Quetiapine-associated dysphagia

We report a case of quetiapine-induced dysphagia in a geriatric patient which improved with discontinuation of the antipsychotic. The patient had developed dysphagia while being treated with antipsychotics for bipolar disorder. The patient's dysphagia showed significant improvement when she was taken off quetiapine. We review the available literature on antipsychotic-related dysphagia and suggest that clinicans need to be aware of the potential for this syndrome even with lower potency antipsychotics.     

Pathophysiology of oropharyngeal dysphagia in the frail elderly

Background Oropharyngeal dysphagia is a major complaint among the elderly. Our aim was to assess the pathophysiology of oropharyngeal dysphagia in frail elderly patients (FEP). Methods A total of 45 FEP (81.5 ± 1.1 years) with oropharyngeal dysphagia and 12 healthy volunteers (HV, 40 ± 2.4 years) were studied using videofluoroscopy. Each subject’s clinical records, signs of safety and efficacy of swallow, timing of swallow response, hyoid motion and tongue bolus propulsion forces were assessed. Key Results Healthy volunteers presented a safe and efficacious swallow, faster laryngeal closure (0.157 ± 0.013 s) upper esophageal sphincter opening (0.200 ± 0.011 s), and maximal vertical hyoid motion (0.310 ± 0.048 s), and stronger tongue propulsion forces (22.16 ± 2.54 mN) than FEP. By contrast, 63.63% of FEP presented oropharyngeal residue, 57.10%, laryngeal penetration and 17.14%, tracheobronchial aspiration. Frail elderly patients with impaired swallow safety showed delayed laryngeal vestibule (LV) closure (0.476 ± 0.047 s), similar bolus propulsion forces, poor functional capacity and higher 1‐year mortality rates (51.7%vs 13.3%, P = 0.021) than FEP with safe swallow. Frail elderly patients with oropharyngeal residue showed impaired tongue propulsion (9.00 ± 0.10 mN), delayed maximal vertical hyoid motion (0.612 ± 0.071 s) and higher (56.0%vs 15.8%, P = 0.012) 1‐year mortality rates than those with efficient swallow. Conclusion & Inferences Frail elderly patients with oropharyngeal dysphagia presented poor outcome and high mortality rates. Impaired safety of deglutition and aspirations are mainly caused by delayed LV closure. Impaired efficacy and residue are mainly related to weak tongue bolus propulsion forces and slow hyoid motion. Treatment of dysphagia in FEP should be targeted to improve these critical events.     

Ethical issues in the management of dysphagia after stroke

When patients have severe dysphagia after a stroke, tube feeding may be recommended to reduce the risks associated with malnutrition, dehydration, and/or aspiration. Patients may not be able to participate in decision making, but they may have previously expressed strong preferences related to tube feeding. Clinicians must work together with the family to establish a treatment plan that is respectful of the person's previous wishes, yet mindful of the flaws in advance care planning. Although ethical issues cannot be avoided, clinicians can reduce uncertainty by understanding current ethical and legal views on these challenging issues.     

Cough responsiveness in neurogenic dysphagia

OBJECTIVES—In neurogenic dysphagia a good cough is important for airway protection. If triggering of cough, or its effectiveness, is impaired this might result in an increased aspiration risk. Capsaicin, an agent which induces cough through sensory nerve stimulation, was used to test cough sensitivity in groups of patients with and without neurogenic dysphagia.
METHODS—On the basis of swallowing speed (ml/s) in a validated water test 28 alert neurological inpatients (16 women, aged 22-71 years) were classified into 13 with abnormal and 15 with normal swallowing (median swallowing speed 23% and 99%, median volume/swallow 43% and 106% of that predicted for age and sex respectively: p<0.001). Capsaicin nebulised on air in saline was inhaled via a low resistance valve using a mouthpiece and noseclip. Up to seven incremental concentrations of capsaicin ranging from 0.07-20.0 × 10⁻⁴ mol/l were each inhaled for up to a minute. A pneumotachograph connected to the expiratory limb gave a paper recording of expiratory air flow. Coughs were recorded as high flow expirations of short duration. Capsaicin concentrations at first cough (threshold) were recorded; concentrations at frequencies of 10 and 20 coughs/minute were interpolated from the dose-reponse curve.
RESULTS—Cough threshold tended to be lower in those with abnormal swallowing (non-significant): the (log) concentration of capsaicin producing 10 or 20 coughs/minute also tended to be lower (p=0.12 and 0.07 respectively) in those with abnormal swallowing.
CONCLUSION—Contrary to expectation, these results suggest that cough responsiveness is enhanced in alert patients with neurogenic dysphagia even after allowing for diagnostic category, the possible presence of a bulbar upper motor neuron lesion, or voluntary respiratory capacity. It is concluded that these patients with neurogenic dysphagia do not have a reduced sensitivity of cough triggering.

     

Oropharyngeal dysphagia in polymyositis/dermatomyositis

The nature of the oropharyngeal dysphagia in polymyositis/dermatomyositis (PM/DM) has been investigated by EMG methods. Nineteen patients with PM/DM were studied. The oropharyngeal phase of swallowing was evaluated by the electrophysiological methods measuring the laryngeal relocation time, pharyngeal transit time and the triggering of the pharyngeal phase of swallowing reflex. The EMG of cricopharyngeal muscle of the upper esophageal sphincter was also recorded in 10 patients. The patients have been compared with a group of 22 healthy controls matched with age and gender. Dysphagia limit was also measured for all patients and control subjects. Fourteen out of 19 patients could not swallow 20 ml or less amount of water at one go and divided the bolus into two or more pieces (piecemeal deglutition) in comparison to normal subjects. In PM/DM patients, the triggering of the swallowing reflex for the voluntarily initiated swallow was normal while the pharyngeal phase of swallowing was significantly prolonged. The cricopharyngeal sphincter muscle EMG demonstrated severe abnormalities in halves of the patients investigated. These findings demonstrated the weakness of the striated oropharyngeal muscles. Cricopharyngeal sphincter muscle was affected less frequently and showed either hyperreflexic or hyporeflexic states during swallowing. It is concluded that the pharyngeal stage of oropharyngeal swallowing is mainly involved in patients with PM/DM.     

Detecting dysphagia in inclusion body myositis

Dysphagia is an important yet inconsistently recognized symptom of inclusion body myositis (IBM). It can be disabling and potentially life-threatening. We studied the prevalence and symptom-sign correlation of dysphagia. Fifty-seven IBM patients were interviewed using a standard questionnaire for dysphagia and 43 of these underwent swallowing videofluoroscopy (VFS). Symptoms of dysphagia were present in 37 of 57 patients (65%). Nevertheless, only 17 of these patients (46%) had previously and spontaneously complained about swallowing to their physicians. Both symptoms of impaired propulsion (IP) (59%) and aspiration-related symptoms (52%) were frequently mentioned. Swallowing abnormalities on VFS were present in 34 of 43 patients (79%) with IP of the bolus in 77% of this group. The reported feeling of IP was confirmed by VFS in 92% of these patients. Dysphagia in IBM is common but underreported by the vast majority of patients if not specifically asked for. In practice, two questions reliably predict the presence of IP on VFS: ‘Does food get stuck in your throat’ and ‘Do you have to swallow repeatedly in order to get rid of food’. These questions are an appropriate means in selecting IBM patients for further investigation through VFS and eventual treatment.     

Investigation and management of dysphagia

Dysphagia is a common finding in infants and children with neuromuscular disabilities. Dysphagia may be developmental, as in the preterm infant, transient, chronic, or progressive. The evaluation of dysphagia must take into account the age of the patient and typical development of feeding and swallowing for that age. The typical abilities seen in neonatal, early infancy, later infancy and early childhood periods vary in sensorimotor skills and feeding efficiency. In addition to knowing the substrate of expected skills by age, knowledge of the neurophysiology of feeding and swallowing is essential to diagnosis. Each physiologic phase of deglutition: oral, pharyngeal, and esophageal can present with symptoms of dysphagia that can guide investigation. Common symptoms of dysphagia include generalized feeding difficulty such as poor efficiency, food refusal and failure to thrive. Specific symptoms include tongue thrust, choking, cough, and oxygen desaturation. The possibility of dysphagia can be identified through a thorough feeding history. Examination initially includes the infant’s muscle tone and posture in the head, neck and body. Anomalies of structures of the head and neck must be identified and examined for their effect on function. Next, examination of oral structures for reflexes, tongue movements, and symmetry will identify neurologic abnormalities. Observation of feeding is essential and will reveal signs of dysphagia. Aspiration in the infant can present without specific signs. Respiratory abnormalities or Gastroesophageal reflux can be identified during history or examination. Investigation of dysphagia most commonly includes videofluoroscopy, endoscopy, and ultrasonography. The management of dysphagia requires an individualized approach and will include neurologic, respiratory, nutritional and possibly gastrointestinal management. Six broad areas are identified that must be considered in the management of dysphagia in infants and children. They include: normalization of posture and positioning, adaptation of foods and feeding equipment, oromotor therapy, feeding therapy, nutritional support and management of associated disorders. A team of professionals will assist the parent and child in achieving pleasant feedings to foster appropriate growth and development.     

康复训练治疗急性脑梗死患者吞咽困难的疗效观察

目的 观察脑卒中合并吞咽困难患者康复训练的疗效.方法 将96例脑卒中伴吞咽困难患者随机分为康复训练组和对照组,2组均给予常规药物治疗,康复训练组给予吞咽康复训练,在康复训练前及康复训练后分别进行吞咽功能评定,并观察患者体质量、吸入性肺炎、住院天数等情况.结果 康复训练组吞咽功能改善总有效率高于对照组(P<0.05),行康复治疗可降低吸入性肺炎发生率、缩短住院天数.结论 早期康复训练可以改善高脑卒中患者的吞咽功能.     

脑卒中后吞咽障碍的认知训练治疗

目的分析脑卒中后吞咽障碍的认知训练治疗效果。方法以2014-01—2017-03新乡市第一人民医院收治的82例脑卒中后吞咽障碍患者为研究对象,根据随机数字表法分为对照组和观察组,其中对照组仅应用常规康复训练治疗,而观察组在康复训练时增加认知训练治疗,经过3个月、6个月、9个月、12个月治疗后,评价2组MMSE、ADL评分情况。结果治疗后,观察组3个月、6个月、9个月、12个月的MMSE和ADL评分明显优于对照组,2组对比差异有统计学意义(P0.05)。结论脑卒中吞咽障碍患者常规康复训练过程中增加认知训练后,可以明显改善患者的认知功能,使患者病情进展得到有效控制,从而提高患者的生活质量,值得推广应用。     

Experience of using electromyography of the genioglossus in the investigation of paediatric dysphagia

Aim  The aim of the study was to assess, retrospectively, the utility of genioglossus electromyography (gEMG) in evaluating children with suspected neurogenic feeding and swallowing difficulties. Method  Children who were evaluated using gEMG at a tertiary paediatric neurology dysphagia service were reviewed. Data were analysed by the presence/absence of neurogenic changes on gEMG and the method of feeding at their most recent follow‐up. Results  The study group comprised 59 individuals (36 males, 23 females; median age 20mo; range 1mo–15y). The study cohort included individuals with heterogeneous neurological phenotypes (n=40), craniofacial syndrome (n=10), and congenital bulbar palsy (n=9). gEMG identified 35 out of 59 (60%) with neurogenic changes. At follow‐up, 24 individuals were on oral feeds and 35 were on alternative methods of feeding (nasogastric /gastrostomy). Eight out of 24 children on oral feeds showed neurogenic changes compared with 27 out of 35 on alternative feeds. χ² analysis of feeding method at follow‐up and the presence or absence of neurogenic change on EMG was highly significant (p≤0.002). When confounding factors for alternative feeds were accounted for on univariate analysis, the neurogenic changes, severe gastro‐oesophageal reflux disease, and respiratory comorbidities were statistically significant in predicting the alternative feeding, whereas growth failure and behavioural difficulties were not significant confounders. Moreover, multiple logistic regression analysis revealed that the neurogenic changes were independently predictive of an alternative method of feeding after adjusting for other confounders with an odds ratio of 29.6 (95% confidence interval 3.97–220; p<0.007). Conclusion  gEMG is a valuable complementary tool in the evaluation of children with neurogenic dysphagia as the degree of severity is independently correlated with long‐term feeding outcomes.     

The DYMUS questionnaire for the assessment of dysphagia in multiple sclerosis

Swallowing problems can be relevant, even if underestimated, in Multiple Sclerosis (MS) patients. However, no specific questionnaire for the assessment of dysphagia in MS is available.

We built a questionnaire (DYsphagia in MUltiple Sclerosis, DYMUS) that was administered to 226 consecutive MS patients (168 F, 58 M, mean age 40.5 years, mean disease duration 10.1 years, mean EDSS 3.1) during control visits in four Italian MS Centres. DYMUS was abnormal in 80 cases (35%).

The patients who claimed to have swallowing problems had a significantly higher mean DYMUS score that the other patients (p < 0.0001). Mean DYMUS scores were significantly higher in the progressive forms (p = 0.003). DYMUS values were significantly correlated to EDSS (p = 0.0007).

DYMUS showed a very good internal consistency (Cronbach's alpha 0.877). Factor analysis allowed us to sub-divide DYMUS in two sub-scales, ‘dysphagia for solid’ and ‘dysphagia for liquid’, both of them had a very good internal consistency (Cronbach's alpha 0.852 and 0.870 respectively).

DYMUS demonstrated to be an easy and consistent tool to detect dysphagia and its main characteristics in MS. It can be used for preliminary selection of patients to submit to more specific instrumental analyses, and to direct toward programs for prevention of aspiration.     

Assessment of dysarthria and dysphagia in ALS patients

Swallowing and speech disorders are the dramatic consequences of bulbar and pseudo-bulbar syndrome in ALS. Evaluation is necessary to guide speech therapy and to measure the effects of treatment. This article revues the different examinations used to assess bulbar and pseudobulbar involvement in an ALS patient: oromotor assessment, evaluation of the functions with self assessment, perceptive and objective evaluation of speech disorders, fiberoptic endoscopic evaluation of dysphagia (FEES) and videofluoroscopy.     

脑卒中后吞咽困难的影像学分析

目的明确脑卒中后吞咽困难在X线透视影像学上的表现及特点.方法对56例脑卒中后吞咽困难患者及30名健康志愿者进行X线电视透视检查,记录异常表现,测量定量参数.统计方法采用秩和检验、t检验、卡方检验及Logistic回归分析.结果脑卒中后所有吞咽器官都表现功能异常,口期吞咽异常者46例,咽期异常者56例.与正常组对照,误吸组喉上抬幅度、速度降低,环咽肌打开宽度减少,吞咽潜伏期延长.34例存在误吸.误吸与舌运动减弱（P=0.021）、舌与硬腭接触不良（P=0.021）、声门关闭不全（P=0.011）、喉上抬慢且幅度降低（P=0.003）、吞咽延迟（P=0.001）及穿透（P=0.000）有关.结论脑卒中可损伤所有参与吞咽的器官,咽期吞咽更易受损,舌肌无力、声门关闭不全、喉结构上抬差及吞咽延迟可造成误吸.     

Ptosis aggravates dysphagia in oculopharyngeal muscular dystrophy

BACKGROUND: Ptosis and dysphagia are important features in oculopharyngeal muscular dystrophy (OPMD). OBJECTIVE: Retroflexion of the head is a well known compensatory mechanism for ptosis, but generally retroflexion has a negative effect on swallowing. We hypothesised that severity of ptosis is related to degree of retroflexion and that this compensation is responsible for deteriorating dysphagia. METHODS: Nine OPMD patients were examined in the conditions "head position adapted to ptosis" and "head position slightly flexed". Ptosis was quantified by photogrammetry and retroflexion of the head by digital photographs. The severity of dysphagia was measured using visual analogue scales (VAS) and by calculating swallowing volumes and oropharyngeal swallow efficiency (OPSE) based on videofluoroscopy. RESULTS: Statistical analyses show a significant relationship between ptosis and degree of retroflexion. The degree of retroflexion of the head correlated significantly with VAS scores and with the maximum swallowing volume. The slightly flexed head position significantly improved VAS scores as well as swallowing volumes and OPSE. CONCLUSION: In OPMD patients, ptosis significantly correlates with retroflexion of the head, which has a negative effect on swallowing. Subjective and objective reduction of swallowing problems was found when patients were instructed to eat and drink with a slightly flexed head position.     

Early predictors of dysphagia in ischaemic stroke patients

Background and purpose

Post-stroke dysphagia affects outcome. In acute stroke patients, the aim was to evaluate clinical, cognitive and neuroimaging features associated with dysphagia and develop a predictive score for dysphagia.

Methods

Ischaemic stroke patients underwent clinical, cognitive and pre-morbid function evaluations. Dysphagia was retrospectively scored on admission and discharge with the Functional Oral Intake Scale.

Results

In all, 228 patients (mean age 75.8 years; 52% males) were included. On admission, 126 (55%) were dysphagic (Functional Oral Intake Scale ≤6). Age (odds ratio [OR] 1.03, 95% confidence interval [CI] 1.00–1.05), pre-event modified Rankin scale (mRS) score (OR 1.41, 95% CI 1.09–1.84), National Institutes of Health Stroke Scale (NIHSS) score (OR 1.79, 95% CI 1.49–2.14), frontal operculum lesion (OR 8.53, 95% CI 3.82–19.06) and Oxfordshire total anterior circulation infarct (TACI) (OR 1.47, 95% CI 1.05–2.04) were independently associated with dysphagia at admission. Education (OR 0.91, 95% CI 0.85–0.98) had a protective role. At discharge, 82 patients (36%) were dysphagic. Pre-event mRS (OR 1.28, 95% CI 1.04–1.56), admission NIHSS (OR 1.88, 95% CI 1.56–2.26), frontal operculum involvement (OR 15.53, 95% CI 7.44–32.43) and Oxfordshire classification TACI (OR 3.82, 95% CI 1.95–7.50) were independently associated with dysphagia at discharge. Education (OR 0.89, 95% CI 0.83–0.96) and thrombolysis (OR 0.77, 95% CI 0.23–0.95) had a protective role. The 6-point “NOTTEM” (NIHSS, opercular lesion, TACI, thrombolysis, education, mRS) score predicted dysphagia at discharge with good accuracy. Cognitive scores had no role in dysphagia risk.

Conclusions

Dysphagia predictors were defined and a score was developed to evaluate dysphagia risk during stroke unit stay. In this setting, cognitive impairment is not a predictor of dysphagia. Early dysphagia assessment may help in planning future rehabilitative and nutrition strategies.     

卒中后吞咽困难预后的预测指标

吞咽困难是脑卒中后常见的症状和严重的并发症,会降低经口摄食的安全性,导致营养不良、吸入性肺炎、高死亡率和不良的卒中预后.准确预测卒中后吞咽困难的恢复情况是临床医生决定喂养模式、采取适当的康复措施和加强并发症防控的关键,但目前这种预测主要依赖于医生的主观经验和风险评估.鉴于缺乏系统的预测方法和指标,本文系统回顾了脑卒中后...     

Electrodiagnostic methods for neurogenic dysphagia

Objective: Swallowing mechanisms and neurogenic dysphagia have not been systematically studied by the EMG technique. It is desirable to evaluate neurogenic dysphagia for diagnostic and possibly for therapeutic purposes using electrophysiological methods.Results: The following methods were described: mechanical upward/downward movements of the larynx were detected using a piezoelectric sensor, while submental integrated EMG activity was recorded during dry and wet swallowing. The EMG activity of cricopharyngeal muscle of the upper oesophageal sphincter was also recorded in some normal subjects and patients. Piecemeal deglutition and the dysphagia limit were determined in all patients to detect dysphagia objectively. In this study 75 normal subjects and 177 neurological patients with various degrees of dysphagia were investigated.Results: Voluntarily triggered oropharyngeal swallowing was commonly pathological in the majority of patients, with or without overt dysphagia. The dysphagia limit appeared to be an objective measure of the degree of dysphagia in more than 90% of patients. Pathophysiological mechanisms were different in at least three groups of patients with neurogenic dysphagia. In the group of patients with muscular disorders, laryngeal elevators were involved while the CP-sphincterwas intact. The second group included patients with the clinical signs of corticobulbar fibre involvement such as amyotrophic lateral sclerosis and pseudobulbar palsy. In these patients, there was incoordination between paretic laryngeal elevators and hyperreflexic CP-sphincter. In the third group (patients with Parkinson's disease), the swallowing reflex was delayed and prolonged.Conclusions: EMG methods described in the present study are very useful for the diagnosis of neurogenic dysphagia, objectively and quickly. They are important to understand the physiological mechanisms for deglutition and its disorders.