Oropharynx in patients with cerebrovascular disease: evaluation with videofluoroscopy

Quantifying Oropharyngeal Swallowing Impairment in Response to Bolus Viscosity

PURPOSE

The purpose of this study was to test the feasibility for quantifying changes in oropharyngeal swallowing impairment in response to alteration in bolus viscosity using a reliable and valid method of observational measurement-the Modified Barium Swallow Impairment Profile (MBSImP).

METHOD

This retrospective analysis included a heterogeneous cohort of 119 patients with suspected dysphagia that underwent a videofluoroscopic swallowing study as part of clinical care. Using consensus scoring, two expert clinicians assigned MBSImP scores to components related to oropharyngeal swallowing function between two bolus viscosities (thin liquid and pudding): epiglottic movement, laryngeal elevation, anterior hyoid excursion, tongue base retraction, pharyngeal stripping wave, and pharyngoesophageal segment opening (PESO). Comparisons between the two bolus viscosities were investigated for each component.

RESULTS

Higher (worse) scores were observed in the thin-liquid trial compared with the pudding trial for the following MBSImP components: anterior hyoid excursion (p = .03), epiglottic movement (p < .001), pharyngeal stripping wave (p < .001), and PESO (p = .002). Lower (better) scores were observed in the liquid trial compared with the pudding trial for one component-tongue base retraction (Component 15) only (p < .001).

CONCLUSION

These findings provide further evidence for positive influences of viscosity on the swallow mechanism, including influences of sensory feedback on the sensorimotor swallow program.

Effects of dual-task interference on swallowing in healthy aging adults

A wide body of literature has demonstrated that the neural representation of healthy swallowing is mostly bilateral, with one hemisphere dominant over the other. While several studies have demonstrated the presence of laterality for swallowing related functions among young adults, the data on older adults are still growing. The purpose of this paper is to investigate potential changes in hemispheric dominance in healthy aging adults for swallowing related tasks using a behavioral dual-task paradigm. A modified dual-task paradigm was designed to investigate the potential reduction in hemispherical specialization for swallowing function. Eighty healthy right-handed participants in the study were divided into two groups [Group 1: young adults (18–40 years) and Group 2: older adults (65 and above)]. All the participants performed a timed water swallow test at baseline and with two interference conditions (silent word repetition, and facial recognition). The results of the study revealed the following 1) a statistically significant effect of age on swallow performance; 2) statistically significant effect of each of the interference tasks on two of the swallow measures (VPS and VPT) in younger adults; and 3) no significant effect of the interference tasks on the swallowing performance of older adults. These findings suggest that aging substantially affects swallowing in older individuals, and this potentially accompanies a reduction in the hemispheric specialization for swallowing related tasks.

Achados videoendoscópicos da deglutição em diferentes consistências de alimento na Esclerose Lateral Amiotrófica

RESUMO Objetivo Este estudo teve por objetivo comparar os achados videoendoscópicos da deglutição orofaríngea em distintas consistências de alimento na Esclerose Lateral Amiotrófica (ELA). Método Estudo clínico retrospectivo com amostra de conveniência. Foram incluídos 20 indivíduos com diagnóstico de ELA e disfagia orofaríngea confirmada por avaliação clínica e objetiva de deglutição, independentemente do tipo, bulbar ou esquelética, e tempo de diagnóstico neurológico, 13 do sexo masculino e sete do sexo feminino, faixa etária variando de 34 a 78 anos, média de 57 anos. Foram analisados os achados da videoendoscopia de deglutição (VED) nas consistências líquida (N=18), líquida espessada (N=19) e pastosa (N=20) no volume de cinco ml. Os achados sobre escape oral posterior, resíduos faríngeos, penetração laríngea e/ou aspiração foram comparados nas três consistências de alimento e a análise estatística utilizou o teste ANOVA de Friedman. Resultados Não foi encontrada alteração na sensibilidade laríngea nessa população. Não houve diferença estatística significativa entre as consistências de alimento na presença de escape oral posterior, penetração e/ou aspiração. Houve diferença estatística significativa somente com resíduos faríngeos na consistência líquida espessada e pastosa na ELA. Conclusão Dentre os achados videoendoscópicos da deglutição na ELA, somente o resíduo faríngeo teve maior frequência na dependência da consistência de alimento.

Effect of Bolus Viscosity on the Safety and Efficacy of Swallowing and the Kinematics of the Swallow Response in Patients with Oropharyngeal Dysphagia: White Paper by the European Society for Swallowing Disorders (ESSD)

BACKGROUND

Fluid thickening is a well-established management strategy for oropharyngeal dysphagia (OD). However, the effects of thickening agents on the physiology of impaired swallow responses are not fully understood, and there is no agreement on the degree of bolus thickening.

AIM

To review the literature and to produce a white paper of the European Society for Swallowing Disorders (ESSD) describing the evidence in the literature on the effect that bolus modification has upon the physiology, efficacy and safety of swallowing in adults with OD.

METHODS

A systematic search was performed using the electronic Pubmed and Embase databases. Articles in English available up to July 2015 were considered. The inclusion criteria swallowing studies on adults over 18 years of age; healthy people or patients with oropharyngeal dysphagia; bolus modification; effects of bolus modification on swallow safety (penetration/aspiration) and efficacy; and/or physiology and original articles written in English. The exclusion criteria consisted of oesophageal dysphagia and conference abstracts or presentations. The quality of the selected papers and the level of research evidence were assessed by standard quality assessments.

RESULTS

At the end of the selection process, 33 articles were considered. The quality of all included studies was assessed using systematic, reproducible, and quantitative tools (Kmet and NHMRC) concluding that all the selected articles reached a valid level of evidence. The literature search gathered data from various sources, ranging from double-blind randomised control trials to systematic reviews focused on changes occurring in swallowing physiology caused by thickened fluids. Main results suggest that increasing bolus viscosity (a) results in increased safety of swallowing, (b) also results in increased amounts of oral and/or pharyngeal residue which may result in post-swallow airway invasion, (c) impacts the physiology with increased lingual pressure patterns, no major changes in impaired airway protection mechanisms, and controversial effects on oral and pharyngeal transit time, hyoid displacements, onset of UOS opening and bolus velocity-with several articles suggesting the therapeutic effect of thickeners is also due to intrinsic bolus properties, (d) reduces palatability of thickened fluids and (e) correlates with increased risk of dehydration and decreased quality of life although the severity of dysphagia may be an confounding factor.

CONCLUSIONS

The ESSD concludes that there is evidence for increasing viscosity to reduce the risk of airway invasion and that it is a valid management strategy for OD. However, new thickening agents should be developed to avoid the negative effects of increasing viscosity on residue, palatability, and treatment compliance. New randomised controlled trials should establish the optimal viscosity level for each phenotype of dysphagic patients and descriptors, terminology and viscosity measurements must be standardised. This white paper is the first step towards the development of a clinical guideline on bolus modification for patients with oropharyngeal dysphagia.

Effectiveness of Chin-tuck Maneuver to Facilitate Swallowing in Neurologic Dysphagia

Introduction The chin-tuck maneuver is the most frequently employed postural maneuver in the treatment of neurogenic oropharyngeal dysphagia caused by encephalic vascular strokes and degenerative diseases.

Objective The purpose of this study was to investigate the effectiveness of this maneuver in patients with neurogenic dysphagia and factors that could interfere in it.

Methods In this retrospective cohort, we analyzed the medical files and videofluoroscopy exams of 35 patients (19 male – 54% and 16 female – 46%; age range between 20 and 89 years old; mean = 69 years).

Results The results suggest that the effectiveness of chin-tuck maneuver is related to the overall degree of dysphagia: the more severe the dysphagia, the less effective the maneuver.

Conclusion Chin-tuck maneuver should benefit dysphagic patients with delay in the swallowing trigger, reduced laryngeal elevation, and difficulties to swallow liquids, but is not the best compensatory strategy for patients with severe dysphagia.

A cost-effectiveness analysis of screening methods for dysphagia after stroke

OBJECTIVE

To provide a cost-effectiveness analysis of dysphagia screening in the acute poststroke period with use of a videofluoroscopic swallowing study, a clinical bedside swallowing evaluation, or a combined approach.

DESIGN

Decision-analysis model.

METHODS

A decision-analysis model was used with information derived from multiple data sources, including meta-analyses and other relevant clinical studies. Univariate and probabilistic sensitivity analyses were performed.

MAIN OUTCOME MEASURES

The analysis assessed direct medical costs of pneumonia. Strategies were compared on the basis of an incremental cost-effectiveness analysis, with effectiveness measured in quality-adjusted life-years.

RESULTS

The strategy of having each patient undergo a videofluoroscopic swallowing study for dysphagia was more effective and less costly than the strategies of clinical bedside swallowing evaluation alone or a combined approach. The model was most influenced by the reduction in the risk of pneumonia attributable to the treatment of mild/moderate and severe dysphagia, the effectiveness of treatment with clinical bedside swallowing evaluation, the baseline probability of pneumonia, and the cost of a videofluoroscopic swallowing study.

CONCLUSIONS

A videofluoroscopic swallowing study is cost-effective and often saves costs compared with a clinical bedside swallowing evaluation alone or a combined approach. Research aimed at improving the understanding of the effectiveness of treatment for dysphagia in the prevention of aspiration pneumonia and resulting mortality would improve the model.

Supranuclear control of swallowing

Swallowing is an act requiring complex sensorimotor integration. Using a variety of methods first used to study limb physiology, initial efforts to study swallowing have yielded information that multiple cortical and subcortical regions are active participants. Not surprisingly, the regions activated appear to overlap those involved in both oral and nonoral motor behaviors. This review offers a perspective that considers the supranuclear control of swallowing in light of these physiological similarities.

Gastrointestinal disorders in elderly patients

Gastrointestinal disorders are common in elderly patients, and the clinical presentation, complications, and management may differ from those in younger patient. Most impairment occurs in the proximal and distal tract of the gastrointestinal system. Swallowing abnormalities with a wide span of symptoms and pelvic floor pathologies involving all the pelvic compartments are common. Acute abdomen, often from small bowel obstruction or mesenteric ischemia, can pose a diagnostic challenge, because a mild clinical presentation may hide serious visceral involvement. In this setting, the radiologist often is asked to suggest the appropriate management options and to guide the management.

Swallowing lateralization: the effects of modified dual-task interference

A modified dual-task paradigm was designed to learn whether swallowing functions are selectively mediated by the left or right hemisphere. Healthy right-handed men (N = 38) were studied using videofluoroscopy to examine continuous straw drinking at baseline and with three interference conditions (silent word repetition, line orientation, finger tapping). Results indicate that activation of both right and left hemispheres can interfere with some swallowing behaviors. Findings suggest possibly different roles of the two hemispheres in the mediation of swallowing and support the notion that specific components of swallowing may be preferentially mediated by the left versus the right hemisphere.

Reabilitação em disfagia orofaríngea neurogênica: sabor azedo e temperatura fria

TEMA: reabilitação em disfagia orofaríngea neurogênica OBJETIVO: apresentar revisão de literatura sobre os controles neurofisiológicos da deglutição orofaríngea e a influência do sabor azedo e da temperatura fria no mecanismo da deglutição. CONCLUSÃO: quanto à questão do controle central da deglutição, ainda existem controvérsias em relação ao sabor azedo e a temperatura fria. Esses dois parâmetros provocam mudanças na dinâmica da deglutição, podendo trazer benefícios aos indivíduos acometidos por disfagia orofaríngea neurogênica. Porém, tais achados sugerem a necessidade de investigações futuras com populações randomizadas.

Normal swallowing and functional magnetic resonance imaging: a systematic review

Unknowns about the neurophysiology of normal and disordered swallowing have stimulated exciting and important research questions. Previously, these questions were answered using clinical and animal studies. However, recent technologic advances have moved brain-imaging techniques such as functional magnetic resonance imaging (fMRI) to the forefront of swallowing neurophysiology research. This systematic review has summarized the methods and results of studies of swallowing neurophysiology of healthy adults using fMRI. A comprehensive electronic and hand search for original research was conducted, including few search limitations to yield the maximum possible number of relevant studies. The participants, study design, tasks, and brain image acquisition were reviewed and the results indicate that the primary motor and sensory areas were most consistently active in the healthy adult participants across the relevant studies. Other prevalent areas of activation included the anterior cingulate cortex and insular cortex. Review limitations and suggested future directions are also discussed.

Disfagia orofaríngea pós-acidente vascular encefálico no idoso

Resumo A deglutição é um processo complexo, que envolve estruturas relacionadas à cavidade oral, faringe, laringe e esôfago, submetidas a um controle neural que permite a condução do conteúdo oral até o estômago. Dessa maneira, uma lesão neurológica, tal como o acidente vascular encefálico (AVE), ao comprometer qualquer uma dessas estruturas, pode acarretar um distúrbio de deglutição, denominado de disfagia. O termo AVE refere-se aos déficits neurológicos decorrentes de alterações na circulação encefálica, que podem ser divididos em isquêmico e hemorrágico. A idade avançada é um dos maiores fatores de risco. A disfagia pode trazer déficits nutricionais e de hidratação ao indivíduo, bem como comprometimentos do seu estado pulmonar. Este trabalho propõe apresentar uma revisão bibliográfica na qual serão enfocados pontos e questões importantes da atuação do fonoaudiólogo na disfagia orofaríngea pós-AVE no idoso.

Swallowing and speech dysfunction in patients undergoing anterior cervical discectomy and fusion: a prospective, objective preoperative and postoperative assessment

Swallowing difficulties and dysphonia may occur in patients undergoing anterior cervical discectomy and fusion. The etiology and incidence of these abnormalities, however, are not well defined. In view of this, we performed a prospective, objective analysis of swallowing function and vocal cord approximation in patients undergoing anterior cervical discectomy and fusion. Twenty-three consecutive patients (22 male and one female, mean age 59 years) undergoing anterior cervical discectomy and fusion had standardized modified barium swallow study and videolaryngoendoscopy performed preoperatively and again at 1 week and 1 month postoperatively. Eleven patients (48%) had radiographic evidence of preoperative swallowing abnormalities. The majority of these patients had myelopathic rather than radicular findings (p = 0.03). None, however, had symptoms of swallowing dysfunction. Among these patients, one had worse function postoperatively, three had improvement, and function remained unchanged in seven. The preoperative swallowing assessment was normal in 12 patients (52%). Postoperative radiographic swallowing abnormalities were demonstrated in eight of these patients (67%). Preoperative vocal cord movement was normal in all patients. Postoperatively, vocal cord paresis was detected in two patients. The paresis was transient in one and permanent in the other. Age, previous medical history, operation duration, and spinal level decompressed were not significantly associated with the incidence of swallowing dysfunction. There was, however, a tendency for patients undergoing multilevel surgery to demonstrate an increased incidence of swallowing abnormalities on postoperative radiographic studies. In addition, soft tissue swelling was more frequent in patients whose swallowing function was worse postoperatively (p = 0.007). Postoperative voice and swallowing dysfunction are common complications of anterior cervical discectomy and fusion, although in the majority of patients these abnormalities are not symptomatic. Patients undergoing multilevel procedures are at an increased risk for these complications, in part because of soft tissue swelling in the neck.

Cortical representation of swallowing: a modified dual task paradigm

It is unclear whether the cortical representation of swallowing is lateralized to the left cerebral hemisphere, right hemisphere, or bilaterally represented. As dysphagia is common in acute stroke, it is important to elucidate swallowing lateralization to facilitate earlier detection of stroke patients who may be at greater risk for dysphagia and aspiration. In this study, a modified dual task paradigm was designed to study laterality of swallowing in a group of 14 healthy, young, right-handed, male adults. The subjects were studied at baseline and with interference. Baseline conditions, performed separately, were continuous swallowing, finger tapping using the right and left index fingers, and word repetition. Interference tasks, including tapping with the right index finger, tapping with the left index finger, and word repetition, were completed with and without swallowing. Finger-tapping rate was measured, and x-ray samples of the swallowing task were taped to measure swallowing rate and volume swallowed. At baseline, the rate of tapping the right index finger was significantly faster than that of the left index finger. There was a significant decline in the tapping rates of both left and right index fingers with swallowing interference. The volume per swallow was significantly reduced during the interfering language task of silent repetition. These results offer partial support for a bilateral representation of swallowing as well as suggest an important left hemispheric contribution to swallowing. However, it cannot be concluded that the left hemisphere is more important than the right, as a comparable right hemisphere task was not studied.

Lesion localization in acute stroke patients with risk of aspiration

The objective of this prospective study was to determine whether specific neuroanatomical sites were associated with increased risk of aspiration in acute stroke patients. Videofluoroscopic swallow studies (VSS) and computed tomography or magnetic resonance imaging scans were completed on consecutive male stroke patients (n = 54). Videofluoroscopic swallow studies were scored on a scale from 0 (normal swallowing) to 4 (severe dysphagia). Patients with scores of 0-1 were grouped together as having no risk of aspiration, and patients with scores of 2-4 were grouped together as having a risk of aspiration. Lesion analyses revealed that location appeared to be more critical than hemisphere or lesion size in predicting patients at risk of aspiration. Anterior locations and subcortical periventricular white matter sites were commonly lesioned in patients with risk of aspiration, whereas patients without risk of aspiration were more likely to have posterior lesions and lesions to subcortical gray matter structures. These data demonstrate that swallowing appears to be mediated by a distributed neural network that involves both cerebral hemispheres with descending input to the medulla; however, specific lesion locations may put patients at a greater risk of aspiration.

Swallowing in patients with tracheotomies

Swallowing and respiration are well-coordinated and interdependent functions. When one of these processes is impaired, the ramifications may be negative for the other. This article describes the mechanics of normal swallowing, the disorders of swallowing, the effects of tracheotomy and mechanical ventilation on swallowing, and the procedures used to assess and treat swallowing. Combining a basic understanding of these concepts with practical management can increase safe and efficient oral intake in patients with artificial airways.

Gut feelings about recovery after stroke: the organization and reorganization of human swallowing motor cortex

Swallowing problems can affect as many as one in three patients in the period immediately after a stroke. In some cases this can lead to serious morbidity, in particular malnutrition and pulmonary aspiration. Despite this, swallowing usually recovers completely in the vast majority of patients within weeks. This impressive propensity for recovery is likely to relate to how the area of the motor cortex concerned with swallowing is organized and then reorganized after cerebral injury. Recent studies have indicated that swallowing has a bilateral but asymmetric inter-hemisphere representation within motor and premotor cortex. Damage to the hemisphere that has the greater swallowing output appears to predispose that individual to swallowing problems. However, because there is additional substrate for swallowing in the undamaged hemisphere, the capacity for compensatory reorganization in the contralateral motor cortex might be increased, leading to a greater likelihood of recovery. Swallowing might be an excellent system for studying cortical plasticity, and might prove useful in the development of new therapies aimed at accelerating reorganization in the undamaged hemisphere after unilateral cerebral injury.

Aspiration in patients with acute stroke

OBJECTIVES

To determine the frequency and clinical predictors of aspiration within 5 days of acute stroke.

DESIGN

Case series.

SETTING

Tertiary care center.

PATIENTS

Consecutive stroke patients (n = 55) with new neurologic deficit evaluated within 5 days of acute stroke.

MAIN OUTCOME MEASURES

Comparison of features identified on clinical swallowing and oromotor examinations and occurrence of aspiration (silent or overt) evident on videofluoroscopic swallow study (VSS).

RESULTS

Aspiration occurred in 21 of 55 patients (38%). Whereas 7 of 21 patients (33%) aspirated overtly, 14 (67%) aspirated silently on VSS. Chi-square analyses revealed that dysphonia, dysarthria, abnormal gag reflex, abnormal volitional cough, cough after swallow, and voice change after swallow were significantly related to aspiration and were predictors of the subset of patients with silent aspiration. Logistic regression revealed that abnormal volitional cough and cough with swallow, in conjunction, predicted aspiration with 78% accuracy.

CONCLUSIONS

Silent aspiration appears to be a significant problem in acute stroke patients because silent aspiration occurred in two thirds of the patients who aspirated. The prediction of patients at risk for aspiration was significantly improved by the presence of concurrent findings of abnormal volitional cough and cough with swallow on clinical examination.

Explaining oropharyngeal dysphagia after unilateral hemispheric stroke

BACKGROUND

Oropharyngeal dysphagia occurs in up to a third of patients presenting with a unilateral hemiplegic stroke, yet its neurophysiological basis remains unknown. To explore the relation between cortical motor function of swallowing and oropharyngeal dysphagia, mylohyoid, pharyngeal, and thenar electromyographic responses to stimulation of affected and unaffected hemispheres were recorded in dysphagic and non-dysphagic patients.

METHODS

The 20 patients studied had unilateral hemispheric stroke confirmed by computed tomography. Eight of them had associated swallowing difficulties. Electromyographic responses were recorded after suprathreshold transcranial magneto-electric stimulation of affected and unaffected hemispheres with a figure-of-eight coil.

FINDINGS

Stimulation of the unaffected hemisphere evoked smaller pharyngeal responses in dysphagic patients than in non-dysphagic patients (mean 64 microV, median 48, interquartile range 44-86 vs 118 microV, 81, 73-150) (p < 0.02). With stimulation of the affected hemisphere, the pharyngeal responses were smaller than for the unaffected hemisphere but similar between the two patient groups (26 microV, 0, 0-48 vs 54 microV, 0, 0-80). Dysphagic and non-dysphagic patients showed similar mylohyoid and thenar responses to stimulation of the unaffected hemisphere as well as to stimulation of the affected hemisphere-unaffected mylohyoid (269 microV, 239, 89-372 vs 239 microV, 163, 133-307), thenar (572 microV, 463, 175-638 vs 638 microV, 485, 381-764); affected mylohyoid (60 microV, 41, 0-129 vs 96 microV, 0, 0-195); thenar (259 microV, 258, 0-538 vs 451 microV, 206, 8-717).

INTERPRETATION

The findings indicate that dysphagia after unilateral hemispheric stroke is related to the magnitude of pharyngeal motor representation in the unaffected hemisphere.

Assessment of respiration during video fluoroscopy of dysphagic patients

RATIONALE AND OBJECTIVES

The authors evaluated the coordination of swallowing and respiration in dysphagic patients.

MATERIALS AND METHODS

Video fluoroscopy and respirometry were performed simultaneously during 98 swallows in 33 patients (18 women, 15 men) with a median age of 70 years (interquartile range, 52-78 years). Pharyngeal transit time, deglutition apnea, and the ratio between the two (swallowing safety index) were calculated. Presence of a misdirected swallow (aspiration or penetration) was indicated.

RESULTS

Pharyngeal transit time was not associated with deglutition apnea. Misdirected swallow was associated with a slightly prolonged pharyngeal transit time, a slightly shorter deglutition apnea, and a significantly lower swallowing safety index (1.8 [1.0-4.2] vs 4.5 [2.4-6.7]; P < .001) compared with normally directed swallow. The association between misdirected swallow and lower swallowing safety index was independent of pharyngeal transit time.

CONCLUSION

Assessment of respiration is important in the evaluation of dysphagia. Aspiration, especially in elderly dysphagic patients, may be a consequence of primarily disturbed respiration. A low swallowing safety index may indicate risk of misdirected swallow.

Aspiration following stroke: is it related to the side of the stroke?

OBJECTIVE

To investigate the relationship between the side of stroke and the presence of aspiration on videofluoroscopy.

DESIGN

Observational prospective study.

SUBJECTS

Eighty-seven patients (50% female) admitted with an acute stroke to the University Hospital of South Manchester.

METHODS

Patients admitted to the study underwent brain CT scanning and repeated videofluoroscopy.

RESULTS

CT scanning was performed within a median three days (interquartile range 2-4 days) following stroke and videofluoroscopic (VF) examination (median 2, interquartile range 1-4 days following stroke) of their swallow. Seventeen (19.5%) patients were noted to be aspirating. There were no significant relationships at this time between side or site of lesion and the presence of aspiration. A second assessment was carried out at a median time of 29 days (interquartile range 26-45) following acute stroke. Nine of 69 (13.5%) patients were noted to be aspirating, seven of whom, had right hemisphere lesions (p < 0.01).

CONCLUSIONS

Continuing aspiration may be related to the side of the cerebral lesion.

Lesion site in unilateral stroke patients with dysphagia

The purpose of this retrospective study was to elucidate specific lesion sites associated with deglutition disorders by studying unilateral left- and right-hemispheric stroke patients with dysphagia. We reviewed computed tomography and magnetic resonance imaging scans and videofluoroscopic swallow studies of 16 consecutive patients with unilateral ischemic infarcts and dysphagia. Results suggest that unilateral hemispheric lesions may produce dysphagia and that patients with left- and right-hemispheric strokes may have different dysphagia characteristics. Although right-hemispheric lesions were significantly smaller than left-hemispheric lesions, dysphagia seemed to be clinically more significant in patients with right-hemispheric strokes, because a higher incidence of delayed pharyngeal swallow (consistency specific) and pharyngeal stasis was recorded in this population. Cytoarchitectonic lesion mapping showed that the insular cortex was the commonest lesion site, suggesting that the insula may be important in swallowing. A prospective double-blind study in a larger sample of unilateral stroke patients with and without dysphagia is warranted to confirm these preliminary findings.

Modified barium swallow: clinical and radiographic correlation and relation to feeding recommendations

Clinical and videofluoroscopic evaluation of swallowing were correlated to determine their agreement and relationship to feeding recommendations. We reviewed a total of 148 patients with swallowing difficulties, of which 93 (45 women, 48 men; mean age 62 years) were evaluated by both clinical and radiographic examinations. A variety of materials were used for clinical bedside evaluation of oral and pharyngeal function. Radiographic examination was done with variable viscosity materials and videotape recording of the oral cavity and pharynx. The severity of oral and pharyngeal abnormalities was graded and findings of the examinations were compared. The combined results of both evaluations generated an index of swallowing difficulty which was correlated to the type of diet used if oral feeding was recommended or to a nonoral route of nutrition. In the assessment of oral and pharyngeal dysfunction, clinical evaluation and radiographic examination correlated closely in 94% of patients; however, the status of pharyngeal function was not determined in 61 (66%) of the 93 patients by clinical examination alone. The combined swallowing index was calculated in 89 patients and its severity correlated significantly with the type of feeding recommended; 64 patients were placed on one of three types of diets and 25 had enteral feedings. In conclusion, combined clinical and radiographic examinations correlated well, but clinical evaluation alone was limited by failure to evaluate the pharynx in many patients. The swallowing severity correlated well with final feeding recommendations.

Swallow management in patients on an acute stroke pathway: quality is cost effective

OBJECTIVE

To assess the effects of swallowing management in patients with acute nonhemorrhagic stroke placed on a clinical pathway, and to evaluate whether swallow function on admission can be used as a predictor of length of stay (LOS) and outcome disposition.

DESIGN

Intervention study to reduce complications of dysphagia in patients with acute stroke.

SETTING

Urban community hospital.

PATIENTS

Data were collected on 124 patients with acute nonhemorrhagic stroke admitted from January to December 1993.

INTERVENTIONS

A swallow screen was completed within one day of admission and before any oral intake.

MAIN OUTCOME MEASURES

Dysphagia and functional independence measure (FIM) scores on admission, occurrence of aspiration pneumonia, LOS, outcome disposition and cost effectiveness analysis.

RESULTS

Thirty-nine percent of all patients (p < .05) failed the initial swallow screen and required altered dietary texture and intervention. No patients developed aspiration pneumonia. Of those with dysphagia, 21% recovered intact swallowing by discharge; 19% required gastrostomy tube placement. Patients with dysphagia had lower admission FIM scores than nondysphagia patients. The LOS was longer for the dysphagia group (8.4 +/- 0.9 days) compared with patients without dysphagia (6.4 +/- 0.6 days, p < .05). Patients with dysphagia were less likely to be discharged to home (27%) than were nondysphagia patients (55%), and twice as likely to be discharged to a nursing home (p < .05).

CONCLUSIONS

This study demonstrates that early swallow screening and dysphagia management in patients with acute stroke reduces the risk of aspiration pneumonia, is cost effective, and assures quality care with optimal outcome.

Dynamic evaluation of swallowing in patients with cerebrovascular accident

To determine the specific effects of cerebrovascular accident (CVA) on deglutition, especially relative to the site of CVA, we studied videotapes of barium swallow examinations in 74 patients who had had a CVA. Although there was no distinct correlation between the prevalence of oral and pharyngeal dysfunction and the site of CVA, left CVA was prone to impair only the oral phase, and right CVA tended to impair both phases.

Oral function test for monitoring suction and swallowing in the neurologic patient

Disturbances in swallowing are common in neurologic disease but difficult to evaluate in the clinical setting. Fundamental variables such as bolus volume, swallow capacity (volume ingested over time), and the relation between ingestion and time for important events in oral and pharyngeal swallowing have not been sufficiently studied. We therefore employed a composite method for monitoring oral and pharyngeal swallowing function: the test of Repetitive Oral Suction Swallow (the ROSS test). The technical details are described as well as preliminary results from a pilot study of 20 healthy subjects and 5 patients with neurologic swallowing impairment. The correlation with respect to time sequences for major events in bolus ingestion and oral processing as monitored by the ROSS test and by videoradiography is explained. With this simple and rapid bedside test, the immediate and long-time result of therapeutic interventions in dysphagic patients may be monitored.

Assessment of risk factors for pneumonia in dysphagic children: significance of videofluoroscopic swallowing evaluation

The purpose of this study was to investigate the relationship between aspiration, as identified by videofluoroscopic swallowing (VFS) study, and pneumonia in children with suspected dysphagia. Data were retrospectively collected and analysed from 142 children referred for VFS over a one-year period. The median age was 33 months. Aspiration was identified in 44 per cent of the children studied. A history of pneumonia within one year of the VFS was found in 35 per cent. Aspiration, gastro-oesophageal reflux, and age one year or less were significant risk factors for pneumonia. Children with traumatic brain-injury were at less risk for pneumonia than all other children with suspected dysphagia. These results lend objective support to the previously suspected relationship between aspiration and pneumonia in this patient population.

Epidemiology and dysphagia

With few exceptions, epidemiology of dysphagia is unexplored, particularly with regard to risk and protective factors, and underutilized. The range of incidence of dysphagia in selected primary diagnoses often associated with dysphagia is summarized.

Neurogenic dysphagia: what is the cause when the cause is not obvious?

The potential causes of neurogenic oropharyngeal dysphagia in cases in which the underlying neurologic disorder is not readily apparent are discussed. The most common basis for unexplained neurogenic dysphagia may be cerebrovascular disease in the form of either confluent periventricular infarcts or small, discrete brainstem stroke, which may be invisible by magnetic resonance imaging. The diagnosis of occult stroke causing pharyngeal dysphagia should not be overlooked, because this diagnosis carries important treatment implications. Motor neuron disease producing bulbar palsy, pseudobulbar palsy, or a combination of the two can present as gradually progressive dysphagia and dysarthria with little if any limb involvement. Myopathies, especially polymyositis, and myasthenia gravis are potentially treatable disorders that must be considered. A variety of medications may cause or exacerbate neurogenic dysphagia. Psychiatric disorders can masquerade as swallowing apraxia. The basis for unexplained neurogenic dysphagia can best be elucidated by methodical evaluation including careful history, neurologic examination, videofluoroscopy of swallowing, blood studies (CBC, chemistry panel, creatine kinase, B12, thyroid screening, and anti-acetylcholine receptor antibodies), electromyography, and magnetic resonance imaging (MRI) of the brain, plus additional procedures such as lumbar puncture and muscle biopsy as indicated. Little is known about aging and neurogenic dysphagia, specifically the relative contributions of natural age-related changes in the oropharynx and of diseases of the elderly, including periventricular MRI abnormalities, in producing dysphagia symptoms and videofluoroscopic abnormalities in this population.

Swallowing after unilateral stroke of the cerebral cortex

We report differential patterns of swallowing in 40 patients with their first ischemic middle cerebral artery (MCA) stroke and compare these to 20 nonstroke controls. Stroke patients were divided a priori, into groups by right or left and, post hoc, primarily anterior or posterior MCA territory lesions. The left hemisphere subgroup was differentiated from controls by longer pharyngeal transit durations and from the right hemisphere group by shorter pharyngeal response durations. The right hemisphere subgroup was characterized by longer pharyngeal stage durations and higher incidences of laryngeal penetration and aspiration of liquid. Anterior lesion subjects demonstrated significantly longer swallowing durations on most variables compared to both normal and posterior lesion subjects. Changes in the consistency of foods and other modifications for safe nutrition should be considered during the first month of recovery for unilateral stroke patients with swallowing difficulty.

The role of the cerebral cortex in swallowing

This paper reviews clinical, neuroanatomical, and neurophysiological studies that have implicated the cerebral cortex in the initiation and/or regulation of swallowing as well as related functions such as mastication. Cortical dysfunction has been reported to result in a variety of swallowing impairments. Furthermore, swallowing can be evoked and/or modulated by stimulation applied to restricted regions of the cortex. Neuroanatomical investigations and single neuron recording studies also provide some insights into the cortical structures, pathways, and mechanisms that may mediate deglutition.