下咽颈食段食管环周缺损修复方法的探讨

目的探讨不同手术方法修复重建下咽颈食管环周缺损的适应证，对不同方法的优缺点进行比较。方法对1993年6月至2006年6月期间收治的72例下咽颈食管区肿瘤进行手术切除，并根据肿瘤切除术后缺损的范围，采用胸大肌肌皮瓣、喉管、游离空肠、游离前臂皮瓣和胃上提咽胃吻合5种方法对肿瘤切除术后所致的下咽颈食管环周缺损进行一期修复重建，并重点对所有患者术后的吞咽功能恢复情况进行观察和客观评估。结果胸大肌肌皮瓣修复重建31例，喉管代下咽颈食管8例，游离空肠移植12例，游离前臂皮瓣移植4例，胃上提咽胃吻合术17例。其中15例患者出现了不同程度的并发症，包括创口感染、咽漏、皮瓣部分坏死、胃壁部分坏死和食管吻合口狭窄等，除1例死亡外，其他患者经处理全部治愈。本组患者术后吞咽功能恢复满意，除2例食管吻合口狭窄患者可以进半流食外，其余患者均恢复了正常的进食功能。平均随访时间为1．6年，术后2年生存率为45．3％。结论下咽颈段食管癌切除术后所致的环周缺损可依据缺损的范围和患者的情况选择不同的修复方法，只要适应证掌握得当均可获得满意的修复重建效果。     

电刺激疗法治疗脑卒中后吞咽障碍的疗效研究

目的探讨电刺激疗法治疗脑卒中所致吞咽障碍的临床疗效。方法75例脑卒中后吞咽障碍患者分为电刺激组,针灸组及康复训练组各25例,前两组在接受常规药物治疗及康复训练基础上分别加用电刺激治疗和针灸。三组治疗前、治疗第1周及第2周以吞咽障碍程度分级评分评定疗效。结果三组治疗后吞咽障碍程度分级评分均明显高于治疗前（P〈0.01）;电刺激组评分明显高于针灸组和康复训练组（P〈0.01）;电刺激组治疗第1、第2周后有效率明显高于针灸组和康复训练组（P〈0.05）。结论电刺激疗法可明显改善脑卒中所致吞咽障碍,配合针灸,康复训练等综合疗法可加强治疗效果。     

Use of Reaction Time in the Temporal Analysis of Normal Swallowing

This study was performed to establish the swallowing trigger by using the reaction time from an auditory stimulus. With this stable temporal starting point, we described the chronology of the different acoustic, electrophysiologic, and respiratory events that occurred during swallowing in a population of normal adults. We studied the swallowing reaction time (SRT) in 18 subjects aged 23 to 73 years by using acoustic, electroglottographic (EGG), and aerodynamic recordings. The chronology (the beginning of EGG activity, apnea, and respiratory sound and release) was identified in 91% of the recordings. The average SRT was 264 ms and the average swallowing duration was 977 ms, without any significant difference with respect to gender. The swallowing sound produced during apnea was composed of either two or three components. The reaction time procedure also demonstrated that the first sound component was unstable. By using this procedure for studying swallowing, we were able to stabilize the chronology of the different events, improve the subjects' attention, and establish a fixed benchmark for performing temporal measurements.     

Real-time ultrasound visualization of tongue movement during swallowing

Using noninvasive real-time ultrasound, tongue movement was visualized during single swallowing in eight normal subjects and one neurologically impaired patient with dysphagia and chronic aspiration. In normals, a clearly defined muscular wave of the tongue, traveling at approximately 15 cm/sec, carried a 5-cc test water bolus posteriorly. In the patient who had 12th cranial nerve weakness, there was complete absence of normal tongue activity and no midtongue bolus formation or transmission.     

Swallowing and Voice Outcomes in Patients Hospitalized With COVID-19: An Observational Cohort Study

ObjectiveTo evaluate the presentations and outcomes of inpatients with coronavirus disease 2019 (COVID-19) presenting with dysphonia and dysphagia to investigate trends and inform potential pathways for ongoing care.DesignObservational cohort study.SettingAn inner-city National Health Service Hospital Trust in London, United Kingdom.ParticipantsAll adult inpatients hospitalized with COVID-19 (N=164) who were referred to Speech and Language Therapy (SLT) for voice and/or swallowing assessment for 2 months starting in April 2020.InterventionsSLT assessment, advice, and therapy for dysphonia and dysphagia.Main Outcome MeasuresEvidence of delirium, neurologic presentation, intubation, tracheostomy, and proning history were collected, along with type of SLT provided and discharge outcomes. Therapy outcome measures were recorded for swallowing and tracheostomy pre- and post-SLT intervention and Grade Roughness Breathiness Asthenia Strain Scale for voice.ResultsPatients (N=164; 104 men) aged 56.8±16.7 years were included. Half (52.4%) had a tracheostomy, 78.7% had been intubated (mean, 15±6.6d), 13.4% had new neurologic impairment, and 69.5% were delirious. Individualized compensatory strategies were trialed in all and direct exercises with 11%. Baseline assessments showed marked impairments in dysphagia and voice, but there was significant improvement in all during the study (P<.0001). On average, patients started some oral intake 2 days after initial SLT assessment (interquartile range [IQR], 0-8) and were eating and drinking normally on discharge, but 29.3% (n=29) of those with dysphagia and 56.1% (n=37) of those with dysphonia remained impaired at hospital discharge. A total of 70.9% tracheostomized patients were decannulated, and the median time to decannulation was 19 days (IQR, 16-27). Among the 164 patients, 37.3% completed SLT input while inpatients, 23.5% were transferred to another hospital, 17.1% had voice, and 7.8% required community follow-up for dysphagia.ConclusionsInpatients with COVID-19 present with significant impairments of voice and swallowing, justifying responsive SLT. Prolonged intubations and tracheostomies were the norm, and a minority had new neurologic presentations. Patients typically improved with assessment that enabled treatment with individualized compensatory strategies. Services preparing for COVID-19 should target resources for tracheostomy weaning and to enable responsive management of dysphagia and dysphonia with robust referral pathways.     

Cricopharyngeal myotomy may be effective treatment for selected patients with neurogenic oropharyngeal dysphagia

The role of cricopharyngeal (CP) myotomy in the management of neurogenic oropharyngeal dysphagia remains controversial. A review of the literature regarding outcomes of CP myotomy for dysphagia in the setting of a variety of neurological disorders indicates a preponderance of favorable results. There are several potential explanations for reported improvement after CP myotomy for neurogenic dysphagia, including the possibility that it is an effective treatment, at least for selected patients. If this is true, appropriate selection criteria for this treatment of neurogenic dysphagia may include (1) intact voluntary initiation of swallowing, (2) adequate propulsive force generated by the tongue and pharyngeal constrictors, (3) videofluorographic demonstration of obstruction to bolus flow at the CP segment (rather than merely retention in the pharyngeal recesses), (4) manometric evidence of relatively elevated CP pressure in relation to the pharynx, and (5) relatively favorable neurological prognosis. The effectiveness and safety of CP myotomy for patients with neurogenic dysphagia are unlikely to be resolved without a prospective, controlled multicenter study enrolling patients who meet such criteria.     

Oropharyngeal dysphagia in children with cerebral palsy: comparisons between a high- and low-resource country

Purpose: There is paucity of research investigating oropharyngeal dysphagia (OPD) in young children with cerebral palsy (CP), and most studies explore OPD in high-resource countries. This study aimed at determining the proportion and severity of OPD in preschool children with CP in Bangladesh, compared to Australia.

Method: Cross-sectional, comparison of two cohorts. Two hundred and eleven children with CP aged 18–36 months, 81 in Bangladesh (mean?=?27.6 months, 61.7% males), and 130 in Australia (mean?=?27.4 months, 62.3% males). The Dysphagia Disorders Survey (DDS) – Part 2 was the primary OPD outcome for proportion and severity of OPD. Gross motor skills were classified using the Gross Motor Function Classification System (GMFCS), motor type/distribution.

Results: (i) Bangladesh sample: proportion OPD?=?68.1%; severity?=?10.4 SD?=?7.9. Australia sample: proportion OPD?=?55.7%; severity?=?7.0 SD?=?7.5. (ii) There were no differences in the proportion or severity of OPD between samples when stratified for GMFCS (OR?=?2.4, p?=?0.051 and β?=?1.2, p?=?0.08, respectively).

Conclusions: Despite overall differences in patterns of OPD between Bangladesh and Australia, proportion and severity of OPD (when adjusted for the functional gross motor severity of the samples) were equivalent. This provides support for the robust association between functional motor severity and OPD proportion/severity in children with CP, regardless of the resource context.

• Implications for Rehabilitation

• The proportion and severity of OPD according to gross motor function level were equivalent between high- and low-resource countries (LCs).

• Literature from high-resource countries may be usefully interpreted by rehabilitation professionals for low-resource contexts using the GMFCS as a framework.

• The GMFCS is a useful classification in LCs to improve earlier detection of children at risk of OPD and streamline management pathways for optimal nutritional outcomes.

• Rehabilitation professionals working in LCs are likely to have a caseload weighted towards GMFCS III–V, with less compensatory OPD management options available (such as non-oral nutrition through tubes).

     

The significance of accumulated oropharyngeal secretions and swallowing frequency in predicting aspiration

This study retrospectively investigated the value of both endoscopically visible oropharyngeal secretions in the hypopharynx and swallowing frequency in the prediction of aspiration of food and liquid. Fiberoptic endoscopic evaluation of swallowing (FEES) was performed on a total of 69 individuals that included hospitalized elderly, nonhospitalized elderly, and young normal subjects. A four-level rating scale for determining the severity of accumulated orpharyngeal secretions was developed and employed to rate subjects prior to the presentation of food or liquid during the FEES. Spontaneous dry swallows were also counted during the observation period of the FEES. It was found that the accumulation of endoscopically visible oropharyngeal secretions located within the laryngeal vestibule was highly predictive of aspiration of food or liquid. There were significantly fewer spontaneous swallows in hospitalized subjects when compared with nonhospitalized subjects. There was also a significant decrease in the frequency of spontaneous swallows in aspirating hospitalized subjects when compared with nonaspirating hospitalized subjects. Results are discussed in terms of integrating this information with clinical bedside examination techniques.     

Masticatory ability in experimentally induced xerostomia

The masticatory ability of 15 nondysphagic volunteers with complete natural dentition was tested using different chewing parameters including preparation of a two-color plastic chewing gum (bolus shape, and color mixture), particle reduction of a piece of silicone, and number of strokes before swallow of almonds. The tests were performed under conditions of normal salivation and experimental oral dryness caused by intramuscular injection of methylscopolamine. The chewing gum tests as well as the silicone particle reduction tests were not influenced by lack of salivation. The number of chewing strokes prior to the initiation of swallowing of almonds was significantly increased. Oral dryness seems to cause accumulation of particles in the oral cavity from friable food and the particulate material is not transported posteriorly into a “readyto-swallow” positioning. The absorption of saliva by dry oral content such as an almond further impaired oral manipulation of food.     

Acute thermal injury of the esophagus

Acute thermal injury to the esophagus has not been reported previously in the radiographic literature. We present a case of a young adult who developed an intramura blister that ultimately communicated with the esophageal lumen. A double-contrast esophagogram outlined the resulting mucosal flap. A brief review of other injuries to the esophagus is included.