颈前路多节段融合术后吞咽困难的原因分析

目的 比较多节段颈前路椎间盘切除减压融合术中采用传统钢板+cage和“零切迹”颈椎椎间融合器植入患者术后吞咽困难的发生情况,并分析其原因.方法 2008年9月至2011年9月,接受颈前路椎间盘切除减压+前路钢板+cage植入的118例多节段颈椎病患者为钢板cage组,接受颈前路椎间盘切除减压+Zero-p颈椎椎间融合器植入的108例患者为Zero-p组.分别于术前、术后第2天、术后3、6、12个月及末次随访时采用日本矫形外科学会评分法(Japan orthopedic association,JOA)对患者的神经功能情况进行评估;摄颈椎X片评价植骨融合程度、内固定相关并发症及椎前软组织肿胀程度;采用Bazaz吞咽困难分级及改良吞咽生活质量量表(swallowing-quality of life,SWAL-QOL)评估患者吞咽困难的发生率及相关症状发生情况.结果 随访时间平均为2.4年(1.0～3.5年).术后第2天钢板cage组发生吞咽困难49例(41.53％)明显高于Zero-p组(36例,33.33％);钢板cage组术后第2天及术后2个月椎前软组织厚度明显大于Zero-p组.术后第2天Zero-p组中手术范围为C3～C6的患者吞咽困难发生率(43.1％)明显高于手术范围为C4～C7的患者(22％).结论 颈前路多节段融合术后吞咽困难不可避免,内固定的选择和手术范围是术后吞咽困难发生的重要影响因素.使用颈椎“零切迹”植入物可以减少术后吞咽困难的发生率,手术节段越高术后吞咽困难的发生率越高.     

澳大利亚悉尼西南区内镜下胃造瘘术在脑卒中后吞咽功能障碍患者中的应用分析

目的 探讨脑卒中后吞咽功能障碍患者经皮内镜下胃造瘘术(PEG)术前各种因素与术后死亡之间的关系,评估放置PEG管的必要性.方法 52例入组患者,详细记录了PEG前各种参数及术后生存情况,并分析病例的死亡时间特点.对术前和术后的肺炎以及消化道出血情况进行比较分析.结果 52例患者随访期内总共死亡16例,其中15例(93.4％)在术后3个月内死亡.年龄和美国麻醉师协会(ASA)评分显示与死亡有独立相关性,P值分别为0.026及0.001.PEG管置放前后吸入性肺炎发生率(50.0％比34.6％)及上消化道出血的发生率(5.8％比7.7％)比较,差异无统计学意义.结论 放置了PEG管后多数死亡病例是在短期内(3个月)出现.年龄、ASA评分与卒中患者放置PEG管后的死亡风险相关.PEG并不能降低卒中患者吸入性肺炎及消化道出血的发生率.     

卒中后吞咽障碍的筛查工具

卒中后吞咽障碍发生率高,可影响患者康复并增加病死率.早期进行吞咽障碍的客观检查评估意义重大,其中床边筛查试验是日常临床工作中最常采用的评估方法.本文对常用床边吞咽障碍筛查试验的研究进展进行综述.     

徒手呼吸训练干预脑卒中后吞咽功能障碍患者的疗效观察

目的 观察在常规康复治疗的基础上配合徒手呼吸训练治疗脑卒中后吞咽功能障碍的疗效。 方法 选取2017年1月至2018年6月期间在武汉市第一医院就诊且符合入选标准的脑卒中后伴吞咽功能障碍患者48例,按照随机区组法分为观察组与对照组,各24例。2组患者均接受脑卒中后常规康复治疗,包括运动功能训练、作业活动训练、物理因子治疗和吞咽功能训练等,观察组在常规康复治疗的基础上增加徒手呼吸功能训练,主要包括咳嗽声门练习、缩唇呼吸训练、胸廓活动训练、腹肌收缩与放松练习、腹式呼吸训练和腹式呼吸强化训练等。2组患者观察周期均为6周。评价2组患者治疗前、治疗6周后（治疗后）肺功能指标［最长呼气时间、第一秒用力呼气容积（FEV1）、用力肺活量（FVC）］最大吸气压（PImax）、洼田饮水试验(KDWT)、标准吞咽功能评定（SSA）、功能性吞咽困难评分（FDS）。 结果 治疗后,观察组患者的最长呼气时间［（6.00±0.77）s］、FEV1［（3.43±0.30）L］、FVC［（3.90±0.17）L］、PImax［（63.53±10.76）cmH2O］均高于组内治疗前和对照组治疗后,差异均具有统计学意义（P<0.05）。治疗后,观察组的KDWT疗效等级与对照组比较,差异无统计学意义（P>0.05）,但观察组的KDWT显效率高于对照组。治疗后,观察组患者的SSA和FDS评分显著低于组内治疗前和对照组治疗后,差异均有统计学意义（P<0.05）。 结论 在常规康复的基础上辅以徒手呼吸训练可显著改善脑卒中患者的呼吸功能,并有效地促进患者吞咽功能的恢复。     

Pattern of Tongue Pressure on Hard Palate During Swallowing

Contact of the tongue against the hard palate plays an important role in swallowing. This study aimed to clarify the pattern of contact between the tongue and hard palate by analyzing tongue pressure produced in swallowing 15 ml of water by healthy subjects wearing an experimental palatal plate with seven pressure sensors. Tongue pressure was generated initially by close contact with the anteriomedian part of the hard palate, then with the circumferential part, and finally softly with the posteriomedian part. Tongue pressure reached a peak quickly, then decreased gradually before disappearing almost simultaneously at each measured part of the hard palate. Magnitude and duration were significantly larger in the anteriomedian part compared to the other six parts measured, and was significantly smaller in the posteriomedian part. No laterality was found in tongue pressure produced at the circumferential parts of the hard palate. Our findings indicate that the order of tongue contact against each part of the hard palate as well as duration and magnitude of tongue pressure are coordinated precisely during swallowing. These findings could aid assessment of the tongue movement of dysphagic patients during rehabilitation.     

Influence of Bolus Consistency on Lingual Behaviors in Sequential Swallowing

Thickened liquids are a commonly recommended intervention for dysphagia. Previous research has documented differences in temporal aspects of bolus transit for paste versus liquid consistencies; however, the influence of liquid viscosity on tongue movements during swallowing remains unstudied. We report an analysis of the influence of bolus consistency on lingual kinematics during swallowing. Electromagnetic midsagittal articulography was used to trace tongue body and dorsum movement during sequential swallows of three bolus consistencies: thin, nectar-thick, and honey-thick liquids. Rheological profiling was conducted to characterize viscosity and density differences among six liquids (two of each consistency). Eight healthy volunteers participated; four were in a younger age cohort (under age 30) and four were over the age of 50. The primary difference observed across the liquids of interest was a previously unreported phenomenon of sip-mass modulation; both flavor and density appeared to influence sip-sizing behaviors. Additionally, significantly greater variability in lingual movement patterns was observed in the older subject group. Systematic variations in lingual kinematics related to bolus consistency were restricted to the variability of downward tongue dorsum movement. Otherwise, the present analysis failed to find empirical evidence of significant modulations in tongue behaviors across the thin to honey-thick consistency range.     

A new application for electropalatography: Swallowing

Electropalatography (EPG) has been applied to linguistic research and speech pathology. This study evaluated whether EPG could provide useful information on swallow-related tongue action. Specifically, the investigation focused on the quantification of tongue-palate contact patterns for swallowing and on the effects of bolus volume and consistency. Five normal subjects were tested during swallows of 5 and 30 ml of water, 5 and 30 ml of gelatin, and saliva. By segmenting the EPG time-motion sequences into four stages (prepropulsion, propulsion, full contact, withdrawal) and compartmentalizing the palate into six bins (front, central, back, lateral, medial, midline), temporal and spatial characteristics of deglutitive tongue-palate contact were revealed. Significant differences (p<0.01) were found in contact timing across bolus sizes and consistencies for the propulsion and full contact stages. Water was propelled faster than gelatin, and 30-ml gelatin faster than 5-ml gelatin. Dry swallows had a longer full contact stage than water. Contact patterns, though not statistically analyzed at this time, appeared to vary little as a function of bolus properties. Our findings suggest potential value in using EPG to investigate the timing and patterning of abnormal tongue movements associated with disordered swallowing.     

Swallowing in torticollis before and after rhizotomy

To determine risk factors for dysphagia after ventral rhizotomy, videofluoroscopic barium swallowing examinations were done on 41 spasmodic torticollis patients before and after surgery. Radiologic abnormalities were present in 68.3% of the patients before surgery, but these were only mildly abnormal in the majority. After surgery 95.1% showed radiologic abnormalities which were moderate or severe in one-third of the patients. Swallowing abnormalities correlated significantly with duration of torticollis and subjective complaints of swallowing difficulty both before and after surgery, but not with age, sex, or type of torticollis. The major acute postoperative finding was aggravation of preexisting pharyngeal dysfunction. Follow-up from about half of our original sample showed that gradual improvement occurred from 4 to 24 weeks after surgery by subjective report. We review the innervation of intrinsic and extrinsic pharyngeal musculature, and suggest that C1–3 rhizotomies and selective sectioning of the spinal accessory nerve are responsible for aggravation of pharyngeal swallowing dysfunction in the acute postsurgical period.     

Is mis-swallowing or smoking a cause of respiratory symptoms in patients with gastroesophageal reflux disease?

Respiratory symptoms were studied in 119 patients operated on for fundoplication and crural repair because of gastroesophageal reflux disease (GERD). The effect of antireflux surgery and of smoking habits on their respiratory symptoms was evaluated. A questionnaire was completed before and after surgery in connection with esophageal investigations. Chronic bronchitis was present in 20% of the patients, 38% of whom were smokers. In the rest of the patients, 18% were smokers. Cough was reported by 34% and expectoration by 21%. After surgery the number of patients with cough and chronic bronchitis was reduced significantly in nonsmokers and to some extent in smokers. It is believed that fundoplication with distal anchoring of the longitudinal esophageal muscle will improve pharyngoesophageal function and thereby decrease aspiration and respiratory symptoms due to mis-swallowing.