Prevalence and risk factors for dysphagia: a USA community study

Prevalence of Dysphonia and Dysphagia Among Adults in the United States in 2012 and 2022

PURPOSE

The purpose of this study was to compare the prevalence of dysphonia and dysphagia among adults in the United States between 2012 and 2022.

METHOD

A retrospective and cross-sectional design with national surveys was used. The 2012 and 2022 National Health Interview Surveys were utilized to estimate the number of adults reporting dysphonia and dysphagia in the past 12 months. Multivariate logistic regression models were used to examine associations between the survey year (2022 vs. 2012) and the prevalence rate of dysphonia and dysphagia while accounting for demographics and clinical characteristics.

RESULTS

The population-estimated mean age was 46.63 years in 2012, which increased to 48.12 years in 2022. In 2012, adults reporting dysphonia and dysphagia were 17.89 million (7.62%) and 9.44 million (4.02%), respectively. In 2022, these estimates increased to 29.92 million adults (11.71%) and 15.10 million adults (5.91%), respectively. Adults in 2022 had significantly higher odds for reporting dysphonia (odds ratio [OR] = 1.602, 95% confidence intervals [CIs] [1.486, 1.726], p < .0001) and dysphagia (OR = 1.461, 95% CI [1.328, 1.606], p < .0001) in the past 12 months compared to adults in 2012.

CONCLUSIONS

The population-estimates indicated that in 2022, dysphonia affected one in 8.5 adults and dysphagia affected one in 17 adults. The increase in prevalence of these disorders should serve as a call-to-action to improve access to care and research for voice and swallowing disorders.

The prevalence of gastroesophageal reflux disease and laryngopharyngeal reflux in patients with dysphagia after radiotherapy for nasopharyngeal carcinoma

BACKGROUND

The prevalence of gastroesophageal reflux disease (GERD) and laryngopharyngeal reflux (LPR) in post-irradiated patients with nasopharyngeal carcinoma (NPC) is unknown.

MATERIALS AND METHODS

In a cross-sectional study, 31 NPC and 12 control patients completed questionnaires for GERD/LPR before esophageal manometry and 24-h pH monitoring. The DeMeester score and reflux finding score (RFS) were used to define GERD and LPR, respectively. Risk factors were identified.

RESULTS

51.6% of NPC and 8.3% of control patients, and 77.4% of NPC and 33% of control patients, were GERD-positive and LPR-positive, respectively. The GERD/LPR questionnaire failed to identify either condition in patients with NPC. No parameter differences in esophageal manometry or pneumonia incidence were noted between GERD/LPR-positive and GERD/LPR-negative patients. Post radiotherapy duration, high BMI, lack of chemotherapy, and dysphagia were positive risk factors for GERD/LPR.

CONCLUSIONS

A high prevalence of GERD/LPR in patients with post-irradiated NPC exists, but reflux symptoms are inadequate for diagnosis.

Comprehensive assessment and treatment strategies for dysphagia in the elderly population: Current status and prospects

As the population ages, the prevalence of dysphagia among older adults is a growing concern. Age-related declines in physiological function, coupled with neurological disorders and structural changes in the pharynx associated with aging, can result in weakened tongue propulsion, a prolonged reaction time of the submental muscles, delayed closure of the laryngeal vestibule, and delayed opening of the upper esophageal sphincter (UES), increasing the risk of dysphagia. Dysphagia impacts the physical health of the elderly, leading to serious complications such as dehydration, aspiration pneumonia, malnutrition, and even life-threatening conditions, and it also detrimentally affects their psychological and social well-being. There is a significant correlation between frailty, sarcopenia, and dysphagia in the elderly population. Therefore, older adults should be screened for dysphagia to identify both frailty and sarcopenia. A reasonable diagnostic approach for dysphagia involves screening, clinical assessment, and instrumental diagnosis. In terms of treatment, multidisciplinary collaboration, rehabilitation training, and the utilization of new technologies are essential. Future research will continue to concentrate on these areas to enhance the diagnosis and treatment of dysphagia, with the ultimate aim of enhancing the quality of life of the elderly population.

Enhancing drug administration flexibility: evaluation of pharmacokinetic properties of tegoprazan orally disintegrating tablet (ODT) administered via nasogastric tube or oral dosing

Tegoprazan orally disintegrating tablet (ODT) formulation is a novel formulation to improve a convenience in comparison to taking the conventional tablet of tegoprazan, a potassium-competitive acid blocker. The purpose of this study was to evaluate the pharmacokinetic and safety profiles of tegoprazan ODT when administered via two routes: nasogastric tube or oral dosing. This study is expected to expand the administration route of tegoprazan ODT. The study was conducted in an open-label, randomized, single-dose, two-way crossover design with a 1-week washout period. Healthy subjects aged 19 to 45 years were administered 50 mg of tegoprazan ODT orally or dissolved in water via nasogastric tube. Tegoprazan, the active ingredient, was quantified using a ultra-high performance liquid chromatography tandem mass spectroscopy (UPLC-MS/MS), and pharmacokinetic parameters were determined through non-compartmental analysis. Safety was monitored throughout the study. A total of 48 subjects, successfully completed the trial. The geometric mean ratios for log-transformed Cmax and AUCt, representing the ratio of nasogastric tube group to oral dosing group, along with 90% confidence intervals, were 1.1087 (1.0243-1.2000) and 1.0023 (0.9620-1.0442), respectively. All adverse events were unrelated to tegoprazan and mild in intensity. The pharmacokinetic profiles of tegoprazan ODT were equivalent between the nasogastric tube and oral administration. Considering the demonstrated linear pharmacokinetics and concentration-dependent pharmacodynamics of tegoprazan, the administration via nasogastric tube is expected to yield effects equivalent to those of oral administration. This approach offers a viable alternative, especially beneficial for patients with oral intake difficulties.

Advancements and Challenges in Non-Invasive Sensor Technologies for Swallowing Assessment: A Review

Dysphagia is a pervasive health issue that impacts diverse demographic groups worldwide, particularly the elderly, stroke survivors, and those suffering from neurological disorders. This condition poses substantial health risks, including malnutrition, respiratory complications, and increased mortality. Additionally, it exacerbates economic burdens by extending hospital stays and escalating healthcare costs. Given that this disorder is frequently underestimated in vulnerable populations, there is an urgent need for enhanced diagnostic and therapeutic strategies. Traditional diagnostic tools such as the videofluoroscopic swallowing study (VFSS) and flexible endoscopic evaluation of swallowing (FEES) require interpretation by clinical experts and may lead to complications. In contrast, non-invasive sensors offer a more comfortable and convenient approach for assessing swallowing function. This review systematically examines recent advancements in non-invasive swallowing function detection devices, focusing on the validation of the device designs and their implementation in clinical practice. Moreover, this review discusses the swallowing process and the associated biomechanics, providing a theoretical foundation for the technologies discussed. It is hoped that this comprehensive overview will facilitate a paradigm shift in swallowing assessments, steering the development of technologies towards more accessible and accurate diagnostic tools, thereby improving patient care and treatment outcomes.

Assessing Adhesiveness Levels in a Dysphagia Diet for Older Adults

BACKGROUND

Viscosity is a common focus in the diet of patients with dysphagia. However, adhesiveness is an equally significant property that can affect swallowing function, even in semi-solid foods with similar levels of viscosity. The purpose of this study was to classify the adhesiveness of food into stages and determine whether these classifications are relevant to swallowing function.

METHODS

This study included 30 healthy elderly adults aged 65 years. After categorizing adhesiveness into three levels based on the results of the sensory test, 30 participants were asked to swallow representative foods at each level. A videofluoroscopic swallowing study (VFSS) was performed to determine the presence or absence of pharyngeal residues based on the level of adhesiveness. The chi-square test was used to verify whether there was a difference in remnants according to the level of adhesiveness, and significance was judged with a p-value of less than 0.05.

RESULTS

Adhesiveness was categorized into three distinct levels: level 1 (0-4 mJ), level 2 (4-18 mJ), and level 3 (>18 mJ). Upon examining the subjects presenting with residual material, we observed three cases of level 1 adhesiveness, 16 cases of level 2, and 25 cases of level 3. The chi-square test was used to assess the statistical significance between the levels, revealing a significant difference with a p-value < 0.0001.

CONCLUSIONS

We presented the level of adhesiveness by dividing it into three stages and proved that it is meaningful in relation to the swallowing function. Selecting and recommending foods with an appropriate level of adhesiveness will help enhance swallowing safety in older adults.

The associations of daily steps and body mass index with incident gastroesophageal reflux disease in older adults

Background

High body mass index (BMI) is a major risk factor of gastroesophageal reflux disease (GERD), a prevalent morbidity of older adulthood linked to lower quality of life and an increased risk of esophageal cancers. Daily stepping behavior, the most common physical activity of older adulthood, is associated with an array of favorable health outcomes, sometimes independent of high BMI. Whether stepping behavior is associated with the incidence of GERD independently or in combination with BMI is currently unclear.

Materials and methods

We followed 442 individuals (58.4% female) aged 65-91 years enrolled in the Physical Activity and Aging Study. Baseline steps were obtained by pedometer and categorized by tertiles (lower, middle, upper), while BMI was categorized into normal weight, overweight, and obesity. To explore joint associations, daily steps were dichotomized into "high steps" (middle/upper tertiles) and "low steps" (lower tertile), while BMI was dichotomized into normal weight and overweight/obesity. The joint exposure categories included "low steps and overweight/obesity," "low steps and normal weight," "high steps and overweight/obesity," and "high steps and normal weight."

Results

We identified 35 (7.9%) cases of GERD over a mean follow-up of 2.5 years. Compared to the lower tertile of steps, the hazard ratios (HRs) [95% confidence intervals (95% CIs)] of GERD were 0.44 (0.20-0.96) and 0.17 (0.05-0.54) for the middle and upper tertiles, respectively, after adjusting for confounders (including BMI). Compared to normal weight, the HRs (95% CIs) of GERD were 1.35 (0.54-3.37) and 3.00 (1.19-7.55) for overweight and obesity, respectively, after adjusting for confounders (including steps). In a joint analysis, compared to "low steps and overweight/obesity," the HRs (95% CIs) of GERD were 0.32 (0.10-1.00), 0.23 (0.10-0.54), and 0.20 (0.07-0.58) for "low steps and normal weight," "high steps and overweight/obesity," and "high steps and normal weight," respectively.

Conclusion

Higher daily steps were associated with a lower risk of GERD in older adults, independent of BMI. Since accumulating steps through walking is an achievable and acceptable modality of physical activity in older adulthood, future lifestyle interventions designed to achieve high daily steps counts may have favorable implications for the development of GERD in older adults of any BMI status.

Contained Rupture of a Thoracic Aortic Aneurysm: A Rare and Life-Threatening Cause of Dysphagia

Dysphagia is commonly seen in the elderly and has both benign and malignant causes. A difficulty in swallowing due to the esophageal compression by the aorta, or dysphagia aortica, is a rare entity, little described in literature. However, diagnostic error or diagnostic and treatment delays of aortic dysphagia can be fatal. Herein, we report a case of dysphagia aortica caused by the contained rupture of a descending aneurysmatic thoracic aorta, presenting at the emergency department with acute dysphagia and diffuse chest pain, successfully treated by thoracic endovascular aneurysm repair.

Crushing tablets or sprinkling capsules: Implications for clinical strategy and study performance based on BE studies of rivaroxaban and deferasirox

Administration of oral medicinal products as crushed tablets or open capsules is an important delivery option for patients suffering from dysphagia. To obtain full interchangeability of generics with the original products, demonstration of bioequivalence (BE) between both products administered as crushed tablets/open capsules was required for poorly soluble product by European Medicines Agency (EMA) at the time of development of our rivaroxaban and deferasirox generic products. We present the results of two BE studies with modified administration of these products, which compared relative bioavailability between generic and reference products. In the rivaroxaban study, the test product was administered as a capsule sprinkled on and mixed with applesauce, whereas the reference tablet was crushed and administered with applesauce under fed conditions. In the deferasirox study, both treatments were administered as crushed tablets under fasting conditions. Both studies applied a two-way crossover design and were conducted after a single-dose in healthy volunteers. The 90% confidence interval of the geometric mean ratio area under the analyte concentration versus time curve, from time zero to the time of the last measurable analyte concentration and maximum measured analyte concentration over the sampling period of the test to reference ratio were 103.36-110.37% and 97.98-108.45% for rivaroxaban, respectively, and 96.69-107.29% and 94.19-109.45% for deferasirox, respectively. Thus, the BE criteria (80.00-125.00%) were met in both studies which demonstrated that bioavailability was not affected when the test and reference products were administered in the form of crushed tablet/open capsule. These results support the argument of redundancy of crushed product studies for poorly soluble drugs, which is in line with the currently revised position of the EMA on this topic.

Laryngological Complaint Prevalence in Hypermobile Ehlers-Danlos or Hypermobility Spectrum Disorders

OBJECTIVE

The aim was to study laryngological complaints in patients with hypermobile Ehlers-Danlos syndrome (hEDS) or hypermobility spectrum disorders (HSD).

METHODS

A total of 363 patients met inclusion for the study by completing questions related to voice, upper airway, and swallowing between July 7, 2020 and July 13, 2022. Demographic data, voice-related questions, and hypermobility diagnosis were analyzed retrospectively. From those, 289 patients were diagnosed with hEDS or HSD with 74 that did not meet the diagnostic criteria for either diagnosis serving as controls.

RESULTS

There were no statistically significant differences between patients with hEDS and HSD regarding Voice Handicap Index (VHI-10) scores, voice, upper airway, or swallow complaints. However, more hEDS/HSD patients answered positively to the laryngeal dysfunction question versus controls (p = 0.031). 22.5% of hEDS/HSD patients (n = 65) reported hoarseness, of which 52.3% reported hoarseness >2 days/month. 33.9% (n = 98) with hEDS/HSD reported symptoms of dysphagia, and 27.0% (n = 78) reported laryngeal dysfunction symptoms. Controls demonstrated 20.3% prevalence of hoarseness, of which 46.7% reported hoarseness >2 days/month. 24.3% of controls had dysphagia and 14.9% laryngeal dysfunction symptoms. Of the 363 patients, VHI-10 scores >11 were more likely in patients reporting >2 days of hoarseness/month (p = 0.001) versus those with <2 days of hoarseness/month. There was an increased prevalence of voice, upper airway, and dysphagia symptoms in hEDS/HSD patients compared with previously reported prevalence data in the general population.

CONCLUSION

A significant proportion of patients diagnosed with hypermobility due to hEDS or HSD were found to have voice, upper airway, and dysphagia symptoms. These rates are higher than those previously reported in the general population.

LEVEL OF EVIDENCE

3 Laryngoscope, 134:773-778, 2024.

Submucosal Epstein-Barr Virus Positive Polymorphic B-cell Lymphoproliferative Disorder of the Larynx: A Case Report

Epstein-Barr virus (EBV) belongs to the group of human herpes virus and can cause clinical and subclinical infections. Although EBV-related disease presentations are similar, they can lead to oncogenic transformation with various clinical manifestations. A thorough workup with morphology, immunohistochemistry, and molecular studies is crucial for the diagnosis of EBV-positive polymorphic B-cell lymphoproliferative disorder, not otherwise specified (NOS), which is a new entity introduced by International Consensus Classification in 2022. We describe an interesting presentation of EBV-positive polymorphic B-cell lymphoproliferative disorder with laryngeal involvement to bring awareness to this entity and we would like to address the need for more accessible treatment options.

Oral Health-Related Factors Associated with Dysphagia Risk among Older, Healthy, Community-Dwelling Korean Adults: A Pilot Study

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.

Factors affecting quality of life among patients with corrosive injury

This study aimed to investigate the factors influencing quality of life (QOL) among patients with corrosive injuries, considering the rising incidence of such cases, particularly in developing countries. Corrosive ingestion is a serious global public health problem and a common form of self-harm. This was a cross-sectional study using purposive sampling. A total of 82 patients with corrosive injuries who were admitted to the gastroenterology ward of a medical center in Taiwan between June 2018 and July 2020 completed the Perceived Stress Scale, Coping Strategy Scale, and World Health Organization Quality of Life Scale. We used an independent t-test and analysis of variance to examine the distribution and differences in demographic and disease characteristics, perceived stress, and the coping strategy scale. Multiple linear regression was then used to analyze the main predictors of QOL. The mean patient age was 58.2 (standard deviation = 2.4) years. A significant difference was observed between patients with a history of mental illness and perceived stress (P < .05). The patients were highly stressed and used emotional coping strategies to solve problems. Stress perception was significantly negatively correlated with overall QOL. Multiple linear regression analysis showed that a history of mental illness was a significant factor for overall QOL. The results of this study suggest that a history of mental illness significantly affects the QOL of patients with corrosive gastrointestinal injuries, and regular assessment and monitoring are essential.

Prevalence and risk factors for dysphagia in older adults after thyroid and parathyroid surgery

BACKGROUND

We aimed to determine the prevalence and risk factors for dysphagia in adults 65 years and older before and after thyroidectomy or parathyroidectomy.

METHODS

We performed a longitudinal prospective cohort study of older adults undergoing initial thyroidectomy or parathyroidectomy. We administered the Dysphagia Handicap Index questionnaire preoperatively and 1, 3, and 6 months postoperatively. We compared preoperative and postoperative total and domain-specific scores using paired t tests and identified risk factors for worse postoperative scores using multivariable logistic regression.

RESULTS

Of the 175 patients evaluated, the mean age was 71.1 years (range = 65-94), 73.7% were female, 40.6% underwent thyroidectomy, 57% underwent bilateral procedures, and 21.1% had malignant diagnoses. Preoperative swallowing dysfunction was reported by 77.7%, with the prevalence 22.4% greater in frail than robust patients (P = .013). Compared to preoperative scores, 43.4% and 49.1% had worse scores at 3 and 6 months postoperatively. Mean functional domain scores increased by 62.3% at 3 months postoperatively (P = .007). Preoperative swallowing dysfunction was associated with a 3.07-fold increased likelihood of worse functional scores at 3 months. Whereas frailty was associated with preoperative dysphagia, there was no association between worse postoperative score and age, sex, race, frailty, body mass index, smoking status, gastroesophageal reflux disease, comorbidity index, malignancy, surgical extent, or type of surgery.

CONCLUSION

Adults 65 years and older commonly report swallowing impairment preoperatively, which is associated with a 3.07-fold increased likelihood of worsened dysphagia after thyroid and parathyroid surgery that may persist up to 6 months postoperatively.

Prevalence of Stroke-Associated Pneumonia and Its Predictors Among Hyperglycaemia Patients During Acute Ischemic Stroke

BACKGROUND

Hyperglycaemia (HG) during an acute ischemic stroke (AIS) is not only associated with unfavourable functional outcomes but also associated with stroke-associated pneumonia (SAP). This study aimed to determine the prevalence of SAP among Malaysian patients with AIS and the predictors of SAP among patients with HG during AIS.

METHODS

This is a retrospective cross-sectional study that included patients with AIS admitted to Hospital Sultanah Nur Zahirah, Malaysia from 2017 to 2020. SAP was defined as infection with pneumonia during the first seven days after IS. HG was defined as a blood glucose level > 7.8 mmol/L within 72 h after admission. Patients with SAP were divided into two groups according to HG status. Multivariate logistic regression analysis was performed using SPSS software, version 22 (IBM Corp., Armonk, NY) to identify SAP predictors among patients with HG. Kaplan-Meier log-rank test was used to compare the survival rate from unfavourable functional outcomes between hyperglycaemic patients with and without SAP.

RESULTS

Among 412 patients with AIS, 69 (16.74%) had SAP. The prevalence of SAP among patients with HG and normoglycemia during AIS was 20.98%, and 10.65%, respectively. Age above 60 years, leucocytosis, and National Institute of Health Stroke Scale (NIHSS) > 14 on admission were independent predictors of SAP with aOR of 2.08 (95% CI;1.01-4.30), 2.83 (95% CI; 1.41-5.67), and 3.67 (95% CI; 1.53-8.80), respectively. No significant difference in unfavourable functional outcomes survival was found among patients with and without SAP (p = 0.653).

CONCLUSION

This study demonstrated the prevalence of SAP was higher among patients with HG compared to normoglycemia during AIS. The patient being old, leucocytosis and severe stroke upon admission predict the occurrence of SAP among patients with HG during AIS.

Current Approach to Dysphagia: A Review Focusing on Esophageal Motility Disorders and Their Treatment

Background

Dysphagia is a prevalent condition which may severely impact the patient's quality of life. However, there are still lacking standardized therapeutic options for esophageal motility disorders.

Summary

Dysphagia is defined as a subjective sensation of difficulty swallowing which can result from oropharyngeal or esophageal etiologies. Regarding esophageal dysphagia, after excluding structural causes and esophageal mucosal lesions, high-resolution manometry (HRM) is the gold standard for the diagnosis of esophageal motility disorders. HRM has not only improved the sensitivity for detecting achalasia but has also expanded our understanding of spastic and hypomotility disorders of the esophageal body. The Chicago Classification v4.0 uses a hierarchical approach and provides a standardized diagnosis of esophageal motility disorders, allowing a tailored therapeutic approach. Dysphagia is often a long-term health problem that broadly impacts health and well-being and leads to physical and psychosocial disability, namely, malnutrition and aspiration pneumonia, as well as social isolation, depression, and anxiety. Apart from achalasia, most esophageal motility disorders tend to have a benign long-term course with symptoms of dysphagia and noncardiac chest pain that can improve significantly over time. Patient-reported outcomes (PROs) are self-assessment tools that capture the patients' illness experience and help providers better understand symptoms from the patients' perspective. Therefore, PROs have a critical role in providing patient-centered care.

Key Messages

Motility disorders should be ruled out in the presence of nonobstructive esophageal dysphagia, and treatment options should be considered according to the severity of symptoms reported by the patient.

Crushed Tablet Administration for Patients with Dysphagia and Enteral Feeding: Challenges and Considerations

Dysphagia is increasingly common in older adults; it is especially prevalent in long-term care settings. Patients with dysphagia likely require pharmacologic treatment for multiple comorbidities but may find it difficult or impossible to swallow oral medications. Administering crushed medications mixed with a soft food or liquid vehicle, or via a feeding tube, is a common strategy to circumvent swallowing difficulties in patients with dysphagia. However, inappropriate medication use and improper crushing technique can reduce the medication dose a patient receives, alter medication pharmacokinetics and pharmacodynamics, and compromise treatment efficacy and patient safety. Clinical judgment is needed to identify medications that can and cannot be crushed, select a crushing methodology and vehicle for administering crushed medications, and create a strategy for administering multiple medications. A coordinated effort from the entire care team-including physicians, pharmacists, nurses, advanced practice providers, speech therapists, patients, and caregivers-is necessary to develop and implement an individualized plan for administering medications to patients with dysphagia. This review details the current literature regarding the administration of medications that have been altered, such as by crushing tablets or opening capsules, for patients with dysphagia or who are receiving enteral feeding and provides recommendations on best practices.

Dysphagia

Dysphagia is an important clinical symptom that increases in prevalence with age. Both oropharyngeal and esophageal processes can contribute to dysphagia, and these can be differentiated with a careful history. Neuromuscular processes are more prevalent than structural causes in oropharyngeal dysphagia, therefore, investigation should start with a modified barium swallow. In contrast, structural processes dominate in esophageal dysphagia, and endoscopy can offer biopsy and therapy by way of dilation. Manometry is performed for esophageal dysphagia when no structural etiology is found. Specific management of dysphagia is dependent on the etiology and mechanism of dysphagia.

Dysphagia in Neurological Disorders

Dysphagia is a common symptom in many neurologic disorders. Patients with oropharyngeal dysphagia present with difficulties when they start to swallow, often with coughing and choking; whereas patients with esophageal dysphagia describe the feeling that swallowed food stops in the chest. Chronic neurologic diseases such stroke, Parkinson's disease, or dementia often have dysphagia as a symptom, particularly oropharyngeal dysphagia, and the term "neurogenic dysphagia" is often used. A disruption of the sophisticated, integrated sensorimotor swallowing system is usually the main reason behind dysphagia. Dysphagia can be associated with aspiration leading to aspiration pneumonia, and chronic dysphagia can lead to weight loss and malnutrition. Patients with dysphagia, when accurately and promptly diagnosed through medical history, physical examination, and diagnostic tests, often can be treated and experience improved quality of life. The pathophysiological mechanisms behind dysphagia, its diagnosis, and potential treatments are discussed in this manuscript.

Impact of anxiety and depression on the swallowing process among patients with neurological disorders and head and neck neoplasia: systemic review

Background

Dysphagia is associated with depression and anxiety due to the severity, impact of symptoms itself or secondary to the underlying cause. This is more recognizable to brain diseases that has consequences common to the neural supply of the swallowing act and the cognition and behavior. Limited data are available to explore, quantitate and monitor these neurological outcomes. Our aim of this research to review the literature pertinent to depressive disorders, anxiety, and/or the quality of life (QoL) and psychological well-being. Search of Medline and Google Scholar databases for relevant articles had revealed a total of 1568 citations; 30 articles met the inclusion and exclusion criteria.

Results

Data about the direct effect of dysphagia on psychiatric aspects are limited. Studies of the relationship between severity of dysphagia and depressive symptoms demonstrated that several evaluation tools are available for objective and subjective assessment. The severity and progression of dysphagia was significantly associated with increased depressive symptoms.

Conclusion

Dysphagia is associated with and positively correlated to depression and anxiety scores observed in Parkinson disease (PD), multiple sclerosis (MS) and stroke. Similar association is observed in patients with head and neck cancer, tongue cancer and oral cancer. A bidirectional positive correlation exists with a vicious circle that loops between dysphagia and psychological disease. Moreover, the severity of dysphagia shows correlation with depression and/or anxiety scores (Fig. 1, Graphical abstract).

Graphical Abstract

Impact of varying food hardness on mastication/swallowing

The purpose of this study was to analyze mastication and swallowing in the elderly and confirm the association with dysphagia characteristics. A questionnaire was developed to evaluate the masticating and swallowing functions of the elderly. Mastication was analyzed using electromyography, and tongue/lip pressures were measured using Iowa Oral Performance Instrument. The results of the questionnaire showed that statistical difference in the number of teeth between the group without and with, decreased ability to swallow, and there was a correlation with lip pressure. Additionally, the higher number of teeth, the higher muscle activity, and there is a positive correlation between the number of chews and the lip pressure. Consequently, our findings suggested oral health parameters are closely associated with mastication/swallowing ability. Finally, based on the results obtained for different foods tested, we suggested that texture-modified foods are necessary to enhance swallowing ability.

Disparities in the prevalence of self-reported dysphagia and treatment among U.S. adults

OBJECTIVE

To assess sociodemographic differences in the prevalence of self-reported dysphagia and treatment and to identify barriers in access to care.

STUDY DESIGN

Cross-sectional analysis.

SETTING

National healthcare survey database.

METHODS

The 2012 National Health Interview Survey was used to analyze adults who reported a swallowing problem in the prior 12 months. Associations of sociodemographic variables with dysphagia prevalence and treatment as well as access to care were determined by multivariate logistic regression.

RESULTS

Among 235 million adults in the United States, 9.4 ± 0.3 million (4.0 % ± 0.1 %) adults (mean age 52.1 ± 0.6 years; 60.2 % female) reported swallowing problems, only 19.2 % ± 2.0 % of whom reported receiving treatment or therapy for their swallowing problem. In a multivariate model controlling for sociodemographic factors, female gender, older age, lower income level, public insurance status and unemployment were independently associated with increased odds of reporting dysphagia, while also associated with decreased odds of receiving treatment. Conversely, Black, Hispanic and other racial/ethnic minorities were less likely to report swallowing problems, but among those who did report dysphagia, non-white adults were more likely to receive treatment. Barriers leading to delayed care for women, low-income adults and adults with public or no health insurance included cost, not being able to get an appointment soon enough, limited office hours, inability to get through to an office by phone, lack of transportation, and long office wait times.

CONCLUSION

Sociodemographic groups at higher risk for dysphagia are less likely to receive treatment. Targeted interventions are needed to address barriers to care.

LEVEL OF EVIDENCE

IV.

Defining dysphagia - a modified multi-professional Danish Delphi study

OBJECTIVE

To establish a generally accepted Danish definition of dysphagia to enhance collaboration across sectors and professions.

METHODS

The study was initiated by a multi-professional group of experienced researchers and board members of the Danish Society for Dysphagia. We used a modified Delphi methodology to achieve consensus among experienced health care professionals from different professions and contexts. The initial stage consisted of a literature search leading to the draft of different definitions followed by two Delphi rounds between professionals and a stakeholder consultation round.

RESULTS

We conducted two Delphi rounds until one definition was clearly preferred. A total of 194 participants responded in round one, and 279 in round two. Both rounds had a broad representation of sectors and geography and most participants had worked with dysphagia for more than four years.

CONCLUSION

The preferred definition was 'Dysphagia is a functional impairment that either prevents or limits the intake of food and fluids, and which makes swallowing unsafe, inefficient, uncomfortable or affects quality of life'. The definition was widely accepted among different health professional groups, patients and across sectors.

The role of pH-impedance monitoring in swallowing disorders

PURPOSE OF REVIEW

To review the current evidence about the usefulness and the place of pH study in the management of patients with swallowing disorders.

RECENT FINDINGS

Gastroesophageal reflux disease (GERD) and laryngopharyngeal reflux (LPR) are found in approximately 30% of patients with esophageal or oropharyngeal dysphagia. Patients with suspected GERD may benefit from gastrointestinal endoscopy and proton pump inhibitors according to guidelines. The diagnosis of LPR in patients with oropharyngeal dysphagia is more controversial because there are no gold standard and diagnostic guidelines. The clinical diagnosis based on empirical therapeutic trial is a reasonable first-line strategy, but many dysphagic patients should not respond to treatment. These patients require hypopharyngeal-esophageal multichannel intraluminal impedance-pH monitoring (HEMII-pH), which is the most effective examination providing important information on GERD and LPR features. At the HEMII-pH, GERD patients often report upright (daytime) and supine (nighttime) liquid acid esophageal events with significant esophageal distal acid exposure time. LPR patients have more frequently upright (daytime) gaseous weakly acid or nonacid pharyngeal reflux events without distal esophageal acid exposure abnormalities in many times. The features of reflux at the HEMII-pH may indicate a personalized treatment for dysphagic patients combining proton pump inhibitors, alginate/magaldrate or gastroprokinetic in cases of esophageal dysmotility.

SUMMARY

GERD and LPR are prevalent causes of dysphagia. The large number of reflux patients who do not respond to empirical treatment makes important the awareness of otolaryngologists about pH-impedance monitoring indication, features, and interpretation.

The Brief Esophageal Dysphagia Questionnaire shows better discriminative capacity for clinical and manometric findings than the Eckardt score: Results from a multicenter study

INTRODUCTION

Grading dysphagia is crucial for clinical management of patients. The Eckardt score (ES) is the most commonly used for this purpose. We aimed to compare the ES with the recently developed Brief Esophageal Dysphagia Questionnaire (BEDQ) in terms of their correlation and discriminative capacity for clinical and manometric findings and evaluate the effect of gastroesophageal reflux symptoms on both.

METHODS

Symptomatic patients referred for high-resolution manometry (HRM) were prospectively recruited from seven centers in Spain and Latin America. Clinical data and several scores (ES, BEDQ, GERDQ) were collected and contrasted to HRM findings. Standard statistical analysis was performed.

KEY RESULTS

426 patients were recruited, 31.2% and 41.5% being referred exclusively for dysphagia and GERD symptoms, respectively. Both BEDQ and ES were independently associated with achalasia. Only BEDQ was independently associated with being referred for dysphagia and with relevant HRM findings. ROC curve analysis for achalasia diagnosis showed AUC of 0.809 for BEDQ and 0.765 for ES, with the main difference being higher BEDQ sensitivity (80.0% vs 70.8% for ES). GERDQ independently predicted ES but not BEDQ. In the absence of dysphagia (BEDQ = 0), GERD symptoms significantly determine ES.

CONCLUSIONS AND INFERENCES

Our study suggests both the BEDQ and ES can complementarily describe symptomatic burden in achalasia. BEDQ has several advantages over the ES in the dysphagia evaluation, basically due to its higher sensitivity for manometric diagnosis and independence of GERD symptoms. ES should be used as an achalasia-specific metric, while BEDQ is a better symptom-generic evaluating tool.

The Relationship Between Dysphagia and Pneumonia in Acute Stroke Patients: A Systematic Review and Meta-Analysis

Background

Dysphagia is a common complication after stroke and is associated with the development of pneumonia. This study aimed to summarize the relationship between dysphagia and pneumonia in post-stroke patients.

Materials and Methods

Articles published up to November 2021 were searched in the PubMed, Embase, Cochrane library, and Scopus databases. Studies that investigated the development of pneumonia in acute stroke patients with and without dysphagia were included. The methodological quality of individual studies was evaluated using the Risk Of Bias In Non-randomized Studies-of Interventions tool, and publication bias was evaluated using a funnel plot and Egger's test.

Results

Of 5,314 studies, five studies were included in the meta-analysis. The results revealed that the incidence of pneumonia was significantly higher in the dysphagia group than in the non-dysphagia group (OR 9.60; 95% CI 5.75–16.04; p &lt; 0.0001; I2 = 78%). There was no significant difference in the mortality rate between the two groups (OR 5.64; 95% CI 0.83–38.18; p = 0.08; I2 = 99%).

Conclusion

Dysphagia is a significant risk factor for pneumonia after stroke. The early diagnosis and treatment of dysphagia in stroke patients are important to prevent stroke-associated pneumonia.

A risk prediction model for dysphagia in older patients: a single-center prospective study

Surveys based on western populations have identified many risk factors for dysphagia in older people, but the potential risk factors consistent with the demographic characteristics of older, hospitalized Chinese patients require further study. This single-center prospective study aimed to determine the incidence of dysphagia in western China, and to develop and validate a model to predict the risk of dysphagia among older patients. A total of 343 inpatients (aged ≥ 65 years without dysphagia and cognitive impairment) were included. A score ≥ 2 on the Eating Assessment Tool-10 was defined as dysphagia. After a six-month follow-up, 70 (20.4%) patients were found to have dysphagia. The final model included age, wearing dentures, activities of daily living, cerebral vascular disease, coronary heart disease, and malignancy. The developed model has high predictive accuracy and can be easily implemented in daily practice.

Evaluation of post-operative dysphagia following anti-reflux surgery

BACKGROUND

Anti-reflux surgery (ARS) has known long-term complications, including dysphagia, bloat, and flatulence, among others. The factors affecting the development of post-operative dysphagia are poorly understood. We investigated the correlation of intra-operative esophagogastric junction (EGJ) characteristics and procedure type with post-operative dysphagia following ARS.

METHODS

Robotic ARS was performed on 197 consecutive patients with pathologic reflux utilizing EndoFLIP™ technology. Intraoperative EGJ measurements including distensibility index (DI), cross-sectional area (CSA), and high-pressure zone (HPZ) length were collected. Dysphagia was assessed pre-operatively and at 3 months post-operatively.

RESULTS

The median pre-operative DI for all procedures was 2.6 (IQR 1.6-4.5) mm²/mmHg. There was no difference in post-operative DI between procedures [Hill: 0.9 (IQR 0.7-1.1) mm²/mmHg, Nissen: 1.0 (IQR 0.7-1.4) mm²/mmHg, Toupet: 1.2 (IQR 0.8-1.5) mm²/mmHg, Linx: 1.0 (IQR 0.7-1.2) mm²/mmHg, p = 0.24], whereas post-operative HPZ length differed by augmentation type [Hill: 3 (IQR 2.8-3) cm, Nissen: 3.5 (IQR 3-3.5) cm, Toupet: 3 (IQR 2.5-3.5) cm, Linx: 2.5 (IQR 2.5-3) cm, p = 0.032]. Eighty-nine patients (45.2%) had pre-operative dysphagia. Thirty-two patients (27.6%) reported any dysphagia at their 3-month post-operative visit and 12 (10.3%) developed new or worsening post-operative dysphagia [Hill: 2/18 (11.1%), Nissen: 2/35 (5.7%), Toupet: 4/54 (7.4%), Linx: 4/9 (44.4%), p = 0.006]. The median pre-operative and post-operative DI of patients who developed new or worsening dysphagia was 2.0 (IQR 0.9-3.8) mm²/mmHg and 1.2 (IQR 1.0-1.8) mm²/mmHg, respectively, and that of those who did not was 2.5 (IQR 1.6-4.0) mm²/mmHg and 1.0 (IQR 0.7-1.4) mm²/mmHg (p = 0.21 and 0.16, respectively).

CONCLUSIONS

Post-operative DI was similar between procedures, and there was no correlation with new or worsening post-operative dysphagia. Linx placement was associated with higher rates of new or worsening post-operative dysphagia despite a shorter post-procedure HPZ length and similar post-operative DI when compared to other methods of LES augmentation.

Identifying Dysphagia and Demographic Associations in Older Adults Using Electronic Health Records: A National Longitudinal Observational Study in Wales (United Kingdom) 2008-2018

Dysphagia is increasingly being recognised as a geriatric syndrome (giant). There is limited research on the prevalence of dysphagia using electronic health records. To investigate associations between dysphagia, as recorded in electronic health records and age, frailty using the electronic frailty index, gender and deprivation (Welsh index of multiple deprivation). A Cross-sectional longitudinal cohort study in over 400,000 older adults was undertaken (65 +) in Wales (United Kingdom) per year from 2008 to 2018. We used the secure anonymised information linkage databank to identify dysphagia diagnoses in primary and secondary care. We used chi-squared tests and multivariate logistic regression to investigate associations between dysphagia diagnosis and age, frailty (using the electronic Frailty index), gender and deprivation. Data indicated < 1% of individuals were recorded as having a dysphagia diagnosis per year. We found dysphagia to be statistically significantly associated with older age, more severe frailty and individuals from more deprived areas. Multivariate analyses indicated increased odds ratios [OR (95% confidence intervals)] for a dysphagia diagnosis with increased age [reference 65-74: aged 75-84 OR 1.09 (1.07, 1.12), 85 + OR 1.23 (1.20, 1.27)], frailty (reference fit: mild frailty 2.45 (2.38, 2.53), moderate frailty 4.64 (4.49, 4.79) and severe frailty 7.87 (7.55, 8.21)] and individuals from most deprived areas [reference 5. Least deprived, 1. Most deprived: 1.10 (1.06, 1.14)]. The study has identified that prevalence of diagnosed dysphagia is lower than previously reported. This study has confirmed the association of dysphagia with increasing age and frailty. A previously unreported association with deprivation has been identified. Deprivation is a multifactorial problem that is known to affect health outcomes, and the association with dysphagia should not be a surprise. Research in to this relationship is indicated.

Efficacy of empiric esophageal dilation in patients with non-obstructive dysphagia: systematic review and meta-analysis

BACKGROUND AND AIMS

Empiric esophageal dilation is frequently performed for non-obstructive dysphagia. Studies evaluating its efficacy have reported conflicting results. In this meta-analysis, we have evaluated the efficacy of esophageal dilation in the management of non-obstructive dysphagia.

METHODS

We reviewed several databases from inception to 26 May 2021 to identify randomized controlled trials (RCTs) and observational studies that evaluated the role of empiric esophageal dilation for non-obstructive dysphagia. Our outcomes of interest were clinical success (improvement in dysphagia after dilation) and difference in post-operative dysphagia score between groups. For categorical variables, we calculated pooled odds ratios (OR) with 95% confidence intervals (CI); for continuous variables, we calculated standardized mean difference (SMD) with 95% CI. Data were analyzed using a random effects model. We used GRADE framework to ascertain the quality of evidence.

RESULTS

We included 4 studies (3 RCTs and one observational) with 243 patients; there were 133 treated with empiric dilation and 110 controls. We found no significant difference in clinical success (OR (95% CI) 1.91 (0.89, 4.08)) or post-procedure dysphagia score between groups (SMD (95% CI) 0.38 (-0.37, 1.14)). Our findings remained consistent on subgroup analysis including RCTs only. Quality of evidence ranged from low to very low based on GRADE framework.

CONCLUSIONS

Our meta-analysis does not support the use of empiric esophageal dilation in patients with non-obstructive dysphagia. More studies are required to confirm these findings.

Dysphagia aortica

Background

Dysphagia aortica is an umbrella term to describe swallowing obstruction from external aortic compression secondary to a dilated, tortuous, or aneurysmal aorta. We performed a systematic literature review to clarify clinical features and outcomes of patients with dysphagia aortica.

Materials and methods

We searched PubMed, EMBASE, Web of Science, and the Cochrane Library. The terms “aortic dysphagia,” “dysphagia aortica,” “dysphagia AND aortic aneurysm” were matched. We also queried the prospectively updated database of our esophageal center to identify patients with aortic dysphagia referred for diagnosis and treatment over the past two decades.

Results

A total of 57 studies including 69 patients diagnosed with dysphagia aortica were identified, and one patient from our center was added to the database. The mean age was 72 years (range 22–98), and the male to female ratio 1.1:1. Of these 70 patients, the majority (n = 63, 90%) had an aortic aneurysm, pseudoaneurysm, or dissection. Overall, 37 (53%) patients received an operative treatment (81.1% a vascular procedure, 13.5% a digestive tract procedure, 5.4% both procedures). Thoracic endovascular aortic repair (TEVAR) accounted for 60% of all vascular procedures. The postoperative mortality rate was 21.2% (n = 7/33). The mortality rate among patients treated conservatively was 55% (n = 11/20). Twenty-six (45.6%) studies were deemed at a high risk of bias.

Conclusion

Dysphagia aortica is a rare clinical entity with high morbidity and mortality rates and no standardized management. Early recognition of dysphagia and a high suspicion of aortoesophageal fistula may be lifesaving in this patient population.

DISHphagia – A Riddle Unwrapped a Clinical Case with Literature Review

Diffuse idiopathic skeletal hyperostosis (DISH) is a common but underdiagnosed systemic skeletal disease. It is characterized by calcifications affecting mainly the spinal anterior longitudinal ligament. In the majority of cases, the patients are asymptomatic, but cervical osteophytes can sometimes cause hoarseness, dysphagia (DISHphagia) and even dyspnea.

Case description: A 61-year-old man was admitted to our department with complaints of difficulty in swallowing and weight loss. Dysphagia had been increasing gradually for nine months. Barium swallow esophagram revealed asymmetric swallowing with expansion above the upper esophageal sphincter without other abnormalities. The extension was confirmed by esophago-gastro-duodenoscopy (EGD). Furthermore, CT scan of the thorax clearly demonstrated degenerative changes of the cervical and thoracic region, extensive ossification of the anterior longitudinal ligament, and osteophytes from C2-C7 with a forward displacement of the esophagus by 14 mm. The so-called “wax dripping down the candle” phenomenon was as well observed.

Conclusion: DISH is a systematic, musculo-skeletal disease of older adults with unknown etiology. Dysphagia is the most common symptom of the disease and might be caused by osteophytes of the cervical region. We presented a case of DISH with a rare localization of the osteophytes in the cervical region C2-C7. Due to the increasing incidence of the Forestier’s syndrome and its associated “DISHphagia”, the gastroenterologist should increase the awareness of this underestimated disease and improve the diagnostic approach.

Association between Schatzki ring and eosinophilic esophagitis: a systematic review and meta-analysis

BACKGROUND/OBJECTIVE

The involvement of hydrochloric acid in the etiology of eosinophilic esophagitis and numerous reports on its coexistence and interaction with reflux disease, as well as the rings of the esophageal mucosa formed with the advancement of the disease, suggest a potential association of eosinophilic esophagitis with another disorder of esophageal morphology potentially caused by exposure to acid reflux-Schatzki ring. Therefore, it seems reasonable to check the relationship of eosinophilic esophagitis with the coexistence of the Schatzki ring as a potential effect of advanced esophageal trachealization, which is the subject of this systematic review with a meta-analysis.

METHODS

The protocol of this meta-analysis was performed according to the guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analysis. A systematic search of the indexed literature in the MEDLINE and Scopus databases from early to December 2019 was performed to identify all original research articles on the association between the occurrence of the Schatzki ring and eosinophilic esophagitis in adults.

RESULTS

Out of 68 searched studies, after the analysis and evaluation of the works, only 4 met the criteria set according to the protocol and were included in the meta-analysis. Based on the performed meta-analysis, no relationship was found between the occurrence of Schatzki ring and eosinophilic esophagitis.

CONCLUSION

The present study did not show a significant relationship between the occurrence of the Schatzki ring and eosinophilic esophagitis in the adult population, which suggests that these are two independent causes of dysphagia in this patient population.

Dysphagia: clinical evaluation and management

Dysphagia is a common problem affecting all ages. It is increasing in frequency particularly among the younger population due to the rising incidence of eosinophilic oesophagitis, a condition which often leads to acute presentation to hospital for the first time with food bolus obstruction requiring endoscopic removal. Careful history taking remains the first and most important step in evaluating dysphagia, and it is especially important to distinguish an oropharyngeal versus oesophageal origin, which helps to guide further investigation and therapy. The three main investigations for dysphagia remain endoscopy, barium study and manometry, with endoscopy also offering therapeutic potential. Management is largely determined by the eventual diagnosis, often in a multi-disciplinary setting.

Evaluation of the Swallowing and Voice Functions in Ankylosing Spondylitis Patients

This study aimed to evaluate the swallowing and voice functions in patients with ankylosing spondylitis. Thirty patients with ankylosing spondylitis (Group 1) and 30 healthy individuals (Group 2) were included in the study. Following the laryngoscopic evaluation of the patients, the fiberoptic endoscopic evaluation of swallowing was performed, and then, the penetration-aspiration score was determined. The participants were asked to fill the eating assessment tool form. Voice recordings obtained to evaluate sound disorders were measured acoustically and analyzed using the PRAAT program. In terms of swallowing, the penetration-aspiration score obtained as a result of the flexible endoscopic swallowing assessment and eating assessment tool score was found to be higher in Group 1 than in Group 2, and a statistically significant difference was noted (p ≤ 0.001). When analyzing the maximum phonation time (p < 0.001) and fundamental frequency (p = 0.408) values in phonation evaluation, a statistically significant difference was found between the two groups. Group 1 showed a deterioration in terms of jitter (p = 0.040) and shimmer (p = 0.007) compared to Group 2, and a statistically significant difference was noted. There was no statistically significant difference in the harmonic/noise ratio (mean ± standard deviation) between the two groups (p = 0.051). Swallowing and voice functions significantly affect quality of life. Therefore, approaches aimed to improve the associated symptoms have become increasingly important. In patients with ankylosing spondylitis, swallowing quality and phonation ability may be negatively affected. These patients should be monitored for hidden or overt food aspiration.Trial Registry: https://clinicaltrials.gov/ct2/show/NCT04437394.

Manual Cervical Traction and Trunk Stabilization Cause Significant Changes in Upper and Lower Esophageal Sphincter: A Randomized Trial

OBJECTIVES

Dysfunctions in the lower esophageal sphincter (LES) and the upper esophageal sphincter (UES) levels can occur owing to poor muscle coordination, contraction, or relaxation. Such condition can possibly be addressed by functional rehabilitation. The aim of this study was to measure pressure changes in the UES and LES at rest and during routine rehabilitation techniques, that is, cervical manual traction and trunk stabilization maneuver.

METHODS

This study was conducted in a University Hospital Gastrointestinal Endoscopy Center. Cervical manual traction and a trunk stabilization maneuver were performed in a convenient group of 54 adult patients with gastroesophageal reflux disease. High-resolution manometry was used to measure pressure changes in the LES and UES at rest and during manual cervical traction and trunk stabilization maneuver.

RESULTS

Average initial resting UES pressure was 90.91 mmHg. A significant decrease was identified during both cervical traction (average UES pressure = 42.13 mmHg, P < .001) and trunk stabilization maneuver (average UES pressure = 62.74 mmHg, P = .002). The average initial resting LES pressure was 14.31 mmHg. A significant increase in LES pressure was identified both during cervical traction (average LES pressure = 21.39 mmHg, P < .001) and during the trunk stabilization maneuver, (average pressure = 24.09 mmHg, P < .001).

CONCLUSION

Cervical traction and trunk stabilization maneuvers can be used to decrease pressure in the UES and increase LES pressure in patients with gastroesophageal reflux disease.

Progression of swallowing dysfunction and associated complications of dysphagia in a cohort of patients with serial videofluoroscopic swallow examinations

OBJECTIVE

Dysphagia is a common symptom with associated complications ranging from mild discomfort to life-threatening pulmonary compromise. Videofluoroscopic swallow is the 'gold standard' evaluation for oropharyngeal dysphagia, but little is known about how patients' performance changes over time.

METHOD

This was a retrospective cohort study evaluating dysphagia patients' clinical course by serial videofluoroscopic swallow study. Univariate analysis followed by multivariate analysis were used to identify correlations between pneumonia outcomes, diet allocation, aetiology and comorbidities.

RESULTS

This study identified 104 patients (53 per cent male) stratified into risk groups by penetration-aspiration scale scores. Mean penetration-aspiration scale worsened over time (p < 0.05), but development of pneumonia was not associated with worsened penetration-aspiration scale score over time (p = 0.57) or severity of dysphagia (p = 0.88).

CONCLUSION

Our dataset identified a large cohort of patients with oropharyngeal dysphagia and demonstrated mean penetration-aspiration scale tendency to worsen. Identifying prognostic factors associated with worsening radiological findings and applying this to patients at risk of clinical swallowing difficulty is needed.

Dysphagia symptoms in obstructive sleep apnea: prevalence and clinical correlates

BACKGROUND

Epidemiology of dysphagia and its drivers in obstructive sleep apnea (OSA) are poorly understood. The study aims to investigate the prevalence of dysphagia symptoms and their association with demographic and clinical factors in patients with OSA.

METHODS

Patients with OSA referring to an Academic Sleep Outpatient Clinic were enrolled in a prospective study. Demographic, clinical characteristics, and OSA symptoms were collected. All patients underwent home sleep cardiorespiratory polygraphy and the Eating-Assessment Tool questionnaire (EAT-10) to investigate dysphagia symptoms. Patients with a positive EAT-10 were offered to undergo a fiberoptic endoscopic evaluation of swallowing (FEES) to confirm the presence of dysphagia. FEES findings were compared with a healthy control group. Univariate and multivariate analyses were performed to assess predictors of dysphagia.

RESULTS

951 patients with OSA (70% males, age 62 IQR51-71) completed the EAT-10, and 141 (15%) reported symptoms of dysphagia. Female gender (OR = 2.31), excessive daily sleepiness (OR = 2.24), number of OSA symptoms (OR = 1.25), anxiety/depression (OR = 1.89), and symptoms of gastroesophageal reflux (OR = 2.75) were significantly (p < 0.05) associated with dysphagia symptoms. Dysphagia was confirmed in 34 out of 35 symptomatic patients that accepted to undergo FEES. Patients with OSA exhibited lower bolus location at swallow onset, greater pharyngeal residue, and higher frequency and severity of penetration and aspiration events than healthy subjects (p < 0.05).

CONCLUSION

A consistent number of patients with OSA show symptoms of dysphagia, which are increased in females and patients with a greater OSA symptomatology, anxiety and depression, and gastroesophageal reflux. The EAT-10 appears a useful tool to guide the selection of patients at high risk of dysphagia. In clinical practice, the integration of screening for dysphagia in patients with OSA appears advisable.

Validation and psychometric evaluation of the Spanish version of Brief Esophageal Dysphagia Questionnaire (BEDQ): Results of a multicentric study

BACKGROUND

The recently developed Brief Esophageal Dysphagia Questionnaire (BEDQ) evaluates esophageal obstructive symptoms. Its initial evaluation showed strong psychometric properties. The aims of this study were to (a) translate and validate an international Spanish version of BEDQ and (b) evaluate its psychometric properties in a large Hispano-American sample of symptomatic individuals.

METHODS

A Spanish BEDQ version was performed by Hispano-American experts using a Delphi process and reverse translation. Patients were prospectively recruited from seven centers in Spain and Latin America among individuals referred for high-resolution manometry (HRM). Patients completed several scores: Hospital Anxiety & Depression Scale (HADS), Eckardt score (ES), Gastroesophageal Reflux Questionnaire (GERDQ), and the BEDQ. Standardized psychometric analyses were performed.

KEY RESULTS

A total of 426 patients were recruited. Spanish BEDQ showed excellent reliability (Cronbach's alpha = 0.91). Factor analysis confirmed its unidimensional character. Moderate significant correlations between BEDQ and other symptomatic scores were found, suggesting sufficient convergent validity. Patients with abnormal or obstructive HRM findings scored significantly higher when compared to normal or non-obstructive findings, respectively. Using a cutoff of 10, BEDQ showed a sensitivity of 65.38% and a specificity of 66.21% and an area under the curve of 0.71 for obstructive or major manometric diagnosis.

CONCLUSIONS AND INFERENCES

A widely usable Spanish BEDQ version has been validated. We confirm its excellent psychometric properties in our patients, confirming the appropriateness of its use in different populations.

White Paper by the European Society for Swallowing Disorders: Screening and Non-instrumental Assessment for Dysphagia in Adults

This White Paper by the European Society for Swallowing Disorders (ESSD) reports on the current state of screening and non-instrumental assessment for dysphagia in adults. An overview is provided on the measures that are available, and how to select screening tools and assessments. Emphasis is placed on different types of screening, patient-reported measures, assessment of anatomy and physiology of the swallowing act, and clinical swallowing evaluation. Many screening and non-instrumental assessments are available for evaluating dysphagia in adults; however, their use may not be warranted due to poor diagnostic performance or lacking robust psychometric properties. This white paper provides recommendations on how to select best evidence-based screening tools and non-instrumental assessments for use in clinical practice targeting different constructs, target populations and respondents, based on criteria for diagnostic performance, psychometric properties (reliability, validity, and responsiveness), and feasibility. In addition, gaps in research that need to be addressed in future studies are discussed. The following recommendations are made: (1) discontinue the use of non-validated dysphagia screening tools and assessments; (2) implement screening using tools that have optimal diagnostic performance in selected populations that are at risk of dysphagia, such as stroke patients, frail older persons, patients with progressive neurological diseases, persons with cerebral palsy, and patients with head and neck cancer; (3) implement measures that demonstrate robust psychometric properties; and (4) provide quality training in dysphagia screening and assessment to all clinicians involved in the care and management of persons with dysphagia.

Assessment and management of dysphagia and achalasia

Dysphagia is a common symptom which can vary in severity and aetiology; at one end, it can be a benign inconvenience, on the other, there can be serious morbidity associated with malnutrition. It is crucial to identify those with mucosal and structural disease, including malignancy as a priority first. Reflux disease is commonly a culprit and treating empirically with acid reducing medicines should follow exclusion of organic disease. Other benign conditions (including eosinophilic oesophagitis) should be considered. The clinical assessment of dysphagia begins with a detailed history and a focus on symptom severity as well as the pre-test probability of a given condition. Tests are then directed at assessing function, and should employ both high-resolution manometry and barium studies. For motility disorders, begin by assessing the oesophago-gastric junction for obstruction (eg achalasia), followed by oesophageal body function. The latter is divided into major and minor motility disorders. Treatment is directed according to the dysmotility phenotype and is based upon background fitness, age and appetite to intervention. Invasive treatment for achalasia is aimed at disrupting the lower oesophageal sphincter muscle while that of oesophageal body disorders is directed at reducing hypercontraction, improving peristalsis or reducing symptoms.

The Natural History of Chronic Unexplained Gastrointestinal Disorders and Gastroesophageal Reflux During 20 Years: A US Population-Based Study

OBJECTIVE

To explore the natural history of chronic unexplained gastrointestinal (GI) symptoms and to determine the longitudinal trends of prevalence during a 20-year period in a single US community.

METHODS

Between January 1, 1990, and December 31, 2009, valid self-report questionnaires of GI symptoms were mailed to randomly selected cohorts of a community. The study used respondents who answered questions on 1 or more of 3 surveys (initial, 1990-1992; second, 2003-2004; and third, 2008-2009). The trends of prevalence of GI symptoms over time were analyzed in responders who completed 3 surveys, and the natural history or transition was evaluated.

RESULTS

The overall prevalence of major symptom groupings including gastroesophageal reflux disease was consistent among residents in a community on 3 survey time points (1990-1992, 2003-2004, and 2008-2009). The transitions of GI symptoms were common in 228 patients who responded to all 3 surveys; only 29% had the same symptom category in 3 surveys; otherwise, symptoms changed over time, resolving, recurring, or transitioning to another disorder. Observed proportions of symptom transitions were significantly different from expected during 20 years (P<.001). Higher non-GI somatic symptom scores were significantly associated with both symptom transitions (odds ratio, 3.9; 95% CI, 1.38 to 10.77) and having sustained symptoms (odds ratio, 12.7; 95% CI, 4.62 to 34.90).

CONCLUSION

The overall population prevalence of chronic unexplained GI symptoms is stable, but in individuals, transitions seem to be the rule. As these various GI syndromes appear to be so intimately interconnected, the common underlying pathogenesis may account for a major subgroup of chronic unexplained GI disorders.

[Approach of Dysphagia]

Dysphagia has been reported to be relatively common and seems to be increased in Korea. Dysphagia can be classified as oropharyngeal dysphagia or esophageal dysphagia. In patients with swallowing difficulties, it is important to determine whether the dysphagia is oropharyngeal or esophageal. Patients with orophayngeal dysphagia are likely to develop aspiration and aspiration pneumonia, so accurate diagnosis should be made in the early stages of complaining of swallowing difficulties. Patients with orophayngeal dysphagia complained difficulty initiating a swallow. Swallowing may be accompanied by coughing, choking, nasopharyngeal regurgitation, aspiration, and a sensation of residual food remaining in the pharynx. Patients with esophageal dysphagia complained difficulty swallowing several seconds after initiating a swallow and a sensation of food getting stuck in the esophagus. Esophageal dysphagia should be characterized by analyzing whether foods that cause swallowing difficulties are solid, liquids or both, whether symptoms are progressive or intermittent, how severe, and associated symptoms, such as weight loss, heartburn, or regurgitation. The approach to diagnostic testing to determine the cause of esophageal dysphagia is based upon the medical history. If esophageal motility disorder is suspected, barium esophagogram is performed first, and upper endoscopy is performed first if structural abnormalities are suspected. If an upper endoscopy shows normal findings, but the esophagus is still suspected of mechanical obstruction, a barium esophagogram is performed. Esophageal manometry should be performed in patients with swallowing difficulties who are suspected of esophageal motility disorder or have normal findings in upper endoscopy.

Dysphagia in Older Adults

Dysphagia, which is a geriatric syndrome affecting 10% to 33% of older adults, is commonly seen in older adults who have experienced a stroke or neurodegenerative diseases such as Alzheimer or Parkinson disease. Patients diagnosed as having dysphagia can experience malnutrition, pneumonia, and dehydration. Patients can also experience increased rates of mortality and long-term care admission. Providers can identify the specific type of dysphagia for treatment in approximately 80% of patients by asking 5 questions in the patient's history: What happens when you try to swallow? Do you have trouble chewing? Do you have difficulty swallowing solids, liquids, or both? Describe the symptom onset, duration, and frequency? What are the associated symptoms? Providers can then request a videofluoroscopic swallow study or a fiberoptic endoscopic evaluation of swallowing for further evaluation of oropharyngeal dysphagia. If providers are diagnosing esophageal dysphagia, barium esophagraphy or esophagogastroduodenoscopy (EGD) can be used as part of the assessment. Patients can be treated for oropharyngeal dysphagia by using compensatory interventions, including behavioral changes, oral care, dietary modification, or rehabilitative interventions such as exercises and therapeutic oral trials. Providers often address treatment of esophageal dysphagia by managing the underlying etiology, which could include removal of caustic medications or using EGD as a therapeutic modality for esophageal rings. High-quality, large research studies are necessary to further manage the diagnosis and appropriate treatment of this growing geriatric syndrome.

Is Dysphagia Under Diagnosed or is Normal Swallowing More Variable than We Think? Reported Swallowing Problems in People Aged 18-65 Years

Purpose

Dysphagia prevalence in younger community dwelling adults and across nations is sparse. We investigated the prevalence of swallowing problems in an unselected cohort of people aged 18–65 years.

Methods

The EAT-10 Assessment Tool was converted into an anonymized online survey. Invitations were e-mailed to author contacts and onwards dispersal encouraged. Analysis was performed using non-parametric test for group comparison (Mann–Whitney U) and Spearman’s rho correlation.

Results

From March 2014 to October 2017: 2054 responses (32 reported ages outside of 18–65 or undeclared) from Africa, Asia, Australasia/Oceania, Europe, and North and South America. Responses: 1,648 female, 364 male, (10 reported as both), median age 34, (range 18–65, mean 37.12, SD 12.40) years. Total EAT-10 scores: median 0 (range 0–36, mean 1.57, SD 3.49). EAT-10 score ≥ 3 (337) median 5 (range 3–36, mean 7.02 SD 5.91). Median age 36 (range 19–65, mean 37.81, SD 13.21) years. Declared sex was not statistically significantly associated with non-pathological vs. pathological EAT-10 score (p = 0.665). Female scores (median 0.00, mean 1.56, SD 3.338) were significantly higher than for males (median 0.00, mean 1.62, SD 4.161): U (Nfemale = 1648, Nmale = 364) = 275,420.000, z = − 2.677, p = 0.007. Age and EAT-10 score were not associated: females r_s = − 0.043, p = 0.079, N = 1648, males r_s = − 0.003, p = 0.952, N = 364. Considerable impact on people: “I take ages to eat a main course … This is embarrassing and I often leave food even though I am still hungry.” (no diagnosis, EAT-10 = 17).

Conclusion

Concerns regarding swallowing exist in people undiagnosed with dysphagia, who may feel uncomfortable seeking professional help. Dysphagia may be under reported resulting in a hidden population. Subtle changes are currently seen as subtle markers of COVID-19. Further work is required to ensure that what is an essentially normal swallow does not become medicalized.

Pharyngoesophageal Segment Distention Across Volumes and Pathology

Purpose Patients receive multiple bolus trials during a videofluoroscopic swallowing study (VFSS) to assess swallow function, inclusive of narrowing within the pharyngoesophageal segment (PES). While differences in the narrowest and widest segments are visualized, the ratio of distention across boluses is not well understood. Method A retrospective review of 50 consecutive VFSSs with five boluses of varied viscosity and volume was performed. Still images at maximal PES distention were captured and scaled using a 19-mm disk. Measurements of the narrowest and widest segments were obtained, and a distention ratio was calculated. Studies were categorized by PES phenotype as normal, esophageal web, cricopharyngeal bar, or narrow PES. PES distention ratios were evaluated across bolus trials and within PES phenotypes using a mixed-methods repeated-measures analysis of variance. Results Of the 50 studies, there were 11 normal, 16 web, 10 bar, and 13 narrow PES. Quantitative differences were present for the narrowest (p = .01) and widest (p = .002) points across bolus volumes. No difference was present in distention ratio (p = .2) across volumes. Evaluating the PES phenotype, web, normal, bar, and narrow PES distention ratios differed (p = .03). Bar and PES narrow distention ratios were lower compared to that of the normal group (p = .01 for normal vs. bar and p = .02 for normal vs. PES narrow). Conclusions PES distention ratio stability across varying bolus volumes and phenotypes suggests that a reduction in trials during a VFSS may permit an equivalent PES evaluation to traditional exams. Ultimately, this could improve our understanding and accurate diagnosis of PES dysfunction.

Updates on diagnostic modalities for esophageal dysphagia

Esophageal dysphagia is a common symptom in adults. Fluoroscopic contrast studies, endoscopy, and esophageal manometry have been used in the diagnosis of esophageal dysphagia for many years. The diagnostic yield has been improved with new test protocols that highlight abnormal bolus transit in the esophagus and outflow obstruction, as well as new high-definition and high-resolution technical advances in equipment. Functional luminal impedance planimetry and the addition of impedance to high-resolution esophageal manometry have also allowed the assessment of new parameters to better understand esophageal structure and function. In this concise review, we describe the role and utility of various diagnostic modalities in the assessment of patients with esophageal dysphagia.

Prevalence and Characteristics of Dysphagia Based on a Population-Based Survey

BACKGROUND & AIMS

Although dysphagia is common, there is limited information about the prevalence and burden of illness of dysphagia in the United States. We performed a population-based survey of more than 31,000 adults to evaluate the epidemiology, clinical characteristics, and health care-seeking behavior of individuals with dysphagia.

METHODS

We performed a cross-sectional analysis of adults in the United States who completed an online, self-administered health survey from April 4 through April 19, 2018. All respondents were asked which of the following symptoms they had ever experienced (presented in random order): dysphagia, abdominal pain, bloating, bowel incontinence, constipation, diarrhea, heartburn/reflux, nausea/vomiting, or none of the above. Only respondents who selected dysphagia continued the remaining survey, which included questions about dysphagia severity, use of compensatory maneuvers, health care seeking, and esophageal comorbidities. We used multivariable regression methods to adjust for confounding.

RESULTS

Of 31,129 individuals who participated in the survey, 4998 respondents (16.1%) reported experiencing dysphagia; 92.3% of these had symptoms in the previous week. We found that 16.3% of respondents described their dysphagia over the previous 7 days as either quite a bit or very severe. Drinking liquids to help with dysphagia (86.0%) and taking longer to finish eating (76.5%) were the most common compensatory maneuvers. Overall, 51.1% of individuals sought care for their difficulty swallowing; older age, male sex, having a usual source of care and insurance, having comorbidities, and more severe dysphagia symptoms increased the odds for seeking care (P < .05). The most commonly reported esophageal comorbidities were gastroesophageal reflux disease (30.9%), eosinophilic esophagitis (8.0%), and esophageal stricture (4.5%).

CONCLUSIONS

In a large population-based survey, we found that dysphagia is common; 1 of 6 adults reported experiencing difficulty swallowing. However, half of individuals have not discussed their symptoms with a clinician and many could have treatable disorders.

Characterization of Geriatric Dysphagia Diagnoses in Age-Based Cohorts

OBJECTIVE

An aging population requires increased focus on geriatric otolaryngology. Patients aged ≥65 years are not a homogenous population, and important physiologic differences have been documented among the young-old (65-74 years), middle-old (75-84), and old-old (≥85). We aim to analyze differences in dysphagia diagnoses and swallowing-related quality-of-life among these age subgroups.

STUDY DESIGN

Retrospective chart review.

SETTING

Tertiary care laryngology clinic.

SUBJECTS AND METHODS

We identified chief complaint, diagnosis, and self-reported swallowing handicap (Eating Assessment Tool [EAT-10] score) of all new patients aged ≥65 years presenting to the Johns Hopkins Voice Center between April 2015 and March 2017. Dysphagia diagnoses were classified by physiologic etiology and anatomic source. Diagnostic categories and EAT-10 score were evaluated as functions of patient age and sex.

RESULTS

Of 839 new patients aged ≥65 years, 109 (13.0%) reported a chief complaint of dysphagia and were included in this study. The most common dysphagia etiologies were neurologic and esophageal. Most common diagnoses were diverticula (15.6%), reflux (13.8%), and radiation induced (8.3%). Diverticula, cricopharyngeal hypertonicity, and radiation-induced changes were associated with higher EAT-10 score (P < .001). Significant differences by sex were found in anatomic source of dysphagia, as men and women were more likely to present with oropharyngeal and esophageal disease, respectively (P = .023). Dysphagia etiology and EAT-10 score were similar across age subgroups.

CONCLUSION

Important differences among dysphagia diagnosis and EAT-10 score exist among patients aged ≥65 years. Knowledge of these differences may inform diagnostic workup, management, and further investigations in geriatric otolaryngology.