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To investigate the impact of tracheostomy tube capping on swallowing physiology in stroke patients with dysphagia via videofluoroscopic swallowing study (VFSS).
This study was conducted as a prospective study that involved 30 stroke patients. Then, 4 mL semisolid swallowing was conducted with capping of the tracheostomy tube or without capping of the tracheostomy tube. The following five parameters were measured: laryngeal elevation, pharyngeal transit time, post-swallow pharyngeal remnant, upper esophageal sphincter width (UES), and penetration-aspiration scale (PAS) score.
On assessment of the differences in swallowing parameters during swallowing between ‘with capping’ and ‘without capping’ statuses, statistically significant differences were found in the post-swallow pharyngeal remnant (without capping, 48.19%±28.70%; with capping, 25.09%±19.23%; p<0.001), normalized residue ratio scale for the valleculae (without capping, 0.17±0.12; with capping, 0.09±0.12; p=0.013), normalized residue ratio scale for the piriform sinus (without capping, 0.16±0.12; with capping, 0.10±0.07; p=0.015), and UES width (without capping, 3.32±1.61 mm; with capping, 4.61±1.95 mm; p=0.003). However, there were no statistically significant differences in laryngeal elevation (x-axis without capping, 2.48±1.45 mm; with capping, 3.26±2.37 mm; y-axis without capping, 11.11±5.24 mm; with capping, 12.64±6.16 mm), pharyngeal transit time (without capping, 9.19± 10.14 s; with capping, 9.09±10.21 s), and PAS score (without capping, 4.94±2.83; with capping, 4.18±2.24).
Tracheostomy tube capping is a useful way to reduce post-swallow remnants and it can be considered an alternative method for alleviating dysphagia in stroke patients who can tolerate tracheostomy tube capping when post-swallow remnants are observed.
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To investigate the improvement of dysphagia after balloon dilatation and balloon swallowing at the vallecular space with a Foley catheter in stroke patients.
This study was conducted between May 1, 2012 and December 31, 2015, and involved 30 stroke patients with complaints of difficulty in swallowing. All patients underwent videofluoroscopic swallowing study (VFSS) before and after vallecular ballooning. VFSS was performed with a 4 mL semisolid bolus. For vallecular ballooning, two trainings were performed for at least 10 minutes, including backward stretching of the epiglottis and swallowing of a balloon located in the vallecular space, by checking the movement of the Foley catheter tip in real time using VFSS.
After examination of the dysphagia improvement pattern before and after vallecular ballooning, laryngeal elevation (x-axis: pre 2.62±1.51 mm and post 3.54±1.93 mm, p=0.038; y-axis: pre 17.11±4.24 mm and post 22.11±3.46 mm, p=0.036), pharyngeal transit time (pre 5.76±6.61 s and post 4.08±5.49 s, p=0.043), rotation of the epiglottis (pre 53.24°±26.77° and post 32.45°±24.60°, p<0.001), and post-swallow pharyngeal remnant (pre 41.31%±23.77% and post 32.45%±24.60%, p=0.002) showed statistically significant differences. No significant difference was observed in the penetration-aspiration scale score (pre 4.73±1.50 and post 4.46±1.78, p=0.391).
For stroke patients with dysmotility of the epiglottis and post-swallowing residue, vallecular ballooning can be considered as an alternative method that can be applied without risk of aspiration in dysphagia treatment.
Citations
To present a new stimulation method based on the use of a head-mounted display (HMD) during pattern reversal visual evoked potential (PR-VEP) testing and to compare variables of HMD to those of conventional cathode ray tube (CRT).
Twenty-three normal subjects without visual problems were recruited. PR-VEPs were generated using CRT or HMD stimuli. VEP outcome measures included latencies (N75, P100, and N145) and peak-to-peak amplitudes (N75–P100 and P100–N145). Subjective discomfort associated with HMD was determined using a self-administered questionnaire.
PR-VEPs generated by HMD stimuli showed typical triphasic waveforms, the components of which were found to be correlated with those obtained using conventional CRT stimuli. Self-administered discomfort questionnaires revealed that HMD was more comfortable in some aspects. It allowed subjects to concentrate better than CRT.
The described HMD stimulation can be used as an alternative to the standard CRT stimulation for PR-VEPs. PR-VEP testing using HMD has potential applications in clinical practice and visual system research because HMD can be used on a wider range of subjects compared to CRT.
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To investigate improved dysphagia after the decannulation of a tracheostomy in patients with brain injuries.
The subjects of this study are patients with brain injuries who were admitted to the Department of Rehabilitation Medicine in Myongji Hospital and who underwent a decannulation between 2012 and 2014. A video fluoroscopic swallowing study (VFSS) was performed in order to investigate whether the patients' dysphagia had improved. We measured the following 5 parameters: laryngeal elevation, pharyngeal transit time, post-swallow pharyngeal remnant, upper esophageal width, and semisolid aspiration. We analyzed the patients' results from VFSS performed one month before and one month after decannulation. All VFSS images were recorded using a camcorder running at 30 frames per second. An AutoCAD 2D screen was used to measure laryngeal elevation, post-swallow pharyngeal remnant, and upper esophageal width.
In this study, a number of dysphagia symptoms improved after decannulation. Laryngeal elevation, pharyngeal transit time, and semisolid aspiration showed no statistically significant differences (p>0.05), however after decannulation, the post-swallow pharyngeal remnant (pre 37.41%±24.80%, post 21.02%±11.75%; p<0.001) and upper esophageal width (pre 3.57±1.93 mm, post 4.53±2.05 mm; p<0.001) showed statistically significant differences.
When decannulation is performed on patients with brain injuries who do not require a ventilator and who are able to independently excrete sputum, improved esophageal dysphagia can be expected.
Citations
To investigate the relationship between dysphagia severity and opening of the upper esophageal sphincter (UES), and to assess the effect of balloon size on functional improvement after rehabilitative balloon swallowing treatment in patients with severe dysphagia with cricopharyngeus muscle dysfunction (CPD).
We reviewed videofluoroscopic swallowing studies (VFSS) conducted in the Department of Physical Medicine and Rehabilitation, Myongji Hospital from January through December in 2012. All subjects diagnosed with CPD by VFSS further swallowed a 16-Fr Foley catheter filled with barium sulfate suspension for three to five minutes. We measured the maximum diameter of the balloon that a patient could swallow into the esophagus and subsequently conducted a second VFSS. Then, we applied a statistical technique to correlate the balloon diameter with functional improvement after the balloon treatment.
Among 283 inpatients who received VFSS, 21 subjects were diagnosed with CPD. It was observed that the degree of UES opening evaluated by swallowing a catheter balloon had inverse linear correlations with pharyngeal transit time and post-swallow pharyngeal remnant. Videofluoroscopy guided iterative balloon swallowing treatment for three to five minutes, significantly improved the swallowing ability in terms of pharyngeal transit time and pharyngeal remnant (p<0.005 and p<0.001, respectively). Correlation was seen between balloon size and reduction in pharyngeal remnants after balloon treatment (Pearson correlation coefficient R=-0.729, p<0.001), whereas there was no definite relationship between balloon size and improvement in pharyngeal transit time (R=-0.078, p=0.738).
The maximum size of the balloon that a patient with CPD can swallow possibly indicates the maximum UES opening. The iterative balloon swallowing treatment is safe without the risk of aspiration, and it can be an effective technique to improve both pharyngeal motility and UES relaxation.
Citations
Authors have previously experienced the effect of balloon dilation at the vallecular by utilizing the video-fluoroscopic swallowing study (VFSS) and the urethral catheter to physically stretch and spread in the direction of the posterior inferior towards the patients who have claimed for dysphagia symptoms due to epiglottic dysfunction. A 72-year-old male patient has been diagnosed with rectal cancer and have been treated with an ileocolostomy after the intubation. After the removal of tracheal intubation, the patient complained of dysphagia. Foods and drinks could not be transmigrated into the esophagus due to the inability of the epiglottis to bend backward in the direction of posterior inferior on VFSS. The epiglottis was physically stretched and spread in the direction of posterior inferior by utilizing the balloon attached to a urethral catheter. After stretching and spreading the epiglottis in the direction of posterior inferior, the bolus remaining in the epiglottic vallecula was decreased. For a patient who is experiencing dysphagia due to an epiglottis disorder, it seems that an epiglottis balloon dilation supported by VFSS and a urethral catheter may be appropriate for the treatment of dysphagia symptoms.
Citations
Acquired tracheoesophageal fistula through esophageal diverticulum is infrequent. We report tracheoesophageal fistula through esophageal diverticulum in a 55-year-old male who had a prolonged tracheostomy tube during 6 months, and a NG tube during 18 months. He suffered from recurrent pneumonia. He complained of a cough associated with eating, and production of sputum mixed with food. To help evaluate the aspiration to the lung and the cause of aspiration, he was tested using gastrointestinal scintigraphy (gastric emptying study), a chest CT scan (pre & post contrast), and esophagoduodenoscopy. The chest CT scan revealed an acquired tracheoesophageal fistula through esophageal diverticulum, and esophagoduodenoscopy revealed a 3 mm sized fistula that was located -33 cm from the upper incisor. We treated the tracheoesophageal fistula by clipping under esophagoduodenoscopy. The symptoms of fever, cough, and aspiration were no long observed after the clipping was completed.
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