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Kashima K, Watanabe K, Sato T, Katori Y. Analysis of Dysphagia and Cough Strength in Patients with Unilateral Vocal Fold Paralysis. Dysphagia 2023; 38:510-516. [PMID: 33728514 DOI: 10.1007/s00455-021-10274-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2019] [Accepted: 02/16/2021] [Indexed: 11/26/2022]
Abstract
The association between swallowing function and cough strength in patients with unilateral vocal fold paralysis (UVFP) is unknown. We evaluated the relationship between voluntary cough strength and dysphagia among patients with UVFP (UVFP group) by comparing their data with that of corresponding healthy participants (healthy control [HC] group) in a prospective observational study. From February 1st, 2018 to March 30th, 2019, we recruited patients with a voice disorder due to UVFP, who were referred to our university hospital. Patients with a history of laryngeal surgery, vagal nerve paralysis, or cardiac and respiratory failure were excluded. Descriptive and clinical data regarding swallowing, voice, and cough peak flow (CPF) were collected as a measure of cough strength. The UVFP group comprised six women and seven men (median age, 68.0 years), and the HC group comprised six women and eight men (median age 65.5 years). The groups differed significantly in the Eating Assessment Tool (EAT)-10 scores and CPF rates (P < 0.001). Among patients with UVFP, 84.6% had an abnormal EAT-10 score of ≥ 3. Additionally, 16.7% of the patients exhibited liquid aspiration with contrast medium on a videofluorographic swallowing study (VFSS). There was no correlation between the CPF values, EAT-10 scores, or the VFSS results. Therefore, patients with severe UVFP, whose condition had been fixed, had difficulties when swallowing (85% of cases), and some even presented with aspiration on VFSS (20% of cases), while receiving a regular diet.
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Affiliation(s)
- Kazutaka Kashima
- Department of Otolaryngology, Head and Neck Surgery, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai, 980-8574, Japan.
| | - Kenichi Watanabe
- Department of Otolaryngology, Head and Neck Surgery, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai, 980-8574, Japan
| | - Takeshi Sato
- Department of Otolaryngology, Head and Neck Surgery, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai, 980-8574, Japan
| | - Yukio Katori
- Department of Otolaryngology, Head and Neck Surgery, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai, 980-8574, Japan
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2
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Watanabe K, Kashima K, Sato T, Machida T, Fukudo S, Katori Y. Impact on swallowing functions of arytenoid adduction in patients with unilateral vocal fold paralysis. Auris Nasus Larynx 2023; 50:102-109. [PMID: 35691778 DOI: 10.1016/j.anl.2022.05.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Revised: 05/08/2022] [Accepted: 05/31/2022] [Indexed: 01/28/2023]
Abstract
OBJECTIVE Although the pathophysiology of swallowing dysfunction in patients with unilateral vocal fold paralysis (UVFP) remains uncertain, glottal insufficiency is known to be a possible major cause, and other factors due to vagus nerve or recurrent laryngeal nerve damage may contribute to dysphagia or aspiration. This study aimed to evaluate the effect of arytenoid adduction (AA) surgery on the swallowing functions of UVFP patients and to investigate the important role of glottic closure during swallowing. METHODS We prospectively analyzed the data of thirteen patients with UVFP who underwent AA in combination with medialization laryngoplasty (ML) for improving voice quality. The subjects received a series of examinations for not only voice function but also swallowing function and cough strength both preoperatively and approximately 6 months after surgery. The evaluations of voice function included the Voice Handicap Index and aerodynamic measures; the evaluations of swallowing function included the Eating Assessment Tool-10, liquid aspiration, a videofluorographic examination of swallowing study, and high-resolution manometry; and the evaluation of cough strength included the measurement of cough peak flow. All measurements before and after surgery were statistically compared and examined. RESULTS Considerable improvements in voice measures were observed after the procedure, as sufficient glottic closure was achieved during phonation and swallowing. In terms of swallowing evaluation, there were significant differences in the subjective assessment methods after the operation. Additionally, our intervention improved two cases of aspiration according to abnormal findings on the videofluorographic examination of swallowing. There was a significant difference in cough peak flow, with all participants having better values after surgery. High-resolution manometry revealed no significant differences between pre- and postsurgery in any parameters at the level of the mesopharynx or upper esophageal sphincter. CONCLUSION The findings of our study suggest an important effect on the dysphagia of UVFP patients who undergo AA combined with ML. In addition, we revealed improvements in swallowing by strengthening incomplete glottic closure; thus, we consider that sufficient glottic closure must play an important role in swallowing function in patients with UVFP.
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Affiliation(s)
- Kenichi Watanabe
- Department of Otolaryngology, Head and Neck Surgery, Tohoku University Graduate School of Medicine, Sendai, Japan.; Department of Otolaryngology, Tohoku Rosai Hospital, Sendai, Japan..
| | - Kazutaka Kashima
- Department of Otolaryngology, Head and Neck Surgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Takeshi Sato
- Department of Otolaryngology, Head and Neck Surgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Tomomi Machida
- Department of Psychosomatic Medicine, Tohoku University Hospital, Sendai, Japan.; Department of Psychosomatic Medicine, Tohoku Rosai Hospital, Sendai, Japan
| | - Shin Fukudo
- Department of Psychosomatic Medicine, Tohoku University Hospital, Sendai, Japan.; Department of Behavioral Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Yukio Katori
- Department of Otolaryngology, Head and Neck Surgery, Tohoku University Graduate School of Medicine, Sendai, Japan
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Jo S, Yeo MS, Shin YK, Shin KH, Kim SH, Kim HR, Kim SJ, Cho SR. Therapeutic Singing as a Swallowing Intervention in Head and Neck Cancer Patients With Dysphagia. Integr Cancer Ther 2021; 20:15347354211065040. [PMID: 34903088 PMCID: PMC8679067 DOI: 10.1177/15347354211065040] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Background: Head and neck cancer patients often suffer from dysphagia after surgery and
radiotherapy. A singing-enhanced swallowing protocol was established to
improve their swallowing function. This study aimed to evaluate the
beneficial effects of therapeutic singing on dysphagia in head and neck
cancer (HNC) patients. Methods: Patients who participated in this study were allocated to the intervention
group (15 patients) and the control group (13 patients). Patients assigned
to the intervention group received therapeutic singing 3 times per week for
4 weeks. Each group was divided into 2 subgroups, including the oral cavity
cancer group and the pharyngeal cancer group. The patients’ vocal functions
were evaluated in maximum phonation time, pitch, intensity, jitter, shimmer,
harmonics to noise ratio, and laryngeal diadochokinesis (L-DDK). To evaluate
swallowing function, videofluoroscopic swallowing study was done, and the
results were analyzed by videofluoroscopic dysphagia scale (VDS) and dynamic
imaging grade of swallowing toxicity (DIGEST). Results: Among the voice parameters, L-DDK of the intervention group significantly
increased compared to that of the control group. Swallowing functions of the
intervention group were significantly improved in VDS and DIGEST after the
intervention. Detailed items of VDS and DIGEST showed improvements
especially in the pharyngeal phase score of VDS, such as laryngeal
elevation, pharyngeal transit time, and aspiration. In addition, the
pharyngeal cancer group showed significant improvements in VDS and DIGEST
scores after the intervention. Conclusions: Our outcomes highlight the beneficial effects of singing for HNC patients
with dysphagia. The notable improvements in the pharyngeal phase suggest
that therapeutic singing would be more appropriate for HNC patients who need
to improve their intrinsic muscle movements of vocal fold and laryngeal
elevation.
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Affiliation(s)
- Seongmoon Jo
- Department and Research Institute of Rehabilitation Medicine, Yonsei University College of Medicine, Seoul, Korea.,Brain Korea 21 PLUS Project for Medical Science, Yonsei University College of Medicine, Seoul, Korea
| | - Myung Sun Yeo
- Department of Music Therapy, Graduate School, Ewha Womans University, Seoul, Korea.,Music Therapy Education, Graduate School of Education, Ewha Womans University, Seoul, Korea
| | - Yoon-Kyum Shin
- Department and Research Institute of Rehabilitation Medicine, Yonsei University College of Medicine, Seoul, Korea.,Brain Korea 21 PLUS Project for Medical Science, Yonsei University College of Medicine, Seoul, Korea
| | - Ki Hun Shin
- Yonsei University College of Medicine, Seoul, Korea
| | - Se-Heon Kim
- Department of Otorhinolaryngology, Yonsei University College of Medicine, Seoul, Korea
| | - Hye Ryun Kim
- Division of Medical Oncology, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, Korea
| | - Soo Ji Kim
- Department of Music Therapy, Graduate School, Ewha Womans University, Seoul, Korea.,Music Therapy Education, Graduate School of Education, Ewha Womans University, Seoul, Korea
| | - Sung-Rae Cho
- Department and Research Institute of Rehabilitation Medicine, Yonsei University College of Medicine, Seoul, Korea.,Brain Korea 21 PLUS Project for Medical Science, Yonsei University College of Medicine, Seoul, Korea.,Rehabilitation Institute of Neuromuscular Disease, Yonsei University College of Medicine, Seoul, Korea
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4
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Stanley C, Paddle P, Griffiths S, Safdar A, Phyland D. Detecting Aspiration During FEES with Narrow Band Imaging in a Clinical Setting. Dysphagia 2021; 37:591-600. [PMID: 33937938 DOI: 10.1007/s00455-021-10309-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Accepted: 04/20/2021] [Indexed: 12/29/2022]
Abstract
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.
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Affiliation(s)
- Claire Stanley
- Department of Otolaryngology; Head & Neck Surgery, Monash Health, Melbourne, Australia.
- Speech Pathology Department, Monash Health, Melbourne, Australia.
| | - Paul Paddle
- Department of Otolaryngology; Head & Neck Surgery, Monash Health, Melbourne, Australia
- Department of Surgery, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Australia
| | - Susie Griffiths
- Department of Otolaryngology; Head & Neck Surgery, Monash Health, Melbourne, Australia
| | - Adnan Safdar
- Department of Otolaryngology; Head & Neck Surgery, Monash Health, Melbourne, Australia
- Department of Surgery, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Australia
| | - Debra Phyland
- Department of Otolaryngology; Head & Neck Surgery, Monash Health, Melbourne, Australia
- Department of Surgery, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Australia
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5
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Neuromuscular Specializations of the Human Hypopharyngeal Muscles. Dysphagia 2020; 36:769-785. [PMID: 33159539 DOI: 10.1007/s00455-020-10212-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Accepted: 11/03/2020] [Indexed: 10/23/2022]
Abstract
The hypopharyngeal muscles in humans play a vital role in swallowing, speech, and respiration. Increasing evidence indicates that these muscles are specialized to perform life-sustaining upper aerodigestive functions. This review aims to provide current knowledge regarding the key structural, physiological, and biochemical features of the hypopharyngeal muscles, including innervation, contractile properties, histochemistry, biochemical properties, myosin heavy chain (MyHC) expression and regulation, and age-related alterations. These would clarify the unique neuromuscular specializations of the human hypopharyngeal muscles for a better understanding of the functions and pathological conditions of the pharynx and for the development of novel therapies to treat related upper airway disorders.
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6
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Ha JF. Unilateral vocal fold palsy & dysphagia: A review. Auris Nasus Larynx 2020; 47:315-334. [DOI: 10.1016/j.anl.2020.03.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2019] [Revised: 02/11/2020] [Accepted: 03/05/2020] [Indexed: 12/11/2022]
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7
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Pinna BR, Herbella FAM, de Biase N. Pharyngeal motility in patients submitted to type I thyroplasty. Braz J Otorhinolaryngol 2020; 87:538-544. [PMID: 31932212 PMCID: PMC9422657 DOI: 10.1016/j.bjorl.2019.11.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Revised: 10/09/2019] [Accepted: 11/22/2019] [Indexed: 11/28/2022] Open
Abstract
Introduction Type 1 thyroplasty is performed to improve glottis closure as well as dysphagic symptoms in patients with unilateral vocal fold immobility. Objectives This study aims to compare the motility of the pharynx and upper esophageal sphincter in patients with unilateral vocal fold immobility before and after thyroplasty Type I. Methods We prospectively studied 15 patients with unilateral vocal fold immobility who underwent thyroplasty Type I. Subjects were divided according to the topography of vagal injury and presence of dysphagia. High resolution manometry was performed before and 30 days after surgery. Time and pressure manometric parameters at the topography of the velopharynx, epiglottis and upper esophageal sphincter were recorded. Results Dysphagia was present in 67% of patients. 63% had lower vagal injuries. Manometric parameters did not change after thyroplasty for the whole population. The group of dysphagic patients, however, had an increase in residual pressure at the upper esophageal sphincter after thyroplasty (1.2 vs. 5.2 mmHg; p = 0.05). Patients with low vagal injury developed higher peak pressure (100 vs. 108.9 mmHg p ≤ 0.001), lower rise time (347 vs. 330 ms p = 0.04), and higher up stroke (260 vs. 266.2 mmHg/ms p = 0.04) at the topography of the velopharynx after thyroplasty. Conclusion Pharyngeal motility is affected by thyroplasty Type I in patients with dysphagia and low vagal injury.
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Affiliation(s)
- Bruno Rezende Pinna
- Universidade Federal de São Paulo, Escola Paulista de Medicina, Departamento de Otorrinolaringologia, São Paulo, SP, Brazil.
| | - Fernando A M Herbella
- Universidade Federal de São Paulo, Escola Paulista de Medicina, Departamento de Cirurgia, São Paulo, SP, Brazil
| | - Noemi de Biase
- Universidade Federal de São Paulo, Escola Paulista de Medicina, Departamento de Otorrinolaringologia, São Paulo, SP, Brazil; Pontifícia Universidade Católica de São Paulo, São Paulo, SP, Brazil
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8
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Mororó WC, Herbella FA, de Oliveira KVG, De Biase NG. Pharyngeal Motility Before and After Thyroarytenoid Muscle Botulinum Toxin Injection. Dysphagia 2019; 35:806-813. [PMID: 31863177 DOI: 10.1007/s00455-019-10086-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Accepted: 12/03/2019] [Indexed: 10/25/2022]
Abstract
Botulinum toxin type A (BTA) injection in intrinsic laryngeal musculature may result in dysphagia and consequent loss of quality of life (QOL) in a percentage of patients. This study aims to evaluate pharyngeal motility as a putative cause for this change in swallow quality in light of high-resolution manometry (HRM). Twenty patients (95% females, median age 66 years) underwent high-resolution manometry before and after BTA injection. Dysphagia was evaluated based on a QOL dedicated questionnaire (SWAL-QOL) before and after BTA injection. Pharyngeal motility at the topography of the vellum, epiglottis, and upper esophageal sphincter (UES) were recorded. Eleven (55%) subjects had worsened QOL after BTA injection. In patients with worsened QOL, UES extension decreased (p = 0.005), UES residual pressure increased (p = 0.02), UES basal pressure decreased (p = 0.04), and velopharynx contraction duration decreased (p = 0.04). UES residual pressure increased (p = 0.01), velopharynx peak pressure (p = 0.04) and upstroke (p = 0.007) decreased in patients with maintained QOL. There was no difference between groups when comparing pre-injection values. UES extension (p = 0.01) and UES maximum relaxation time (p = 0.03) was lower in the group with worsened QOL after BTA as compared to no change in QOL. Pharyngeal motility as measured by HRM was not a predictor for post procedure dysphagia and the changes in motility after BTA injection does not seem to be a strong contributor to dysphagia.
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Affiliation(s)
- Welber Chaves Mororó
- Department of Ear, Nose and Throat, Escola Paulista de Medicina, Federal University of Sao Paulo, Rua Pedro de Toledo 947, Sao Paulo, SP, 04038-002, Brazil.
| | - Fernando Augusto Herbella
- Department of Surgery, Escola Paulista de Medicina, Federal University of Sao Paulo, Rua Diogo de Faria 1087 cj 301, Sao Paulo, SP, 04037-003, Brazil
| | - Karine Valéria Gonçalves de Oliveira
- Department of Ear, Nose and Throat, Escola Paulista de Medicina, Federal University of Sao Paulo, Rua Pedro de Toledo 947, Sao Paulo, SP, 04038-002, Brazil
| | - Noemi Grigoletto De Biase
- Department of Ear, Nose and Throat, Escola Paulista de Medicina, Federal University of Sao Paulo, Rua Pedro de Toledo 947, Sao Paulo, SP, 04038-002, Brazil.,Pontifícia Universidade Católica de São Paulo, Rua Monte Alegre 984, Sao Paulo, SP, 05014-901, Brazil
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9
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Schiedermayer B, Kendall KA, Stevens M, Ou Z, Presson AP, Barkmeier-Kraemer JM. Prevalence, incidence, and characteristics of dysphagia in those with unilateral vocal fold paralysis. Laryngoscope 2019; 130:2397-2404. [PMID: 31763701 DOI: 10.1002/lary.28401] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2019] [Revised: 08/05/2019] [Accepted: 10/23/2019] [Indexed: 11/07/2022]
Abstract
OBJECTIVES/HYPOTHESIS The purpose of this study was to investigate the impact of dysphagia definition on the incidence and overall prevalence of dysphagia in patients with unilateral vocal fold paralysis (UVP) stratified by etiology. STUDY DESIGN Retrospective medical chart review. METHODS Data was collected from the records of individuals diagnosed with UVP from 2013 to 2018, including patient demographics, dysphagia questionnaire total scores, clinical evaluation dysphagia symptoms, and instrumental swallow assessment outcomes. The annual incidence and overall prevalence of dysphagia were calculated by etiology as counts and percentages across five operational definitions of dysphagia. RESULTS A total of 415 individuals met inclusion criteria for the study. Annual prevalence estimates ranged from 19% to 55%, depending on the definition of dysphagia used. The highest prevalence of dysphagia occurred when defined by symptoms or signs identified by the clinician (55%). The lowest prevalence of dysphagia occurred using a definition of abnormal swallowing function documented during instrumental assessment (19%). Dysphagia questionnaire scores were more frequently abnormal in those with iatrogenic than idiopathic etiology of UVP (adjusted P = 0.014). Rate of instrumental assessment and documentation of aspiration was highest for central UVP etiology (33%). On average, pneumonia was rare (6%) irrespective of UVP etiology. CONCLUSION Up to 55% of patients diagnosed with UVP complained of dysphagia, but only 21% had dysphagia symptoms severe enough to prompt instrumental assessment. Incidence and severity of dysphagia varied depending on UVP etiologic category as well as dysphagia definition. The etiology of UVP may impact dysphagia risk and severity in this population and warrants further investigation. LEVEL OF EVIDENCE IV Laryngoscope, 130:2397-2404, 2020.
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Affiliation(s)
- Benjamin Schiedermayer
- Department of Surgery, Division of Otolaryngology, University of Utah, Salt Lake City, Utah
| | - Katherine A Kendall
- Department of Surgery, Division of Otolaryngology, University of Utah, Salt Lake City, Utah
| | - Maya Stevens
- Department of Communication Sciences and Disorders, University of Utah, Salt Lake City, Utah
| | - Zhining Ou
- Department of Internal Medicine, Division of Epidemiology, University of Utah, Salt Lake City, Utah
| | - Angela P Presson
- Department of Internal Medicine, Division of Epidemiology, University of Utah, Salt Lake City, Utah
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10
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Haney MM, Hamad A, Woldu HG, Ciucci M, Nichols N, Bunyak F, Lever TE. Recurrent laryngeal nerve transection in mice results in translational upper airway dysfunction. J Comp Neurol 2019; 528:574-596. [PMID: 31512255 DOI: 10.1002/cne.24774] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2019] [Revised: 08/21/2019] [Accepted: 08/28/2019] [Indexed: 02/06/2023]
Abstract
The recurrent laryngeal nerve (RLN) is responsible for normal vocal-fold (VF) movement, and is at risk for iatrogenic injury during anterior neck surgical procedures in human patients. Injury, resulting in VF paralysis, may contribute to subsequent swallowing, voice, and respiratory dysfunction. Unfortunately, treatment for RLN injury does little to restore physiologic function of the VFs. Thus, we sought to create a mouse model with translational functional outcomes to further investigate RLN regeneration and potential therapeutic interventions. To do so, we performed ventral neck surgery in 21 C57BL/6J male mice, divided into two groups: Unilateral RLN Transection (n = 11) and Sham Injury (n = 10). Mice underwent behavioral assays to determine upper airway function at multiple time points prior to and following surgery. Transoral endoscopy, videofluoroscopy, ultrasonic vocalizations, and whole-body plethysmography were used to assess VF motion, swallow function, vocal function, and respiratory function, respectively. Affected outcome metrics, such as VF motion correlation, intervocalization interval, and peak inspiratory flow were identified to increase the translational potential of this model. Additionally, immunohistochemistry was used to investigate neuronal cell death in the nucleus ambiguus. Results revealed that RLN transection created ipsilateral VF paralysis that did not recover by 13 weeks postsurgery. Furthermore, there was evidence of significant vocal and respiratory dysfunction in the RLN transection group, but not the sham injury group. No significant differences in swallow function or neuronal cell death were found between the two groups. In conclusion, our mouse model of RLN injury provides several novel functional outcome measures to increase the translational potential of findings in preclinical animal studies. We will use this model and behavioral assays to assess various treatment options in future studies.
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Affiliation(s)
- Megan M Haney
- Department of Veterinary Pathobiology, University of Missouri, Columbia, Missouri
| | - Ali Hamad
- Department of Electrical Engineering and Computer Science, University of Missouri, Columbia, Missouri
| | - Henok G Woldu
- Department of Health Management & Informatics, University of Missouri, Columbia, Missouri
| | - Michelle Ciucci
- Department of Communication Sciences and Disorders, University of Wisconsin-Madison, Madison, Wisconsin.,Department of Surgery, Division of Otolaryngology, University of Wisconsin-Madison, Madison, Wisconsin
| | - Nicole Nichols
- Department of Biomedical Sciences, University of Missouri, Columbia, Missouri
| | - Filiz Bunyak
- Department of Electrical Engineering and Computer Science, University of Missouri, Columbia, Missouri
| | - Teresa E Lever
- Department of Biomedical Sciences, University of Missouri, Columbia, Missouri.,Department of Otolaryngology-Head and Neck Surgery, University of Missouri, Columbia, Missouri
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11
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Prevalence of Dysphagia in Patients With Non-neoplastic Vocal Fold Pathology. J Voice 2019; 33:708-711. [DOI: 10.1016/j.jvoice.2018.05.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2018] [Accepted: 05/16/2018] [Indexed: 12/22/2022]
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12
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Evaluation of upper oesophageal sphincter in unilateral vocal fold paralysis. The Journal of Laryngology & Otology 2019; 133:149-154. [PMID: 30706840 DOI: 10.1017/s0022215119000045] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
OBJECTIVE To evaluate dysphagia and manometric changes in the upper oesophageal sphincter in patients with unilateral vocal fold paralysis. METHODS Thirty patients with unilateral vocal fold paralysis due to vagal nerve paralysis scheduled for evaluation were enrolled in the study group; 24 healthy subjects were included in the control group. Upper oesophageal sphincter basal and residual pressure, relaxation time, and pharyngeal pressure values were evaluated by manometry. All patients completed the Turkish Eating Assessment Tool 10 questionnaire, the MD Anderson dysphagia questionnaire and the reflux symptom index form. RESULTS Swallowing assessment questionnaires and reflux symptom index results were significantly higher in the study group. Upper oesophageal sphincter basal and relaxation pressures were lower in the study group. Upper oesophageal sphincter relaxation time was shorter in the study group, but pressure values recorded from the pharynx were higher. CONCLUSION Upper oesophageal sphincter manometric pressure was lower in patients with unilateral vocal fold paralysis. A hypotonic sphincter likely contributes to dysphagia and aspiration.
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13
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Zhou D, Jafri M, Husain I. Identifying the Prevalence of Dysphagia among Patients Diagnosed with Unilateral Vocal Fold Immobility. Otolaryngol Head Neck Surg 2018; 160:955-964. [PMID: 30526299 DOI: 10.1177/0194599818815885] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
OBJECTIVE To identify dysphagia prevalence and characteristics among patients with unilateral vocal fold immobility (UVFI) through a systematic review of current literature. DATA SOURCES Embase, PubMed, ScienceDirect, Wiley Online Library. REVIEW METHODS Four electronic databases were reviewed according to the PRISMA criteria. Original English-language studies examining dysphagia among adult patients with UVFI met eligibility. Two researchers independently analyzed qualified articles. RESULTS Of 227 studies discovered through the literature search, 17 satisfied eligibility criteria. The prevalence of symptomatic dysphagia ranged from 55.6% to 69.0%, and the aspiration rate was 20.0% to 50.0%. Self-reporting and clinical evaluation were used to identify symptomatic dysphagia, while videofluoroscopic swallowing study and functional endoscopic evaluation of swallowing evaluated aspiration. Left-sided UVFI predominated. The most common causes of UVFI were iatrogenic and idiopathic. Central lesions and acute-onset UVFI were each associated with more severe dysphagia. Patients were more likely to aspirate on liquids versus purées and pastes. Benefits of medialization thyroplasty and vocal cord injection were equivocal. CONCLUSION A significant portion of patients with UVFI present with dysphagia due to anatomic and physiologic disruptions during the swallow. Study population heterogeneity and small sample sizes in the reviewed studies may have compromised reliability, calling for large-scale studies with rigorous methodology. Future studies should not only strive to identify the mechanics of the disordered swallow but also explore patients' quality of life and the effectiveness of current treatments for dysphagia with underlying UVFI.
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Affiliation(s)
- Dimin Zhou
- 1 Chicago Medical School, Rosalind Franklin University, North Chicago, Illinois, USA
| | - Mohsin Jafri
- 2 Northwestern University, Evanston, Illinois, USA
| | - Inna Husain
- 3 Department of Otorhinolaryngology-Head and Neck Surgery, Rush University Medical Center, Chicago, Illinois, USA
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Irace AL, Dombrowski ND, Kawai K, Dodrill P, Perez J, Hernandez K, Davidson K, Hseu A, Nuss R, Rahbar R. Aspiration in children with unilateral vocal fold paralysis. Laryngoscope 2018; 129:569-573. [DOI: 10.1002/lary.27410] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/04/2018] [Indexed: 11/09/2022]
Affiliation(s)
- Alexandria L. Irace
- Department of Otolaryngology and Communication Enhancement; Boston Children's Hospital; Boston Massachusetts
| | - Natasha D. Dombrowski
- Department of Otolaryngology and Communication Enhancement; Boston Children's Hospital; Boston Massachusetts
| | - Kosuke Kawai
- Department of Otolaryngology and Communication Enhancement; Boston Children's Hospital; Boston Massachusetts
- Department of Otolaryngology; Harvard Medical School; Boston Massachusetts U.S.A
| | - Pamela Dodrill
- Department of Otolaryngology and Communication Enhancement; Boston Children's Hospital; Boston Massachusetts
| | - Jennifer Perez
- Department of Otolaryngology and Communication Enhancement; Boston Children's Hospital; Boston Massachusetts
| | - Kayla Hernandez
- Department of Otolaryngology and Communication Enhancement; Boston Children's Hospital; Boston Massachusetts
| | - Kathryn Davidson
- Department of Otolaryngology and Communication Enhancement; Boston Children's Hospital; Boston Massachusetts
| | - Anne Hseu
- Department of Otolaryngology and Communication Enhancement; Boston Children's Hospital; Boston Massachusetts
- Department of Otolaryngology; Harvard Medical School; Boston Massachusetts U.S.A
| | - Roger Nuss
- Department of Otolaryngology; Harvard Medical School; Boston Massachusetts U.S.A
| | - Reza Rahbar
- Department of Otolaryngology and Communication Enhancement; Boston Children's Hospital; Boston Massachusetts
- Department of Otolaryngology; Harvard Medical School; Boston Massachusetts U.S.A
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15
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Best SR, Ahn J, Langmead S, Dhillon V, Hillel AT, Akst LM, Blakeley JO. Voice and Swallowing Dysfunction in Neurofibromatosis 2. Otolaryngol Head Neck Surg 2017; 158:505-510. [PMID: 29160153 DOI: 10.1177/0194599817741839] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Objective Neurofibromatosis 2 (NF2) is a neuro-oncologic condition that presents with bilateral vestibular schwannomas of the cerebellopontine angle (CPA). Voice and swallowing impairment can occur from direct involvement or compression of the vagus nerve or as the result of surgical excision of CPA tumors. The objectives in this study are to (1) assess the prevalence of voice and swallowing impairments and (2) analyze the effects of vagal dysfunction in patients with NF2. Study Design Cross-sectional. Setting Academic tertiary care center. Subjects and Methods Patients at a neurofibromatosis center were mailed Voice Handicap Index and Sydney Swallow Questionnaire surveys. Stroboscopic, voice, and swallowing evaluations were performed for patients who elected to participate in screening exams. Results There were high rates of self-assessed and objective voice and swallowing handicaps in this population. Fourteen of 40 (35%) patients had a self-assessed voice handicap, and 20 of 40 (50%) patients had a self-assessed swallow handicap. Vocal fold motion impairment (VFMI) was observed in 22 of 31 (71%) patients examined, with 27 of 62 (44%) possible vocal cords affected. Velopharyngeal insufficiency (45%) and piriform sinus pooling or residue (39%) were seen in a significant percentage of patients. There was a significant relationship between vocal cord motion impairment and CPA surgical intervention ipsilateral to the impairment ( P = .002). The presence of VFMI was strongly associated with voice ( P = .002) and swallowing ( P = .01) impact on quality of life. Conclusion Speech and swallowing impairments are highly prevalent in patients with NF2, cause significant impact on quality of life, and are most commonly related to surgical interventions in the CPA region.
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Affiliation(s)
- Simon R Best
- 1 Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Julie Ahn
- 1 Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Shannon Langmead
- 2 Department of Neurology, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Vaninder Dhillon
- 1 Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Alexander T Hillel
- 1 Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Lee M Akst
- 1 Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Jaishri O Blakeley
- 2 Department of Neurology, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
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16
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Pinna BR, Herbella FAM, de Biase N, Vaiano TCG, Patti MG. High-Resolution Manometry Evaluation of Pressures at the Pharyngo-upper Esophageal Area in Patients with Oropharyngeal Dysphagia Due to Vagal Paralysis. Dysphagia 2017; 32:657-662. [PMID: 28528491 DOI: 10.1007/s00455-017-9811-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2016] [Accepted: 05/11/2017] [Indexed: 01/08/2023]
Abstract
The motility of the pharynx, upper esophageal sphincter (UES), and proximal esophagus in patients with oropharyngeal dysphagia is still not entirely understood. High-resolution manometry (HRM) was recently added to the armamentarium for the study of this area. This study aims to describe HRM findings in patients with vagal paralysis. Sixteen patients (mean age 54 years, 69% females) with oropharyngeal dysphagia due to unilateral vagal paralysis were prospectively studied. All patients underwent HRM. Motility of the UES and at the topography of the velopharynx and epiglottis were recorded. (1) UES relaxation is compromised in a minority of patients, (2) epiglottis pressure does not follow a specific pattern, (3) vellum is hypotonic in half of the patients, (4) dysphagia is related to a low pharyngeal pressure, not to a flow obstruction at the level of the UES, and (5) aspiration is related to low pressures at the level of the UES and epiglottis and higher pressures at the level of the vellum. Pharyngeal motility is significantly impaired in patients with oropharyngeal dysphagia and unilateral vagal paralysis. In half of the cases, UES resting pressure is preserved due to unilateral innervation and relaxation is normal in most patients. Dysphagia therapy in these patients must be directed toward improvement in the oropharyngeal motility not at the UES.
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Affiliation(s)
- Bruno Rezende Pinna
- Department of Ear, Nose and Throat, Escola Paulista de Medicina, Federal University of Sao Paulo, Sao Paulo, Brazil
| | - Fernando A M Herbella
- Department of Surgery, Escola Paulista de Medicina, Federal University of Sao Paulo, Rua Diogo de Faria 1087 cj 301, Sao Paulo, SP, 04037-003, Brazil.
| | - Noemi de Biase
- Department of Ear, Nose and Throat, Escola Paulista de Medicina, Federal University of Sao Paulo, Sao Paulo, Brazil
| | - Thays C G Vaiano
- Speech-Language Pathology and Audiology Department, Escola Paulista de Medicina, Federal University of Sao Paulo, Sao Paulo, Brazil
| | - Marco G Patti
- Department of Surgery, University of North Carolina, Chapel Hill, NC, USA
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17
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Hsu J, Tibbetts KM, Wu D, Nassar M, Tan M. Swallowing function in pediatric patients with bilateral vocal fold immobility. Int J Pediatr Otorhinolaryngol 2017; 93:37-41. [PMID: 28109495 DOI: 10.1016/j.ijporl.2016.12.010] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2016] [Revised: 11/03/2016] [Accepted: 12/10/2016] [Indexed: 01/29/2023]
Abstract
INTRODUCTION Infants with bilateral vocal fold immobility (BVFI) often have poor swallow function in addition to potential airway compromise. While there are several reports on BVFI and its effect on patients' airway status, little is known about long term swallow function. OBJECTIVES We aim to characterize the swallowing function over time in pediatric patients with bilateral vocal fold immobility. METHODS A retrospective review of medical records of infants diagnosed with BVFI at a tertiary care children's hospital between 2005 and 2014 was conducted. Patient demographics, nature and etiology of immobility, laryngoscopy findings, comorbidities, and swallow outcomes at diagnosis and follow-up were recorded. Swallowing outcomes as measured by presence or absence of a gastrostomy tube were compared by etiology, vocal fold status, and normal or developmentally delay using the Fisher's exact test. RESULTS 110 patients with a diagnosis of vocal fold immobility were identified. Twenty-nine (26%) had BVFI and twenty-three had complete medical records. Etiologies of vocal fold immobility include cardiac related in 13% (3/23), idiopathic in 30% (7/23) prolonged intubation in 26% (6/23) central neurologic in 22% (5/23), trauma in 4% (1/23), and infection in 4% (1/23). Average follow-up time was 44 months (range 5-94 months). Ten patients (56.5%) required a gastrostomy tube at time of diagnosis. Of this cohort who received gastrostomy tubes, three (30%) ultimately transitioned to complete oral feeds. Return of vocal fold mobility did not correlate with swallow function. In those with non-neurologic etiologies, the need for gastrostomy tube at end of follow up was unlikely. There was a statistically significant difference in the percentage of gastrostomy tube-free children at most recent follow up in patients who were normally developed (86%) versus those who were developmentally delayed (33%) (p = 0.02). CONCLUSION We characterized the swallowing function of 23 pediatric patients with BVFI. Comorbidities are significant predictors of long term swallow function in patients with BVFI while return of vocal fold function is not.
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Affiliation(s)
- Jeffrey Hsu
- Montefiore Medical Center Albert Einstein College of Medicine, Department of Otorhinolaryngology, Bronx, NY, United States.
| | - Kathleen M Tibbetts
- Montefiore Medical Center Albert Einstein College of Medicine, Department of Otorhinolaryngology, Bronx, NY, United States
| | - Derek Wu
- Montefiore Medical Center Albert Einstein College of Medicine, Department of Otorhinolaryngology, Bronx, NY, United States
| | - Michel Nassar
- Montefiore Medical Center Albert Einstein College of Medicine, Department of Otorhinolaryngology, Bronx, NY, United States
| | - Melin Tan
- Montefiore Medical Center Albert Einstein College of Medicine, Department of Otorhinolaryngology, Bronx, NY, United States
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18
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Postdeglutitive residue in vagus nerve paralysis and its association with feeding style. Eur Arch Otorhinolaryngol 2016; 273:4369-4375. [DOI: 10.1007/s00405-016-4182-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2016] [Accepted: 06/25/2016] [Indexed: 10/21/2022]
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Abstract
Swallowing disorders (dysphagia) have been recognized by the WHO as a medical disability associated with increased morbidity, mortality and costs of care. With increasing survival rates and ageing of the population, swallowing disorders and their role in causing pulmonary and nutritional pathologies are becoming exceedingly important. Over the past two decades, the study of oropharyngeal dysphagia has been approached from various disciplines with considerable progress in understanding its pathophysiology. This Review describes the most frequent manifestations of oropharyngeal dysphagia and the clinical as well as instrumental techniques that are available to diagnose patients with dysphagia. However, the clinical value of these diagnostic tests and their sensitivity to predict outcomes is limited. Despite considerable clinical research efforts, conventional diagnostic methods for oropharyngeal dysphagia have limited proven accuracy in predicting aspiration and respiratory disease. We contend that incorporation of measurable objective assessments into clinical diagnosis is needed and might be key in developing novel therapeutic strategies.
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Affiliation(s)
- Nathalie Rommel
- KU Leuven, Department of Neurosciences, Experimental Otorhinolaryngology, B-3000 Leuven, Belgium
| | - Shaheen Hamdy
- Centre for Gastrointestinal Sciences, Institute of Inflammation and Repair, Faculty of Medical and Human Sciences, University of Manchester, Clinical Sciences Building, Salford Royal Hospital, Eccles Old Road, Salford M6 8HD, UK
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20
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Gould FDH, Ohlemacher J, Lammers AR, Gross A, Ballester A, Fraley L, German RZ. Central nervous system integration of sensorimotor signals in oral and pharyngeal structures: oropharyngeal kinematics response to recurrent laryngeal nerve lesion. J Appl Physiol (1985) 2015; 120:495-502. [PMID: 26679618 DOI: 10.1152/japplphysiol.00946.2015] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2015] [Accepted: 12/10/2015] [Indexed: 01/13/2023] Open
Abstract
Safe, efficient liquid feeding in infant mammals requires the central coordination of oropharyngeal structures innervated by multiple cranial and spinal nerves. The importance of laryngeal sensation and central sensorimotor integration in this system is poorly understood. Recurrent laryngeal nerve lesion (RLN) results in increased aspiration, though the mechanism for this is unclear. This study aimed to determine the effect of unilateral RLN lesion on the motor coordination of infant liquid feeding. We hypothesized that 1) RLN lesion results in modified swallow kinematics, 2) postlesion oropharyngeal kinematics of unsafe swallows differ from those of safe swallows, and 3) nonswallowing phases of the feeding cycle show changed kinematics postlesion. We implanted radio opaque markers in infant pigs and filmed them pre- and postlesion with high-speed videofluoroscopy. Markers locations were digitized, and swallows were assessed for airway protection. RLN lesion resulted in modified kinematics of the tongue relative to the epiglottis in safe swallows. In lesioned animals, safe swallow kinematics differed from unsafe swallows. Unsafe swallow postlesion kinematics resembled prelesion safe swallows. The movement of the tongue was reduced in oral transport postlesion. Between different regions of the tongue, response to lesion was similar, and relative timing within the tongue was unchanged. RLN lesion has a pervasive effect on infant feeding kinematics, related to the efficiency of airway protection. The timing of tongue and hyolaryngeal kinematics in swallows is a crucial locus for swallow disruption. Laryngeal sensation is essential for the central coordination in feeding of oropharyngeal structures receiving motor inputs from different cranial nerves.
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Affiliation(s)
- Francois D H Gould
- Department of Anatomy and Neurobiology, Northeast Ohio Medical University, Rootstown, and
| | - Jocelyn Ohlemacher
- Department of Anatomy and Neurobiology, Northeast Ohio Medical University, Rootstown, and
| | - Andrew R Lammers
- School of Health Sciences, Cleveland State University, Cleveland, Ohio
| | - Andrew Gross
- Department of Anatomy and Neurobiology, Northeast Ohio Medical University, Rootstown, and
| | - Ashley Ballester
- Department of Anatomy and Neurobiology, Northeast Ohio Medical University, Rootstown, and
| | - Luke Fraley
- Department of Anatomy and Neurobiology, Northeast Ohio Medical University, Rootstown, and
| | - Rebecca Z German
- Department of Anatomy and Neurobiology, Northeast Ohio Medical University, Rootstown, and
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21
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Abstract
The upper esophageal sphincter (UES) forms a barrier between the pharynx and the esophagus. When closed, the barrier function serves to prevent reflux and aerophagia; when open, swallowing, belching and vomiting are possible. The closing muscles include caudal parts of the inferior pharyngeal sphincter and cranial parts of the upper esophagus musculature. Sphincter opening is achieved by muscles that insert from the outside to connect to the larynx and pharynx in the sphincter region. The closing muscles are innervated by branches of the glossopharyngeal and vagal nerves, and central control is probably mediated by several reflexes. This article presents an overview of the current understanding of the complex UES anatomy.
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22
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Kupferman ME, Acevedo J, Hutcheson KA, Lewin JS. Addressing an unmet need in oncology patients: rehabilitation of upper aerodigestive tract function. Ann Oncol 2011; 22:2299-303. [PMID: 21321090 PMCID: PMC3968308 DOI: 10.1093/annonc/mdq733] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND Laryngeal dysfunction in the oncology population is common and may detract from quality of life (QoL) due to vocal restriction and aspiration. Therapies to address this complex issue have not been explored to date. We examined the outcomes among oncology patients treated with a minimally invasive office-based surgical approach for the rehabilitation of laryngeal dysfunction. PATIENTS AND METHODS A retrospective analysis was carried out of oncology patients referred for laryngeal dysfunction. Patients who underwent minimally invasive injection laryngoplasty (IL) were selected. Subjective outcome measures, objective voice analysis parameters, and swallowing studies were annotated. RESULTS Sixty-one patients underwent IL for the management of laryngeal dysfunction. Lung cancer was the most common cancer diagnosis (39.3%), and 52% of patients had thoracic malignancies. All patients had a self-reported improvement in vocal function with a single injection, and 55 patients (90%) reported lasting effects at 3 months. In patients with pre- and postoperative voice analysis, phonatory function increased from 5.0 to 10.5 s, more than twofold improvement compared with baseline functioning. Seventy-one percent of patients who aspirated before injection no longer required a modified diet. There were no major complications. CONCLUSIONS Interventions to improve the QoL in oncology patients continue to evolve. We report significant improvements in both subjective and objective measures of laryngeal function after IL for vocal fold dysfunction that are both immediate and sustained. We conclude that IL is a safe and efficacious procedure for the treatment of laryngeal dysfunction in oncology patients, resulting in palliation and improved QoL.
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Affiliation(s)
- M. E. Kupferman
- Department of Head and Neck Surgery, MD Anderson Cancer Center, Houston,Correspondence to: Dr M. E. Kupferman, Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, 1400 Pressler Street, Unit Number: 1445, Houston, TX 77030, USA. Tel: +1 713-794-1910; Fax: +1 713-794-4662; E-mail:
| | - J. Acevedo
- Department of Otolaryngology, Head and Neck Surgery, National Capitol Consortium, Washington
| | - K. A. Hutcheson
- Department of Speech Pathology, MD Anderson Cancer Center, Houston, USA
| | - J. S. Lewin
- Department of Otolaryngology, Head and Neck Surgery, National Capitol Consortium, Washington
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23
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Leder SB, Suiter DM, Duffey D, Judson BL. Vocal fold immobility and aspiration status: a direct replication study. Dysphagia 2011; 27:265-70. [PMID: 21858715 DOI: 10.1007/s00455-011-9362-0] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2011] [Accepted: 07/29/2011] [Indexed: 11/28/2022]
Abstract
The purpose of this direct replication study was to confirm the incidence of vocal fold immobility (VFI) and its relationship to pharyngeal dysphagia and aspiration. Using a single-group consecutively referred case series, a total of 2,650 participants underwent fiberoptic endoscopic evaluation of swallowing between August 2003 and December 2007. Main outcome measures included overall incidence of VFI and aspiration status, with specific emphasis on age, gender, etiology and pharyngeal phase bolus flow characteristics, and side of VFI (right, left, or bilateral). These data were compared to and then combined with the original study (n = 1,452) for a total of 4,102 participants. Results indicated that the incidence of VFI was 4.3% (112/2,650), i.e., 27% (31/112) unilateral right, 58% (65/112) unilateral left, and 14% (16/112) bilateral. Incidence of aspiration was 22% (580/2,650). Of those with VFI, 40% (45/112) aspirated, i.e., 42% (13/31) unilateral right, 37% (24/65) unilateral left, and 50% (8/16) bilateral. An individual with VFI had 2.50 times the odds of aspirating as someone without VFI (95% CI = 1.86-3.37). For liquid aspiration, the odds ratio (OR) = 2.41 (95% CI = 1.77-3.28), and for puree aspiration, OR = 2.08 (95% CI = 1.47-2.93). Left VFI occurred most frequently due to surgical trauma. Liquid was aspirated more often than a puree. Males exhibited VFI more often than females. Side of VFI and age were not factors that increased the incidence of aspiration significantly. It was confirmed that VFI is not an uncommon finding during dysphagia testing and, when present, increased the odds of aspiration compared to a population already being evaluated for dysphagia.
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Affiliation(s)
- Steven B Leder
- Department of Surgery, Section of Otolaryngology, Yale University School of Medicine, New Haven, CT 06520-8041, USA.
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24
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Analysis of video fluoroscopic swallowing study in patients with vocal cord paralysis. Dysphagia 2011; 27:185-90. [PMID: 21773847 DOI: 10.1007/s00455-011-9351-3] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2010] [Accepted: 06/22/2011] [Indexed: 10/18/2022]
Abstract
We reviewed the findings of a video fluoroscopic swallowing study (VFSS) of 28 patients with vocal cord paralysis (VCP) who complained of swallowing difficulties. VFSSs were performed with thick and thin liquid using modified Logemann methods. The patients were grouped according to whether their VCP was of central or peripheral origin, and the VFSS findings of the groups were compared. The patients showed oral phase dysfunction and pharyngeal dysfunction, especially when the cause was of central origin. Oral phase abnormalities were found in 13 patients and pharyngeal phase abnormalities were found in all patients, including penetration in 20 patients and aspiration in 14 patients. Improper lip closure (LC) and bolus formation (BF) and a delay in triggering pharyngeal swallow (TPS) and upper esophageal sphincter release (UESR) were significantly more frequent in patients with central VCP. With thin-liquid swallowing, pharyngeal transit time (PTT) and pharyngeal delay time (PDT) were significantly more prolonged in central VCP. The results suggest that the delay in triggering and poor coordination of swallowing were profound in patients with central VCP, but dysfunction in peripheral VCP may originate from poor pharyngeal movement.
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25
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Aneas GCG, Ricz HMA, Mello-Filho FV, Dantas RO. Swallowing Evaluation in Patients With Unilateral Vocal Fold Immobility. Gastroenterology Res 2010; 3:245-252. [PMID: 27942304 PMCID: PMC5139852 DOI: 10.4021/gr270w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/15/2010] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND Unilateral vocal fold immobility is the neurological disorder most frequently seen in the larynx that may cause swallowing dysfunction. The objective of this investigation was to evaluate the oral and pharyngeal phases of swallowing in patients with unilateral vocal fold immobility. METHODS It was evaluated by videofluoroscopy of the swallowing of 14 patients with unilateral vocal fold immobility and 11 control subjects. The examination was performed with swallows of 5 mL and 10 mL of liquid and paste boluses. The oral transit, pharyngeal transit and clearance, the duration of upper esophageal sphincter (UES) transit, the duration of the hyoid movement, and the timing of the events were measured. RESULTS With swallows of 10 mL of liquid bolus (controls: 0.23 ± 0.04s, patients: 0.27 ± 0.05s, p = 0.03) and 5 mL of paste bolus (controls: 0.18 ± 0.04s, patients: 0.22 ± 0.04s, p = 0.01) there was a longer duration of UES transit in patients compared with controls. The UES opened earlier in the control subjects with the increase in bolus volume from 5 mL to 10 mL (p < 0.05), an effect that was not seen in patients with vocal fold immobility. CONCLUSIONS We conclude that patients with unilateral vocal fold immobility may have alteration of bolus transit through the UES and have no adaptation in the swallowing timing related to the increase in bolus volume.
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Affiliation(s)
- Geruza Costa Gonzaga Aneas
- Department of Medicine, Medical School of Ribeirao Preto, University of Sao Paulo, Ribeirao Preto, SP, Brazil
| | - Hilton Marcos Alves Ricz
- Department of Ophthalmology, Otolaryngology / Head and Neck Surgery Medical School of Ribeirao Preto, University of Sao Paulo, Ribeirao Preto, SP, Brazil
| | - Francisco Verissimo Mello-Filho
- Department of Ophthalmology, Otolaryngology / Head and Neck Surgery Medical School of Ribeirao Preto, University of Sao Paulo, Ribeirao Preto, SP, Brazil
| | - Roberto Oliveira Dantas
- Department of Medicine, Medical School of Ribeirao Preto, University of Sao Paulo, Ribeirao Preto, SP, Brazil
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26
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Roe JWG, Leslie P, Drinnan MJ. Oropharyngeal dysphagia: the experience of patients with non-head and neck cancers receiving specialist palliative care. Palliat Med 2007; 21:567-74. [PMID: 17942494 DOI: 10.1177/0269216307082656] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Difficulty swallowing is a well-documented symptom in head and neck cancer and oesophageal malignancy. The frequency of oropharyngeal swallowing difficulties in the palliative phase of other malignancies is less reported. AIM 1) To describe the patient experience of swallowing and associated difficulties while receiving specialist palliative care for malignancies other than those affecting the head and neck and 2) to identify the quality of life issues for the participants with dysphagia and compare with normative and dysphagic data provided by SWAL-QOL. DESIGN Four month prospective pilot study - questionnaire design. SETTING Acute teaching hospital. PARTICIPANTS Eleven patients receiving specialist palliative care. METHODS Participants were interviewed using a modified version of the SWAL-QOL, a validated quality of life assessment tool for use specifically with people with oropharyngeal dysphagia. Eight quality of life domains were explored as well as fourteen dysphagic symptoms. RESULTS Seven of the 11 participants had dysphagic symptoms detailed in the SWAL-QOL and a further two patients reported transient dysphagic symptoms since diagnosis of their disease. Nine participants reported an impact on their quality of life and three reported a considerable impact in four or more domains. Eight of the 11 participants had self-selected softer textured foods. A notable group were three patients with lung cancer and one with lung metastases with a history of vocal fold motion impairment, all of who had experienced dysphagic symptoms since diagnosis. CONCLUSIONS Patients with cancers not affecting the head and neck are at risk of developing symptoms of oropharyngeal dysphagia and subsequently, compromized nutrition, hydration and quality of life. Areas for further research are suggested.
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Affiliation(s)
- Justin W G Roe
- Speech and Language Therapy Department, Head and Neck Centre, University College London Hospitals NHS Foundation Trust, London.
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27
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Leder SB, Bayar S, Sasaki CT, Salem RR. Fiberoptic Endoscopic Evaluation of Swallowing in Assessing Aspiration after Transhiatal Esophagectomy. J Am Coll Surg 2007; 205:581-5. [PMID: 17903733 DOI: 10.1016/j.jamcollsurg.2007.05.027] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2007] [Revised: 05/04/2007] [Accepted: 05/22/2007] [Indexed: 11/23/2022]
Abstract
BACKGROUND Pulmonary complications after transhiatal esophagectomy occur commonly and frequently cause severe morbidity and possible mortality. Aspiration, both overt and silent, can also be present with some regularity after this procedure, and it appears intuitive that identification of aspiration with the appropriate measures of avoidance of oral intake and avoidance of oral contrast studies may help reduce the consequences of aspiration pneumonia. STUDY DESIGN In an attempt to help identify patients at risk for aspiration, we prospectively studied 73 patients who had recently undergone transhiatal esophagectomy using fiberoptic endoscopic evaluation of swallowing (FEES). Evaluation of premature spillage, pharyngeal residue, pooling, penetration, and aspiration was carried out. RESULTS Twenty-one percent of patients showed evidence of aspiration and were kept npo, with deferral of oral contrast studies. Of all the potential predictors of aspiration studied, only vocal fold immobility was a notable predictor of aspiration. But 40% of patients who aspirated had normal vocal fold function. Vocal fold immobility was also identified in several patients thought to have completely normal voice quality. There were no complications of FEES. All patients who demonstrated aspiration and all those with vocal fold immobility eventually demonstrated swallowing without aspiration and recovery of cord function. CONCLUSIONS This study demonstrated the safety and efficacy of FEES in evaluation of laryngeal function in the postoperative setting after transhiatal esophagectomy. A FEES is recommended before the contrast study or oral feeding challenge for objective determination of aspiration risk from pharyngeal or laryngeal pathology. Early determination of aspiration status may reduce or eliminate pulmonary complications.
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Affiliation(s)
- Steven B Leder
- Department of Surgery, Section of Otolaryngology, Yale University School of Medicine, New Haven, CT 06520, USA
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28
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Abstract
This study prospectively investigated the incidence of vocal fold immobility, unilateral and bilateral, and its influence on aspiration status in a referred population of 1452 patients for a dysphagia evaluation from a large, urban, tertiary-care, teaching hospital. Main outcome measures included overall incidence of vocal fold immobility and aspiration status, with specific emphasis on age, etiology, and side of vocal fold immobility, i.e., right, left, or bilateral. Overall incidence of vocal fold immobility was 5.6% (81 of 1452 patients), including 47 males (mean age 55.7 yr) and 34 females (mean age 59.7 yr). In the subgroup of patients with vocal fold immobility, 31% (25 of 81) exhibited unilateral right, 60% (49 of 81) unilateral left, and 9% (7 of 81) bilateral impairment. Overall incidence of aspiration was found to be 29% (426 of 1452) of all patients referred for a swallow evaluation. Aspiration was observed in 44% (36 of 81) of patients presenting with vocal fold immobility, i.e., 44% (11 of 25) unilateral right, 43% (21 of 49) unilateral left, and 57% (4 of 7) bilateral vocal fold immobility. Left vocal fold immobility occurred most frequently due to surgical trauma. A liquid bolus was aspirated more often than a puree bolus. Side of vocal fold immobility and age were not factors that increased incidence of aspiration. In conclusion, vocal fold immobility, with an incidence of 5.6%, is not an uncommon finding in patients referred for a dysphagia evaluation in the acute-care setting, and vocal fold immobility, when present, was associated with a 15% increased incidence of aspiration when compared with a population already being evaluated for dysphagia.
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Affiliation(s)
- Steven B Leder
- Department of Surgery, Section of Otolaryngology, Yale University School of Medicine, New Haven, Connecticut 06520-8041, USA.
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Tabaee A, Murry T, Zschommler A, Desloge RB. Flexible endoscopic evaluation of swallowing with sensory testing in patients with unilateral vocal fold immobility: incidence and pathophysiology of aspiration. Laryngoscope 2005; 115:565-9. [PMID: 15805859 DOI: 10.1097/01.mlg.0000161358.20450.12] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES/HYPOTHESIS The objective was to examine the incidence and pathophysiology of aspiration in patients with unilateral vocal fold immobility presenting with dysphagia. STUDY DESIGN Retrospective review of flexible endoscopic evaluation of swallowing with sensory testing (FEESST) data and medical records in two tertiary medical care centers. METHODS The data for all patients with unilateral vocal fold immobility who underwent FEESST between 2000 and 2003 were reviewed. RESULTS Eighty-one patients (45 male and 36 female patients) were included in the study. The mean age was 59 years. The most common causes or origins were iatrogenic (42%), malignancy (23%), and neurological (18%). The immobility was left-sided in 59% of patients. A majority of the patients exhibited laryngeal edema/erythema (90%), difficulty with secretions (60%), and decreased laryngopharyngeal sensation (83%). The laryngeal adductor reflex was absent in 34% of the patients. An aspiration rate of 35% was detected with thin liquids. Trials of purees revealed a 76% rate of pooling, 44% rate of spillage, 32% rate of penetration, 18% rate of aspiration, and 24% rate of regurgitation. Rates of penetration and aspiration with purees were significantly higher in patients who had decreased laryngopharyngeal sensation, absent pharyngeal squeeze, and absent laryngeal adductor reflex. CONCLUSION Dysphagia in patients with unilateral vocal fold immobility is demonstrated during FEESST by pooling, spillage, penetration, and aspiration. The pathophysiology of dysphagia is multifactorial with decreased sensation and limitation of airway protective mechanisms both acting as contributing factors.
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Affiliation(s)
- Abtin Tabaee
- Department of Otorhinolaryngology-Head and Neck Surgery, New York Presbyterian Hospitals, Weill Medical College of Cornell University, New York, New York 10021, USA
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Fukushima SI, Shingai T, Takahashi Y, Taguchi Y, Noda T, Yamada Y. Genesis of the decrement of intraluminal pressure in the UES during swallowing in rabbits. Brain Res 2005; 1044:122-6. [PMID: 15862797 DOI: 10.1016/j.brainres.2005.03.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2004] [Revised: 02/25/2005] [Accepted: 03/01/2005] [Indexed: 11/16/2022]
Abstract
The intraluminal pressure in the upper esophageal sphincter (UES) briefly decreases during swallowing. This decrement in pressure plays an important role in smooth transport of the ingested bolus from the pharynx to the esophagus. It is known that the decrement is caused by cessation of tonic activity of the cricopharyngeus (CP) muscle and also by elevation of the larynx. On the other hand, it is suspected that the recurrent laryngeal nerve (RLN) also contributes to the decrement, since our preliminary study showed for the first time that the decrement in UES pressure was much reduced after the RLN was sectioned. In the present study, we examined the genesis of the decrement of the UES pressure in anesthetized rabbits. When swallowing was elicited by repetitive electrical stimulation of the superior laryngeal nerve, the UES pressure briefly decreased and then abruptly increased. After bilateral sectioning of the RLN, the decrement of the pressure was significantly reduced, whereas the increment was little altered. Sectioning of the pharyngeal branch of the vagus nerve (X-ph) and the RLN mostly eliminated both the decrement and increment of the pressure, and abolished tonic and burst activities of the CP muscle. Electrical stimulation of peripheral end of the RLN decreased the pressure. These results indicate that the RLN and X-ph are involved in the decrement of the UES pressure during swallowing. The RLN generates the decrement by adducting the arytenoid cartilage and closing the glottis. The X-ph contributes to the decrement both by suppressing the tonic activity of the CP muscle and by regulating the laryngeal elevation.
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Affiliation(s)
- Shin-Ichi Fukushima
- Division of Pediatric Dentistry, Niigata University Graduate School of Medical and Dental Sciences, 2-5274 Gakkocho-dori, Niigata 951-8514, Japan.
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31
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Fang TJ, Li HY, Tsai FC, Chen IH. The role of glottal gap in predicting aspiration in patients with unilateral vocal paralysis. ACTA ACUST UNITED AC 2004; 29:709-12. [PMID: 15533165 DOI: 10.1111/j.1365-2273.2004.00876.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Aspiration has been frequently noted among patients suffering from vocal-fold paralysis. The association between a defect of glottal closure and aspiration in patients with unilateral vocal paralysis appears to have been rarely reported. The current study reviews collected data consisting of videotaped flexible nasoendoscopy and stroboscopy for patients with a unilateral vocal-fold paralysis. Mean normalized glottal gap areas for patients suffering vocal paralysis with associated aspiration are significant greater than that for the non-aspiration group. Subsequent to the surgical correction of the glottal gap, all patients recovered well from their earlier aspiration. The investigation of objectively derived data revealed that poor airway protection due to incomplete closure of the vocal fold was the major cause of aspiration for patients suffering unilateral vocal-fold paralysis. Intracordal autologous fat injection can successfully improve the breath control and eliminate aspiration in patients with vocal-fold paralysis.
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Affiliation(s)
- T J Fang
- Department of Otolaryngology, Chang Gung Memorial Hospital, Taipei, Taiwan, ROC.
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Kohr LM, Dargan M, Hague A, Nelson SP, Duffy E, Backer CL, Mavroudis C. The incidence of dysphagia in pediatric patients after open heart procedures with transesophageal echocardiography. Ann Thorac Surg 2003; 76:1450-6. [PMID: 14602266 DOI: 10.1016/s0003-4975(03)00956-1] [Citation(s) in RCA: 76] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Pediatric patients who undergo open heart operations may be at risk for the development of dysphagia because of interventions such as intubation and transesophageal echocardiography. Although the occurrence of dysphagia after cardiac surgical procedures in adults is reported to be 3% to 4%, the incidence in children and adolescents has not been documented. This study was undertaken to determine the incidence of and risk factors contributing to dysphagia in pediatric patients after open heart procedures. METHODS Fifty patients were evaluated after open heart operations with transesophageal echocardiography between March 1, 1999, and September 30, 1999. The diagnosis of dysphagia was made by a speech pathologist using a clinical swallowing evaluation. Potential predictors examined included demographic variables, anatomical diagnosis, surgical procedure, size of the transesophageal echocardiographic probe in relation to body size, length of probe insertion time, preoperative patient acuity status, duration of intubation, and time until discharge. RESULTS Dysphagia was found in 9 (18%) of the 50 patients. Risk factors identified were age of less than 3 years (odds ratio, 20.4; 95% confidence interval, 2.7 to 157; p = 0.002), intubation prior to operation (odds ratio, 17.7; 95% confidence interval, 9.4 to 210; p = 0.004), intubation for more than 7 days (odds ratio, 74.7; 95% confidence interval, 13.8 to 405; p = 0.001), and operation for left-sided obstructive lesions (odds ratio, 1.9; 95% confidence interval, 2.2 to 8.3; p = 0.038). The size of the transesophageal echocardiographic probe in relation to the weight of the patient was found to be predictive (p = 0.0001) of dysphagia. Vocal cord paralysis was noted in 4 (8%) of the 50 patients postoperatively. Adverse events related to aspiration occurred in 2 patients (4%). At discharge, nasogastric tube feedings were required in 6 patients (12%), and thickened feedings were recommended for 3 (6%) of the 50 patients. Resolution of dysphagia ranged from 13 to 150 days. CONCLUSIONS Eighteen percent of patients had dysphagia after an open heart operation with transesophageal echocardiography. Age of less than 3 years, preoperative patient acuity status, longer intubation times, and operation for left-sided obstructions are risk factors for dysphagia in this cohort of pediatric patients. The size of the transesophageal echocardiography probe in relation to the patient's weight was predictive of dysphagia. Physicians should consider using the new mini-multiplane transesophageal echocardiographic probes in patients weighing less than 5.5 kg. Vigilance in monitoring for the signs of preoperative and postoperative dysphagia with prompt referral to a speech therapist can substantially reduce patient morbidity, length of hospital stay, and requirement of prolonged nasogastric tube use.
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MESH Headings
- Adolescent
- Age Distribution
- Analysis of Variance
- Cardiac Surgical Procedures/adverse effects
- Cardiac Surgical Procedures/methods
- Child
- Child, Preschool
- Cohort Studies
- Deglutition Disorders/diagnosis
- Deglutition Disorders/epidemiology
- Deglutition Disorders/etiology
- Echocardiography, Transesophageal/adverse effects
- Echocardiography, Transesophageal/methods
- Esophagoscopy
- Female
- Follow-Up Studies
- Heart Defects, Congenital/diagnostic imaging
- Heart Defects, Congenital/mortality
- Heart Defects, Congenital/surgery
- Humans
- Incidence
- Infant
- Infant, Newborn
- Logistic Models
- Male
- Monitoring, Intraoperative/adverse effects
- Monitoring, Intraoperative/methods
- Odds Ratio
- Postoperative Complications/diagnosis
- Postoperative Complications/epidemiology
- Probability
- Risk Assessment
- Sex Distribution
- Statistics, Nonparametric
- Survival Rate
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Affiliation(s)
- Lisa M Kohr
- Division of Cardiovascular-Thoracic Surgery, Department of Speech and Language Pathology, Children's Memoiral Hospital, Chicago, Illinois, USA
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Périé S, Roubeau B, Lacau St Guily J. Laryngeal paralysis: distinguishing Xth nerve from recurrent nerve paralysis through videoendoscopic swallowing study (VESS). Dysphagia 2003; 18:276-83. [PMID: 14571333 DOI: 10.1007/s00455-003-0025-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Distinction between unilateral recurrent laryngeal nerve paralysis and Xth nerve paralysis is a rarely addressed issue in the literature. However, it may be crucial to examine the cause of the paralysis and to perform the appropriate investigation. The videoendoscopic swallowing study has been demonstrated to be a useful tool in assessing pharyngeal function. Since in unilateral Xth nerve paralysis the pharynx is impaired on the same side as the vocal fold immobility, it may be easily detected by videoendoscopic swallowing study. The rotation of the posterolateral pharyngeal wall toward the opposite side during swallowing is a sign of impaired motor pharyngeal branches. To demonstrate the usefulness of the videoendoscopic swallowing study in distinguishing unilateral Xth nerve from isolated recurrent nerve paralysis, a series of six patients were studied prospectively. Diagnosis of Xth nerve paralysis focused the investigation toward the high neck or the skull base area. Paralysis of the Xth nerve was suspected in all cases and diagnosis was achieved in five cases by the workup performed. Videoendoscopic swallowing study is a cost-effective and easily available tool which should be performed in all cases of vocal fold paralysis.
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Affiliation(s)
- Sophie Périé
- Service d'Oto-Rhino-Laryngologie et Chirurgie Cervico-faciale, Faculté de Médecine Saint Antoine, Université Paris VI, Hôpital Tenon, Paris, France.
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Schneider B, Denk DM, Bigenzahn W. Functional results after external vocal fold medialization thyroplasty with the titanium vocal fold medialization implant. Laryngoscope 2003; 113:628-34. [PMID: 12671418 DOI: 10.1097/00005537-200304000-00008] [Citation(s) in RCA: 53] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES/HYPOTHESIS A persistent insufficiency of glottal closure is mostly a consequence of a unilateral vocal fold movement impairment. It can also be caused by vocal fold atrophy or scarring processes with regular bilateral respiratory vocal fold function. Because of consequential voice, breathing, and swallowing impairments, a functional surgical treatment is required. The goal of the study was to outline the functional results after medialization thyroplasty with the titanium vocal fold medialization implant according to Friedrich. METHODS In the period of 1999 to 2001, an external vocal fold medialization using the titanium implant was performed on 28 patients (12 women and 16 men). The patients were in the age range of 19 to 84 years. Twenty-two patients had a paralysis of the left-side vocal fold, and six patients, of the right-side vocal fold. Detailed functional examinations were executed on all patients before and after the surgery: perceptive voice sound analysis according to the "roughness, breathiness, and hoarseness" method, judgment of the s/z ratio and voice dysfunction index, voice range profile measurements, videostroboscopy, and pulmonary function tests. In case of dysphagia/aspiration, videofluoroscopy of swallowing was also performed. The respective data were statistically analyzed (paired t test, Wilcoxon-test). RESULTS All patients reported on improvement of voice, swallowing, and breathing functions postoperatively. Videostroboscopy revealed an almost complete glottal closure after surgery in all of the patients. All voice-related parameters showed a significant improvement. An increase of the laryngeal resistance by the medialization procedure could be excluded by analysis of the pulmonary function test. CONCLUSIONS The results confirm the external medialization of the vocal folds as an adequate method in the therapy of voice, swallowing, and breathing impairment attributable to an insufficient glottal closure. The titanium implant offers, apart from good tissue tolerability, the advantage of an easy, time-saving, and individually adjustable application during the operation.
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Affiliation(s)
- Berit Schneider
- Department of Otorhinolaryngology, University Hospital of Vienna, School of Medicine, Vienna, Austria.
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Schneider B, Bigenzahn W, End A, Denk DM, Klepetko W. External vocal fold medialization in patients with recurrent nerve paralysis following cardiothoracic surgery. Eur J Cardiothorac Surg 2003; 23:477-83. [PMID: 12694763 DOI: 10.1016/s1010-7940(02)00839-4] [Citation(s) in RCA: 40] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVES Recurrent laryngeal nerve injury is a possible complication following cardiothoracic surgery. Due to insufficient glottal closure, dysphonia and dysphagia with aspiration may occur. The purpose of the study was to outline the effect of vocal fold medialization thyroplasty on voice, swallowing and breathing impairments. METHODS Between 1999 and 2001, medialization thyroplasty using the titanium implant (TVFMI) according to Friedrich was performed in 14 patients with postoperative left-sided recurrent nerve paralysis (five female and nine male patients, mean age 64 years) by an external approach. Previous surgical procedures comprised six lobectomies (combined with resection and replacement of the subclavian artery in one case), two pneumonectomies, one resection of a schwannoma in the aortopulmonary window, two replacements of the descending aorta, one aortocoronary bypass procedure (with LIMA), and two esophageal resections using Akiyama technique, respectively. Before and after thyroplasty, the patients underwent an otolaryngological/phoniatric examination including videostroboscopy, voice sound analysis, voice range profile measurement, pulmonary function testing, and in selected cases videofluoroscopy of swallowing. RESULTS Following thyroplasty, all patients reported on subjective improvement of voice, swallowing and breathing functions. Videostroboscopy revealed an improved glottal closure (six complete, six with posterior gap). All voice related parameters (e.g. roughness, breathiness, hoarseness, maximum sound pressure levels of the singing and shouting voices) were significantly improved. CONCLUSIONS Due to potential risk of recurrent nerve alteration in left-sided intrathoracic procedures, a preoperative and postoperative laryngoscopic examination is recommended. The external medialization of the vocal folds can be regarded as an excellent method for improvement of voice, swallowing and breathing, in particular, when the quality of life is impaired due to persistent recurrent nerve paralysis.
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Affiliation(s)
- Berit Schneider
- Section of Phoniatrics-Logopedics, Department of Otorhinolaryngology, General Hospital, University Hospital of Vienna, Vienna, Austria.
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Pereira JA, Girvent M, Sancho JJ, Parada C, Sitges-Serra A. Prevalence of long-term upper aerodigestive symptoms after uncomplicated bilateral thyroidectomy. Surgery 2003; 133:318-22. [PMID: 12660645 DOI: 10.1067/msy.2003.58] [Citation(s) in RCA: 107] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
BACKGROUND Subjective nonspecific upper aerodigestive symptoms (UADS) are not uncommon after thyroidectomy. Their type, duration, and prevalence, however, have not been investigated in a controlled design. The objective of this study was to investigate the prevalence of UADS after thyroidectomy. METHODS A consecutive cohort of 60 patients who had undergone uncomplicated total (n = 38) or near total (n = 22) thyroidectomy were investigated retrospectively at a mean of 4 years after surgery. An independent unblinded researcher interviewed each patient and asked for the presence or frequency of voice changes, cough, dysphagia, neck strangling, and annual incidence of common colds, before and after thyroidectomy. Sixty patients, matched for age, sex, and smoking habits, who had undergone laparoscopic cholecystectomy during the same years served as control subjects. RESULTS The prevalence of UADS was similar before thyroidectomy (13%) and cholecystectomy (15%). After operation, UADS had a higher prevalence among thyroidectomized patients: nonspecific voice changes (28% vs 3%), neck strangling (22% vs 0%), and impaired swallowing (15% vs 3%) (P < or = .02 in each). Neck strangling was associated with voice changes and dysphagia (P < or = .03 each). CONCLUSIONS Subjective UADS are common long after thyroidectomy. These symptoms may be related to injury to the extrinsic perithyroidal neural plexus innervating the pharyngeal and laryngeal structures.
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Affiliation(s)
- José A Pereira
- Department of Health Sciences, Universitat Pompeu Fabra, Barcelona, Spain
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Périé S, Roubeau B, Liesenfelt I, Chaigneau-Debono G, Bruel M, St Guily JL. Role of medialization in the improvement of breath control in unilateral vocal fold paralysis. Ann Otol Rhinol Laryngol 2002; 111:1026-33. [PMID: 12450179 DOI: 10.1177/000348940211101114] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
A prospective study was performed on 18 adults to analyze disturbances of voice and respiratory function in unilateral vocal fold paralysis and the role of medialization in the improvement of breath control. In addition to physical examination, an acoustic and aerodynamic analysis, as well as patient self-assessment, were performed both before and after medialization (14 fat injections, 4 thyroplasties) to evaluate voice and both phonatory breath control and respiratory function outcome. Preoperative and postoperative results, at short, middle, and long term, were compared to data from 14 control subjects and evaluated by statistical analysis. Preoperative acoustic and aerodynamic parameters were significantly disturbed in comparison to controls. Independently of the pulmonary status, medialization induced an improvement in most of the parameters at short and long terms, whereas a diminished effect was observed at middle term. Phonatory breath control, as evaluated by maximum phonation time, mean flow rate, and expired volume, was statistically improved, with the best results being obtained in women. From the questionnaire, it was clear that voice, as well as phonatory breath control and respiratory function, showed considerable improvement, although some difficulties persisted during effort. This study demonstrates that there is a disturbance of phonatory breath control and respiratory function in adult unilateral vocal fold paralysis. Improvement following medialization supports the concept that the respiratory dysfunction seen beforehand is most probably the result of air escape rather than laryngeal obstruction. Although medialization may provoke an extrathoracic obstruction, its feature of variability appears to improve breath control.
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Affiliation(s)
- Sophie Périé
- Service d'Oto-Rhino-Laryngologie et de Chirurgie Cervico-Faciale, Faculté de Médecine Saint Antoine, Université Paris VI, Hĵpital Tenon, Paris, France
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Hartl DM, Brasnu DF. Recurrent Laryngeal Nerve Paralysis: Current Concepts and Treatment: Part I-Phylogenesis and Physiology. EAR, NOSE & THROAT JOURNAL 2000. [DOI: 10.1177/014556130007901109] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Dana M. Hartl
- Laboratory of voice, biomaterials and cervicofacial oncology, CNRS-UPRESA 7018, University of Paris V, Laennec Hospital, 42 rue de Sevres, 75007 Paris, France
| | - Daniel F. Brasnu
- Laboratory of voice, biomaterials and cervicofacial oncology, CNRS-UPRESA 7018, University of Paris V, Laennec Hospital, 42 rue de Sevres, 75007 Paris, France
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Périé S, Coiffier L, Laccourreye L, Hazebroucq V, Chaussade S, St Guily JL. Swallowing disorders in paralysis of the lower cranial nerves: a functional analysis. Ann Otol Rhinol Laryngol 1999; 108:606-11. [PMID: 10378531 DOI: 10.1177/000348949910800614] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Deficits of the lower cranial nerves (nerves IX, X, XI, and XII) occurring after treatment of skull base tumors may cause disabling swallowing disorders. To assess the mechanisms of swallowing disorders involved in such cases, we performed functional examinations: a videoendoscopic swallowing study and simultaneous manometry and videofluoroscopy in 7 patients. This study shows that the main mechanism of the swallowing disorders was a disturbance of the pharyngeal stage, including a decrease of pharyngeal propulsion, reduced laryngeal closure, and cricopharyngeal dysfunction, which led to aspiration. Decreased pharyngeal propulsion was found in 6 patients, with a very high correlation between fiberoscopy and simultaneous manometry-fluoroscopy. The responsibility of the upper esophageal sphincter in swallowing disorders was more difficult to assess. The role of the upper esophageal sphincter and pharyngeal propulsion in the onset of the problem is discussed in regard to the cricopharyngeal myotomy.
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Affiliation(s)
- S Périé
- Department of Otorhinolaryngology-Head and Neck Surgery, Faculté de Médecine, Saint Antoine, Université Paris VI, Hôpital Tenon, France
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