Evaluation and treatment of swallowing disorders

The efficacy of orofacial myofunctional therapy in oral dysphagia accompanying temporomandibular dysfunction

OBJECTIVE

Patients with temporomandibular dysfunction (TMD) may develop oral-stage dysphagia (OD) in the chronic phase.

METHODS

This study investigated the effect of orofacial myofunctional therapy (OMT) in individuals with TMD-related OD. Fifty-one patients aged 18-65 years with TMD-related OD were separated into three groups using a simple randomization method: the control group (n = 12) underwent patient education and a home-exercise program; additionally, to an exercise program the manual therapy (MT) group (n = 19) received MT; and the OMT group (n = 20) received the OMT program. MT and OMT were applied in two sessions per week for 10 weeks. The patients were re-evaluated after treatment and at 3 months.

RESULTS

The OMT group showed the most improvement in jaw functionality, swallowing-related quality of life, pain, and dysphagia (p < .05).

DISCUSSION

OMT was superior to MT and exercises alone in reducing dysphagia and improving the swallowing-related quality of life.

Botulinum toxin A injection using ultrasound combined with balloon guidance for the treatment of cricopharyngeal dysphagia: analysis of 21 cases

BACKGROUND

As an upper oesophageal sphincter (UES) dysfunction disorder, cricopharyngeal achalasia (CPA) is a common cause of dysphagia and is associated with an increased risk of pulmonary complications. The aim of this study was to investigate the effectiveness and safety of BTX-A injection using ultrasound combined with balloon guidance for the treatment of CPA caused by stroke.

METHODS

A total of 21 patients diagnosed with CPA were treated with BTX-A injection into the cricopharyngeal muscle using ultrasound combined with balloon guidance. Primary outcome measures, including the functional oral intake scale (FOIS), videofluoroscopic dysphagia scale (VDS) and penetration aspiration scale (PAS), which are quantitative measures for a video fluoroscopic swallowing study (VFSS), and scores of the self-rating anxiety scale (SAS) and self-rating depression scale (SDS) were assessed from baseline to 12 weeks after treatment. Repeated measures analysis of variance was used to compare the scores between time points.

RESULTS

BTX-A injection led to improved dysphagia symptoms and scores in 19 patients (90.48%). Among them, 5 cases were cured (23.81%), 11 cases showed significant improvement (52.38%), and 3 cases showed improvement (14.29%). Two cases were absolutely ineffective (9.52%). Compared with the scores prior to treatment, the scores on the FOIS, VDS, PAS, SAS and SDS significantly improved beginning at 3 days (p < .05) and lasting for at least 12 weeks after injection.

CONCLUSIONS

Ultrasound with balloon-guided BTX-A injection is probably a relatively safe, easy, and effective technique for the treatment of CPA caused by stroke, with better visualization of the injection procedure. A well-designed controlled trial with a larger sample size is needed for more convincing conclusions.

Bionic design of the oral swallowing in vitro and its application in the dysphagia

Dysphagia, the swallowing disorder, is a common disease among the elders and stroke patients. Therefore, based on the bionic swallowing device (BSD) in vitro of similar human-tongue motion during swallowing, the development of functional food is necessary to improve the food swallowing quality of the deglutition disorders patients. In this study, the tongue motion was thoroughly investigated by extracting the characteristic data, and appropriate mechanisms in vitro were adopted to replicate the motion of the tongue swallowing according to the normal swallowing oropharyngeal data. The application of the BSD was also investigated at different swallowing grades (SGs). The study results indicated that the tongue motion consisted of tongue root point (TRP) and several tongue motor points (TMPs). The cam-link and push-rod mechanisms showed ellipse lines for TRP motion and straight lines for TMPs, respectively. Higher correlation coefficients between the tongue trajectories in the oropharyngeal data and simulated curves of the combined mechanism were observed. The average correlation coefficients between the tongue trajectories of patients at five SGs and those of the BSD were 0.87, proving its effectiveness and potential application. Furthermore, the corn-paste experiments of the BSD showed that dysphagia at five SGs could be a suitable choice for certain food concentrations. This will provide valuable insight into developing more functional foods in vitro for high deglutition disorders.

Risk factors for dysphagia after a spinal cord injury: a systematic review and meta-analysis

STUDY DESIGN

Systematic review and meta-analysis.

OBJECTIVE

To determine the risk factors predictive of dysphagia after a spinal cord injury (SCI).

SETTING

None.

METHODS

A comprehensive literature search was performed in five scientific databases for English articles that identified risk factors for dysphagia after a SCI in adult (≥19 years) individuals. Data extracted included: author name, year and country of publication, participant demographics, sample size, study design, method of dysphagia diagnosis, and risk factor percentages. Methodological quality of studies was assessed using the Newcastle-Ottawa Scale. For identified risk factors, risk percentages were transformed into risk ratios (RR) with 95% confidence intervals. Quantitative synthesis was performed for risk factors reported in two or more studies using restricted maximum-likelihood estimator random effects models.

RESULTS

Eleven studies met inclusion criteria of which ten studies were of moderate quality (n = 10). Significant risk factors included: age, injury severity, level of injury, presence of tracheostomy, coughing, voice quality, bronchoscopy need, pneumonia, mechanical ventilation, nasogastric tubes, comorbid injury, and a cervical surgery. Results of the quantitative synthesis indicated that the presence of a tracheostomy posed a threefold greater risk of the development of dysphagia (RR: 3.67); while, cervical surgery posed a 1.3 times greater risk of the development of dysphagia (RR: 1.30).

CONCLUSIONS

Knowledge of these risk factors can be a resource for clinicians in the early diagnosis and appropriate medical management of dysphagia post SCI.

Preliminary Evaluation of the Pathomechanisms of Dysphagia After Occipitospinal Fusion: Kinematic Analysis by Videofluoroscopic Swallowing Study

STUDY DESIGN

Kinematic analysis of swallowing function using videofluoroscopic swallowing study (VFSS).

OBJECTIVES

The aims of this study were to analyze swallowing process in the patients who underwent occipitospinal fusion (OSF) and elucidate the pathomechanism of dysphagia after OSF.

SUMMARY OF BACKGROUND DATA

Although several hypotheses about the pathomechanisms of dysphagia after OSF were suggested, there has been little tangible evidence to support these hypotheses since these hypotheses were based on the analysis of static radiogram or CT. Considering that swallowing is a compositive motion of oropharyngeal structures, the etiology of postoperative dysphagia should be investigated through kinematic approaches.

METHODS

Each four patients with or without postoperative dysphagia (group D and N, respectively) participated in this study. For VFSS, all patients were monitored to swallow 5-mL diluted barium solution by fluoroscopy, and then dynamic passing pattern of the barium solution was analyzed. Additionally, O-C2 angle (O-C2A) was measured for the assessment of craniocervical alignment.

RESULTS

O-C2A in group D was -7.5 degrees, which was relatively smaller than 10.3 degrees in group N (P = 0.07). In group D, all cases presented smooth medium passing without any obstruction at the upper cervical level regardless of O-C2A, whereas the obstruction to the passage of medium was detected at the apex of mid-lower cervical ocurvature, where the anterior protrusion of mid-lower cervical spine compressed directly the pharyngeal space. In group N, all cases showed smooth passing of medium through the whole process of swallowing.

CONCLUSION

This study presented that postoperative dysphagia did not occur at the upper cervical level even though there was smaller angle of O-C2A and demonstrated the narrowing of the oropharyngeal space towing to direct compression by the anterior protrusion of mid-lower cervical spine was the etiology of dysphagia after OSF. Therefore, surgeon should pay attention to the alignment of mid-cervical spine as well as craniocervical junction during OSF.

LEVEL OF EVIDENCE

4.

Inter-rater Reliability of Videofluoroscopic Dysphagia Scale

Objective

To investigate the inter-rater agreement using the Videofluoroscopic Dysphagia Scale (VDS).

Method

The present study was designed as a multicenter, single-blind trial. A Videofluoroscopic Swallowing Study (VFSS) was performed using the protocol described by J.A Logemann. Thick-fluid, pureed food, mechanically altered food, regularly textured food, and thin-fluid boluses were sequentially swallowed. Each participant received a 3 ml bolus followed by a 5 ml bolus of each food material, in the order mentioned above. All study procedures were video recorded. Discs containing these video recordings in random order were distributed to interpreters who were blinded to the participant information. The video recordings were evaluated using a standardized VDS sheet and the inter-rater reliability was calculated.

Results

In total, 100 patients participated in this study and 10 interpreters analyzed the findings. Inter-rater reliability was fair in terms of lip closure (κ: 0.325), oral transit time (0.253), delayed triggering of pharyngeal swallowing (0.300), vallecular residue (0.275), laryngeal elevation (0.345), pyriform sinus residue (0.310), coating of the pharyngeal wall (0.310), and aspiration (0.393). However, other parameters of the oral phase were lower than those of the pharyngeal phase (0.06-0.153). Moreover, the summation of VDS reliability (intraclass correlation coefficient: 0.556) showed moderate agreement.

Conclusion

VDS shows a moderate rate of agreement for evaluating the swallowing function. However, many of the parameters demonstrated a lower rate of agreement, particularly the oral phase parameters.

A prospective investigation of swallowing, nutrition, and patient-rated functional impact following altered fractionation radiotherapy with concomitant boost for oropharyngeal cancer

Altered fractionation radiotherapy for head and neck cancer has been associated with improved locoregional control, overall survival, and heightened toxicity compared with conventional treatment. Swallowing, nutrition, and patient-perceived function for altered fractionation radiotherapy with concomitant boost (AFRT-CB) for T1-T3 oropharyngeal squamous cell carcinoma (SCC) have not been previously reported. Fourteen consecutive patients treated with AFRT-CB for oropharyngeal SCC were recruited from November 2006 to August 2009 in a tertiary hospital in Brisbane, Australia. Swallowing, nutrition, and patient-perceived functional impact assessments were conducted pretreatment, at 4-6 weeks post-treatment, and at 6 months post-treatment. Deterioration from pretreatment to 4-6 weeks post-treatment in swallowing, nutrition, and functional impact was evident, likely due to the heightened toxicity associated with AFRT-CB. There was significant improvement at 6 months post-treatment in functional swallowing, nutritional status, patient-perceived swallowing, and overall function, consistent with recovery from acute toxicity. However, weight and patient perception of physical function and side effects remained significantly worse than pretreatment scores. The ongoing deficits related to weight and patient-perceived outcomes at 6 months revealed that this treatment has a long-term impact on function possibly related to the chronic effects of AFRT-CB.

Videofluoroscopy and swallowing studies for neurologic disease: a primer

Many patients with neurologic impairment due to stroke, multiple sclerosis, trauma, bulbar palsy, and other disorders have difficulty swallowing. Videofluoroscopy can provide important information on patterns of impairment of the swallowing mechanism, allowing important changes in patient treatment. The detailed videofluoroscopic evaluation required to provide this information is now seldom taught and is practiced by relatively few radiologists. The aim of this article is to (a) describe the indications for videofluoroscopic swallowing studies in the evaluation of patients with neurologic conditions affecting swallowing, (b) describe the techniques for evaluating the swallow mechanism with videofluoroscopy in a standardized manner, and (c) use cine videofluoroscopy to illustrate the range of abnormalities that can be demonstrated for some of these conditions and discuss the effect of patient treatment.

Prevalence of dysphagia among community-dwelling elderly individuals as estimated using a questionnaire for dysphagia screening

The objective of this cross-sectional study was to determine the prevalence of dysphagia among elderly persons living at home in a community using a questionnaire for dysphagia screening. As the reliability of the questionnaire had not yet been confirmed in an epidemiological study, it was also verified. The relationship between dysphagia and the level of daily living competence was also clarified. The subjects consisted of 1313 elderly persons 65 years and older (575 males and 738 females) living at home in a community. The questionnaire included questions concerning the individual's past history of stroke, and questions for dysphagia screening, competence scoring, and perceived ill health. The reliability of the questionnaire was confirmed after calculating the Cronbach's alpha coefficient to be 0.83. The results of a factor analysis showed that the cumulative contribution rate was 61.8%. The prevalence rate of dysphagia was 13.8%. After matching for age and sex, there were significant differences in the competence scores, history of stroke, and perceived ill health status observed between the group with dysphagia and the group without dysphagia.