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Dentofacial morphology and tongue function during swallowing.

To understand the role of the tongue in the development of occlusion, we examined the relationship between tongue movements during swallowing and dentofacial morphology with ultrasonography, cephalometric radiography, and dental casts. Duration, magnitude, and speed of tongue movements were measured in 112 healthy adult volunteers and compared with their dentofacial morphology with a simple correlation analysis. The results showed that the movements of tongue during swallowing are related to dentofacial morphology, especially in the motion magnitude of the early final phase (phase IIIa), but that few correlations are found when analyzing the duration and the speed of swallowing. The results also showed that the intermaxillary vertical dimension is significantly and positively correlated with the motion magnitude of the tongue movements. Furthermore, we found that arch length increased with prolonged duration of swallowing. This study showed that the computer-aided B+M mode of ultrasonography combined with the cushion-scanning technique is a valuable tool for investigating the relationship between tongue movements during swallowing and dentofacial morphology.

Adult↗

The maturation and coordination of sucking, swallowing, and respiration in preterm infants.

OBJECTIVES: Our objectives were to establish normative maturational data for feeding behavior of preterm infants from 32 to 36 weeks of postconception and to evaluate how the relation between swallowing and respiration changes with maturation. STUDY DESIGN: Twenty-four infants (28 to 31 weeks of gestation at birth) without complications or defects were studied weekly between 32 and 36 weeks after conception. During bottle feeding with milk flowing only when infants were sucking, sucking efficiency, pressure, frequency, and duration were measured and the respiratory phase in which swallowing occurs was also analyzed. Statistical analysis was performed by repeated-measures analysis of variance with post hoc analysis. RESULTS: The sucking efficiency significantly increased between 34 and 36 weeks after conception and exceeded 7 mL/min at 35 weeks. There were significant increases in sucking pressure and frequency as well as in duration between 33 and 36 weeks. Although swallowing occurred mostly during pauses in respiration at 32 and 33 weeks, after 35 weeks swallowing usually occurred at the end of inspiration. CONCLUSIONS: Feeding behavior in premature infants matured significantly between 33 and 36 weeks after conception, and swallowing infrequently interrupted respiration during feeding after 35 weeks after conception.

Bottle Feeding↗

Swallowing, urine flow, and amniotic fluid volume responses to prolonged hypoxia in the ovine fetus.

OBJECTIVE: Four days of hypoxia produce an extensive fetal polyuria with little change in amniotic fluid volume in the ovine fetus. We hypothesized that fetal swallowing and intramembranous absorption would increase with prolonged hypoxia to offset the polyuria. STUDY DESIGN: After a 24-hour normoxic period, nine ovine fetuses were subjected to 4 days of hypoxia induced by lowering maternal inspired oxygen content. Seven fetuses were monitored for 5 days as normoxic time controls. Measurements included fetal swallowed volume by a computerized system with Transonic flow probes, urine production by gravity drainage, and amniotic fluid volume by an indicator dilution technique. Data were averaged over 12-hour intervals, and a three-factor repeated-measures analysis of variance was used for statistical testing. RESULTS: During days 2 to 5, arterial oxygen tension was 20.7+/-1.1 (SE) mm Hg in the normoxic and 13.9+/-0.8 mm Hg in the hypoxic fetuses (P<.0001). Urine flow was unchanged over time in the normoxic fetuses and increased gradually from 693+/-88 to 2189+/-679 mL per day during hypoxia (P<.0001). The prehypoxia swallowed volume was similar in the two groups, averaging 447+/-95 mL per day. Although transiently decreased in eight of nine hypoxic fetuses, the 12-hour average swallowed volumes were not significantly different at any time in the hypoxic versus normoxic fetuses (P=.62). Amniotic fluid volume increased in the hypoxic fetuses relative to that in the normoxic fetuses (520+/-338 mL vs -226+/-136 mL, P<.01), although the increase was small (P<.01) relative to the excess volume of urine (4269+/-1306 mL). Estimated intramembranous absorption increased from 209+/-95 mL per day during normoxia to average 1032+/-396 mL per day during hypoxia. CONCLUSIONS: The current study supports the concept that prolonged hypoxia produces a progressive fetal polyuria with relatively small changes in amniotic fluid volume. Concomitantly, hypoxia does not induce prolonged changes in fetal swallowing; rather, intramembranous absorption greatly increases, thereby preventing severe polyhydramnios.

Absorption↗

Health of tree swallows (Tachycineta bicolor) nesting in pesticide-sprayed apple orchards in Ontario, Canada. I. Immunological parameters.

The degree of pesticide exposure and its effects on the immune system and its development were determined in 16-d-old tree swallow (Tachycineta bicolor) chicks from 4 sprayed apple orchards and three nonsprayed sites in southern Ontario, Canada, during 1994-1995. Persistent contaminant residues were measured in tree swallow eggs and in each chick hepatic ethoxyresorufin O-deethylase (EROD) activity; body, immune organ, and liver masses; lymphocyte blastogenesis response; respiratory burst and phagocytic responses; hemarological evaluation; and histological development of thymus, bursa of fabricius, and spleen were determined. Chemicals sprayed on apple orchards were mainly ethylene bisdithiocarbamate and myclobutanil fungicides and organophosphorus, carbamate, and synthetic pyrethroid insecticides. During the period between oviposition of the first egg in each nest to d 16 after hatching, individual nests in orchards were exposed to between 4 and 11 individual chemical applications and up to 3 mixtures of pesticide sprays. Concentrations of pesticides, polychlorinated biphenyls (PCBs), and lead and arsenic residues in tree swallow eggs and liver were low and not variable among sites except p,p'-DDE, which was as high as 2.29 microg/g wet weight in eggs. EROD activity was not different among sites. Organochlorine and trace metal residues and EROD activity were not correlated with any immune parameter. In sprayed birds, we found a significantly increased blastogenic response to pokeweed mitogen (12.5 microg/ml). However, nests were initiated over a period of several weeks and we also found changes in other tree swallow immune parameters that were related to the date of chick collection. Hematological parameters, bursal and thymic masses, phagocytic response, and thymic development were all correlated with the day the chicks were 16 d of age. After accounting for the collection date of birds from each nest, we found cell proliferation in the cortex and delayed thymic involution correlated positively with increasing spray exposure. We also found that birds in sprayed orchards were slightly anemic compared to birds from nonsprayed sites, and there were smaller bursal masses and an increase in relative heterophil concentrations in the sprayed orchard birds. The local inflammation may have been caused by trematode parasite infections, although pesticide exposure also correlated positively with these parameters. This is the first study of the immunology and effects of current pesticide exposures in wild passerines; therefore it is difficult to predict the long-term consequences of the apparent stimulated immune systems in sprayed birds. However, some environmental contaminants that overtly stimulate the immune system in mammals have induced hypersensitivity and/or autoimmunity. Therefore we speculate that these effects are possible in tree swallows.

Animals↗

Effects of increasing depth of anaesthesia on phrenic nerve and hypoglossal nerve activity during the swallowing reflex in cats.

The effects of increasing depths of anaesthesia on phrenic nerve (PN) activity and hypoglossal nerve (HN) activity during the swallowing reflex elicited by stimulation of the superior laryngeal nerve (SLN) were investigated in 10 cats. Swallowing induced by SLN stimulation always coincided with a characteristic brief burst of PN activity and a large amplitude burst of HN activity. These characteristic responses of PN and HN activities were not influenced by either bilateral vagotomy or neuromuscular blockade, indicating that the characteristic responses of PN and HN activities can be used as indicators of the swallowing reflex in vagotomized and paralysed animals. The results obtained in such animals showed that increasing depth of anaesthesia depressed progressively the swallowing reflex. Detailed analysis of HN activity revealed also that SLN stimulation elicited three different responses of HN activity which had different sensitivities to anaesthesia. However, the characteristic response observed during the swallowing reflex was the most sensitive to increasing depth of anaesthesia.

Anesthesia, Inhalation↗

Comparison of speech and swallowing function in patients with tremor disorders and in normal geriatric patients: a cinefluorographic study.

In a study of vocal tract and esophageal function during speech and swallowing, unmedicated Parkinson patients were found to have specific disorders in oral and esophageal stages of deglutition and a predictable sequence of deterioration in speech. To determine whether these disorders are exclusive to parkinsonism or are typical of all patients with tremor or of geriatric patients in general, a cinefluoroscopic study was initiated to examine the physiology of speech and swallowing in these other patients. Subjects were 10 normal geriatric patients and 10 patients with essential tremor. Results of the studies for these two groups were compared with data from earlier studies on unmedicated Parkinson patients. Parkinson patients showed most severely disordered swallowing and speech function. Patients with essential tremor showed only slight slowing in esophageal transit during swallowing and vocal tremor during speech, but no progressive deterioration. Normal geriatric patients revealed no swallowing or speech disturbances.

Age Factors↗

The effect of swallowing or rinsing alcohol solution on the mouth alcohol effect and slope detection of the intoxilyzer 5000.

Nine female and 21 male alcohol-free subjects introduced 10 mL of diluted gin (20% v/v alcohol) into their mouths under two conditions. The subjects either rinsed the alcohol for 10 s and then expectorated or immediately swallowed. They then provided breath samples into an Intoxilyzer 5000 at 5 and 10 min postadministration for both conditions. The mean Intoxilyzer results plus or minus one standard deviation (n = 30) were 0.091+/-0.051; 0.036+/-0.027; 0.014+/-0.011, and 0.004+/-0.006 g/210 L for 5 min after rinsing, 5 min after swallowing, 10 min after rinsing, and 10 min after swallowing, respectively. The percentages of times that mouth alcohol was correctly detected by the Intoxilyzer 5000 were 90%, 66%, 62% and 30% for these conditions, respectively. Ten minutes after the introduction of alcohol into the mouth, 63% of the Intoxilyzer results were > 0.010 g/210L after rinsing compared with only 7% after swallowing. The mouth alcohol effect is greater for rinsing than for swallowing alcohol.

Alcoholic Intoxication↗

Assessment of swallowing and referral to speech and language therapists in acute stroke.

The best clinical assessment of swallowing following acute stroke, in order to decide whether to refer a patient to a speech and language therapist (SLT), is uncertain. Independently of the managing clinical team, we prospectively investigated 115 patients (51 male) with acute stroke, mean age 75 years (range 24-94) within 72 h of admission, using a questionnaire, structured examination and timed water swallowing test. Outcome variables included referral to and intervention by a speech and language therapist (SLT), dietary modification, respiratory complications and death. Of those patients in whom an SLT recommended intervention, 97% were detected by an abnormal quantitative water swallowing test; specificity was 69%. An SLT was very unlikely to recommend any intervention if the test was normal. Inability to perform a water test and/or abnormality of the test was associated with significantly increased relative risks of death, chest infection and dietary modification. A timed water swallowing test can be a useful test of swallowing and may be used to screen patients for referral to a speech and language therapist after acute stroke.

Acute Disease↗

Effects of partial paralysis on the swallowing reflex in conscious humans.

The ability to swallow may be affected by administration of a small dose of muscle relaxant. To test the hypothesis that a subparalyzing dose of a muscle relaxant can impair swallowing, effects of partial paralysis produced by pancuronium on the swallowing reflex were investigated in eight conscious subjects. The swallowing reflex was induced by a bolus injection or a continuous infusion of distilled water into the mesopharynx. The swallowing function was assessed by electromyogram of suprahyoid muscles (EMGSH), mesopharyngeal pressure (Pmeso), and hypopharyngeal pressure (Phypo). Peripheral muscle activity was simultaneously determined by train of four ratio (TOFR) of hypothenar muscles to electrical stimulation of ulnar nerve and by hand grip strength (HGS). Following control measurements, measurements during partial paralysis and after recovery from partial paralysis were performed after intravenous administration of pancuronium 0.02 mg/kg. Partial paralysis significantly depressed EMGSH (bolus injection 44.1 +/- 10.0%, continuous infusion 55.9 +/- 10.2% of control value, P less than 0.01). Pmeso also significantly decreased (bolus injection 64.9 +/- 6.7 to 47.8 +/- 5.8 mmHg, P less than 0.01; continuous infusion 63.4 +/- 7.7 to 52.5 +/- 5.8 mmHg, P less than 0.05). The TOFR of peripheral muscles decreased to 81.4 +/- 6.7% of control value (P less than 0.01), and HGS was reduced from 44.6 +/- 1.9 to 39.4 +/- 2.0 kg (P less than 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗

Cortical processing of esophageal sensation is related to the representation of swallowing.

The esophagus plays a major role in the act of swallowing. The aim of the present investigation was to apply whole-head magnetoencephalography in order to study the cortical processing of esophageal sensation in healthy humans in whom the cortical representation of swallowing had been established previously. The proximal esophagus was stimulated in nine participants by intermittent 5 ml water infusion. Submental EMG recording was used to identify trials, which were contaminated by subsequent swallowing. Esophageal stimulation led to changes in rhythmic activity of the brain that were localized in the left lateral primary sensorimotor cortex. The pattern of cortical activation showed the same hemispheric lateralization as that of volitional swallowing, however, being localized more lateral. The close anatomical vicinity of these two functions points to an important physiological link between the cortical processing of esophageal sensation and the cortical control of swallowing.

Adult↗

Laryngeal activity during swallow, phonation, and the Valsalva maneuver: an electromyographic analysis.

To better understand the mechanisms of airway protection during swallow, the authors of this study performed an electromyographic (EMG) analysis on the thyroarytenoid (TA) and interarytenoid (IA) muscles during a variety of tasks. The tasks included high, low, and comfortable pitch phonation, the Valsalva maneuver, saliva swallow, and 5- and 10-mL water swallows. Raw EMG signals were analyzed to obtain root mean square data, which correspond to a relative magnitude of muscle activation. The data show that both TA and IA muscles generate a similar level of relative activation, with the greatest electrical activity observed during swallow tasks followed by the Valsalva maneuver and phonation. The duration, onset, offset, and pattern of activity during the swallowing tasks also showed close synchronization between the two muscles. These data can be used in designing therapy for voice disorders and pharyngeal dysphagia.

Adult↗

Evaluation of swallowing safety with fiberoptic endoscope: comparison with videofluoroscopic technique.

Videofluoroscopy has long been viewed as the "gold standard" of swallowing examination for the comprehensive information it provides. However, it is not very efficient and accessible in some practical situations. In this study, we tried to use a modified technique of fiberoptic endoscopic examination of swallowing (FEES) in evaluating dysphagic patients. For each examination, a spoonful of pudding and dyed water were fed in sequence three times. The pharyngeal swallowing events were observed with fiberscope panoramically and videotaped. Twenty-eight chronic dysphagic patients underwent both videofluoroscopy and FEES in 2 weeks. Comparison of the results revealed that disagreements in premature oral leakage to the pharynx, pharyngeal stasis, laryngeal penetration, aspiration, effective cough reflex, and velopharyngeal incompetence were 39.3%, 10.7%, 14.3%, 14.3%, 39.3%, and 32.1%, respectively. FEES was found to be more sensitive in detecting these risky features of swallowing, except with respect to premature leakage. Possible causes of the discrepant results are discussed, and the limitation of videofluoroscopy in practical usage is discussed. FEES is conclusively a safer, more efficient, and sensitive method than videofluoroscopy in evaluating swallowing safety.

Adult↗

Prospective, randomized outcome study of endoscopy versus modified barium swallow in patients with dysphagia.

OBJECTIVE: Aspiration pneumonia is a significant cause of morbidity and mortality in both acute and long-term care settings While there are many reasons for patients to develop aspiration pneumonia, there exists a strong association between difficulty swallowing, or dysphagia, and the development of aspiration pneumonia The modified barium swallow test (MBS) and endoscopic evaluations of swallowing are considered to be the most comprehensive tests used to evaluate and manage patients with dysphagia in an effort to reduce the incidence of pneumonia. The purpose of this study was to provide an initial investigation of whether flexible endoscopic evaluation of swallowing with sensory testing (FEESST) or MBS is superior as the diagnostic test for evaluating and guiding the behavioral and dietary management of outpatients with dysphagia. FEESST combines the standard endoscopic evaluation of swallowing with a technique that determines laryngopharyngeal sensory discrimination thresholds by endoscopically delivering air pulse stimuli to the mucosa innervated by the superior laryngeal nerve. STUDY DESIGN: Randomized, prospective cohort outcome study in a hospital-based outpatient setting. METHODS: One hundred twenty-six outpatients with dysphagia were randomly assigned to either FEESST or MBS as the diagnostic test used to guide dietary and behavioral management (postural changes, small bites and sips, throat clearing). The outcome variables were pneumonia incidence and pneumonia-free interval. The patients were enrolled for 1 year and followed for 1 year. RESULTS: Seventy-eight MBS examinations were performed in 76 patients with 14 patients (18.41%) developing pneumonia; 61 FEESST examinations were performed in 50 patients with 6 patients (12.0%) developing pneumonia These differences were not statistically significant (chi2 = 0.93, P = .33). In the MBS group the median pneumonia-free interval was 47 days; in the FEESST group the median pneumonia-free interval was 39 days Based on Wilcoxon's signed-rank test, this difference was not statistically significant (z = 0.04, P = .96). CONCLUSION: Whether dysphagic outpatients have their dietary and behavioral management guided by the results of MBS or of FEESST, their outcomes with respect to pneumonia incidence and pneumonia-free interval are essentially the same.

Aged↗

Patterns of swallowing after supraglottic laryngectomy.

OBJECTIVE: To understand the anatomical and physiological basis for early recovery of swallowing function after supraglottic laryngectomy. STUDY DESIGN: Retrospective review. METHODS: The records of nine patients who had undergone supraglottic laryngectomy at the Stratton Veteran's Administration Hospital (Albany, NY) between 1994 and 1998 were reviewed. Videofluoroscopic swallowing studies were obtained on all patients as early as was safely possible and were reviewed by a multidisciplinary team of physicians, nurses, and speech pathologists with regard to anatomical and functional differences between successful and unsuccessful recovery of swallowing function. RESULTS: Five of nine patients resumed regular diets including thin liquids within 1 year of surgery; three patients remained dependent on enteral support. Swallowing success was most closely associated with short oropharyngeal transit time and an anterosuperior position of the larynx. Laryngeal positioning, tongue base mobility, and placement and coordination of the bolus for maximum swallowing efficiency can be improved with time and speech therapy. CONCLUSIONS: Factors that placed patients at significantly higher risk for aspiration included low laryngeal position and delayed oropharyngeal transit time. Tight lingual-laryngeal closure did not completely prevent aspiration. At the time of the initial surgical procedure it may be important to position the laryngeal remnant as far superior and anterior under the tongue base as possible.

Aged↗

Voice, speech, and swallowing outcomes in laser-treated laryngeal cancer.

OBJECTIVE: To describe preliminary voice, speech, and swallowing outcomes in patients treated by endoscopic laser excision of laryngeal cancer with or without adjuvant radiation therapy. STUDY DESIGN: Retrospective review. METHODS: Seventeen surgically treated patients (five T2 glottic and 12 clinically staged T2 supraglottic squamous cell carcinomas) participated in the study. Self-ratings of voice (Voice Handicap Index) and swallowing (M. D. Anderson Dysphagia Inventory) were completed, as well as independent auditory-perceptual ratings of voice and speech recordings. RESULTS: Although no significant difference between Voice Handicap Index, M. D. Anderson Dysphagia Inventory, and listener ratings was identified based on tumor site and irradiation status, there was a trend toward poorer outcomes in patients who received adjuvant radiation therapy. Whereas the patients having supraglottic cancer tended to report better voice but poorer swallowing outcomes, the glottic cancer group displayed the opposite pattern. Severity on Voice Handicap Index correlated significantly with listener severity ratings of speech, suggesting that the patients' perception of their voice handicap was similar to the listeners' judgments of their speech severity. CONCLUSIONS: The results suggest the following trends: 1) Adjuvant radiation therapy was associated with poorer outcomes for voice, speech, and swallowing and may be associated with more impairment than surgery alone and 2) poorer outcomes on voice and swallowing were observed for the glottic and supraglottic cancer groups, respectively. To bolster these preliminary findings, additional outcomes studies in patients treated with conservation therapy are needed.

Adult↗

Swallowing in patients with tracheotomies.

Swallowing and respiration are well-coordinated and interdependent functions. When one of these processes is impaired, the ramifications may be negative for the other. This article describes the mechanics of normal swallowing, the disorders of swallowing, the effects of tracheotomy and mechanical ventilation on swallowing, and the procedures used to assess and treat swallowing. Combining a basic understanding of these concepts with practical management can increase safe and efficient oral intake in patients with artificial airways.

Deglutition↗

Pretreatment, preoperative swallowing exercises may improve dysphagia quality of life.

OBJECTIVES: Dysphagia is commonly associated with head and neck cancer treatment. Traditional dysphagia management strategies focus on post-treatment therapy. This study evaluated the utility of pretreatment swallowing exercises in improving post-treatment swallowing quality of life (QOL). STUDY DESIGN: Prospective cohort study and cross-sectional QOL analysis. METHODS: This study includes 37 patients who underwent primary radiation or combined chemoradiation treatment for newly diagnosed hypopharyngeal, laryngeal, or oropharyngeal primary tumors at the University of Alabama at Birmingham. Of the 37, 25 patients underwent swallowing exercises beginning 2 weeks prior to the start of radiation. The M.D. Anderson Dysphagia Inventory (MDADI) was administered an average of 14 months after treatment to assess the success of the protocol. Analysis of QOL scores related to gender, primary site, stage, and race were obtained. RESULTS: Patients who performed pretreatment swallowing exercises (n = 25) showed improvement in the overall MDADI score (P = .0002) compared to the control population (n = 12) who underwent post-treatment therapy. Furthermore, a separate analysis of individual domains of the MDADI (global, emotional, functional, and physical) demonstrated improved quality of life. CONCLUSIONS: Implementation of pretreatment swallowing education and exercise may improve dysphagia-specific QOL in head and neck cancer patients undergoing radiation and/or chemoradiation therapy.

Cohort Studies↗

Chewing and swallowing after surgical treatment for oral cancer: functional evaluation in 196 selected cases.

One hundred ninety-six patients treated for oral cancer between 1992 and 1999 self-scored their speech, chewing, and swallowing using a new self-questionnaire (Functional Intraoral Glasgow Scale) developed at Canniesburn Hospital, Glasgow, to assess the functional efficiency of patients treated for intraoral cancer. The patients were distributed into 12 homogeneous groups, according to the site and size of surgical resection, carefully mapped out on standard diagrams of the oral cavity. The functional outcome for chewing and swallowing was correlated to the site and size of resected tissue, to the reconstruction modality, and to radiotherapy and compared with the speech quality. The general trend is very similar for both chewing and swallowing; the smaller the resections, the better the functional outcome. Chewing was mostly affected by resections of the floor of the mouth, whereas swallowing was mostly affected by demolition of the base of the tongue and of the retromolar trigone. Speech showed a better postoperative recovery than chewing and swallowing. The reconstruction modality did not influence the eventual outcome for either function. Radiotherapy in combination with surgery is a negative functional prognostic factor. A correlation between site and size of excision and functional outcome is presented using color multiple-view diagrams for immediate appreciation to identify positive and negative prognostic factors.

Adult↗