球囊扩张术对脑卒中后吞咽障碍康复疗效及不良并发症研究

目的:研究球囊扩张术对脑卒中后吞咽障碍的康复疗效及不良并发症的影响。方法:选取我院经吞咽造影检查确诊为脑卒中后环咽肌失弛缓导致的吞咽障碍患者50例,随机分为2组各25例。对照组接受常规吞咽功能训练、Vitalstim神经肌肉低频电刺激,观察组另外给予球囊扩张术治疗。比较2组患者的总有效率、吞咽功能、并发症发生率,同时比较治疗前和治疗后的咽通过时间、吞咽造影检查(VFSS)评分及功能性经口摄食评估(FOIS)评分。结果:观察组的可进水、可进食流质物、可进食糊状物、可进食固体食物比例均明显高于对照组(均P0.01);观察组的吸入性肺炎发生率明显低于对照组(P0.05);治疗后,观察组的咽通过时间明显低于对照组(P0.01),VFSS和FOIS评分均明显高于对照组(均P0.01);观察组的康复总有效率明显高于对照组(96.0%,72.0%,P0.05)。结论:球囊扩张术对脑卒中后吞咽障碍具有显著疗效,缩短患者康复时间,降低误吸等并发症的发生。     

Predictors of dysphagia after spinal cord injury.

OBJECTIVE: To quantify the incidence of swallowing deficits (dysphagia) and to identify factors that predict risk for dysphagia in the rehabilitation setting following acute traumatic spinal cord injury. DESIGN: Retrospective case-control study. SETTING: Freestanding rehabilitation hospital. PATIENTS: Data were collected on 187 patients with acute traumatic spinal cord injury admitted for rehabilitation over a 4-year period who underwent a swallowing screen, in which 42 underwent a videofluoroscopic swallowing study (VFSS). MAIN OUTCOME MEASURES: VFSS was performed on patients with suspected swallowing problems. Possible antecedents of dysphagia were recorded from the medical record including previous history of spine surgery, surgical approach and technique, tracheostomy and ventilator status, neurologic level of injury, ASIA Impairment Classification, orthosis, etiology of injury, age, and gender. RESULTS: On admission to rehabilitation 22.5% (n = 42) of spinal cord injury patients had symptoms suggesting dysphagia. In 73.8% (n = 31) of these cases, testing confirmed dysphagia (aspiration or requiring a modified diet), while VFSS ruled out dysphagia in 26.2% (n = 11) cases. Logistic regression and other analyses revealed three significant predictors of risk for dysphagia: age (p < .028), tracheostomy and mechanical ventilation (p < .001), and spinal surgery via an anterior cervical approach (p < .016). Other variables analyzed had no relation or at best a slight relation to dysphagia. Tracheostomy at admission was the strongest predictor of dysphagia. The combination of tracheostomy at rehabilitation admission and anterior surgical approach had an extremely high rate of dysphagia (48%). CONCLUSION: Swallowing abnormalities are present in a significant percentage of patients presenting to rehabilitation with acute traumatic cervical spinal cord injury. Patients with a tracheostomy appear to have a substantially increased risk of development of dysphagia, although other factors are also relevant. Risk of dysphagia should be evaluated to decrease the potential for morbidity related to swallowing abnormalities.     

The addition of respiratory muscle strength training to facilitate swallow and pulmonary rehabilitation following massive tissue loss and severe deconditioning: A case series

IntroductionImpaired respiratory and swallow function in patients with intensive care unit–acquired deconditioning, such as associated with massive tissue loss, is not uncommon and can require prolonged rehabilitation.AimThe aim of the study was to examine the effect of combined inspiratory and expiratory respiratory muscle strength training (RMST) on respiratory and swallow function in two critical care patients with marked deconditioning after massive tissue loss.MethodsCase 1 was a 19-year-old male patient with 80% body surface area burns; case 2 was a 45-year-old man with group A streptococcus myositis necessitating quadruple amputation. Both required prolonged intensive care and mechanical ventilation. Both received routine intensive pulmonary and swallow rehabilitation before the trial; however, chronic aspiration and poor secretion clearance remained. At 25 and 26 weeks after initial injury, RMST was performed using EMST150 (expiratory) and Threshold IMT (inspiratory) devices, respectively. At baseline and throughout treatment, data collected included peak expiratory flow (PEF), anthropometry measures, aspiration risk (Penetration-Aspiration Scale [PAS]), pharyngeal clearance (Yale Pharyngeal Residue Scale), secretions (New Zealand Secretion Scale [NZSS]), and functional diet (Functional Oral Intake Scale [FOIS]) via endoscopy.Results/discussionAt baseline, the PEF score of case 1 was 41% (predicted age–height norm) and the PEF score of case 2 was 14%, indicating severe expiratory compromise. Both had extreme energy requirements (3300 kcal/day; 3500 kcal/day). The baseline swallowing scores of case 1 and 2 were as follows: PAS, 8 and 8; Yale, 9 and 10; NZSS, 4 and 7; and FOIS, 1 and 1, respectively, indicating profound dysphagia. At week 3 of 7 of RMST, swallow function improved to allow both to commence oral intake, followed by tracheostomy decannulation. At weeks 10 and 11, full dysphagia resolution was achieved (FOIS = 7; PAS = 1, Yale = 2, NZSS = 0), with PEF at 70% and 48% predicted respectively. Both patients continued RMST, and at discharge from the acute facility, PEF was 84% and 80% predicted respectively.ConclusionThe addition of RMST assisted swallow and pulmonary rehabilitation in both cases and was clinically viable to deliver. Controlled validation trials are now required.     

Swallow Screen Associated With Airway Protection and Dysphagia After Acute Stroke

ObjectiveThe goal was to examine the outcomes of an existing swallow screen protocol in comparison to results from a formal videofluoroscopic protocol.DesignProspective cohort study.SettingAcute hospital.ParticipantsPatients after acute stroke (N=48).InterventionsNot applicable.Main Outcome MeasuresThe Johns Hopkins Hospital Brain Rescue Unit 3 oz Swallow Screen was implemented by nursing staff upon admission. Videofluoroscopy was conducted within 72 hours of diagnostic neuroimaging and initial swallow screen. Predictive values of the bedside swallow screen (pass/fail) for clinical judgment of dysphagia on videofluoroscopy (presence/absence) were calculated. Overall impairment scores from the Modified Barium Swallowing Impairment Profile were analyzed with respect to swallow screen results.ResultsThirteen participants failed the swallow screen, and 35 passed. Of the 35 patients who passed the swallow screen, 15 were clinically diagnosed with dysphagia on videofluoroscopy. Although pass/fail of the swallow screen was not a significant predictor of presence/absence of dysphagia, a logistic regression model including components of Laryngeal Elevation, Laryngeal Vestibule Closure, and Anterior Hyoid Excursion, and sex was statistically significant for swallow screen outcome.ConclusionThe results of this study suggest that a swallow screen of aspiration risk can identify patients with the most need for videofluoroscopic evaluation and dysphagia management. Additionally, patients who fail a swallow screen are more likely to present with physiologic impairments related to airway protection on videofluoroscopy.     

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.     

Determining the Efficacy of the Chin-Down Maneuver Following Esophagectomy With Fiberoptic Endoscopic Evaluation of Swallowing

ObjectivesTo clarify the reliability of fiberoptic endoscopic evaluation of swallowing (FEES) compared to videofluoroscopic swallowing studies (VFSSs). Second, we explored the effect of the chin-down maneuver in the presence or absence of vocal fold paralysis (VFP) using FEES in patients with 3-field lymphadenectomy (3FL) postesophagectomy.DesignRetrospective data collection from FEES and VFSS.SettingDysphagic clinics in the ear, nose, and throat department.ParticipantsPatients (N=15) underwent esophagectomy with 3FL at the Department of Gastroenterologic Surgery, during a period of 12 months.InterventionsThe patients underwent FEES and VFSS with neutral and chin-down maneuvers 2 weeks postoperatively. Two raters of speech pathology blindly scored aspiration, penetration, delayed initiation, and pharyngeal clearance in the pyriform sinus and vallecula, respectively, from recorded movie clips of both examinations, using the penetration aspiration scale (PAS) and modified Hyodo FEES rating scale.Main Outcome MeasuresThe intrarater and interrater correlation coefficients of each parameter examined with FEES. Statistical comparison of each parameter between FEES and VFSS and of each parameter evaluated using FEES between 2 maneuvers with or without VFP.ResultsThe intrarater and interrater correlation coefficients of the PAS and pyriform sinus examined with FEES were both statistically consistent between the 2 raters. The PAS and pyriform sinus evaluated using FEES were significantly correlated with those evaluated in a VFSS (P<.05). The 2 parameters evaluated using FEES were significantly (P<.05) improved with the chin-down maneuver compared to the neutral maneuver, especially in VFP patients.ConclusionFEES performed postesophagectomy with 3FL for evaluation of aspiration is as reliable statistically as VFSSs. The chin-down maneuver is especially useful for reducing the PAS score and pyriform sinus in VFP patients.     

Identification of a simple screening tool for dysphagia in patients with stroke using factor analysis of multiple dysphagia variables.

OBJECTIVE: To identify a most useful and simple clinical screening tool to predict videofluoroscopic aspiration in patients with stroke.Design: Factor analysis of multiple dysphagia variables and sensitivity and specificity testing with chi-square test. PATIENTS: Sixty-one consecutive stroke patients with symptoms suggestive of dysphagia admitted to a university hospital and its 4 affiliated hospitals in Japan. METHODS: Factors were extracted from 6 oromotor examinations (lip closure, tongue movement, palatal elevation, gag reflex, voice quality and motor speech function), 2 swallow screen tests (saliva swallowing test and our modified water swallowing test using 30 ml of water) and 4 parameters evaluated with a videofluoroscopic swallow study. Sensitivity and specificity of each dysphagia-related variable was determined against aspiration in a videofluoroscopic swallow study. RESULTS: Factor analysis revealed that cough/voice change in the water swallowing test and aspiration on videofluoroscopic swallow study belonged to the same factor. Chi-square analysis showed that cough/voice change in the water swallowing test was the only variable that was significantly associated with aspiration on videofluoroscopic swallow study, with a sensitivity of 72% (95% CI: 61-83%) and a specificity of 67% (CI: 55-79%) as a predictor of aspiration (p<0.05). CONCLUSION: We recommend our modified 30 ml water-swallowing test as a useful single task-screening tool to detect aspiration.     

外周磁刺激与神经肌肉电刺激治疗脑卒中后咽期吞咽障碍的疗效对比

目的 观察对比外周磁刺激（PMS）与神经肌肉电刺激（NMES）治疗脑卒中后咽期吞咽障碍的疗效。 方法 采用随机数字表法将60例符合筛选标准的脑卒中咽期吞咽障碍患者分成对照组、电刺激组及磁刺激组,每组20例。3组患者均给予常规吞咽功能训练,电刺激组在此基础上辅以神经肌肉电刺激,磁刺激组则辅以外周磁刺激,上述干预均每天治疗2次,每周治疗6d。于治疗前、治疗4周后分别采用标准吞咽量表（SSA）、功能性经口摄食量表（FOIS）及包括渗透-误吸量表评分（PAS)和视频吞咽障碍分级（VDS)在内的视频透视吞咽检查（VFSS）对3组患者治疗效果进行评价。 结果 治疗4周后发现3组患者SSA评分、渗透-误吸量表（PAS)评分、视频吞咽障碍分级（VDS)评分及FOIS评分均较治疗前明显改善（P<0.05）;进一步分析发现,电刺激组、磁刺激组SSA评分［分别为(30.6±3.2)分、(24.1±2.8)分］、VDS评分［分别为(24.4±5.6)分、(18.2±8.2)分］、PAS评分［分别为(3.25±1.12)分、(2.56±0.66)分］及FOIS评分［分别为(4.31±0.97)分、(4.94±0.81)分］改善幅度均显著优于对照组（P<0.05）,并且磁刺激组上述指标的改善幅度亦显著优于电刺激组,组间差异具有统计学意义（P<0.05）。 结论 外周磁刺激可明显改善脑卒中后咽期吞咽障碍,其治疗效果明显优于神经肌肉电刺激。     

A randomized controlled trail of combination therapy of neuromuscular electrical stimulation and balloon dilatation in the treatment of radiation-induced dysphagia in nasopharyngeal carcinoma patients

Dysphagia is a most common complication induced by radiotherapy in nasopharyngeal carcinoma (NPC) patients. This randomized controlled trail (RCT) was performed to evaluate the therapeutic effect of combination therapy of neuromuscular electrical stimulation (NMES) and balloon dilatation in the treatment of radiation-induced dysphagia in NPC patients. Sixty NPC patients with radiation-induced dysphagia were assigned to either the combination rehabilitation group (treatment group) or the routine rehabilitation group (control group) at random. Both groups were subjected to routine rehabilitation treatment, while the combination rehabilitation group also received combination therapy of NMES and balloon dilatation for 4 months. The water swallow test (WST) and videofluoroscopic swallowing study (VFSS) were used to evaluate the severity of dysphagia. The treatment group showed a significant improvement in swallowing function when compared with the control group. When the WST was used, the efficacy rate (percentage of patients with excellent and effective results) of treatment group was higher than that of control group (90.1 vs. 76.3%), and the difference was statistically significant (χ² = 8.55, p = 0.036). When the VFSS was used, the videofluoroscopy results in our study showed that the values of oral transit time (OTT), swallow reaction time (SRT), pharyngeal transit time (PTT) and laryngeal closure duration (LCD) in treatment group were notably improved when compared with those in control group. In conclusion, combination rehabilitation treatment can improve swallow function in the treatment of radiation-induced dysphagia in NPC patients.

Implications for Rehabilitation

• Dysphagia is also a most important complication associated with radiotherapy and may result in serious complications, such as aspiration pneumonia, and permanent or long-term feeding tube dependence which significantly decrease the quality of life of nasopharyngeal carcinoma patients (NPC).

• Rehabilitation treatment is the most important therapy scheme for radiation-induced dysphagia, and neuromuscular electrical stimulation and balloon dilatation are useful therapy method for dysphagia.

• Combination rehabilitation treatment can improve swallow function in the treatment of radiation-induced dysphagia in NPC.

     

电视透视下吞咽能力检查在口咽期吞咽障碍中的应用

目的 分析吞咽障碍患者电视透视下吞咽能力检查(VFSS)结果.方法 16例知情同意吞咽障碍患者接受VFSS检查.分别采用稀钡餐(50％ w/v)、稠钡餐(270％ w/v)、饼干沾稠钡餐进行咀嚼测试.一口量为10 ml.采用正位、侧位动态造影测试,依次观察双侧梨状窝对称情况、口期时长、咽期起始时间、咽期时长、滞留、误吸及其时间、剂量等.结果5例为口期吞咽障碍;3例为咽期吞咽障碍,显示存在咽期起始迟缓,并且有1例表现为吞咽后误吸;8例为口咽期吞咽障碍,其中5例不伴误吸,3例伴有误吸,其中2例为安静误吸,1例表现为吞咽前误吸,1例表现为吞咽后误吸(梨状窝滞留引起),1例无法判断误吸时间.4例误吸患者中,3例存在钡剂25％以上的重度误吸,1例存在5％的轻度误吸,同时配合吞咽康复治疗.结论VFSS检测可为制订吞咽障碍的康复方案提供参考.     

在电视X线透视吞咽功能检查指导下进行治疗性进食结合吞咽训练对脑卒中后吞咽障碍患者功能的影响

目的:探讨在电视X线透视吞咽功能检查(VFSS)指导下进行治疗性进食结合吞咽训练对脑卒中后吞咽障碍的疗效。方法:选取脑卒中后留置胃管的吞咽障碍患者60例,随机分为对照组和观察组各30例,2组入院后都进行VFSS,对照组给予常规吞咽训练,观察组给予吞咽训练后进行治疗性进食,每周5d,共3周。2组患者分别于治疗前后进行洼田饮水试验(WST),渗漏-误吸分级(PAS)及功能性经口摄食评估(FIOS),并比较2组患者拔管率、患者出院后咳嗽咳痰情况。结果:治疗前,2组患者WST、PAS、FIOS结果比较差异无统计学意义,治疗3周后,对照组WST、PAS分级情况改善(P<0.01,0.05),FIOS等级无明显变化;观察组各项评分较治疗前均有改善(均P<0.01),与对照组相比,观察组3项评估指标、拔管率均有显著改善(均P<0.01),出院1个月后咳嗽咳痰情况有显著改善(P<0.01)。结论:在VFSS指导下进行治疗性进食结合吞咽训练能显著改善脑卒中后吞咽障碍患者的吞咽功能。     

Implementing a systematic care pathway for management of dysphagia after cardiothoracic surgery

ObjectivesThis longitudinal quality improvement study explored the impact of a new multidisciplinary dysphagia care pathway on swallow screening referrals, patient journeys and swallow outcomes in patients after cardiac surgery.Research methodologyThe new dysphagia care pathway consisted of i) nurse chart review triaging using established risk factors, ii) nurse swallow screening (including a cough reflex test and water swallow test) and iii) rapid referral routes to speech pathology. All patients referred for swallow screening in 2020 after the commencement of the new dysphagia care pathway were included (n = 114). Data was compared to two historical, published data sets at the research site (n-41 in 2012–2013 and n = 121 in 2013–2016).SettingCardiovascular intensive care unit.Results52% failed chart review and 29% failed cough reflex test. All patients who passed chart review and cough reflex test returned to a normal diet without need for speech pathology referral. Silent aspiration rates were high in those who failed chart review and the cough reflex test (42%, 43% respectively). For those who received a swallow screen, enteral feeding rates were 70% on first assessment and 27% by discharge from the unit in historical data (2013–2016). In comparison, in 2020, enteral feeding rates were 44% and 8% respectively.ConclusionsReferrals for nurse swallow screening and speech pathology increased following the introduction of the care pathway. There has been a reduction in enteral feeding rates and length of enteral feeding at discharge. High rates of silent aspiration in those who fail screening suggests stepwise nurse dysphagia screening successfully picks up at-risk patients.     

Quantifying swallowing function after stroke: A functional dysphagia scale based on videofluoroscopic studies

OBJECTIVE: To develop a sensitive, specific scale for quantifying functional dysphagia in stroke patients, using results obtained from videofluoroscopic swallowing studies. DESIGN: Data collected from a serial oral and pharyngeal videofluoroscopic swallowing study. SETTING: A dysphagia clinic in a department of rehabilitation medicine at a tertiary care university hospital. PARTICIPANTS: One hundred three consecutively admitted stroke patients. INTERVENTIONS: Videoflurorscopy to measure a scale of 11 variables: lip closure score, bolus formation, residue in oral cavity, oral transit time, triggering of pharyngeal swallow, laryngeal elevation and epiglottic closure, nasal penetration, residue in valleculae, coating of pharyngeal wall after swallow, and pharyngeal transit time. MAIN OUTCOME MEASURES: Polychotomous linear logistic regression analysis of videofluoroscopic and aspiration results. Scale sensitivity and specificity, and the correlation between the total score of the scale and aspiration grade were analyzed. RESULTS: The scale's sensitivity and specificity for detecting supraglottic penetration and subglottic aspiration were 81%, 70.7%, and 78.1%, 77.9%, respectively. A significant positive correlation was found between the scale's total score and the severity of aspiration (Spearman's r =.58943, p =.00001). CONCLUSION: This functional dysphagia scale, which was based on a videofluoroscopic swallowing study in stroke patients, is a sensitive and specific method for quantifying the severity of dysphagia.     

Pulse oximetry does not reliably detect aspiration on videofluoroscopic swallowing study

OBJECTIVE: To examine the reliability of pulse oximetry for identifying aspiration by comparing it with the videofluoroscopic swallowing study (VFSS). DESIGN: Nonrandomized, prospective, double-blind study. SETTING: VFSS laboratory in a teaching hospital. PARTICIPANTS: Sixty patients from among 130 patients with clinically diagnosed dysphagia between September and December 2002. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Simultaneously monitoring the arterial oxygen saturation (Sp o 2 ) by pulse oximetry while patients were performing VFSS. A decrease in Sp o 2 exceeding 3% was considered as significant desaturation. Bolus or portion of bolus passing through the vocal cords and entering the subglottic space was defined as aspiration on VFSS. The results of pulse oximetry and VFSS were compared. RESULTS: No significant correlation existed between desaturation measured by pulse oximetry and aspiration on VFSS (chi 2 test, P =.87). The positive predictive rate of pulse oximetry in detecting aspiration on VFSS was 39.1%, and the negative predictive rate was 59.4%. CONCLUSIONS: Aspiration occurring on VFSS cannot be predicted based on decrease in Sp o 2 in pulse oximetry. The application of pulse oximetry to detect aspiration during regular meals requires further investigation.     

Lateral Pharyngeal Wall Motion Analysis Using Ultrasonography in Stroke Patients with Dysphagia

We aimed to analyze lateral pharyngeal wall (LPW) motion using ultrasonography. The subjects were stroke patients with dysphagia (n = 26) and normal controls (n = 15). The stroke patients were divided into two groups based on a videofluoroscopic swallowing study (VFSS). Group A (n = 12) had a penetration or aspiration in VFSS findings, while group B (n = 14) had no evidence of a penetration or aspiration. We assessed LPW motion using B/M-mode ultrasonography. We performed the comparative analysis among each group and the relationship between LPW motion parameters and the VFSS parameters of the pharyngeal phase. The mean LPW displacement of group A, B was significantly decreased than that of normal controls. The mean LPW duration of group A, B was increased than that of normal controls, but not statistically significant. The mean LPW displacement of group A was significantly correlated with the residue in valleculae, pharyngeal delay time and laryngeal elevation, but that of group B was not significantly correlated. The mean LPW duration of group A, B was not significantly correlated with the VFSS parameters of the pharyngeal phase. We suggest that LPW motion analysis could be a useful alternative method for the evaluation of the pharyngeal phase in stroke patients with a penetration or aspiration in VFSS findings.     

Impact of formal training on agreement of videofluoroscopic swallowing study interpretation across and within disciplines

Purpose

Formal agreement studies on interpretation of the videofluoroscopic swallowing study (VFSS) procedure among speech-language pathologists, radiology house officers, and staff radiologists have not been pursued. Each of these professions participates in the procedure, interprets the examination, and writes separate reports on the findings. The aim of this study was to determine reliability of interpretation between and within the disciplines and to determine if structured training improved reliability.

Methods

Thirteen speech-language pathologists (SLPs), ten diagnostic radiologists (RADs) and twenty-one diagnostic radiology house officers (HOs) participated in this study. Each group viewed 24 VFSS samples and rated the presence or absence of seven aberrant swallowing features as well as the presence of dysphagia and identification of oral dysphagia, pharyngeal dysphagia, or both. During part two, the groups were provided with a training session on normal and abnormal swallowing, using different VFSS samples from those in part one, followed by re-rating of the original 24 VFSS samples. A generalized estimating equations (GEE) approach with a binomial link function was used to examine each question separately. For each cluster of tests, as example, all pairwise comparisons between the three groups in the pretraining period, a Hochberg’s correction for multiple testing was used to determine significance. A GEE approach with a binomial link function was used to compare the premeasure to postmeasure for each of the three groups of raters stratified by experience.

Results

The primary result revealed that the HO group scored significantly lower than the SLP and RAD group on identification of the presence of dysphagia (p = 0.008; p = 0.001, respectively), identification of oral phase dysphagia (p = 0.003; p = 0.001, respectively), and identification of both oral and pharyngeal phase dysphagia, (p = 0.014, p = 0.001, respectively) pretraining. Post training there was no statistically significant difference between the three groups on identification of dysphagia and identification of combined oral and pharyngeal dysphagia.

Conclusions

Formal training to identify oropharyngeal dysphagia characteristics appears to improve accuracy of interpretation of the VFSS procedure for radiology house officers. Consideration to include formal training in this area for radiology residency training programs is recommended.

     

Reliability for detecting oropharyngeal aspiration in children using cervical auscultation

Purpose: Limited data exist that support the reproducibility of cervical auscultation (CA) use in children. This study aimed to determine the reliability of CA in detecting oropharyngeal aspiration (OPA) in children within a controlled environment.

Method: This observational study included eight speech-language pathologists who rated clips of 40 normal and 40 OPA swallowing sounds on two separate occasions (i.e.160 sound clips rated by each speech-language pathologist) to comprise a total of 1280 swallow clips rated. Swallowing sound clips were collected from (1) a volunteer sample of 20 healthy children from the general community (mean 16.2?±?10.7 months; 65% female); (2) a referred sample of 19 children with demonstrated OPA (mean 22.8?±?25.5 months; 36.8% female), as determined on videofluoroscopic swallow studies (VFSS) using the Penetration-Aspiration Scale (PAS) (≥6 score).

Result: Inter-rater reliability was very good (kappa =0.81, 95%CI 0.79–0.84). Intra-rater reliability for each rater was good to very good (kappa range 0.72–0.98). Overall sensitivity was 93.9% (95%CI 91.8–95.6) and specificity was 94.5% (95%CI 92.5–96.2). High reliability values were found for the detection of OPA versus normal swallows using CA alone.

Conclusion: Future research should investigate the use of CA in a variety of clinical settings with less environmental control before CA can be advocated for use in routine clinical practice.     

Retropharyngeal abscess initially diagnosed by the videofluoroscopic swallowing study

In this article, we report a case where a videofluoroscopic swallowing study (VFSS) revealed the cause of a recently developed idiopathic dysphagia in a 66-year-old patient and enabled emergent treatment. The patient reported a 10-day history of fever, cough, sputum production, and progressive jaundice. He was then admitted to the hospital with suspicion of aspiration pneumonia. Despite treatment with antibiotics, fever and leukocytosis were persistent. As he also reported dysphagia, we performed the VFSS, which showed subglottic aspiration on all types of food and revealed a retropharyngeal mass causing mechanical compression. A contrast-enhanced computerized tomography (CT) of his neck was performed following the VFSS, which helped diagnose the mass as an extensive retropharyngeal abscess with mediastinitis. Following this diagnosis, emergent surgical incision and drainage was performed on the patient. Although the VFSS is primarily designed to evaluate swallowing function rather than to diagnose a disease, it can be used to reveal the primary medical cause of dysphagia while it studies the mechanical and structural abnormalities in the oropharyngeal and esophageal regions. This study also proposes that retropharyngeal abscess should be considered in the differential diagnosis of cases showing progressive dysphagia with fever. As confirmed through this work, the VFSS can function as a useful tool for detecting crucial diseases accompanying deglutition disorder.     

Assessment of aspiration in patients with tracheostomies: comparison of the bedside colored dye assessment with videofluoroscopic examination

BACKGROUND: Aspiration is a serious clinical concern in patients with long-term artificial airways. The purpose of this study was to determine the reliability of a bedside colored dye assessment of aspiration in tracheostomized patients and to determine its comparability to a more sophisticated videofluoroscopic study. METHODS: This was a prospective, blinded comparison study conducted in a large, urban, university teaching hospital. We studied 20 consecutive patients who underwent tracheostomy for bronchial hygiene needs and who were referred for videofluorographic evaluation for suspected oropharyngeal dysphagia and possible aspiration. Excluded were patients unable to follow verbal commands and those requiring mechanical ventilatory support. All patients were brought to the videofluorography suite for colored dye assessment for aspiration and videofluorographic assessment of oropharyngeal swallow. A nurse, blinded to the results of videofluorographic swallow study, performed colored dye assessments for aspiration. Speech-language pathologists, blinded to the results of the colored dye assessments, interpreted simultaneous (preliminary) and subsequent complete (final) videofluorographic evaluations of swallow. RESULTS: The colored dye aspiration assessments and the videofluoroscopic studies were compared for the frequency of aspiration detection. Sensitivity and specificity were determined using standard methods. Seven patients showed no aspiration on either the colored dye test or videofluoroscopic examination. Eight patients were judged to aspirate by videofluorography but not by the colored dye test. Five patients were judged to aspirate by both the colored dye test and videofluorography. The data indicate that the colored dye test for aspiration carries a low sensitivity of 38% (95% confidence interval = +/- 7%), but a high specificity of 100%. The videofluoroscopic study detected a significantly greater frequency of aspiration than did the colored dye test (p < 0.01). CONCLUSIONS: The colored dye test for aspiration can provide useful information when positive, but because there is a significant false negative rate, decisions made on the basis of a negative test must be made with caution.     

Swallowing disorders in severe brain injury: risk factors affecting return to oral intake

OBJECTIVE: To determine the incidence and type of swallowing disorders that accompany severe brain injury and to identify factors that affect oral intake. DESIGN: Inception cohort study. SETTING: Level I trauma center. PATIENTS: Consecutively admitted patients with severe brain injury who achieved cognitive levels during admission to assess swallowing and who did not sustain injuries preventing swallowing assessment (n = 54). MAIN OUTCOME MEASURES: Type of swallowing abnormalities and presence of aspiration evident on videofluoroscopic swallow studies (VFSS), days to initiation and achievement of oral feeding, ventilation days, presence of a tracheostomy, and cognitive levels at initiation and achievement of oral feeding. RESULTS: Sixty-one percent of subjects exhibited abnormal swallowing. Loss of bolus control and reduced lingual control occurred most commonly. Aspiration rate was 41%. Normal swallowers achieved oral feeding in 19 days versus 57 days for abnormal swallowers. Rancho Los Amigos (RLA) Level IV was needed for initiation of oral feeding; Level VI was needed for total oral feeding. Risk factors for abnormal swallowing included: lower admission Glasgow Coma Scale (GCS) and RLA scores, presence of a tracheostomy, and ventilation time longer than 2 weeks. Risk factors for aspiration were lower admission GCS and RLA scores. CONCLUSIONS: Swallowing disorders and behavioral/cognitive skills are frequently present in patients with severe brain injury and significantly affect oral intake of food. Persons who swallow abnormally take significantly longer to start eating and to achieve total oral feeding, and they require nonoral supplementation three to four times longer than those who swallow normally.