吞咽过程舌压力测量的研究进展

吞咽时舌与上腭之间的压力测量是一种非侵入性的、定量的舌功能评估方法。本文从吞咽过程中舌压力测定的方法,不同姿势、不同食团状态、不同人群中舌压力的变化,以及舌压力对吞咽困难的预测等方面对舌压力测量进行综述。     

Isolated unilateral hypoglossal nerve palsy due to vertebral artery dissection

We report the case of a patient with unilateral tongue weakness secondary to an isolated lower motor neuron hypoglossal nerve palsy that was caused by a right vertebral artery dissection in the lower neck. The patient had a boggy tongue with a deviation to the right side but an otherwise normal neurological examination. Magnetic resonance angiography showed a narrow lumen of the right vertebral artery in the neck. After initially treating the patient with aspirin in the emergency room and later with warfarin for three months, there was complete recanalization of the right vertebral artery. Only one other case of vertebral artery dissection and twelfth nerve palsy has been reported before.     

Multiple schwannomas with pseudoglandular element synchronously occurring under the tongue: A case report

BACKGROUNDSchwannoma is a rare benign, encapsulated tumor of the nerve sheath under the tongue, mostly occurring as solitary tumors with classical histological pattern and several common morphological variants. To our knowledge, multiple schwannomas with pseudoglandular element synchronously occurring under the tongue are rare; we report herein the first such case.CASE SUMMARYA 53-year-old man had first noticed an isolated asymptomatic mass under the tongue, and as the mass grew, the tongue was elevated. Physical examination showed multiple oval neoplasms, and the overlying mucosa was normal. Computed tomography showed three low-density oval neoplasms under the tongue, which were cystic-solid with unclear boundary. The patient has no cutaneous tumors, VIII nerve tumors, or lens opacities and no history of neurofibromatosis 2 or confirmed schwannomatosis in any first-degree relative. Magnetic resonance imaging showed no evidence of vestibular schwannoma. The preoperative diagnosis was mucoepidermoid carcinoma. During hospitalization, all neoplasms were completely excised by surgeons through an intraoral approach under general anesthesia. The diagnosis of the multiple schwannomas with pseudoglandular element was made by histopathology after surgery. At the 15-mo follow-up visit, the patient had no sign of recurrence or development of other peripheral nerve tumors.CONCLUSIONAlthough rare, multiple schwannomas with pseudoglandular element do exist in patients presenting with masses under the tongue. Oral surgeons should be aware of the existence of multiple schwannomas with pseudoglandular element when considering masses under the tongue due to the different prognosis between multiple schwannomas with pseudoglandular element and mucoepidermoid carcinoma.     

Unilateral black hairy tongue in trigeminal neuralgia

Unilateral hairlike discoloration of the tongue is described in a patient with ipsilateral mandibular division trigeminal neuralgia. This unusual physical sign coincided with the patient's painful trigger zone and was attributed to hypertrophy of keratinized filiform papillae, where guarded avoidance of mechanical stimulation over time prevented normal desquamation.     

Ultrasound in dysphagia rehabilitation: a novel approach following partial glossectomy

Purpose: While the presence of dysphagia following partial glossectomy has been widely reported, there is insufficient quality evidence to guide clinical decision making about the treatment of this disorder. This study investigated a novel dysphagia rehabilitation approach using ultrasound tongue imaging for patient training.

Method: Initially, a pilot study was conducted to investigate the feasibility of ultrasound visual feedback during swallow tasks. The protocol was then replicated using a single-case experimental designed study to investigate therapeutic effect. Swallow, speech, and oromotor functions were measured across multiple baselines using an A-B-A intervention study design.

Results: During intervention, both participants were able to interpret ultrasound tongue images during swallow tasks. Following intervention, positive therapeutic effect was achieved with reduced frequency of aspiration and self-initiated swallow strategies. Generalization of intervention was evidenced by reduced bolus transit duration on videofluoroscopy and improved functional oral intake scores. Speech and oromotor functions remained stable throughout the study demonstrating experimental control.

Conclusions: This study establishes that ultrasound visual feedback is feasible in dysphagia rehabilitation following partial glossectomy. In addition, the predicted therapeutic effect specifically to swallow but not speech or oromotor functions were demonstrated.

• Implications for Rehabilitation

• Partial glossectomy results in altered tongue shape, movement, and function which negatively impact on speech and swallowing

• There is limited research evidence to support previously used speech pathology interventions (in particular, tongue range of movement exercises) to rehabilitate dysphagia following tongue cancer surgery

• The tongue, and hence oral phase of swallowing, can be viewed by placing an ultrasound probe under the chin

• Ultrasound scanning of the tongue is not invasive, can be repeated without dosage side effect. It’s also comfortable for the patient and if a portable probe and monitor are used, can be performed within a variety of clinical settings for assessment or therapy

• This study shows specific therapeutic benefit following ultrasound visual feedback along with a motor learning approach to rehabilitate swallow function following partial glossectomy

• Visual and verbal feedback that focus specifically on the motor movements undergoing adaptation (e.g., tongue wave movement, tongue elevation, bolus clearance) following partial glossectomy are recommended

• Patients who are able to see the ultrasound monitor, hear the feedback given, are cognitively able to self-evaluate tongue movement, and remember intervention goals will most benefit from ultrasound tongue visual feedback in therapy

• Clinicians also benefit from visualizing the tongue with ultrasound during assessment and therapy as a direct view reduces the subjectivity of rating task performance

     

Multiple boluses of alteplase followed by extracorporeal membrane oxygenation for massive pulmonary embolism

Thrombolytics and extracorporeal membrane oxygenation (ECMO) are potential management options for massive pulmonary embolism (PE). There are early data supporting the use of repeated alteplase 50 mg bolus for massive PE. However, there is sparse literature addressing placement of ECMO catheters after systemic thrombolysis, and there are no reports of initiating ECMO after repeated bolus of alteplase. We present the case of a patient with massive PE who received two boluses of alteplase for recurrent cardiac arrest, followed by initiation of ECMO. The patient stabilized with these interventions, and ultimately had a good outcome with normal neurologic and functional status.     

Dissociating the spatio-temporal characteristics of cortical neuronal activity associated with human volitional swallowing in the healthy adult brain

Human swallowing represents a complex highly coordinated sensorimotor function whose functional neuroanatomy remains incompletely understood. Specifically, previous studies have failed to delineate the temporo-spatial sequence of those cerebral loci active during the differing phases of swallowing. We therefore sought to define the temporal characteristics of cortical activity associated with human swallowing behaviour using a novel application of magnetoencephalography (MEG). In healthy volunteers (n = 8, aged 28-45), 151-channel whole cortex MEG was recorded during the conditions of oral water infusion, volitional wet swallowing (5 ml bolus), tongue thrust or rest. Each condition lasted for 5 s and was repeated 20 times. Synthetic aperture magnetometry (SAM) analysis was performed on each active epoch and compared to rest. Temporal sequencing of brain activations utilised time-frequency wavelet plots of regions selected using virtual electrodes. Following SAM analysis, water infusion preferentially activated the caudolateral sensorimotor cortex, whereas during volitional swallowing and tongue movement, the superior sensorimotor cortex was more strongly active. Time-frequency wavelet analysis indicated that sensory input from the tongue simultaneously activated caudolateral sensorimotor and primary gustatory cortex, which appeared to prime the superior sensory and motor cortical areas, involved in the volitional phase of swallowing. Our data support the existence of a temporal synchrony across the whole cortical swallowing network, with sensory input from the tongue being critical. Thus, the ability to non-invasively image this network, with intra-individual and high temporal resolution, provides new insights into the brain processing of human swallowing.     

Pulsatile growth hormone secretion in normal man during a continuous 24-hour infusion of human growth hormone releasing factor (1-40). Evidence for intermittent somatostatin secretion.

Growth hormone (GH) secretory patterns were studied in a patient with ectopic growth hormone releasing factor (GRF) secretion and in normal men given continuous infusions of human growth hormone releasing factor (1-40)-OH (hGRF-40). In the patient with ectopic GRF secretion, GH secretion was pulsatile despite continuously elevated immunoreactive GRF levels. To determine if pulsatile GH secretion is maintained in normal subjects, we administered to six healthy young men vehicle or hGRF-40, 2 ng/kg per min, for 24 h and gave a supramaximal intravenous bolus dose of hGRF-40, 3.3 micrograms/kg, after 23.5 h of infusion. hGRF-40 infusion resulted in greater GH secretion than did vehicle infusion and pulsatile GH secretion was maintained throughout hGRF-40 infusion. During the 23.5 h of vehicle infusion, total GH secretion (microgram; mean +/- SEM) was 634 +/- 151 compared with 1,576 +/- 284 during hGRF-40 infusion (P = 0.042). The GH response to the intravenous bolus of hGRF-40 was greater after vehicle infusion than after hGRF-40 infusion; 877 +/- 170 and 386 +/- 125 micrograms of GH was secreted after the bolus on vehicle and hGRF-40 days, respectively (P = 0.015). The total amount of GH secreted during the 25.5 h of the two study days was not different; 1,504 +/- 260 and 1,952 +/- 383 micrograms were secreted during vehicle and hGRF-40 days, respectively (P = 0.36). Not only was pulsatile GH secretion maintained during hGRF-40 infusion, but there was augmentation of naturally occurring GH pulses, which is in contrast to the effect of gonadotropin-releasing hormone on gonadotropin secretion. We suggest that GH pulses are a result of GRF secretion that is associated with a diminution or withdrawal of somatostatin secretion.     

Ultrasound perfusion imaging: determination of thresholds for the identification of critically disturbed perfusion in acute ischemic stroke--a pilot study

Ultrasound harmonic imaging of perfusion after ultrasound contrast agent (UCA) bolus injection (BHI) can detect cerebral perfusion deficits. In a pilot study, we evaluated the ability of time-intensity curve (TIC) measurements to differentiate between normal and hypoperfused brain areas in acute ischemic stroke. Ten patients with symptoms of acute middle cerebral artery infarction were investigated (SONOS 5500, Harmonic Imaging 1.6/3.8 MHz, diencephalic plane, 10 cm investigation depth, SonoVue 2.4 mL bolus). Peak signal increase (PSI), time-to-peak intensity (TPI) and area under the curve (AUC) were calculated for 60 regions-of-interest (ROIs) in each patient. Reference methods: Perfusion- and diffusion-weighted MRI (PWI/DWI) within 4 h before/after BHI (PWI threshold: 4 s). Receiver operating characteristics (ROC) analysis defined cut-off values for each TIC variable to distinguish between normal and affected brain areas as defined by PWI/DWI. In five patients, PWI showed a perfusion delay >4 s; seven patients had a DWI lesion. In three patients, both PWI and DWI findings showed pathology; one patient had a normal MRI of the insonation plane. Cut-off values for PWI delay: PSI: 5.53% (sensitivity .98, specificity .89); TPI: 4.04 s (sensitivity .74, specificity .69) and AUC: .63 (sensitivity .94, specificity .58). Referred to the mean value in unaffected brain areas the relative thresholds were 17.6%, 109.5% and 16.1%, respectively. Regarding DWI, only for PSI, a significant cut-off value was defined: 10.86%, sensitivity .84, specificity .60 (34.6% of mean). In conclusion, these thresholds distinguish between normal and affected brain areas in acute ischemic stroke.     

Biofeedback therapy using accelerometry for treating dysphagic patients with poor laryngeal elevation: case studies

Dysphagia, a swallowing disorder, is a problem encountered frequently in the rehabilitation of stroke and head injury patients. In normal individuals, safe passage of a food bolus into the esophagus is ensured by laryngeal elevation and closure of the airway. Inadequate laryngeal elevation can lead to aspiration, choking, and even death. The course of recovery in the current clinical practice is rather tedious. Recently, investigators have developed and evaluated the accelerometry technique for noninvasive assessment of laryngeal elevation. The purpose of the present paper is to present case reports of patients with poor laryngeal elevation treated with computerized biofeedback therapy using dynamic acceleration measurements. Acceleration was measured from the dysphagic patient during swallowing, and was dynamically displayed on the computer screen along with an acceleration signal from a typical, normal subject. The patient was asked to elicit a swallow response such that his/her acceleration display matched the display of the normal subject. Each patient had nine therapy sessions, lasting about half an hour each. All five patients improved significantly in acceleration magnitude and in swallowing function as confirmed by the videofluorography evaluation.     

The effect of ketamine with remifentanil for improving the quality of anaesthesia and recovery in paediatric patients undergoing middle-ear ventilation tube insertion

This prospective randomized study evaluated the effects of ketamine with remifentanil to improve the quality of anaesthesia and postoperative recovery, following brief procedures, in 60 paediatric patients undergoing middle-ear ventilation tube insertion (MEVTI). Patients were randomly assigned to either ketamine 2 mg/kg intravenous [i.v.] bolus plus normal saline by i.v. infusion (K group, n = 30) or ketamine 2 mg/kg i.v. bolus, plus remifentanil 0.15 μg/kg per min i.v. infusion (KR group, n = 30). Parameters that were assessed included intraoperative patient movement, surgeon satisfaction, anaesthesia time, total ketamine dose, postoperative recovery time, agitation and side-effects. Intraoperative patient movement scores were significantly lower, and surgeon satisfaction scores were significantly higher, in the KR group than in the K group. Time to recovery was significantly shorter in the KR group than in the K group. In conclusion, remifentanil was a good adjuvant to ketamine, improving the quality of anaesthesia and postoperative recovery in children undergoing MEVTI.     

Dysphagia without clinically relevant pathological correlation: to exclude tumours of the floor of the mouth and the base of the tongue ultrasound diagnosis is mandatory

In patients suffering from dysphagia, a tumour of the tongue and its base must be excluded. This is not always possible by means of endoscopy and palpation. In contrast it is possible to visualize deep-seated structures of this region by ultrasound. Unfortunately, this technique is rarely used, as shown in the cases demonstrated. We present five patients suffering from dysphagia for a long period of time (up to 30 years) where ultrasound was not performed and a tumour of the floor of the mouth and the base of the tongue was overlooked. Thus, adequate therapy was delayed, which proved to be especially relevant in three patients suffering from a malignoma. Three patients suffered from a malignant tumour of the base of the tongue. Up to two years passed between the beginning of dysphagia and the necessary surgical treatment. One of these patients even underwent psychological treatment for his symptoms. In two other patients a dermoid cyst and ectopic thyroid tissue were removed. In patients suffering from dysphagia with normal endoscopic findings and normal palpation of the neck ultrasound of the floor of the mouth and the base of the tongue is imperative. Tumours of this area can be detected early with high sensitivity and cost-effectiveness by ultrasound.     

Is thrombolytic therapy safe during active menstruation?

A 39-year-old female presented to the Emergency Department during the fourth day of menstruation and within 2 hours of the onset of chest pain associated with dyspnea, diaphoresis, and emesis. An electrocardiogram showed acute inferior myocardial infarction and serial CPK enzyme levels peaked at 958 IU/L with 9% MB fraction. Along with aspirin and intravenous nitroglycerin, the patient was given thrombolytic therapy consisting of tPA with an initial bolus of 35 units, followed by 65 units infused within 60 minutes together with heparin 5000 units intravenous bolus, and 1000 units/hour maintenance infusion for 5 days. The menses were prolonged 1 day longer than her usual 5 days; however, there was no increase in the amount of bleeding during any day. The hemoglobin dropped from 12.5 G/dl to 11.3 G/dl in the first 6 hours, but remained stable thereafter. This initial drop in hemoglobin was considered a dilutional effect of 1.5 L of normal saline the patient received intravenously during that period. Although no available guidelines exist regarding the safety of thrombolytic agents during active menstruation, this case report and a few others reported in the literature suggest that normal menstruation is not a contraindication to thrombolytic therapy during acute myocardial infarction.     

Ultrasonographic measurement of tongue movement during swallowing.

Previous ultrasonographic studies on tongue functions were limited by the possibility of artifacts caused by movement of the submental area during function. Consequently, tongue movements were misinterpreted. A dynamic tongue imaging technique, the cushion-scanning technique, was used to overcome this problem. Later, swallowing was investigated and divided into five phases using cushion-scanning technique-aided M-mode ultrasonograms. In this study, cushion-scanning technique in combination with the B-mode and M-mode ultrasonography was applied to investigate and measure the tongue movement during swallowing in 55 normal persons. The average duration, range of motion and speed of swallowing were found to be 2.43 s, 24.06 mm, and 10.34 mm/s, respectively. The computer-aided B-mode plus M-mode ultrasonography in combination with the cushion-scanning technique is a valuable tool for study of tongue functions.     

Unilateral anterior uveitis in Melkersson-Rosenthal syndrome: a case report

Melkersson-Rosenthal syndrome (MRS) is an uncommon granulomatous condition characterized by persistent or recurrent orofacial oedema, relapsing facial paralysis and fissured tongue. We report here a case of MRS with the classical triad of signs accompanied by unilateral anterior uveitis. A 35-year-old man with a fissured tongue, recurrent facial palsy and orofacial oedema presented with a 3-month history of conjunctival redness and decreased vision in the right eye. On evaluation of visual acuity, the patient was only able to count fingers. Slit lamp examination revealed severe conjunctival injection, cells and flare, posterior synechiae and keratic precipitates. Examination of the left eye revealed no evidence of inflammation. Examination of the other systems was normal. The patient was treated with topical corticosteroids and cycloplegics and the visual acuity improved to 7/10. To our knowledge, there are no previous reports of an association between uveitis and MRS.     

Progressive speech deterioration and dysphagia in amyotrophic lateral sclerosis: case report.

Amyotrophic lateral sclerosis (ALS) is a degenerative neurologic disease having both upper and lower motor neuron signs and symptoms. When the speech musculature is involved, a mixed dysarthria and dysphagia usually result. In a 49-year-old man with ALS, dysarthria and dysphagia progressed from mild to severe forms over 17 months. Eleven months after the patient first experienced symptoms, neurologic examination showed fasciculations of the extremities and tongue, limb weakness, and hyperreflexia of the limbs and velopharyngeal mechanism. Tongue strength was one-fourth that of normal. Lingual alternate motions rates for consonant-vowel syllables were also reduced. To enhance lingual strength and swallowing, a tongue-strengthening program was developed for use with articulation training; to augment velopharyngeal function, a palatal lift was fitted; and to increase extremity strength, physical therapy was initiated. Six months after the initial neurologic examination, medical and speech reevaluation showed progressive weakness of the body parts affected initially; continued decline in tongue strength and lingual alternate motion rate; hypoactive reflex activity, indicative of progressive involvement of the lower motor neuron system; and continued deterioration of articulation and phonation owing to the progressive nature of the disease.     

The human parietal cortex is involved in spatial processing of tongue movement-an fMRI study

The human tongue is so sensitive and dexterous that spatial representations of the inside of the oral cavity for the tongue movement are naturally expected to exist. In the present study, we examined the brain activity associated with spatial processing during tongue movements using a functional magnetic resonance imaging technique. Twenty-four normal subjects participated in the study, which consisted of a periodic series of three blocks; resting of the tongue, tongue movement (pressing the inside of a tooth with the tip of the tongue), and tongue retraction. The cerebral fields of activation during the tongue movement to the left and right side relative to those during rest were found in the primary sensorimotor area and supplementary motor area bilaterally, and in the left inferior parietal lobule (IPL). The activation areas during the tongue retraction relative to those during rest were almost the same, except that activation in the left IPL was not observed. The fields of activation during tongue movement to the left and right side relative to those during tongue retraction were found bilaterally in the dorsal premotor area, superior parietal lobule (SPL), and the IPL. The results indicate that the bilateral SPL and IPL were specifically involved in the processing for human tongue movement. Although no significant laterality was observed, the left parietal area tended to show greater activation in statistical values and area than the right parietal area, thus indicating the possibility that this processing for human tongue movement is related to that for language.     

Respiratory depression after cimetidine reversed by physostigmine

A state of severe respiratory depression and mental confusion after cimetidine administration in a patient with normal renal and hepatic function is described. The condition was reversed by a bolus dose of 2 mg physostigmine IV followed by a continuous infusion of 3.75 mg/h. The possibility of CNS side effects from cimetidine and the antagonism of physostigmine is emphasized, particularly in cases with stress ulcers related to intracranial disorders where sedation and respiratory depression have to be avoided.     

Bed-side assessment of cerebral perfusion in stroke patients based on optical monitoring of a dye bolus by time-resolved diffuse reflectance

We present a minimally invasive optical method, that is, multi-channel time-domain diffuse near-infrared reflectometry of the head to assess cerebral blood perfusion that is applicable at the bed-side and repetitively at short intervals. Following intravenous injection of an ICG bolus, its transit through intra- and extracerebral tissue is monitored based on changes in moments of distributions of times of flight of photons, recorded with a 4-channel instrument simultaneously on both hemispheres. In healthy volunteers, we found that variance of distributions of times of flight of photons is well suited to assess latency and initial slope of the increase in absorption of intracerebral tissue due to the bolus. We successfully applied our method in two patients demonstrating a reversible cerebral perfusion deficit in an ischemic stroke patient who was treated by thrombolysis and in another patient with a permanent impaired unilateral perfusion due to ipsilateral internal carotid artery occlusion. In either case, we observed a difference in bolus transit time between the hemispheres. In the stroke patient, this difference resolved when re-evaluated 1 day after thrombolysis. The study demonstrates the necessity of a technique with sub-nanosecond time resolution to allow for depth discrimination if clinical perfusion monitoring of cerebrovascular diseases is addressed by optical methods.     

The Comparison of Two Different Techniques of Remifentanil Administration During Implantable Vascular Access Device Procedures

PurposeThe aim was to compare analgesic efficacy and adverse effects of two different techniques of intravenous remifentanil administration in patients undergoing vascular; access device procedures with monitored anesthesia care.DesignA randomized, single-blinded controlled study.MethodsThe patients (N = 92) were 30-80 years old and of American Society of Anesthesiologists Physical Status I-III. The first group was the continuous infusion group (group CI). Intravenous continuous remifentanil was infused after starting at a dosage of 0.1 mcg/kg/min, and the dose was raised incrementally up to 1 mcg/kg/min if required. The second group was intravenous bolus patient-controlled sedation analgesia (PCSA) with remifentanil infusion at a dose of 0.05 mcg/kg per minute and bolus of 0.1 mcg/kg with lock-out time of 3 minutes. In both groups, a bolus dose of 0.1 mcg/kg remifentanil was administered. The data evaluated include level of pain and sedation, total amount of remifentanil consumption, bolus doses of remifentanil, patient and surgeon satisfaction, hemodynamic data, and adverse events.FindingsIn comparison between techniques, pain and sedation scores during procedure, duration of procedure, patient and surgeon satisfaction, additional rescue medication, and bolus doses were not statistically different (P > .05). The total amount of remifentanil administered was significantly lower in the infusion group than that in the bolus group (P = .031).ConclusionsFor central venous access device procedures under monitored anesthesia care, remifentanil use in both infusion and bolus techniques could provide sufficient sedation and analgesia without serious adverse effects. Total remifentanil consumption amount in infusion group is lower than that in the bolus group.