Postoperative dysphagia versus neurogenic dysphagia: scintigraphic assessment

In order to differentiate the features of dysphagia that occur after supraglottic horizontal laryngectomy from those that occur during neurologic diseases, we divided 38 subjects into 3 groups and submitted them to oropharyngoesophageal scintigraphy. Group 1 (control group) included 15 healthy volunteeers; group 2 comprised 8 patients who had residual dysphagia at least 1 year after supraglottic laryngectomy; and group 3 included 15 patients with various neurologic and neuromuscular disorders. In group 1, the mean values (+/- 2 SD) of selected semiquantitative parameters were consistent with those reported in the literature for normal subjects. In group 2, oral, pharyngeal, and esophageal transit times were not significantly altered, and moderate tracheobronchial post-deglutitive aspiration was present (maximum value, 6.7%; mean value, 2.04%). The pharyngeal retention index was significantly increased (p = .0003) as compared to normal subjects in all cases (maximum value, 40%; mean value, 23%) and was associated in all cases with slight but consistent post-deglutitive aspiration. In group 3, the oral and esophageal phases were significantly prolonged and the retention indices were significantly increased. Statistical analysis documented a significant increase in oral transit time (p = .003), esophageal transit time (p = .01), oral retention index (p = .006), pharyngeal retention index (p = .0007), and esophageal retention index (p = .009) as compared to normal subjects. The swallowing pattern was also altered by 1) an early loss of the bolus from the oral cavity; 2) bolus fragmentation due to double or triple deglutition, reduced lingual propulsion, or the return of a small part of the bolus into the oral cavity during deglutition; and/or 3) double pharyngeal peaks in the activity-time curves. Tracheobronchial aspiration (maximum value, 90%; mean value, 9.70%) was present in some cases, mainly in patients affected by post-stroke dysphagia. On the basis of the obtained results and considering the low doses of radiation delivered to the patient (0.043 Gy), the limited invasiveness, and the excellent patient tolerance, scintigraphy appears to be clinically valid in the functional study of swallowing and in identifying different deglutition disorders.     

Expert assessment of oropharyngeal dysphagia

The number of patients with chronic dysphagia is increasing as more patients with neurologic diseases and carcinomas of the head and neck can be successfully treated and survive. The expert assessment of a dysphagia should be based not only on anamnestic data, as proposed by the German guidelines “Anhaltspunkte für die ärztliche Gutachtertätigkeit im sozialen Entschädigungsrecht und nach dem Schwerbehindertengesetz,” but also on clinical, endoscopic, and radiologic examinations. Modern procedures of treatment enable us to prevent aspiration or insufficient nutrition; nevertheless, dysphagia causes severe limitations for the patients.     

Sleep nasendoscopy: a technique of assessment in snoring and obstructive sleep apnoea

It appears that uvulopalatopharyngoplasty (UVPP) is a reliable procedure for reducing snoring, but much less reliable when used as a treatment for OSAS. This is thought to be because of poor patient selection in that the site of the problem is not always the site of the operation. We present the technique of sleep nasendoscopy which allows direct visualization of the site or sites of obstruction in a sleeping patient. Our study has shown that there are patients with obstructive sleep apnoea syndrome (OSAS) in whom the only site of pharyngeal obstruction is at the velopharynx. These patients should do well with the relatively simple procedure of UVPP. This is not true for many other OSAS patients in whom we found that obstruction was multisegmental. This helps to explain the frequently poor results of UVPP in OSAS patients. We feel that this form of preoperative assessment will avoid unnecessary surgery.     

Validation of sleep nasendoscopy for assessment of snoring with bispectral index monitoring

Bispectral index (BIS) monitor is a neurophysiological monitoring device which continually analyses a patient’s electroencephalogram during sedation and general anaesthesia to assess the level of consciousness and depth of anaesthesia. BIS monitoring, whilst performing sleep nasendoscopy (using midazolam and propofol), has helped validate depth of sedation and allowed comparison with levels of sedation of control patients during natural sleep. A prospective study of 30 patients with snoring undergoing sleep nasendoscopy with BIS monitoring was conducted. BIS monitoring was recorded throughout the procedure and assessment of snoring was made at the appropriate level of sedation and snoring. BIS values were compared with control patients. The 30 patients undergoing sleep nasendoscopy had average BIS values ranging from 50.72 to 61.2. Similar results were seen with BIS and oxygen saturation in the control group. BIS monitoring provides an adjunct to the assessment of sleep nasendoscopy in determining the level of sedation required for snoring assessment. Comparable BIS values and oxygen saturation levels were obtained between controls and patients during sedation-induced sleep, thus validating the role of sleep nasendoscopy.     

A comparison of sleep nasendoscopy and the Muller manoeuvre.

Knowledge of the level of pharyngeal obstruction during sleep is an important factor in deciding whether or not a patient suffering from obstructive sleep apnoea syndrome (OSAS) will benefit from uvulopalatopharyngoplasty. The Muller manoeuvre has been advocated as a method of obtaining this information. We compared the findings from the technique of sleep nasendoscopy, which actually allows visualization of the level of obstruction in the sleeping patient, with the results of the Muller manoeuvre performed in the same patients while awake. We found the Muller manoeuvre to be less accurate than previously believed.     

A combined approach to the assessment of neurological dysphagia

The dysphagia encountered by patients with neurological disorders can be both distressing and life threatening because of the associated problems of aspiration. Decisions regarding management are often difficult because the exact nature of the underlying disorder varies from patient to patient and is frequently complex. A new approach to the assessment and evaluation of acquired neurological dysphagia is presented. Management of the first 50 patients assessed by this method is described. The advantages of a joint dysphagia clinic comprising neurology, speech therapy, ENT and radiology departments are discussed.     

经鼻内窥镜视神经管减压术

目的:探索治疗视神经外伤的手术方法.方法:为视神经外伤8例行经鼻内窥镜视神经管减压术.结果:8例中5例从术前的无光感,眼前手动到术后的视力1.0,3例由术前的无光感到术后视力0.3.术后随访3～11个月无颅内出血,脑脊液鼻漏、感染等并发症.结论:只要掌握经鼻内窥镜视神经管减压术的适应证及操作熟练,可获得良好的效果.     

Observation of the mechanism of snoring using sleep nasendoscopy

We have performed sleep nasendoscopy on 54 adult snorers in whom obstructive sleep apnoea had been excluded by an overnight sleep study. The purpose of the study was to identify the site or sites of noise production in each case. This was successfully achieved in 50 of the 54 and 70% showed palatal flutter snoring only. In a further 20%, palatal flutter snoring was combined with evidence of noise generation at another site. The second site was supraglottic in 10%, tonsillar in 8% and tongue base in 2%. The tongue base was also the sole site of noise generation in 8% and the epiglottis was the sole site in 2%. This study suggests that sleep nasendoscopy can identify different mechanisms of snoring in individual patients. This information is likely to be of use in formulating a logical surgical treatment plan.     

Predictive value of sleep nasendoscopy in the management of habitual snorers

Sleep nasendoscopy (SN) is claimed to identify the site of obstruction in habitual snoring and is used to select patients for palatal surgery. The validity of SN is, however, unproven. This is the first prospective blind assessment of the role of SN in the management of habitual snorers. Fifty-five consecutive patients listed for laser-assisted uvulopalatoplasty (LAUP) for simple snoring on clinical criteria underwent SN immediately before surgery. Snoring severity and Epworth Sleepiness Scales were completed before the operation and at least 3 months after the operation. The postoperative scores on the snoring severity scale had significantly improved after LAUP, for each SN grade: grade 1 (palatal obstruction; p = .04) and grade 2 (multisegmental obstruction; grade 2A, p = .003, and grade 2B, p = .01). The Epworth Sleepiness Scale showed significant improvement in the whole group (p = .02). We conclude that SN grading of sites of pharyngeal collapse is an insufficient basis to exclude patients from LAUP. Sleep nasendoscopy is thus not of value in the management of habitual snoring, as the measure is a poor predictor of favorable outcome after palatal surgery.     

A comparison of sleep nasendoscopy and the Muller manoeuvre

Knowledge of the level of pharyngeal obstruction during sleep is an important factor in deciding whether or not a patient suffering from obstructive sleep apnoea syndrome (OSAS) will benefit from uvulopalatopharyngoplasty. The Muller manoeuvre has been advocated as a method of obtaining this information. We compared the findings from the technique of sleep nasendoscopy, which actually allows visualization of the level of obstruction in the sleeping patient, with the results of the Muller manoeuvre performed in the same patients while awake. We found the Muller manoeuvre to be less accurate than previously believed.     

Video sleep nasendoscopy: the Hong Kong experience

Video sleep nasendoscopy is a valuable technique for the study of upper airway dynamics in obstructive sleep apnea syndrome. The authors' 10-year experience with its use in Hong Kong has allowed technique refinement for safety and optimal evaluation. Its use in the evaluation of patients who snore, patients with obstructive sleep apnea syndrome, and continuous positive airway pressure titration is presented.     

Validity of sleep nasendoscopy in the investigation of sleep related breathing disorders

OBJECTIVE: To validate the technique of sleep nasendoscopy using target controlled infusion in symptomatic patients and a control group of asymptomatic individuals. DESIGN: Prospective cohort study. SETTING: Department of otolaryngology-head and neck surgery and anesthesia in a teaching hospital. PARTICIPANTS: Two groups of patients were compared and matched for their body mass index. The first group consisted of 53 patients with a history suggestive of obstructive sleep apnea. The second group consisted of 54 patients with partner-confirmed history of no snoring. These patients were undergoing anesthesia for other reasons. Both groups of patients were free of associated otorhinolaryngologic symptoms. MAIN OUTCOME MEASURE: Assessment of production of snoring or obstruction in patients with no documented history of snoring when sedation was administered as part of general anesthesia using target controlled infusion with propofol. RESULTS AND CONCLUSIONS: None of the patients in the asymptomatic group snored or obstructed at any level of propofol, and this was clearly significant on comparison with the symptomatic group (P < .001). All of the symptomatic patients were induced to become symptomatic (snoring/obstruction).     

The technique of nasendoscopy in the evaluation of nasolacrimal duct obstruction in children

Epiphora in infancy is most commonly the result of failure of canalisation of the nasolacrimal duct and most cases resolve spontaneously within 12 months. Lacrimal probing is the standard operative treatment when conservative expectant management fails. While this carries a high success rate, it does not reliably localise the site of obstruction, can create a false passage and may induce traumatic stenosis in the lacrimal passages. Nasendoscopy in conjunction with the lacrimal probing overcomes these problems as the procedure is performed under direct vision. The precise site of opening of the nasolacrimal duct is ascertained, the nature of obstruction established and the risks of false passage creation minimised. We report this technique of endoscopic assessment of lacrimal probing, and the outcome results of twenty such procedures performed on thirteen children.     

Investigation of aspiration: milk nasendoscopy versus videofluoroscopy

Videofluoroscopy has become the gold standard investigation for assessment of aspiration in patients with clinically diagnosed dysphagia due to neurological causes. Modified nasendoscopy has been described for detection of aspiration with varying findings. Milk nasendoscopy is a simple clinic-based technique to evaluate swallow dysfunction, requiring no radiological input. This paper aims to review the correlation of milk nasendoscopy and videofluoroscopy in the detection of aspiration among patients with clinically diagnosed neurological dysphagia. Retrospective notes of 100 patients attending a combined Swallow Clinic for clinically diagnosed aspiration were reviewed. All patients were subjected to both milk nasendoscopy and videofluoroscopy. Correlation of investigation results was reviewed by Kappa test, and difference was statistically examined with Chi square test. Assessment of aspiration in pre-swallow, swallow and post-swallow phases was reviewed using milk nasendoscopy and videofluoroscopy. The significance of difference was measured using Chi square test. Milk nasendoscopy detected post-swallow phase aspiration significantly more than videofluoroscopy with no significant difference in pre-swallow phase, whereas videofluoroscopy was the investigation of choice in detecting aspiration during the swallow phase. In the investigation of clinically diagnosed neurological dysphagia, substantial correlation was seen in detection between videofluoroscopy and milk nasendoscopy. We suggest that milk nasendoscopy should be used as a preliminary clinic-based test thereby reducing the need for investigations requiring radiation doses.     

Otolaryngology and Speech Therapy evaluation in the assessment of oropharyngeal dysphagia: a combined protocol proposal

Dysphagia is a symptom associated with an array of anatomical and functional changes which must be assessed by a multidisciplinary team to guarantee optimal evaluation and treatment, preventing potential complications.AimThe aim of the present study is to present the combined protocol of clinical and swallowing videoendoscopy carried by ENT doctors and speech therapists in the Dysphagia Group of the ENT Department - University Hospital.Materials and MethodsRetrospective study concerning the use of a protocol made up of patient interview and clinical examination, followed by an objective evaluation with swallowing videoendoscopy. The exam was performed in 1,332 patients from May 2001 to December 2008. There were 726 (54.50%) males and 606 (45.50%) females, between 22 days and 99 years old.ResultsWe found: 427 (32.08%) cases of normal swallowing, 273 (20.48%) mild dysphagia, 224 (16.81%) moderate dysphagia, 373 (27.99%) severe dysphagia and 35 (2.64%) inconclusive exams.ConclusionThe combined protocol (Otolaryngology and Speech Therapy), is a good way to approach the dysphagic patient, helping to achieve early and safe deglutition diagnosis as far as disorder severity and treatment are concerned.