Characteristics of dysphagia in children with cerebral palsy

Videofluoroscopic modified barium swallow (VMBS) examinations may provide clinically relevant information regarding deglutition in children with cerebral palsy and dysphagia. A retrospective review of clinical evaluations and VMBS studies on 90 consecutive children with cerebral palsy and dysphagia was completed. Most children were referred because of concerns regarding airway protection during oral feedings. Most children had multiple disabilities and 93% were nonambulatory. The majority of children were totally dependent for oral feedings (80%). Oral and pharyngeal phase abnormalities were present in almost all patients. Abnormalities of deglutition were observed only while swallowing specific food textures in the majority of patients. Aspiration of specific food textures was significantly more common than aspiration of all food textures (p<0.0001). Finally, aspiration was silent in 97% of the patients. VMBS studies can provide clinicians with valuable information regarding the most appropriate food textures and rates of oral feeding for children with cerebral palsy and dysphagia.     

Central nervous system control mechanisms of swallowing: A neuropharmacological perspective

Neuropharmacologicalin vivo andin vitro investigations are beginning to provide insight into chemical signaling processes within brainstem networks controlling the individual stages of swallowing. Different subtypes of excitatory amino acid (EAA) receptors operate at the level of solitarial interneurons programming the buccopharyngeal and esophageal stage, as well as motoneurons innervating esophageal striated musculature. Muscarinic cholinoceptors (MAChRs), probably activated via a propriobulbar input, are critically involved in generating output from solitarial neurons to esophageal motoneurons. Inhibition to tonically active GABA_A-receptor mediated afferents to solitarial premotor neurons results in rhythmic deglutitive output, reflecting disinhibition of EAA and MACK receptor activity. Motoneuronal EAA receptors may be regulated by a somatostatinergic input arising from solitarial premotoneurons. The available evidence is consistent with a transmitter heterogeneity in esophageal premotor neurons that may operate to provide chemical coding of afferents to the motor output stage of the pattern generator for esophageal peristalsis.     

Dysphagia in Patients with Chagas' Disease

Some patients with Chagas' disease and apparent normal esophageal function complain of dysphagia. With the objective of investigating the esophageal motility of these patients we studied the esophageal contraction amplitude, duration, velocity, and lower esophageal sphincter (LES) pressure of 34 patients with a positive serologic test for Chagas' disease, normal radiologic esophageal examination, peristaltic contractions in the esophageal body, and complete LES relaxation. Fourteen patients complained of dysphagia and 20 had no symptoms. The results were compared with those of 22 healthy controls. We used the manometric method with continuous perfusion. In patients without dysphagia, the LES pressure (17.8 ± 1.2 mmHg, mean ± SEM) and distal esophageal amplitude (71.8 ± 7.9 mmHg) were lower than those of control subjects (24.3 ± 1.8 mmHg and 100.4 ± 10.6 mmHg, respectively). The velocity of peristaltic contractions was higher in patients than in controls, but there was no difference between patients with or without dysphagia. The duration of contraction in the distal esophagus was longer in patients with dysphagia (3.9 ± 0.2 sec) than in patients without dysphagia (3.1 ± 0.2 sec) and controls (3.2 ± 0.2 sec). We conclude that dysphagia in patients with Chagas' disease and a nondilated esophagus with peristaltic contractions and complete LES relaxation is related to a longer duration of contractions in the middle and distal esophageal body.     

Lateral Pharyngeal Wall Motion during Swallowing Using Real Time Ultrasound

B-mode ultrasound imaging has been used primarily to detect temporal and spatial movements of the tongue during the oral preparatory and oral stages of swallowing. The purpose of this study was to investigate the application of M-mode (motion mode) ultrasound imaging as a method to quantify the duration and displacement of single regions along the lateral pharyngeal wall during swallows of two bolus volumes and during three swallow maneuvers (supraglottic, super-supraglottic and Mendelsohn maneuver). In 5 normal subjects, simultaneous B/M-mode images were captured at two regions along the lateral pharyngeal wall. Computer-assisted video analysis of each swallow sequence provided spatial coordinates and durational measures. Results indicated no significant differences in displacements of the lateral pharyngeal wall across bolus volumes, swallow maneuvers, or recording sites. Significant differences (p < 0.001) in lateral pharyngeal wall duration occurred as a function of volitional swallow maneuvers. Greater durations (p < 0.05) were found for the Mendelsohn and super-supraglottic swallow maneuvers. The data demonstrate that B/M-mode ultrasound imaging provides a simple, noninvasive method to visually examine movements of the lateral pharyngeal wall and may provide a clinical method for assessing the effects of direct swallowing therapies at the level of the mid-oropharynx.     

舌体对舌力介导器的静息压力分析

目的:探讨坐位静息状态下舌肌对不同矢状向和垂直向位置舌力介导器的压力,以初步探索舌力介导器作为一种支抗方式的效用范围. 方法:纳入19例个别正常牙合志愿者(男4名,女15名,年龄23~33岁) ,分别个体化制作舌力介导器,矢状向测量选取正中线上对应于第二前磨牙远中、第一磨牙远中和第二磨牙远中3个部位,垂直向测量以舌位记录为参考零点,分别测量-3 mm、0 mm和3 mm这3个高度对应于第一磨牙远中处的压力. 所用传感器型号为美国Honeywell公司生产的FSS1500NS,压力校验仪、监测仪以及分析软件由厦门福芯微电子科技有限公司设计制作. 志愿者取坐位,测量舌体处于自然放松状态时的静息压力. 使用Friedman test对矢状向及垂直向各组数据进行多样本比较的秩和检验,P<0. 05为差异有统计学意义. 结果:在垂直向上,随着舌力介导器高度增加,压力逐渐增大(P<0. 001),-3 mm、0 mm和3 mm高度的压力均值分别为105. 83 Pa、167. 75 Pa和254. 25 Pa. 在矢状向上,压力由近中至远中逐渐减小(P<0. 001),其均值分别为177. 64 Pa、126. 72 Pa和109. 37 Pa. 结论:舌肌在静息状态下对舌力介导器的压力随基托高度增加而增大,并且由近中至远中逐渐减小,但在实际应用时应综合考虑效果和舒适度,不宜过高和偏远中.     

Gradual Onset of Dysphagia: A Study of Patients with Oculopharyngeal Muscular Dystrophy

This study describes five patients with slowly developing dysphagia secondary to oculopharyngeal muscular dystrophy (OPMD), a progressive neurological disorder characterized by gradual onset of dysphagia, ptosis, and facial and trunk limb weakness. OPMD is a genetic disorder that affects formerly healthy adults who typically begin to experience symptoms in the fourth or fifth decade of life. Despite the debilitating nature of the disease, it is common for affected individuals to live to old age. Because of the gradual progression of dysphagia, as well as the deterioration of articulation, resonance, and breath support, patients with OPMD may come to the attention of physicians, nurses, and speech pathologists before a diagnosis is made. We hope to heighten awareness of how these subjects developed strategies to cope with their swallowing problems without medical intevention until the disease was producing marked symptoms. Patients with suspected dysphagia should be questioned about overt problems with eating and swallowing, but also about their adaptations and compensatory strategies. A Clinical Interview Questionnaire is included that may yield additional information about hidden dysphagia.     

Drug-induced dysphagia

Dysphagia describes the disability or problems in swallowing a wet or dry bolus properly and is normally associated with an impaired transport of the bolus. Dysphagia can be accompanied by a pain sensation in the chest mostly caused by impaction of the food bolus in the esophagus. Odynophagia describes only the status of painful swallowing without an impairment of the swallow and transport function. Drug-induced dysphagia can be caused in two different ways. First as a normal drug side effect of the pharmacological action of the drug or as a complication of the therapeutic action of the drug. The normal drug side effect is most likely in drugs that affect smooth or striated muscle function or the sensitivity of the mucosa. The drug effect on smooth muscle function that causes dysphagia can be inhibitory or excitatory. Dysphagia is a common clinical symptom in patients with reduced perception of the pharyngeal mucosa which leads to an subjective impairment of swallowing. Dysphagia caused by a complication of the therapeutic action of a drug includes viral or fungal esophagitis in patients treated with immunosuppressive drugs or cancer therapeutic agents, or antibiotics and immunological reactions to certain drugs such as erythema exsudativa multiforme or Stevens-Johnson syndrome. Second, drug-induced dysphagia can be due to medication-induced esophageal injury (MIEI). In most cases this mucosal injury appears to be the direct result of prolonged contact of a potentially caustic drug with the esophageal mucosa. This form of medication-induced esophagitis is most likely to be found in elderly patients and patients with esophageal motility disorders. The medication-induced esophageal injury is further promoted by taking the medication at bedtime without enough fluid. In conclusion, drug-induced dysphagia can be caused in many different ways. A carefully taken history in a patient, especially of the current medication, is important for the clinical diagnosis. MIEI can be prevented by concurrent ingestion of adequate amounts of fluid and avoidance of unnecessary bedtime medication, especially in elderly patients.     

How Thick Is Thick? Multicenter Study of the Rheological and Material Property Characteristics of Mealtime Fluids and Videofluoroscopy Fluids

Objective rheological assessment of fluids given to dysphagic patients at mealtime and during videofluoroscopy was carried out using a multicenter format. Thin, quarter-thick, half-thick and full-thick fluids were examined for the degree of correlation between mealtime fluids and their allegedly matched videofluoroscopy counterparts. The study was carried out to determine whether perceived subjective differences between mealtime fluids and videofluoroscopy fluids could be quantified using the rheological parameters of viscosity, density, and yield stress. The results showed poor correlation between mealtime fluids and videofluoroscopy fluids over all parameters. In general, the videofluoroscopy fluids were more viscous, more dense, and showed higher yield stress values than their mealtime counterparts. Given these results, it is reasonable to assume that the fluids used during videofluoroscopy do not provide an accurate indication of swallowing ability at mealtime. Therefore, it is suggested that clinicians use objective methods to rheologically match videofluoroscopy fluids to mealtime fluids.     

Pharmacological Treatment of Dysphagia in Stroke

The pharynx is important for a normal swallow and it has been suggested that pharmacological agents may play a role in the management of pharyngeal dysphagia, but none have been formally evaluated. A pilot double-blind, placebo-controlled study was undertaken in 17 hospitalized patients with persistent dysphagia 2 weeks after stroke. Patients were randomized to treatment with slow-release nifedipine 30 mg orally (n = 8) or placebo (n = 9) following specialist swallowing assessment and videofluoroscopy to exclude severe dysphagia. Videofluoroscopy was repeated after 4 weeks of treatment. Fourteen patients (active 6, placebo 8) completed the study. Two patients died (active 1, placebo 1) and 1 patient in the active group had to be withdrawn because of progressive heart failure. Initial assessment showed impairment in the pharyngeal phase with delayed triggering of swallow, poor laryngeal elevation, and prolonged pharyngeal transit times in all patients. Silent aspiration was seen in 4 patients (active 2, placebo 2). Improvement in swallowing was seen in 8 patients (active 5, placebo 3) at the end of 4 weeks. There were significant changes in the pharyngeal transit time (mean −1.34 second; 95% C.I. −2.56, −0.11) and swallow delay (mean −1.91 seconds; 95% C.I. −3.58, −0.24) in the active group suggesting improvement in the initiation of pharyngeal contractions and reduction in the time taken for the bolus to transverse the pharynx. A similar change was not seen in the placebo group. It is suggested that pharmacological agents such as nifedipine may have a role in the management of stroke-related dysphagia and merit further investigation.