Swallowing Disorders

Postoperative dysphagia versus neurogenic dysphagia: scintigraphic assessment

In order to differentiate the features of dysphagia that occur after supraglottic horizontal laryngectomy from those that occur during neurologic diseases, we divided 38 subjects into 3 groups and submitted them to oropharyngoesophageal scintigraphy. Group 1 (control group) included 15 healthy volunteeers; group 2 comprised 8 patients who had residual dysphagia at least 1 year after supraglottic laryngectomy; and group 3 included 15 patients with various neurologic and neuromuscular disorders. In group 1, the mean values (+/- 2 SD) of selected semiquantitative parameters were consistent with those reported in the literature for normal subjects. In group 2, oral, pharyngeal, and esophageal transit times were not significantly altered, and moderate tracheobronchial post-deglutitive aspiration was present (maximum value, 6.7%; mean value, 2.04%). The pharyngeal retention index was significantly increased (p = .0003) as compared to normal subjects in all cases (maximum value, 40%; mean value, 23%) and was associated in all cases with slight but consistent post-deglutitive aspiration. In group 3, the oral and esophageal phases were significantly prolonged and the retention indices were significantly increased. Statistical analysis documented a significant increase in oral transit time (p = .003), esophageal transit time (p = .01), oral retention index (p = .006), pharyngeal retention index (p = .0007), and esophageal retention index (p = .009) as compared to normal subjects. The swallowing pattern was also altered by 1) an early loss of the bolus from the oral cavity; 2) bolus fragmentation due to double or triple deglutition, reduced lingual propulsion, or the return of a small part of the bolus into the oral cavity during deglutition; and/or 3) double pharyngeal peaks in the activity-time curves. Tracheobronchial aspiration (maximum value, 90%; mean value, 9.70%) was present in some cases, mainly in patients affected by post-stroke dysphagia. On the basis of the obtained results and considering the low doses of radiation delivered to the patient (0.043 Gy), the limited invasiveness, and the excellent patient tolerance, scintigraphy appears to be clinically valid in the functional study of swallowing and in identifying different deglutition disorders.

Differential diagnosis of dysphagia in children

Dysphagia in children often presents a difficult diagnostic challenge. A systematic approach in each individual can help with diagnosis and treatment. An overview of the differential diagnosis and the diagnostic and treatment options available is provided.

Swallowing in neurological outpatients: use of a timed test

Swallowing was studied prospectively in a consecutive group of 90 neurology outpatients under 70 years of age. No patient had been referred primarily because of dysphagia. Patients were classified into four groups: those with (1) neurological or (2) non-neurological diagnoses possibly relevant to disordered swallowing, (3) functional disorders, and (4) definite diagnoses not likely to be relevant. They were defined as having abnormal or probably abnormal swallowing if two or more of the following were present: a complaint of swallowing problem, abnormal symptoms or signs, a slow swallowing speed (< 10 ml.s-1). Nineteen patients among the four groups (21%) were found to have abnormal/probably abnormal swallowing. Swallowing speed was significantly slower in patients who perceived a swallowing problem or who had abnormal symptoms or signs compared with those who did not, providing further evidence for the validity of a timed test of swallowing capacity. The study also provides evidence of a significant incidence of disordered swallowing in outpatients who may not have complained spontaneously but who have diagnoses potentially relevant to swallowing.

Approaches to the patient with aspiration and swallowing disabilities

Aspiration, or soiling of the tracheobronchial tree, can produce life-threatening pulmonary disease. Intermittent or persistent aspiration may cause symptoms including cough, intermittent fever, recurrent tracheobronchitis, atelectasis, pneumonia, and/or empyema. The pulmonary disease may be associated with weight loss, cachexia, and dehydration. In many cases the aspiration is caused by laryngeal dysfunction, allowing pulmonary contamination by swallowed material. In other cases the aspiration is caused by a dysfunction of the oral, pharyngeal, or esophageal phases of swallowing. In some cases the aspiration is caused by a combination of laryngeal and swallowing dysfunction. Geriatric patients are more likely to experience aspiration, since muscle weakness causing mechanical disability and neurologic impairment are more common in this age group. Therefore, with the ever-increasing aging of our population, these disabilities will be on the rise, with an associated increase in pulmonary disease and death. The approach to evaluation and management of these disorders must be based on an understanding of the underlying functional impairment.