The gastroenterologist's approach to dysphagia

In the gastroenterological diagnostic armamentarium, dysphagia is considered as an important symptom for diseases of the esophagus. Concerning the history of illness, symptoms such as retrosternal pain and heartburn are often associated with gastroesophageal reflux disease. Morphological changes of the mucosa can be diagnosed by flexible endoscopy and radiographic examinations. Investigation with 24-h pH monitoring, manometry, and pharmacological tests is necessary for the diagnosis of functional disorders. Additionally, dysphagia can be associated with multiple internal diseases, including muscular diseases such as dermatomyositis, progressive systemic sclerosis, as well as lupus erythematosus. Difficulties in swallowing associated with hypo- and hyperthyrodism can also be interpreted as muscular lesions. Metabolic disorders such as alcoholism, and diabetes mellitus can be the cause of dysphagia. Increasing importance in the differential diagnosis of dysphagia is attached to infections of the upper GI tract. Especially in immunocompromised patients, infections ofCandida albicans, mycobacterias, herpes, varicella zoster, and cytomegaloviruses can produce dysphagia and odynophagia. The differential diagnosis of the angina-like chest pain has to differentiate between cardiac disease and a noncardiac genesis. Therefore, besides the cardiac diagnostic investigation, endoscopy, radiography, and manometry are often indicated.     

Evaluating Swallowing Dysfunction Using a 100-ml Water Swallowing Test

This study used comparison with videofluoroscopic examination of swallowing (VFES) to examine the validity of a 100-ml water swallowing test (WST) in assessing swallowing dysfunction. Fifty-nine consecutive outpatients (15 females, 44 males) with clinically suspected dysphagia were enrolled in this study. Each subject underwent a 100-ml WST followed by VFES. Data was obtained on swallowing speed and signs of choking (coughing and a wet-hoarse voice). The analytical results revealed that 49 subjects had abnormal swallowing speeds (< 10 ml/s) in the 100-ml WST, and 47 of them were identified as having dysphagia by VFES. Among the ten participants with normal swallowing speed (> 10 ml/s), eight were diagnosed with dysphagia by VFES. Notably, 14 participants choked in the 100-ml WST, 11 of whom exhibited aspiration or penetration in VFES. Among the 45 participants without choking in WST, 12 displayed aspiration or penetration in VFES. The sensitivity of swallowing speed in detecting the swallowing dysfunction was 85.5%, and the specificity was 50%. Moreover, the sensitivity of using choking or wet-horse voice in the 100-ml WST as the sole factor for predicting the presence of aspiration was 47.8%, while the specificity was 91.7%. Therefore, this study concluded that swallowing speed is a sensitive indicator for identifying patients at risk for swallowing dysfunction. Moreover, choking in the 100-ml WST may be a potential specific indicator for followup aspiration.     

Pharyngeal motility in patients submitted to type I thyroplasty

IntroductionType 1 thyroplasty is performed to improve glottis closure as well as dysphagic symptoms in patients with unilateral vocal fold immobility.ObjectivesThis study aims to compare the motility of the pharynx and upper esophageal sphincter in patients with unilateral vocal fold immobility before and after thyroplasty Type I.MethodsWe prospectively studied 15 patients with unilateral vocal fold immobility who underwent thyroplasty Type I. Subjects were divided according to the topography of vagal injury and presence of dysphagia. High resolution manometry was performed before and 30 days after surgery. Time and pressure manometric parameters at the topography of the velopharynx, epiglottis and upper esophageal sphincter were recorded.ResultsDysphagia was present in 67% of patients. 63% had lower vagal injuries. Manometric parameters did not change after thyroplasty for the whole population. The group of dysphagic patients, however, had an increase in residual pressure at the upper esophageal sphincter after thyroplasty (1.2 vs. 5.2 mmHg; p = 0.05). Patients with low vagal injury developed higher peak pressure (100 vs. 108.9 mmHg p ≤ 0.001), lower rise time (347 vs. 330 ms p = 0.04), and higher up stroke (260 vs. 266.2 mmHg/ms p = 0.04) at the topography of the velopharynx after thyroplasty.ConclusionPharyngeal motility is affected by thyroplasty Type I in patients with dysphagia and low vagal injury.     

肠内营养对卒中后进食困难老年患者营养状况改善及并发症预防的作用

目的 探讨肠内营养对卒中后进食困难老年患者营养状况改善及并发症预防的作用,为临床治疗提供理论指导.方法 82例卒中后进食困难老年患者根据入院时间随机分为两组,对照组41例给予肠外营养,治疗组41例给予肠内营养.于治疗前和治疗后第3周测量患者三头肌皮褶厚度（TSF）、上臂肌围（AMC）,检测血清血红蛋白（Hb）、白蛋白（ALB）、总蛋白（TP）、高密度脂蛋白胆固醇（HDL-C）、低密度脂蛋白胆固醇（LDLC）、三酰甘油（TG）、总胆固醇（TC）和空腹血糖（FPG）水平,并进行比较,观察患者并发症的发生情况.结果 治疗后第3周,对照组TSF、AMC、Hb、ALB、TP、HDLC、LDL-C、TG、TC、FPG较治疗前显著降低,差异有统计学意义（P＜0.05）;治疗组上述指标与治疗前比较差异无统计学意义（P＞0.05）.治疗组治疗后第3周TSF、AMC、Hb、ALB、TP、HDL-C、LDL-C、TG、TC、FPG显著高于对照组,差异有统计学意义（P＜0.05）.对照组肺部感染19例,肠源性感染3例,褥疮2例,泌尿系统感染8例,总感染率78.0％（32/41）;治疗组肺部感染11例,泌尿系统感染3例,褥疮1例,总感染率36.6％（15/41）,两组总感染率比较差异有统计学意义（P＜0.05）.结论 肠内营养有利于卒中后进食困难老年患者营养状况的改善,并可大大减少并发症的发生,最终提高生存率,值得临床推广.     

喉部分切除术对患者吞咽相关生存质量的远期影响

目的 探讨各种喉部分切除术1年以后对患者吞咽相关生存质量的影响.方法 采用吞咽相关生存质量量表(Swallowing quality-of-life questionnaire,SWAL-QOL)香港中文版,对96例喉部分切除术后1年以上患者的生存质量进行调查.按照手术方式分为4组:环状软骨上喉部分切除环舌骨吻合术(supracricoid partial laryngectomy-cricohyoidopexy,SCPL-CHP,以下简称CHP)、环状软骨上喉部分切除环舌骨会厌吻合术(supracricoid partial laryngectomy-cricohyoidoepiglottopexy,SCPL-CHEP,以下简称CHEP)、声门上喉水平部分切除术、喉垂直部分切除术.结果 采用多元方差分析,可见喉癌术式对生存质量各维度的总体效应差异具有统计学意义(F=8.5,P＜0.01)；除外疲倦和睡眠2个维度,另外9个维度差异均具有统计学意义(P值均＜0.01).Bonferroni法两两比较4种术式在这9个维度得分的差异:除了言语交流维度,喉垂直部分切除术组均是近满分表现,CHP、CHEP、喉水平部分切除术组在多个维度得分显著低于喉垂直部分切除术组,差异均有统计学意义(P值均＜0.05)；CHP组在多个维度均为4组中的最低分,差异均有统计学意义(P值均＜0.05)；喉水平部分切除术和CHEP组在除外言语频率的其他维度中差异均无统计学意义(P值均＞0.05)；误咽患者在社会功能等维度得分偏低.结论 喉癌术式对患者术后吞咽相关的长期生存质量有显著影响,CHP对吞咽相关生存质量影响最大,喉垂直部分切除术患者吞咽相关生存质量最好.长期误咽对患者的影响是多维的,可导致患者的社会功能退化.     

The Interdependency of Protein-Energy Malnutrition, Aging, and Dysphagia

Advancing age is increasingly associated with confounding chronic and acute ailments, predisposing elderly individuals to conditions such as malnutrition and swallowing dysfunction. This enhanced susceptibility to malnutrition and dysphagia in this aging demographic lends itself to exacerbating, disabling conditions that may result in increased morbidity and mortality in the event of an aspiration episode. Early identification of substandard nutritional status and subsequent interventiion in the elderly dysphagic population may circumvent the deleterious effects of malnutrition.     

CT Study of Closure of the Hemipharynx with Head Rotation in a Case of Lateral Medullary Syndrome

In a patient with unilateral pharyngeal paralysis, rotation of the head to the paralyzed side can effectively close the hemipharynx on that side. However, the exact level or place of closure is unknown. Serial computed tomography of the pharynx in a patient with lateral medullary syndrome showed that hemipharyngeal closing occurred at the level of the hyoid bone, or the hypopharyngeal cavity above the pyriform sinus, and that the entire space of the bilateral pyriform sinuses remained open despite the head rotation.     

Interjudge and intrajudge reliabilities in fiberoptic endoscopic evaluation of swallowing (fees) using the penetration-aspiration scale: a replication study

This study used Fiberoptic Endoscopic Evaluation of Swallowing (FEES(R)) to assess the reliability of the Penetration-Aspiration Scale (PAS) using 79 swallows and four judges in a replication of a study using videofluoroscopy (VFSS). The swallows were diagnosed using FEES, which allowed for comparison between the two techniques. The findings indicated that all categories of the PAS achieved adequate reliability, both on intrajudge and interjudge assessments. Reliabilities, with the exception of Scale Score 7, were higher in this study than in the original study by Rosenbek and associates. Data analysis indicated that judges were more highly consistent on second ratings compared with their original ratings, indicating a learning curve on the PAS. In addition, findings suggested that the FEES was more reliable on assessing penetration than VFSS, but that VFSS was more reliable on the assessment of the various severities of aspiration. The two techniques were equally effective in discriminating between penetration and aspiration. This study found that FEES was just as reliable as VFSS when using the PAS.     

针灸治疗卒中后吞咽困难的系统评价

目的评价针灸治疗卒中后吞咽困难的疗效及可能的不良反应。方法对针灸治疗卒中后吞咽困难的随机对照试验(RCT)或半随机对照试验(quasi-RCT)按Cochrane协作网推荐的方法进行系统评价。结果7篇中文文献506例患者满足纳入标准,均为低质量试验。纳入的6个试验Meta-分析结果表明针刺对卒中后吞咽困难的疗效优于对照组[RR1·17,95%CI(1·08,1·27),Z=3·78,P=0·0002]。病死率、肺部感染率针刺组与非针刺组无差异[分别是RR0·25,95%CI(0·03,2·18)和RR3·02,95%CI(0·39,23·10)]。电视透视检查(VF)示在常规治疗基础上针刺对比康复训练可缩短胶钡咽通过时间[WMD-7·23,95%CI(-13·18,-1·28)]。结论由于纳入研究数量和质量上的缺陷,尤其是缺乏远期功能性结局指标,虽显示针刺有短期改善卒中后吞咽困难的趋势,无不良反应,但目前尚不能对其疗效得出肯定结论。开展更多高质量、内在真实性好的大规模、多中心的RCT非常必要。