Principles of experience-dependent neural plasticity: implications for rehabilitation after brain damage.

PURPOSE: This paper reviews 10 principles of experience-dependent neural plasticity and considerations in applying them to the damaged brain. METHOD: Neuroscience research using a variety of models of learning, neurological disease, and trauma are reviewed from the perspective of basic neuroscientists but in a manner intended to be useful for the development of more effective clinical rehabilitation interventions. RESULTS: Neural plasticity is believed to be the basis for both learning in the intact brain and relearning in the damaged brain that occurs through physical rehabilitation. Neuroscience research has made significant advances in understanding experience-dependent neural plasticity, and these findings are beginning to be integrated with research on the degenerative and regenerative effects of brain damage. The qualities and constraints of experience-dependent neural plasticity are likely to be of major relevance to rehabilitation efforts in humans with brain damage. However, some research topics need much more attention in order to enhance the translation of this area of neuroscience to clinical research and practice. CONCLUSION: The growing understanding of the nature of brain plasticity raises optimism that this knowledge can be capitalized upon to improve rehabilitation efforts and to optimize functional outcome.     

Translating principles of neural plasticity into research on speech motor control recovery and rehabilitation.

PURPOSE: To review the principles of neural plasticity and make recommendations for research on the neural bases for rehabilitation of neurogenic speech disorders. METHOD: A working group in speech motor control and disorders developed this report, which examines the potential relevance of basic research on the brain mechanisms involved in neural plasticity and discusses possible similarities and differences for application to speech motor control disorders. The possible involvement of neural plasticity in changes in speech production in normalcy, development, aging, and neurological diseases and disorders was considered. This report focuses on the appropriate use of functional and structural neuroimaging and the design of feasibility studies aimed at understanding how brain mechanisms are altered by environmental manipulations such as training and stimulation and how these changes might enhance the future development of rehabilitative methods for persons with speech motor control disorders. CONCLUSIONS: Increased collaboration with neuroscientists working in clinical research centers addressing human communication disorders might foster research in this area. It is hoped that this article will encourage future research on speech motor control disorders to address the principles of neural plasticity and their application for rehabilitation.     

Detection, evaluation, and management of aspiration in rehabilitation hospitals: role of the otolaryngologist--head and neck surgeon.

CONTEXT: Reductions in the length of acute care hospitalizations have resulted in earlier transfer of patients with significant neurologic disease, such as head injury or stroke, to inpatient rehabilitation facilities. In many instances, these patients arrive at the rehabilitation hospital with multiple unresolved acute processes, including undetected or inadequately evaluated dysphagia. These patients may be at significant risk for the development of aspiration pneumonia, especially if elderly or debilitated. OBJECTIVE: To review the role of otolaryngologic consultation in the management of inpatients in two rehabilitation hospitals. DESIGN AND SETTING: Retrospective review of 1046 consultations performed by two otolaryngologists over a 4-year period at two long-term inpatient rehabilitation hospitals in the Pittsburgh, PA, metropolitan area. RESULTS: A total of 833 patients were evaluated. Three hundred were seen for a variety of common disease processes, including hearing loss, and cerumen removal. A total of 548 consultations were for recommendations regarding swallowing dysfunction. Fibre-optic endoscopic examination of swallowing function was performed in 478 patients. Two hundred consultations were for assistance in decannulation of patients who were transferred from the acute care hospital with an indwelling tracheostomy tube. CONCLUSIONS: The detection and evaluation of the aspiration risk of dysphagic patients in rehabilitation hospitals are enhanced by an onsite dysphagia team with access to instrumented measures of swallowing, especially videofluoroscopy or videoendoscopy. Otolaryngologic consultation can provide considerable benefit for many inpatients in rehabilitation hospitals, even those with apparent "minor" dysfunction. The otolaryngologist-head and neck surgeon is uniquely qualified to provide consultation in the management of those inpatients with complex clinical problems involving the upper aerodigestive tract. Consultation may be critical for some patients, assessing the cause and severity of dysphagia and assisting in the safe decannulation of those with indwelling tracheostomy tubes.     

The benefit of head rotation on pharyngoesophageal dysphagia from three cases of paraganglioma in the parapharyngeal space

The benefit of head rotation to the affected side is indicated during swallowing in patients complaining of dysphagia with unilateral pharyngeal palsy and/or laryngeal palsy. We experienced three cases of severe dysphagia after operations for giant paragangliomas (two vagal paraganglioma and one carotid body tumor) in the parapharyngeal space. During operation, the transmandibular transpterygoid approaches were applied to ensure better surgical views, and tracheostomy was performed to keep the airway open after operation. In each case, dysphagia during the pharyngeal stage of swallowing was significantly improved with rehabilitation using of this head rotation. We believe that rather than forbid oral intake, using an active bolus with head rotation is important for cases where dysphagia in the pharyngeal stage of swallowing is present with unilateral pharyngeal and/or laryngeal palsy. Repetitive swallowing exercises are important to reacquire the complicated movement of swallowing. Additionally, an active bolus flowing into the pyriform sinus on the healthy side will prevent a relaxation disorder of the cricopharyngeal muscle on that side. Furthermore, compensatory movement of the arytenoid on the healthy side improves dysphagia. We emphasize the usefulness of head rotation during swallowing rehabilitation for dysphagia with unilateral pharyngeal and/or laryngeal palsy in spite of its simplicity.     

Translational research in aphasia: from neuroscience to neurorehabilitation.

PURPOSE: In this article, the authors encapsulate discussions of the Language Work Group that took place as part of the Workshop in Plasticity/NeuroRehabilitation Research at the University of Florida in April 2005. METHOD: In this narrative review, they define neuroplasticity and review studies that demonstrate neural changes associated with aphasia recovery and treatment. The authors then summarize basic science evidence from animals, human cognition, and computational neuroscience that is relevant to aphasia treatment research. They then turn to the aphasia treatment literature in which evidence exists to support several of the neuroscience principles. CONCLUSION: Despite the extant aphasia treatment literature, many questions remain regarding how neuroscience principles can be manipulated to maximize aphasia recovery and treatment. They propose a framework, incorporating some of these principles, that may serve as a potential roadmap for future investigations of aphasia treatment and recovery. In addition to translational investigations from basic to clinical science, the authors propose several areas in which translation can occur from clinical to basic science to contribute to the fundamental knowledge base of neurorehabilitation. This article is intended to reinvigorate interest in delineating the factors influencing successful recovery from aphasia through basic, translational, and clinical research.     

Searching for factors underlying cerebral plasticity in the normal and injured brain

Brain plasticity refers to the capacity of the nervous system to change its structure and ultimately its function over a lifetime. There have been major advances in our understanding of the principles of brain plasticity and behavior in laboratory animals and humans. Over the past decade there have been advances in the application of these principles to brain-injured laboratory animals. To date, there have been few major applications of this knowledge to establish postinjury interventions in humans. A significant challenge for the next 20 years will be the translation of this work to improve the outcome from brain injury and disease in humans. The goal of this review is to synthesize the multidisciplinary laboratory work on brain plasticity and behavior in the injured brain to inform the development of rehabilitation programs. LEARNING OUTCOMES: Readers will be able to: (a) identify principles of brain plasticity, (b) review the application of these principles to the treatment of brain-injured laboratory animals, and (c) consider the translation of the new treatments to brain-injured humans.     

Causes, diagnosis and treatment of neurogenic dysphagia as an interdisciplinary clinical problem

The intricate mechanism of swallowing can be divided into three phases: oral, pharyngeal, and esophageal. Dysphagia is a disruption in the swallowing process, which include difficulty in transporting (or a lack of transporting) a food or liquid bolus from the mouth through the pharynx and esophagus into the stomach. Causes of disruptions in the swallowing process can be divided into superior (oropharyngeal) and inferior (esophageal) according to Paradowski et al. Neurlologic dysphagia may be caused by a disruption in different parts of the central nervous system (supranuclear level, level of motor and sensory nuclei taking part in swallowing process, peripherial nerves level and a pathology of muscle cells and spindles) or neuromuscular and muscular disorders. Neuromuscular disorders causes according to Wa?ko-Czopnik et al. are: stroke, brain tumors, brain injury, bulbar and pseudobulbar paralysis, neurodegenerative diseases (amyotrophic lateral sclerosis, multiple sclerosis), tabes dorsalis, multisystem degenerations, Parkinson's disease, delayed dyskineses, Huntington's disease, myasthenia and myasthenic syndromes, myopathies and peripherial neuropathies. The correct diagnosis evaluation include history taking, physical examination with palpation and consultations (laryngological, gastrological and neurological). According to Halama radiological esophagogram, videofluoroscopy, flexible endoscopic examination, ultrasound examination, manometry, electromyography, scintigraphy and 24 hour pH monitoring are main diagnostic procedures of dysphagia. Some of the reasons for the neurologic dysphagia may be treated by surgical and pharmacological methods. Neurologic dysphagia rehabilitation is difficult, long-lasting and often falling far short of expected results. Primary it should include neurologic cause treatment if it is possible. According to WHO International Classification of Functioning and Health in 2001 non-invasive methods of dysphagia treatment may be divided into reconstitution, compensatory and adaptive techniques. The most popular reconstitution methods are thermal stimulation (Lazzar's) or tactilethermal application (Rosenbeck's) techniques which may be applied for abnormal duration of stage transition (DST). Abnormal duration of stage transition considerably increase probability of aspiration. Dysphagia treatment by compensatory methods consist in various techniques of swallowing and posture changes application. Adaptive techniques include dietary changes--avoiding of sustenances strengthening dysphagia and adequate dietary intake. The basic principle of dysphagia rehabilitation is that the most effective way to regain efficiency is the regeneration on remains of lost function. Carrying out imperfect swallowing acts is probably the best way of increasing effectiveness and efficiency of swallowing. On the other hand imperfect swallowing acts may be hazardous because of the danger of aspiration and inhalation pneumonia.     

Quality indicators for integrated care of dysphagia in hospital settings

This article proposes a panel of quality indicators for the management of swallowing rehabilitation (SR) therapy in a hospital setting. There were four stages in developing these indicators: identifying procedures to be managed; generating indicators and standardizing data collection; identifying the correlation among indicators; and formulating the panel of indicators. The following 12 quality indicators were developed: swallowing evaluation index; individual care index; speech-language pathologist (SLP) care index; number of assisted patients index; severity rate; swallowing diagnosis rate per hospital unit; swallowing rehabilitation demand index; time until first swallowing evaluation; SLP index per hospital bed; time until removal of feeding tube; time until reintroduction of oral feeding; and time until decannulation. The proposed indicators were designed to improve the management of dysphagia in a hospital setting. Measuring these indicators is essential to understanding the patient's needs and providing quality care. Managing care using these indicators will make it easier to track the patient's rehabilitation process, measure the effectiveness of new therapeutic processes and technologies, and evaluate the performance of hospital units relative to other providers in the area. The management of SR using quality indicators allows the effectiveness and efficiency of rehabilitation programs to be clearly evaluated.     

咽喉疾病与吞咽功能障碍的相关研究

随着咽喉功能异常及结构性病变所致吞咽障碍发病率的逐渐增加,吞咽障碍对相关疾病患者生存质量的影响也越来越引起人们的重视,以往神经源性吞咽障碍在康复科及神经科研究较多,但对咽喉局部因素导致的吞咽障碍关注不够,相关研究也不多。为了提高耳鼻咽喉科医师对咽喉疾病所致吞咽障碍的了解,本文从吞咽的生理过程、参与吞咽的相关神经肌肉、吞咽障碍及误吸的病因、喉癌及下咽癌对吞咽功能的影响、吞咽评估方法等几个方面进行综述。     

Evaluation of pharyngeal swallowing elicited by fluid infusion using videoendoscopy in dysphagia patients

The purpose of this study was to investigate the clinical value of assessing pharyngeal swallowing elicited by fluid infusion. Videoendoscopic examinations were performed in 126 patients with dysphagia, after injecting a fluid infusion into the pharyngeal cavity. Blue dye fluid was instilled into the unilateral vallecula through a catheter that was inserted into the biopsy channel of an endoscope. Pharyngeal swallowing elicited by the fluid infusion was classified according to 5 grades: grade 1, normal pharyngeal swallowing; grade IIa, laryngeal penetration before the triggering of pharyngeal swallowing; grade IIb, pharyngeal residue after swallowing; grade IIa + b; and grade III, no the pharyngeal swallowing. The recovery rates for oral intake using several approaches for dysphagia were 98% in grade I patients and 75% in grade IIb patients. However, the oral intake of food was more difficult in grade IIa, grade IIa + b and grade III patients. These results suggest that the classification of dysphagia based on the triggering and output situation of pharyngeal swallowing may be a useful guideline for demonstrating impaired oral food intake. We conclude that videoendoscopic examination using a fluid infusion is a valuable method for evaluating pharyngeal swallowing minus the influence of bolus transport from oral cavity to the pharynx.     

Is the information about a test important? Applying the methods of evidence-based medicine to the clinical examination of swallowing

A hotly debated topic in oropharyngeal dysphagia is the Clinical Swallowing Examination's (CSE) importance in clinical practice. That debate can profit from the application of evidence-based medicine's (EBM) principles and procedures. These can guide both appropriate data collection and interpretation as will be demonstrated in the present report. The study's purpose from which data for this report are drawn was to determine the relationship among signs elicited by a CSE and aspiration on a subsequent videofluoroscopic swallowing examination (VFSE). Sensitivity, specificity; positive and negative predictive values (NPV); likelihood ratios; and post-test probabilities for a variety of signs in isolation and in combinations are reported. These data, if judiciously selected and interpreted contribute to the clinician's knowledge about whether to follow a CSE with a VFSE and about what to expect if the VFSE is completed. LEARNING OUTCOMES: (1) Clinicians will learn how to use EBM principles in conjunction with clinical assessments of swallowing to enhance patient care. (2) Clinicians will learn how to identify combinations of patient signs during he CSE to predict VFSE performance.     

Adjunctive neuromuscular electrical stimulation for treatment-refractory dysphagia

OBJECTIVES: Neuromuscular electrical stimulation (NMES) has been proposed as an adjunctive modality for the treatment of swallowing disorders. We present data from a prospective case series to define and measure effects of a systematic therapy for chronic pharyngeal dysphagia using adjunctive NMES. METHODS: Six adult patients with pharyngeal dysphagia received 15 sessions of a standardized protocol of swallowing exercises with adjunctive NMES. The patients completed clinical and instrumental baseline, posttreatment, and 6-month follow-up evaluations. Outcome measures included the proportion of patients who improved in clinical swallowing ability, functional oral intake, and change in body weight; patient perception of swallowing ability; and changes in kinematic aspects of swallowing. RESULTS: Significant change was demonstrated for clinical swallowing ability (p < .042), functional oral intake (p < .02), weight gain (p < .026), and patient perception of swallowing ability (p < .043). Hyoid and laryngeal elevation during swallowing demonstrated bolus-specific patterns of change. No patient experienced a treatment-related or swallowing-related complication. Patients (4 of 5) who were followed out to 6 months after treatment maintained functional gains. CONCLUSIONS: A systematic therapy for chronic pharyngeal dysphagia using adjunctive NMES produced improvement in clinical swallowing ability and functional oral intake without significant weight loss or complications.     

A retrospective study of 91 injections of botulinus toxin into the upper sphincter of the oesophagus

OBJECTIVE: To evaluate the results of botulinus toxin in dysphagia arising in the upper sphincter of the oesophagus. MATERIALS AND METHODS: Since June 1995, 64 patients have had botulinus toxin injected into the upper sphincter of the oesophagus for major swallowing disorders. All cases were treated in the dysphagia service, and underwent clinical assessment, video-swallow screening, and swallowing therapy. The patient cohort included various pathological groups--neurological (vascular accident, head injury, cranial nerve disorders, degenerative diseases), postoperative (surgery for carcinoma of the laryngo-pharynx), and functional, whether purely idiopathic or attributable. RESULTS AND CONCLUSIONS: Global analysis of the results shows that botulinus toxin has good efficacy in relaxing the upper sphincter of the oesophagus; this does not always lead to recovery of normal swallowing, but can bring about improvement by assisting in the therapeutic management of the swallowing problem, and in improving the dietary intake.     

Dysphagia in the elderly: preliminary evidence of prevalence, risk factors, and socioemotional effects

OBJECTIVES: Epidemiological studies of dysphagia in the elderly are rare. A non-treatment-seeking, elderly cohort was surveyed to provide preliminary evidence regarding the prevalence, risks, and socioemotional effects of swallowing disorders. METHODS: Using a prospective, cross-sectional survey design, we interviewed 117 seniors living independently in Utah and Kentucky (39 men and 78 women; mean age, 76.1 years; SD, 8.5 years; range, 65 to 94 years) regarding 4 primary areas related to swallowing disorders: lifetime and current prevalence, symptoms and signs, risk and protective factors, and socioemotional consequences. RESULTS: The lifetime prevalence of a swallowing disorder was 38%, and 33% of the participants reported a current problem. Most seniors with dysphagia described a sudden onset with chronic problems that had persisted for at least 4 weeks. Stepwise logistic regression identified 3 primary symptoms uniquely associated with a history of swallowing disorders: taking a longer time to eat (odds ratio [OR], 9.5; 95% confidence interval [CI], 2.3 to 40.2); coughing, throat clearing, or choking before, during, or after eating (OR, 3.4; 95% CI, 1.1 to 10.2); and a sensation of food stuck in the throat (OR, 5.2; 95% CI, 1.8 to 10.0). Stroke (p = .02), esophageal reflux (p = .003), chronic obstructive pulmonary disease (p = .05), and chronic pain (p = .03) were medical conditions associated with a history of dysphagia. Furthermore, dysphagia produced numerous adverse socioemotional effects. CONCLUSIONS: This study provides preliminary evidence to suggest that chronic swallowing disorders are common among the elderly, and highlights the need for larger epidemiological studies of these disorders.     

Improved Infant Swallowing After Gastroesophageal Reflux Disease Treatment: A Function of Improved Laryngeal Sensation?

OBJECTIVE: The objective of this study was to describe improvements in pediatric swallowing after gastroesophageal reflux treatment. STUDY DESIGN: The authors conducted a retrospective database and chart review at two tertiary care children's hospitals. PARTICIPANTS: Patients (21 males, 7 females) ranged in age from 1 to 32 months. All patients had clinical evidence of gastroesophageal reflux disease (GERD) as well as evidence of dysphagia with aspiration (laryngeal vestibule and/or trachea) or hypopharyngeal pooling on flexible endoscopic evaluation of swallowing and sensation testing (FEESST) or videofluoroscopic swallow study (VSS). INTERVENTION: Each child underwent either medical or surgical intervention for control of their GERD. OUTCOME MEASURES: Outcome measures were change in laryngopharyngeal sensation and swallowing function with repeat swallow evaluation after GERD treatment. RESULTS: A significant improvement in both swallow function and sensory testing was demonstrated after GERD treatment. CONCLUSIONS: GERD may result in decreased laryngopharyngeal sensitivity, which may contribute to pediatric swallowing dysfunction. Control of GERD may improve swallow function. These findings have important clinical implications that need further study.     

Motor cortex reorganization across the lifespan

The brain is a highly dynamic structure with the capacity for profound structural and functional change. Such neural plasticity has been well characterized within motor cortex and is believed to represent one of the neural mechanisms for acquiring and modifying motor behaviors. A number of behavioral and neural signals have been identified that modulate motor cortex plasticity throughout the lifespan in both the intact and damaged brain. Specific signals discussed in this review include: motor learning in the intact brain, motor relearning in the damaged brain, cortical stimulation, stage of development and genotype. Clinicians are encouraged to harness these signals in the development and implementation of treatment so as to maximally drive neural plasticity and functional improvements in speech, language and swallowing.Learning outcomes: Readers will be able to: (1) describe a set of behavioral and neural signals that modulate motor cortex plasticity in the intact and damaged brain; (2) describe the influence of stage of development on plasticity and functional outcomes; and (3) identify a known genotype that alters the capacity for motor learning and brain plasticity.     

Society of swallowing and dysphagia of Japan: Position statement on dysphagia management during the COVID-19 outbreak

On April 14, the Society of Swallowing and Dysphagia of Japan (SSDJ) proposed its position statement on dysphagia treatment considering the ongoing spread of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2).The main routes of transmission of SARS-CoV-2 are physical contact with infected persons and exposure to respiratory droplets. In cases of infection, the nasal cavity and nasopharynx have the highest viral load in the body. Swallowing occurs in the oral cavity and pharynx, which correspond to the sites of viral proliferation. In addition, the possibility of infection by aerosol transmission is also concerning.Dysphagia treatment includes a broad range of clinical assessments and examinations, dysphagia rehabilitation, oral care, nursing care, and surgical treatments. Any of these can lead to the production of droplets and aerosols, as well as contact with viral particles. In terms of proper infection control measures, all healthcare professionals involved in dysphagia treatment must be fully briefed and must appropriately implement all measures. In addition, most patients with dysphagia should be considered to be at a higher risk for severe illness from COVID-19 because they are elderly and have complications including heart diseases, diabetes, respiratory diseases, and cerebrovascular diseases.This statement establishes three regional categories according to the status of SARS-CoV-2 infection. Accordingly, the SSDJ proposes specific infection countermeasures that should be implemented considering 1) the current status of SARS-CoV-2 infection in the region, 2) the patient status of SARS-CoV-2 infection, and 3) whether the examinations or procedures conducted correspond to aerosol-generating procedures, depending on the status of dysphagia treatment. This statement is arranged into separate sections providing information and advice in consideration of the COVID-19 outbreak, including “terminology”, “clinical swallowing assessment and examination“, “swallowing therapy”, “oral care”, “surgical procedure for dysphagia”, “tracheotomy care”, and “nursing care”. In areas where SARS-CoV-2 infection is widespread, sufficient personal protective equipment should be used when performing aerosol generation procedures.The current set of statements on dysphagia management in the COVID-19 outbreak is not an evidence-based clinical practice guideline, but a guide for all healthcare workers involved in the treatment of dysphagia during the COVID-19 epidemic to prevent SARS-CoV-2 infection.     

Cricopharyngeal myotomy in the treatment of dysphagia

Deglutition is a complex neuromuscular act. Alterations in anatomy and physiology may lead to dysphagia. The role of the cricopharyngeus appears to be the keystone in the rehabilitation of many patients with dysphagia. This paper examines the physiology of swallowing as well as the patho-physiology of its aberrations. Techniques and complications of cricopharyngeal myotomy are presented. Cases of dysphagia due to ablative surgery of the head and neck, dermatomyositis, cerebrovascular accidents, and cricopharyngeal achalasia in which cricopharyngeal myotomy was utilized, are reported. It would appear from this small number of cases, that cricopharyngeal myotomy is indicated in the rehabilitation of dysphagia in patients with varied disease states.     

Transcutaneous neuromuscular electrical stimulation (VitalStim) curative therapy for severe dysphagia: myth or reality?

OBJECTIVES: VitalStim therapy was approved by the US Food and Drug Administration in 2001 for the treatment of dysphagia through the application of neuromuscular electrical stimulation to cervical swallowing muscles. This approval was based upon submission of data on more than 800 patients who received this therapy collected by the principal developer and patent-holder of the device. The therapy is marketed as successful in restoring long-term swallowing function in 97.5% of dysphagic patients past the point of requiring a feeding tube and as significantly better than existing therapies. More than 2,500 speech-language pathologists have taken the certification course, and thousands of devices have been sold. To date, however, aside from the developer's own studies, there are no peer-reviewed publications supporting these claims. We sought to evaluate the effectiveness of VitalStim therapy in a heterogeneous group of dysphagic patients. METHODS: We performed a retrospective analysis of 18 patients who received this therapy at an urban tertiary referral center. All patients underwent pretherapy evaluation by speech-language pathologists, including modified barium swallow and/or functional endoscopic evaluation of swallowing and clinical evaluation of swallowing that included assessment of laryngeal elevation, diet tolerance, and swallowing delay, and were then assigned an overall dysphagia severity score. After therapy, all patients underwent the same assessments. Twelve of the 18 also underwent a functional swallowing telephone survey months (range, 1 to 21 months) after their therapy to assess whether the improvement was worthwhile and sustained. RESULTS: Eleven of the 18 patients (61%) demonstrated some improvement in their swallowing. Six of the 18 patients (33%) were improved enough to no longer require a feeding tube. However, of the 5 patients categorized as having "severe dysphagia" before therapy, only 2 showed any improvement, and these patients still required a feeding tube for adequate nutrition. Telephone surveys did confirm that those who improved with their therapy seemed to maintain their progress and that most patients were satisfied with their therapy. CONCLUSIONS: VitalStim therapy seems to help those with mild to moderate dysphagia. However, the patients with the most severe dysphagia in our study did not gain independence from their feeding tubes. The authors conclude that VitalStim therapy clearly has a place in the management of dysphagia, but that the most severely afflicted are unlikely to gain dramatic improvement.     

Failure of cricopharyngeal myotomy to improve dysphagia following head and neck cancer surgery.

OBJECTIVE: To determine whether cricopharyngeal myotomy can improve dysphagia associated with head and neck cancer surgery. DESIGN: Prospective, randomized, multicenter trial. SETTING: Twelve clinical sites across the United States. PATIENTS: Between 1989 and 1994, 125 patients undergoing combined modality therapy for head and neck cancer, including resection of the tongue base or supraglottic larynx, were prospectively entered into the trial. INTERVENTION: Cricopharyngeal myotomy on a randomized basis. MAIN OUTCOME MEASURES: Videofluoroscopic examination to determine oropharyngeal swallowing efficiency, which is defined as the ratio of percentage of the bolus swallowed to total swallowing time using 3 different bolus consistencies. RESULTS: No significant difference in oropharyngeal swallowing efficiency between myotomy vs no myotomy was seen at 6 months of follow-up regardless of bolus consistency. CONCLUSIONS: In this prospective test of cricopharyngeal myotomy, the procedure fails to significantly improve dysphagia associated with head and neck cancer surgery. The efficacy of this surgical procedure in other disease entities should also be rigorously explored.