Acute characteristics of pediatric Dysphagia subsequent to traumatic brain injury: videofluoroscopic assessment

Sensitivity and Specificity of Bedside Screening Tests for Detection of Aspiration in Patients Admitted to a Public Rehabilitation Hospital

Early detection of dysphagia and specifically aspiration is essential to prevent and reduce complications of hospitalized patients in rehabilitation centers. Bedside screening test are often used to evaluate swallowing disorders, but their results may be questionable due to insufficient and inconsistent sensitivity and specificity. To compare the sensitivity and specificity of various bedside screening tests for detecting aspiration in hospitalized rehabilitation patients. A prospective observational study was performed in 150 consecutive patients of a tertiary rehabilitation hospital. Patients were evaluated regarding clinical predictors for aspiration, maximum phonation time (MPT), Eating Assessment Tool 10 (EAT-10) questionnaire, tongue strength and endurance (Iowa Oral Performance Instrument [IOPI]) and a swallowing test (Volume-Viscosity Swallow Test [V-VST]). Flexible Endoscopic Evaluation of Swallowing (FEES) was the reference test. Of the 144 patients included, 22% aspirated on FEES. Previous history of pneumonia, dysarthria, wet voice, and abnormal cough reflex were significantly associated with aspiration. The sensitivity, specificity and accuracy for V-VST (83.3%, 72.6%, 74.8%, respectively) and EAT-10 (82.8%, 57.7%, 62.8%, respectively) to detect aspiration were superior than those of other methods. Maximum tongue strength on IOPI and MPT presented high sensitivity but low specificity to detect aspiration. Clinical predictors of aspiration (previous history of pneumonia, dysarthria, wet voice, and abnormal cough reflex) associated with either V-VST or EAT-10 may be good screening methods to detect aspiration in patients hospitalized in a rehabilitation center.

Influence of Nasogastric Tubes on Swallowing in Stroke Patients: Measuring Hyoid Bone Movement With Ultrasonography

OBJECTIVE

To investigate the influence of a nasogastric tube (NGT) on swallowing simulated saliva in stroke patients.

METHODS

Three groups of participants were enrolled into the study: group A (20 stroke patients with a NGT), a control group B (25 stroke patients without a NGT), and group C (25 healthy adults with no brain lesions or dysphagia). Participants swallowed 1 mL of water to simulate saliva. Patients in group A were tested twice: once with a NGT (group A1) and once after the NGT was removed (group A2). The distance of hyoid bone movement was measured by subtracting the shortest distance between the mandible and hyoid bone (S) from the distance at resting state (R) measured with ultrasonography. The degree of the movement was calculated by (R-S)/R. The trajectory area of hyoid bone movement (Area) and the interval between the beginning of hyoid bone movement and the moment of the shortest hyoid-mandible approximation (Interval) was calculated by a computer program.

RESULTS

From group A: R-S and (R-S)/R of group A2 at 1.14±0.36 cm and 0.30±0.09 cm and were significantly greater than those of group A1 at 0.81±0.36 cm and 0.22±0.08 cm (p=0.009 and p=0.005). After removing the NGT as seen in group A2, R-S and (R-S)/R were improved to the level of those of group B at 1.20±0.32 cm and 0.30±0.09 cm (p=0.909 and p=0.997). The Area of group A2 was larger and the Interval of group A2 was shorter than those of group A1 though a comparison of these factors between A2 and A1 did not show a statistically significant difference.

CONCLUSION

A NGT interferes with the movement of the hyoid bone when swallowing 1 mL of water in stroke patients though the movement is restored to normal after removing the NGT.

An unusual late complication in traumatic brain injury: Persistent dysphagia due to tracheoesophageal fistula

Traumatic brain injury (TBI), which leads to cognitive, physical, emotional and behavioral deficits according to the severity of trauma, is a disability with high morbidity and mortality. In addition to primary effects of TBI, direct trauma to the face, neck, and chest also contributes to increased morbidity. Recovery in swallowing functions in TBI patients is often parallel with recovery in functional daily activities. Herein, contrary to that expectation, we present a TBI case with persistent dysphagia symptoms lasting for even 1.5 years after trauma, despite the fact that she gained independence in dailylife activities under supervision.

Assessment of Oropharyngeal Dysphagia in Patients With Parkinson Disease: Use of Ultrasonography

Objective

To compare tongue thickness, the shortest hyoid-thyroid approximation (distance between the hyoid bone and thyroid cartilage), and the time interval between the initiation of tongue movement and the time of the shortest hyoid-thyroid approximation, by using ultrasonography in healthy controls and patients with Parkinson disease (PD).

Methods

Healthy controls and PD patients with dysphagia were compared. Ultrasonography was performed 3 times for the evaluation of tongue thickness, the shortest hyoid-thyroid approximation, and the time between the initiation of tongue movement and the shortest hyoid-thyroid approximation.

Results

A total of 24 healthy controls and 24 PD patients with dysphagia were enrolled. No significant differences were demonstrated between the two groups for the shortest hyoid-thyroid approximation (controls, 1.19±0.34 cm; PD patients, 1.37±0.5 cm; p=0.15) and tongue thickness (controls, 4.42±0.46 cm; PD patients, 4.27±0.51 cm; p=0.3). In contrast, the time to the shortest hyoid-thyroid approximation was significantly different between the two groups (controls, 1.53±0.87 ms; PD patients, 2.4±1.4 ms, p=0.048).

Conclusion

Ultrasonography can be useful in evaluating dysphagia in patients with PD by direct visualization and measurement of the hyoid bone. Moreover, ultrasonography might contribute to a greater understanding of the pathophysiology of dysphagia in PD.

Fluoroscopic findings of swallowing: comparison between preterm and full-term infants

PURPOSE

To describe the fluoroscopic findings of swallowing in preterm infants with zero to six months of age, as well as the related diseases and clinical signs and symptoms, and to compare these findings with data obtained from full-term infants.

METHODS

The retrospective findings of fluoroscopic studies carried out in infants with zero to six months of age and their respective files were analyzed. Participants were 40 subjects divided into two groups: Preterm Group, composed by 23 preterm infants, and Full-Term Group, with 17 infants born full-term.

RESULTS

Nasopharyngeal and gastroesophageal reflux were the main fluoroscopic findings of swallowing in both groups. There was no difference between the groups regarding the presence of swallowing disorders. The Preterm Group presented more cardiac problems than the Full-Term Group. No differences were found between the groups regarding neurologic and respiratory problems. With respect to clinical signs and symptoms suggestive of swallowing disorders, the Preterm Group presented more oxygen desaturation and the Full-Term Group, more vomiting.

CONCLUSION

Nasopharyngeal reflux and gastroesophageal reflux were the main fluoroscopic findings of swallowing in preterm infants with zero to six months of age. New follow-up studies with this population must be carried out to confirm the hypothesis that the swallowing alterations observed were due to immaturity in the swallowing function.

Evaluating service delivery for speech and swallowing problems following paediatric brain injury: an international survey

RATIONALE, AIMS AND OBJECTIVES

Little is documented about contemporary management of speech and swallowing disorders associated with paediatric acquired brain injury (ABI). It is therefore challenging for clinicians in this field to benchmark their clinical management against current evidence or practices undertaken in other centres. To address this issue, we aimed to provide much-needed baseline data on speech and language pathology management of speech and swallowing disorders associated with childhood ABI. Key objectives were to: (i) determine whether clinicians use formalized referral criteria, clinical guidelines, protocols or care pathways; and (ii) to document the specific assessment and treatment approaches used.

METHODS

Speech and language pathology managers and clinicians at 31 major paediatric rehabilitation centres across Australia, New Zealand, the UK and Ireland were invited to participate in an online survey.

RESULTS

Fifty-one speech and language pathologists responded representing 26 centres (84% response rate). Routine referrals of ABI patients to speech and language pathology occurred relatively infrequently in these centres (12%). Centres utilized assessment protocols (23%) and guidelines (35%) more frequently than treatment guidelines (8%). Multidisciplinary care pathways were applied by 31%. Most centres used adult-based motor speech assessments and informal ('in-house developed') swallowing assessment tools.

CONCLUSIONS

The limited use of referral criteria, protocols, care pathways and guidelines invites the possibility of unequal care, and less than optimal outcomes. Reliance on adult-based or in-house assessments is inappropriate, yet frequently a necessity due to an absence of paediatric-specific tools in this field. Further research is required in parallel with the formation of consensus groups to support the development of: (i) paediatric-specific assessment tools and management approaches; and (ii) clinical protocols and guidelines.

Oropharyngeal aspiration and silent aspiration in children

BACKGROUND

Limited information exists about the nature of and factors associated with oropharyngeal aspiration (OPA) and silent aspiration (SA) in children. A prospective study was undertaken to determine the factors associated with fluoroscopically identified OPA and SA.

METHODS

Three hundred children presenting with feeding difficulties underwent a videofluoroscopic swallow study (VFSS) for evaluation of swallowing. Swallowing performance on each food and fluid consistency was rated using the penetration-aspiration scale, and children were classified into the following groups: OPA, SA, overt aspiration (OA), and no aspiration (NA).

RESULTS

OPA occurred in 34% of children; of these, 81% had SA. SA was significantly associated with neurologic impairment (OR, 4.65; 95% CI, 2.26-9.54), developmental delay (OR, 4.62; 95% CI, 2.28-9.35), aspiration lung disease (OR, 3.22; 95% CI, 1.29-8.05), and enteral feeding (OR, 2.03; 95% CI, 1.04-3.62). Similar results were found for OPA. Children with SA were more likely to have neurologic disease (OR, 4.1; 95% CI, 1.1-15.8) than those with OA. Age or gender differences, gastroesophageal reflux disease, recurrent respiratory tract infections, and asthma were no more likely to occur in children with OPA, SA, or OA.

CONCLUSIONS

SA is very common in children with feeding difficulties and is most likely to occur in children with a neurologic problem. Limited medical diagnoses distinguished between aspirators (OPA, SA) and those with NA. VFSS should be performed in children with feeding difficulties and diagnoses of neurologic impairment, cerebral palsy, aspiration lung disease, and/or enteral feeding because of the increased likelihood of SA.

Dysphagia in childhood traumatic brain injury: a reflection on the evidence and its implications for practice

BACKGROUND

Children with traumatic brain injury (TBI) may develop swallowing impairment or dysphagia with possible deleterious consequences of compromised nutritional intake or aspiration with subsequent respiratory complications.

OBJECTIVE

To examine the evidence base for clinical management of dysphagia by reviewing empirical data on the epidemiology, assessment and diagnosis, and prognosis for dysphagia associated with childhood TBI.

METHODS

A systematic review of the literature on dysphagia in children with TBI was conducted. Non-data driven studies or studies including data on individuals 18 years and over were excluded.

RESULTS

Available data was sparse. Only nine studies met inclusion criterion. Current preliminary data revealed that acute dysphagia incidence is high (68-76%) for children with severe TBI. Children with severe injury (GCS <or= 8) and a ventilation period of >or=1.5 days following motor vehicle accident are at increased risk for dysphagia. Resolution of dysphagia is typically achieved by 12 weeks in children with cortical injury.

CONCLUSION

There is a clear need for multi-centre prospective research studies in this field, however preliminary evidence can be used to inform aspects of clinical practice. First, routine swallowing screening may be implemented for children meeting criterion for being 'at risk' for dysphagia. Systematic referral of targeted patients is lacking in paediatric rehabilitative care, but early screening of these cases would optimize early dysphagia identification and management. Secondly, the positive prognosis for most cases with cortical injury suggests that long-term feeding options (i.e. gastrostomy) may not be indicated until at least 3 months have passed with minimal change in function.

Exploration of the relationships among medical health history variables and aspiration

OBJECTIVES

(1) Determine the relationships among a family's specific answers to health history questions and their child's risk for aspiration as determined by a swallow study. (2) Identify key factors which may predict a child's risk for aspiration.

METHODS

Answers to questions and results of Functional Endoscopic Evaluation of Swallow (FEES) and/or Video Swallow Study (VSS) for a sample of 198 children were collected. Subjects were categorized into groups: "aspiration", "penetration" or "no aspiration or penetration". Logistic regression modeling was used to determine the contribution of certain characteristics to the odds of aspiration. A model for predicting aspiration or penetration based on those characteristics was assessed. The sensitivity and specificity of the model in predicting aspiration and penetration was determined.

RESULTS

One hundred ninety eight subjects had a FEES or VSS. Of these, 18% (n=36) aspirated and 21% (n=42) were found to have penetration. Many of the factors identified in the health history were found to be significantly associated with aspiration or penetration. The variables "demonstrated aspiration" (this included parent or caregiver seeing food in the tracheotomy tube or aspiration noted on a previous FEES or VSS) (p=0.02), "hypotonia" (p=0.02) and "tracheotomy" (p=0.001) were most predictive of aspiration. History of tracheotomy was found to have an inverse relationship with aspiration. "gastroesophageal reflux" (GER) (p=0.0007) was most significantly associated with penetration, followed by "prematurity" (p=0.03) and "developmental delays" (p=0.04). Based on the prediction model, the probabilities for a child with a history of combinations of the above variables to have aspiration or penetration were calculated.

CONCLUSIONS

Significant relationships exist between aspiration or penetration and the family's answers about their child's medical history. Practitioners should consider a swallow assessment whenever a child has a history which includes variables with a strong association with aspiration or penetration.

Incidence and clinical presentation of dysarthria and dysphagia in the acute setting following paediatric traumatic brain injury

BACKGROUND

A lack of data on dysarthria and dysphagia outcomes for children following traumatic brain injury (TBI) limits our clinical evidence base, and poses daily challenges for the speech language pathologist (SLP) managing this group. The present study aimed to examine dysarthria and dysphagia incidence and the clinical presentation of children with these disorders in the acute phase following TBI.

METHODS

Incidence and characteristics were determined via a comprehensive retrospective medical chart review of children consecutively referred to a tertiary paediatric hospital over an 8-year period. Cases (n= 22 dysarthria, n= 72 dysphagia) and matched controls were compared across ancillary variables (e.g. age, severity of TBI, motor impairment).

RESULTS

Incidence across the entire cohort was low [i.e. dysarthria (1.2%, 22/1895), dysphagia (3.8%, 72/1895)], but was markedly higher for the sub-category of children with severe TBI [e.g. dysphagia (76%, 63/83)]. Speech deficits were reported across respiration, phonation, resonance, articulation and prosody. Swallowing deficits included reduced lip closure, delayed swallow initiation, wet voice and coughing. Language and swallowing deficits were often co-morbid with dysarthria. Motor impairment was frequently co-morbid with both dysarthria and dysphagia. Cases had longer periods of hospitalization, ventilation and supplementary feeding compared with controls.

CONCLUSION

Despite the low incidence of dysarthria and dysphagia across the entire TBI cohort, this sub-group may place longer-term burden on SLP services, having prolonged periods of ventilation, extended periods of hospitalization and a complex co-morbid clinical presentation compared with controls. The prevalence of co-morbid communication and swallowing impairments suggests a need for integrated rather than single discipline (i.e. dysphagia stream only) SLP services.

Current practice in paediatric videofluoroscopy

Use of the videofluoroscopy swallow study (VFSS), also known as the modified barium swallow (MBS), continues to increase in children. This article reviews the scope and limitations of the examination, explores the current techniques and illustrates some of the main findings. As moving images are key to the understanding of the use of this technique short videos are available in the on-line version of this paper.

Videofluoroscopy and swallowing studies for neurologic disease: a primer

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

Silent Aspiration: What Do We Know?

Although clinically evident aspiration is common in subjects with dysphagia, a significant proportion may aspirate silently, i.e., without any outward signs of swallowing difficulty. This article reviews the literature on the prevalence, etiology, and prognostic significance of silent aspiration. An electronic database search was performed using silent aspiration, aspiration, dysphagia, and stroke as search terms, together with hand-searching of articles. Silent aspiration has been described in many conditions and subgroups of patients (including normal individuals), using a number of detection methods, making comparisons a challenge. The best data are for acute stroke, in which 2%-25% of patients may aspirate silently. Mechanisms associated with silent aspiration may include central or local weakness/incoordination of the pharyngeal musculature, reduced laryngopharyngeal sensation, impaired ability to produce a reflexive cough, and low substance P or dopamine levels. In terms of prognosis, silent aspiration has been associated with increased morbidity and mortality in many but not all studies. However, some degree of silent aspiration at night may be normal in healthy individuals. The phenomenon of silent aspiration is poorly understood and further research is needed to improve methods of detection and thereby better define its prevalence and prognostic significance.

A case study of the resolution of paediatric dysphagia following brainstem injury: clinical and instrumental assessment

The coexistance of a swallowing impairment can severely impact upon the medical condition and recovery of a child with traumatic brain injury [ref.: Journal of Head Trauma Rehabilitation 9 (1) (1994) 43]. Limited data exist on the progression or outcome of dysphagia in the paediatric population with brainstem injury. The present prospective study documents the resolution of dysphagia in a 14-year-old female post-brainstem injury using clinical, radiological and endoscopic evaluations of swallowing. The subject presented with a pattern of severe oral-motor and oropharyngeal swallowing impairment post-injury that resolved rapidly for the initial 12 weeks, slowed to gradual progress for weeks 12-20, and then plateaued at 20 weeks post-injury. Whilst a clinically functional swallow was present at 10 months post-injury, radiological examination revealed a number of residual physiological impairments, reduced swallowing efficiency, and reduced independence for feeding, indicating a potential increased risk for aspiration. The data highlight the need for early and continued evaluation and intensive treatment programs, to focus on the underlying physiological swallowing impairment post-brainstem injury, and to help offset any potential deleterious effects of aspiration that may affect patient recovery, such as pneumonia.

Advances in the evaluation and management of pediatric dysphagia

PURPOSE OF REVIEW

Feeding and swallowing problems in the pediatric population, commonly referred to as pediatric dysphagia, are often complex. Multiple disciplines are frequently involved in both the evaluation and the management of symptoms exhibited by an increasing number of infants and children. The efficacy of commonly employed diagnostic and treatment strategies has been largely unexplored, although there has been a steadily increasing amount of research specific to pediatric dysphagia. Recent research efforts are reviewed which contribute data necessary for development of evidence-based evaluation and management methods.

RECENT FINDINGS

Research contributions over the past year have included continued work in the classification and categorization of the widely varied causes of pediatric dysphagia. Research efforts have also focused on objective data of swallowing mechanics by use of diagnostic tools such as videofluoroscopy, endoscopy, and electromyography. Recent advances in approaches to the management of pediatric dysphagia symptoms secondary to achalasia and eosinophilic esophagitis are discussed.

SUMMARY

Research that contributes to the base of knowledge regarding diagnosis and treatment of pediatric dysphagia has been consistently accumulating in recent years, yet much work remains to be done. Continued research studies, both retrospective and prospective in nature, are clearly needed to continue to build evidence-based evaluation and treatment protocols for pediatric dysphagia.