Gray and White Matter Correlates of Dysphagia in Progressive Supranuclear Palsy

BACKGROUND

Dysphagia is a common symptom of progressive supranuclear palsy often leading to aspiration pneumonia and death.

OBJECTIVE

The aim of this study was to examine how impairments of the oral and pharyngeal phases of the swallow and airway incursion during liquid swallows relate to gray and white matter integrity.

METHODS

Thirty-eight participants with progressive supranuclear palsy underwent videofluorographic swallowing assessment and structural and diffusion tensor head magnetic resonance imaging. Penalized linear regression models assessed relationships between swallowing metrics and regional gray matter volumes and white matter fractional anisotropy and mean diffusivity.

RESULTS

Oral phase impairments were associated with reduced superior parietal volumes and abnormal diffusivity in parietal and sensorimotor white matter, posterior limb of the internal capsule, and superior longitudinal fasciculus. Pharyngeal phase impairments were associated with disruption to medial frontal lobe, corticospinal tract, and cerebral peduncle. No regions were predictive of airway incursion.

CONCLUSIONS

Differential patterns of neuroanatomical impairment corresponded to oral and pharyngeal phase swallowing impairments. © 2021 International Parkinson and Movement Disorder Society.

The effect of time on the automated detection of the pharyngeal phase in videofluoroscopic swallowing studies

Convolutional Neural Networks (CNNs) have recently been proposed to automatically detect the pharyngeal phase in videofluoroscopic swallowing studies (VFSS). However, there is a lack of consensus regarding the best algorithmic strategy to adopt for segmenting this important yet rapid phase of the swallow. Moreover, additional information is needed to understand how small the detection error should be, in view of translating this approach for use in clinical practice. In this manuscript we compare multiple CNN-based algorithms for detecting the pharyngeal phase in VFSS bolus-level clips, specifically looking at 2DCNN and 3DCNN approaches with different temporal windows as input. Our results showed that a 2DCNN analysis on 3-frame windows outperformed both frame-by-frame approaches and 3DCNNs. We also demonstrated that the detection accuracy of the pharyngeal phase is very close to the clinical gold standard (i.e., trained clinical raters). These results demonstrate the feasibility of deep learning-based algorithms for developing intelligent approaches to automatically support clinicians in the analysis of VFSS data.Clinical relevance- Accurate and reliable segmentation of the pharyngeal phase will support clinicians by reducing the time needed for rating VFSS data. Moreover, automatic detection of this phase can be seen as a foundation for building novel and intelligent approaches to detect clinical features of interest in VFSS, such as the presence of penetration-aspiration.

Association Between Objective Ratings of Swallowing and Dysphagia-Specific Quality of Life in Patients Receiving (Chemo)radiotherapy for Oropharyngeal Cancer

The pervasive nature of dysphagia in the head/neck cancer (HNC) population necessitates a comprehensive evaluation approach, including both objective assessment of dysphagia, and subjective patient-reported functional measures. However, the congruence between clinician-rated and patient-perceived function is still not well understood. The current study investigated the association between objective clinician-rated swallow physiology (using the MBSImP) and patient-reported measures of swallowing-related quality of life (using the MDADI) in a secondary analysis of patients with oropharyngeal HNC treated with (chemo)radiotherapy. Seventy-nine patients with oropharyngeal HNC receiving (chemo)radiotherapy completed a standardised videofluoroscopic swallow study (VFSS) rated using the MBSImP, and the MDADI, at pre-treatment (baseline), 6 weeks and 3 months post-treatment as per a previous prospective RCT. Data on n = 67 participants were analysed as part of the secondary analysis. Association between MBSImP oral and pharyngeal composite scores versus MDADI Global and subscale scores was examined using ordinary least squares regression and mixed-effects general linear modelling (GLM). Univariable analyses demonstrated significant associations between MBSImP oral composite scores and each of the MDADI subscales, as well as the MBSImP pharyngeal composite scores and all MDADI subscales. GLM analysis revealed significant associations were maintained between MBSImP pharyngeal scores and the MDADI global and emotional subscale scores at the multivariable level, with the physical subscale trending towards significance. No significant association was observed between the MBSImP oral composite scores and any of the MDADI subscales at the multivariable level. This study found significant associations between objective measures of pharyngeal swallow physiology and patient-perceived swallowing-related quality of life. These findings suggest a higher degree of concordance between clinician-rated and patient-reported measures up to 3 months post-(C)RT than previously reported.

Training for videofluoroscopic swallowing analysis: A systematic review

PURPOSE

To synthesise the available evidence relating to best practice in training videofluoroscopy and barium swallow analysts.

METHOD

The review was conducted according to the PRISMA statement and registered in PROSPERO (CRD42017053744). Data were extracted from nine databases. Studies were included if they described training approaches for clinicians or students of any profession learning to interpret videofluoroscopic (VFSS) or barium swallow studies and were written in English. The methods were heterogeneous and a metanalysis was not possible; a narrative review is presented.

RESULT

Sixteen studies were eligible, including those designed to evaluate the influence of training as well as those that described training as part of validating an assessment tool or method. The quality of the studies was assessed with the Hawker scale and assigned an NHMRC rating. While the evidence was low quality (NHMRC level IV), training consistently improved the accuracy and reliability of clinicians and students conducting VFSS. No studies reported the outcome of training for barium swallow analysis. There was significant variability in the dose, method, and setting of training.

CONCLUSION

To elucidate best practice in VFSS analysis to ensure training is cost effective and results in accurate diagnosticians requires further research.

[Dysphagia and Aspiration Pneumonia Caused by Kommerell's Diverticulum and the Vascular Ring Associated with Right-sided Aortic Arch:Report of a Case]

We report a case of an 80-year-old man complaining of dysphagia followed by aspiration pneumonia. Computed tomography of the chest revealed Kommerell's diverticulum associated with the right-sided aortic arch and the vascular ring which was formed by the aortic arch, the left subclavian artery, the ductus arteriosus, and the pulmonary artery around the esophagus and the trachea. Enlargement of the diverticulum was considered to be the cause of dysphagia. The surgery was performed at 20 ℃ under deep hypothermic circulatory arrest. We performed resection of the Kommerell's diverticulum, reconstruction of the left subclavian artery, and transection of the ductus arteriosus to relieve the compression by the esophagus and the trachea. The postoperative course was uneventful and dysphagia disappeared.

Risk of aspiration pneumonia in paediatric patients with dysphagia who were found to have laryngeal penetration on the instrumental swallow evaluation: a systematic review protocol

INTRODUCTION

Dysphagia affects several children in USA and around the globe. Videofluoroscopic Swallow Study (VFSS) and Fiberoptic Endoscopic Evaluation of Swallowing (FEES) are the most objective studies to define swallowing function. The presence of tracheal aspiration during VFSS or FEES in children with dysphagia is associated with an increased risk of aspiration pneumonia. However, the association of laryngeal penetration with aspiration pneumonia remains unclear. This systematic review aims to assess the risk of aspiration pneumonia in children with dysphagia with laryngeal penetration on VFSS/FEES and compare it with children with tracheal aspiration and children with neither tracheal aspiration nor laryngeal penetration.

METHODS AND ANALYSIS

This study will be a systematic review and meta-analysis. Systematic electronic searches will be conducted on PubMed, EMBASE, Web of Science, CINHAL, Scopus, Cochrane CENTRAL, LILACS and WHO Global Index Medicus. We will include studies published through 6 October 2021. Primary outcome will be the incidence of aspiration pneumonia. Secondary outcomes will be incidence of hospitalisation, paediatric intensive care unit admission, enteral tube requirement, growth, symptoms improvement and mortality. The Cochrane Risk of Bias In Non-Randomised Studies of Interventions tool will be used to assess the risk of bias. Meta-analysis will be used to pool the studies. We will pool dichotomous outcomes to obtain an odd ratio (OR) and report with 95% CI. Continuous outcomes will be pooled to obtain mean difference and reported with 95% CI. Overall grade of evidence will be assessed using Grading of Recommendations Assessment, Development and Evaluation (GRADE) criteria, and findings will be presented in a summary of findings table.

ETHICS AND DISSEMINATION

This study is a systematic review without contact with patients. Therefore, IRB approval is not required. Authors consent to publishing this review. Data will be kept for review by editors and peer reviewers. Data will be available to general public on request.

PROSPERO REGISTRATION NUMBER

CRD42020222145.

Adaptation and Validation of the Dynamic Imaging Grade of Swallowing Toxicity for Flexible Endoscopic Evaluation of Swallowing: DIGEST-FEES

Purpose While flexible endoscopic evaluation of swallowing (FEES) is a common clinical procedure used in the head and neck cancer (HNC) population, extant outcome measures for FEES such as bolus-level penetration-aspiration and residue scores are not well suited as global patient-level endpoint measures of dysphagia severity in cooperative group trials or clinical outcomes research. The Dynamic Imaging Grade of Swallowing Toxicity (DIGEST) was initially developed and validated for use during videofluoroscopic evaluations as a way to grade safety, efficiency, and overall pharyngeal swallowing impairment. The purpose of this study was to adapt and validate DIGEST for use with FEES. Method A modified Delphi exercise was conducted for content validation, expert consensus, adaptation, and operationalization of DIGEST-FEES. Three blinded, expert raters then evaluated 100 de-identified post-HNC treatment FEES examinations. Intra- and interrater reliability were tested with quadratic weighted kappa. Criterion validity against the MD Anderson Dysphagia Inventory, Functional Oral Intake Scale, Secretion Severity Scale, and Yale Residue Rating Scale was assessed with Spearman correlation coefficients. Results Interrater reliability was almost perfect for overall DIGEST-FEES grade (κ_w = 0.83) and safety grade (κ_w = 0.86) and substantial for efficiency grade (κ_w = 0.74). Intrarater reliability was excellent for all raters (0.9-0.91). Overall DIGEST-FEES grade correlated with MD Anderson Dysphagia Inventory (r = -.43, p < .0001), Functional Oral Intake Scale (r = -.43, p < .0001), Secretion Severity Scale (r = .47, p < .0001), Yale Vallecular Residue (r = .73, p < .0001), and Yale Pyriform Sinus Residue (r = .65, p < .0001). Conclusion DIGEST-FEES is a valid and reliable scale to describe the severity of pharyngeal dysphagia in patients with HNC. Supplemental Material https://doi.org/10.23641/asha.14642787.

Objective measurement of acoustic intensity of coughing for clearance of penetration and aspiration on video-fluoroscopy

PURPOSE

This preliminary, exploratory study evaluated the acoustic intensity of effective and ineffective clearance of penetrated and aspirated material from the laryngeal vestibule in patients with dysphagia.

METHOD

A lapel microphone was attached anterior to participants' tragus and recorded coughing in decibels during their videofluoroscopic swallowing studies (VFSS).

RESULT

Eighty-eight patients were recruited. Thirteen patients, with visible airway invasion and coughing were included in the final analysis. No coughs were effective at expelling aspirated material from the airway (n = 10). Both effective (4/7) and ineffective (3/7) coughing to penetration were recorded. The mean acoustic intensity of effective coughing to penetration was -44.0 dBFS (decibel level relative to full scale) [SD = 7.3, 95% CI = -51.14, -36.86], and ineffective coughing to penetration was only marginally lower at -42.9 dBFS [SD = 2.0, 95% CI = -45.21, -40.59].

CONCLUSION

No coughs were effective at expelling aspirated material from the airway. Some coughs effectively expelled penetrated material from the airway. However, the relationship between acoustic intensity and cough effectiveness is unclear due to the limited number of observations. Given that perceptual evaluation of coughing is widely used in dysphagia clinical practice to determine cough effectiveness, this is an important area for future research.

Ultrasound: an emerging modality for the dysphagia assessment toolkit?

PURPOSE OF REVIEW

Videofluoroscopy (VFSS) and fibreoptic endoscopic evaluation of swallowing (FEES) are established instrumental techniques to support differential diagnosis and treatment of oropharyngeal dysphagia. Whilst their value is undisputed, each tool is not without limitations. The COVID-19 pandemic has restricted access to VFSS and FEES leading clinicians to explore alternative or augmentative tools to support swallowing assessment.Ultrasound (US) is an established tool for visualisation of head and neck anatomy, including structures implicated in swallowing. Although US has been utilised in swallowing research for many years, its application has not translated into common clinical practice. This review presents and debates the evidence for and against use of US for clinical swallowing assessment.

RECENT FINDINGS

Evaluation of swallowing muscle morphometry and measurement of isolated swallowing kinematics are two primary uses of US in swallowing assessment that have been identified in the literature. Use of US to detect bolus flow, aspiration and residues is in its early stages and needs further research.

SUMMARY

US shows promise as an adjunctive modality to support assessment of swallowing. With standardisation, these measurements may have potential for transition into clinical care. Reliability and validity testing and development of normative data are imperative to ensure its use as an evidence-based instrumentation.

Detecting Aspiration During FEES with Narrow Band Imaging in a Clinical Setting

The use of narrow band imaging (NBI) during flexible endoscopic evaluation of swallowing (FEES) is recognised as an emerging technology to improve the contrast of the test fluid during endoscopic dysphagia evaluation. This study tested the hypothesis that the use of NBI in FEES would improve the detection of laryngeal penetration and aspiration in patients with unilateral vocal fold paralysis/paresis (UVFP), a typically difficult population in which to detect the presence of aspiration with FEES. Twenty-one consecutive outpatients with UVFP were evaluated with FEES using white light (WL) and NBI under 150 test conditions (75 WL & 75 NBI). Three speech pathologists, highly experienced in FEES using WL but novices to using NBI, rated laryngeal penetration and aspiration for green dyed thin fluid (5 ml and 90 ml) and mildly thick fluid (5 ml) milk, and were compared to two raters more experienced in using NBI during FEES. Laryngeal penetration and aspiration were significantly higher for larger volumes (90 ml) (p < 0.05). With NBI-naïve raters, there was a trend towards lower intra-rater and inter-rater reliability compared to WL on all bolus trials reaching significance on mildly thick fluid (p < 0.01). There was lower rater confidence when using NBI compared to WL in NBI-naïve raters to detect aspiration (p < 0.01). Sensitivity was lower regardless of NBI experience; 80.77-84.21% with WL compared to 46.15-50.00% with NBI. Findings indicate that the improved contrast of a dyed opaque milk trial under WL may negate the potential benefits of using NBI to increase the contrast of the test fluid and supports the use of an opaque test fluid such as milk. NBI may also not be as useful to clinicians with no experience with the altered light condition, and can result in lower sensitivity in even the experienced user.

Quantifying Bolus Residue and Its Risks in Children: A Videofluoroscopic Study

Purpose Postswallow residue is a clinical sign of swallow impairment and has shown a strong association with aspiration. Videofluoroscopy (videofluoroscopic study of swallowing [VFSS]) is commonly used to visualize oropharyngeal swallowing and to identify pharyngeal residue. However, subjective binary observation (present or absent) fails to provide important information on volume or location and lacks objectivity and reproducibility. Reliable judgment of changes in residue over time and with treatment is therefore challenging. We aimed to (a) determine the reliability of quantifying pharyngeal residue in children using the bolus clearance ratio (BCR), (b) determine associations between BCR and other timing and displacement measures of oropharyngeal swallowing, and (c) explore the association between BCR and penetration-aspiration in children. Method In this single-center retrospective observational study, we obtained a set of quantitative and descriptive VFSS measures from 553 children (0-21 years old) using a standard protocol. VFSS data were recorded at 30 frames per second for quantitative analysis using specialized software. Results Good interrater (ICC = .86, 95% CI [.74, .961], p < .001) and excellent intrarater reliability was achieved for BCR (ICC = .97, 95% CI [.91, 1.000], p = 001). Significant correlations between BCR and pharyngeal constriction ratio and total pharyngeal transit time were reported (p < .05). Using binomial logistic regression modeling, we found BCR was predictive of penetration-aspiration in children, χ²(13) = 58.093, p < .001, 64.9%. Children with BCR of ≥ 0.1 were 4 times more likely to aspirate. Conclusion BCR is a reliable, clinically useful measure to quantify postswallow residue in children, which can be used to identify and treat children with swallow impairments, as well as to measure outcomes of intervention.

Detection of poststroke oropharyngeal dysphagia with swallowing screening by ultrasonography

There are currently no standard evaluation tools for poststroke neurogenic oropharyngeal dysphagia. We previously suggested calculating the relative movements of the hyoid bone and larynx by ultrasonography to evaluate swallowing movement. Swallowing movement is altered in neurogenic oropharyngeal dysphagia. Therefore, the present study aimed to verify whether an ultrasonographic evaluation of swallowing movement facilitates the detection of neurogenic oropharyngeal dysphagia. Eighteen healthy male elderly participants (the healthy group) and 18 male stroke patients diagnosed with neurogenic oropharyngeal dysphagia (the dysphagia group) were enrolled. Participants swallowed 5 mL of liquid and water with an adjusted viscosity and the movements of the hyoid bone and larynx were visualized by ultrasonography. The results obtained revealed significant differences in laryngeal duration (static phase), laryngeal displacement (elevation phase), and the hyoid bone–laryngeal motion ratio (HL motion ratio) between the two groups. A multiple regression analysis was performed to adjust for confounding factors, and laryngeal duration (static phase) and the HL motion ratios were identified as factors affecting dysphagia. In the receiver operation characteristic curve of the two variations, the area under the curve for laryngeal duration (static phase) was 0.744 and the cut-off was 0.26 sec with 72.2% sensitivity and 88.9% specificity; the area under the curve for the HL motion ratio was 0.951 and the cut-off was 0.56 with 88.9% sensitivity and 88.9% specificity. Therefore, the objective evaluation of hyoid bone and larynx movements during swallowing by ultrasonography facilitated the detection of neurogenic oropharyngeal dysphagia.

Dysphagia in the elderly population: A Videofluoroscopic study

OBJECTIVE

To examine the impact of age and underlying comorbid conditions on swallowing in elderly patients with dysphagia.

METHODS

Charts of consecutive patients aged >64 studied by Videofluoroscopic swallowing study (VFSS) between 2010 and 2018 at our institution were reviewed (n = 731). Patients were categorized based on age into young old (aged 65-74), older old (aged 75-84) and oldest old (aged 85+). The underlying comorbidities and VFSS results were compared between different age groups.

RESULTS

Dysphagia was more likely to be caused by presbyphagia (p < 0.01) and dementia (p < 0.0001) in the oldest old, whereas, head and neck cancers (p < 0.0001) were more common in the young old cohort. In the absence of organic disease (e.g. cancer, stroke, dementia), aging was associated with prolonged oral transit time (OTT) (p < 0.05) and aspiration after swallow (p < 0.05). Compared to those with presbyphagia, patients with organic disease were more likely to have delayed pharyngeal swallow response (p < 0.05) and aspiration during swallow (p < 0.005).

CONCLUSION

There are significant differences in the etiology of dysphagia between different age cohorts amongst the dysphagic elderly population. In addition, organic diseases affect swallowing differently than does mere aging. The rate of prolonged OTT and post-swallow aspiration increase with aging in patients with presbyphagia, likely due to age-related sarcopenia of the swallowing muscles. Whereas, those with organic diseases have a higher rate of delayed pharyngeal swallow response and aspiration during swallow, likely due to sensorineural impairment. Thus, it is important to view the elderly as a heterogeneous group when evaluating patients with dysphagia.

Dysphagia Megalatriensis: An Uncommon Cause of Dysphagia

Dysphagia megalatriensis is a rarely reported entity of cardiovascular dysphagia. Affected patients present with dysphagia to solid foods and regurgitation secondary to esophageal compression from an enlarged left atrium (LA). Here we report a case of a 68-year-old man with long standing atrial fibrillation who presented with chest pressure, bloating and dysphagia to solids. Esophagogastroduodenoscopy revealed a large area of extrinsic compression of the middle third of the esophagus that varied with cardiac contractions. Computerized tomography of the chest did not reveal any masses and transthoracic echocardiogram showed moderate LA enlargement. Based on those findings, a diagnosis of cardiac dysphagia was made. While severe LA enlargement is usually reported in cardiac dysphagia, our patient developed symptoms with moderate LA enlargement. Surgical intervention, dietary modifications, treatment of the underlying cause of LA enlargement and enteric tube feeding are available treatment options for cardiovascular dysphagia.

Quantitative imaging of tongue kinematics during infant feeding and adult swallowing reveals highly conserved patterns

Tongue motility is an essential physiological component of human feeding from infancy through adulthood. At present, it is a challenge to distinguish among the many pathologies of swallowing due to the absence of quantitative tools. We objectively quantified tongue kinematics from ultrasound imaging during infant and adult feeding. The functional advantage of this method is presented in several subjects with swallowing difficulties. We demonstrated for the first time the differences in tongue kinematics during breast- and bottle-feeding, showing the arrhythmic sucking pattern during bottle-feeding as compared with breastfeeding in the same infant with torticollis. The method clearly displayed the improvement of tongue motility after frenotomy in infants with either tongue-tie or restrictive labial frenulum. The analysis also revealed the absence of posterior tongue peristalsis required for safe swallowing in an infant with dysphagia. We also analyzed for the first time the tongue kinematics in an adult during water bolus swallowing demonstrating tongue peristaltic-like movements in both anterior and posterior segments. First, the anterior segment undulates to close off the oral cavity and the posterior segment held the bolus, and then, the posterior tongue propelled the bolus to the pharynx. The present methodology of quantitative imaging revealed highly conserved patterns of tongue kinematics that can differentiate between swallowing pathologies and evaluate treatment interventions. The method is novel and objective and has the potential to advance knowledge about the normal swallowing and management of feeding disorders.

Hyoid kinematic features for poor swallowing prognosis in patients with post-stroke dysphagia

Identification of prognostic factors for swallowing recovery in patients with post-stroke dysphagia is crucial for determining therapeutic strategies. We aimed at exploring hyoid kinematic features of poor swallowing prognosis in patients with post-stroke dysphagia. Of 122 patients who experienced dysphagia following ischemic stroke, 18 with poor prognosis, and 18 age- and sex-matched patients with good prognosis were selected and retrospectively reviewed. Positional data of the hyoid bone during swallowing were obtained from the initial videofluoroscopic swallowing study after stroke onset. Normalized hyoid profiles of displacement/velocity and direction angle were analyzed using functional regression analysis, and maximal or mean values were compared between the good and poor prognosis patient groups. Kinematic analysis showed that maximal horizontal displacement (P = 0.031) and velocity (P = 0.034) in forward hyoid motions were significantly reduced in patients with poor prognosis compared to those with good prognosis. Mean direction angle for the initial swallowing phase was significantly lower in patients with poor prognosis than in those with good prognosis (P = 0.0498). Our study revealed that reduced horizontal forward and altered initial backward motions of the hyoid bone during swallowing can be novel kinematic features indicating poor swallowing prognosis in patients with post-stroke dysphagia.

An Octogenarian with Progressive Dysphagia

We report a rare case of dysphagia characterized by extrinsic mechanical compression of the esophagus secondary to the highly tortuous anatomical variation in the descending thoracic aorta.

Self-reported Dysphagia and Pharyngeal Volume Following Whiplash Injury

Difficulty swallowing has been reported following whiplash injury; however, the reasons remain poorly understood. A possible factor may be the observed changes in pharyngeal volume. The current exploratory study was designed to examine the prevalence of self-reported dysphagia after whiplash and the relationship with recovery status and change in pharyngeal volume. Data were available from a longitudinal study of adults with whiplash. Data included magnetic resonance imaging (MRI) of the cervical spine, the Dysphagia Handicap Index (DHI), and Neck Disability Index (NDI) collected over four timepoints (< 1 week, 2 weeks, 3 months, and 12 months post-injury). Initial cross-sectional analysis examined 60 patients with DHI data from at least one timepoint. A second, longitudinal analysis was conducted on 31 participants with MRI, NDI, and DHI data at both early (< 1-2 weeks) and late (3-12 months) timepoints. The pharynx was contoured on axial T2-weighted MRI slices using OsiriX image processing software and pharyngeal volume (mm³) was quantified. In the 60-patient cohort, prevalence of self-reported dysphagia (DHI ≥ 3) was observed in 50% of participants at least once in 12 months (M = 4.9, SD 8.16, range 0-40). In the longitudinal cohort (n = 31), mean total DHI significantly (p = 0.006) increased between early and late stages. There was no relationship (p = 1.0) between dysphagia and recovery status, per the NDI% score. Pharyngeal volume remained stable and there was no relationship between dysphagia and pharyngeal volume change (p = 1.0). This exploratory study supports the need for further work to understand the nature of dysphagia, extent of functional compromise, and the underlying pathophysiology post-whiplash.

The Mass of Geniohyoid Muscle Is Associated with Maximum Tongue Pressure and Tongue Area in Patients with Sarcopenic Dysphagia

OBJECTIVES

We investigated the associations about the mass of geniohyoid and tongue muscle and the maximum tongue pressure in patients with sarcopenic dysphagia using ultrasonography.

DESIGN

Cross sectional study.

SETTING

5 hospitals including 3 acute and 2 rehabilitation hospitals and 1 older facility.

PARTICIPANTS

36 inpatients with sarcopenic dysphagia.

MEASUREMENTS

Ultrasonography was performed for geniohyoid muscle and tongue. The area for geniohyoid and tongue muscles in sagittal plane and the mean brightness level (0-255) in the muscle area were calculated. Maximum tongue pressure as strength of swallowing muscle were investigated. Partial correlation coefficient and multiple regression analysis adjusting for age and sex were performed.

RESULTS

The mean age was 81.1 ± 7.9. Men were 23. The mean BMI was 19.0 ± 4.1. The mean maximum tongue pressure was 21.3 ± 9.3 kPa. The mean cross sectional area for geniohyoid muscles was 140 ± 47 mm2. The mean brightness for geniohyoid muscle was 18.6 ± 9.0. The mean cross sectional area for tongue muscles was 1664.1 ± 386.0 mm2. The mean brightness for tongue muscles was 34.1 ± 10.6. There was a significant positive correlation between area of geniohyoid muscle and maximum tongue pressure (r = 0.38, p = 0.04). Geniohyoid muscle area was an explanatory factor for maximum tongue pressure (p = 0.012) and tongue muscle area (p = 0.031) in multivariate analysis.

CONCLUSIONS

Geniohyoid muscle mass was an independent explanatory factor for maximum tongue pressure and tongue muscle mass.

Risk factors for aspiration pneumonia in patients with dysphagia undergoing videofluoroscopic swallowing studies: A retrospective cohort study

Prediction of aspiration pneumonia development in at-risk patients is vital for implementation of appropriate interventions to reduce morbidity and mortality. Unfortunately, studies utilizing a comprehensive approach to risk assessment are still lacking. The objective of this study was to analyze the clinical features and videofluoroscopic swallowing study (VFSS) findings that predict aspiration pneumonia in patients with suspected dysphagia.Medical records of 916 patients who underwent VFSS between September 2014 and June 2018 were retrospectively analyzed. Patients were divided into either a pneumonia group or a non-pneumonia group based on diagnosis of aspiration pneumonia. Clinical information and VFSS findings were evaluated.One hundred seven patients (11.7%) were classified as having pneumonia. Multivariate analysis indicated that aspiration during the 2- cubic centimeter thick-liquid trial of VFSS (odds ratio [OR] = 3.23, 95% confidence interval [CI]: 1.93-5.41), smoking history (OR = 2.63, 95% CI: 1.53-4.53), underweight status (OR = 2.27, 95% CI: 1.31-3.94), abnormal pharyngeal delay time (OR = 1.60, 95% CI: 1.01-2.53), and a Penetration-Aspiration Scale level of 8 (OR = 3.73, 95% CI: 2.11-6.59) were significantly associated with aspiration pneumonia development. Integrated together, these factors were used to develop a predictive model for development of aspiration pneumonia (DAP), with a sensitivity of 82%, specificity of 56%, and an area under the receiver operating characteristic curve of 0.73.The best predictors for DAP included videofluoroscopic findings of aspiration during a 2-cubic centimeter thick-liquid trial, prolonged pharyngeal delay time, a Penetration-Aspiration Scale level of 8, history of smoking, and underweight status. These 5 proposed determinants and the associated DAP score are relatively simple to assess and may constitute a clinical screening tool that can readily identify and improve the management of patients at risk for aspiration pneumonia.

Quantitative Videofluoroscopic Analysis of Swallowing Physiology and Function in Individuals With Chronic Obstructive Pulmonary Disease

Purpose Dysphagia is a serious extra pulmonary manifestation of chronic obstructive pulmonary disease (COPD). However, the nature of abnormalities in swallowing physiology in COPD has yet to be clearly established. We explored the frequency of swallowing measures outside the healthy reference range in adults with COPD. Method Participants were 28 adults aged 41-79 years (18 men, 20 women) with stable COPD. Disease severity was classified as GOLD (Global Initiative For Chronic Obstructive Lung Disease) Stages 1 (4%), 2 (25%), 3 (53%), and 4 (18%). Participants underwent a videofluoroscopy and swallowed 20% w/v thin barium in, followed by 20% w/v mildly, moderately, and extremely thick barium prepared with a xanthan gum thickener. Blinded duplicate ratings of swallowing safety, efficiency, kinematics, and timing were performed according to the ASPEKT method (Analysis of Swallowing Physiology: Events, Kinematics and Timing). Comparison data for healthy adults aged < 60 years were extracted from an existing data set. Chi-square and Fisher's exact tests compared the frequencies of measures falling < 1 SD/ > 1 SD from mean reference values (or < the first or > the third quartile for skewed parameters). Results Participants with COPD did not display greater frequencies of penetration-aspiration, but they were significantly more likely (p < .05) to display incomplete laryngeal vestibule closure (LVC), longer time-to-LVC, and shorter LVC duration. They also displayed significantly higher frequencies of short upper esophageal sphincter opening, reduced pharyngeal constriction, and pharyngeal residue. Conclusion This analysis reveals differences in swallowing physiology in patients with stable COPD characterized by impaired safety related to the mechanism, timing, and duration of LVC and by impaired swallowing efficiency with increased pharyngeal residue related to poor pharyngeal constriction.

Relationship between tongue muscle quality and swallowing speed in community-dwelling older women

OBJECTIVE

The aim of this study was to investigate the relationship between tongue muscle quality index, which was represented as tongue muscle pressure divided by tongue muscle mass, and swallowing speed in community-dwelling older women.

METHODS

The inclusion criteria for this cross-sectional study were that participants be community-dwelling older women aged 65 years and above without dysphagia. The exclusion criteria were stroke and Parkinson's disease that directly cause dysphagia. We measured tongue muscle thickness and maximum tongue pressure and the tongue muscle quality index, which was defined as the maximum tongue pressure divided by tongue muscle thickness. We investigated swallowing speed via a 100 ml water swallowing test. To assess the relationship between tongue muscle characteristics and swallowing speed, we performed stepwise multiple regression analysis.

RESULTS

Ninety-three participants were enrolled in this study (mean age: 84.2 ± 4.7 years). A stepwise multiple regression analysis showed that age (β = - 0.292, p < 0.01) and tongue muscle quality index (β = 0.267, p < 0.01) were related to swallowing speed.

CONCLUSION

We found that tongue muscle quality index was related to swallowing speed in community-dwelling older women. According to our findings, it is possible that the tongue muscle quality index is a useful parameter for assessing swallowing speed in older women without dysphagia.

Cricopharyngeal bar on videofluoroscopy: high specificity for inclusion body myositis

OBJECTIVE

To determine the prevalence and characteristics of the cricopharyngeal bar (CPB), defined as marked protrusion with lacking relaxation and stricture of the upper esophageal sphincter on videofluoroscopy, in patients with inclusion body myositis (IBM).

METHODS

We conducted a case-control study of comprehensive series of adult healthy individuals and consecutive patients with neuropsychiatric disorders aged over 45 (52 versus 2486). A standard videofluoroscopy was performed.

RESULTS

Overall, 47 individuals with CPB were identified. Of the individuals with CPB, 36% were IBM followed by neurodegenerative disorders, muscular disorders, neuromuscular disorders, and others (32%, 21%, 2.1%, and 8.5%, respectively), indicating the heterogeneity of the etiologies. Against muscular disorders, the sensitivity and specificity of the CPB for IBM were 33% (= 17/52; 95% confidence interval [CI], 20-45%) and 96% (= 264/274; 95% CI, 94-99%), respectively. IBM with CPB showed a higher frequency of obstruction-related dysphagia (88% versus 22%, p < 0.001) and severe CPB (76% versus 23%, p < 0.001) than the control with one. The ratio of the upper esophageal distance at the maximum distension at the level of C6 to that of C4 was lower in IBM with CPB than in the controls with one (0.50 versus 0.77, p < 0.001), which suggests the insufficient opening of the upper esophageal sphincter.

CONCLUSION

A CPB could be indicative of IBM. The upper esophagus in IBM with CPB became narrow, like a bottleneck. We provide new perspectives of dysphagia diagnosis by videofluoroscopy, especially for IBM-associated dysphagia, to expand the knowledge on the CPB.