two distal esophageal segments demarcated by mucosal clips and manometric recording sites positioned within those segments underwent concurrent manometry and fluoroscopy. Peristaltic amplitude and change in distal segment lengths were quantified during single swallows, paired swallows separated by progressively prolonged intervals, and a series of rapid repetitive swallows. During grouped swallows, deglutitive inhibition with complete attenuation of both the manometric contraction and segment shortening was evident with short-interval swallows and rapid-sequence swallows. No inhibition of either was evident with long-interval pairs. With intermediate interswallow intervals, the occurrence and degree of deglutitive inhibition between peristaltic amplitude and segment shortening were closely correlated. Deglutitive inhibition affects both the longitudinal and circular muscle layers of the esophageal wall, and the occurrence of inhibition evident in one layer is strongly correlated with the other.

Adult↗

PubMed1999

[Role of deglutitive inhibition in the pathophysiology of esophageal primary motor disorders].

The esophageal primary motor disorders like achalasia, diffuse esophageal spasm or the nutcracker can involve the upper esophageal sphincter, the esophageal body, the lower esophageal sphincter or a combination of them. This article will focus on the esophageal body and abnormal peristalsis. A normal esophageal peristaltic contraction occurs after a latency period following a swallow and requires a minimum amplitude to be propulsive. Abnormal latencies may generate simultaneous contractions whereas low amplitude contractions may be inefficient i.e. GERD and high amplitude contractions my provoke chest pain or dysfagia i.e. diffuse spasm. The latency period between deglutition and contraction is due to a muscle inhibition immediately after the swallow. This inhibition is due to release of NO by an inhibitory neurone located in the myenteric plexus. At the end of the inhibition, the contraction occurs due to release of acetyl choline by an excitatory cholinergic neurone. The exact interplay between these two neurones will determine the < > or propagation velocity and the amplitude of esophageal contractions. Patients with achalasia have a predominant loss of inhibitory neurones (VIP and NOS) with a relative preservation of excitatory cholinergic neurones. The histophatologic and immunohistochemical status in patients with esophageal primary motor disorders other than achalasia is poorly characterised Examples of deglutitive inhibition in the esophagus can be observed during the relaxation of the lower esophageal sphincter or when a subject swallows very frequently. In order to quantify deglutitive inhibition we developed a method that induces an artificial high pressure zone in the mid esophageal body. During the latency period after a swallow, the high pressure zone relaxes (is inhibited). With this method, we could measure the magnitude and duration of the inhibitory phenomenon. There is a very good correlation between the degree of deglutitive inhibition and propagation velocity of esophageal contractions. The less inhibition, the faster the propagation velocity of contractions. Simultaneous contractions are the consequence of absent inhibition. Patients with esophageal primary motor disorders may have very fast propagating contractions and a small percentage of simultaneous contractions or up to 100% of simultaneous contractions. The correlation between the degree of inhibition and propagation velocity of contractions suggests that the different primary motor disorders are the expression of a progressive failure in esophageal inhibition.

Deglutition↗

PubMed2000

Pharyngeal dysphagia in postesophagectomy patients: correlation with deglutitive biomechanics.

BACKGROUND: Because of the transient nature of pharyngeal phase dysphagia, posttranshiatal esophagectomy patients provide a model for studying the correlation of dysphagic symptoms and aspiration with deglutitive biomechanics. METHODS: We studied 8 transhiatal esophagectomy patients (age range, 51 to 78 years) and 8 normal age-matched controls in upright position using lateral and anteroposterior (AP) projection videofluoroscopy during three 5 mL barium swallows. RESULTS: The maximum upper esophageal sphincter (UES) AP diameter and maximum anterior excursion of the hyoid bone in patients with transhiatal esophagectomy who experienced aspiration (6.2+/-0.6 and 9.0+/-2.0 mm, respectively) were significantly smaller than those of age-matched normal controls (9.4+/-0.7 and 17.0+/-1.0 mm, respectively). Resolution of aspiration was associated with a significant increase in AP diameter of the UES as well as anterior and superior excursion of the hyoid bone (p<0.05). CONCLUSIONS: Dysphagic symptoms and aspiration in posttranshiatal esophagectomy patients are associated with significant abnormalities of deglutitive biomechanics. Improvement in deglutitive biomechanics is associated with resolution of dysphagic symptoms as well as postdeglutitive aspiration in these patients.

Aged↗

PubMed1990

Deglutition after near-fatal choking episode: radiologic evaluation.

Acute airway obstruction during oral intake is a relatively common event that may be fetal if not relieved immediately. Deglutition was studied in 75 individuals who had experienced a near-fatal choking episode (NFCE) or sudden inability to breathe during food intake that was promptly relieved by means of a Heimlich maneuver, suctioning, or intubation. Videofluoroscopy supplemented by static imaging revealed abnormal stages of deglutition in 58 individuals: oral, 32; pharyngeal, 19; pharyngoesophageal segment (PES), 28; and esophageal, 23. Forty individuals aspirated a liquid bolus; this was more often due to oral dysfunction (bolus leakage, n = 17; delayed initiation, n = 18) than pharyngeal abnormality (defective closure, n = 13; incomplete transport, n = 9). Oral-stage dysfunction was common in those with neurologic disease, a history of dysphagia, and structural or motor abnormalities of the PES or esophagus. Fourteen patients were able to vocalize during the NFCE, and each demonstrated an abnormality of the PES or esophagus that could obstruct a solid bolus, suggesting that symptoms were not due to airway obstruction. A variety of unsuspected deglutition abnormalities were documented, indicating the usefulness of radiographic evaluation after NFCE.

Adult↗

PubMedDate not supplied

Deglutition following supraglottic horizontal laryngectomy.

In order to determine factors that may contribute to deglutition problems following supraglottic horizontal laryngectomy or its modified techniques, clinical records of 38 patients were studied. Contribution of the following factors was investigated: age; sex; tumor classification; radical neck dissection; extent of and symmetry in removal of the aryepiglottic folds, arytenoid cartilages, and false folds; removal of the base of the tongue, hyoid bone, and a part of the vocal folds; extent of removal of the epiglottis and thyroid cartilage; cricopharyngeal myotomy; and some complications and concomitant diseases. The results suggest that removal of the arytenoid cartilage and asymmetrical removal of the false folds contribute to deglutition problems. We conclude that the standard supraglottic horizontal laryngectomy associated with surgical approximation of the larynx to the base of the tongue and cricopharyngeal myotomy does not usually cause serious deglutition problems. When the arytenoid cartilage is removed, reconstruction of the structure is required for the prevention of severe aspiration.

Aged↗

PubMed1997

Laryngeal deglutition movement in Parkinson's disease.

Laryngeal muscle function is defective in Parkinson's disease (PD) patients; the intrinsic group (vocal cords) is defective during phonation and the extrinsic group (laryngeal strap muscles) is slow during deglutition. There are no studies of vocal cord motility during deglutition in PD. We investigated laryngeal motility during deglutition in 71 patients with PD in a videofluoroscopic swallowing study. Patients were subdivided into two groups by the Hoehn and Yahr disability scale, stages II and III (n = 38) and stages IV and V (n = 33). At least one abnormality of laryngeal movement was present in 68 of 71 patients (95.8%); most patients had multiple abnormalities. There was statistically significant slowing of vertical laryngeal excursion; true vocal cord closure; or delayed, incomplete, or absent opening of the true vocal cords. Patients with more advanced disease manifested more deficits of laryngeal movement. Laryngeal dysmotility in PD may be related to defective descending basal ganglionic control of medullary deglutory and phonatory motor functions.

Aged↗

PubMedDate not supplied

Demonstration of the deglutitive wave of inhibition by extrinsic esophageal vascular compression.

In the human esophagus a wave of inhibition precedes the primary peristaltic contraction. To study this wave of deglutitive inhibition an artificial high-pressure zone has to be created in the esophageal body. The inflation of an intraesophageal balloon is the way to demonstrate the inhibition. In this paper we show another possibility of manometric recording of esophageal deglutitive inhibition. Esophageal extrinsic vascular compression may cause a zone of high-pressure in the esophageal body which can be seen in all segments of the esophagus. With deglutition there is a relaxation in this zone that precedes the primary peristaltic contraction.

Deglutition↗

PubMed1996

Deglutition after supracricoid laryngectomy: compensatory mechanisms and sequelae.

This study is based on the videofluorographic exploration of deglutition in 14 patients who were treated by supracricoid laryngectomy. The choice of this population rests on two criteria: a 1-year postoperative delay, and absence of residual deglutition disorders elicited by patient history. Asymptomatic aspiration was seen in 6 cases. In the cricohyoidoepiglottopexies (CHEP), aspiration occurred uniquely in patients who did not recuperate satisfactorily from epiglottic dynamics. The deglutition sequelae are less invalidating relative to the cricohyoidopexies (CHP), with a possible recuperation of the dynamic sequence of the pharyngeal swallow. On the other hand, in the CHP, a complete reorganization of the stepwise sequence of the different neuromuscular events is necessary.

Adult↗

PubMed1991

Neuropharmacologic correlates of deglutition: lessons from fictive swallowing.

Pharmacologic investigations into the transmission processes underlying fictive swallowing in the rat have disclosed the potential diversity of chemical signals used in central deglutitive pathways. Monoaminergic mechanisms appear to serve as links between subcortical structures and the medullary pattern generator of swallowing (PGS), and may play a critical role in maintaining internal facilitatory drive, required by the PGS for optimal responsivity to peripheral sensory input. Cholinergic bulbar interneurons form an integral component of the PGS subnetwork controlling esophageal peristalsis. Local GABA neurons exert a tonic inhibition of the buccopharyngeal stage, may regulate buccopharyngeal-esophageal coupling, and may contribute to peristaltic rhythmic generation at both the premotoneuronal and motoneuronal level. Receptor subtypes for excitatory amino acids (glutamate, aspartate) are differentially associated with deglutitive premotoneurons for both the buccopharyngeal and esophageal stage, as well as with ambiguus motoneurons. Preliminary evidence suggests the existence of excitatory peptidergic mechanisms involving thyrotropin-releasing hormone, vasopressin, oxytocin, and somatostatin, a probable candidate for excitatory transmitter in the solitarioambigual internuncial projection to motoneurons innervating esophageal striated musculature. Further validation of this experimental model may ultimately help to establish a framework for the clinical recognition, management, and exploitation of drug actions on central deglutitive neuroeffectors.

Animals↗

PubMed2006

Real-time balanced turbo field echo cine-magnetic resonance imaging evaluation of tongue movements during deglutition in subjects with anterior open bite.

INTRODUCTION: The aim of this study was to evaluate tongue movements in subjects with anterior dental open bites during deglutition by using real-time balanced turbo field echo cine-magnetic resonance imaging. METHODS: The study included 28 subjects. Two groups were formed according to the presence of anterior open bite (at least 2 mm). The open-bite group (OBG) consisted of 18 patients (14 girls, 4 boys) with a mean age of 14.5 +/- 2.7 years. The control group (CG) consisted of 10 patients (5 girls, 5 boys) with a mean age of 14.5 +/- 2.6 years. We evaluated deglutition during 3 stages: oral (stage 1), pharyngeal (stage 2), and esophageal stage (3). RESULTS: Results indicated that (1) in the OBG, from stage 2 to stage 3, the anterior portion of the tongue dorsum was elevated [corrected] whereas its midportion was lowered [corrected]; (2) in the CG, its posterior portion was lowered [corrected] from stage 2 to stage 3; (3) in the CG, the tongue tip was positioned more posteriorly [corrected] at stage 2 than at stage 1; (4) in the OBG, the tongue tip moved more anteriorly in all stages of deglutition than in the CG. CONCLUSIONS: Compensatory tongue functions occur in patients with anterior dental open bites. Dynamic MRI is a promising tool for evaluating swallowing patterns in these patients.

Adolescent↗

PubMed2000

Distal and deglutitive inhibition in the rat esophagus: role of inhibitory neurotransmission in the nucleus tractus solitarii.

BACKGROUND & AIMS: This study aimed to show the presence of deglutitive and distal inhibition in the rat esophagus and to differentiate the underlying neural mechanisms. METHODS: Under urethane anesthesia, the pharyngoesophageal tract was fitted with water-filled balloons for luminal distention and pressure recording. Neural activity was recorded in the nucleus tractus solitarii subnucleus centralis and rostral nucleus ambiguous. RESULTS: Distal esophageal distention evoked both rhythmic local contractions and burst discharges of ambiguous neurons that were simultaneously inhibited by a swallow or proximal esophageal distention. In subnucleus centralis interneurons, type I rhythmic burst discharges correlated with distal esophageal pressure waves and were suppressed by midthoracic esophageal distention; type II non-rhythmic excitatory responses, like type III inhibitory responses, were evoked by distention of either the thoracic or distal esophagus. When applied to the surface of the solitarius complex, bicuculline and, less effectively, strychnine suppressed distal inhibition, and 2-(OH)-saclofen and 3-aminopropylphosphonic acid were ineffective. None of the drugs tested, including systemic picrotoxin, affected deglutitive inhibition. CONCLUSIONS: Distal and deglutitive inhibition are present in the rat esophagus. The former, unlike the latter, depends on activation of ligand-gated chloride channels associated with subnucleus centralis premotor neurons. Inhibitory aminoacidergic local interneurons are a probable source of type II responses.

Animals↗

PubMed1999

Alteration of swallowing and oesophageal peristalsis by different initiators of deglutition.

It has long been believed that once initiated, the involuntary phase of deglutition follows a stereotypical pattern, that is modified only by ongoing sensory input from the transported bolus. To test the hypothesis that the mode of sensory activation of deglutition can modify the motor response irrespective of bolus characteristics, the mylohyoid, lower oesophageal sphincter (LES) and oesophageal body response to swallows induced in anaesthetized opossums by pharyngeal stroking or superior laryngeal nerve (SLN) stimulation (unilateral and bilateral) were compared. In comparison with unilateral SLN stimulation, swallows triggered by pharyngeal stroking resulted in a greater mylohyoid spike burst and LES relaxation. There was no significant difference in the oesophageal and LES motor response to pharyngeal stroking vs bilateral SLN stimulation, although the mylohyoid response was of greater magnitude with pharyngeal stroking. These studies demonstrate that the motor component of deglutition can be altered by different sensory initiators of swallowing, and provides a possible link between oropharyngeal and oesophageal motor disorders.

Animals↗

PubMed2006

Deglutitive upper esophageal sphincter relaxation: a study of 75 volunteer subjects using solid-state high-resolution manometry.

This study aimed to use a novel high-resolution manometry (HRM) system to establish normative values for deglutitive upper esophageal sphincter (UES) relaxation. Seventy-five asymptomatic controls were studied. A solid-state HRM assembly with 36 circumferential sensors spaced 1 cm apart was positioned to record from the hypopharynx to the stomach. Subjects performed ten 5-ml water swallows and one each of 1-, 10-, and 20-ml volume swallows. Pressure profiles across the UES were analyzed using customized computational algorithms that measured 1) the relaxation interval (RI), 2) the median intrabolus pressure (mIBP) during the RI, and 3) the deglutitive sphincter resistance (DSR) defined as mIBP/RI. The automated analysis succeeded in confirming bolus volume modulation of both the RI and the mIBP with the mean RI ranging from 0.32 to 0.50 s and mIBP ranging from 5.93 to 13.80 mmHg for 1- and 20-ml swallows, respectively. DSR was relatively independent of bolus volume. Peak pharyngeal contraction during the return to the resting state postswallow was almost 300 mmHg, again independent of bolus volume. We performed a detailed analysis of deglutitive UES relaxation with a novel HRM system and customized software. The enhanced spatial resolution of HRM allows for the accurate, automated assessment of UES relaxation and intrabolus pressure characteristics, in both cases confirming the volume-dependent effects and absolute values of these parameters previously demonstrated by detailed analysis of concurrent manometry/fluoroscopy data. Normative values were established to aid in future clinical and investigative studies.

Adult↗

PubMed1997

Augmentation of deglutitive upper esophageal sphincter opening in the elderly by exercise.

Earlier studies have shown that the cross-sectional area of the deglutitive upper esophageal sphincter (UES) opening in healthy asymptomatic elderly individuals is reduced compared with healthy young volunteers. The aim of this study was to determine the effect of a head-raising exercise on swallow-induced UES opening and hypopharyngeal intrabolus pressure in the elderly. We studied a total of 31 asymptomatic healthy elderly subjects by videofluoroscopy and manometry before and after real (19 subjects) and sham (12 subjects) exercises. A significant increase was found in the magnitude of the anterior excursion of the larynx, the maximum anteroposterior diameter, and the cross-sectional area of the UES opening after the real exercise (P < 0.05). These changes were associated with a significant decrease in the hypopharyngeal intrabolus pressure studied in 12 (real-exercise) and 6 (sham-exercise) subjects (P < 0.05). A similar effect was not found in the sham-exercise group. In normal elderly subjects, deglutitive UES opening is amenable to augmentation by exercise aimed at strengthening the UES opening muscles. This augmentation is accompanied by a significant decrease in hypopharyngeal intrabolus pressure, indicating a decrease in pharyngeal outflow resistance. This approach may be helpful in some patients with dysphagia due to disorders of deglutitive UES opening.

Aged↗

PubMed1994

Myotonic dystrophy revealed at videoradiography of deglutition and speech in adult patients with velopharyngeal insufficiency: presentation of four cases.

Patients with velopharyngeal insufficiency (VPI) without cleft palate, who appear for the first time in adulthood for treatment, will probably reveal a high percentage of undiagnosed myotonic dystrophy (MD). Videoradiography of deglutition and speech reveals the diagnosis. Eleven adult noncleft palate patients with VPI were studied with videoradiography of the pharynx and esophagus. Three exhibited functional radiographic manifestations of MD during deglutition and speech. The diagnosis confirmed by neurologic examination was not known or suspected prior to videoradiography. An additional patient with VPI and suspected MD displayed the same constellation of radiographic findings. Follow-up examinations confirmed the diagnosis of MD. Three of the four patients had had symptoms of VPI since childhood, but none had complaints of deglutition problems except for accidental nasal regurgitations.

Adult↗