Swallowing in hereditary sensory ataxia

The oral, pharyngeal, and esophageal stages of swallowing were evaluated in 8 patients with recessively or dominantly inherited pure sensory ataxia. Six patients had swallowing difficulties: solid bolus obstruction, coughs during eating, and choking episodes. One patient had chronic bronchitis and another had recurrent pneumonia. The patients underwent a biphasic radiological barium swallow, including videofluoroscopy. No patient had a completely normal swallow. All had normal oral function, whereas pharyngeal function was abnormal in 6 patients. Esophageal function was abnormal in 6 patients. The swallowing dysfunction did not correlate with the severity of motor or sensory dysfunction in the limbs, nor with age or duration of ataxia. Our study shows that swallowing dysfunction is common in hereditary sensory ataxia. This dysfunction is likely to be due to involvement of the nucleus of the solitary tract in the brainstem. Despite some of the patients having suffered from choking episodes and others from bronchopulmonary complications, they did not spontaneously admit dysphagia. Swallowing should be evaluated thoroughly in patients with hereditary sensory ataxia since dysphagia in these patients might bring serious and potentially fatal complications.     

Accuracy of Bedside Clinical Methods Compared with Fiberoptic Endoscopic Examination of Swallowing (FEES) in Determining the Risk of Aspiration in Acute Stroke Patients

This prospective study was undertaken to determine the accuracy of bedside clinical methods compared with fiberoptic endoscopic examination of swallowing (FEES) for detecting aspiration in acute stroke patients. Fifty patients underwent an examination of their ability to swallow 50 ml of water in 10-ml aliquots. Later their oxygen saturation levels before and after swallowing 10 ml of water were measured using a pulse oximeter. Oxygen desaturation of more than 2%, was considered to be clinically significant. All patients then underwent a FEES assessment by a speech therapist and were followed up during their inpatient stay for evidence of aspiration pneumonia. The oxygen desaturation test had a sensitivity of 76.9% and specificity of 83.3% (chi2 = 18.154, p = 0.00002), while the 50-ml water swallow test had a sensitivity of 84.6% and specificity of 75.0% (chi2 = 18.001, p = 0.00002). However, when these two tests were combined into one test called "bedside aspiration," the sensitivity rose to 100% with a specificity of 70.8% (chi2 = 27.9, p = 0.000001). Five (10%) patients developed pneumonia during their inpatient stay. The relative risk (RR) of developing pneumonia, if there was evidence of aspiration on FEES, was 1.24 (1.03 < RR < 1.49). We conclude that the oxygen desaturation test combined with the 50-ml water swallow test is suitable as a screening test to identify all acute stroke patients at risk of aspiration for further evaluation and management.     

Effects of the Removal of the Tracheotomy Tube on Swallowing During the Fiberoptic Endoscopic Exam of the Swallow (FEES)

This study investigated the effects, if any, that the presence of a tracheotomy tube has on the incidence of laryngeal penetration and aspiration in patients with a known or suspected dysphagia. This was a prospective, repeated-measure design study. A total of 37 consecutive patients with a tracheotomy tube underwent a fiberoptic endoscopic evaluation of swallowing (FEES). Patients were first provided with pureed food boluses with the tracheotomy tube in place. The tracheotomy tube was then removed and the tracheostoma site was covered with gauze and gentle hand pressure was applied. The patients were then evaluated without the tracheotomy tube in place with additional puree. Aspiration status was in agreement with and without the tracheotomy tube in place in 95% (35/37) of the patients. The two patients who demonstrated a different swallowing pattern with regard to aspiration demonstrated aspiration only when the tracheotomy tube was removed. Laryngeal penetration status was in agreement with and without the tracheotomy tube in place in 78% (29/37) of the patients. For the majority of the patients, the removal of the tracheotomy tube made no difference in the incidence of aspiration and/or laryngeal penetration. Results of this study do not support the clinical notion that the patient’s swallowing function will improve once the tracheotomy tube has been removed. Work for this project was completed at Marianjoy Rehabilitation Hospital, Wheaton, Illinois.     

Adding Endoscopist-Directed Flexible Endoscopic Evaluation of Swallowing to the Videofluoroscopic Swallowing Study Increased the Detection Rates of Penetration,Aspiration, and Pharyngeal Residue

Background/AimsCurrently, the videofluoroscopic swallowing study (VFSS) is the standard tool for evaluating dysphagia. We evaluated whether the addition of endoscopist-directed flexible endoscopic evaluation of swallowing (FEES) to VFSS could improve the detection rates of penetration, aspiration, and pharyngeal residue, compared the diagnostic efficacy between VFSS and endoscopist-directed FEES and assessed the adverse events of the FEES.MethodsIn single tertiary referral center, a retrospective analysis of prospectively collected data was conducted. Fifty consecutive patients suspected of oropharyngeal dysphagia were enrolled in this study between January 2012 and July 2012.ResultsThe agreement in the detection of penetration and aspiration between VFSS and FEES of viscous food (κ=0.34; 95% confidence interval [CI], 0.15 to 0.53) and liquid food (κ=0.22; 95% CI, 0.02 to 0.42) was “fair.” The agreement in the detection of pharyngeal residue between the two tests was “substantial” with viscous food (κ=0.63; 95% CI, 0.41 to 0.94) and “fair” with liquid food (κ=0.37; 95% CI, 0.10 to 0.63). Adding FEES to VFSS significantly increased the detection rates of penetration, aspiration, and pharyngeal residue. No severe adverse events were noted during FEES, except for two cases of epistaxis, which stopped spontaneously without requiring any packing.ConclusionsThis study demonstrated that the addition of endoscopist-directed FEES to VFSS increased the detection rates of penetration, aspiration, and pharyngeal residue.     

Effects of Surface Electrical Stimulation Both at Rest and During Swallowing in Chronic Pharyngeal Dysphagia

We tested two hypotheses using surface electrical stimulation in chronic pharyngeal dysphagia: that stimulation (1) lowered the hyoid bone and/or larynx when applied at rest, and (2) increased aspiration, penetration, or pharyngeal pooling during swallowing. Bipolar surface electrodes were placed on the skin overlying the submandibular and laryngeal regions. Maximum tolerated levels of stimulation were applied while patients held their mouth closed at rest. Videofluoroscopic recordings were used to measure hyoid movements in the superior-inferior and anterior-posterior dimensions and the subglottic air column position while stimulation was on or off. Patients swallowed 5 ml liquid when stimulation was off, at low sensory stimulation levels, and at maximum tolerated levels (motor). Speech pathologists, blinded to condition, tallied the frequency of aspiration, penetration, pooling, and esophageal entry from videofluorographic recordings of swallows. Only significant (p = 0.0175) hyoid depression occurred during stimulation at rest. Aspiration and pooling were significantly reduced only with low sensory threshold levels of stimulation (p = 0.025) and not during maximum levels of surface electrical stimulation. Those patients who had reduced aspiration and penetration during swallowing with stimulation had greater hyoid depression during stimulation at rest (p = 0.006). Stimulation may have acted to resist patients’ hyoid elevation during swallowing. The research was performed at the Laryngeal and Speech Section, National Institute of Neurological Disorders and Stroke, Bethesda, Maryland, and supported by the Intramural Research Program of the National Institute of Neurological Disorders and Stroke, Project No. Z01 NS 02980.     

Effects of Carbonated Liquids on Oropharyngeal Swallowing Measures in People with Neurogenic Dysphagia

Aspiration is common in adults with neurogenic dysphagia and pharyngeal delay. This can lead to dehydration, malnutrition, and aspiration pneumonia. Diet modifications aimed at reducing thin liquid aspiration are partially successful or unpalatable or both. Carbonated liquids show some potential in influencing swallowing behavior. However, there is a paucity of evidence to support this intervention. This study compares the effects of carbonated thin liquids (CTL) with that of noncarbonated thin liquids (NCTL) on oropharyngeal swallowing in adults with neurogenic dysphagia and examines the palatability of the CTL stimulus. Seventeen people with pharyngeal delay attended for videofluoroscopy (VFSS). Outcome measures were oral transit time (OTT), pharyngeal transit time (PTT), stage transition duration (STD), initiation of the pharyngeal swallow (IPS), penetration-aspiration scale (PENASP), and pharyngeal retention (PR). A modification of Quartermaster Hedonic Scale (AQHS) was employed to assess palatability of the CTL. CTL vs. NCTL significantly decreased penetration and aspiration on 5-ml (P?=?0.028) and 10-ml (P?=?0.037) swallows. CTL had no significant effect on OTT, PTT, IPS, and PR for any volume of bolus. Only one participant disliked the CTL stimulus. These findings support the hypothesis that oropharyngeal swallowing can be modulated in response to sensory stimuli. Implications for research and clinical practice are discussed.     

Swallowing Function Outcomes Following Nonsurgical Therapy for Advanced-Stage Laryngeal Carcinoma

The purposes of this study were to (1) evaluate swallowing function using both subjective and objective measures in patients treated nonsurgically for stages III and IV laryngeal squamous cell carcinoma, (2) assess the effect of time from treatment completion on swallowing function, and (3) assess sequelae associated with modality of treatment. To achieve these objectives, a retrospective study of 14 patients was conducted. Fiberoptic endoscopic evaluation of swallowing (FEES) was performed and evaluated by three independent judges for seven functional criteria: standing secretions, valleculae spillage, valleculae residue, postcricoid residue, laryngeal penetration, aspiration, and cough. Patient interviews were performed to establish patient perception of swallowing and his/her current posttreatment diet. Results revealed that each patient exhibited swallowing abnormalities in at least one of the seven objective functional categories studied. Ten patients suffered from variable degrees of dysphagia, ranging from mild to severe, on all measures. No significant differences were noted between those patients with less than or greater than 12 months posttreatment. Common treatment sequelae included PEG tube placement for nutritional supplementation, tracheostomy placement for airway security and/or pulmonary toilet, repeated episodes of aspiration pneumonia requiring hospital admission, and radiation-induced oropharyngeal stricture. Further studies using subjective and objective swallowing function measures for patients treated with alternative chemoradiation regimens versus surgery (with or without adjuvant therapies) for advanced stage laryngeal cancer are needed.     

Preliminary Investigation of Swallowing Apnea Duration and Swallow/Respiratory Phase Relationships in Individuals with Cerebral Vascular Accident

Swallowing apnea duration (SAD) and swallow-respiratory phase relationships were examined in individuals with cerebral vascular accident (CVA) and dysphagia who aspirated (n = 11) and did not aspirate (n = 15). Simultaneous videofluoroscopic and respiratory measures were recorded across 5-, 10-, 15-, and 20-ml thin and thick liquid bolus trials. These data were also compared with that previously acquired with healthy older adults (n = 20). A moderate amount of systematic missing data was evidenced in the individuals who were dysphagic and especially those who aspirated subsequently limiting inferential analyses. Only 1 of the 11 participants who aspirated and 7 of the 15 who did not aspirate completed all 16 conditions. Six of the remaining ten who aspirated had missing data subsequent to termination of trials due to aspiration risk. The remaining four and seven of the eight who did not aspirate had missing data due to poor respiratory waveforms. From the remaining data, it was found that SAD and respiratory phase relationships differed among individuals with dysphagia and CVA (i.e., those who aspirate vs. those who do not aspirate) and healthy older adults. SAD was found to be longer for those who aspirated versus those who did not for all bolus viscosities and volumes with the exception of thick-liquid 10-ml boluses. In addition, SAD from those that aspirated was twice as long as that found in healthy older adults for all conditions. Regarding respiratory phase relationships, there was a difference between the proportions of respiratory patterns in those who aspirated versus those who did not. Those who aspirated demonstrated a markedly greater percentage of swallows that interrupted inhalation. In addition, the inhale-swallow-inhale pattern occurred with a greater frequency as swallowing severity increased. Healthy older adults, those who did not aspirate, and those who aspirated used the inhale-swallow-inhale pattern 0.1%, 3.0%, and 9.0%, respectively.     

Simple Swallowing Provocation Test Has Limited Applicability as a Screening Tool for Detecting Aspiration, Silent Aspiration, or Penetration

A number of tests for evaluating dysphagia without using videofluoroscopic examination of swallowing (VF) or videoendoscopic evaluation of swallowing (VE) have been developed. The simple swallowing provocation test (SSPT) is unique because it is performed while in a supine position and does not require the patient’s cooperation. However, whether the SSPT detects aspiration or penetration correctly is unclear because its validity determined by VF or VE has not been evaluated. Therefore, we determined the sensitivity, specificity, and predictive accuracy of SSPT followed by VF in 45 patients. The sensitivities of the first-step and the second-step SSPT for the detection of aspiration, silent aspiration, or penetration were 72–75% and 13–17%, respectively; the specificities of the first-step and the second-step SSPT were 38–44% and 80–89%, respectively; and the predictive accuracies of the first-step and the second-step SSPT were 58–67% and 31–49%, respectively. These data suggest that SSPT has limited applicability as a screening tool for aspiration, silent aspiration, or penetration because of its low sensitivity. This test may be useful for patients who cannot undergo other tests due to cognitive and/or linguistic dysfunction.     

Fiberoptic Endoscopic Evaluation of Swallowing (FEES) with and without Blue-Dyed Food

The purpose of this prospective study was to determine if fiberoptic endoscopic evaluation of swallowing (FEES) maintains high intra- and interrater reliability in detecting pharyngeal dysphagia and aspiration without the addition of FD&C Blue No. 1 to food. Twenty consecutive adults referred for a swallow evaluation participated. Nine subjects received blue-dyed food and 11 subjects received regular nondyed food, i.e., yellow pudding and white skim milk. Four variables were rated: (1) the stage transition characterized by depth of bolus flow to at least the vallecula prior to the pharyngeal swallow; (2) evidence of bolus retention in the vallecula or pyriform sinuses after the pharyngeal swallow; (3) laryngeal penetration defined as material in the laryngeal vestibule but not passing below the level of the true vocal folds either before or after the pharyngeal swallow; and (4) tracheal aspiration defined as material below the level of the true vocal folds either before or after the pharyngeal swallow. Three speech–language pathologists experienced in interpreting FEES results independently and blindly reviewed the digitized videotape three times. Intrarater agreements for the four variables with blue-dyed and non-blue-dyed food trials were 100% and monochrome trials ranged from 95% to 100%. Average kappa values for interrater reliability ranged from moderate to excellent agreement (0.61–1.00) for all viewing conditions. Kappa values for blue-dyed trials versus monochrome trials were 0.83 and for non-blue-dyed trials versus monochrome trials were 0.88, indicative of excellent reliability under both viewing conditions. FEES maintains both high intra- and interrater reliability in detecting the critical features of pharyngeal dysphagia and aspiration using either blue-dyed or non-blue-dyed foods. The endoscopist, therefore, can be assured of reliable FEES results using regular, non-dyed food trials.This research was supported in part by the McFadden, Harmon, and Mirikitani Endowments.     

Three Tests for Predicting Aspiration without Videofluorography

The videofluorographic swallowing study (VFSS) is the definitive test to identify aspiration and other abnormalities of swallowing. When a VFSS is not feasible, nonvideofluorographic (non-VFG) clinical assessment of swallowing is essential. We studied the accuracy of three non-VFG tests for assessing risk of aspiration: (1) the water swallowing test (3 ml of water are placed under the tongue and the patient is asked to swallow); (2) the food test (4 g of pudding are placed on the dorsum of the tongue and the patient asked to swallow); and (3) the X-ray test (static radiographs of the pharynx are taken before and after swallowing liquid barium). Sixty-three individuals with dysphagia were each evaluated with the three non-VFG tests and a VFSS; 29 patients aspirated on the VFSS. The summed scores of all three non-VFG tests had a sensitivity of 90% for predicting aspiration and specificity of 71% for predicting its absence. The summed scores of the water and food tests (without X-ray) had a sensitivity of 90% and specificity of 56%. These non-VFG tests have limitations but may be useful for assessing patients when VFSS is not feasible. They may also be useful as screening procedures to determine which dysphagia patients need a VFSS. Experiments were performed in the Department of Rehabilitation Medicine, Fujita Health University, Aichi, Japan. This study was funded in part by Health Science Research Grant (H12-choujyu-21 and H13-21EBM-018.     

Swallowing in neurological outpatients: Use of a timed test

Swallowing was studied prospectively in a consecutive group of 90 neurology outpatients under 70 years of age. No patient had been referred primarily because of dysphagia. Patients were classified into four groups: those with (1) neurological or (2) non-neurological diagnoses possibly relevant to disordered swallowing, (3) functional disorders, and (4) definite diagnoses not likely to be relevant. They were defined as having abnormal or probably abnormal swallowing if two or more of the following were present: a complaint of swallowing problem, abnormal symptoms or signs, a slow swallowing speed (<10 ml.s^-1). Nineteen patients among the four groups (21%) were found to have abnormal/probably abnormal swallowing. Swallowing speed was significantly slower in patients who perceived a swallowing problem or who had abnormal symptoms or signs compared with those who did not, providing further evidence for the validity of a timed test of swallowing capacity. The study also provides evidence of a significant incidence of disordered swallowing in outpatients who may not have complained spontaneously but who have diagnoses potentially relevant to swallowing.     

Swallowing therapy in patients with neurological disorders causing cricopharyngeal dysfunction

The results of swallowing therapy in 28 patients with neurological disorders causing cricopharyngeal (CP) dysfunction are reported. Variables described include the type of swallowing disorder, type and degree of aspiration, and therapeutic strategies. Patients were monitored by cineradiography before, during, and after therapy. Success of therapy was defined by progress in type, ease and safety of feeding, and range of diet. As an example, a case of an unusually severe disorder of a CP opening subsequent to brainstem meningoencephalitis is described. The bedside clinical evaluation, otolaryngologic findings, and radiographic studies helped determine an individualized program of swallowing therapy. Therapy goals, direct and indirect therapeutic strategies, and the treatment outcome are presented. Ninety percent of patients with CP dysfunction improved with swallowing therapy, 65% by objective and 25% by subjective criteria. We conclude that in neurological patients with CP, dysfunction can effectively be treated with swallowing therapy and that surgical approaches to CP dysfunction should be deferred pending the outcome of conservative management.     

Awareness of Dysphagia by Patients Following Stroke Predicts Swallowing Performance

Patients awareness of their disability after stroke represents an important aspect of functional recovery. Our study aimed to assess whether patient awareness of the clinical indicators of dysphagia, used routinely in clinical assessment, related to an appreciation of a swallowing problem and how this awareness influenced swallowing performance and outcome in dysphagic stroke patients. Seventy patients were studied 72 h post hemispheric stroke. Patients were screened for dysphagia by clinical assessment, followed by a timed water swallow test to examine swallowing performance. Patient awareness of dysphagia and its significance were determined by detailed question-based assessment. Medical records were examined at three months. Dysphagia was identified in 27 patients, 16 of whom had poor awareness of their dysphagic symptoms. Dysphagic patients with poor awareness drank water more quickly (5 ml/s vs. <1 ml/s, p = 0.03) and took larger volumes per swallow (10 ml vs. 6 ml, p = 0.04) than patients with good awareness. By comparison, neither patients with good awareness or poor awareness perceived they had a swallowing problem. Patients with poor awareness experienced numerically more complications at three months. Stroke patients with good awareness of the clinical indicators of dysphagia modify the way they drink by taking smaller volumes per swallow and drink more slowly than those with poor awareness. Dysphagic stroke patients, regardless of good or poor awareness of the clinical indicators of dysphagia, rarely perceive they have a swallowing problem. These findings may have implications for longer-term outcome, patient compliance, and treatment of dysphagia after stroke. This work was presented in abstract form at the Dysphagia Research Society meeting, Burlington, Vermont, 1999     

Initial Clinical and Demographic Predictors of Swallowing Impairment Following Acute Stroke

Swallowing impairment (dysphagia) is a frequent sequela of acute stroke; however, the ability to accurately detect dysphagia at the bedside and predict which patients may be at risk of dysphagic complications, such as aspiration, remains limited. Despite this, clinical assessment batteries continue to be the first point of assessment for acute dysphagia. We examined the predictive value of clinical factors suggestive of swallowing dysfunction in an attempt to identify the important independent clinical signs at initial presentation that are associated with dysphagia, aspiration, and the combined variable aspiration and/or penetration (ASPEN) in acute stroke patients. For the purposes of this study, dysphagia was defined as a disorder of bolus flow. Aspiration was defined as entry of swallowed material below the level of the true vocal cords which was not expectorated. The clinical items identified as independent predictors of dysphagia (measured radiographically) at initial presentation were age > 70 years, male gender, disabling stroke (Barthel score < 60), palatal weakness or asymmetry, incomplete oral clearance, and impaired pharyngeal response (cough/gurgle). The clinical predictors of aspiration (determined radiographically) at initial presentation were delayed oral transit and incomplete oral clearance. Incorporating clinical signs, such as those identified by this study, into clinical assessments of swallowing impairment may increase their predictive utility.     

Effect of Citric Acid and Citric Acid–Sucrose Mixtures on Swallowing in Neurogenic Oropharyngeal Dysphagia

The ability of sour and sweet–sour mixtures to improve swallowing in 11 nursing home residents with neurogenic oropharyngeal dysphagia was investigated using fiberoptic endoscopic evaluation of swallowing. Citric acid (2.7%) significantly reduced aspiration and penetration compared with water. Teaspoon delivery of liquids significantly reduced aspiration and penetration compared with natural cup drinking. Subjects tended to appropriately self-regulate the cup volume they consumed after the first trial. A significant increase in spontaneous dry swallows was observed after both taste stimuli. The mechanisms for improved swallowing due to citric acid are not understood but may be due to increased gustatory and trigeminal stimulation of acid to the brainstem in neurologically impaired subjects. This research was conducted in partial fulfillment of the requirements for a PhD by CAP at Cornell University.     

Swallowing in torticollis before and after rhizotomy

To determine risk factors for dysphagia after ventral rhizotomy, videofluoroscopic barium swallowing examinations were done on 41 spasmodic torticollis patients before and after surgery. Radiologic abnormalities were present in 68.3% of the patients before surgery, but these were only mildly abnormal in the majority. After surgery 95.1% showed radiologic abnormalities which were moderate or severe in one-third of the patients. Swallowing abnormalities correlated significantly with duration of torticollis and subjective complaints of swallowing difficulty both before and after surgery, but not with age, sex, or type of torticollis. The major acute postoperative finding was aggravation of preexisting pharyngeal dysfunction. Follow-up from about half of our original sample showed that gradual improvement occurred from 4 to 24 weeks after surgery by subjective report. We review the innervation of intrinsic and extrinsic pharyngeal musculature, and suggest that C1–3 rhizotomies and selective sectioning of the spinal accessory nerve are responsible for aggravation of pharyngeal swallowing dysfunction in the acute postsurgical period.     

Fiberoptic Endoscopic Evaluation of Swallowing with Sensory Testing (FEESST) in Healthy Controls

The purpose of this study was to introduce a new method of bedside assessment of both the motor and sensory components of swallowing called fiberoptic endoscopic evaluation of swallowing with sensory testing (FEESST). This approach combines the established bedside endoscopic swallowing evaluation with a more recently described technique that allows objective determination of laryngopharyngeal (LP) sensory discrimination thresholds by delivering air pulse stimuli to the mucosa innervated by the superior laryngeal nerve via a flexible endoscope. A prospective study was conducted of FEESST in 20 healthy control subjects, mean age of 34 ± 11 years. LP sensory thresholds were defined as either normal (<4.0 mmHg air pulse pressure [APP]), moderate deficit (4.0–6.0 mmHg APP), or severe deficits (>6.0 mmHg APP). Subsequent to LP sensory testing, food of varying consistencies, mixed with green food coloring, was given and attention was paid to spillage, laryngeal penetration, pharyngeal residue, aspiration, and reflux. Therapeutic maneuvers such as postural changes and airway protection techniques were performed on each subject to determine if the assessed swallowing parameters were affected by maneuvers. All patients completed the study; all had normal LP sensory discrimination thresholds (2.9 ± 0.7 mmHg APP). There were no instances of spillage, laryngeal penetration, or aspiration. Two of 20 subjects had pharyngeal residue and 2 of 20 had reflux. Institution of therapeutic maneuvers resulted in a predictable change in the endoscopic view of the laryngopharyngeal anatomy. FEESST provides comprehensive, objective sensory and motor information about deglutition in the bedside setting and might have implications for the bedside diagnosis and management of patients with dysphagia.