Videofluoroscopy of swallowing abnormalities in 22 symptomatic patients after cardiovascular surgery

OBJECTIVE: The aim of this study was to evaluate the types of swallowing abnormalities that occur in symptomatic patients who have undergone cardiovascular surgery. MATERIALS AND METHODS: From 1994 to 2001, 22 patients (17 males and five females; age range, 4-89 years; mean age, 64 years) who had swallowing abnormalities after cardiovascular surgery were referred for a videofluoroscopic swallowing study. Each study was analyzed for functional abnormalities of the tongue, soft palate, epiglottis, hyoid and larynx, pharynx, upper esophageal sphincter, and esophagus. Also, the performance of transesophageal echocardiography, long-term intubation, or both was noted. RESULTS: Swallowing abnormalities were present in 18 patients (81.8%) (range, one to eight functional abnormalities; mean, 3.9 functional abnormalities). The distribution of abnormalities across the functional units statistically significantly deviated (chi(2) = 14.4; df = 6; p = 0.025) from uniform distribution, with abnormalities most commonly involving the hyoid and larynx (13 patients [59.1%]) and the pharynx (10 patients [45.5%]). Aspiration was found in 13 patients (59.1%) (predeglutitive, n = 1; intradeglutitive, n = 4; postdeglutitive, n = 3; and mixed, n = 5). In the 14 patients (63.6%) who underwent transesophageal echocardiography, long-term intubation, or both, we frequently found incomplete tilting of the epiglottis, pharyngeal weakness, and postdeglutitive aspiration. CONCLUSION: Most patients with swallowing problems after cardiovascular surgery present with multiple abnormalities that most commonly affect the hyoid and larynx and the pharynx and result predominantly in intra- or postdeglutitive aspiration. The performance of transesophageal echocardiography and long-term intubation may influence the types of swallowing abnormalities.     

Neurologisch bedingte und neuromuskuläre Funktionsstörungen des Pharynx und Ösophagus

Neurologic swallowing disorders are an increasing diagnostic problem in our overaged population. Undiagnosed chronic aspiration pneumonia is the cause of death in 20-40% of all inhabitants of nursing homes. In neurologic diseases of the pharynx, the physiologic interaction of pharyngeal contraction, closure of the pharynx, and esophageal motility are frequently disturbed. This may be due to cortical, bulbar, or cerebellar brain damage of ischemic or traumatic origin. Furthermore diseases or peripheral nerves, muscles, and synapses cause disturbances. The most life-threatening complication of these disturbances is tracheal aspiration, which requires an iso-osmolar contrast medium for imaging studies that cause no or minimal pulmonary problems. Utilizing fast dynamic documentation we can analyze the swallowing act in 35 images within the passage time of 0.7 s.This requires digital frame sequences from 15-50 images/s, which can be provided by DSI or videofluoroscopy. Neurologic and neuromuscular patterns are demonstrated with and without tracheal aspiration. The differentiation of aspiration in a so-called pre-, intra-, and postdeglutitive form is possible. We distinguish four grades of severity of aspiration, which is also of great clinical impact for the differential rehabilitation therapy. The efficiency of the rehabilitation protocol can be assessed by the dynamic swallowing studies.     

Morphological findings in dynamic swallowing studies of symptomatic patients

The aim of this study was to assess the role of videofluoroscopy in the detection of structural abnormalities of the pharynx and esophagus in patients with different symptoms of impaired deglutition. Dynamic radiographic recording of deglutition was performed in 3193 consecutive patients (1578 men, 1615 women; mean age 54 years) suffering from dysphagia, suspicion of aspiration, globus sensation, and non-cardiac chest pain. We assessed different structural lesions from the oral cavity to the esophagus and classified them into eight categories. Their frequency and association with the different clinical symptoms were evaluated. Videofluoroscopy revealed 1040 structural abnormalities in 833 patients (26%) including mass lesions from the oral cavity to hyoid/larynx ( n=66), pharyngeal diverticula ( n=181), pharyngeal masses ( n=78), other pharyngeal narrowings ( n=71), webs ( n=98), masses ( n=39), and other narrowings ( n=73) of the upper esophageal sphincter, esophageal diverticula ( n=80), esophageal webs, rings and strictures ( n=194), and intrinsic and extrinsic esophageal lesions ( n=160). There was a considerable variance of findings for different symptoms. In a large proportion of symptomatic patients videofluoroscopy detects morphological abnormalities along pharynx and esophagus often combined with functional disorders. This fact underlines the role of videofluoroscopy as a diagnostic test for function as well as morphology.     

Videofluoroscopic identification of two types of swallowing

Two forms of swallowing were observed during videofluoroscopy in 166 asymptomatic patients, consisting of an air-containing ("open") pharynx in 120 (72%) and an occluded ("closed") pharynx in 46 (28%). The epiglottis inverted differently in the two forms of swallowing.     

Correlation between the radiologic study of deglutition and the clinical picture in systemic sclerosis (scleroderma)

Fifty-one patients with systemic sclerosis (scleroderma) were studied by means of videofluoroscopy in order to evaluate the abnormalities in the oropharyngeal and esophageal phases of deglutition and to correlate the radiological patterns with the clinical features of the disease. Thirteen patients (25.5%) exhibited swallowing disorders such as oral leakage, retention, penetration, mild or moderate aspiration and abnormal upper esophageal sphincter behavior. These dysfunctions were more evident in patients with esophageal motility abnormalities. A normal radiological pattern in the esophagus was not associated with swallowing alterations. Remarkably, patients with oral-pharyngeal disorders had a higher incidence of lung diseases. Forty-five patients (88%) exhibited disorders of the esophageal phase of deglutition, such as mild or severe motility abnormalities or hiatal hernia, gastro-esophageal reflux, reflux esophagitis, and stricture. Radiological findings in the esophagus can be abnormal in the early stages of the disease. On the other hand, the radiological pattern of esophageal motility can be occasionally negative in advanced or extensive disease. This indicates a discrepancy between clinical symptoms and radiological picture of the esophagus. The radiological examination of the oral-pharyngeal and esophageal phases of deglutition is important in patients with scleroderma in order to evaluate visceral involvement, motility disorders, and risk of aspiration. Such radiological information can be useful in preventing esophagitis and pulmonary complications.     

Swallowing abnormalities in multiple sclerosis: correlation between videofluoroscopy and subjective symptoms

Cartilage degenerative diseases, such as osteoarthritis, affect million of people. Magnetic resonance imaging is presently the most accurate imaging modality in evaluating the state of hyaline cartilage; however, clinical MRI does not accurately reveal early degenerative alterations in cartilage, due mainly to low spatial resolution. Magnetic resonance microscopy (MRM, or μMRI) appears exceptionally well suited to the in vitro or ex vivo study of this heterogeneous tissue, due to its high spatial resolution; however, despite this, further studies are necessary to evaluate the potential of MRM in the detection of early cartilage damage. Herein we briefly review the current applications of MRM in the study of hyaline cartilage. In particular, we review the MR appearance of hyaline cartilage on high-resolution images, the different MRM techniques used to image normal and enzymatically or chemically degraded cartilage and the potential use of contrast agents. The future directions and the relevance of MRM findings for a better understanding of cartilage physiology in health and disease are also discussed. Electronic Publication     

Cervical osteophytes impinging on the pharynx: importance of size and concurrent disorders for development of aspiration

OBJECTIVE: This study evaluated the clinical significance of cervical osteophytes impinging on the pharynx in patients with dysphagia and the importance of concurrent disorders that may affect swallowing function. MATERIALS AND METHODS: On videofluoroscopy, anterior cervical osteophytes were found in 55 (32 men, 23 women; mean age, 69 years) of 3318 patients with dysphagia (1.7%). Coexisting diseases that affected swallowing function were found in 28 patients (stroke, n = 7; thyroidectomy, n = 7; tongue base or laryngeal cancer surgery, n = 5; other diseases, n = 9). Swallowing function was assessed with videofluoroscopy evaluating epiglottic tilting, laryngeal closure, impression of the hypopharynx, pharyngeal residue, and aspiration. RESULTS: With advancing age, the probability of aspiration (odds ratio, 1.07; p < 0.05) and of enlarging osteophytes (odds ratio, 1.26; p < 0.01) increased; the probability was higher for osteophytes at more than one vertebrae (odds ratio, 8.00; p < 0.01) and for concurrent diseases (odds ratio, 8.02; p < 0.01). Aspiration was found in 75% of patients with osteophytes larger than 10 mm and in 34% with osteophytes smaller than or equal to 10 mm. In 88% of patients with small osteophytes who aspirated, other diseases affected swallowing function. CONCLUSION: Aspiration is common in patients with dysphagia and cervical osteophytes larger than 10 mm. Aspiration is rare in patients with osteophytes smaller than or equal to 10 mm unless these patients suffer from other disorders that may affect swallowing.     

Assessment of swallowing and its disorders—A dynamic MRI study

Magnetic resonance imaging overcomes the limitations of videofluoroscopy in assessing without radiation exposure. The clinical utility of dynamic MRI for swallowing disorders is not well documented. This study demonstrates the feasibility of using dynamic MRI in assessment of swallowing disorders. Ten normal and three brainstem lesion patients participated in this study. GE Signa HDxt 1.5 Tesla MRI scanner with head-and-neck coil as a receiver and fast imaging employing steady state acquisition sequence was used. The swallow was analyzed in terms of symmetry and amplitude of movements of velum, faucial pillars, tongue, epiglottis and cricopharyngeous and images from the sagittal, coronal and axial planes. In sagittal plane posterior movement of tongue and its compression on velum, elevation of hyoid bone, elevation of larynx and lid action of epiglottis, in the coronal view the symmetrical movements of the faucial pillars and pharyngeal constrictor muscles and in axial plane three anatomical landmarks were targeted based on their role in swallowing, viz. velum, epiglottis and cricopharyngeous were studied. In brainstem lesion individuals, posterior movement of tongue, and elevation of larynx were not seen. Asymmetrical movements of faucial pillars and cricopharyngeous muscle were appreciated in the dynamic MRI. This demonstrates that, dynamic MRI is an efficient tool to understand the swallowing physiology and helps the speech language pathologist in modifying the swallowing maneuvers. Dynamic MRI is an effective tool in assessing swallowing and its disorders. This muscle specific information is not appreciated in videofluoroscopy and this information is necessary to modify the therapy maneuvers.     

Videofluoroscopic assessment of patients with dysphagia: pharyngeal retention is a predictive factor for aspiration.

OBJECTIVE: This study evaluated the clinical significance of pharyngeal retention to predict aspiration in patients with dysphagia. MATERIALS AND METHODS: At videofluoroscopy, pharyngeal retention was found in 108 (28%; 73 males, 35 females; mean age, 60 years) of 386 patients with a suspected deglutition disorder. Swallowing function was assessed videofluoroscopically. The amount of residual contrast material in the valleculae or piriform sinuses was graded as mild, moderate, or severe. The frequency, type, and grade of aspiration were assessed. RESULTS: Pharyngeal retention was caused by pharyngeal weakness or paresis in 103 (95%) of 108 patients. In 70 patients (65%) with pharyngeal retention, postdeglutitive overflow aspiration was found. Aspiration was more often found in patients who had additional functional abnormalities such as incomplete laryngeal closure or impaired epiglottic tilting (p < 0.05). Postdeglutitive aspiration was diagnosed in 25% patients with mild, in 29% with moderate, and in 89% with severe pharyngeal retention (p < 0.05). CONCLUSION: Postdeglutitive overflow aspiration is a frequent finding in patients with pharyngeal retention, and the risk of aspiration increases markedly with the amount of residue. Functional abnormalities other than pharyngeal weakness, such as impaired laryngeal closure, may contribute to aspiration.     

Videofluoroscopy of deglutition in children after repair of esophageal atresia

PURPOSE: To evaluate the functional disorders of the oral and pharyngeal phases of deglutition after repair of esophageal atresia in children. MATERIAL AND METHODS: 19 children (10 girls, 9 boys, mean age 22 months) underwent videofluoroscopy of deglutition after repair of esophageal atresia. The videofluoroscopic studies were assessed according to functional and morphological changes in the oral, pharyngeal and esophageal phases. The persistence of radiologic findings on videofluoroscopy was determined. RESULTS: The oral phase was normal in all patients. The main functional disorder of the pharyngeal phase was aspiration in 7 (37%) children. A completely normal deglutition in the pharyngeal and esophageal phases was not seen in any patient. CONCLUSION: Videofluoroscopy after repair of esophageal atresia is helpful in differentiation of functional and morphological disorders that can lead to prandial aspiration and have an influence on the decision about continued therapy.     

The effect of high- vs low-density barium preparations on the quantitative features of swallowing

We compared the effect of high-density and low-density barium preparations on the quantitative features of swallowing. The two barium preparations differed primarily in density but also differed somewhat in viscosity. Concurrent videofluoroscopic and manometric studies were done in nine healthy control subjects. Videofluoroscopy was recorded in the lateral projection at 30 frames/sec while concurrent manometry was done with five intraluminal transducers that straddled the pharynx and upper esophageal sphincter. Swallows of 5 and 10 ml of high- and low-density barium preparations were recorded. Analysis indicated that, compared with the low-density barium (1.4 g/cm3), the high-density barium (2.5 g/cm3) preparation had a slower oral and pharyngeal bolus transit time and caused significant quantitative differences in the function of the upper esophageal sphincter. Compared with low-density barium boluses, the high-density barium boluses were associated with later sphincter opening and closure, longer duration of sphincter opening and flow, lower flow rate, greater maximal anterior hyoid movement, greater sagittal sphincter diameter, and higher intrabolus pressure upstream of and within the sphincter. We conclude that the density as well as the viscosity of the barium preparation used in radiologic examination of the oral-pharyngeal phases of swallowing has an influence on bolus transit time through the mouth and pharynx, and on the quantitative features of upper esophageal sphincter opening. Although these quantitative differences cannot generally be recognized visually at fluoroscopy, they become important for the quantitative assessment of swallowing in patients with suspected disorders of oral-pharyngeal swallowing. Therefore, the basic barium preparations used to examine such patients should be either standardized or at least specified.     

Complications after laryngeal surgery: videofluoroscopic evaluation of 120 patients

AIM: Videofluoroscopic assessment of the spectrum and incidence of swallowing complications after state-of-the-art laryngeal cancer surgery. MATERIALS AND METHODS: We retrospectively studied videofluoroscopic examinations of 120 patients (94 men, 26 women; mean age, 58 years) with suspected complications after laryngeal resection (partial laryngectomy, 65; total laryngectomy, 55). Swallowing function (i.e., oral bolus control, laryngeal elevation and closure, presence of pharyngeal residue, aspiration) and structural abnormalities such as strictures, fistulas and tumour recurrence were assessed by videofluoroscopy. RESULTS: Abnormalities were found in 110 patients, including strictures in nine, fistulas in six and mass lesions in 13 patients. Aspiration was found in 63 patients overall (partial laryngectomy, 61/65; total laryngectomy, 2/55), occurring before swallowing in five, during swallowing in 34, after swallowing in nine and at more than one phase in 15 patients. Pharyngeal paresis was detected in three and pharyngeal weakness in 19 patients. Pharyngo-oesophageal sphincter dysfunction was observed in 10 cases. CONCLUSION: Aspiration is a very common complication after partial laryngeal resection. It is mainly caused by incomplete laryngeal closure, sphincter dysfunction or pharyngeal pooling. Videofluoroscopy is the only radiological technique able to identify both disordered swallowing function and structural changes after laryngeal resection. Detection of these complications is crucial for appropriate further therapy.Kreuzer, S. H. (2000). Clinical Radiology55, 775-781.     

Dynamic radiologic study of deglutition in oro-pharyngeal-laryngeal neoplasms and results of their treatment

Swallowing disorders due to oro-pharyngo-laryngeal cancer, or due to the consequences of surgical resection and radiotherapy, should be accurately evaluated to manage properly both nutritional therapy and dysphagia rehabilitation techniques. The site, size, and local spread of such tumors and, especially, the nature and extent of surgical resection and reconstruction, are important factors which are closely related to the functional disorders of deglutition. The aim of this paper is to demonstrate video-fluoroscopy capability to evaluate the incidence, type, and severity of such functional disorders. For this purpose we studied by means of dynamic radiology 23 patients with oral cancer and 33 patients with pharyngeal-laryngeal cancer, most of them after surgical and/or radiological treatment. Eighty-four per cent of the patients had swallowing disorders such as poor oral processing (25%), retention of the bolus in the pharynx (41%), penetration (41%) or aspiration (37%) of the bolus in the airway, dysmotility of upper esophageal sphincter (9%), and structural lesions (61%). The association of these functional disorders was closely related to the pathological background of each patient. In conclusion, a dynamic radiological study is recommended for both pre and postoperative evaluation of these patients, to choose the appropriate nutritional therapy and dysphagia rehabilitation technique.     

咽部正常形态和结构性病变的MRI观察

目的：研究MRI对咽部结构性病变的诊断价值．材料和方法：对189例健康成人咽部正中矢状面磁共振图像分析，观察正常人的软腭、咽后壁，会厌、喉及食管环咽段的形态、位置、厚度、长度以及在MRI上的信号强度，对11例有吞咽困难症状的咽部异常者进行MRI对比观察．结果：正常人咽部形态(与吞咽活动有关结构)在MRI矢状面上显示较好．T1加权和质子加权图像上咽部结构解剖清晰。T2加权图像上虽结构轮廓模糊，但有助于咽部肿瘤病灶的定性．结论：MRI对咽部软组织病变的显示远优于常规X线和CT，并可作出正确的定位、定性诊断。     

Esophageal motor disorders: videofluoroscopic and manometric evaluation--prospective study in 88 symptomatic patients.

Esophageal motor disorders are best evaluated with manometry, which, however, is time-consuming and not generally available. The authors prospectively investigated the yield of videofluoroscopy in detection of esophageal motor disorders in comparison with that of manometry. Eighty-eight patients with dysphagia, globus sensation, noncardiac chest pain, or progressive systemic sclerosis underwent both manometry and videofluoroscopy at 0-32-day intervals. Videofluoroscopy was performed with one swallowing study in the upright position and up to three swallowing studies in the prone oblique position. Manometric diagnoses of achalasia (n = 15), diffuse esophageal spasm (n = 1), nonspecific esophageal motor disorders (n = 44), and adynamic esophagus (n = 9) were made. Videofluoroscopically, 87% of the patients with achalasia, the one patient with diffuse spasms, 73% of the patients with nonspecific esophageal motor disorders, and all of the patients with adynamic esophagus received a correct diagnosis, for an overall sensitivity of 80%. The radiographic specificity was 79%. The authors conclude that videofluoroscopy is a valuable and reasonably sensitive technique for screening for esophageal motor disorders.     

Globus sensation: findings on videofluoroscopic examinations.

OBJECTIVE: To determine the findings on videofluoroscopy of the pharynx and esophagus in patients with a globus sensation and compare them with a similar group of patients with dysphagia. METHODS: A computerized search of radiology files revealed 83 patients with a globus sensation who had videofluoroscopic examinations of the pharynx and esophagus during a 10-year period from 1989-1999. A computerized search was also performed to generate an age- and sex-matched group of 83 patients with dysphagia who also had videofluoroscopic examinations during this period. Original radiologic reports were reviewed to determine the frequency of morphologic and functional abnormalities of the pharynx and esophagus in these 2 groups. RESULTS: Early closure of the cricopharyngeus was found in 13 (16%) patients with globus versus 2 (2%) with dysphagia (p < 0.01). Enlarged pharyngeal tonsils were found in 31 (37%) patients with globus versus 17 (21%) with dysphagia (p < 0.05). Enlarged lingual tonsils were characterized on barium studies by nodularity or lobulation of the posterior-inferior base of the tongue and valleculae in all patients, and the palatine tonsils were symmetrically enlarged in all but 2 patients. No other radiographic findings were significantly associated with a globus sensation. CONCLUSION: Early closure of the cricopharyngeus and enlarged lingual or palatine tonsils may contribute to the development of a globus sensation, but the pathophysiologic basis for this association remains unclear.     

Videofluoroscopic evaluation of complications after laryngeal resection

Summary In past decades, the surgical techniques for treating laryngeal carcinoma have been vastly improved. For circumscribed tumors, voice-conserving resections are possible and for extensive neoplasms, radical laryngectomy, sometimes combined with chemoradiation, has been developed. Postoperative complications regarding swallowing function are not uncommon. Radiologic examinations, especially pharyngography and videofluoroscopy, are most often used to evaluate patients with complications after laryngeal surgery. An optimized videofluoroscopic technique for evaluation of complications is described. The radiologic appearance of early and late complications, such as fistulas, hematomas, aspiration, strictures, dysfunction of the pharyngoesophageal sphincter, tumor recurrence, and metachronous tumors is demonstrated.      

Videofluoroscopic analysis of the infant swallow

A better understanding of the abnormal infant swallowing mechanism requires better knowledge of the normal infant swallow. Twenty-one full-term infants under six months of age were examined using videofluoroscopy of the swallowing portion of upper gastrointestinal examinations. Components of the oral and pharyngeal stages of swallowing were evaluated. Results showed high reliability between two raters in obtaining measurement data. There was variability in suck and oral transit time, which was correlated to the number of sucks per swallow. All infants appeared to move their tongue in a "stripping" motion, and collected the material in various sites in the oral cavity or oropharynx before initiation of the swallow. The incidence of nasopharyngeal reflux was low (9.5%). The majority of infants demonstrated a slight residue in their valleculae and hesitation in the cervical esophagus. These findings indicate that videofluoroscopy provides an objective and systematic method for analyzing the infant swallowing mechanism.     

Functional and morphological changes in the pharynx in achalasia and diffuse esophageal spasm

Since the pharynx and the esophagus are a functional unit, functional radiodiagnosis has to be directed at pharyngo-esophageal interaction. Among our collective of 73 patients suffering from achalasia or diffuse esophageal spasm, we were able to recognize a substantially increased incidence of morphological or functional pharyngeal disorders by means of cineradiography. The functional alterations in particular were often not revealed by conventional fluoroscopy. High-speed cineradiography, with its high temporal and spatial resolution, turned out to be a valuable tool in analysis of the origin of pharyngeal dysphagia. Manometry correlated very well with the radiologic findings in tubular esophagus, but proved unreliable in the detection of alterations of the upper esophageal sphincter region, because of problems inherent in the method. Furthermore, membranous stenosis (webs), lateral or dorsal diverticula, and asymmetry of the pharynx were observed strikingly often.     

Esophageal lesions after total laryngectomy

Clinical and endoscopic evaluation of the post-total laryngectomy patient with dysphagia may be limited by postoperative fibrosis or strictures. The barium esophagogram is a valuable adjunctive tool in further assessing these patients, as both functional and anatomic abnormalities can be evaluated. A 10-year retrospective review yielded 204 patients who had had total laryngectomies for squamous cell carcinoma of the larynx; 85 of these patients had postoperative barium esophagograms. Dysphagia was the chief complaint in 73 of these 85 patients. The studies were reviewed for anatomic abnormalities of the surgically deformed pharynx (neopharynx) and the esophagus distal to it. While most patients (51%) with dysphagia had abnormalities in the neopharynx, 17 (23%) had abnormalities distal to the neopharynx; these included four esophageal carcinomas and 13 benign esophageal strictures. These results emphasize the importance of evaluating the entire esophagus and maintaining a high index of suspicion for distal esophageal disease in the total laryngectomy patient with dysphagia.