Observation of Arytenoid Movement During Laryngeal Elevation Using Videoendoscopic Evaluation of Swallowing

The purpose of this study was to confirm that the arytenoid regions dynamically adduct and extend upward toward the epiglottis during laryngeal elevation. While 14 healthy volunteers aged 19?C32?years old swallowed 5?ml of white soft yogurt in one gulp without chewing, the movement of the arytenoid regions was observed for videoendoscopic evaluation of swallowing (VE). Each moving image was stored simultaneously on videotape. A cross-sectional area surrounded by the epiglottis and the bilateral arytenoid regions (S) and the length of a straight line passing through the anterior borders of the left and right arytenoid regions (L) were measured. The relative area of the entrance in the laryngeal vestibule was calculated as [S/L ²] before the swallowing reflex (resting condition), just before laryngeal closure, and just after laryngeal closure. [S/L ²] was smaller just before epiglottal descent than at the resting condition, and became smallest just after the epiglottis started to ascend. The mean area narrowed to 37.9% of the resting area just after laryngeal closure and in the most extreme case to 8.7% of the resting area. It was demonstrated that the arytenoid regions adducted and extended up toward the epiglottis during laryngeal elevation. The technique used to measure the cross-sectional area of the entrance in the laryngeal vestibule employing VE was an effective analytical procedure.     

Oral Motor Movements and Swallowing in Patients with Myotonic Dystrophy Type 1

Oropharyngeal dysphagia and esophageal motility disorders were found to be the most important causes of aspiration pneumonia in patients with myotonic dystrophy. The purpose of this report was to evaluate clinical characteristics of the oral motor movements and swallowing of individuals with myotonic dystrophy type 1 (DM1) using a standardized clinical protocol and surface electromyography (sEMG). Participants were 40 individuals divided in two groups: G1 composed of 20 adults with DM1 and G2 composed of 20 healthy volunteers paired by age and gender to the individuals in G1. Statistical analysis included one-way ANOVA with two factors for within- and between-group comparisons and Bonferroni correction for multiple comparisons. Patients with DM1 presented deficits in posture, position, and mobility of the oral motor structures, as well as compromised mastication and deglutition. The sEMG data indicated that these patients had longer muscle activations during swallowing events. The longer duration of sEMG in the group of patients with DM1 is possibly related to myotonia and/or incoordination of the muscles involved in the swallowing process or could reflect a physiological adaptation for safe swallowing.     

Preliminary Temporal Measurement Analysis of Normal Oropharyngeal Swallowing in Infants and Young Children

Temporal measures of normal pediatric oropharyngeal deglutition have not been studied. Knowledge of range and variation of normative temporal measures could define abnormal deglutition and assist in design of appropriate compensatory and rehabilitative treatment techniques. The purpose of this retrospective study was to determine temporal measurements for oral filling, oral transit, onset of laryngeal closure, time of bolus arrival at the valleculae, pharyngeal delay, pharyngeal transit, and UES opening. Videofluoroscopic swallow studies of 15 normally swallowing pediatric subjects were divided into three age groups and method of liquid delivery. Mean, standard deviation, percentages, and extension of the median were utilized to determine relationships of temporal measures. Mean temporal duration increased with age for oral filling, oral transit time, time of laryngeal closure, UES opening, and pharyngeal delay time. However, no significant differences were found between age groups indicating a deglutitive biomechanical adaptation to growth of the oral and pharyngeal cavity. Feeding method for bottle versus cup mean duration increased for oral transit time, laryngeal closure time, UES opening, and pharyngeal delay time. Bolus head location relative to onset of laryngeal vestibule closure changed with increased age and method of feeding. Temporal measures were not significantly different for age groups or feeding methods. Bolus location was at or fully contained in the valleculae at the onset of laryngeal closure and appeared to be a normal finding in functional pediatric swallows and is not indicative of a delay or disorder.     

Measurement of Hyoid and Laryngeal Displacement in Video Fluoroscopic Swallowing Studies: Variability, Reliability, and Measurement Error

Video fluoroscopy is commonly used in the study of swallowing kinematics. However, various procedures used in linear measurements obtained from video fluoroscopy may contribute to increased variability or measurement error. This study evaluated the influence of calibration referent and image rotation on measurement variability for hyoid and laryngeal displacement during swallowing. Inter- and intrarater reliabilities were also estimated for hyoid and laryngeal displacement measurements across conditions. The use of different calibration referents did not contribute significantly to variability in measures of hyoid and laryngeal displacement but image rotation affected horizontal measures for both structures. Inter- and intrarater reliabilities were high. Using the 95% confidence interval as the error index, measurement error was estimated to range from 2.48 to 3.06?mm. These results address procedural decisions for measuring hyoid and laryngeal displacement in video fluoroscopic swallowing studies.     

Utility of a Clinical Swallowing Exam for Understanding Swallowing Physiology

A clinical swallowing examination (CSE) is generally believed to be inadequate for making judgments regarding swallowing physiology compared to objective assessments. A large volume of studies has heavily focused on identifying aspiration using a CSE and research addressing physiologic information gathered from a CSE is sparse. The purpose of this study was to examine the utility of the CSE for assessing physiology compared to videofluoroscopic swallowing studies (VFSS). Data were derived from a prior investigation of sixty adult patients post-stroke tested with CSE and VFSS. The CSE included an examination of historical measures, oral motor/speech/voice, and trial swallows. The VFSS consisted of swallows of controlled portions of thin, thick, puree, and solid boluses. Previous results from these patients demonstrated significant accuracy in making binary estimates of aspiration and the presence of dysphagia. This analysis of data focused on physiologic measures, as well as overall dysphagia severity and diet recommendations. Significant associations between CSE and VFSS ratings were observed for hyolaryngeal elevation, overall swallowing severity, and diet recommendations. These findings were specific for certain bolus consistencies. These data suggest that the CSE may not provide significant physiological information other than hyolaryngeal excursion. This does not preclude the fact that the CSE is important in providing substantial information about overall dysphagia severity. It appears that the CSE is more powerful than simply a “screening” tool. More prospective research designs are warranted to substantiate the strengths of the CSE.     

The Effect of Voluntary Pharyngeal Swallowing Maneuvers on Esophageal Swallowing Physiology

The purpose of our study was to evaluate whether swallowing maneuvers designed to impact pharyngeal physiology would also impact esophageal physiology. Healthy volunteers underwent high-resolution manometry while performing three randomized swallowing maneuvers with and without a 5-ml bolus: normal swallowing, Mendelsohn maneuver, and effortful swallowing. We examined esophageal parameters of peristaltic swallows, hypotensive or failed swallows (“nonperistaltic swallows”), distal contractile integral (DCI), contractile front velocity (CFV), intrabolus pressure, and transition zone (TZ) defect. Four females and six males (median age 39 years; range 25–53) were included in the study. The overall number of nonperistaltic swallows was 21/40 (53 %) during normal swallowing, 27/40 (66 %) during the Mendelsohn maneuver, and 13/40 (33 %) during effortful swallowing. There were significantly more overall nonperistaltic swallows with the Mendelsohn maneuver compared with effortful swallowing (p = 0.003). While swallowing a 5-ml bolus, there were more nonperistaltic swallows during the Mendelsohn maneuver (12/20, 60 %) compared to that during normal swallowing (6/20, 30 %) (p = 0.05) and more peristaltic swallows during effortful swallowing as compared to Mendelsohn maneuver (p = 0.003). Intrabolus esophageal pressure was greater during the Mendelsohn maneuver swallows in the bolus-swallowing condition as compared to normal swallowing (p = 0.02). There was no statistical difference in DCI, CFV, or TZ defect between swallowing conditions. The Mendelsohn maneuver may result in decreased esophageal peristalsis while effortful swallowing may improve esophageal peristalsis. Because it is important to understand the implications for the entire swallowing mechanism when considering retraining techniques for our patients, further investigation is warranted.     

Effects of Physostigmine on Swallowing and Oral Motor Functions in Patients with Progressive Supranuclear Palsy: A Pilot Study

The purpose of this pilot study was to investigate whether cholinergic stimulation reduces swallowing and oral motor disturbances in patients with progressive supranuclear palsy (PSP). A controlled, double-blind crossover trial of physostigmine, a centrally active cholinesterase inhibitor, and placebo was conducted. Patients were randomized to a 10-day crossover placebo-controlled double-blind trial of physostigmine at their previously determined best dose administered orally every 2 hr, six times per day. Patients were evaluated with ultrasound imaging of the oropharynx and an oral motor examination at baseline and during the third or fourth days of each study phase (placebo and drug). Under the double-blind placebo-controlled conditions, patients showed no statistically significant improvement in oral motor functions or swallow durations. Because patients with PSP have increased sensitivity to cholinergic blockade compared with control subjects, studies with newer, more potent cholinergic stimulating agents need further exploration. Suggestions for future research include the evaluation of newer direct cholinergic agonists in the treatment of the less-impaired PSP patients who may have a greater number of cholinergic neurons preserved and the evaluation of combined therapies.     

Change in Palatoglossus Muscle Activity in Relationto Swallowing Volume During the Transition from the Oral Phaseto the Pharyngeal Phase

The purpose of this study was to examine whether the palatoglossus (PG) muscle is involved in the regulation of function during the transition from the oral to the pharyngeal phase. Seven normal adults participated in the study. Smoothed electromyography (EMG) signals of the PG muscle and levator veli palatini (LVP) muscle were collected. Each subject swallowed water at five different volumes: 12.5%, 25%, 50%, 100%, and 150% (or 200%) of his/her optimum swallowing volume. PG muscle waveform showed two patterns of activity: one of a single peak and the other of two peaks. There was no significant difference (p < 0.01) in the timing of emergence between the single peak and the second peak of the two-peak pattern. There were two patterns of PG muscle activity in response to a change in swallowing volume, i.e., one was a pattern in which the activity was correlated to the change in swallowing volume, the other was a pattern in which the activity was not changed but almost at the maximum activity level, irrespective of swallowing volume. We conclude that the PG muscle could be involved in the regulation of swallowing from the oral to the pharyngeal phase. The activity could be influenced by swallowing volume.     

Swallowing problems in the elderly

Swallowing problems are increasingly recognized in the elderly population, in whom the maintenance of proper nutrition can be a significant problem. We describe here the general factors that affect the function of the pharynx, and the esophagus proper. These include a variety of local mechanical factors, disorders affecting the reflex swallowing mechanism, and the strength and sequence of pharyngeal contractions. Normal aging changes in both the pharynx and esophagus sometimes progress imperceptibly into true pathologic conditions. A better understanding of these non-specific and pathologic changes may be very helpful in planning appropriate therapy. Specific disease processes considered include cerebrovascular disease, Parkinson’s disease, achalasia, and gastroesophageal reflux disease.     

Swallowing in hereditary sensory ataxia

The oral, pharyngeal, and esophageal stages of swallowing were evaluated in 8 patients with recessively or dominantly inherited pure sensory ataxia. Six patients had swallowing difficulties: solid bolus obstruction, coughs during eating, and choking episodes. One patient had chronic bronchitis and another had recurrent pneumonia. The patients underwent a biphasic radiological barium swallow, including videofluoroscopy. No patient had a completely normal swallow. All had normal oral function, whereas pharyngeal function was abnormal in 6 patients. Esophageal function was abnormal in 6 patients. The swallowing dysfunction did not correlate with the severity of motor or sensory dysfunction in the limbs, nor with age or duration of ataxia. Our study shows that swallowing dysfunction is common in hereditary sensory ataxia. This dysfunction is likely to be due to involvement of the nucleus of the solitary tract in the brainstem. Despite some of the patients having suffered from choking episodes and others from bronchopulmonary complications, they did not spontaneously admit dysphagia. Swallowing should be evaluated thoroughly in patients with hereditary sensory ataxia since dysphagia in these patients might bring serious and potentially fatal complications.     

Supranuclear Control of Swallowing

Swallowing is an act requiring complex sensorimotor integration. Using a variety of methods first used to study limb physiology, initial efforts to study swallowing have yielded information that multiple cortical and subcortical regions are active participants. Not surprisingly, the regions activated appear to overlap those involved in both oral and nonoral motor behaviors. This review offers a perspective that considers the supranuclear control of swallowing in light of these physiological similarities.     

Swallowing disorders in the elderly.

The classic symptoms of dysphagia, heartburn, and chest pain are the presenting manifestation of oropharyngeal and esophageal disorders in the elderly as well as the young. Several unique conditions, including Zenker's diverticulum and vascular compression of the esophagus, may occur in the elderly. Certain disorders, such as oropharyngeal dysphagia due to neurologic disorder, increase in frequency with age. Treatment approaches are similar in elderly and younger patients, but the potential for adverse drug effects and interaction is greater in the elderly than in the young.     

Voluntary Versus Spontaneous Swallowing in Man

This review examines the evidence regarding the clinical and neurophysiological differences between voluntary and spontaneous swallows. From the clinical point of view, voluntary swallow (VS) occurs when a human has a desire to eat or drink during the awake and aware state. Spontaneous swallow (SS) is the result of accumulated saliva and/or food remnants in the mouth. It occurs without awareness while awake and also during sleep. VS is a part of eating behavior, while SS is a type of protective reflex action. In VS, there is harmonized and orderly activation of perioral, lingual, and submental striated muscles in the oral phase. In SS, the oral phase is bypassed in most cases, although there may be partial excitation. Following the oral phase, both VS and SS have a pharyngeal phase, which is a reflex phenomenon that protects the upper airway from any escape of food and direct the swallowed material into the esophagus. This reflexive phase of swallowing should not be confused with SS. VS and SS are similar regarding their dependence on the swallowing Central Pattern Generator (CPG) at the brainstem, which receives sensory feedback from the oropharynx. There are differences in the role of the corticobulbar input between VS and SS.     

Swallowing Disorders in the Older Population

Swallowing problems, or dysphagia, are common as people age, and are associated with significant negative outcomes, including weight loss, pneumonia, dehydration, shortened life expectancy, reduced quality of life, and increased caregiver burden. In this article, we will discuss the complex process of swallowing in normal circumstances and with healthy aging, then review etiologies that contribute to dysphagia. We will discuss approaches to evaluating and treating dysphagia, providing relevant data where they are available. We highlight the desperate need for high‐quality research to guide best practices in treating dysphagia in older adults. J Am Geriatr Soc 67:2643–2649, 2019     

Videofluorographic Study of Swallowing in Parkinson's Disease

We studied 16 patients with Parkinson's disease (PD) with dysphagia and 8 young and 7 elderly normal controls videofluorographically to evaluate the nature of swallowing disorders in PD patients. In 13 patients, abnormal findings in the oral phase were residue on the tongue or residue in the anterior and lateral sulci, repeated pumping tongue motion, uncontrolled bolus or premature loss of liquid, and piecemeal deglutition. Thirteen patients showed abnormal findings in the pharyngeal phase, including vallecular residue after swallow, residue in pyriform sinuses, and delayed onset of laryngeal elevation. Ten of these patients also showed abnormal findings in both the oral and pharyngeal phases. Aspiration was seen in 9 patients. The oral transit duration was significantly longer in the patients with and without aspiration than in the control subjects. The stage transition duration, pharyngeal transit duration, duration of the upper esophageal sphincter (UES) opening, and total swallow duration were significantly longer in the patients with and without aspiration than in the young controls, but were not longer than in the elderly controls. These durational changes in the pharyngeal phase of swallowing were similar to those in the elderly controls. The findings suggest that the disturbed motility in the oral phase of swallowing may be due to bradykinesia. Although PD patients with dysphagia evince a variety of swallowing abnormalities, the duration of pharyngeal swallowing may remain within the age-related range until the symptoms worsen.