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Hunter CJ, Tulunay-Ugur OE. Dysphagia in the Aging Population. Otolaryngol Clin North Am 2024; 57:685-693. [PMID: 38806319 DOI: 10.1016/j.otc.2024.03.006] [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] [Indexed: 05/30/2024]
Abstract
Older adults are projected to outnumber children aged under 18 years for the first time in United States history by 2034, according to Census Bureau projections. This will lead to significant increase in age-related disorders. One of the most important disorders that will increase in prevalence is dysphagia, as it leads to malnutrition, dehydration, aspiration pneumonia, and death. In this article, the physiology of dysphagia in the elderly, as well as the management options is discussed.
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Affiliation(s)
- Courtney J Hunter
- Department of Otolaryngology-Head and Neck Surgery, University of Arkansas for Medical Sciences, 4301 W. Markham Street, Slot 543, Little Rock, AR 72205, USA
| | - Ozlem E Tulunay-Ugur
- Division of Laryngology, University of Arkansas for Medical Sciences, 4301 W. Markham Street, Slot 543, Little Rock, AR 72205, USA.
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2
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Lee DS, Kim HE, Choi JS. Oral Health-Related Factors Associated with Dysphagia Risk among Older, Healthy, Community-Dwelling Korean Adults: A Pilot Study. Healthcare (Basel) 2024; 12:267. [PMID: 38275546 PMCID: PMC10815140 DOI: 10.3390/healthcare12020267] [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: 12/24/2023] [Revised: 01/15/2024] [Accepted: 01/18/2024] [Indexed: 01/27/2024] Open
Abstract
Most previous studies addressing dysphagia examined individuals who already had diseases causing dysphagia and did not pay much attention to oral health conditions as a risk factor. This pilot study investigated 62 healthy adults aged 65 years or older who were living independently in the community, performed basic activities of daily living independently, and had no history of a causative disease of dysphagia to identify the factors associated with dysphagia risk, especially oral health. The Dysphagia Risk Assessment Scale was used to screen the patients for dysphagia. Hyposalivation was diagnosed by evaluating the unstimulated salivary flow rate, and orofacial muscle strength (anterior tongue elevation, buccinator muscle, and lip strength) was quantitatively measured using the Iowa Oral Performance Instrument. To analyze the factors associated with dysphagia risk, the Mann-Whitney test, Kruskal-Wallis test, and multiple logistic regression analyses were conducted. In the final regression model adjusted for sociodemographic characteristics, the oral health-related factors independently associated with dysphagia risk were buccinator muscle strength, hyposalivation, and subjective masticatory discomfort (p < 0.05). Therefore, our findings suggest that weak buccinator muscle strength, hyposalivation, and subjective masticatory discomfort are valuable indicators for the early detection of dysphagia in older, healthy, independent, community-dwelling adults.
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Affiliation(s)
- Da-Som Lee
- Department of Dental Hygiene, Graduate School, Gachon University, Incheon 21936, Republic of Korea;
| | - Hee-Eun Kim
- Department of Dental Hygiene, College of Medical Science, Gachon University, Incheon 21936, Republic of Korea;
| | - Jun-Seon Choi
- Department of Dental Hygiene, College of Medical Science, Gachon University, Incheon 21936, Republic of Korea;
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Chou KR, Huang MS, Chiu WC, Chen YH, Chen YY, Xiao Q, Yang SC. A comprehensive assessment of oral health, swallowing difficulty, and nutritional status in older nursing home residents. Sci Rep 2023; 13:19914. [PMID: 37964096 PMCID: PMC10645724 DOI: 10.1038/s41598-023-47336-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Accepted: 11/12/2023] [Indexed: 11/16/2023] Open
Abstract
Declines in oral consumption and swallowing function are common reasons which may elevate the risk of malnutrition in the older adults. This study aimed to provide valuable information and contribute to the existing body of knowledge in this field as well as highlight the importance of a comprehensive assessment of oral health, swallowing function, and nutritional status in long-term care residents. This was a cross-sectional study. Thirty-nine participants were recruited from a nursing home. The comprehensive assessment was evaluated in participants, including oral health (Oral Health Assessment Tool (OHAT)), swallowing function (Functional Oral Intake Scale (FOIS) and Eating Assessment Tool (EAT)-10), and nutritional status (Mini Nutritional Assessment-Short Form (MNA-SF). The average age of participants was 80.4 ± 11.7 years, and 46% of these older adults were found to be at the risk of malnutrition. There was a negative correlation between the OHAT and MNA-SF scores. In addition, subjects with poor oral health (OHAT score = 5~8), oral consumption of a modified diet (FOIS score = 4~6), and reduced swallowing function (EAT-10 score ≥ 3) were more likely to be at risk of malnutrition. A comprehensive evaluation of oral health and swallowing function was closely connected with the nutritional status of older nursing home dwellers.
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Affiliation(s)
- Kuei-Ru Chou
- School of Nursing, College of Nursing, Taipei Medical University, Taipei, Taiwan
- Center for Nursing and Healthcare Research in Clinical Practice Application, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
- Department of Nursing, Taipei Medical University-Shuang Ho Hospital, New Taipei City, Taiwan
- Psychiatric Research Center, Taipei Medical University Hospital, Taipei, Taiwan
- Neuroscience Research Center, Taipei Medical University, Taipei, Taiwan
| | - Mao-Suan Huang
- School of Oral Hygiene, College of Oral Medicine, Taipei Medical University, Taipei, Taiwan
| | - Wan-Chun Chiu
- School of Nutrition and Health Sciences, College of Nutrition, Taipei Medical University, Taipei, Taiwan
- Research Center of Geriatric Nutrition, College of Nutrition, Taipei Medical University, 250 Wu-Hsing Street, Taipei, 11031, Taiwan
- Department of Nutrition, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
| | - Yi-Hsiu Chen
- School of Nutrition and Health Sciences, College of Nutrition, Taipei Medical University, Taipei, Taiwan
| | - Yu-Yoh Chen
- Graduate Institute of Health and Biotechnology Law, Taipei Medical University, Taipei, Taiwan
| | - Qian Xiao
- School of Nutrition and Health Sciences, College of Nutrition, Taipei Medical University, Taipei, Taiwan
| | - Suh-Ching Yang
- School of Nutrition and Health Sciences, College of Nutrition, Taipei Medical University, Taipei, Taiwan.
- Research Center of Geriatric Nutrition, College of Nutrition, Taipei Medical University, 250 Wu-Hsing Street, Taipei, 11031, Taiwan.
- Nutrition Research Center, Taipei Medical University Hospital, Taipei, Taiwan.
- School of Gerontology and Long-Term Care, College of Nursing, Taipei Medical University, Taipei, Taiwan.
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Han H, Park Y, Kwon H, Jeong Y, Joo S, Cho MS, Park JY, Jung HW, Kim Y. Newly developed care food enhances grip strength in older adults with dysphagia: a preliminary study. Nutr Res Pract 2023; 17:934-944. [PMID: 37780213 PMCID: PMC10522817 DOI: 10.4162/nrp.2023.17.5.934] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Revised: 07/02/2023] [Accepted: 07/06/2023] [Indexed: 10/03/2023] Open
Abstract
BACKGROUND/OBJECTIVES Maintaining total muscle mass in the older adults with swallowing difficulty (dysphagia) is important for preserving swallowing function. Increasing protein intake can help sustain lean body mass in the older adults. The aim of this study was to evaluate the effect of various high-protein texture-modified foods (HPTMFs) on muscle mass and perform dietary assessment in ≥ 65-yrs-old patients with dysphagia. SUBJECTS/METHODS Participants (n = 10) received the newly developed HPTMFs (average 595.23 ± 66.75 kcal/day of energy, 54.22 ± 6.32 g/day of protein) for 10 days. Relative hand-grip strength (RHS), mid-upper arm circumference (MUAC), body composition, mini nutritional assessment (MNA), mini dietary assessment (MDA), and Euro Quality-of-Life questionnaire 5-dimensional classification (EQ-5D) were assessed. RESULTS After 10 days, an increase in MUAC (26.36 ± 2.35 cm to 28.50 ± 3.17 cm, P = 0.013) and RHS (0.38 ± 0.24 kg/kg body weight to 0.42 ± 0.22 kg/kg body weight, P = 0.046) was observed. Although MNA, MDA, EQ-5D, subjective health status, muscle mass, and calf circumference showed a tendency to increase after intervention, no significant differences were found. CONCLUSIONS These results suggest that the HPTMFs can be used for improving the nutritional and health status in patients with dysphagia.
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Affiliation(s)
- Hyejin Han
- Department of Nutritional Science and Food Management, Ewha Womans University, Seoul 03760, Korea
- Graduate Program in System Health Science & Engineering, Ewha Womans University, Seoul 03760, Korea
| | - Yoonhee Park
- Department of Clinical Nutrition, The Graduate School of Clinical Biohealth, Ewha Womans University, Seoul 03760, Korea
| | - Hyeji Kwon
- Department of Nutritional Science and Food Management, Ewha Womans University, Seoul 03760, Korea
- Graduate Program in System Health Science & Engineering, Ewha Womans University, Seoul 03760, Korea
| | - Yeseung Jeong
- Department of Nutritional Science and Food Management, Ewha Womans University, Seoul 03760, Korea
| | - Soyoung Joo
- Department of Nutritional Science and Food Management, Ewha Womans University, Seoul 03760, Korea
| | - Mi Sook Cho
- Department of Nutritional Science and Food Management, Ewha Womans University, Seoul 03760, Korea
| | | | - Hee-Won Jung
- Division of Geriatrics, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul 05505, Korea
| | - Yuri Kim
- Department of Nutritional Science and Food Management, Ewha Womans University, Seoul 03760, Korea
- Graduate Program in System Health Science & Engineering, Ewha Womans University, Seoul 03760, Korea
- Department of Clinical Nutrition, The Graduate School of Clinical Biohealth, Ewha Womans University, Seoul 03760, Korea
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Leira J, Maseda A, Lorenzo-López L, Cibeira N, López-López R, Lodeiro L, Millán-Calenti JC. Dysphagia and its association with other health-related risk factors in institutionalized older people: A systematic review. Arch Gerontol Geriatr 2023; 110:104991. [PMID: 36906939 DOI: 10.1016/j.archger.2023.104991] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Revised: 02/21/2023] [Accepted: 03/05/2023] [Indexed: 03/09/2023]
Abstract
BACKGROUND Dysphagia is considered a geriatric syndrome that is characterized by inability to or difficulty in safely and effectively forming or moving the food bolus toward the esophagus. This pathology is very common and affects approximately 50% of institutionalized older people. Dysphagia is often accompanied by high nutritional, functional, social, and emotional risks. This relationship implies a higher rate of morbidity, disability, dependence, and mortality in this population. This review is aimed at studying the relationship between dysphagia and different health-related risk factors in institutionalized older people. METHOD We conducted a systematic review. The bibliographic search was performed in the Web of Science, Medline, and Scopus databases. Data extraction and methodological quality were evaluated by two independent researchers. RESULTS Twenty-nine studies met the inclusion and exclusion criteria. A clear relationship between the development and progression of dysphagia and a high nutritional, cognitive, functional, social, and emotional risk in institutionalized older adults was found. CONCLUSIONS There is an important relationship between these health conditions that shows the need for research and new approaches to considerations such as their prevention and treatment as well as the design of protocols and procedures that will help reduce the percentage of morbidity, disability, dependence, and mortality in older people.
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Affiliation(s)
- Julia Leira
- Gerontology and Geriatrics Research Group, Instituto de Investigación Biomédica de A Coruña (INIBIC), Universidade da Coruña, Complexo Hospitalario Universitario de A Coruña (CHUAC), SERGAS, 15071 A Coruña, Spain.
| | - Ana Maseda
- Gerontology and Geriatrics Research Group, Instituto de Investigación Biomédica de A Coruña (INIBIC), Universidade da Coruña, Complexo Hospitalario Universitario de A Coruña (CHUAC), SERGAS, 15071 A Coruña, Spain.
| | - Laura Lorenzo-López
- Gerontology and Geriatrics Research Group, Instituto de Investigación Biomédica de A Coruña (INIBIC), Universidade da Coruña, Complexo Hospitalario Universitario de A Coruña (CHUAC), SERGAS, 15071 A Coruña, Spain.
| | - Nuria Cibeira
- Gerontology and Geriatrics Research Group, Instituto de Investigación Biomédica de A Coruña (INIBIC), Universidade da Coruña, Complexo Hospitalario Universitario de A Coruña (CHUAC), SERGAS, 15071 A Coruña, Spain.
| | - Rocío López-López
- Gerontology and Geriatrics Research Group, Instituto de Investigación Biomédica de A Coruña (INIBIC), Universidade da Coruña, Complexo Hospitalario Universitario de A Coruña (CHUAC), SERGAS, 15071 A Coruña, Spain.
| | - Leire Lodeiro
- Gerontology and Geriatrics Research Group, Instituto de Investigación Biomédica de A Coruña (INIBIC), Universidade da Coruña, Complexo Hospitalario Universitario de A Coruña (CHUAC), SERGAS, 15071 A Coruña, Spain.
| | - José C Millán-Calenti
- Gerontology and Geriatrics Research Group, Instituto de Investigación Biomédica de A Coruña (INIBIC), Universidade da Coruña, Complexo Hospitalario Universitario de A Coruña (CHUAC), SERGAS, 15071 A Coruña, Spain.
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Rech RS, de Goulart BNG, Dos Santos KW, Marcolino MAZ, Hilgert JB. Frequency and associated factors for swallowing impairment in community-dwelling older persons: a systematic review and meta-analysis. Aging Clin Exp Res 2022; 34:2945-2961. [PMID: 36207669 DOI: 10.1007/s40520-022-02258-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Accepted: 09/13/2022] [Indexed: 11/27/2022]
Abstract
INTRODUCTION Swallowing impairment (SI) is an underdiagnosed dysfunction frequently seen as an expected condition of aging. However, SI can lead to health complications and considerable social impact. METHODS The objective of this systematic review with meta-analysis was to evaluate the frequency and associated factors with SI in community-dwelling older persons. Searches were performed in 13 electronic databases including MEDLINE and EMBASE (from inception to September 18, 2021). Data extraction and methodological quality assessment of included studies were performed by two independent reviewers. Meta-analysis of proportions with 95% confidence interval (CI) and prediction interval (PI) was used to pool estimates. Subgroup analysis by Country and Assessment Method was performed. General meta-analysis was used to pool measures of association between potential risk factors and SI occurrence (odds ratio [OR] or prevalence ratio [PR]). RESULTS The worldwide estimated frequency of SI in community-dwelling older persons was 20.35% (95%CI 16.61-24.68%, 95%PI 4.79-56.45, I2 99%, n = 33,291). This estimation varied across assessment methods and by country. The main factors associated with SI were a dry mouth (OR 8.1, 95%CI 4.9-13.4), oral diadochokinesis (OR 5.3, 95%CI 1.0-27.3), ≥ 80 years old (OR 4.9, 95%CI 2.6-9.2), genetic factor (SNPrs17601696) (OR 4.8, 95%CI 2.7-8.3), and partial dependence (OR 4.3, 95%CI 2.0-9.3). And the main factors associated with SI estimated by PR were dry mouth sensation (PR 4.1, 95%CI 2.6-6.5), oral sensorimotor alteration (PR 2.6, 95%CI 1.4-4.9), osteoporosis (PR 2.51, 95%CI 1.2-5.3), and heart diseases (PR 2.31, 95%CI 1.1-5.0). CONCLUSION One in five older adults worldwide are expected to experience SI and factors associated with this underdiagnosed dysfunction included biological and physiological changes related to aging, physical and psychological conditions, and poor oral health. Early assessment is paramount for the prevention of future clinical complications and should be a high priority in health care practices.
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Affiliation(s)
- Rafaela Soares Rech
- Graduate Studies Program in Epidemiology, Faculty of Medicine, Universidade Federal Do Rio Grande Do Sul, Porto Alegre, Brazil
| | | | - Karoline Weber Dos Santos
- Graduate Studies Program in Dentistry, Faculty of Dentistry, Universidade Federal Do Rio Grande Do Sul, Porto Alegre, Brazil
| | - Miriam Allein Zago Marcolino
- Graduate Studies Program in Epidemiology, Faculty of Medicine, Universidade Federal Do Rio Grande Do Sul, Porto Alegre, Brazil
| | - Juliana Balbinot Hilgert
- Graduate Studies Program in Epidemiology, Faculty of Medicine, Universidade Federal Do Rio Grande Do Sul, Porto Alegre, Brazil. .,Graduate Studies Program in Dentistry, Faculty of Dentistry, Universidade Federal Do Rio Grande Do Sul, Porto Alegre, Brazil. .,Department of Preventive and Social Dentistry, Faculty of Dentistry, Universidade Federal Do Rio Grande Do Sul, Brazil, Rio Grande do Sul, Porto Alegre, Santa Cecília, Ramiro Barcelos, 2492.
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Yang RY, Yang AY, Chen YC, Lee SD, Lee SH, Chen JW. Association between Dysphagia and Frailty in Older Adults: A Systematic Review and Meta-Analysis. Nutrients 2022; 14:nu14091812. [PMID: 35565784 PMCID: PMC9105461 DOI: 10.3390/nu14091812] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2022] [Revised: 04/23/2022] [Accepted: 04/24/2022] [Indexed: 12/23/2022] Open
Abstract
Background: Increasing bodies of epidemiological evidence indicate potential associations between dysphagia and the risk of frailty in older adults. We hypothesized that older adults with symptoms of dysphagia might have a higher prevalence of frailty or prefrailty than those without dysphagia. Methods: We systematically searched the PubMed, Embase, and Cochrane Library databases for relevant studies published through 20 April 2022. Cross-sectional and longitudinal studies that examined the associations between dysphagia and the existence of frailty or prefrailty in community-dwelling, facility-dwelling, or hospitalized adults aged 50 years or older were synthesized. The Newcastle–Ottawa Scale was used to evaluate study quality. Results: The meta-analysis comprised 12 cohorts, including 5,503,543 non-frailty participants and 735,303 cases of frailty or prefrailty. Random-effect meta-analysis demonstrated a significant association between dysphagia and the risk of frailty and prefrailty (OR, 3.24; 95% CI, 2.51–4.20). In addition, we observed consistent results across the subgroups and heterogeneity assessments. Conclusions: We propose including dysphagia assessment as a critical factor in the cumulative deficit model for identifying frailty in older adults. Understanding dysphagia and the potential role of nutritional supplements in older adults may lead to improved strategies for preventing, delaying, or mitigating frailty.
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Affiliation(s)
- Ru-Yung Yang
- Graduate Institute of Business Administration, Fu Jen Catholic University, New Taipei City 242062, Taiwan;
| | - An-Yun Yang
- Department of Otolaryngology-Head and Neck Surgery, Cardinal Tien Hospital and School of Medicine, Fu Jen Catholic University, New Taipei City 23148, Taiwan;
- Master Program of Big Data in Biomedicine, College of Medicine, Fu Jen Catholic University, New Taipei City 242062, Taiwan;
| | - Yong-Chen Chen
- Master Program of Big Data in Biomedicine, College of Medicine, Fu Jen Catholic University, New Taipei City 242062, Taiwan;
- School of Medicine, College of Medicine, Fu Jen Catholic University, New Taipei City 242062, Taiwan
| | - Shyh-Dye Lee
- Fu Jen Affiliated Clinics, Fu Jen Catholic University Hospital, New Taipei City 242062, Taiwan;
- Graduate Program of Long-Term (Custodial) Care, College of Medicine, Fu Jen Catholic University, New Taipei City 242062, Taiwan
| | - Shao-Huai Lee
- Department of Oral Hygiene and Healthcare, Cardinal Tien Junior College of Healthcare and Management, New Taipei City 23143, Taiwan;
| | - Jeng-Wen Chen
- Department of Otolaryngology-Head and Neck Surgery, Cardinal Tien Hospital and School of Medicine, Fu Jen Catholic University, New Taipei City 23148, Taiwan;
- Master Program of Big Data in Biomedicine, College of Medicine, Fu Jen Catholic University, New Taipei City 242062, Taiwan;
- Department of Medical Education and Research, Cardinal Tien Hospital, New Taipei City 23148, Taiwan
- Department of Otolaryngology-Head and Neck Surgery, National Taiwan University Hospital, Taipei 100225, Taiwan
- Correspondence:
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Shu K, Mao S, Coyle JL, Sejdic E. Improving Non-Invasive Aspiration Detection With Auxiliary Classifier Wasserstein Generative Adversarial Networks. IEEE J Biomed Health Inform 2022; 26:1263-1272. [PMID: 34415842 PMCID: PMC8942096 DOI: 10.1109/jbhi.2021.3106565] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Aspiration is a serious complication of swallowing disorders. Adequate detection of aspiration is essential in dysphagia management and treatment. High-resolution cervical auscultation has been increasingly considered as a promising noninvasive swallowing screening tool and has inspired automatic diagnosis with advanced algorithms. The performance of such algorithms relies heavily on the amount of training data. However, the practical collection of cervical auscultation signal is an expensive and time-consuming process because of the clinical settings and trained experts needed for acquisition and interpretations. Furthermore, the relatively infrequent incidence of severe airway invasion during swallowing studies constrains the performance of machine learning models. Here, we produced supplementary training exemplars for desired class by capturing the underlying distribution of original cervical auscultation signal features using auxiliary classifier Wasserstein generative adversarial networks. A 10-fold subject cross-validation was conducted on 2079 sets of 36-dimensional signal features collected from 189 patients undergoing swallowing examinations. The proposed data augmentation outperforms basic data sampling, cost-sensitive learning and other generative models with significant enhancement. This demonstrates the remarkable potential of proposed network in improving classification performance using cervical auscultation signals and paves the way of developing accurate noninvasive swallowing evaluation in dysphagia care.
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Zabat MA, Mottole NA, Patel H, Norris ZA, Ashayeri K, Sissman E, Balouch E, Maglaras C, Protopsaltis TS, Buckland AJ, Roberts T, Fischer CR. Incidence of dysphagia following posterior cervical spine surgery. J Clin Neurosci 2022; 99:44-48. [PMID: 35240474 DOI: 10.1016/j.jocn.2022.02.024] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Revised: 02/15/2022] [Accepted: 02/16/2022] [Indexed: 11/24/2022]
Abstract
Abundant literature exists describing the incidence of dysphagia following anterior cervical surgery; however, there is a paucity of literature detailing the incidence of dysphagia following posterior cervical procedures. Further characterization of this complication is important for guiding clinical prevention and management. Patients ≥ 18 years of age underwent posterior cervical fusion with laminectomy or laminoplasty between C1-T1. Pre- and post-operative dysphagia was assessed by a speech language pathologist. The patient cohort was categorized by approach: Laminectomy + Fusion (LF) and Laminoplasty (LP). Patients were excluded from radiographic analyses if they did not have both baseline and follow-up imaging. The study included 147 LF and 47 LP cases. There were no differences in baseline demographics. There were three patients with new-onset dysphagia in the LF group (1.5% incidence) and no new cases in the LP group (p = 1.000). LF patients had significantly higher rates of post-op complications (27.9% LF vs. 8.5% LP, p = 0.005) but not intra-op complications (6.1% LF vs. 2.1% LP, p = 0.456). Radiographic analysis of the entire cohort showed no significant changes in cervical lordosis, cSVA, or T1 slope. Both group comparisons showed no differences in incidence of dysphagia pre and post operatively. Based on this study, the likelihood of developing dysphagia after LF or LP are similarly low with a new onset dysphagia rate of 1.5%.
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Affiliation(s)
- Michelle A Zabat
- Department of Orthopaedic Surgery, NYU Langone Health, New York, NY, USA
| | - Nicole A Mottole
- Department of Orthopaedic Surgery, NYU Langone Health, New York, NY, USA
| | - Hershil Patel
- Department of Orthopaedic Surgery, NYU Langone Health, New York, NY, USA
| | - Zoe A Norris
- Department of Orthopaedic Surgery, NYU Langone Health, New York, NY, USA
| | - Kimberly Ashayeri
- Department of Orthopaedic Surgery, NYU Langone Health, New York, NY, USA
| | - Ethan Sissman
- Department of Orthopaedic Surgery, NYU Langone Health, New York, NY, USA
| | - Eaman Balouch
- Department of Orthopaedic Surgery, NYU Langone Health, New York, NY, USA
| | - Constance Maglaras
- Department of Orthopaedic Surgery, NYU Langone Health, New York, NY, USA
| | | | - Aaron J Buckland
- Department of Orthopaedic Surgery, NYU Langone Health, New York, NY, USA
| | - Timothy Roberts
- Department of Orthopaedic Surgery, NYU Langone Health, New York, NY, USA
| | - Charla R Fischer
- Department of Orthopaedic Surgery, NYU Langone Health, New York, NY, USA.
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Ebihara S, Naito T. A Systematic Review of Reported Methods of Stimulating Swallowing Function and their Classification. TOHOKU J EXP MED 2022; 256:1-17. [DOI: 10.1620/tjem.256.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- Satoru Ebihara
- Department of Rehabilitation Medicine, Toho University Graduate School of Medicine
| | - Toru Naito
- Section of Geriatric Dentistry, Department of General Dentistry, Fukuoka Dental College
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Veronese N, Ferrari G, Barbagallo M. Nutritional Issues of Older People in Primary Care. PRACTICAL ISSUES IN GERIATRICS 2022:59-69. [DOI: 10.1007/978-3-030-78923-7_4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/02/2023]
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12
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Hawkins D, Cabrera CI, Kominsky R, Nahra A, Howard NS, Maronian N. Dysphagia Evaluation: The Added Value of Concurrent MBS and Esophagram. Laryngoscope 2021; 131:2666-2670. [PMID: 33502017 DOI: 10.1002/lary.29377] [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: 05/14/2020] [Revised: 11/25/2020] [Accepted: 12/17/2020] [Indexed: 11/10/2022]
Abstract
OBJECTIVES/HYPOTHESIS Dysphagia is associated with increased mortality and healthcare costs. The modified barium swallow study (MBS) is the gold standard in assessing oropharyngeal dysphagia, but does not evaluate the esophagus. A barium esophagram can visualize the esophagus but does not evaluate the oropharyngeal swallow, nor does it utilize the expertise of speech and language pathologists. Providers may order one or both studies yet still risk missing critical pathology. STUDY DESIGN Retrospective cohort study. METHODS A retrospective chart review was conducted at an academic medical center between January 2016 and June 2019 focused on patients who had both MBS and esophagram as imaging for dysphagia evaluation. Analysis determined whether MBS and esophagram performed concomitantly improved diagnostic clarity. RESULTS A total of 5,183 patients underwent 6,066 swallow studies for dysphagia in the study period. Of which, 124 of these patients had concurrent MBS and esophagram. 10.5% of concurrent studies demonstrated a congruent negative evaluation. 59.7% of patients had an unremarkable MBS or esophagram paired with abnormal findings within the corresponding esophagram or MBS, respectively. 29.8% had both MBS and esophagrams that demonstrated an abnormality, but with unique pathologies identified by each study. In total, 85.1% of unremarkable MBS or esophagrams were paired with abnormal findings in the corresponding esophagram or MBS, respectively. CONCLUSION Selection of diagnostic testing is variable among providers and may be influenced by healthcare systems. This analysis revealed that MBS and esophagrams provide unique diagnoses. Concurrent MBS and esophagrams may improve diagnostic accuracy, yet minimize additional studies. National practices around dysphagia diagnostics are inconsistent and would benefit from standardization. LEVEL OF EVIDENCE 4 Laryngoscope, 2021.
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Affiliation(s)
- Daniel Hawkins
- Department of Otolaryngology - Head and Neck Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Claudia I Cabrera
- Department of Otolaryngology - Head and Neck Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Rachel Kominsky
- Department of Otolaryngology - Head and Neck Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Alexis Nahra
- Department of Speech-Language Pathology, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - N Scott Howard
- Department of Otolaryngology - Head and Neck Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Nicole Maronian
- Department of Otolaryngology - Head and Neck Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
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Groher ME. Dysphagia Unplugged. Dysphagia 2021. [DOI: 10.1016/b978-0-323-63648-3.00001-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Swallowing impairment in older adults: association with sensorimotor peripheral nerve function from the Health, Aging and Body Composition study. Aging Clin Exp Res 2021; 33:165-173. [PMID: 32277432 DOI: 10.1007/s40520-020-01522-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Accepted: 02/21/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND The purpose of this study was to examine whether impairments in sensorimotor peripheral nerve function are associated with a higher likelihood of swallowing impairment in older adults. METHODS Health, Aging and Body Composition participants (n = 607, age = 75.8 ± 2.7 years, 55.8% women, 32.3% black) underwent peripheral nerve testing at Year 4 and 11 with swallowing difficulty assessed at Year 4 and 15. Nerve conduction amplitude and velocity were measured at the peroneal motor nerve. Sensory nerve function was assessed with the vibration detection threshold and monofilament (1.4-g/10-g) testing at the big toe. Symptoms of lower extremity peripheral neuropathy and difficulty swallowing were collected by self-report. Data analysis was performed using a hierarchical approach. Odds ratios (ORs) were estimated using non-conditional logistic regression. RESULTS At Year 15 108 (17.8%) participants had swallowing impairments. In fully adjusted models, the peripheral nerve impairments associated with swallowing impairment were numbness (OR 4.67; 95%CI 2.24-9.75) and poor motor nerve conduction velocity (OR 2.26; 95%CI 1.08-4.70). Other peripheral nerve impairments were not related to swallowing. CONCLUSIONS The association between slow motor nerve conduction velocity and numbness and a higher likelihood of swallowing difficulties a decade later in our prospective study identifies an important area for further investigation in older adults.
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Hanaie K, Yamamoto A, Umehara K, Bessho Y, Nakamoto H, Nakayama K, Sawada K, Osawa S, Ogasawara T, Tsuneishi S, Wakasugi Y, Ishikawa A. Measurement of laryngeal elevation time using a flexible surface stretch sensor. J Oral Rehabil 2020; 47:1489-1495. [DOI: 10.1111/joor.13082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Revised: 08/08/2020] [Accepted: 08/11/2020] [Indexed: 11/27/2022]
Affiliation(s)
- Kaoru Hanaie
- Kobe University Graduate School of Health Science Kobe Japan
- Senior Citizens' Policy Promotion Division Senior Citizens' Welfare Department Sakai City Government, Health and Welfare Bureau Sakai Japan
| | - Akio Yamamoto
- Kobe University Graduate School of Health Science Kobe Japan
- Faculty of Nursing Osaka Medical College Takatsuki Japan
| | - Ken Umehara
- Kobe University Graduate School of Health Science Kobe Japan
- Rehabilitation in Mie Central Medical Center Tsu Japan
| | | | | | - Kimiko Nakayama
- Kobe University Graduate School of Health Science Kobe Japan
| | | | | | | | | | - Yoko Wakasugi
- Gerodontology and Oral Rehabilitation Graduate School of Medical and Dental Sciences Tokyo Medical and Dental University Bunkyo Japan
| | - Akira Ishikawa
- Kobe University Graduate School of Health Science Kobe Japan
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Sag E, Bahadir A, Imamoglu M, Sag S, Reis GP, Erduran E, Cakir M. Acquired noncaustic esophageal strictures in children. Clin Exp Pediatr 2020; 63:447-450. [PMID: 33137248 PMCID: PMC7642133 DOI: 10.3345/cep.2020.00199] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Accepted: 05/20/2020] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Esophageal stricture (ES) is an uncommon clinic entity in pediatrics that may be congenital or acquired in childhood. Acquired noncaustic ES is very rare, and clinical features of affected patients are unknown. PURPOSE We aimed to evaluate the clinical findings, and outcomes of patients with acquired noncaustic ES to aid physicians in the early referral of patients to gastroenterologists. METHODS The medical data of patients with acquired noncaustic ES who were followed in our gastroenterology clinic between January 2009 and December 2019 were reviewed. RESULTS Acquired noncaustic ES was found in 12 of the 4,950 patients (0.24%) who underwent endoscopy during the study period. The main symptoms were dysphagia (58.3%), vomiting (33.3%), and chronic anemia (8.3%). Chronic malnutrition and underweight were found in 66.6% of the patients. The most common etiological factors were radiotherapy, peptic reflux, and achalasia (16.6%, each), while chemotherapy, squamous-cell carcinoma (SC) of the esophagus, eosinophilic esophagitis (EoE), esophageal web, epidermolysis bullosa, and esophageal diverticulum (8.2%, each) were the other etiological factors. Patients with EoE underwent endoscopic bougie dilation in addition to steroid use and elimination diet. Patients with epidermolysis bullosa and esophageal web underwent bougie dilation. Patients with peptic reflux-related ES were initially put on antireflux therapy, but during follow-up, one patient required esophageal replacement with colonic interposition. Patients with radiotherapy-related ES recovered with medical therapy. The patient with initially underwent surgical gastrostomy and tumoral mass excision. The patient then received chemotherapy and radiotherapy and underwent jejunal interposition. Patients with achalasia underwent surgical esophagomyotomy. CONCLUSION The presence of solid dysphagia, malnutrition, and an associated disease may alert physicians to the presence of ES.
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Affiliation(s)
- Elif Sag
- Department of Pediatric Gastroenterology Hepatology and Nutrition, Faculty of Medicine, Karadeniz Technical University, Trabzon, Turkey
| | - Aysenur Bahadir
- Department of Pediatric Hematology and Oncology, Faculty of Medicine, Karadeniz Technical University, Trabzon, Turkey
| | - Mustafa Imamoglu
- Department of Pediatric Surgery, Faculty of Medicine, Karadeniz Technical University, Trabzon, Turkey
| | - Sefa Sag
- Department of Pediatric Surgery, Kanuni Education and Research Hospital, Trabzon, Turkey
| | - Gokce Pinar Reis
- Department of Pediatric Hematology and Oncology, Faculty of Medicine, Karadeniz Technical University, Trabzon, Turkey
| | - Erol Erduran
- Department of Pediatric Hematology and Oncology, Faculty of Medicine, Karadeniz Technical University, Trabzon, Turkey
| | - Murat Cakir
- Department of Pediatric Gastroenterology Hepatology and Nutrition, Faculty of Medicine, Karadeniz Technical University, Trabzon, Turkey
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Hayashi T, Fujiwara Y, Ariji Y, Sakai H, Kubota K, Kawano O, Masuda M, Morishita Y, Maeda T. Mechanism of Dysphagia after Acute Traumatic Cervical Spinal Cord Injury. J Neurotrauma 2020; 37:2315-2319. [PMID: 32486896 DOI: 10.1089/neu.2020.6983] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Swallowing dysfunction, which may cause aspiration pneumonia, is one of the most important complications of treatment of traumatic cervical spinal cord injury (CSCI); however, the mechanism of dysphagia is not well understood. No previous studies have reported the association between morphological changes of the soft tissue and dysphagia. We aimed to determine the factors associated with severity of dysphagia after CSCI and elucidate its mechanism. We conducted a prospective analysis of patients with acute traumatic CSCI who were admitted within 2 weeks of the injury. Dysphagia was evaluated using the Dysphagia Severity Scale (DSS) 2 weeks after the injury. The widths of the retropharyngeal and retrotracheal spaces were measured to assess soft tissue damage owing to the injury using sagittal images of computed tomography. We also assessed age, surgery of the injured cervical spine, presence of tracheostomy, osteophyte behind the pharynx, level of injury, and motor score 2 weeks after the injury. A total of 136 persons met our criteria. Given that 44 persons were categorized under grades <5 of the DSS, which were defined as different types of aspirations, the incidence of aspiration was 32%. The multiple regression analysis revealed that age, motor score, tracheostomy, and retropharyngeal space were significantly associated with DSS. Severe paresis, tracheostomy, old age, and swelling of the retropharyngeal space were significantly affected by dysphagia after CSCI. Morphological changes in the pharynx, situated right behind the larynx, after the injury affects the mechanism of dysphagia.
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Affiliation(s)
- Tetsuo Hayashi
- Department of Rehabilitation Medicine, Japan Organization of Occupational Health and Safety, Spinal Injuries Center, Iizuka City, Fukuoka Prefecture, Japan.,Department of Orthopaedic Surgery, Japan Organization of Occupational Health and Safety, Spinal Injuries Center, Iizuka City, Fukuoka Prefecture, Japan
| | - Yuichi Fujiwara
- Nursing Department, Japan Organization of Occupational Health and Safety, Spinal Injuries Center, Iizuka City, Fukuoka Prefecture, Japan
| | - Yuto Ariji
- Department of Rehabilitation Medicine, Japan Organization of Occupational Health and Safety, Spinal Injuries Center, Iizuka City, Fukuoka Prefecture, Japan
| | - Hiroaki Sakai
- Department of Orthopaedic Surgery, Japan Organization of Occupational Health and Safety, Spinal Injuries Center, Iizuka City, Fukuoka Prefecture, Japan
| | - Kensuke Kubota
- Department of Rehabilitation Medicine, Japan Organization of Occupational Health and Safety, Spinal Injuries Center, Iizuka City, Fukuoka Prefecture, Japan.,Department of Orthopaedic Surgery, Japan Organization of Occupational Health and Safety, Spinal Injuries Center, Iizuka City, Fukuoka Prefecture, Japan
| | - Osamu Kawano
- Department of Orthopaedic Surgery, Japan Organization of Occupational Health and Safety, Spinal Injuries Center, Iizuka City, Fukuoka Prefecture, Japan
| | - Muneaki Masuda
- Department of Orthopaedic Surgery, Japan Organization of Occupational Health and Safety, Spinal Injuries Center, Iizuka City, Fukuoka Prefecture, Japan
| | - Yuichiro Morishita
- Department of Orthopaedic Surgery, Japan Organization of Occupational Health and Safety, Spinal Injuries Center, Iizuka City, Fukuoka Prefecture, Japan
| | - Takeshi Maeda
- Department of Orthopaedic Surgery, Japan Organization of Occupational Health and Safety, Spinal Injuries Center, Iizuka City, Fukuoka Prefecture, Japan
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Kunen L, Fontes L, Moraes-Filho J, Assirati F, Navarro-Rodriguez T. Esophageal motility patterns are altered in older adult patients. REVISTA DE GASTROENTEROLOGÍA DE MÉXICO (ENGLISH EDITION) 2020. [DOI: 10.1016/j.rgmxen.2019.07.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
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19
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Kunen LCB, Fontes LHS, Moraes-Filho JP, Assirati FS, Navarro-Rodriguez T. Esophageal motility patterns are altered in older adult patients. REVISTA DE GASTROENTEROLOGIA DE MEXICO (ENGLISH) 2020; 85:264-274. [PMID: 31902552 DOI: 10.1016/j.rgmx.2019.07.005] [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: 02/10/2019] [Revised: 07/06/2019] [Accepted: 07/26/2019] [Indexed: 06/10/2023]
Abstract
INTRODUCTION AND AIMS Since the 1960s, several studies have shown the effect of aging on esophageal motility, with inconsistent results. The aim of the present study was to evaluate the manometric results in older adult patients (=60 years of age) with an esophageal disorder and compare them with adults under 60 years of age. MATERIALS AND METHODS A cross-sectional, retrospective study was conducted that included a sample of 1,175 patients (936 older adults and 239 non-older adults). The patients were evaluated and compared with respect to (i) sex, (ii) main complaint for which esophageal manometry was indicated, (iii) comorbidities, (iv) current medications, (v) smoking, and (vi) manometry results. RESULTS Patient age ranged from 19 to 92 years (women made up 76.5% of the older adults and 72.8% of the non-older adults). Normal lower esophageal sphincter relaxation and normal peristalsis were more frequent in the non-older patient group (91.1% vs. 84.8% and 87.4% vs. 76%, respectively). The manometry results for the non-older adults vs. the older adults, respectively, were: achalasia (2.9% vs. 5.9%); hypercontractile disorder (9.2% vs. 10.4%); hypocontractile disorder (38.5% vs. 47.6%); and normal values (49.4% vs. 36.1%). After excluding the variables that could change esophageal motility, the results revealed significant differences between the two study groups. CONCLUSIONS Esophageal manometry demonstrated statistically significant differences between the older adult and non-older adult study population evaluated.
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Affiliation(s)
- L C B Kunen
- Departamento de Gastroenterología, Escuela de Medicina de la Universidad de Sao Paulo, São Paulo, Brasil; Hospital Estatal de Servidores Públicos, São Paulo, Brasil
| | - L H S Fontes
- Departamento de Gastroenterología, Escuela de Medicina de la Universidad de Sao Paulo, São Paulo, Brasil; Hospital Estatal de Servidores Públicos, São Paulo, Brasil
| | - J P Moraes-Filho
- Departamento de Gastroenterología, Escuela de Medicina de la Universidad de Sao Paulo, São Paulo, Brasil
| | - F S Assirati
- Departamento de Gastroenterología, Escuela de Medicina de la Universidad de Sao Paulo, São Paulo, Brasil; Hospital Estatal de Servidores Públicos, São Paulo, Brasil
| | - T Navarro-Rodriguez
- Departamento de Gastroenterología, Escuela de Medicina de la Universidad de Sao Paulo, São Paulo, Brasil.
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Aging and nutrition. Paving the way to better health. ROMANIAN JOURNAL OF INTERNAL MEDICINE 2020; 58:55-68. [PMID: 32134741 DOI: 10.2478/rjim-2020-0005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Indexed: 01/04/2023] Open
Abstract
Sufficient caloric intake is important to maintain the balanced health status, especially during the period of aging, as aging and sickness share paths. Maintaining adequate nutritional balance is the best preventive measure to counteract the risk of malnutrition. There are several causes for malnutrition in elderly people, and some techniques such as anthropometric measurements, laboratory and clinical parameters could help to diagnose malnutrition in these patients. The use of a simple validated questionnaire called the 'Mini Nutritional Assessment' measures the nutritional status of elderly patients. In this review, we discuss about the malnutrition in elderly people with and without a known cause and we present some of nutritional intervention. There are promising strategies that help overcoming malnutrition.
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Howell RJ, Edelmayer LW, Postma GN. The Utility of Flexible Esophagoscopy During Open Hypopharyngeal (Zenker's) Diverticulum Surgery. Laryngoscope 2019; 130:E764-E766. [PMID: 31854455 DOI: 10.1002/lary.28485] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2019] [Revised: 10/18/2019] [Accepted: 11/28/2019] [Indexed: 11/11/2022]
Affiliation(s)
- Rebecca J Howell
- Department of Otolaryngology-Head & Neck Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio, U.S.A
| | - Luke W Edelmayer
- Department of Otolaryngology-Head & Neck Surgery, Medical College of Georgia at Augusta University, Augusta, GA, U.S.A
| | - Gregory N Postma
- Department of Otolaryngology-Head & Neck Surgery, Medical College of Georgia at Augusta University, Augusta, GA, U.S.A
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García-Hernández C, Carvajal-Figueroa L, Archivaldo-García C, Pique-Aragon C, Landa-Juarez S. Laparoscopic Approach of the Obstruction of the Lower Third of the Esophagus in Children. J Laparoendosc Adv Surg Tech A 2019; 30:201-205. [PMID: 31721630 DOI: 10.1089/lap.2019.0371] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Objective: To review the diagnostic methodology in pediatric patients with obstruction of the lower third of the esophagus as well as minimally invasive therapeutic options. Materials and Methods: Retrospective study carried out reviewing records of children with esophageal obstruction diagnostic, from 2000 to 2018. They were divided into Group I stenosis secondary to reflux; Group II achalasia; and Group III embryonic remnants. Results: Thirty-three patients. Group I: 7; esophageal barium swallow irregular stenosis of the distal third and endoscopy irregular stenosis in 7. Treated with laparoscopic fundoplication 2, Collis Nissen 5. Group II: 22 patients, age X = 11.55 years. All with dysphagia and symmetrical stenosis of esophagogastric junction. Fifteen underwent manometry and all underwent intraoperative endoscopy. All had laparoscopic myotomy, with 2 perforations and no conversions, 2 patients had subsequent dysphagia to solids, and they did not need esophageal dilatation. Group III: 4 patients, stenosis was above esophagogastric junction. On endoscopy, inflammation was present in all 3 with irregular esophagogastric junction and difficulty passing endoscope. Three patients underwent laparoscopic resection and anastomosis. One patient leaked and developed a fistula. One patient has not been operated upon as yet. Conclusions: In those patients, the best surgical option depends upon the diagnosis. Esophageal barium studies and endoscopy allow discerning among them.
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Affiliation(s)
- Carlos García-Hernández
- Departamento de Cirugía Pediátrica, Hospital Infantil Privado, Curso de Alta Especialidad Postgrado Universidad Nacional Autónoma de México, Ciudad de México, México
| | - Lourdes Carvajal-Figueroa
- Departamento de Cirugía Pediátrica, Hospital Infantil Privado, Curso de Alta Especialidad Postgrado Universidad Nacional Autónoma de México, Ciudad de México, México
| | - Cristian Archivaldo-García
- Departamento de Cirugía Pediátrica, Hospital Infantil Privado, Curso de Alta Especialidad Postgrado Universidad Nacional Autónoma de México, Ciudad de México, México
| | - Carlos Pique-Aragon
- Departamento de Cirugía Pediátrica, Hospital Infantil Privado, Curso de Alta Especialidad Postgrado Universidad Nacional Autónoma de México, Ciudad de México, México
| | - Sergio Landa-Juarez
- Departamento de Cirugía Pediátrica, Hospital Infantil Privado, Curso de Alta Especialidad Postgrado Universidad Nacional Autónoma de México, Ciudad de México, México
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24
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[Dysphagia in cervical spine diseases]. HNO 2019; 67:801-814. [PMID: 31485696 DOI: 10.1007/s00106-019-00738-7] [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: 10/26/2022]
Abstract
Dysphagia is a common symptom and can be indicative of a variety of heterogeneous diseases. "Classical" diseases of the head and neck region, such as acute tonsillitis, peritonsillar abscesses, diverticula, and benign or malignant tumors are common causes of dysphagia. However, it can also occur in the context of neurological diseases, e.g., as a result of stroke or as an age-related phenomenon (presbyphagia). Pathologies of the cervical spine can also be a cause of dysphagia. In this context, congenital or acquired diseases, inflammatory or degenerative processes, cervical spine surgery, and (malignant) masses of the cervical spine should be taken into account. Particular dysphagia with a positive history of previous operative interventions on the cervical spine or symptoms such as chronic back pain and trauma should give rise to consideration of a cervical spine-related cause.
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Butler AJ, Ghasem A, Al Maaieh M. Dysphagia following lumbar spine surgery in the setting of undiagnosed DISH of the cervical spine: a case report. AME Case Rep 2019; 3:13. [PMID: 31231714 DOI: 10.21037/acr.2019.05.03] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2018] [Accepted: 02/28/2019] [Indexed: 11/06/2022]
Abstract
Dysphagia is an often multifactorial pathology affecting many elderly patients. In addition to global neuromuscular change with normal aging, one component of its etiology may be direct compression of the pharynx or esophagus from overgrown bone from the anterior cervical spine. Diffuse idiopathic skeletal hyperostosis (DISH) is one condition that may contribute to this phenomenon. Of relatively high incidence (2.5% to 33.3%) in elderly populations, DISH has been described in the cervical spine though more frequently affects other spinal regions. The clinical case of an elderly man who developed significant dysphagia after undergoing lumbar spine surgery for spinal stenosis caused by DISH is presented. Awareness of the involvement in his cervical spine before surgery would likely have enabled a more prompt diagnosis of the etiology of dysphagia and allowed for peri-operative optimization of swallowing function to reduce morbidity. We recommend routine preoperative imaging of the cervical spine in all patients with a diagnosis of DISH to stratify risk for development of postoperative dysphagia.
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Affiliation(s)
- Alexander J Butler
- Department of Orthopaedic Surgery, University of Miami Hospital, Miami, FL, USA
| | - Alexander Ghasem
- Department of Orthopaedic Surgery, University of Miami Hospital, Miami, FL, USA
| | - Motasem Al Maaieh
- Department of Orthopaedic Surgery, University of Miami Hospital, Miami, FL, USA
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Risk factors for dysphagia after a spinal cord injury: a systematic review and meta-analysis. Spinal Cord 2018; 56:1116-1123. [PMID: 29955090 DOI: 10.1038/s41393-018-0170-3] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2017] [Revised: 06/07/2018] [Accepted: 06/07/2018] [Indexed: 12/23/2022]
Abstract
STUDY DESIGN Systematic review and meta-analysis. OBJECTIVE To determine the risk factors predictive of dysphagia after a spinal cord injury (SCI). SETTING None. METHODS A comprehensive literature search was performed in five scientific databases for English articles that identified risk factors for dysphagia after a SCI in adult (≥19 years) individuals. Data extracted included: author name, year and country of publication, participant demographics, sample size, study design, method of dysphagia diagnosis, and risk factor percentages. Methodological quality of studies was assessed using the Newcastle-Ottawa Scale. For identified risk factors, risk percentages were transformed into risk ratios (RR) with 95% confidence intervals. Quantitative synthesis was performed for risk factors reported in two or more studies using restricted maximum-likelihood estimator random effects models. RESULTS Eleven studies met inclusion criteria of which ten studies were of moderate quality (n = 10). Significant risk factors included: age, injury severity, level of injury, presence of tracheostomy, coughing, voice quality, bronchoscopy need, pneumonia, mechanical ventilation, nasogastric tubes, comorbid injury, and a cervical surgery. Results of the quantitative synthesis indicated that the presence of a tracheostomy posed a threefold greater risk of the development of dysphagia (RR: 3.67); while, cervical surgery posed a 1.3 times greater risk of the development of dysphagia (RR: 1.30). CONCLUSIONS Knowledge of these risk factors can be a resource for clinicians in the early diagnosis and appropriate medical management of dysphagia post SCI.
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Oh BM, Lee JH, Seo HG, Lee WH, Han TR, Jeong SU, Jeong HJ, Sim YJ. Changes in Hyolaryngeal Movement During Swallowing in the Lateral Decubitus Posture. Ann Rehabil Med 2018; 42:416-424. [PMID: 29961739 PMCID: PMC6058586 DOI: 10.5535/arm.2018.42.3.416] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2017] [Accepted: 09/15/2017] [Indexed: 12/23/2022] Open
Abstract
Objective To investigate the differences in hyolaryngeal kinematics at rest and during swallowing in the upright sitting (UP) and the lateral decubitus (LD) postures in healthy adults, and delineating any potential advantages of swallowing while in the LD posture. Methods Swallowing was videofluoroscopically evaluated in 20 healthy volunteers in UP and LD postures, based on the movements of hyoid bone, vocal folds, and the bolus head. Parameters included the Penetration-Aspiration Scale (PAS), horizontal and vertical displacement, horizontal and vertical initial position, horizontal and vertical peak position, time to peak position of the hyoid bone and vocal folds, and pharyngeal transit time (PTT). Results Nine participants were rated PAS 2 in the UP and 1 was rated PAS 2 in the LD (p=0.003) at least 1 out of 3 swallows each posture. The hyoid and vocal folds showed more anterior and superior peak and initial positions in the LD. In addition, swallowing resulted in greater vertical and smaller horizontal displacement of the hyoid in LD posture compared with UP. Time to peak position of the hyoid was shorter in LD. The maximal vertical and horizontal displacement of the vocal folds, and PTT were comparable between postures. Conclusion The results showed that the peak and initial positions of the hyoid and larynx and the pattern of hyoid movement varied significantly depending on the body postures. This study suggests that the LD posture was one of the safe feeding postures without any increased risk compared with UP posture.
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Affiliation(s)
- Byung-Mo Oh
- Department of Rehabilitation Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Jae Hyun Lee
- Department of Physical Medicine and Rehabilitation, Kosin University College of Medicine, Busan, Korea
| | - Han Gil Seo
- Department of Rehabilitation Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Woo Hyung Lee
- Department of Rehabilitation Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea.,Department of Biomedical Engineering, Seoul National University College of Medicine, Seoul, Korea
| | - Tai Ryoon Han
- Department of Rehabilitation Medicine, Gangwon-Do Rehabilitation Hospital, Chuncheon, Korea
| | - Seoung Uk Jeong
- Department of Physical Medicine and Rehabilitation, Kosin University College of Medicine, Busan, Korea
| | - Ho Joong Jeong
- Department of Physical Medicine and Rehabilitation, Kosin University College of Medicine, Busan, Korea
| | - Young-Joo Sim
- Department of Physical Medicine and Rehabilitation, Kosin University College of Medicine, Busan, Korea
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Psychogios G, Jering M, Zenk J. Cervical Hyperostosis Leading to Dyspnea, Aspiration and Dysphagia: Strategies to Improve Patient Management. Front Surg 2018; 5:33. [PMID: 29740589 PMCID: PMC5928235 DOI: 10.3389/fsurg.2018.00033] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2017] [Accepted: 04/09/2018] [Indexed: 12/21/2022] Open
Abstract
Diffuse idiopathic skeletal hyperostosis (DISH) is a rare but well known cause of dysphagia. In very few cases aspiration and dyspnea are described as a clinical manifestation. An 82-year-old man presented himself in our clinic with severe dyspnea, aspiration, and pneumonia. After performing a microlaryngoscopy an emergency tracheotomy became necessary. In laryngoscopy a severe bulging of the posterior oropharyngeal and hypopharyngeal wall was detected. The glottis area was not observable and immobilisation of the right vocal cord could be detected. The CT showed anterior osteophytes and ossification of the anterior longitudinal ligament from C2-C7. We performed a panendoscopy in order to explore the upper aerodigestive area. Postoperatively an emergency tracheotomy was needed due to the development of laryngeal edema. The osteophytes were removed in cooperation with the department of orthopaedics. Three months postoperative the patient had no dyspnea or dysphagia, so the tracheotomy could be closed. Cervical hyperostosis is commonly described in elderly patients and usually presenting without symptoms, therefore a surgical treatment is usually not necessary. Nevertheless it can lead to severe morbidity and dyspnea with airway obstruction. Therefore it is essential that cervical hyperostosis is recognized early enough and appropriate treatment is initiated. Flexible endoscopy should be preferred over direct panendoscopy because it could lead to life-threatening edema and a prophylactic tracheostomy should be strongly considered in patients that present with severe dyspnea.
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Affiliation(s)
- Georgios Psychogios
- Department of Otorhinolaryngology, Head and Neck Surgery, Klinikum Augsburg, Augsburg, Germany
| | - Monika Jering
- Department of Otorhinolaryngology, Head and Neck Surgery, Klinikum Augsburg, Augsburg, Germany
| | - Johannes Zenk
- Department of Otorhinolaryngology, Head and Neck Surgery, Klinikum Augsburg, Augsburg, Germany
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Mazzola P, Carissimi F, Floris P, Pittella F, Galeazzi M, Moretti D, Bellelli G, Dinelli M, Annoni G. Megaesophagus in an elderly man with achalasia: a "not so benign" condition. Aging Clin Exp Res 2017; 29:809-814. [PMID: 27714664 DOI: 10.1007/s40520-016-0633-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2016] [Accepted: 09/16/2016] [Indexed: 11/28/2022]
Affiliation(s)
- Paolo Mazzola
- Acute Geriatrics Unit, School of Medicine and Surgery, University of Milano-Bicocca, Via Pergolesi, 33, 20900, Monza, MB, Italy.
- Clinical Neurosciences Research Area, NeuroMI - Milan Center for Neuroscience, 20126, Milan, MI, Italy.
| | | | - Patrizia Floris
- Acute Geriatrics Unit, School of Medicine and Surgery, University of Milano-Bicocca, Via Pergolesi, 33, 20900, Monza, MB, Italy
| | - Francesca Pittella
- Acute Geriatrics Unit, School of Medicine and Surgery, University of Milano-Bicocca, Via Pergolesi, 33, 20900, Monza, MB, Italy
| | - Marianna Galeazzi
- Acute Geriatrics Unit, School of Medicine and Surgery, University of Milano-Bicocca, Via Pergolesi, 33, 20900, Monza, MB, Italy
| | - Daniela Moretti
- Acute Geriatrics Unit, San Gerardo Hospital ASST Monza, Monza, Italy
| | - Giuseppe Bellelli
- Acute Geriatrics Unit, School of Medicine and Surgery, University of Milano-Bicocca, Via Pergolesi, 33, 20900, Monza, MB, Italy
- Clinical Neurosciences Research Area, NeuroMI - Milan Center for Neuroscience, 20126, Milan, MI, Italy
- Acute Geriatrics Unit, San Gerardo Hospital ASST Monza, Monza, Italy
| | - Marco Dinelli
- Endoscopy Unit, San Gerardo Hospital ASST Monza, Monza, Italy
| | - Giorgio Annoni
- Acute Geriatrics Unit, School of Medicine and Surgery, University of Milano-Bicocca, Via Pergolesi, 33, 20900, Monza, MB, Italy
- Clinical Neurosciences Research Area, NeuroMI - Milan Center for Neuroscience, 20126, Milan, MI, Italy
- Acute Geriatrics Unit, San Gerardo Hospital ASST Monza, Monza, Italy
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Madalozzo B, Aoki MCDS, Soria F, Santos RS, Furkim AM. Análise acústica do tempo de deglutição através do Sonar Doppler. REVISTA CEFAC 2017. [DOI: 10.1590/1982-0216201719312316] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
RESUMO Objetivo: comparar o parâmetro acústico de tempo da deglutição orofaríngea nos adultos e idosos, nas diferentes consistências e volumes, através do Sonar Doppler. Métodos: a pesquisa foi realizada em duas etapas. Na primeira foi aplicado o Protocolo de Triagem de Risco para Deglutição. Na segunda os indivíduos foram submetidos à avaliação da deglutição com o Sonar Doppler. Os indivíduos receberam as seguintes consistências alimentares durante a avaliação - deglutição seca (saliva), líquida, néctar, mel e pudim, nos volumes de 5 ml, 10 ml e deglutição livre. O parâmetro acústico analisado neste estudo foi o Tempo acústico da deglutição (T). Resultados: dados objetivos e mensuráveis foram obtidos; a diferença do tempo de deglutição entre adultos e idosos em relação à consistência e o volume foi, na maioria, significante. Conclusão: verificou-se que há modificação do tempo da deglutição, tanto em relação à consistência quanto a volume do bolo alimentar, quando comparados idosos e adultos.
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Risk factors for severe dysphagia in acute cervical spinal cord injury. Spinal Cord 2017; 55:940-943. [DOI: 10.1038/sc.2017.63] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2017] [Revised: 04/08/2017] [Accepted: 05/02/2017] [Indexed: 12/23/2022]
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Moon HI, Nam JS, Leem MJ, Kim KH. Periventricular White Matter Lesions as a Prognostic Factor of Swallowing Function in Older Patients with Mild Stroke. Dysphagia 2017; 32:480-486. [PMID: 28349208 DOI: 10.1007/s00455-017-9788-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2016] [Accepted: 02/24/2017] [Indexed: 11/28/2022]
Abstract
Older patients with stroke have poor functional prognosis compared to younger patients. Patients with stroke who have severe white matter (WM) lesions have been reported to have poor functional prognosis such as cognitive dysfunction, increased propensity for falling, and gait and balance problems. The aim of this study was to determine whether WM lesions exert negative effects on swallowing function in older patients with mild stroke. We conducted a retrospective analysis of 63 patients aged >65 years who had a National Institutes of Health Stroke Scale score ≤5 and who underwent videofluoroscopic swallowing examination after their first stroke. Linear regression analysis showed that oral transit time tended to increase as Fazekas grade increased (p = 0.003). In addition, inadequate mastication was related to the presence of lesions in the left hemisphere (p = 0.039). The presence of penetration could also be predicted by Fazekas grade (p = 0.015). Our findings suggest that WM lesions observed in brain magnetic resonance imaging scans can impact swallowing problems in older patients with mild stroke, regardless of initial stroke severity or other factors associated with lesion location. Accordingly, our data indicate that WM lesions are a predictive factor by which patients can be stratified into favorable or unfavorable outcomes with respect to dysphagia.
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Affiliation(s)
- Hyun Im Moon
- Department of Rehabilitation Medicine, Bundang Jesaeng General Hospital, 20 Seohyeon-ro 180 Beon-gil, Bundang-gu, Seoungnam-si, 13590, Gyeonggi-do, Republic of Korea.
| | - Je-Shik Nam
- Department of Rehabilitation Medicine, Bundang Jesaeng General Hospital, 20 Seohyeon-ro 180 Beon-gil, Bundang-gu, Seoungnam-si, 13590, Gyeonggi-do, Republic of Korea
| | - Min Jeong Leem
- Department of Rehabilitation Medicine, Bundang Jesaeng General Hospital, 20 Seohyeon-ro 180 Beon-gil, Bundang-gu, Seoungnam-si, 13590, Gyeonggi-do, Republic of Korea
| | - Kee Hoon Kim
- Department of Rehabilitation Medicine, Bundang Jesaeng General Hospital, 20 Seohyeon-ro 180 Beon-gil, Bundang-gu, Seoungnam-si, 13590, Gyeonggi-do, Republic of Korea
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Scharitzer M, Pokieser P, Wagner-Menghin M, Otto F, Ekberg O. Taking the history in patients with swallowing disorders: an international multidisciplinary survey. Abdom Radiol (NY) 2017; 42:786-793. [PMID: 27730327 PMCID: PMC5355505 DOI: 10.1007/s00261-016-0931-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Purpose Clinical assessment of swallowing disorders (dysphagia) requires accurate and comprehensive medical history-taking to further tailor the diagnostic work-up, but functional health care questionnaires show a large variability and various limitations. The aim of this study was to assess the way in which international swallowing experts from various disciplines asses swallowing problems in order to improve the radiologist´s ability to take a thorough medical history in this specific patient group. Methods A two-step Delphi method was used to collect swallowing experts’ ways of taking the medical history in patients with swallowing disorders. The questions obtained in a first interview round were pooled and structured by dividing them into general and specific questions, including several subcategories, and these were scored by the experts in a second step based on to their clinical relevance. Results Eighteen experts provided 25 different questions categorized as general questions and 34 dimension-specific questions (eight attributed to ‘suspicion of aspiration,’ 13 to ‘dysphagia,’ six to ‘globus sensation,’ four to ‘non-cardiac chest pain,’ and three to ‘effect of life.’) In the second interview round, the experts´ average predictive values attributed to those questions showed the varying importance of the presented items. Seven general and 13 specific questions (six of them attributed to ‘effect on life’ and seven ‘others’) were also added. Conclusions This collection of questions reflects the fact that a multidisciplinary approach when obtaining the medical history in patients with swallowing disorders may contribute to an improved technique for performing a symptom-oriented medical history-taking for radiologists of all training levels.
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Affiliation(s)
- Martina Scharitzer
- Department of Biomedical Imaging and Image-guided Therapy, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria.
| | - Peter Pokieser
- Unified Patient Project, Teaching Center, Medical University of Vienna, Vienna, Austria
| | | | - Ferdinand Otto
- Department of Neurology, University Hospital Salzburg, Salzburg, Austria
| | - Olle Ekberg
- Department of Translational Medicine, Division of Medical Radiology, Skåne University Hospital, Malmö, Sweden
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Nakato R, Manabe N, Kamada T, Matsumoto H, Shiotani A, Hata J, Haruma K. Age-Related Differences in Clinical Characteristics and Esophageal Motility in Patients with Dysphagia. Dysphagia 2016; 32:374-382. [DOI: 10.1007/s00455-016-9763-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2016] [Accepted: 11/22/2016] [Indexed: 12/14/2022]
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Abstract
Alterations in nutritional status are common and can be associated with increased morbidity and mortality. However, for healthcare providers, the definition of malnutrition is vague, insensitive, and poorly standardized. In contrast, nutrition risk is more easily defined, and recognizes that both poor nutritional status and disease severity contribute to increased morbidity and mortality. Clinicians need to identify patients who may already have evidence of nutrient deficiencies or have disease processes that affect nutrition risk. This article reviews risk assessment tools and provides practical tips to screen patients and identify those whose nutrition risk warrants specialized nutrition therapy.
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Affiliation(s)
- Ryan T Hurt
- Division of General Internal Medicine, Mayo Clinic, Rochester, MN, USA; Division of Gastroenterology and Hepatology, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA; Division of Gastroenterology, Hepatology and Nutrition, University of Louisville School of Medicine, 550 South Jackson Street, Louisville, KY 40292, USA
| | - Stephen A McClave
- Division of Gastroenterology, Hepatology and Nutrition, University of Louisville School of Medicine, 550 South Jackson Street, Louisville, KY 40292, USA.
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Abstract
Oropharyngeal dysphagia is a frequent consequence of several medical aetiologies, and even considered part of the normal ageing process. Early and accurate identification provides the opportunity for early implementation of dysphagia treatments. This Review describes the current state of the evidence related to dysphagia therapies - focusing on treatments most clinically utilized and of current interest to researchers. Despite successes in select studies, the level of evidence to support the efficacy of these treatments remains limited. Heterogeneity exists across studies in both how interventions are administered and how their therapeutic value is assessed, thereby making it difficult to establish external validation. Future work needs to address these caveats. Also, to be most efficacious, dysphagia therapies need to account for influences from pre-morbid patient characteristics as these factors have potential to increase the risk of dysphagia and the resulting complications of aspiration, malnutrition and psychological burden. Dysphagia therapies therefore need to incorporate the medical aetiology that is at its root, the resulting swallow physiology captured from comprehensive clinical and/or instrumental assessments, and the existing needs and supports of patients.
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Affiliation(s)
- Rosemary Martino
- Departments of Speech Language Pathology, Rehabilitation Sciences Institute, and Otolaryngology-Head and Neck Surgery, University of Toronto, 160-500 University Avenue, Ontario M5G 1V7, Canada.,Krembil Research Institute, University Health Network, 399 Bathurst Street (MP 11-331), Toronto, Ontario M5T 2S8, Canada
| | - Timothy McCulloch
- Division of Otolaryngology-Head and Neck Surgery, Department of Surgery, School of Medicine and Public Health, University of Wisconsin, 600 Highland Avenue, Madison, Wisconsin 53792, USA
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An Epidemiologic Study on Ageing and Dysphagia in the Acute Care Geriatric-Hospitalized Population: A Replication and Continuation Study. Dysphagia 2016; 31:619-25. [PMID: 27384436 DOI: 10.1007/s00455-016-9714-x] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2016] [Accepted: 05/17/2016] [Indexed: 12/22/2022]
Abstract
United States census data project dramatic increases in the geriatric population ageing demographics by 2060 with concomitant health-care consequences. The purpose of this replication and continuation study was to collect new 2014 demographic data relative to ageing, swallow evaluation referral rates, and oral feeding status in geriatric-hospitalized patients for comparison with published data from 2000 to 2007. This was a planned data acquisition study of consecutive hospitalized patients referred for swallow assessments. Swallow evaluation referral rates for 2014 were described according to inpatient discharges, age range 60-105 years grouped by decade, gender, admitting diagnostic category, results of swallow evaluations, and oral feeding status. Determination of aspiration risk status was made with the Yale Swallow Protocol and diagnosis of dysphagia made with fiberoptic endoscopic evaluation of swallowing (FEES). There were 1348 referrals and 961 patients ≥60 years of age participated. Overall swallow evaluation referral rates increased an average of 63 % between the comparison years 2007 and 2014 with consistent increases corresponding to the decades, i.e., 60-69 (46 %), 70-79 (68 %), 80-89 (53 %), and 90+ (222 %). A total of 75 % of participants resumed oral alimentation and oral medications. Swallow evaluation referral rates increased by 63 % for 60-90+ year-old acute care geriatric-hospitalized participants despite only a 23 % increase in inpatient discharges for the years 2007 versus 2014. This corroborated previously reported increases for individual years from 2000 to 2007. For timely, safe, and successful initiation of oral alimentation, it is important to perform a reliable swallow screen for aspiration risk assessment with the Yale Swallow Protocol and, if failed, instrumental testing with FEES. More dysphagia specialists are needed through 2060 and beyond due to projections of continued population ageing resulting in ever increasing referral rates for swallow assessments.
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Affiliation(s)
- J.A.Y. Cichero
- School of Pharmacy, The University of Queensland; Brisbane QLD Australia
- The Wesley Hospital; Brisbane QLD Australia
- International Dysphagia Diet Standardisation Initiative; Brisbane QLD Australia
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Abstract
PURPOSE OF THE REPORT Approximately 30% of patients with motor neuron disease (MND) present swallowing difficulties even in early disease stages. The aim of this study was to examine the usefulness of esophageal scintigraphy in detecting early stage of dysphagia in MND. METHODS Esophageal scintigraphy (ES) including mean transit time (MTT) estimation was performed in 121 MND patients presenting various levels of upper (UMN) and lower motor neuron (LMN) degeneration. RESULTS ES detected dysphagia in more than 80% of MND patients who had referenced swallowing difficulties. In MND patients with ES-confirmed dysphagia, the MTT was increased approximately 2-fold without significant differences between the clinical phenotypes. The MTT was significantly longer in patients with bulbar-pseudobulbar syndrome in comparison to patients with isolated pseudobulbar syndrome, which indicates a higher involvement of the LMN deficiency in developing dysphagia in MND. The esophageal passage in MND was not dependent on age, sex, disease duration, or diagnosis delay. Interestingly, ES was also able to detect dysphagia in almost 70% of MND individuals who had no swallowing complaints (subclinical dysphagia). A more benign disease course and a higher percentage of male patients characterized this group. CONCLUSIONS Esophageal scintigraphy is a helpful screening tool in determining early swallowing impairment in a high percent of patients with MND of various clinical phenotypes.
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Groher ME, Puntil-Sheltman J. Dysphagia Unplugged. Dysphagia 2016. [DOI: 10.1016/b978-0-323-18701-5.00001-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Arens C, Herrmann IF, Rohrbach S, Schwemmle C, Nawka T. Position paper of the German Society of Oto-Rhino-Laryngology, Head and Neck Surgery and the German Society of Phoniatrics and Pediatric Audiology - Current state of clinical and endoscopic diagnostics, evaluation, and therapy of swallowing disorders in children. GMS CURRENT TOPICS IN OTORHINOLARYNGOLOGY, HEAD AND NECK SURGERY 2015; 14:Doc02. [PMID: 26770277 PMCID: PMC4702052 DOI: 10.3205/cto000117] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Swallowing disorders are frequent. The main concern is mortality due to aspiration-induced pneumonia and malnutrition. In addition, quality of life is severely affected. The demographic trend indicates an increase of dysphagia in the future. Neurodegenerative diseases, tumors of the digestive tract, and sequelae of tumor treatment in the head and neck region are the main pathologic entities. Predominantly ENT physicians and phoniatricians are asked for diagnostics and therapy, and will coordinate the interdisciplinary treatment according to the endoscopic findings. A differentiated approach in history, diagnostics, and symptom-oriented treatment is necessary for these mostly complex disorders. Integration of non-medical staff such as speech therapists, physiotherapists, and occupational therapists in planning and executing an effective therapy expands and completes the patient-oriented care. Conservative treatment by these therapists is an important pillar in the treatment. Parts of the specific diagnostics can be taken over in close cooperation. In particular, an interdisciplinary cooperation with the staff of intensive care medicine is essential. The diagnostic procedures of specific endoscopy as described in this position paper are part of the primary and fundamental tasks of ENT specialists and phoniatrists. Endoscopy is a medical service that is basically not delegable. Consequently, substitution of the physician is excluded.
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Affiliation(s)
- Christoph Arens
- Department of Otorhinolaryngology, Head and Neck Surgery, University Hospitals Magdeburg, Otto-von-Guericke-University Magdeburg, Germany
| | | | - Saskia Rohrbach
- Department of Audiology and Phoniatrics, Charité - University Medicine of Berlin, Germany
| | - Cornelia Schwemmle
- Department of Otorhinolaryngology, Head and Neck Surgery, University Hospitals Magdeburg, Otto-von-Guericke-University Magdeburg, Germany
| | - Tadeus Nawka
- Department of Audiology and Phoniatrics, Charité - University Medicine of Berlin, Germany
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Acoustic analysis of oropharyngeal swallowing using Sonar Doppler. Braz J Otorhinolaryngol 2015; 82:39-46. [PMID: 26718958 PMCID: PMC9444651 DOI: 10.1016/j.bjorl.2015.12.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2014] [Accepted: 02/27/2015] [Indexed: 12/23/2022] Open
Abstract
INTRODUCTION During the aging process, one of the functions that changes is swallowing. These alterations in oropharyngeal swallowing may be diagnosed by methods that allow both the diagnosis and biofeedback monitoring by the patient. One of the methods recently described in the literature for the evaluation of swallowing is the Sonar Doppler. OBJECTIVE To compare the acoustic parameters of oropharyngeal swallowing between different age groups. METHODS This was a field, quantitative, study. Examination with Sonar Doppler was performed in 75 elderly and 72 non-elderly adult subjects. The following acoustic parameters were established: initial frequency, first peak frequency, second peak frequency; initial intensity, final intensity; and time for the swallowing of saliva, liquid, nectar, honey, and pudding, with 5- and 10-mL free drinks. RESULTS Objective, measurable data were obtained; most acoustic parameters studied between adult and elderly groups with respect to consistency and volume were significant. CONCLUSION When comparing elderly with non-elderly adult subjects, there is a modification of the acoustic pattern of swallowing, regarding both consistency and food bolus volume.
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A bitter pill to swallow: dysphagia in cervical spine injury. J Surg Res 2015; 201:388-93. [PMID: 27020823 DOI: 10.1016/j.jss.2015.11.031] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2015] [Revised: 10/26/2015] [Accepted: 11/20/2015] [Indexed: 12/22/2022]
Abstract
BACKGROUND Dysphagia is a common complication after cervical spine trauma with spinal cord injury. We sought to characterize the prevalence of dysphagia within a total cervical spinal injury (CSI) population, considering the implications of spinal cord injury status and age on dysphagia development. We hypothesized that while greater rates of dysphagia would be found in geriatric and spinal cord-injured subgroups, all patients presenting with CSI would be at heightened risk for swallowing dysfunction. METHODS All trauma admissions to a level II trauma center from January 2010 to April 2014 with CSI were retrospectively reviewed. CSI was classified as any ligamentous or cervical spinous fracture with or without cord injury. Patients failing a formal swallow evaluation were considered dysphagic. The implications of dysphagia development on age and spinal cord injury status were assessed in univariate and multivariate analyses. RESULTS A total of 481 patients met study inclusion criteria, of which 123 (26%) developed dysphagia. Within the dysphagic subpopulation, 90 patients (73%) were geriatric, and 23 (19%) sustained spinal cord injury. The dysphagic subpopulation was predominantly free from spinal cord injury (81%). Multivariate analyses found age (adjusted odds ratio: 1.06; 95% confidence interval 1.04-1.07; P < 0.001) and spinal cord injury (adjusted odds ratio: 2.69; 95% confidence interval 1.30-5.56; P = 0.008) to be significant predictors of dysphagia development. CONCLUSIONS Despite spinal cord-injured patients being at increased risk for dysphagia, most of the dysphagic subpopulation was free from spinal cord injury. Geriatric and CSI patients with or without cord injury should be at heightened suspicion for dysphagia development.
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Sogawa Y, Kimura S, Harigai T, Sakurai N, Toyosato A, Nishikawa T, Inoue M, Murasawa A, Endo N. New Swallowing Evaluation Using Piezoelectricity in Normal Individuals. Dysphagia 2015; 30:759-67. [PMID: 26487065 DOI: 10.1007/s00455-015-9654-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2014] [Accepted: 10/03/2015] [Indexed: 12/22/2022]
Abstract
This study aimed to elucidate the relationship between the piezoelectric waveform latency, hyoid bone movement, surface electromyogram (sEMG), and the pharyngeal transit time (PTT) during swallowing. Forty-one healthy subjects were divided into three age groups: younger (20-39 years, n = 8), middle-aged (40-59 years, n = 9), and older (60-79 years, n = 24). Motion analysis of the hyoid bone using videofluorography (VF), waveform analysis of the front neck using piezoelectric films, and sEMG of the suprahyoid muscle group were performed simultaneously. Latencies of the three movement phases were defined as upward (VFS1), forward (VFS2), and returning to starting position (VFS3). The three phases of the piezoelectric waveform-from wave initiation of the negative wave to the start of the second deep negative wave; from the start of the second deep negative wave to the start of the last positive wave (SLPW); and from the SLPW to the end of the last positive wave-were defined as PS1, PS2, and PS3, respectively. VFS1-3 and PS1-3 were significantly correlated. VFS1 and PS1 latencies were significantly longer with thick liquid than with thin liquid. VFS2, PS1, and PS2 latencies were longer in the older group than in the other two groups. The start of PS1 was nearly equal to those of sEMG and VFS1. Bolus arrival time in the valleculae was statistically equal to the end of the PS1 with both thin and thick liquids. To establish the swallowing screening using Piezoelectric film, further investigation is necessary in the dysphagia patients.
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Affiliation(s)
- Yuichiro Sogawa
- Rehabilitation Center, Niigata University Medical and Dental Hospital, 1-754, Asahimachi-Dori, Chuo-ku, Niigata-Shi, 951-8520, Japan
| | - Shinji Kimura
- Rehabilitation Center, Niigata University Medical and Dental Hospital, 1-754, Asahimachi-Dori, Chuo-ku, Niigata-Shi, 951-8520, Japan.
| | - Toru Harigai
- Rehabilitation Center, Niigata University Medical and Dental Hospital, 1-754, Asahimachi-Dori, Chuo-ku, Niigata-Shi, 951-8520, Japan
| | - Naoki Sakurai
- Division of Comprehensive Prosthodontics, Department of Tissue Regeneration and Reconstruction, Course for Oral Life Science, Niigata University Graduate School of Medical and Dental Sciences, 2-5274, Gakkocho-dori, Chuo-ku, Niigata-Shi, 951-8514, Japan
| | - Akira Toyosato
- Heart Dental Clinic, 76, Kanabachiyamacho, Sekiya, Chuo-ku, Niigata-Shi, 951-8165, Japan
| | - Taro Nishikawa
- Rehabilitation Center, Niigata University Medical and Dental Hospital, 1-754, Asahimachi-Dori, Chuo-ku, Niigata-Shi, 951-8520, Japan
| | - Makoto Inoue
- Division of Dysphagia Rehabilitation, Niigata University Graduate School of Medical and Dental Sciences, 2-5274, Gakkocho-dori, Chuo-ku, Niigata-Shi, 951-8514, Japan
| | - Akira Murasawa
- Department of Rehabilitation Medicine, Niigata Rheumatic Center, 1-2-8, Honcho, Shibata-Shi, 957-0054, Japan
| | - Naoto Endo
- Rehabilitation Center, Niigata University Medical and Dental Hospital, 1-754, Asahimachi-Dori, Chuo-ku, Niigata-Shi, 951-8520, Japan
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46
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Arens C, Herrmann IF, Rohrbach S, Schwemmle C, Nawka T. [Position paper of the German Society of Oto-Rhino-Laryngology, Head and Neck Surgery and the German Society of Phoniatrics and Pediatric Audiology - current state of clinical and endoscopic diagnostics, evaluation, and therapy of swallowing disorders in children and adults]. Laryngorhinootologie 2015; 94 Suppl 1:S306-S354. [PMID: 25860495 DOI: 10.1055/s-0035-1545298] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Position Paper of the German Society of Oto-Rhino-Laryngology, Head and Neck Surgery and the German Society of Phoniatrics and Pediatric Audiology - Current State of Clinical and Endoscopic Diagnostics, Evaluation, and Therapy of Swallowing Disorders in Children and AdultsSwallowing disorders are frequent. The main concern is mortality due to aspiration induced pneumonia and malnutrition. On the other hand quality of life is severely affected. The demographic trend indicates an increase of dysphagia in the future. Neurodegenerative diseases, tumors of the digestive tract and sequelae of tumor treatment in the head and neck region are the main pathologic entities.Predominantly ENT physicians and phoniatrists, are asked for diagnostics and therapy who will coordinate the interdisciplinary treatment according to the endoscopic findings.A differentiated approach in history, diagnostics, and symptom oriented treatment is necessary for the mostly complex disorders. The integration of non-medical personnel such as logopeds (speech language pathologists), physiotherapists, and occupational therapists in planning and executing an effective therapy expands and completes the patient-oriented care. Conservative treatment by these therapists is an important pillar in the treatment. Parts of the specific diagnostics can be taken over by them in close cooperation.In particular an interdisciplinary cooperation with the staff from intensive care medicine is indispensable.The diagnostic procedures of specific endoscopy as described in this position paper are part of the primary and fundamental tasks of ENT specialists and phoniatrists.Endoscopy is a medical service that is basically not delegable. Consequently substitution of the physician is precluded.
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Affiliation(s)
- C Arens
- Universitätsklinik für Hals-Nasen-Ohrenheilkunde, Universitätsklinikum Magdeburg AöR, Otto-von-Guericke-Universität, Magdeburg
| | | | - S Rohrbach
- Klinik für Audiologie und Phoniatrie, Charité - Universitätsmedizin Berlin, Berlin
| | - C Schwemmle
- Universitätsklinik für Hals-Nasen-Ohrenheilkunde, Universitätsklinikum Magdeburg AöR, Otto-von-Guericke-Universität, Magdeburg
| | - T Nawka
- Klinik für Audiologie und Phoniatrie, Charité - Universitätsmedizin Berlin, Berlin
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Affiliation(s)
- T Yap
- Melbourne Dental School; The University of Melbourne; Victoria Australia
| | - M McCullough
- Melbourne Dental School; The University of Melbourne; Victoria Australia
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48
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Jung KW, Jung HY, Myung SJ, Kim SO, Lee J, Yoon IJ, Seo SY, Lee JH, Kim DH, Choi KD, Song HJ, Lee GH, Murray JA, Romero Y, Kim JH. The effect of age on the key parameters in the Chicago classification: a study using high-resolution esophageal manometry in asymptomatic normal individuals. Neurogastroenterol Motil 2015; 27:246-57. [PMID: 25521290 DOI: 10.1111/nmo.12482] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2014] [Accepted: 11/10/2014] [Indexed: 12/21/2022]
Abstract
BACKGROUND High-resolution manometry using the Chicago classification, which utilizes parameters including integrated relaxation pressure (IRP), distal contractile integral (DCI), and contractile front velocity (CFV), shows better diagnostic ability than previous conventional criteria. However, the current normal cut-off values for the Chicago classification are based on individuals aged 19-48 years and do not include older people. Here, we aimed to assess the normal values for the Chicago classification in individuals aged 20-67 years and compare the parameters across age groups. METHODS Fifty-four asymptomatic healthy individuals (27 male and 27 female; age range. 20-67 years) were prospectively enrolled. To evaluate the effect of age and sex on manometric profiles, we attempted to enroll equal numbers of male and female subjects for each decade. Manometry was performed in both the supine and sitting positions. KEY RESULTS The distal latency (DL) was significantly shorter with increasing age in both measurement positions. Furthermore, IRP was significantly higher with increasing age in both positions. Spearman's ranked correlation coefficient analysis indicated that DCI and IRP in both positions were positively correlated with age. CONCLUSIONS & INFERENCES Age affects the key parameters currently used in the Chicago classification, including IRP, DCI, and DL. Larger prospective studies with older subjects are needed to determine the age-related normal values for the Chicago classification system.
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Affiliation(s)
- K W Jung
- Department of Gastroenterology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
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Cho SY, Choung RS, Saito YA, Schleck CD, Zinsmeister AR, Locke GR, Talley NJ. Prevalence and risk factors for dysphagia: a USA community study. Neurogastroenterol Motil 2015; 27:212-9. [PMID: 25376877 PMCID: PMC4308532 DOI: 10.1111/nmo.12467] [Citation(s) in RCA: 83] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2014] [Accepted: 10/05/2014] [Indexed: 12/12/2022]
Abstract
BACKGROUND Dysphagia is considered an alarm symptom but detailed population-based data on dysphagia are lacking. We aimed to estimate in a representative USA Caucasian population, the prevalence of dysphagia and potential risk factors. METHODS A modified version of the previously validated Bowel Disease Questionnaire was mailed to a population-based cohort (n = 7640) of Olmsted County, MN. Dysphagia was measured by one validated question 'In the last year, how often have you had difficulty swallowing (a feeling that food sticks in your throat or chest)?' The medical records were reviewed for organic causes of dysphagia. The associations of reported frequency of dysphagia with potential risk factors were assessed using logistic regression models. KEY RESULTS The sex-specific, age-adjusted (US White 2000) prevalence for dysphagia experienced at least weekly was 3.0% (95% CI: 2.2, 3.7) in females and 3.0% (95% CI: 2.0, 4.0) in males. Those with frequent heartburn (OR = 5.9 [4.0, 8.6]) and acid regurgitation (OR = 10.6 [6.8, 16.6]) were significantly more likely to report frequent dysphagia. Proton pump inhibitor (PPI) use was significantly associated with frequent (3.1, 95% CI 2.2, 4.4) and infrequent dysphagia (1.5, 955 CI 1.3, 1.8). Gastro-esophageal reflux disease (GERD) was the most common diagnosis in those reporting dysphagia on the medical record; other organic explanations were rare and only found in the frequent dysphagia group. CONCLUSIONS & INFERENCES Frequent dysphagia is not rare in the community (3%), occurs in both women and men across all adult age groups, and is most likely to indicate underlying GERD.
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Affiliation(s)
- So Yang Cho
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Rok Seon Choung
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA,Division of Gastroenterology and Hepatology, Department of Internal Medicine, Korea University College of Medicine, Seoul, South Korea
| | - Yuri A. Saito
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Cathy D Schleck
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN, USA
| | - Alan R Zinsmeister
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN, USA
| | - G. Richard Locke
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Nicholas J. Talley
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA,Faculty of Health and Medicine, University of Newcastle, New Lambton, NSW, Australia
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50
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Schlitzkus LL, Melin AA, Johanning JM, Schenarts PJ. Perioperative management of elderly patients. Surg Clin North Am 2015; 95:391-415. [PMID: 25814114 DOI: 10.1016/j.suc.2014.12.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
The older population only represents 13.7% of the US population but has grown by 21% since 2002. The centenarian population is growing at a faster rate than the total US population. This unprecedented growth has significantly increased surgical demand. The establishment of quality and performance improvement data has allowed researchers to focus attention on the older patient population, resulting in an exponential increase in studies. Although there is still much work to be done in this field, overlying themes regarding the perioperative management of elderly patients are presented in this article based on a thorough literature review.
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Affiliation(s)
- Lisa L Schlitzkus
- Department of Surgery, University of Nebraska Medical Center, 983280 Nebraska Medical Center, Omaha, NE 68198-3280, USA
| | - Alyson A Melin
- Department of Surgery, University of Nebraska Medical Center, 983280 Nebraska Medical Center, Omaha, NE 68198-3280, USA
| | - Jason M Johanning
- Department of Surgery, University of Nebraska Medical Center, 983280 Nebraska Medical Center, Omaha, NE 68198-3280, USA
| | - Paul J Schenarts
- Department of Surgery, University of Nebraska Medical Center, 983280 Nebraska Medical Center, Omaha, NE 68198-3280, USA.
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