Biomechanical changes in the pharynx and upper esophageal sphincter after modified balloon dilatation in brainstem stroke patients with dysphagia

Mechanism of the Immediate Effect of Balloon Dilation Therapy in Spinal Muscular Atrophy With Dysphagia: A High-Resolution Manometric Study

Balloon dilation therapy (BDT) is used to treat pharyngeal dysphagia in patients with impaired upper esophageal sphincter (UES) relaxation due to cricopharyngeal dysfunction. However, the mechanism underlying this immediate effect remains unclear. Here, we present a case in which we investigated the immediate effects of BDT on UES dysfunction using high-resolution manometry (HRM). A 67-year-old man was diagnosed with spinal muscular atrophy (SMA). He gradually developed dysphagia, and a gastrostomy was performed. Despite continuing oral intake of supplemental nutrition, the patient developed dysphagia. Videofluoroscopic (VF) examination of swallowing revealed pharyngeal residue, while HRM showed weak pharyngeal contractility and impaired UES opening. BDT was performed to address the UES dysfunction. Immediately following BDT, VF demonstrated improved pharyngeal bolus passage. As for the UES function during swallowing, HRM revealed that the UES relaxation duration was significantly longer and the UES nadir pressure was significantly decreased. The patient continued the BDT before oral intake. HRM revealed immediate and prolonged UES opening with decreased UES pressure during swallowing as an immediate effect of BDT. This suggests that these findings represent the mechanisms underlying dysphagia in this patient with SMA. BDT resulted in an immediate improvement in UES function, potentially leading to dysphagia improvement. BDT should be combined with conventional rehabilitation for impaired UES opening. However, further studies are needed to confirm the long-term effectiveness of BDT for dysphagia due to SMA.

Effect of thickened water swallow training in tube-feeding and dysphagia patients in the acute and early subacute phases of stroke: A quasi-experimental study

BACKGROUND

Thickened water has been widely used in patients with dysphagia who receive oral feeding, but there is little evidence for tube-feeding patients.

OBJECTIVE

To explore the effects of thickened water swallow training in tube-feeding and dysphagia patients in the acute and early subacute phases of stroke.

METHODS

A quasi-experimental study. Hospitalised patients with acute and early subacute stroke who received tube feeding due to dysphagia were recruited from March to December 2021. Patients assigned to the intervention group (n = 23) received thickened water swallow training three times daily until the feeding tube was removed or they were discharged, and patients in the control group (n = 23) received usual care. The main outcomes were duration of tube feeding and rates of weaning at discharge.

RESULTS

Patients in the intervention group had a shorter tube-feeding duration (p = .046) and a higher rate of weaning at discharge (p = .017) than those in the control group. Significant interaction effects between time and group were detected regarding quality of life except for the swallowing burden dimension.

CONCLUSIONS

Thickened water swallow training is feasible and effective for stroke patients with tube feeding and can shorten the duration of tube feeding and improve the rates of weaning and quality of life. Healthcare providers in nonrehabilitation units should actively conduct swallowing function intervention training to maximise the potential for acute and early subacute phase rehabilitation.

Clinical Practice Guidelines for Oropharyngeal Dysphagia

OBJECTIVE

Dysphagia is a common clinical condition characterized by difficulty in swallowing. It is sub-classified into oropharyngeal dysphagia, which refers to problems in the mouth and pharynx, and esophageal dysphagia, which refers to problems in the esophageal body and esophagogastric junction. Dysphagia can have a significant negative impact one's physical health and quality of life as its severity increases. Therefore, proper assessment and management of dysphagia are critical for improving swallowing function and preventing complications. Thus a guideline was developed to provide evidence-based recommendations for assessment and management in patients with dysphagia.

METHODS

Nineteen key questions on dysphagia were developed. These questions dealt with various aspects of problems related to dysphagia, including assessment, management, and complications. A literature search for relevant articles was conducted using Pubmed, Embase, the Cochrane Library, and one domestic database of KoreaMed, until April 2021. The level of evidence and recommendation grade were established according to the Grading of Recommendation Assessment, Development and Evaluation methodology.

RESULTS

Early screening and assessment of videofluoroscopic swallowing were recommended for assessing the presence of dysphagia. Therapeutic methods, such as tongue and pharyngeal muscle strengthening exercises and neuromuscular electrical stimulation with swallowing therapy, were effective in improving swallowing function and quality of life in patients with dysphagia. Nutritional intervention and an oral care program were also recommended.

CONCLUSION

This guideline presents recommendations for the assessment and management of patients with oropharyngeal dysphagia, including rehabilitative strategies.

Empirical Dilation of Non-obstructive Dysphagia: Current Understanding and Future Directions

Non-obstructive dysphagia (NOD) is defined as symptomatic dysphagia in patients with negative endoscopic and radiographic workup. The management of NOD remains controversial as there is a discrepancy between different guidelines and clinical practice. Despite the lack of high-quality studies, empiric dilation for NOD is a common clinical practice among endoscopists and the approach varies between different clinical centers. In this review, we summarize the published literature on empiric dilation for NOD and propose a management algorithm for offering empiric dilation to patients presenting with dysphagia.

Effect of Topical Nasal Anesthetic on Comfort and Swallowing in High-Resolution Impedance Manometry

OBJECTIVES/HYPOTHESIS

Use of topical nasal anesthetic (TNA) is common in high-resolution impedance manometry (HRIM). This study investigated the effect of TNA on swallowing and procedure tolerability during HRIM with a 4.2-mm catheter, a more commonly used catheter size with impedance capabilities.

STUDY DESIGN

Randomised experimental study with blinding of participants.

METHODS

Twenty healthy participants (mean age = 33 years, 16 female) were randomized to undergo HRIM using the ManoScan™ ESO Z 4.2-mm catheter twice, 1 week apart, under two conditions: with TNA (viscous lidocaine) and with placebo. Analyses included esophageal data of three saliva, three saline (5 mL), and three bread swallows (2 cm × 2 cm) performed while reclined 45°, and pharyngeal data under the same conditions while seated upright. Pharyngeal and upper esophageal sphincter (UES) HRIM parameters were analyzed using the Swallow Gateway analysis platform. Visual analogue scale (VAS) scores rating procedural comfort were analyzed.

RESULTS

There were no significant physiological differences in pharyngeal and UES parameters between conditions. There were also no significant differences in VAS scores under placebo (mean = 54.8, standard deviation (SD) = 19.3) and TNA (mean = 60.0, SD = 21.9) (t[19] = -0.9, P = .4) conditions; however, there was a significant difference in the first versus second session (t[19]) = 5.1, P < .05).

CONCLUSIONS

TNA did not improve comfort, but it also did not significantly affect swallowing behavior. There was, however, a practice effect regardless of TNA use with improved tolerance of the 4.2-mm catheter and likely more natural swallowing behavior during the second session of HRIM.

LEVEL OF EVIDENCE

3 Laryngoscope, 2022.

Comparison studies of ultrasound-guided botulinum toxin injection and balloon catheter dilatation in the treatment of neurogenic cricopharyngeal muscle dysfunction

BACKGROUND

Cricopharyngeal muscle dysfunction (CPD) management has been challenging in clinical practice.

OBJECTIVE

To compare the efficacy and safety of ultrasound-guided botulinum toxin injection and balloon catheter dilatation in treating CPD.

METHODS

Forty patients with CPD were randomly divided into two groups, namely the botulinum toxin injection group (BTX group) and balloon dilatation group (BD group). Patients in the BTX group received a single ultrasound-guided injection of 50 units of botulinum toxin type A, while the BD group received dilatation therapy five times per week, consecutively for two weeks. Relative opening percentage of the upper esophageal sphincter (UES), the penetration-aspiration scale (PAS), and the Dysphagia Outcome Severity Scale (DOSS) were evaluated by a videofluoroscopic swallowing study (VFSS) at baseline, 1-month, and 3-months posttreatment. The Functional Oral Intake Scale (FOIS) and Standardized Swallowing Assessment (SSA) were also used to evaluate participants' swallowing function at baseline and the 1-week, 2-week, 1-month, and 3-month follow-ups.

RESULTS

A generalized estimating equation (GEE) model revealed the significant main effect for time in UES, PAS, DOSS, FOIS, and SSA compared to baseline (P <0.05), while no group-by-time interactions (except for the PAS assessment) or main effect for treatment was detected among the above multiple variances. No systematic complications or severe adverse effects were noted.

CONCLUSION

Both ultrasound-guided botulinum toxin type A injections and balloon dilatation therapy have been proven as safe and effective treatments for CPD patients. Future clinical trials with longer follow-up periods and more participants are warranted.

The upper esophageal sphincter in the high-resolution manometry era

BACKGROUND

The evaluation of the upper esophageal sphincter (UES) has been neglected during routine manometric tests for decades, mostly due to the limitations of the conventional manometry which were eventually overcome by high-resolution manometry (HRM).

METHODS

This study reviewed the current knowledge of the manometric evaluation of the UES in health and disease in the HRM era.

RESULTS

We found that HRM allowed more precise measurements, in addition to the parameters as compared to conventional manometry, but most of them still need confirmation of the clinical significance. The parameters used to evaluate the UES were extension, basal pressure, residual pressure, relaxation duration, relaxation time to nadir, recovery time, intrabolus pressure, and deglutitive sphincter resistance. UES may be affected by different diseases: achalasia (UES is hypertonic with impaired relaxation), gastroesophageal reflux disease (UES is short and hypotonic), globus (UES ranges from normal to impaired relaxation to hypertonic), neurologic diseases (stroke and Parkinson - UES is hypotonic in early-stage to impaired relaxation in end-stage disease), and Zenker's diverticulum (UES has impaired relaxation).

CONCLUSION

This review shows that UES dysfunction is part of several disease processes and that the study of the UES is possible and valuable with the aid of HRM.

Ultrasound, electromyography, and balloon guidance for injecting botulinum toxin for cricopharyngeal achalasia: A case report

INTRODUCTION

Botulinum toxin (BTX) injection is a widely used treatment option for dysphagia associated with cricopharyngeal (CP) muscle achalasia, but uniform standards and protocols for administration techniques and injection sites are still lacking. This case study suggests that a unique administration technique involving a combination of ultrasound, electromyography, and balloon guidance for injecting the CP muscle can reduce inadvertent migration of BTX to non-injected tissues and increase the effectiveness and safety of BTX treatment.

PATIENT CONCERNS

We describe the case of a 74-year-old man who could not swallow food or saliva for 8 months.

DIAGNOSIS

The patient showed signs of true bulbar paralysis, including dizziness, hoarseness, and dysphagia. The fiberoptic endoscopic evaluation of swallowing showed massive mucilage secretion and residual materials in the postcricoid region and aspiration when swallowing 1 ml of yogurt. The video fluoroscopic swallowing study showed profoundly limited epiglottic folding and CP muscle non-relaxation, despite several unsuccessful swallow attempts.

INTERVENTIONS

To manage insufficient relaxation opening of the CP muscle, BTX injection was performed using ultrasound, electromyography, and balloon catheter guidance. The narrow CP muscle situated above the balloon was identified as the target of injection by ultrasound.

OUTCOMES

The patient was able to eat a soft diet. The follow-up fibrotic endoscopic swallowing study demonstrated a reduction in the amount of pharyngeal residue. The video fluoroscopic swallowing study showed that CP muscle relaxation was significantly enhanced and no penetration was shown.

CONCLUSION

The unique administration technique with triple guidance holds several advantages, suggesting that it may be a promising treatment for CP muscle achalasia.

Evaluation of a palatal lift prosthesis with a flexible lift in a lower cranial nerve palsy patient with dysphagia using high-resolution manometry: A case report

PATIENT

Palatal lift prostheses (PLPs) are used for dysarthria caused by velopharyngeal incompetence (VPI) and improving hypernasal speech. In this case, we used a PLP with a flexible lift (f-PLP) in a patient with dysphagia associated with VPI due to right-sided cranial nerve injuries after a skull base surgery. We examined its efficacy in swallowing biomechanics and swallowing function using high-resolution manometry (HRM) and videofluoroscopic examination of swallowing (VF). The patient felt that it was easier to swallow with f-PLP. Furthermore, VF indicated that the pharyngeal residue with f-PLP was less than without it. HRM showed that velopharyngeal pressure and intrabolus pressure (IBP) with f-PLP were higher than those without it. Additionally, the upper esophageal sphincter (UES) relaxation time and UES nadir pressure on the patient's healthy left side compared to the right side improved with f-PLP.

DISCUSSION

We discovered two clinical outcomes. First, the f-PLP ensured velopharyngeal closure and an increase in the hypopharyngeal IBP, which potentially improved the UES opening on the healthy side. Second, the f-PLP improved pharyngeal clearance, and the patient felt that it was easier to swallow with the f-PLP. This implies that an f-PLP potentially exhibits a positive effect on swallowing.

CONCLUSIONS

In this case, the f-PLP contributed to improving the pharyngeal passage of a bolus. We suggest that f-PLPs can be used for patients with dysarthria and those with dysphagia with VPI.

Adequate Number of Swallows for Pharyngeal Pressure Measurement of a Subject using High-resolution Manometry

Introduction  The number of pressure measurements that need to be recorded using high-resolution manometry (HRM) for the accurate evaluation of pharyngeal function is not well established.

Objective  The purpose of this study is to clarify the number of swallows required to obtain an accurate pharyngeal manometric profile of a person.

Methods  Forty healthy adults performed a dry swallow and bolus swallows using 3-, 5-, or 10 ml of water and underwent measurements using the Starlet HRM system. Each subject underwent 10 swallows for each of the four bolus volume conditions.

Results  The mean of up to seven measurements of maximum pre-swallow upper esophageal sphincter pressure with 10 ml of swallow was close to the mean of up to eight measurements in 95% of the subjects. Similarly, the rate of change of the average for the eighth and ninth measurements and the rate of change for the average of the ninth and tenth measurements were less than 5%. When the other parameters were similarly measured up to the sixth measurement, no major change in the average value was observed even if more measurements were taken.

Conclusion  A minimum of six measurements are required, and seven swallows are sufficient for evaluating the pharyngeal manometric profile of a single person. This number of measurements can be a useful criterion when performing HRM measurements on individual subjects.

Simultaneous double balloon dilatation using double channel therapeutic endoscope in patients with cricopharyngeal muscle dysfunction: An observative study

The role of endoscopic balloon dilatation (EBD) using double-balloon catheters in patients with cricopharyngeal muscle dysfunction (CPD) is still unclear. Thus, the aim of this study was to compare the functional outcomes between patients receiving EBD and rehabilitative balloon swallowing (RBS).A total of 36 patients with CPD, who visited a teaching hospital from February 2014 to June 2017, were included in the study. Among them, 12 patients with severe dysphagia underwent EBD. After propensity score matching, 24 patients who underwent RBS were selected for comparison. We compared the effects of EBD and RBS using 4 functional swallowing parameters: functional dysphagia scale score, penetration-aspiration scale score, pharyngeal transit time, and percentage of pharyngeal remnant (PR) at baseline and after the first and second treatments. Using simple and multiple regression, we examined the associations between EBD/RBS and changes of 4 parameters after the treatments since the baselineAll functional parameters significantly decreased after RBS and EBD (P < .05). After the first therapy session, significant differences in the pharyngeal transit time (P = .034), percentage of PR (P = .008), and penetration-aspiration scale score (P = .014) were observed in the EBD group, compared with those in the RBS group. The regression analysis showed significant improvements in the PR after EBD compared with that after RBS (β = 0.95, SE = 0.31, P = .005).EBD may be an alternative treatment for patients with severe CPD. A significant improvement would be expected in such patients with PR.

Cricopharyngeal Achalasia: Management and Associated Outcomes-A Scoping Review

OBJECTIVE

There is little consensus regarding the efficacy and safety of treatment options for cricopharyngeal (CP) achalasia. The purpose of this scoping review is to assess the literature regarding the various treatments for this disease.

DATA SOURCES

PubMed was searched for all articles addressing treatment of adult CP achalasia between January 1990 and June 2019.

REVIEW METHODS

In total, 351 peer-reviewed results were reviewed by 3 otolaryngologists for inclusion. After review of titles, abstracts, and full texts, 60 articles were selected.

RESULTS

Among included studies, 55% were retrospective and 45% were prospective. Forty-five percent of studies were case series. CP achalasia etiologies included idiopathic (28%), cerebrovascular accident (CVA) (28%), neurologic disease (17%), head and neck radiation treatment (11%), Zenker's diverticulum (10%), and myositis (5%). Most commonly employed treatments were botulinum toxin injection (40%), endoscopic CP myotomy (30%), dilation with either balloon or bougie (25%), and open CP myotomy (15%). A proportion of patients were treated with more than 1 approach. Most studies included both subjective and objective outcome measures. Complications were reported most often in patients with a history of head and neck radiation.

CONCLUSIONS

Small sample sizes and heterogeneity of causes and treatments of CP achalasia, as well as short duration of follow-up, make it challenging to assess the superiority of one treatment over another. There is a need for a prospective study that more directly compares outcomes of administration of botulinum toxin, dilation, and CP myotomy in patients with CP achalasia of similar etiologies.

Hyoid-complex elevation and stimulation technique restores swallowing function in patients with lateral medullary syndrome: Two case reports

BACKGROUND

A swallowing disorder may occur following a brainstem stroke, especially one that occurs in the swallowing centers. Lateral medullary syndrome (referred to as LMS), a rare condition in which a vascular event occurs in the territory of the posterior inferior cerebellar artery or the vertebral artery, has been reported to lead to more severe and longer lasting dysphagia.

CASE SUMMARY

We report two patients with dysphagia due to LMS and propose a novel technique named hyoid-complex elevation and stimulation technique (known as HEST). The two patients had no other functional incapacity back into life, but nasogastric feeding was the only possible way for nutrition because of severe aspirations. Swallowing function was evaluated by functional oral intake scale, modified water swallow test, surface electromyographic signal associated with video fluorography swallowing study to assess the situation of aspiration, pharyngeal residue, pharyngeal peristalsis, upper esophageal opening and the ability of deglutition. Both patients were treated with the HEST method for dysphagia and recovered quickly.

CONCLUSION

HEST is effective for shortening the in-hospital time and improving the quality of life for patients with dysphagia who suffer from LMS and likely other strokes.

Transcranial direct current stimulation improves the swallowing function in patients with cricopharyngeal muscle dysfunction following a brainstem stroke

OBJECTIVE

This study investigated the effects of transcranial direct current stimulation (tDCS) combined with conventional swallowing training on the swallowing function in brainstem stroke patients with cricopharyngeal muscle dysfunction (CPD).

METHODS

Twenty-eight brainstem stroke patients with CPD were assigned randomly to an anodal tDCS group or a sham tDCS group. The patients received anodal tDCS or sham tDCS over the bilateral oesophageal cortical area combined with simultaneous catheter balloon dilatation and conventional swallowing therapy for 20 days. Swallowing function was assessed using the functional oral intake scale (FOIS) and the functional dysphagia scale (FDS) and by measuring the pharyngoesophageal Segment Opening (PESO) before and immediately after the intervention.

RESULTS

Both groups showed a significant improvement in the FDS, FOIS and PESO scores immediately after the intervention (all p < .005). However, compared with the sham stimulation group, the anodal tDCS group showed greater improvements in the FDS, FOIS and PESO scores immediately after the intervention (all p < .005).

CONCLUSION

The bihemispheric anodal tDCS combined with simultaneous catheter balloon dilatation and conventional swallowing therapy effectively improves the swallowing function in patients with CPD caused by a brainstem stroke. tDCS may be an effective adjuvant therapy in CPD rehabilitation.

High-Resolution Pharyngeal Manometry and Impedance: Protocols and Metrics-Recommendations of a High-Resolution Pharyngeal Manometry International Working Group

High-resolution manometry has traditionally been utilized in gastroenterology diagnostic clinical and research applications. Recently, it is also finding new and important applications in speech pathology and laryngology practices. A High-Resolution Pharyngeal Manometry International Working Group was formed as a grass roots effort to establish a consensus on methodology, protocol, and outcome metrics for high-resolution pharyngeal manometry (HRPM) with consideration of impedance as an adjunct modality. The Working Group undertook three tasks (1) survey what experts were currently doing in their clinical and/or research practice; (2) perform a review of the literature underpinning the value of particular HRPM metrics for understanding swallowing physiology and pathophysiology; and (3) establish a core outcomes set of HRPM metrics via a Delphi consensus process. Expert survey results were used to create a recommended HRPM protocol addressing system configuration, catheter insertion, and bolus administration. Ninety two articles were included in the final literature review resulting in categorization of 22 HRPM-impedance metrics into three classes: pharyngeal lumen occlusive pressures, hypopharyngeal intrabolus pressures, and upper esophageal sphincter (UES) function. A stable Delphi consensus was achieved for 8 HRPM-Impedance metrics: pharyngeal contractile integral (CI), velopharyngeal CI, hypopharyngeal CI, hypopharyngeal pressure at nadir impedance, UES integrated relaxation pressure, relaxation time, and maximum admittance. While some important unanswered questions remain, our work represents the first step in standardization of high-resolution pharyngeal manometry acquisition, measurement, and reporting. This could potentially inform future proposals for an HRPM-based classification system specifically for pharyngeal swallowing disorders.

Office-Based Cricopharyngeus Balloon Dilation for Post Chemoirradiation Dysphagia in Nasopharyngeal Carcinoma Patients: A Pilot Study

Dysphagia is a common sequela post chemo/radiotherapy for nasopharyngeal carcinoma (NPC), with cricopharyngeal dysfunction often a contributing factor. This study examined the impact of balloon dilation of the cricopharyngeus and cervical oesophagus on swallow competence for dysphagic patients with cricopharyngeal dysfunction post NPC. Patients with NPC were screened for dysphagia and cricopharyngeal dysfunction using fiberoptic endoscopic evaluation. Thirteen symptomatic patients, median 14.1 years post chemoradiotherapy for NPC, then underwent balloon dilation under local anesthesia. Before and 1 month post dilation, swallow function was assessed with fluoroscopy, and rated using the penetration-aspiration scale, temporal swallowing measures, and MBSImP pharyngoesophageal segment opening and esophageal clearance parameter. The MD Anderson Dysphagia Inventory (MDADI; Chinese version) and the Functional Oral Intake Scale (FOIS) were collected pre-, 1 month, and approximately 3 months post dilation. Post-dilation, significant improvements were noted in mean FOIS scores (5.00 to 5.62), duration of cricopharyngeus opening (0.42 s to 0.53 s), MBSImP pharyngoesophageal opening scores (1.61 to 1.08), penetration-aspiration scale scores (4.85 to 3.92) and MDADI Composite score (46.48 to 52.43). At 3 months post dilation, the MDADI Composite Score showed sustained benefit. The procedure was well tolerated and without complication. In patients with cricopharyngeal dysfunction post NPC, balloon dilation significantly improved swallow function, reduced aspiration risk and improved quality of life. Evidence from a larger cohort with long-term follow-up is warranted to determine sustained benefit.

A systematic review of current methodology of high resolution pharyngeal manometry with and without impedance

PURPOSE

This systematic review appraises and summaries methodology documented in studies using high resolution pharyngeal manometry (HRM) with and without impedance technology (HRIM) in adult populations.

METHODS

Four electronic databases CINAHL, EMBASE, MEDLINE, and Cochrane Library were searched up to, and including March 2017. Studies reporting pharyngeal HRM/HRIM for swallowing and/or phonatory assessment, published in peer-reviewed journals in English, German, or Spanish were assessed for the inclusion criteria. Of the selected studies, methodological aspects of data acquisition and analysis were extracted. Publications were graded based on their level of evidence and quality of methodological aspects was assessed.

RESULTS

Sixty-two articles were identified eligible, from which 50 studies reported the use of HRM and 12 studies used HRIM. Of all included manuscripts, the majority utilized the ManoScan™ system (64.5%), a catheter diameter of 4.2 mm was most prevalently documented (30.6%). Most publications reported the application of topical anesthesia (53.2%). For data analysis in studies using HRM, software intrinsic to the recording system was reported most frequently (56%). A minority of the studies using HRM provided data about measurement reliability (10%). This is higher for studies using HRIM (50%).

CONCLUSIONS

Considerable methodological variability exists regarding data acquisition and analysis in published studies using HRM/HRIM. Lacking reports of methodology make study replications difficult and reduce the comparability across studies. More data regarding the impact of individual methodological aspects on study outcomes are further required for the development of methodological recommendations.

Swallowing therapy for dysphagia in acute and subacute stroke

BACKGROUND

Dysphagia (swallowing problems), which is common after stroke, is associated with increased risk of death or dependency, occurrence of pneumonia, poor quality of life, and longer hospital stay. Treatments provided to improve dysphagia are aimed at accelerating recovery of swallowing function and reducing these risks. This is an update of the review first published in 1999 and updated in 2012.

OBJECTIVES

To assess the effects of swallowing therapy on death or dependency among stroke survivors with dysphagia within six months of stroke onset.

SEARCH METHODS

We searched the Cochrane Stroke Group Trials Register (26 June 2018), the Cochrane Central Register of Controlled Trials (CENTRAL; 2018, Issue 6) in the Cochrane Library (searched 26 June 2018), MEDLINE (26 June 2018), Embase (26 June 2018), the Cumulative Index to Nursing and Allied Health Literature (CINAHL) (26 June 2018), Web of Science Core Collection (26 June 2018), SpeechBITE (28 June 2016), ClinicalTrials.Gov (26 June 2018), and the World Health Organization International Clinical Trials Registry Platform (26 June 2018). We also searched Google Scholar (7 June 2018) and the reference lists of relevant trials and review articles.

SELECTION CRITERIA

We sought to include randomised controlled trials (RCTs) of interventions for people with dysphagia and recent stroke (within six months).

DATA COLLECTION AND ANALYSIS

Two review authors independently applied the inclusion criteria, extracted data, assessed risk of bias, used the GRADE approach to assess the quality of evidence, and resolved disagreements through discussion with the third review author (PB). We used random-effects models to calculate odds ratios (ORs), mean differences (MDs), and standardised mean differences (SMDs), and provided 95% confidence intervals (CIs) for each.The primary outcome was functional outcome, defined as death or dependency (or death or disability), at the end of the trial. Secondary outcomes were case fatality at the end of the trial, length of inpatient stay, proportion of participants with dysphagia at the end of the trial, swallowing ability, penetration aspiration score, or pneumonia, pharyngeal transit time, institutionalisation, and nutrition.

MAIN RESULTS

We added 27 new studies (1777 participants) to this update to include a total of 41 trials (2660 participants).We assessed the efficacy of swallowing therapy overall and in subgroups by type of intervention: acupuncture (11 studies), behavioural interventions (nine studies), drug therapy (three studies), neuromuscular electrical stimulation (NMES; six studies), pharyngeal electrical stimulation (PES; four studies), physical stimulation (three studies), transcranial direct current stimulation (tDCS; two studies), and transcranial magnetic stimulation (TMS; nine studies).Swallowing therapy had no effect on the primary outcome (death or dependency/disability at the end of the trial) based on data from one trial (two data sets) (OR 1.05, 95% CI 0.63 to 1.75; 306 participants; 2 studies; I² = 0%; P = 0.86; moderate-quality evidence). Swallowing therapy had no effect on case fatality at the end of the trial (OR 1.00, 95% CI 0.66 to 1.52; 766 participants; 14 studies; I² = 6%; P = 0.99; moderate-quality evidence). Swallowing therapy probably reduced length of inpatient stay (MD -2.9, 95% CI -5.65 to -0.15; 577 participants; 8 studies; I² = 11%; P = 0.04; moderate-quality evidence). Researchers found no evidence of a subgroup effect based on testing for subgroup differences (P = 0.54). Swallowing therapy may have reduced the proportion of participants with dysphagia at the end of the trial (OR 0.42, 95% CI 0.32 to 0.55; 1487 participants; 23 studies; I² = 0%; P = 0.00001; low-quality evidence). Trial results show no evidence of a subgroup effect based on testing for subgroup differences (P = 0.91). Swallowing therapy may improve swallowing ability (SMD -0.66, 95% CI -1.01 to -0.32; 1173 participants; 26 studies; I² = 86%; P = 0.0002; very low-quality evidence). We found no evidence of a subgroup effect based on testing for subgroup differences (P = 0.09). We noted moderate to substantial heterogeneity between trials for these interventions. Swallowing therapy did not reduce the penetration aspiration score (i.e. it did not reduce radiological aspiration) (SMD -0.37, 95% CI -0.74 to -0.00; 303 participants; 11 studies; I² = 46%; P = 0.05; low-quality evidence). Swallowing therapy may reduce the incidence of chest infection or pneumonia (OR 0.36, 95% CI 0.16 to 0.78; 618 participants; 9 studies; I² = 59%; P = 0.009; very low-quality evidence).

AUTHORS' CONCLUSIONS

Moderate- and low-quality evidence suggests that swallowing therapy did not have a significant effect on the outcomes of death or dependency/disability, case fatality at the end of the trial, or penetration aspiration score. However, swallowing therapy may have reduced length of hospital stay, dysphagia, and chest infections, and may have improved swallowing ability. However, these results are based on evidence of variable quality, involving a variety of interventions. Further high-quality trials are needed to test whether specific interventions are effective.

Quantitative Analysis of Swallowing Function Between Dysphagia Patients and Healthy Subjects Using High-Resolution Manometry

Objective

To compare swallowing function between healthy subjects and patients with pharyngeal dysphagia using high resolution manometry (HRM) and to evaluate the usefulness of HRM for detecting pharyngeal dysphagia.

Methods

Seventy-five patients with dysphagia and 28 healthy subjects were included in this study. Diagnosis of dysphagia was confirmed by a videofluoroscopy. HRM was performed to measure pressure and timing information at the velopharynx (VP), tongue base (TB), and upper esophageal sphincter (UES). HRM parameters were compared between dysphagia and healthy groups. Optimal threshold values of significant HRM parameters for dysphagia were determined.

Results

VP maximal pressure, TB maximal pressure, UES relaxation duration, and UES resting pressure were lower in the dysphagia group than those in healthy group. UES minimal pressure was higher in dysphagia group than in the healthy group. Receiver operating characteristic (ROC) analyses were conducted to validate optimal threshold values for significant HRM parameters to identify patients with pharyngeal dysphagia. With maximal VP pressure at a threshold value of 144.0 mmHg, dysphagia was identified with 96.4% sensitivity and 74.7% specificity. With maximal TB pressure at a threshold value of 158.0 mmHg, dysphagia was identified with 96.4% sensitivity and 77.3% specificity. At a threshold value of 2.0 mmHg for UES minimal pressure, dysphagia was diagnosed at 74.7% sensitivity and 60.7% specificity. Lastly, UES relaxation duration of <0.58 seconds had 85.7% sensitivity and 65.3% specificity, and UES resting pressure of <75.0 mmHg had 89.3% sensitivity and 90.7% specificity for identifying dysphagia.

Conclusion

We present evidence that HRM could be a useful evaluation tool for detecting pharyngeal dysphagia.

Change in Excitability of Cortical Projection After Modified Catheter Balloon Dilatation Therapy in Brainstem Stroke Patients with Dysphagia: A Prospective Controlled Study

Although the modified balloon dilatation therapy has been demonstrated to improve pharyngeal swallowing function post stroke, the underlying neural mechanisms of improvement are unknown. Our aims are (1) to investigate the effect of modified balloon dilatation on the excitability of corticobulbar projections to the submental muscle in dysphagic patients with brainstem stroke and (2) the relation between changes in excitability and pharyngeal kinematic modifications. Thirty patients with upper esophageal sphincter (UES) dysfunction due to unilateral brainstem stroke were recruited into two groups. The patients in dilatation group received modified balloon dilatation and conventional therapies, and those in control were only treated by conventional therapies (twice per day). The amplitudes of bilateral submental motor evoked potentials (MEPs) induced by transcranial magnetic stimulations over bilateral motor cortex, diameters of UES opening (UOD) and maximal displacement of hyoid (HD) were all assessed at baseline and the endpoint of treatments. Repeated ANOVA analysis revealed significant main effect of group, time and MEP laterality on MEP amplitudes (p = 0.02). There were no differences in the pretreatment measures between groups (all p > 0.05). After treatment, the amplitudes of affected submental MEP evoked by ipsilateral cortical pulse as well as UOD and HD were significantly different in dilatation group compared to control (amplitude: p = 0.02, UOD: p < 0.001, HD: p = 0.03). The differences of pre- and post-treatment amplitudes of the affected MEP evoked by ipsilateral stimulation showed a positive correlation with the improvement of HD (dilatation: R ² = 0.51, p = 0.03; control: R ² = 0.39, p = 0.01), rather than UOD in both groups (all p > 0.05). In conclusion, modified balloon dilatation therapy can increase the excitability of affected projection in patients with unilateral brainstem stroke.

Failed Deglutitive Upper Esophageal Sphincter Relaxation Is a Risk Factor for Aspiration in Stroke Patients with Oropharyngeal Dysphagia

Background/Aims

We attempted to examine the relationship between abnormal findings on high-resolution manometry (HRM) and videofluoroscopic swallowing study (VFSS) of the pharynx and upper esophageal sphincter (UES), and to identify the risk factors for aspiration.

Methods

We performed VFSS and HRM on the same day in 36 ischemic stroke patients (mean age, 67.5 years) with dysphagia. Pressure (basal, median intra bolus, and nadir), relaxation time interval of the UES, and mesopharyngeal and hypopharyngeal contractility (as a contractile integral) were examined using HRM. The parameters of VFSS were vallecular residue, pyriform sinus residue, vallecular overflow, penetration, and aspiration. The association between the parameters of VFSS and HRM was analyzed by the Student’s t test.

Results

Three (8.3%) and 4 (11.1%) stroke patients with dysphagia had pyriform sinus residue and vallecular sinus residue, respectively, and 5 (13.8%) patients showed aspiration. Mesopharyngeal and hypopharyngeal contractile integrals in patients with residue in the pyriform sinus were significantly lower than those in patients without residue in the pyriform sinus (P < 0.05). Relaxation time intervals in patients with aspiration were significantly shorter than those in patients without aspiration (P < 0.05), and multivariate regression analysis revealed a shorter relaxation time interval as the main risk factor for aspiration (OR, 0.03; 95% CI, 0.01–0.65; P < 0.05).

Conclusions

Manometric measurements of the pharynx and UES were well correlated with abnormal findings in the VFSS, and a shorter relaxation time interval of the UES during deglutition is an important parameter for the development of aspiration.

Pressure topography metrics for high-resolution pharyngeal-esophageal manofluorography-a normative study of younger and older adults

BACKGROUND

We aimed to define normative values for novel pressure topography metrics for high-resolution pharyngeal-esophageal manofluorography. The effects of age, gender, and bolus properties were examined.

METHODS

Concurrent high-resolution manometry (HRM) and videofluoroscopy data were collected from 22 younger (aged 21-40) and 22 older (aged 60-80) healthy subjects. Pressure topography was analyzed by correlating pressure domains with videofluoroscopic events. Nine pressure topography metrics of the pharyngeal and proximal esophageal swallow were extracted; four of these were also compared with previously obtained esophageal HRM studies to assess the effects of catheter diameter.

KEY RESULTS

Older individuals exhibited more vigorous contractility in the pharynx than did younger subjects with all bolus types, but the greatest values for both groups were with effortful swallow and on that measure the age groups were similar. Upper esophageal sphincter (UES) intrabolus pressure during sphincter opening was also greater in the older subjects. Some gender differences were observed, particularly related to proximal esophageal contractile vigor. Bolus consistency had no consistent effect. Studies using the larger catheter diameter resulted in significantly greater contractile vigor in the UES and proximal esophagus.

CONCLUSIONS & INFERENCES

Older adults exhibited more vigorous pharyngeal contractions than young adults, albeit within a similar range of capacity, perhaps reflecting a compensatory response to other age-related physiological changes. Greater UES intrabolus pressures observed during bolus transit in the older group likely reflect reduced UES compliance with age. Normative data on novel HRM metrics collected in this study can serve as a reference for future clinical studies.

Predicting the activation states of the muscles governing upper esophageal sphincter relaxation and opening

The swallowing muscles that influence upper esophageal sphincter (UES) opening are centrally controlled and modulated by sensory information. Activation and deactivation of neural inputs to these muscles, including the intrinsic cricopharyngeus (CP) and extrinsic submental (SM) muscles, results in their mechanical activation or deactivation, which changes the diameter of the lumen, alters the intraluminal pressure, and ultimately reduces or promotes flow of content. By measuring the changes in diameter, using intraluminal impedance, and the concurrent changes in intraluminal pressure, it is possible to determine when the muscles are passively or actively relaxing or contracting. From these "mechanical states" of the muscle, the neural inputs driving the specific motor behaviors of the UES can be inferred. In this study we compared predictions of UES mechanical states directly with the activity measured by electromyography (EMG). In eight subjects, pharyngeal pressure and impedance were recorded in parallel with CP- and SM-EMG activity. UES pressure and impedance swallow profiles correlated with the CP-EMG and SM-EMG recordings, respectively. Eight UES muscle states were determined by using the gradient of pressure and impedance with respect to time. Guided by the level and gradient change of EMG activity, mechanical states successfully predicted the activity of the CP muscle and SM muscle independently. Mechanical state predictions revealed patterns consistent with the known neural inputs activating the different muscles during swallowing. Derivation of "activation state" maps may allow better physiological and pathophysiological interpretations of UES function.

Oropharyngeal dysphagia: manifestations and diagnosis

Swallowing disorders (dysphagia) have been recognized by the WHO as a medical disability associated with increased morbidity, mortality and costs of care. With increasing survival rates and ageing of the population, swallowing disorders and their role in causing pulmonary and nutritional pathologies are becoming exceedingly important. Over the past two decades, the study of oropharyngeal dysphagia has been approached from various disciplines with considerable progress in understanding its pathophysiology. This Review describes the most frequent manifestations of oropharyngeal dysphagia and the clinical as well as instrumental techniques that are available to diagnose patients with dysphagia. However, the clinical value of these diagnostic tests and their sensitivity to predict outcomes is limited. Despite considerable clinical research efforts, conventional diagnostic methods for oropharyngeal dysphagia have limited proven accuracy in predicting aspiration and respiratory disease. We contend that incorporation of measurable objective assessments into clinical diagnosis is needed and might be key in developing novel therapeutic strategies.

Effects of Head Rotation and Head Tilt on Pharyngeal Pressure Events Using High Resolution Manometry

Objective

To observe changes in pharyngeal pressure during the swallowing process according to postures in normal individuals using high-resolution manometry (HRM).

Methods

Ten healthy volunteers drank 5 mL of water twice while sitting in a neutral posture. Thereafter, they drank the same amount of water twice in the head rotation and head tilting postures. The pressure and time during the deglutition process for each posture were measured with HRM. The data obtained for these two postures were compared with those obtained from the neutral posture.

Results

The maximum pressure, area, rise time, and duration in velopharynx (VP) and tongue base (TB) were not affected by changes in posture. In comparison, the maximum pressure and the pre-upper esophageal sphincter (UES) maximum pressure of the lower pharynx in the counter-catheter head rotation posture were lower than those in the neutral posture. The lower pharynx pressure in the catheter head tilting posture was higher than that in the counter-catheter head tilting. The changes in the VP peak and epiglottis, VP and TB peaks, and the VP onset and post-UES time intervals were significant in head tilting and head rotation toward the catheter postures, as compared with neutral posture.

Conclusion

The pharyngeal pressure and time parameter analysis using HRM determined the availability of head rotation as a compensatory technique for safe swallowing. Tilting the head smoothes the progress of food by increasing the pressure in the pharynx.

Upper esophageal sphincter mechanical states analysis: a novel methodology to describe UES relaxation and opening

The swallowing muscles that influence upper esophageal sphincter (UES) opening are centrally controlled and modulated by sensory information. Activation of neural inputs to these muscles, the intrinsic cricopharyngeus muscle and extrinsic suprahyoid muscles, results in their contraction or relaxation, which changes the diameter of the lumen, alters the intraluminal pressure and ultimately inhibits or promotes flow of content. This relationship that exists between the changes in diameter and concurrent changes in intraluminal pressure has been used previously to calculate the “mechanical states” of the muscle; that is when the muscles are passively or actively, relaxing or contracting. Diseases that alter the neural pathways to these muscles can result in weakening the muscle contractility and/or decreasing the muscle compliance, all of which can cause dysphagia. Detecting these changes in the mechanical state of the muscle is difficult and as the current interpretation of UES motility is based largely upon pressure measurement (manometry), subtle changes in the muscle function during swallow can be missed. We hypothesized that quantification of mechanical states of the UES and the pressure-diameter properties that define them, would allow objective characterization of the mechanisms that govern the timing and extent of UES opening during swallowing. To achieve this we initially analyzed swallows captured by simultaneous videofluoroscopy and UES pressure with impedance recording. From these data we demonstrated that intraluminal impedance measurements could be used to determine changes in the internal diameter of the lumen when compared to videofluoroscopy. Then using a database of pressure-impedance studies, recorded from young and aged healthy controls and patients with motor neuron disease, we calculated the UES mechanical states in relation to a standardized swallowed bolus volume, normal aging and dysphagia pathology. Our results indicated that eight different mechanical states were almost always seen during healthy swallowing and some of these calculated changes in muscle function were consistent with the known neurally dependent phasic discharge patterns of cricopharyngeus muscle activity during swallowing. Clearly defined changes in the mechanical states were observed in motor neuron disease when compared to age matched healthy controls. Our data indicate that mechanical state predictions were simple to apply and revealed patterns consistent with the known neural inputs activating the different muscles during swallowing.