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Walters RK, Gudipudi R, Gordis T, Davidson K, Nguyen SA, O'Rourke AK. A Systematic Review of Pharyngeal High-Resolution Manometry Normative Data. AMERICAN JOURNAL OF SPEECH-LANGUAGE PATHOLOGY 2024; 33:1059-1068. [PMID: 38127890 DOI: 10.1044/2023_ajslp-23-00221] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/23/2023]
Abstract
PURPOSE The utilization of high-resolution pharyngeal manometry (HRPM) in the evaluation of pharyngeal dysphagia has been increasing; however, standardization of its use has lagged behind. Without standardization using normative values, it is difficult for clinicians to adopt this emerging technology into meaningful use. Our goal is to map and compare the published normative values for common HRPM metrics in order to help establish consensus reference values. METHOD A systematic review was conducted on prospective and retrospective studies that included HRPM metrics, defined by an international working group consensus, in healthy adult populations. Data on the following variables were extracted when available: contractile integrals of the pharynx (PhCI), velopharynx, mesopharynx, and hypopharynx, as well as the upper esophageal sphincter (UES) integrated relaxation pressure (IRP), relaxation time (RT), maximum admittance, and hypopharyngeal intrabolus pressure. RESULTS Thirty studies were included. Significant variation existed in the technique and equipment used to perform procedures between the different studies. Lower PhCIs and UES IRPs were seen in younger compared to older individuals. Higher UES RTs were found in individuals in the upright position compared to the supine position and in those using larger boluses sizes or smaller catheters. CONCLUSIONS Due to the wide variety of protocols, catheter configurations, manufacturers, and software used in the existing literature, it is difficult to formulate consensus on HPRM normative values using pooled data. Prospective studies adhering to standardized HRPM protocols for specific catheter configurations and manufacturers with larger cohorts of normal individuals are necessary to establish proper reference values for HRPM metrics. SUPPLEMENTAL MATERIAL https://doi.org/10.23641/asha.24843753.
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Affiliation(s)
- Rameen K Walters
- Department of Otolaryngology-Head & Neck Surgery, Medical University of South Carolina, Charleston
| | - Rachana Gudipudi
- Department of Otolaryngology-Head & Neck Surgery, Medical University of South Carolina, Charleston
| | - Tamar Gordis
- Department of Otolaryngology-Head & Neck Surgery, Medical University of South Carolina, Charleston
| | - Kate Davidson
- Department of Speech-Language Pathology, Medical University of South Carolina, Charleston
| | - Shaun A Nguyen
- Department of Otolaryngology-Head & Neck Surgery, Medical University of South Carolina, Charleston
| | - Ashli K O'Rourke
- Department of Otolaryngology-Head & Neck Surgery, Medical University of South Carolina, Charleston
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Martínez-Guillén M, Clavé P, Zavala M, Carrión S. High-resolution manometry with impedance for the study of pharyngeal motility and the upper esophageal sphincter: Keys for its use in the study of the pathophysiology of oropharyngeal dysphagia. GASTROENTEROLOGIA Y HEPATOLOGIA 2024; 47:272-285. [PMID: 37816469 DOI: 10.1016/j.gastrohep.2023.09.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Revised: 09/15/2023] [Accepted: 09/22/2023] [Indexed: 10/12/2023]
Abstract
Oropharyngeal dysphagia (OD) is a pathology with a high prevalence in different patient phenotypes. High-resolution pharyngoesophageal manometry (HRPM) with impedance (HRPM-I) has become in recent years a fundamental technique for better understanding the pathophysiology of pharynx and upper oesophageal sphincter (UES) dysfunctions in patients with OD. Various groups of experts have proposed a methodology for the practice of the HRPM-I and for the standardization of the different metrics for the study of pharyngeal motility and UES dysfunctions based on the quantification of 3main phenomena: relaxation of the UES, resistance to flow through the UES and propulsion of the bolo through the pharynx into the oesophagus. According to the alterations of these metrics, 3patterns of dysfunction are proposed that allow a specific therapeutic approach: (a) UES flow restriction with normal pharyngeal propulsión; (b) UES flow restriction with ineffective pharyngeal propulsion, and (c) ineffective pharyngeal contraction with normal relaxation of the UES. We present a practical review of the methodology and metrics used by the main working groups together with the description of the main patterns of dysfunction according to our experience to highlight the usefulness of the HRPM-I in the study of the pathophysiology and selection of a specific treatment in patients with OD.
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Affiliation(s)
| | - Pere Clavé
- Unidad de Pruebas Funcionales Digestivas, Hospital de Mataró, Mataró, Barcelona, España; Centro de Investigación Biomédica en Red de enfermedades hepáticas y digestivas (CIBERehd), Instituto de Salud Carlos III, Barcelona, España
| | - Mónica Zavala
- Unidad de Pruebas Funcionales Digestivas, Hospital de Mataró, Mataró, Barcelona, España; Universidad La Salle México, Ciudad de México, México
| | - Silvia Carrión
- Unidad de Pruebas Funcionales Digestivas, Hospital de Mataró, Mataró, Barcelona, España; Centro de Investigación Biomédica en Red de enfermedades hepáticas y digestivas (CIBERehd), Instituto de Salud Carlos III, Barcelona, España.
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Cheriyan SS, Schar MS, Woods CM, Bihari S, Cock C, Athanasiadis T, Omari TI, Ooi EH. Swallowing biomechanics in tracheostomised critically ill patients compared to age- and gender-matched healthy controls. CRIT CARE RESUSC 2023; 25:97-105. [PMID: 37876599 PMCID: PMC10581277 DOI: 10.1016/j.ccrj.2023.05.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2023]
Abstract
Objective The mechanistic effects of a tracheostomy on swallowing are unclear. Pharyngeal high-resolution manometry with impedance (P-HRM-I) is a novel swallow assessment tool providing quantifiable metrics. This study aimed to characterise swallowing biomechanics in tracheostomised critically ill (non-neurological) patients. Design Cohort study. Setting Australian tertiary hospital intensive care unit. Participants Tracheostomised adults, planned for decannulation. Main outcome measures Swallowing assessment using P-HRM-I, compared to healthy age- and gender-matched controls. Results In this tracheostomised cohort (n = 10), the Swallow Risk Index, a global measure of swallow function, was significantly elevated (p < 0.001). At the upper oesophageal sphincter (UOS), hypopharyngeal intrabolus pressure and UOS integrated relaxation pressure were significantly elevated (control 0.65 mmHg [-1.02, 2.33] v tracheostomy 13.7 mmHg [10.4, 16.9], P < 0.001; control -4.28 mmHg [-5.87, 2.69] v tracheostomy 12.2 mmHg [8.83, 15.6], P < 0.001, respectively). Furthermore, UOS opening extent and relaxation time were reduced (control 4.83 mS [4.60, 5.07] v tracheostomy 4.33 mS [3.97, 4.69], P = 0.002; control 0.52 s [0.49, 0.55] v tracheostomy 0.41 s [0.37, 0.45], P < 0.001, respectively). Total pharyngeal contractility (PhCI) measuring pharyngeal pressure generation was significantly elevated (control 199.5 mmHg cm.s [177.4, 221.6] v tracheostomy 326.5 mmHg cm.s [253.3, 399.7]; P = 0.001). Conclusion In a critically ill tracheostomised cohort, UOS dysfunction was the prevalent biomechanical feature, with elevated pharyngeal pressures. Pharyngeal weakness is not contributing to dysphagia in this cohort. Instead, elevated pharyngeal pressures may represent a compensatory mechanism to overcome the UOS dysfunction. Further studies to extend these findings may inform the development of timely and targeted rehabilitation.
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Affiliation(s)
- Sanith S. Cheriyan
- Department of Otolaryngology, Head and Neck Surgery, Flinders Medical Centre, Bedford Park, SA, Australia
- Flinders Health and Medical Research Institute, College of Medicine and Public Health, Flinders University, Bedford Park, SA, Australia
| | - Mistyka S. Schar
- Flinders Health and Medical Research Institute, College of Medicine and Public Health, Flinders University, Bedford Park, SA, Australia
- Department of Speech Pathology and Audiology, Flinders Medical Centre, Bedford Park, SA, Australia
| | - Charmaine M. Woods
- Department of Otolaryngology, Head and Neck Surgery, Flinders Medical Centre, Bedford Park, SA, Australia
- Flinders Health and Medical Research Institute, College of Medicine and Public Health, Flinders University, Bedford Park, SA, Australia
| | - Shailesh Bihari
- Flinders Health and Medical Research Institute, College of Medicine and Public Health, Flinders University, Bedford Park, SA, Australia
- Department of Intensive & Critical Care, Flinders Medical Centre, Bedford Park, SA, Australia
| | - Charles Cock
- Department of Gastroenterology & Hepatology, College of Medicine and Public Health, Flinders University, Adelaide, Australia
| | - Theodore Athanasiadis
- Department of Otolaryngology, Head and Neck Surgery, Flinders Medical Centre, Bedford Park, SA, Australia
- Flinders Health and Medical Research Institute, College of Medicine and Public Health, Flinders University, Bedford Park, SA, Australia
| | - Taher I. Omari
- Flinders Health and Medical Research Institute, College of Medicine and Public Health, Flinders University, Bedford Park, SA, Australia
| | - Eng H. Ooi
- Department of Otolaryngology, Head and Neck Surgery, Flinders Medical Centre, Bedford Park, SA, Australia
- Flinders Health and Medical Research Institute, College of Medicine and Public Health, Flinders University, Bedford Park, SA, Australia
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Omari T, Cock C, Wu P, Szczesniak MM, Schar M, Tack J, Rommel N. Using high resolution manometry impedance to diagnose upper esophageal sphincter and pharyngeal motor disorders. Neurogastroenterol Motil 2023; 35:e14461. [PMID: 36121685 DOI: 10.1111/nmo.14461] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Revised: 07/01/2022] [Accepted: 08/24/2022] [Indexed: 12/31/2022]
Abstract
BACKGROUND Oro-pharyngeal pathophysiology, including upper esophageal sphincter (UES) and pharyngeal disorders, can be assessed by pharyngeal high-resolution manometry impedance (P-HRM-I). We aimed to establish methodology to diagnose disorders utilizing P-HRM-I, hypothesizing that the objective measures could be used to diagnose disordered deglutition evidenced by greater aspiration scores. METHODS Patients (n = 509, 18-91 years) were compared to controls (n = 120, 20-94 years). Variables measuring UES relaxation, UES opening extent, intrabolus pressure, and pharyngeal contractile strength were derived for 10 ml liquid swallows. Three associated pharyngeal pressurization patterns, which may be indicative of obstructed flow, were characterized: pan-pressurization (Type 1), distal compartmentalized pressurization (Type 2), and transient pressurization (Type 3). Deglutitive aspiration was determined from video fluoroscopy. RESULTS UES relaxation pressure was best able to differentiate patients from controls (T 6.528, p < 0.0001). Patients with abnormal relaxation pressure (>8 mmHg) more frequently exhibited pharyngeal pressurization patterns and had adjunct evidence of reduced luminal distensibility (high intrabolus pressure and/or reduced UES opening). Utilizing this information, a diagnostic scheme was devised identifying 138 patients with UES disorder. A further 96 patients without evidence of UES disorder had abnormally weak pharyngeal pressures, confirming propulsive disorder. Amongst a sub-sample of 320 patients undergoing video fluoroscopy, those with pharyngeal pressurizations and adjunct evidence of reduced UES relaxation and/or distensibility had higher aspiration scores (Chi-square 60.169, p < 0.0001). CONCLUSION P-HRM-I can provide evidence for UES disorder based on pharyngeal pressurization patterns and abnormal findings for UES relaxation pressure, UES opening, and intrabolus pressure. Measuring pharyngeal contractility requires further optimization.
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Affiliation(s)
- Taher Omari
- Flinders Health and Medical Research Institute and College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia
| | - Charles Cock
- Flinders Health and Medical Research Institute and College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia.,Department of Gastroenterology & Hepatology, Flinders Medical Centre, Southern Adelaide Local Health Network, Adelaide, South Australia, Australia
| | - Peter Wu
- Department of Gastroenterology and Hepatology, St George Hospital, University of New South Wales, Sydney, New South Wales, Australia
| | - Michal Marcin Szczesniak
- Department of Gastroenterology and Hepatology, St George Hospital, University of New South Wales, Sydney, New South Wales, Australia
| | - Mistyka Schar
- Flinders Health and Medical Research Institute and College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia
| | - Jan Tack
- Department of Gastroenterology, Neurogastroenterology & Motility, University Hospitals Leuven, Leuven, Belgium.,Translational Research Centre Gastrointestinal Disease (TARGID), KU Leuven, Leuven, Belgium
| | - Nathalie Rommel
- Department of Gastroenterology, Neurogastroenterology & Motility, University Hospitals Leuven, Leuven, Belgium.,Translational Research Centre Gastrointestinal Disease (TARGID), KU Leuven, Leuven, Belgium.,Deglutology, Department of Neurosciences, ExpORL, University of Leuven, Leuven, Belgium
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Accuracy of High-Resolution Pharyngeal Manometry Metrics for Predicting Aspiration and Residue in Oropharyngeal Dysphagia Patients with Poor Pharyngeal Contractility. Dysphagia 2022; 37:1560-1575. [PMID: 35182246 DOI: 10.1007/s00455-022-10417-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Accepted: 02/07/2022] [Indexed: 12/16/2022]
Abstract
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.
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Grobman M, Carluen E, Reinero CR. Incidence, clinical signs, and videofluoroscopic swallow study abnormalities associated with airway penetration and aspiration in 100 dogs. J Vet Intern Med 2022; 36:2149-2159. [PMID: 36259261 DOI: 10.1111/jvim.16553] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Accepted: 09/16/2022] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Videofluoroscopic swallow studies (VFSS) utilizing penetration-aspiration (P-A) scoring assesses airway protection in people. On VFSS, penetration (ingesta or secretions immediately cranial to the vocal folds) and aspiration (material caudal to the vocal folds) are associated with increased risk of lung injury in people. Penetration-aspiration (P-A) scoring has been validated in animal models, but the incidence of P-A, clinical signs (CS), and dysphagic disorders associated with P-A in dogs are unknown. OBJECTIVES Using VFSS, identify the incidence of P-A, compare CS between dogs with and without P-A, and identify predisposing dysphagic abnormalities for P-A. ANIMALS One hundred client-owned dogs. METHODS Sequential VFSS and associated medical records from dogs presenting to the veterinary teaching hospitals at Auburn University (n = 53) and the University of Missouri (n = 47) were retrospectively reviewed. Statistical comparisons were made using Mann-Whitney tests, one-way analysis of variance (ANOVA) on ranks, multiple linear regression, and Spearman rank order correlation (P < .05). RESULTS On VFSS, the incidence of pathologic P-A was 39%. No significant differences in CS were found between dogs with or without P-A (P > .05), with 14/39 dogs with P-A presenting without respiratory CS. Pharyngeal (P < .001) and esophageal (P = .009), but not oral-preparatory (P = .2) dysphagia was more common with P-A. Pharyngeal weakness (P < .001) and esophago-oropharyngeal reflux (EOR; P = .05) were independent predictors of P-A and were moderately and weakly positively correlated with P-A score respectively (P < .001, r = 0.489; P = .04, r = 0.201). CONCLUSIONS Penetration-aspiration occurs in dogs in the absence of respiratory CS (i.e., occult P-A). Dogs with pharyngeal weakness and EOR should be considered at risk for P-A.
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Affiliation(s)
- Megan Grobman
- Department of Clinical Sciences, Auburn University College of Veterinary Medicine, Auburn, Alabama, USA.,Department of Veterinary Medicine and Surgery, University of Missouri College of Veterinary Medicine, Columbia, Missouri, USA
| | - Enrico Carluen
- Department of Clinical Sciences, Auburn University College of Veterinary Medicine, Auburn, Alabama, USA.,Arizona Veterinary Emergency and Critical Care Center, Peoria, Arizona, USA
| | - Carol R Reinero
- Department of Veterinary Medicine and Surgery, University of Missouri College of Veterinary Medicine, Columbia, Missouri, USA
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Omari TI, Zifan A, Cock C, Mittal RK. Distension contraction plots of pharyngeal/esophageal peristalsis: next frontier in the assessment of esophageal motor function. Am J Physiol Gastrointest Liver Physiol 2022; 323:G145-G156. [PMID: 35788152 PMCID: PMC9377784 DOI: 10.1152/ajpgi.00124.2022] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Revised: 06/16/2022] [Accepted: 06/27/2022] [Indexed: 01/31/2023]
Abstract
Esophageal peristalsis consists of initial inhibition (relaxation) followed by excitation (contraction), both of which move sequentially in the aboral direction. Initial inhibition results in receptive relaxation and bolus-induced luminal distension, which allows propulsion by the contraction with minimal resistance to flow. Similar to the contraction wave, luminal distension has unique waveform characteristics in normal subjects; both are modulated by bolus volume, bolus viscosity, and posture, suggesting a possible cause-and-effect relationship between the two. Distension contraction plots in patients with dysphagia with normal bolus clearance [high-amplitude esophageal contractions (HAECs), esophagogastric junction outflow obstruction (EGJOO), and functional dysphagia (FD)] reveal two major findings: 1) unlike normal subjects, there is luminal occlusion distal to bolus during peristalsis in certain patients, i.e., with type 3 achalasia and nonobstructive dysphagia; and 2) bolus travels through a narrow lumen esophagus during peristalsis in patients with HAECs, EGJOO, and FD. Aforementioned findings indicate a relative dynamic obstruction to the bolus flow during peristalsis and reduced distensibility of esophageal wall in the bolus segment of the esophagus. We speculate that a normal or supernormal contraction wave pushing bolus against resistance is the mechanism of dysphagia sensation in significant number of patients. Representations of distension and contraction, combined with objective measures of flow timing and distensibility are complementary to the current scheme of classifying esophageal motility disorders based solely on the characteristics of contraction phase of peristalsis. Better understanding of the distensibility of the bolus-containing segment of the esophagus during peristalsis will lead to the development of novel medical and surgical therapies in the treatment of dysphagia in significant number of patients.
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Affiliation(s)
- Taher I Omari
- Flinders Health and Medical Research Institute and College of Medicine and Public Health, Flinders University, Adelaide, Australia
| | - Ali Zifan
- Division of Gastroenterology, Department of Medicine, University of California, San Diego, California
| | - Charles Cock
- Department of Gastroenterology and Hepatology, Flinders Medical Centre, Southern Adelaide Local Health Network, Adelaide, Australia
| | - Ravinder K Mittal
- Division of Gastroenterology, Department of Medicine, University of California, San Diego, California
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Schar MS, Omari TI, Woods CM, Footner LR, Marshall N, Cock C, Thompson A, Nguyen T, Athanasiadis T, Ooi EH. Pharyngeal tongue base augmentation for dysphagia therapy: A prospective case series in patients post head and neck cancer treatment. Head Neck 2022; 44:1871-1884. [PMID: 35665556 DOI: 10.1002/hed.27104] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2021] [Revised: 03/03/2022] [Accepted: 05/16/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Dysphagia post head and neck cancer (HNC) multimodality treatment is attributed to reduced pharyngeal strength. We hypothesized that pharyngeal tongue base augmentation for dysphagia (PAD therapy) would increase pharyngeal pressures during swallowing thereby improving swallow symptoms. METHODS Adults with moderate-severe dysphagia post-HNC treatment had PAD therapy using a temporary filler (hyaluronic acid [HA]), with follow-up long-lasting lipofilling. Swallowing preprocedure and postprocedure was assessed with the Sydney Swallow Questionnaire (SSQ), High-Resolution Pharyngeal Manometry (HRPM), and Videofluoroscopic Swallowing Study (VFSS). Statistical comparison utilized paired tests. RESULTS Six participants (all male; median age 64 years [IQR 56, 71]) underwent PAD therapy at a median of 47 [IQR 8, 95] months post-treatment. SSQ scores reduced from baseline (mean 1069 [95%CI 703, 1434]) to post-HA (mean 579 [76, 1081], p > 0.05), and post-lipofilling (491 [95%CI 913, 789], p = 0.003, n = 4). Individual participants demonstrated reduced Swallow Risk Index, Bolus Presence Time, and increased Upper Esophageal Sphincter opening, but mesopharyngeal contractile pressures were unchanged. VFSS measures of aspiration, residue, and severity were unchanged. CONCLUSIONS Novel PAD therapy is safe and improves dysphagia symptoms. Biomechanical swallowing changes are suggestive of more efficacious bolus propulsion with conservative filler volume, but this was unable to resolve residue or aspiration measures.
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Affiliation(s)
- Mistyka S Schar
- Flinders Health and Medical Research Institute, College of Medicine & Public Health, Flinders University, Bedford Park, South Australia, Australia
| | - Taher I Omari
- Flinders Health and Medical Research Institute, College of Medicine & Public Health, Flinders University, Bedford Park, South Australia, Australia
| | - Charmaine M Woods
- Flinders Health and Medical Research Institute, College of Medicine & Public Health, Flinders University, Bedford Park, South Australia, Australia.,Otolaryngology Head & Neck Surgery Unit, Flinders Medical Centre, Adelaide, South Australia, Australia
| | - Lauren R Footner
- Otolaryngology Head & Neck Surgery Unit, Flinders Medical Centre, Adelaide, South Australia, Australia
| | - Nicholas Marshall
- Department of Plastics & Reconstructive Surgery, Flinders Medical Centre, Adelaide, South Australia, Australia
| | - Charles Cock
- Flinders Health and Medical Research Institute, College of Medicine & Public Health, Flinders University, Bedford Park, South Australia, Australia.,Department of Gastroenterology & Hepatology, Flinders Medical Centre, Adelaide, South Australia, Australia
| | - Alison Thompson
- Department of Gastroenterology & Hepatology, Flinders Medical Centre, Adelaide, South Australia, Australia
| | - Thi Nguyen
- South Australian Medical Imaging, Flinders Medical Centre, Adelaide, South Australia, Australia
| | - Theodore Athanasiadis
- Flinders Health and Medical Research Institute, College of Medicine & Public Health, Flinders University, Bedford Park, South Australia, Australia.,Otolaryngology Head & Neck Surgery Unit, Flinders Medical Centre, Adelaide, South Australia, Australia
| | - Eng H Ooi
- Flinders Health and Medical Research Institute, College of Medicine & Public Health, Flinders University, Bedford Park, South Australia, Australia.,Otolaryngology Head & Neck Surgery Unit, Flinders Medical Centre, Adelaide, South Australia, Australia
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Schar MS, Omari TI, Woods CM, Cock C, Doeltgen SH, Chai-Coetzer CL, Eckert DJ, Athanasiadis T, Ooi EH. Swallowing biomechanics before and following multi-level upper airway surgery for obstructive sleep apnea. J Clin Sleep Med 2022; 18:1167-1176. [PMID: 34913869 PMCID: PMC8974379 DOI: 10.5664/jcsm.9824] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2021] [Revised: 11/29/2021] [Accepted: 12/02/2021] [Indexed: 11/13/2022]
Abstract
STUDY OBJECTIVES The effect of contemporary multi-level upper airway surgery for obstructive sleep apnea on swallowing is unclear. This study assessed the biomechanical swallowing function in participants with obstructive sleep apnea pre- and post-modified uvulopalatopharyngoplasty and coblation channeling of the tongue. METHODS In this prospective, longitudinal study, adults diagnosed with moderate-severe obstructive sleep apnea who underwent modified uvulopalatopharyngoplasty and coblation channeling of the tongue surgery had swallowing biomechanics assessed using high-resolution pharyngeal manometry and analyzed with swallowgateway.com. Symptomatic swallowing difficulty was evaluated using the Sydney Swallow Questionnaire (≥ 234). General linear mixed-model analysis was conducted to evaluate the difference pre- and post-modified uvulopalatopharyngoplasty and coblation channeling of the tongue. Data are presented as mean [95% confidence intervals]. RESULTS High-resolution pharyngeal manometry assessments were conducted in 10 participants (7 men; median age 50 [interquartile range 36-65]) preoperatively and repeated postoperatively at 9 months [interquartile range 6-13]. Self-reported dysphagia was unchanged following surgery (Sydney Swallow Questionnaire =149 [53, 447] to 168 [54, 247]; P = .093). High-resolution pharyngeal manometry outcomes indicated reduced mesopharyngeal pressures (148 [135, 161] to 124 [112, 137] mm Hg s cm; P = .011), reduced hypopharyngeal pressures (113 [101, 125] to 93 [84, 102] mm Hg s cm; P = 0.011), and reduced upper esophageal sphincter relaxation pressure (5 [4, 6] to 2 [1,3] mm Hg; P = 0.001) but no change to velopharyngeal pressures (135 [123, 147] to 137 [117, 157] mm Hg s cm; P = .850) postsurgery. CONCLUSIONS Modified uvulopalatopharyngoplasty may have less implications on the swallow mechanism than previously suspected. In contrast, the reduction in mesopharyngeal contractile pressures associated with coblation channeling of the tongue, although within normal limits, may affect bolus propulsion. Biomechanical alterations were insufficient to worsen self-reported swallowing function. CITATION Schar MS, Omari TI, Woods CW, et al. Swallowing biomechanics before and following multi-level upper airway surgery for obstructive sleep apnea. J Clin Sleep Med. 2022;18(4):1167-1176.
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Affiliation(s)
- Mistyka S. Schar
- Department of Speech Pathology, Flinders Medical Centre, South Australia, Australia
- Flinders Health and Medical Research Institute, College of Medicine & Public Health, Flinders University, South Australia, Australia
| | - Taher I. Omari
- Flinders Health and Medical Research Institute, College of Medicine & Public Health, Flinders University, South Australia, Australia
| | - Charmaine M. Woods
- Flinders Health and Medical Research Institute, College of Medicine & Public Health, Flinders University, South Australia, Australia
- Otolaryngology Head & Neck Surgery Unit, Flinders Medical Centre, Adelaide, South Australia, Australia
| | - Charles Cock
- Flinders Health and Medical Research Institute, College of Medicine & Public Health, Flinders University, South Australia, Australia
- Department of Gastroenterology & Hepatology, Flinders Medical Centre, Adelaide, South Australia, Australia
| | - Sebastian H. Doeltgen
- College of Nursing & Health Sciences, Caring Futures Institute, Flinders University Adelaide, South Australia, Australia
| | - Ching Li Chai-Coetzer
- Adelaide Institute for Sleep Health, Flinders University, Adelaide, South Australia, Australia
- Respiratory and Sleep Services, Flinders Medical Centre, Adelaide, South Australia, Australia
| | - Danny J. Eckert
- Adelaide Institute for Sleep Health, Flinders University, Adelaide, South Australia, Australia
| | - Theodore Athanasiadis
- Flinders Health and Medical Research Institute, College of Medicine & Public Health, Flinders University, South Australia, Australia
- Otolaryngology Head & Neck Surgery Unit, Flinders Medical Centre, Adelaide, South Australia, Australia
| | - Eng H. Ooi
- Flinders Health and Medical Research Institute, College of Medicine & Public Health, Flinders University, South Australia, Australia
- Otolaryngology Head & Neck Surgery Unit, Flinders Medical Centre, Adelaide, South Australia, Australia
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10
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Kwong SL, Hernandez EG, Winiker K, Gozdzikowska K, Macrae P, Huckabee ML. Effect of Topical Nasal Anesthetic on Comfort and Swallowing in High-Resolution Impedance Manometry. Laryngoscope 2022; 132:2124-2131. [PMID: 34989412 DOI: 10.1002/lary.30010] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Revised: 12/03/2021] [Accepted: 12/22/2021] [Indexed: 11/10/2022]
Abstract
OBJECTIVES/HYPOTHESIS Use of topical nasal anesthetic (TNA) is common in high-resolution impedance manometry (HRIM). This study investigated the effect of TNA on swallowing and procedure tolerability during HRIM with a 4.2-mm catheter, a more commonly used catheter size with impedance capabilities. STUDY DESIGN Randomised experimental study with blinding of participants. METHODS Twenty healthy participants (mean age = 33 years, 16 female) were randomized to undergo HRIM using the ManoScan™ ESO Z 4.2-mm catheter twice, 1 week apart, under two conditions: with TNA (viscous lidocaine) and with placebo. Analyses included esophageal data of three saliva, three saline (5 mL), and three bread swallows (2 cm × 2 cm) performed while reclined 45°, and pharyngeal data under the same conditions while seated upright. Pharyngeal and upper esophageal sphincter (UES) HRIM parameters were analyzed using the Swallow Gateway analysis platform. Visual analogue scale (VAS) scores rating procedural comfort were analyzed. RESULTS There were no significant physiological differences in pharyngeal and UES parameters between conditions. There were also no significant differences in VAS scores under placebo (mean = 54.8, standard deviation (SD) = 19.3) and TNA (mean = 60.0, SD = 21.9) (t[19] = -0.9, P = .4) conditions; however, there was a significant difference in the first versus second session (t[19]) = 5.1, P < .05). CONCLUSIONS TNA did not improve comfort, but it also did not significantly affect swallowing behavior. There was, however, a practice effect regardless of TNA use with improved tolerance of the 4.2-mm catheter and likely more natural swallowing behavior during the second session of HRIM. LEVEL OF EVIDENCE 3 Laryngoscope, 2022.
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Affiliation(s)
- Seh Ling Kwong
- Department of Psychology, Speech and Hearing, University of Canterbury, Christchurch, New Zealand.,The University of Canterbury Rose Centre for Stroke Recovery and Research, Christchurch, New Zealand.,Tan Tock Seng Hospital, Singapore
| | - Ester G Hernandez
- Department of Psychology, Speech and Hearing, University of Canterbury, Christchurch, New Zealand.,The University of Canterbury Rose Centre for Stroke Recovery and Research, Christchurch, New Zealand
| | - Katharina Winiker
- Department of Psychology, Speech and Hearing, University of Canterbury, Christchurch, New Zealand.,The University of Canterbury Rose Centre for Stroke Recovery and Research, Christchurch, New Zealand.,Swiss University of Speech and Language Sciences SLHR, Rorschach, Switzerland
| | - Kristin Gozdzikowska
- Department of Psychology, Speech and Hearing, University of Canterbury, Christchurch, New Zealand.,The University of Canterbury Rose Centre for Stroke Recovery and Research, Christchurch, New Zealand.,Research and Innovation, University of Canterbury, Christchurch, New Zealand
| | - Phoebe Macrae
- Department of Psychology, Speech and Hearing, University of Canterbury, Christchurch, New Zealand.,The University of Canterbury Rose Centre for Stroke Recovery and Research, Christchurch, New Zealand
| | - Maggie-Lee Huckabee
- Department of Psychology, Speech and Hearing, University of Canterbury, Christchurch, New Zealand.,The University of Canterbury Rose Centre for Stroke Recovery and Research, Christchurch, New Zealand
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11
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Sude NS, Karanam VPK. Endoscopic Retrieval of Ingested Foreign Bodies: A Single Surgeon Experience. Cureus 2021; 13:e19293. [PMID: 34754707 PMCID: PMC8570916 DOI: 10.7759/cureus.19293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/05/2021] [Indexed: 11/30/2022] Open
Abstract
Introduction Foreign body (FB) ingestion either accidental or intentional is a common clinical scenario encountered by general surgeons. This article reports a single surgeon's experience of endoscopic retrieval of foreign bodies from the upper gastrointestinal (UGI) tract. Methods A retrospective analysis of data of all the patients who underwent endoscopic management for foreign body removal by a single surgeon in a tertiary care hospital in southern India between 2015 and 2020 was conducted. Patient variables in terms of age, sex, type of foreign body, its location in the gastrointestinal (GI) tract, the time between ingestion and presentation, the time between presentation and endoscopy, treatment outcomes were reviewed. Results A total of 97 patients were studied. The age range of the patients studied was one month to 71 years. Males were predominant (n=64, 65.97%). The most common retrieved foreign body were coins (n=31, 31.9%). The most common site of foreign body lodgment was the esophagus (n=75, 77.31%), with the upper third esophagus (n=38; 39.37%) being the predominant site. The success rate of endoscopic retrieval in our study was 97%. No procedure-related complications were encountered in any patient. Endoscopic management failed in two patients who ultimately required surgical intervention. Conclusion Endoscopic retrieval of foreign bodies in the UGI tract is a safe and effective modality. Early endoscopy in such patients avoids surgical intervention and reduces morbidity.
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Affiliation(s)
- Nandkishor Sopanrao Sude
- General Surgery, Employees State Insurance Corporation Medical College and Hospital, Hyderabad, IND
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12
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Schar MS, Omari TI, Woods CM, Ferris LF, Doeltgen SH, Lushington K, Kontos A, Athanasiadis T, Cock C, Chai Coetzer CL, Eckert DJ, Ooi EH. Altered swallowing biomechanics in people with moderate-severe obstructive sleep apnea. J Clin Sleep Med 2021; 17:1793-1803. [PMID: 33904392 DOI: 10.5664/jcsm.9286] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
STUDY OBJECTIVES Dysphagia is a common but under-recognized complication of obstructive sleep apnea (OSA). However, the mechanisms remain poorly described. Accordingly, the aim of this study was to assess swallowing symptoms and use high-resolution pharyngeal manometry (HRPM) to quantify swallowing biomechanics in patients with moderate-severe OSA. METHODS Nineteen adults (4 female, mean age 46±26-68y) with moderate-severe OSA underwent HRPM testing with 5,10 & 20 ml volumes of thin and extremely thick liquids. Data were compared to 19 age- and sex-matched healthy controls (mean age 46±27-68y). Symptomatic dysphagia was assessed using the Sydney Swallow Questionnaire (SSQ). Swallow metrics were analyzed using the online application swallowgateway.com. General linear mixed model analysis was performed to investigate potential differences between people with moderate-severe OSA and controls. Data presented are means (95% CI). RESULTS 26% (5/19) of the OSA group but none of the controls reported symptomatic dysphagia (SSQ>234). Compared to healthy controls, the OSA group had increased upper esophageal sphincter (UES) relaxation pressure (-2 [-1] vs. 2 [1]mmHg, F = 32.1, p <0.0001), reduced UES opening (6 vs. 5mS, F = 23.6, p<0.0001) and increased hypopharyngeal intrabolus pressure (2 [1] vs 7 [1]mmHg, F= 19.0, p <0.05). Additionally, upper pharyngeal pressures were higher, particularly at the velopharynx (88 [12] vs. 144 [12]mmHg.cm.s, F = 69.6, p<0.0001). CONCLUSIONS HRPM identified altered swallowing biomechanics in people with moderate-severe OSA, which is consistent with a subclinical presentation. Potential contributing mechanisms include UES dysfunction with associated upstream changes of increased hypopharyngeal distension pressure and velopharyngeal contractility.
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Affiliation(s)
- Mistyka S Schar
- Department of Speech Pathology & Audiology, Flinders Medical Centre.,Flinders Health and Medical Research Institute, College of Medicine & Public Health, Flinders University
| | - Taher I Omari
- Flinders Health and Medical Research Institute, College of Medicine & Public Health, Flinders University
| | - Charmaine M Woods
- Flinders Health and Medical Research Institute, College of Medicine & Public Health, Flinders University.,Otolaryngology Head & Neck Surgery Unit, Flinders Medical Centre
| | - Lara F Ferris
- College of Nursing & Health Sciences, Caring Futures Institute, Flinders University
| | - Sebastian H Doeltgen
- College of Nursing & Health Sciences, Caring Futures Institute, Flinders University
| | - Kurt Lushington
- Psychology, Justice & Society Academic Unit, University of South Australia
| | - Anna Kontos
- Department of Respiratory and Sleep Medicine, Women's and Children's Hospital
| | - Theodore Athanasiadis
- Flinders Health and Medical Research Institute, College of Medicine & Public Health, Flinders University.,Otolaryngology Head & Neck Surgery Unit, Flinders Medical Centre
| | - Charles Cock
- Flinders Health and Medical Research Institute, College of Medicine & Public Health, Flinders University.,Department of Gastroenterology & Hepatology, Flinders Medical Centre
| | - Ching-Li Chai Coetzer
- Flinders Health and Medical Research Institute, College of Medicine & Public Health, Flinders University.,Respiratory & Sleep Services, Flinders Medical Centre
| | - Danny J Eckert
- Flinders Health and Medical Research Institute, College of Medicine & Public Health, Flinders University
| | - Eng H Ooi
- Flinders Health and Medical Research Institute, College of Medicine & Public Health, Flinders University.,Otolaryngology Head & Neck Surgery Unit, Flinders Medical Centre
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13
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Baijens LWJ, Walshe M, Aaltonen LM, Arens C, Cordier R, Cras P, Crevier-Buchman L, Curtis C, Golusinski W, Govender R, Eriksen JG, Hansen K, Heathcote K, Hess MM, Hosal S, Klussmann JP, Leemans CR, MacCarthy D, Manduchi B, Marie JP, Nouraei R, Parkes C, Pflug C, Pilz W, Regan J, Rommel N, Schindler A, Schols AMWJ, Speyer R, Succo G, Wessel I, Willemsen ACH, Yilmaz T, Clavé P. European white paper: oropharyngeal dysphagia in head and neck cancer. Eur Arch Otorhinolaryngol 2021; 278:577-616. [PMID: 33341909 PMCID: PMC7826315 DOI: 10.1007/s00405-020-06507-5] [Citation(s) in RCA: 57] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Accepted: 11/17/2020] [Indexed: 12/14/2022]
Abstract
PURPOSE To develop a European White Paper document on oropharyngeal dysphagia (OD) in head and neck cancer (HNC). There are wide variations in the management of OD associated with HNC across Europe. METHODS Experts in the management of specific aspects of OD in HNC across Europe were delegated by their professional medical and multidisciplinary societies to contribute to this document. Evidence is based on systematic reviews, consensus-based position statements, and expert opinion. RESULTS Twenty-four sections on HNC-specific OD topics. CONCLUSION This European White Paper summarizes current best practice on management of OD in HNC, providing recommendations to support patients and health professionals. The body of literature and its level of evidence on diagnostics and treatment for OD in HNC remain poor. This is in the context of an expected increase in the prevalence of OD due to HNC in the near future. Contributing factors to increased prevalence include aging of our European population (including HNC patients) and an increase in human papillomavirus (HPV) related cancer, despite the introduction of HPV vaccination in various countries. We recommend timely implementation of OD screening in HNC patients while emphasizing the need for robust scientific research on the treatment of OD in HNC. Meanwhile, its management remains a challenge for European professional associations and policymakers.
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Affiliation(s)
- Laura W J Baijens
- Department of Otorhinolaryngology, Head and Neck Surgery, Maastricht University Medical Center, Maastricht, The Netherlands.
- GROW School for Oncology and Developmental Biology, Maastricht University Medical Center, Maastricht, The Netherlands.
| | - Margaret Walshe
- Department of Clinical Speech and Language Studies, Trinity College Dublin, Dublin, Ireland
| | - Leena-Maija Aaltonen
- Department of Otorhinolaryngology, Head and Neck Surgery, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Christoph Arens
- Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital Magdeburg, Otto-von-Guericke University, Magdeburg, Germany
| | - Reinie Cordier
- Department of Special Needs Education, University of Oslo, Oslo, Norway
- School of Occupational Therapy, Social Work and Speech Pathology, Curtin University, Perth, Australia
| | - Patrick Cras
- Department of Neurology, Born Bunge Institute, Antwerp University Hospital, University of Antwerp, Antwerp, Belgium
| | - Lise Crevier-Buchman
- Voice, Speech, Swallowing Lab, Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital UVSQ and Research lab CNRS-UMR7018, Hôpital Foch, Suresnes, France
| | - Chris Curtis
- Swallows Head and Neck Cancer Charity, Blackpool, UK
| | - Wojciech Golusinski
- Department of Head and Neck Surgery, The Greater Poland Cancer Centre, Poznan University of Medical Sciences, Poznan, Poland
| | - Roganie Govender
- Head and Neck Cancer Centre, University College London Hospital, London, UK
| | - Jesper Grau Eriksen
- Department of Experimental Clinical Oncology, Aarhus University Hospital, Aarhus, Denmark
| | - Kevin Hansen
- Department of Otorhinolaryngology, Head and Neck Surgery, Medical Faculty, University of Cologne, Cologne, Germany
| | - Kate Heathcote
- Robert White Centre for Airway, Voice and Swallow, Poole Hospital NHS Foundation Trust, Dorset, UK
| | - Markus M Hess
- Deutsche Stimmklinik, Hamburg, Germany
- Departement of Voice, Speech and Hearing Disorders, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Sefik Hosal
- Department of Otolaryngology, Head and Neck Surgery, Faculty of Medicine, Atılım University, Medicana International Ankara, Ankara, Turkey
| | - Jens Peter Klussmann
- Department of Otorhinolaryngology, Head and Neck Surgery, Medical Faculty, University of Cologne, Cologne, Germany
| | - C René Leemans
- Department of Otolaryngology, Head and Neck Surgery, Amsterdam University Medical Centres, Vrije Universiteit, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam University Medical Centres, Vrije Universiteit, Amsterdam, The Netherlands
| | - Denise MacCarthy
- Division of Restorative Dentistry and Periodontology, Faculty of Health Sciences, Trinity College Dublin, Dublin Dental University Hospital, Dublin, Ireland
| | - Beatrice Manduchi
- Department of Clinical Speech and Language Studies, Trinity College Dublin, Dublin, Ireland
| | - Jean-Paul Marie
- Department of Otorhinolaryngology, Head and Neck Surgery, Rouen University Hospital, Rouen, France
| | - Reza Nouraei
- Department of Ear Nose and Throat Surgery, The Robert White Centre for Airway Voice and Swallowing, Poole Hospital NHS Foundation Trust, University of Southampton, Southampton, UK
| | - Claire Parkes
- Department of Speech and Language Therapy, St. James's Hospital, Dublin, Ireland
| | - Christina Pflug
- Departement of Voice, Speech and Hearing Disorders, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Walmari Pilz
- Department of Otorhinolaryngology, Head and Neck Surgery, Maastricht University Medical Center, Maastricht, The Netherlands
- MHeNs School for Mental Health and Neuroscience, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Julie Regan
- Department of Clinical Speech and Language Studies, Trinity College Dublin, Dublin, Ireland
| | - Nathalie Rommel
- Department Neurosciences, Experimental Otorhinolaryngology, Deglutology, University of Leuven, Leuven, Belgium
| | - Antonio Schindler
- Department of Biomedical and Clinical Sciences "L. Sacco", University of Milan, Milan, Italy
| | - Annemie M W J Schols
- Department of Respiratory Medicine, NUTRIM School of Nutrition and Translational Research in Metabolism, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Renee Speyer
- Department of Special Needs Education, University of Oslo, Oslo, Norway
- School of Occupational Therapy, Social Work and Speech Pathology, Curtin University, Perth, Australia
- Department of Otorhinolaryngology and Head and Neck Surgery, Leiden University Medical Centre, Leiden, The Netherlands
- Faculty of Health, School of Health and Social Development, Victoria, Australia
| | - Giovanni Succo
- Head and Neck Oncology Service, Candiolo Cancer Institute, FPO - IRCCS, Candiolo, TO, Italy
- Department of Oncology, University of Turin, Orbassano, TO, Italy
| | - Irene Wessel
- Department of Otorhinolaryngology, Head and Neck Surgery and Audiology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Anna C H Willemsen
- GROW School for Oncology and Developmental Biology, Maastricht University Medical Center, Maastricht, The Netherlands
- Department of Respiratory Medicine, NUTRIM School of Nutrition and Translational Research in Metabolism, Maastricht University Medical Center, Maastricht, The Netherlands
- Division of Medical Oncology, Department of Internal Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Taner Yilmaz
- Department of Otorhinolaryngology, Head and Neck Surgery, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Pere Clavé
- Gastrointestinal Physiology Laboratory, Hospital de Mataró, Universitat Autònoma de Barcelona, Mataró, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Barcelona, Spain
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14
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Cock C, Omari TI, Burgstad CM, Thompson A, Doeltgen SH. Biomechanical correlates of sequential drinking behavior in aging. Neurogastroenterol Motil 2021; 33:e13945. [PMID: 32666615 DOI: 10.1111/nmo.13945] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2020] [Revised: 06/13/2020] [Accepted: 06/23/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND The timed water swallow test (TWST) is a test of sequential swallowing where a measured volume is ingested as quickly as comfortably possible. We undertook a study of the biomechanics underpinning the TWST in healthy young and older participants. METHODS Thirty healthy volunteers underwent high-resolution impedance manometry (MMS; Unisensor, 2.7 mm diameter, 32 pressure sensors, 16 impedance segments). Participants were asked to drink 150 mL, 0.9% normal saline solution rapidly. Swallowing biomechanics and bolus flow characteristics were assessed using pressure-flow analysis and compared using t test and Fisher's exact test with significance as P < .05. KEY RESULTS Older participants (n = 18; 76 ± 11 years) took longer to complete the TWST (21.2 ± 2.5 vs 9.2 ± 1.0 seconds; P < .001) and displayed reduced volume per swallow (16.6 ± 1.3 vs 27.8 ± 2.9 mL; P < .001) compared to younger participants (n = 12; 29 ± 5 years). Two distinctive pharyngeal swallowing patterns were observed: (a) a single rapid sequence of swallows with or without a clearing swallow (Pattern I) or (b) multiple, shorter sequences interrupted and/or interspersed with single swallows or breaks (Pattern II). Some older participants showed biomechanical evidence of upper esophageal sphincter restriction (n = 7) or impaired deglutitive inhibition (n = 7), associated with the more prolonged Pattern II (TWST duration 30.1 ± 1.5 vs Pattern I 11.9 ± 1.5 seconds; P < .001). CONCLUSIONS AND INFERENCES Healthy older participants had an increased duration of TWST, suggesting a need to adapt normative values for this population. Rapid sequential swallowing was associated with evidence of UES restriction and impaired deglutitive inhibition in some older participants.
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Affiliation(s)
- Charles Cock
- Department of Gastroenterology & Hepatology, College of Medicine and Public Health, Flinders University, Adelaide, Australia.,Department of Gastroenterology & Hepatology, Flinders Medical Centre, Southern Adelaide Local Health Network, Adelaide, Australia
| | - Taher I Omari
- Department of Gastroenterology & Hepatology, College of Medicine and Public Health, Flinders University, Adelaide, Australia.,Department of Human Physiology, College of Medicine and Public Health, Flinders University, Adelaide, Australia
| | - Carly M Burgstad
- Department of Gastroenterology & Hepatology, Flinders Medical Centre, Southern Adelaide Local Health Network, Adelaide, Australia
| | - Alison Thompson
- Department of Gastroenterology & Hepatology, Flinders Medical Centre, Southern Adelaide Local Health Network, Adelaide, Australia
| | - Sebastian H Doeltgen
- Speech Pathology, Caring Futures Institute, College of Nursing and Health Sciences, Flinders University, Adelaide, Australia
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15
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Ferris L, Doeltgen S, Cock C, Rommel N, Schar M, Carrión S, Scholten I, Omari T. Modulation of pharyngeal swallowing by bolus volume and viscosity. Am J Physiol Gastrointest Liver Physiol 2021; 320:G43-G53. [PMID: 33112160 DOI: 10.1152/ajpgi.00270.2020] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Oropharyngeal swallowing involves complex neuromodulation to accommodate changing bolus characteristics. The pressure events during deglutitive pharyngeal reconfiguration and bolus flow can be assessed quantitatively using high-resolution pharyngeal manometry with impedance. An 8-French solid-state unidirectional catheter (32 pressure sensors, 16 impedance segments) was used to acquire triplicate swallows of 3 to 20 ml across three viscosity levels using a Standardized Bolus Medium (SBMkit) product (Trisco, Pty. Ltd., Australia). An online platform (https://swallowgateway.com/; Flinders University, South Australia) was used to semiautomate swallow analysis. Fifty healthy adults (29 females, 21 males; mean age 46 yr; age range 19-78 yr old) were studied. Hypopharyngeal intrabolus pressure, upper esophageal sphincter (UES) maximum admittance, UES relaxation pressure, and UES relaxation time revealed the most significant modulation effects to bolus volume and viscosity. Pharyngeal contractility and UES postswallow pressures elevated as bolus volumes increased. Bolus viscosity augmented UES preopening pressure only. We describe the swallow modulatory effects with quantitative methods in line with a core outcome set of metrics and a unified analysis system for broad reference that contributes to diagnostic frameworks for oropharyngeal dysphagia.NEW & NOTEWORTHY The neuromodulation of the healthy oropharyngeal swallow response was described in relation to bolus volume and viscosity challenges, using intraluminal pressure and impedance topography methods. Among a wide range of physiological measures, those indicative of distension pressure, luminal opening, and flow timing were most significantly altered by bolus condition, and therefore can be considered to be potential markers of swallow neuromodulation. The study methods and associated findings inform a diagnostic framework for swallow assessment in patients with oropharyngeal dysphagia.
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Affiliation(s)
- Lara Ferris
- College of Medicine and Public Health, Flinders University, Adelaide, Australia
| | - Sebastian Doeltgen
- College of Nursing and Health Sciences, Flinders University, Adelaide, Australia
| | - Charles Cock
- College of Medicine and Public Health, Flinders University, Adelaide, Australia.,Department of Luminal Gastroenterology, Flinders Medical Centre, Adelaide, Australia
| | - Nathalie Rommel
- Department of Neurosciences, Oto-rhino-laryngology Research Group, KU Leuven, Belgium
| | - Mistyka Schar
- College of Medicine and Public Health, Flinders University, Adelaide, Australia.,Department of Speech Pathology and Audiology, Flinders Medical Centre, Adelaide, Australia
| | - Silvia Carrión
- Gastrointestinal Physiology Laboratory, Department of Surgery, Hospital de Mataró, Universitat Autònoma de Barcelona, Mataró, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Instituto de Salud Carlos III, Barcelona, Spain
| | - Ingrid Scholten
- College of Nursing and Health Sciences, Flinders University, Adelaide, Australia
| | - Taher Omari
- College of Medicine and Public Health, Flinders University, Adelaide, Australia
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16
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Sweis R, Fox M. High-Resolution Manometry-Observations After 15 Years of Personal Use-Has Advancement Reached a Plateau? Curr Gastroenterol Rep 2020; 22:49. [PMID: 32767186 PMCID: PMC7413906 DOI: 10.1007/s11894-020-00787-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
PURPOSE OF REVIEW In the absence of mucosal or structural disease, the aim of investigating the oesophagus is to provide clinically relevant measurements of function that can explain the cause of symptoms, identify pathology and guide effective management. One of the most notable recent advances in the field of oesophageal function has been high-resolution manometry (HRM). This review explores how innovation in HRM has progressed and has far from reached a plateau. RECENT FINDINGS HRM technology, methodology and utility continue to evolve; simple additions to the swallow protocol (e.g. eating and drinking), shifting position, targeting symptoms and adding impedance sensors to the HRM catheter have led to improved diagnoses, therapeutic decision-making and outcomes. Progress in HRM persists and shows little sign of abating. The next iteration of the Chicago Classification of motor disorders will highlight these advances and will also identify opportunities for further research and innovation.
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Affiliation(s)
- Rami Sweis
- Gastrointestinal Services, University College London Hospital, London, UK
| | - Mark Fox
- Division of Gastroenterology and Hepatology, University Hospital Zürich, Zürich, Switzerland
- Digestive Function: Basel, Laboratory and Clinic for Motility Disorders and Functional GI Diseases Center for Integrative Gastroenterology, Klinik Arlesheim, Arlesheim, Switzerland
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17
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Bahia MM, Lowell SY. A Systematic Review of the Physiological Effects of the Effortful Swallow Maneuver in Adults With Normal and Disordered Swallowing. AMERICAN JOURNAL OF SPEECH-LANGUAGE PATHOLOGY 2020; 29:1655-1673. [PMID: 32463714 DOI: 10.1044/2020_ajslp-19-00132] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
Purpose This systematic review summarizes the biomechanical and functional effects of the effortful swallow in adults with and without dysphagia, highlighting clinical implications and future research needs. Specifically, the effects of the effortful swallow on swallowing physiology, safety, and efficiency were identified, as well as the strengths and limitations of current research. Method Recommendations specified by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses were followed. A literature search of three databases and relevant articles cited in the searched studies was performed. Two evaluators independently analyzed the studies for eligibility criteria, and final inclusion of studies was decided by consensus. Evaluators also assessed each study for quality of evidence. Results Twenty-three studies were included in this systematic review. Main findings indicated that the effortful swallow generated greater pressures in the tongue-to-palate, pharynx, upper esophageal sphincter, and esophageal regions. Inconsistent results for hyolaryngeal excursion were reported, as well as for swallowing function. Instructions of the effortful swallow varied greatly across studies. Two of the 23 studies were judged to be of high quality, and the remaining studies were of medium quality based on the quality indicators of this review. Conclusions Biomechanical effects of the effortful swallow included increased pressures in the oral, pharyngeal, and esophageal regions. Future investigations should address the effects of the effortful swallow in individuals with dysphagia and its potential role as a rehabilitative maneuver. Moreover, standardization of the effortful swallow instructions based on its physiological and functional effects is essential.
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Affiliation(s)
- Mariana M Bahia
- Department of Communication Sciences and Disorders, Syracuse University, NY
| | - Soren Y Lowell
- Department of Communication Sciences and Disorders, Syracuse University, NY
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18
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Twenty years of quantitative instrumental measures of swallowing in children: a systematic review. Eur J Pediatr 2020; 179:203-223. [PMID: 31900589 DOI: 10.1007/s00431-019-03546-x] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Revised: 12/02/2019] [Accepted: 12/05/2019] [Indexed: 01/21/2023]
Abstract
Early identification and intervention has shown better health outcomes for children with dysphagia. Instrumental swallowing assessments are vital and have been a focus of dysphagia research in the last two decades. This systematic review explores published quantitative instrumental measures of swallowing in children. Five subject-related databases were searched to identify original scientific articles published in English, using instrumental quantitative measures of swallowing to study swallowing/feeding mechanism in children since 1998. Two thousand two hundred and two articles were found from the initial database search and 36 were included in the final qualitative synthesis following PRISMA guidelines. Selected studies showed great diversity in target population, phase/s of swallowing studied, instrumentation used (n = 10) and quantitative measures reported (n = 144). Videofluoroscopy and manometry have been studied most repeatedly. With less frequency, a variety of other instruments has been used to describe suck-swallow patterns and swallowing-related respiration. High-resolution manometry shows the greatest increase in publications with validated, reliable quantitative measures of pharyngeal and oesophageal pressures and timing. More recently, quantification of videofluoroscopy analysis has been a focus.Conclusion: A diverse range of quantitative measures of swallowing is available for children in the literature. However, further reliability and validity testing is needed. Opportunities for clinical application of these quantitative manometric and videofluoroscopic measures are restricted by limited normative comparisons and vast variability in published measures.What is known?• Instrumental swallowing assessments are reliable and accurate in diagnosing swallowing difficulties in children.• However, subjective interpretation of observational findings often questions the optimal use of instrumentation.What is new?• High-resolution manometry has shown promising progress with the development of quantitative objective swallow measures for children. While attempts to quantify video-fluoroscopic measures have been increased in the recent past.• A vast variety of instruments has been used to obtain quantitative and/or objective swallow measures of children, yet clinical application is still in progress.
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Singendonk MMJ, Ferris LF, McCall L, Seiboth G, Lowe K, Moore D, Hammond P, Couper R, Abu‐Assi R, Cock C, Benninga MA, van Wijk MP, Omari TI. High-resolution esophageal manometry in pediatrics: Effect of esophageal length on diagnostic measures. Neurogastroenterol Motil 2020; 32:e13721. [PMID: 31569287 PMCID: PMC7064899 DOI: 10.1111/nmo.13721] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2019] [Revised: 07/30/2019] [Accepted: 08/26/2019] [Indexed: 12/13/2022]
Abstract
BACKGROUND High-resolution esophageal manometry (HREM), derived esophageal pressure topography metrics (EPT), integrated relaxation pressure (IRP), and distal latency (DL) are influenced by age and size. Combined pressure and intraluminal impedance also allow derivation of metrics that define distension pressure and bolus flow timing. We prospectively investigated the effects of esophageal length on these metrics to determine whether adjustment strategies are required for children. METHODS Fifty-five children (12.3 ± 4.5 years) referred for HREM, and 30 healthy adult volunteers (46.9 ± 3.8 years) were included. Studies were performed using the MMS system and a standardized protocol including 10 × 5 mL thin liquid bolus swallows (SBM kit, Trisco Foods) and analyzed via Swallow Gateway (www.swallowgateway.com). Esophageal distension pressures and swallow latencies were determined in addition to EGJ resting pressure and standard EPT metrics. Effects of esophageal length were examined using partial correlation, correcting for age. Adult-derived upper limits were adjusted for length using the slopes of the identified linear equations. KEY RESULTS Mean esophageal length in children was 16.8 ± 2.8 cm and correlated significantly with age (r = 0.787, P = .000). Shorter length correlated with higher EGJ resting pressure and 4-s integrated relaxation pressures (IRP), distension pressures, and shorter contraction latencies. Ten patients had an IRP above the adult upper limit. Adjustment for esophageal length reduced the number of patients with elevated IRP to three. CONCLUSIONS & INFERENCES We prospectively confirmed that certain EPT metrics, as well as potential useful adjunct pressure-impedance measures such as distension pressure, are substantially influenced by esophageal length and require adjusted diagnostic thresholds specifically for children.
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Affiliation(s)
- Maartje M. J. Singendonk
- Department of Pediatric Gastroenterology and NutritionEmma Children's HospitalAmsterdam UMCUniversity of AmsterdamAmsterdamThe Netherlands
| | - Lara F. Ferris
- College of Medicine and Public HealthFlinders UniversityAdelaideSouth AustraliaAustralia
| | - Lisa McCall
- Gastroenterology UnitWomen's and Children's HospitalAdelaideSouth AustraliaAustralia
| | - Grace Seiboth
- Gastroenterology UnitWomen's and Children's HospitalAdelaideSouth AustraliaAustralia
| | - Katie Lowe
- Gastroenterology UnitWomen's and Children's HospitalAdelaideSouth AustraliaAustralia
| | - David Moore
- Gastroenterology UnitWomen's and Children's HospitalAdelaideSouth AustraliaAustralia
| | - Paul Hammond
- Gastroenterology UnitWomen's and Children's HospitalAdelaideSouth AustraliaAustralia
| | - Richard Couper
- Gastroenterology UnitWomen's and Children's HospitalAdelaideSouth AustraliaAustralia
| | - Rammy Abu‐Assi
- Gastroenterology UnitWomen's and Children's HospitalAdelaideSouth AustraliaAustralia
| | - Charles Cock
- Department of Gastroenterology & HepatologySouthern Adelaide Local Health NetworkBedford ParkSouth AustraliaAustralia
| | - Marc A. Benninga
- Department of Pediatric Gastroenterology and NutritionEmma Children's HospitalAmsterdam UMCUniversity of AmsterdamAmsterdamThe Netherlands
| | - Michiel P. van Wijk
- Department of Pediatric Gastroenterology and NutritionEmma Children's HospitalAmsterdam UMCUniversity of AmsterdamAmsterdamThe Netherlands,Department of Pediatric GastroenterologyEmma Children's HospitalAmsterdam UMC–VU UniversityAmsterdamThe Netherlands
| | - Taher I. Omari
- College of Medicine and Public HealthFlinders UniversityAdelaideSouth AustraliaAustralia
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20
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Regan J. Impact of Sensory Stimulation on Pharyngo-esophageal Swallowing Biomechanics in Adults with Dysphagia: A High-Resolution Manometry Study. Dysphagia 2020; 35:825-833. [DOI: 10.1007/s00455-019-10088-9] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2019] [Accepted: 12/19/2019] [Indexed: 01/29/2023]
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21
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Schar MS, Omari TI, Fraser RJ, Bersten AD, Bihari S. Disordered swallowing associated with prolonged oral endotracheal intubation in critical illness. Intensive Care Med 2019; 46:140-142. [PMID: 31713057 DOI: 10.1007/s00134-019-05844-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/26/2019] [Indexed: 10/25/2022]
Affiliation(s)
- Mistyka S Schar
- College of Medicine and Public Health, Flinders University, Bedford Park, Adelaide, SA, Australia
| | - Taher I Omari
- College of Medicine and Public Health, Flinders University, Bedford Park, Adelaide, SA, Australia. .,Centre for Neuroscience, Flinders University, Adelaide, SA, Australia.
| | - Robert J Fraser
- College of Medicine and Public Health, Flinders University, Bedford Park, Adelaide, SA, Australia
| | - Andrew D Bersten
- College of Medicine and Public Health, Flinders University, Bedford Park, Adelaide, SA, Australia
| | - Shailesh Bihari
- College of Medicine and Public Health, Flinders University, Bedford Park, Adelaide, SA, Australia
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22
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Singendonk M, Kritas S, Omari T, Feinle-Bisset C, Page AJ, Frisby CL, Kentish SJ, Ferris L, McCall L, Kow L, Chisholm J, Khurana S. Upper Gastrointestinal Function in Morbidly Obese Adolescents Before and 6 Months After Gastric Banding. Obes Surg 2019; 28:1277-1288. [PMID: 29103072 DOI: 10.1007/s11695-017-3000-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND The effects of laparoscopic adjustable gastric band (LAGB) placement on upper gastrointestinal tract function in obese adolescents are unknown. Therefore, our aim was to determine the short-term effects of LAGB on esophageal motility, gastroesophageal reflux, gastric emptying, appetite-regulatory hormones, and perceptions of post-prandial hunger and fullness. METHODS This study was part of a prospective cohort study (March 2009-December 2015) in one tertiary referral hospital. The study included obese adolescents (14-18 years) with a body mass index (BMI) > 40 (or ≥ 35 with comorbidities). Gastric emptying was assessed by 13C-octanoic acid breath test, pharyngeal, and esophageal motor function by high-resolution manometry with impedance (HRIM), and appetite and other perceptions using 100-mm visual analogue scales. Dysphagia symptoms were scored using a Dakkak questionnaire. Data were compared pre- and post-LAGB placement and at a 6-month follow-up. RESULTS Based upon analysis of 15 adolescents, at the 6-month follow-up, LAGB placement: (i) led to a significant reduction in weight and BMI; (ii) increased fullness and decreased hunger post-meal; (iii) increased symptoms of dysphagia after solid food; and, despite these effects, (iv) caused little or no changes to appetite hormones, while (v) effects on gastric emptying, esophageal motility, esophageal bolus transport, and esophageal emptying were not significant. CONCLUSION In adolescents, LAGB improved BMI and altered the sensitivity to nutrients without significant effects on upper gastrointestinal tract physiology at the 6-month follow-up.
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Affiliation(s)
- M Singendonk
- Department of Pediatric Gastroenterology and Nutrition, Emma Children's Hospital/AMC, Amsterdam, The Netherlands
| | - S Kritas
- Gastroenterology Unit, Women's & Children's Hospital, Adelaide, Australia
| | - T Omari
- Human Physiology, Medical Science and Technology, School of Medicine, Flinders University, Adelaide, South Australia, Australia.
| | - C Feinle-Bisset
- Centre for Nutrition and Gastrointestinal Diseases, Adelaide Medical School, University of Adelaide, Adelaide, Australia.,NHMRC Centre of Research Excellence in Translating Nutritional Science to Good Health, University of Adelaide, Adelaide, Australia
| | - A J Page
- South Australian Health and Medical Research Institute (SAHMRI), Adelaide, Australia
| | - C L Frisby
- Centre for Nutrition and Gastrointestinal Diseases, Adelaide Medical School, University of Adelaide, Adelaide, Australia.,South Australian Health and Medical Research Institute (SAHMRI), Adelaide, Australia
| | - S J Kentish
- Centre for Nutrition and Gastrointestinal Diseases, Adelaide Medical School, University of Adelaide, Adelaide, Australia.,South Australian Health and Medical Research Institute (SAHMRI), Adelaide, Australia
| | - L Ferris
- Gastroenterology Unit, Women's & Children's Hospital, Adelaide, Australia.,Human Physiology, Medical Science and Technology, School of Medicine, Flinders University, Adelaide, South Australia, Australia
| | - L McCall
- Gastroenterology Unit, Women's & Children's Hospital, Adelaide, Australia
| | - L Kow
- Department of Surgery, Flinders Medical Centre, Adelaide, Australia
| | - J Chisholm
- Department of Surgery, Flinders Medical Centre, Adelaide, Australia
| | - S Khurana
- Paediatric Surgery & Urology, Women's & Children's Hospital, Adelaide, Australia.,Department of Surgery, Flinders Medical Centre, Adelaide, Australia
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Borders JC, Brates D. Use of the Penetration-Aspiration Scale in Dysphagia Research: A Systematic Review. Dysphagia 2019; 35:583-597. [PMID: 31538220 DOI: 10.1007/s00455-019-10064-3] [Citation(s) in RCA: 64] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2019] [Accepted: 09/04/2019] [Indexed: 12/12/2022]
Abstract
The penetration-aspiration scale (PAS) is an 8-point scale used to characterize the depth and response to airway invasion during videofluoroscopy. Though widely used in the field of deglutition, there is a lack of consensus regarding the statistical properties of the scale. In order to better understand the state of the literature and the statistical use of the PAS, a systematic review was undertaken to descriptively examine trends in statistical and reporting practices of the PAS since its inception. Online databases were searched for studies citing the original PAS article, which yielded 754 unique articles. Of these, 183 studies were included in the review. Results showed inconsistencies in the statistical use of the scale; 79 studies treated the PAS as ordinal, 71 as categorical, and 49 as interval. Ten types of categorizations were identified. Reporting of power analyses (9%), as well as inter- (26%) and intra-rater (17%) reliability, was uncommon. Among studies that administered multiple bolus volumes or consistencies, 55% reported PAS analyses at the participant/group level only. This review confirms the existence of discrepancies in the statistical treatment of the PAS. A lack of consensus among researchers limits comparisons between studies. The approach to handling this scale dictates the statistical tests used, potentially affecting results and interpretations. Consistent application of statistically sound approaches to PAS analyses is vital for the future of deglutition research.
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Affiliation(s)
- James C Borders
- Department of Otolaryngology, Boston Medical Center, Boston, MA, USA.
| | - Danielle Brates
- Department of Communication Sciences and Disorders, New York University, New York, NY, USA
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A Systematic Review of Physiological Changes in Swallowing in the Oldest Old. Dysphagia 2019; 35:509-532. [PMID: 31489507 DOI: 10.1007/s00455-019-10056-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2019] [Accepted: 08/21/2019] [Indexed: 02/02/2023]
Abstract
Age-related swallowing changes are well-researched in deglutology, usually distinguishing those over 60 years as older aged. World-wide, older adults are healthier and forecast to live longer: many over 85 years. It is necessary for clinicians to understand healthy swallowing changes in this 'oldest old' in order to appropriately manage swallowing complaints in older patients. This systematic review collated and critically appraised studies investigating swallowing changes in adults over 85 years using instrumental assessment. Criteria for inclusion were healthy subjects over 85 years. Exclusion criteria included studies focused on anatomy and oral processing. Studies published until December 2018 were retrieved from BIOSIS, CINAHL, Embase, Medline, and Scopus, totaling 2125 articles. During data screening, 64% of studies investigating age-related swallowing changes were excluded, as the oldest old were not recruited. After PRISMA screening, 44 articles met criteria. These were further reviewed for data extraction, bias and quality. Main quantitative age-related changes in swallowing included increases in delay in swallow onset, bolus transit times, duration of UES opening, pressure above the UES and UES relaxation pressure, and reduction in pressure at the UES. Few studies detected increased residue or airway compromise in the form of aspiration. Results were not easily comparable due to differences in age ranges, methods for deeming participants 'healthy', measures used to define swallowing physiology, and swallowing tasks. Age-related swallowing changes are identified that do not compromise safety. The oldest old are underrepresented in normative deglutition research. It is essential future studies plan accordingly to recruit those over 85 years.
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Abstract
The literal definition of dysphagia is "disturbed eating". However, it is more accurately described in clinical practice as a sensation of food or liquid being stuck in the esophagus or chest. If this sensation is associated with pain, it is labeled odynophagia, and if it is associated with persistent obstruction and bolus retention, it is categorized as a food impaction. Through research and technological advances, we continue to expand our understanding of the etiologies and underlying pathophysiology relating to this complaint. However, for now, our clinical algorithms focus on endoscopy and manometry to break down dysphagia into three categories: obstructive dysphagia, esophageal motility disorders, and functional dysphagia. Here, we review some critical pitfalls in our current clinical diagnoses, new proposed underlying mechanisms of esophageal motor disorders, and developing technologies to aid in diagnosis and treatment.
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Affiliation(s)
- Joseph Triggs
- Department of Medicine, Division of Gastroenterology and Hepatology, Northwestern Medicine, Northwestern University, Feinberg School of Medicine, 676 St Clair Street, Suite 14-009, Chicago, IL, 60611-2951, USA
| | - John Pandolfino
- Department of Medicine, Division of Gastroenterology and Hepatology, Northwestern Medicine, Northwestern University, Feinberg School of Medicine, 676 St Clair Street, Suite 14-009, Chicago, IL, 60611-2951, USA
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Characterization of Esophageal Motility in Infants With Congenital Diaphragmatic Hernia Using High-resolution Manometry. J Pediatr Gastroenterol Nutr 2019; 69:32-38. [PMID: 30889138 DOI: 10.1097/mpg.0000000000002325] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVES The aim of the study was to characterize esophageal motility and esophagogastric junction (EGJ) function in infants who underwent repair of an isolated congenital diaphragmatic hernia (iCDH). METHODS High-resolution manometry with impedance was used to investigate esophageal motility and EGJ function after diaphragmatic repair in 12 infants with iCDH (11 left-sided; 9 patch repair). They had esophageal motility studies during neonatal admission (n = 12), at 6 months (n = 10) and at 12 months of life (n = 7). Swallows were analyzed using conventional esophageal pressure topography and pressure flow analysis and were compared with 11 healthy preterm born infants at near-term age. RESULTS Esophageal peristaltic motor patterns in patients with iCDH were comparable to controls. EGJ end-expiratory pressure was higher in patients with patch repair compared with controls (P = 0.050) and those without patch (P = 0.009). The difference between inspiratory and expiratory pressures at the EGJ was lower in patients with iCDH with patch (P = 0.045) compared to patients without. Patients with iCDH with patch showed increased Pressure Flow Index, resistance of bolus flow at the EGJ, compared with controls (P = 0.043). CONCLUSIONS Normal esophageal wave patterns are present in the investigated patients with iCDH. EGJ end-expiratory pressure seems lower in patients with iCDH without patch suggesting a decreased EGJ barrier function hence increased vulnerability to gastroesophageal reflux. Patch repair appears to increase end-expiratory pressure at the EGJ above that of controls suggesting that patch surgery tightens the EGJ, thereby increasing flow resistance. This is in line with the increased Pressure Flow Index. In infants with a patch, the inspiration-expiration pressure difference is lower, reflecting diminished activity of the crural diaphragm.
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High-Resolution Pharyngeal Manometry and Impedance: Protocols and Metrics-Recommendations of a High-Resolution Pharyngeal Manometry International Working Group. Dysphagia 2019; 35:281-295. [PMID: 31168756 DOI: 10.1007/s00455-019-10023-y] [Citation(s) in RCA: 64] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2018] [Revised: 03/28/2019] [Accepted: 05/25/2019] [Indexed: 02/08/2023]
Abstract
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.
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Savarino E, Marabotto E, Bodini G, Furnari M, Della Coletta M, Ghisa M, Barberio B, Frazzoni M, De Bortoli N, Zentilin P, Pellegatta G, Tolone S, Ottonello A, Savarino V. Advancements in the use of manometry and impedance testing for esophageal functional disorders. Expert Rev Gastroenterol Hepatol 2019; 13:425-435. [PMID: 30896306 DOI: 10.1080/17474124.2019.1595587] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The utilization of high-resolution manometry (HRM) has enhanced our understanding and assessment of esophageal motor disorders. Moreover, the combination of impedance technology with HRM (HRIM) has further improved our knowledge of esophageal physiology and the clinical evaluation of dysmotility, thanks to the addition of accurate measurement of bolus transit. Areas covered. This paper provides an overview of current knowledge in the use of HRIM for the study of esophageal functional disorders by reporting mainly the results of many publications and several systematic reviews in this field. Expert opinion. HRIM has represented a relevant improvement in the assessment of esophageal motility and has required the development of new metrics, such as the esophageal impedance integral ratio, the bolus flow time, the nadir impedance pressure and the impedance bolus height, which increase the evaluation of esophageal bolus transit. An extension of impedance is represented by functional lumen imaging probe (FLIP), which determines the biophysical properties and the distensibility of the esophagus and permits to detect contractility patterns not seen on HRM alone. We eagerly wait for a new and fruitful iteration of the Chicago Classification, now in version 3.0, which can cover the ongoing clinical experience of HRIM.
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Affiliation(s)
- Edoardo Savarino
- a Gastrointestinal Unit, Department of Surgery, Oncology and Gastroenterology , University of Padua , Padua , Italy
| | - Elisa Marabotto
- b Gastrointestinal Unit, Department of Internal Medicine and Medical Specialties , University of Genoa , Genoa , Italy
| | - Giorgia Bodini
- b Gastrointestinal Unit, Department of Internal Medicine and Medical Specialties , University of Genoa , Genoa , Italy
| | - Manuele Furnari
- b Gastrointestinal Unit, Department of Internal Medicine and Medical Specialties , University of Genoa , Genoa , Italy
| | - Marco Della Coletta
- a Gastrointestinal Unit, Department of Surgery, Oncology and Gastroenterology , University of Padua , Padua , Italy
| | - Matteo Ghisa
- a Gastrointestinal Unit, Department of Surgery, Oncology and Gastroenterology , University of Padua , Padua , Italy
| | - Brigida Barberio
- a Gastrointestinal Unit, Department of Surgery, Oncology and Gastroenterology , University of Padua , Padua , Italy
| | - Marzio Frazzoni
- c Digestiva Pathophysiology Unit , Baggiovara Hospital , Modena , Italy
| | - Nicola De Bortoli
- d Gastrointestinal Unit, Department of Translational Research and New Technologies in Medicine and Surgery , University of Pisa , Pisa , Italy
| | - Patrizia Zentilin
- b Gastrointestinal Unit, Department of Internal Medicine and Medical Specialties , University of Genoa , Genoa , Italy
| | - Gaia Pellegatta
- b Gastrointestinal Unit, Department of Internal Medicine and Medical Specialties , University of Genoa , Genoa , Italy
| | - Salvatore Tolone
- e Surgery Unit, Department of Surgery , University of Campania Luigi Vanvitelli , Caserta , Italy
| | - Andrea Ottonello
- f Department of Surgical Science and Integrated Diagnostics , University of Genoa , Genoa , Italy
| | - Vincenzo Savarino
- b Gastrointestinal Unit, Department of Internal Medicine and Medical Specialties , University of Genoa , Genoa , Italy
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Abstract
PURPOSE OF REVIEW High-resolution pharyngeal manometry (HRPM) is a well tolerated, catheter-based, method for recording the pressures and bolus flow generated by the pharyngeal muscles during swallowing. Despite a body of published evidence and a critical mass of investigators in the field, there is a lack of consensus surrounding what biomechanical phenomena to measure. The purpose of this review is to provide some insights into the information on swallowing physiology that can be gathered using HRPM. RECENT FINDINGS HRPM literature has focused on measuring biomechanical phenomena that may be relevant to measure in relation to dysphagia research. This review focuses on the measurement of pharyngeal luminal occlusive forces, intrabolus distension pressure, bolus presence and bolus flow timing as key features of pharyngeal swallowing that require measurement and allow for derivation of the Swallow Risk Index, a global measure of swallow function indicative of swallowing functional reserve. SUMMARY HRPM allows objective derivation of measures of swallow function that may have value for diagnosis and research in relation to swallowing disorders. HRPM has demonstrated clinical applicability in specific patient populations and offers unique advantages that compliment current assessment methods.
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Sia I, Crary MA, Kairalla J, Carnaby GD, Sheplak M, McCulloch T. Derivation and measurement consistency of a novel biofluid dynamics measure of deglutitive bolus-driving function-pharyngeal swallowing power. Neurogastroenterol Motil 2019; 31:e13465. [PMID: 30246422 PMCID: PMC6296874 DOI: 10.1111/nmo.13465] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2018] [Revised: 08/09/2018] [Accepted: 08/15/2018] [Indexed: 02/08/2023]
Abstract
BACKGROUND The primary function of the pharyngeal swallowing mechanism is to drive ingested materials into the esophagus. Currently, a definitive measure of pharyngeal bolus-driving function that accounts for bolus movement remains lacking. The primary objectives of this study were to describe the derivation of a novel biofluid dynamics measure of deglutition-that is, pharyngeal swallowing power (PSP)-and to demonstrate the consistency of PSP in normal swallowing. METHODS The pharyngeal swallowing mechanism was conceptualized as a hydraulic power system with the upper esophageal sphincter (UES) as a conduit. PSP was calculated as the product of bolus pressure and flow across the UES. Thirty-four young healthy subjects swallowed materials consisting of two bolus volumes (10, 20 mL) and four bolus viscosities (thin liquid, nectar-thick liquid, honey-thick liquid, pudding). High-resolution impedance manometry was used for data collection. The consistency of PSP across specific bolus conditions was evaluated using standardized Cronbach's coefficient alpha. KEY RESULTS Standardized Cronbach's coefficient alphas in specific bolus conditions ranged between 0.85 and 0.93. Fisher weighted mean Cronbach's coefficient alphas for swallow trials across bolus volumes and across bolus viscosities ranged from 0.86 to 0.90. Fisher weighted mean Cronbach's coefficient alpha for overall consistency of PSP across all swallow trials was 0.88. CONCLUSIONS AND INFERENCES PSP estimates the output power of the pharyngeal bolus-driving mechanism during deglutition. PSP's high consistency indicates that it can be a useful biofluid dynamics measure of pharyngeal bolus-driving function. Current results also demonstrate that consistency in pharyngeal bolus propulsion is an important physiological target for the pharyngeal swallowing mechanism.
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Affiliation(s)
- Isaac Sia
- Department of Rehabilitation, National University Hospital, 5 Lower Kent Ridge Road, Singapore 119074, Singapore, , Fax: +65 6779 7740, Tel: +65 9694 3929
| | - Michael A. Crary
- Swallowing Research Laboratory, University of Central Florida, Orlando, Florida
| | - John Kairalla
- Department of Biostatistics, University of Florida, Gainesville, Florida
| | - Giselle D. Carnaby
- Swallowing Research Laboratory, University of Central Florida, Orlando, Florida
| | - Mark Sheplak
- Department of Mechanical and Aerospace Engineering and Department of Electrical and Computer Engineering, University of Florida, Gainesville, Florida
| | - Timothy McCulloch
- Division of Otolaryngology–Head and Neck Surgery, University of Wisconsin-Madison, Madison, Wisconsin
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A systematic review of current methodology of high resolution pharyngeal manometry with and without impedance. Eur Arch Otorhinolaryngol 2018; 276:631-645. [PMID: 30547253 DOI: 10.1007/s00405-018-5240-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2018] [Accepted: 12/06/2018] [Indexed: 01/08/2023]
Abstract
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.
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Sia I, Crary MA, Kairalla J, Carnaby GD, Sheplak M, McCulloch T. Bolus volume and viscosity effects on pharyngeal swallowing power-How physiological bolus accommodation affects bolus dynamics. Neurogastroenterol Motil 2018; 30:e13481. [PMID: 30324641 DOI: 10.1111/nmo.13481] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2018] [Revised: 08/09/2018] [Accepted: 09/04/2018] [Indexed: 02/08/2023]
Abstract
BACKGROUND Pharyngeal swallowing power (PSP) is a novel measure of pharyngeal bolus-driving function derived from fluid dynamics principles. This study examined the impact of bolus volume and viscosity on PSP to determine bolus effects on pharyngeal bolus dynamics. The impact of bolus accommodation and physical characteristics of boluses were also explored. METHODS Thirty-four healthy subjects swallowed materials consisting of two bolus volumes (10 and 20 mL) and four bolus viscosities (thin liquid, nectar-thick liquid, honey-thick liquid and pudding). High-resolution impedance manometry was used for data collection. The pharyngeal swallowing mechanism was conceptualized as a hydraulic power system with the UES as a conduit, and PSP was calculated as the product of bolus pressure and flow across the UES. The impact of bolus characteristics on PSP was evaluated using a mixed model approach. KEY RESULTS Both bolus volume (F1,32.8 = 412.73, P < 0.0001) and viscosity (F3,84.7 = 28.94, P < 0.0001) were significant predictors of PSP. PSP for 20 mL bolus volume was greater than for 10 mL bolus volume. PSP was lowest in the thin liquid bolus condition and highest in the pudding bolus. All pairwise comparisons among bolus viscosities were significant except between thin liquid and nectar-thick liquid bolus viscosities. Test of linear trend across bolus viscosities was significant (F1,97.2 = 77.25, P < 0.0001). CONCLUSIONS & INFERENCES Pharyngeal swallowing power variation across bolus conditions illustrates bolus-related changes in bolus dynamics. Bolus effects on PSP likely result from physiological bolus accommodation combined with physical characteristics of boluses.
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Affiliation(s)
- Isaac Sia
- Department of Rehabilitation, National University Hospital, Singapore, Singapore
| | - Michael A Crary
- Swallowing Research Laboratory, University of Central Florida, Orlando, Florida
| | - John Kairalla
- Department of Biostatistics, University of Florida, Gainesville, Florida
| | - Giselle D Carnaby
- Swallowing Research Laboratory, University of Central Florida, Orlando, Florida
| | - Mark Sheplak
- Department of Mechanical and Aerospace Engineering and Department of Electrical and Computer Engineering, University of Florida, Gainesville, Florida
| | - Timothy McCulloch
- Division of Otolaryngology-Head and Neck Surgery, University of Wisconsin-Madison, Madison, Wisconsin
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Lee TH, Lee JS. Safety of flexible endoscopic evaluation of swallowing examination in gastroenterological practice. TURKISH JOURNAL OF GASTROENTEROLOGY 2018; 30:148-154. [PMID: 30459134 DOI: 10.5152/tjg.2018.18279] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
BACKGROUND/AIMS In South Korea, the flexible endoscopic evaluation of swallowing (FEES) has been increasingly performed by gastroenterologists. The principal concern was the safety of the FEES performed by gastroenterologists without any involvement of speech-language pathologists. We aimed to characterize the safety and tolerance of gastroenterologist-directed FEES examinations (GDFEES). MATERIALS AND METHODS We evaluated the GDFEES failures, safety profile (laryngospasm, epistaxis, vasovagal syncope, airway compromise, heart rate, blood pressure, and significant change in cardiovascular function), and discomfort level in patients undergoing GDFEES. These outcomes were also analyzed based on gender, age, and calendar period. RESULTS A total 303 examinations in 268 adult patients with dysphagia were performed during the study period. The GDFEES failures occurred in 5 patients (1.7%). The causes of failures were poor co-operation and insertion difficulty. There were no instances of laryngospasm or vasovagal syncope or significant cardiovascular changes in any of the examinations. Self-limiting epistaxis occurred in 22 examinations (7.3%). The discomfort ratings were as follows: 128 examinations (43.0%) rated the overall discomfort of the test as none, 150 (50.3%) as mild, 18 (6.0%) as moderate, and 2 (0.7%) as severe discomfort. The discomfort level was significantly different only between the first and second half periods (p <0.001), but it was related to neither gender nor age. CONCLUSION The GDFEES can be endorsed as an appropriate paradigm for clinical practice based on our study investigating its safety and tolerance.
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Affiliation(s)
- Tae Hee Lee
- Institute for Digestive Research, Digestive Disease Center, Soonchunhyang University Seoul Hospital, Seoul, Republic of Korea
| | - Joon Seong Lee
- Institute for Digestive Research, Digestive Disease Center, Soonchunhyang University Seoul Hospital, Seoul, Republic of Korea
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Singendonk M, Cock C, Bieckmann L, Szczesniak M, Ferris L, Benninga M, Omari T. Reliability of an online analysis platform for pharyngeal high-resolution impedance manometry recordings. SPEECH LANGUAGE AND HEARING 2018. [DOI: 10.1080/2050571x.2018.1535564] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Affiliation(s)
- Maartje Singendonk
- Department of Paediatric Gastroenterology and Nutrition, Emma Children’s Hospital Amsterdam UMC, Amsterdam, Netherlands
| | - Charles Cock
- Department of Gastroenterology and Hepatology, Flinders Medical Centre, Adelaide, Australia
- College of Medicine and Public Health, Flinders University, Adelaide, Australia
| | - Luc Bieckmann
- Department of Paediatric Gastroenterology and Nutrition, Emma Children’s Hospital Amsterdam UMC, Amsterdam, Netherlands
| | - Michal Szczesniak
- Department of Gastroenterology and Hepatology, St George Hospital, Sydney, Australia
- St George Clinical School, University of New South Wales, Sydney, Australia
| | - Lara Ferris
- College of Medicine and Public Health, Flinders University, Adelaide, Australia
| | - Marc Benninga
- Department of Paediatric Gastroenterology and Nutrition, Emma Children’s Hospital Amsterdam UMC, Amsterdam, Netherlands
| | - Taher Omari
- College of Medicine and Public Health, Flinders University, Adelaide, Australia
- Centre for Neuroscience, Flinders University, Adelaide, Australia
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Dinning PG. A new understanding of the physiology and pathophysiology of colonic motility? Neurogastroenterol Motil 2018; 30:e13395. [PMID: 29971850 DOI: 10.1111/nmo.13395] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2018] [Accepted: 05/18/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND In recent years, high-resolution manometry has been used in an attempt to gain a greater insight into the physiology/pathophysiology of colonic contractile activity in healthy adults and patients with colonic motility disorders. New colonic motor patterns have been identified and characterized, however, the clinical significance of these findings remains undetermined. PURPOSE This review will assess the current literature on colonic high-resolution manometry and determine if this procedure has advanced our understanding of colonic motility. The limitations, future directions, and the potential of this technique to assess the effects of treatment upon colonic motor patterns will also be discussed.
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Affiliation(s)
- P G Dinning
- The Department of Gastroenterology & Surgery, Flinders Medical Centre & the College of Medicine and Public Health & Centre for Neuroscience, Flinders University, Bedford Park, SA, Australia
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Doeltgen SH, Rigney L, Cock C, Omari T. Effects of cortical anodal transcranial direct current stimulation on swallowing biomechanics. Neurogastroenterol Motil 2018; 30:e13434. [PMID: 30101445 DOI: 10.1111/nmo.13434] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2018] [Revised: 06/27/2018] [Accepted: 06/28/2018] [Indexed: 02/08/2023]
Abstract
BACKGROUND Anodal transcranial direct current stimulation (tDCS) has demonstrated effects on corticobulbar excitability and swallowing function as assessed via clinical rating scales in stroke cohorts. Biomechanical effects of anodal tDCS on swallowing remain largely unexplored. We investigated how anodal tDCS applied over the floor of mouth (FOM) representation on the primary motor cortex affects swallowing biomechanics in healthy participants. METHODS Anodal and sham tDCS were applied for 20 minutes at 1.5 mA. Corticobulbar excitability was assessed using motor evoked potentials at baseline and 0, 15, 30 and 45 minutes post-tDCS, as assessed by transcranial magnetic stimulation. Swallowing function was assessed pre- and post-tDCS using routine clinical assessments (Study 1) and pharyngeal high resolution impedance manometry (Study 2). KEY RESULTS Study 1 (n = 17) showed increased corticobulbar excitability and performance on a skilled swallowing task following anodal wetDCS, but not sham tDCS. In Study 2 (n = 10) anodal tDCS resulted in increased bolus admittance across the upper esophageal sphincter, but decreased pharyngeal and upper esophageal contractile vigor. CONCLUSIONS Clinical improvements of dietary intake are likely driven by swallowing neuroplastic reorganization which improves bolus admittance across the upper esophageal sphincter (UES). INFERENCES The documented changes make motor cortical application of anodal tDCS a promising adjunct to swallowing rehabilitation practice.
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Affiliation(s)
- Sebastian H Doeltgen
- Speech Pathology, Swallowing Neurorehabilitation Research Laboratory, College of Nursing and Health Sciences, Flinders University, Bedford Park, SA, Australia.,Centre for Neuroscience, College of Medicine and Public Health, Flinders University, Bedford Park, SA, Australia
| | - Lakkari Rigney
- Speech Pathology, Swallowing Neurorehabilitation Research Laboratory, College of Nursing and Health Sciences, Flinders University, Bedford Park, SA, Australia
| | - Charles Cock
- Gastroenterology, College of Medicine and Public Health, Flinders University, Bedford Park, SA, Australia
| | - Taher Omari
- Centre for Neuroscience, College of Medicine and Public Health, Flinders University, Bedford Park, SA, Australia.,Human Physiology, College of Medicine and Public Health, Flinders University, Bedford Park, SA, Australia
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Szczesniak MM, Wu PI, Maclean J, Omari TI, Cook IJ. The critical importance of pharyngeal contractile forces on the validity of intrabolus pressure as a predictor of impaired pharyngo-esophageal junction compliance. Neurogastroenterol Motil 2018; 30:e13374. [PMID: 29797467 DOI: 10.1111/nmo.13374] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2018] [Accepted: 04/12/2018] [Indexed: 02/08/2023]
Abstract
INTRODUCTION Restrictive defects of the pharyngo-esophageal junction (PEJ) are common in both structural and neurological disorders and are amenable to therapies aiming to reduce outflow resistance. Intrabolus pressure (IBP) acquired with high-resolution manometry and impedance (HRMI) is an indicator of resistance and a marker of reduced PEJ compliance. Constraints and limitations of IBP as well as the optimal IBP parameter remain undefined. AIMS To determine: (i) the impact of peak pharyngeal pressure (PeakP) on the diagnostic accuracy of IBP for the detection of a restrictive defect at the PEJ and (ii) the optimal IBP parameter for this purpose. METHODS In 52 dysphagic patients previously treated for head and neck cancer. Five candidate IBP measures and PeakP were obtained with HRMI, as well as a presence of a stricture determined by a mucosal tear after endoscopic dilatation. Predictive values of IBP measures were evaluated by receiver operating characteristic (ROC) analysis for all patients and reiterated as patients with lowest PeakP were progressively removed from the cohort. RESULTS All IBP parameters had fair to good accuracy at predicting strictures. Intrabolus pressure measured at a discrete point of maximum admittance 1 cm above the maximal excursion of the upper esophageal sphincter had highest sensitivity (0.76) and specificity (0.78). When PeakP was at least 57 mm Hg both sensitivity and specificity improved to 0.9. CONCLUSIONS Pharyngeal propulsive force has substantial impact on the accuracy of IBP as a predictor of a PEJ stricture. When PeakP is ≥57 mm Hg, an elevated IBP is highly predictive of a restrictive defect at the PEJ.
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Affiliation(s)
- M M Szczesniak
- Department of Gastroenterology and Hepatology, St George Hospital & University, Kogarah, NSW, Australia
| | - P I Wu
- Department of Gastroenterology and Hepatology, St George Hospital & University, Kogarah, NSW, Australia
| | - J Maclean
- Department of Speech Pathology, St George Hospital, Sydney, NSW, Australia
| | - T I Omari
- School of Medical Science, Flinders University, Adelaide, SA, Australia
| | - I J Cook
- Department of Gastroenterology and Hepatology, St George Hospital & University, Kogarah, NSW, Australia
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Clinical measurement of gastrointestinal motility and function: who, when and which test? Nat Rev Gastroenterol Hepatol 2018; 15:568-579. [PMID: 29872118 DOI: 10.1038/s41575-018-0030-9] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Symptoms related to abnormal gastrointestinal motility and function are common. Oropharyngeal and oesophageal dysphagia, heartburn, bloating, abdominal pain and alterations in bowel habits are among the most frequent reasons for seeking medical attention from internists or general practitioners and are also common reasons for referral to gastroenterologists and colorectal surgeons. However, the nonspecific nature of gastrointestinal symptoms, the absence of a definitive diagnosis on routine investigations (such as endoscopy, radiology or blood tests) and the lack of specific treatments make disease management challenging. Advances in technology have driven progress in the understanding of many of these conditions. This Review serves as an introduction to a series of Consensus Statements on the clinical measurements of gastrointestinal motility, function and sensitivity. A structured, evidence-based approach to the initial assessment and empirical treatment of patients presenting with gastrointestinal symptoms is discussed, followed by an outline of the contribution of modern physiological measurement on the management of patients in whom the cause of symptoms has not been identified with other tests. Discussions include the indications for and utility of high-resolution manometry, ambulatory pH-impedance monitoring, gastric emptying studies, breath tests and investigations of anorectal structure and function in day-to-day practice and clinical management.
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Arai N, Hanayama K, Yamazaki T, Tomita T, Tsubahara A, Sugamoto K. A novel fluoroscopic method for multidimensional evaluation of swallowing function. Auris Nasus Larynx 2018; 46:83-88. [PMID: 29753584 DOI: 10.1016/j.anl.2018.04.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2018] [Revised: 03/30/2018] [Accepted: 04/20/2018] [Indexed: 01/05/2023]
Abstract
OBJECTIVE Dynamic videofluoroscopic swallow study (VFSS) is used to investigate swallowing movements. However, it requires prolonged radiation exposure and mainly provides qualitative information. Herein, we present a multi-dimensional method for analyzing swallowing based on a pulsed, low-dose fluoroscopy technique that uses serial-shot images and evaluates the size, position, and temporal profile of the bolus to obtain a more comprehensive and realistic analysis of swallowing movements. METHODS Fifteen healthy adults drank two liquids: 20mL of pure water followed by 20mL of contrast medium mixture in a fluoroscopic study. Data were recorded in serial-shot images (7.5 frames/second, 1024×1024-pixel resolution, DICOM format). The images from the water and contrast swallows were inverted, synchronized, and subtracted to visualize the bolus in each frame. The pathway of the bolus was divided into 15 parts traversing the oropharynx, hypopharynx, and upper esophagus, and the total gray value was measured in each section. The results were presented as contour graphs. RESULTS The contour graphs allowed for information on the size, anatomical location, and temporal location of the bolus during swallowing to be displayed simultaneously. Two distinct swallowing patterns were observed in the subjects. The bolus showed two peaks-one in the hypopharynx and one in the upper esophagus-in all subjects. However, in nine of the 15 subjects, the two peaks were in different frames, whereas in six of the subjects, the two peaks were in the same frame. CONCLUSION We developed a new method for quantitatively evaluating swallowing. The technique allows for multidimensional assessment of the size, position, and temporal profile of the movement of the bolus across the pharynx. This method evaluates the swallowing movements using sharp, high-resolution images obtained by serial-shot, pulsed fluoroscopy with low radiation exposure. Additional studies are required to further clarify the variability of swallowing patterns and their clinical relevance in the evaluation of swallowing movements in healthy subjects and in patients with swallowing disorders.
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Affiliation(s)
- Nobuyuki Arai
- Department of Orthopedic Biomaterial Science, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, Osaka 565-0871, Japan; Department of Rehabilitation Medicine, Satou Memorial Hospital, 45 Kurotsuchi, Syoo-Cho, Katsuta-Gun, Okayama 709-4312, Japan.
| | - Kozo Hanayama
- Department of Rehabilitation Medicine, Kawasaki Medical School, 577 Matsushima, Kurashiki, Okayama 701-0192, Japan
| | - Takaharu Yamazaki
- Department of Information Systems, Saitama Institute of Technology, 1690 Fusaiji, Fukaya, Saitama 369-0293, Japan
| | - Tetsuya Tomita
- Department of Orthopedic Biomaterial Science, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, Osaka 565-0871, Japan
| | - Akio Tsubahara
- Kawasaki University of Medical Welfare, 288 Matsushima, Kurashiki City, Okayama 701-0193, Japan
| | - Kazuomi Sugamoto
- Department of Orthopedic Biomaterial Science, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, Osaka 565-0871, Japan
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Schar M, Woods C, Ooi EH, Athanasiadis T, Ferris L, Szczesniak MM, Cock C, Omari T. Pathophysiology of swallowing following oropharyngeal surgery for obstructive sleep apnea syndrome. Neurogastroenterol Motil 2018; 30:e13277. [PMID: 29266554 DOI: 10.1111/nmo.13277] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2017] [Accepted: 12/04/2017] [Indexed: 02/08/2023]
Abstract
BACKGROUND Uvulopalatopharyngoplasty (UPPP) and coblation channeling of the tongue (CCT) are oropharyngeal surgeries used to treat obstructive sleep apnea syndrome. The extent to which UPPP and CCT affect pharyngeal swallow has not been determined. We therefore conducted a novel case series study employing high-resolution impedance manometry (HRIM) to quantify the swallowing-related biomechanics following UPPP and/or CCT surgery. METHODS Twelve patients who underwent UPPP+CCT or CCT only were assessed an average 2.5 years postsurgery. Swallow function data were compared with ten healthy controls. All patients completed the Sydney swallow questionnaire (SSQ). Pharyngeal pressure-flow analysis of HRIM recordings captured key distension, contractility and pressure-flow timing swallow parameters testing 5, 10, and 20 mL volumes of thin and thick fluid consistencies. KEY RESULTS Postoperative patients had more dysphagia symptoms with five returning abnormal SSQ scores. Swallowing was biomechanically altered compared to controls, consistent with diminished swallowing reserve, largely driven by elevated hypopharyngeal intrabolus pressure due to a reduced capacity to open the upper esophageal sphincter to accommodate larger volumes. CONCLUSIONS & INFERENCES Patients who have undergone UPPP and/or CCT surgery appear to have a deficiency in normal modulation of the swallowing mechanism and a reduced swallowing functional reserve. We speculate that these changes may become relevant in later life with the onset of age-related stressors to the swallowing mechanism. This case series strikes a note of caution that further studies are needed to determine the role of preoperative swallow assessment in patients undergoing UPPP and/or CCT surgery.
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Affiliation(s)
- M Schar
- Speech Pathology, Flinders Medical Centre, Adelaide, SA, Australia
| | - C Woods
- Otolaryngology, Head & Neck Surgery, Flinders Medical Centre, Adelaide, SA, Australia
| | - E H Ooi
- Otolaryngology, Head & Neck Surgery, Flinders Medical Centre, Adelaide, SA, Australia.,Department of Surgery, College of Medicine and Public Health, Flinders University, Adelaide, SA, Australia
| | - T Athanasiadis
- Otolaryngology, Head & Neck Surgery, Flinders Medical Centre, Adelaide, SA, Australia.,Department of Surgery, College of Medicine and Public Health, Flinders University, Adelaide, SA, Australia
| | - L Ferris
- Department of Human Physiology, College of Medicine and Public Health, Flinders University, Adelaide, SA, Australia.,Centre for Neuroscience, College of Medicine and Public Health, Flinders University, Adelaide, SA, Australia
| | - M M Szczesniak
- Department of Gastroenterology & Hepatology, St George Clinical School University of New South Wales, Sydney, NSW, Australia
| | - C Cock
- Department of Gastroenterology, College of Medicine and Public Health, Flinders University, Adelaide, SA, Australia
| | - T Omari
- Department of Human Physiology, College of Medicine and Public Health, Flinders University, Adelaide, SA, Australia.,Centre for Neuroscience, College of Medicine and Public Health, Flinders University, Adelaide, SA, Australia.,Department of Gastroenterology, College of Medicine and Public Health, Flinders University, Adelaide, SA, Australia
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Mohd Rosli R, Leibbrandt RE, Wiklendt L, Costa M, Wattchow DA, Spencer NJ, Brookes SJ, Omari TI, Dinning PG. Discriminating movements of liquid and gas in the rabbit colon with impedance manometry. Neurogastroenterol Motil 2018; 30:e13263. [PMID: 29235207 DOI: 10.1111/nmo.13263] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2017] [Accepted: 11/14/2017] [Indexed: 02/08/2023]
Abstract
BACKGROUND High-resolution impedance manometry is a technique that is well established in esophageal motility studies for relating motor patterns to bolus flow. The use of this technique in the colon has not been established. METHODS In isolated segments of rabbit proximal colon, we recorded motor patterns and the movement of liquid or gas boluses with a high-resolution impedance manometry catheter. These detected movements were compared to video recorded changes in gut diameter. Using the characteristic shapes of the admittance (inverse of impedance) and pressure signals associated with gas or liquid flow we developed a computational algorithm for the automated detection of these events. KEY RESULTS Propagating contractions detected by video were also recorded by manometry and impedance. Neither pressure nor admittance signals alone could distinguish between liquid and gas transit, however the precise relationship between admittance and pressure signals during bolus flow could. Training our computational algorithm upon these characteristic shapes yielded a detection accuracy of 87.7% when compared to gas or liquid bolus events detected by manual analysis. CONCLUSIONS & INFERENCES Characterizing the relationship between both admittance and pressure recorded with high-resolution impedance manometry can not only help in detecting luminal transit in real time, but also distinguishes between liquid and gaseous content. This technique holds promise for determining the propulsive nature of human colonic motor patterns.
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Affiliation(s)
- R Mohd Rosli
- Department of Gastroenterology & Surgery, Flinders Medical Centre, Bedford Park, South Australia, Australia.,College of Medicine and Public Health & Centre for Neuroscience, Flinders University, Bedford Park, South Australia, Australia
| | - R E Leibbrandt
- College of Medicine and Public Health & Centre for Neuroscience, Flinders University, Bedford Park, South Australia, Australia
| | - L Wiklendt
- College of Medicine and Public Health & Centre for Neuroscience, Flinders University, Bedford Park, South Australia, Australia
| | - M Costa
- College of Medicine and Public Health & Centre for Neuroscience, Flinders University, Bedford Park, South Australia, Australia
| | - D A Wattchow
- Department of Gastroenterology & Surgery, Flinders Medical Centre, Bedford Park, South Australia, Australia.,College of Medicine and Public Health & Centre for Neuroscience, Flinders University, Bedford Park, South Australia, Australia
| | - N J Spencer
- College of Medicine and Public Health & Centre for Neuroscience, Flinders University, Bedford Park, South Australia, Australia
| | - S J Brookes
- College of Medicine and Public Health & Centre for Neuroscience, Flinders University, Bedford Park, South Australia, Australia
| | - T I Omari
- Department of Gastroenterology & Surgery, Flinders Medical Centre, Bedford Park, South Australia, Australia.,College of Medicine and Public Health & Centre for Neuroscience, Flinders University, Bedford Park, South Australia, Australia
| | - P G Dinning
- Department of Gastroenterology & Surgery, Flinders Medical Centre, Bedford Park, South Australia, Australia.,College of Medicine and Public Health & Centre for Neuroscience, Flinders University, Bedford Park, South Australia, Australia
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ESPEN guideline clinical nutrition in neurology. Clin Nutr 2018; 37:354-396. [DOI: 10.1016/j.clnu.2017.09.003] [Citation(s) in RCA: 193] [Impact Index Per Article: 32.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2017] [Accepted: 09/05/2017] [Indexed: 12/12/2022]
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Effects of remifentanil on pharyngeal swallowing: A double blind randomised cross-over study in healthy volunteers. Eur J Anaesthesiol 2018; 33:622-30. [PMID: 27191923 DOI: 10.1097/eja.0000000000000461] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Exposure to remifentanil increases the incidence of pulmonary aspiration in healthy volunteers. This effect may be explained by impairment of airway defence mechanisms and/or altered swallowing function. Pressure-flow analysis is a technique that allows objective assessment of swallowing based on pressure-impedance patterns recorded during bolus swallowing. OBJECTIVES The aim of this study was to use pressure-flow analysis to quantify the effect of remifentanil on healthy pharyngeal swallowing and to compare these effects with morphine. DESIGN A double-blind, randomised, cross-over study. SETTING A tertiary care teaching hospital. VOLUNTEERS Eleven young volunteers (mean age, 23 years) and seven older volunteers (mean age, 73 years). INTERVENTIONS Volunteers were studied twice and received either a target-controlled remifentanil infusion (target concentrations: young, 3 ng ml; old, 2 ng ml) or a bolus injection of morphine (dose: young, 0.1 mg kg; old, 0.07 mg kg). Pharyngeal pressure and impedance were recorded with an indwelling catheter while swallowing 10 boluses of liquid during each measuring phase. Variables defining swallowing function were calculated and compared to determine drug effects. MAIN OUTCOME MEASURES Pharyngeal pressure-flow variables following remifentanil exposure. RESULTS Changes produced by remifentanil in the measured variables were consistent with greater dysfunction of swallowing. Both the strength of the pharyngeal contractions and pharyngeal bolus propulsion were reduced, whereas flow resistance was increased. The swallow risk index, a global index of swallowing dysfunction, increased overall. At the experimental doses tested, morphine produced similar, but less extensive effects on swallowing. CONCLUSION Remifentanil induced dysfunction of the pharyngeal swallowing mechanism. This may contribute to an increased risk of aspiration. TRIAL REGISTRATION NCT01924234 (www.clinicaltrials.gov).
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Carrión S, Costa A, Ortega O, Verin E, Clavé P, Laviano A. Complications of Oropharyngeal Dysphagia: Malnutrition and Aspiration Pneumonia. Dysphagia 2018. [DOI: 10.1007/174_2017_168] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
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45
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High-Resolution Manometry of the Pharynx and Esophagus. Dysphagia 2018. [DOI: 10.1007/174_2018_177] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
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Ferris L, Schar M, McCall L, Doeltgen S, Scholten I, Rommel N, Cock C, Omari T. Characterization of swallow modulation in response to bolus volume in healthy subjects accounting for catheter diameter. Laryngoscope 2017; 128:1328-1334. [DOI: 10.1002/lary.26820] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2017] [Revised: 05/31/2017] [Accepted: 06/30/2017] [Indexed: 12/12/2022]
Affiliation(s)
- Lara Ferris
- Gastroenterology DepartmentWomen's and Children's HospitalAdelaide Australia
- Gastroenterology Department and Human Physiology DepartmentFlinders UniversityAdelaide Australia
| | - Mistyka Schar
- Gastroenterology Department and Human Physiology DepartmentFlinders UniversityAdelaide Australia
| | - Lisa McCall
- Gastroenterology DepartmentWomen's and Children's HospitalAdelaide Australia
| | - Sebastian Doeltgen
- School of Health SciencesDiscipline of Speech Pathology, Flinders UniversityAdelaide Australia
| | - Ingrid Scholten
- School of Health SciencesDiscipline of Speech Pathology, Flinders UniversityAdelaide Australia
| | - Nathalie Rommel
- Neurosciences DepartmentResearch Group Experimental Otorhinolaryngology, University of LeuvenLeuven Belgium
| | - Charles Cock
- Gastroenterology Department and Human Physiology DepartmentFlinders UniversityAdelaide Australia
| | - Taher Omari
- Gastroenterology Department and Human Physiology DepartmentFlinders UniversityAdelaide Australia
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Doeltgen SH, Ong E, Scholten I, Cock C, Omari T. Biomechanical Quantification of Mendelsohn Maneuver and Effortful Swallowing on Pharyngoesophageal Function. Otolaryngol Head Neck Surg 2017; 157:816-823. [DOI: 10.1177/0194599817708173] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objective To quantify the effects of 2 swallowing maneuvers used in dysphagia rehabilitation—the Mendelsohn maneuver and effortful swallowing—on pharyngoesophageal function with novel, objective pressure-flow analysis. Study Design Evaluation of intervention effects in a healthy control cohort. Setting A pharyngoesophageal motility research laboratory in a tertiary education facility. Subjects Twelve young healthy subjects (9 women, 28.6 ± 7.9 years) from the general public, without swallowing impairment, volunteered to participate in this study. Methods Surface electromyography from the floor-of-mouth musculature and high-resolution impedance manometry–based pressure flow analysis were used to assess floor-of-mouth activation and pharyngoesophageal motility, respectively. Subjects each performed 10 noneffortful control swallows, Mendelsohn maneuver swallows, and effortful swallows, with a 5-mL viscous bolus. Repeated measures analyses of variance was used to compare outcome measures across conditions. Results Effortful and Mendelsohn swallows generated greater floor-of-mouth contraction ( P = .001) and pharyngeal pressure ( P < .0001) when compared with control swallows. There were no changes at the level of the upper esophageal sphincter, except for a faster opening to maximal diameter during maneuver swallows ( P = .01). The proximal esophageal contractile integral was reduced during Mendelsohn swallows ( P = .001). Conclusion Effortful and Mendelsohn maneuver swallows significantly alter the pharyngoesophageal pressure profile. Faster opening of the upper esophageal sphincter may facilitate bolus transfer during maneuver swallows; however, reduced proximal esophageal contractility during Mendelsohn maneuver swallows may impair bolus flow and aggravate dysphagic symptoms.
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Affiliation(s)
| | - Ellisa Ong
- Department of Speech Pathology, School of Health Sciences, Flinders University, Bedford Park, Australia
| | - Ingrid Scholten
- Department of Speech Pathology, School of Health Sciences, Flinders University, Bedford Park, Australia
| | - Charles Cock
- Department of Gastroenterology, School of Medicine, Flinders University, Bedford Park, Australia
| | - Taher Omari
- Department of Human Physiology, School of Medicine, Flinders University, Bedford Park, Australia
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Pinna BR, Herbella FAM, de Biase N, Vaiano TCG, Patti MG. High-Resolution Manometry Evaluation of Pressures at the Pharyngo-upper Esophageal Area in Patients with Oropharyngeal Dysphagia Due to Vagal Paralysis. Dysphagia 2017; 32:657-662. [PMID: 28528491 DOI: 10.1007/s00455-017-9811-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2016] [Accepted: 05/11/2017] [Indexed: 01/08/2023]
Abstract
The motility of the pharynx, upper esophageal sphincter (UES), and proximal esophagus in patients with oropharyngeal dysphagia is still not entirely understood. High-resolution manometry (HRM) was recently added to the armamentarium for the study of this area. This study aims to describe HRM findings in patients with vagal paralysis. Sixteen patients (mean age 54 years, 69% females) with oropharyngeal dysphagia due to unilateral vagal paralysis were prospectively studied. All patients underwent HRM. Motility of the UES and at the topography of the velopharynx and epiglottis were recorded. (1) UES relaxation is compromised in a minority of patients, (2) epiglottis pressure does not follow a specific pattern, (3) vellum is hypotonic in half of the patients, (4) dysphagia is related to a low pharyngeal pressure, not to a flow obstruction at the level of the UES, and (5) aspiration is related to low pressures at the level of the UES and epiglottis and higher pressures at the level of the vellum. Pharyngeal motility is significantly impaired in patients with oropharyngeal dysphagia and unilateral vagal paralysis. In half of the cases, UES resting pressure is preserved due to unilateral innervation and relaxation is normal in most patients. Dysphagia therapy in these patients must be directed toward improvement in the oropharyngeal motility not at the UES.
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Affiliation(s)
- Bruno Rezende Pinna
- Department of Ear, Nose and Throat, Escola Paulista de Medicina, Federal University of Sao Paulo, Sao Paulo, Brazil
| | - Fernando A M Herbella
- Department of Surgery, Escola Paulista de Medicina, Federal University of Sao Paulo, Rua Diogo de Faria 1087 cj 301, Sao Paulo, SP, 04037-003, Brazil.
| | - Noemi de Biase
- Department of Ear, Nose and Throat, Escola Paulista de Medicina, Federal University of Sao Paulo, Sao Paulo, Brazil
| | - Thays C G Vaiano
- Speech-Language Pathology and Audiology Department, Escola Paulista de Medicina, Federal University of Sao Paulo, Sao Paulo, Brazil
| | - Marco G Patti
- Department of Surgery, University of North Carolina, Chapel Hill, NC, USA
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Abstract
PURPOSE OF REVIEW We provide an overview of the clinical application of novel pharyngeal high-resolution impedance manometry (HRIM) with pressure flow analysis (PFA) in our hands with example cases. RECENT FINDINGS In our Centre, we base our interpretation of HRIM recordings upon a qualitative assessment of pressure-impedance waveforms during individual swallows, as well as a quantitative assessment of averaged PFA swallow function variables. We provide a description of two global swallowing efficacy measures, the swallow risk index (SRI), reflecting global swallowing dysfunction (higher SRI = greater aspiration risk) and the post-swallow impedance ratio (PSIR) detecting significant post-swallow bolus residue. We describe a further eight swallow function variables specific to the hypopharynx and upper esophageal sphincter (UES), assessing hypo-pharyngeal distension pressure, contractility, bolus presence and flow timing, and UES basal tone, relaxation, opening and contractility. Pharyngeal HRIM has now come of age, being applicable for routine clinical practice to assess the biomechanics of oropharyngeal swallowing dysfunction. In the future, it may guide treatment strategies and allow more objective longitudinal follow-up on clinical outcomes.
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Affiliation(s)
- Charles Cock
- Gastroenterology & Hepatology, Southern Adelaide Local Health Network, Adelaide, Australia.
- Department of Gastroenterology & Hepatology, School of Medicine, Flinders University of South Australia, Flinders Medical Centre, Flinders Drive, Bedford Park, 5042, Australia.
| | - Taher Omari
- Department of Gastroenterology & Hepatology, School of Medicine, Flinders University of South Australia, Flinders Medical Centre, Flinders Drive, Bedford Park, 5042, Australia
- Human Physiology, Medical Science and Technology, Flinders University of South Australia, Bedford Park, Australia
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Jadcherla SR. Advances with Neonatal Aerodigestive Science in the Pursuit of Safe Swallowing in Infants: Invited Review. Dysphagia 2017; 32:15-26. [PMID: 28044203 PMCID: PMC5303645 DOI: 10.1007/s00455-016-9773-z] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2016] [Accepted: 12/21/2016] [Indexed: 11/26/2022]
Abstract
Feeding, swallowing, and airway protection are three distinct entities. Feeding involves a process of sequential, neurosensory, and neuromotor interactions of reflexes and behaviors facilitating ingestion. Swallowing involves anterograde bolus movement during oral-, pharyngeal-, and esophageal phases of peristalsis into stomach. During these events, coordination with airway protection is vital for homeostasis in clearing any material away from airway vicinity. Neurological-airway-digestive inter-relationships are critical to the continuum of successful feeding patterns during infancy, either in health or disease. Neonatal feeding difficulties encompass a heterogeneous group of neurological, pulmonary, and aerodigestive disorders that present with multiple signs posing as clinical conundrums. Significant research breakthroughs permitted understanding of vagal neural pathways and functional aerodigestive connectivity involved in regulating swallowing and aerodigestive functions either directly or indirectly by influencing the supra-nuclear regulatory centers and peripheral effector organs. These neurosensory and neuromotor pathways are influenced by pathologies during perinatal events, prematurity, inflammatory states, and coexisting medical and surgical conditions. Approaches to clarify pathophysiologic mapping of aerodigestive interactions, as well as translating these discoveries into the development of personalized and simplified feeding strategies to advance child health are discussed in this review article.
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Affiliation(s)
- Sudarshan R Jadcherla
- The Neonatal and Infant Feeding Disorders Program, Department of Neonatology, Nationwide Children's Hospital, Columbus, OH, USA.
- Innovative Infant Feeding Disorders Research Program, Center for Perinatal Research, The Research Institute at Nationwide Children's Hospital, Columbus, OH, USA.
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH, USA.
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