电视透视吞咽检查定量评价脑干梗死患者吞咽障碍特点的临床研究

目的 采用电视透视吞咽检查（VFSS）数字化分析方法,定量分析脑干梗死后吞咽障碍患者吞咽障碍的特点,并分析各项参数与误吸严重程度的相关性。 方法 采用吞咽造影数字化分析方法采集脑干梗死后吞咽障碍患者12例（患者组）和健康受试者10例（健康组）的VFSS影像资料,每例受检者按要求1次性吞咽浓流质5ml,每例完成2次吞咽。分析的参数包括口腔运送时间（OTT）,吞咽反应时间（SRT）,舌骨运动时间（HMT）,食道上括约肌开放时间（UOT）,喉关闭时间（LCT）;同时采用8分制渗漏误吸量表（PAS）评估患者误吸严重程度,并分析各项参数与误吸严重程度的相关性。 结果 患者组的OTT［（3.091±1.803）s］、HMT［（1.498±0.550）s］、LCT［（0.651±0.186）s］与健康组比较,均显著延长,差异均有统计学意义（P<0.05）,且SRT与误吸严重程度呈正相关（r=0.440,P=0.032）。 结论 脑干梗死患者的吞咽障碍表现涉及口腔期及咽期。OTT、HMT、LCT等参数可用于脑干梗死后吞咽障碍的评估,SRT可用于预测误吸的发生。     

How Thick Is Thick? Multicenter Study of the Rheological and Material Property Characteristics of Mealtime Fluids and Videofluoroscopy Fluids

Objective rheological assessment of fluids given to dysphagic patients at mealtime and during videofluoroscopy was carried out using a multicenter format. Thin, quarter-thick, half-thick and full-thick fluids were examined for the degree of correlation between mealtime fluids and their allegedly matched videofluoroscopy counterparts. The study was carried out to determine whether perceived subjective differences between mealtime fluids and videofluoroscopy fluids could be quantified using the rheological parameters of viscosity, density, and yield stress. The results showed poor correlation between mealtime fluids and videofluoroscopy fluids over all parameters. In general, the videofluoroscopy fluids were more viscous, more dense, and showed higher yield stress values than their mealtime counterparts. Given these results, it is reasonable to assume that the fluids used during videofluoroscopy do not provide an accurate indication of swallowing ability at mealtime. Therefore, it is suggested that clinicians use objective methods to rheologically match videofluoroscopy fluids to mealtime fluids.     

Kinematic pharyngeal transit times in myopathy: Evaluation for dysphagia

Measurement of kinematic pharyngeal transit times, a new videofluoroscopy technique, provides useful quantitative data to supplement the qualitative data previously available from videofluoroscopy swallowing studies. Kinematic pharyngeal transit times have not previously been reported for subjects with myopathy. This study demonstrates the use of quantitative kinematic pharyngeal transit times for dysphagia evaluation in 15 patients with myopathy. The successful treatment of dysphagia by cricopharyngeal myotomy is reported in two patients with limb-girdle syndrome.     

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.     

Evaluating Swallowing Dysfunction Using a 100-ml Water Swallowing Test

This study used comparison with videofluoroscopic examination of swallowing (VFES) to examine the validity of a 100-ml water swallowing test (WST) in assessing swallowing dysfunction. Fifty-nine consecutive outpatients (15 females, 44 males) with clinically suspected dysphagia were enrolled in this study. Each subject underwent a 100-ml WST followed by VFES. Data was obtained on swallowing speed and signs of choking (coughing and a wet-hoarse voice). The analytical results revealed that 49 subjects had abnormal swallowing speeds (< 10 ml/s) in the 100-ml WST, and 47 of them were identified as having dysphagia by VFES. Among the ten participants with normal swallowing speed (> 10 ml/s), eight were diagnosed with dysphagia by VFES. Notably, 14 participants choked in the 100-ml WST, 11 of whom exhibited aspiration or penetration in VFES. Among the 45 participants without choking in WST, 12 displayed aspiration or penetration in VFES. The sensitivity of swallowing speed in detecting the swallowing dysfunction was 85.5%, and the specificity was 50%. Moreover, the sensitivity of using choking or wet-horse voice in the 100-ml WST as the sole factor for predicting the presence of aspiration was 47.8%, while the specificity was 91.7%. Therefore, this study concluded that swallowing speed is a sensitive indicator for identifying patients at risk for swallowing dysfunction. Moreover, choking in the 100-ml WST may be a potential specific indicator for followup aspiration.     

Dysphagia and aspiration after chemoradiotherapy for head-and-neck cancer: which anatomic structures are affected and can they be spared by IMRT?

PURPOSE: To identify the anatomic structures whose damage or malfunction cause late dysphagia and aspiration after intensive chemotherapy and radiotherapy (RT) for head-and-neck cancer, and to explore whether they can be spared by intensity-modulated RT (IMRT) without compromising target RT. METHODS AND MATERIALS: A total of 26 patients receiving RT concurrent with gemcitabine, a regimen associated with a high rate of late dysphagia and aspiration, underwent prospective evaluation of swallowing with videofluoroscopy (VF), direct endoscopy, and CT. To assess whether the VF abnormalities were regimen specific, they were compared with the VF findings of 6 patients presenting with dysphagia after RT concurrent with high-dose intra-arterial cisplatin. The anatomic structures whose malfunction was likely to cause each of the VF abnormalities common to both regimens were determined by literature review. Pre- and posttherapy CT scans were reviewed for evidence of posttherapy damage to each of these structures, and those demonstrating posttherapy changes were deemed dysphagia/aspiration-related structures (DARS). Standard three-dimensional (3D) RT, standard IMRT (stIMRT), and dysphagia-optimized IMRT (doIMRT) plans in which sparing of the DARS was included in the optimization cost function, were produced for each of 20 consecutive patients with advanced head-and-neck cancer. RESULTS: The posttherapy VF abnormalities common to both regimens included weakness of the posterior motion of the base of tongue, prolonged pharyngeal transit time, lack of coordination between the swallowing phases, reduced elevation of the larynx, and reduced laryngeal closure and epiglottic inversion, contributing to a high rate of aspiration. The anatomic structures whose malfunction was the likely cause of each of these abnormalities, and that also demonstrated anatomic changes after RT concurrent with gemcitabine doses associated with dysphagia and aspiration, were the pharyngeal constrictor muscles (median thickness near midline 2.5 mm before therapy vs. 7 mm after therapy; p = 0.001), the supraglottic larynx (median thickness, 2 mm before therapy vs. 4 mm after therapy; p < 0.001), and, similarly, the glottic larynx. The constrictors and the glottic and supraglottic larynx were, therefore, deemed the DARS. The lowest maximal dose delivered to a stricture volume was 50 Gy. Reducing the volumes of the DARS receiving > or =50 Gy (V(50)) was, therefore, a planning and evaluation goal. Compared with the 3D plans, stIMRT reduced the V(50) of the pharyngeal constrictors by 10% on average (range, 0-36%, p < 0.001), and doIMRT reduced these volumes further, by an additional 10% on average (range, 0-38%; p <0.001). The V(50) of the larynx (glottic + supraglottic) was reduced marginally by stIMRT compared with 3D (by 7% on average, range, 0-56%; p = 0.054), and doIMRT reduced these volumes by an additional 11%, on average (range, 0-41%; p = 0.002). doIMRT reduced laryngeal V(50) compared with 3D, by 18% on average (range 0-61%; p = 0.001). Certain target delineation rules facilitated sparing of the DARS by IMRT. The maximal DARS doses were not reduced by IMRT because of their partial overlap with the targets. stIMRT and doIMRT did not differ in target doses, parotid gland mean dose, spinal cord, or nonspecified tissue maximal dose. CONCLUSIONS: The structures whose damage may cause dysphagia and aspiration after intensive chemotherapy and RT are the pharyngeal constrictors and the glottic and supraglottic larynx. Compared with 3D-RT, moderate sparing of these structures was achieved by stIMRT, and an additional benefit, whose extent varied among the patients, was gained by doIMRT, without compromising target doses. Clinical validation is required to determine whether the dosimetric gains are translated into clinical ones.     

Interrater Reliability of Videofluoroscopic Swallow Evaluation

Abstract The past two decades have brought an enormous widening of interest in and knowledge about swallowing disorders. The most frequently used technique for swallow evaluation is X-ray videofluoroscopy. Most interventions are based on this examination. Only a few studies assessing interobserver reliability of videofluoroscopy have been published. The aim of our study was to assess the interobserver reliability of videofluoroscopy for swallow evaluation. Fifty-one consecutive dysphagic patients referred for videofluoroscopy were entered into the study regardless of their underlying disorder. The first swallow (5 ml of a semisolid radio-opague contrast media) of each patient was assessed in the lateral projection by 9 independent, experienced observers from different international swallow centers. All studies were evaluated according to a standardized protocol sheet and the interobserver reliability was calculated. The interobserver reliabilities assessed as kappa coefficient for parameters of the oral and pharyngeal phase, for the temporal occurrence of penetration/aspiration, and for the location of bolus residue ranged from 0.01 to 0.56. High reliability with an intraclass coefficient of 0.80 was achieved only with the well defined penetration/aspiration score. Our study underlines the need for exact definitions of the parameters assessed by videofluoroscopy, in order to raise interobserver reliability. To date, only aspiration is evaluated with high reliability by videofluoroscopy, whereas the reliability of all other parameters of oropharyngeal swallow is poor.     

针刺结合神经肌肉电刺激对脑卒中后咽期吞咽障碍的影响

目的:观察针刺结合神经肌肉电刺激对脑卒中后咽期吞咽障碍患者康复的影响。方法:按随机数字表法将40例脑卒中患者分为2组各20例,对照组给予常规药物治疗、吞咽功能训练和神经肌肉电刺激,观察组在对照组的基础上给予针刺治疗。治疗前后采用表面肌电分析(记录sEMG最大波幅)、透视吞咽功能检查(VFSS)对患者吞咽功能进行评价。结果:治疗20d后,2组患者的sEMG最大波幅、VFSS总评分及咽期VFSS评分明显高于治疗前(P0.05),且观察组更高于对照组(P0.05)。结论:针刺结合神经肌肉电刺激能明显提高脑卒中后咽期吞咽障碍患者的康复效果。     

Radiation Dose in Videofluoroscopic Swallow Studies

Videofluoroscopy has become an increasingly important armament in the investigation and assessment of swallowing disorders. However, very little work has been published on the radiation dose used in such examinations and currently there is no national diagnostic reference level in the United Kingdom. Videofluoroscopy in our hospital is performed predominantly by one radiologist (IZM) in a single fluoroscopy room. We recorded the screening times of 230 patients over a 45-month period. Screening time ranged from 18 to 564 s (median = 171 s) associated with a median dose-area product of 1.4 Gy cm². This is below the third quartile level of 2.7 Gy cm² for all such examinations performed across the northern England. The effective dose associated with a typical videofluoroscopy dose-area product is 0.2 mSv. Videofluoroscopy is the most appropriate instrumental examination for assessing oropharyngeal swallow biomechanics and intervention strategies. This data set is based on the largest number of videofluoroscopy swallow studies published to date. Our results show that videofluoroscopy can be performed using minimal radiation doses. This study was performed at Freeman Hospital, Newcastle upon Tyne, UK.