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PubMed2004

Relationship between strength, balance, and swallowing deficits and outcome after traumatic brain injury: a multicenter analysis.

OBJECTIVE: To examine the relation among strength, balance, and swallowing deficits, as measured on rehabilitation admission, and functional outcome at discharge and 1 year after traumatic brain injury (TBI). DESIGN: Multicenter analysis of consecutive admissions to designated Traumatic Brain Injury Model Systems (TBIMS) facilities. SETTING: Seventeen TBIMS centers. PARTICIPANTS: Adults and children older than 16 years of age with TBI (N=2363) enrolled in the national database from January 1989 to November 2000. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Transfers, locomotion, stairs, lower-body dressing, grooming, bathing, upper-body dressing, toileting, and eating as measured by the FIM instrument at acute rehabilitation discharge and at 1 year after TBI. RESULTS: Lower-extremity strength less than 3/5 on admission to acute rehabilitation was associated with increased need for assistance in locomotion, transfers, and lower-body dressing and less than 3/5 upper-extremity strength was associated with the need for assistance in self-care at rehabilitation discharge and at 1 year postinjury. Similar relations were found between impaired swallowing and assistance with eating, grossly impaired dynamic sitting, or standing balance and assistance with locomotion, transfers, eating, and self-care at rehabilitation discharge and at 1 year after TBI. CONCLUSIONS: Assessments of physical strength, swallowing ability, and dynamic balance on acute rehabilitation admission are helpful as screening tests in predicting the need for assistance of another person for mobility and self-care at rehabilitation discharge. This association remains strong at 1 year after TBI. By using this information, clinicians should initiate therapeutic interventions that optimize rehabilitation of the identified impairments and should make necessary arrangement for the patient's anticipated postdischarge needs. Further studies are necessary to delineate the amount of unique variance that these early physical examination findings contribute to outcome prediction.

Activities of Daily Living↗
PubMed2005

Genesis of the decrement of intraluminal pressure in the UES during swallowing in rabbits.

The intraluminal pressure in the upper esophageal sphincter (UES) briefly decreases during swallowing. This decrement in pressure plays an important role in smooth transport of the ingested bolus from the pharynx to the esophagus. It is known that the decrement is caused by cessation of tonic activity of the cricopharyngeus (CP) muscle and also by elevation of the larynx. On the other hand, it is suspected that the recurrent laryngeal nerve (RLN) also contributes to the decrement, since our preliminary study showed for the first time that the decrement in UES pressure was much reduced after the RLN was sectioned. In the present study, we examined the genesis of the decrement of the UES pressure in anesthetized rabbits. When swallowing was elicited by repetitive electrical stimulation of the superior laryngeal nerve, the UES pressure briefly decreased and then abruptly increased. After bilateral sectioning of the RLN, the decrement of the pressure was significantly reduced, whereas the increment was little altered. Sectioning of the pharyngeal branch of the vagus nerve (X-ph) and the RLN mostly eliminated both the decrement and increment of the pressure, and abolished tonic and burst activities of the CP muscle. Electrical stimulation of peripheral end of the RLN decreased the pressure. These results indicate that the RLN and X-ph are involved in the decrement of the UES pressure during swallowing. The RLN generates the decrement by adducting the arytenoid cartilage and closing the glottis. The X-ph contributes to the decrement both by suppressing the tonic activity of the CP muscle and by regulating the laryngeal elevation.

Animals↗
PubMed2006

Radiofrequency ablation of swallowing-induced atrial tachycardia: case report and review of literature.

We report the case of a 47-year-old white man who presented with 1-year history of palpitations while swallowing. Event monitor confirmed the episodes were atrial tachycardia. Medical management with a calcium channel blocker did not alleviate the patient's symptoms. Gastrointestinal endoscopy did not reveal any abnormality. Electrophysiologic study was performed to identify and map the tachycardia. Swallowing during the procedure was used to repeatedly induce the tachycardia. A focal right atrial tachycardia that was mapped to the lower posterior right atrium was successfully ablated. Follow-up at 6 months and 1 year showed complete resolution of symptoms. An in-depth review of the literature and all published case reports of swallowing-induced atrial tachycardia is presented, and possible mechanisms of this rare form of tachycardia are discussed.

Atrial Function↗
PubMedDate not supplied

Is the information about a test important? Applying the methods of evidence-based medicine to the clinical examination of swallowing.

UNLABELLED: A hotly debated topic in oropharyngeal dysphagia is the Clinical Swallowing Examination's (CSE) importance in clinical practice. That debate can profit from the application of evidence-based medicine's (EBM) principles and procedures. These can guide both appropriate data collection and interpretation as will be demonstrated in the present report. The study's purpose from which data for this report are drawn was to determine the relationship among signs elicited by a CSE and aspiration on a subsequent videofluoroscopic swallowing examination (VFSE). Sensitivity, specificity; positive and negative predictive values (NPV); likelihood ratios; and post-test probabilities for a variety of signs in isolation and in combinations are reported. These data, if judiciously selected and interpreted contribute to the clinician's knowledge about whether to follow a CSE with a VFSE and about what to expect if the VFSE is completed. LEARNING OUTCOMES: (1) Clinicians will learn how to use EBM principles in conjunction with clinical assessments of swallowing to enhance patient care. (2) Clinicians will learn how to identify combinations of patient signs during he CSE to predict VFSE performance.

Adult↗
PubMed2006

Swallowing motor pattern triggered and modified by sucrose stimulation in the larvae of the silkworm, Bombyx mori.

To determine the contribution of sucrose signals to swallowing motor patterns, a series of behavioral, morphological and electrophysiological experiments were carried out in the larvae of the silkworm, Bombyx mori. The larvae ingested a droplet of sucrose solution applied to the mouth. The rate of ingestion was increased for higher sucrose concentrations. The swallowing movements were produced by a cibarial pump system that consisted of a circular compressor and pairs of dilators. The circular compressor was innervated by at least two dorsal motor neurons with the somata in the frontal ganglion. One of these neurons with arborized in both the frontal ganglion and the tritocerebrum of the brain. Both extra- and intracellular recording from the compressor showed that the rhythmic motor patterns were modified by different concentration of sucrose. A higher concentration of sucrose lengthened the duration of a burst or caused more excitatory junction potentials (EJPs) in the compressor, resulting in stronger swallowing contractions. Transection of both frontal connectives deleted the sucrose response, but spontaneous rhythmic motor patterns remained in the compressor, suggesting that the motor rhythm could be generated in the frontal ganglion, and triggered and/or modified by sucrose signals processed through the tritocerebrum of the brain.

Animals↗
PubMed2004

Individual variation in microsatellite mutation rate in barn swallows.

The hypermutable nature of some microsatellite loci implies realistic possibilities for the large-scale detection of germline mutations by pedigree analysis. We have developed a model system for mutation analysis by the characterisation of patterns of mutation at three hypervariable microsatellites (two tetranucleotide and one pentanucleotide repeat loci) in barn swallows, all three markers having mutation rates at the percentage level. Here, we study how the mutation rate varies between individual birds of a Spanish population of barn swallows. A total of 53 mutations were identified from 2920 germline transmissions in 90 families with a total of 694 offspring. Mutations were not randomly distributed among individuals (P = 0.020). Attempts to correlate mutation rate with allele size, degree of inbreeding, immunocompetence and male age only revealed a strong effect of allele size. The mean mutation rate differed between colonies of breeding swallows which was probably due to a corresponding variation in allele size between colonies. There was no difference in the mean mutation rate between the Spanish and an Italian population. These results corroborate earlier findings, at the population level, of an allele size effect on the microsatellite mutation rate.

Animals↗
PubMed2004

Effects of viscosity, taste, and bolus volume on swallowing apnea duration of normal adults.

OBJECTIVE: The effects of viscosity, taste, and nectar-thick liquid bolus volume on swallowing apnea duration (SAD) were examined. STUDY DESIGN AND SETTING: Twenty-two adults, comprised of 10 males and 12 females, participated. SAD was assessed via nasal airflow during swallow conditions of viscosity (thin liquid, thick liquid, and puree), taste (water, apple juice, lemon concentrate), and nectar-thick liquid bolus volumes (5, 10, 15, and 20 mL) across three trials. RESULTS: A significant main effect of nectar-thick liquid bolus volume was found (P < 0.05). Viscosity and taste were not significant. CONCLUSIONS: SAD increased with increases in bolus volume; however, neither changes in bolus viscosity nor changes in taste affected SAD. SIGNIFICANCE: These findings indicate that since viscosity was not significant, the normative data previously published (by this PI) with 60 healthy adults stratified by age and gender can be utilized for comparison to disordered swallowing without regard to the bolus viscosity being used. EBM RATING: D.

Adult↗
PubMed2006

Voice and swallowing changes after thyroidectomy in patients without inferior laryngeal nerve injuries.

BACKGROUND: We performed a prospective analysis on voice and swallowing alterations following total thyroidectomy (TT), in the absence of recurrent nerve injury. METHODS: Patients aged 21 to 65 years undergoing TT, in the absence of laryngeal/pulmonary disease, previous neck surgery, or malignant diseases, were subjected to videostrobolaryngoscopy (VSL), acoustic voice analysis (AVA), and maximum phonation time (MPT) tests preoperatively and 3 months postoperatively. Voice impairment scores (VIS) and swallowing impairment scores (SIS) were obtained preoperatively, and at 1 week, 1 month, and 3 months postoperatively. RESULTS: Among the 127 selected patients, 39 completed the postoperative evaluation. No recurrent nerve injury was observed during the postoperative VSL in any of the patients. Preoperative and postoperative AVA and MPT scores did not differ significantly. The mean postoperative VIS was significantly higher than the preoperative VIS at 1 week and 1 month after TT (13.7 and 9.6 vs 4.4, respectively; P < .05) but not 3 months after TT (6.7). The mean SIS was higher than the preoperative SIS at 1 week, 1 month, and 3 months after TT (10.3, 6.0, and 2.8 vs 0.5, respectively; P < .05). CONCLUSIONS: Physicians should inform patients that transient voice and swallowing symptoms may occur following total thyroidectomy, and our data suggest mild symptoms may occur in the majority of operated patients.

Adult↗
PubMed2001

Neural circuits in swallowing and abdominal vagal afferent-mediated lower esophageal sphincter relaxation.

The purpose of this review is to identify the medullary subnuclei that house neural circuits for lower esophageal sphincter (LES) relaxation. LES relaxation may occur as a component of primary peristalsis elicited by superior laryngeal nerve (SLN) afferent stimulation, secondary peristalsis elicited by esophageal distention or as a component of belch reflex, and transient LES relaxation elicited by gastric vagal afferent stimulation. In mice, SLN stimulation at 10 Hz elicited complete swallowing reflex, including pharyngeal and esophageal peristalsis, and LES relaxation. SLN stimulation at 5 Hz elicited pharyngeal contractions and isolated LES relaxation, which is not accompanied by esophageal peristalsis. Electric stimulation of afferents in the ventral branch of the subdiaphragmatic vagus (vSDV) at 10 Hz also elicited isolated LES relaxation. Using these defined stimuli, c-fos expression was examined in the entire craniocaudal extent of the medullary nuclei. SLN stimulation at 10 Hz induced c-fos expression in neurons in: (1) interstitial (SolI), intermediate (SolIM), central (SolCe), occasional medial (SolM), and dorsomedial (SolDM) solitary subnuclei; (2) motor neurons in the nucleus ambiguus, including its semicompact (NAsc), loose (NAl), and compact (NAc) formations; and (3) dorsal motor nucleus of vagus, including its rostral (DMVr) and caudal (DMVc) parts. The activated neurons represent neurons involved with afferent SLN-mediated reflexes, including swallowing. SLN stimulation at 5 Hz evoked c-fos expression in neurons in SolI, SolIM, SolM, and SolDM but not in SolCe; and motor neurons in NAsc, NAl, and DMVc but not in NAc or DMVr. Stimulation of vSDV induced c-fos expression in neurons in SolM and SolDM and in motoneurons in DMVc. When considered with published reports in other animal species, these data support the speculation that (1) swallow-evoked primary peristalsis involves the following neural circuits: SolI/SolIM --> NAsc/NAl for pharyngeal and SolCe --> NAc for esophageal (striated muscle) peristalsis, SolM/SolDM --> preganglionic neurons in DMVc and DMVr and nitrergic and cholinergic neurons in myenteric plexus for esophageal (smooth muscle) peristalsis, and SolM/SolDM --> preganglionic neurons in DMVc --> postganglionic nitrergic neurons in the myenteric plexus for LES relaxation; and (2) abdominal vagus-stimulated isolated LES relaxation may involve neurons in SolM and SolDM --> preganglionic motor neurons in DMVc --> postganglionic nitrergic neurons in the myenteric plexus.

Afferent Pathways↗
PubMed1988

Limitations and dangers of gastrografin swallow after esophageal and upper gastric operations.

In a series of 135 patients who underwent esophageal and upper stomach surgery, the incidence of anastomotic leakage was 20.4 percent. One hundred four patients had either Gastrografin swallow or the methylene blue test to evaluate anastomotic integrity before resumption of oral feeding. Both tests were disappointing in that methylene blue failed to detect any case of leakage and Gastrografin swallow could only detect three cases of subclinical leakage. The high false-negative detection rate of Gastrografin swallow might be related to the inferior radiographic detail provided by this contrast medium. Aspiration of Gastrografin is potentially dangerous and could be fatal. We believe that barium sulfate, which provides better radiographic detail and is not so hazardous when aspirated, should be the contrast medium of choice.

Anastomosis, Surgical↗
PubMed1998

Serial fiberoptic endoscopic swallowing evaluations in the management of patients with dysphagia.

OBJECTIVE: To determine whether serial fiberoptic endoscopic evaluation of swallowing (FEES) can be used successfully and efficiently in deciding to change a patient's feeding status from nonoral (NPO) to oral (PO) with no adverse health outcome. DESIGN: A prospective, consecutive, cohort study. SETTING: Inpatient population of a tertiary-care university teaching hospital. SUBJECTS: Thirty-two adults were recruited from a cohort of 400 consecutive subjects who participated in a previous dysphagia study. INTERVENTION: Serial FEES was performed 3 to 6 times in each subject to detect objectively pharyngeal phase dysphagia, aspiration, and aspiration risk and to provide information for recommendations regarding oral feeding status and therapeutic intervention. The number of FEES was based on the subject's medical status, evidence of dysphagia, and clinical judgement. MAIN OUTCOME MEASURES: Identification of pharyngeal phase dysphagia, aspiration, and aspiration risk, and recommendations for initial feeding status, when to resume oral feeding, and what bolus consistencies to use for optimal swallowing success. RESULTS: In all subjects, serial FEES detected pharyngeal phase dysphagia, aspiration, and aspiration risk and enabled determination of initial feeding status (NPO or PO), when to resume successful oral feeding, and what bolus consistencies to use for optimal swallowing success. Specifically, 15 of 32 (47%) subjects received FEES 3 to 5 times within only 6 to 22 days. Timely serial FEES allowed 22 of 32 (69%) subjects to resume an oral diet as early and safely as possible. CONCLUSIONS: No subject who resumed an oral diet based on results of FEES developed an aspiration pneumonia. Serial FEES, therefore, enabled feeding status to be successful and efficiently changed from NPO to PO with no adverse health outcome. FEES was an efficient procedure with regard to appointment scheduling, transportation, patient issues, and personnel requirements.

Adult↗
PubMed1998

Recovery of swallowing after dysphagic stroke relates to functional reorganization in the intact motor cortex.

BACKGROUND & AIMS: The aim of this study was to determine the mechanism for recovery of swallowing after dysphagic stroke. METHODS: Twenty-eight patients who had a unilateral hemispheric stroke were studied 1 week and 1 and 3 months after the stroke by videofluoroscopy. Pharyngeal and thenar electromyographic responses to magnetic stimulation of multiple sites over both hemispheres were recorded, and motor representations were correlated with swallowing recovery. RESULTS: Dysphagia was initially present in 71% of patients and in 46% and 41% of the patients at 1 and 3 months, respectively. Cortical representation of the pharynx was smaller in the affected hemisphere (5 +/- 1 sites) than the unaffected hemisphere (13 +/- 1 sites; P </= 0.001). Nondysphagic and persistently dysphagic patients showed little change in pharyngeal representation in either hemisphere at 1 and 3 months compared with presentation, but dysphagic patients who recovered had an increased pharyngeal representation in the unaffected hemisphere at 1 and 3 months (15 +/- 2 and 17 +/- 3 vs. 9 +/- 2 sites; P </= 0.02) without change in the affected hemisphere. In contrast, thenar representation increased in the affected hemisphere but not the unaffected hemisphere at 1 and 3 months (P </= 0.01). CONCLUSIONS: Return of swallowing after dysphagic stroke is associated with increased pharyngeal representation in the unaffected hemisphere, suggesting a role for intact hemisphere reorganization in recovery.

Aged↗
PubMed1998

Solitarial premotor neuron projections to the rat esophagus and pharynx: implications for control of swallowing.

BACKGROUND & AIMS: The buccopharyngeal and esophageal phases of swallowing are controlled by distinct networks of premotor neurons localized in the nucleus tractus solitarius. The neuronal circuitry coordinating the two phases was investigated using a combination of central and peripheral tracing techniques. METHODS: Using pseudorabies virus, a transsynaptic tracer, in anesthetized rats, third-order esophageal neurons (neurons projecting to premotor neurons) were identified. In a separate protocol that combined transsynaptic and retrograde fluorescent tracing, third-order esophageal neurons projecting to pharyngeal motoneurons (buccopharyngeal premotor neurons) were then identified. RESULTS: Third-order esophageal neurons were identified in the interstitial and intermediate subnuclei of the nucleus tractus solitarius and in other medullary, pontine, midbrain, and forebrain nuclei. A subpopulation of these neurons (double labeled) in the interstitial and intermediate subnuclei were found to project to pharyngeal motoneurons (buccopharyngeal premotor neurons) and to be linked synaptically to esophageal premotor neurons. CONCLUSIONS: The synaptic link between buccopharyngeal and esophageal premotor neurons provides an anatomic pathway for the central initiation of esophageal peristalsis and its coordination with the pharyngeal phase of swallowing. This neural circuitry within the nucleus tractus solitarius is consistent with a complex central control mechanism for the swallowing motor sequence that can function independently of afferent feedback.

Animals↗
PubMed1997

Functional units, chewing, swallowing, and food avoidance among the elderly.

PURPOSE: The number of teeth in the dentition was compared with the number and types of dental functional units (opposing tooth pairs) to correlate the number of functional units with complaints about chewing and swallowing in the elderly. MATERIAL AND METHODS: Complaints of oral pharyngeal function and food avoidance practices were compared with the number and types of functional units. A convenience sample of 602 elderly subjects (468 men, 134 women, mean age 70 years) were interviewed and examined dentally. RESULTS: Functional unit measures, which included functional arrangement of the teeth and the number and type of teeth present, were found to be more discriminatory and descriptive of masticatory potential than the more number of teeth. Elderly persons (> or = 60 years of age) with reduced numbers of functional units tended to report difficulty chewing, avoidance of stringy foods (including meat), crunchy foods (including vegetables), and dry solid foods (including breads), and difficulty in swallowing. Removable prostheses did not appear to prevent these consequences and, at least in this elderly population, did not appear to be equivalent to natural teeth in terms of masticatory potential. CONCLUSIONS: It is possible that compromised dental function results in the swallowing of poorly chewed food, food avoidance patterns, dietary inadequacies, and systemic changes favoring illness, reduced vigor, debilitation, and shortened life expectancy. Emphasis should be placed on maintaining natural teeth whenever possible.

Aged↗
PubMed1999

Swallowing disorders.

Swallowing disorders affect a large and growing number of people in the United States, particularly the elderly. An appreciation of the anatomy, physiology and pathophysiology of swallowing disorders allows the practitioner to assess these problems and to make arrangements for their treatment. The purpose of this article, therefore, is to give an overview of the diagnosis and treatment of swallowing disorders.

Aged↗
PubMed1999

Double-blind placebo-controlled evaluation of sublingual-swallow immunotherapy with standardized Parietaria judaica extract in children with allergic rhinoconjunctivitis.

BACKGROUND: Sublingual-swallow immunotherapy was recently recognized in the World Health Organization Position Paper (Allergen immunotherapy: therapeutic vaccines for allergic diseases) "as a viable alternative to parenteral injection therapy to treat allergic diseases" in adults. More controlled studies were required to assess the efficacy and safety of this treatment in children. OBJECTIVE: This study was carried out to assess the clinical efficacy and safety profile of sublingual-swallow immunotherapy with high-dose allergen in children with allergies. METHODS: We used a double-blind placebo-controlled design. Forty-one children with Parietaria -induced rhinoconjunctivitis were randomized to receive sublingual standardized Parietaria judaica extract (n = 20) or placebo (n = 21) for 2 years. The cumulative dose of allergen was 375 times higher than that used in parenteral immunotherapy and the cumulative dose of Par j 1 major allergen was 52.5 mg over 2 years. The main efficacy assessment criteria were symptoms and rescue medication scores recorded on the patients' diary cards. Secondary criteria were changes in skin and conjunctival specific reactivity as well as blood parameters, analyzed after 1 and 2 years of immunotherapy. The safety of the treatment was assessed by evaluating the frequency and severity of adverse effects. RESULTS: A significant reduction in rhinitis symptoms was observed in the active treatment group during the second season (P =.02), with no difference in medication scores. A significant decrease in skin reactivity (P =.002 after 2 years of treatment) and an increase in the threshold dose for conjunctival allergen provocation test (P =.02) were observed in the active treatment group compared with the group receiving placebo. A significant increase in specific IgG(4 ) levels (P =.02) was also observed in the active group. Immunotherapy was well tolerated. CONCLUSION: Sublingual-swallow immunotherapy in Parietaria -allergic children provided a clinical benefit and a decreased specific reactivity to the allergen. The safety profile of this treatment, which constitutes an important issue, indicated good tolerance and compliance.

Administration, Sublingual↗
PubMed2000

Chewing and swallowing as indices of the stimulation to eat during meals in humans: effects revealed by the edogram method and video recordings.

Patterns of chewing and swallowing were recorded during standardized meals in humans. Cocktail size (3 cm2) open sandwiches were served in one of five different flavors. An oscillographic recording of chewing and swallowing showed that chewing activity varied with the palatability and variety of foods. Chewing time was shorter and fewer chews were observed as palatability increased. Swallowing did not change as a function of stimulus flavor. Pause duration between two successive food pieces became shorter as palatability increased. The effects of sensory factors were most evident at the beginning of meals and decreased until the end of meals. A later study which compared eating parameters in sandwich, semi-solid, and traditional French meals (different courses ingested in succession: appetizer, main course, cheese and dessert), as assessed from video recordings, found that different microstructure parameters responded to palatability manipulation in different meal types. Strength of mastication and prandial drinking might be other important parameters to look at in order to understand the motivation to eat and its fluctuations during the meal.

Adolescent↗
PubMed2000

Tumor size and pretreatment speech and swallowing in patients with resectable tumors.

The pretreatment relationship of tumor burden to speech and swallowing function in 230 patients with oral or oropharyngeal cancer before surgery was assessed. Reduced articulation, reduced conversational understandability, or self-reported dysphagia were present in at least 34% of patients before treatment. Videofluoroscopy showed at least 9% of patients had reduced swallowing efficiency on liquid, paste, or cookie boluses. By use of regression techniques, the percentages of the oral tongue and of the anterior floor of mouth affected by neoplasm were found to be significantly related to reduced articulation; T stage and the percentage of the oral tongue affected with tumor were mildly related to reduced understandability; tumor volume and having soft palate affected by neoplasm were significantly related to self-reported dysphagia; and percentages of affected oral tongue and of affected tongue base were significantly related to reduced swallowing efficiency. Tumor burden may contribute to functional deficits at diagnosis in patients who have resectable tumors.

Adult↗