Swallowing kinematics and submental muscles activation during a newly designed maneuver called Mouth Open Swallowing Maneuver: A comparative study

The aim of this study was to design a new maneuver called the Mouth Open Swallowing Maneuver (MOSM), and to compare swallowing kinematics and submental muscles activation (SMA) between MOSM and two current approaches used in dysphagia rehabilitation. Fifty healthy volunteers were asked to perform three repetitions of dry swallowing (DS) (control task), the MOSM, the Mendelsohn Maneuver (MM), and the Tongue-Hold Maneuver (THM) during videofluoroscopic swallowing study accompanied with simultaneous SMA recording. Swallowing kinematics were measured by frame-by-frame analysis on hyolaryngeal movement using ImageJ. Swallowing with maximum hyolaryngeal movement and SMA during these tasks was used for comparative analysis. Vertical movement of the hyoid during the MOSM was significantly greater than those observed during the DS and the THM (p<0.001, p<0.001). Horizontal movement of the hyoid during DS and the THM was significantly greater than that observed during the MM (p = 0.001, p = 0.001). Vertical movement of the larynx during the MOSM was significantly greater than those observed during DS, MM, and THM (p<0.001). There was no significant difference between tasks in horizontal movement of the larynx (p = 0.785). SMA during the THM was significantly greater than that observed during MOSM (p = 0.002). No significant difference was found between other tasks in terms of SMA (p>0.05). The MOSM as a newly designed maneuver was significantly superior to other maneuvers in increasing vertical hyolaryngeal movement. The THM has as much effect on hyolaryngeal movement as the MM. In this study, the MOSM was shown to be effective in increasing hyolaryngeal movement. ClinicalTrials.gov Protocol Registration and Results System (PRS); the clinical trial registration number (NCT05579041).

Are sucking patterns and early spontaneous movements related to later developmental functioning outcomes? A cohort study

Sucking patterns and early spontaneous movements have an important role in the determination of later developmental problems, but the relationship of the two together with long-term outcomes has not been investigated. The objectives of this study were to (i) examine the relationship between sucking patterns using the Neonatal Oral Motor Assessment Scale (NOMAS) and fidgety movements and other movement patterns using detailed General Movements Assessment (GMA), and (ii) investigate the relationship between these early assessment methods and developmental functioning outcomes at later ages. We analyzed the NOMAS from 34 weeks' postmenstrual age up to 10 weeks post-term and GMA between 9 and 20 weeks post-term age, and the Bayley Scales of Infant and Toddler Development-Third Edition (Bayley-III) was applied for the developmental functioning outcomes to 62 infants (61%, 62/102) between 12 and 42 months of age. Among 102 infants at-risk, 70 (69%) showed a normal sucking pattern, and 85 (83%) had fidgety movements. The median Motor Optimality Score-Revised (MOS-R), as determined by GMA, of all infants was 24. The NOMAS was related to the MOS-R and its subcategories (p < 0.05) in all infants at-risk. The NOMAS, MOS-R and its subcategories were also related to cognitive, language, and motor development at later ages according to Bayley-III (p < 0.05).   Conclusion: This longitudinal study showed that the quality of sucking patterns, fidgety movements, and MOS-R were related to later developmental functioning, indicating that abnormal sucking patterns, aberrant fidgety movements, and lower MOS-R might predict developmental disorders. What is Known: • Sucking patterns and early spontaneous movements in which central pattern generators play an important role are related. • Sucking patterns and early spontaneous movements might be used separately to predict developmental outcomes. What is New: • Sucking patterns and early spontaneous movements, when used together, were related to later developmental functioning, including cognitive, language, and motor development in at-risk infants. • Predictive value of sucking patterns was lower for each developmental functioning outcome than early spontaneous movements.

Effectiveness of Conventional Dysphagia Therapy (CDT), Neuromuscular Electrical Stimulation (NMES), and Transcranial Direct Current Stimulation (tDCS) in Acute Post-Stroke Dysphagia: A Comparative Evaluation

This study aims to compare the effectiveness of conventional dysphagia therapy (CDT), neuromuscular electrical stimulation (NMES), and transcranial direct current stimulation (tDCS) in the treatment of post-stroke dysphagia. A single-blind randomized controlled trial was conducted with 40 acute stroke patients - 18 females and 22 males with a mean age of 65.8 ± 11.9. The subjects were grouped into 4, with 10 individuals in each. The procedures administered to groups were as follows: the first group, sham tDCS and sham NMES; the second group, tDCS and sham NMES; the third group, NMES and sham tDCS; and the fourth group, all therapy procedures. CDT was applied to all groups either as a standalone procedure or combined with one or two of the instrumental techniques. Gugging Swallowing Screen (GUSS) and Videofluoroscopic Swallowing Study (VFSS) were employed to determine the severity of dysphagia and the effectiveness of treatment modalities. Additionally, the Penetration Aspiration Scale (PAS), Functional Oral Intake Scale (FOIS), and Dysphagia Severity Rating Scale (DSRS) were administered to interpret VFSS data. Pre- and post-treatment comparisons of all groups have revealed a statistically significant difference for all parameters except for the PAS scores at International Dysphagia Diet Standardization Initiative (IDDSI)-Level 4 consistencies. However, the differences between pre- and post-treatment scores of the fourth group across all parameters were significant - GUSS (p = 0.005), FOIS (p = 0.004), DSRS (p = 0.005), PAS IDDSI-4 (p = 0.027), PAS IDDSI-0 (p = 0.004). Inter-group comparisons, on the other hand, pointed out that the difference between pre- and post-treatment GUSS, FOIS, DSRS, and PAS scores at IDDSI Level-0 consistencies was statistically significant for all groups - GUSS (p = 0,009), FOIS (p = 0,004), DSRS (p = 0,002), PAS IDDSI-0 (p = 0,049). Closer examination of treatment groups indicated that the tDCS + CDT group, the NMES + CDT group, and the group that underwent the combination of three modalities made better progress than the one that was treated with only CDT. Though not statistically significant, the NMES + CDT group achieved better improvement than the tDCS + CDT group. This study has yielded that the group in which NMES, tDCS, and CDT were applied in combination has achieved better results than all the other groups. All treatment modalities applied to accelerate the general recovery process in acute stroke patients with dysphagia were found to be effective for the treatment of post-stroke swallowing disorders. The use of instrumental treatments such as NMES and tDCS enhanced the effectiveness of the treatment and provided more significant progress. Furthermore, combining treatment modalities such as NMES and tDCS was more effective when compared to using only conventional therapy. As a result, the most effective treatment outcomes were obtained by the group receiving CDT, NMES, and tDCS in combination. Therefore, the use of combined approaches has been recommended in appropriate patients; yet the provisional results should be tested in randomized trials with more participants.

The Role of Bolus Residue and Its Relation with Respiratory Problems in Children with Esophageal Atresia

Bolus residue is significant risk factor for postswallow aspiration. A retrospective study was performed to evaluate the role of bolus residue and its relation with respiratory problems in children with esophageal atresia. Children were evaluated for demographic features, type of esophageal atresia, associated anomalies, and respiratory problems. The videofluoroscopic swallowing evaluation (VFSE) was performed, and scored by using the penetration aspiration scale (PAS), bolus residual score (BRS) and normalized residual ratio scale (NRRS). Children with and without respiratory problems were also compared in terms of aspiration and bolus residue. Forty-one children with a median age of 15 months (1-138 months), male:female ratio of 26:15 was included. 65.9% (n = 27) of children were type-C and 24.4% (n = 10) were type-A EA. In 61% (n = 25) of children had liquid aspiration (PAS ≥ 6) and 9.8% (n = 4) had aspiration in pudding consistencies. Children with aspiration in liquids had significantly higher NRRS and BRS scores in vallecular residue for pudding consistencies when compared to children without aspiration (p < 0.05). No difference was detected in terms of PAS scores and bolus residual parameters between children with and without respiratory problems (p > 0.05). Children with aspiration in liquids have higher scores of BRS and NRRS at the level of vallecular especially in pudding consistencies. VFSE findings for bolus residue did not show significant relation with respiratory problems. Respiratory morbidity in children with EA is multifactorial and may not only explained by bolus residuals and aspiration.

Dynamic Imaging Grade of Swallowing Toxicity in Children with Esophageal Atresia

INTRODUCTION

 The Dynamic Imaging Grade of Swallowing Toxicity (DIGEST) scale was developed to evaluate the safety, efficiency, and overall pharyngeal swallowing performance in patients with dysphagia (DIGESTs, DIGESTe, and DIGESTt, respectively). Although various types of swallowing dysfunction are encountered in children with esophageal atresia (EA), oropharyngeal dysphagia poses risk for aspiration. Therefore, a retrospective study was performed to evaluate the safety and efficacy of swallowing by using DIGEST score in children with EA.

PATIENTS AND METHODS

 Thirty-nine EA patients were included. The demographic features, respiratory problems, results, and outcomes of surgical treatment were evaluated from medical records. The videofluoroscopic swallowing evaluation investigated for both airway protection and bolus residuals at the level of vallecula, posterior pharyngeal wall, and pyriform sinus at liquid and pudding consistencies. The penetration and aspiration scale (PAS) was used to define penetration and aspiration severity, and DIGEST was used to evaluate DIGESTs, DIGESTe, and DIGESTt.

RESULTS

 The median age of the patients were 13 months (7-39 months), and male-to-female ratio was 25:14. Sixty-seven percent of patients were type-C EA and 61% of them has associated anomalies; 38% of patients had aspiration (PAS = 6-8) in liquids and 10% in pudding consistency. Life-threatening/profound swallowing dysfunction in DIGESTe (DIGEST = 4) was seen in 13% (n = 5) of patients; 40% of EA patients showed severe problems in DIGESTt.

CONCLUSION

 DIGEST is a valid and reliable tool to define the efficacy and safety of swallowing in children with EA.

Re: 'Turkish turban' sign: a rare phenotype of acrania-exencephaly-anencephaly sequence

Linked article: This Correspondence comments on Tonni et al. Click here to view the article.

Surface Electromyographic Activity of Submental Muscles During Different Types of Swallow-Specific Tasks: A Comparative Study

BACKGROUND

Repetitive performance of a motor task has been proposed to increase the ability to perform that motor task. Therefore, exercise training including swallow-specific task may be an optimal training to improve swallowing function.

OBJECTIVES

To determine the submental muscles activity during different types of swallow-specific tasks (Effortful Swallow, ES; Tongue-Hold Swallow, THS; Swallow with Kinesio Taping, SwKT; Head extension swallowing exercise, HESE) compared to normal swallow (NS), and also compare these tasks within themselves.

METHODS

35 healthy adults participated in this prospective experimental study with one participant group. The surface electromyography (sEMG) was used to evaluate submental muscles activity while performing swallow-specific tasks.

RESULTS

While the greatest submental muscles activity was revealed during the ES, HESE, NS and THS tasks, respectively, the lowest was obtained during SwKT. When compared to NS, ES caused a statistically greater submental muscles activity (p₁ =.000 and p₂ =.000), although SwKT revealed a lower submental muscles activity (p₁ =.002 and p₂ =.000). When swallow-specific tasks were compared within themselves, ES caused the highest muscles activity (p<.005) than all other tasks, and HESE caused higher muscles activity than THS and SwKT (p<.005).

CONCLUSION

Different swallow-specific tasks can cause increased or decreased submental muscles activity compared to NS task. Since ES and HESE are superior in selective submental muscles contraction, they appear to be more promising in terms of submental muscles gains in long-term exercise training.

The Role of Oral Feeding Time and Sham Feeding on Oropharyngeal Swallowing Functions in Children with Esophageal Atresia

A retrospective study was performed to evaluate the role of oral feeding (OF) time and sham feeding (SF) on oral-pharyngeal swallowing functions in children with esophageal atresia (EA). Patients with EA were evaluated for age, sex, and types of atresia, time to start OF and surgical complications. Three to six weeks after full OF, videofluoroscopic swallowing evaluation (VFSE) was performed, and Penetration Aspiration Score (PAS, no aspiration = 1, penetration = 2-5, aspiration = 6-8), delay in swallowing reflex and residue after liquid and pudding consistency were noted. Patients were divided into three groups according to repair time; early primary repair (EPR, < 1 month of age), delayed primary repair (DPR, ≥ 1 month of age) and colonic interposition (CI). VFSE findings were compared between groups. In CI group, patients without aspiration in VFSE were encouraged to sham SF before CI. Patients with and without SF in CI group were also compared for oro-pharyngeal dysphagia (OPD). PAS scores were significantly higher in DPR (n = 13) group when compared to CI group (n = 12) in liquid swallowing (p = 0.032) and higher than EPR (n = 30) in pudding consistency (p = 0.03). Patients with CI showed significant OPD when compared to EPR (p = 0.017). Swallowing reflex delay was similar in both groups (p > 0.05). DPR group had significantly higher liquid residue at the level of vallecula (p = 0.028). The residue at other levels (oral, tongue base, pharyngeal wall and pyriform sinus) were similar in all groups in both liquid and pudding consistencies. There was no significant difference between sham-fed (n = 6) and not sham-fed (n = 6) infants in VFSE of OPD (p > 0.05). Patients with DPR without SF had significantly higher incidence of OPD and PAS scores when compared to EPR and CI. Although CI groups has the latest OF time, SF may improve oral motor abilities and cause better OF swallowing functions than patients with delayed repair.

Reliability of Bigliani's Classification using Magnetic Resonance Imaging for Determination of Acromial Morphology

Introduction

Bigliani classification is used for determination of acromial morphology, but poor inter-observer reliability has been reported on conventional radiographs. This study aims to assess inter- and intra-observer reliability using magnetic resonance imaging (MRI).

Materials and methods

Forty consecutive patients diagnosed with subacromial impingement syndrome were included to study. All subjects underwent standard shoulder MRI scan and acromial shape was evaluated by nine observers of different level of expertise (three attending surgeons, three senior orthopaedic residents and three radiologists). A second set of evaluation was performed in order to assess intra-observer reproducibility. Kappa (κ) coefficient analyses both for interobserver reliability and intra-observer reproducibility were then performed.

Results

Overall inter-observer agreement among nine observers was fair (κ=0.323). κ values for all 4 individual types ranged from 0.234 to 0.720 with highest agreement for type 4 and lowest agreement for type 3. Second evaluation did not result with an increase of inter-observer agreement (κ=0.338, fair). The κ coefficients for intra-observer reproducibility of nine observers ranged from 0.496 to 0.867. Overall intra-observer reproducibility was substantial. Comparison of inter- and intra-observer reliability among three groups showed no significant difference (p=0.92 and 0.22, respectively).

Conclusion

Results showed that MRI did not show superior reliability compared to conventional radiographs. Moreover, inter- and intra-observer agreement did not differ between observers of different level of expertise. Findings of present study suggest that despite a sophisticated imaging modality like MRI, Bigliani's classification apparently lacks accuracy and additional criteria, or different assessment methods are required to assess acromial morphology for clinical guidance.

The cause of dysphagia in patients with esophageal atresia: a systematic review and meta-analysis

PURPOSE

Dysphagia is the most common symptom in patients with esophageal atresia (EA) of all ages. There is no study addressing the direct relation between dysphagia and surgical results. Therefore, a systematic review was performed to define the relationship between surgical complications and dysphagia in patients with EA.

METHODS

The systematic review was drafted under PRISMA guidelines. Systematic literature search was performed for the period 2000 (Jan) to 2019 (Dec)-20 years-in the databases: MEDLINE, EMBASE, and PubMed. Statistical analysis was performed using Comprehensive Meta-Analysis Version 3.0 software.

RESULTS

Among 767 articles, 486 abstracts were screened for the inclusion criteria. The full-texts of 64 articles were assessed for eligibility. The sub-group analysis could be performed in 4 articles for anastomotic strictures. Heterogeneity was calculated by I² statistic as 18,487 and pooled odds ratio was measured under the fixed effect model (Q = 3.68; P = 0.298, I² = 18,487). There was no significant relationship with an odds ratio of 1.37 between anastomotic stricture (AS) and dysphagia (95% CI 0.631-2.973, p = 0.426). There was no publication bias for the data (Begg's test, p = 0.496; Egger's tests, p = 0.335).

CONCLUSION

This meta-analysis did not reveal a significant relationship between AS and dysphagia in children with EA. Since many other factors contribute to dysphagia, comprehensive variable information such as detailed standardized registry systems for rare diseases for pooling analysis is needed regarding other potential factors including surgical complications.

The Status of Dysphagia Clinics During the COVID-19 Pandemic

The study aimed to determine the status of dysphagia clinics and procedures applied in dysphagia clinics during the COVID-19 pandemic. Clinicians working in an outpatient dysphagia clinic were included. A 30-question survey inquiring about the descriptive information of the participants and their clinics, their clinical practice, and the tele-health applications during the COVID-19 pandemic. The survey was administered via Google forms. The participants were asked to fill out the survey on behalf of their clinics. One survey was completed per dysphagia clinic. Twenty-three clinicians responded on behalf of their clinics. The number of patients and dysphagia evaluations decreased during the COVID-19 pandemic (p < 0.05). The COVID-19 screening procedures mostly performed before dysphagia evaluations were temperature check (n = 14, 60.9%), nasopharyngeal swab test (n = 9, 39.1%), anamnestic risk assessment (n = 6, 26.1%), and saturation test (n = 6, 26.1%). Protective equipments mostly used while dysphagia evaluations were surgical mask, FFP3 mask, standard gloves, glasses, and face shield. It was found that 69.6% (n = 16) of the dysphagia clinics were reported to be suitable for working under pandemic conditions, and 30.4% (n = 7) were reported to be unsuitable. The use of tele-health applications significantly increased from 13.0% (n = 3) to 52.2% (n = 12) (p = 0.003). The present study provides a general overview of the status of dysphagia clinics and procedures applied in dysphagia clinics during the COVID-19 pandemic period. The study showed that working conditions, the number of patients, and the total number of evaluations have changed throughout the pandemic, and the use of tele-health applications increased.

Assessment of swallowing function in pediatric patients with Wilson's disease: Results of a videofluoroscopic swallowing study

BACKGROUND AND STUDY AIMS

Wilson's disease (WD) is a complex disorder related to copper metabolism and neurological involvement may lead to swallowing disorders. The purpose of this study was to evaluate swallowing function in pediatric patients with WD by using videofluoroscopic swallowing study (VFSS).

PATIENTS AND METHODS

A total of 21 patients were included in the study, prospectively. The VFSS was conducted to evaluate swallowing function of the patients. The penetration-aspiration scale (PAS) was used to assess penetration-aspiration severity.

RESULTS

According to the VFSS, abnormal results were detected in nine patients (42.9%) with WD. Of these nine patients, oral phase dysfunction was present in one patient, laryngeal penetration was present in one patient and moreover, abnormal esophageal body function was detected in all nine patients. Of these nine patients, five had neurological presentation at the time of diagnosis, and remaining four patients had hepatic presentation. Mean PAS score of the patients was 1.

CONCLUSION

The current study results suggest that subclinical swallowing dysfunction may be observed in patients with either neurological or hepatic WD. Further studies are necessary to reveal the real incidence of esophageal phase problems of swallowing function in pediatric patients with WD.

Orofacial functions and oral health: An analysis on children aged 5-8 years old

The aim of this study is to assess the orofacial function performance and oral health status of healthy children as well as their potential correlations. In this descriptive study, the oral functions of four hundred systemically healthy children who applied for the pediatric dentistry clinic were evaluated. Three scales, namely Karaduman Chewing Performance Scale (KCPS), Pediatric version of the Eating Assessment Tool (PEDI-EAT-10), and Nordic Orofacial Test Screening (NOT-S) protocol, are used to collect the data. These children's carious lesions were evaluated by using the decayed, missing, filled tooth/surface (DMFT/S, dmft/s) indices, the International Caries Detection and the Assessment-II System (ICDAS-II). In total, 400 (6.5 years [78.02 months]) children were participated in the study. Their KCPS scores indicate that 58.0% of the children were at level 0 and 35.8% were at level 1. The results of the KCPS levels and the DMFT, dmft, DT, dt, MT, mt (as =0 and ≥1) were found to be statistically significant; p = .044, p = .009, p = .008, p = .000, p = .032, and p = .003, respectively. The total PEDI-EAT-10 score of 13.4% of the children was found to be 3 or higher, suggesting that they experience a problem in swallowing. According to the NOT-S, the most affected domains were "habits" (51.0%), "facial expression" (49.3%), and "chewing and swallowing" (45.3%). Among healthy children without a defined problem in swallowing and orofacial functions, the oral health status may affect orofacial functions. Decayed (particularly, extensive caries existence) or missing tooth may have critical importance for adequate chewing in children. Especially in the presence of so many decayed or missing teeth, evaluating the orofacial functions through different scales may considerably contribute to early diagnosis of functional problems.

Intercellular bridges coordinate the transition from pluripotency to meiosis in mouse fetal oocytes

Meiosis is critical to generating oocytes and ensuring female fertility; however, the mechanisms regulating the switch from mitotic primordial germ cells to meiotic germ cells are poorly understood. Here, we implicate intercellular bridges (ICBs) in this state transition. We used three-dimensional in toto imaging to map meiotic initiation in the mouse fetal ovary and revealed a radial geometry of this transition that precedes the established anterior-posterior wave. Our studies reveal that appropriate timing of meiotic entry across the ovary and coordination of mitotic-meiotic transition within a cyst depend on the ICB component Tex14, which we show is required for functional cytoplasmic sharing. We find that Tex14 mutants more rapidly attenuate the pluripotency transcript Dppa3 upon meiotic initiation, and Dppa3 mutants undergo premature meiosis similar to Tex14 Together, these results lead to a model that ICBs coordinate and buffer the transition from pluripotency to meiosis through dilution of regulatory factors.

Dysphagia in Children with EA-TEF From the Perspective of Pediatric Surgeons in Clinical Settings

The current study was aimed to define clinical practice, knowledge and awareness, and best practice regarding dysphagia in children with esophageal atresia with/without tracheoesophageal fistula (EA-TEF) from the perspective of pediatric surgeons in Turkey. Pediatric surgeons practice EA repair were included. A survey related to clinical practice, knowledge and awareness, and best practice regarding dysphagia in EA-TEF was used. The survey was electronically sent to potential participants. Seventy-two pediatric surgeons with a mean professional experience of 14.73 ± 9.66 years (min = 1, max = 41) completed the survey. 19.4% (n = 14) had a standardized protocol for dysphagia screening and %51.4 (n = 37) provided swallowing rehabilitation to their patients. Most of the participants (80.6%) reported that they do not have an appropriate team approach for dysphagia management. The mean knowledge and awareness score was 11.04 ± 1.27 (min = 7, max = 12). The mean VAS score related to the need for standardized protocol in dysphagia management was 9.23 ± 1.44 (min = 3, max = 10). The mean VAS score related to the need for routine screening for dysphagia after surgery was 8.67 ± 2.17 (min = 1, max = 10). The mean score for the degree of the contribution of diagnosis and management of dysphagia to the surgical treatment in children operated for EA-TEF was 7.98 ± 2.08 (min = 3, max = 10). The participants mostly suggested the necessity of a standardized protocol in dysphagia and routine dysphagia screening in children with EA-TEF. Knowledge and awareness is found to be high among pediatric surgeons in Turkey. However, their clinical practice does not include a standardized protocol regarding dysphagia screening and management.

Cystinosis beyond kidneys: gastrointestinal system and muscle involvement

Background

Cystinosis is a multisystemic disease resulting from cystine accumulation primarily in kidney and many other tissues. We intended to study the evolution of less commonly seen extrarenal complications of cystinosis in a group of patients who have periods without cysteamine treatment.

Methods

Gastrointestinal and muscular complications of cystinosis were studied in a group of 21 patients.

Results

Twenty one patients were included in the study. Among them, 14 were homozygous and 3 were compound heterozygous for CTNS mutations. The median age of diagnosis was 15 months (range; 5 months-14 years) and the mean age at last visit was 11.3 ± 6.5 years. Nine patients (42%) had end stage renal disease at a mean age of 10.6 years (6.5–17 years). Abdominal ultrasonography and portal vein doppler ultrasonography were performed in19 patients, 14 of them (74%) had hepatomegaly, 10 patients (53%) had granular pattern or heterogeneity of liver. Only one patient had high transaminase levels and liver biopsy showed cystine crystals in the liver. Eleven patients (58%) had borderline or increased portal vein minimum and maximum flow velocities. One patient had CK level of 9024 U/L and electromyographic study showed active myopathic involvement. Two patients were found to have gastroesaphageal reflux only and 4 patients were found to have esophageal remnants in addition to reflux.

Conclusions

In addition to renal functions, extrarenal organs may be affected from cystine accumulation even in childhood, especially in patients who are incompliant to treatment, resulting in complications such as swallowing difficulty, hepatomegaly and portal hypertension.

The functional chewing training for chewing dysfunction in children with repaired EA-TEF

BACKGROUND/PURPOSE

Chewing disorders (CD) may cause restrictions in solid food intake and can be seen in 37% of children with esophageal atresia-tracheoesophageal fistula (EA-TEF). The Functional Chewing Training (FCT) is a holistic approach to improve chewing function (CF) in children. The study aimed to evaluate the effects of FCT on CF in children with EA-TEF.

METHODS

Twenty children with CD were included. Patients received 12 weeks FCT including impairment-based and adaptive components. Chewing performance level was scored with Karaduman Chewing Performance Scale (KCPS), and tolerated food texture was determined by the International Dysphagia Diet Standardization Initiative (IDDSI). The baseline and final levels of KCPS and IDDSI were compared to evaluate the effects of FCT on CF.

RESULTS

Forty-five percent of cases were isolated-EA, and 55% were EA-distal TEF with a median age of 31 (min = 25, max = 84) months, of which 65% (n = 13) were male. Baseline evaluation showed that 12 cases were in level-1, 6 cases in level-3 and 2 cases in level-4 according to KCPS. Eight children with CD (40%) had IDDSI level-3 and 12 (60%) had level-7. There was a significant improvement in KCPS scores and IDDSI scores after 12 weeks of training (p < 0.01, p = 0.005,respectively). KCPS scores showed level-0 in 15 cases, and level-1 in 5 cases. All children had IDSSI level-7.

CONCLUSIONS

The FCT is an effective method to improve chewing function in children EA-TEF who had CD.

TYPE OF STUDY

Single group treatment study.

LEVEL OF EVIDENCE

Level 4.

Assessment of pediatric cricopharyngeal achalasia with high resolution manometry

Boybeyi Türer Ö, Demir N, Ciecieraga T, Günaydın RÖ, Soyer T. Assessment of pediatric cricopharyngeal achalasia with high resolution manometry. Turk J Pediatr 2019; 61: 804-809. Cricopharyngeal achalasia (CPA) is an uncommon cause of oropharyngeal dysphagia (OPD) which is the failure of upper esophageal sphincter (UES) to relax during bolus passage. The diagnostic challenges in OPD have been overcome with the use of high resolution manometry (HRM) in children where a catheter based biomechanical evaluation testing of the oropharyngeal swallowing is performed. Herein, we present a case with severe dysphagia diagnosed as CPA utilizing HRM testing. An 8-year-old boy was seen in our clinic with a two-year history of difficult swallowing, recurrent respiratory tract infections, hypoxia and seizure secondary to aspiration. Esophagography revealed an indentation of the cricopharangeal muscle (CPM) in the cervical part of the esophagus. Videofluroscopic swallow studies (VFSS) revealed cricopharyngeal bar at level of C5-6 and diffuse dysmotility in esophagus. Conventional esophageal manometry revealed absence of peristaltic activity throughout the esophagus. Esophagogastroduodenoscopy revealed narrowing in upper esophagus that with applied force allowed passage of the endoscope. The patient underwent UES dilatation 6 times. He had temporary relief of symptoms. Since he did not have sustained response to dilatation, a botulinium toxin (5IU/each quadrant) injection (BTI) to CPM was performed twice. His symptoms recurred at the end of 3 months. HRM was performed revealing weakness of CPM and uncoordinated contractions and relaxations in UES. We could not reliably differentiate if HRM findings were a sign of primary illness or secondary to BTI. Swallowing rehabilitation was adjusted based on HRM findings. He is still under follow-up with mild dysphagia to certain solids. CPA is an uncommon cause of dysphagia with limited therapeutic options. HRM should be performed in OPD before considering any treatment modality including esophageal dilatation and BTI. HRM has become gold standard diagnostic tool in OPD that provides objective evaluation of pharyngeal and UES motility in children.

Is the proprioceptive neuromuscular facilitation technique superior to Shaker exercises in swallowing rehabilitation?

PURPOSE

This prospective study was planned to investigate whether the combined isotonic technique of proprioceptive neuromuscular facilitation (PNF) is superior to Shaker exercises in improving the function of swallowing muscles.

METHODS

Fifty individuals (30 females and 20 males; mean age 68 ± 3.89 years) with swallowing difficulties were separated into two groups randomly. The treatment groups were Shaker and PNF groups, which performed these exercises three times in a week for6 weeks. Swallowing difficulties were determined with the Turkish version of the eating assessment tool (T-EAT-10). The 100 ml-water swallow test was used to measure capacity, volume, and speed of swallowing. Contraction amplitude changes used as a universal measurement of motor unit activity during the muscle action were measured with superficial electromyography.

RESULT

After 6 weeks of exercise training, T-EAT-10 scores decreased in both groups (p < 0.001). Water swallowing capacity and volume improved in both groups (p < 0.001). There was no change in swallowing speed in both groups (p > 0.05). Maximal voluntary contraction values of suprahyoid muscles were higher in PNF than the Shaker group (p < 0.05).

CONCLUSION

Both the types of exercise can be used in the rehabilitation of swallowing difficulties. However, the PNF technique increased the contraction amplitude values that occur during maximum contraction more than the Shaker exercises. Different functional evaluations are needed to determine the effectiveness of PNF on swallowing difficulty.

Assessment of the Concerns of Caregivers of Children with Repaired Esophageal Atresia-Tracheoesophageal Fistula Related to Feeding-Swallowing Difficulties

The study aimed to assess concerns of caregivers of children with EA-TEF related to feeding-swallowing difficulties, compare the concerns according to type of atresia and repair time, and investigate its relationship with time to start oral feeding. Caregivers accompanying 64 children with EA-TEF were included. Age, sex, type of atresia, repair time, and time to start oral feeding were noted. Parents completed the Turkish version of the Feeding/Swallowing Impact Survey (T-FS-IS) to assess the concerns of caregivers related to feeding-swallowing difficulties. The T-FS-IS has three subscales including daily activities, worry, and feeding difficulties. The median age of patients was 3 (min = 1, max = 12) years, of which 57.8% were male. 43.8% of cases were isolated-EA, and 56.3% were EA-distal TEF. 57.8% of cases received early repair, and 42.2% had delayed repair. The median time to start oral feeding was 4 weeks (min = 1, max = 128). The mean scores of daily activities, worry, feeding difficulties, and total score from the T-FS-IS were 2.43 ± 1.18, 2.73 ± 1.28, 2.10 ± 0.97, and 2.44 ± 1.09, respectively. Caregivers of children with isolated-EA reported more problems in total score and all subscales of the T-FS-IS than EA-distal TEF (p < 0.01). Caregivers of children who received delayed repair reported more problems in total score and all subscales of the T-FS-IS than children with early repair (p < 0.05). Moderate to strong correlations were found between the T-FS-IS and time to start oral feeding (p < 0.01, r = 0.55-0.65). This study suggests that caregivers of children with isolated-EA and/or delayed repair and/or delay in oral intake may have higher concerns related to feeding-swallowing difficulties.

Turkish Version of the Mastication Observation and Evaluation (MOE) Instrument: A Reliability and Validity Study in Children

The Mastication Observation and Evaluation (MOE) instrument is an objective assessment of the chewing process in children. This study aimed to translate the MOE into Turkish and to test its reliability and validity in children with cerebral palsy (CP). A total of 53 children with CP and 27 typical children were included in the study. The MOE was translated from Dutch into Turkish by using the forward, backward, forward translation method. The internal consistency, intra- and inter-observer reliability, criterion, and discriminant validity of the Turkish version of the MOE (T-MOE) were investigated. Internal consistency was excellent with a Cronbach's alpha value of 0.98. The Intraclass correlation coefficient ranged from 0.89 to 0.97 for intra-rater reliability and from 0.86 to 0.94 for inter-rater reliability. The median score from Karaduman Chewing Performance Scale (KCPS) was 7 (min = 1, max = 8). All of the items in the T-MOE and the total T-MOE score had a negative and strong correlation with the KCPS score. Typical children without chewing disorders had greater T-MOE scores than the children with CP suffering from chewing disorders (p < 0.01). The T-MOE is a reliable and valid instrument for evaluating the observed oral motor behaviors of chewing function in children. It can be used in clinical practice and research.Clinical trial number: NCT03811353.

Timing of Dysphagia Screening in Alzheimer's Dementia

BACKGROUND

Dysphagia is an important and frequent symptom in Alzheimer's dementia (AD). We hypothesized that dysphagia could be seen in the early stages of AD and sarcopenia presence rather than the severity of the AD affecting dysphagia. The main aim of this study was to investigate swallowing functions in AD patients according to stages. The second aim was to investigate the correlation between sarcopenia and dysphagia in AD.

METHODS

This study involved 76 probable AD patients. For all participants, diagnosis of sarcopenia was based on definitions from the revised version of European Working Group on Sarcopenia in Older People at 2018. Dysphagia symptom severity was evaluated by the Turkish version of the Eating Assessment Tool, a videofluoroscopic swallowing study (VFSS) was performed for instrumental evaluation of swallowing. The patients were divided into 3 groups according to the clinical dementia rating (CDR) scale as CDR 1 (mild dementia), CDR 2 (moderate dementia), and CDR 3 (severe dementia). Swallowing evaluation parameters were analyzed between these groups.

RESULTS

Mean age was 78.9 ± 6.4 years, and 56.4% were female. Twenty-six patients had mild dementia, 31 patients had moderate dementia, 19 patients had severe dementia (CDR 3). We found that sarcopenia rates were similar between AD stages according to CDR in our study population and dysphagia could be seen in every stage of AD. In a multivariate analysis, polypharmacy and sarcopenia were found to be independently associated factors for dysphagia, irrespective of stage of AD (OR: 6.1, CI: 1.57-23.9, P = 0.009; OR: 4.9, CI: 1.24-19.6, P = 0.023, respectively).

CONCLUSION

Aspirations may be subtle so that AD patients and caregivers may not be aware of swallowing difficulties. Therefore, all AD patients, especially those who have polypharmacy and/or sarcopenia (probable-sarcopenia-severe sarcopenia), should be screened for dysphagia in every stage.

Effects of Low-Frequency Repetitive Transcranial Magnetic Stimulation on Swallowing Function and Quality of Life of Post-stroke Patients

Repetitive transcranial magnetic stimulation (rTMS) is one of the non-invasive techniques, which is used to modulate cortical regions in patients with stroke. The aim of this single blind, controlled study was to investigate the effect of rTMS on swallowing function and quality of life of mono-hemispheric post-stroke patients with dysphagia. Twenty-eight patients were randomized and split between study and control group. Each group received conventional dysphagia rehabilitation 3 days a week for 4 weeks, and study group also received 1 Hz rTMS to unaffected hemisphere in the final week. The descriptive information was noted. The clinical and radiological swallowing evaluation and quality of life assessment have been performed at four different times including before and after the treatment, 1 month and 3 months after the treatment. At baseline, no significant differences were observed between groups in terms of demographic and clinical features (p > 0.05). Swallowing function and quality of life of the patients were statistically improved in both groups towards the third month (p < 0.05). Swallowing function was comparable between two groups. However, a significant improvement was observed on appetite, fear of eating, and mental health parameters of quality of life assessment in the study group compared to the control group (p < 0.05). In conclusion, despite positive changes in some aspects of quality of life, rTMS did not enhance the swallowing function when compared conventional dysphagia rehabilitation. Therefore, the application of 1 Hz rTMS should be reconsidered to improve swallowing function in the chronic period.

Chewing Function in Children with Repaired Esophageal Atresia-Tracheoesophageal Fistula

INTRODUCTION

 Feeding problems are common in children with esophageal atresia and tracheoesophageal fistula (EA-TEF); however, chewing disorders, which may cause inability to intake solid food, have not been evaluated. Therefore, we aimed to evaluate the chewing function in children with repaired EA-TEF.

MATERIALS AND METHODS

 Age, sex, the type of atresia, the type of repair, and the time to start oral feeding were recorded. The level of the chewing performance was scored according to the Karaduman Chewing Performance Scale (KCPS). The International Dysphagia Diet Standardization Initiative (IDDSI) was used to determine the tolerated food texture in children.

RESULTS

 A group of 30 patients were included, of which 53.3% was male. The percentages of the isolated-EA and that of the EA-distal TEF were 40% and 60%, respectively. The median value for the time to start oral feeding was 4.5 weeks (min = 1, max = 72). Eleven (36.7%) children had chewing disorder. The KCPS scores showed level I in six cases, level III in four cases, and level IV in one case. Five children with chewing disorder had IDDSI level 3 and six had level 7, along with the sensation of stuck food. We found no significant difference between the KCPS scores according to the repair type (p = 0.07). The median values of the KCPS scores of children with primary repair, delayed repair, and colon interposition were 0 (min = 0, max = 4), 0.5 (min = 0, max = 3), 2 (min = 0, max = 3), respectively. A significant positive correlation was found between the time to start oral feeding and the KCPS scores (r = 0.63, p = 0.001).

CONCLUSION

 Chewing disorders can be observed in children with EA-TEF, and the type of repair and the delay in oral feeding may be related to chewing disorder. Therapeutic maneuvers are needed to improve the chewing function in children with EA-TEF.

The pediatric version of the eating assessment tool-10 has discriminant ability to detect aspiration in children with neurological impairments

BACKGROUND

The aim of this study was to determine the ability of the Pediatric version of the Eating Assessment Tool-10 (PEDI-EAT-10) to detect aspiration in children with neurological impairments.

METHODS

Two hundred and fifty-four children were included. Swallowing function was imaged with videofluoroscopic swallowing study (VFSS). The penetration and aspiration scale (PAS) was used to determine the penetration and aspiration severity. Parents completed the PEDI-EAT-10, which is a 10 item, reliable, and valid dysphagia symptom specific outcome instrument.

KEY RESULTS

The mean age of children was 59.91 ± 55.33 months (min = 18, max = 315), of which 52.8% were male. The mean PEDI-EAT-10 of children with airway aspiration (PAS > 5) was 22.32 ± 10.73 (min = 0, max = 40) and the mean PEDI-EAT-10 of children who did not have aspiration (PAS < 6) was 12.35 ± 8.64 (min = 0, max = 40). A linear correlation was found between PEDI-EAT-10 and PAS scores of children (r = 0.41, P < 0.001). The sensitivity of a PEDI-EAT-10 score greater than 12 in predicting aspiration was 77% and the specificity was 54%. A PEDI-EAT-10 score greater than 12 has a positive predictive value of 69% and a negative predictive value of 64%.

CONCLUSIONS AND INFERENCES

The PEDI-EAT-10 could be used to detect unsafe airway issues to identify and refer children for further instrumental swallowing evaluation.

Shear bond strength of a novel porcelain repair system for different computer-aided design/computer-assisted manufacturing ceramic materials

Objectives

The purpose of this study was to compare the shear bond strength of a novel repair system, Nova Compo SF with Ceramic Repair, Ivoclar, to computer-aided design/computer-assisted manufacturing (CAD/CAM) restorative materials (IPS e.max CAD and Empress CAD).

Materials and Methods

The specimens of each CAD/CAM restorative material were randomly divided into two subgroups of nine specimens, using one of two repair systems. All specimens were etched with hydrofluoric acid and rinsed under a water spray for 10 s, then air-dried for 10 s. Next, repair systems were applied according to the manufacturer's instructions. All specimens were stored in distilled water at 37°C for 24 h and then additionally aged for 5000 thermal cycles. A shear bond strength test was performed using a universal testing machine. Each fracture type was examined under a stereomicroscope at ×12.5 magnification. A two-way ANOVA test was used to detect significant differences between the CAD/CAM restorative materials and the composite repair systems. Subgroup analyses were performed using Tukey's honest significant difference.

Results

No statistically significant differences were observed between the repair systems (P = 0.9). The bond strength values from Empress CAD were statistically higher than those from e.max CAD (P < 0.05).

Conclusions

Within limitations, SuperFlow may be an alternative to the ceramic repair materials we routinely used in the clinic. Empress CAD can be preferable to e.max CAD in terms of esthetically suitable clinical indications.

Effect of Swallowing Rehabilitation Protocol on Swallowing Function in Patients with Esophageal Atresia and/or Tracheoesophageal Fistula

Aim The aim of this study was to evaluate the results of Swallowing Rehabilitation Protocol (SRP) on swallowing function (SF) of esophageal atresia and tracheoesophageal fistula (EA-TEF) patients with pharyngeal swallowing disorder. Materials and Methods In this study, 24 children with EA-TEF who had deglutitive and respiratory problems were grouped into either study (n = 12) or control group (n = 12) by basic randomization. Study group received the SRP including neuromuscular electrical stimulation, thermal tactile stimulation, and hyolaryngeal mobilization. The control group received nonnutritive stimulations. SF was evaluated with 3 mL liquid and pudding barium by videofluoroscopic swallowing study (VFSS) before and after 20 sessions of interventions. Results No statistical differences were found between groups in terms of descriptive characteristics including age, sex, weight, height, type of atresia, repair type, repair time, and start time of oral intake (p > 0.05). There were no statistical differences between groups in term of swallowing parameters (p > 0.05), except reflux (p = 0.004) according to VFSS findings. After 20 sessions of interventions, the study group showed improvement in penetration-aspiration scale scores, oral phase dysfunction, delay in swallowing reflex, and residue in valleculae and pyriform sinuses after pudding swallow. The control group showed improvement only in oral phase dysfunction. Conclusion SRP can be recommended to improve SF in patients with EA/TEF who have pharyngeal swallowing disorders.

Does Nissen fundoplication improve deglutition in children?

Soyer T, Yalçın Ş, Demir N, Karhan AN, Saltık-Temizel İN, Demir H, Tanyel FC. Does Nissen fundoplication improve deglutition in children? Turk J Pediatr 2017; 59: 28-34. A prospective study was performed to evaluate the effect of Nissen fundoplication (NF) on deglutition in children. Children who underwent NF between 2011-2015 were evaluated for demographic features, clinical findings, diagnostic methods for gastroesophageal reflux (GER) and indications for NF. Penetration aspiration scale (PAS), functional oral intake scale (FOIS) and esophageal functions were evaluated by videoflouroscopy (VFS). Preoperative and postoperative VFS findings were compared to evaluate the effect of NF on clinical findings and deglutition. Twenty-three children with a mean age of 5.08 ± 3.7 years were included. Female to male ratio was 15:8. Recurrent respiratory infections (RTI) (n: 14, 60.8%), swallowing dysfunction (n:13, 56.5%) and vomiting (n:10, 43.4%) were the most common symptoms. Preoperatively GER was diagnosed with barium swallowing study (BSS) contrast graphs (n:20, 87%) and with 24-hour esophageal pH monitorization (n:8, 34.8%). In 39.1% of patients, medical treatment for GER was used with a mean duration of 8 ± 5.8 months. Indications for NF were swallowing dysfunction (n: 18, 78%), GER complications (n:6, 26%), associated anatomical problems (n:4, 17.3%) and unresponsiveness to medical treatment (n: 3, 13%). Postoperative barium swallowing study and 24-hour esophageal pH monitorization showed no GER after NF in 95% of patients. Number of RTI were significantly decreased after NF (preoperative vs postoperative infection rate 4.21 vs 1.6 respectively, p < 0.05). VFS findings showed that PAS was significantly decreased after NF during both liquid and semi-liquid swallowing (p < 0.05). After NF, upper esophageal opening (UEO) was decreased when compared to preoperative VFS findings (p < 0.05 Esophageal cleaning, esophageal motility, esophageal backflow and lower esophageal sphincter narrowing did not alter after NF (p > 0.05). FOIS were significantly improved after NF (p < 0.05). VFS findings showed that penetration and aspiration were significantly decreased after NF and children had less RTI. Although, esophageal motility evaluated by VFS did not changed after NF, functional oral intake significantly improved in children.

Reliability and validity of a tool to measure the severity of tongue thrust in children: the Tongue Thrust Rating Scale

This study aimed to develop a scale called Tongue Thrust Rating Scale (TTRS), which categorised tongue thrust in children in terms of its severity during swallowing, and to investigate its validity and reliability. The study describes the developmental phase of the TTRS and presented its content and criterion-based validity and interobserver and intra-observer reliability. For content validation, seven experts assessed the steps in the scale over two Delphi rounds. Two physical therapists evaluated videos of 50 children with cerebral palsy (mean age, 57·9 ± 16·8 months), using the TTRS to test criterion-based validity, interobserver and intra-observer reliability. The Karaduman Chewing Performance Scale (KCPS) and Drooling Severity and Frequency Scale (DSFS) were used for criterion-based validity. All the TTRS steps were deemed necessary. The content validity index was 0·857. A very strong positive correlation was found between two examinations by one physical therapist, which indicated intra-observer reliability (r = 0·938, P < 0·001). A very strong positive correlation was also found between the TTRS scores of two physical therapists, indicating interobserver reliability (r = 0·892, P < 0·001). There was also a strong positive correlation between the TTRS and KCPS (r = 0·724, P < 0·001) and a very strong positive correlation between the TTRS scores and DSFS (r = 0·822 and r = 0·755; P < 0·001). These results demonstrated the criterion-based validity of the TTRS. The TTRS is a valid, reliable and clinically easy-to-use functional instrument to document the severity of tongue thrust in children.

The Ability of the Eating Assessment Tool-10 to Detect Aspiration in Patients With Neurological Disorders

Background/Aims

Dysphagia is common in patients with neurological disorders. There is a need to identify patients at risk early by a useful clinical tool to prevent its serious complications. The study aims to determine the ability of the Turkish version of Eating Assessment Tool-10 (T-EAT-10) to detect aspiration in patients with neurological disorders.

Methods

Two hundred fifty-nine patients with neurological disorders who had complaints about swallowing difficulty and referred for a swallowing evaluation were included. Oropharyngeal dysphagia was evaluated with the T-EAT-10 and videofluoroscopic swallowing study in the same day. The penetration-aspiration scale (PAS) was used to document the penetration and aspiration severity.

Results

The mean age of the patients was 59.72 ± 17.24 years (minimum [min] = 18, maximum [max] = 96), of which 57.1% were male. The mean T-EAT-10 of patients who had aspiration (PAS > 5) was 25.91 ± 10.31 (min = 1, max = 40) and the mean T-EAT-10 of patients who did not have aspiration (PAS < 6) was 15.70 ± 10.54 (min = 0, max = 40) (P < 0.001). Patients with a T-EAT-10 score higher than 15 were 2.4 times more likely to aspirate. A linear correlation was found between T-EAT-10 and PAS scores of the patients (r = 0.416, P < 0.001). The sensitivity of a T-EAT-10 higher than 15 in detecting aspiration was 81.0% and the specificity was 58.0%. A T-EAT-10 score of higher than 15 has a positive predictive value of 72.0% and a negative predictive value of 69.0%.

Conclusion

The T-EAT-10 can be used to detect unsafe airway protection in neurology clinics to identify and refer dysphagic patients for further evaluation.

Pediatric Eating Assessment Tool-10 as an indicator to predict aspiration in children with esophageal atresia

AIM

Airway aspiration is a common problem in children with esophageal atresia (EA). Pediatric Eating Assessment Tool-10 (pEAT-10) is a self-administered questionnaire to evaluate dysphagia symptoms in children. A prospective study was performed to evaluate the validity of pEAT-10 to predict aspiration in children with EA.

METHODS

Patients with EA were evaluated for age, sex, type of atresia, presence of associated anomalies, type of esophageal repair, time of definitive treatment, and the beginning of oral feeding. Penetration-aspiration score (PAS) was evaluated with videofluoroscopy (VFS) and parents were surveyed for pEAT-10, dysphagia score (DS) and functional oral intake scale (FOIS). PAS scores greater than 7 were considered as risk of aspiration. EAT-10 values greater than 3 were assessed as abnormal. Higher DS scores shows dysphagia whereas higher FOIS shows better feeding abilities.

RESULTS

Forty patients were included. Children with PAS greater than 7 were assessed as PAS+ group, and scores less than 7 were constituted as PAS- group. Demographic features and results of surgical treatments showed no difference between groups (p>0.05). The median values of PAS, pEAT-10 and DS scores were significantly higher in PAS+ group when compared to PAS- group (p<0.05). The sensitivity and specificity of pEAT-10 to predict aspiration were 88% and 77%, and the positive and negative predictive values were 22% and 11%, respectively. Type-C cases had better pEAT-10 and FOIS scores with respect to type-A cases, and both scores were statistically more reliable in primary repair than delayed repair (p<0.05). Among the postoperative complications, only leakage had impact on DS, pEAT-10, PAS and FOIS scores (p<0.05).

CONCLUSIONS

The pEAT-10 is a valid, simple and reliable tool to predict aspiration in children. Patients with higher pEAT-10 scores should undergo detailed evaluation of deglutitive functions and assessment of risks of aspiration to improve safer feeding strategies.

LEVEL OF EVIDENCE

Level II (Development of diagnostic criteria in a consecutive series of patients and a universally applied "gold standard").