Accuracy of High-Resolution Pharyngeal Manometry Metrics for Predicting Aspiration and Residue in Oropharyngeal Dysphagia Patients with Poor Pharyngeal Contractility

Effect of Thickened Fluids on Swallowing Function in Oropharyngeal Dysphagia: Impact of Shear Rheology and Disorder Subtype

INTRODUCTION

Fluid thickeners used in the management of oropharyngeal dysphagia exhibit non-Newtonian shear-thinning rheology, impacting their viscosity during deglutition. This study investigated how the rheological properties of thickened fluids affect pharyngeal swallowing parameters in patients with oropharyngeal motor disorders diagnosed by pharyngeal high-resolution manometry impedance (P-HRM-I).

METHODS

Seventy-two patients (18-89 years) referred for P-HRM-I were diagnostically assessed with a 10 mL thin bolus. In 57 of the patients, 10 mL swallows of two moderately thick formulations-xanthan gum (XG) and sodium carboxymethylcellulose gum (CMC)-were also tested. The XG and CMC fluids had equivalent empirical thickness but different viscosity at pharyngeal phase shear rates: XG 87 mPa.s (83-91) versus CMC mean 157 mPa.s (148-164) at 300 s-1. Standard metrics of pharyngeal and upper esophageal sphincter (UES) function were derived from P-HRM-I recordings and analyzed to characterize patients into one of four disorder subtypes: (i) No Disorder, (ii) UES Disorder, (iii) Pharyngeal Disorder, and (iv) Combination UES/Pharyngeal Disorder. Impedance recordings also assessed pharyngeal bolus transit.

RESULTS

Patients with a Combination UES/Pharyngeal Disorder were most likely to have abnormal bolus transit (82%, p < 0.001). Increasing bolus viscosity significantly influenced UES residual pressure, UES opening area, and post-swallow residue. Patients with UES Disorder exhibited pronounced increases in UES residual pressure with CMC compared to XG. Pharyngeal contractility was unaffected by viscosity changes. Post-swallow residue increased with CMC, particularly in patients with a Combination Disorder. Case-by-case analysis revealed individual variability in response to the different viscosities.

CONCLUSION

The rheological properties of thickened fluids significantly affect swallowing function, with these effects dependent upon the disorder subtype.

The Effect of Oropharyngeal Resting Tremor on Swallowing Function in a Clinical Cohort of People with Parkinson's Disease

Parkinson's Disease (PD) is a progressive neurodegenerative disease, with hallmark symptomology typically consisting of tremor, bradykinesia, and rigidity. Though the classic "pill-rolling" rest tremor in the hand or upper limb are often the most salient, it can occur throughout the body including the lower limbs, jaw, face, or tongue. There have been investigations into other motor related phenomena potentially affecting swallow function in PwPD previously. However, there have been no investigations of how oropharyngeal resting tremor in structures such as the tongue or larynx explicitly affects swallowing physiology. A retrospective analysis of previously conducted VFSS on 34 patients diagnosed with idiopathic PD (IPD) was performed to examine how individuals that displayed resting tremor during VFSS (Tremor +) and those who did not (Tremor-) differ in swallowing function. Measures of swallowing function including timing intervals of key swallow events, post-swallow residue, and penetration-aspiration scale (PAS) scores were recorded, and key demographic information including time since diagnosis and medication status were extracted from the medical records available. Multivariate models were used to identify differences between tremor groups for timing intervals and post-swallow residue, and chi-squares were computed for differences in PAS score distribution by group and bolus. Sixty-eight percent (23/34) of this sample displayed oropharyngeal resting tremor in at least one structure during VFSS. There were no instances of other tremor types observed in this sample. All participants were taking medication to manage PD symptomology. Significant effects of tremor group were observed for swallow timing intervals related to airway closure (p < 0.001), post-swallow residue (p < 0.05), and swallow safety at the bolus level in the Tremor + group (p < 0.001). These results suggest that PwPD who present with resting tremor in oropharyngeal structures may manifest with different variations in swallowing physiology, including altered timings of swallow events, increased pharyngeal residue, and greater associations of airway invasion with thinner and larger volume boluses. This study highlights the need for substantially more research into how motor fluctuations and phenotypes of PwPD contribute to alterations in swallowing function.

Tongue brushing enhances the myoelectric activity of the suprahyoid muscles in older adults: a six-week randomized controlled trial

Tongue brushing improves respiratory function in older adults. Considering connection between the respiratory-related and suprahyoid muscles, this study aimed to investigate whether tongue-brushing interventions can improve myoelectric activity during respiration. A six-week randomized controlled trial was conducted in Kitakyushu, Japan, with 50 participants aged ≥ 65 years. The participants were allocated to the intervention (tongue brushing with routine oral hygiene) or control (routine oral hygiene alone) groups. Surface electromyography (sEMG) was used to assess the myoelectric activity of the suprahyoid muscles during inhalation, exhalation, and forced vital capacity (FVC). A survey was conducted at baseline and the end of the follow-up period. Thirty-six participants were recruited for the analysis. The root mean squares (RMS) of sEMG during exhalation increased significantly at the end of the follow-up period compared with that at baseline in the intervention group [48.7 (18.0-177.5) vs. 64.9 (21.6-163.0), p = 0.001], but not in the control group. The generalized linear model revealed that the ratio of change in FVC was correlated with the change in the RMS of sEMG of the suprahyoid muscles during exhalation after adjusting for potential confounders. Tongue brushing enhances the myoelectric activity of the suprahyoid muscle.

Impact of low pharyngeal/esophageal pressure associated with sarcopenia on postendoscopic submucosal dissection pneumonia in patients with superficial esophageal cancer

OBJECTIVES

The aging population, including patients with superficial esophageal cancer, encounters critical dysphagia- and postoperative pneumonia-related issues. Although endoscopic submucosal dissection (ESD) provides advantages over other modalities, older patients are at higher risk of postoperative pneumonia. Furthermore, the etiologies of pneumonia are complex and include patient- (such as sarcopenia) and treatment- (including ESD) related factors. Therefore, this study evaluated swallowing function in patients with superficial esophageal cancer and identified post-ESD pneumonia-associated factors.

METHODS

Comprehensive swallowing function and sarcopenia were evaluated in patients pre-ESD and 2 months post-ESD using high-resolution manometry and several swallowing studies by multiple experts. The effects of mucosal resection and sarcopenia on swallowing function changes post-ESD, the relationship between preoperative swallowing function and sarcopenia, and the factors influencing postoperative pneumonia were investigated.

RESULTS

Twenty patients were included in the study. Patients with preoperative sarcopenia had significantly lower pharyngeal/upper esophageal sphincter and tongue pressures than those without sarcopenia. However, ESD did not worsen pharyngeal or upper esophageal pressure. Post-ESD pneumonia incidence tended to be higher in patients with sarcopenia than in those without sarcopenia. The lower upper esophageal sphincter-integrated relaxation pressure (UES-IRP) was a significant factor in pneumonia development. Furthermore, the receiver operating characteristic curve for UES-IRP in pneumonia yielded an area under the curve of 0.82.

CONCLUSIONS

Sarcopenia is associated with preoperative dysphagia, which increases post-ESD pneumonia risk. Therefore, postoperative pneumonia incidence is expected to increase with an aging population, making preoperative sarcopenia and swallowing function evaluation crucial.

Investigating Parkinson's disease with dual high resolution pharyngeal manometry with impedance and videofluoroscopy

PURPOSE

To characterize pharyngeal function in people with Parkinson's Disease using both high resolution impedance manometry (HRIM) and videofluoroscopy (VFSS) and to explore correlations between VFSS and HRIM metrics.

METHODS

All participants received both VFSS and HRIM within 24 h-time window. A standard VFSS protocol (IDDSI 0: 1 mL, 3 mL, 20 mL, and 100 mL) was performed. A solid-state unidirectional catheter (36 pressure sensors) was used to acquire manometric data for triplicate swallows (IDDSI 0: 5 mL, 10 mL, 20 mL), quantitative swallow analysis was completed through Swallowtail™ and SwallowGateway™. Parameters were compared to published norms and statistical tests explored correlational associations (p < 0.05).

RESULTS

Twenty-one participants (76% male; mean age 70 years, SD7.16) with mild-moderate severity PD were recruited with 73% reporting Eating Assessment Tool (EAT-10) scores ≥3 indicating swallow impairment. Compared to normal metrics, one third of participants had abnormally elevated hypopharyngeal contractile integral (HPCI), hypopharyngeal peak pressure, upper esophageal sphincter (UES) integrated relaxation pressure (UES IRP), and reduced UES maximum admittance. Five participants showed compromised swallow safety (Penetration-Aspiration Scale score ≥6). One third of participants had abnormal VFSS values for pharyngoesophageal segment (PES) opening duration, maximum PES opening distance, and maximum hyoid displacement measures. Some HRIM metrics had a strong correlation with pharyngeal VFSS measures (r > 0.60, p < 0.05).

CONCLUSION

This study identifies early manometric signs of pharyngeal dysfunction in people with PD. The congruence of the VFSS and HRIM measures confirms the hypothesis of insidious early decline in swallow function in PD despite maintenance of airway safety (i.e., low aspiration rates).

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.

Pediatric Aerodigestive Medicine: Advancing Collaborative Care for Children With Oropharyngeal Dysphagia

OBJECTIVES

Aerodigestive disorders encompass various pathological conditions affecting the lungs, upper airway, and gastrointestinal tract in children. While advanced care has primarily occurred in specialty centers, many children first present to general pediatric gastroenterologists with aerodigestive symptoms necessitating awareness of these conditions. At the 2021 Annual North American Society for Pediatric Gastroenterology, Hepatology and Nutrition meeting, the aerodigestive Special Interest Group held a full-day symposium entitled, Pediatric Aerodigestive Medicine: Advancing Collaborative Care of Children with Aerodigestive Disorders. The symposium aimed to underline the significance of a multidisciplinary approach to achieve better outcomes for these complex patients.

METHODS

The symposium brought together leading experts to highlight the growing aerodigestive field, promote new scientific and therapeutic strategies, share the structure and benefits of a multidisciplinary approach in diagnosing common and rare aerodigestive disorders, and foster multidisciplinary discussion of complex cases while highlighting the range of therapeutic and diagnostic options. In this article, we showcase the diagnostic and therapeutic approach to oropharyngeal dysphagia (OPD), one of the most common aerodigestive conditions, emphasizing the role of a collaborative model.

CONCLUSIONS

The aerodigestive field has made significant progress and continues to grow due to a unique multidisciplinary, collaborative model of care for these conditions. Despite diagnostic and therapeutic challenges, the multidisciplinary approach has enabled and greatly improved efficient, high-quality, and evidence-based care for patients, including those with OPD.

A Novel Approach to Severe Chronic Neurogenic Dysphagia Using Pharyngeal Sensory Electrical Stimulation

ABSTRACT

The treatment options for severe chronic neurogenic dysphagia are limited. A patient, after resection of medulla oblongata hemangioblastoma, who failed to respond to 7 mos of traditional dysphagia rehabilitation therapy, was treated with prolonged pharyngeal sensory electrical stimulation for 39 sessions over 57 days. For the first time, this case report showed improvement in hypopharyngeal peak pressure (9.1 vs. 90.8 mm Hg) using high-resolution manometry. Reductions in the penetration and aspiration scale, secretion, and residue of the vallecular and pyriform sinus were verified by videofluoroscopic swallowing study and flexible endoscopic evaluation of swallowing. The Functional Oral Intake Scale score increased from 1 to 6. No adverse event was observed. This case report presented a potential therapeutic protocol for severe chronic neurogenic dysphagia, which might be instructive for clinical practice.

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.

Exploring the Influence of Dysphagia and Tracheostomy on Pneumonia in Patients with Stroke: A Retrospective Cohort Study

Background: Pneumonia is common in patients with tracheostomy and dysphagia. However, the influence of dysphagia and tracheostomy on pneumonia in patients with stroke remains unclear. The aim of this study was to explore the risk factors related to pneumonia, and the association between dysphagia, tracheostomy and pneumonia in patients with stroke was investigated. Methods: Patients with stroke who experienced tracheostomy and dysphagia were included and divided into two groups based on record of pneumonia at discharge. Clinical manifestations and physical examination were used to diagnose pneumonia, whereas clinical swallowing examination, and videofluoroscopy swallowing studies (VFSS) were used to evaluate swallowing function. Results: There were significant differences between the pneumonia group and the no pneumonia group in total tracheostomy time (6.3 ± 5.9 vs. 4.3 ± 1.7 months, p = 0.003), number of instances of ventilator support (0.41 ± 0.49 vs. 0.18 ± 0.38, p = 0.007), PAS score (5.2 ± 1.92 vs. 4.3 ± 1.79, p = 0.039), impaired or absent cough reflex (76.4 vs. 55.6%, p = 0.035), oropharyngeal phase dysfunction (60.6 vs. 40.8%, p = 0.047), length of hospital stay (36.0 ± 7.2 vs. 30.5 ± 11.7 days, p = 0.025) and direct medical costs (15,702.21 ± 14,244.61 vs. 10,923.99 ± 7250.14 United States dollar [USD], p = 0.042). Multivariate logistic regression showed that the total tracheostomy time (95% confidence interval [CI], 1.966−12.922, p = 0.001), impaired or absent cough reflex (95% CI, 0.084−0.695, p = 0.008), and oropharyngeal phase dysfunction (95% CI, 1.087−8.148, p = 0.034) were risk factors for pneumonia. Spearman’s correlation analysis demonstrated that PAS scores were significantly correlated with cough reflex dysfunction (r = 0.277, p = 0.03), oropharyngeal phase dysfunction (r = 0.318, p < 0.01) and total tracheostomy time (r = 0.178, p = 0.045). The oropharyngeal phase dysfunction was significantly correlated with cough reflex (r = 0.549, p < 0.001) and UES opening (r = 0.643, p < 0.01). Conclusions: Tracheostomy and dysphagia increased the risk of pneumonia in patients with stroke. Total tracheostomy time, duration of ventilator support, degree of penetration and aspiration, and oropharyngeal phase dysfunction are risk factors. Given this, we also found that there may be a correlation between tracheostomy and dysphagia.