Dysphagia with Bilateral Lesions of the Insular Cortex

It has been demonstrated that the insular cortex plays an important role in the swallowing mechanism. This case report describes a patient with bilateral insular cortex lesions and dysphagia secondary to viral meningitis. Recent evaluations of the insulas role in the swallowing mechanism are discussed.     

Sounds of swallowing following total laryngectomy

Accelerometer transduced sounds of swallowing in total laryngectomees did not show acoustical differences for liquid vs paste swallows, as are found in normals. Compared with normal swallows, tongue propulsion of the bolus in laryngectomee swallows occurred closer in time to a distinctive spectral change associated with bolus flow into the esophagus. Interpretation stressed the lack of mechanical traction from laryngeal elevation contributing to pharyngoesophageal sphincter opening, and the increased role of tongue propulsion in laryngectomee swallows. Supported by grant no. CA 43838 from the National Cancer Institute     

Cricopharyngeal myotomy may be effective treatment for selected patients with neurogenic oropharyngeal dysphagia

The role of cricopharyngeal (CP) myotomy in the management of neurogenic oropharyngeal dysphagia remains controversial. A review of the literature regarding outcomes of CP myotomy for dysphagia in the setting of a variety of neurological disorders indicates a preponderance of favorable results. There are several potential explanations for reported improvement after CP myotomy for neurogenic dysphagia, including the possibility that it is an effective treatment, at least for selected patients. If this is true, appropriate selection criteria for this treatment of neurogenic dysphagia may include (1) intact voluntary initiation of swallowing, (2) adequate propulsive force generated by the tongue and pharyngeal constrictors, (3) videofluorographic demonstration of obstruction to bolus flow at the CP segment (rather than merely retention in the pharyngeal recesses), (4) manometric evidence of relatively elevated CP pressure in relation to the pharynx, and (5) relatively favorable neurological prognosis. The effectiveness and safety of CP myotomy for patients with neurogenic dysphagia are unlikely to be resolved without a prospective, controlled multicenter study enrolling patients who meet such criteria.     

Multiple swallows and piecemeal deglutition; Observations from normal adults and patients with head and neck cancer

The incidence of multiple swallows for liquid and paste, and the time delay between multiple swallows, was determined from videofluoroscopic records of modified barium swallow tests. In a comparison of liquid and paste, the overall incidence of multiple swallows did not differ, for either patients with head and neck cancer or normal controls. However, for liquid swallows the incidence in patients with cancer was abnormally high, predominantly in patients with pharyngeal cancer.     

Pattern of Tongue Pressure on Hard Palate During Swallowing

Contact of the tongue against the hard palate plays an important role in swallowing. This study aimed to clarify the pattern of contact between the tongue and hard palate by analyzing tongue pressure produced in swallowing 15 ml of water by healthy subjects wearing an experimental palatal plate with seven pressure sensors. Tongue pressure was generated initially by close contact with the anteriomedian part of the hard palate, then with the circumferential part, and finally softly with the posteriomedian part. Tongue pressure reached a peak quickly, then decreased gradually before disappearing almost simultaneously at each measured part of the hard palate. Magnitude and duration were significantly larger in the anteriomedian part compared to the other six parts measured, and was significantly smaller in the posteriomedian part. No laterality was found in tongue pressure produced at the circumferential parts of the hard palate. Our findings indicate that the order of tongue contact against each part of the hard palate as well as duration and magnitude of tongue pressure are coordinated precisely during swallowing. These findings could aid assessment of the tongue movement of dysphagic patients during rehabilitation.     

The Effects of Intraoral Pressure Sensors on Normal Young and Old Swallowing Patterns

Lingual pressure generation plays a crucial role in oropharyngeal swallowing. To more discretely study the dynamic oropharyngeal system, a 3-bulb array of pressure sensors was designed with the Kay Elemetrics Corporation (Lincoln Park, NJ). The influence of the device upon normal swallowing mechanics and boluses representative of flow relative to age and bolus condition was the focus of this study. Twelve healthy adults in two age groups (31 ± 5 years, 2 males and 4 females, and 78 ± 7 years, 2 males and 4 females) participated. Each subject was instructed to swallow four boluses representative of conditions with and without three pressure sensors affixed to the hard palate. Postswallow residue at four locations, Penetration/Aspiration Scale scores, and three bolus flow timing measures were assessed videofluoroscopically with respect to age and bolus condition. The only statistically significant influences attributable to the presence of the pressure sensors were slight increases in residue in the oral cavity and upper esophageal sphincter with some bolus consistencies, 8% more frequent trace penetration of the laryngeal vestibule predominantly with effortful swallowing, and variances in oral clearance duration. We conclude that the presence of the pressure sensors does not significantly alter normal swallowing patterns of healthy individuals. This article is GRECC No. 03-01. This work was supported by NIH Grant NS24427 and VA Grant E727-2RA.     

Is There a Relationship Between the pH and Volume of Saliva and Esophageal pH-metry Results?

There are several implications in the buffer capacity and in the protective role of saliva in gastroesophageal reflux disease (GERD) and other digestive disorders. The lack of knowledge about the production and quality of saliva and the fact that saliva plays an important role in digestive homeostasis motivated the authors to study the relationship between reflux measured by esophageal pH-metry and the pH and volume of saliva in individuals with GERD and its laryngopharyngeal manifestations (LPR). The study was designed as a randomized clinical trial. The studied population consisted of 39 adults with GERD and LPR confirmed by a positive 24-hour double-probe esophageal pH-metry. Unstimulated whole saliva was collected and its pH and volume were compared to pH-metry results. Patients were divided into four groups according to the number of distal episodes of reflux and two groups according to the presence or absence of proximal reflux. A highly significant difference was found between the groups with distal reflux when comparing salivary volume alone and salivary volume/salivary pH. The same occurred for the presence or absence of proximal reflux. These results suggest a direct correlation between salivary volume and “salivary pH × volume” with the number of distal and proximal episodes of reflux on the esophageal pH-metry. If larger studies confirm this finding, in the future it might be possible to diagnose GERD and LPR through a simple “spit test,” avoiding more costly and invasive procedures.     

Drug-induced dysphagia

Dysphagia describes the disability or problems in swallowing a wet or dry bolus properly and is normally associated with an impaired transport of the bolus. Dysphagia can be accompanied by a pain sensation in the chest mostly caused by impaction of the food bolus in the esophagus. Odynophagia describes only the status of painful swallowing without an impairment of the swallow and transport function. Drug-induced dysphagia can be caused in two different ways. First as a normal drug side effect of the pharmacological action of the drug or as a complication of the therapeutic action of the drug. The normal drug side effect is most likely in drugs that affect smooth or striated muscle function or the sensitivity of the mucosa. The drug effect on smooth muscle function that causes dysphagia can be inhibitory or excitatory. Dysphagia is a common clinical symptom in patients with reduced perception of the pharyngeal mucosa which leads to an subjective impairment of swallowing. Dysphagia caused by a complication of the therapeutic action of a drug includes viral or fungal esophagitis in patients treated with immunosuppressive drugs or cancer therapeutic agents, or antibiotics and immunological reactions to certain drugs such as erythema exsudativa multiforme or Stevens-Johnson syndrome. Second, drug-induced dysphagia can be due to medication-induced esophageal injury (MIEI). In most cases this mucosal injury appears to be the direct result of prolonged contact of a potentially caustic drug with the esophageal mucosa. This form of medication-induced esophagitis is most likely to be found in elderly patients and patients with esophageal motility disorders. The medication-induced esophageal injury is further promoted by taking the medication at bedtime without enough fluid. In conclusion, drug-induced dysphagia can be caused in many different ways. A carefully taken history in a patient, especially of the current medication, is important for the clinical diagnosis. MIEI can be prevented by concurrent ingestion of adequate amounts of fluid and avoidance of unnecessary bedtime medication, especially in elderly patients.     

Squamous cell carcinoma of the esophagus after partial gastrectomy

Twelve patients (10.4%) had a history of partial gastrectomy among the 115 patients with squamous cell carcinoma of the esophagus. The clinical characteristics, nutritional parameters, and incidences of esophagitis of the resected specimens were investigated between 11 patients with esophageal carcinoma who had partial gastrectomy for peptic ulcer diseases (Group A) and 103 patients with esophageal carcinoma without any previous history of gastrectomy (Group B). Age, sex, tumor location, clinical stages, and cigarette and alcohol consumption were not different between the two groups. Hemoglobin, mean corpuscular volume, and mean corpuscular hemoglobin level in Group A were lower than those in Group B (p<0.05). Serum zinc level in Group A was lower than that in Group B, but this difference was not significant. There was no difference in the incidences of esophagitis between the two groups. In conclusion, there is an association between partial gastrectomy and later development of squamous esophageal carcinoma. The role of malnutritional factors and gastroesophageal reflux, however, remain unclear. The long-term follow-up of patients after partial gastrectomy is warranted.     

Decreased Tongue Pressure Reflects Symptom of Dysphagia

The tongue plays a key role in oropharyngeal swallowing. It has been reported that maximum isometric tongue pressure decreases with age. The risk for dysphagia resulting from low tongue strength remains unclear. This study was designed to reveal the relationship between tongue pressure and clinical signs of dysphagic tongue movement and cough and to demonstrate the clinical value of tongue pressure measurement in the evaluation of swallowing function. One hundred forty-five institutionalized elderly in five nursing homes participated. Evaluation of physical activity with self-standing up capability and mental condition with Mini Mental Status Examination (MMSE) were recorded. Maximum tongue pressure was determined using a newly developed tongue pressure measurement device. Voluntary tongue movement and signs of dysphagic cough at mealtime were inspected and evaluated by one clinically experienced dentist and speech therapist. The relationship between level of tongue pressure and incidence of cough was evaluated using logistic regression analysis with physical and mental conditions as covariates. Tongue pressure as measured by the newly developed device was significantly related to the voluntary tongue movement and incidence of cough (p < 0.05). The results of this study suggest that tongue pressure measurement reflects clinical signs of dysphagic tongue movement and cough and that measurement of tongue pressure is useful for the bedside evaluation of swallowing.This study was supported by a grant-in-aid from the Ministry of Health, Labour and Welfare (tyoujyu-14-020).     

Lip closing pressure in disabled children: A comparison with normal children

Lip functions play an important role in the oral stages of feeding. Lip closing is an important early motor act in food acquisition and is essential for controlling chewing and swallowing. To date, there have been few papers on the developmental aspects of lip closing strength when taking in food, especially with regard to disabled children. This investigation was designed to produce an ordinal scale of midline lip pressure measurements for a cross-sectional, age-grouped population of normal children. Developmental changes in lip pressure were then compared with those of two populations of disabled children. Pressure measurements were obtained with a strain gauge transducer that was embedded in a spoon during normal feeding. The study population consisted of 104 normal children ranging in age from 5 months to 5 years, 11 children who showed developmental delay (mean 4.5 years), and 10 children with cerebral palsy (mean 5.0 years). Lip pressure was found to increase steadily from 5 months to 3 years and to increase slightly from 3 to 5 years in the normal population. The developmentally delayed group and the cerebral palsied group produced lip pressures and coefficients of variation below those of the normal 1 to 2-year-old group.     

Scintigraphic quantification of pharyngeal retention following deglutition

A procedure is described for quantifying the amount of bolus material retained in the pharynx after completion of a swallow, using radionuclide swallow techniques. Data are derived from scintigraphic time-activity curves. The procedure takes into consideration the differential attenuation of radioactivity through various regions in the body, and expresses the result as a percentage of the total radioactivity in the ingested bolus. Illustrative examples are provided for swallows by normal individuals and patients with head and neck cancer.     

Nonsurgical treatment of drooling in a patient with closed head injury and severe dysarthria

The purpose of this investigation was to measure the effectiveness of the antimuscarinic drug atropine sulfate in the treatment of chronic drooling in a patient with a history of severe closed head injury and resultant widespread oral neuromuscular and higher cortical disturbances. Results of the A-B-A-B-A-B withdrawal paradigm, chosen to demonstrate the functional relationship between drug therapy and the degree of drooling, revealed that administration of atropine sulfate reduced by more than 50% of baseline levels the amount of resting secretion, intraoral accumulation, and pharyngeal-laryngeal pooling of saliva, with negligible side effects. These results are discussed and compared to the alternative drug and surgical approaches to the alternative drug and surgical approaches to treatment that have been the primary focus of recent research on drooling.     

Role of the Pharyngeal Branch of the Vagus Nerve in Laryngeal Elevation and UES Pressure During Swallowing in Rabbits

Abstract Elevation of the larynx during swallowing plays an important role in protecting the laryngeal inlet and in the opening of the upper esophageal sphincter (UES). The thyrohyoid (TH) muscle is the most important muscle for laryngeal elevation, and it is thought to be innervated by the thyrohyoid branch. However, in preliminary studies we found that laryngeal elevation was severely disturbed after sectioning of the pharyngeal branch of the vagus nerve (X-ph). In the present study, we examined the role of the X-ph in laryngeal elevation and the contribution of this nerve to UES pressure. Ten male rabbits under anesthesia were used. Sectioning of the X-ph not only abolished the electromyographic activities of the TH and cricopharyngeus (CP) muscles, it also greatly reduced the maximal value of laryngeal elevation during swallowing. On the other hand, sectioning of the hypoglossal nerve, which contains the thyrohyoid branch, produced no appreciable change in the electromyographic activity of either muscle and it reduced the maximal value of the elevation only slightly. These results indicate that the X-ph innervates the TH and CP muscles and suggest that the X-ph plays an important role in elevating the larynx and in regulating the UES pressure in rabbits.     

Image quality and radiation levels in videofluoroscopy for swallowing studies: A review

Inexpensive video recording equipment coupled to conventional x-ray fluoroscopes is now in widespread use by clinicians for the evaluation of patients with swallowing disorders. The prevalence and simplicity of this apparatus have encouraged its use by clinical specialists who are often not specifically trained in the safe use of x-ray equipment, and this may not be in the best interest of either the patient or the examiner. This has prompted an overview of the operating principles of videofluorescopy equipment. The factors governing image quality are discussed as well as potential hazards and protective measures for both patients and operator. A method of estimating the radiation dose to sensitive tissues from a typical swallowing study is included.     

Novel primitive swallowing reflex: Facial receptor distribution and stimulus characteristics

We recently described a primitive swallowing reflex: swallowing as a response to a puff of air administered to the face. To identify the facial afferent distribution of this response, the necessary characteristics of the stimulus, and the role of the infant's antecedent behavior, we studied 13 infants who had demonstrated this reflex. We evaluated nine infants by clinically observing for swallowing in response to a total of 135 stimulus applications. All nine had consistently positive responses to the maxillary-ophthalmic area and to the maxillary-mandibular area. Two had consistent responses to stimulation of the mandibular area alone; these were positive. Six had consistent responses to stimulation of the ophthalmic area alone; these were negative. Four infants, evaluated by manometric documentation of swallowing (a total of 137 stimulus applications) demonstrated 47 of 79 (59%) positive responses to stimuli applied to facial areas including any parts of the lips, but only 7 of 28 (25%) positive responses to stimuli applied to facial areas excluding all parts of the lips (chi-squareP=0.002). Light touch to any facial area, including the cornea, failed to produce a swallow in any infant. Crying and sleep were incompatible with the reflex. This newly identified primitive swallow reflex seems to require diffuse stimulation, possibly thermal, to the perioral area of the face in an awake and noncrying infant. Supported in part by National Institutes of Health grant R23 HD21445. Preliminary abstract published inPediatric Research 1990; 27(4, Part 2)113A.     

An Epidemiological Study of Achalasia Among the South Asian Population of Leicester, 1986–2005

Achalasia is an uncommon esophageal motility disorder of unknown etiology that predominantly affects people over the age of 50. The overall incidence in this study was 0.89 cases/10(5)/year. There was no significant difference in the proportion of South Asian women with achalasia compared to the proportion of men affected in the whole population nor between the male-to-female ratio in the patient group compared to the healthy population. Throughout the twentieth century there have been sporadic attempts to find any etiological link but to date none have been confirmed. However, there is evidence that environmental factors may be important and these are reflected in geographical differences in the distribution of the disease. In this study we were also unable to identify any triggering factor responsible for the development of achalasia.     

Morphologic Characteristics of the Superior Pharyngeal Constrictor Muscle in Relation to the Function During Swallowing

To clarify the morphologic characteristics of the superior pharyngeal constrictor muscle, which plays an important role in swallowing, the gross anatomy of the pterygopharyngeal, buccopharyngeal, mylopharyngeal, and glossopharyngeal parts of the muscle was examined. Morphology of the origin of the muscle at the buccopharyngeal part could be divided into three types: type A, membranous morphology from superior to inferior areas; type B, membranous only in superior area; and type C, complete lack of membrane. In all three types, the muscle at the buccopharyngeal part transitionally originated from the buccinator muscle. Morphology of the origin of the muscle at the mylopharyngeal part could be divided into two types: type A, tip of the origin on the mylohyoid line; and type B, tip of the origin away from the mylohyoid line. The present study found that the superior pharyngeal constrictor muscle is attached to the buccinator muscle (which plays an important role in mastication) with mucosa and originates from the mandible and root of the tongue. These findings suggest that the superior pharyngeal constrictor muscle may also play an important role in the expression of smooth coordinated movements associated with ingestion, from mastication to swallowing.     

Ethical dilemmas in dysphagia management and the right to a natural death

Speech pathologists are at the forefront in dealing with the consequences of life-saving measures and the technological advances that promote surival. Many ethical dilemmas exist in the area of dysphagia management and these are often emphasized in the nursing home environment. A client's autonomy and ability to make informed decisions will invariably determine the role of the speech pathologist in making decisions or facilitating debate regarding eating and feeding status.