Effect of Tongue-Hold Swallow on Pharyngeal Contractile Properties in Healthy Individuals

Do We Know the Long-Term Effects of the Most Popular Traditional Swallow Maneuvers on the Submental Muscles?

BACKGROUND

Various trainings focus on the submental muscles (SMs) for dysphagia rehabilitation because of their importance for swallowing safety and efficiency. According to the current literature, swallow-specific tasks may be optimal exercises for dysphagia. The effortful swallow (ES) and the Masako maneuver (MM) are the most commonly used swallow-specific tasks in the clinical settings for dysphagia for years, but long-term effects for these trainings is insufficient.

OBJECTIVES

This study aims to investigate and compare the effects of ES and MM on SM activity, strength and thickness.

METHODS

Thirty-seven healthy adults were randomised to ES, MM and control groups, and ES and MM groups completed 6 weeks of swallowing training. Participants in both training groups performed a total of 120 swallows in each session, while control group did not participate in any swallowing training. Surface electromyography was used to evaluate SM activity, digital dynamometer for SM strength and ultrasonography for SM thickness.

RESULTS

Both trainings did not change SM activity (p > 0.05), but increased SM strength (p < 0.05). MM increased the thickness of all SM (p < 0.05), and ES increased the thickness of mylohyoid (right, left) and digastric muscle (right) (p < 0.05), and there was no change in all evaluation parameters in the control group (p > 0.05). Also, trainings were not superior to each other in any parameter (p > 0.05).

CONCLUSION

The results of this study provided new evidence to the literature to show that ES and MM trainings are effective for improving SM strength and thickness. Considering that SM is important in terms of swallowing safety and effectiveness, it is thought that both trainings may be promising by increasing the strength and mass of SM, especially in individuals with reduced SM strength and mass.

Integration of Dysphagia Therapy Techniques into Voice Rehabilitation: Design and Content Validation of a Cross-Therapy Protocol

BACKGROUND

The intricate relationship between swallowing and phonation, sharing anatomical and physiological substrates, underscores a clinical demand for integrated therapeutic approaches. Existing interventions often address these functions in isolation, overlooking their interconnected dynamics.

OBJECTIVE

To design and validate a cross-therapy protocol incorporating dysphagia therapy techniques (maneuvers/exercises) into voice rehabilitation. This protocol aims to exploit the shared biomechanical components of swallowing and phonation to improve both functions simultaneously in patients with underlying hypofunctional laryngeal pathology.

METHODS

A descriptive research design was employed, consisting of three phases: a comprehensive literature review and expert discussions in a German seminar format to conceptualize the protocol; detailed analysis and categorization of swallowing maneuvers/exercises; and content validation by a panel of seven experts through a structured evaluation instrument. The process integrated motor learning and exercise physiology principles to ensure the protocol's clinical applicability and theoretical coherence.

RESULTS

The developed cross-therapy protocol incorporates four core swallowing therapy techniques to voice therapy procedures. Selected swallowing therapy techniques target laryngeal excursion and vocal fold closure because they are critical components of swallowing and phonation. Expert validation yielded a Content Validity Coefficient exceeding 0.90 for most items, indicating high consensus on the protocol's relevance, clarity, and applicability. Adjustments were made based on feedback, enhancing the protocol's precision and user-friendliness.

CONCLUSION

We present a novel, evidence-based therapy protocol for voice and swallowing difficulties resulting from hypofunctional laryngeal pathology. Its development marks a significant step toward bridging the gap between swallowing and voice therapy. Future empirical studies are needed to assess its effectiveness in clinical settings.

Effect of Tongue-Hold Swallow on Laryngeal Elevation During Swallowing in Healthy Older Men

OBJECTIVE

This study aimed to determine whether tongue-hold swallow (THS) training affects laryngeal elevation in healthy older men during swallowing and whether THS induces muscle activity comparable to that of the Mendelsohn maneuver (MM), which is known to improve laryngeal elevation.

METHODS

In study 1, 10 healthy older men were trained (two sets/day, five days/week for six weeks) with THS. They visited the clinic four times to evaluate the training effect with the maximum tongue pressure as well as the distance and peak velocity of laryngeal elevation. Laryngeal elevation was measured in a total of four conditions, two bolus conditions (saliva and water) and two swallowing methods (normal swallow (NS) and effortful swallow (ES)), using a noninvasive laryngeal elevation measurement device. In study 2, surface electromyography was performed on the same participants as in study 1 to measure integrated electromyography (iEMG) and iEMG/s during NS, THS, and MM by placing the surface electrodes on the submental muscle region and the thyrohyoid muscle region.

RESULTS

In study 1, the maximum tongue pressure was significantly different between the first and other three evaluation visits and between the second and fourth visits, increasing gradually. Regarding the laryngeal elevation, only the distance showed a statistically significant increase between the first and fourth visits in the saliva/ES condition. In study 2, the iEMG/s of the submental muscles was greater in THS than in NS, while the iEMG value was greater in THS and MM than in NS. The iEMG value of the thyrohyoid muscle region was greater in MM than in NS and also in MM than in THS.

CONCLUSIONS

The maximum tongue pressure and laryngeal elevation distance in the saliva/ES condition were greater after the training. THS and MM showed similar levels of muscle activity in the submental muscles but not in the thyrohyoid muscle region. Therefore, the combination of THS with other training is recommended in strengthening the laryngeal elevation. THS may contribute not only to an increase of the posterior pharyngeal wall constriction and tongue retraction but also to an enhancement of the laryngeal elevation.

Preventing radiation-induced dysphagia and trismus in head and neck cancer-A randomized controlled trial

BACKGROUND

Radiation-induced dysphagia and restricted mouth opening are common problems among patients with head and neck cancer. The aim of the present randomized controlled trial was to determine if an exercise protocol could prevent swallowing and mouth opening impairment.

METHODS

Eighty-nine participants were randomly assigned to either an active group performing preventive swallowing and mouth opening exercises (n = 45) or to a control group (n = 44). Outcome measures were collected at baseline before radiotherapy and approximately 1-month post-treatment. Primary endpoints were changes in swallowing function according to the Penetration Aspiration Scale and mouth opening ability measured in millimeters. Intention-to-treat analysis was used.

RESULTS

Swallowing function and mouth opening deteriorated in both groups, with no statistically significant positive effect of the protocol detected at follow-up. Among patients who completed >75% of exercises, there was a trend toward better outcomes.

CONCLUSIONS

Preventive exercises did not improve short-term swallowing function and mouth opening after radiotherapy.

Characterization of pharyngeal contractile integral using pharyngeal manometry in children

OBJECTIVES

Pharyngeal contractile integral (PhCI) is the product of mean pharyngeal contractile amplitude, length, and duration, and provides a single metric for the vigor of entire pharyngeal contraction. A major limitation in children is lack of characterization of PhCI on high-resolution pharyngeal manometry. We aimed to determine and compare the values of PhCI in children with the abnormal and normal videofluoroscopic study of swallow (VFSS).

METHODS

Children who underwent high-resolution pharyngeal and esophageal manometry (HRPM/HREM), as well as VFSS, were divided into two groups; "normal VFSS" and "abnormal VFSS" groups. PhCI was calculated from the pharyngo-esophageal manometry analysis software (MMS, v9.5, Laborie Medical Technologies), and compared in these two groups.

RESULTS

Of 67 children, 9 had abnormal VFSS (mean age 64 ± 50 months; 66.7% males), while 58 had normal VFSS (mean age 123 ± 55 months; 47% males). The mean PhCI in abnormal and normal VFSS groups was 82.00 ± 51.90 and 147.28 ± 53.89 mmHg.s.cm, respectively (p = 0.001). Subjects with abnormal VFSS were significantly younger than those with normal VFSS (p = 0.003). However, after adjusting for the VFSS result, age was no longer related to PhCI (p = 0.364). In subgroup analysis of children presenting with dysphagia, the mean PhCI in abnormal (9 subjects) and normal (36 subjects) VFSS groups was 82.00 ± 51.90 and 141.86 ± 50.39 mmHg.s.cm, respectively (p = 0.003).

CONCLUSIONS

PhCI was significantly lower in children with abnormal VFSS than in those with normal VFSS. We did not find a significant impact of age on PhCI in our pediatric populations.

Swallowing kinematics and submental muscles activation during a newly designed maneuver called Mouth Open Swallowing Maneuver: A comparative study

The aim of this study was to design a new maneuver called the Mouth Open Swallowing Maneuver (MOSM), and to compare swallowing kinematics and submental muscles activation (SMA) between MOSM and two current approaches used in dysphagia rehabilitation. Fifty healthy volunteers were asked to perform three repetitions of dry swallowing (DS) (control task), the MOSM, the Mendelsohn Maneuver (MM), and the Tongue-Hold Maneuver (THM) during videofluoroscopic swallowing study accompanied with simultaneous SMA recording. Swallowing kinematics were measured by frame-by-frame analysis on hyolaryngeal movement using ImageJ. Swallowing with maximum hyolaryngeal movement and SMA during these tasks was used for comparative analysis. Vertical movement of the hyoid during the MOSM was significantly greater than those observed during the DS and the THM (p<0.001, p<0.001). Horizontal movement of the hyoid during DS and the THM was significantly greater than that observed during the MM (p = 0.001, p = 0.001). Vertical movement of the larynx during the MOSM was significantly greater than those observed during DS, MM, and THM (p<0.001). There was no significant difference between tasks in horizontal movement of the larynx (p = 0.785). SMA during the THM was significantly greater than that observed during MOSM (p = 0.002). No significant difference was found between other tasks in terms of SMA (p>0.05). The MOSM as a newly designed maneuver was significantly superior to other maneuvers in increasing vertical hyolaryngeal movement. The THM has as much effect on hyolaryngeal movement as the MM. In this study, the MOSM was shown to be effective in increasing hyolaryngeal movement. ClinicalTrials.gov Protocol Registration and Results System (PRS); the clinical trial registration number (NCT05579041).

A Systematic Review of Pharyngeal High-Resolution Manometry Normative Data

PURPOSE

The utilization of high-resolution pharyngeal manometry (HRPM) in the evaluation of pharyngeal dysphagia has been increasing; however, standardization of its use has lagged behind. Without standardization using normative values, it is difficult for clinicians to adopt this emerging technology into meaningful use. Our goal is to map and compare the published normative values for common HRPM metrics in order to help establish consensus reference values.

METHOD

A systematic review was conducted on prospective and retrospective studies that included HRPM metrics, defined by an international working group consensus, in healthy adult populations. Data on the following variables were extracted when available: contractile integrals of the pharynx (PhCI), velopharynx, mesopharynx, and hypopharynx, as well as the upper esophageal sphincter (UES) integrated relaxation pressure (IRP), relaxation time (RT), maximum admittance, and hypopharyngeal intrabolus pressure.

RESULTS

Thirty studies were included. Significant variation existed in the technique and equipment used to perform procedures between the different studies. Lower PhCIs and UES IRPs were seen in younger compared to older individuals. Higher UES RTs were found in individuals in the upright position compared to the supine position and in those using larger boluses sizes or smaller catheters.

CONCLUSIONS

Due to the wide variety of protocols, catheter configurations, manufacturers, and software used in the existing literature, it is difficult to formulate consensus on HPRM normative values using pooled data. Prospective studies adhering to standardized HRPM protocols for specific catheter configurations and manufacturers with larger cohorts of normal individuals are necessary to establish proper reference values for HRPM metrics.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.24843753.

Comparison of electromyography, sound, bioimpedance, and high-resolution manometry for differentiating swallowing and vocalization events

OBJECTIVES

Non-invasive surface recording devices used for detecting swallowing events include electromyography (EMG), sound, and bioimpedance. However, to our knowledge there are no comparative studies in which these waveforms were recorded simultaneously. We assessed the accuracy and efficiency of high-resolution manometry (HRM) topography, EMG, sound, and bioimpedance waveforms, for identifying swallowing events.

METHODS

Six participants randomly performed saliva swallow or vocalization of "ah" 62 times. Pharyngeal pressure data were obtained using an HRM catheter. EMG, sound, and bioimpedance data were recorded using surface devices on the neck. Six examiners independently judged whether the four measurement tools indicated a saliva swallow or vocalization. Statistical analyses included the Cochrane's Q test with Bonferroni correction and the Fleiss' kappa coefficient.

RESULTS

Classification accuracy was significantly different between the four measurement methods (P < 0.001). The highest classification accuracy was for HRM topography (>99%), followed by sound and bioimpedance waveforms (98%), then EMG waveform (97%). The Fleiss' kappa value was highest for HRM topography, followed by bioimpedance, sound, and then EMG waveforms. Classification accuracy of the EMG waveform showed the greatest difference between certified otorhinolaryngologists (experienced examiners) and non-physicians (naive examiners).

CONCLUSION

HRM, EMG, sound, and bioimpedance have fairly reliable discrimination capabilities for swallowing and non-swallowing events. User experience with EMG may increase identification and interrater reliability. Non-invasive sound, bioimpedance, and EMG are potential methods for counting swallowing events in screening for dysphagia, although further study is needed.

Toward a robust swallowing detection for an implantable active artificial larynx: a survey

Total laryngectomy consists in the removal of the larynx and is intended as a curative treatment for laryngeal cancer, but it leaves the patient with no possibility to breathe, talk, and swallow normally anymore. A tracheostomy is created to restore breathing through the throat, but the aero-digestive tracts are permanently separated and the air no longer passes through the nasal tracts, which allowed filtration, warming, humidification, olfaction, and acceleration of the air for better tissue oxygenation. As for phonation restoration, various techniques allow the patient to talk again. The main one consists of a tracheo-esophageal valve prosthesis that makes the air passes from the esophagus to the pharynx, and makes the air vibrate to allow speech through articulation. Finally, swallowing is possible through the original tract as it is now isolated from the trachea. Yet, many methods exist to detect and assess a swallowing, but none is intended as a definitive restoration technique of the natural airway, which would permanently close the tracheostomy and avoid its adverse effects. In addition, these methods are non-invasive and lack detection accuracy. The feasibility of an effective early detection of swallowing would allow to further develop an implantable active artificial larynx and therefore restore the aero-digestive tracts. A previous attempt has been made on an artificial larynx implanted in 2012, but no active detection was included and the system was completely mechanic. This led to residues in the airway because of the imperfect sealing of the mechanism. An active swallowing detection coupled with indwelling measurements would thus likely add a significant reliability on such a system as it would allow to actively close an artificial larynx. So, after a brief explanation of the swallowing mechanism, this survey intends to first provide a detailed consideration of the anatomical region involved in swallowing, with a detection perspective. Second, the swallowing mechanism following total laryngectomy surgery is detailed. Third, the current non-invasive swallowing detection technique and their limitations are discussed. Finally, the previous points are explored with regard to the inherent requirements for the feasibility of an effective swallowing detection for an artificial larynx. Graphical Abstract.

Swallowing outcome to speech therapy intervention in resistant hypertensive patients with obstructive sleep apnea

PURPOSE

To evaluate (i) the outcome of swallowing therapy program on the rehabilitation of oropharyngeal dysphagia in resistant hypertensive patients with obstructive sleep apnea (OSA) and (ii) the association between the clinical and anthropometric characteristics of these individuals and this outcome.

METHODS

This was a prospective interventional study in which resistant hypertensives diagnosed with OSA by polysomnography and dysphagia by fiberoptic endoscopic evaluation of swallowing (FESS) participated. All participants underwent a FEES and assessment of the risk of dysphagia (Eating Assessment Tool, EAT-10) and swallowing-related quality of life (Swal-QoL) before and after the intervention. The therapeutic program was performed daily by the participants, with weekly speech-therapist supervision for eight weeks, including the following strategies: Masako, chin tuck against resistance, and expiratory muscle training.

RESULTS

A total of 26 (78.8%) of the participants exhibited improvement in the degree of dysphagia in the intervention outcome. After the intervention, there was a statistically significant improvement in the level of penetration-aspiration (p = 0.007), the degree of pharyngeal residue (p = 0.001), the site of onset of the pharyngeal phase (p = 0.001), and the severity of dysphagia (p = 0.001) compared to before intervention. The EAT-10 score was 2 (0-6) before and 0 (0-3) after intervention (p = 0.023). Swal-QoL had a score on the symptom frequency domain of 92.8 (75-100) before and 98.2 (87.5-100) after intervention (p = 0.002).

CONCLUSIONS

Resistant hypertensive patients with OSA showed improved swallowing performance after swallowing therapy program.

Using high resolution manometry impedance to diagnose upper esophageal sphincter and pharyngeal motor disorders

BACKGROUND

Oro-pharyngeal pathophysiology, including upper esophageal sphincter (UES) and pharyngeal disorders, can be assessed by pharyngeal high-resolution manometry impedance (P-HRM-I). We aimed to establish methodology to diagnose disorders utilizing P-HRM-I, hypothesizing that the objective measures could be used to diagnose disordered deglutition evidenced by greater aspiration scores.

METHODS

Patients (n = 509, 18-91 years) were compared to controls (n = 120, 20-94 years). Variables measuring UES relaxation, UES opening extent, intrabolus pressure, and pharyngeal contractile strength were derived for 10 ml liquid swallows. Three associated pharyngeal pressurization patterns, which may be indicative of obstructed flow, were characterized: pan-pressurization (Type 1), distal compartmentalized pressurization (Type 2), and transient pressurization (Type 3). Deglutitive aspiration was determined from video fluoroscopy.

RESULTS

UES relaxation pressure was best able to differentiate patients from controls (T 6.528, p < 0.0001). Patients with abnormal relaxation pressure (>8 mmHg) more frequently exhibited pharyngeal pressurization patterns and had adjunct evidence of reduced luminal distensibility (high intrabolus pressure and/or reduced UES opening). Utilizing this information, a diagnostic scheme was devised identifying 138 patients with UES disorder. A further 96 patients without evidence of UES disorder had abnormally weak pharyngeal pressures, confirming propulsive disorder. Amongst a sub-sample of 320 patients undergoing video fluoroscopy, those with pharyngeal pressurizations and adjunct evidence of reduced UES relaxation and/or distensibility had higher aspiration scores (Chi-square 60.169, p < 0.0001).

CONCLUSION

P-HRM-I can provide evidence for UES disorder based on pharyngeal pressurization patterns and abnormal findings for UES relaxation pressure, UES opening, and intrabolus pressure. Measuring pharyngeal contractility requires further optimization.

Effects of Aspiration Prevention Surgery on the Dynamics of the Pharynx and Upper Esophageal Sphincter

Objective

Oral intake after aspiration prevention surgery (APS) is influenced by postoperative pharyngeal pressure and the dynamics of the upper esophageal sphincter (UES). We examined the effects of less invasive APS combined with UES relaxation techniques (laryngeal closure with cricopharyngeal myotomy [LC-CPM] and central-part laryngectomy [CPL]) on pharyngeal pressure and UES dynamics.

Study Design

Retrospective, observational study.

Setting

Single center.

Methods

We assessed the high-resolution pharyngeal manometric parameters of patients who underwent APS from 2018 to 2020. Then, we compared the effects of bilateral cricopharyngeal myotomy (combined with LC: LC-CPM group) and total cricoidectomy (CPL group) on both pharyngeal pressure and UES dynamics pre- and postoperatively.

Results

Eighteen patients (median age, 68 years; 17 men [94%]) were enrolled. Primary diseases associated with severe aspiration were neuromuscular disorders in 13, stroke in 3, and others in 2 patients. Pharyngeal swallowing pressure did not significantly change before and after APS. UES resting pressure and UES relaxation duration were significantly reduced (P < .001) and prolonged (P < .001), respectively, after APS. Only the CPL group (8 patients: median 62 years, all men) showed an increase in the velopharyngeal closure integral after APS (P < .05). More prolonged UES relaxation duration was recognized postoperatively in the CPL group (P < .01) than in the LC-CPM group.

Conclusion

Less invasive APS minimally affects pharyngeal swallowing pressure, decreases UES resting pressure, and prolongs UES relaxation duration. CPL may be more effective for postoperative UES relaxation in patients with a short UES relaxation time.

The upper esophageal sphincter in the high-resolution manometry era

BACKGROUND

The evaluation of the upper esophageal sphincter (UES) has been neglected during routine manometric tests for decades, mostly due to the limitations of the conventional manometry which were eventually overcome by high-resolution manometry (HRM).

METHODS

This study reviewed the current knowledge of the manometric evaluation of the UES in health and disease in the HRM era.

RESULTS

We found that HRM allowed more precise measurements, in addition to the parameters as compared to conventional manometry, but most of them still need confirmation of the clinical significance. The parameters used to evaluate the UES were extension, basal pressure, residual pressure, relaxation duration, relaxation time to nadir, recovery time, intrabolus pressure, and deglutitive sphincter resistance. UES may be affected by different diseases: achalasia (UES is hypertonic with impaired relaxation), gastroesophageal reflux disease (UES is short and hypotonic), globus (UES ranges from normal to impaired relaxation to hypertonic), neurologic diseases (stroke and Parkinson - UES is hypotonic in early-stage to impaired relaxation in end-stage disease), and Zenker's diverticulum (UES has impaired relaxation).

CONCLUSION

This review shows that UES dysfunction is part of several disease processes and that the study of the UES is possible and valuable with the aid of HRM.

Effect of tongue-hold swallow on posterior pharyngeal wall using dynamic area detector computed tomography

Purpose

The purpose of this study was to elucidate the effects of the tongue‐hold swallow (THS) on the pharyngeal wall by quantifying posterior pharyngeal wall (PPW) anterior bulge during the THS. In addition, the effect of tongue protrusion length on the extent of pharyngeal wall anterior bulge was analysed.

Methods

Thirteen healthy subjects (6 males and 7 females, 23–43 years) underwent 320‐row area detector CT during saliva swallow (SS) and THS at two tongue protrusion lengths (THS1 protrude the tongue as much as 1/3 of premeasured maximum tongue protrusion length (MTP‐L) and THS2 protrude the tongue as much as 2/3 of MTP‐L). To acquire images of the pharynx at rest, single‐phase volume scanning was performed three times during usual breathing with no tongue protrusion (rest), protrusion of the tongue at 1/3 of MTP‐L (rTHS1) and protrusion of the tongue at 2/3 of MTP‐L (rTHS2). Length from cervical spine to PPW (PPW‐AP) and the volume of pharyngeal cavity was measured and was compared between rest, rTHS1 and rTHS2 and between SS, THS1 and THS2. Correlation between MTP‐L and PPW‐AP was calculated in three conditions, SS, THS1 and THS2.

Results

PPW‐AP at rest, rTHS1 and rTHS2 was 2.9 ± 0.6 mm, 3.0 ± 0.5 mm and 3.0 ± 0.5 mm, respectively, showing no significant differences across swallows. PPW‐AP at the maximum pharyngeal constriction was 8.1 ± 2.0 mm, 9.1 ± 2.4 mm and 8.7 ± 2.0 mm in SS, THS1 and THS2, respectively. Compared to SS, PPW‐AP in THS1 was significantly larger (p = 0.04) and PPW‐AP in THS2 was not significantly different (p = 0.09). Pharyngeal volume at rest, rTHS1 and rTHS2 was 16.4 ± 5.2 mm³, 18.4 ± 4.5 mm³ and 21.3 ± 6.2 mm³, respectively. It was significantly larger during rTHS2 compared with rest or rTHS1 (rTHS2‐rest p = 0.007, rTHS2‐rTHS1 p = 0.007). Pharyngeal volume was completely obliterated (zero volume) at maximum pharyngeal contraction in all except one subject. There was no correlation between MTP‐L and PPW‐AP in any of the three conditions (SS, THS1 and THS2).

Discussion

This study demonstrated that the expanded pharyngeal cavity due to the tongue protrusion was completely obliterated by the increase in anterior motion of pharyngeal wall during THS. It also became clear that the degree of tongue protrusion did not linearly correlate with the movement of PPW during THS. There was no relationship between PPW motion and the MTP‐L, suggesting that the effect of tongue protrusion is better determined in each subject by analysing the motion of PPW using imaging tools.