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PubMed2004

A UK multi-centre pilot study of speech and swallowing outcomes following head and neck cancer.

Speech and swallowing are important components of health-related quality of life following head and neck cancer treatment. The aim of this study was to demonstrate the value of prospective multi-centre evaluation by Speech and Language Therapists and to compare health-related quality of life with speech and swallowing impairments. The University of Washington Head and Neck questionnaire version 4 (UW-QOL) and Therapy Outcome Measures (TOM) were rated before and 6 months after cancer treatment in 95 patients from 12 centres. There was deterioration in TOM scores at 6 months. Pretreatment UW-QOL swallowing was ranked equal first, with speech fourth. At 6 months speech was first and swallowing second. There were positive correlations between UW-QOL swallowing and TOM dysphagia and between UW-QOL speech and TOM laryngectomy, voice, phonology and dysarthria disorders. Both outcome measures are suitable for routine practice. Adaptation of TOM scales for use with head and neck cancer patients may improve sensitivity, validity and therapist compliance.

Aged↗
PubMed2005

Predictors of speech and swallowing function following primary surgery for oral and oropharyngeal cancer.

OBJECTIVES: To examine the association between the speech and swallowing aspect of health-related quality of life (HRQOL) and selected clinical parameters, and particularly to determine those that are predictive of good outcomes at 1 year after surgery. DESIGN: Prospective questionnaire and clinical study. SETTING: Regional Maxillofacial Unit. PARTICIPANTS: A total of 278 consecutive patients undergoing primary surgery for squamous cell carcinoma between 1995 and 1999. HRQOL was assessed using the University of Washington Quality of Life questionnaire (UW-QOL) pre-surgery, and post-surgery at 6 months, 1 year and later (median 39 months). MAIN OUTCOME MEASURES: Presentation of results was mainly descriptive, involving percentages and mean scores. Association of clinico-demographic factors with tumour site, and with UW-QOL swallowing and speech after 12 months, was tested with Fisher's exact or chi-squared tests as appropriate and modelled using logistic regression methods. RESULTS: Univariate relationships were seen between speech and swallowing scores and with tumour size, T staging, radiotherapy, type of surgery (primary closure or free tissue transfer), tumour site, extent of resection of posterior tongue and soft palate, and UW-QOL taste and saliva scores. Multiple logistic regression showed that no radiotherapy (P<0.001) and primary surgical closure/laser surgery (P=0.003) were the main predictors of good swallowing, and primary surgical closure/laser surgery was the main predictor of good speech (P<0.001) at 1 year. CONCLUSIONS: A number of clinical parameters can influence the speech and swallowing aspect of quality of life in these patients and when feasible, primary closure results in a better outcome than free flap reconstruction.

Aged↗
PubMed2004

The diagnostic value of barium swallow in globus syndrome.

Serious lesions presenting as globus syndrome appear to be extremely rare, but many clinicians routinely request barium swallow to exclude these. No data yet exist on the diagnostic yield of contrast radiography. We reviewed 2854 barium swallows from one department over 7 years. The false-positive rate (37%) depended on presenting symptoms and differed between radiology departments, suggesting substantial subjectivity. No serious radiological abnormalities occurred in the estimated 2011 patients with globus syndrome. The 95% confidence interval for the likelihood of finding a significant abnormality on routine barium swallow in a patient with globus symptoms is 0-0.00145. The 2854 barium swallows cost an estimated pounds sterling 685,000 and 0.22-0.48 deaths. As the risk of missing a serious lesion in a patient with globus is very unlikely to exceed one in 700, we support the opinion that barium swallow should be reserved for those with risk factors or atypical features.

Adult↗
PubMed1986

An ultrasonographic study of the organisation of sucking and swallowing by newborn infants.

Healthy infants' sucking, swallowing and breathing movements were observed ultrasonographically during breast- and bottle-feeding between two and five days after birth. Sucks were found to occur either on their own or in combination with a swallow. Swallows did not occur on their own. Younger babies' swallowing invariably was associated with a pause in breathing. Older babies generally showed better co-ordination of sucking, swallowing and breathing than younger ones, whether breast- or bottle-feeding.

Bottle Feeding↗
PubMed1992

Ventilation and swallowing interactions of normal children and children with cerebral palsy.

The respiratory inductance plethysmograph was used to analyse the ventilatory cycle during drinking, chewing and swallowing of normal and cerebral-palsied children aged between five and 12 years. 33 children were divided equally into three groups: normal, spastic CP and athetoid CP. A few of the children with spastic CP and over half of those with athetoid CP were unable to perform the 'big breath' task. In the remaining trials, the children with CP held their breath for a shorter time than normal children. Many children with CP required multiple swallows to consume 5mL of liquid. In the majority of trials, normal children swallowed liquids at or near the peak of inspiration, whereas the children with CP did not. Supplementary swallows and solid-bolus swallows occurred at any point in the ventilatory cycle in all groups. The children with CP had a greater need to inspire at the end of liquid tasks, especially during the 75mL task.

Cerebral Palsy↗
PubMed1980

Aging and mastication: changes in performance and in the swallowing threshold with natural dentition.

Few comprehensive studies of oral function have been conducted on adult populations. A "Longitudinal and Cross-Sectional Study of Oral Health in Healthy Veterans" was activated at the VA Outpatient Clinic in Boston in 1969; it included general oral and dental examinations as well as tests of masticatory performance and the swallowing threshold. The current investigation involved 863 subjects from the "Dental Study" who had either their natural teeth or a fixed replacement for missing teeth. Masticatory performance as measured by the subject's ability to reduce a test portion of cut carrot by a mandatory number of chewing stroked remained constant for persons with complete or partially compromised natural dentition. Swallowing threshold performance as measured by the particle size acceptable for swallowing remained constant for persons with complete dentition. Tooth loss significantly decreased the swallowing threshold performance and increased the particle size which the subject was willing to swallow. Older subjects increased the number of chewing strokes and the time required for this test, an observation not related to performance as measured by final particle size. Only with compromised dentition, however, did this increased effort result in increased performance.

Adult↗
PubMed2003

Vocal fold motion impairment in patients with multiple system atrophy: evaluation of its relationship with swallowing function.

BACKGROUND: Vocal fold motion impairment (VFMI), especially vocal fold abductor paralysis, is frequently seen in multiple system atrophy (MSA). Since the regulation system of laryngeal function is closely related to swallowing function, swallowing function is considered to be more involved in MSA patients with VFMI than in patients that do not have VFMI. However, the relationship between dysphagia and VFMI in MSA patients has not been systematically explored. OBJECTIVE: To elucidate the relationship between VFMI and dysphagia in MSA. METHODS: We evaluated swallowing function of 36 MSA patients with and without VFMI, by videofluoroscopy, and investigated the relationship between VFMI and pharyngeal swallowing function. RESULTS: VFMI was found in 17 patients (47.2%). Patients with VFMI had advanced severity of the disease. Although there was a tendency for bolus stasis at the pyriform sinus and the upper oesophageal sphincter opening to be more involved in patients with VFMI, statistical analysis did not show significant differences in swallowing function of MSA patients between with and without VFMI. In contrast, patients who underwent a tracheotomy ultimately required tube feeding or a laryngectomy. CONCLUSIONS: Appearance of VFMI is a sign of disease progression but does not necessary mean patients should change their way of taking nutrition. However, MSA patients who need a tracheotomy might have advanced to a high-risk group for dysphagia. Appropriate evaluation and treatment for VFMI and dysphagia are required to maintain patients' quality of life in MSA.

Aged↗
PubMedDate not supplied

Videofluoroscopy and swallowing studies for neurologic disease: a primer.

Many patients with neurologic impairment due to stroke, multiple sclerosis, trauma, bulbar palsy, and other disorders have difficulty swallowing. Videofluoroscopy can provide important information on patterns of impairment of the swallowing mechanism, allowing important changes in patient treatment. The detailed videofluoroscopic evaluation required to provide this information is now seldom taught and is practiced by relatively few radiologists. The aim of this article is to (a) describe the indications for videofluoroscopic swallowing studies in the evaluation of patients with neurologic conditions affecting swallowing, (b) describe the techniques for evaluating the swallow mechanism with videofluoroscopy in a standardized manner, and (c) use cine videofluoroscopy to illustrate the range of abnormalities that can be demonstrated for some of these conditions and discuss the effect of patient treatment.

Deglutition↗
PubMed2005

Assessment of intraluminal impedance for the detection of pharyngeal bolus flow during swallowing in healthy adults.

Intraluminal impedance, a nonradiological method for assessing bolus flow within the gut, may be suitable for investigating pharyngeal disorders. This study evaluated an impedance technique for the detection of pharyngeal bolus flow during swallowing. Patterns of pharyngoesophageal pressure and impedance were simultaneously recorded with videofluoroscopy in 10 healthy volunteers during swallowing of liquid, semisolid, and solid boluses. The timing of bolus head and tail passage recorded by fluoroscopy was correlated with the timing of impedance drop and recovery at each recording site. Bolus swallowing produced a drop in impedance from baseline followed by a recovery to at least 50% of baseline. The timing of the pharyngeal and esophageal impedance drop correlated with the timing of the arrival of the bolus head. In the pharynx, the timing of impedance recovery was delayed relative to the timing of clearance of the bolus tail. In contrast, in the upper esophageal sphincter (UES) and proximal esophagus, the timing of impedance recovery correlated well with the timing of clearance of the bolus tail. Impedance-based estimates of pharyngoesophageal bolus clearance time correlated with true pharyngoesophageal bolus clearance time. Patterns of intraluminal impedance recorded in the pharynx during bolus swallowing are therefore more complex than those in the esophagus. During swallowing, mucosal contact between the tongue base and posterior pharyngeal wall prolongs the duration of pharyngeal impedance drop, leading to overestimation of bolus tail timing. Therefore, we conclude that intraluminal impedance measurement does not accurately reflect the bolus transit in the pharynx but does accurately reflect bolus transit across the UES and below.

Adult↗
PubMed1994

Influence of aging on oral-pharyngeal bolus transit and clearance during swallowing: scintigraphic study.

The aim of the study was to determine the influence of normal aging on regional transit and the efficiency of bolus clearance during the oral and pharyngeal phases of swallowing. We compared scintigraphically derived oral-pharyngeal transit times and isotope clearance during swallowing in 21 healthy aged volunteers (mean age 68 +/- 8 yr) and 9 young controls (mean age 28 +/- 7.5 yr). Subjects swallowed 5- and 10-ml water boluses mixed with 30 MBq 99mtechnetium tin colloid. Oral and pharyngeal transit times, pharyngeal clearance time, and postswallow residual counts in each region were derived from time-activity curves. Pharyngeal residual counts were significantly greater in the aged than in controls (P = 0.0008), but age did not influence oral residual. Aging significantly prolonged oral transit time (P = 0.02), pharyngeal transit time (P = 0.0004), and pharyngeal clearance time (P = 0.0001). We conclude that normal impairs the efficiency of pharyngeal clearance during swallowing, prolongs scintigraphic measures of oral-pharyngeal transit, and increases the exposure time of the glottis to the swallowed bolus.

Adult↗
PubMed1995

Mechanism and timing of nasopharyngeal closure during swallowing and belching.

The mechanism(s) of nasopharyngeal closure (NPC) and its temporal relationship with other biomechanical events during swallowing and belching were studied in seven healthy volunteers, aged 26-39 yr, by concurrent videoendoscopic, videofluoroscopic, and manometric technique. Analysis of the videoendoscopic recordings showed that deglutitive NPC consisted of elevation of the soft palate and adduction of the superior pharyngeal constrictor muscle. Videofluoroscopy identified only the palatal elevation clearly. During belching, however, only palatal elevation occurred. Deglutitive NPC ranged between 0.73 and 0.94 s (0.8 +/- 0.04 SE), with a tendency to be longer with larger swallowed volumes. Onset of NPC was identified earlier endoscopically than as seen fluoroscopically. Complete NPC preceded the arrival of barium bolus into the pharynx, and this pattern was seen for all volumes tested. Manometric onset of upper esophageal sphincter (UES) relaxation was seen before the onset of NPC, but the physical opening of the UES as seen fluoroscopically occurred after complete closure of the nasopharynx. We conclude the following: 1) The mechanism of NPC during swallowing and belching is different. During swallowing, NPC has two tiers of closure, palatal elevation and superior pharyngeal muscle adduction; during belching only palatal elevation occurs. 2) NPC is tightly coordinated with other biomechanical events during swallowing and belching.

Adult↗
PubMed1989

Swallowing reflex elicited by water and taste solutions in humans.

We investigated whether water and taste solutions are adequate stimuli for elicitation of the swallowing reflex from the pharyngolaryngeal region in humans. Subjects were five healthy males. Small amounts of water and taste solutions were applied to the posterior tongue of the subject as he reclined on a dental chair. The latency between the onset of application of the stimuli and the occurrence of swallowing was measured. Water was a most effective stimulus for elicitation of the swallowing reflex. The stimulatory effect was altered by anions, particularly Cl-, added to the water. Gustatory factors affected the latency of swallowing. The results suggest that humans have water-sensitive receptors in the pharyngolaryngeal region and that these receptors are responsible for initiation of the swallowing reflex by water.

Adult↗
PubMed1994

Swallowing and urine flow responses of ovine fetuses to 24 h of hypoxia.

The aim of this study was to determine the effects of 24 h of hypoxia on fetal swallowing and urine flow rates. The study design included successive 24-h control, hypoxia, and recovery periods. To induce hypoxia, we infused nitrogen into the trachea of late-gestation pregnant sheep. During hypoxia, there were decreases in fetal arterial oxygen saturation [from 62.7 +/- 2.2 to 30.9 +/- 2.9% (SE)] and PO2 (from 21.1 +/- 1.0 to 14.1 +/- 0.9 mmHg) (n = 7). Fetal arterial pH decreased maximally by 0.04 +/- 0.01 at 6 h and returned to control thereafter. Fetal swallowing decreased from 13.4 +/- 2.1 to 0.6 +/- 0.2 ml.h-1.kg fetal wt-1 with the onset of hypoxia and gradually increased, but only to one-half control levels, during the last 12 h of hypoxia. Fetal urine flow gradually decreased from 9.6 +/- 1.6 ml.h-1.kg-1 to a minimum of 5.3 +/- 0.5 ml.h-1.kg-1 at 2-3 h of hypoxia and returned to control thereafter. During the first hour of the recovery period, fetal swallowing transiently increased to twice control levels before returning to control. This was followed by a delayed, transient increase in urine flow to 63% above control levels at 2-6 h after hypoxia. We conclude that the fetal swallowing and urine flow responses to prolonged hypoxia in the absence of acidemia are distinctly different from the initial inhibitory responses, in that swallowing partially and urine flow fully recovers from the initial suppression.

Animals↗
PubMed1991

Fetal swallowing: response to graded maternal hypoxemia.

A computer-based system, incorporating electromyography (EMG) and esophageal fluid flow measurement, was used to determine fetal breathing and swallowing responses to graded maternal hypoxemia. Five chronically prepared ewes with singleton fetuses at a gestational age of 130 +/- 2 (SE) days were subjected to successive 30-min periods of mild and moderate hypoxemia (inspired O2 fraction = 0.16 and 0.13, respectively). Mild and moderate maternal hypoxemia evoked significant reductions in fetal arterial PO2 (21 +/- 1 to 17 +/- 1 and 13 +/- 1 Torr, respectively), while fetal arterial pH, hematocrit, plasma osmolality, heart rate, and mean blood pressure did not change. Moderate hypoxemia was associated with significant increases in fetal plasma arginine vasopressin and renin activity and significant reductions from basal values in percent time breathing (53 +/- 4 to 25 +/- 12%), percent time swallowing (11.5 +/- 3.1 to 1.3 +/- 0.7%), and volume swallowed (21.3 +/- 2.1 to 4.8 +/- 2.7 ml/30 min). Fetal swallowing activity was better correlated with arterial PO2 (r = 0.8) than breathing activity (r = 0.45). We conclude that fetal swallowing is suppressed during mild and moderate hypoxemia. It is suggested that several sites and/or mechanisms may account for the hypoxemic inhibition of fetal activities.

Animals↗
PubMed1994

Coordination between respiration and swallowing: respiratory phase relationships and temporal integration.

The coordination of breathing and swallowing was studied in 13 young healthy adult subjects during the administration of graduated volumes of water (3, 10, and 20 ml). Simultaneous submental electromyography, respiratory plethysmography, and fiber-optic endoscopy revealed a well-timed pattern between physiological respiratory events and related swallowing events. Expiration was the phase of respiration that was most closely associated with deglutition. Respiration was usually maintained at the onset of deglutition and halted before the onset of laryngeal elevation. The apneic interval was approximately 1 s for the 3-, 10-, and 20-ml boluses. A large-volume (100-ml) straw swallow resulted in variable respiration-swallowing patterns and in statistically significant differences (P < 0.01) in the duration of apneic pause and laryngeal excursion. The expiratory phase of respiration resumed nearly 0.50 s before the completion of swallowing. Clinical implications of the findings are addressed and related to aspiration and pulmonary complications in dysphagic patients.

Adolescent↗
PubMed1994

Central angiotensin II stimulation of ovine fetal swallowing.

In the late-gestation ovine fetus, spontaneous swallowing occurs primarily during fetal low-voltage electrocortical (ECoG) activity in association with fetal breathing movements. Fetal swallowing activity may be stimulated in response to systemic or carotid plasma hyperosmolality, although not to increased plasma angiotensin II (ANG II) levels. In view of the potent dipsogenic effects of central, but not peripheral, ANG II in adult sheep, the present study investigated the effect of intracerebroventricular (ICV) ANG II on fetal swallowing activity. Six ovine fetuses (127 +/- 1 days) were chronically prepared with electromyogram and cortical electrodes and with vascular and lateral ventricle catheters. After a 2-h control period, fetuses received ICV injections of artificial cerebrospinal fluid and increasing concentrations of ANG II (0.1, 1.0, 10, 100, and 500 ng/kg). Fetal ECoG activity did not change, although fetal swallowing activity significantly increased in response to the 100- and 500- ng/kg ANG II doses (1.20 +/- 0.14 to 3.34 +/- 0.59 and 3.46 +/- 0.81 swallows/min of low-voltage ECoG, respectively). In response to the highest ANG II dose, fetal plasma arginine vasopressin levels significantly increased (5.7 +/- 1.2 to 17.2 +/- 4.6 pg/ml). ICV ANG II stimulation of fetal swallowing and arginine vasopressin secretion demonstrates that central ANG II dipsogenic mechanisms are intact by 0.9 of ovine gestation.

Amniotic Fluid↗
PubMed2002

Laryngeal activity during upright vs. supine swallowing.

Previous investigations of human pharyngeal muscle activation patterns during swallowing found a relatively invariant muscle activation onset sequence in the upright position. However, different gravitational forces influence a liquid bolus when supine and could modify the central timing control of laryngeal airway protection during swallowing. The purpose of this study was to determine whether laryngeal muscle onset timing during swallowing differed between the supine and upright positions. Nine subjects performed six swallowing trials with a 2-ml water bolus in each position. Simultaneous electromyographic recordings were obtained from the submental complex (SMC) and the right and left thyroarytenoid (TA) muscles. Regardless of body position, the timing, amplitude, and duration of the TA muscles did not vary relative to the SMC. Therefore, the sequence of TA muscle activation relative to the SMC during swallowing appeared unaffected by gravitational influences.

Adult↗
PubMed2006

Electromyographic activity during the reflex pharyngeal swallow in the pig: Doty and Bosma (1956) revisited.

The currently accepted description of the pattern of electromyographic (EMG) activity in the pharyngeal swallow is that reported by Doty and Bosma in 1956; however, those authors describe high levels of intramuscle and of interindividual EMG variation. We reinvestigated this pattern, testing two hypotheses concerning EMG variation: 1) that it could be reduced with modern methodology and 2) that it could be explained by selective detection of different types of motor units. In eight decerebrate infant pigs, we elicited radiographically verified pharyngeal swallows and recorded EMG activity from a total of 16 muscles. Synchronization signals from the video-radiographic system allowed the EMG activity associated with each swallow to be aligned directly with epiglottal movement. The movements were highly stereotyped, but the recorded EMG signals were variable at both the intramuscle and interanimal level. During swallowing, some muscles subserved multiple functions and contained different task units; there were also intramuscle differences in EMG latencies. In this situation, statistical methods were essential to characterize the overall patterns of EMG activity. The statistically derived multimuscle pattern approximated to the classical description by Doty and Bosma (Doty RW, Bosma JF. J Neurophysiol 19: 44-60, 1956) with a leading complex of muscle activities. However, the mylohyoid was not active earlier than other muscles, and the geniohyoid muscle was not part of the leading complex. Some muscles, classically considered inactive, were active during the pharyngeal swallow.

Animals↗