Videofluoroscopic swallowing study: esophageal alterations in patients with dysphagia

The Role of Imaging Modalities in Diagnosing Dysphagia: A Clinical Review

Dysphagia, which is characterized by difficulty in oro-gastric bolus transit, is a common condition. It is broadly classified into oropharyngeal or esophageal pathology. A wide array of differentials for dysphagia and initial clinical suspicion of oropharyngeal or esophagus etiology can assist in further evaluation. Fiberoptic endoscopic evaluation of swallowing (FEES) and videofluoroscopic swallow study (VFSS) are the preferred modalities for assessing oropharyngeal bolus transit, residual, as well as determining the risk of laryngeal aspiration. High-resolution pharyngeal manometry (HRPM) is an emerging modality for optimal topographical and pressure assessment of pharyngeal anatomy. HRPM provides improved assistance in evaluating the strength of the pharyngeal muscular contraction. Esophagogastroduodenoscopy (EGD) is the preferred exam for patients with suspected esophageal etiology of dysphagia. Barium swallow provides luminal assessment and assists in evaluating esophageal motility; it is non-invasive, but therapeutic interventions like biopsy cannot be performed. High-resolution esophageal manometry (HREM) has added another dimension in the diagnosis of esophageal motility disorders. The purpose of this review article is to help internists and primary care providers get a better understanding of the role of various imaging modalities in diagnosing dysphagia in the elderly population. This article also provides a comprehensive review and detailed comparison of these imaging modalities based on the latest evidence.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Effect of an indwelling nasogastric tube on swallowing function in elderly post-stroke dysphagia patients with long-term nasal feeding

BACKGROUND

In clinical practice, a large number of post-stroke survivors require nasogastric tube (NGT) placement and nasal feeding for a relatively long period. However, its impact on the swallowing function remains largely unknown. This study examines the impact of prolonged placement of an NGT on the swallowing function of elderly post-stroke patients.

METHODS

The participants of this study were 30 elderly post-stroke patients who had been using an NGT for more than 2 months. A videofluoroscopic swallowing study (VFSS) was performed before and 5 h after removal of the NGT. The following parameters were analyzed and compared, the functional dysphagia scale (FDS), residue in the valleculae, residue in the pyriform sinuses, and the penetration-aspiration scale (PAS). In addition, prior to the VFSS, the pharynx and larynx were examined using a fiberoptic laryngoscope.

RESULTS

Significant differences were observed between the total scores of the FDS, pharyngeal transit times (PTTs), the residue in the valleculae, and the residue in the pyriform sinuses before and after the NGT removal, suggesting an improved swallowing function following the removal of the NGT. A significantly lower penetration-aspiration degree was found after removing the NGT compared with that before its removal. In addition, examinations using the fiberoptic laryngoscope showed that laryngopharyngeal edema was present in three quarters of the patients.

CONCLUSIONS

Our results demonstrate that prolonged placement of the NGT had a negative impact on the swallowing function of elderly post-stroke dysphagia patients, mainly on the pharyngeal phase.

New ultrasonographic screening method for oropharyngeal dysphagia: tissue Doppler imaging

Ultrasound tissue Doppler imaging (US-TDI) has been used to diagnose regional wall motion (WM) abnormalities in coronary artery disease but has not been applied to oropharyngeal diseases. This study aimed first to validate an US-TDI method to assess cervical esophageal (CE) WM and secondly to use the method to evaluate CE WM in patients with oropharyngeal dysphagia (OD). First, we enrolled 22 healthy men (mean age: 59.7 yr) who all underwent both US-TDI and videofluoroscopy (VF) and then esophageal high-resolution manometry (HRM) in the same week. We evaluated the reproducibility of the US-TDI and the relationship between US-TDI and other modalities (VF and HRM). Second, we enrolled 56 mild OD patients (mean age: 58.0 yr) and age- and sex-matched healthy controls. Difference in CE WM between these groups was evaluated by US-TDI. All healthy subjects underwent US-TDI, VF, and HRM successfully, with a sufficiently high reproducibility coefficient for this method, and significant correlation between US-TDI and VF/HRM parameters. US-TDI showed mean time to open CE wall and mean velocity of CE wall opening significantly differed between patients and healthy controls ( P < 0.01). In conclusion, we have developed a US-TDI method for easily assessing CE WM in daily practice and also found significant differences in CE WM between mild OD patients and healthy controls. NEW & NOTEWORTHY A new ultrasonographic screening method using tissue Doppler imaging for oropharyngeal dysphagia was found to be a reliable, reproducible, and well-tolerated method. There is a significant correlation between this new method and conventional methods. This method revealed that patients having mild symptoms of oropharyngeal dysphagia had already significantly delayed cervical esophageal wall opening.

Percutaneous endoscopic gastrostomy versus nasogastric tube feeding for adults with swallowing disturbances

BACKGROUND

A number of conditions compromise the passage of food along the digestive tract. Nasogastric tube (NGT) feeding is a classic, time-proven technique, although its prolonged use can lead to complications such as lesions to the nasal wing, chronic sinusitis, gastro-oesophageal reflux, and aspiration pneumonia. Another method of infusion, percutaneous endoscopy gastrostomy (PEG), is generally used when there is a need for enteral nutrition for a longer time period. There is a high demand for PEG in patients with swallowing disorders, although there is no consistent evidence about its effectiveness and safety as compared to NGT.

OBJECTIVES

To evaluate the effectiveness and safety of PEG compared with NGT for adults with swallowing disturbances.

SEARCH METHODS

We searched The Cochrane Library, MEDLINE, EMBASE, and LILACS from inception to January 2014, and contacted the main authors in the subject area. There was no language restriction in the search.

SELECTION CRITERIA

We planned to include randomised controlled trials comparing PEG versus NGT for adults with swallowing disturbances or dysphagia and indications for nutritional support, with any underlying diseases. The primary outcome was intervention failure (e.g. feeding interruption, blocking or leakage of the tube, no adherence to treatment).

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by The Cochrane Collaboration. For dichotomous and continuous variables, we used risk ratio (RR) and mean difference (MD), respectively with the random-effects statistical model and 95% confidence interval (CI). We assumed statistical heterogeneity when I² > 50%.

MAIN RESULTS

We included 11 randomised controlled studies with 735 participants which produced 16 meta-analyses of outcome data. Meta-analysis indicated that the primary outcome of intervention failure, occurred in lower proportion of participants with PEG compared to NGT (RR 0.18, 95% CI 0.05 to 0.59, eight studies, 408 participants, low quality evidence) and this difference was statistically significant. For this outcome, we also subgrouped the studies by endoscopic gastrostomy technique into pull, and push and not reported. We observed a significant difference favouring PEG in the pull subgroup (RR 0.07, 95% CI 0.01 to 0.35, three studies, 90 participants). Thepush subgroup contained only one clinical trial and the result favoured PEG (RR 0.05, 95% CI 0.00 to 0.74, one study, 33 participants) techniques. We found no statistically significant difference in cases where the technique was not reported (RR 0.43, 95% CI 0.13 to 1.44, four studies, 285 participants).There was no statistically significant difference between the groups for meta-analyses of the secondary outcomes of mortality (RR 0.86, 95% CI 0.58 to 1.28, 644 participants, nine studies, very low quality evidence), overall reports of any adverse event at any follow-up time point (ITT analysis, RR 0.83, 95% CI 0.51 to 1.34), 597 participants, 6 studies, moderate quality evidence), specific adverse events including pneumonia (aspiration) (RR 0.70, 95% CI 0.46 to 1.06, 645 participants, seven studies, low quality evidence), or for the meta- analyses of the secondary outcome of nutritional status including weight change from baseline, and mid-arm circumference at endpoint, although there was evidence in favour of PEG for meta-analyses of mid-arm circumference change from baseline (MD 1.16, 95% CI 1.01 to 1.31, 115 participants, two studies), and levels of serum albumin were higher in the PEG group (MD 6.03, 95% CI 2.31 to 9.74, 107 participants).For meta-analyses of the secondary outcomes of time on enteral nutrition, there was no statistically significant difference (MD 14.48, 95% CI -2.74 to 31.71; 119 participants, two studies). For meta-analyses of quality of life measures (EuroQol) outcomes in two studies with 133 participants, for inconvenience (RR 0.03, 95% CI 0.00 to 0.29), discomfort (RR 0.03, 95% CI 0.00 to 0.29), altered body image (RR 0.01, 95% CI 0.00 to 0.18; P = 0.001) and social activities (RR 0.01, 95% CI 0.00 to 0.18) the intervention favoured PEG, that is, fewer participants found the intervention of PEG to be inconvenient, uncomfortable or interfered with social activities. However, there were no significant differences between the groups for pain, ease of learning to use, or the secondary outcome of length of hospital stay (two studies, 381 participants).

AUTHORS' CONCLUSIONS

PEG was associated with a lower probability of intervention failure, suggesting the endoscopic procedure may be more effective and safe compared with NGT. There is no significant difference in mortality rates between comparison groups, or in adverse events, including pneumonia related to aspiration. Future studies should include details of participant demographics including underlying disease, age and gender, and the gastrostomy technique.