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Prolonged intubation is known to bring on postextubation dysphagia (PED) in some patients. We have noted that there were some studies to investigate specific type and pattern of PED, which showed large variety of different swallowing abnormalities as mechanisms of PED that are multifactorial. There are several options of treatment in accordance with the management of these abnormalities. A botulinum toxin (BoT) injection into the upper esophageal sphincter (UES) can improve swallowing functions for patients with this disorder, by working to help the muscle relax. In this case, the conventional treatment was not effective in patients with PED, whereas the BoT injection made a great improvement for these patients. This study suggests that the UES pathology could be the main cause of PED.
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Palatal myoclonus (PM) is a rare disease that may induce dysphagia. Since dysphagia related to PM is unique and is characterized by myoclonic movements of the involved muscles, specific treatments are needed for rehabilitation. However, no study has investigated the treatment effectiveness for this condition. Therefore, the aim of this case report was to describe the benefit of combining behavioral treatment with valproic acid administration in patients with dysphagia triggered by PM. The two cases were treated with combined treatment. The outcomes evaluated by videofluoroscopic swallowing studies before and after the treatment showed significant decreases in myoclonic movements and improved swallowing function. We conclude that the combined treatment was effective against dysphagia related to PM.
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To prospectively assess the association between impoverished sensorimotor integration of the tongue and lips and post-extubation dysphagia (PED).
This cross-sectional study included non-neurologic critically ill adult patients who required endotracheal intubation and underwent videofluoroscopic swallowing study (VFSS) between October and December 2016. Participants underwent evaluation for tongue and lip performance, and oral somatosensory function. Demographic and clinical data were retrieved from medical records.
Nineteen patients without a definite cause of dysphagia were divided into the non-dysphagia (n=6) and the PED (n=13) groups based on VFSS findings. Patients with PED exhibited greater mean duration of intubation (11.85±3.72 days) and length of stay in the intensive care unit (LOS-ICU; 13.69±3.40 days) than those without PED (6.83±5.12 days and 9.50±5.96 days; p=0.02 and p=0.04, respectively). The PED group exhibited greater incidence of pneumonia, higher videofluoroscopy swallow study dysphagia scale score, higher oral transit time, and lower tongue power and endurance and lip strength than the non-dysphagia groups. The differences in two-point discrimination and sensations of light touch and taste among the two groups were insignificant. Patients intubated for more than 7 days exhibited lower maximal tongue power and tongue endurance than those intubated for less than a week.
Duration of endotracheal intubation, LOS-ICU, and oromotor degradation were associated with PED development. Oromotor degradation was associated with the severity of dysphagia. Bedside oral performance evaluation might help identify patients who might experience post-extubation swallowing difficulty.
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To evaluate the correlation between radionuclide salivagram findings and clinical characteristics in dysphagic patients with brain lesions.
The medical records of 35 dysphagic patients with brain lesions who simultaneously underwent both a videofluoroscopic swallowing study (VFSS) and radionuclide salivagram were analyzed retrospectively. The subjects were divided into two groups according to the presence of aspiration on a salivagram (group A, patients with aspiration on the salivagram; group B, patients with no aspiration on the salivagram). The differences between clinical characteristics and VFSS findings (penetration-aspiration scale [PAS]) between the two groups were analyzed.
Eleven out of 35 patients displayed salivary aspiration on the radionuclide salivagram. There were no significant differences between the two groups according to age, sex, disease duration, PAS on VFSS and feeding methods (p≥0.05). The incidence of aspiration pneumonia was significantly higher in group A. In a multivariate logistic regression analysis with forward stepwise method, the Mini-Mental State Examination (MMSE) score was the only significant parameter in predicting positive findings in salivagrams (odds ratio=0.760; 95% confidence interval [CI], 0.625–0.923; p=0.006). The area under the receiver operating characteristic curve (AUC) of the MMSE score for positive detection in salivagrams was 0.855 (95% CI, 0.689–0.953; p<0.0001). The optimal cut-off value was 7 for the MMSE score (sensitivity 72.73%, specificity 100%).
In patients with brain lesions who complain of dysphagia, the MMSE score was correlated with salivary aspiration. If patients present with a score of 7 or less on the MMSE, performing a radionuclide salivagram may helpful for early detection of patients at high risk of aspiration pneumonia induced from salivary aspiration.
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To compare swallowing function between healthy subjects and patients with pharyngeal dysphagia using high resolution manometry (HRM) and to evaluate the usefulness of HRM for detecting pharyngeal dysphagia.
Seventy-five patients with dysphagia and 28 healthy subjects were included in this study. Diagnosis of dysphagia was confirmed by a videofluoroscopy. HRM was performed to measure pressure and timing information at the velopharynx (VP), tongue base (TB), and upper esophageal sphincter (UES). HRM parameters were compared between dysphagia and healthy groups. Optimal threshold values of significant HRM parameters for dysphagia were determined.
VP maximal pressure, TB maximal pressure, UES relaxation duration, and UES resting pressure were lower in the dysphagia group than those in healthy group. UES minimal pressure was higher in dysphagia group than in the healthy group. Receiver operating characteristic (ROC) analyses were conducted to validate optimal threshold values for significant HRM parameters to identify patients with pharyngeal dysphagia. With maximal VP pressure at a threshold value of 144.0 mmHg, dysphagia was identified with 96.4% sensitivity and 74.7% specificity. With maximal TB pressure at a threshold value of 158.0 mmHg, dysphagia was identified with 96.4% sensitivity and 77.3% specificity. At a threshold value of 2.0 mmHg for UES minimal pressure, dysphagia was diagnosed at 74.7% sensitivity and 60.7% specificity. Lastly, UES relaxation duration of <0.58 seconds had 85.7% sensitivity and 65.3% specificity, and UES resting pressure of <75.0 mmHg had 89.3% sensitivity and 90.7% specificity for identifying dysphagia.
We present evidence that HRM could be a useful evaluation tool for detecting pharyngeal dysphagia.
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To investigate the characteristics of cognitive deficits in patients with post-stroke dysphagia, and to analyze the relationships between cognitive dysfunction and severity of dysphagia in supratentorial stroke.
A total of 55 patients with first-ever supratentorial lesion stroke were enrolled retrospectively, within 3 months of onset. We rated dysphagia from 0 (normal) to 4 (severe) using the dysphagia severity scale (DSS) through clinical examinations and videofluoroscopic swallowing studies (VFSS). The subjects were classified either as non-dysphagic (scale 0) or dysphagic (scale 1 to 4). We compared general characteristics, stroke severity and the functional scores of the two groups. We then performed comprehensive cognitive function tests and investigated the differences in cognitive performance between the two groups, and analyzed the correlation between cognitive test scores, DSS, and parameters of oral and pharyngeal phase.
Fugl-Meyer motor assessment, the Berg Balance Scale, and the Korean version of the Modified Barthel Index showed significant differences between the two groups. Cognitive test scores for the dysphagia group were significantly lower than the non-dysphagia group. Significant correlations were shown between dysphagia severity and certain cognitive subtest scores: visual span backward (p=0.039), trail making tests A (p=0.042) and B (p=0.002), and Raven progressive matrices (p=0.002). The presence of dysphagia was also significantly correlated with cognitive subtests, in particular for visual attention and executive attention (odds ratio [OR]=1.009; 95% confidence interval [CI], 1.002–1.016; p=0.017). Parameters of premature loss were also significantly correlated with the same subtests (OR=1.009; 95% CI, 1.002–1.016; p=0.017).
Our results suggest that cognitive function is associated with the presence and severity of post-stroke dysphagia. Above all, visual attention and executive functions may have meaningful influence on the oral phase of swallowing in stroke patients with supratentorial lesions.
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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.
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To evaluate the functional characteristics of swallowing and to analyze the parameters of dysphagia in head and neck cancer patients after concurrent chemoradiotherapy (CCRT).
The medical records of 32 patients with head and neck cancer who were referred for a videofluoroscopic swallowing study from January 2012 to May 2015 were retrospectively reviewed. The patients were allocated by duration after starting CCRT into early phase (<1 month after radiation therapy) and late phase (>1 month after radiation therapy) groups. We measured the modified penetration aspiration scale (MPAS) and American Speech-Language-Hearing Association National Outcome Measurement System swallowing scale (ASHA-NOMS). The oral transit time (OTT), pharyngeal delay time (PDT), and pharyngeal transit time (PTT) were recorded to assess the swallowing physiology.
Among 32 cases, 18 cases (56%) were of the early phase. In both groups, the most common tumor site was the hypopharynx (43.75%) with a histologic type of squamous cell carcinoma (75%). PTT was significantly longer in the late phase (p=0.03). With all types of boluses, except for soup, both phases showed a statistically significant difference in MPAS results. The mean ASHA-NOMS level for the early phase was 5.83±0.78 and that for the late phase was 3.79±1.80, with statistical significance (p=0.01). The PTT and ASHA-NOMS level showed a statistically significant correlation (correlation coefficient=–0.52, p=0.02). However, it showed no relationship with the MPAS results.
The results of our study suggest that in the late phase that after CCRT, the OTT, PDT, and PTT were longer than in the early phase and the PTT prolongation was statistically significant. Therefore, swallowing therapy targeting the pharyngeal phase is recommended after CCRT.
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To investigate the characteristics and risk factors of dysphagia with the Videofluoroscopic Dysphagia Scale (VDS) using a videofluoroscopic swallowing study (VFSS) in patients with ruptured aneurysmal subarachnoid hemorrhage (aSAH).
Data of 64 patients presenting with first-ever ruptured aSAH were analyzed. Characteristics of dysphagia were evaluated using VFSS and all subjects were divided into a high (>47) and low risk group (≤47) by the VDS score. Clinical and functional parameters were assessed by medical records including demographics, hypertension and diabetes mellitus (DM), the Glasgow Coma Scale (GCS), the Hunt and Hess scale, endotracheal intubation, acute management modalities, as well as Korean version of the Mini-Mental Status Examination (K-MMSE) and Korean version of Modified Barthel Index (K-MBI). Radiologic factors identified the amount of hemorrhage, ventricular rupture, and aneurysmal location.
About a half of the subjects showed oral phase abnormalities and the oral transit time was delayed in 46.8% of the patients. The pharyngeal transit time was also prolonged in 39.0% of the subjects and the proportion of penetration and aspiration observed was 46.8%. The parameters-GCS score (p=0.048), hemorrhagic volume (p=0.028), presence of intraventricular hemorrhage (p=0.038), and K-MMSE (p=0.007)-were predisposing factors for dysphagia in patients with aSAH.
Abnormalities in the oral phase were more prominent in patients with aSAH than in those with other types of stroke. The risk factors associated with dysphagia persisting over 6 months after stroke onset were the initial GCS, hemorrhage volume, presence of intraventricular hemorrhage, and cognitive status as measured by the K-MMSE.
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To confirm a relationship between the pharyngeal response and bolus volume, and examine whether increasing the fluid bolus volume can improve penetration and aspiration for stroke dysphagic patients.
Ten stroke patients with a delayed pharyngeal response problem confirmed by a videofluoroscopic swallowing study (VFSS) were enrolled. Each subject completed two swallows each of 2 mL, 5 mL, and 10 mL of barium liquid thinned with water. The pharyngeal delay time (PDT) and penetration-aspiration scale (PAS) were measured and the changes among the different volumes were analyzed.
PDTs were shortened significantly when 5 mL and 10 mL of thin barium were swallowed compared to 2 mL. However, there was no significant difference in PAS as the bolus volume increased.
The increased fluid bolus volume reduced the pharyngeal delay time, but did not affect the penetration and aspiration status.
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To evaluate the normal thickness of the thyrohyoid muscle, which is one of the key muscles related to swallowing, by ultrasonography.
The thickness of the left and right thyrohyoid muscles was measured in normal male and female adults ranging in age from 20 to 79 years by ultrasonography. The groups were classified according to age as follows: subjects ranging in age from 20 to 39 years were classified into group A, subjects ranging in age from 40 to 59 years were classified into group B, and subjects ranging in age from 60 to 79 years were classified into group C. The measurement level was the line that joins the upper tip of the superior thyroid notch and the oblique line of the thyroid cartilage. Also, a correlation with the thyrohyoid muscle was investigated by collecting information regarding height, weight, body mass index (BMI), age, and gender of subjects in the healthy group.
The number of subjects in each group was as follows: group A (n=82), group B (n=62), and group C (n=60). Also, the thicknesses of the left and right muscles were 2.72±0.65 mm and 2.87±0.76 mm in group A, 2.83±0.61 mm and 2.93±0.67 mm in group B, and 2.59±054 mm and 2.73±0.55 mm in group C, respectively. Thyrohyoid muscle had a correlation with height, weight, and BMI. The thickness of the left and right thyrohyoid muscles was greater in male subjects than in female subjects and the right side muscle was thicker than the left side muscle.
The average thickness of the left and right thyrohyoid muscles was 3.20±0.54 mm in male subjects and 2.34±0.37 mm in female subjects. The thickness of the thyrohyoid muscle was positively correlated with height, weight, and BMI, and the thyrohyoid muscle was thicker in male subjects than in female subjects and the right side muscle was thicker than the left side muscle.
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To determine the supratentorial area associated with poststroke dysphagia, we assessed the diffusion tensor images (DTI) in subacute stroke patients with supratentorial lesions.
We included 31 patients with a first episode of infarction in the middle cerebral artery territory. Each subject underwent brain DTI as well as a videofluoroscopic swallowing study (VFSS) and patients divided were into the dysphagia and non-dysphagia groups. Clinical dysphagia scale (CDS) scores were compared between the two groups. The corticospinal tract volume (TV), fractional anisotropy (FA) and apparent diffusion coefficient (ADC) values were calculated for 11 regions of interest in the supratentorial area—primary motor cortex, primary somatosensory cortex, supplementary motor cortex, anterior cingulate cortex, orbitofrontal cortex, parieto-occipital cortex, insular cortex, posterior limb of the internal capsule, thalamus, and basal ganglia (putamen and caudate nucleus). DTI parameters were compared between the two groups.
Among the 31 subjects, 17 were diagnosed with dysphagia by VFSS. Mean TVs were similar across the two groups. Significant inter-group differences were observed in two DTI values: the FA value in the contra-lesional primary motor cortex and the ADC value in the bilateral posterior limbs of the internal capsule (all p<0.05).
The FA value in the primary motor cortex on the contra-lesional side and the ADC value in the bilateral PLIC can be associated with dysphagia in middle cerebral artery stroke.
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To investigate the effect of laryngopharyngeal neuromuscular electrical stimulation (NMES) on dysphonia in patients with dysphagia caused by stroke or traumatic brain injury (TBI).
Eighteen patients participated in this study. The subjects were divided into NMES (n=12) and conventional swallowing training only (CST, n=6) groups. The NMES group received NMES combined with CST for 2 weeks, followed by CST without NMES for the next 2 weeks. The CST group received only CST for 4 weeks. All of the patients were evaluated before and at 2 and 4 weeks into the study. The outcome measurements included perceptual, acoustic and aerodynamic analyses. The correlation between dysphonia and swallowing function was also investigated.
There were significant differences in the GRBAS (grade, roughness, breathiness, asthenia and strain scale) total score and sound pressure level (SPL) between the two groups over time. The NMES relative to the CST group showed significant improvements in total GRBAS score and SPL at 2 weeks, though no inter-group differences were evident at 4 weeks. The improvement of the total GRBAS scores at 2 weeks was positively correlated with the improved pharyngeal phase scores on the functional dysphagia scale at 2 weeks.
The results demonstrate that laryngopharyngeal NMES in post-stroke or TBI patients with dysphonia can have promising effects on phonation. Therefore, laryngopharyngeal NMES may be considered as an additional treatment option for dysphonia accompanied by dysphagia after stroke or TBI.
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To assess the impact of aging on masticatory muscle function according to changes in hardness of solid food.
Each of fifteen healthy elderly and young people were selected. Subjects were asked to consume cooked rice, which was processed using the guidelines of the Universal Design Foods concept for elderly people (Japan Care Food Conference 2012). The properties of each cooked rice were categorized as grade 1, 2, 3 and 4 (5×103, 2×104, 5×104, and 5×105 N/m2) respectively. Surface electromyography (sEMG) was used to measure masseter activity from food ingestion to swallowing of test foods. The raw data was normalized by the ratio of sEMG activity to maximal voluntary contraction and compared among subjects. The data was divided according to each sequence of mastication and then calculated within the parameters of EMG activities.
Intraoral tongue pressure was significantly higher in the young than in the elderly (p<0.05). Maximal value of average amplitude of the sequence in whole mastication showed significant positive correlation with hardness of food in both young and elderly groups (p<0.05). In a comparisons between groups, the maximal value of average amplitude of the sequence in whole mastication and peak amplitude in whole mastication showed that mastication in the elderly requires a higher percentage of maximal muscle activity than in the young, even with soft foods (p<0.05).
sEMG data of the masseter can provide valuable information to aid in the selection of foods according to hardness for the elderly. The results also support the necessity of specialized food preparation or products for the elderly.
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To compare the swallowing characteristics of dysphagic patients with traumatic brain injury (TBI) with those of dysphagic stroke patients.
Forty-one patients with TBI were selected from medical records (between December 2004 to March 2013) and matched to patients with stroke (n=41) based on age, sex, and disease duration. Patients' swallowing characteristics were analyzed retrospectively using a videofluoroscopic swallowing study (VFSS) and compared between both groups. Following thorough review of medical records, patients who had a history of diseases that could affect swallowing function at the time of the study were excluded. Dysphagia characteristics and severity were evaluated using the American Speech-Language-Hearing Association National Outcome Measurement System swallowing scale, clinical dysphagia scale, and the videofluoroscopic dysphagia scale.
There was a significant difference in radiological lesion location (p=0.024) between the two groups. The most common VFSS finding was aspiration or penetration, followed by decreased laryngeal elevation and reduced epiglottis inversion. Swallowing function, VFSS findings, or quantified dysphagia severity showed no significant differences between the groups. In a subgroup analysis of TBI patients, the incidence of tube feeding was higher in patients with surgical intervention than in those without (p=0.011).
The swallowing characteristics of dysphagic patients after TBI were comparable to those of dysphagic stroke patients. Common VFSS findings comprised aspiration or penetration, decreased laryngeal elevation, and reduced epiglottis inversion. Patients who underwent surgical intervention after TBI were at high risk of tube feeding requirement.
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Association Between Active Gait Training for Severely Disabled Patients with Nasogastric Tube Feeding or Gastrostoma and Recovery of Oral Feeding: A Retrospective Cohort Study
To investigate the usefulness of ultrasonographic measurement of hyoid bone movement during swallowing.
Fifty-two patients who had swallowing dysfunction were enrolled in this study. When a patient swallowed 5 mL of water while maintaining an upright sitting position, hyoid bone movement during swallowing was measured with ultrasonography. Recorded images were analyzed to measure the maximum change in hyoid bone displacement. Mandible was used as reference point to calculate hyoid bone displacement. The farthest distance from resting position and the nearest distance during swallowing were measured and their differences were recorded. Participants also underwent videofluoroscopic swallowing study (VFSS). Based on penetration-aspiration scale (PAS), they were grouped to non-aspirators (PAS 1), penetrators (PAS 2–5), or aspirators (PAS 6–8). Measured hyoid bone displacements by submental ultrasonography were compared among groups.
The mean hyoid bone displacement in non-aspirators group (n=21, 15.9±2.7 mm) was significantly (p<0.05) greater than that in penetrators group (n=20, 11.5±2.8 mm) or aspirators group (n=11, 8.0±1.0 mm). Hyoid bone displacement below 13.5 mm as a cutoff point for detecting penetration or aspiration had a sensitivity and specificity of 83.9% and 81.0%, respectively.
Submental ultrasonographic evaluation was well correlated with PAS measured by VFSS. Therefore, submental ultrasonographic evaluation could be a useful screening tool for dysphagic patients.
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To investigate the final diagnosis of patients with unexplained dysphagia and the clinical and laboratory findings supporting the diagnosis.
We retrospectively analyzed 143 patients with dysphagia of unclear etiology who underwent a videofluoroscopic swallowing study (VFSS). The medical records were reviewed, and patients with a previous history of diseases that could affect swallowing were categorized into a missed group. The remaining patients were divided into an abnormal or normal VFSS group based on the VFSS findings. The clinical course and final diagnosis of each patient were examined.
Among the 143 patients, 62 (43%) had a previous history of diseases that could affect swallowing. Of the remaining 81 patients, 58 (72.5%) had normal VFSS findings and 23 (27.5%) had abnormal VFSS findings. A clear cause of dysphagia was not identified in 9 of the 23 patients. In patients in whom a cause was determined, myopathy was the most common cause (n=6), followed by laryngeal neuropathy (n=4) and drug-induced dysphagia (n=3). The mean ages of the patients in the normal and abnormal VFSS groups differed significantly (62.52±15.00 vs. 76.83±10.24 years, respectively; p<0.001 by Student t-test).
Careful history taking and physical examination are the most important approaches for evaluating patients with unexplained swallowing difficulty. Even if VFSS findings are normal in the pharyngeal phase, some patients may need additional examinations. Electrodiagnostic studies and laboratory tests should be considered for patients with abnormal VFSS findings.
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Many reports of changes in cervical alignment after posterior occipitocervical (O-C) fusion causing dysphagia are available. The clinical course can range from mild discomfort to severe aspiration. However, the underlying pathogenesis is not well known. We report an 80-year-old female with videofluoroscopic swallowing study evidence of aspiration that developed after occiput-C3/4 posterior fusion. Pharyngeal pressure was analyzed using high resolution manometry (HRM). Impaired upper esophageal sphincter opening along with diminished peristalsis and pharyngeal pressure gradient were revealed by HRM to be the main characteristics in such patients. The patient fully recovered after a revision operation for cervical angle correction. Distinct pressure patterns behind reversible dysphagia caused by a change in cervical alignment were confirmed using HRM analysis.
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To develop a quantitative and organ-specific practical test for the diagnosis and treatment of dysphagia based on assessment of stroke patients.
An initial test composed of 24 items was designed to evaluate the function of the organs involved in swallowing. The grading system of the initial test was based on the analysis of 50 normal adults. The initial test was performed in 52 stroke patients with clinical symptoms of dysphagia. Aspiration was measured via a videofluoroscopic swallowing study (VFSS). The odds ratio was obtained to evaluate the correlation between each item in the initial test and the VFSS. A polychotomous linear logistic model was used to select the final test items.
Eighteen of 24 initial items were selected as significant for the final tests. These 18 showed high initial validity and reliability. The Spearman correlation coefficient for the total score of the test and functional dysphagia scale was 0.96 (p<0.001), indicating a statistically significant positive correlation.
This study was carried out to design a quantitative and organ-specific test that assesses the causes of dysphagia in stroke patients; therefore, this test is considered very useful and highly applicable to the diagnosis and treatment of dysphagia.
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To identify the associations between the duration of endotracheal intubation and developing post-extubational supraglottic and infraglottic aspiration (PEA) and subsequent aspiration pneumonia.
This was a retrospective observational study from January 2009 to November 2014 of all adult patients who had non-neurologic critical illness, required endotracheal intubation and were referred for videofluoroscopic swallowing study. Demographic information, intensive care unit (ICU) admission diagnosis, severity of critical illness, duration of endotracheal intubation, length of stay in ICU, presence of PEA and severity of dysphagia were reviewed.
Seventy-four patients were enrolled and their PEA frequency was 59%. Patients with PEA had significantly longer endotracheal intubation durations than did those without (median [interquartile range]: 15 [9-21] vs. 10 [6-15] days; p=0.02). In multivariate logistic regression analysis, the endotracheal intubation duration was significantly associated with PEA (odds ratio, 1.09; 95% confidence interval [CI], 1.01-1.18; p=0.04). Spearman correlation analysis of intubation duration and dysphagia severity showed a positive linear association (r=0.282, p=0.02). The areas under the receiver operating characteristic curves (AUCs) of endotracheal intubation duration for developing PEA and aspiration pneumonia were 0.665 (95% CI, 0.542-0.788; p=0.02) and 0.727 (95% CI, 0.614-0.840; p=0.001), respectively.
In non-neurologic critically ill patients, the duration of endotracheal intubation was independently associated with PEA development. Additionally, the duration was positively correlated with dysphagia severity and may be helpful for identifying patients who require a swallowing evaluation after extubation.
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To identify the differences in the movement of the hyoid bone and the vocal cord with and without electrical stimulation in normal subjects.
Two-dimensional motion analysis using a videofluoroscopic swallowing study with and without electrical stimulation was performed. Surface electrical stimulation was applied during swallowing using electrodes placed at three different locations on each subject. All subjects were analyzed three times using the following electrode placements: with one pair of electrodes on the suprahyoid muscles and a second pair on the infrahyoid muscles (SI); with placement of the electrode pairs on only the infrahyoid muscles (IO); and with the electrode pairs placed vertically on the suprahyoid and infrahyoid muscles (SIV).
The main outcomes of this study demonstrated an initial downward displacement as well as different movements of the hyoid bone with the three electrode placements used for electrical stimulation. The initial positions of the hyoid bone with the SI and IO placements resulted in an inferior and anterior displaced position. During swallowing, the hyoid bone moved in a more superior and less anterior direction, resulting in almost the same peak position compared with no electrical stimulation.
These results demonstrate that electrical stimulation caused an initial depression of the hyoid bone, which had nearly the same peak position during swallowing. Electrical stimulation during swallowing was not dependent on the position of the electrode on the neck, such as on the infrahyoid or on both the suprahyoid and infrahyoid muscles.
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To evaluate the effects of the videofluoroscopic swallowing study (VFSS) timing after the nasogastric tube (NGT) removal on swallowing function of the patients with dysphagia.
This study was conducted on 40 NGT-fed patients with dysphagia. To assess the patients' swallowing function, VFSS was performed twice using a 5-mL 35% diluted barium solution. For the initial examination, VFSS was performed immediately after the NGT removal (VFSS 1). For the second examination, VFSS was performed five hours after the NGT removal (VFSS 2). We used the functional dysphagia scale (FDS) to assess swallowing function. In the FDS, a significant difference in the four items in the oral phase, seven items in the pharyngeal phase, and total scores were assessed (p<0.05). We also used modified penetration-aspiration scale (mPAS) to compare the two examinations (p<0.05).
A paired t-test was performed to confirm the statistical significance of the two examinations (p<0.05). The overall swallowing function was assessed as better in VFSS 2 than in VFSS 1. In the FDS, significant differences in the residue in valleculae (p=0.002), the residue in pyriform sinuses (p=0.001), the coating of pharyngeal wall after swallow (p=0.001), and the total scores (p<0.001) were found between the two examinations. Also, in the mPAS that assessed the degree of penetration-aspiration, a significant difference was found between the two examinations (p<0.001).
The results of this study confirmed that the timing of the VFSS after the NGT removal affects the swallowing function. Thus, to accurately assess the swallowing function, VFSS must be performed in NGT-fed patients after they have rested for a certain period following the removal of their NGT.
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