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 Effect of an Effortful Swallow on the Normal Adult Esophagus

The effect of an effortful swallow on the healthy adult esophagus was investigated using concurrent oral and esophageal manometry (water perfusion system) on ten normal adults (5 males and 5 females, 20-35 years old) while swallowing 5-ml boluses of water. The effects of gender, swallow condition (effortful versus noneffortful swallows), and sensor site within the oral cavity, esophageal body, and lower esophageal sphincter (LES) were examined relative to amplitude, duration, and velocity of esophageal body contractions, LES residual pressure, and LES relaxation duration. The results of this study provide novel evidence that an effortful oropharyngeal swallow has an effect on the esophageal phase of swallowing. Specifically, effortful swallowing resulted in significantly increased peristaltic amplitudes within the distal smooth muscle region of the esophagus, without affecting the more proximal regions containing striated muscle fibers. The findings pertaining to the LES are inconclusive and require further exploration using methods that permit more reliable measurements of LES function. The results of this study hold tremendous clinical potential for esophageal disorders that result in abnormally low peristaltic pressures in the distal esophageal body, such as achalasia, scleroderma, and ineffective esophageal motility. However, additional studies are necessary to both replicate and extend the present findings, preferably using a solid-state manometric system in conjunction with bolus flow testing on both normal and disordered populations, to fully characterize the effects of an effortful swallow on the esophagus.     

Decreased Tongue Pressure Reflects Symptom of Dysphagia

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

Cervical Auscultation Synchronized with Images from Endoscopy Swallow Evaluations

Cervical auscultation is the use of a listening device, typically a stethoscope in clinical practice, to assess swallow sounds and by some definitions airway sounds. Judgments are then made on the normality or degree of impairment of the sounds. Listeners interpret the sounds and suggest what might be happening with the swallow or causing impairment. A major criticism of cervical auscultation is that there is no evidence on what causes the sounds or whether the sounds correspond to physiologically important, health-threatening events. We sought to determine in healthy volunteers (1) if a definitive set of swallow sounds could be identified, (2) the order in which swallow sounds and physiologic events occur, and (3) if swallow sounds could be matched to the observed physiologic events. Swallow sounds were computer recorded via a Littmann stethoscope from 19 healthy volunteers (8 males, 11 females, age range = 18–73 years) during simultaneous fiberoptic laryngoscopy and respiration monitoring. Six sound components could be distinguished but none of these occurred in all swallows. There was a wide spread and a large degree of overlap of the timings of swallow sounds and physiologic events. No individual sound component was consistently associated with a physiologic event, which is a clinically significant finding. Comparisons of groups of sounds and events suggest associations between the preclick and the onset of apnea; the preclick and the start of epiglottic excursion; the click and the epiglottis returning to rest; the click and the end of the swallow apnea. There is no evidence of a causal link. The absence of a swallow sound in itself is not a definite sign of pathologic swallowing, but a repeated abnormal pattern may indicate impairment. At present there is no robust evidence that cervical auscultation of swallow sounds should be adopted in routine clinical practice. There are no data to support the inclusion of the technique into clinical guidelines or management protocols. More evaluation using imaging methods such as videofluoroscopy is required before this subjective technique is validated for clinical use by those assessing swallowing outside of a research context. Study performed at the Freeman Hospital, Newcastle upon Tyne, UK. This project was supported by the Stroke Association (grant 11/98). Presented in part at the ASHA Convention, Chicago, Illinois, 13–15 November 2003     

Standardized Instrument for Lingual Pressure Measurement

Disease-related atrophy of the tongue muscles can lead to diminished lingual strength and swallowing difficulties. The devastating physical and social consequences resulting from this condition of oropharyngeal dysphagia have prompted investigators to study the effects of tongue exercise in improving lingual strength. We developed the Madison Oral Strengthening Therapeutic (MOST) device, which provides replicable mouth placement, portability, affordability, and a simple user interface. Our study (1) compared the MOST to the Iowa Oral Performance Instrument (IOPI), a commercial pressure-measuring device, and (2) identified the optimal tongue pressure sampling rate for isometric exercises. While initial use of the MOST is focused on evaluating and treating swallowing problems, it is anticipated that its greatest impact will be the prevention of lingual muscle mass and related strength diminishment, which occurs even in the exponentially increasing population of healthy aging adults.     

Volume accommodation during swallowing

Bolus volume is an important modifier of the biomechanical events of the oropharyngeal swallow. The biomechanical events comprising a swallow can be divided into events associated with the reconfiguration of the pharynx into a swallow pathway and events associated with bolus transport from the oropharynx into the esophagus. Volume modification is achieved differently for the events of reconfiguration and propulsion. In the case of reconfiguration, a longer time is allocated to the process, as exemplified by sustained laryngeal elevation and hyoid excursion during larger volume swallows. On the other hand, in the case of bolus expulsion, volume accommodation is accomplished within the same period of time by utilizing increased vigor of expulsion. The result of deglutitive volume accommodation is a remarkably different fluoroscopic appearance of a small vs. a large volume swallow. The larger volume swallow seemingly takes longer and results in much more vigorous bolus expulsion than a small volume. However, this is more related to the bolus than the swallow.     

Clinical Utility of the 3-ounce Water Swallow Test

The 3-ounce water swallow test is frequently used to screen individuals for aspiration risk. Prior research concerning its clinical usefulness, however, is confounded by inadequate statistical power due to small sample sizes and varying methodologies. Importantly, research has been limited to a few select patient populations, thereby limiting the widespread generalizability and applicability of the 3-ounce test. The purpose of this study was to investigate the clinical utility of the 3-ounce water swallow test for determining aspiration status and oral feeding recommendations in a large and heterogeneous patient population. Fiberoptic endoscopic evaluation of swallowing (FEES) was performed in conjunction with the 3-ounce water swallow test on 3000 participants with a wide range of ages and diagnoses. A total of 1151 (38.4%) passed and 1849 (61.6%) failed the 3-ounce water swallow test. Sensitivity of the 3-ounce water swallow test for predicting aspiration status during FEES = 96.5%, specificity = 48.7%, and false positive rate = 51.3%. Sensitivity for identifying individuals who were deemed safe for oral intake based on FEES results = 96.4%, specificity = 46.4%, and false positive rate = 53.6%. Passing the 3-ounce water swallow test appears to be a good predictor of ability to tolerate thin liquids. However, failure often does not indicate inability to tolerate thin liquids, i.e., low specificity and high false-positive rate. Use of the 3-ounce water swallow test alone to make decisions regarding safety of liquid intake results in over-referral and unnecessary restriction of liquid intake for nearly 50% of patients tested. In addition, because 71% of participants who failed the 3-ounce water swallow test were deemed safe for an oral diet, nonsuccess on the 3-ounce water swallow test is not indicative of swallowing failure. The clinical utility of the 3-ounce water swallow test has been extended to include a wide range of medical and surgical diagnostic categories. Importantly, for the first time it has been shown that if the 3-ounce water swallow test is passed, diet recommendations can be made without further objective dysphagia testing.     

Influence of Bolus Consistency on Lingual Behaviors in Sequential Swallowing

Thickened liquids are a commonly recommended intervention for dysphagia. Previous research has documented differences in temporal aspects of bolus transit for paste versus liquid consistencies; however, the influence of liquid viscosity on tongue movements during swallowing remains unstudied. We report an analysis of the influence of bolus consistency on lingual kinematics during swallowing. Electromagnetic midsagittal articulography was used to trace tongue body and dorsum movement during sequential swallows of three bolus consistencies: thin, nectar-thick, and honey-thick liquids. Rheological profiling was conducted to characterize viscosity and density differences among six liquids (two of each consistency). Eight healthy volunteers participated; four were in a younger age cohort (under age 30) and four were over the age of 50. The primary difference observed across the liquids of interest was a previously unreported phenomenon of sip-mass modulation; both flavor and density appeared to influence sip-sizing behaviors. Additionally, significantly greater variability in lingual movement patterns was observed in the older subject group. Systematic variations in lingual kinematics related to bolus consistency were restricted to the variability of downward tongue dorsum movement. Otherwise, the present analysis failed to find empirical evidence of significant modulations in tongue behaviors across the thin to honey-thick consistency range.     

Differences in Tongue Strength Across Age and Gender: Is There a Diminished Strength Reserve?

Maximum tongue strength was investigated and compared to mean swallowing pressure elicited by the anterior tongue to calculate the percentage of maximum tongue strength used during swallowing in 96 participants with normal swallowing, divided into three 20-year age groups. The purposes of this investigation were to investigate normal swallowing physiology and to determine whether tongue strength reserves diminished according to age or gender. The results of the study yielded significant maximum tongue strength differences between the youngest and oldest and middle and oldest age groups; the oldest group had the weakest tongues. Mean swallowing pressure did not differ based on age, but women were found to have significantly higher pressures than men. The percentage of maximum tongue strength used during swallowing did not vary as a function of age, but women used a significantly higher percentage of tongue strength to swallow than men. Based on the results, it appears that a diminishing strength reserve does not exist based on age, but it does exist based on gender. Specifically, it appears that women have a reduced tongue strength reserve compared to men. Clinical implications are discussed.

Radiation Dose in Videofluoroscopic Swallow Studies

Videofluoroscopy has become an increasingly important armament in the investigation and assessment of swallowing disorders. However, very little work has been published on the radiation dose used in such examinations and currently there is no national diagnostic reference level in the United Kingdom. Videofluoroscopy in our hospital is performed predominantly by one radiologist (IZM) in a single fluoroscopy room. We recorded the screening times of 230 patients over a 45-month period. Screening time ranged from 18 to 564 s (median = 171 s) associated with a median dose-area product of 1.4 Gy cm². This is below the third quartile level of 2.7 Gy cm² for all such examinations performed across the northern England. The effective dose associated with a typical videofluoroscopy dose-area product is 0.2 mSv. Videofluoroscopy is the most appropriate instrumental examination for assessing oropharyngeal swallow biomechanics and intervention strategies. This data set is based on the largest number of videofluoroscopy swallow studies published to date. Our results show that videofluoroscopy can be performed using minimal radiation doses. This study was performed at Freeman Hospital, Newcastle upon Tyne, UK.     

Quality of Life Related to Swallowing After Tongue Cancer Treatment

The surgical treatment of tongue cancer, with or without reconstruction and/or radiotherapy, leads to different levels of voice, speech, and deglutition disorders. Evaluating the quality of life related to these swallowing alterations is important to further our knowledge about the impact of such alterations from the patient's point of view. Our objective was to describe the quality of life related to swallowing in patients treated for tongue cancer, using specific questionnaires. Twenty-nine patients participated in the study for a minimum of one year after oncologic treatment. Patients with advanced disease who underwent radiotherapy had significantly worse scores in most domains. The aspects related to how to deal with deglutition problems, time taken for meal consumption, pleasure in eating, chewing problems, food sticking in throat and mouth, choking, and the knowledge of feeding restrictions, which were evaluated by different domains of SWAL-QOL, were factors that contributed to a negative impact for patients with advanced-stage tumors who underwent radiotherapy.     

The Dynamics of Lingual-Mandibular Coordination During Liquid Swallowing

Previous literature on tongue-jaw relationships during swallowing has focused on behaviors observed with chewable solid foods. The present investigation was undertaken to evaluate both the nature and stability of coordinative relationships between the jaw and three points located along the midsagittal groove of the tongue—anterior (blade), middle (body), and posterior (dorsum)—during swallowing of thin and honey-thick liquids. A reiterative swallowing paradigm was used, with two task conditions (discrete and sequential), to explore the stability of tongue-jaw coordination across different frequencies of swallowing. Eight healthy participants in two age groups (young, older) performed sets of repeated swallows. Tongue and jaw movements were measured using electromagnetic midsagittal articulography. The data were analyzed in terms of variability in the spatiotemporal movement pattern for each fleshpoint of interest, and the temporal coupling (frequency entrainment) and relative phasing of movement for each tongue segment compared to the mandible. The results illustrate a stereotypical but not invariant sequence of movement phasing in the tongue-jaw complex during liquid swallowing and task-related reductions in variability at higher frequencies of swallowing in tongue dorsum movements. This evidence supports the idea that different segments of the tongue couple with the jaw as a synergy for swallowing, but can modify their coupling relationship to accommodate task demands.     

Hyoid-Bolus Transit Latencies in Normal Swallow

Pharyngeal swallow delay is frequently found in dysphagic patients and is thought to be a factor in a range of swallowing problems, including aspiration. Implicit in notions of swallow “delay” is a temporal interval between two events that is longer than normal. However, there appears to be little agreement about which referent events should be considered in determining delay. A number of pharyngeal bolus transit points and various pharyngeal gestures have been used in delays determined from fluoroscopic evidence, and other referents have been used in electromyographic and manometric studies of swallow. In this study latencies between the first movement of the hyoid and several pharyngeal bolus transit points were calculated from fluoroscopic swallow studies in normal nondysphagic adults. Means and standard deviations of these latencies are provided for a 3-cc and a 20-cc bolus and for both nonelderly and elderly adults. The data may be a useful resource for relating the specific latencies investigated to concepts of pharyngeal swallow delay, in particular, when assessing videofluoroscopic studies using a similar protocol.     

Swallowing therapy of neurologic patients: Correlation of outcome with pretreatment variables and therapeutic methods

The results of swallowing therapy in 58 patients with neurologic disorders are presented. All patients received tube feeding, either partially or exclusively, at admission, and successful outcomes, defined as exclusively oral feeding, were achieved in 67% of patients over a median treatment interval of 15 weeks. A subset of 11 patients who had experienced disease onset 25 weeks or more prior to admission nonetheless had a similar success rate of 64%. No other pretreatment variable, including age, localization of lesion, type or degree of aspiration, or cognitive status, correlated with successful outcome. Indirect therapy methods such as stimulation techniques and exercises to enhance the swallowing reflex, alter muscle tone, and improve voluntary function of the orofacial, lingual, and laryngeal musculature were utilized in all but 1 patient. Direct methods including compensatory strategies such as head and neck positioning, and techniques such as supraglottic swallowing and the Mendelsohn maneuver were additionally employed in nearly one-half of patients. Swallowing therapy is associated with successful outcome, as defined by exclusively oral feeding, among patients with neurogenic dysphagia, regardless of pretreatment variables including time since disease onset. Indirect treatment methods appear to be effective when used either alone or in combination with direct methods. Achievement of oral feeding is not associated with undue risk of pneumonia. Further rigorous scientific studies are needed.     

Effect of Gender on Swallow Event Duration Assessed by Videofluoroscopy

There are data suggesting that women swallow liquids at a lower flow rate and ingest smaller volumes in each swallow than men. Our objective in this work was to compare swallowing in asymptomatic men and women by videofluoroscopy. We studied 18 men [age = 33–77 years, mean = 61 (10) years] and 12 women [age = 29–72 years, mean = 53 (15) years] who swallowed in duplicate 5 and 10 ml of liquid and paste barium boluses. None of the volunteers had dysphagia, neurologic diseases, or oral, pharyngeal, or esophageal diseases. The videofluoroscopic examination showed that for the 5-ml bolus, women had a longer oropharyngeal transit [liquid: men, 0.63 (0.21) s, women, 0.88 (0.39) s; paste: men, 0.64 (0.35) s, women, 0.94 (0.58) s], longer oral transit [liquid: men, 0.41 (0.21) s, women, 0.59 (0.35) s; paste: men, 0.39 (0.28) s, women, 0.59 (0.42) s], and longer pharyngeal clearance [liquid: men, 0.36 (0.11) s, women, 0.45 (0.16) s; paste: men, 0.42 (0.25) s, women, 0.56 (0.27) s] compared with men (p < 0.05). We conclude that there are differences in swallowing between men and women, with women having a longer oropharyngeal transit than men for a 5-ml bolus.

Simultaneous Modified Barium Swallow and Blue Dye Tests: A Determination of the Accuracy of Blue Dye Test Aspiration Findings

Abstract The overall objective of this pilot study was to determine blue dye test reliability and validity for the identification of aspiration of secretions, food, and/or drink in 50 simultaneously administered blue dye (BDT) and modified barium swallow (MBS) tests of tracheostomized individuals. With the MBS as an objective test of aspiration, BDT sensitivity and specificity identifying aspiration were less than 80% and 62%, respectively. Certain tracheostomy tube conditions and food consistencies were associated with more accurate BDT aspiration results than others. Characteristics of the aspiration episodes, interpretation of the results, and needs for further research are discussed.     

Dysphagia Referrals to a District General Hospital Gastroenterology Unit: Hard to Swallow

The aim of our study was to audit dysphagia referrals received by a specialist gastroenterology unit during an entire year. We used a prospective audit carried out over a 12- month period at the District General Hospital gastroenterology unit. The audit included 396 consecutive patients who were referred with swallowing difficulties. We found that 60 referrals (15.2%) were inaccurate and the patients had no swallowing problem. Of the 336 patients with genuine dysphagia, only 29 (8.6%) were new cancer cases. The large majority of subjects had benign disease mostly related to acid reflux. Weight loss was significantly associated with malignancy but also occurred in one third of patients with reflux alone. The temporal pattern of dysphagia was not significantly predictive of cancer. All the cancer patients were above the age of 50 years. Although patients were in general assessed rapidly after hospital referral, the productivity, in terms of early tumor diagnosis, was extremely low. We conclude that there is a substantial rate of inaccurate referrals of dysphagia patients. Most true cases of swallowing difficulty relate to benign disease. Even the devotion of considerable resources to the early diagnosis of esophago gastric malignancy in an attempt to conform with best practice guidelines results in a very low success rate in terms of the detection of potentially curable tumors.     

Swallowing therapy with neurologic patients: Results of direct and indirect therapy methods in 66 patients suffering from neurological disorders

The results of direct and indirect therapy methods applied to 66 patients suffering from neurological disorders are presented. Variables considered were age, time since lesion, localization of central nervous system lesion, type of swallowing disorder (defined according to swallowing phase, type of aspiration and degree of aspiration), cognitive deficits (memory, planning/problem-solving, and attention deficits), and duration of therapy. Success of therapy was defined by progress in type, ease, and safety of feeding and by range of diet. Therapeutic outcome was correlated with the above-listed variables. The findings suggest that swallowing therapy is effective for patients with neurological disorders.     

Use of the electroglottograph for measurement of temporal aspects of the swallow: Preliminary observations

The electroglottograph (EGG) is a noninvasive, electrical impedance device that was developed for observing vocal fold contact during phonation. After a thorough study of the frequency response characteristics of the EGG, we found that the EGG output can be used to identify maximum laryngeal displacement and the duration of laryngeal movement during swallowing. With a small intranasal pressure transducer placed beneath the velum and the EGG electrodes placed externally on the thyroid cartilage, additional information on the temporal aspects of the swallow can be measured. The EGG has direct clinical application when teaching such techniques as the safe swallow and Mendelsohn maneuver and it is useful as a research technique when using repeated measures designed to study the swallow reflex.