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PubMed2003

Guidelines for the pathoanatomical examination of the lower brain stem in ingestive and swallowing disorders and its application to a dysphagic spinocerebellar ataxia type 3 patient.

Despite the fact that considerable progress has been made in the last 20 years regarding the three-phase process of ingestion and the lower brain stem nuclei involved in it, no comprehensive descriptions of the ingestion-related lower brain stem nuclei are available for neuropathologists confronted with ingestive malfunctions. Here, we propose guidelines for the pathoanatomical investigation of these nuclei based on current knowledge with respect to ingestion and the nuclei responsible for this process. The application of these guidelines is described by drawing upon the example of the lower brain stem of a male patient with spinocerebellar ataxia type 3, also known as Machado-Joseph disease, who displayed malfunctions during the preparatory phase of ingestion, as well as lingual and pharyngeal phases of swallowing. By way of the representative application of the recommended investigation procedure to 100 microm serial sections through the patient's brain stem stained for lipofuscin pigment and Nissl material, we observed neuronal loss together with astrogliosis in nearly all of the ingestion-related lower brain stem nuclei (motor, principal and spinal trigeminal nuclei; facial nucleus; parvocellular reticular nucleus; ambiguous nucleus, motor nucleus of the dorsal glossopharyngeal and vagal area; gelatinous, medial, parvocellular and pigmented solitary nuclei; hypoglossal nucleus). In view of their known functional role in the three-phase process of ingestion, damage to these nuclei not only offers an explanation of the patient's malfunctions related to the preparatory phase of ingestion and lingual and pharyngeal phases of swallowing, but also suggests that the patient may have suffered from additional esophageal phase swallowing malfunctions not mentioned in his medical records.

Adult↗
PubMed2003

A new species of parasitic mites of the genus Syringophiloidus Kethley 1970 (Acari: Syringophilidae) from the barn swallow Hirundo rustica Linnaeus, 1758.

A new quill mite species Syringophiloidus hirundinis (Acari: Syringophilidae) is described from the Barn Swallow Hirundo rustica. The species Syringophiloidus hirundinis had a prevalence of 17.1% in the two outermost tail feathers (N = 208 adult Barn Swallows) during the breeding season of the Barn Swallow host. Intensity of infestation was 9.7 adult mites per pair of infested tail feathers. The sex ratio was highly biased towards females, with only 7.5% of all individuals being males (20:3).

Animals↗
PubMed2002

Scattered radiation level during videofluoroscopy for swallowing study.

AIM: To evaluate the scattered radiation exposure to the surroundings during videofluoroscopy for swallowing study (VFSS). MATERIALS AND METHODS: Scattered radiation exposure was measured using an ion chamber survey meter for 17 adult patients undergoing videofluoroscopy for swallowing study. The cumulative dose area product of each case was also recorded. Data were presented as mean +/- standard deviation. RESULTS: The scattered radiation exposure at a distance of 150 cm from the patient and the dose area product recorded were 149 +/- 78 microR (range 42-308 microR) and 842 +/- 544 cGy.cm(2) (range 258-2151 cGy.cm(2)), respectively, for a single study of 18 +/- 6 minutes. A formula was then derived for estimating the scattered radiation dose to muscle tissue at an arbitrary distance based on the accumulated dose area product. With this formula, the mean scattered radiation dose to naked muscle tissue of the surrounding people at a distance of 30-100 cm from the patient were estimated to be 33.68-3.03 microSv respectively. CONCLUSION: The scattered radiation detriment associated with videofluoroscopy for swallowing study was well within acceptable levels.

Adult↗
PubMed2001

Dysphagia in a patient with lateral medullary syndrome: insight into the central control of swallowing.

BACKGROUND & AIMS: Central control of swallowing is regulated by a central pattern generator (CPG) positioned dorsally in the solitary tract nucleus and neighboring medullary reticular formation. The CPG serially activates the cranial nerve motor neurons, including the nucleus ambiguus and vagal dorsal motor nucleus, which then innervate the muscles of deglutition. This case provides insight into the central control of swallowing. METHODS: A 65-year-old man with a right superior lateral medullary syndrome presented with a constellation of symptoms, including dysphagia. The swallow was characterized using videofluoroscopy and esophageal motility and the results were compared with magnetic resonance imaging (MRI) findings. RESULTS: Videofluoroscopy showed intact lingual propulsion and volitional movements of the larynx. Distal pharyngeal peristalsis was absent, and the bolus did not pass the upper esophageal sphincter. Manometry showed proximal pharyngeal contraction and normal peristaltic activity in the lower esophagus (smooth muscle), but motor activity of the upper esophageal sphincter and proximal esophagus (striated muscle) was absent. MRI showed a lesion of the dorsal medulla. CONCLUSIONS: These findings are compatible with a specific lesion of the connections from a programming CPG in the solitary tract nucleus to nucleus ambiguus neurons, which supply the distal pharynx, upper esophageal sphincter, and proximal esophagus. There is functional preservation of the CPG control center in the solitary tract nucleus and of the vagal dorsal motor nucleus neurons innervating the smooth muscle esophagus.

Aged↗
PubMed2002

Rehabilitation of swallowing by exercise in tube-fed patients with pharyngeal dysphagia secondary to abnormal UES opening.

BACKGROUND & AIMS: We evaluated the effect of a novel rehabilitative exercise on restoration of deglutition in a group of patients with deglutitive failure caused by abnormal upper esophageal sphincter (UES) opening manifested by postswallow residue and aspiration necessitating percutaneous tube feeding. METHODS: We studied a total of 27 patients by videofluoroscopy and functional assessment of swallowing scores before and after 6 weeks of a head-raising exercise program. Seven of 27 patients, assigned randomly, participated in a sham exercise before entering the tested exercise program. Eleven of 27 were randomized to the real exercise program. RESULTS: Although there was no change in swallow function and biomechanics after the sham exercise, following 6 weeks of real exercise, all 11 patients exhibited a significant improvement in their UES opening, anterior laryngeal excursion (P < 0.01), as well as resolution of postdeglutitive aspiration and were able to resume oral feeding. Similar results were found when the 7 patients in the sham group were crossed over to the real exercise group. Comparison of before and after exercise values for anteroposterior UES opening (P < 0.01) and laryngeal anterior excursion (P < 0.05), as well as functional outcome assessment of swallowing (P < 0.05) in the entire group of 27 patients also showed significant improvement. Etiology and duration of dysphagia did not affect the outcome. CONCLUSIONS: The proposed suprahyoid muscle strengthening exercise program is effective in restoring oral feeding in some patients with deglutitive failure because of abnormal UES opening.

Aged↗
PubMed1999

Current evaluation and treatment of patients with swallowing disorders.

To determine the varied causes of oropharyngeal dysphagia and their respective pathophysiology, a working understanding of the normal anatomy and function of the highly integrated mechanism of swallowing is outlined. This information is presented as the basis for a reasoned and detailed approach to the history, physical examination, and endoscopic evaluation of normal and altered oropharyngeal swallowing. The management of swallowing disorders depends on the nature and magnitude of the responsible clinical condition. Conservative and surgical approaches are discussed. These modalities and their indications are described in detail.

Deglutition↗
PubMed1995

Lack of mandibular movement manifested by absent fetal swallowing: a possible factor in the pathogenesis of micrognathia.

This study was performed to assess the association of lack of mandibular movement as manifested by absent fetal swallowing and micrognathia in a nonrestrictive intrauterine environment. Over a 5-year period, 14 fetuses with sonographic findings of polyhydramnios (amniotic fluid index [AFI] more than 20 cm), absent mandibular movement, and a nonvisualized fetal stomach, all consistent with absent fetal swallowing, were followed. A group of 14 fetuses, each with polyhydramnios (AFI more than 20 cm), yet with sonographic detection of fetal swallowing, served as controls. All gravidas in both groups were normoglycemic throughout gestation. Subsequent mandibular development was assessed at delivery or autopsy. Analysis of the data revealed that in the study group, 12 of these infants were liveborn, and two were stillborn. Eleven of the liveborn infants had an early neonatal death. All 14 infants of the study group demonstrated micrognathia. None of the control infants (all of whom survived) had micrognathia. In conclusion, this study supports the concept that normal mandibular growth may depend on the presence of mandibular movement during intrauterine development.

Adult↗
PubMed1996

Swallowing problems in adults with traumatic brain injury.

In patients with traumatic brain injury, the anatomic and physiologic status of the swallowing mechanism may be impaired. Patients typically compensate for these impairments by learning and using compensatory strategies to ensure safe and efficient food intake. However, when cognitive-communicative and behavioral impairments are also present, the rehabilitation of dysphagia is more complex and challenging. To facilitate maximum recovery from dysphagia, an interdisciplinary team approach is essential. Teams may include several medical and allied healthcare professionals such as the physician, nurse, speech-language pathologist, clinical dietitian, and physical and occupational therapist. The psychologist may be consulted to provide expertise in behavioral management strategies. The patient and caregiver also are integral members of this treatment team. Each team member needs to be aware of the food consistencies that are appropriate and the specific feeding techniques that are required. It is critical that all team members be consistent in their approach to feeding for the patient to learn and generalize the use of compensatory strategies. This article has presented a review of the literature on swallowing problems in traumatic brain injury. It is apparent that there are relatively few data-based studies that describe the impairments and even fewer that discuss the efficacy of treatment for dysphagia in these patients. In view of the frequency of oral intake problems in individuals with traumatic brain injury, and the added challenge of the cognitive-communicative problems, further studies are needed to increase our understanding of swallowing problems, their treatment, and recovery in this patient population.

Brain Injuries↗
PubMed2005

Radiopaque contrast dye in nasopharynx reaches the middle ear during swallowing and/or yawning.

CONCLUSION: Contrast dye in the nasopharynx reaches the middle ear during swallowing and yawning in normal adults. This suggests that displacement of bacteria in nasopharyngeal secretion to the middle ear may occur frequently during sleep. OBJECTIVE: The middle ear is sterile under normal conditions. The purpose of this study was to examine by means of CT whether radiopaque contrast dye in the nasopharynx would reflux into the middle ear of normal adults during swallowing and/or yawning. MATERIAL AND METHODS: Six normal adult volunteers were studied. Contrast dye was kept at the orifices of the Eustachian tube during swallowing and/or yawning by placing volunteers in either a head-down or lateral decubitus position. Reflux was determined by the presence of contrast dye in the middle ear on CT scanning of the temporal bone. RESULTS: Two of the three volunteers in each group (four out of six in total) had contrast material detected in one or both middle ear cavities.

Administration, Intranasal↗
PubMed2003

Feasibility of swallowing interventions for tracheostomized individuals with severely disordered consciousness following traumatic brain injury.

PRIMARY OBJECTIVE: To report the ability of 12 tracheostomized acute rehabilitation hospital inpatients with severely disordered consciousness post-traumatic brain injury (TBI) to participate in an objective swallowing assessment. RESEARCH DESIGN: Post hoc analysis of data from a larger, prospective blinded comparison study. METHODS AND PROCEDURES: Subjects completed a modified barium swallow (MBS) study. Food/drink and tracheostomy tube management recommendations were made. MAIN OUTCOMES AND RESULTS: All subjects participated successfully during an MBS. Post-MBS, 10 subjects began receiving small amounts of food and/or drink. Prior to hospital discharge, all subjects received some food and/or drink and were extubated. Subjects were deemed representative of this patient population and, from a swallowing perspective, other tracheostomized patient populations at the same facility. CONCLUSIONS: Clinicians should routinely consider tracheostomized, acute rehabilitation hospital inpatients with severely disordered consciousness post-TBI potential MBS candidates. Implications and continued research needs are discussed.

Adult↗
PubMed2003

Magnetoencephalographic study of the starting point of voluntary swallowing.

Clear findings relative to where in the brain the starting point of voluntary swallowing is controlled were obtained in the present magnetoencephalographic study. Namely, the cerebral activity was observed in the cingulate gyrus and supplementary motor area for about 80 ms between 1,000 and 1,500 ms before swallowing in all test subjects. Thus, it is clear that this type of central control mechanism also plays an important role in complicated swallowing movements.

Adult↗
PubMed1998

Corrosion injury of the upper gastrointestinal tract after swallowing strong alkali.

OBJECTIVE: To review our experience of 9 patients who had attempted suicide by swallowing alkaline substances. DESIGN: Retrospective study. SETTING: Two university hospitals, Finland. PATIENTS: During the years 1987-1996. 9 patients who had swallowed more than 100 ml of strong alkali. RESULTS: 2 patients with oesophagorespiratory fistulas of the four with third degree injuries died in hospital, the first died of overwhelming sepsis and the second of multiple organ failure. The other two survived emergency staged resection and subsequent reconstruction. Delay between swallowing the alkali and the initial operation, and development of oesophagorespiratory fistulas were the most important predictors of death. Four patients with second degree injuries underwent oesophageal resection and reconstruction after they had developed oesophageal strictures. Two of these six survivors developed anastomotic strictures after reconstruction, both of which necessitated repeated oesophageal dilatations. One patient with a first degree injury was treated conservatively. CONCLUSIONS: An early and aggressive approach to severe third degree corrosive injuries of the upper gastrointestinal tract is needed to resect all necrotic tissue and to make it possible to do a successful reconstruction later. The development of oesophagorespiratory fistulas requires immediate attention, whereas first and second degree injuries can be treated after the patient has been stabilized.

Adolescent↗
PubMed2003

Difficulty swallowing and lack of receipt of highly active antiretroviral therapy predict acute weight loss in human immunodeficiency virus disease.

In human immunodeficiency virus (HIV) disease, symptoms of underlying illness may promote weight loss through decreased caloric intake, increased metabolic needs, or nutrient malabsorption. We evaluated disease symptoms as predictors of acute weight loss (i.e., loss of > or =5% of weight). HIV-infected men and women (n=415) were telephoned every 5 weeks to obtain information about weight and recent symptoms. Weight change between each pair of consecutive calls (telephone intervals, 2814) was calculated. Acute weight loss occurred across 4.5% of intervals and among 24% of individuals. Patients reported > or =1 symptom before 58% of telephone intervals. The most common symptoms or symptom complexes before intervals were diarrhea (21% of patients), anorexia (17%), upper respiratory symptoms (16%), skin symptoms (12%), and abdominal pain (12%). Trouble swallowing (6%) and oral symptoms (7%) were less common. Risk of acute weight loss was significantly increased when oral symptoms or trouble swallowing were present, and it was decreased when highly active antiretroviral therapy (HAART) was used or when diarrhea was not present. Even when HAART is being administered, clinicians should remain vigilant regarding weight loss, oral symptoms, and trouble swallowing.

Adult↗
PubMed1985

Swallowing difficulties in stroke patients: a new treatment.

Difficulty with swallowing is one of the most distressing symptoms experienced by patients who have suffered strokes and one which previously has been particularly difficult to help. An intra-oral appliance which stimulates the involuntary swallowing mechanism has been tested with 170 consecutive stroke patients with dysphagia and drooling, and the results show substantial improvement. The appliance is relatively cheap to construct and fit, requiring little professional time. It is worn during the whole day, helping to rehabilitate the swallowing mechanism with saliva as well as with food and drink. The treatment is appropriate for patients in hospital or at home and avoids the use of medication.

Adult↗
PubMed1998

Does artificial enteral nutrition prolong the survival of institutionalized elders with chewing and swallowing problems?

BACKGROUND: There is a lack of prognostic data regarding tube feeding of institutionalized elderly people. The objective of this study was to determine the impact of feeding tubes on the survival of nursing home residents with chewing and swallowing problems, and to follow the course of the tube-fed residents over one year. METHODS: We conducted a cohort study with 12-month follow-up using Minimum Data Set resident assessments from 1991. Participants included 5,266 nursing home residents over the age of 65 with chewing and swallowing problems living in 272 Washington state nursing homes. Residents who had a feeding tube were identified. Baseline clinical characteristics and 12-month survival were compared for residents with and without feeding tubes. The proportion of tube-fed residents who became tube-free during the follow-up period was determined, and clinical features that predicted this outcome were examined. RESULTS: Among the residents with chewing and swallowing problems, 10.5% had a feeding tube. After adjusting for potential confounding covariates, tube-fed residents had a significantly higher one-year mortality rate than those without feeding tubes (risk ratio, 1.44; 95% CI, 1.17-1.76). Of the 430 residents with feeding tubes who survived the follow-up period, 25.1% became free of a feeding tube. Age less than 87 years was associated with a significantly greater likelihood of becoming tube-free (odds ratio, 1.66; 95% CI, 1.03-2.6). CONCLUSIONS: Residents selected for feeding tube placement have poorer survival after one year than residents who are not tube-fed. However, the feeding tubes are removed in a significant proportion of residents who survive one year. Residents with a potentially reversible condition, for whom the feeding tubes are a temporary intervention, need to be identified.

Age Factors↗
PubMed2002

Primary closure versus radial forearm flap reconstruction after hemiglossectomy: functional assessment of swallowing and speech.

The authors compared the postoperative speech and swallowing function of six patients who underwent free radial forearm flap reconstruction after hemiglossectomy with that of six control patients who underwent primary closure of the defect. Clinical speech pathologic evaluations included the Fletcher time-to-time maximum repetition rate of syllables, multiple rhyme test, and overall quality and intelligibility of the patients' speech. Evaluation of swallowing included the duration of deglutition, bolus volume, and ingestion rate. Speech quality, including intelligibility and articulation, was better in patients with primary closure. However, the bolus volume and ingestion rate in deglutition were better in those with flap reconstruction. These results suggest that the flap adds bulk, thus improving pharyngeal clearance by maintaining the tongue-to-mouth roof contact that is necessary in the swallowing process. The nonfunctional flap, however, hinders articulation by restricting the mobility of the remaining portion of the normal tongue.

Adult↗
PubMed1998

Pharyngeal swallowing disorders: selection for and outcome after myotomy.

OBJECTIVE: To develop selection criteria based on the mechanical properties of pharyngoesophageal swallowing that indicate when patients with pharyngeal dysphagia will benefit from a myotomy. SUMMARY BACKGROUND DATA: The pathophysiology of pharyngoesophageal swallowing disorders is complex. The disorder is of interest to several medical specialists (gastroenterologists, otorhinolaryngologists, general and thoracic surgeons), which contributes to confusion about the entity. The management is compounded because it is most frequently seen in the elderly, is often associated with generalized neuromuscular disease, and occurs with a high prevalence of concomitant disease. The selection of patients for myotomy is difficult and of major importance to the quality of life of the affected patients. METHOD: One hundred seven patients without a Zenker diverticulum but with pharyngeal dysphagia underwent a detailed manometric assessment of the upper esophageal sphincter (UES). Cricopharyngeal opening was identified by the presence of a subatmospheric pressure drop before bolus arrival. Impaired pharyngoesophageal segment compliance resulting in a resistance to pharyngoesophageal flow was determined by measuring the intrabolus pressure generated by a 5-ml liquid bolus. RESULTS: Thirty-one of 107 patients underwent a myotomy (29%). Both impaired sphincter opening and increased intrabolus pressure predicted a good outcome. CONCLUSION: Myotomy is beneficial in patients with pharyngeal swallowing disorders and manometric evidence of defective sphincter opening and increased intrabolus pressure.

Adult↗
PubMed1999

Fiberoptic endoscopic evaluation of swallowing in patients with acute traumatic brain injury.

Dysphagia and aspiration in intensive care unit patients with acute traumatic brain injury (TBI) is a frequent and potentially life-threatening problem. Any diagnostic technique used with this population, therefore, must be able to be performed in a timely and efficient manner while providing objective information on the nature of the swallowing problem. The purpose of the present study was to investigate the utility of using the fiberoptic endoscopic evaluation of swallowing (FEES) technique to diagnosis pharyngeal stage dysphagia and determine aspiration status in patients who presented with acute TBI. A total of 47 subjects were assessed with FEES. Thirty of 47 (64%) subjects swallowed successfully and were able to take an oral diet: 2 of 30 (7%) thickened liquids and purée consistencies, 8 of 30 (27%) a soft diet, and 20 of 30 (67%) a regular diet. Seventeen of 47 (36%) subjects exhibited pharyngeal stage dysphagia with aspiration and were not permitted an oral diet based on objective results provided by FEES. Of the 17 subjects who aspirated, 9 of 17 (53%) exhibited silent aspiration. Younger subjects (mean age 34 years, 3 months) aspirated significantly less often than older subjects (mean age 51 years, 8 months). No significant age difference was observed for gender or between overt and silent aspirators. It was concluded that FEES is an objective and sensitive tool that can be used successfully to diagnose pharyngeal stage dysphagia, determine aspiration status, and make recommendations for oral or nonoral feeding in patients with acute TBI.

Acute Disease↗