[Effect of posture strategies on preventing aspiration]

A Case of Post-trauma Dysphagia: Peculiar Swallowing Dynamics Due to Associated Laryngeal Paralysis

Background:

Associated laryngeal paralysis (ALP) is defined as vagus nerve impairment combined with other lower cranial nerve paralysis. Traumatic ALP is reported infrequently.

Case:

A 72-year-old man was injured on the back of the head when a large tree fell on him; he was admitted to a general hospital, where he was diagnosed with brain concussion and Guillain-Barre syndrome (GBS). The patient developed aspiration pneumonia due to severe dysphagia. Although he underwent treatment and rehabilitation for 6 months, some disabilities persisted, and a percutaneous endoscopic gastrostomy tube was placed. Six months after the accident, the patient was transferred to our rehabilitation hospital. Videoendoscopic examination and videofluoroscopy revealed persistent upper esophageal sphincter (UES) opening, left dominant bilateral IX and X nerve paralysis, and left XII nerve paralysis; moreover, these examinations showed that the swallowing reflex was absent, although a bolus could pass through the UES. We suspected that the patient’s condition was not GBS and performed head computed tomography and magnetic resonance imaging; these revealed a bone fracture at the skull base. Consequently, the patient’s diagnosis was changed to bilateral ALP. He received swallowing rehabilitation for 2 months and could orally consume alternative nutrition. Finally, the patient was able to eat orally texture-modified foods (Food Intake LEVEL Scale level 8).

Discussion:

While post-trauma dysphagia due to bilateral ALP might be severe, patients can regain the ability to eat orally if clinicians understand the etiology of dysphagia and provide appropriate swallowing rehabilitation techniques, including patient position adjustment while eating and selection of food textures.

Sole-ground contact and sitting leg position influence suprahyoid and sternocleidomastoid muscle activity during swallowing of liquids

Clinically, the stable sole-ground contact in the diet is considered as important for achieving safe swallows in the dysphagic patients. However, the effects of varied sole-ground contacts on swallow-related muscles activities remain unclear. The aim of this study was to investigate the effects of sole-ground contacts on the muscle activities during swallow for various materials; 26 healthy adult subjects participated in this study. Three different sole-ground contact conditions were investigated; sole-ground contact with knees bent to 90° (KB 90°), sole-ground contact with knees bent to 135° (KB 135°), and sole-ground off the floor (Off). Participants swallowed four bolus materials (saliva, 5-ml water, 10-ml water, and 5-ml yogurt) in each sole-ground contact condition. The muscular activities of the suprahyoid (SH) muscle and the sternocleidomastoid muscle during swallowing were detected and recorded using surface electromyography. The sole-ground contact pressure was evaluated using the data acquisition system. Duration of SH during 10-ml water swallow for Off was significantly longer than that for KB 90°. Duration of SH during 5-ml yogurt swallow for Off was significantly longer than that for KB 90°. Integration of SH during 10-ml water swallow for Off was significantly greater than that for KB 135°. Integration of SH during 5-ml yogurt swallow for Off was significantly greater than that for KB 90°. No significant differences were found in peak of SH. Sole-ground contact conditions had significant effect on swallow-related muscles activities. The stable sitting positions might be more advantageous for performing effective swallows compared with less stable sitting positions.

Clinical inter-rater reliability of postural control techniques

Effectiveness of postural control techniques to compensate for oropharyngeal dysphagia have been recommended and used by several clinicians. However, the inter-rater reliability of these techniques is not well understood. The purpose of this study was to clarify the ambiguity of postural control techniques using statistical analyses. A total of 50 clinicians involved in dysphagia treatment participated in this study, where a healthy male served as the simulated patient. The following clinically used postures were measured by two investigators on two separate days: chin down, right/left incline, and right/left rotation. Postural angles were measured twice by two investigators on each day. Data obtained for the angle of each posture were visually displayed. Data from both investigators were assessed for each posture using the Youden plot, which analyzes data variability for systematic errors and accidental errors separately. The correlation coefficient for examining the measurement error between investigators was calculated. The results showed considerable variation between clinicians regarding the postures used, and significant differences were noted each day. The correlation coefficient for a total of four measurements was more often lower on Day 2 than that on Day 1. The details of the instructions provided by clinicians were not fixed, and the same specified posture was not reproduced even when instructions were provided to the same subject. These findings suggest poor inter-rater reliability because of the variability of selected postures when using statistical analyses. Therefore, standardized postures need to be developed that can be easily measured and reproduced.

Clinical Factors of Enteral Tube Feeding in Acute Ischemic Stroke Patients

OBJECTIVE

The aim of this study was to identify possible clinical factors associated with enteral tube feeding use and duration in acute ischemic stroke patients.

DESIGN

The medical records of 410 acute ischemic stroke patients were reviewed. Brain lesions were classified into nine regions of interest according to the cerebral vascular system. Brain lesion volume, lesion side, National Institutes of Health Stroke Scale (NIHSS) score, type of feeding during admission, and demographic characteristics were compared between enteral tube feeding and non-enteral tube feeding groups.

RESULTS

Of the 410 patients, 61 used enteral feeding tubes. The mean age, NIHSS score, and brain lesion volume were significantly higher in the tube group than the nontube group (P < 0.001). Of the nine regions of interest, the right and left middle cerebral artery areas were strongly correlated with enteral tube feeding (P < 0.001). The NIHSS scores were significantly related to the duration of tube feeding (P < 0.05). The NIHSS consciousness subscores were significantly higher in the tube feeding group than in the non-tube feeding group (P < 0.05).

CONCLUSIONS

Older age, lesions in the middle cerebral artery territory, and larger lesions were identified as significant risk factors of enteral tube feeding. Especially, the NIHSS consciousness subscore needs to be evaluated precisely because it was the factor most closely related to the implementation and duration of enteral tube feeding.

Investigation of compensatory postures with videofluoromanometry in dysphagia patients

AIM: To investigate the effectiveness of head compensatory postures to ensure safe oropharyngeal transit.

METHODS: A total of 321 dysphagia patients were enrolled and assessed with videofluoromanometry (VFM). The dysphagia patients were classified as follows: safe transit; penetration without aspiration; aspiration before, during or after swallowing; multiple aspirations and no transit. The patients with aspiration or no transit were tested with VFM to determine whether compensatory postures could correct their swallowing disorder.

RESULTS: VFM revealed penetration without aspiration in 71 patients (22.1%); aspiration before swallowing in 17 patients (5.3%); aspiration during swallowing in 32 patients (10%); aspiration after swallowing in 21 patients (6.5%); multiple aspirations in six patients (1.9%); no transit in five patients (1.6%); and safe transit in 169 patients (52.6%). Compensatory postures guaranteed a safe transit in 66/75 (88%) patients with aspiration or no transit. A chin-down posture achieved a safe swallow in 42/75 (56%) patients, a head-turned posture in 19/75 (25.3%) and a hyperextended head posture in 5/75 (6.7%). The compensatory postures were not effective in 9/75 (12%) cases.

CONCLUSION: VFM allows the speech-language the-rapist to choose the most effective compensatory posture without a trial-and-error process and check the effectiveness of the posture.

Search for compensation postures with videofluoromanometric investigation in dysphagic patients affected by amyotrophic lateral sclerosis

PURPOSE

This study was undertaken to verify the effectiveness of compensatory postures, suggested on the basis of the type of dysphagia identified at videofluoromanometric (VFM) investigation to ensure safe oropharyngeal transit.

MATERIALS AND METHODS

Eighty-one patients with amyotrophic lateral sclerosis (ALS) underwent speech therapy assessment and VFM investigation of the swallowing process. In the event of altered transit, penetration or aspiration of contrast material into the airways, compensation postures for correction of the swallowing disorder were suggested and verified during VFM examination.

RESULTS

In 37 patients, contrast agent transport was preserved and safe; in 19, we observed penetration of the contrast agent into the laryngeal inlet without aspiration; in 24, there was aspiration (four preswallowing, eight intraswallowing, nine postswallowing, three mixed), whereas in one patient no transit was seen. Penetration without aspiration was resolved by coughing or throat clearing; aspiration was resolved in 13 patients by assuming the chin-tuck posture and in six by rotating the head; in five patients, it was not resolved. A hyperextended head posture proved to be effective to resolve lack of transit.

CONCLUSIONS

By correlating morphological with functional data, VFM enables one not only to precisely characterise the dysphagic disorder but also to identify the most appropriate compensation posture for each patient and verify its effectiveness.

Rehabilitation of dysphagia following head and neck cancer

Patients who have cancers of the oral cavity, pharynx, or larynx may be treated with surgery, radiotherapy, chemotherapy, or a combination of these modalities. Each treatment type may have a negative impact on posttreatment swallowing function; these effects are presented in this article. A number of rehabilitative procedures are available to the clinician to reduce or eliminate swallowing disorders in patients treated for cancer of the head and neck. The various procedures-including postures, maneuvers, modifications to bolus volume and viscosity, range-of-motion exercises, and strengthening exercises-and their efficacy in patients treated for head and neck cancer are discussed.