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Le HV, Javidan Y, Khan SN, Klineberg EO. Dysphagia After Anterior Cervical Spine Surgery: Pathophysiology, Diagnosis, and Management. J Am Acad Orthop Surg 2024; 32:627-636. [PMID: 38657173 DOI: 10.5435/jaaos-d-23-00778] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Accepted: 02/20/2024] [Indexed: 04/26/2024] Open
Abstract
Anterior cervical spine surgery (ACSS) is a surgical intervention widely used for a myriad of indications including degenerative, oncologic, inflammatory, traumatic, and congenital spinal conditions. A primary concern for surgeons performing ACSS is the postoperative development of oropharyngeal dysphagia. Current literature reports a wide incidence of this complication ranging from 1 to 79%. Dysphagia after ACSS is multifactorial, with common risk factors being prolonged duration of operation, revision surgeries, multilevel surgeries, and use of recombinant human bone morphogenetic protein-2. Many technical strategies have been developed to reduce the risk of postoperative dysphagia, including the development of low-profile implants and retropharyngeal local steroid application. In this article, we review the most recent literature regarding the epidemiology and pathophysiology, diagnostic criteria, risk factors, and management of dysphagia after ACSS.
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Affiliation(s)
- Hai V Le
- From the Department of Orthopaedic Surgery, University of California Davis School of Medicine, Sacramento, CA (Le, Javidan, Khan), and the Department of Orthopaedic Surgery, John P. and Kathrine G. McGovern Medical School at UTHealth, Houston, TX (Klineberg)
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Ye Q, Hu J, Dai Y, Wen H, Dou Z. Mapping research trends regarding the mechanism of dysphagia from 1993 to 2023: a bibliometrics study and visualization analysis. Front Neurol 2024; 15:1363928. [PMID: 39026580 PMCID: PMC11254800 DOI: 10.3389/fneur.2024.1363928] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2024] [Accepted: 06/17/2024] [Indexed: 07/20/2024] Open
Abstract
As a common consequence of various neurogenic disorders, dysphagia has a significant impact on the quality of life for patients. To promote the development the field of swallowing, it will be helpful to clarify the pathological and therapeutic mechanisms of dysphagia. Through visual analysis of related papers from 1993 to 2023 in the Web of Science Core Collection (WoSCC) database, the research status and development trend of the pathogenesis of dysphagia were discussed. The co-occurrence study was finished using CiteSpace 6.2 R4 software, including keywords, countries, institutions, and authors. Finally, 1,184 studies satisfied the inclusion requirements. The findings of the visualization analysis suggested that aspiration and gastroesophageal reflux disease would be the areas of greatest interest for researchers studying the mechanism of dysphagia. As for the latest occurred research trends, fMRI, signals and machine learning emerging into the field of view of researchers. Based on an analysis of country co-occurrence, United States, Japan and China rank the top three, in terms of the number of publications on dysphagia. University System of Ohio is the organization that has published the most amount of articles regarding the mechanism of dysphagia. Other highly published schools in the top three include State University System of Florida and Northwestern University. For the prolific authors, German, Rebecca Z published the most articles at present, whose own research team working closely together. Several closely cooperating research teams have been formed at present, including the teams centered around German, Rebecca Z, Warnecke, Tobias and Hamdy Shaheen. This study intuitively analyzed the current research status of the mechanism of dysphagia, provided researchers with research hotspots in this field.
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Affiliation(s)
- Qiuping Ye
- Department of Rehabilitation Medicine, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Jiahui Hu
- Clinical Medical College of Acupuncture Moxibustion and Rehabilitation, Guangzhou University of Traditional Chinese Medicine, Guangzhou, China
| | - Yong Dai
- Clinical Medical College of Acupuncture Moxibustion and Rehabilitation, Guangzhou University of Traditional Chinese Medicine, Guangzhou, China
| | - Hongmei Wen
- Department of Rehabilitation Medicine, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Zulin Dou
- Department of Rehabilitation Medicine, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
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Howe S, Steer K, Johnson M, Adjerid K, Edmonds C, German R, Mayerl C. Exploring the interaction of viscosity and nipple design on feeding performance in an infant pig model. J Texture Stud 2023; 54:936-946. [PMID: 37673688 PMCID: PMC10872838 DOI: 10.1111/jtxs.12797] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Revised: 07/30/2023] [Accepted: 08/10/2023] [Indexed: 09/08/2023]
Abstract
Infant feeding behaviors are modulated via sensorimotor feedback, such that sensory perturbations can significantly impact performance. Properties of the nipple and milk (e.g., nipple hole size and viscosity) are critical sources of sensory information. However, the direct effects of varying milk and nipple properties on infant motor output and the subsequent changes in feeding performance are poorly understood. In this study, we use an infant pig model to explore the interaction between nipple hole size and milk viscosity. Using high-speed videofluoroscopy and electromyography, we measured key performance metrics including sucks per swallow and suck duration, then synchronized these data with the onset and offset of activity of jaw opening and closing muscles. The combination of a small nipple hole and thick milk resulted in negative effects on both suck and swallow performance, with reduced feeding efficiency compared to the other treatments. It also appears that this combination of viscosity and hole size disrupts the coordination between correlates of tongue and jaw movements. We did not see a difference in feeding efficiency between viscosities when infants fed on the large-hole nipple, which may be the result of non-Newtonian fluid mechanics. Our results emphasize the importance of considering both fluid and nipple properties when considering alterations to an infant's feeding system.
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Affiliation(s)
- Stephen Howe
- Northeast Ohio Medical University, Rootstown, Ohio, USA
| | - Kendall Steer
- Northeast Ohio Medical University, Rootstown, Ohio, USA
- University of Akron, Akron, Ohio, USA
| | | | | | - Chloe Edmonds
- Northeast Ohio Medical University, Rootstown, Ohio, USA
- Kent State University, Kent, Ohio, USA
| | - Rebecca German
- Northeast Ohio Medical University, Rootstown, Ohio, USA
- Kent State University, Kent, Ohio, USA
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Meisner JW, Izadi S, Kamran A, Shieh HF, Smithers CJ, Bennett J, Demehri FR, Mohammed S, Lawlor C, Choi SS, Zendejas B. Screening for Vocal Fold Movement Impairment in Children Undergoing Esophageal and Airway Surgery. Laryngoscope 2023; 133:3564-3570. [PMID: 36892035 DOI: 10.1002/lary.30646] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Revised: 02/04/2023] [Accepted: 02/27/2023] [Indexed: 03/10/2023]
Abstract
INTRODUCTION Children undergoing cervical and/or thoracic operations are at risk for recurrent laryngeal nerve injury, resulting in vocal fold movement impairment (VFMI). Screening for VFMI is often reserved for symptomatic patients. OBJECTIVE Identify the prevalence of VFMI in screened preoperative patients prior to an at-risk operation to evaluate the value of screening all patients at-risk for VFMI, regardless of symptoms. METHODS A single center, retrospective review of all patients undergoing a preoperative flexible nasolaryngoscopy between 2017 and 2021, examining the presence of VFMI and associated symptoms. RESULTS We evaluated 297 patients with a median (IQR) age of 18 (7.8, 56.3) months and a weight of 11.3 (7.8, 17.7) kilograms. Most had a history of esophageal atresia (EA, 60%), and a prior at-risk cervical or thoracic operation (73%). Overall, 72 (24%) patients presented with VFMI (51% left, 26% right, and 22% bilateral). Of patients with VFMI, 47% did not exhibit the classic symptoms (stridor, dysphonia, and aspiration) of VFMI. Dysphonia was the most prevalent classic VFMI symptom, yet only present in 18 (25%) patients. Patients presenting with a history of at-risk surgery (OR 2.3, 95%CI 1.1, 4.8, p = 0.03), presence of a tracheostomy (OR 3.1, 95%CI 1.0, 10.0, p = 0.04), or presence of a surgical feeding tube (OR 3.1, 95%CI 1.6, 6.2, p = 0.001) were more likely to present with VFMI. CONCLUSION Routine screening for VFMI should be considered in all at-risk patients, regardless of symptoms or prior operations, particularly in those with a history of an at-risk surgery, presence of tracheostomy, or a surgical feeding tube. LEVEL OF EVIDENCE 3 Laryngoscope, 133:3564-3570, 2023.
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Affiliation(s)
- Jay W Meisner
- Department of Surgery, Boston Children's Hospital, Boston, Massachusetts, U.S.A
| | - Shawn Izadi
- Department of Surgery, Boston Children's Hospital, Boston, Massachusetts, U.S.A
| | - Ali Kamran
- Department of Surgery, Boston Children's Hospital, Boston, Massachusetts, U.S.A
| | - Hester F Shieh
- Department of Surgery, Johns Hopkins All Childrens, St Petersburg, Florida, U.S.A
| | - C Jason Smithers
- Department of Surgery, Johns Hopkins All Childrens, St Petersburg, Florida, U.S.A
| | - John Bennett
- Department of Surgery, Boston Children's Hospital, Boston, Massachusetts, U.S.A
| | - Farokh R Demehri
- Department of Surgery, Boston Children's Hospital, Boston, Massachusetts, U.S.A
| | - Somala Mohammed
- Department of Surgery, Boston Children's Hospital, Boston, Massachusetts, U.S.A
| | - Claire Lawlor
- Department of Ear, Nose and Throat Surgery, Children's National, Washington, District of Columbia, U.S.A
| | - Sukgi S Choi
- Department of Otolaryngology and Communication Enhancement, Boston Children's Hospital, Boston, Massachusetts, U.S.A
| | - Benjamin Zendejas
- Department of Surgery, Boston Children's Hospital, Boston, Massachusetts, U.S.A
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Adjerid K, Johnson M, Edmonds C, Steer K, Gould F, German R, Mayerl C. The effect of stiffness and hole size on nipple compression in infant suckling. JOURNAL OF EXPERIMENTAL ZOOLOGY. PART A, ECOLOGICAL AND INTEGRATIVE PHYSIOLOGY 2023; 339:92-100. [PMID: 36121049 PMCID: PMC9771940 DOI: 10.1002/jez.2657] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Revised: 08/04/2022] [Accepted: 08/24/2022] [Indexed: 12/24/2022]
Abstract
During infant feeding, the nipple is an important source of sensory information that affects motor outputs, including ones dealing with compression of the nipple, suction, milk bolus movement, and swallowing. Despite known differences in behavior across commercially available nipples, little is known about the in vivo effects of nipple property variation. Here we quantify the effect of differences in nipple stiffness and hole size on an easily measured metric representing infant feeding behavior: nipple compression. We bottle-fed 7-day old infant pigs (n = 6) on four custom fabricated silicone nipples. We recorded live X-ray fluoroscopic imaging data of feeding on nipples of two levels of hardness/stiffness and two hole sizes. We tested for differences in nipple compression at the nipple's maximum compression across different nipple types using a mixed model analysis of variance. Stiffer nipples and those with smaller holes were compressed less than compliant nipples and nipples with larger holes (p < 0.001). We also estimated the force applied on the nipple during feeding and found that more force was applied to the compliant nipple with disproportionately larger strains. Our results suggest that infant pigs' nipple compression depends on material type and hole size, which is likely detected by the infant pigs' initial assessment of compressibility and flow. By isolating nipple properties, we demonstrated a relationship between properties and suckling behavior. Our results suggest that sensory information affects feeding behaviors and may also inform clinical treatment of poor feeding performance.
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Affiliation(s)
- K. Adjerid
- Northeast Ohio Medical University, Rootstown, OH
| | - M.L. Johnson
- Northeast Ohio Medical University, Rootstown, OH
| | - C.E. Edmonds
- Northeast Ohio Medical University, Rootstown, OH
| | - K.E. Steer
- Northeast Ohio Medical University, Rootstown, OH
| | - F.D.H. Gould
- Rowan University School of Osteopathic Medicine, Glassboro, NJ
| | - R.Z. German
- Northeast Ohio Medical University, Rootstown, OH
| | - C.J. Mayerl
- Northeast Ohio Medical University, Rootstown, OH
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Alain C, Samson N, Nadeau C, Beaudoin JF, Lienhart C, Counil C, Praud JP. Nasal respiratory support and tachypnea and oral feeding in full-term newborn lambs. J Appl Physiol (1985) 2021; 130:1436-1447. [PMID: 33661723 DOI: 10.1152/japplphysiol.00567.2020] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Newborn infants with respiratory difficulties frequently require nasal respiratory support such as nasal continuous positive airway pressure (nCPAP) or high-flow nasal cannulae (HFNC). Oral feeding of these infants under nasal respiratory support remains controversial out of fear of aspiration and cardiorespiratory events. The main objective of this study was to evaluate the safety of oral feeding under different types of nasal respiratory support in newborn lambs without or with tachypnea. Eight lambs aged 4-5 days were instrumented to record sucking, swallowing, respiration, ECG, oxygen saturation, and arterial blood gases. Each lamb was given two bottles of 30 mL of milk with a pause of 30 s under videofluoroscopy in four conditions [no respiratory support, nCPAP 6 cmH2O, HFNC 7 L/min, HFNCCPAP (= HFNC 7 L/min + CPAP 6 cmH2O)] administered in random order. The study was conducted in random order over 2 days, with or without standardized tachypnea induced by thoracic compression with a blood pressure cuff. Generalized linear mixed models were used to compare the four nasal respiratory supports in terms of safety (cardiorespiratory events and aspiration), sucking-swallowing-breathing coordination, and efficacy of oral feeding. Results reveal that no nasal respiratory support impaired the safety of oral feeding. Most of the few laryngeal penetrations we observed occurred with HFNCCPAP. Nasal CPAP modified sucking-swallowing-breathing coordination, whereas the efficiency of oral feeding decreased under HFNCCPAP. Results were similar with or without tachypnea. In conclusion, oral feeding under nasal respiratory support is generally safe in a term lamb, even with tachypnea.NEW & NOTEWORTHY The practice of orally feeding newborns suffering from respiratory problems while on nCPAP or HFNC remains controversial for fear of triggering cardiorespiratory events or aspiration pneumonia, or aggravating chronic lung disease. The present results show that bottle-feeding is generally safe in full-term lambs under nasal respiratory support, both without and with tachypnea.
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Affiliation(s)
- Charles Alain
- Neonatal Respiratory Research Unit, Departments of Pediatrics and Pharmacology-Physiology, Université de Sherbrooke, Sherbrooke, Quebec, Canada
| | - Nathalie Samson
- Neonatal Respiratory Research Unit, Departments of Pediatrics and Pharmacology-Physiology, Université de Sherbrooke, Sherbrooke, Quebec, Canada
| | - Charlène Nadeau
- Neonatal Respiratory Research Unit, Departments of Pediatrics and Pharmacology-Physiology, Université de Sherbrooke, Sherbrooke, Quebec, Canada
| | - Jean-François Beaudoin
- Centre d'imagerie moléculaire de Sherbrooke (CIMS), Université de Sherbrooke, Sherbrooke, Quebec, Canada
| | - Camille Lienhart
- Neonatal Respiratory Research Unit, Departments of Pediatrics and Pharmacology-Physiology, Université de Sherbrooke, Sherbrooke, Quebec, Canada
| | - Clément Counil
- Neonatal Respiratory Research Unit, Departments of Pediatrics and Pharmacology-Physiology, Université de Sherbrooke, Sherbrooke, Quebec, Canada
| | - Jean-Paul Praud
- Neonatal Respiratory Research Unit, Departments of Pediatrics and Pharmacology-Physiology, Université de Sherbrooke, Sherbrooke, Quebec, Canada
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Stevens M, Schiedermayer B, Kendall KA, Ou Z, Presson AP, Barkmeier-Kraemer JM. Physiology of Dysphagia in Those with Unilateral Vocal Fold Immobility. Dysphagia 2021; 37:356-364. [PMID: 33791864 DOI: 10.1007/s00455-021-10286-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Accepted: 03/16/2021] [Indexed: 10/21/2022]
Abstract
Quantitative measures of swallowing function were extracted from modified barium swallowing studies (MBS) to characterize swallowing pathophysiology in patients with unilateral vocal fold immobility (UVFI). All individuals with UVFI completing a MBS during the prior 5 years were included. Demographic information, penetration-aspiration score, timing of aspiration and quantitative measures from the MBS were extracted from electronic medical records and compared across 1, 3, and 20 cc liquid bolus swallows. UVFI patient measures were compared to normal age-matched controls to identify swallowing pathophysiology associated with aspiration. The incidence of aspiration by UVFI etiology groups (i.e., central nervous system, idiopathic, iatrogenic, skull base tumor, or peripheral tumor) was also compared. Of the 61 patients who met inclusion criteria, aspiration was observed in 23%. Maximum pharyngeal constriction was abnormal in 79% of aspirators compared to 34% of non-aspirators (p = .003). Delay in airway closure was the most common swallowing abnormality identified in the study population (62%) but was not associated with aspiration. Among the 14 individuals who aspirated, the iatrogenic and skull base tumor etiology groups comprised the majority (i.e., 36% each). However, the incidence of aspiration for the iatrogenic group was 19% compared to 50% of the skull base tumor group. Aspiration in patients with UVFI was associated with abnormally reduced pharyngeal constriction. Delayed airway closure was common in both aspirators and non-aspirators.
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Affiliation(s)
- Maya Stevens
- Division of Otolaryngology, Department of Surgery, University of Utah, Salt Lake City, UT, USA. .,Department of Communication Sciences and Disorders, University of Utah, Salt Lake City, UT, USA. .,Division of Otolaryngology, University of Utah, 50 N Medical Dr, Rm 3C120 SOM, Salt Lake City, UT, 84132, USA.
| | - Ben Schiedermayer
- Division of Otolaryngology, Department of Surgery, University of Utah, Salt Lake City, UT, USA
| | - Katherine A Kendall
- Division of Otolaryngology, Department of Surgery, University of Utah, Salt Lake City, UT, USA
| | - Zhining Ou
- Division of Epidemiology, Department of Internal Medicine, University of Utah, Salt Lake City, UT, USA
| | - Angela P Presson
- Division of Epidemiology, Department of Internal Medicine, University of Utah, Salt Lake City, UT, USA
| | - Julie M Barkmeier-Kraemer
- Division of Otolaryngology, Department of Surgery, University of Utah, Salt Lake City, UT, USA.,Department of Communication Sciences and Disorders, University of Utah, Salt Lake City, UT, USA
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Characterization of Esophageal and Sphincter Reflexes across Maturation in Dysphagic Infants with Oral Feeding Success vs Infants requiring Gastrostomy. Dysphagia 2021; 37:148-157. [PMID: 33576892 DOI: 10.1007/s00455-021-10258-8] [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: 06/11/2020] [Accepted: 01/27/2021] [Indexed: 10/22/2022]
Abstract
To test the hypothesis that esophageal and sphincteric sensory-motor reflexes are distinct across maturation in infants with dysphagia receiving gastrostomy-tube (G-tube). This is a retrospective review of 29 dysphagic infants (N = 15 study requiring gastrostomy, N = 14 age matched control achieving oral feeds) that underwent longitudinal pharyngeal-esophageal manometry at 42.3 (37-50.2) weeks postmenstrual age (PMA) and 48.9 (43.3-57.9) weeks PMA. Graded stimuli (0.1-5 mL) of varying media (air, water, and apple juice) tested esophageal peristaltic reflex, upper esophageal sphincter contractile reflex (UESCR), and lower esophageal sphincter relaxation reflex (LESRR). Comparisons were performed between study and controls and across maturation (time-1 vs time-2). Data represented as mean ± SE or OR (95% CI). Across maturation (time-1 vs time-2): Study infants did not exhibit significant differences across in peristaltic, UES, or LES reflexes (all p > 0.05). In contrast, controls exhibited increased UES resting pressure (13 ± 3 vs 17 ± 3 mmHg, p = 0.001), LES resting pressure (22 ± 3 vs 25 ± 3 mmHg, p < 0.009), LES nadir pressure (0.5 ± 1 vs 4.3 ± 1 mmHg, p = 0.001), and esophago-deglutition responses [2.5 (1.23-4.88), p = 0.04], and decreased secondary peristalsis [0.44 (0.31-0.61), p = 0.001], UESCR [0.4 (0.25-0.65), p = 0.001], LESRR [0.4 (0.24-0.75), p = 0.01], and symptoms [0.6 (0.45-0.83), p = 0.005]. Among infants with dysphagia, esophageal provocation induced peristaltic reflex, UESCR, and LESRR advance with longitudinal maturation when infants are oral-fed successfully, but not in those who received gastrostomy. Underlying mechanisms may be related to esophageal sensitivity, afferent or efferent transmission, and coordination of upstream excitation and downstream inhibition, which can be potential therapeutic targets for improving feeding capabilities after gastrostomy placement in infants with dysphagia.
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Stevens M, Mayerl C, Bond L, German RZ, Barkmeier-Kraemer JM. Pathophysiology of aspiration in a unilateral SLN lesion model using quantitative analysis of VFSS. Int J Pediatr Otorhinolaryngol 2021; 140:110518. [PMID: 33310447 PMCID: PMC7770015 DOI: 10.1016/j.ijporl.2020.110518] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Revised: 10/23/2020] [Accepted: 11/22/2020] [Indexed: 10/22/2022]
Abstract
OBJECTIVE The purpose of this study was to elucidate the pathophysiology of aspiration in previously studied female infant piglets after a unilateral superior laryngeal nerve (uSLN) lesion. METHODS Videofluoroscopic swallow studies (VFSS) were acquired from 15 female piglets ages 2-3 weeks (9 with uSLN lesion and 6 controls). VFSS were analyzed at 30 frames/second sampling rate. Quantitative measures were conducted and compared between groups using published methodologies for VFSS assessment in adult and infant humans. Measures included the: 1) number of lingual-palatal contacts (LPC) (i.e. pre-swallow), 2) total pharyngeal transit time (TPT), 3) offset of swallow (offP), as well as onset of: 4) pharyngeal stage (onP), 5) pharyngoesophageal segment opening (oPES), 6) maximum PES opening (maxPES), 7) airway closure onset (oAC), and 8) maximum airway closure (maxAC). Measures 5-7 were determined relative to onP. Bolus residue was rated by severity (0 (none) to 3 (severe)). A gamma regression was used to compare continuous measures between lesioned and control groups. RESULTS The number of LPC (p = .006), TPT (p = .023) and timing of maxAC (p = .041) were significantly greater in the uSLN lesion than the control group. CONCLUSIONS Outcomes of this study replicated prior published findings and elucidated that piglets with right uSLN lesions exhibited delayed maxAC. Noteworthy was the use of clinically relevant quantitative videofluoroscopic measures in piglets for comparison to future studies in human pediatric populations.
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Affiliation(s)
- Maya Stevens
- Department of Communication Sciences and Disorders, University of Utah, Salt Lake City, UT, USA; Department of Surgery, Division of Otolaryngology, University of Utah, Salt Lake City, UT, USA.
| | - Christopher Mayerl
- Department of Anatomy and Neurobiology, Northeast Ohio Medical University, Rootstown, OH
| | - Laura Bond
- Department of Anatomy and Neurobiology, Northeast Ohio Medical University, Rootstown, OH, USA.
| | - Rebecca Z. German
- Department of Anatomy and Neurobiology, Northeast Ohio Medical University, Rootstown, OH
| | - Julie M Barkmeier-Kraemer
- Department of Communication Sciences and Disorders, University of Utah, Salt Lake City, UT, USA; Department of Surgery, Division of Otolaryngology, University of Utah, Salt Lake City, UT, USA.
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Lammers AR, Abid S, Ding P, German RZ. Effects of Superior Laryngeal Nerve Lesion on Kinematics of Swallowing and Airway Protection in an Infant Pig Model. Dysphagia 2020; 35:907-917. [PMID: 32140904 DOI: 10.1007/s00455-020-10100-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2019] [Accepted: 02/20/2020] [Indexed: 10/24/2022]
Abstract
The superior laryngeal nerve provides detailed sensory information from the mucosal surfaces of laryngeal structures superior to the vocal folds, including the valleculae. Injury to this nerve results in airway penetration and aspiration. Furthermore, such injuries might have an impact on the function of multiple structures involved in intraoral transport and swallowing due to connections within the brainstem. We sought to determine the effects of a surgical lesion of the superior laryngeal nerve on kinematics of the tongue, hyoid, and epiglottis during swallowing. We implanted radio-opaque markers into five infant pigs under anesthesia. Then we fed milk mixed with contrast agent to the pigs while they were recorded via video fluoroscopy, before and after a surgery to transect the superior laryngeal nerve. We digitized and rated airway protection in 177 swallows. We found that in most animals, swallow duration was shorter after nerve lesion. The hyoid also traveled a shorter distance after lesion. Frequently, individuals reacted differently to the same nerve lesion. We suggest that these differences are due to individual differences in neurological connections. When comparing hyoid kinematics between swallows with successful or failed airway protection, we found more consistency among individuals. This indicates that protecting the airway requires specific sets of kinematic events to occur, regardless of the neurological differences among individuals.
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Affiliation(s)
- Andrew R Lammers
- School of Health Sciences, Cleveland State University, 2121 Euclid Ave, Cleveland, OH, 44115, USA.
- Department of Anatomy and Neurobiology, Northeast Ohio Medical University, Rootstown, OH, 44272, USA.
| | - Saja Abid
- School of Health Sciences, Cleveland State University, 2121 Euclid Ave, Cleveland, OH, 44115, USA
| | - Peng Ding
- Johns Hopkins Medicine International, 601 N. Caroline Street Suite 1080, Baltimore, MD, 21287, USA
| | - Rebecca Z German
- Department of Anatomy and Neurobiology, Northeast Ohio Medical University, Rootstown, OH, 44272, USA
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Gould FDH, Lammers AR, Mayerl C, Ohlemacher J, German RZ. Muscle activity and kinematics show different responses to recurrent laryngeal nerve lesion in mammal swallowing. J Neurophysiol 2020; 124:1743-1753. [PMID: 32966748 DOI: 10.1152/jn.00409.2020] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Understanding the interactions between neural and musculoskeletal systems is key to identifying mechanisms of functional failure. Mammalian swallowing is a complex, poorly understood motor process. Lesion of the recurrent laryngeal nerve, a sensory and motor nerve of the upper airway, results in airway protection failure (liquid entry into the airway) during swallowing through an unknown mechanism. We examined how muscle and kinematic changes after recurrent laryngeal nerve lesion relate to airway protection in eight infant pigs. We tested two hypotheses: 1) kinematics and muscle function will both change in response to lesion in swallows with and without airway protection failure, and 2) differences in both kinematics and muscle function will predict whether airway protection failure occurs in lesion and intact pigs. We recorded swallowing with high-speed videofluoroscopy and simultaneous electromyography of oropharyngeal muscles pre- and postrecurrent laryngeal nerve lesion. Lesion changed the relationship between airway protection and timing of tongue and hyoid movements. Changes in onset and duration of hyolaryngeal muscles postlesion were less associated with airway protection outcomes. The tongue and hyoid kinematics all predicted airway protection outcomes differently pre- and postlesion. Onset and duration of activity in only one infrahyoid and one suprahyoid muscle showed a change in predictive relationship pre- and postlesion. Kinematics of the tongue and hyoid more directly reflect changes in airway protections pre- and postlesion than muscle activation patterns. Identifying mechanisms of airway protection failure requires specific functional hypotheses that link neural motor outputs to muscle activation to specific movements.NEW & NOTEWORTHY Kinematic and muscle activity patterns of oropharyngeal structures used in swallowing show different patterns of response to lesion of the recurrent laryngeal nerve. Understanding how muscles act on structures to produce behavior is necessary to understand neural control.
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Affiliation(s)
- François D H Gould
- Department of Cell Biology and Neuroscience, Rowan School of Osteopathic Medicine, Stratford, New Jersey
| | | | - Christopher Mayerl
- Department of Anatomy and Neuroscience, Northeast Ohio Medical University, Rootstown, Ohio
| | - Jocelyn Ohlemacher
- Department of Anatomy and Neuroscience, Northeast Ohio Medical University, Rootstown, Ohio
| | - Rebecca Z German
- Department of Anatomy and Neuroscience, Northeast Ohio Medical University, Rootstown, Ohio
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Yang F, Zou L, Li L, Zou Q, Chen P, Sun H, Liu X, Xu X. Effect of Chin-down-plus-larynx-tightening maneuver on swallowing function after minimally invasive esophagectomy: A randomized controlled trail. Cancer Med 2020; 9:5889-5898. [PMID: 32627975 PMCID: PMC7433833 DOI: 10.1002/cam4.3280] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2020] [Revised: 05/21/2020] [Accepted: 06/11/2020] [Indexed: 12/30/2022] Open
Abstract
Background The incidence of swallowing abnormality was high after minimally invasive esophagectomy (MIE) for esophageal cancer (EC). Few reports, however, focused on interventions for dysphagia after esophagectomy. Aim The purpose of this research was to estimate the effect of Chin‐down‐plus‐larynx‐tightening maneuver on swallowing function for patients receiving esophagectomy. Method This was a 2‐arm, parallel‐group, single‐blind randomized clinical trial, performed in patients suffered from EC from November 2018 to January 2020. Patients were randomly assigned to the intervention group (IG) or the control group (CG). The participants in CG received routine care, and the IG received Chin‐down‐plus‐larynx‐tightening maneuver during feeding. The incidence of choking cough, swallowing function, and dietary outcomes were evaluated before and after intervention for 7 days. Results A total of 237 EC cases were enrolled and randomized to the IG (n = 118) or CG (n = 119). There was no significant difference between the two groups in terms of demographic and clinical characteristics. Postoperative choking cough occurred in 5 of 118 cases (4.24%) in IG and 18 of 119 cases (19.4%) in CG, the differences showed statistically significant (P < .001). The analysis showed that the participants in the IG compared with the CG have more total caloric intake of 24 hours and higher K/R (the ratio of calories oral achieved to total calories required of body) significantly from D1 to D7 of intervention (P < .05). Conclusion The findings suggest that the Chin‐down‐plus‐larynx‐tightening maneuver can improve swallowing function recovery and oral total food intake and calories in EC patients undergoing MIE.
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Affiliation(s)
- Funa Yang
- Nursing Department, Affiliated Cancer Hospital of Zhengzhou University, Henan Cancer Hospital, Zhengzhou, China
| | - Limin Zou
- Department of Thoracic Surgery, The Affiliated Cancer Hospital of Zhengzhou University, Zhengzhou, China
| | - Lijuan Li
- Department of Thoracic Surgery, The Affiliated Cancer Hospital of Zhengzhou University, Zhengzhou, China
| | - Qiyun Zou
- Department of Thoracic Surgery, The Affiliated Cancer Hospital of Zhengzhou University, Zhengzhou, China
| | - Peinan Chen
- Department of Thoracic Surgery, The Affiliated Cancer Hospital of Zhengzhou University, Zhengzhou, China
| | - Haibo Sun
- Department of Thoracic Surgery, The Affiliated Cancer Hospital of Zhengzhou University, Zhengzhou, China
| | - Xianben Liu
- Department of Thoracic Surgery, The Affiliated Cancer Hospital of Zhengzhou University, Zhengzhou, China
| | - Xiaoxia Xu
- Nursing Department, Affiliated Cancer Hospital of Zhengzhou University, Henan Cancer Hospital, Zhengzhou, China
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13
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Mayerl CJ, Myrla AM, Gould FDH, Bond LE, Stricklen BM, German RZ. Swallow Safety is Determined by Bolus Volume During Infant Feeding in an Animal Model. Dysphagia 2020; 36:120-129. [PMID: 32328794 DOI: 10.1007/s00455-020-10118-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2019] [Accepted: 04/15/2020] [Indexed: 12/14/2022]
Abstract
Feeding difficulties are especially prevalent in preterm infants, although the mechanisms driving these difficulties are poorly understood due to a lack of data on healthy infants. One potential mechanism of dysphagia in adults is correlated with bolus volume. Yet, whether and how bolus volume impacts swallow safety in infant feeding is unknown. A further complication for safe infant swallowing is recurrent laryngeal nerve (RLN) injury due to patent ductus arteriosus surgery, which exacerbates the issues that preterm infants face and can increase the risk of dysphagia. Here, we used a validated animal model feeding freely to test the effect of preterm birth, postnatal maturation and RLN lesion and their interactions on swallow safety. We also tested whether bolus size differed with lesion or birth status, and the relationship between bolus size and swallow safety. We found very little effect of lesion on swallow safety, and preterm infants did not experience more penetration or aspiration than term infants. However, term infants swallowed larger boluses than preterm infants, even after correcting for body size. Bolus size was the primary predictor of penetration or aspiration, with larger boluses being more likely to result in greater degrees of dysphagia irrespective of age or lesion status. These results highlight that penetration and aspiration are likely normal occurrences in infant feeding. Further, when comorbidities, such as RLN lesion or preterm birth are present, limiting bolus size may be an effective means to reduce incidences of penetration and aspiration.
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Affiliation(s)
- Christopher J Mayerl
- Department of Anatomy and Neurobiology, Northeast Ohio Medical University (NEOMED), Rootstown, OH, 44272, USA.
| | - Alexis M Myrla
- Department of Anatomy and Neurobiology, Northeast Ohio Medical University (NEOMED), Rootstown, OH, 44272, USA
| | - Francois D H Gould
- Department of Cell Biology and Neuroscience, Rowan School of Osteopathic Medicine, Stratford, NJ, USA
| | - Laura E Bond
- Department of Anatomy and Neurobiology, Northeast Ohio Medical University (NEOMED), Rootstown, OH, 44272, USA
| | - Bethany M Stricklen
- Department of Anatomy and Neurobiology, Northeast Ohio Medical University (NEOMED), Rootstown, OH, 44272, USA
| | - Rebecca Z German
- Department of Anatomy and Neurobiology, Northeast Ohio Medical University (NEOMED), Rootstown, OH, 44272, USA
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14
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Mayerl CJ, Catchpole EA, Edmonds CE, Gould FDH, McGrattan KE, Bond LE, Stricklen BM, German RZ. The effect of preterm birth, recurrent laryngeal nerve lesion, and postnatal maturation on hyoid and thyroid movements, and their coordination in infant feeding. J Biomech 2020; 105:109786. [PMID: 32307182 DOI: 10.1016/j.jbiomech.2020.109786] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2019] [Revised: 03/31/2020] [Accepted: 04/02/2020] [Indexed: 01/03/2023]
Abstract
Movements of the hyoid and thyroid are critical for feeding. These structures are often assumed to move in synchrony, despite evidence that neurologically compromised populations exhibit altered kinematics. Preterm infants are widely considered to be a neurologically compromised population and often experience feeding difficulties, yet measuring performance, and how performance matures in pediatric populations is challenging. Feeding problems are often compounded by complications arising from surgical procedures performed to ensure the survival of preterm infants, such as damage to the recurrent laryngeal nerve (RLN) during patent ductus arteriosus correction surgery. Here, we used a validated infant pig model for infant feeding to test how preterm birth, postnatal maturation, and RLN lesion interact to impact hyoid and thyroid excursion and their coordination. We filmed infant pigs when feeding using videofluorscopy at seven days old (1-2 months human equivalent) and 17 days old (6-9 months human equivalent) and tracked movements of the hyoid and thyroid on both days. We found that preterm birth impacted the coordination between hyoid and thyroid movements, but not their actual excursion. In contrast, excursion of the two structures increased with postnatal age in term and preterm pigs. RLN lesion decreased thyroid excursion, and primarily impacted hyoid movements by increasing variation in hyoid excursion. This work demonstrates that RLN lesion and preterm birth have distinct, but pervasive effects on feeding performance in infants, and suggest that interventions targeted towards reducing dysphagia should be prescribed based off the etiology driving dysphagia, rather than the prognosis of dysphagia.
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Affiliation(s)
- Christopher J Mayerl
- Department of Anatomy and Neurobiology, Northeast Ohio Medical University (NEOMED), Rootstown, OH, 44272, United States.
| | - Emily A Catchpole
- Department of Anatomy and Neurobiology, Northeast Ohio Medical University (NEOMED), Rootstown, OH, 44272, United States
| | - Chloe E Edmonds
- Department of Anatomy and Neurobiology, Northeast Ohio Medical University (NEOMED), Rootstown, OH, 44272, United States
| | - Francois D H Gould
- Department of Cell Biology and Neuroscience, Rowan School of Osteopathic Medicine, Stratford, NJ, 08854, United States
| | - Katlyn E McGrattan
- Department of Speech-Language-Hearing Science, University of Minnesota, Minneapolis, MN, 55455, United States
| | - Laura E Bond
- Department of Anatomy and Neurobiology, Northeast Ohio Medical University (NEOMED), Rootstown, OH, 44272, United States
| | - Bethany M Stricklen
- Department of Anatomy and Neurobiology, Northeast Ohio Medical University (NEOMED), Rootstown, OH, 44272, United States
| | - Rebecca Z German
- Department of Anatomy and Neurobiology, Northeast Ohio Medical University (NEOMED), Rootstown, OH, 44272, United States
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15
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Stricklen BM, Bond LE, Gould FDH, German RZ, Mayerl CJ. Swallow Safety in Infant Pigs With and Without Recurrent Laryngeal Nerve Lesion. Dysphagia 2020; 35:978-984. [PMID: 32112144 DOI: 10.1007/s00455-020-10099-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2019] [Accepted: 02/17/2020] [Indexed: 01/22/2023]
Abstract
Aerodigestive coordination is critical for safe feeding in mammals, and failure to do so can result in aspiration. Using an infant pig model, we analyzed the impact of recurrent laryngeal nerve (RLN) lesion on aerodigestive coordination and swallow safety at two time points prior to weaning. We used high-speed videofluoroscopy to record 23 infant pigs longitudinally at two ages (7 days, 17 days) feeding on barium milk. We measured respiration with a plethysmograph and used the Infant Mammalian Penetration-Aspiration Scale (IMPAS) to identify unsafe swallows. We tested for changes in swallow safety longitudinally in control and lesion pigs, and whether there was any interaction between the four different groups. On postnatal day 7, lesioned pigs exhibited differences in the frequency distribution of IMPAS scores relative to control pigs on day 7, and 17 day old lesion and control pigs. There were longitudinal changes in performance following RLN lesion through time, suggesting that the impact of RLN lesion decreases with time, as older lesioned pigs performed similarly to older control pigs. We found minimal differences in the impact of aerodigestive coordination on swallow safety, with shorter delays of inspiration onset reflecting higher rates of penetration in young lesioned pigs. Healthy pigs aspirated at a similar rate to those with an RLN lesion indicating that the occasional occurrence of dysphagia in infants may be a normal behavior.
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Affiliation(s)
- Bethany M Stricklen
- Department of Anatomy and Neurobiology, Northeast Ohio Medical University (NEOMED), Rootstown, OH, 44272, USA
| | - Laura E Bond
- Department of Anatomy and Neurobiology, Northeast Ohio Medical University (NEOMED), Rootstown, OH, 44272, USA
| | - Francois D H Gould
- Department of Cell Biology and Neuroscience, Rowan School of Osteopathic Medicine, Stratford, NJ, USA
| | - Rebecca Z German
- Department of Anatomy and Neurobiology, Northeast Ohio Medical University (NEOMED), Rootstown, OH, 44272, USA
| | - Christopher J Mayerl
- Department of Anatomy and Neurobiology, Northeast Ohio Medical University (NEOMED), Rootstown, OH, 44272, USA.
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16
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Gould FDH, Lammers AR, Mayerl CJ, German RZ. Specific Vagus Nerve Lesion Have Distinctive Physiologic Mechanisms of Dysphagia. Front Neurol 2019; 10:1301. [PMID: 31920925 PMCID: PMC6920241 DOI: 10.3389/fneur.2019.01301] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2019] [Accepted: 11/26/2019] [Indexed: 01/17/2023] Open
Abstract
Swallowing is complex at anatomical, functional, and neurological levels. The connections among these levels are poorly understood, yet they underpin mechanisms of swallowing pathology. The complexity of swallowing physiology means that multiple failure points may exist that lead to the same clinical diagnosis (e.g., aspiration). The superior laryngeal nerve (SLN) and the recurrent laryngeal nerve (RLN) are branches of the vagus that innervate different structures involved in swallowing. Although they have distinct sensory fields, lesion of either nerve is associated clinically with increased aspiration. We tested the hypothesis that despite increased aspiration in both case, oropharyngeal kinematic changes and their relationship to aspiration would be different in RLN and SLN lesioned infant pigs. We compared movements of the tongue and epiglottis in swallows before and after either RLN or SLN lesion. We rated swallows for airway protection. Posterior tongue ratio of safe swallows changed in RLN (p = 0.01) but not SLN lesioned animals. Unsafe swallows post lesion had different posterior tongue ratios in RLN and SLN lesioned animals. Duration of epiglottal inversion shortened after lesion in SLN animals (p = 0.02) but remained unchanged in RLN animals. Thus, although SLN and RLN lesion lead to the same clinical outcome (increased aspiration), the mechanisms of failure of airway protection are different, which suggests that effective therapies may be different with each injury. Understanding the specific pathophysiology of swallowing associated with specific neural insults will help develop targeted, disease appropriate treatments.
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Affiliation(s)
- François D H Gould
- Department of Cell Biology and Neuroscience, Rowan University School of Osteopathic Medicine, Stratford, NJ, United States
| | - Andrew R Lammers
- School of Health Sciences, Cleveland State University, Cleveland, OH, United States
| | | | - Rebecca Z German
- Department of Anatomy and Neurobiology, NEOMED, Rootstown, OH, United States
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17
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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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18
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Yu Y, Li Y, Lu Y, Hua X, Ma H, Li H, Wei X, Zhang J, Chen X, Liu Q, Zhu Z, Xu L, Zhang R, Sun H, Wang Z. Chin-down-plus-larynx-tightening maneuver improves choking cough after esophageal cancer surgery. ANNALS OF TRANSLATIONAL MEDICINE 2019; 7:376. [PMID: 31555690 DOI: 10.21037/atm.2019.07.08] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background Esophageal cancer patients can benefit from dissection of the recurrent laryngeal nerve (RLN) lymph node (LN); however, this procedure increases the risk of RLN injury. After nerve injury, many complications can occur, including choking cough, which can affect patients' quality of life. This study examined the effectiveness of the chin-down-plus-larynx-tightening maneuver for improving choking cough after radical thoracic esophageal cancer surgery. Methods Sixty-two patients with resectable thoracic esophageal cancer presented with choking cough, hoarseness or vocal cord paralysis after radical operations. Twenty-two patients who choked on water were guided to swallow 1 mL of warm water using a chin-down-plus-larynx-tightening maneuver. Choking cough relief results and their relationships with clinical factors were analyzed. Results No correlation was found between the occurrence of post-operative choking cough and gender, age, surgical method, hoarseness, vocal cord fixation type, vocal cord fixation, or glottal closure. Multivariate regression analysis revealed no independent risk factors associated with choking cough. Choking cough was completely relieved in 17 of 22 (77.3%) patients. Fifteen of 19 (78.9%) patients with choking cough and hoarseness, and 2 of 3 patients with only choking cough reported complete relief when they tried the new maneuver. The chin-down-plus-larynx-tightening maneuver was more effective for males than for females. Conclusions The chin-down-plus-larynx-tightening maneuver significantly relieved choking cough; thus, this maneuver can aid in managing choking cough after radical thoracic esophageal cancer surgery.
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Affiliation(s)
- Yongkui Yu
- Department of Thoracic Surgery, The Affiliated Cancer Hospital of Zhengzhou University, Zhengzhou 450000, China
| | - Yin Li
- Department of Thoracic Surgery, The Affiliated Cancer Hospital of Zhengzhou University, Zhengzhou 450000, China.,Department of Thoracic Surgery, Cancer Hospital Chinese Academy of Medical Sciences, Beijing 100000, China
| | - Yingmin Lu
- Department of Thoracic Surgery, The Zhengzhou Center Hospital Affiliated to Zhengzhou University, Zhengzhou 450000, China
| | - Xionghuai Hua
- Department of Thoracic Surgery, He'nan Chest Hospital, Zhengzhou 450000, China
| | - Haibo Ma
- Department of Thoracic Surgery, The Affiliated Cancer Hospital of Zhengzhou University, Zhengzhou 450000, China
| | - Haomiao Li
- Department of Thoracic Surgery, The Affiliated Cancer Hospital of Zhengzhou University, Zhengzhou 450000, China
| | - Xiufeng Wei
- Department of Thoracic Surgery, The First Affiliated Hospital of Xinxiang Medical University, Xinxiang 453000, China
| | - Jun Zhang
- Department of Thoracic Surgery, The Affiliated Cancer Hospital of Zhengzhou University, Zhengzhou 450000, China
| | - Xiankai Chen
- Department of Thoracic Surgery, Cancer Hospital Chinese Academy of Medical Sciences, Beijing 100000, China
| | - Qi Liu
- Department of Thoracic Surgery, The Affiliated Cancer Hospital of Zhengzhou University, Zhengzhou 450000, China
| | - Zhengshuai Zhu
- Department of Thoracic Surgery, Nanyang Central Hospital, Nanyang 473000, China
| | - Lei Xu
- Department of Thoracic Surgery, Cancer Hospital Chinese Academy of Medical Sciences, Beijing 100000, China
| | - Ruixiang Zhang
- Department of Thoracic Surgery, The Affiliated Cancer Hospital of Zhengzhou University, Zhengzhou 450000, China
| | - Haibo Sun
- Department of Thoracic Surgery, The Affiliated Cancer Hospital of Zhengzhou University, Zhengzhou 450000, China
| | - Zongfei Wang
- Department of Thoracic Surgery, The Affiliated Cancer Hospital of Zhengzhou University, Zhengzhou 450000, China
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19
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Mok A, Allen J, Haney MM, Deninger I, Ballenger B, Caywood V, Osman KL, Zitsch B, Hopewell BL, Thiessen A, Szewczyk M, Ohlhausen D, Newberry CI, Leary E, Lever TE. A Surgical Mouse Model for Advancing Laryngeal Nerve Regeneration Strategies. Dysphagia 2019; 35:419-437. [PMID: 31388736 DOI: 10.1007/s00455-019-10045-6] [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: 09/25/2018] [Revised: 02/06/2019] [Accepted: 07/31/2019] [Indexed: 01/16/2023]
Abstract
Iatrogenic recurrent laryngeal nerve (RLN) injury is a morbid complication of anterior neck surgical procedures. Existing treatments are predominantly symptomatic, ranging from behavioral therapy to a variety of surgical approaches. Though laryngeal reinnervation strategies often provide muscle tone to the paralyzed vocal fold (VF), which may improve outcomes, there is no clinical intervention that reliably restores true physiologic VF movement. Moreover, existing interventions neglect the full cascade of molecular events that affect the entire neuromuscular pathway after RLN injury, including the intrinsic laryngeal muscles, synaptic connections within the central nervous system, and laryngeal nerve anastomoses. Systematic investigations of this pathway are essential to develop better RLN regenerative strategies. Our aim was to develop a translational mouse model for this purpose, which will permit longitudinal investigations of the pathophysiology of iatrogenic RLN injury and potential therapeutic interventions. C57BL/6J mice were divided into four surgical transection groups (unilateral RLN, n = 10; bilateral RLN, n = 2; unilateral SLN, n = 10; bilateral SLN, n = 10) and a sham surgical group (n = 10). Miniaturized transoral laryngoscopy was used to assess VF mobility over time, and swallowing was assessed using serial videofluoroscopy. Histological assays were conducted 3 months post-surgery for anatomical investigation of the larynx and laryngeal nerves. Eight additional mice underwent unilateral RLN crush injury, half of which received intraoperative vagal nerve stimulation (iVNS). These 8 mice underwent weekly transoral laryngoscopy to investigate VF recovery patterns. Unilateral RLN injury resulted in chronic VF immobility but only acute dysphagia. Bilateral RLN injury caused intraoperative asphyxiation and death. VF mobility was unaffected by SLN transection (unilateral or bilateral), and dysphagia (transient) was evident only after bilateral SLN transection. The sham surgery group retained normal VF mobility and swallow function. Mice that underwent RLN crush injury and iVNS treatment demonstrated accelerated and improved VF recovery. We successfully developed a mouse model of iatrogenic RLN injury with impaired VF mobility and swallowing function that can serve as a clinically relevant platform to develop translational neuroregenerative strategies for RLN injury.
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Affiliation(s)
- Alexis Mok
- Department of Communication Science and Disorders, University of Missouri School of Health Professions, Columbia, MO, USA
| | - Jakob Allen
- Department of Medicine, University of Missouri School of Medicine, Columbia, MO, USA
| | - Megan M Haney
- Department of Veterinary Pathobiology, University of Missouri College of Veterinary Medicine, Columbia, MO, USA
| | - Ian Deninger
- Department of Otolaryngology - Head & Neck Surgery, University of Missouri School of Medicine, Columbia, MO, USA
| | - Brayton Ballenger
- Department of Otolaryngology - Head & Neck Surgery, University of Missouri School of Medicine, Columbia, MO, USA
| | - Victoria Caywood
- Department of Otolaryngology - Head & Neck Surgery, University of Missouri School of Medicine, Columbia, MO, USA
| | - Kate L Osman
- Department of Otolaryngology - Head & Neck Surgery, University of Missouri School of Medicine, Columbia, MO, USA
| | - Bradford Zitsch
- Department of Medicine, University of Missouri School of Medicine, Columbia, MO, USA
| | - Bridget L Hopewell
- Department of Otolaryngology - Head & Neck Surgery, University of Missouri School of Medicine, Columbia, MO, USA
| | - Aaron Thiessen
- Department of Otolaryngology - Head & Neck Surgery, University of Missouri School of Medicine, Columbia, MO, USA
| | - Marlena Szewczyk
- Department of Medicine, University of Missouri School of Medicine, Columbia, MO, USA
| | - Daniel Ohlhausen
- Department of Otolaryngology - Head & Neck Surgery, University of Missouri School of Medicine, Columbia, MO, USA
| | | | - Emily Leary
- Department of Orthopedic Surgery, University of Missouri School of Medicine, Columbia, MO, USA
| | - Teresa E Lever
- Department of Otolaryngology - Head & Neck Surgery, University of Missouri School of Medicine, Columbia, MO, USA. .,One Hospital Dr. MA314, Columbia, MO, 65212, USA.
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20
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Catchpole E, Bond L, German R, Mayerl C, Stricklen B, Gould FDH. Reduced Coordination of Hyolaryngeal Elevation and Bolus Movement in a Pig Model of Preterm Infant Swallowing. Dysphagia 2019; 35:334-342. [PMID: 31297599 DOI: 10.1007/s00455-019-10033-w] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2018] [Revised: 05/30/2019] [Accepted: 07/02/2019] [Indexed: 01/13/2023]
Abstract
Preterm infants often have dysphagia. Because reducing lifetime cumulative exposure to radiation in the context of diagnosis and treatment is a continuing goal of all medical fields which use X-ray imaging, efforts exist to reduce reliance on the gold standard diagnostic tool for dysphagia, VFSS. Alternatives, such as video of external hyolaryngeal movement using video recordings of the anterior surface of the neck, must be evaluated and validated against videofluoroscopy, a task for which non-human animal models are appropriate. In this study, we tested the hypotheses that (1) swallows could be identified equally well from video of external hyolaryngeal movement and bolus movement in videofluoroscopy, and that (2) the two measures would be tightly temporally linked in both term and preterm infant pigs. We recorded 222 swallows in simultaneous and precisely synchronized high-speed videofluoroscopy and high-speed camera films of 4 preterm and 3 term infant pigs drinking milk from a bottle. In term pigs, the two measures consistently identified the same swallows in each image stream. However, in preterm pigs there was a high rate of false positives (~ 10% per feeding sequence) and false negatives (~ 27% per feeding sequence). The timing of hyolaryngeal elevation (external video) and bolus movement (videofluoroscopy) was correlated and consistent in terms pigs, but not in preterm pigs. Magnitude of hyolaryngeal elevation was less in preterm pig swallows than term pig swallows. Absence of epiglottal inversion in preterm pigs was not linked to variation in the timing of the two swallow events. Video of external hyolaryngeal movement, though a reliable swallow indicator in term infant pigs, was unreliable in preterm infant pigs. The coordination of swallowing events differs in preterm and term infant pigs. More research is needed into the distinctive biomechanics of preterm infant pigs.
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Affiliation(s)
| | | | | | | | | | - François D H Gould
- Department of Cell Biology and Neuroscience, Rowan University School of Osteopathic Medicine, 42 East Laurel road, Stratford, NJ, 08084, USA.
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21
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Mayerl CJ, Gould FDH, Bond LE, Stricklen BM, Buddington RK, German RZ. Preterm birth disrupts the development of feeding and breathing coordination. J Appl Physiol (1985) 2019; 126:1681-1686. [PMID: 31018743 DOI: 10.1152/japplphysiol.00101.2019] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
All mammals must breathe and breathe continuously from birth. Similarly, all mammals, including infants, have high functional demands for feeding. However, the pathway that food takes through the pharynx interrupts respiration. The coordination between swallowing and breathing is therefore critical for all infant mammals. Clinically, this coordination differs between term and preterm infants. However, the neurological mechanisms underlying this coordination and how it matures as infants grow are poorly understood. Here, we integrate high-resolution data from multiple physiologic processes across a longitudinal time frame to study suck-swallow-breathe dynamics in a preterm animal model, the infant pig. In doing so, we test the hypothesis that preterm birth will have an impact on some, but not all, behaviors associated with suck-swallow-breath performance. We hypothesize that coordination will be disrupted, reflecting incomplete connections in the brainstem. We found that preterm pigs became rhythmic and mature in sucking and swallowing behaviors, suggesting substantial postnatal maturation in the coordination of these behaviors. However, their ability to coordinate swallowing and breathing never developed. These results have implications for the nature of clinical care of human infants, as well as for how feeding processes develop in mammals. Clinically, they provide a foundation for developing interventions for preterm infants. Additionally, these results suggest that the lack of coordination between swallowing and breathing may be a significant factor in determining the minimum gestation time across mammals. NEW & NOTEWORTHY Preterm infants face a variety of challenges associated with safe feeding, but obtaining high-resolution longitudinal data to understand these challenges in humans is challenging. We used a pig model to acquire high-speed videofluoroscopic and respiratory inductance plethysmograph data throughout the nursing period to show that preterm birth does not have substantial impacts on the ability of infants to perform isolated behaviors. However, it does decrease the ability of preterm infants to coordinate among behaviors during feeding.
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Affiliation(s)
- Christopher J Mayerl
- Department of Anatomy and Neurobiology, Northeast Ohio Medical University (NEOMED), Rootstown Ohio
| | - Francois D H Gould
- Department of Anatomy and Neurobiology, Northeast Ohio Medical University (NEOMED), Rootstown Ohio
| | - Laura E Bond
- Department of Anatomy and Neurobiology, Northeast Ohio Medical University (NEOMED), Rootstown Ohio
| | - Bethany M Stricklen
- Department of Anatomy and Neurobiology, Northeast Ohio Medical University (NEOMED), Rootstown Ohio
| | - Randal K Buddington
- University of Tennessee Health Science Center, College of Nursing , Memphis, Tennessee
| | - Rebecca Z German
- Department of Anatomy and Neurobiology, Northeast Ohio Medical University (NEOMED), Rootstown Ohio
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22
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Hasenstab KA, Nawaz S, Lang IM, Shaker R, Jadcherla SR. Pharyngoesophageal and cardiorespiratory interactions: potential implications for premature infants at risk of clinically significant cardiorespiratory events. Am J Physiol Gastrointest Liver Physiol 2019; 316:G304-G312. [PMID: 30543445 PMCID: PMC6397335 DOI: 10.1152/ajpgi.00303.2018] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
The aims of this study were to 1) examine pharyngoesophageal and cardiorespiratory responses to provoking pharyngeal stimuli, and 2) to determine potential contributory factors impacting heart rate (HR) changes to provide insight into cardiorespiratory events occurring in preterm infants. Forty-eight neonates (19 females and 29 males, born at 27.7 ± 0.5 wk; mean ± SE) pending discharge on full oral feeds were studied at 38.7 ± 0.2 wk postmenstrual age using concurrent pharyngoesophageal manometry, electrocardiography, respiratory inductance plethysmography, and nasal airflow thermistor. Pharyngoesophageal and cardiorespiratory responses (prevalence, latency, and duration) were quantified upon abrupt pharyngeal water stimuli (0.1, 0.3, and 0.5 ml in triplicate). Mixed linear models and generalized estimating equations were used for comparisons between HR changes. Contributory factors included stimulus characteristics and subject characteristics. Of 338 pharyngeal stimuli administered, HR increased in 23 (7%), decreased in 108 (32%), and remained stable in 207 (61%) neonates. HR decrease resulted in repetitive swallowing, increased respiratory-rhythm disturbance, and decreased esophageal propagation rates (all, P < 0.05). HR responses were related to stimulus volume, stimulus flow rate, and extreme prematurity (all, P < 0.05). In preterm infants, HR remains stable in a majority of pharyngeal provocations. HR decrease, due to pharyngeal stimulation, is related to aberrant pharyngoesophageal motility and respiratory dysregulation and is magnified by prematurity. We infer that the observed aberrant responses across digestive, respiratory, and cardiovascular systems are related to maladaptive maturation of the parasympathetic nervous system. These aberrant responses may provide diagnostic clues for risk stratification of infants with troublesome cardiorespiratory events and swallowing difficulty. NEW & NOTEWORTHY Cardiorespiratory rhythms concurrent with pharyngeal, upper esophageal sphincter, and esophageal body responses were examined upon pharyngeal provocation in preterm-born infants who were studied at full-term maturation. Decreased heart rate (HR) was associated with extreme preterm birth and stimulus flow/volume. With HR decrease responses, aerodigestive reflex abnormalities were present, characterized by prolonged respiratory rhythm disturbance, repetitive multiple swallowing, and poor esophageal propagation. Promoting esophageal peristalsis may be a potential therapeutic target.
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Affiliation(s)
- Kathryn A. Hasenstab
- 1Innovative Neonatal and Infant Feeding Disorders Research Program, Center for Perinatal Research, The Research Institute at Nationwide Children’s Hospital, Columbus, Ohio
| | - Saira Nawaz
- 1Innovative Neonatal and Infant Feeding Disorders Research Program, Center for Perinatal Research, The Research Institute at Nationwide Children’s Hospital, Columbus, Ohio
| | - Ivan M. Lang
- 2Medical College of Wisconsin Dysphagia Institute, Division of Gastroenterology and Hepatology, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Reza Shaker
- 2Medical College of Wisconsin Dysphagia Institute, Division of Gastroenterology and Hepatology, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Sudarshan R. Jadcherla
- 1Innovative Neonatal and Infant Feeding Disorders Research Program, Center for Perinatal Research, The Research Institute at Nationwide Children’s Hospital, Columbus, Ohio,3Department of Pediatrics, The Ohio State University College of Medicine, Columbus, Ohio,4Division of Neonatology, Pediatric Gastroenterology and Nutrition, Nationwide Children’s Hospital, Columbus, Ohio
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23
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DeLozier KR, Gould FDH, Ohlemacher J, Thexton AJ, German RZ. Impact of recurrent laryngeal nerve lesion on oropharyngeal muscle activity and sensorimotor integration in an infant pig model. J Appl Physiol (1985) 2018; 125:159-166. [PMID: 29648522 DOI: 10.1152/japplphysiol.00963.2017] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023] Open
Abstract
The successful performance of a swallow requires dynamic integration between a wide range of sensory inputs and muscle activities to produce the coordinated kinematics of oropharyngeal structures. Damage to the recurrent laryngeal nerve (RLN) produces dysphagia in infants, with food or liquid entering the airway despite this nerve having minimal direct sensory or motor connections to the act of swallowing, apart from vocal fold closure. Previous results have demonstrated that a complete RLN lesion disrupts both performance and kinematics before initiation of the pharyngeal swallow in infants. We tested the hypothesis that a RLN lesion produces changes in the normal activity of oral floor, tongue, and infrahyoid muscles during a swallow. We recorded swallowing in our validated infant pig model, with synchronous high-speed imaging and fine-wire, chronic electromyography. We found changes in the timing, duration, and amplitude of the motor pattern in an array of muscles that are supplied by several different cranial and cervical nerves. Some of these changes in muscle activity are associated with the preparatory aspects of bolus aggregation or movement and so occur before the pharyngeal swallow. Taken with previous biomechanical results, these patterns suggest an intricate brain stem sensorimotor integration that occurs as part of a swallow. In particular, the execution of oral motor function is changed as a result of this simple lesion. NEW & NOTEWORTHY Damage to the recurrent laryngeal nerve compromises swallowing despite an absent or minimal contribution to either the motor or sensory aspects of this function. This study documents EMG changes, following RLN lesion, to non-RLN innervated muscles that are active during swallowing in an infant model. Some of these muscles fire before the pharyngeal swallow and are associated with the preparatory aspects of bolus aggregation and movement, suggesting important sensorimotor integration at a brain stem level.
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Affiliation(s)
- Katherine R DeLozier
- Department of Anatomy and Neurobiology, Northeast Ohio Medical University, Rootstown, Ohio
| | - Francois D H Gould
- Department of Anatomy and Neurobiology, Northeast Ohio Medical University, Rootstown, Ohio
| | - Jocelyn Ohlemacher
- Department of Anatomy and Neurobiology, Northeast Ohio Medical University, Rootstown, Ohio
| | - Allan J Thexton
- Department of Physiology, King's College , London , United Kingdom
| | - Rebecca Z German
- Department of Anatomy and Neurobiology, Northeast Ohio Medical University, Rootstown, Ohio
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24
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Ballester A, Gould F, Bond L, Stricklen B, Ohlemacher J, Gross A, DeLozier K, Buddington R, Buddington K, Danos N, German R. Maturation of the Coordination Between Respiration and Deglutition with and Without Recurrent Laryngeal Nerve Lesion in an Animal Model. Dysphagia 2018; 33:627-635. [PMID: 29476275 DOI: 10.1007/s00455-018-9881-z] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2017] [Accepted: 02/15/2018] [Indexed: 01/02/2023]
Abstract
The timing of the occurrence of a swallow in a respiratory cycle is critical for safe swallowing, and changes with infant development. Infants with damage to the recurrent laryngeal nerve, which receives sensory information from the larynx and supplies the intrinsic muscles of the larynx, experience a significant incidence of dysphagia. Using our validated infant pig model, we determined the interaction between this nerve damage and the coordination between respiration and swallowing during postnatal development. We recorded 23 infant pigs at two ages (neonatal and older, pre-weaning) feeding on milk with barium using simultaneous high-speed videofluoroscopy and measurements of thoracic movement. With a complete linear model, we tested for changes with maturation, and whether these changes are the same in control and lesioned individuals. We found (1) the timing of swallowing and respiration coordination changes with maturation; (2) no overall effect of RLN lesion on the timing of coordination, but (3) a greater magnitude of maturational change occurs with RLN injury. We also determined that animals with no surgical intervention did not differ from animals that had surgery for marker placement and a sham procedure for nerve lesion. The coordination between respiration and swallowing changes in normal, intact individuals to provide increased airway protection prior to weaning. Further, in animals with an RLN lesion, the maturation process has a larger effect. Finally, these results suggest a high level of brainstem sensorimotor interactions with respect to these two functions.
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Affiliation(s)
- Ashley Ballester
- Department of Anatomy and Neurobiology, NEOMED, Rootstown, OH, 44272, USA.,Division of Obstetrics and Gynecology, Akron General Hospital, Akron, OH, USA
| | - François Gould
- Department of Anatomy and Neurobiology, NEOMED, Rootstown, OH, 44272, USA
| | - Laura Bond
- Department of Anatomy and Neurobiology, NEOMED, Rootstown, OH, 44272, USA
| | - Bethany Stricklen
- Department of Anatomy and Neurobiology, NEOMED, Rootstown, OH, 44272, USA
| | - Jocelyn Ohlemacher
- Department of Anatomy and Neurobiology, NEOMED, Rootstown, OH, 44272, USA
| | - Andrew Gross
- Department of Anatomy and Neurobiology, NEOMED, Rootstown, OH, 44272, USA
| | - Katherine DeLozier
- Department of Anatomy and Neurobiology, NEOMED, Rootstown, OH, 44272, USA
| | - Randall Buddington
- School of Health Studies, University of Memphis, Memphis, TN, 38152, USA
| | - Karyl Buddington
- Department of Biological Sciences, University of Memphis, Memphis, TN, 38152, USA
| | | | - Rebecca German
- Department of Anatomy and Neurobiology, NEOMED, Rootstown, OH, 44272, USA.
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25
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Gross A, Ohlemacher J, German R, Gould F. LVC Timing in Infant Pig Swallowing and the Effect of Safe Swallowing. Dysphagia 2017; 33:51-62. [PMID: 28780633 DOI: 10.1007/s00455-017-9832-0] [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: 04/27/2017] [Accepted: 08/01/2017] [Indexed: 11/27/2022]
Abstract
Recurrent laryngeal nerve (RLN) injury in neonates, a complication of head and neck surgeries, leads to increased aspiration risk and swallowing dysfunction. The severity of resulting sequelae range from morbidity, such as aspiration pneumonia, to mortality from infection and failure to thrive. The timing of airway protective events including laryngeal vestibule closure (LVC) is implicated in aspiration. We unilaterally transected the RLN in an infant pig model to observe changes in the timing of swallowing kinematics with lesion and aspiration. We recorded swallows using high-speed video-fluoroscopic swallow studies (VFSS) and scored them using the Infant Mammalian Penetration and Aspiration Scale (IMPAS). We hypothesized that changes would occur in swallowing kinematics (1) between RLN lesion and control animals, and (2) among safe swallows (IMPAS 1), penetration swallows (IMPAS 3), and aspiration swallows (IMPAS 7). We observed numerous changes in timing following RLN lesion in safe and unsafe swallows, suggesting pervasive changes in the coordination of oropharyngeal function. The timing of LVC, posterior tongue, and hyoid movements differed between pre- and post-lesion in safe swallows. Posterior tongue kinematics differed for post-lesion swallows with penetration. The timing and duration of LVC and posterior tongue movement differed between aspiration swallows pre- and post-lesion. After lesion, safe swallows and swallows with aspiration differed in timing of LVC, laryngeal vestibule opening, and posterior tongue and hyoid movements. The timing of thyrohyoid muscle activity varied with IMPAS, but not lesion. Further study into the pathophysiology of RLN lesion-induced swallowing dysfunction is important to developing novel therapies.
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Affiliation(s)
- Andrew Gross
- Department of Anatomy and Neurobiology, Northeast Ohio Medical University, 4209 St. Rt. 44, PO Box 95, Rootstown, OH, 44272, USA.
| | - Jocelyn Ohlemacher
- Department of Anatomy and Neurobiology, Northeast Ohio Medical University, 4209 St. Rt. 44, PO Box 95, Rootstown, OH, 44272, USA
| | - Rebecca German
- Department of Anatomy and Neurobiology, Northeast Ohio Medical University, 4209 St. Rt. 44, PO Box 95, Rootstown, OH, 44272, USA
| | - Francois Gould
- Department of Anatomy and Neurobiology, Northeast Ohio Medical University, 4209 St. Rt. 44, PO Box 95, Rootstown, OH, 44272, USA
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26
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Animal Models for Dysphagia Studies: What Have We Learnt So Far. Dysphagia 2017; 32:73-77. [PMID: 28132098 DOI: 10.1007/s00455-016-9778-7] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2016] [Accepted: 12/30/2016] [Indexed: 10/20/2022]
Abstract
Research using animal models has contributed significantly to realizing the goal of understanding dysfunction and improving the care of patients who suffer from dysphagia. But why should other researchers and the clinicians who see patients day in and day out care about this work? Results from studies of animal models have the potential to change and grow how we think about dysphagia research and practice in general, well beyond applying specific results to human studies. Animal research provides two key contributions to our understanding of dysphagia. The first is a more complete characterization of the physiology of both normal and pathological swallow than is possible in human subjects. The second is suggesting of specific, physiological, targets for development and testing of treatment interventions to improve dysphagia outcomes.
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27
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Pre-pharyngeal Swallow Effects of Recurrent Laryngeal Nerve Lesion on Bolus Shape and Airway Protection in an Infant Pig Model. Dysphagia 2016; 32:362-373. [PMID: 27873091 DOI: 10.1007/s00455-016-9762-2] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2016] [Accepted: 11/08/2016] [Indexed: 01/05/2023]
Abstract
Recurrent laryngeal nerve (RLN) damage in infants leads to increased dysphagia and aspiration pneumonia. Recent work has shown that intraoral transport and swallow kinematics change following RLN lesion, suggesting potential changes in bolus formation prior to the swallow. In this study, we used geometric morphometrics to understand the effect of bolus shape on penetration and aspiration in infants with and without RLN lesion. We hypothesized (1) that geometric bolus properties are related to airway protection outcomes and (2) that in infants with RLN lesion, the relationship between geometric bolus properties and dysphagia is changed. In five infant pigs, dysphagia in 188 swallows was assessed using the Infant Mammalian Penetration-Aspiration Scale (IMPAS). Using images from high-speed VFSS, bolus shape, bolus area, and tongue outline were quantified digitally. Bolus shape was analyzed using elliptical Fourier analysis, and tongue outline using polynomial curve fitting. Despite large inter-individual differences, significant within individual effects of bolus shape and bolus area on airway protection exist. The relationship between penetration-aspiration score and both bolus area and shape changed post lesion. Tongue shape differed between pre- and post-lesion swallows, and between swallows with different IMPAS scores. Bolus shape and area affect airway protection outcomes. RLN lesion changes that relationship, indicating that proper bolus formation and control by the tongue require intact laryngeal sensation. The impact of RLN lesion on dysphagia is pervasive.
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28
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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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