Swallowing dysfunction in myotonic dystrophy: a retrospective study of symptomatology and radiographic findings

BACKGROUND

Swallowing dysfunction is a common symptom of myotonic dystrophy, but it is poorly documented in large patient series. This retrospective study was designed to investigate the presence of swallowing symptoms in a large study population and to describe a specific pattern of clinical and radiographic abnormalities.

METHODS

A retrospective analysis was made of 169 files of patients with confirmed MD. Neuromuscular assessment was made by means of a standardised neurological examination; clinical swallowing symptoms were listed, and video-fluoroscopic images were analysed.

RESULTS

More than half the patients reported swallowing complaints. The major symptoms were frequent choking, difficult pharyngeal transport and piecemeal deglutition. The pharyngeal phase of swallowing was most frequently compromised. This was shown radiographicaly in reduced pharyngeal peristalsis, hypopharyngeal stasis and fragmented swallowing. Aspiration was seen in half of the patients, mostly during swallowing. A typical 'hung position' of the hyoid was also seen. Different onset types of MD seem to be accompanied by comparable subjective complaints and radiographic symptoms.

CONCLUSIONS

Pharyngeal transport was most affected in this patient population. Muscular weakness seems to be the major contributor to swallowing impairment in MD. Swallowing abnormalities may be present even if patients report only a few symptoms and even if the severity of the disease is not pronounced.

Automatische Impedantie Manometrie (AIM): objectieve diagnostiek van oro-faryngale dysfagie

AUTOMATED IMPEDANCE MANOMETRY (AIM): OBJECTIVE DIAGNOSIS OF OROPHARYNGEAL DYSPHAGIA: This review article aims to demonstrate the clinical potential of Automated Impedance Manometry (AIM) as a new, non-radiological technique for screening and diagnosis of oro-pharyngeal dysphagia. An integrated - rather than separate - analysis of pressure and impedance patterns generated in the pharynx when swallowing a food bolus, can be a useful complement to the radiological investigations considered as gold standard today. Major advantages are the objective nature of this technique and the fully automated calculation of various swallow parameters. A global measure of swallowing function can be derived (a Swallow Risk Index, SRI) and is related to (the severity of) the risk of aspiration and the presence of pharyngeal post-swallow residue. It was shown that aspiration on videofluoroscopy was accurately detected by using AIM with a sensitivity of 0.88 and a specificity of 0.96. AIM analysis can be performed quickly and is reliable in the hands of different end users. Various parameters are sufficiently sensitive to detect changes in bolus consistency and - as was recently found - are influenced by swallowing manoeuvers. Furthermore, different patterns of deviant swallow parameters can be found in different patient populations. Whether this observation can provide specific diagnoses and - as a consequence - more targeted treatments is currently under investigation.

Underlying neurological dysfunction in children with language, speech or learning difficulties and a verbal IQ--performance IQ discrepancy

INTRODUCTION AND AIM

We investigated the relationship between possible underlying neurological dysfunction and a significant discrepancy between verbal IQ/performance IQ (VIQ-PIQ) in children with language, speech or learning difficulties.

METHODS

In a retrospective study, we analysed data obtained from intelligence testing and neurological evaluation in 49 children with a significant VIQ-PIQ discrepancy (> or = 25 points) who were referred because of language, speech or learning difficulties to the Multidisciplinary University Centre for Logopedics and Audiology (MUCLA) of the University Hospitals of Leuven, Belgium.

RESULTS

The group of children broke down into a group of 35 children with PIQ > VIQ and a group of 14 children with VIQ > PIQ. In the first group, neurological data were present for 24 children. The neurological history and clinical neurological examination were normal in all cases. Brain MRI was performed in 15 cases and proved to be normal in all children. Brain activity was assessed with long-term video EEG monitoring in ten children. In two children, the EEG results were abnormal: there was an epileptic focus in one child and a manifest alteration in the EEG typical of Landau-Kleffner syndrome in the other. In the second group of 14 children whose VIQ was higher than the PIQ, neurological data were available for ten children. Neurological history and clinical neurological examination were normal in all cases. Brain MRI was performed in five cases and was normal in all children. EEG monitoring was performed in one child. This revealed benign childhood epilepsy with centrotemporal spikes.

CONCLUSIONS

In a small number of children (9%) with speech, language and learning difficulties and a discrepancy between VIQ and PIQ, an underlying neurological abnormality is present. We recommend referring children with a significant VIQ-PIQ mismatch to a paediatric neurologist. As an epileptic disorder seems to be the most common underlying neurological pathology in this specific group of children, EEG monitoring should be recommended in these children. Neuro-imaging should only be used in selected patients.

[Multidisciplinary approach to patients with persistent swallowing problems; the first experiences, 1996/'02 in Louvain]

OBJECTIVE

To inventory the experiences of a multidisciplinary team for the treatment of patients with chronic swallowing problems.

DESIGN

Descriptive, retrospective.

METHOD

Data were collected on the cause, treatment and course in 400 consecutive ambulatory patients who had had swallowing problems for at least several months. During the period from 1 October 1996 to 30 April 2002 they had been referred to a multidisciplinary team consisting of a radiologist, an otorhinolaryngologist, a thoracic surgeon, a logopaedician, a neurologist and an internist-geriatrician in the University Hospitals of the Catholic University of Louvain (Belgium).

RESULTS

The group of 4oo patients consisted of 236 men and 164 women, one-third of whom were 70 years of age or older. Half of the patients had problems swallowing solid food and more than 10% were unable to take any food by mouth. Most of the underlying conditions were neurological. The most commonly prescribed treatments were adjustments to the diet and posture (41%) and logopaedic guidance (36%). The safety and comfort of swallowing were improved in 44% of the patients, 13% were able to feed themselves orally once more after the intervention and in 11% there was still an indication for a percutaneous endoscopic gastrostomy (PEG) catheter.

Swallowing and functional outcome after partial laryngectomy: a literature review

There is a wide range of partial surgical resections for the treatment of laryngeal tumours. In addition to good cure rates, the main aim is to preserve a competent and functional larynx. Functional outcomes have proven to have a substantial effect on postoperative quality of life and are usually included in clinical studies. This article reviews reported functional outcomes after partial laryngectomies, particularly when related to swallowing. In the majority of patients, reports indicate acceptable feeding without the presence of a permanent tracheostomy. However, a wide variety of methods and variables are used to describe these functional outcomes, making the comparison of functional outcome after different treatment modalities and resections difficult. More objective evaluation procedures are needed for swallowing to reveal the exact pathophysiology, spontaneous progression and prognostic factors after well-defined laryngeal resections.

Results of larynx preservation surgery for advanced laryngeal cancer through tracheal autotransplantation

OBJECTIVE

To evaluate the use of tracheal autotransplantation for reconstruction of the hemilaryngectomy defect that includes the hemicricoid cartilage and results from resection of laryngeal or hypopharyngeal cancer.

DESIGN

The clinical records of 28 patients undergoing primary or salvage hemicrico-hemilaryngectomy for laryngeal (26 patients) and pyriform sinus (2 patients) cancer were analyzed for function and local control.

SETTING

Academic center.

PATIENTS

Case series review of 28 consecutive patients treated during a 3(1/2)-year period who had an average follow-up period of 19 months.

INTERVENTION

Twenty-five men and 3 women, aged from 28 to 79 years, underwent a hemilaryngectomy that included the hemicricoid cartilage, the ipsilateral thyroid lobe, and a unilateral or bilateral lymph node dissection. In 26 patients, these extensive defects were reconstructed with a tracheal autotransplantation that restored the larynx at the glottic and subglottic levels. In 2 patients, the defect was converted into a total laryngectomy because of tumor extension beyond the resection margins of a hemicrico-hemilaryngectomy.

MAIN OUTCOME MEASURES

The times to decannulation and retake of full oral feeding, the quality of speech, and the incidence and site of recurrent cancer were assessed.

RESULTS

Of the 26 patients undergoing tracheal autotransplantation, 24 were decannulated and all regained the ability to maintain nutrition by mouth. Ultimate voice quality was "subnormal" to "moderately hoarse" in all patients. Five recurrences developed of which 2 were treated with total laryngectomy.

CONCLUSIONS

Functional reconstruction of extensive laryngeal defects can be achieved with an autotransplantation of cervical trachea, with favorable functional results and acceptable morbidity. This technique expands the limits of conservation surgery for selected laryngeal and hypopharyngeal tumors.

Tracheal autotransplantation: a reliable reconstructive technique for extended hemilaryngectomy defects

OBJECTIVES

Current surgical treatment for a glottic cancer with significant subglottic extension is a total laryngectomy. The objective of this study was to expand laryngeal conservation procedures by using a reconstructive technique that allows for the repair of hemicricolaryngectomy defects.

STUDY DESIGN

After resection of the ipsilateral thyroid, cricoid, and arytenoid for advanced T3 glottic cancer, the laryngeal defect was reconstructed by means of an autotransplanted segment of trachea in four patients. The reconstruction consisted of a transferable patch that was constructed from a segment of revascularized cervical trachea.

METHODS

During a 14-day period, a 4-cm segment of cervical trachea was wrapped by a free radial forearm fascial flap. In the second stage, the glottic cancer was removed and the cervical trachea was isolated on its fascial blood supply and transformed into a patch that was used to repair the extended hemilaryngectomy defect. Two different patch designs were used. Two patients underwent reconstruction with a patch augmented at the glottic level (group A); two patients underwent reconstruction without glottic augmentation on the patch (group B). Tracheal continuity was restored by an end-to-end reanastomosis. The postreconstruction morphology of the two patch designs was compared with the preoperative laryngeal morphology.

RESULTS

The autotransplantation technique led to complete restoration of the subglottic airway lumen in all four patients. Although the anterior-posterior glottic diameter was reduced by 36% in group A patients and by 43.5% in group B patients, a sufficient glottic airway lumen was obtained. The glottic sphincteric function was restored in both groups.

CONCLUSIONS

Tracheal autotransplantation may be used reliably to repair hemicricolaryngectomy defects. Augmentation of the patch at the level of the glottis is not essential for successful rehabilitation.