Simultaneous Videofluoroscopic Swallow Study and Modified Evans Blue Dye Procedure: An Evaluation of Blue Dye Visualization in Cases of Known Aspiration

The reliability of the modified Evans blue dye (MEBD) test for the detection of aspirated materials in patients with tracheostomy has been questioned. The videofluoroscopic swallow study (VFSS) has been the standard procedure used to detect aspiration, but there are known risks and the VFSS is not always an available evaluation option for aspiration detection. The purpose of the present study was to investigate the visualization of blue tracheal secretions in cases of known aspiration as documented by the VFSS. Twenty consecutive simultaneous MEBD study and VFSS were completed on patients with tracheostomies at an acute rehabilitation hospital. Overall, the MEBD showed a 50% false-negative error rate. The MEBD identified aspiration in 100% of patients who aspirated more than trace amounts but failed to identify aspiration of trace amounts (0%).     

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.     

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.     

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.     

Radiographic techniques and efficacy in evaluating esophageal dysphagia

The radiographic examination of the esophagus to determine structural and/or functional causes of dysphagia is best performed with multiple techniques. These include full-column studies to produce distended films with or without the use of a solid bolus, mucosal relief films to identify mucosal defects such as esophagitis or the presence of varices, double-contrast films, and motion recording (fluoroscopy). The efficacy of each technique depends on the quality of the study and the specific disorder to be detected. Esophageal lesions producing dysphagia are classified into extrinsic structural lesions, intrinsic structural lesions, and esophageal motility disorders. Radiographic studies are the preferred screening techniques for patients with dysphagia. Although not as sensitive for the evaluation of mucosal lesions, radiographic studies are superior to endoscopy for the detection of abnormal motility, esophageal rings, and strictures.     

The Effects of Cervical Bracing Upon Swallowing in Young,Normal, Healthy Volunteers

Abstract The purpose of this study was to evaluate radiographically the effects of cervical bracing upon swallowing thin liquids and solid food in normal adults under three cervical bracing conditions. This was a prospective, repeated measures design study. Seventeen healthy adult volunteers between the ages of 30 and 50 were recruited from hospital staff. All subjects reported no previous history of swallowing difficulty or diseases that might affect swallowing. Subjects were radiographically observed swallowing thin liquids and solid food without cervical bracing and with three common cervical orthoses (Philadelphia collar, SOMI, and halo-vest brace). Order of bracing and type of bolus were randomized. Changes in swallowing function (point of initiation of swallow response, presence of pharyngeal residue, airway penetration, hyoid bone movement, diameter of oropharyngeal airway, and durational measurements) were analyzed by two independent raters. Eighty-two percent (14/17) of the subjects demonstrated radiographic changes under one or more of the bracing conditions. Forty-seven percent (8/17) of subjects demonstrated changes with point of initiation of the swallow response, 59% (10/17) demonstrated increased pharyngeal residue, and 23.5% (4/17) demonstrated changes with bolus flow with laryngeal penetration present. Aspiration did not occur under any of the bracing conditions. Changes noted in durational measurements for oral containment and total pharyngeal transit under the bracing conditions were not considered statistically significant. This study shows that cervical bracing does change swallowing physiology in normal healthy adults.     

Effect of Tactile Stimulation on Lingual Motor Function in Pediatric Lingual Dysphagia

There is a scarcity of empirical evidence on effective treatments of swallowing dysfunction in young children who do not suck or swallow. There is no literature testing the effects of shaping a reflex or specifically shaping a swallow reflex. The purpose of this retrospective study was to investigate and isolate the specific regional mechanical functions of the tongue during swallowing. This study included 45 patients who did not swallow because of multiple congenital anomalies and gastroenterologic dysfunctions before and after corrective surgery and had histories of unsuccessful traditional feeding therapies. Evaluation included clinical gastroenterologic, nutritional, and neurologic examination, routine laboratory tests, and radiologic swallowing studies. A ten-year study analyzed the behavioral science procedures shaping both a swallow reflex and lingual surface geometry. Treatment variables were (1) a tactile stimulus to the posterior tongue and (2) sequential tactile stimuli to varied locations on the lingual surface. There were significant differences in lingual responses for all patients who were transferred from artificial feedings to independent prototypical swallowing capability and acquired oral consumption of recommended daily hydration and nutrition in 5-7 days of treatment. The initial tactile stimulus and six-level sequential stimuli resulted in six sequential lingual responses within each wavelike swallow reflex. Results of stimuli shaping varied lingual responses across 45 patients with severe multiple medical and anatomical deficits in swallowing, suggest that the etiology was not relevant in this population. These behavioral science approaches are novel treatment for pediatric lingual dysphagia.     

The association of swallowing dysfunction and aspiration pneumonia

The medical literature has emphasized that aspiration of gastric contents or oral bacteria is a common cause of aspiration pneumonia. Swallowing disorders have been implicated in this disease but not studied at the time that aspiration pneumonia was diagnosed. A significant difference was found in the incidence of videofluoroscopically confirmed oropharyngeal swallowing problems in a group of patients diagnosed with aspiration pneumonia (AP) when compared with patients with nonaspiration pneumonia (NAP). Six of the 9 patients in the AP group aspirated during the videofluoroscopic evaluation and 2 others were considered to be at risk for aspiration. None of the 7 NAP patients demonstrated swallowing problems or aspiration. A significant difference in oral transit time also occurred between the two groups. Liquid was found to have a significantly faster oral transit time than paste or a cookie. Pharyngeal transit times were not found to be significantly different. Although there were only a small number of patients who met the criteria for this pilot study, a strong association was found between swallowing dysfunction and aspiration pneumonia.This study was conducted at Clement J. Zablocki VA Medical Center, Milwaukee, Wisconsin.     

Effects of Cuff Deflation and One-Way Tracheostomy Speaking Valve Placement on Swallow Physiology

This study examined the effects of tracheostomy cuff deflation and one-way speaking valve placement on swallow physiology. Fourteen nonventilator-dependent patients completed videofluoroscopic swallow studies (VFSS) under three conditions: (1) cuff inflated, (2) cuff deflated, and (3) one-way valve in place. Four additional patients with cuffless tracheostomy tubes completed VFSS with and without the one-way valve in place. All swallows were analyzed for the severity of penetration/aspiration using an 8-point penetration–aspiration scale. Seven preselected swallow duration measures, extent of hyolaryngeal elevation and anterior excursion, and oropharyngeal residue were also determined. Scores on the penetration–aspiration scale were not significantly affected by cuff status, i.e., inflation or deflation. However, one-way valve placement significantly reduced scores on the penetration–aspiration scale for the liquid bolus. Patients who are unable to tolerate thin liquids may be able to safely take thin liquids when the valve is in place. However, one-way valve placement may not be beneficial for all patients. Clinicians who complete VFSS with tracheostomized patients should include several bolus presentations with a one-way speaking valve in place before making any decisions regarding the use of the valve as a means to reduce aspiration. Work was performed at The University of Tennessee Medical Center, Knoxville, Tennessee.     

Neurogenic dysphagia: What is the cause when the cause is not obvious?

The potential causes of neurogenic oropharyngeal dysphagia in cases in which the underlying neurologic disorder is not readily apparent are discussed. The most common basis for unexplained neurogenic dysphagia may be cerebrovascular disease in the form of either confluent periventricular infacts or small, discrete brainstem stroke, which may be invisible by magnetic resonance imaging. The diagnosis of occult stroke causing pharyngeal dysphagia should not be overlooked, because this diagnosis carries important treatment implications. Motor neuron disease producing bulbar palsy, pseudobulbar palsy, or a combination of the two can present as gradually progressive dysphagia and dysarthria with little if any limb involvement. Myopathies, especially polymyositis, and myasthenia gravis are potentially treatable disorders that must be considered. A variety of medications may cause or exacerbate neurogenic dysphagia. Psychiatric disorders can masquerade as swallowing apraxia. The basis for unexplained neurogenic dysphagia can best be elucidated by methodical evaluation including careful history, neurologic examination, videofluoroscopy of swallowing, blood studies (CBC, chemistry panel, creatine kinase, B12, thyroid screening, and anti-acetylcholine receptor antibodies), electromyography, and magnetic resonance imaging (MRI) of the brain, plus additional procedures such as lumbar puncture and muscle biopsy as indicated. Little is known about aging and neurogenic dysphagia, specifically the relative contributions of natural age-related changes in the oropharynx and of diseases of the elderly, including periventricular MRI abnormalities, in producing dysphagia symptoms and videofluoroscopic abnormalities in this population.     

Does an Exercise Aimed at Improving Swallow Function Have an Effect on Vocal Function in the Healthy Elderly?

Age-related sarcopenia or muscle wasting contributes to changes in the ability to perform activities of daily living, changes in deglutition, and changes in vocal function. The Shaker Exercise, an isometric and isokinetic exercise, has been shown to strengthen suprahyoid muscles and increase deglutitive anteroposterior (AP) upper esophageal sphincter (UES) opening diameter. The aim of this study was to determine if this exercise has an effect on the age-related changes in vocal function and deglutition in healthy older adults. Eleven females and 10 males, aged 65-78 years (mean = 70 +/- 4 years) and with a negative history for dysphagia and voice disorders, participated by exercising three times per day for 6 weeks. Five age-matched controls did not perform the exercise. Acoustic analysis of voice and biomechanical analysis of deglutition were performed before and after 6 weeks of exercise. Controls participated in voice analysis only. Dysphonia Severity Index (DSI), a multivariate voice index, was used to compare voice production initially and after 6 weeks. Deglutitive biomechanical measures increased and DSI scores improved in 10 of 21 participants following 6 weeks of the exercise. DSI for controls did not change over the 6-week period. Ten of 21 exercise participants experienced improved deglutitive biomechanics and DSI scores. Accuracy of exercise performance, compliance, and/or disclosed alterations in health status may contribute to the lack of deglutitive and DSI change in the participants who did not experience change in function. A large randomized control study, including periodic monitoring of health status, exercise performance accuracy, and compliance, is warranted to evaluate the affect of this exercise on deglutition as well as voice. The Shaker Exercise could be recommended as a preventative measure to diminish the effect of sarcopenia on the muscles used in deglutition and voice and alter the progression of the characteristic senescent voice and swallow changes.     

A prospective psychological evaluation of patients with dysphagia of various etiologies

We hypothesized that patients who complain of dysphagia without demonstrable organic abnormality may have an underlying psychological dysfunction. We thus conducted a comprehensive assessment in three groups of patients with dysphagia. Dysphagia was classified as obstructive (Obst) when an obstructive lesion was present on esophagoscopy or barium swallow, motility-related (Mot) when abnormal motility was shown on esophageal manometry in the presence of normal esophagoscopy or barium swallow, or nonobstructive, nonmotility-related (NONM) when manometry and esophagoscopy or barium swallow were both normal. We prospectively evaluated 71 patients with Obst-dysphagia, 15 patients with Mot-dysphagia and 10 patients with NONM-dysphagia with a battery of standardized psychological tests including the Minnesota Multiphasic Personality Inventory (MMPI), the Symptom Checklist-90-Revised (SCL-90-R), and the Millon Behavioral Health Inventory (MBHI). The results indicate that patients with NONM-dysphagia have psychological attributes similar to those found in patients with Obst-dysphagia or Mot-dysphagia. Combination of scores for parameters such as somatization, depression, and anxiety could not distinguish among the three groups of dysphagia patients. We thus conclude that patients with NONM-dysphagia, as a group, have similar psychological profiles compared to patients with dysphagia due to organic causes.     

Dysphagia and dementia in subjects with Parkinson's disease

This study reviewed the medical records of 19 patients with a diagnosis of Parkinson's disease listed on the death certificate who died between June 1985 and July 1990. The presence or absence of dementia separated the patients into two groups. The study examined the age at time of death, number and type of secondary diagnoses, frequency of dysphagia diagnosis, and therapeutic dietary differences. The presence of dementia did not influence the age at time of death. Dysphagia was a common diagnosis for each group. Differences in treatment of dysphagia were found to be dependent on the presence or absence of dementia.     

Aging and the esophagus: Common pathologic conditions and their effect upon swallowing in the geriatric population

Dysphagia in the elderly is most often oropharyngeal or hypopharyngeal in location and neuropathologic in etiology. Aging itself, although causing demonstrable structural and functional changes in the esophagus, does not cause any clinically relevant esophageal dysphagia. A variety of pathologic conditions seen in the geriatric population affect the esophagus and can alter esophageal function, resulting in symptomatic dysphagia. Accurate diagnosis requires a thorough evaluation performed in an unhurried fashion, often with the assistance of ancillary personnel. Treatment of these esophageal disorders is multidisciplinary and may involve dietary manipulations, the administration of medications, therapeutic endoscopic procedures, and occasionally surgery.     

Temperature acceleration in cold oral stimulation

This study measured the temperature acceleration of a cold probe as it contacts human tissue. Both the effects of touching a cold probe to the oral cavity and maintaining contact of the cold probe with the oral cavity were investigated. The results indicated a rapid warming pattern. This warming is effected first by temperature changes resulting from the probe being moved from ice into room temperature and second by the contact to oral mucosa. In fact, in some cases, the probe had reached minimal cold sensation levels by the time it reached the oral cavity. Results also indicated that 6 sec after the probe is lifted from the ice, the temperature closely aproximates temperatures perceived as warm or at least neutral, but not cold.This investigation was supported in part by Veterans Administration Merit Review (Research Advisory Group) grant #331.     

A penetration-aspiration scale

The development and use of an 8-point, equalappearing interval scale to describe, penetration and aspiration events are described. Scores are determined primarily by the depth to which material passes in the airway and by whether or not material entering the airway is expelled. Intra-and interjudge reliability have been established. Clinical and scientific uses of the scale are discussed.This work was performed at the William S. Middleton Memorial Veterans Hospital and the University of Wisconsin Clinical Science Center. This is publication number 94-10 of the Madison Geriatrics Research Education and Clinical Center     

Limb girdle muscular dystrophy: A radiologic and manometric study of the pharynx and esophagus

Limb girdle muscular dystrophy (LGMD) is not a recognized cause of dysphagia. However, a systematic study of pharyngoesophageal function in LGMD has not been performed or reported. We determined whether the dystrophic process involves the pharyngoesophageal musculature in 20 LGMD patients with and without complaints of deglutition. Pharyngeal and esophageal function was evaluated by conventional cineradiography and manometry. Abnormalities were demonstrated in 30% (6/20) of patients: dysphagia in 10% (2/20), an abnormal radiologic study in 30% (6/20), and an abnormal manometric study in 20% (4/20). Mean manometric pressures were not significantly different when patients were compared with a healthy, age-and sex-matched volunteer group. In 2 patients, dysfunction of the pharyngeal striated muscle was likely, or possibly, due to dystrophic affection of the upper alimentary tract. Significant upper alimentary tract dysfunction in LGMD is not common. The cause-effect relationship between the dystrophic process and the nonspecific pharyngoesophageal motility disorders is unclear and requires pathologic study.     

Videofluoroscopic evidence of aspiration predicts pneumonia and death but not dehydration following stroke

In order to assess the risk of pneumonia, dehydration, and death associated with videofluoroscopic evidence of aspiration following stroke, the clinical records of 26 patients with aspiration and 33 randomly selected, case-matched, dysphagic controls without videofluoroscopic evidence of aspiration were reviewed. The videofluoroscopic modified barium swallow technique included 5 ml-thin and thick liquid barium, 5 ml barium pudding, and 1/4 cookie coated with barium, plus additional 20 and 30 ml of thin liquid barium. Patients were assessed a mean of 2±1 SD months poststroke and were followed for a mean of 16±8 SD months poststroke. The odds ratio for developing pneumonia was 7.6 times greater for those who aspirated any amount of barium irrespective of its consistency (p=0.05). The odds ratio for developing pneumonia was 5.6 times greater for those who aspirated thickened liquids or more solid consistencies compared with those who did not aspirate, or who aspirated thin liquids only (p=0.06). Dehydration was unrelated to the presence or absence of aspiration. The odds ratio for death was 9.2 times greater for those aspirating thickened liquids or more solid consistencies compared with those who did not aspirate or who aspirated thin liquids only (p=0.01). Aspiration documented by modified videofluoroscopic barium swallow technique is associated with a significant increase in risk of pneumonia and death but not dehydration following stroke.     

Efficacy of behavioral treatment for oropharyngeal dysphagia

In this critique of research in behavioral treatment of dysphagia, three types of investigations are briefly reviewed: general managment guides, specific behavioral treatments applied to single patients or a few patients, and dysphagia programs applied to large numbers of patients. Efficacy of treatment has been demonstrated in some of the single-case or small-group studies where specific techniques have been utilized. Unfortunately, efficacy has not been demonstrated in any of the studies where large groups of patients have been enrolled in dysphagia programs. Some of the critical factors that have been lacking in many of these studies are discussed and the need to include functional outcome measures in efficacy studies is emphasized.