Anatomical Variations in Stylopharyngeus Muscle Insertions Suggest Interindividual and Left/Right Differences in Pharyngeal Clearance Function of Elderly Patients: A Cadaveric Study

The stylopharyngeus plays a critical role in the clearance of the piriform recess. We dissected 78 sides of the pharynx from 55 donated cadavers and observed histology of another seven sides of the pharynx from seven cadavers. The stylopharyngeus consistently comprised (1) a descending muscle bundle surrounding the piriform recess and (2) an additional short sheet inserting into the tonsillar bed. Histologically, the former bundle connected to a thick fascia providing the lateral glossoepiglottic fold, extending along the submucosa of the piriform recess, and covering the thyroid cartilage, whereas the latter sheet intermingled with other pharyngeal wall muscles at and near the tonsillar bed. Notably, in 44.4% of female specimens, the additional sheet occupied a greater proportion in cross section than the descending muscle bundle. Given the different directions, the additional sheet seemed to check clearance function of the descending bundle for the piriform recess. Thus, particularly in women, interindividual differences in pharyngeal clearance were likely to depend on whether the additional sheet is strong or weak. Chin down in combination with tilting and rotating the head may represent effective exercises of the stylopharyngeus that could compensate for the disadvantages of additional insertion.     

Barrett's esophagus: Pathogenesis,epidemiology, functional abnormalities,malignant degeneration,and surgical management

Barrett's esophagus (i.e. columnar epithelial metaplasia in the distal esophagus) is an acquired condition that in most patients results from chronic gastroesophageal reflux. It is a disorder of the white male in the Western world with a prevalence of about 1/400 population. Due to the decreased sensitivity of the columnar epithelium to symptoms, Barrett's esophagus remains undiagnosed in the majority of patients. Gastroesophageal reflux disease in patients with Barrett's esophagus has a more severe character and is more frequently associated with complications as compared with reflux patients without columnar mucosa. This appears to be due to a combination of a mechanically defective lower esophageal sphincter, inefficient esophageal clearance function, and gastric acid hypersecretion. Excessive reflux of alkaline duodenal contents may be responsible for the development of complications (i.e., stricture, ulcer, and dysplasia). Therapy of benign Barrett's esophagus is directed towards treatment of the underlying reflux disease. Barrett's esophagus is associated with a 30- to 125-fold increased risk for adenocarcinoma of the esophagus. The reasons for the dramatic rise in the incidence of esophageal adenocarcinoma, which occurred during the past years, are unknown. High grade dysplasia in a patient with columnar mucosa is an ominous sign for malignant degeneration. Whether an esophagectomy should be performed in patients with high grade dysplasia remains controversial. Complete resection of the tumor and its lymphatic drainage is the procedure of choice in all patients with a resectable carcinoma who are fit for surgery. In patients with tumors located in the distal esophagus, this can be achieved by a transhiatal en-bloc esophagectomy and proximal gastrectomy. Early adenocarcinoma can be cured by this approach. The value of multimodality therapy in patients with advanced tumors needs to be shown in randomized prospective trials.     

Kinematic pharyngeal transit times in myopathy: Evaluation for dysphagia

Measurement of kinematic pharyngeal transit times, a new videofluoroscopy technique, provides useful quantitative data to supplement the qualitative data previously available from videofluoroscopy swallowing studies. Kinematic pharyngeal transit times have not previously been reported for subjects with myopathy. This study demonstrates the use of quantitative kinematic pharyngeal transit times for dysphagia evaluation in 15 patients with myopathy. The successful treatment of dysphagia by cricopharyngeal myotomy is reported in two patients with limb-girdle syndrome.     

Dysphagia in cerebral palsy: A comparative study of the exeter dysphagia assesment technique and a multidisciplinary assessment

Eighteen children with cerebral palsy in a special school, most of whom had feeding difficulties, were studied to compare the diagnostic value of the Exeter Dysphagia Assessment Technique (EDAT) with an exhaustive clinical assessment undertaken by a multidisciplinary team experienced in the diagnosis and treatment of dysphagia of neurological origin. Four feeding skills were assessed by each method independently, viz. anticipation, intraoral sensory perception, oral-motor efficiency, and pharyngeal triggering. Comparison of the two sets of results showed agreement in at least 78% of the assessed skills. The possible reasons for the few discrepancies are discussed. The noninvasive EDAT equipment was easy to use with the children, who had a range of type and severity of cerebral palsy. The test was undertaken in their familiar surroundings and took 15 to 20 min per child. Interpretation of the results showed that EDAT provided a rapid, reliable diagnostic aid which assisted in the assessment of the degree of feeding impairment within each of the four feeding skills tested. The authors are very grateful for the financial support for this project which was provided partially by Action Research and partially by the Northcott Devon Medical Foundation     

Effect of Liquid Bolus Consistency and Delivery Method on Aspiration and Pharyngeal Retention in Dysphagia Patients

There is no empirically derived consensus as to what food consistency types and method of food delivery (spoon, cup, straw) should be included in the videofluoroscopic swallowing (VFSS) studies. In the present study, we examine the rates of aspiration and pharyngeal retention in 190 dysphagic patients given thin (apple juice) and thick (apricot nectar) liquids delivered by teaspoon and cup and ultrathick (pudding-like) liquid delivered by teaspoon. Each patient was tested with each of the bolus/delivery method combinations. The fractions of patients exhibiting aspiration for each bolus/method of delivery combination were (1) thick liquids (cup), 13.2%; (2) thick liquids (spoon), 8.9%; (3) thin liquids (cup), 23.7%; (4) thin liquids (spoon), 15.8%, (5) ultrathick liquids (spoon), 5.8%. In each comparison [thick liquid (cup) vs. thick liquid (spoon), thin liquid (cup) vs. thin liquid (spoon), thick liquid (cup) vs. thin liquid (cup), thick liquid (spoon) vs. thin liquid (spoon), and thick liquid (spoon) vs. ultrathick liquid (spoon)], the p value for χ² was <0.001. These results suggest that utilizing thin, thick, and ultrathick liquids and delivery by cup and spoon during a VFSS of a patient with mild or moderate dysphagia can increase the chances of identifying a consistency that the patient can swallow without aspirating and without pharyngeal retention after swallowing. Submitted December 22, 1999; accepted September 6, 2000 with revision     

Pharyngo-Esophageal Dysphagia in Parkinson's Disease

The radiologic characteristics of pharyngo-esophageal (PE) dysfunction in Parkinson's disease (PD) are not well established, partly because most previous studies have examined only small numbers of patients. We administered a dynamic videofluoroscopic swallowing function study to 71 patients with idiopathic PD. Using the Hoehn and Yahr disease severity scale, patients were subdivided into those with mild/moderate disease, subgroup I (n = 38), and advanced PD disease, subgroup II (n = 33). From pharyngeal ingestion to gastric emptying, bolus transport was normal in only 2 patients. The most common abnormalities occurring during pharyngeal ingestion included impaired motility, vallecular and pyriform sinus stasis, supraglottic and glottic aspiration, and deficient epiglottic positioning and range of motion. Esophageal abnormalities were multiple but most commonly included delayed transport, stasis, bolus redirection, and tertiary contractions. Typical aberrations of lower esophageal sphincter (LES) function included an open or delayed opening of the LES and gastro-esophageal reflux. A pathogenesis linking PE with the pathology of PD is proposed.     

Nonsurgical treatment of drooling in a patient with closed head injury and severe dysarthria

The purpose of this investigation was to measure the effectiveness of the antimuscarinic drug atropine sulfate in the treatment of chronic drooling in a patient with a history of severe closed head injury and resultant widespread oral neuromuscular and higher cortical disturbances. Results of the A-B-A-B-A-B withdrawal paradigm, chosen to demonstrate the functional relationship between drug therapy and the degree of drooling, revealed that administration of atropine sulfate reduced by more than 50% of baseline levels the amount of resting secretion, intraoral accumulation, and pharyngeal-laryngeal pooling of saliva, with negligible side effects. These results are discussed and compared to the alternative drug and surgical approaches to the alternative drug and surgical approaches to treatment that have been the primary focus of recent research on drooling.     

Proximal Esophageal Contractions in Laryngectomized Patients

After laryngectomy for treatment of laryngeal cancer, the distal esophageal contractions have low amplitude. Our hypothesis is that proximal esophageal contractions are also impaired. We studied the proximal esophageal contractions in 20 laryngectomized patients (16 men) with a mean age of 44.2 years, 12 rehabilitated patients with esophageal speech, and 12 controls (7 men, mean age of 46.5 years). We used the manometric method with continuous perfusion. All subjects were studied in the sitting position and performed five swallows of a 5-ml bolus of water alternated with five dry swallows. The contractions were measured 2 cm below the high-pressure zone of the pharyngoesophageal transition. The results showed that the amplitude and duration of contractions were different in laryngectomized patients compared with controls. The amplitude of contractions of patients (wet swallows: 37.3 ± 20.7 mmHg, mean ± SD) was lower than that of controls (81.1 ± 31.7 mmHg). The duration of contractions was also lower in laryngectomized patients (2.2 ± 0.7 s) than in controls (2.6 ± 0.6 s). We conclude that the proximal esophageal contraction amplitude and duration of laryngectomized patients are lower than controls, a fact suggesting that laryngectomy may affect the proximal esophageal contractions.     

重复经颅磁刺激治疗卒中后吞咽功能障碍的系统文献回顾

目的系统评价重复经颅磁刺激(rTMS)治疗卒中后吞咽功能障碍的有效性及安全性。方法采用计算机检索Pubmed、EMbase、MEDLINE、Cochrane图书馆、中文期刊全文数据库、中国生物医学文献数据库、万方数据库中关于rTMS治疗卒中后吞咽功能障碍的临床研究,截止日期为2013年12月。由2名研究者按纳入和排除标准选择文献、提取资料、交叉核对,而后进行分析。结果共纳入7篇研究(228例,其中rTMS 136例,对照92例),对4篇随机对照试验(RCT)进行Meta分析(rTMS组54例,对照组42例),另外3篇非RCT进行系统综述。(1)Meta分析表明,rTMS治疗后吞咽功能评分的改善优于对照组(SMD=1.73,95%CI:0.45~3.01,P=0.008)。(2)高频rTMS(1 Hz)治疗后吞咽功能评分的改善与对照组比较,差异有统计学意义(SMD=1.60,95%CI:0.10~3.11,P=0.04);低频rTMS(1 Hz)与对照组相比,在一些吞咽功能评分的改善方面差异亦有统计学意义,提示低频治疗潜在的优势。(3)rTMS治疗后,卒中患者Barthel指数的改善与对照组相比差异有统计学意义(MD=-21.60,95%CI:-36.21~-7.00,P=0.004)。(4)在不良反应方面,7篇研究均未报道有头痛、耳鸣或癫痫等任何不良事件发作。结论对卒中后存在吞咽功能障碍的患者,采用rTMS治疗可显著促进患者吞咽功能的恢复,并且安全、有效。     

Deglutitive tongue movement after correction of mandibular protrusion: A pilot study

Objective:To investigate any change in deglutitive tongue movement following the correction of malocclusion by orthognathic surgery.Materials and Methods:The subjects were nine patients with mandibular protrusion. A control group consisted of 10 individuals with a similar age range and normal occlusion. Swallowing events before and after mandibular setback via sagittal split ramus osteotomy were recorded by cineradiography, and the tongue movement was analyzed. Time and linear measurements were compared before and after surgical treatment by the Wilcoxon signed rank test; control and test subjects were compared with the Mann-Whitney U-test.Results:Tongue-palate contact and the tongue-tip position changed after orthognathic surgery and became similar to those of the controls. Movements of the anterior and middorsal regions of the tongue did not change after orthognathic surgery and remained different from those of the controls.Conclusion:Our findings suggest that tongue-palate contact and tongue-tip position during deglutition adapted to the corrected oral and maxillofacial morphology, but the anterior and middorsal regions of the tongue during deglutition may have been affected by pharyngeal constrictors rather than by the oral and maxillofacial morphology.