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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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To investigate the characteristics and risk factors of dysphagia with the Videofluoroscopic Dysphagia Scale (VDS) using a videofluoroscopic swallowing study (VFSS) in patients with ruptured aneurysmal subarachnoid hemorrhage (aSAH).
Data of 64 patients presenting with first-ever ruptured aSAH were analyzed. Characteristics of dysphagia were evaluated using VFSS and all subjects were divided into a high (>47) and low risk group (≤47) by the VDS score. Clinical and functional parameters were assessed by medical records including demographics, hypertension and diabetes mellitus (DM), the Glasgow Coma Scale (GCS), the Hunt and Hess scale, endotracheal intubation, acute management modalities, as well as Korean version of the Mini-Mental Status Examination (K-MMSE) and Korean version of Modified Barthel Index (K-MBI). Radiologic factors identified the amount of hemorrhage, ventricular rupture, and aneurysmal location.
About a half of the subjects showed oral phase abnormalities and the oral transit time was delayed in 46.8% of the patients. The pharyngeal transit time was also prolonged in 39.0% of the subjects and the proportion of penetration and aspiration observed was 46.8%. The parameters-GCS score (p=0.048), hemorrhagic volume (p=0.028), presence of intraventricular hemorrhage (p=0.038), and K-MMSE (p=0.007)-were predisposing factors for dysphagia in patients with aSAH.
Abnormalities in the oral phase were more prominent in patients with aSAH than in those with other types of stroke. The risk factors associated with dysphagia persisting over 6 months after stroke onset were the initial GCS, hemorrhage volume, presence of intraventricular hemorrhage, and cognitive status as measured by the K-MMSE.
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To confirm a relationship between the pharyngeal response and bolus volume, and examine whether increasing the fluid bolus volume can improve penetration and aspiration for stroke dysphagic patients.
Ten stroke patients with a delayed pharyngeal response problem confirmed by a videofluoroscopic swallowing study (VFSS) were enrolled. Each subject completed two swallows each of 2 mL, 5 mL, and 10 mL of barium liquid thinned with water. The pharyngeal delay time (PDT) and penetration-aspiration scale (PAS) were measured and the changes among the different volumes were analyzed.
PDTs were shortened significantly when 5 mL and 10 mL of thin barium were swallowed compared to 2 mL. However, there was no significant difference in PAS as the bolus volume increased.
The increased fluid bolus volume reduced the pharyngeal delay time, but did not affect the penetration and aspiration status.
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To evaluate the normal thickness of the thyrohyoid muscle, which is one of the key muscles related to swallowing, by ultrasonography.
The thickness of the left and right thyrohyoid muscles was measured in normal male and female adults ranging in age from 20 to 79 years by ultrasonography. The groups were classified according to age as follows: subjects ranging in age from 20 to 39 years were classified into group A, subjects ranging in age from 40 to 59 years were classified into group B, and subjects ranging in age from 60 to 79 years were classified into group C. The measurement level was the line that joins the upper tip of the superior thyroid notch and the oblique line of the thyroid cartilage. Also, a correlation with the thyrohyoid muscle was investigated by collecting information regarding height, weight, body mass index (BMI), age, and gender of subjects in the healthy group.
The number of subjects in each group was as follows: group A (n=82), group B (n=62), and group C (n=60). Also, the thicknesses of the left and right muscles were 2.72±0.65 mm and 2.87±0.76 mm in group A, 2.83±0.61 mm and 2.93±0.67 mm in group B, and 2.59±054 mm and 2.73±0.55 mm in group C, respectively. Thyrohyoid muscle had a correlation with height, weight, and BMI. The thickness of the left and right thyrohyoid muscles was greater in male subjects than in female subjects and the right side muscle was thicker than the left side muscle.
The average thickness of the left and right thyrohyoid muscles was 3.20±0.54 mm in male subjects and 2.34±0.37 mm in female subjects. The thickness of the thyrohyoid muscle was positively correlated with height, weight, and BMI, and the thyrohyoid muscle was thicker in male subjects than in female subjects and the right side muscle was thicker than the left side muscle.
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To determine the supratentorial area associated with poststroke dysphagia, we assessed the diffusion tensor images (DTI) in subacute stroke patients with supratentorial lesions.
We included 31 patients with a first episode of infarction in the middle cerebral artery territory. Each subject underwent brain DTI as well as a videofluoroscopic swallowing study (VFSS) and patients divided were into the dysphagia and non-dysphagia groups. Clinical dysphagia scale (CDS) scores were compared between the two groups. The corticospinal tract volume (TV), fractional anisotropy (FA) and apparent diffusion coefficient (ADC) values were calculated for 11 regions of interest in the supratentorial area—primary motor cortex, primary somatosensory cortex, supplementary motor cortex, anterior cingulate cortex, orbitofrontal cortex, parieto-occipital cortex, insular cortex, posterior limb of the internal capsule, thalamus, and basal ganglia (putamen and caudate nucleus). DTI parameters were compared between the two groups.
Among the 31 subjects, 17 were diagnosed with dysphagia by VFSS. Mean TVs were similar across the two groups. Significant inter-group differences were observed in two DTI values: the FA value in the contra-lesional primary motor cortex and the ADC value in the bilateral posterior limbs of the internal capsule (all p<0.05).
The FA value in the primary motor cortex on the contra-lesional side and the ADC value in the bilateral PLIC can be associated with dysphagia in middle cerebral artery stroke.
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To investigate the effect of laryngopharyngeal neuromuscular electrical stimulation (NMES) on dysphonia in patients with dysphagia caused by stroke or traumatic brain injury (TBI).
Eighteen patients participated in this study. The subjects were divided into NMES (n=12) and conventional swallowing training only (CST, n=6) groups. The NMES group received NMES combined with CST for 2 weeks, followed by CST without NMES for the next 2 weeks. The CST group received only CST for 4 weeks. All of the patients were evaluated before and at 2 and 4 weeks into the study. The outcome measurements included perceptual, acoustic and aerodynamic analyses. The correlation between dysphonia and swallowing function was also investigated.
There were significant differences in the GRBAS (grade, roughness, breathiness, asthenia and strain scale) total score and sound pressure level (SPL) between the two groups over time. The NMES relative to the CST group showed significant improvements in total GRBAS score and SPL at 2 weeks, though no inter-group differences were evident at 4 weeks. The improvement of the total GRBAS scores at 2 weeks was positively correlated with the improved pharyngeal phase scores on the functional dysphagia scale at 2 weeks.
The results demonstrate that laryngopharyngeal NMES in post-stroke or TBI patients with dysphonia can have promising effects on phonation. Therefore, laryngopharyngeal NMES may be considered as an additional treatment option for dysphonia accompanied by dysphagia after stroke or TBI.
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To assess the impact of aging on masticatory muscle function according to changes in hardness of solid food.
Each of fifteen healthy elderly and young people were selected. Subjects were asked to consume cooked rice, which was processed using the guidelines of the Universal Design Foods concept for elderly people (Japan Care Food Conference 2012). The properties of each cooked rice were categorized as grade 1, 2, 3 and 4 (5×103, 2×104, 5×104, and 5×105 N/m2) respectively. Surface electromyography (sEMG) was used to measure masseter activity from food ingestion to swallowing of test foods. The raw data was normalized by the ratio of sEMG activity to maximal voluntary contraction and compared among subjects. The data was divided according to each sequence of mastication and then calculated within the parameters of EMG activities.
Intraoral tongue pressure was significantly higher in the young than in the elderly (p<0.05). Maximal value of average amplitude of the sequence in whole mastication showed significant positive correlation with hardness of food in both young and elderly groups (p<0.05). In a comparisons between groups, the maximal value of average amplitude of the sequence in whole mastication and peak amplitude in whole mastication showed that mastication in the elderly requires a higher percentage of maximal muscle activity than in the young, even with soft foods (p<0.05).
sEMG data of the masseter can provide valuable information to aid in the selection of foods according to hardness for the elderly. The results also support the necessity of specialized food preparation or products for the elderly.
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To compare the swallowing characteristics of dysphagic patients with traumatic brain injury (TBI) with those of dysphagic stroke patients.
Forty-one patients with TBI were selected from medical records (between December 2004 to March 2013) and matched to patients with stroke (n=41) based on age, sex, and disease duration. Patients' swallowing characteristics were analyzed retrospectively using a videofluoroscopic swallowing study (VFSS) and compared between both groups. Following thorough review of medical records, patients who had a history of diseases that could affect swallowing function at the time of the study were excluded. Dysphagia characteristics and severity were evaluated using the American Speech-Language-Hearing Association National Outcome Measurement System swallowing scale, clinical dysphagia scale, and the videofluoroscopic dysphagia scale.
There was a significant difference in radiological lesion location (p=0.024) between the two groups. The most common VFSS finding was aspiration or penetration, followed by decreased laryngeal elevation and reduced epiglottis inversion. Swallowing function, VFSS findings, or quantified dysphagia severity showed no significant differences between the groups. In a subgroup analysis of TBI patients, the incidence of tube feeding was higher in patients with surgical intervention than in those without (p=0.011).
The swallowing characteristics of dysphagic patients after TBI were comparable to those of dysphagic stroke patients. Common VFSS findings comprised aspiration or penetration, decreased laryngeal elevation, and reduced epiglottis inversion. Patients who underwent surgical intervention after TBI were at high risk of tube feeding requirement.
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Association Between Active Gait Training for Severely Disabled Patients with Nasogastric Tube Feeding or Gastrostoma and Recovery of Oral Feeding: A Retrospective Cohort Study
To investigate the usefulness of ultrasonographic measurement of hyoid bone movement during swallowing.
Fifty-two patients who had swallowing dysfunction were enrolled in this study. When a patient swallowed 5 mL of water while maintaining an upright sitting position, hyoid bone movement during swallowing was measured with ultrasonography. Recorded images were analyzed to measure the maximum change in hyoid bone displacement. Mandible was used as reference point to calculate hyoid bone displacement. The farthest distance from resting position and the nearest distance during swallowing were measured and their differences were recorded. Participants also underwent videofluoroscopic swallowing study (VFSS). Based on penetration-aspiration scale (PAS), they were grouped to non-aspirators (PAS 1), penetrators (PAS 2–5), or aspirators (PAS 6–8). Measured hyoid bone displacements by submental ultrasonography were compared among groups.
The mean hyoid bone displacement in non-aspirators group (n=21, 15.9±2.7 mm) was significantly (p<0.05) greater than that in penetrators group (n=20, 11.5±2.8 mm) or aspirators group (n=11, 8.0±1.0 mm). Hyoid bone displacement below 13.5 mm as a cutoff point for detecting penetration or aspiration had a sensitivity and specificity of 83.9% and 81.0%, respectively.
Submental ultrasonographic evaluation was well correlated with PAS measured by VFSS. Therefore, submental ultrasonographic evaluation could be a useful screening tool for dysphagic patients.
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To investigate the final diagnosis of patients with unexplained dysphagia and the clinical and laboratory findings supporting the diagnosis.
We retrospectively analyzed 143 patients with dysphagia of unclear etiology who underwent a videofluoroscopic swallowing study (VFSS). The medical records were reviewed, and patients with a previous history of diseases that could affect swallowing were categorized into a missed group. The remaining patients were divided into an abnormal or normal VFSS group based on the VFSS findings. The clinical course and final diagnosis of each patient were examined.
Among the 143 patients, 62 (43%) had a previous history of diseases that could affect swallowing. Of the remaining 81 patients, 58 (72.5%) had normal VFSS findings and 23 (27.5%) had abnormal VFSS findings. A clear cause of dysphagia was not identified in 9 of the 23 patients. In patients in whom a cause was determined, myopathy was the most common cause (n=6), followed by laryngeal neuropathy (n=4) and drug-induced dysphagia (n=3). The mean ages of the patients in the normal and abnormal VFSS groups differed significantly (62.52±15.00 vs. 76.83±10.24 years, respectively; p<0.001 by Student t-test).
Careful history taking and physical examination are the most important approaches for evaluating patients with unexplained swallowing difficulty. Even if VFSS findings are normal in the pharyngeal phase, some patients may need additional examinations. Electrodiagnostic studies and laboratory tests should be considered for patients with abnormal VFSS findings.
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Many reports of changes in cervical alignment after posterior occipitocervical (O-C) fusion causing dysphagia are available. The clinical course can range from mild discomfort to severe aspiration. However, the underlying pathogenesis is not well known. We report an 80-year-old female with videofluoroscopic swallowing study evidence of aspiration that developed after occiput-C3/4 posterior fusion. Pharyngeal pressure was analyzed using high resolution manometry (HRM). Impaired upper esophageal sphincter opening along with diminished peristalsis and pharyngeal pressure gradient were revealed by HRM to be the main characteristics in such patients. The patient fully recovered after a revision operation for cervical angle correction. Distinct pressure patterns behind reversible dysphagia caused by a change in cervical alignment were confirmed using HRM analysis.
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To identify the associations between the duration of endotracheal intubation and developing post-extubational supraglottic and infraglottic aspiration (PEA) and subsequent aspiration pneumonia.
This was a retrospective observational study from January 2009 to November 2014 of all adult patients who had non-neurologic critical illness, required endotracheal intubation and were referred for videofluoroscopic swallowing study. Demographic information, intensive care unit (ICU) admission diagnosis, severity of critical illness, duration of endotracheal intubation, length of stay in ICU, presence of PEA and severity of dysphagia were reviewed.
Seventy-four patients were enrolled and their PEA frequency was 59%. Patients with PEA had significantly longer endotracheal intubation durations than did those without (median [interquartile range]: 15 [9-21] vs. 10 [6-15] days; p=0.02). In multivariate logistic regression analysis, the endotracheal intubation duration was significantly associated with PEA (odds ratio, 1.09; 95% confidence interval [CI], 1.01-1.18; p=0.04). Spearman correlation analysis of intubation duration and dysphagia severity showed a positive linear association (r=0.282, p=0.02). The areas under the receiver operating characteristic curves (AUCs) of endotracheal intubation duration for developing PEA and aspiration pneumonia were 0.665 (95% CI, 0.542-0.788; p=0.02) and 0.727 (95% CI, 0.614-0.840; p=0.001), respectively.
In non-neurologic critically ill patients, the duration of endotracheal intubation was independently associated with PEA development. Additionally, the duration was positively correlated with dysphagia severity and may be helpful for identifying patients who require a swallowing evaluation after extubation.
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To investigate whether patterns of dysphagia and swallowing laterality differ according to the location of brain lesions in patients with stroke.
Patients with stroke >20 years of age were enrolled in this study. A videofluoroscopic swallowing study (VFSS) including the anterior-posterior view was used to assess swallowing. Patterns of swallowing were classified into three types according to the width of barium sulfate flow while passing the pharyngoesophageal segment: right-side-dominant flow, left-side-dominant flow, and no laterality in flow. Laterality was defined when the width of one side was twice or more the width of the other side.
A total of 92 patients who underwent swallowing function evaluations by VFSS were enrolled from Sep-tember 2012 to May 2013. Of these, 72 patients had supratentorial lesions (group I) and 20 patients had infratento-rial lesions (group II). Only 10 patients (13.9%) in group I and three patients (15.0%) in group II showed laterality. Of these 13 patients, laterality occurred on the left side regardless of the side of the brain lesion. No relationships were found between swallowing laterality and location of stroke or motor weakness.
The results suggest that swallowing laterality was not prevalent among patients with stroke and that lesion side, location of the brain lesion, or motor weakness did not influence swallowing laterality. Although stroke can cause symptoms of dysphagia, it is difficult to conclude that stroke has a crucial impact on swallowing laterality.
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Systemic vasculitis is a rare disease, and the diagnosis is very difficult when patient shows atypical symptoms. We experienced an unusual case of dysphagia caused by Churg-Strauss syndrome with lower cranial nerve involvement. A 74-year-old man, with a past history of sinusitis, asthma, and hearing deficiency, was admitted to our department for evaluation of dysphagia. He also complained of recurrent bleeding of nasal cavities and esophagus. Brain magnetic resonance imaging did not show definite abnormality, and electrophysiologic findings were suggestive of mononeuritis multiplex. Dysphagia had not improved after conventional therapy. Biopsy of the nasal cavity showed extravascular eosinophilic infiltration. All these findings suggested a rare form of Churg-Strauss syndrome involving multiple lower cranial nerves. Dysphagia improved after steroid therapy.
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To investigate the effect of repetitive transcranial magnetic stimulation (rTMS) according to the stimulation site in subacute stroke patients with dysphagia.
This study was designed as a matched comparative study. Twenty-four patients who had dysphagia after ischemic stroke were recruited, and they were divided into two groups after matching for age and stroke lesion. The patients in group A received rTMS over the brain cortex where motor evoked potential (MEP) was obtained from the suprahyoid muscle. Group B received rTMS over the brain cortex where MEP was obtained from the abductor pollicis brevis muscle. rTMS was performed at 110% of MEP threshold, 10 Hz frequency for 10 seconds, and then repeated every minute for 10 minutes. Dysphagia status was measured by the Functional Dysphagia Scale (FDS), the Penetration-Aspiration Scale (PAS), and the Dysphagia Outcome and Severity Scale (DOSS) using the results of a videofluoroscopic swallowing study. These evaluations were measured before, immediately, and 4 weeks after rTMS.
Group A showed significant improvement compared to group B in the DOSS score immediately and 4 weeks after rTMS. There were no significant differences in the changes of FDS and PAS scores between groups A and B immediately and 4 weeks after rTMS.
rTMS over a hot spot for the suprahyoid muscle caused more improvement in swallowing function when compared to that over the interconnected site.
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To observe changes in pharyngeal pressure during the swallowing process according to postures in normal individuals using high-resolution manometry (HRM).
Ten healthy volunteers drank 5 mL of water twice while sitting in a neutral posture. Thereafter, they drank the same amount of water twice in the head rotation and head tilting postures. The pressure and time during the deglutition process for each posture were measured with HRM. The data obtained for these two postures were compared with those obtained from the neutral posture.
The maximum pressure, area, rise time, and duration in velopharynx (VP) and tongue base (TB) were not affected by changes in posture. In comparison, the maximum pressure and the pre-upper esophageal sphincter (UES) maximum pressure of the lower pharynx in the counter-catheter head rotation posture were lower than those in the neutral posture. The lower pharynx pressure in the catheter head tilting posture was higher than that in the counter-catheter head tilting. The changes in the VP peak and epiglottis, VP and TB peaks, and the VP onset and post-UES time intervals were significant in head tilting and head rotation toward the catheter postures, as compared with neutral posture.
The pharyngeal pressure and time parameter analysis using HRM determined the availability of head rotation as a compensatory technique for safe swallowing. Tilting the head smoothes the progress of food by increasing the pressure in the pharynx.
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Spasmodic dysphonia is defined as a focal laryngeal disorder characterized by dystonic spasms of the vocal cord during speech. We described a case of a 22-year-old male patient who presented complaining of idiopathic difficulty swallowing that suddenly developed 6 months ago. The patient also reported pharyngolaryngeal pain, throat discomfort, dyspnea, and voice change. Because laryngoscopy found no specific problems, an electrodiagnostic study and videofluoroscopic swallowing study (VFSS) were performed to find the cause of dysphagia. The VFSS revealed continuous twitch-like involuntary movement of the laryngeal muscle around the vocal folds. Then, he was diagnosed with spasmodic dysphonia by VFSS, auditory-perceptual voice analysis, and physical examination. So, we report the first case of spasmodic dysphonia accompanied with difficulty swallowing that was confirmed by VFSS.
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To investigate the prevalence of chronic obstructive pulmonary disease (COPD) in stroke patients, and to assess the difference in swallowing function between stroke patients with COPD (COPD group) and stroke patients without COPD (control group).
The subjects included 103 stroke patients. They underwent the pulmonary function test and were assigned to either the COPD group or the control group. Their penetration-aspiration scale (PAS) scores and functional dysphagia scale scores were compared by performing a videofluoroscopic swallowing study. The intergroup differences in lip closure, bolus formation, mastication, and the oral transit time, laryngeal elevation, cricopharyngeal dysfunction, oronasal regurgitation, residue in pyriform sinus and vallecula, pharyngeal transit time, aspiration, and esophageal relaxation were also compared.
Thirty patients were diagnosed with COPD. The COPD group showed statistically higher PAS scores (4.67±2.15) compared to the control group (2.89±1.71). Moreover, aspiration occurred more frequently in the COPD group with statistical significance (p<0.05). The COPD group also showed higher occurrence of cricopharyngeal dysfunction, albeit without statistical significance.
This study shows that a considerable number of stroke patients had COPD, and stroke patients with COPD had higher risk of aspiration than stroke patients without COPD.
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This retrospective case series included five patients who underwent surgical resection of the cervical anterior osteophyte due to dysphagia. Videofluoroscopic swallowing studies (VFSSs) were performed before and after surgery on each patient, and kinematic analysis of the video clips from the VFSS of a 5-mL liquid barium swallow was carried out. Functional oral intake improved after surgery in 3/4 patients who had required a modified diet before surgery. Kinematic analysis showed increases in the maximal hyoid vertical movement length (13.16±5.87 to 19.09±4.77 mm, p=0.080), hyoid movement velocities (170.24±84.71 to 285.53±104.55 mm/s, p=0.043), and upper esophageal sphincter opening width (3.97±0.42 to 6.39±1.32 mm, p=0.043) after surgery. In conclusion, improved upper esophageal sphincter opening via enhancement of hyoid movement after cervical anterior osteophyte resection may be the kinetic mechanism of improved swallowing function.
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