Temporal measurements of deglutition in dynamic magnetic resonance imaging versus videofluoroscopy

Swallowing analysis in hemi-tongue reconstruction using motor-innervated free flaps: A cine-magnetic resonance imaging study

BACKGROUND

This study aimed to explore the outcomes of motor-innervated free flaps in hemi-tongue reconstruction by assessing the tongue mobility through midsagittal images from cine-magnetic resonance imaging.

METHODS

In this retrospective study, 47 patients who underwent tongue reconstruction following hemi-glossectomy and 10 control subjects without any surgical history were included. Patients were classified into two groups: the motor and no-motor innervation group. Various spatial parameters related to tongue mobility that were acquired from midsagittal sections were compared during consecutive swallowing phases.

RESULTS

Overall, the motor group showed improved functional swallowing scale compared with the no-motor group. In case of tongue base resection, the motor group showed improved mobility of the tongue base during pharyngeal phase, whereas the no-motor group showed increased laryngeal elevation for compensatory movement.

CONCLUSION

The tongue reconstruction with motor-innervated free flaps may facilitate swallowing capacity in patients with a hemi-tongue defect combined with tongue base resection.

Diagnosis and treatment of neurogenic dysphagia - S1 guideline of the German Society of Neurology

Introduction

Neurogenic dysphagia defines swallowing disorders caused by diseases of the central and peripheral nervous system, neuromuscular transmission, or muscles. Neurogenic dysphagia is one of the most common and at the same time most dangerous symptoms of many neurological diseases. Its most important sequelae include aspiration pneumonia, malnutrition and dehydration, and affected patients more often require long-term care and are exposed to an increased mortality. Based on a systematic pubmed research of related original papers, review articles, international guidelines and surveys about the diagnostics and treatment of neurogenic dysphagia, a consensus process was initiated, which included dysphagia experts from 27 medical societies.

Recommendations

This guideline consists of 53 recommendations covering in its first part the whole diagnostic spectrum from the dysphagia specific medical history, initial dysphagia screening and clinical assessment, to more refined instrumental procedures, such as flexible endoscopic evaluation of swallowing, the videofluoroscopic swallowing study and high-resolution manometry. In addition, specific clinical scenarios are captured, among others the management of patients with nasogastric and tracheotomy tubes. The second part of this guideline is dedicated to the treatment of neurogenic dysphagia. Apart from dietary interventions and behavioral swallowing treatment, interventions to improve oral hygiene, pharmacological treatment options, different modalities of neurostimulation as well as minimally invasive and surgical therapies are dealt with.

Conclusions

The diagnosis and treatment of neurogenic dysphagia is challenging and requires a joined effort of different medical professions. While the evidence supporting the implementation of dysphagia screening is rather convincing, further trials are needed to improve the quality of evidence for more refined methods of dysphagia diagnostics and, in particular, the different treatment options of neurogenic dysphagia. The present article is an abridged and translated version of the guideline recently published online (https://www.awmf.org/uploads/tx_szleitlinien/030-111l_Neurogene-Dysphagie_2020-05.pdf).

A new swallowing supplement for dysphagia in patients with Parkinson's disease

Dysphagia associated with Parkinson's disease (PD) affects the mortality and quality of life of patients with PD. Avoiding aspiration and maintaining swallowing ability are among the concerns regarding PD care. Therefore, we developed a swallowing supplement for easier swallowing and tolerability in patients with PD. Thirty patients with PD and 50 healthy controls were enrolled and their swallowing function measured using the videofluoroscopic swallowing study (VFSS) and several dysphagia scales. The Unified Parkinson's Disease Rating Scale motor scores, Hoehn and Yahr stage, and levodopa doses were evaluated in patients with PD. The VFSS and survey were used to assess the viscosity, color, taste, nutrition, safety, and tolerability of the swallowing supplement. The MMSE score, serum albumin, and hemoglobin levels, and oral conditions were worse in the PD group than in the control group. Compared with controls, patients with PD had significantly lower total and sub-item scores of the swallowing quality of life (swal-QoL). Using commercialized yogurt, the pharyngeal delay time (PDT) and the modified penetration aspiration scale were higher in the PD group than in the control group. The swallowing supplement significantly shortened the PDT and pharyngeal transit time (PTT). Moreover, compared with commercialized yogurt, it improved pharyngeal wall coating, PTT, and aspiration in the videofluoroscopic dysphagia subscales. The survey scores were above average to good in the "easy swallowing" and "pharyngeal residual sense" items and tolerable in the remaining 6 preference items. This swallowing supplement could prevent aspiration and dysphagia complications in patients with PD.

Assessing Upper Esophageal Sphincter Function in Clinical Practice: a Primer

The upper esophageal sphincter constitutes an important anatomic and functional landmark in the physiology of pharyngeal swallowing. A variety of clinical circumstances may call for a dedicated evaluation of this mechanism, from the etiologic evaluation of indeterminate symptoms to the generation of complex locoregional therapeutic strategies. Multiple diagnostic tools exist for the assessment of pharyngeal swallowing generally and of upper esophageal sphincter function specifically, some well established and others not yet settled into routine practice. This report reviews five specific modalities for use in making this assessment, outlining the strengths, weaknesses, and logistical considerations of each with respect to its potential use in clinical settings. In many cases, these studies will provide complementary information regarding pharyngeal function, suggesting the relative advantage of a multimodal evaluation.

Oropharyngeal dysphagia: manifestations and diagnosis

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

Magnetic resonance imaging of the effortful swallow

OBJECTIVE

The effortful swallow was designed to improve posterior mobility of the tongue base and increase intraoral pressures. We characterized the effects of this maneuver via dynamic magnetic resonance imaging (dMRI) in healthy patients.

METHODS

A 3-T scanner was used to obtain dMRI images of patients swallowing pudding using normal as well as effortful swallows. Ninety sequential images were acquired at the level of the oropharynx in the axial plane for each swallow; 3 series were obtained for each swallow type for each patient. Images were acquired every 113 ms during swallowing. The images were analyzed with respect to oropharyngeal closure duration, anteroposterior and transverse distance between the oropharyngeal walls, and oropharyngeal area before and after closure.

RESULTS

Preswallow reduced pharyngeal area was observed (P = .02; mean = 212.61 mm² for effortful, mean = 261.92 mm² for normal) as well as prolonged pharyngeal closure during the swallow (P < .0001; mean = 742.18 ms for effortful, mean = 437.31 ms for normal). No other differences were noted between swallow types. Interrater and intrarater reliability of all measurements was excellent.

CONCLUSION

This preliminary investigation is the first to evaluate the effects of effortful swallows via dMRI. In our cohort, consistent physiologic changes were elicited, consistent with clinical dogma regarding this maneuver.