Findings of Abnormal Videofluoroscopic Swallowing Study Identified by High-Resolution Manometry Parameters

Residual effect of sequential 4-channel neuromuscular electrical stimulation evaluated by high-resolution manometry

BACKGROUND

High-resolution manometry (HRM) can quantify swallowing pathophysiology to evaluate the status of the pharynx. Sequential 4-channel neuromuscular electrical stimulation (NMES) was recently developed based on the normal contractile sequences of swallowing-related muscles. This study aimed to examine the effects of sequential 4-channel NMES for compensatory application during swallowing and to observe the residual effects after the application of NMES using HRM.

RESULTS

Sequential 4-channel NMES significantly improved the HRM parameters, with respect to the maximal pressure and area of the velopharynx (VP), maximal pressure and area of the mesopharynx (MP), and upper esophageal sphincter (UES) activation and nadir duration. Furthermore, the improvement in the pressure and area variables of the VP and MP showed a tendency to maintain even when measured after NMES, but there are no significant differences.

CONCLUSIONS

The present study suggests that the sequential 4-channel NMES application of the suprahyoid and infrahyoid muscles during swallowing improves the pressure, area, and time variables of the oropharynx, as measured by HRM, and it is likely that the effects may persist even after stimulation. Trial Registration Clinicaltrials.gov, registration number: NCT02718963 (initial release: 03/20/2016, actual study completion date: 06/24/2016, last release: 10/20/2020).

Oral Intake Difficulty and Aspiration Pneumonia Assessment Using High-Resolution Manometry

OBJECTIVE

The sequential generation of swallowing pressure (SP) from the nasopharynx to the proximal esophagus is important for the bolus to pass from the oral cavity to the esophagus. The purpose of this study was to investigate the correlation of the SP sequence mode on high-resolution manometry (HRM) with oral intake difficulty and aspiration pneumonia.

METHODS

Consecutive patients with dysphagia who were admitted to our dysphagia clinic between November 2016 and November 2020 were enrolled in this cross-sectional study. We classified the HRM pressure topography data according to the SP sequence mode into type A, normal; B, partially decreased; C, totally decreased; and D, sequence disappeared, and according to the upper esophageal sphincter (UES) during pharyngeal swallowing into type 1, flattening and 2, non-flattening. Clinical dysphagia severity was determined based on oral intake difficulty and aspiration pneumonia.

RESULTS

In total, 202 patients with dysphagia (mean [standard deviation] age, 68.3 [14.5] years; 140 [69.8%] male) were enrolled. Type C (odds ratio [OR], 10.48; 95% confidence interval [CI], 2.89-51.45), type D (OR, 19.90; 95% CI, 4.18-122.35), and type 2 (OR, 6.36; 95% CI, 2.88-14.57) were significantly related to oral intake difficulty. Type C (OR, 3.23; 95% CI, 1.08-11.12) and type 2 (OR, 4.18; 95% CI, 1.95-9.15) were significantly associated with aspiration pneumonia.

CONCLUSION

The failure of sequential generation of SP was associated with higher risk of oral intake difficulty and aspiration pneumonia. These assessments are useful in understanding the pathophysiology and severity of dysphagia and in selecting safety nutritional management methods.

LEVEL OF EVIDENCE

4 Laryngoscope, 134:2127-2135, 2024.

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).

Association between Anterior Surgical Approach and Dysphagia Severity in Patients with Cervical Spinal Cord Injury

INTRODUCTION

Early detection and management of dysphagia are essential for preventing aspiration pneumonia and reducing mortality in patients with cervical spinal cord injury (C-SCI). In this study, we identified risk factors for dysphagia in patients with C-SCI by analyzing the correlation between the clinical factors and the severity of dysphagia, not the presence or absence of dysphagia. Combined with the analysis results of previous studies, we thought that this additional analysis method could more accurately reveal the risk factors for dysphagia in patients with C-SCI.

METHODS

The presence and severity of dysphagia in patients with C-SCI was evaluated using a modified videofluoroscopic dysphagia scale (mVDS) and penetration-aspiration scale (PAS). All included patients with C-SCI performed a video fluoroscopic swallowing study (VFSS). Clinical factors such as age, sex, the presence of tracheostomy, spinal cord independence measure (SCIM), pulmonary function test (PFT), including forced vital capacity (FVC), forced expiratory volume in 1 s (FEV1), FVC/FEV1, maximal inspiratory pressure (MIP), and maximal expiratory pressure (MEP), American Spinal Cord Injury Association (ASIA) score, Berg Balance Scale (BBS), and operation method were investigated.

RESULTS

In the multivariate regression analysis, the anterior surgical approach was the only clinical factor that had a significant correlation in both mVDS and PAS, which represents the severity of dysphagia in C-SCI patients (p < 0.05).

CONCLUSION

The anterior surgical approach was correlated with the severity of dysphagia in patients with C-SCI. Considering this, as one of the risk factors affecting dysphagia in patients with C-SCI, surgical method may also need to be considered. Additionally, we recommend that clinicians should pay particular attention to the potential for development of dysphagia in patients who received anterior cervical surgery. However, further prospective studies with larger sample sizes are needed for more accurate generalization.

Evaluation of Dysphagia and Inhalation Risk in Neurologically Impaired Children Using Esophageal High-Resolution Manometry with Swallowing Analysis

BACKGROUND

Dysphagia in neurologically impaired children is associated with feeding difficulties, malnutrition and aspiration pneumonia. Esophageal high-resolution manometry (HRM) has been used in the diagnosis of motility disorders affecting the swallowing process. The aim of this study was to analyze swallowing functions in NI children by using HRM in order to establish swallow parameters identifying inhalation risk.

METHODS

Twenty-five NI children with cerebral palsy were submitted to esophageal HRM with UES analysis, comparing the results with non-NI children. The following parameters were evaluated: maximum pressure and duration of contraction of the velopharynx (VP) and tongue base (TB), and maximal, minimal, resting pressure and relaxation duration of the upper esophageal sphincter (UES).

RESULTS

pVP max, pTB max, pUES max and resting pressure were lower, while p UES minimal was higher and relaxation duration was shorter in NI children vs. the control group. Predictive values of inhalation risk were evaluated.

CONCLUSIONS

This study evaluates inhalation risk in NI children using HRM to study UES function. Our results confirm the alterations described in NI children: insufficient contraction and clearing force for bolus transmission through the pharynx and incomplete UES relaxation can predispose to pharyngeal residues and inhalation independently of swallowing because of lower values of UES resting.

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

Several physiological metrics can be derived from pharyngeal high-resolution impedance manometry (HRPM), but their clinical relevance has not been well established. We investigated the diagnostic performance of these metrics in relation to videofluoroscopic (VFS) assessment of aspiration and residue in patients with oropharyngeal dysphagia. We analyzed 263 swallows from 72 adult patients (22-91 years) with diverse medical conditions. Metrics of contractility, upper esophageal sphincter (UES) opening and relaxation, flow timing, intrabolus distension pressure, and a global Swallow Risk Index (SRI) were derived from pressure-impedance recordings using pressure-flow analysis. VFS data were independently scored for airway invasion and pharyngeal residue using the Penetration-Aspiration Scale and the Normalized Residue Ratio Scale, respectively. We performed multivariate logistic regression analyses to determine the relationship of HRPM metrics with radiological outcomes and receiver-operating characteristic (ROC) analysis to evaluate their diagnostic accuracy. We identified aspiration in 25% and pharyngeal residue in 84% of the swallows. Aspiration was independently associated with hypopharyngeal peak pressure < 65 mmHg (HypoPeakP) [adjusted odds ratio (OR) 5.27; 95% Confidence Interval (CI) (0.99-28.1); p = 0.051], SRI > 15 [OR 4.37; 95% CI (1.87-10.2); p < 0.001] and proximal esophageal contractile integral (PCI) < 55 mmHg·cm·s [OR 2.30; 95% CI (1.07-4.96); p = 0.034]. Pyriform sinus residue was independently predicted by HypoPeakP < 65 mmHg [OR 7.32; 95% CI (1.93-27.7); p = 0.003], UES integrated relaxation pressure (UES-IRP) > 3 mmHg [OR 2.96; 95% CI (1.49-5.88); p = 0.002], and SRI > 15 [OR 2.17; 95% CI (1.04-4.51); p = 0.039]. Area under ROC curve (AUC) values for individual HRPM metrics ranged from 0.59 to 0.74. Optimal cut-off values were identified. This study demonstrates the diagnostic value of certain proposed and adjunct HRPM metrics for identifying signs of unsafe and inefficient bolus transport in patients with oropharyngeal dysphagia.

Biomechanical mechanism of reduced aspiration by the Passy-Muir valve in tracheostomized patients following acquired brain injury: Evidences from subglottic pressure

Objective

Aspiration is a common complication after tracheostomy in patients with acquired brain injury (ABI), resulting from impaired swallowing function, and which may lead to aspiration pneumonia. The Passy-Muir Tracheostomy and Ventilator Swallowing and Speaking Valve (PMV) has been used to enable voice and reduce aspiration; however, its mechanism is unclear. This study aimed to investigate the mechanisms underlying the beneficial effects of PMV intervention on the prevention of aspiration.

Methods

A randomized, single-blinded, controlled study was designed in which 20 tracheostomized patients with aspiration following ABI were recruited and randomized into the PMV intervention and non-PMV intervention groups. Before and after the intervention, swallowing biomechanical characteristics were examined using video fluoroscopic swallowing study (VFSS) and high-resolution manometry (HRM). A three-dimensional (3D) upper airway anatomical reconstruction was made based on computed tomography scan data, followed by computational fluid dynamics (CFD) simulation analysis to detect subglottic pressure.

Results

The results showed that compared with the non-PMV intervention group, the velopharynx maximal pressure (VP-Max) and upper esophageal sphincter relaxation duration (UES-RD) increased significantly (P < 0.05), while the Penetration-Aspiration Scale (PAS) score decreased in the PMV intervention group (P < 0.05). Additionally, the subglottic pressure was successfully detected by CFD simulation analysis, and increased significantly after 2 weeks in the PMV intervention group compared to the non-PMV intervention group (P < 0.001), indicating that the subglottic pressure could be remodeled through PMV intervention.

Conclusion

Our findings demonstrated that PMV could improve VP-Max, UES-RD, and reduce aspiration in tracheostomized patients, and the putative mechanism may involve the subglottic pressure.

Clinical trial registration

[http://www.chictr.org.cn], identifier [ChiCTR1800018686].

Usefulness of the Modified Videofluoroscopic Dysphagia Scale in Determining the Allowance of Oral Feeding in Patients with Dysphagia Due to Deconditioning or Frailty

Introduction: In patients with dysphagia due to deconditioning or frailty, as with other disorders that cause swallowing disorders, the videofluoroscopic swallowing study (VFSS) is the gold standard for dysphagia evaluation. However, the interpretation of VFSS results is somewhat complicated and requires considerable experience in the field. Therefore, in this study we evaluated the usefulness of the modified videofluoroscopic dysphagia scale (mVDS) in determining whether to allow oral feeding in patients with dysphagia due to deconditioning or frailty. Methods: Data from the VFSS of 50 patients with dysphagia due to deconditioning or frailty were retrospectively collected. We evaluated the association between mVDS and the selected feeding method based on VFSS findings, and between mVDS and the presence of aspiration pneumonia. Results: Multivariate logistic analysis showed that the mVDS total score had a significant association with oral feeding methods based on VFSS findings in patients with dysphagia due to deconditioning or frailty (p < 0.05). In the receiver operating characteristic (ROC) curve analysis, the area under the ROC curve for the selected feeding method was 0.862 (95% confidence interval, 0.747−0.978; p < 0.0001). Conclusions: mVDS seems a valid scale for determining the allowance of oral feeding, and it can be a useful tool in the clinical setting and in studies that aim to interpret VFSS findings in patients with dysphagia due to deconditioning or frailty. However, studies involving a more general population of patients with dysphagia due to deconditioning or frailty are needed.

Correlation between Forced Vital Capacity and the Severity of Frailty-Induced Dysphagia

Introduction: Frailty syndrome is a complex condition characterized by the gradual deterioration of an individual’s physical, mental, and social functions. Dysphagia is a dysfunction triggered by frailty. However, in patients with frailty syndrome, dysphagia is often undermined, and a proper evaluation is not performed. Therefore, we tried to identify the factors that can provide proper information regarding dysphagia in the frail population. Methods: Patients with dysphagia were divided into those with frailty-induced dysphagia and those with brain-lesion-induced dysphagia. Factors related to the participants’ pulmonary function test (PFT) results were evaluated. The severity of dysphagia was evaluated by determining modified videofluoroscopic dysphagia scale (mVDS) and penetration−aspiration scale (PAS) scores based on videofluoroscopic swallowing studies. Statistical analysis was performed to determine the correlation between PFT results and the parameters indicating dysphagia severity. Results: Multivariate logistic regression analysis revealed that forced vital capacity (FVC) was significantly correlated with mVDS scores in frailty-induced dysphagia (p < 0.05). However, no such significance was detected in brain-lesion-induced dysphagia (p ≥ 0.05). Conclusion: FVC was correlated with the severity of dysphagia (mVDS scores) in patients with frailty-induced dysphagia. Thus, serial FVC-based follow-up can be helpful for understanding patients’ dysphagia status. However, studies with a general population of patients with frailty-induced dysphagia are needed for definite generalization.

Deep Learning Analysis to Automatically Detect the Presence of Penetration or Aspiration in Videofluoroscopic Swallowing Study

BACKGROUND

Videofluoroscopic swallowing study (VFSS) is currently considered the gold standard to precisely diagnose and quantitatively investigate dysphagia. However, VFSS interpretation is complex and requires consideration of several factors. Therefore, considering the expected impact on dysphagia management, this study aimed to apply deep learning to detect the presence of penetration or aspiration in VFSS of patients with dysphagia automatically.

METHODS

The VFSS data of 190 participants with dysphagia were collected. A total of 10 frame images from one swallowing process were selected (five high-peak images and five low-peak images) for the application of deep learning in a VFSS video of a patient with dysphagia. We applied a convolutional neural network (CNN) for deep learning using the Python programming language. For the classification of VFSS findings (normal swallowing, penetration, and aspiration), the classification was determined in both high-peak and low-peak images. Thereafter, the two classifications determined through high-peak and low-peak images were integrated into a final classification.

RESULTS

The area under the curve (AUC) for the validation dataset of the VFSS image for the CNN model was 0.942 for normal findings, 0.878 for penetration, and 1.000 for aspiration. The macro average AUC was 0.940 and micro average AUC was 0.961.

CONCLUSION

This study demonstrated that deep learning algorithms, particularly the CNN, could be applied for detecting the presence of penetration and aspiration in VFSS of patients with dysphagia.

Comparison studies of ultrasound-guided botulinum toxin injection and balloon catheter dilatation in the treatment of neurogenic cricopharyngeal muscle dysfunction

BACKGROUND

Cricopharyngeal muscle dysfunction (CPD) management has been challenging in clinical practice.

OBJECTIVE

To compare the efficacy and safety of ultrasound-guided botulinum toxin injection and balloon catheter dilatation in treating CPD.

METHODS

Forty patients with CPD were randomly divided into two groups, namely the botulinum toxin injection group (BTX group) and balloon dilatation group (BD group). Patients in the BTX group received a single ultrasound-guided injection of 50 units of botulinum toxin type A, while the BD group received dilatation therapy five times per week, consecutively for two weeks. Relative opening percentage of the upper esophageal sphincter (UES), the penetration-aspiration scale (PAS), and the Dysphagia Outcome Severity Scale (DOSS) were evaluated by a videofluoroscopic swallowing study (VFSS) at baseline, 1-month, and 3-months posttreatment. The Functional Oral Intake Scale (FOIS) and Standardized Swallowing Assessment (SSA) were also used to evaluate participants' swallowing function at baseline and the 1-week, 2-week, 1-month, and 3-month follow-ups.

RESULTS

A generalized estimating equation (GEE) model revealed the significant main effect for time in UES, PAS, DOSS, FOIS, and SSA compared to baseline (P <0.05), while no group-by-time interactions (except for the PAS assessment) or main effect for treatment was detected among the above multiple variances. No systematic complications or severe adverse effects were noted.

CONCLUSION

Both ultrasound-guided botulinum toxin type A injections and balloon dilatation therapy have been proven as safe and effective treatments for CPD patients. Future clinical trials with longer follow-up periods and more participants are warranted.

Usefulness of the Modified Videofluoroscopic Dysphagia Scale in Evaluating Swallowing Function among Patients with Amyotrophic Lateral Sclerosis and Dysphagia

INTRODUCTION

The videofluoroscopic dysphagia scale (VDS) is used to predict the long-term prognosis of dysphagia among patients with the condition. Previously, a modified version of the VDS (mVDS) was established to overcome the relatively low inter-rater reliability of VDS, and was verified in patients with dysphagia, such as stroke patients. However, the validity of mVDS in patients with amyotrophic lateral sclerosis (ALS) has never been proved. Therefore, in this study, we attempted to seek the validity of the mVDS score in patients with ALS suffering from dysphagia.

METHOD

Data from the videofluoroscopic swallowing study (VFSS) of 34 patients with ALS and dysphagia were retrospectively collected. We investigated the presence of aspiration pneumonia and the selected feeding method based on the VFSS. We also evaluated the correlations between the mVDS and the selected feeding method, and between the mVDS and the presence of aspiration pneumonia. Multivariate logistic regression and receiver operating characteristic (ROC) analyses were performed during the data analysis.

RESULTS

In patients with ALS and dysphagia, the mVDS scores were statistically correlated with the selected feeding method (p < 0.05) and the presence of aspiration pneumonia (p < 0.05). In the ROC curve analysis, the area under the ROC curve values for the selected feeding method and the presence of aspiration pneumonia were 0.886 (95% confidence interval (CI), 0.730-0.969; p < 0.0001) and 0.886 (95% CI, 0.730-0.969; p < 0.0001), respectively.

CONCLUSION

The mVDS can be a useful tool for quantifying the severity of dysphagia and interpreting the VFSS findings in patients with ALS and dysphagia. However, further studies involving a more general population of patients with ALS are needed to elucidate a more accurate cut-off value for the allowance of oral feeding and the presence of aspiration pneumonia.

Validation and Inter-rater Reliability of the Modified Videofluoroscopic Dysphagia Scale (mVDS) in Dysphagic Patients with Multiple Etiologies

BACKGROUND

the Videofluoroscopic Dysphagia Scale (VDS) is used to interpret and predict the long-term prognosis of patients with dysphagia. However, the inter-rater agreement of the VDS was shown to be lower in a previous study. To overcome the mentioned limitation of the VDS, a modified version (mVDS) was created and applied clinically. We aimed to validate its usefulness in determining the appropriate feeding method and predicting the prognosis of dysphagia.

METHODS

the videofluroscopic swallowing study (VFSS) data of 50 patients with dysphagia were collected retrospectively. The VFSS data were evaluated using the mVDS, and the inter-rater reliability was calculated. We also evaluated the association between the mVDS and type of feeding method selected, and between the mVDS and presence of aspiration pneumonia in patients with dysphagia.

RESULTS

among the different parameters of mVDS, "aspiration" showed the highest reliability (k = 0.767), followed by "mastication" and "lip closure" (k = 0.648 and k = 0.634, respectively). Conversely, "triggering pharyngeal swallow" and "pyriformis residue" demonstrated the lowest reliabilities (k = 0.312 and k = 0.324, respectively). The intraclass correlation coefficient (ICC), which is used as a measure of the reliability of the total mVDS score, was 0.876. In all patients with dysphagia, the mVDS score correlated significantly with the type of feeding method selected (p < 0.05), and the presence of aspiration pneumonia (p < 0.05).

CONCLUSION

the ICC of the total mVDS score was 0.876. Therefore, the mVDS could be a useful tool for quantifying the severity of dysphagia. It could be helpful in the analysis of the VFSS findings among patients with dysphagia in clinical settings and research.

Usefulness of the Modified Videofluoroscopic Dysphagia Scale in Choosing the Feeding Method for Stroke Patients with Dysphagia

INTRODUCTION

The Videofluoroscopic Dysphagia Scale (VDS) is used to predict the long-term prognosis of dysphagia in patients with strokes. However, the inter-rater reliability of the VDS was low in a previous study. To overcome the mentioned limitations of the VDS, the modified version of the VDS (mVDS) was created and clinically applied to evaluate its usefulness in choosing the feeding method for stroke patients with dysphagia.

METHODS

The videofluoroscopic swallowing study (VFSS) data of 56 stroke patients with dysphagia were collected retrospectively. We investigated the presence of aspiration pneumonia and the selected feeding method. We also evaluated the correlations between the mVDS and the selected feeding method, and between the mVDS and the presence of aspiration pneumonia after stroke. Univariate logistic regression and receiver operating characteristic analyses were used in the data analysis.

RESULTS

The inter-rater reliability (Cronbach α value) of the total score of the mVDS was 0.886, which was consistent with very good inter-rater reliability. In all patients with dysphagia, the supratentorial stroke subgroup, and the infratentorial stroke subgroup, the mVDS scores were statistically correlated with the feeding method selected (p < 0.05) and the presence of aspiration pneumonia (p < 0.05).

CONCLUSIONS

The mVDS can be a useful scale for quantifying the severity of dysphagia, and it can be a useful tool in the clinical setting and in studies for interpreting the VFSS findings in stroke patients with dysphagia. Further studies with a greater number of patients and various stroke etiologies are required for more generalized applications of the mVDS.

Submandibular Push Exercise Using Visual Feedback from a Pressure Sensor in Patients with Swallowing Difficulties: A Pilot Study

Objectives: We aimed to determine the usefulness and effectiveness of a submandibular push exercise with visual feedback from a pressure sensor in patients with dysphagia through continuous exercise sessions. Methods: Twelve patients with dysphagia of various etiologies were included. A total of five exercise sessions (every 3 or 4 days) over three weeks were conducted. During the submandibular push exercise, patients were instructed to maintain a maximum force for 3 s, repeated for 1 min to measure the number of exercises, the maximum pressure, and the area of the pressure-time graph. We statistically compared the values of each exercise trial. Results: Among the 12 patients, eight completed the exercise sessions. As the number of exercise trials increased, the maximum pressure and the area in the pressure-time graph showed a significant increase compared to the previous attempt (p < 0.05). The maximum pressure and the area of the pressure-time graph improved from the first to the fourth session (p < 0.05). The values were maintained after the fourth session, and there was no significant difference between the fourth and the fifth exercise (p > 0.05). There was no significant difference between successful and non-successful groups, except for the Modified Barthel Index (p < 0.05). Conclusion: Through repetitive exercise training, the submandibular push exercise using visual feedback from a pressure sensor can be applied as an exercise method to strengthen swallowing related muscles, such as the suprahyoid and infrahyoid muscles. However, additional studies including more patients and a long-term study period are warranted to evaluate the effects of the exercise for improvement of dysphagia.

Comparison of three different types of exercises for selective contractions of supra- and infrahyoid muscles

Several exercise methods, such as the Shaker exercise, tongue press exercise, chin tuck against resistance (CTAR) exercise, and submandibular push exercise, have been introduced to strengthen the muscles involved in swallowing. In this study, we compared the effectiveness of the CTAR, submandibular push, and Shaker exercises for the induction of selective supra- and infrahyoid muscle contractions using surface electromyography (EMG). This study is a prospective non-randomized controlled study. Twenty-five healthy subjects and 20 patients experiencing swallowing difficulty were enrolled. During the three different types of exercises, the root mean square (RMS) values of the sternocleidomastoid (SCM), suprahyoid (anterior belly of the digastric and mylohyoid muscles), and infrahyoid (sternothyroid and thyrohyoid muscles) muscles were analyzed using surface EMG. Differences in the activity of swallowing muscles among the three different exercises were analyzed using one-way repeated measured analysis of variance. In terms of both the maximum and mean RMS values of the suprahyoid muscle, the submandibular push exercise showed a larger RMS value than the CTAR and Shaker exercises in healthy subjects (p < 0.05). In terms of both the maximum and mean RMS values of the suprahyoid muscle, the Shaker exercise and submandibular push exercise showed a larger RMS value than the CTAR exercise in patients with swallowing difficulty (p < 0.05). The submandibular push exercise may be effective as a swallowing muscle exercise owing to its superiority in inducing selective contractions of the supra- and infrahyoid muscles. The CTAR and Shaker exercises are also effective in this regard.

Effects of Chin-Down Maneuver on Pharyngeal Pressure Generation According to Dysphagia and Viscosity

Objective

To demonstrate the effects of chin-down maneuver on swallowing by using high-resolution manometry (HRM).

Methods

HRM data of 20 healthy subjects and 64 dysphagic patients were analyzed. Participants swallowed 5 mL of thin and honey-like liquids in neutral and chin-down positions. HRM was used to evaluate maximal velopharyngeal pressure/area, maximal tongue base pressure/area, maximal pharyngeal constrictor pressure, pre-/post-swallow upper esophageal sphincter (UES) peak pressure, minimal UES pressure, UES activity time, and nadir duration.

Results

Compared to the neutral position, the chin-down maneuver significantly increased tongue base pressure in both normal and dysphagic groups as well as for both honey-like and thin viscosities, although the honey-like liquid did not reach statistical significance in the dysphagic group. Regarding pharyngeal constrictors and pre-swallow peak UES pressure, the healthy group showed a significant decrease in thin liquid swallowing and decreasing tendency in honeylike liquid swallowing. UES nadir duration was significantly decreased for honey-like liquid swallowing in the dysphagic group and for both thin and honey-like liquids in the healthy group. UES nadir duration of honey-like and thin flow swallowing in the dysphagia group was 0.26 seconds after the chin-down maneuver, which was severely limited.

Conclusion

This study showed a different kinetic effect of the chin-down maneuver between the healthy and dysphagic groups, as well as between thin and honey-like viscosities. The chin-down maneuver increased tongue base pressure and decreased UES nadir duration, which the latter was severely limited in dysphagic patients. Therefore, appropriate application of the chin-down maneuver in clinical practice is required.

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

Tongue-hold swallow (THS) is a swallow exercise in which an individual swallows saliva while holding the anterior portion of the tongue between the front teeth. The effect of THS on pharyngeal contractile vigor is still unclear. The purpose of this study was to quantify THS using high-resolution manometry with a contractile integral analysis. Twenty-two healthy participants performed three different saliva swallow tasks: normal swallow, weak THS (in which the tongue was protruded 1 cm outside the upper incisors), and strong THS (in which the tongue was protruded 2 cm outside the upper incisors). The participants repeated each task twice randomly. Pharyngeal and upper esophageal sphincter metrics, including the pharyngeal contractile integral, were analyzed. Both weak and strong THS enhanced the velopharyngeal contractile integral and peak pressure compared with normal swallow (P < 0.01). THS also prolonged mesopharyngeal contraction (P < 0.01). Holding the tongue anteriorly during swallow requires significant biomechanical changes to pharyngeal contractile properties at the superior and middle pharyngeal constrictor levels; thus, it may serve as a resistance exercise for the muscles that are involved in bolus propulsion.

High-Resolution Pharyngeal Manometry and Impedance: Protocols and Metrics-Recommendations of a High-Resolution Pharyngeal Manometry International Working Group

High-resolution manometry has traditionally been utilized in gastroenterology diagnostic clinical and research applications. Recently, it is also finding new and important applications in speech pathology and laryngology practices. A High-Resolution Pharyngeal Manometry International Working Group was formed as a grass roots effort to establish a consensus on methodology, protocol, and outcome metrics for high-resolution pharyngeal manometry (HRPM) with consideration of impedance as an adjunct modality. The Working Group undertook three tasks (1) survey what experts were currently doing in their clinical and/or research practice; (2) perform a review of the literature underpinning the value of particular HRPM metrics for understanding swallowing physiology and pathophysiology; and (3) establish a core outcomes set of HRPM metrics via a Delphi consensus process. Expert survey results were used to create a recommended HRPM protocol addressing system configuration, catheter insertion, and bolus administration. Ninety two articles were included in the final literature review resulting in categorization of 22 HRPM-impedance metrics into three classes: pharyngeal lumen occlusive pressures, hypopharyngeal intrabolus pressures, and upper esophageal sphincter (UES) function. A stable Delphi consensus was achieved for 8 HRPM-Impedance metrics: pharyngeal contractile integral (CI), velopharyngeal CI, hypopharyngeal CI, hypopharyngeal pressure at nadir impedance, UES integrated relaxation pressure, relaxation time, and maximum admittance. While some important unanswered questions remain, our work represents the first step in standardization of high-resolution pharyngeal manometry acquisition, measurement, and reporting. This could potentially inform future proposals for an HRPM-based classification system specifically for pharyngeal swallowing disorders.

Feasibility of high-resolution manometry for decision of feeding methods in patients with amyotrophic lateral sclerosis

As amyotrophic lateral sclerosis (ALS) progresses, dysphagia gets worse due to the weakening of pharyngeal musculature. As oral feeding becomes more difficult or dangerous due to worsening dysphagia, tracheal aspiration, or undernutrition, the necessity for tube feeding becomes increasingly important. This study aims to establish a standard pressure point by applying pharyngeal pressure using high-resolution manometry (HRM) to start tube feeding in patients with ALS.This study was designed as a retrospective analysis of prospectively collected data. Forty-one patients with ALS and 20 healthy subjects were participated. Both groups were evaluated using HRM, videofluoroscopic swallowing study (VFSS), and pulmonary function test. The swallowing pressure along the velopharynx (VP), tongue base (TB), pre-upper esophageal sphincter (UES), lower pharynx, and cricopharyngeus, as well as minimal UES pressure were measured using HRM.There was significantly positive correlation between the pressure of cricopharyngeus and forced expiratory volume in 1 second (FEV1). And there were significant correlations between results of VFSS and FEV1, FEV1%, forced vital capacity (FVC), and FVC%. There was a significant difference in the pressure of TB and cricopharyngeus between the control group and the ALS patient group. The pressures of VP, TB, lower pharynx, and cricopharyngeus have a significant correlation with the recommended feeding type by VFSS.Because it is possible to use HRM to quantitatively assess pharyngeal and respiratory weaknesses and it is more sensitive than other evaluation tools, the cutoff value of HRM parameters may be used to decide the feeding type in patients with ALS.

Clinical characteristics of dysphagic stroke patients with salivary aspiration: A STROBE-compliant retrospective study

The aim of this study was to evaluate the correlation between radionuclide salivagram findings and clinical characteristics in stroke patient with swallowing difficulty.In this study, dysphagic stroke patients who had undergone both a radionuclide salivagram and videofluoroscopic swallowing study (VFSS) were included retrospectively. To evaluate the correlations between clinical parameters and salivary aspiration, clinical parameters, such as stroke lesion, the degree of paralysis, sex, age, onset duration of stroke, the score of the Mini-Mental State Examination (MMSE), the score of the Global Deterioration Scale (GDS), the total score of the Modified Barthel Index (MBI), and each sub-score of the MBI were collected and analyzed.In the results of this study, the MMSE score was the only significant parameter for predicting positive findings in a salivagram in a multivariate logistic regression analysis in patients with supratentorial stroke. In patients with infratentorial stroke, however, the transfer sub-score of MBI was the only significant parameter for predicting positive findings in a salivagram in a multivariate logistic regression analysis.In conclusion, care should be taken to prevent salivary aspiration when the MMSE score is less than eight in patients with supratentorial stroke, and the transfer sub-score of MBI score is less than three in patients with infratentorial stroke.

A systematic review of current methodology of high resolution pharyngeal manometry with and without impedance

PURPOSE

This systematic review appraises and summaries methodology documented in studies using high resolution pharyngeal manometry (HRM) with and without impedance technology (HRIM) in adult populations.

METHODS

Four electronic databases CINAHL, EMBASE, MEDLINE, and Cochrane Library were searched up to, and including March 2017. Studies reporting pharyngeal HRM/HRIM for swallowing and/or phonatory assessment, published in peer-reviewed journals in English, German, or Spanish were assessed for the inclusion criteria. Of the selected studies, methodological aspects of data acquisition and analysis were extracted. Publications were graded based on their level of evidence and quality of methodological aspects was assessed.

RESULTS

Sixty-two articles were identified eligible, from which 50 studies reported the use of HRM and 12 studies used HRIM. Of all included manuscripts, the majority utilized the ManoScan™ system (64.5%), a catheter diameter of 4.2 mm was most prevalently documented (30.6%). Most publications reported the application of topical anesthesia (53.2%). For data analysis in studies using HRM, software intrinsic to the recording system was reported most frequently (56%). A minority of the studies using HRM provided data about measurement reliability (10%). This is higher for studies using HRIM (50%).

CONCLUSIONS

Considerable methodological variability exists regarding data acquisition and analysis in published studies using HRM/HRIM. Lacking reports of methodology make study replications difficult and reduce the comparability across studies. More data regarding the impact of individual methodological aspects on study outcomes are further required for the development of methodological recommendations.

Different clinical predictors of aspiration pneumonia in dysphagic stroke patients related to stroke lesion: A STROBE-complaint retrospective study

Although stroke is one of the most common causes of dysphagia, no studies have investigated the radionuclide salivagram as a predictor of aspiration pneumonia in patients with stroke. In addition, few researches on the risk factors of aspiration pneumonia in patients with subacute and chronic stroke undergoing rehabilitation in the rehabilitation unit have been rarely conducted. In this study, therefore, we investigated whether a radionuclide salivagram could predict aspiration pneumonia, and tried to find other clinical factors that may be helpful in predicting aspiration pneumonia in stroke patients undergoing rehabilitation in the rehabilitation department.From March 2013 and January 2018, a retrospective review of the medical records of 1182 subacute and chronic stroke patients who were admitted to rehabilitation department (South Korea) was carried out. We included 117 stroke patients with swallowing difficulties who were admitted to our rehabilitation department and satisfied our criteria retrospectively. Stroke lesion, the degree of paralysis, sex, age, onset duration, feeding methods, the Mini-Mental State Examination (MMSE), the Global Deterioration Scale (GDS), the presence of aspiration in VFSS or salivagram, the penetration-aspiration scale (PAS), and the total score of the Modified Barthel Index (MBI) were investigated by reviewing medical records.To evaluate the predictor of aspiration pneumonia for patients with stroke, multivariate logistic regression analysis with forward stepwise was performed. In the results of this study, only MMSE was significant as a clinical predictor, but not aspiration in VFSS or salivagram in multivariate analysis of supratentorial stroke patients (OR, 0.895) (95% CI, 0.830-964). In multivariate analysis of infratentorial stroke patients, combined results of salivagram and VFSS (aspiration in a salivagram or VFSS) (OR, 0.956) (95% CI, 0.919-995), and total MBI scores were significant as clinical predictors (OR, 24.882) (95% CI, 1.298-477.143).In conclusion, MMSE can be a clinical predictor of the occurrence of aspiration pneumonia in patients with supratentorial stroke. In contrast, total MBI score and combined results of a salivagram and VFSS can be clinical predictors of the occurrence of aspiration pneumonia in patients with infratentorial stroke.

The effect of radionuclide solution volume on the detection rate of salivary aspiration in the radionuclide salivagram: A STROBE-compliant retrospective study

Despite the possibility that the methodological difference of this salivagram may influence the results for detection rate, there has been no study on the effect of the solution volume on detection rate. Moreover, to date, since the introduction of the nucleotide salivagram, there has been a tendency that a constant solution volume and nucleotide dose is not used in studies. Therefore, the aim of this study is to investigate the effect of solution volume on the detection rate of a salivagram in patients with brain lesion, and to determine the optimal solution volume of salivagram. We retrospectively reviewed clinical data and solution volume of radionuclide used in the salivagram of 77 patients with dysphagia, and the patients were divided into 2 groups according to the solution volume of the radionuclide (Group A-0.1 mL vs Group B-0.5 mL). Although, there was no significant difference between 2 groups in clinical data, there was a statistically significant difference in the detection rate of salivary aspiration between the 2 groups (3.3% vs 19.1%). Even a small difference of the solution volume of radionuclide in salivagram can affect the detection rate of salivary aspiration in patients with brain lesion. Further study with various solution volumes of radionuclide is warranted to determine the optimal solution volume of the radionuclide salivagram.

The pharyngeal contractile integral is a useful indicator of pharyngeal swallowing impairment

BACKGROUND

A limitation to the expanded use of high-resolution pharyngeal manometry (HRPM) in clinical practice is the lack of useful pharyngeal parameters that are easy to interpret, generalizable between patients, and do not require specialized software. In this study, we sought to test the relationship between the pharyngeal contractile integral (PhCI) with videofluoroscopic abnormalities as assessed with the Modified Barium Swallow Impairment Profile^© ™.

METHODS

Adult dysphagic patients were recruited to undergo simultaneous HRPM and videofluoroscopy during a standardized swallowing protocol.

KEY RESULTS

Thirty-six patients were included in the study. The mean PhCI was 247 mm Hg·cm·s (range 2-488 mm Hg·cm·s). The lower pharyngeal total (PT) group (N=20; mean PT=3.9) had a mean PhCI of 299 mm Hg·cm·s, while the higher PT group (N=16; mean PT=12.7) had a mean PhCI score of 188 mm Hg·cm·s (P=.01). There was also a significant negative correlation between normalized PhCI to PT scores (r=-.47; P=.004). Patients with higher PhCIs exhibited less severe penetration-aspiration scores on thin liquids (1.44 vs 3.78; P=.03) and all consistencies combined (1.21 vs 1.99; P=.03).

CONCLUSIONS & INFERENCES

The PhCI is a useful indicator of the presence of pharyngeal swallowing impairment and is technically simple to calculate with currently available software programs. Advancement of software is necessary to refine the clinical value of this parameter. High-resolution pharyngeal manometry has the potential to be a valuable adjunct procedure for the evaluation and treatment of dysphagic individuals.

Quantitative Analysis of Swallowing Function Between Dysphagia Patients and Healthy Subjects Using High-Resolution Manometry

Objective

To compare swallowing function between healthy subjects and patients with pharyngeal dysphagia using high resolution manometry (HRM) and to evaluate the usefulness of HRM for detecting pharyngeal dysphagia.

Methods

Seventy-five patients with dysphagia and 28 healthy subjects were included in this study. Diagnosis of dysphagia was confirmed by a videofluoroscopy. HRM was performed to measure pressure and timing information at the velopharynx (VP), tongue base (TB), and upper esophageal sphincter (UES). HRM parameters were compared between dysphagia and healthy groups. Optimal threshold values of significant HRM parameters for dysphagia were determined.

Results

VP maximal pressure, TB maximal pressure, UES relaxation duration, and UES resting pressure were lower in the dysphagia group than those in healthy group. UES minimal pressure was higher in dysphagia group than in the healthy group. Receiver operating characteristic (ROC) analyses were conducted to validate optimal threshold values for significant HRM parameters to identify patients with pharyngeal dysphagia. With maximal VP pressure at a threshold value of 144.0 mmHg, dysphagia was identified with 96.4% sensitivity and 74.7% specificity. With maximal TB pressure at a threshold value of 158.0 mmHg, dysphagia was identified with 96.4% sensitivity and 77.3% specificity. At a threshold value of 2.0 mmHg for UES minimal pressure, dysphagia was diagnosed at 74.7% sensitivity and 60.7% specificity. Lastly, UES relaxation duration of <0.58 seconds had 85.7% sensitivity and 65.3% specificity, and UES resting pressure of <75.0 mmHg had 89.3% sensitivity and 90.7% specificity for identifying dysphagia.

Conclusion

We present evidence that HRM could be a useful evaluation tool for detecting pharyngeal dysphagia.

Ability of High-Resolution Manometry to Determine Feeding Method and to Predict Aspiration Pneumonia in Patients With Dysphagia

OBJECTIVES

The introduction of high-resolution manometry (HRM) offered an improved method to objectively analyze the status of pharynx and esophagus. At present, HRM for patients with oropharyngeal dysphagia has been poorly studied. We aimed to determine feeding method and predict the development of aspiration pneumonia in patients with oropharyngeal dysphagia using HRM.

METHODS

We recruited 120 patients with dysphagia who underwent both HRM and videofluoroscopic swallow study. HRM was used to estimate pressure events from velopharynx (VP) to upper esophageal sphincter (UES). Feeding methods were determined to non-oral or oral feeding according to dysphagia severity. We prospectively followed patients to assess the development of aspiration pneumonia.

RESULTS

VP maximal pressure and UES relaxation duration were independently associated with non-oral feeding. Non-oral feeding was determined based on optimal cutoff value of 105.0 mm Hg for VP maximal pressure (95.0% sensitivity and 70.0% specificity) and 0.45 s for UES relaxation duration (76.3% sensitivity and 57.5% specificity), respectively. During a mean follow-up of 18.8 months, 15.8% of patients developed aspiration pneumonia. On multivariate Cox regression analysis, VP maximal pressure (P<0.01) and UES relaxation duration (P<0.05) independently predicted the development of aspiration pneumonia. Cumulative incidence of aspiration pneumonia was significantly increased in patients with readings below optimal cutoff values for VP maximal pressure (P<0.01) and UES relaxation duration (P<0.01), individually.

CONCLUSIONS

We first established the optimal thresholds for HRM parameters to determine feeding method and predict the development of aspiration pneumonia in patients with oropharyngeal dysphagia.

Effects of laryngeal restriction on pharyngeal peristalsis and biomechanics: Clinical implications

To date, rehabilitative exercises aimed at strengthening the pharyngeal muscles have not been developed due to the inability to successfully overload and fatigue these muscles during their contraction, a necessary requirement for strength training. The purpose of this study was to test the hypothesis that applying resistance against anterosuperior movement of the hyolaryngeal complex will overload the pharyngeal muscles and by repetitive swallowing will result in their fatigue manifested by a reduction in pharyngeal peristaltic amplitude. Studies were done in two groups. In group 1 studies 15 healthy subjects (age: 42 ± 14 yr, 11 females) were studied to determine whether imposing resistance to swallowing using a handmade device can affect the swallow-induced hyolaryngeal excursion and related upper esophageal sphincter (UES) opening. In group 2, an additional 15 healthy subjects (age 56 ± 25 yr, 7 females) were studied to determine whether imposing resistance to the anterosuperior excursion of the hyolaryngeal complex induces fatigue manifested as reduction in pharyngeal contractile pressure during repeated swallowing. Analysis of the video recordings showed significant decrease in maximum deglutitive superior laryngeal excursion and UES opening diameter (P < 0.01) due to resistive load. Consecutive swallows against the resistive load showed significant decrease in pharyngeal contractile integral (PhCI) values (P < 0.01). Correlation analysis showed a significant negative correlation between PhCI and successive swallows, suggesting "fatigue" (P < 0.001). In conclusion, repeated swallows against a resistive load induced by restricting the anterosuperior excursion of the larynx safely induces fatigue in pharyngeal peristalsis and thus has the potential to strengthen the pharyngeal contractile function.