Swallowing in myotonic muscular dystrophy: a videofluoroscopic study

Congenital hypotonia: systematic approach for prenatal detection

OBJECTIVES

Congenital hypotonic conditions are rare and heterogeneous, and some are severely debilitating or lethal. Contrary to its prominent postnatal manifestation, the prenatal presentation of hypotonia is frequently subtle, inhibiting prenatal detection. We aimed to characterize the prenatal sonographic manifestation of congenital hypotonia throughout pregnancy, evaluate the yield of diagnostic tests and propose diagnostic models to increase its prenatal detection.

METHODS

This was a retrospective observational study of singleton pregnancies with congenital hypotonia, diagnosed either prenatally or immediately after birth, at a single tertiary center between the years 2012 and 2020. Prenatally, hypotonia was diagnosed if a fetus showed sonographic or clinical signs suggestive of hypotonia and had a confirmed underlying genetic condition, or in the absence of a known genetic abnormality if the fetus exhibited multiple prominent signs suggestive of hypotonia. Postnatally, it was diagnosed in neonates displaying reduced muscle tone leading to reduced spontaneous movement, reduced swallowing or feeding difficulty. We reviewed the medical records of pregnant patients carrying fetuses subsequently diagnosed with congenital hypotonia and assessed the yield of ultrasound scans, fetal magnetic resonance imaging, computed tomography and genetic tests. The detection rate of sonographic signs suggesting fetal hypotonia was calculated. The prevalence of non-specific signs, including polyhydramnios, persistent breech presentation, intrauterine growth restriction and maternal perception of reduced fetal movement, were compared between the study group and the local liveborn singleton population. Potential detection rates of different theoretical semiotic diagnostic models, differing in the threshold for referral for a targeted scan, were assessed based on the cohort's data.

RESULTS

The study group comprised 26 cases of congenital hypotonia, of which 10 (38.5%) were diagnosed prenatally, and the controls included 95 105 singleton live births, giving a prevalence of congenital hypotonia of 1:3658. Nuchal translucency thickness and the early anomaly scan at 13-17 weeks were normal in all 22 and 23 cases, respectively, in which this was performed. The mid-trimester scan performed at 19-25 weeks was abnormal in four of 24 (16.7%) cases. The overall prenatal detection rate of congenital hypotonic conditions in our cohort was 38.5%. Only cases which underwent a targeted scan were detected and, among the 16 cases which underwent this scan, the prenatal detection rate was 62.5% compared with 0% in pregnancies that did not undergo this scan (P = 0.003). An abnormal genetic diagnosis was obtained in 21 (80.8%) cases using the following modalities: chromosomal microarray analysis (CMA) in two (9.5%), whole-exome sequencing (WES) in 14 (66.7%) and methylation analysis in five (23.8%). CMA was abnormal in 8% (2/25) of the cases and WES detected a causative genetic mutation in 87.5% (14/16) of the cases in which these were performed. Comparison of non-specific signs in the study group with those in the local singleton population showed that hypotonic fetuses had significantly more polyhydramnios (64.0% vs 3.0%, P < 0.0001), persistent breech presentation (58.3% vs 4.2%, P < 0.0001), intrauterine growth restriction (30.8% vs 3.0%, P < 0.0001) and maternal perception of reduced fetal movement (32.0% vs 4.7%, P < 0.0001). Prenatally, the most commonly detected signs supporting a diagnosis of hypotonia were structural anomaly (62.5%, 10/16), reduced fetal movement (46.7%, 7/15), joint contractures (46.7%, 7/15) and undescended testes ≥ 30 weeks (42.9%, 3/7 males). Proposed diagnostic strategies that involved performing a targeted scan for a single non-specific ultrasound sign or two such signs, and then carrying out a comprehensive genetic evaluation for any additional sign, offered theoretical detection rates in our cohort of 88.5% and 57.7%, respectively.

CONCLUSIONS

Congenital hypotonic conditions are rare and infrequently detected prenatally. Sonographic signs are visible from the late second trimester. A targeted scan increases prenatal detection significantly. Comprehensive genetic testing, especially WES, is the cornerstone of diagnosis in congenital hypotonia. Theoretical diagnostic models which may increase prenatal detection are provided. © 2023 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Alterations of posterior pharyngeal wall movement during swallowing in postoperative tongue cancer patients: assessment with a videofluoroscopic swallowing study

This study aimed to determine the association between the progressive contraction of the posterior pharyngeal wall and dysphagia in postoperative patients with tongue cancer. A videofluoroscopic swallowing study (VFSS) was performed in 34 patients after tongue cancer surgery. Images were analyzed using a two-dimensional video measurement software. Cases in which the processes on the posterior pharyngeal wall moved downward from the 2nd to 4th vertebral regions were defined as "normal type", other cases were defined as "abnormal type". Twenty-four patients showed normal movement of the posterior pharyngeal wall, whereas 10 patients showed the abnormal type. The results showed that there was a significant difference in dysphagia scores between the postoperative swallowing type and swallowing dysfunction score. This implies that dysphagia is related to the movement of the posterior pharyngeal wall after tongue cancer surgery. Furthermore, the extent of resection and stage were significantly different between the normal and abnormal groups in the posterior pharyngeal wall movement. There was also a significant difference between the two groups in terms of the following: whether the tongue base was included in the excision range (p < 0.01), whether neck dissection was performed (p < 0.01), or whether reconstruction was not performed (p < 0.01). VFSS results showed that posterior pharyngeal wall movement was altered after surgery in patients with tongue cancer who had severe dysphagia.

Characteristics that predict penetration - aspiration in elderly patients following supracricoid laryngectomy with cricohyoidoepiglottopexy - a videofluoroscopic study

Objective

This study aimed to determine the incidence of laryngeal penetration and aspiration in elderly patients who underwent supracricoid laryngectomy with cricohyoidoepiglottopexy for laryngeal cancer.

Method

A retrospective analysis of dynamic videofluoroscopic swallowing studies was performed in patients who had received supracricoid laryngectomy with cricohyoidoepiglottopexy as a treatment for laryngeal cancers. Digital analysis of videofluoroscopic swallowing studies included measurements of displacement and timing related to swallowing safety.

Results

Videofluoroscopic swallowing studies from 52 patients were analysed. All participants were male and over 65 years old. Studies were performed five years after surgery. Among 52 videofluoroscopic swallowing studies, analysis showed that elevated pharyngeal constriction ratio (pharyngeal constriction ratio more than 0.0875, odds ratio = 5.2, p = 0.016), reduced pharyngoesophageal sphincter opening time (pharyngoesophageal sphincter open less than 0.6 seconds, odds ratio = 11.6, p = 0.00018) and reduced airway closure time (airway close less than 0.6 seconds, odds ratio = 10.6, p = 0.00057) were significantly associated with aspiration.

Conclusion

Deteriorated pharyngeal constriction, shortened airway closure and reduced pharyngoesophageal sphincter opening time are key factors for predicting laryngeal penetration or aspiration after supracricoid laryngectomy with cricohyoidoepiglottopexy.

Compensatory Effects of Sequential 4-Channel Neuromuscular Electrical Stimulation for the Treatment of Acute, Subacute, and Chronic Dysphagia in a Prospective, Double-Blinded Randomized Clinical Trial

Background. The precise mechanism of 2-channel neuromuscular electrical stimulation (NMES) treatment is unknown, and controversy remains over its efficacy. The sequential 4-channel NMES was newly developed based on normal contractile sequences of swallowing-related muscles. Objective. To assess the clinical efficacy of sequential 4-channel NMES during swallowing. Methods. In this prospective RCT, 52 inpatients with dysphagia (acute, subacute, and chronic state) after stroke, brain tumor, or encephalitis were enrolled. Participants who underwent a videofluoroscopic swallowing study (VFSS) and clinical evaluation were enrolled and were randomly assigned to the 4-channel NMES or sham group. The 4-channel NMES and sham groups swallowed thin and honey-like fluids under NMES (sequential stimulation on suprahyoid and infrahyoid) and sham stimulation, respectively. The procedures were evaluated with the VFSS. Pre- and post-treatment evaluations were performed with the videofluoroscopic dysphagia scale (VDS), penetration-aspiration scale (PAS), Likert scale, and kinematic analysis. Results. The 4-channel NMES group showed significantly greater improvements than the sham group with respect to oral VDS, pharyngeal VDS, total VDS, and PAS (P < .05). Furthermore, the Likert scale for satisfaction, easiness, and discomfort for swallowing showed favorable results for the 4-channel NMES group (P < .05). In the kinematic analysis, the peak speed point, distance, and velocity of hyoid movement were significantly greater in the 4-channel NMES group (P < .05). Conclusions. Sequential 4-channel NMES activating the suprahyoid, thyrohyoid, and other infrahyoid muscles during swallowing showed significant clinical improvement with respect to VDS, PAS, and kinematic analysis. Therefore, sequential 4-channel NMES is a potential new functional electrical stimulation system for the treatment of dysphagia.

Classification of Stroke Patients With Dysphagia Into Subgroups Based on Patterns of Submental Muscle Strength and Skill Impairment

OBJECTIVES

To identify and characterize subgroups of stroke patients with clinical signs of dysphagia, based on swallowing-related strength and skill impairments of the submental muscle group.

DESIGN

Prospective observational study.

SETTING

Inpatient rehabilitation centers and community dwellings.

PARTICIPANTS

Individuals (N=114), including stroke patients with dysphagia (n=55) and 2 control groups including myopathic patients with dysphagia (n=19) and healthy volunteers (n=40) were included in this study.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Novel clinical assessment of strength (force generation) and skill (spatial and temporal precision of muscle activation) of the submental muscle group during swallowing and nonswallowing behaviors, using surface electromyography and dynamometry.

RESULTS

Hierarchical cluster analysis revealed 4 clusters, which could be broadly characterized as cluster 1: intact strength and skill, cluster 2: poor strength and poor nonswallowing skill, cluster 3: poor strength, and cluster 4: poor strength and poor swallowing skill. Membership in cluster was significantly associated with medical diagnosis (P<.001). The majority of healthy and myopathic participants were assigned to clusters 1 and 3, respectively, whereas stroke patients were found in all 4 clusters. Skill outcome measures were more predictive of cluster assignment than strength measures.

CONCLUSIONS

Although healthy and myopathic participants demonstrated predominantly homogeneous swallowing patterns of submental muscle function within their etiology, several subgroups were identified within stroke, possibly reflecting different subtypes of swallowing function. Future research should focus on the nature and rehabilitation needs of these subtypes. Assessment of skill in swallowing may be an important but overlooked aspect of rehabilitation.

Silent dysphagia in two patients with Steinert disease and recurrent respiratory exacerbations

We describe two cases of patients with Steinert’s dystrophy or myotonic dystrophy type 1 (DM1) who presented with frequent respiratory exacerbations and pneumonia. They did not report any risk factors for asthma, allergy, bronchopathy or dysphagia in their history. The Videofluoroscopic swallow study test allowed to highlight post-swallowing aspiration phenomena responsible for respiratory exacerbations.

A Cross-Sectional, Quantitative Videofluoroscopic Analysis of Swallowing Physiology and Function in Individuals With Amyotrophic Lateral Sclerosis

Purpose To date, research characterizing swallowing changes in individuals with amyotrophic lateral sclerosis (ALS) has primarily relied on subjective descriptions. Thus, the degree to which swallowing physiology is altered in ALS, and relationships between such alterations and swallow safety and/or efficiency are not well characterized. This study provides a quantitative representation of swallow physiology, safety, and efficiency in a sample of individuals with ALS, to estimate the degree of difference in comparison to published healthy reference data and identify parameters that pose risk to swallow safety and efficiency. Secondary analyses explored the therapeutic effect of thickened liquids on swallowing safety and efficiency. Method Nineteen adults with a diagnosis of probable-definite ALS (El-Escorial Criteria-Revised) underwent a videofluoroscopic swallowing study, involving up to 15 sips of barium liquid (20% w/v), ranging in thickness from thin to extremely thick. Blinded frame-by-frame videofluoroscopy analysis yielded the following measures: Penetration-Aspiration Scale, number of swallows per bolus, amount of pharyngeal residue, degree of laryngeal vestibule closure (LVC), time-to-LVC, duration of LVC (LVCdur), pharyngeal area at maximum constriction, diameter of upper esophageal sphincter opening, and duration of UES opening (UESOdur). Measures of swallow physiology obtained from thin liquid trials were compared against published healthy reference data using unpaired t tests, chi-squared tests, and Cohen's d effect sizes (adjusted p < .008). Preliminary relationships between parameters of swallowing physiology, safety, and efficiency were explored using nonparametric Cochrane's Q, Friedman's test, and generalized estimating equations (p < .05). Results Compared to healthy reference data, this sample of individuals with ALS displayed a higher proportion of swallows with partial or incomplete LVC (24% vs. < 1%), increased time-to-LVC (d = 1.09), reduced UESwidth (d = 0.59), enlarged pharyngeal area at maximum constriction, prolonged LVCdur (d = 0.64), and prolonged UESOdur (d = 1.34). Unsafe swallowing (i.e., PAS ≥ 3) occurred more frequently when LVC was partial/incomplete or time-to-LVC was prolonged. Pharyngeal residue was associated with larger pharyngeal areas at maximum constriction. Unsafe swallowing occurred less frequently with extremely thick liquids, compared to thin liquids. No significant differences in pharyngeal residue were observed based on liquid thickness. Conclusions Quantitative videofluoroscopic measurements revealed moderate-to-large differences in swallow physiology between this sample of individuals with ALS and healthy reference data. Increased time-to-LVC, noncomplete LVC, and enlarged pharyngeal area at maximum constriction were associated with impaired swallow safety or efficiency. Thickened liquids may mitigate the risk of acute episodes of aspiration in individuals with ALS. Further work is needed to corroborate these preliminary findings and explore how swallowing profiles evolve throughout disease progression.

Congenital Myotonic Dystrophy and Brugada Syndrome: A Report of Two Cases

BACKGROUND Congenital myotonic dystrophy is a subtype of type 1 myotonic dystrophy presenting in the neonatal period. Cardiac involvement is commonly seen in patients with type 1 myotonic dystrophy beyond the neonatal period. Brugada syndrome is a conduction abnormality associated with a mutation in the sodium voltage-gated channel alpha subunit 5 (SCN5A) gene and has been described in adult patients with type 1 myotonic dystrophy. Two cases are presented of type 1 myotonic dystrophy in neonates, one who had family members with a confirmed diagnosis of Brugada syndrome. CASE REPORT Case 1: A female infant at 40 weeks gestational age, birth weight of 3,395 grams was born to a 40-year-old gravida 4, para 3 (G4P3) mother. The mother had previously been diagnosed with Brugada syndrome. Multiple family members were identified and diagnosed with type 1 myotonic dystrophy and Brugada syndrome. The infant is being monitored closely with a plan to perform genetic testing for Brugada syndrome if she develops cardiac conduction abnormalities. Case 2: A male infant at 37 weeks gestational age, with a birth weight of 2,900 grams, was born to a 24-year-old gravida 2, para 1 (G2P1) mother. He was admitted to the neonatal intensive care unit (NICU) secondary to poor respiratory effort and generalized hypotonia. Severe polyhydramnios was diagnosed during pregnancy. The mother had previously been diagnosed with type 1 myotonic dystrophy. CONCLUSIONS Infants with congenital myotonic dystrophy should be carefully monitored for both structural and conduction abnormalities of the heart, supported by genetic testing.

Application of Automatic Kinematic Analysis Program for the Evaluation of Dysphagia in ALS patients

Dysphagia in amyotrophic lateral sclerosis (ALS) increases the risk of malnutrition, dehydration, and aspiration pneumonia. Kinematic analysis of videofluoroscopic swallowing study (VFSS) can provide detailed movement of the hyoid bone, revealing abnormalities of swallowing in ALS patients. We developed an automated kinematic analysis program (AKAP) that analyzes the trajectory of the hyoid bone via a visual tracking method. The aim of this study was to investigate the hyoid movement in ALS patients using AKAP and compare it with non-dysphagic subjects. Thirty ALS patients who underwent VFSS in Seoul National University Bundang Hospital between 2015 and 2017 were recruited. For comparison, 30 age-matched control subjects were also enrolled; the same swallowing study was conducted using thin fluid and yogurt. The hyoid bone movement was analyzed by evaluating the vertical and horizontal distances with four peak points (A, B, C, D), and the time of each point were also calculated. With respect to distance parameters, only vertical peak distance (distance between B, D points) during thin fluid swallowing was significantly decreased in ALS patients. (p = 0.038) With respect to temporal parameters, Time ABC, Time ABCD, and Duration C were significantly increased in ALS patients when swallowing both thin fluid and yogurt. (Time ABC p = 0.019, p = 0.002; Time ABCD p = 0.001, p = 0.004; Duration C p = 0.004, p = 0.025 respectively). This result revealed that dysphagia in ALS patient is caused by decreased velocity of hyoid bone movement due to the development of weakness in swallowing-related muscles. The parameters of kinematic analysis could be used to quantitatively evaluate dysphagia in motor neuron disease.

Oropharyngeal dysphagia in early stages of myotonic dystrophy type 1

INTRODUCTION

Myotonic dystrophy type 1 (DM1) is a multisystemic disorder characterized mainly by skeletal muscle alterations. Although oropharyngeal dysphagia is a prominent clinical feature of DM1, it remains poorly studied in its early disease stages.

METHODS

Dysphagia was investigated in 11 presymptomatic DM1 carriers, 14 patients with DM1 and 12 age-matched healthy controls, by using fiberoptic endoscopic evaluation of swallowing (FEES) and clinical scores.

RESULTS

Scores for the FEES variables, delayed pharyngeal reflex, posterior pooling, and postswallow residue were significantly greater in patients with DM1 and in presymptomatic DM1 carriers than in healthy controls (P < 0.05); oropharyngeal dysfunction was more severe in patients than in presymptomatic carriers. Penetration/aspiration was found altered exclusively in patients with DM1 (P < 0.05).

DISCUSSION

Swallowing dysfunction occurs in presymptomatic DM1 carriers. Timely diagnosis of dysphagia in preclinical stages of the disease will aid in the timely management of presymptomatic carriers, potentially preventing medical complications. Muscle Nerve, 2019.

Clinical characteristics of pregnancies complicated by congenital myotonic dystrophy

Objective

Although the conventional prevalence of myotonic dystrophy is 1:8,000, the prevalence in Korean population was recently reported as 1:1,245. With higher domestic result than expected, we aimed to investigate the clinical characteristics of pregnancies complicated by congenital myotonic dystrophy in our institution.

Methods

We have reviewed 11 paired cases of neonates diagnosed with congenital myotonic dystrophy and their mothers between July 2004 and May 2014, with clinical features including maternal history of infertility, prenatal ultrasonographic findings, and neonatal outcomes. Cytosine-thymine-guanine (CTG) repeat expansion in the myotonic dystrophy protein kinase gene of both neonates and their mothers was also examined.

Results

None of mother was aware of their myotonic dystrophy traits before pregnancy. History of infertility followed by assisted reproductive technology accounted for 57.1% (4/7). Distinctive prenatal ultrasonographic finding was severe idiopathic polyhydramnios (66.7%, 4/6) with median amniotic fluid index of 43 (range, 37 to 66). In 37.5% (3/8) cases, decreased fetal movement was evident during prenatal ultrasound examination. For neonatal outcomes, more than half (6/11) were complicated with preterm birth and the proportion of 1-minute Apgar score <4 and 5-minute Apgar score <7 was 44.4% (4/9) and 66.7% (6/9), respectively. Most of neonates were admitted to the neonatal intensive care unit (9/10) because of hypotonia with respiratory problems and there was one infant death. Median number of cytosine-thymine-guanine repeats in mothers and neonates was 400 (range, 166 to 1,000) and 1,300 (range, 700 to 2,000), respectively.

Conclusion

Our data suggest that severe idiopathic polyhydramnios with decreased fetal movement in pregnant women, especially with a history of infertility, requires differential diagnosis of congenital myotonic dystrophy.

Characteristics of tongue and pharyngeal pressure in patients with neuromuscular diseases

Background

Tongue and pharyngeal pressure is an essential factor associated with the swallowing function; however, little is known about the difference in tongue and pharyngeal pressure between neuromuscular diseases. This study aimed to characterize tongue and pharyngeal pressure in myotonic dystrophy type 1 (DM1), Duchenne muscular dystrophy (DMD), and amyotrophic lateral sclerosis (ALS) patients.

Methods

This study recruited 17 DMD patients, 32 DM1 patients, and 26 ALS patients. They underwent separate measurements of tongue and pharyngeal pressure under videofluoroscopy, swallowing 5 mL of barium water. We measured the largest change in pharyngeal pressure in the hypopharynx and the upper esophageal sphincter (UES) over several swallows.

Results

The mean tongue pressure (TP) was greatest in the DMD group than in the other groups (p<0.01). There was a significant difference in pressure changes in the hypopharynx and UES between the DM1 group and other groups (p<0.01). Significant correlations were observed between pressure change in the UES and the patient’s age in the DMD group (R=–0.500, p=0.045) and between pressure change in the hypopharynx and TP in the DM1 group (R=0.421, p=0.016). There was a significant correlation between pressure change in the hypopharynx and disease severity in the ALS group (R=0.435, p=0.030).

Conclusion

Patients with DMD, DM1, and ALS have weakness in the muscles involved in swallowing; however, the results of this study suggested that each disorder has a distinctive profile of impairment in the swallowing function.

Subjective Assessment of Videofluoroscopic Swallow Studies

Objective

The videofluoroscopic swallow study (VFSS) is the gold standard diagnostic tool to evaluate oropharyngeal dysphagia. Although objective measurements on VFSS have been described, there is no universal method of analysis, and the majority of clinicians use subjective interpretation alone. The purpose of this investigation was to evaluate the accuracy of subjective VFSS analysis.

Study Design

Double-blinded experiment.

Setting

Tertiary care laryngology center.

Subjects and Methods

Seventy-six de-identified videos from VFSS evaluations of patients with dysphagia were presented to blinded, experienced speech-language pathologists and laryngologists individually. Evaluators rated each video as normal or abnormal for hyoid elevation (HE), pharyngeal area (PA), pharyngeal constriction ratio (PCR), and pharyngoesophageal segment opening (PESo). A blinded investigator assessed evaluators’ inter- and intrarater agreement and compared their responses to objectively measured results for these parameters to examine accuracy.

Results

Evaluators correctly classified only 61.5% of VFSS videos as normal or abnormal, with moderate interrater agreement (κ = 0.48, P < .0001). Intrarater agreement was highly variable (κ = 0.43-0.83). Accuracy was greatest for PCR (71.6%), with poorer performance for HE (61.3%), PESo (59.2%), and PA (45.3%). Interrater agreement was moderate for all parameters, with greater concordance for PCR (κ = 0.59) and PESo (κ = 0.54) and less for HE (κ = 0.40) and PA (κ = 0.44). Evaluators unanimously agreed on a correct interpretation of a VFSS only 28% of the time.

Conclusion

Subjective assessment of VFSS parameters is inconsistently accurate when compared with objective measurements, with accuracy ratings ranging from 45.3% to 71.6% for specific parameters. Inter- and intrarater reliability for subjective assessment was moderate and highly variable.

Application and Verification of Quantitative Objective Videofluoroscopic Swallowing Measures in a Pediatric Population with Dysphagia

OBJECTIVE

To investigate the feasibility of obtaining and utilizing objective measures of timing and displacement from videofluoroscopy performed in pediatrics.

STUDY DESIGN

Children (n = 121; mean age 38 months, range 9 days-21 years, SD 4 years) referred for videofluoroscopy were recruited. All underwent a standardized protocol including a mid-feed 20-second loop recorded at 25 frames per second. Videos were analyzed using objective digital measures of timing and displacement. Radiation dose was recorded.

RESULTS

Quantitative measures were obtained in all children. Maximum opening of the pharyngoesophageal segment and timing measures were correlated with increasing age. Values were congruent with validated adult data. Mean radiation time was 1.58 minutes (range 0.15-3.47, SD 0.66), and mean radiation dose was 30.16 cGycm² (range 6.5-85 SD 15.17). Radiation dose (P = .21) and radiation time (P = .72) were not significantly different using the increased frame rate compared with an age-matched cohort (n =100) prior to protocol change.

CONCLUSIONS

Objective quantitative measures of swallowing measurements can be obtained successfully from pediatric videofluoroscopy performed at high frame rates, without increasing radiation dose. Measures are biologically consistent, reproducible, demonstrate internal cross-correlation, and mirror adult data. These measures have potential to support targeted management and objective monitoring of change by pediatric feeding teams in the future.

[High resolution manometry study of pharyngeal function in patients with myotonic dystrophy]

BACKGROUND

Patients with myotonic dystrophy (MD) are known to suffer from oropharyngeal dysphagia and esophageal motility disorders, which are often the cause of aspiration pneumonia. So far only little is known about the pharyngeal contractility and the function of the upper esophageal sphincter in these patients, in particular only few data are available for manometric investigations allowing assessment of the pharyngeal pressure build-up during swallowing. The aim of this study was to collect such data in patients with MD using high resolution manometry.

METHOD

In two patients with MD high resolution manometry studies were performed during swallowing and phonation to determine pressure-dependent parameters. The results were compared with normal values from healthy subjects.

RESULTS

In both patients a reduced pressure in the entire pharynx during swallowing was determined. The duration of the contraction in the velopharynx and tongue base region was shortened. The structural course of the swallowing process and the opening and closing functions of the upper esophageal sphincter were regular. During realization of closed vowels a reduced pressure build-up in the velopharyngeal region was observed.

CONCLUSION

The force of contraction and the associated pharyngeal pressure build-up during swallowing were reduced resulting in an incomplete clearing of the pharynx. Beside myopathic disorders, neuromuscular disorders also have to be considered. The functional course of the swallowing process and the swallowing pattern was retained. The reduced pressure build-up in the velopharyngeal region can be considered as the cause for rhinophonia. To evaluate the pharyngeal function in patients with MD, high resolution manometry is a useful tool for assessing the pharyngeal function besides the basic diagnostics.

Objective Measures of Swallowing Function Applied to the Dysphagia Population: A One Year Experience

Quantitative, reliable measures of swallowing physiology can be made from an modified barium swallowing study. These quantitative measures have not been previously employed to study large dysphagic patient populations. The present retrospective study of 139 consecutive patients with dysphagia seen in a university tertiary voice and swallowing clinic sought to use objective measures of swallowing physiology to (1) quantify the most prevalent deficits seen in the patient population, (2) identify commonly associated diagnoses and describe the most prevalent swallowing deficits, and (3) determine any correlation between objective deficits and Eating Assessment Tool (EAT-10) scores and body mass index. Poor pharyngeal constriction (34.5 %) and airway protection deficits (65.5 %) were the most common swallowing abnormalities. Reflux-related dysphagia (36 %), nonspecific pharyngeal dysphagia (24 %), Parkinson disease (16 %), esophageal abnormality (13 %), and brain insult (10 %) were the most common diagnoses. Poor pharyngeal constriction was significantly associated with an esophageal motility abnormality (p < 0.001) and central neurologic insult. In general, dysphagia symptoms as determined by the EAT-10 did not correlate with swallowing function abnormalities. This preliminary study indicates that reflux disease is common in patients with dysphagia and that associated esophageal abnormalities are common in dysphagic populations and may be associated with specific pharyngeal swallowing abnormalities. However, symptom scores from the EAT-10 did not correspond to swallowing pathophysiology.

Pharyngeal transit in patients with chronic progressive external ophthalmoplegia

PURPOSE

A common presentation of mitochondrial myopathies is chronic progressive external ophthalmoplegia (CPEO). Dysphagia is a complaint in about 50% of cases.

METHOD

This investigation evaluated pharyngeal transit in patients with CPEO. Videofluoroscopic swallowing evaluation was performed with paste, liquid and solid boluses in 14 patients with CPEO and in 16 normal volunteers.

RESULT

There was no difference between patients and volunteers in the duration of pharyngeal swallowing events with the liquid bolus. Compared to control participants, patients with CPEO had significantly shorter duration of pharyngeal transit for paste and solid boluses, of pharyngeal clearance for paste bolus, and of upper oesophageal sphincter transit for paste and solid boluses. Spontaneous multiple swallows and effortful swallows were performed by patients but not by the volunteers.

CONCLUSION

It was concluded that patients with CPEO have shorter pharyngeal transit duration of paste and solid boluses than normal volunteers, which may be a consequence of a spontaneous smaller bolus volume in each swallow and/or effortful swallows.

Análise quantitativa da deglutição de parkinsonianos pré e pós-riboflavina

Objetivo verificar as mudanças quantitativas na dinâmica da deglutição em pacientes portadores da doença de Parkinson, submetidos à administração de riboflavina e restrição de carnes vermelhas e de aves, no período de um ano. Métodos participaram do estudo 16 pacientes com doença de Parkinson, com media de idade de 67,25 anos, media do nível de severidade da doença de II para III e com media de 3,5 anos de tempo de diagnóstico da doença. As avaliações videofluoroscópicas da deglutição foram realizadas antes e após um ano de administração de riboflavina e restrição de carne vermelha e de aves. Foram analisadas presença de queixas relacionadas à deglutição e análise quantitativa por meio de medidas computadorizadas do deslocamento do osso hióide e da cartilagem cricóidea, abertura da transição faringoesofágica (TFE) e da constrição da faringe. Resultados verificou-se redução no percentual de queixas relacionadas à deglutição no momento pós-administração de riboflavina. Com relação às medidas quantitativas, observou-se no momento pós um discreto aumento na abertura da TFE para todas as consistências oferecidas, aumento da constrição da faringe para a consistência líquido engrossado, discreta redução dos valores de deslocamento do osso hióide, e tanto discreta redução como discreto aumento dos valores de deslocamento da cartilagem cricóidea dependendo da consistência alimentar, sendo redução significante para o líquido. Conclusões as medidas quantitativas realizadas na movimentação dos órgãos relacionados à deglutição não demonstraram diferenças significantes entre os momentos pré e pós-riboflavina e a restrição de carne vermelha e de aves.

Swallowing assessment in myotonic dystrophy type 1 using fiberoptic endoscopic evaluation of swallowing (FEES)

This study describes the swallowing function of patients with myotonic dystrophy type 1 (DM1) and the effect of bolus consistency on swallowing in this group. The aim of the study is twofold: (a) to identify which (and to what extent) swallowing variables change for DM1 patients relative to healthy control subjects and (b) to examine whether the degree of oropharyngeal dysphagia is associated with disease severity. Forty-five consecutive DM1 patients and ten healthy subjects underwent a swallowing assessment, at Maastricht University medical Center in the Netherlands. The assessment included a standardized fiberoptic endoscopic evaluation of swallowing (FEES) protocol using different bolus consistencies. Clinical severity of the disease was assessed using the muscular impairment rating scale (MIRS). Significant differences were found between patients and controls for all FEES variables. The magnitude of these differences depended on the bolus consistency. The odds of a more pathological swallowing outcome increased significantly with higher MIRS levels. In conclusion, swallowing function is found to be significantly altered in DM1 patients. The results emphasize the importance of conducting a detailed swallowing assessment in all patients, even those with mild muscle weakness.

Dysphagia in Duchenne muscular dystrophy versus myotonic dystrophy type 1

INTRODUCTION

In this study we aimed to demonstrate the distinctive features of dysphagia in patients with myotonic dystrophy type 1 (DM1) and Duchenne muscular dystrophy (DMD).

METHODS

Diet-type score (DTS) and maximum tongue pressure (MTP) were measured in 20 DM1 and 24 DMD patients; all patients were also examined by videofluoroscopy (VF). We used VF to measure the range of hyoid bone excursion (RHBE) during pharyngeal transit time and the area of pharyngeal residue (APR) after the first swallow.

RESULTS

RHBE and APR values for DM1 patients were significantly greater than those for DMD patients. DTS and MTP did not differ between patients. A significant correlation was observed between DTS, MTP, and RHBE in DMD patients, but not in DM1 patients.

CONCLUSIONS

Our findings reveal the differences in the distinctive features of dysphagia in DM1 and DMD. Adjustments in the diet of DMD patients in accordance with swallowing ability could be useful.

Masticatory dysfunction in patients with myotonic dystrophy (type 1): a 5-year follow-up

Eight patients with myotonic dystrophy type 1, DM1 (age range 45-63 years) were followed for a period of 5 years. Two sets of data analyzing masticatory function and activities of daily living (ADL) were obtained at baseline and at 5 years. The results from both time points were compared. The number of food items considered easy to chew, maximum bite force, occlusal contact area, number of teeth, and ADLs were significantly reduced (p < 0.05) at the second assessment when compared to the first. During the intervening 5 years, six of the eight patients adopted a soft diet. These results suggest deterioration in ADLs and masticatory function of patients with DM1. Continuous evaluation of the feeding ability and the type of diet are necessary for patients with DM1.

Fluoroscopic surrogate for pharyngeal strength: the pharyngeal constriction ratio (PCR)

The pharyngeal constriction ratio (PCR), derived directly from videofluoroscopy without the need for manometry, requires validation as a surrogate for pharyngeal strength. A correlation of −0.70 was previously identified between PCR and pharyngeal clearing pressures (PP) on separate fluoroscopic and manometric studies. As PP increases, PCR decreases. The objective of the current study was to evaluate the correlation between PCR and PP in 25 patients undergoing simultaneous fluoroscopy and pharyngeal manometry. The effect of the manometric catheter on PCR was also investigated. The correlation between the PCR and averaged pharyngeal clearing pressures was −0.72 (p < 0.001). All patients with a PCR > 0.25 had a PP < 60 mmHg. PCR did not differ significantly as a consequence of the manometric catheter. Results suggest the utility of an objective fluoroscopic measure in assessing pharyngeal strength when manometry may not be available or possible.

Dysphagia in patients with Duchenne muscular dystrophy evaluated with a questionnaire and videofluorography

PURPOSE

To investigate swallowing problems in patients with Duchenne muscular dystrophy (DMD) using a questionnaire and videofluorography (VF).

METHOD

A questionnaire survey was performed of swallowing-related symptoms and VF in 31 male patients with DMD (mean age 19.9 years, range 9 - 26 years). The relationships among age, frequency of symptoms and VF abnormalities were analysed using Spearman's rank correlation. The differences in VF abnormalities among different food textures were analysed with the Kruskal - Wallis test.

RESULTS

Symptoms related to pharyngeal phase dysfunction were more frequent than those related to oral and oesophageal phases. Coughing while eating was seen in 71% of the patients, choking while eating in 32% and the need to clear the throat in 26%. VF abnormalities were observed in 30 patients (96.8%). Common VF abnormalities included pooling in the valleculae (90.3%) and in the pyriform sinus (90.3%). Pharyngo-oral regurgitation was seen in 35.5% of the patients. Pooling in the pyriform sinus after repeated swallowing seen in VF correlated significantly with symptoms related to the pharyngeal phase (Spearman's rho 0.356 - 0.544).

CONCLUSION

Because oropharyngeal dysphagia in DMD was evident in teenage patients as well as those without clinical symptoms, VF is recommended in patients with DMD.

Movement of the hyoid bone and the epiglottis during swallowing in patients with dysphagia from different etiologies

PURPOSE

(1) To compare the kinematic motion of the hyoid bone and the epiglottis in healthy controls and a sample of patients with dysphagia of different etiologies, and (2) to evaluate the potential value of kinematic swallowing analysis to differentiate the mechanism of dysphagia.

METHODS

We performed two-dimensional video motion analysis of the hyoid bone using videofluoroscopic images in nine controls without any swallowing difficulty, and seven patients with supratentorial stroke, three patients with inflammatory myopathy who showed dysphagia. Main outcome measures were: (1) horizontal and vertical excursion of the hyoid bone, and rotation of the epiglottis, and (2) trajectory of the hyoid bone and epiglottis during swallowing.

RESULTS

Horizontal excursion of the hyoid bone and rotation of the epiglottis were reduced in patients with myopathy as compared to control and patients with stroke (P<0.05). Patients with dysphagia showed different patterns as compared to control in trajectory analysis according to their etiology.

CONCLUSION

We conclude that extent and pattern of movement of the hyoid bone and the epiglottis during swallowing were different according to etiology of dysphagia, and swallowing motion analysis could be applied to differentiate the mechanism of dysphagia.

Dysphagia in inflammatory myopathy: clinical characteristics, treatment strategies, and outcome in 62 patients

OBJECTIVE

To assess the clinical characteristics, treatment, and outcome of patients with inflammatory myopathy-associated dysphagia.

PATIENTS AND METHODS

We retrospectively reviewed the medical records of all patients with inflammatory myopathy-associated dysphagia seen at the Mayo Clinic in Rochester, Minn, between January 1, 1997, and December 31, 2001.

RESULTS

A total of 783 patients were diagnosed as having inflammatory myopathy during the 5-year study period. Of these, 62 patients (41 women and 21 men; mean age, 68.6 years) had inflammatory myopathy-associated dysphagia: 26 with inclusion body myositis (IBM), 18 with dermatomyositis, 9 with polymyositis, and 9 with overlap syndrome. Dysphagia was a presenting symptom in 13 patients (21%), with the highest incidence in the IBM group. Videofluoroscopic examinations revealed pharyngeal pooling and impaired oropharyngeal and cricopharyngeal function. The benefits of swallowing compensation techniques and exercises were difficult to establish. Interventional procedures were performed in 24 patients (39%) and most frequently (62%) in patients with IBM, with cricopharyngeal myotomy being most beneficial. Patients with IBM had the least symptomatic improvement. Overall, 11 patients died during the median follow-up of 38 months, with respiratory failure due to aspiration pneumonia as the most common cause. Mortality was high in patients who required percutaneous endoscopic gastrostomy (7/11, 64%), and 1- year mortality was highest (31%) in those with dermatomyositis.

CONCLUSION

Dysphagia is a serious and at times presenting problem in patients with inflammatory myopathy. It occurs most frequently and appears to be most refractory in patients with IBM. The mortality rate was high in patients who required percutaneous endoscopic gastrostomy, and the 1-year mortality rate was the highest in patients with dermatomyositis.

Congenital myotonic dystrophy: prenatal ultrasound findings and pregnancy outcome

OBJECTIVE

The objective of this study was to assess the maternal and prenatal ultrasound findings and outcome in pregnancies complicated by congenital myotonic dystrophy Type 1 (DM1).

METHODS

A retrospective chart review of all patients with a diagnosis of DM1 and pregnancy presenting to the Oxford Radcliffe Hospital between 1990 and 2004 was undertaken. Obstetric case notes were reviewed and details of all pregnancies obtained. This included data on prenatal diagnostic tests and obstetric ultrasound scans performed as well as pregnancy complications and pregnancy outcome. Maternal and fetal CTG expansion size was also recorded where available. Maternal genetic case notes were reviewed for details of maternal grip myotonia.

RESULTS

Sixty pregnancies among 26 couples in which one of the parents was a carrier of DM1 were identified during the study period. These resulted in 36 (60%) pregnancies affected by congenital DM1 and 19 (31.7%) unaffected pregnancies. There were four miscarriages and one termination of pregnancy for non-medical reasons. Nineteen of the 36 affected pregnancies ended in termination following the antenatal diagnosis of congenital DM1 by either chorionic villus sampling (CVS) or amniocentesis. In the remaining 17 affected pregnancies (16 singleton and one twin) there was one miscarriage of an affected fetus with co-existing Down syndrome and eight perinatal deaths. The principal cause of perinatal death was respiratory failure in the early neonatal period. Antenatally noted clinical/sonographic abnormalities in these pregnancies included polyhydramnios (100%), talipes (26.6%) and borderline ventriculomegaly (13.3%). Uni- or bilateral talipes was noted at delivery in 10 of 16 (62.5%) neonates. Maternal grip myotonia was present in all but one of these cases.

CONCLUSION

The antenatal findings of polyhydramnios and talipes should prompt a search for maternal grip myotonia. If present, definitive testing for congenital DM1 should be considered.

Relationship between fluoroscopic and manometric measures of pharyngeal constriction: the pharyngeal constriction ratio

OBJECTIVES

The gold standard objective measure of pharyngeal strength is pharyngeal manometry. We have developed an objective fluoroscopic measure of pharyngeal strength, the pharyngeal constriction ratio (PCR). A high PCR indicates poor pharyngeal constriction. The objective of the current study was to evaluate the correlation between the PCR and peak pressures on pharyngeal manometry.

METHODS

The charts of 20 consecutive individuals who underwent a dynamic fluoroscopic swallow evaluation and pharyngeal manometry at the Center for Voice and Swallowing of the University of California, Davis, were retrospectively reviewed. Information regarding patient demographics, diagnoses, PCR, and manometric pharyngeal peak pressures was abstracted. The correlation between the PCR and pharyngeal pressure was determined with the Pearson correlation coefficient.

RESULTS

The mean (+/-SD) age of the cohort was 63 +/- 11 years. Fourteen of the 20 patients (70%) were male. The most common diagnoses were reflux (7 of 20) and cerebrovascular accident (4 of 20). The mean PCR was 0.26 +/- 0.31. The mean pharyngeal pressure was 83 +/- 43 mm Hg. The correlation between the PCR and pharyngeal pressure was -0.70 (p < .01).

CONCLUSIONS

There was a high inverse correlation between the PCR and the peak pharyngeal pressure on manometry (-0.70). The PCR appears to be a valid objective surrogate measure of pharyngeal strength.

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.

Nonmolecular treatment for muscular dystrophies

PURPOSE OF REVIEW

This review highlights emerging evidence on the management of patients with muscular dystrophies.

RECENT FINDINGS

New diagnostic modalities based on muscle biopsy and DNA analysis mean that diagnoses within the heterogeneous group of muscular dystrophies can be much more precise; also, as the phenotypes associated with these different disorders are clarified, new management implications can be recognized. At the same time, the spread of evidence based medicine into this area has led to an increase in clinical trial activity and the development of evidence based guidelines. Because many if not all muscular dystrophies are multisystem disorders, these guidelines relate not only to the limited number of interventions aimed at improving strength but also to the management of potentially life threatening complications.

SUMMARY

Because specific diagnoses carry specific management implications in many areas for these hitherto rather neglected disorders, a more proactive approach to patients with muscular dystrophies is needed. Complications involving, for example, the cardiovascular, respiratory and gastrointestinal systems may need to be sought and actively managed, whereas caution for complications of anaesthesia and other interventions may also be necessary. However, areas remain where there is little evidence from which practice guidelines can be developed and these will need to be addressed with well planned clinical trials.