Evaluation and treatment of swallowing impairments

Swallowing disorders are common, especially in the elderly, and may cause dehydration, weight loss, aspiration pneumonia and airway obstruction. These disorders may affect the oral preparatory, oral propulsive, pharyngeal and/or esophageal phases of swallowing. Impaired swallowing, or dysphagia, may occur because of a wide variety of structural or functional conditions, including stroke, cancer, neurologic disease and gastroesophageal reflux disease. A thorough history and a careful physical examination are important in the diagnosis and treatment of swallowing disorders. The physical examination should include the neck, mouth, oropharynx and larynx, and a neurologic examination should also be performed. Supplemental studies are usually required. A videofluorographic swallowing study is particularly useful for identifying the pathophysiology of a swallowing disorder and for empirically testing therapeutic and compensatory techniques. Manometry and endoscopy may also be necessary. Disorders of oral and pharyngeal swallowing are usually amenable to rehabilitative measures, which may include dietary modification and training in specific swallowing techniques. Surgery is rarely indicated. In patients with severe disorders, it may be necessary to bypass the oral cavity and pharynx entirely and provide enteral or parenteral nutrition.     

When it's hard to swallow. Feeding techniques for dysphagia management

There are three phases of swallowing: oral, where the food is chewed; pharyngeal, where the bolus begins to move downward; and esophageal, where the bolus enters the esophagus. Signs of difficulty in swallowing may include difficulty initiating the swallow, packing food into cheeks, drooling, cough after a swallow or absent or weak cough, or fluid leaking from the nose after swallowing. Take your time when feeding patients and do not wash food down with liquids. Also, remember to position the patient properly and teach both the patient and his family effective feeding techniques.     

鼻咽癌放疗术后吞咽障碍患者的吞咽造影影像学研究

目的 观察鼻咽癌放疗术后患者吞咽障碍的吞咽造影表现及不同性状食物对其吞咽功能的影响。 方法 选取20例鼻咽癌放疗后吞咽障碍患者进行吞咽造影检查,患者进食3种不同粘稠度的对比剂,观察其吞咽功能情况并分析不同性状对比剂对其吞咽功能的影响。观察指标包括口腔运送时间、口腔残留量、咽部残留量、渗漏误吸分级、环咽肌开放率。 结果 患者进食3种食物的各项观察指标比较,差异均有统计学意义（P<0.05）。两两比较中,患者进食稀流质与糊状食物比较,各项观察指标的差异均有统计学意义（P<0.05）,进食浓流质与糊状食物的各项观察指标比较,差异均有统计学意义（P<0.05）,患者进食稀流质与浓流质比较,口腔运送时间、口腔残留量和咽部残留量的差异有统计学意义（P<0.05）。 结论 鼻咽癌放疗后吞咽障碍患者的吞咽功能严重程度不一,不同食物性状对其吞咽功能的影响也不同,吞咽造影检查可以客观评价患者的吞咽功能,并为选择食物提供客观依据。     

吞咽造影检查在脑卒中患者口服胶囊吞咽功能评估中的应用研究

目的 运用吞咽造影检查评估脑卒中后患者的口服胶囊吞咽功能,探讨其应用价值。 方法 选取脑卒中后功能性经口摄食量表（FOIS）分级4～7级且饮水无误吸的患者27例（脑卒中组）及健康人16例（对照组）。脑卒中组及对照组均在吞咽造影检查过程中用水送服硫酸钡混悬剂填充的胶囊。由专业人员对造影视频进行分析,获取吞服胶囊的成功率,记录胶囊吞咽的口腔期运送时间（OTT）、咽期吞咽的启动时间（STT）、胶囊在咽期的运送时间(PTT)、环咽肌开放时间(UOT)、胶囊与水通过环咽肌的时间间隔(DT),记录舌骨的向上位移（HSM）、向前位移（HAM）及环咽肌开放幅度(UOD)等运动学参数。 结果 脑卒中组患者胶囊吞咽的成功率为78.3%,较对照组低（P<0.05）,吞咽障碍主要表现为口腔或咽腔运送障碍,在口咽期滞留。脑卒中组的STT［ms,66.0（-66.5,217.0）］、DT［ms,67.0（283.5,184.0）］较对照组有显著差异（P<0.05）。 结论 脑卒中后患者的经口进食能力虽然有一定程度的恢复,但仍存在口服药物吞咽困难。吞咽造影可作为一种评估手段,用于临床评估患者的口服药物能力。     

Rehabilitation of dysphagia following head and neck cancer

Patients who have cancers of the oral cavity, pharynx, or larynx may be treated with surgery, radiotherapy, chemotherapy, or a combination of these modalities. Each treatment type may have a negative impact on posttreatment swallowing function; these effects are presented in this article. A number of rehabilitative procedures are available to the clinician to reduce or eliminate swallowing disorders in patients treated for cancer of the head and neck. The various procedures-including postures, maneuvers, modifications to bolus volume and viscosity, range-of-motion exercises, and strengthening exercises-and their efficacy in patients treated for head and neck cancer are discussed.     

Oral and pharyngeal dysphagia

A severe impairment of nutrition frequently occurs with morphological alterations in the oral cavity and the pharynx as well as with neurogenic disorders of the swallowing articulation. Complications like frequent aspirations are life-threatening. If the natural protection reflex for the respiratory tract, the cough reflex, does not work because of a reduced tracheal sensitivity, swallowing disorders often remain unrecognized. The ability of swallowing must be examined particularly with stroke-patients and weakened old patients. With radiological and endoscopic evaluations, oropharyngeal dysphagias can be assessed in detail. A wide spectrum of surgical measures and exercise treatment can clearly improve the life quality of the patients even if the aim, to make a complete and safe oral nutrition possible again, is not reached in every case.     

Anatomy and physiology of the pharynx

Radiographic evaluation of the passage of a bolus from the mouth through the pharynx into the esophagus is based upon identification of specific anatomical landmarks and the integrated motion accomplished by the oral and pharyngeal muscles during swallowing. Twenty-six muscles and 6 cranial nerves must be coordinated to enable the safe performance of the complex physiological task of transporting liquids and firm food from the mouth into the esophagus. The following discussion and illustrations of pharyngeal anatomy and physiology are pertinent to an understanding of normal swallowing function.     

Evaluation of Oropharyngeal Dysphagia With the Videofluoroscopic Swallowing Study

This article will discuss suspected oropharyngeal dysphagia, which is typically evaluated with a videofluoroscopic swallowing study (VFSS). The VFSS is different from a regular barium swallow with a focus on the oral cavity, pharynx, and proximal esophagus as the patient ingests multiple volumes of liquids, semisolids, and solids. The goals of the VFSS are to assess oropharyngeal biomechanical function and dysfunction, determine swallowing safety and efficiency, identify effectiveness of compensatory strategies, establish an appropriate diet, and construct an evidence-based rehabilitation plan.     

The importance of postural control for feeding

Children with cerebral palsy and other neurodisabilities often have decreased postural control that exacerbates their feeding/swallowing disorders. Correct postural alignment is important in the normal feeding/swallowing process. In the child with cerebral palsy, the alignment and stability of the oral structures for feeding/swallowing may be compromised by abnormal muscle tone and movement patterns. Effective oral functioning for feeding begins with attaining better head stability to improve jaw control. Head control is influenced by trunk alignment, which depends upon the stability of the pelvic area. Techniques such as therapeutic seating and oral control can enhance postural alignment and improve oral functioning for the safe intake of food.     

Oral motor functioning, frequency of swallowing and drooling in normal children and in children with cerebral palsy

Attempts to eliminate drooling in children with cerebral palsy have ranged from speech therapy to radical surgery. Drooling primarily results from an overflow of saliva from the mouth due to dysfunctional voluntary oral motor activity, improper swallowing, or oral sphincter deficits and rarely from hypersalivation. A study was undertaken to determine typical orofacial electromyographic patterns and swallowing frequencies of normal children and children with cerebral palsy with oral involvement who do, and who do not drool, as well as to determine the correlation between swallowing frequency and drooling rate. Results suggest that drooling in the pediatric cerebral palsy population is caused by both inefficient and infrequent swallowing.     

Prenatal Magnetic Resonance Imaging (MRI) Findings of a Foregut Duplication Cyst of the Tongue

Foregut duplication cysts of the oral cavity or lingual choristomas have a potential risk of airway obstruction. Two cases are reported that were initially detected by screening sonography. Further imaging with both static and real‐time cine magnetic resonance imaging confirmed the lingual origin, relationship of the mass to fluid‐filled spaces within the oral cavity, motion of the mass with the tongue during fetal swallowing, and airway patency. The additional information provided by magnetic resonance imaging aided in planning delivery and obviated the need for an ex utero intrapartum treatment procedure because airway patency was confirmed in both cases.     

A 12-month-old With Dysphagia and Cough

Oropharyngeal dysphagia is a dysfunction of the oral and pharyngeal phase of swallowing and can be caused by a variety of disorders. Swallowing dysfunction can allow laryngeal penetration or aspiration of small volumes of food or liquids. Infants with dysphagia may present with a history of feeding difficulties; choking episodes during feedings; and chronic symptoms, such as coughing, wheezing, or stridor. This case presentation involves a 12-month-old infant with a history of dysfunctional swallowing and coughing during feeds.     

脑卒中患者吞咽障碍的康复护理

总结了112例脑卒中患者吞咽障碍的康复护理体会。护理措施主要包括：做好心理护理，保持口腔清洁，进行摄食前训练和摄食训练。认为对脑卒中患者进行康复训练有助于吞咽困难患者恢复吞咽功能。     

Tongue movements in normal 2- to 8-year-old children: extended profile of an eating assessment

In this study tongue movements of 103 normal 5-, 6-, 7-, and 8-year-old children were measured and compared. The 5-year-olds were compared with children of an earlier study and data were combined for 2- to 8-year-old children. Two different tongue positions were measured as three standard textures of food were presented: first, the position of the tongue as the food was 5 cm away from the lips, and second, the position of the tongue or other oral characteristics as the food was swallowed. For the anticipation of food a significant age-texture (p less than .001) as well as an age-sex-texture interaction was noted (p less than .035). For swallowing, significant age (p less than .0001), texture (p less than .0001), and sex-age interactions (p less than .0001) were found. Although food is anticipated in a similar fashion by both sexes, age and texture differences must be taken into account when swallowing is evaluated. A preliminary developmental curve for the two eating behaviors is presented for children 2 to 8 years old.     

Swallowing in individuals with disorders of consciousness: A cohort study

BackgroundAfter a period of coma, a proportion of individuals with severe brain injury remain in an altered state of consciousness before regaining partial or complete recovery. Individuals with disorders of consciousness (DOC) classically receive hydration and nutrition through an enteral-feeding tube. However, the real impact of the level of consciousness on an individual's swallowing ability remains poorly investigated.ObjectiveWe aimed to document the incidence and characteristics of dysphagia in DOC individuals and to evaluate the link between different components of swallowing and the level of consciousness.MethodsWe analyzed clinical data on the respiratory status, oral feeding and otolaryngologic examination of swallowing in DOC individuals. We analyzed the association of components of swallowing and participant groups (i.e., unresponsive wakefulness syndrome [UWS] and minimally conscious state [MCS]).ResultsWe included 92 individuals with DOC (26 UWS and 66 MCS). Overall, 99% of the participants showed deficits in the oral and/or pharyngeal phase of swallowing. As compared with the MCS group, the UWS group more frequently had a tracheostomy (69% vs 24%), with diminished cough reflex (27% vs 54%) and no effective oral phase (0% vs 21%).ConclusionAlmost all DOC participants had severe dysphagia. Some components of swallowing (i.e., tracheostomy, cough reflex and efficacy of the oral phase of swallowing) were related to consciousness. In particular, no UWS participant had an efficient oral phase, which suggests that its presence may be a sign of consciousness. In addition, no UWS participant could be fed entirely orally, whereas no MCS participant orally received ordinary food. Our study also confirms that objective swallowing assessment can be successfully completed in DOC individuals and that specific care is needed to treat severe dysphagia in DOC.     

Prenatal sonographic appearance of laryngeal atresia: A case report

Detailed assessment of the larynx is not easy because of its complex structures and the associated technical difficulties. We performed sonography in multiple planes to assess the laryngeal anatomy and movements of a fetus with laryngeal atresia. The distended trachea ended abruptly with an echogenic non-structured larynx which showed shallow rapid “flutter-like” movements and up and down but not adduction- abduction movements during swallowing. Shadowing from the chin could be reduced by scanning through fluid in the oral cavity or between the transverse processes of vertebrae in a coronal plane.     

过敏性疾病在口腔中表现的研究进展

过敏性疾病是常见的全身疾病,可发生于口腔、皮肤、消化道、呼吸道等全身各系统器官。表现在口腔的过敏性疾病通常发生在摄入某些药物、食物或者接触过敏原后,可能局限于口腔,也可能作为整个病程的首发症状。过敏性疾病在口腔主要表现为药物过敏性口炎、接触过敏性口炎、血管神经性水肿、多形红斑及口腔过敏综合征等,病损形式多样,可无特异性,如充血、水肿、红斑、水疱、糜烂或者溃疡等。熟悉过敏性疾病在口腔中的不同表现,对于其诊治有重要意义。     

Epignathus: prenatal diagnosis by sonography and magnetic resonance imaging

Prenatal diagnosis of a teratoma of the oral cavity (epignathus) is presented using ultrasonography and magnetic resonance imaging as complementary techniques. Chromosome analysis from amniotic fluid revealed an inverted duplication of chromosome 1 that was confined to the tumour, whereas the constitutional karyotype was normal. The development of polyhydramnios, presumably reflecting impaired fetal swallowing, led to premature rupture of membranes and spontaneous delivery at 23 + 4 weeks of pregnancy. The premature neonate succumbed to acute respiratory distress secondary to airway obstruction by the tumour, and died immediately after birth.     

糊状饮食对中度吞咽障碍老年患者营养状态及吞咽功能的影响

目的探讨糊状经口饮食对中度吞咽障碍老年患者营养状况及吞咽功能的影响。方法成立多学科团队小组,对老年吞咽障碍患者进行吞咽功能评估及安全进食宣教和训练,将符合入选标准的长期住院老年中度吞咽障碍患者,根据自愿原则和配对原则,分为观察组和对照组各20例,对照组根据吞咽状况,兼顾患者的口味、意愿,进食半固体软食、浓流质、部分糊状饮食等;观察组将所有食物和液体,按专业的方法制成全糊状饮食,两组患者均自行经口进食或喂食。观察比较干预前后两组患者进食情况、营养状况和吞咽障碍程度。结果干预90 d后,观察组营养素摄入量、营养生化指标均高于对照组(P0.05);才滕氏吞咽障碍程度评估,观察组级数有1例上升,无下降;对照组有5例下降,差异有统计学意义(P0.05)。结论糊状饮食能改善老年中度吞咽障碍患者的营养状况,延缓吞咽障碍的进展,是便于推广的方法。     

Influence of mastication and salivation on swallowing in stroke patients

OBJECTIVE: To determine differences of the oral swallowing functions between stroke and normal subjects and to identify those factors affecting dysphagia of stroke patients. DESIGN: Case-control study. SETTING: University hospital. PARTICIPANTS: Ten stroke and 10 healthy subjects. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Resting saliva flow rate, the total number of chews, and the duration of the oral phase until onset of pharyngeal swallow, and food viscosities both before and after the oral phase using diluted barium, pudding, thick rice gruel, and curd type yogurt. RESULTS: The viscosity of all test foods was significantly reduced after the oral phase in both groups (P<.01). Resting saliva flow rate and the viscosity of thick rice gruel after the oral phase in the stroke group were significantly lower than in the control group (P<.01). However, there were no differences in the viscosities of the other foods between both groups. And a longer oral phase and a greater number of chews prior to pharyngeal swallow were revealed in the stroke group than in the control group (P<.01). CONCLUSIONS: This study shows that the food requiring mastication demands a longer oral phase and a greater number of chews, and has more altered rheologic characteristics during the oral phase in stroke patients. These findings suggest that masticatory function is impaired in stroke patients, which may contribute to their swallowing dysfunction.