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Prolonged intubation is known to bring on postextubation dysphagia (PED) in some patients. We have noted that there were some studies to investigate specific type and pattern of PED, which showed large variety of different swallowing abnormalities as mechanisms of PED that are multifactorial. There are several options of treatment in accordance with the management of these abnormalities. A botulinum toxin (BoT) injection into the upper esophageal sphincter (UES) can improve swallowing functions for patients with this disorder, by working to help the muscle relax. In this case, the conventional treatment was not effective in patients with PED, whereas the BoT injection made a great improvement for these patients. This study suggests that the UES pathology could be the main cause of PED.
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Palatal myoclonus (PM) is a rare disease that may induce dysphagia. Since dysphagia related to PM is unique and is characterized by myoclonic movements of the involved muscles, specific treatments are needed for rehabilitation. However, no study has investigated the treatment effectiveness for this condition. Therefore, the aim of this case report was to describe the benefit of combining behavioral treatment with valproic acid administration in patients with dysphagia triggered by PM. The two cases were treated with combined treatment. The outcomes evaluated by videofluoroscopic swallowing studies before and after the treatment showed significant decreases in myoclonic movements and improved swallowing function. We conclude that the combined treatment was effective against dysphagia related to PM.
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To prospectively assess the association between impoverished sensorimotor integration of the tongue and lips and post-extubation dysphagia (PED).
This cross-sectional study included non-neurologic critically ill adult patients who required endotracheal intubation and underwent videofluoroscopic swallowing study (VFSS) between October and December 2016. Participants underwent evaluation for tongue and lip performance, and oral somatosensory function. Demographic and clinical data were retrieved from medical records.
Nineteen patients without a definite cause of dysphagia were divided into the non-dysphagia (n=6) and the PED (n=13) groups based on VFSS findings. Patients with PED exhibited greater mean duration of intubation (11.85±3.72 days) and length of stay in the intensive care unit (LOS-ICU; 13.69±3.40 days) than those without PED (6.83±5.12 days and 9.50±5.96 days; p=0.02 and p=0.04, respectively). The PED group exhibited greater incidence of pneumonia, higher videofluoroscopy swallow study dysphagia scale score, higher oral transit time, and lower tongue power and endurance and lip strength than the non-dysphagia groups. The differences in two-point discrimination and sensations of light touch and taste among the two groups were insignificant. Patients intubated for more than 7 days exhibited lower maximal tongue power and tongue endurance than those intubated for less than a week.
Duration of endotracheal intubation, LOS-ICU, and oromotor degradation were associated with PED development. Oromotor degradation was associated with the severity of dysphagia. Bedside oral performance evaluation might help identify patients who might experience post-extubation swallowing difficulty.
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To compare swallowing function between healthy subjects and patients with pharyngeal dysphagia using high resolution manometry (HRM) and to evaluate the usefulness of HRM for detecting pharyngeal dysphagia.
Seventy-five patients with dysphagia and 28 healthy subjects were included in this study. Diagnosis of dysphagia was confirmed by a videofluoroscopy. HRM was performed to measure pressure and timing information at the velopharynx (VP), tongue base (TB), and upper esophageal sphincter (UES). HRM parameters were compared between dysphagia and healthy groups. Optimal threshold values of significant HRM parameters for dysphagia were determined.
VP maximal pressure, TB maximal pressure, UES relaxation duration, and UES resting pressure were lower in the dysphagia group than those in healthy group. UES minimal pressure was higher in dysphagia group than in the healthy group. Receiver operating characteristic (ROC) analyses were conducted to validate optimal threshold values for significant HRM parameters to identify patients with pharyngeal dysphagia. With maximal VP pressure at a threshold value of 144.0 mmHg, dysphagia was identified with 96.4% sensitivity and 74.7% specificity. With maximal TB pressure at a threshold value of 158.0 mmHg, dysphagia was identified with 96.4% sensitivity and 77.3% specificity. At a threshold value of 2.0 mmHg for UES minimal pressure, dysphagia was diagnosed at 74.7% sensitivity and 60.7% specificity. Lastly, UES relaxation duration of <0.58 seconds had 85.7% sensitivity and 65.3% specificity, and UES resting pressure of <75.0 mmHg had 89.3% sensitivity and 90.7% specificity for identifying dysphagia.
We present evidence that HRM could be a useful evaluation tool for detecting pharyngeal dysphagia.
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To investigate the characteristics of cognitive deficits in patients with post-stroke dysphagia, and to analyze the relationships between cognitive dysfunction and severity of dysphagia in supratentorial stroke.
A total of 55 patients with first-ever supratentorial lesion stroke were enrolled retrospectively, within 3 months of onset. We rated dysphagia from 0 (normal) to 4 (severe) using the dysphagia severity scale (DSS) through clinical examinations and videofluoroscopic swallowing studies (VFSS). The subjects were classified either as non-dysphagic (scale 0) or dysphagic (scale 1 to 4). We compared general characteristics, stroke severity and the functional scores of the two groups. We then performed comprehensive cognitive function tests and investigated the differences in cognitive performance between the two groups, and analyzed the correlation between cognitive test scores, DSS, and parameters of oral and pharyngeal phase.
Fugl-Meyer motor assessment, the Berg Balance Scale, and the Korean version of the Modified Barthel Index showed significant differences between the two groups. Cognitive test scores for the dysphagia group were significantly lower than the non-dysphagia group. Significant correlations were shown between dysphagia severity and certain cognitive subtest scores: visual span backward (p=0.039), trail making tests A (p=0.042) and B (p=0.002), and Raven progressive matrices (p=0.002). The presence of dysphagia was also significantly correlated with cognitive subtests, in particular for visual attention and executive attention (odds ratio [OR]=1.009; 95% confidence interval [CI], 1.002–1.016; p=0.017). Parameters of premature loss were also significantly correlated with the same subtests (OR=1.009; 95% CI, 1.002–1.016; p=0.017).
Our results suggest that cognitive function is associated with the presence and severity of post-stroke dysphagia. Above all, visual attention and executive functions may have meaningful influence on the oral phase of swallowing in stroke patients with supratentorial lesions.
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To investigate the impact of tracheostomy tube capping on swallowing physiology in stroke patients with dysphagia via videofluoroscopic swallowing study (VFSS).
This study was conducted as a prospective study that involved 30 stroke patients. Then, 4 mL semisolid swallowing was conducted with capping of the tracheostomy tube or without capping of the tracheostomy tube. The following five parameters were measured: laryngeal elevation, pharyngeal transit time, post-swallow pharyngeal remnant, upper esophageal sphincter width (UES), and penetration-aspiration scale (PAS) score.
On assessment of the differences in swallowing parameters during swallowing between ‘with capping’ and ‘without capping’ statuses, statistically significant differences were found in the post-swallow pharyngeal remnant (without capping, 48.19%±28.70%; with capping, 25.09%±19.23%; p<0.001), normalized residue ratio scale for the valleculae (without capping, 0.17±0.12; with capping, 0.09±0.12; p=0.013), normalized residue ratio scale for the piriform sinus (without capping, 0.16±0.12; with capping, 0.10±0.07; p=0.015), and UES width (without capping, 3.32±1.61 mm; with capping, 4.61±1.95 mm; p=0.003). However, there were no statistically significant differences in laryngeal elevation (x-axis without capping, 2.48±1.45 mm; with capping, 3.26±2.37 mm; y-axis without capping, 11.11±5.24 mm; with capping, 12.64±6.16 mm), pharyngeal transit time (without capping, 9.19± 10.14 s; with capping, 9.09±10.21 s), and PAS score (without capping, 4.94±2.83; with capping, 4.18±2.24).
Tracheostomy tube capping is a useful way to reduce post-swallow remnants and it can be considered an alternative method for alleviating dysphagia in stroke patients who can tolerate tracheostomy tube capping when post-swallow remnants are observed.
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To evaluate the functional characteristics of swallowing and to analyze the parameters of dysphagia in head and neck cancer patients after concurrent chemoradiotherapy (CCRT).
The medical records of 32 patients with head and neck cancer who were referred for a videofluoroscopic swallowing study from January 2012 to May 2015 were retrospectively reviewed. The patients were allocated by duration after starting CCRT into early phase (<1 month after radiation therapy) and late phase (>1 month after radiation therapy) groups. We measured the modified penetration aspiration scale (MPAS) and American Speech-Language-Hearing Association National Outcome Measurement System swallowing scale (ASHA-NOMS). The oral transit time (OTT), pharyngeal delay time (PDT), and pharyngeal transit time (PTT) were recorded to assess the swallowing physiology.
Among 32 cases, 18 cases (56%) were of the early phase. In both groups, the most common tumor site was the hypopharynx (43.75%) with a histologic type of squamous cell carcinoma (75%). PTT was significantly longer in the late phase (p=0.03). With all types of boluses, except for soup, both phases showed a statistically significant difference in MPAS results. The mean ASHA-NOMS level for the early phase was 5.83±0.78 and that for the late phase was 3.79±1.80, with statistical significance (p=0.01). The PTT and ASHA-NOMS level showed a statistically significant correlation (correlation coefficient=–0.52, p=0.02). However, it showed no relationship with the MPAS results.
The results of our study suggest that in the late phase that after CCRT, the OTT, PDT, and PTT were longer than in the early phase and the PTT prolongation was statistically significant. Therefore, swallowing therapy targeting the pharyngeal phase is recommended after CCRT.
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