Dysphagia lusoria: A late onset presentation

Dysphagia lusoria is a term used to describe dysphagia secondary to vascular compression of the oesophagus. The various embryologic anomalies of the arterial brachial arch system often remain unrecognised and asymptomatic, but in 30%-40% of cases can result in tracheo-oesophageal symptoms, which in the majority of cases manifest as dysphagia. Diagnosis of dysphagia lusoria is via barium swallow and chest Computed tomography scan. Manometric abnormalities are variable, but age-related manometric changes may contribute to clinically relevant dysphagia lusoria in patients who present later in life. Our report describes a case of lateonset dysphagia secondary to a right aortic arch with an aberrant left subclavian artery, which represents a rare variant of dysphagia lusoria. The patient had proven additional oesophageal dysmotility with solid bolus only and a clinical response to dietary modification.     

Treatment for aspiration related to dysphagia: An overview

Aspiration of food during ingestion is the entry of material into the airway below the true vocal folds. It may occur as the result of a number of anatomical and physiological disturbances in deglutition in the oral, pharyngeal, or esophageal stages. In order for aspiration to be treated effectively and efficiently, it should be defined according to its etiology and timing in relation to the reflexive swallow, i.e., before, during, or after the swallow. Each physiological or anatomical etiology for aspiration requires a different management strategy. Treatment may involve compensatory strategies, such as postural changes or diet restraints, which alter the way food flows through the oral cavity or pharynx and usually have an immediate effect on aspiration. Or treatment may consist of exercise programs designed to have a long-term effect on neuromuscular control during the swallow and that require a longer time to take effect. Both compensatory techniques and exercise programs may be instituted simultaneously in some patients. Treatment procedures for the most frequently occurring physiological disorders of deglutition are described.     

The prevalence of swallowing disorders in two teaching hospitals

The prevalence of swallowing disorders among the adult population of two major medical centers during a 3-week period was investigated. Data on the distribution of swallowing disorders among hospital services were analyzed, yielding a consistent incidence of 12–13% of the patients at each hospital. Implications for hospital planning and for further research are discussed.     

Pharyngeal dysphagia in a patient with unsuspected cervical fracture: A case report

A fracture of the dens of C2 and the resultant chronic anterior dislocation resulted in an extrinsic impression of the posterior pharyngeal wall, giving the patient a choking sensation on attempting to swallow. This fracture is a highly unusual cause of pharyngeal dysphagia.     

Retrotracheal thymoma masquerading as esophageal submucosal tumor

A 42-year-old man presented with a two-year history of progressive dysphagia and hoarseness. Esophagogram and endoscopy revealed submucosal mass effect on the upper esophagus. Computed tomography and magnetic resonance imaging revealed an elongated mass in the retrotracheal region of the lower neck with extension to the posterior mediastinum. Partial tumor resection and histopathological evaluation revealed a WHO type B2 thymoma. Adjuvant radiation and chemotherapy were subsequently administered resulting in complete tumor regression. To our knowledge, this is the first report of ectopic retrotracheal thymoma with clinical and imaging manifestations mimicking those for esophageal submucosal tumor.     

A modification of the modified barium swallow

The ability of 64 patients and 7 normal adult subjects to swallow 2 cc (1/2 teaspoon) and 30 cc (gulp from cup) amounts of radiopaque liquid was tested. Bolus size had no influence on the swallowing ability of the normal subjects. However, six of the patients aspirated on the gulp but not on the teaspoon swallows, and three patients aspirated on the teaspoon swallows but not on the gulp. These findings support the need for continued experimental testing of the modified barium swallow protocol if its clinical utility is to be enhanced further. This work supported in part by NINCDS Grant NS21906     

针刺与康复训练治疗脑卒中后吞咽功能障碍的研究进展

针刺与康复结合治疗法是目前治疗卒中后假性球麻痹的吞咽功能障碍的最佳方案,对降低疾病致残率、提高患者生存质量具有较好的作用。该文经检索收集相关文献,对脑卒中后吞咽功能障碍针刺与康复的治疗方法、机制和效果的研究进展进行综述。     

Transnasal endoscopic evaluation of swallowing: A bedside technique to evaluate ability to swallow pureed diets in elderly patients with dysphagia

BACKGROUND:

Endoscopic evaluation of swallowing (EES) is not commonly used by gastroenterologists to evaluate swallowing in patients with dysphagia.

OBJECTIVE:

To use transnasal endoscopy to identify factors predicting successful or failed swallowing of pureed foods in elderly patients with dysphagia.

METHODS:

EES of pureed foods was performed by a gastroenterologist using a small-calibre transnasal endoscope. Factors related to successful versus unsuccessful swallowing of pureed foods were analyzed with regard to age, comorbid diseases, swallowing activity, saliva pooling, vallecular residues, pharyngeal residues and airway penetration/aspiration. Unsuccessful swallowing was defined in patients who could not eat pureed foods at bedside during hospitalization. Logistic regression analysis was used to identify independent predictors of swallowing of pureed foods.

RESULTS:

During a six-year period, 458 consecutive patients (mean age 80 years [range 39 to 97 years]) were considered for the study, including 285 (62%) men. Saliva pooling, vallecular residues, pharyngeal residues and penetration/aspiration were found in 240 (52%), 73 (16%), 226 (49%) and 232 patients (51%), respectively. Overall, 247 patients (54%) failed to swallow pureed foods. Multivariate logistic regression analysis demonstrated that the presence of pharyngeal residues (OR 6.0) and saliva pooling (OR 4.6) occurred significantly more frequently in patients who failed to swallow pureed foods.

CONCLUSIONS:

Pharyngeal residues and saliva pooling predicted impaired swallowing of pureed foods. Transnasal EES performed by a gastroenterologist provided a unique bedside method of assessing the ability to swallow pureed foods in elderly patients with dysphagia.     

Criteria for studies of treatment for oral-pharyngeal dysphagia

Treatment for oral and pharyngeal dysphagia may take a number of forms. Whether prosthetic devices, medication, surgery, compensatory strategies, or exercise programs are used, objective studies are needed to quantify the effects of these treatments on particular types of patients. Before the initiation of any treatment protocol, the anatomy and physiology of each patient's swallowing process should be documented objectively. Patient groups treated and studied should be homogeneous in the nature of their swallowing disorder, the etiology of that disorder, and the stage of their recovery or deterioration. The treatment protocol should be defined in detail. A variety of study designs may be used, including randomized protocols and single-subject designs.     

Esophageal motility,heartburn, and gastroesophageal reflux: Variations in clinical presentation of esophageal dysphagia

Dysphagia is a potentially important symptom, often leading to the finding of an anatomical or motility disorder of the esophagus. Dysphagia and heartburn represent two of the most common symptoms associated with esophageal motility disorders. To explore the relationship of symptomatic esophageal dysphagia and heartburn and their association with primary esophageal motor disorders, we have performed a retrospective assessment of 1035 patient evaluations performed at our gastrointestinal laboratory. A clear statistical association of symptomatic dysphagia and heartburn was established; however, no pattern diagnostic of a specific motility disorder was discernible. A sizable fraction of our patient population with dysphagia demonstrated normal esophageal motility. A significant portion of dyspeptic patients exhibited both normal motility and acid exposure. The differences observed between the incidence of subjective symptoms and objective dysfunction may be explained in part by an altered or increased esophageal sensitivity of these patients.     

Factors Predicting Outcome of Balloon Dilatation in Achalasia

Background Balloon dilatation of the lower esophageal sphincter (LES) is one of the effective nonsurgical treatment options in the management of achalasia. We aimed to determine the long-term results of graded balloon dilatation and the factors predicting outcome. Patients Patients followed for more than 12 months between January 1995 to March 2005, without history of endoscopic or surgical therapy before the study, were included (n = 111, mean age 46.3 ± 16.9 years; follow-up period 46.3 [12–150] months). Patients were evaluated by barium swallow contrast studies, upper endoscopy, and esophageal manometry. Pneumatic dilatation was performed with the use of polyethylene balloon system. Patient outcome was evaluated according to manometric studies and Van Trappen staging as determined following face-to-face interviews with the patients. Results We determined clinical response rates of 98%, 85.7%, and 75% at months 24, 48, and 60. According to receiver-operating characteristics (ROC) analysis, age ≤37.5 years, LES pressure (LESP) ≥30.5 mmHg, LESP after first balloon dilatation ≥17.5 mmHg, and balloon number >2 were found to negatively affect treatment response. Young age and higher esophageal body pressure at admission were determined to be negative predictive factors (P = 0.038, relative risk (RR) 2.6, 95% confidence interval [CI] 1.05–6.4 and P = 0.05, RR 1.069, 95% CI 0.99–1.14, respectively). Conclusion Balloon dilatation is an effective treatment of achalasia. Young age, higher esophageal body pressure, and high LESP after first balloon dilatation are negative predictive factors. Patients with young age requiring more than two balloon dilatations are likely to be unresponsive to the treatment.     

Dysphagia,dystussia, and aspiration pneumonia in elderly people

Despite the development and wide distribution of guidelines for pneumonia, death from pneumonia is increasing due to population aging. Conventionally, aspiration pneumonia was mainly thought to be one of the infectious diseases. However, we have proven that chronic repeated aspiration of a small amount of sterile material can cause the usual type of aspiration pneumonia in mouse lung. Moreover, chronic repeated aspiration of small amounts induced chronic inflammation in both frail elderly people and mouse lung. These observations suggest the need for a paradigm shift of the treatment for pneumonia in the elderly. Since aspiration pneumonia is fundamentally based on dysphagia, we should shift the therapy for aspiration pneumonia from pathogen-oriented therapy to function-oriented therapy. Function-oriented therapy in aspiration pneumonia means therapy focusing on slowing or reversing the functional decline that occurs as part of the aging process, such as “dementia → dysphagia → dystussia → atussia → silent aspiration”. Atussia is ultimate dysfunction of cough physiology, and aspiration with atussia is called silent aspiration, which leads to the development of life-threatening aspiration pneumonia. Research pursuing effective strategies to restore function in the elderly is warranted in order to decrease pneumonia deaths in elderly people.     

肠内营养液胃管饲养对老年吞咽障碍患者的临床应用

目的:探讨早期肠内营养液胃管饲养对老年吞咽障碍患者并发症及预后的影响。方法:将46例老年伴吞咽障碍患者随机分为治疗组和对照组各23例,于入院后48h内开始分别给予鼻饲肠内营养支持(EN)和普通鼻饲饮食及喂食。观察两组患者的并发症、入住ICU的时间、生存时间、血糖水平以及血清白蛋白(ALB)水平、前白蛋白(PA)水平及美国国立卫生院卒中量表(NHSS)等。结果:EN组在降低并发症的发生率,缩短入住ICU的时间,延长患者生存时间,维持血糖水平以及纠正低蛋白血症等方面明显优于对照组。结论:早期肠内营养能降低老年吞咽障碍患者并发症发生率,改善患者预后。     

脑血管疾病吞咽障碍研究进展

吞咽障碍作为脑血管疾病常见并发症,随着脑血管疾病发病率的逐年升高而日益增多,由此所致的吸入性肺炎、水分营养物质摄入障碍、窒息及心理障碍等并发症,严重影响患者的生存质量,增高了致残率及病死率。该文对近10年来有关脑血管疾病吞咽障碍的发病机理、临床表现、诊断及防治等方面的研究进展进行综述。     

上海地区养护机构老年人吞咽障碍及营养风险调查研究

目的了解上海地区养护机构老年人吞咽障碍的发生率及其伴随的营养风险,为该人群的合理营养治疗提供依据。方法采用问卷调查对6所养护机构60岁及以上老年人进行现况研究。利用吞咽筛查法了解老年人的吞咽障碍发生率,并采用微型营养评定精法（MNA-SF）进行营养风险的评估。结果931名养护机构中老年人吞咽障碍的发生率为32．5％,男女无差异（P〉0．05）。60-99岁、70-79岁、80～89岁、90～99岁及100岁以上各年龄段的吞咽障碍的发生率为：0％,17．6％,35．6％,43．7％,50％。老年吞咽障碍者中既往有脑卒中病史者最多;其次是患有咀嚼功能障碍和痴呆者;以及其他慢性病如：阻塞性呼吸道疾病、帕金森病等。养护机构的老年人营养不良的发生率为16．3％,潜在营养不良风险为34．1％;老年吞咽障碍者营养不良的发生率为40．3％,潜在的营养不良风险为38．6％,两者相加的比例高达78．9％,远远高于无吞咽障碍的老年人。结论（1）上海地区养护机构老年人吞咽障碍的发生率高,并随着年龄的增长而升高;（2）老年吞咽障碍者的营养不良和潜在营养不良风险者比例高,吞咽障碍是老年人营养不良的危险因素。     

Developmental approach to pediatric neurogenic dysphagia

The approach to children with neurogenic dysphagia is unique due to their development, growth, and behavior. Multiple streams of development (cognitive, oral-motor, fine and gross motor) have direct and indirect effects on feeding. Provision of an appropriate feeding program requires that the multiple needs, abilities, and disabilities of each child be assessed and managed appropriately.     

The development of dysphagia and dysphonia due to anterior cervical osteophytes

Cervical osteophytes may cause dysphagia by compressing the esophagus and may cause dysphonia by compressing the larynx and inferior laryngeal nerve. The occurrence of dysphagia and dysphonia due to cervical osteophytes has rarely been reported in literature. In this article, a case, in which the multiple cervical osteophytes were found to be the cause of dysphagia and dysphonia, was evaluated by imaging methods and electrophysiological evaluation of swallowing and the case was discussed in the light of relevant literatures.     

Neurologic causes of dysphagia

Pharyngeal dysphagia may be caused by any of a wide variety of neurologic diseases, but the possibility of neurologic disease is often over-looked in the evaluation of dysphagia. This is especially unfortunate because some of the neurologic causes of dysphagia are treatable. This review organizes the neurologic causes of dysphagia into a simple framework that facilitates consideration of these diseases. Methods of evaluating neurogenic dysphagia, including history taking, physical examination, and laboratory testing, are to be considered separately in a subsequent article.