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Miller S, Kallusky J, Zimmerer R, Tavassol F, Gellrich NC, Ptok M, Jungheim M. Differences in velopharyngeal pressures during speech sound production in patients with unilateral cleft lip and palate (UCLP) and healthy individuals. Ger Med Sci 2024; 22:Doc02. [PMID: 38651020 PMCID: PMC11034380 DOI: 10.3205/000328] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Figures] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Revised: 02/16/2023] [Indexed: 04/25/2024]
Abstract
Background During articulation the velopharynx needs to be opened and closed rapidly and a tight closure is needed. Based on the hypothesis that patients with cleft lip and palate (CLP) produce lower pressures in the velopharynx than healthy individuals, this study compared pressure profiles of the velopharyngeal closure during articulation of different sounds between healthy participants and patients with surgically closed unilateral CLP (UCLP) using high resolution manometry (HRM). Materials and methods Ten healthy adult volunteers (group 1: 20-25.5 years) and ten patients with a non-syndromic surgically reconstructed UCLP (group 2: 19.1-26.9 years) were included in this study. Pressure profiles during the articulation of four sounds (/i:/, /s/, /ʃ/ and /n/) were measured by HRM. Maximum, minimum and average pressures, time intervals as well as detection of a previously described 3-phase-model were compared. Results Both groups presented with similar pressure curves for each phoneme with regards to the phases described and pressure peaks, but differed in total pressures. An exception was noted for the sound /i:/, where a 3-phase-model could not be seen for most patients with UCLP. Differences in velopharynx pressures of 50% and more were found between the two groups. Maximum and average pressures in the production of the alveolar fricative reached statistical significance. Conclusions It can be concluded that velopharyngeal pressures of patients with UCLP are not sufficient to eliminate nasal resonance or turbulence during articulation, especially for more complex sounds. These results support a general understanding of hypernasality during speech implying a (relative) velopharyngeal insufficiency.
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Affiliation(s)
- Simone Miller
- Department of Phoniatrics and Pediatric Audiology of the Department of Otolaryngology, Hannover Medical School, Hanover, Germany
- Institute of General Practice and Palliative Care, Hannover Medical School, Hanover, Germany
| | - Johanna Kallusky
- Department of Phoniatrics and Pediatric Audiology of the Department of Otolaryngology, Hannover Medical School, Hanover, Germany
| | - Rüdiger Zimmerer
- Department of Oral and Maxillifacial Surgery, University Hospital Tübingen, Germany
| | - Frank Tavassol
- Department of Oral and Maxillofacial Surgery, University Medicine Halle, Germany
| | | | - Martin Ptok
- Department of Phoniatrics and Pediatric Audiology, Hannover Medical School, Hanover, Germany
| | - Michael Jungheim
- Department of Phoniatrics and Pediatric Audiology, Hannover Medical School, Hanover, Germany
- HNO Phoniatrie Praxis, Bremen, Germany
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2
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Quigley N, Mistry SG, Vasant DH, Vasani S. Practical multidisciplinary framework for the assessment and management of patients with unexplained chronic aerodigestive symptoms. BMJ Open Gastroenterol 2023; 10:e000883. [PMID: 37996120 PMCID: PMC10668155 DOI: 10.1136/bmjgast-2022-000883] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2023] [Accepted: 10/20/2023] [Indexed: 11/25/2023] Open
Abstract
OBJECTIVE Patients experiencing unexplained chronic throat symptoms (UCTS) are frequently referred to gastroenterology and otolaryngology outpatient departments for investigation. Often despite extensive investigations, an identifiable structural abnormality to account for the symptoms is not found. The objective of this article is to provide a concise appraisal of the evidence-base for current approaches to the assessment and management of UCTS, their clinical outcomes, and related healthcare utilisation. DESIGN This multidisciplinary review critically examines the current understanding of aetiological theories and pathophysiological drivers in UCTS and summarises the evidence base underpinning various diagnostic and management approaches. RESULTS The evidence gathered from the review suggests that single-specialty approaches to UCTS inadequately capture the substantial heterogeneity and pervasive overlaps among clinical features and biopsychosocial factors and suggests a more unified approach is needed. CONCLUSION Drawing on contemporary insights from the gastrointestinal literature for disorders of gut-brain interaction, this article proposes a refreshed interdisciplinary approach characterised by a positive diagnosis framework and patient-centred therapeutic model. The overarching aim of this approach is to improve patient outcomes and foster collaborative research efforts.
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Affiliation(s)
- Nathan Quigley
- Otolaryngology Department, Royal Brisbane and Woman's Hospital Health Service District, Herston, Queensland, Australia
| | - Sandeep G Mistry
- Department of Ear Nose and Throat, Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK
| | - Dipesh H Vasant
- Neurogastroenterology Unit, Gastroenterology Department, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, UK
- Division of Diabetes, Endocrinology and Gastroenterology, University of Manchester, Manchester, UK
| | - Sarju Vasani
- Otolaryngology Department, Royal Brisbane and Woman's Hospital Health Service District, Herston, Queensland, Australia
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Sikavi DR, Cai JX, Leung R, Carroll TL, Chan WW. Impaired Proximal Esophageal Contractility Predicts Pharyngeal Reflux in Patients With Laryngopharyngeal Reflux Symptoms. Clin Transl Gastroenterol 2021; 12:e00408. [PMID: 34597279 PMCID: PMC8487779 DOI: 10.14309/ctg.0000000000000408] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Accepted: 08/04/2021] [Indexed: 12/15/2022] Open
Abstract
OBJECTIVES The pathophysiology of laryngopharyngeal reflux (LPR) remains incompletely understood. Proximal esophageal motor dysfunction may impair bolus clearance, increasing the risk of pharyngeal refluxate exposure. We aimed to evaluate the association of proximal esophageal contractility with objective reflux metrics. METHODS We evaluated adults with LPR symptoms undergoing high-resolution manometry (HRM) and combined hypopharyngeal-esophageal multichannel intraluminal impedance-pH testing at a tertiary center between March 2018 and August 2019. Routine parameters per Chicago classification were obtained on HRM. Proximal esophageal contractility was evaluated using proximal contractile integral (PCI), which quantifies contractile pressure >20 mm Hg for the region spanning the distal margin of the upper esophageal sphincter and transition zone. Univariate (Kendall correlation and Student t test) and multivariable (general linear regression and logistic regression) analyses were performed. RESULTS We enrolled 138 patients (66.7% women, mean age 57.1 years) in this study. Lower PCI was associated with an elevated risk of increased pharyngeal reflux (adjusted odds ratio 0.83 per 100 mm Hg-s-cm change in PCI, 95% confidence interval: 0.69-0.98), with a trend toward increased bolus exposure time and total reflux events, after multivariable adjustment. The relationship between PCI and pharyngeal reflux was strongest among participants without a primary motility disorder on HRM (adjusted odds ratio 0.63, 95% confidence interval: 0.42-0.85, P interaction = 0.04). Among continuously expressed reflux parameters, lower PCI was significantly associated with more distal acid reflux events (β = -0.0094, P = 0.03) and total reflux events (β = -0.0172, P = 0.05), after adjusting for confounders. DISCUSSION Reduced proximal esophageal contractility as assessed by decreased PCI on HRM independently predicted increased pharyngeal reflux in patients with LPR symptoms, particularly among those without a coexisting motility disorder.
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Affiliation(s)
| | - Jennifer X. Cai
- Harvard Medical School, Boston, Massachusetts, USA;
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Boston, Massachusetts, USA;
| | - Ryan Leung
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Boston, Massachusetts, USA;
| | - Thomas L. Carroll
- Harvard Medical School, Boston, Massachusetts, USA;
- Division of Otolaryngology, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Walter W. Chan
- Harvard Medical School, Boston, Massachusetts, USA;
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Boston, Massachusetts, USA;
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Ahmed ST, Lin J, Moskowitz HS, Stupak HD. Can the negative pressures found in obstructive sleep apnea and Eustachian tube dysfunction be related? Am J Otolaryngol 2021; 42:102993. [PMID: 33640801 DOI: 10.1016/j.amjoto.2021.102993] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Accepted: 02/13/2021] [Indexed: 12/12/2022]
Abstract
OBJECTIVE The association between obstructive sleep apnea (OSA) and Eustachian tube dysfunction (ETD) is well known. When both exist in a single pediatric patient, one of the expected culprits is adenoid enlargement. We hypothesize, in contrast, that the negative pharyngeal pressure found in OSA may be transmitted to the middle ear as negative middle ear pressure (MEP), which subsequently results in pathology. The objective of this study was to determine whether the degree of OSA and MEP are associated while using MEP as a quantifiable measurement of ETD. STUDY DESIGN Retrospective chart review. SETTING Tertiary academic center (Jan 2000-Jan 2018). SUBJECTS AND METHODS The relationship between apnea-hypopnea index (AHI) and MEP was examined. A non-anatomic model was utilized to support causality. RESULTS Thirty-four pediatric patients and twenty-three adult patients were included in the analysis. REM AHI showed a moderate negative correlation with MEP in children (r = -0.265), and a weak positive correlation with MEP in adults (r = 0.171). Children with an AHI in the severe OSA category had a more negative mean MEP than those in the mild category (p = 0.36). Adults with an AHI in the severe OSA category had a more positive mean MEP than those in the mild category (p = 0.11). CONCLUSION In children, increasing severity of OSA is associated with a negative MEP, suggesting that negative pressure associated with OSA may be transmitted to the middle ear. In adults, increasing severity of OSA is associated with a more positive MEP.
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Affiliation(s)
- Sadia T Ahmed
- Albert Einstein College of Medicine, United States of America
| | - Juan Lin
- Department of Epidemiology & Population Health, Albert Einstein College of Medicine, United States of America
| | - Howard S Moskowitz
- Department of Otorhinolaryngology-Head and Neck Surgery, Albert Einstein College of Medicine, United States of America.
| | - Howard D Stupak
- Department of Otorhinolaryngology-Head and Neck Surgery, Albert Einstein College of Medicine, United States of America
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Abstract
There are currently no standard evaluation tools for poststroke neurogenic oropharyngeal dysphagia. We previously suggested calculating the relative movements of the hyoid bone and larynx by ultrasonography to evaluate swallowing movement. Swallowing movement is altered in neurogenic oropharyngeal dysphagia. Therefore, the present study aimed to verify whether an ultrasonographic evaluation of swallowing movement facilitates the detection of neurogenic oropharyngeal dysphagia. Eighteen healthy male elderly participants (the healthy group) and 18 male stroke patients diagnosed with neurogenic oropharyngeal dysphagia (the dysphagia group) were enrolled. Participants swallowed 5 mL of liquid and water with an adjusted viscosity and the movements of the hyoid bone and larynx were visualized by ultrasonography. The results obtained revealed significant differences in laryngeal duration (static phase), laryngeal displacement (elevation phase), and the hyoid bone–laryngeal motion ratio (HL motion ratio) between the two groups. A multiple regression analysis was performed to adjust for confounding factors, and laryngeal duration (static phase) and the HL motion ratios were identified as factors affecting dysphagia. In the receiver operation characteristic curve of the two variations, the area under the curve for laryngeal duration (static phase) was 0.744 and the cut-off was 0.26 sec with 72.2% sensitivity and 88.9% specificity; the area under the curve for the HL motion ratio was 0.951 and the cut-off was 0.56 with 88.9% sensitivity and 88.9% specificity. Therefore, the objective evaluation of hyoid bone and larynx movements during swallowing by ultrasonography facilitated the detection of neurogenic oropharyngeal dysphagia.
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Affiliation(s)
- Takao Matsuo
- Faculty of Allied Health Sciences, Division of Speech-Language-Hearing Therapy, Department of Rehabilitation Sciences, Kansai University of Welfare Sciences, Asahigaoka, Kashiwara city, Osaka, Japan
- * E-mail:
| | - Miwa Matsuyama
- Department of Oral Health Care and Rehabilitation, Institute of Biomedical Sciences, Tokushima University Graduate School, Kuramoto-cho, Tokushima city, Tokushima, Japan
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Qin-ying W, Shui-hong Z, Yong-cai L, Hai-hong C. Spindle cell lipoma of the larynx: A case report. Medicine (Baltimore) 2020; 99:e21118. [PMID: 32702862 PMCID: PMC7373547 DOI: 10.1097/md.0000000000021118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/28/2022] Open
Abstract
INTRODUCTION Lipomas are rarely found in primary mesenchymal tumors of the hypopharynx and larynx. When they do appear, they often macroscopically resemble a retention cyst or laryngeal nodule. The laryngeal spindle cell lipoma, a variant, is extremely rare. PATIENT CONCERNS A 65-year-old woman presented with a 3-month history of pharyngeal paraesthesia. Laryngoscopy revealed the presence of a well-encapsulated, smooth-surfaced, yellowish, pedicled mass on the left epiglottis. Magnetic resonance imaging confirmed the epiglottic mass. DIAGNOSIS Following excision of the mass, the diagnosis of an spindle cell lipoma was established and confirmed by immunohistochemistry. INTERVENTIONS Surgical excision of the lesion using a controlled-temperature plasma technique (coblation). OUTCOMES At the last (4-year) follow-up evaluation, the patient was asymptomatic and without recurrence. CONCLUSION SLC involvement of the epiglottis is rare. Coblation is an effective means to remove it.
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van Munster HE, Steur A, Hagleitner MM, Dors N. [Throat and abdominal symptoms in malignant lymphoma; recognize the alarm signals in children]. Ned Tijdschr Geneeskd 2020; 164:D4074. [PMID: 32267635] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
In children, a malignant lymphoma can present with life-threatening complications arising from progressive tumour growth, warranting swift diagnosis and treatment. Early recognition can be challenging if a child with paediatric lymphoma presents with abdominal and throat symptoms because of the frequency, and frequently benign nature, of these symptoms in the general paediatric population. In these cases, it is essential for the physician to recognize the alarm signals for suspicion of malignant lymphoma, to allow timely diagnosis and treatment. We present two cases (children age 8 and 16 years) demonstrating the symptoms of malignant lymphoma that should raise alarm in children presenting with unilateral tonsil enlargement or intussusception, and illustrating the importance of timely recognition of these alarm signals, to prevent life-threatening complications due to tumour progression. In patients presenting with unilateral tonsil enlargement, malignant lymphoma should be considered if atypical macroscopic tonsil morphology, cervical lymphadenopathy, dysphagia, snoring, fever or weight loss is present. The presence of a lead point as the cause of intussusception should be considered in children aged > 2 years of age, in a child with an ileo-iliac intussusception and in patients with longstanding abdominal symptoms. In patients presenting with simultaneous symptoms and alarm signals for malignant lymphoma, the relationship between the presenting symptoms should be recognized. Interdisciplinary and intradisciplinary consultation with colleagues can help in the search for an overarching diagnosis, and it is crucial that this should happen without delay to prevent acute life-threatening situations.
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Affiliation(s)
- H E van Munster
- Radboudumc, Amalia kinderziekenhuis, afd. Kindergeneeskunde, Nijmegen
- Contact: H.E. van Munster
| | - A Steur
- Prinses Máxima Centrum voor kinderoncologie, afd. Hemato-oncologie, Utrecht
| | - M M Hagleitner
- Prinses Máxima Centrum voor kinderoncologie, afd. Hemato-oncologie, Utrecht
| | - N Dors
- Prinses Máxima Centrum voor kinderoncologie, afd. Hemato-oncologie, Utrecht
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Lyons M, Cooper T, Cave D, Witmans M, El-Hakim H. Pharyngeal dysfunction associated with early and late onset sleep disordered breathing in children. Int J Pediatr Otorhinolaryngol 2019; 127:109667. [PMID: 31499263 DOI: 10.1016/j.ijporl.2019.109667] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2019] [Revised: 08/06/2019] [Accepted: 08/30/2019] [Indexed: 01/18/2023]
Abstract
OBJECTIVE To compare the frequency and type of diagnoses associated with pharyngeal dysfunction (PD) in children presenting with early versus late onset sleep disordered breathing (SDB). METHODS This was a retrospective, cross-sectional study. A consecutive series of children ≤3 years old who underwent management for SDB were retrospectively identified from a prospectively kept surgical database. The early onset group was compared with two separate late onset (≥4years old) groups. Diagnoses associated with PD included gastroesophageal reflux disease (GERD), swallowing dysfunction, prematurity, asthma, and obesity. Distribution of PD diagnoses, airway lesions, syndromic conditions, pulse oximetry scores, and endoscopic pattern of airway obstruction were compared. RESULTS 73 patients with early onset SDB were identified (51 boys, mean age 2.25 ± 0.64 years, range 1.75-3 years) and compared with two groups of later onset SDB consisting of 75 and 72 patients with mean ages of 7.58 ± 2.40 years and 8.04 ± 3.34 years respectively (range 4-16 years). The early onset SDB group had a higher prevalence of PD diagnoses compared to the later onset group with 35 of 73 patients being diagnosed compared to 41 of 147 children (p = 0.01). Early onset SDB patients were more likely to have GERD or swallowing dysfunction (p < 0.01) while later onset patients more commonly presented with associated asthma or obesity (p < 0.01). There was no statistically significant difference in airway lesions between groups. CONCLUSION Early-onset SDB is associated with conditions causing PD more often than later-onset SDB. Identifying these conditions and optimizing their management may impact outcomes in treating pediatric SDB.
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Affiliation(s)
- Marie Lyons
- Pediatric Otolaryngology, Division of Pediatric Surgery & Division of Otolaryngology (Department of Surgery), The Stollery Children's Hospital & University of Alberta Hospitals, Edmonton, Alberta, Canada
| | - Timothy Cooper
- Division of Otolaryngology (Department of Surgery), The Stollery Children's Hospital & University of Alberta Hospitals, Edmonton, Alberta, Canada
| | - Dominic Cave
- Division of Pediatric Anesthesiology (Department of Anesthesiology), The Stollery Children's Hospital & University of Alberta Hospitals, Edmonton, Alberta, Canada
| | - Manisha Witmans
- Division of Pediatric Pulmonology (Department of Pediatrics), The Stollery Children's Hospital & University of Alberta Hospitals, Edmonton, Alberta, Canada
| | - Hamdy El-Hakim
- Pediatric Otolaryngology, Division of Pediatric Surgery & Division of Otolaryngology (Department of Surgery), The Stollery Children's Hospital & University of Alberta Hospitals, Edmonton, Alberta, Canada.
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Song B, Li Y, Sun J, Qi Y, Li P, Li Y, Gu Z. Computational fluid dynamics simulation of changes in the morphology and airflow dynamics of the upper airways in OSAHS patients after treatment with oral appliances. PLoS One 2019; 14:e0219642. [PMID: 31721777 PMCID: PMC6853319 DOI: 10.1371/journal.pone.0219642] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2019] [Accepted: 10/23/2019] [Indexed: 01/07/2023] Open
Abstract
OBJECTIVES To explore the changes of morphology and internal airflow in upper airways (UA) after the use of oral appliances (OAs) in patients with obstructive sleep apnea hypopnea syndrome (OSAHS), and investigate the mechanisms by which OAs function as a therapy for OSAHS. METHODS Eight OSAHS patients (all male, aged 37-58, mean age 46.25) underwent CT scans before and after OA use. Then, computational fluid dynamics(CFD) models were built on the base of the CT scans using Mimics and ANSYS ICEM CFD software. The internal airflow of the upper airways was simulated using ANSYS-FLUENT and the results were analyzed using ANSYS-CFD-Post. The data were analyzed to identify the most important changes of biomechanical properties between patients with and without OA intervention. Upper airway morphology and the internal airflow changes were compared using t-tests and Spearman correlation coefficient analysis. RESULTS The narrowest area of upper airways was found to be located in the lower bound of velopharynx, where the volume and pressure were statistically significantly increased (P<0.05) and the air velocity was statistically significantly decreased (P<0.05) in the presence of the OA(P<0.05). After wearing OA, pharyngeal resistance was significantly decreased (P<0.05), from 290.63 to 186.25Pa/L, and the airflow resistance of the pharynx has reduced by 35.9%. CONCLUSION The enlargement of the upper airway after wearing the OA changed its airflow dynamics, which decreased the negative pressure and resistance in narrow areas of the upper airways. Thus, the collapsibility of the upper airways was reduced and patency was sustained.
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Affiliation(s)
- Baolong Song
- State Key Laboratory of Military Stomatology & National Clinical Research Center for Oral Diseases & Shaanxi Clinical Research Center for Oral Diseases, Department of Orthodontics, School of Stomatology, The Fourth Military Medical University, Xi’an, P.R. China
| | - Yibo Li
- Department of Orthodontics, Changsha Stomatological Hospital, Changsha, Hunan, P.R. China
| | - Jianwei Sun
- State Key Laboratory of Military Stomatology & National Clinical Research Center for Oral Diseases & Shaanxi Clinical Research Center for Oral Diseases, Department of Orthodontics, School of Stomatology, The Fourth Military Medical University, Xi’an, P.R. China
| | - Yizhe Qi
- State Key Laboratory of Military Stomatology & National Clinical Research Center for Oral Diseases & Shaanxi Clinical Research Center for Oral Diseases, Department of Orthodontics, School of Stomatology, The Fourth Military Medical University, Xi’an, P.R. China
| | - Peng Li
- State Key Laboratory of Military Stomatology & National Clinical Research Center for Oral Diseases & Shaanxi Clinical Research Center for Oral Diseases, Department of Orthodontics, School of Stomatology, The Fourth Military Medical University, Xi’an, P.R. China
| | - Yongming Li
- State Key Laboratory of Military Stomatology & National Clinical Research Center for Oral Diseases & Shaanxi Clinical Research Center for Oral Diseases, Department of Orthodontics, School of Stomatology, The Fourth Military Medical University, Xi’an, P.R. China
- * E-mail: (LY); (GZ)
| | - Zexu Gu
- State Key Laboratory of Military Stomatology & National Clinical Research Center for Oral Diseases & Shaanxi Clinical Research Center for Oral Diseases, Department of Orthodontics, School of Stomatology, The Fourth Military Medical University, Xi’an, P.R. China
- * E-mail: (LY); (GZ)
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Marques M, Genta PR, Azarbarzin A, Taranto-Montemurro L, Messineo L, Hess LB, Demko G, White DP, Sands SA, Wellman A. Structure and severity of pharyngeal obstruction determine oral appliance efficacy in sleep apnoea. J Physiol 2019; 597:5399-5410. [PMID: 31503323 PMCID: PMC8359733 DOI: 10.1113/jp278164] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2019] [Accepted: 08/25/2019] [Indexed: 11/08/2022] Open
Abstract
KEY POINTS •Some patients with obstructive sleep apnoea (OSA) respond well to oral appliance therapy, whereas others do not for reasons that are unclear. •In the present study, we used gold-standard measurements to demonstrate that patients with a posteriorly-located tongue (natural sleep endoscopy) exhibit a preferential improvement in collapsibility (lowered critical closing pressure) with oral appliances. •We also show that patients with both posteriorly-located tongue and less severe collapsibility (predicted responder phenotype) exhibit greater improvements in severity of obstructive sleep apnoea (i.e. reduction in event frequency by 83%, in contrast to 48% in predicted non-responders). •The present study suggests that the structure and severity of pharyngeal obstruction determine the phenotype of sleep apnoea patients who benefit maximally from oral appliance efficacy. ABSTRACT A major limitation to the administration of oral appliance therapy for obstructive sleep apnoea (OSA) is that therapeutic responses remain unpredictable. In the present study, we tested the hypotheses that oral appliance therapy (i) reduces pharyngeal collapsibility preferentially in patients with posteriorly-located tongue and (ii) is most efficacious (reduction in apnoea-hypopnea index; AHI) in patients with a posteriorly-located tongue and less-severe baseline pharyngeal collapsibility. Twenty-five OSA patients underwent upper airway endoscopy during natural sleep to assess tongue position (type I: vallecula entirely visible; type II: vallecula obscured; type III: vallecula and glottis obscured), as well as obstruction as a result of other pharyngeal structures (e.g. epiglottis). Additional sleep studies with and without oral appliance were performed to measure collapsibility (critical closing pressure; Pcrit) and assess treatment efficacy. Overall, oral appliance therapy reduced Pcrit by 3.9 ± 2.4 cmH2 O (mean ± SD) and AHI by 69 ± 19%. Therapy lowered Pcrit by an additional 2.7 ± 0.9 cmH2 O in patients with posteriorly-located tongue (types II and III) compared to those without (type I) (P < 0.008). Posteriorly-located tongue (p = 0.03) and lower collapsibility (p = 0.04) at baseline were significant determinants of (greater-than-average) treatment efficacy. Predicted responders (type II and III and Pcrit < 1 cmH2 O) exhibited a greater reduction in the AHI (83 ± 9 vs. 48 ± 8% baseline, P < 0.001) and a lower treatment AHI (9 ± 6 vs. 32 ± 15 events h-1 , P < 0.001) than predicted non-responders. The site and severity of pharyngeal collapse combine to determine oral appliance efficacy. Specifically, patients with a posteriorly-located tongue plus less-severe collapsibility are the strongest candidates for oral appliance therapy.
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Affiliation(s)
- Melania Marques
- Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
- Laboratorio do sono, Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, Brazil
| | - Pedro R Genta
- Laboratorio do sono, Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, Brazil
| | - Ali Azarbarzin
- Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Luigi Taranto-Montemurro
- Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Ludovico Messineo
- Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
- Respiratory Medicine and Sleep Laboratory, Department of Experimental and Clinical Sciences, University of Brescia and Spedali Civili, Brescia, Italy
| | - Lauren B Hess
- Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Gail Demko
- Sleep Apnea Dentists of New England, Weston, MA, USA
| | - David P White
- Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Scott A Sands
- Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
- Department of Allergy, Immunology and Respiratory Medicine and Central Clinical School, The Alfred and Monash University, Melbourne, VIC, Australia
| | - Andrew Wellman
- Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
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11
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Bamagoos AA, Cistulli PA, Sutherland K, Madronio M, Eckert DJ, Hess L, Edwards BA, Wellman A, Sands SA. Polysomnographic Endotyping to Select Patients with Obstructive Sleep Apnea for Oral Appliances. Ann Am Thorac Soc 2019; 16:1422-1431. [PMID: 31394914 PMCID: PMC6945467 DOI: 10.1513/annalsats.201903-190oc] [Citation(s) in RCA: 55] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Accepted: 07/15/2019] [Indexed: 01/16/2023] Open
Abstract
Rationale: Oral appliance therapy is efficacious in many patients with obstructive sleep apnea (OSA), but prediction of treatment outcome is challenging. Small, detailed physiological studies have identified key OSA endotypic traits (pharyngeal collapsibility and loop gain) as determinants of greater oral appliance efficacy.Objectives: We used a clinically applicable method to estimate OSA traits from routine polysomnography and identify an endotype-based subgroup of patients expected to show superior efficacy.Methods: In 93 patients (baseline apnea-hypopnea index [AHI], ≥20 events/h), we examined whether polysomnography-estimated OSA traits (pharyngeal: collapsibility and muscle compensation; nonpharyngeal: loop gain, arousal threshold, and ventilatory response to arousal) were associated with oral appliance efficacy (percentage reduction in AHI from baseline) and could predict responses to treatment. Multivariable regression (with interactions) defined endotype-based subgroups of "predicted" responders and nonresponders (based on 50% reduction in AHI). Treatment efficacy was compared between the predicted subgroups (with cross-validation).Results: Greater oral appliance efficacy was associated with favorable nonpharyngeal traits (lower loop gain, higher arousal threshold, and lower response to arousal), moderate (nonmild, nonsevere) pharyngeal collapsibility, and weaker muscle compensation (overall R2 = 0.30; adjusted R2 = 0.19; P = 0.003). Predicted responders (n = 54), compared with predicted nonresponders (n = 39), exhibited a greater reduction in AHI from baseline (mean [95% confidence interval], 73% [66-79] vs. 51% [38-61]; P < 0.0001) and a lower treatment AHI (8 [6-11] vs. 16 [12-20] events/h; P = 0.002). Differences persisted after adjusting for clinical covariates (including baseline AHI, body mass index, and neck circumference).Conclusions: Quantifying OSA traits using clinical polysomnography can identify an endotype-based subgroup of patients that is highly responsive to oral appliance therapy. Prospective validation is warranted.
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Affiliation(s)
- Ahmad A. Bamagoos
- Sleep Research Group, Charles Perkins Centre, University of Sydney, Sydney, New South Wales, Australia
- Centre for Sleep Health and Research, Department of Respiratory and Sleep Medicine, Royal North Shore Hospital, Sydney, New South Wales, Australia
- Department of Physiology, Faculty of Medicine in Rabigh, King Abdulaziz University, Jeddah, Saudi Arabia
- Sleep and Breathing Lab, Neuroscience Research Australia (NeuRA), Randwick, New South Wales, Australia
| | - Peter A. Cistulli
- Sleep Research Group, Charles Perkins Centre, University of Sydney, Sydney, New South Wales, Australia
- Centre for Sleep Health and Research, Department of Respiratory and Sleep Medicine, Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - Kate Sutherland
- Sleep Research Group, Charles Perkins Centre, University of Sydney, Sydney, New South Wales, Australia
- Centre for Sleep Health and Research, Department of Respiratory and Sleep Medicine, Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - Melanie Madronio
- Centre for Sleep Health and Research, Department of Respiratory and Sleep Medicine, Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - Danny J. Eckert
- Sleep and Breathing Lab, Neuroscience Research Australia (NeuRA), Randwick, New South Wales, Australia
- Adelaide Institute for Sleep Health, Flinders University, Bedford Park, South Australia, Australia
| | - Lauren Hess
- Division of Sleep and Circadian Disorders, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
| | - Bradley A. Edwards
- Sleep and Circadian Medicine Laboratory, Department of Physiology, and
- Turner Institute for Brain and Mental Health, School of Psychological Sciences, Monash University, Melbourne, Victoria, Australia
| | - Andrew Wellman
- Division of Sleep and Circadian Disorders, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
| | - Scott A. Sands
- Division of Sleep and Circadian Disorders, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
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Dietsch AM, Dorris HD, Pearson WG, Dietrich-Burns KE, Solomon NP. Taste Manipulation and Swallowing Mechanics in Trauma-Related Sensory-Based Dysphagia. J Speech Lang Hear Res 2019; 62:2703-2712. [PMID: 31335240 DOI: 10.1044/2019_jslhr-s-18-0381] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Purpose This study explored the effects of high-concentration taste manipulation trials on swallow function in persons with sensory-based dysphagia. Method Dysphagia researchers partnered with clinical providers to prospectively identify traumatically injured U.S. military service members (N = 18) with sensory-based dysphagia as evidenced by delayed initiation and/or decreased awareness of residue/penetration/aspiration. Under videofluoroscopy, participants swallowed trials of 3 custom-mixed taste stimuli: unflavored (40% weight/volume [wt/vol] barium sulfate in distilled water), sour (2.7% wt/vol citric acid in 40% wt/vol barium suspension), and sweet-sour (1.11% wt/vol citric acid plus 8% wt/vol sucrose in 40% wt/vol barium suspension). Trials were analyzed and compared via clinical rating tools (the Modified Barium Swallow Impairment Profile [Martin-Harris et al., 2008] and the Penetration-Aspiration Scale [Rosenbek, Robbins, Roecker, Coyle, & Wood, 1996]). Additionally, a computational analysis of swallowing mechanics (CASM) was applied to a subset of 9 swallows representing all 3 tastants from 3 participants. Results Friedman's tests for the 3 stimuli revealed significantly (p < .05) improved functional ratings for Penetration-Aspiration Scale and pharyngoesophageal opening. CASM indicated differences in pharyngeal swallowing mechanics across all tastant comparisons (p ≤ .0001). Eigenvectors revealed increased tongue base retraction, hyoid elevation, and pharyngeal shortening for sweet-sour and, to a lesser extent, sour than for unflavored boluses. Conclusion Advantageous changes in certain parameters of oropharyngeal swallowing physiology were noted with high-intensity tastants per both clinical ratings and subsequent CASM, suggesting potential therapeutic application for taste manipulation.
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Affiliation(s)
- Angela M Dietsch
- University of Nebraska-Lincoln
- Walter Reed National Military Medical Center, Bethesda, MD
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Mulheren RW, Azola A, González-Fernández M. Do Ratings of Swallowing Function Differ by Videofluoroscopic Rate? An Exploratory Analysis in Patients After Acute Stroke. Arch Phys Med Rehabil 2019; 100:1085-1090. [PMID: 30452891 DOI: 10.1016/j.apmr.2018.10.015] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2018] [Revised: 09/28/2018] [Accepted: 10/20/2018] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To determine differences between continuous videofluoroscopic swallow studies (VFSS) with a pulse rate and frame rate of 30 and the same swallows reduced to 15 frames per second (fps) on measures of swallowing function in patients after acute ischemic stroke. DESIGN Blinded comparison. SETTING Acute hospital. PARTICIPANTS Patients after ischemic stroke (N=20). INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Single and sequential sips of thin liquids, single sips of nectar liquids, pudding, and cookie boluses were rated on measures of timing of swallowing events, Modified Barium Swallowing Impairment Profile component scores, and Penetration-Aspiration Scale scores. The ratings for videos at 15 fps and 30 fps were compared by Wilcoxon signed rank tests. RESULTS Pharyngeal transit time was longer and bolus entry into the hypopharynx was later for 30 fps than for 15 fps. Components of Oral Residue and Pharyngoesophageal Segment Opening ratings were more severe for 15 fps than 30 fps, whereas Bolus Transport and Initiation of Pharyngeal Swallow were rated as more severe for 30 fps than for 15 fps. There was no difference between 30 fps and 15 fps on the remaining measures, including Penetration-Aspiration Scale scores. CONCLUSION Continuous VFSS recorded at 30 fps and their down-sampled 15 fps duplicates yielded contrasting results on certain durational and functional measures of swallowing, though not on others. VFSS should be administered continuously or at 30 pulses per second for valid assessment of swallowing while using other methods to reduce radiation exposure.
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Affiliation(s)
- Rachel W Mulheren
- Department of Physical Medicine and Rehabilitation, Johns Hopkins University School of Medicine, Baltimore, MD; Department of Neuroscience, Johns Hopkins University School of Medicine, Baltimore, MD.
| | - Alba Azola
- Department of Physical Medicine and Rehabilitation, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Marlís González-Fernández
- Department of Physical Medicine and Rehabilitation, Johns Hopkins University School of Medicine, Baltimore, MD
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14
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Le TB, Moghaddam MG, Woodson BT, Garcia GJM. Airflow limitation in a collapsible model of the human pharynx: physical mechanisms studied with fluid-structure interaction simulations and experiments. Physiol Rep 2019; 7:e14099. [PMID: 31116516 PMCID: PMC6530458 DOI: 10.14814/phy2.14099] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2019] [Accepted: 04/30/2019] [Indexed: 12/15/2022] Open
Abstract
The classical Starling Resistor model has been the paradigm of airway collapse in obstructive sleep apnea (OSA) for the last 30 years. Its theoretical framework is grounded on the wave-speed flow limitation (WSFL) theory. Recent observations of negative effort dependence in OSA patients violate the predictions of the WSFL theory. Fluid-structure interaction (FSI) simulations are emerging as a technique to quantify how the biomechanical properties of the upper airway determine the shape of the pressure-flow curve. This study aimed to test two predictions of the WSFL theory, namely (1) the pressure profile upstream from the choke point becomes independent of downstream pressure during flow limitation and (2) the maximum flowrate in a collapsible tube is V I max = A 3 / 2 ( ρ d A / d P ) - 1 / 2 , where ρ is air density and A and P are the cross-sectional area and pressure at the choke point respectively. FSI simulations were performed in a model of the human upper airway with a collapsible pharynx whose wall thickness varied from 2 to 8 mm and modulus of elasticity ranged from 2 to 30 kPa. Experimental measurements in an airway replica with a silicone pharynx validated the numerical methods. Good agreement was found between our FSI simulations and the WSFL theory. Other key findings include: (1) the pressure-flow curve is independent of breathing effort (downstream pressure vs. time profile); (2) the shape of the pressure-flow curve reflects the airway biomechanical properties, so that V I max is a surrogate measure of pharyngeal compliance.
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Affiliation(s)
- Trung B. Le
- Department of Biomedical EngineeringMarquette University & The Medical College of WisconsinMilwaukeeWisconsin
- Present address:
Department of Civil and Environmental EngineeringNorth Dakota State UniversityFargoNorth Dakota
| | - Masoud G. Moghaddam
- Department of Biomedical EngineeringMarquette University & The Medical College of WisconsinMilwaukeeWisconsin
| | - B. Tucker Woodson
- Department of Otolaryngology and Communication SciencesMedical College of WisconsinMilwaukeeWisconsin
| | - Guilherme J. M. Garcia
- Department of Biomedical EngineeringMarquette University & The Medical College of WisconsinMilwaukeeWisconsin
- Department of Otolaryngology and Communication SciencesMedical College of WisconsinMilwaukeeWisconsin
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Dong ML, Hu WH, Hu K. [Effects of end⁃expiratory lung volume on pharyngeal collapsibility and obstructive sleep apnea]. Zhonghua Jie He He Hu Xi Za Zhi 2019; 42:222-226. [PMID: 30845401 DOI: 10.3760/cma.j.issn.1001-0939.2019.03.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
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16
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Bakshi SS. A sticking sensation in the throat! Intern Emerg Med 2019; 14:321-322. [PMID: 30414055 DOI: 10.1007/s11739-018-1980-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2018] [Accepted: 10/27/2018] [Indexed: 11/30/2022]
Affiliation(s)
- Satvinder Singh Bakshi
- Department of ENT and Head & Neck Surgery, Mahatma Gandhi Medical College and Research Institute, Sri Balaji Vidyapeeth, Pillaiyarkuppam, Pondicherry, 607402, India.
- , Pondicherry, India.
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Gowda GS, Sastry Nagavarapu LS, Reddy Mukku SS, Farooq Ali S. Amisulpride Induced Oropharyngeal Dyskinesia in a patient with Schizophrenia: A case report and review of literature. Asian J Psychiatr 2019; 41:78-81. [PMID: 29146045 DOI: 10.1016/j.ajp.2017.10.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2017] [Accepted: 10/15/2017] [Indexed: 11/18/2022]
Affiliation(s)
- Guru S Gowda
- Department of Psychiatry, National Institute of Mental Health and Neuro Sciences (NIMHANS), Bangalore, 560029, India; Department of Clinical Neuro Sciences, National Institute of Mental Health and Neuro Sciences (NIMHANS), Bangalore, 560029, India.
| | - Leela Shanker Sastry Nagavarapu
- Department of Psychiatry, National Institute of Mental Health and Neuro Sciences (NIMHANS), Bangalore, 560029, India; Department of Clinical Neuro Sciences, National Institute of Mental Health and Neuro Sciences (NIMHANS), Bangalore, 560029, India
| | - Shiva Shanker Reddy Mukku
- Department of Psychiatry, National Institute of Mental Health and Neuro Sciences (NIMHANS), Bangalore, 560029, India; Department of Clinical Neuro Sciences, National Institute of Mental Health and Neuro Sciences (NIMHANS), Bangalore, 560029, India
| | - Syed Farooq Ali
- Department of Psychiatry, National Institute of Mental Health and Neuro Sciences (NIMHANS), Bangalore, 560029, India; Department of Clinical Neuro Sciences, National Institute of Mental Health and Neuro Sciences (NIMHANS), Bangalore, 560029, India
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Abstract
Purpose Pharyngeal high-resolution manometry is an emerging practice for diagnosis of swallowing disorders in the upper aerodigestive tract. Advancement of a catheter through the upper esophageal sphincter may introduce safety considerations. There are no published studies of catheter placement complications, side effects, or tolerability. This study examines patient-reported side effects and tolerability of pharyngeal high-resolution manometry. Method Data were collected prospectively from 133 adult patients who underwent pharyngeal high-resolution manometry for the 1st time. Patients rated tolerability specific to "nose" and "throat" using a visual analog scale for 4 procedure time points: catheter passage, during the procedure, catheter removal, and after the procedure. Complications during catheter passage and removal were recorded. A telephone call was placed to the patient within 6 days to survey side effects experienced after the procedure. Results The patient sample was composed of 91 males and 42 females with a mean age of 66 years ( SD = 14.4). Tolerability scores for catheter passage showed no significant difference ( p = .7288) in the nose versus throat. Tolerability for females was significantly less ( p = .0144) than that for males. Participants with the shortest procedure duration showed greatest discomfort in the nose ( p = .0592) and throat ( p = .0286). Complications included gag response (14%), emesis (2%), and epistaxis (< 1%). Side effects included sore throat (16%), nose discomfort (16%), coughing (11 %), nosebleed (4%), and nausea/vomiting (4%). Conclusions High-resolution manometry appears to have high patient tolerability with low incidence of side effects. Rates of complications and side effects are similar to those reported for other transnasal procedures.
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19
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Feng Y, Keenan BT, Wang S, Leinwand S, Wiemken A, Pack AI, Schwab RJ. Dynamic Upper Airway Imaging during Wakefulness in Obese Subjects with and without Sleep Apnea. Am J Respir Crit Care Med 2018; 198:1435-1443. [PMID: 30040909 PMCID: PMC6290952 DOI: 10.1164/rccm.201711-2171oc] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2017] [Accepted: 07/24/2018] [Indexed: 01/11/2023] Open
Abstract
RATIONALE Obesity is a major risk factor for obstructive sleep apnea. Although greater dimensional changes in the upper airway during wake respiration have been noted in patients with apnea compared with control subjects, whether these differences remain in the presence of obesity is unknown. OBJECTIVES To evaluate upper airway anatomic characteristics and airway compliance (distensibility) in obese subjects with obstructive sleep apnea compared with obese control subjects. METHODS Dynamic magnetic resonance imaging was performed in 157 obese subjects with apnea and 46 obese control subjects during wakefulness in the midsagittal and three axial upper airway regions (retropalatal, retroglossal, epiglottal). Differences in measurements between subjects with apnea and control subjects, and correlations with apnea-hypopnea index among subjects with apnea, were examined. MEASUREMENTS AND MAIN RESULTS Measurements included airway areas and linear dimensions. Subject-specific coefficients of variation were calculated to examine variability in airway size. Controlling for covariates, the retropalatal area during respiration was significantly smaller in subjects with apnea than control subjects, based on the average (P = 0.003), maximum (P = 0.004), and minimum (P = 0.001) airway area. Airway narrowing was observed in anteroposterior and lateral dimensions (adjusted P < 0.05). Results were similar in an age, sex, and body mass index-matched subsample. There were significant correlations between apnea-hypopnea index and dynamic measures of airway caliber in the retropalatal and retroglossal regions among subjects with apnea. CONCLUSIONS Upper airway caliber during respiration was significantly narrower in obese subjects with apnea than obese control subjects in the retropalatal region. These findings provide further evidence that retropalatal airway narrowing plays an important role in the pathogenesis of obstructive sleep apnea in obese subjects.
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Affiliation(s)
- Yuan Feng
- Sleep Medicine Center, Nanfang Hospital, Southern Medical University, Guangzhou, China; and
- Center for Sleep and Circadian Neurobiology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Brendan T. Keenan
- Center for Sleep and Circadian Neurobiology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Stephen Wang
- Center for Sleep and Circadian Neurobiology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Sarah Leinwand
- Center for Sleep and Circadian Neurobiology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Andrew Wiemken
- Center for Sleep and Circadian Neurobiology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Allan I. Pack
- Center for Sleep and Circadian Neurobiology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Richard J. Schwab
- Center for Sleep and Circadian Neurobiology, University of Pennsylvania, Philadelphia, Pennsylvania
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Garand KL(F, Armeson KE, Hill EG, Martin-Harris B. Identification of Phenotypic Patterns of Dysphagia: A Proof of Concept Study. Am J Speech Lang Pathol 2018; 27:988-995. [PMID: 29800022 PMCID: PMC6195027 DOI: 10.1044/2018_ajslp-17-0173] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/19/2017] [Revised: 01/02/2018] [Accepted: 02/12/2018] [Indexed: 06/08/2023]
Abstract
PURPOSE The purpose of the current project was to explore the feasibility for subtyping dysphagia traits or patterns of scores in a subset of data from the Modified Barium Swallow Impairment Profile global registry in patients referred to videofluoroscopic swallowing studies across 5 common medical categories: (a) cardiothoracic, (b) gastroenterology, (c) head and neck cancer, (d) neurology, and (e) pulmonary. METHOD Videofluoroscopic swallowing study imaging and Modified Barium Swallow Impairment Profile metrics were used to evaluate 235 patients with dysphagia grouped into 1 of the 5 categories. Two summative domain scores (oral total [OT] and pharyngeal total [PT]) and 17 component scores were tested for differences among the categories. RESULTS When compared with the gastroenterology category, significantly higher OT/PT scores were observed in neurology and pulmonary categories (all p values < .05). Four oral and 6 pharyngeal domain components significantly differed across medical categories: tongue control during bolus hold (all p values < .04). CONCLUSIONS The results of this feasibility study demonstrate that summative scores of swallowing physiology alone are not sufficiently robust to distinguish subtypes of dysphagia in broad, heterogeneous medical categories. Using OT/PT as subtypes only separated gastroenterology from the other categories, suggesting overlap in OT/PT scores between the latter categories.
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Affiliation(s)
| | - Kent E. Armeson
- Biostatistics Shared Resource, Hollings Cancer Center, Medical University of South Carolina, Charleston
| | - Elizabeth G. Hill
- Department of Public Health Sciences, Medical University of South Carolina, Charleston
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21
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Whittles LK, Didelot X, Grad YH, White PJ. Testing for gonorrhoea should routinely include the pharynx. Lancet Infect Dis 2018; 18:716-717. [PMID: 29976520 PMCID: PMC7349805 DOI: 10.1016/s1473-3099(18)30341-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/25/2018] [Accepted: 05/14/2018] [Indexed: 02/07/2023]
Affiliation(s)
- Lilith K Whittles
- MRC Centre for Outbreak Analysis and Modelling and NIHR Health Protection Research Unit in Modelling Methodology, Imperial College London, London, W2 1PG, UK
| | - Xavier Didelot
- MRC Centre for Outbreak Analysis and Modelling and NIHR Health Protection Research Unit in Modelling Methodology, Imperial College London, London, W2 1PG, UK
| | - Yonatan H Grad
- Department of Immunology and Infectious Diseases, Harvard TH Chan School of Public Health, Boston, MA, USA; Division of Infectious Diseases, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Peter J White
- MRC Centre for Outbreak Analysis and Modelling and NIHR Health Protection Research Unit in Modelling Methodology, Imperial College London, London, W2 1PG, UK; Modelling and Economics Unit, National Infection Service, Public Health England, London, UK.
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Darquenne C, Elliott AR, Sibille B, Smales ET, DeYoung PN, Theilmann RJ, Malhotra A. Upper airway dynamic imaging during tidal breathing in awake and asleep subjects with obstructive sleep apnea and healthy controls. Physiol Rep 2018; 6:e13711. [PMID: 29845763 PMCID: PMC5974719 DOI: 10.14814/phy2.13711] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2018] [Revised: 04/24/2018] [Accepted: 04/25/2018] [Indexed: 02/07/2023] Open
Abstract
We used magnetic resonance imaging (MRI) to quantify change in upper airway dimension during tidal breathing in subjects with obstructive sleep apnea (OSA, N = 7) and BMI-matched healthy controls (N = 7) during both wakefulness and natural sleep. Dynamic MR images of the upper airway were obtained on a 1.5 T MR scanner in contiguous 7.5 mm-thick axial slices from the hard palate to the epiglottis along with synchronous MRI-compatible electroencephalogram and nasal/oral flow measurements. The physiologic data were retrospectively scored to identify sleep state, and synchronized with dynamic MR images. For each image, the upper airway was characterized by its area, and linear dimensions (lateral and anterior-posterior). The dynamic behavior of the upper airway was assessed by the maximum change in these parameters over the tidal breath. Mean upper airway caliber was obtained by averaging data over the tidal breath. There was no major difference in the upper airway structure between OSA and controls except for a narrower airway at the low-retropalatal/high-retroglossal level in OSA than in controls. Changes in upper airway size over the tidal breath ((maximum - minimum)/mean) were significantly larger in the OSA than in the control group in the low retropalatal/high retroglossal region during both wakefulness and sleep. In the four OSA subjects who experienced obstructive apneas during MR imaging, the site of airway collapse during sleep corresponded to the region of the upper airway where changes in caliber during awake tidal breathing were the greatest. These observations suggest a potential role for dynamic OSA imaging during wakefulness.
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Affiliation(s)
| | - Ann R. Elliott
- Division of PhysiologyUniversity of CaliforniaSan DiegoCalifornia
| | - Bastien Sibille
- Division of PhysiologyUniversity of CaliforniaSan DiegoCalifornia
| | - Erik T. Smales
- Division of PulmonaryCritical Care and Sleep MedicineUniversity of CaliforniaSan DiegoCalifornia
| | - Pamela N. DeYoung
- Division of PulmonaryCritical Care and Sleep MedicineUniversity of CaliforniaSan DiegoCalifornia
| | | | - Atul Malhotra
- Division of PulmonaryCritical Care and Sleep MedicineUniversity of CaliforniaSan DiegoCalifornia
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Winters R, Carter J, Lindhe Guarisco J. A novel technique for superior-based pharyngeal flaps: 10-year results with formal speech outcomes assessment. Am J Otolaryngol 2018; 39:142-145. [PMID: 29254702 DOI: 10.1016/j.amjoto.2017.12.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2017] [Accepted: 12/11/2017] [Indexed: 11/29/2022]
Abstract
PURPOSE Describe a novel technique for superior-based pharyngeal flaps allowing restoration of bulk to the soft palate and intraoperative fine-tuning of lateral port size, while avoiding midline palate-splitting. Validated speech assessment tools are employed for quantitative analysis. METHODS Retrospective review of all patients who underwent superior-based pharyngeal flap in a 10-year period by a single surgeon. Pittsburgh Weighted Values for Speech Symptoms Associated with VPI and the Goldman-Fristoe Test of Articulation were used for formal speech assessment. RESULTS 78 patients met inclusion criteria with clinical data up to 10years postoperatively. 31 patients had congenital velopharyngeal insufficiency (VPI), and the remainder acquired VPI after cleft palate repair or adenoidectomy. 37 patients had a recognized syndrome. All patients noted subjective improvement in nasality, and evaluation with the validated speech assessment tools demonstrated statistically significant improvement in speech. Only one flap takedown was required in a patient with severe midface hypoplasia who developed sleep apnea several years postoperatively. CONCLUSIONS This technique is successful in congenital and acquired VPI, and in patients with complex craniofacial syndromes. Customization of lateral ports based on preoperative nasopharyngoscopy, and avoidance of a midline palate splitting incision, make this an attractive option for superior-based flap surgery.
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Affiliation(s)
- Ryan Winters
- Ochsner Clinic Foundation Department of Otolaryngology - Head & Neck Surgery, New Orleans, LA, USA.
| | - John Carter
- Ochsner Clinic Foundation Department of Otolaryngology - Head & Neck Surgery, New Orleans, LA, USA
| | - J Lindhe Guarisco
- Ochsner Clinic Foundation Department of Otolaryngology - Head & Neck Surgery, New Orleans, LA, USA
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Affiliation(s)
- W S Lund
- Department of Otolaryngology, Radcliffe Infirmary, Oxford
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25
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Chanchareonsook N, Whitehill TL, Samman N. Speech Outcome and Velopharyngeal Function in Cleft Palate: Comparison of Le Fort I Maxillary Osteotomy and Distraction Osteogenesis—Early Results. Cleft Palate Craniofac J 2017; 44:23-32. [PMID: 17214524 DOI: 10.1597/05-003] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Objective: To compare speech outcome and velopharyngeal (VP) status of subjects with repaired cleft palate who underwent either conventional Le Fort I osteotomy or maxillary distraction osteogenesis to correct maxillary hypoplasia. Design: Prospective randomized study with blind assessment of speech outcome and VP status. Subjects: Twenty-two subjects were randomized into conventional Le Fort I osteotomy and Le Fort I distraction groups. All were native Chinese (Cantonese) speakers. Method: Perceptual judgment of resonance and nasal emission, study of VP structures by nasoendoscopy, and instrumental measurement by nasometry. Assessments were performed preoperatively and at 3 months postoperatively. Main Outcome Measures: Assessment of VP closure, perceptual rating of hypernasality and nasal emission, nasalance, and amount of maxillary advancement. Results: There was no statistical difference in any of the outcome measures between the 10 subjects with conventional Le Fort I osteotomy and the 12 subjects with maxillary distraction: hypernasality (chi-square = 3.850, p = 0.221), nasal emission (chi-square = 0.687, p = 0.774), VP gap size (chi-square = 1.527, p = 0.635, and nasalance (t = −0.145, p = 0.886). There was no correlation between amount of maxillary advancement and any of the outcome measures (p = .05 for all). Changes in VP gap size and resonance are described. Conclusion: Results need to be interpreted with caution because of the small sample size and early follow-up. However, this study utilized an assessment protocol involving a variety of outcome measures and careful consideration of reliability factors, which can be a model for further and follow-up studies.
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Molfenter SM, Hsu CY, Lu Y, Lazarus CL. Alterations to Swallowing Physiology as the Result of Effortful Swallowing in Healthy Seniors. Dysphagia 2017; 33:380-388. [PMID: 29147919 DOI: 10.1007/s00455-017-9863-6] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2017] [Accepted: 11/07/2017] [Indexed: 11/24/2022]
Abstract
A significant proportion of healthy seniors report difficulty swallowing, thought to result from age-related decline in muscle bulk/function. Effortful Swallowing (ES) is used both as a compensatory maneuver to improve pharyngeal propulsion/clearance and has been proposed as an exercise to improve pharyngeal strength. This study sought to quantify the immediate kinematic, temporal, and functional changes during an ES maneuver to quantify its exercise potential to combat age-related changes in swallowing. Videofluoroscopy data were collected from 44 healthy seniors (21 male) over 65 years old (mean = 76.9, SD = 7.1). Each participant swallowed six 5 ml boluses of Varibar nectar-thick liquids: three with regular effort and three using ES. Individual swallows (n = 260) were measured on pharyngeal constriction, pharyngeal shortening, laryngeal closure duration, hyoid movement duration, UES opening duration, stage transition duration, pharyngeal transit time, pharyngeal response duration, Normalized Residue Ratio Scale (NRRS), and the Penetration-Aspiration Scale (PAS). Non-parametric Wilcoxon Rank Sum for repeated measures tested the effect of ES on each outcome. Exact p-values were calculated based on permutation methods, individual p values < 0.008 was deemed to be significant. The ES maneuver significantly prolonged all temporal variables. While we found no significant differences for pharyngeal constriction, significantly less (i.e., worse) pharyngeal shortening was observed in ES condition compared with regular effort swallows. Further, significantly worse pyriform sinus residue (NRRSv) was observed in the ES condition. No differences between ES and regular effort swallows were noted for pharyngeal constriction, NRRSv or PAS. We speculate that these negative manifestations of worse kinematics (less pharyngeal shortening) and function (increase in NRRSp) may be the result of forced volitional manipulation of swallowing in the ES condition in an otherwise normal elderly swallow.
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Affiliation(s)
- Sonja M Molfenter
- Department of Communicative Sciences & Disorders, NYU Steinhardt, New York, USA.
| | - Chuan-Ya Hsu
- Department of Applied Statistics Social Science & Humanities, NYU Steinhardt, New York, USA
| | - Ying Lu
- Department of Applied Statistics Social Science & Humanities, NYU Steinhardt, New York, USA
| | - Cathy L Lazarus
- Department of Otolaryngology Head & Neck Surgery, Mount Sinai Beth Israel, New York, USA
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Pavoni C, Cretella Lombardo E, Franchi L, Lione R, Cozza P. Treatment and post-treatment effects of functional therapy on the sagittal pharyngeal dimensions in Class II subjects. Int J Pediatr Otorhinolaryngol 2017; 101:47-50. [PMID: 28964309 DOI: 10.1016/j.ijporl.2017.07.032] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2017] [Revised: 07/22/2017] [Accepted: 07/23/2017] [Indexed: 01/07/2023]
Abstract
OBJECTIVE To evaluate the craniofacial changes induced by functional appliances with special regard to the oro and nasopharyngeal sagittal airway dimensions in subjects with dentoskeletal Class II malocclusions when compared with an untreated Class II control group immediately after therapy and at long-term observation. METHODS A group of 40 patients (21 females and 19 males) with Class II malocclusion treated consecutively either with a Bionator or an Activator followed by fixed appliances was compared with a matched control group of 31 subjects (16 females and 15 males) with untreated Class II malocclusion. The treated sample was evaluated at T1, start of treatment (mean age: 9.9 ± 1.4 years); T2, end of functional treatment and prior to fixed appliances (mean age: 11.9 ± 1.3 years); and T3, long-term observation at the end of growth (mean age: 18.2 ± 2.1 years). Statistical comparisons were performed with independent sample t tests at T1 (baseline characteristics) and for the T1-T2, T2-T3, and T1-T3 changes. RESULTS During active treatment the treated group showed a significant increment in lower airway dimension (PNS-AD1), as well as a significant improvement in the upper airway dimension (PNS-AD2). A significant decrease in the upper adenoid size (AD2-H) was also found. In the longterm evaluation, a significant increase in both lower and upper airway thickness (PNS-AD1; PNS-AD2) and a significant decrease in the upper adenoid thickness were still present in the treated group. CONCLUSION The treatment with functional appliances produced significant favorable changes during active treatment in the oro- and nasopharyngeal sagittal airway dimensions in dentoskeletal Class II subjects when compared with untreated controls, and these changes were stable in the long-term.
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Affiliation(s)
- Chiara Pavoni
- Department of Clinical Sciences and Translational Medicine, University of Rome Tor Vergata, Italy.
| | | | - Lorenzo Franchi
- Department of Surgery and Translational Medicine, University of Florence, Florence, Italy; Thomas M. Graber Visiting Scholar, Department of Orthodontics and Pediatric Dentistry, School of Dentistry, The University of Michigan, Ann Arbor, MI, USA
| | - Roberta Lione
- Department of Clinical Sciences and Translational Medicine, University of Rome Tor Vergata, Italy
| | - Paola Cozza
- Department of Clinical Sciences and Translational Medicine, University of Rome Tor Vergata, Italy; Department of Orthodontics, University Zoja e Këshillit të Mirë, Tirane, Albania
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May NH, Pisegna JM, Marchina S, Langmore SE, Kumar S, Pearson WG. Pharyngeal Swallowing Mechanics Secondary to Hemispheric Stroke. J Stroke Cerebrovasc Dis 2017; 26:952-961. [PMID: 27913200 PMCID: PMC5409864 DOI: 10.1016/j.jstrokecerebrovasdis.2016.11.001] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2016] [Revised: 10/21/2016] [Accepted: 11/02/2016] [Indexed: 01/25/2023] Open
Abstract
BACKGROUND Computational analysis of swallowing mechanics (CASM) is a method that utilizes multivariate shape change analysis to uncover covariant elements of pharyngeal swallowing mechanics associated with impairment using videofluoroscopic swallowing studies. The goals of this preliminary study were to (1) characterize swallowing mechanics underlying stroke-related dysphagia, (2) decipher the impact of left and right hemispheric strokes on pharyngeal swallowing mechanics, and (3) determine pharyngeal swallowing mechanics associated with penetration-aspiration status. METHODS Videofluoroscopic swallowing studies of 18 dysphagic patients with hemispheric infarcts and age- and gender-matched controls were selected from well-controlled data sets. Patient data including laterality and penetration-aspiration status were collected. Coordinates mapping muscle group action during swallowing were collected from videos. Multivariate morphometric analyses of coordinates associated with stroke, affected hemisphere, and penetration-aspiration status were performed. RESULTS Pharyngeal swallowing mechanics differed significantly in the following comparisons: stroke versus controls (D = 2.19, P < .0001), right hemispheric stroke versus controls (D = 3.64, P < .0001), left hemispheric stroke versus controls (D = 2.06, P < .0001), right hemispheric stroke versus left hemispheric stroke (D = 2.89, P < .0001), and penetration-aspiration versus within normal limits (D = 2.25, P < .0001). Differences in pharyngeal swallowing mechanics associated with each comparison were visualized using eigenvectors. CONCLUSIONS Whereas current literature focuses on timing changes in stroke-related dysphagia, these data suggest that mechanical changes are also functionally important. Pharyngeal swallowing mechanics differed by the affected hemisphere and the penetration-aspiration status. CASM can be used to identify patient-specific swallowing impairment associated with stroke injury that could help guide rehabilitation strategies to improve swallowing outcomes.
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Affiliation(s)
- Nelson H May
- Department of Cellular Biology and Anatomy, Medical College of Georgia, Augusta University, Augusta, Georgia
| | - Jessica M Pisegna
- Department of Speech, Language and Hearing Sciences, Boston University, Boston, Massachusetts
| | - Sarah Marchina
- Department of Neurology, Stroke Division, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Susan E Langmore
- Department of Speech, Language and Hearing Sciences, Boston University, Boston, Massachusetts
| | - Sandeep Kumar
- Department of Neurology, Stroke Division, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - William G Pearson
- Department of Cellular Biology and Anatomy, Medical College of Georgia, Augusta University, Augusta, Georgia.
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Abstract
PURPOSE OF REVIEW We provide an overview of the clinical application of novel pharyngeal high-resolution impedance manometry (HRIM) with pressure flow analysis (PFA) in our hands with example cases. RECENT FINDINGS In our Centre, we base our interpretation of HRIM recordings upon a qualitative assessment of pressure-impedance waveforms during individual swallows, as well as a quantitative assessment of averaged PFA swallow function variables. We provide a description of two global swallowing efficacy measures, the swallow risk index (SRI), reflecting global swallowing dysfunction (higher SRI = greater aspiration risk) and the post-swallow impedance ratio (PSIR) detecting significant post-swallow bolus residue. We describe a further eight swallow function variables specific to the hypopharynx and upper esophageal sphincter (UES), assessing hypo-pharyngeal distension pressure, contractility, bolus presence and flow timing, and UES basal tone, relaxation, opening and contractility. Pharyngeal HRIM has now come of age, being applicable for routine clinical practice to assess the biomechanics of oropharyngeal swallowing dysfunction. In the future, it may guide treatment strategies and allow more objective longitudinal follow-up on clinical outcomes.
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Affiliation(s)
- Charles Cock
- Gastroenterology & Hepatology, Southern Adelaide Local Health Network, Adelaide, Australia.
- Department of Gastroenterology & Hepatology, School of Medicine, Flinders University of South Australia, Flinders Medical Centre, Flinders Drive, Bedford Park, 5042, Australia.
| | - Taher Omari
- Department of Gastroenterology & Hepatology, School of Medicine, Flinders University of South Australia, Flinders Medical Centre, Flinders Drive, Bedford Park, 5042, Australia
- Human Physiology, Medical Science and Technology, Flinders University of South Australia, Bedford Park, Australia
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Azarbarzin A, Sands SA, Taranto-Montemurro L, Oliveira Marques MD, Genta PR, Edwards BA, Butler J, White DP, Wellman A. Estimation of Pharyngeal Collapsibility During Sleep by Peak Inspiratory Airflow. Sleep 2017; 40:2666705. [PMID: 28364460 PMCID: PMC6084748 DOI: 10.1093/sleep/zsw005] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Objectives Pharyngeal critical closing pressure (Pcrit) or collapsibility is a major determinant of obstructive sleep apnea (OSA) and may be used to predict the success/failure of non-continuous positive airway pressure (CPAP) therapies. Since its assessment involves overnight manipulation of CPAP, we sought to validate the peak inspiratory flow during natural sleep (without CPAP) as a simple surrogate measurement of collapsibility. Methods Fourteen patients with OSA attended overnight polysomnography with pneumotachograph airflow. The middle third of the night (non-rapid eye movement sleep [NREM]) was dedicated to assessing Pcrit in passive and active states via abrupt and gradual CPAP pressure drops, respectively. Pcrit is the extrapolated CPAP pressure at which flow is zero. Peak and mid-inspiratory flow off CPAP was obtained from all breaths during sleep (excluding arousal) and compared with Pcrit. Results Active Pcrit, measured during NREM sleep, was strongly correlated with both peak and mid-inspiratory flow during NREM sleep (r = -0.71, p < .005 and r = -0.64, p < .05, respectively), indicating that active pharyngeal collapsibility can be reliably estimated from simple airflow measurements during polysomnography. However, there was no significant relationship between passive Pcrit, measured during NREM sleep, and peak or mid-inspiratory flow obtained from NREM sleep. Flow measurements during REM sleep were not significantly associated with active or passive Pcrit. Conclusions Our study demonstrates the feasibility of estimating active Pcrit using flow measurements in patients with OSA. This method may enable clinicians to estimate pharyngeal collapsibility without sophisticated equipment and potentially aid in the selection of patients for non- positive airway pressure therapies.
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Affiliation(s)
- Ali Azarbarzin
- Division of Sleep and Circadian Disorders, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Scott A Sands
- Division of Sleep and Circadian Disorders, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
- Department of Allergy Immunology and Respiratory Medicine and Central Clinical School, The Alfred and Monash University, Melbourne, Australia
| | - Luigi Taranto-Montemurro
- Division of Sleep and Circadian Disorders, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Melania D Oliveira Marques
- Division of Sleep and Circadian Disorders, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
- Pulmonary Division, Heart Institute (InCor), Hospital das Clínicas, University of São Paulo School of Medicine, São Paulo, Brazil
| | - Pedro R Genta
- Pulmonary Division, Heart Institute (InCor), Hospital das Clínicas, University of São Paulo School of Medicine, São Paulo, Brazil
| | - Bradley A Edwards
- Division of Sleep and Circadian Disorders, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
- Sleep and Circadian Medicine Laboratory, Department of Physiology Monash University, Melbourne, Victoria, Australia
- School of Psychological Sciences and Monash Institute of Cognitive and Clinical Neurosciences, Monash University, Melbourne, Victoria, Australia
| | - James Butler
- Division of Sleep and Circadian Disorders, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - David P White
- Division of Sleep and Circadian Disorders, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Andrew Wellman
- Division of Sleep and Circadian Disorders, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
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Edwards BA, Andara C, Landry S, Sands SA, Joosten SA, Owens RL, White DP, Hamilton GS, Wellman A. Upper-Airway Collapsibility and Loop Gain Predict the Response to Oral Appliance Therapy in Patients with Obstructive Sleep Apnea. Am J Respir Crit Care Med 2016; 194:1413-1422. [PMID: 27181367 PMCID: PMC5148143 DOI: 10.1164/rccm.201601-0099oc] [Citation(s) in RCA: 144] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2016] [Accepted: 05/02/2016] [Indexed: 01/20/2023] Open
Abstract
RATIONALE Oral appliances (OAs) are commonly used as an alternative treatment to continuous positive airway pressure for patients with obstructive sleep apnea (OSA). However, OAs have variable success at reducing the apnea-hypopnea index (AHI), and predicting responders is challenging. Understanding this variability may lie with the recognition that OSA is a multifactorial disorder and that OAs may affect more than just upper-airway anatomy/collapsibility. OBJECTIVES The objectives of this study were to determine how OA alters AHI and four phenotypic traits (upper-airway anatomy/collapsibility and muscle function, loop gain, and arousal threshold), and baseline predictors of which patients gain the greatest benefit from therapy. METHODS In a randomized crossover study, 14 patients with OSA attended two sleep studies with and without their OA. Under each condition, AHI and the phenotypic traits were assessed. Multiple linear regression was used to determine independent predictors of the reduction in AHI. MEASUREMENTS AND MAIN RESULTS OA therapy reduced the AHI (30 ± 5 vs. 11 ± 2 events/h; P < 0.05), which was driven by improvements in upper-airway anatomy/collapsibility under passive (1.9 ± 0.7 vs. 4.7 ± 0.6 L/min; P < 0.005) and active conditions (2.4 ± 0.9 vs. 6.2 ± 0.4 L/min; P < 0.001). No changes were seen in muscle function, loop gain, or the arousal threshold. Using multivariate analysis, baseline passive upper-airway collapsibility and loop gain were independent predictors of the reduction in AHI (r2 = 0.70; P = 0.001). CONCLUSIONS Our findings suggest that OA therapy improves the upper-airway collapsibility under passive and active conditions. Importantly, a greater response to therapy occurred in those patients with a mild anatomic compromise and a lower loop gain.
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Affiliation(s)
- Bradley A. Edwards
- Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Brigham & Women's Hospital and Harvard Medical School, Boston, Massachusetts
- Sleep and Circadian Medicine Laboratory, Department of Physiology
- School of Psychological Sciences and Monash Institute of Cognitive and Clinical Neurosciences, and
| | | | - Shane Landry
- Sleep and Circadian Medicine Laboratory, Department of Physiology
| | - Scott A. Sands
- Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Brigham & Women's Hospital and Harvard Medical School, Boston, Massachusetts
- Department of Allergy, Immunology and Respiratory Medicine and Central Clinical School, The Alfred and Monash University, Melbourne, Victoria, Australia
| | - Simon A. Joosten
- School of Clinical Sciences, Monash University, Melbourne, Victoria, Australia
- Monash Lung and Sleep, Monash Medical Centre, Clayton, Victoria, Australia; and
| | - Robert L. Owens
- Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Brigham & Women's Hospital and Harvard Medical School, Boston, Massachusetts
- Division of Pulmonary and Critical Care Medicine, University of California San Diego, San Diego, California
| | - David P. White
- Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Brigham & Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Garun S. Hamilton
- School of Clinical Sciences, Monash University, Melbourne, Victoria, Australia
- Monash Lung and Sleep, Monash Medical Centre, Clayton, Victoria, Australia; and
| | - Andrew Wellman
- Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Brigham & Women's Hospital and Harvard Medical School, Boston, Massachusetts
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Bülow M, Olsson R, Ekberg O. Videoradiographic analysis of how carbonated thin liquids and thickened liquids affect the physiology of swallowing in subjects with aspiration on thin liquids. Acta Radiol 2016; 44:366-72. [PMID: 12846685 DOI: 10.1080/j.1600-0455.2003.00100.x] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Purpose: To analyze how carbonated thin liquids affected the physiology of swallowing in dysphagic patients. Material and Methods: 40 patients were analyzed; 36 were neurologically impaired. During a therapeutic videoradiographic swallowing examination the patients had to swallow liquids with the following consistencies three times: thin, thickened and carbonated. The liquids were given in doses of 3 × 5 ml. The swallows were analyzed regarding penetration/aspiration, pharyngeal transit time and pharyngeal retention. Results: Significant difference was found regarding penetration/aspiration when comparisons were made between thin liquid and carbonated thin liquid ( p<0.0001). Carbonated liquid reduced the penetration to the airways. The comparison between thin liquid and thickened liquid ( p<0.0001) showed significant less penetration with thickened liquids. Pharyngeal transit time was reduced both when comparing thin liquid with thin carbonated liquid ( p<0.0001) and thickened liquid ( p<0.0001). Pharyngeal retention was significantly reduced ( p<0.0001) with carbonated thin liquid compared to thickened liquid. The comparison of thin liquids and carbonated thin liquids showed p = 0.0013, thin and thickened liquids p = 0.0097. Conclusions: Carbonated liquids reduced penetration/aspiration into the airways, reduced pharyngeal retention and pharyngeal transit time became shorter. Therefore, carbonated liquids are a valuable treatment option for patients with penetration/aspiration. Thickened liquids may still be an option for patients who cannot tolerate carbonated liquids and liquids with this consistency are safer than thin liquids.
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Affiliation(s)
- M Bülow
- Department of Diagnostic Radiology, Malmö University Hospital, Lund University, Malmö, Sweden.
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Abstract
Objectives: Fiberoptic endoscopic evaluation of swallowing with sensory testing has been used to assess the integrity of laryngopharyngeal sensory and motor components. The pharyngeal squeeze is a maneuver used during fiberoptic endoscopic evaluation of swallowing with sensory testing to assess pharyngeal motor function. Although the pharyngeal squeeze manuever has been used in numerous scientific publications, its reliability has not been critically evaluated. Therefore, we sought to evaluate the reliability of the pharyngeal squeeze maneuver. Methods: Forty individuals who were undergoing fiberoptic laryngoscopy for various reasons were instructed to perform the pharyngeal squeeze maneuver. Three different clinicians reviewed the videotape on 4 separate occasions. The clinicians were first asked to rate each side of the pharynx as normal, diminished, or absent. They were then instructed to simply rate the maneuver as normal or abnormal. The interobserver and intraobserver reliability of the pharyngeal squeeze maneuver were assessed with the kappa coefficient. Results: The mean age of the cohort was 58 years. Fifty-eight percent (23 of 40) were male. When the clinicians were instructed to rate each side of the pharynx as normal, diminished, or absent, the interobserver and intraobserver reliabilities were poor (63% to 68% agreement; kappa = 0.18 to 0.67). When the clinicians were asked to rate the pharyngeal squeeze maneuver as normal or abnormal, both interobserver and intraobserver reliabilities were excellent (85% to 98% agreement; kappa = 0.75 to 0.95). Conclusions: The pharyngeal squeeze maneuver displayed poor reliability when motor function was classified into unilateral or bilateral normal, diminished, and absent categories. The pharyngeal squeeze maneuver was very reliable when simply graded as normal or abnormal. Clinicians could not reliably distinguish between diminished and absent pharyngeal motor functions.
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Affiliation(s)
- Kimsey H Rodriguez
- Department of Otolaryngology, Tulane University, New Orleans, Louisiana, USA
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35
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Cunningham JJ, Halum SL, Butler SG, Postma GN. Intraobserver and Interobserver Reliability in Laryngopharyngeal Sensory Discrimination Thresholds: A Pilot Study. Ann Otol Rhinol Laryngol 2016; 116:582-8. [PMID: 17847725 DOI: 10.1177/000348940711600805] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objectives: Laryngopharyngeal sensory discrimination threshold (LPSDT) testing is a method used to detect sensory deficits in patients in whom swallowing disorders are suspected. LPSDTs have been used to stratify patient risk status with regard to aspiration and to guide dietary management. The aim of this pilot study was to evaluate the intraobserver and interobserver reliability of LPSDT testing among a group of examiners with differing levels of testing experience. Methods: Twenty-seven healthy volunteers were enrolled in the study to elicit LPSDTs for intraobserver and interobserver reliability measurements. The examiners represented 3 levels of testing experience: An attending laryngologist, a laryngology fellow, and an otolaryngology resident. With the examiners blinded to test results, each subject was examined twice by one examiner and once by a different examiner in an alternating fashion. Results: Six subjects were unable to tolerate the examinations because of coughing and gagging. Spearman rank correlations revealed strong intraobserver reliability for the experienced endoscopists (ie, attending and fellow) but poor reliability for the novice endoscopist (ie, resident). Poor interobserver reliability regardless of endoscopy experience was found. Eighteen percent of the participants demonstrated LPSDTs of more than 4.0 mm Hg (above normal). Conclusions: 1) Intraobserver reliability was good for experienced endoscopists. 2) Interobserver LPSDT agreement between endoscopists was poor. 3) Eighteen percent of the subjects demonstrated elevated LPSDT thresholds of more than 4 mm Hg.
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Affiliation(s)
- Jeffrey J Cunningham
- Center for Voice and Swallowing Disorders, Department of Otolaryngology, Wake Forest University Baptist Medical Center, Winston-Salem, North Carolina, USA
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Salazar Quero JC, Moya Jiménez MJ, Rubio Murillo M, Roldán Pérez S, Rodríguez Martínez A, Valverde Fernández J. Supragastric belches. An entity to know. Gastroenterol Hepatol 2016; 40:396-397. [PMID: 27345533 DOI: 10.1016/j.gastrohep.2016.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/02/2016] [Revised: 05/09/2016] [Accepted: 05/23/2016] [Indexed: 11/18/2022]
Affiliation(s)
- Jose C Salazar Quero
- Unidad de Gestión Clínica de Pediatría, Unidad de Digestivo Infantil, Hospital Universitario Virgen del Rocío, Sevilla, España.
| | - M José Moya Jiménez
- Unidad de Gestión Clínica de Cirugía Infantil, Hospital Universitario Virgen del Rocío, Sevilla, España
| | - María Rubio Murillo
- Unidad de Gestión Clínica de Pediatría, Unidad de Digestivo Infantil, Hospital Universitario Virgen del Rocío, Sevilla, España
| | - Sebastián Roldán Pérez
- Unidad de Gestión Clínica de Cirugía Infantil, Hospital Universitario Virgen del Rocío, Sevilla, España
| | - Alejandro Rodríguez Martínez
- Unidad de Gestión Clínica de Pediatría, Unidad de Digestivo Infantil, Hospital Universitario Virgen del Rocío, Sevilla, España
| | - Justo Valverde Fernández
- Unidad de Gestión Clínica de Pediatría, Unidad de Digestivo Infantil, Hospital Universitario Virgen del Rocío, Sevilla, España
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Lai D, Liu X, Ma W. [Case of neck-originated abnormal sensation of throat]. Zhongguo Zhen Jiu 2016; 36:475. [PMID: 27509604] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
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Pien GW, Keenan BT, Marcus CL, Staley B, Ratcliffe SJ, Jackson NJ, Wieland W, Sun Y, Schwab RJ. An Examination of Methodological Paradigms for Calculating Upper Airway Critical Pressures during Sleep. Sleep 2016; 39:977-87. [PMID: 26951393 PMCID: PMC4835319 DOI: 10.5665/sleep.5736] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2015] [Accepted: 01/18/2016] [Indexed: 11/03/2022] Open
Abstract
STUDY OBJECTIVES The goal of this study was to examine different paradigms for determining critical closing pressures (Pcrit). Methods of determining Pcrit were compared, including direct observation of occluded (no flow) breaths versus inferring Pcrit from extrapolated data, and Pcrit generated by aggregating pressure-flow data from multiple runs versus Pcrit averaged across individual pressure-flow runs. The relationship between Pcrit and obstructive sleep apnea (OSA) was examined. METHODS A total of 351 participants with and without OSA underwent overnight polysomnography with pressure-flow measurements to determine Pcrit. A series of filters were applied to raw data to provide consistent, objective criteria for determining which data to include in Pcrit calculations. Observed Pcrit values were computed as the mean nasal pressure level at which a subject had at least two breaths with peak inspiratory flow < 50 mL/sec. Extrapolated Pcrit was calculated in two ways: (1) separately for each individual run and then averaged; and (2) using all valid data from individual runs combined into one plot. RESULTS Observed Pcrit was calculated in 67% to 69% of participants, a similar or higher proportion of study subjects compared to extrapolated Pcrit values using a ± 3 cm H2O filter. Although raw (unfiltered) extrapolated Pcrit measures were able to be calculated among a greater proportion of participants than filtered, extrapolated Pcrit values, and thus had fewer missing values, they had larger variability. Both extrapolated and observed Pcrit were higher among individuals with OSA compared to those without OSA. CONCLUSIONS Observed Pcrit provides a reliable descriptor of hypotonic upper airway collapsibility. Different methods for determining Pcrit were able to distinguish subjects with and without OSA.
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Affiliation(s)
- Grace W. Pien
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Brendan T. Keenan
- Center for Sleep and Circadian Neurobiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Carole L. Marcus
- Center for Sleep and Circadian Neurobiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
- Sleep Center, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Bethany Staley
- Center for Sleep and Circadian Neurobiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Sarah J. Ratcliffe
- Department of Biostatistics and Epidemiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Nicholas J. Jackson
- Department of Medicine Statistics Core, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - William Wieland
- Center for Sleep and Circadian Neurobiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Yi Sun
- Center for Sleep and Circadian Neurobiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Richard J. Schwab
- Center for Sleep and Circadian Neurobiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
- Sleep Medicine Division and Pulmonary and Critical Care Division, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
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Kendall KA, Ellerston J, Heller A, Houtz DR, Zhang C, Presson AP. Objective Measures of Swallowing Function Applied to the Dysphagia Population: A One Year Experience. Dysphagia 2016; 31:538-46. [PMID: 27106909 DOI: 10.1007/s00455-016-9711-0] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2015] [Accepted: 04/10/2016] [Indexed: 11/25/2022]
Abstract
Quantitative, reliable measures of swallowing physiology can be made from an modified barium swallowing study. These quantitative measures have not been previously employed to study large dysphagic patient populations. The present retrospective study of 139 consecutive patients with dysphagia seen in a university tertiary voice and swallowing clinic sought to use objective measures of swallowing physiology to (1) quantify the most prevalent deficits seen in the patient population, (2) identify commonly associated diagnoses and describe the most prevalent swallowing deficits, and (3) determine any correlation between objective deficits and Eating Assessment Tool (EAT-10) scores and body mass index. Poor pharyngeal constriction (34.5 %) and airway protection deficits (65.5 %) were the most common swallowing abnormalities. Reflux-related dysphagia (36 %), nonspecific pharyngeal dysphagia (24 %), Parkinson disease (16 %), esophageal abnormality (13 %), and brain insult (10 %) were the most common diagnoses. Poor pharyngeal constriction was significantly associated with an esophageal motility abnormality (p < 0.001) and central neurologic insult. In general, dysphagia symptoms as determined by the EAT-10 did not correlate with swallowing function abnormalities. This preliminary study indicates that reflux disease is common in patients with dysphagia and that associated esophageal abnormalities are common in dysphagic populations and may be associated with specific pharyngeal swallowing abnormalities. However, symptom scores from the EAT-10 did not correspond to swallowing pathophysiology.
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Affiliation(s)
- Katherine A Kendall
- Voice Disorders Center, University of Utah, Salt Lake City, UT, USA.
- Division of Otolaryngology, Head & Neck Surgery, University of Utah, 50 Medical Drive, SOM Room 3C120, Salt Lake City, UT, 84132, USA.
| | - Julia Ellerston
- Voice Disorders Center, University of Utah, Salt Lake City, UT, USA
| | - Amanda Heller
- Voice Disorders Center, University of Utah, Salt Lake City, UT, USA
- Communication Sciences & Disorders, University of Utah, Salt Lake City, UT, USA
| | - Daniel R Houtz
- Voice Disorders Center, University of Utah, Salt Lake City, UT, USA
| | - Chong Zhang
- Study Design and Biostatistics Center, University of Utah, Salt Lake City, UT, USA
- Division of Epidemiology, Department of Internal Medicine, University of Utah, Salt Lake City, UT, USA
| | - Angela P Presson
- Study Design and Biostatistics Center, University of Utah, Salt Lake City, UT, USA
- Division of Epidemiology, Department of Internal Medicine, University of Utah, Salt Lake City, UT, USA
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Newman R, Vilardell N, Clavé P, Speyer R. 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). Dysphagia 2016; 31:232-49. [PMID: 27016216 PMCID: PMC4929168 DOI: 10.1007/s00455-016-9696-8] [Citation(s) in RCA: 188] [Impact Index Per Article: 23.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2016] [Accepted: 02/09/2016] [Indexed: 02/06/2023]
Abstract
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.
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Affiliation(s)
- Roger Newman
- College of Healthcare Sciences, James Cook University, Townsville, QLD, Australia
- European Society for Swallowing Disorders (ESSD), Carretera de Cirera s/n, 08304, Mataró, Spain
| | - Natàlia Vilardell
- Unitat d'Exploracions Funcionals Digestives, Department of Surgery, Hospital de Mataró, Universitat Autònoma de Barcelona, Mataró, Spain
- European Society for Swallowing Disorders (ESSD), Carretera de Cirera s/n, 08304, Mataró, Spain
| | - Pere Clavé
- College of Healthcare Sciences, James Cook University, Townsville, QLD, Australia.
- Unitat d'Exploracions Funcionals Digestives, Department of Surgery, Hospital de Mataró, Universitat Autònoma de Barcelona, Mataró, Spain.
- Centro de Investigación Biomédica en Red de enfermedades hepáticas y digestivas (CIBERehd), Instituto de Salud Carlos III, Barcelona, Spain.
- European Society for Swallowing Disorders (ESSD), Carretera de Cirera s/n, 08304, Mataró, Spain.
| | - Renée Speyer
- College of Healthcare Sciences, James Cook University, Townsville, QLD, Australia
- Leiden University Medical Centre, Leiden, The Netherlands
- European Society for Swallowing Disorders (ESSD), Carretera de Cirera s/n, 08304, Mataró, Spain
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Abstract
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.
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Affiliation(s)
- Nitin K Ahuja
- Division of Gastroenterology and Hepatology, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Walter W Chan
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, 75 Francis Street, Boston, MA, 02115, USA.
- Harvard Medical School, Boston, MA, USA.
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Liu Y, Wang H. [Nape acupuncture combined with pharynx acupuncture for 32 cases of true bulbar paralysis after cerebral infarction]. Zhongguo Zhen Jiu 2016; 36:129-130. [PMID: 27348906] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
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Abstract
Real-time magnetic resonance imaging (RT-MRI) is being increasingly used for speech and vocal production research studies. Several imaging protocols have emerged based on advances in RT-MRI acquisition, reconstruction, and audio-processing methods. This review summarizes the state-of-the-art, discusses technical considerations, and provides specific guidance for new groups entering this field. We provide recommendations for performing RT-MRI of the upper airway. This is a consensus statement stemming from the ISMRM-endorsed Speech MRI summit held in Los Angeles, February 2014. A major unmet need identified at the summit was the need for consensus on protocols that can be easily adapted by researchers equipped with conventional MRI systems. To this end, we provide a discussion of tradeoffs in RT-MRI in terms of acquisition requirements, a priori assumptions, artifacts, computational load, and performance for different speech tasks. We provide four recommended protocols and identify appropriate acquisition and reconstruction tools. We list pointers to open-source software that facilitate implementation. We conclude by discussing current open challenges in the methodological aspects of RT-MRI of speech.
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Affiliation(s)
| | - Brad P. Sutton
- University of Illinois at Urbana-Champaign, Urbana-Champaign, Illinois, USA
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Tao X, Liu C, Song B. [Review of ear and nose and throat involvement in IgG4-RD]. Lin Chuang Er Bi Yan Hou Tou Jing Wai Ke Za Zhi 2015; 29:2015-2018. [PMID: 26911076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
IgG4-related disease (IgG4-RD) is a newly recognized disease entity. IgG4-RD is characterized by a single or multiple masses in one or more organs; a lymphoplasmacytic infiltrate with a high percentage of plasma cells within the lesion staining for IgG4; a peculiar pattern of fibrosis known as "storiform" fibrosis; and elevated serum IgG4 concentrations. IgG4-RD can occur in various organs, including pancreas, kidneys, lungs, retroperitoneum, and prostate gland. The head and neck involvements of IgG4-RD have been chiefly described in Mikulicz disease (MD), Küttner's tumor, orbital? inflammatory pseudotumor, and idiopathic hypertrophic pachymeningitis (IHP) previously. Recent studies reported that IgG4-RD could also involve ear, nose and throat. Here we reviewed the literatures about ear, nose and throat involvement by IgG4-RD, in order to provide some theoretical bases for the diagnosis and treatment of IgG4-RD.
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Sogawa Y, Kimura S, Harigai T, Sakurai N, Toyosato A, Nishikawa T, Inoue M, Murasawa A, Endo N. New Swallowing Evaluation Using Piezoelectricity in Normal Individuals. Dysphagia 2015; 30:759-67. [PMID: 26487065 DOI: 10.1007/s00455-015-9654-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2014] [Accepted: 10/03/2015] [Indexed: 12/22/2022]
Abstract
This study aimed to elucidate the relationship between the piezoelectric waveform latency, hyoid bone movement, surface electromyogram (sEMG), and the pharyngeal transit time (PTT) during swallowing. Forty-one healthy subjects were divided into three age groups: younger (20-39 years, n = 8), middle-aged (40-59 years, n = 9), and older (60-79 years, n = 24). Motion analysis of the hyoid bone using videofluorography (VF), waveform analysis of the front neck using piezoelectric films, and sEMG of the suprahyoid muscle group were performed simultaneously. Latencies of the three movement phases were defined as upward (VFS1), forward (VFS2), and returning to starting position (VFS3). The three phases of the piezoelectric waveform-from wave initiation of the negative wave to the start of the second deep negative wave; from the start of the second deep negative wave to the start of the last positive wave (SLPW); and from the SLPW to the end of the last positive wave-were defined as PS1, PS2, and PS3, respectively. VFS1-3 and PS1-3 were significantly correlated. VFS1 and PS1 latencies were significantly longer with thick liquid than with thin liquid. VFS2, PS1, and PS2 latencies were longer in the older group than in the other two groups. The start of PS1 was nearly equal to those of sEMG and VFS1. Bolus arrival time in the valleculae was statistically equal to the end of the PS1 with both thin and thick liquids. To establish the swallowing screening using Piezoelectric film, further investigation is necessary in the dysphagia patients.
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Affiliation(s)
- Yuichiro Sogawa
- Rehabilitation Center, Niigata University Medical and Dental Hospital, 1-754, Asahimachi-Dori, Chuo-ku, Niigata-Shi, 951-8520, Japan
| | - Shinji Kimura
- Rehabilitation Center, Niigata University Medical and Dental Hospital, 1-754, Asahimachi-Dori, Chuo-ku, Niigata-Shi, 951-8520, Japan.
| | - Toru Harigai
- Rehabilitation Center, Niigata University Medical and Dental Hospital, 1-754, Asahimachi-Dori, Chuo-ku, Niigata-Shi, 951-8520, Japan
| | - Naoki Sakurai
- Division of Comprehensive Prosthodontics, Department of Tissue Regeneration and Reconstruction, Course for Oral Life Science, Niigata University Graduate School of Medical and Dental Sciences, 2-5274, Gakkocho-dori, Chuo-ku, Niigata-Shi, 951-8514, Japan
| | - Akira Toyosato
- Heart Dental Clinic, 76, Kanabachiyamacho, Sekiya, Chuo-ku, Niigata-Shi, 951-8165, Japan
| | - Taro Nishikawa
- Rehabilitation Center, Niigata University Medical and Dental Hospital, 1-754, Asahimachi-Dori, Chuo-ku, Niigata-Shi, 951-8520, Japan
| | - Makoto Inoue
- Division of Dysphagia Rehabilitation, Niigata University Graduate School of Medical and Dental Sciences, 2-5274, Gakkocho-dori, Chuo-ku, Niigata-Shi, 951-8514, Japan
| | - Akira Murasawa
- Department of Rehabilitation Medicine, Niigata Rheumatic Center, 1-2-8, Honcho, Shibata-Shi, 957-0054, Japan
| | - Naoto Endo
- Rehabilitation Center, Niigata University Medical and Dental Hospital, 1-754, Asahimachi-Dori, Chuo-ku, Niigata-Shi, 951-8520, Japan
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Gu Y, Qian W. [Analysis of the characteristic of pharyngeal paraesthesia patients by high resolution manometry]. Lin Chuang Er Bi Yan Hou Tou Jing Wai Ke Za Zhi 2015; 29:1553-1555. [PMID: 26647543] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
OBJECTIVE To discuss the pressure changing characteristics of upper esophageal sphincter (UES), lower esophageal sphincter (LES) and the esophagus kinetic characteristics of pharyngeal paraesthesia patients. METHOD To take high resolution manometry in 44 cases of pharyngeal paraesthesia patients and 23 normal subjects separately. According to the RSI score,the 44 patients were divided into group A (the group without reflux, RSI < 13, n = 25) and group B (the group with reflux, RSI ≥ 13, n = 19). RESULT The UES average resting pressure and average residual pressure of patients group were higher than the control group (P < 0.05); The UES average resting pressure and average residual pressure of group B were higher than group A (P < 0.05); The LES average resting pressure and average residual pressure of group B were lower than group A and the control group (P < 0.05); The comparison of LES average resting pressure and average residual pressure between group A and the control group was not statistically significant (P > 0.05). The esophagus DCI of group B was lower than that of group A and control group (P < 0.05). The esophagus DCI comparison between group A and control group was not statistically significant (P > 0.05). CONCLUSION The pharyngeal paresthesia symptoms of'patients was associated with the increasing of UES pressure. The pharyngeal paresthesia symptoms of group with reflux was related to low pressure of LES and high pressure of UES. The last part of esophagus of group with reflux had obstacles in powers, which weaken the peristalsis and declined the ability to clear the bolus and gastric reflux material.
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Wang Z, Chen Y, Guo T. [Analyses of the characteristics of esophageal motility in patients with pharyngeal paraesthesia who visit the Department of gastroenterology]. Zhonghua Er Bi Yan Hou Tou Jing Wai Ke Za Zhi 2015; 50:569-572. [PMID: 26695980] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
OBJECTIVE To investigate the influence of the local sensory abnormality in throat while the change of motility in the upper esophageal sphincter (UES) and lower esophageal sphincter (LES), as well as the change of esophageal body in pharyngeal paraesthesia. METHODS From January 2014 to January 2015 there were sixty-four patients who had pharyngeal susceptible syndrome (PSS) but without confirmed organic disease were enrolled as the PSS group, forty healthy volunteers as the control group. High resolution manometry (HRM) was utilized to distinguish esophageal motility patterns of PSS, including the muscular tension of LES and UES, the integrity, adaptability, amplitude, speed and duration of esophageal peristalsis at 10 swallows. RESULTS The resting LES and UES pressures and the distal contractile integral (DCI) of esophagus in PSS group were lower than that in control group (P < 0.05). The esophageal peristalsis was decelerated and shortened in duration, and amplitude of contraction notably lower in PSS group compared with its counterpart (P < 0.05). The integrity of esophageal peristalsis was impaired in PSS with remarkable changes in motility patterns, involving ratio of major and minor interrupts, and synchronous contraction rate (P < 0.05). As for the time course from relaxation to the lowest pressure point of UES and time for restoration, no definite difference was noticed between the two groups (P > 0.05). The average peak pressure was similar in two groups (P > 0.05). CONCLUSIONS Muscle tension around the UES has no obvious change when pharyngeal paraesthesia occurred, but the reduction of esophageal motor function, clearance ability, anti-reflux gastroesophageal junction, causing the abnormal reflux which hurt the pharyngeal surface mucosa maybe one of the most important reasons leading to pharyngeal paresthesia.
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Affiliation(s)
- Zhenjiang Wang
- Department of Gastroenterology, Zhuhai People's Hospital, Zhuhai 519000, China
| | - Yuping Chen
- Department of Gastroenterology, Zhuhai People's Hospital, Zhuhai 519000, China;
| | - Tingting Guo
- Department of Gastroenterology, Zhuhai People's Hospital, Zhuhai 519000, China
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Davidson Ward SL, Amin R, Arens R, Davis S, Gutmark E, Superfine R, Wong B, Zdanski C, Khoo MCK. Pediatric sleep-related breathing disorders: advances in imaging and computational modeling. IEEE Pulse 2015; 5:33-9. [PMID: 25437473 DOI: 10.1109/mpul.2014.2339293] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
We understand now that sleep of sufficient length and quality is required for good health. This is particularly true for infants and children, who have the added physiologic task of growth and development, as compared to their adult counterparts. Sleep-related breathing disorders (SRBDs) are common in childhood and if unrecognized and not treated can result in significant morbidity. For example, children with obstructive sleep apnea (OSA) can exhibit behavioral, mood, and learning difficulties. If left untreated, alterations in the function of the autonomic nervous system and a chronic inflammatory state result, contributing to the risk of heart disease, stroke, glucose intolerance, and hypertension in adulthood.
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Abstract
Sleep disordered breathing in children ranges from snoring, which has a prevalence of 12%, to obstructive sleep apnea (OSA) syndrome, which has a prevalence of 2?3% in the general population [1]. The underlying causes of pediatric OSA are extremely complex. There are bony structural influences, as seen in craniofacial abnormalities, and soft tissue abnormalities, such as a large tongue, redundant soft tissue, or compliance/collapsibility issues. In some groups, such as those with Down syndrome, a combination of these factors comes into play.
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Xu H, Yu H, Jia R, Gao Z, Huang W, Peng H. [The preliminary study of the origin characters of snore in simple snorers]. Lin Chuang Er Bi Yan Hou Tou Jing Wai Ke Za Zhi 2015; 29:977-983. [PMID: 26536696] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
OBJECTIVE to investigate the origin characters of snore in simple snorers and provide the basis for its treatment. METHOD Thirty-two simple snorers diagnosed by polysomnography were induced to sleep by propofol and dexmedetomidine, then we observed the vibration sites, pattern and concomitant collapse of soft tissue in pharyngeal cavity by nasendoscopy. RESULT Thirteen cases showed palatal fluttering only, and 1 case showed vibration of epiglottis only. Six cases showed palatal fluttering with vibration of epiglottis, and 2 cases showed palatal fluttering with vibration of epiglottis and tongue base. Five cases showed palatal fluttering with vibration of pharyngeal lateral wall, and 5 cases showed palatal fluttering with vibration of lateral wall, epiglottis and tongue base together. Palate and pharyngeal lateral wall vibrated strongly and always collapsed with vibrating, but epiglottis and tongue base usually vibrated slightly and seldom collapsed. CONCLUSION The palatal fluttering is the main source of snoring sounds for most simple snorers, then followed by vibration of palatal and pharyngeal lateral wall together. The site of collapse in pharyngeal cavity is consistent with the main site of vibration.
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