Videofluoroscopic measures of swallowing in people with stable COPD compared to healthy aging

ABSTRACT Purpose Swallowing impairment is a serious extra-pulmonary manifestation of Chronic Obstructive Pulmonary Disease (COPD). Previous studies suggest that individuals with stable COPD show atypical values for several videofluoroscopy measures of swallowing, compared to healthy adults under age 60. However, it is unclear to what degree these changes are attributable to healthy aging. In this study, we aimed to clarify how swallowing in people with stable COPD differs from age-matched healthy controls. Methods We performed a retrospective analysis of videofluoroscopy data from two previously-collected datasets: a) a sample of 28 adults with stable COPD (18 male); b) a sample of 76 healthy adults, from which 28 adults were selected, matched for sex and age to participants in the COPD cohort. In both prior studies, participants swallowed 20% w/v liquid barium prepared in different consistencies (thin; mildly, moderately, and extremely thick). Blinded duplicate ratings were performed according to a standard procedure, yielding measures of laryngeal vestibule closure (LVC) integrity and timing, swallow timing, upper esophageal sphincter (UES) opening, pharyngeal constriction and pharyngeal residue. Mann-Whitney U tests and odds ratios were performed to determine significant group differences (p<.05). Results Across the consistencies tested, participants with COPD showed significantly shorter durations of LVC, earlier onsets and shorter durations of UES opening, and reduced pharyngeal constriction. No significant differences were seen in other measures. Conclusion These results point to features of swallowing in people with stable COPD that differ from changes seen with healthy aging, and which represent risks for potential aspiration.

Electroacupuncture in the treatment of stroke survivors with oropharyngeal dysphagia / 中华物理医学与康复杂志

Objective:To observe any effect of electroacupuncture applied to the Jialianquan points in treating post-stroke oropharyngeal dysphagia.Methods:Forty-five stroke survivors with oropharyngeal dysphagia were randomly divided into an electroacupuncture group ( n=15), a neuromuscular electrical stimulation group ( n=15) and a control group ( n=15). All groups received 30 minutes of routine swallowing function training 5 times a week for 3 weeks. The electroacupuncture group was additionally provided with 30 minutes of electroacupuncture applied to the Jialianquan (CV23) points, and the neuromuscular electrical stimulation group instead received 30 minutes of neuromuscular electrical stimulation over the bilateral submental muscles. Videofluoroscopic swallowing studies were performed before and after the 3 weeks of treatment. Standardized swallowing assessment was conducted producing functional oral intake scale ratings, modified barium swallow impairment profiles and the penetration-aspiration scale scores. Surface electromyography was also employed to evaluate submental muscle functioning through measuring the swallowing time, average EMG (AEMG) value and peak amplitude. Results:After the treatment, significant improvement was observed in all of the evaluations with both groups, but the average scores were significantly better in the electroacupuncture and neuromuscular electrical stimulation groups compared with the control group and significantly better in the electroacupuncture group than in the neuromuscular electrical stimulation group.Conclusion:Electroacupuncture at the Jialianquan point can significantly improve the swallowing of stroke survivors with oropharyngeal dysphagia. It is more effective than neuromuscular electric stimulation.

Cone beam computed tomography with oral contrast for accurate diagnosis and surgical planning of pharyngeal leakage and fistula: a case series

Abstract Objective: Pharyngocutaneous fistula is one of the severe complications related to head and neck surgeries. Detecting the accurate three-dimensional location of both the fistula and leakage is essential for surgical treatment. Videofluoroscopy is usually used for locating these; however, its imaging is two-dimensional. We evaluated pharyngeal leakage and fistulae using Cone Beam Computed Tomography (CBCT), known for its three-dimensional high spatial resolution imaging, taken in a sitting position, with oral contrast (contrast CBCT). Methods: Pharyngeal leakage and fistulae were evaluated in a total of 31 subjects by sequentially performing videofluoroscopy and contrast CBCT. The detection accuracy of videofluoroscopy and contrast CBCT for leakage and fistula, as well as the ability to determine the extent and depth for surgical planning, were investigated and compared. Results: Videofluoroscopy and contrast CBCT showed suspicious leakage and/or fistula in six and three of the 31 subjects, respectively. Surgical findings revealed the presence of leakage and/or fistula in three of the 31 subjects. The positive predictive values of videofluoroscopy and contrast CBCT were 50% (3/6) and 100% (3/3), respectively. Contrast CBCT provided more precise images, showing the extent and depth of leakage and fistula in three-dimensions. Conclusion: The present study's results indicate the usefulness of contrast CBCT in terms of accurate diagnosis of leakage and fistula, due to its three-dimensional imaging being performed with the patient in a sitting position. Level of evidence: 4.

Hyoid displacement patterns in healthy swallowing

ABSTRACT Objective To describe the patterns of displacement of the hyoid bone in healthy individuals, considering their displacements during swallowing of different consistencies. Methods Two hundred one swallowing videofluoroscopy exams of 67 adult and elderly individuals without swallowing disorders were analyzed. Descriptive analysis was performed to identify and describe the patterns of displacement of the hyoid bone. Results Seven types of displacement of the hyoid bone were found: H1 (horizontal), H2 (short vertical and long horizontal), H3 (vertical and diagonal to upper), H4 (long vertical and short horizontal), H5 (vertical), H6 (diagonal), and H7 (brief). The standards were maintained in different consistencies. The most frequent pattern of displacement was type H2. The distribution of the types of displacement of the hyoid was different among men and women. Conclusion Seven patterns of displacement of the hyoid bone during swallowing of normal adults and older people have been described. The most frequent pattern of displacement was horizontal, with variations in distribution between men and women. The displacement pattern was maintained during the swallowing of the three different consistencies (thin, pasty and solid liquid).

Residue localization and risk for aspiration in partial laryngectomy: the relevance of assertive therapeutic strategies and resources

ABSTRACT Objective: To describe the correlation between the residues, their anatomical location and the presence of laryngotracheal penetration and aspiration in patients after supracricoid laryngectomy undergoing cricohyoidoepiglotopexy reconstruction. Methods: This study included 70 patients treated by supracricoid laryngectomy with cricohyoidoepiglotopexy reconstruction in a referral national cancer hospital. The patients were submitted to swallowing videofluoroscopy, and the findings were classified by the penetration and aspiration scale. The images were described observing the presence or absence of residues and their anatomical location. Results: The prevalence of penetration in this study was 68.6% and aspiration was 34.3%. An association was found between the presence of residue on the tongue (p=0.005), posterior pharyngeal wall (p=0.013), pyriform recesses (p=0.002), valecula (p=0.061), and laryngeal penetration. The residue in the upper esophageal sphincter (p=0.039) was associated with the occurrence of laryngotracheal aspiration. Conclusion: Patients undergoing supracricoid laryngectomy with cricohioidoepiglotopexy reconstruction have food residues in different anatomical regions after swallowing. Penetration was associated with the presence of residues on the base of the tongue and posterior pharyngeal wall. Aspiration was associated with the presence of residues in the upper esophageal sphincter.

Oropharyngeal Dysphagia in Mucopolysaccharidoses: Evidence from Videofluoroscopic Swallowing Study

Abstract Mucopolysaccharidoses (MPS) are rare inborn errors of metabolism, leading to the accumulation of glycosaminoglycans (GAG) in distinct tissues. We investigated oropharyngeal dysphagia using the videofluoroscopic swallowing study (VFSS) in patients with different MPS types. Since there is a lack of studies systematically evaluating this disorder in this population, the use of a standard technique should contribute to better evaluate individuals with MPS. A cross-sectional and observational study enrolling patients followed by an outpatient service for lysosomal diseases at the Genetics Service of the Hospital de Clínicas de Porto Alegre (SGM/HCPA) was conducted. Patients underwent semi-structured interviews, clinical evaluation and VFSS. Nineteen patients were evaluated, including patients with MPS types I (16%), II (42%), IIIb (10%) and IVa (32%). Nearly all patients (95%) presented with oropharyngeal dysphagia in the VFSS. The most frequent findings were impaired chewing during oral phase (94%) and reduced laryngeal elevation in the pharyngeal phase (72%). Oropharyngeal dysphagia constituted a prevalent symptom in the studied cohort regardless of MPS type. Our data reinforces the notion that this disorder should be objectively assessed since it can significantly compromise the nutrition and the hydration of these patients as well as lead to tracheobronchial aspiration, thus resulting in aspiration pneumonia and even death eventually.

Risk factors for pulmonary infection among stroke survivors with dysphagia / 中华物理医学与康复杂志

Objective:To analyze the risk factors for aspiration pneumonia among persons with post-stroke dysphagia.Methods:A total of 105 dysphagic stroke survivors were examined using videofluoroscopy. Those suffering from aspiration pneumonia constituted a pneumonia group, and the others were a non-pneumonia group. Univariate and multivariate logistic regression were conducted using data on nasal feeding, pharyngeal transit time (PTT), pharyngeal remnants, active coughing, diet adjustment and Rosenbek Penetration-aspiration Scale (PAS) scores to analyze the risk factors for aspiration pneumonia.Results:There were 29 in the pneumonia group and 76 in the non-pneumonia group. Significant age differences were observed between the two groups, and also significant differences in the location of the stroke, the course of the disease, the incidence of diabetes mellitus, nasal feeding, active coughing, PAS score, PTT, pharyngeal remnants and diet adjustment. But there were no significant differences in gender, Kubota drinking water grade, the incidence of hypertension or atrial fibrillation, or leukocyte count. Univariate analysis showed that stroke site, age≥65, type 2 diabetes, nasal feeding, active coughing, diet adjustment, a PAS score >6, prolonged PTT and pharyngeal residue were all significant predictors of pneumonia. Multivariate logistic analysis indicated that the incidence of pneumonia was significantly higher in patients with a brainstem or bilateral stroke than among those with unilateral stroke. Patients older than 64, with a PAS score >6, pharyngeal residue or prolonged PTT were at significantly greater risk of coming down with pneumonia, though active coughing was correlated with lower risk.Conclusions:Age >64, bilateral or brainstem stroke, a PAS score >6, prolonged pharyngeal transit time and pharynx remnants are independent risk factors for aspiration pneumonia among dysphagic stroke survivors, while active cough is a protective factor.

Characteristics of the swallowing of cortical stroke survivors with dysphagia and cognitive impairment / 中华物理医学与康复杂志

Objective@#To identify the pathophysiological characteristics of cortical stroke survivors′ swallowing.@*Methods@#Sixty cortical stroke survivors with dysphagia and cognitive impairment were enrolled into the observation group, while another 16 with dysphagia but without cognitive impairment formed the unimpaired control group and 16 healthy counterparts were selected for a normal control group. Each subject was recorded videofluoroscopically while swallowing 5ml of a liquid of medium consistency. The occurrence of refusing to eat, mouth opening difficulty, incomplete oral closure, residue in the oral cavity, residue in the pharyngeal cavity, leakage and aspiration were observed. Each subject′s swallowing time and kinematic parameters were analyzed from the fluoroscopic videos.@*Results@#The incidence of refusing to eat (37.5%) and/or incomplete mouth closure (68.75%) were significantly higher in the observation group than in the other two groups. The incidence of difficulty in opening the mouth (37.5%), residue in the oral cavity (81.25%), residue in the pharyngeal cavity (56.25%), leakage (56.25%) and aspiration (50%) of the observation group were significantly higher in the observation group than among the normal controls, but were not significantly different from those incidences among the group without cognitive impairment. The average oral transit time and soft palate elevation time of the observation group were significantly longer than those of the other two groups. The observation group′s average hyoid movement time was significantly longer than that of the normal control group, but not significantly different from that of the group without cognitive impairment. There were no significant differences among the groups in average upper esophageal sphincter opening time, larynx closure time or the kinematic parameters.@*Conclusions@#Stroke survivors with dysphagia and cognitive impairment present dysphagia characteristic of oral phase swallowing difficulties.

Algoritmo para el manejo de la aspiración pulmonar crónica en pediatría / Algorithm for the management of chronic pulmonary aspiration in pediatrics

La aspiración pulmonar es el pasaje de alimentos, reflujo gastroesofágico y/o saliva a la vía aérea de manera suficiente que ocasione síntomas respiratorios crónicos o recurrentes. Es una ausa importante de neumonía recurrente, enfermedad pulmonar progresiva, bronquiectasias e, incluso, muerte. La aspiración es intermitente y, con frecuencia, ocurre en niños con anomalías médicas subyacentes o síndromes que ocasionan síntomas respiratorios similares a la aspiración pulmonar crónica, por lo que, muchas veces, el diagnóstico de aspiración se demora hasta que haya una lesión pulmonar significativa. Se describen los métodos diagnósticos disponibles y sus limitaciones, y las opciones de tratamiento de la aspiración pulmonar crónica en la población pediátrica.

Pulmonary aspiration is the passage of food, gastroesophageal reflux and/or saliva to the airway in a manner sufficient to cause chronic or recurrent respiratory symptoms. It is an important cause of recurrent pneumonia, progressive lung disease, bronchiectasis and even death.Aspiration is intermittent and often occurs in children with underlying medical conditions or syndromes that cause respiratory symptoms similar to chronic pulmonary aspiration, so diagnosis of aspiration is often delayed until there is a significant lung injury. The available diagnostic methods and their limitations, and treatment options of chronic pulmonary aspiration in the pediatric population are described.

Quantitative relationships among tongue pressure, hyoid composite movement and pharynx phase activity among stroke survivors with dysphagia / 中华物理医学与康复杂志

Objective@#To explore the relationships among tongue pressure, hyoid composite movement and pharynx phase activity among stroke survivors with dysphagia.@*Methods@#Videofluoroscopy was used to observe the swallowing performance of 13 stroke survivors with dysphagia. Their tongue pressure was also measured. Correlations were sought among the tongue pressure, hyoid motion, the pharynx contraction ratio and the duration of upper oesophageal sphincter opening.@*Results@#Tongue pressure was found to be significantly positively correlated with the duration of upper oesophageal sphincter opening. The distance of forward movement of the hyoid and the pharynx contraction ratio were also significantly positively correlated.@*Conclusion@#The tongue muscle and hyoid activity can affect the activity in the pharyngeal phase of swallowing.

Videofluoroscopy for assessing the capsule swallowing capability of stroke survivors / 中华物理医学与康复杂志

Objective@#To explore the value of videofluoroscopy in assessing the capsule swallowing ability of stroke survivors.@*Methods@#Twenty-seven stroke survivors with functional oral intake scale ratings of 4-7 with no aspiration were selected as a patient group, while 16 healthy subjects were chosen as a control group. All swallowed capsules filled with barium sulfate with water while being monitored videofluoroscopically. The success rate of capsule swallowing was recorded along with oral transit time, stage transition time (STT), pharyngeal transition time, the upper esophageal sphincter (UES) opening time, delay time (DT), superior hyoid bone movement, anterior hyoid bone movement and UES opening diameter for each swallowing.@*Results@#The swallowing success ratio was 78.3% in the patient group, significantly lower than in the control group. Swallowing failures manifested as hindered transport and retention of the capsule in the oral or pharyngeal cavity. Significant differences were found in STT and DT between the two groups.@*Conclusion@#Even if eating and swallowing ability recover somewhat after a stroke, survivors still have difficulty swallowing oral medication. Clinical assessment for ability to take oral medication is crucial and videofluoroscopy can be one useful tool.

Videofluoroscopy for assessing the capsule swallowing capability of stroke survivors / 中华物理医学与康复杂志

Objective To explore the value of videofluoroscopy in assessing the capsule swallowing ability of stroke survivors. Methods Twenty-seven stroke survivors with functional oral intake scale ratings of 4-7 with no aspiration were selected as a patient group, while 16 healthy subjects were chosen as a control group. All swallowed capsules filled with barium sulfate with water while being monitored videofluoroscopically. The success rate of capsule swallowing was recorded along with oral transit time, stage transition time ( STT) , pharyngeal transition time, the up-per esophageal sphincter ( UES) opening time, delay time ( DT) , superior hyoid bone movement, anterior hyoid bone movement and UES opening diameter for each swallowing. Results The swallowing success ratio was 78.3％ in the patient group, significantly lower than in the control group. Swallowing failures manifested as hindered transport and retention of the capsule in the oral or pharyngeal cavity. Significant differences were found in STT and DT between the two groups. Conclusion Even if eating and swallowing ability recover somewhat after a stroke, survivors still have difficulty swallowing oral medication. Clinical assessment for ability to take oral medication is crucial and videofluoros-copy can be one useful tool.

Analysis of Obstruction Site in Obstructive Sleep Apnea Patients Based on Videofluoroscopy

BACKGROUND AND OBJECTIVES: Upper airway obstruction can occur at the soft palate, tongue base, or epiglottis among obstructive sleep apnea (OSA) patients. Detection of these obstruction sites is very important for choosing a treatment modality for OSA. The purpose of this study was to evaluate the obstruction site of OSA patients and its association with mouth opening and head position. SUBJECTS AND METHOD: Forty-eight consecutive patients with suspicion of OSA were enrolled and underwent videofluoroscopy to evaluate the obstruction site, as well as polysomnography. Obstruction site, mouth opening, and head position were evaluated on videofluoroscopy, and their association was analyzed. RESULTS: According to the videofluoroscopy, 47 (97.9%) of 48 patients showed an obstruction in the soft palate, while 24 (50.0%) were located in the tongue base and 14 (29.2%) in the epiglottis. Multiple obstructions were observed in many patients. Mean apnea-hypopnea index was higher among patients with tongue base obstruction (42.3±26.7) compared to those without obstruction (26.4±21.2, p=0.058). However, epiglottis obstruction did not influence apnea-hypopnea index. Mouth opening did not show any association with tongue base obstruction (p=0.564), while head flexion was highly associated (p<0.001). CONCLUSION: Half of patients with OSA have tongue base obstruction, which worsens the apnea-hypopnea index. Head flexion is associated with tongue base obstruction, while mouth opening is not.

The effects of electromyographic biofeedback on the swallowing function of stroke survivors with dysphagia / 中华物理医学与康复杂志

Objective To evaluate the effect of intensive electromyographic biofeedback ( EMGBF ) on swallowing and the velocity of hyolaryngeal excursion among stroke survivors with dysphagia. Methods Forty-two stroke survivors with dysphagia were randomly divided into a conventional rehabilitation group ( group A, n=15) , an EMGBF group (group B, n=14) and an intensive EMGBF group (group C, n=13).In addition to routine medica-tions and motor function rehabilitation training, all received 30 minutes of conventional swallowing training once a day, 5 days per week for 4 weeks. Group B additionally received 15 minutes of EMGBF once daily and group C twice daily. Videofluoroscopy was conducted to measure the superior and anterior excursion distances and the movement time of the hyoid bone when swallowing semi-liquid food, and the velocity was calculated. The swallowing dysfunction evaluation and a penetration-aspiration scale ( PAS) were also employed to evaluate the subjects'swallowing function before and after the treatment. Results There were no significant differences among the 3 groups in any of the measurements before the treatment. After the 4 weeks of treatment the average swallowing dysfunction evaluation and PAS scores of all three groups had improved significantly, as had the superior and anterior excursion velocity of the hyoid bone. Compared with group A, the average swallowing dysfunction evaluation and PAS scores of groups B and C had improved significantly more. The average swallowing dysfunction evaluation scores of groups B and C were not sig-nificantly different, but the average anterior and superior excursion velocity of the hyoid bone in group C was signifi-cantly higher than in group B. Conclusion EMGBF therapy has advantages over routine rehabilitation training in improving swallowing function after a stroke and speeding the velocity of the hyoid bone's excursions.

Quantitative relationships among tongue pressure, hyoid composite movement and pharynx phase activity among stroke survivors with dysphagia / 中华物理医学与康复杂志

Objective To explore the relationships among tongue pressure, hyoid composite movement and pharynx phase activity among stroke survivors with dysphagia. Methods Videofluoroscopy was used to observe the swallowing performance of 13 stroke survivors with dysphagia. Their tongue pressure was also measured. Correlations were sought among the tongue pressure, hyoid motion, the pharynx contraction ratio and the duration of upper oesophageal sphincter opening. Results Tongue pressure was found to be significantly positively correlated with the duration of upper oesophageal sphincter opening. The distance of forward movement of the hyoid and the pharynx contraction ratio were also significantly positively correlated. Conclusion The tongue muscle and hyoid activity can affect the activity in the pharyngeal phase of swallowing.

Dysphagia after radiotherapy for nasopharyngeal carcinomaas evaluated with videofluoroscopic swallowing study / 中华物理医学与康复杂志

Objective To evaluate the effect of radiotherapy on the swallowing ability of persons with nasopharyngeal carcinoma (NPC) when swallowing food with different consistencies.Methods Twenty NPC patients were monitored fluoroscopically while swallowing materials with three different consistencies after radiotherapy.The oral transit time,oral residue,pharyngeal residue,penetration-aspiration and cricopharyngeal muscle function were observed.Results There were significant differences in all of the measurements when swallowing the three different foods.There were significant differences in all of the measurements between swallowing paste and liquids,but only in the oral transit time,oral residue and pharyngeal residue between swallowing thin and thick liquids.Conclusions The severity of swallowing dysfunction varies in NPC patients after radiotherapy.Foods with different consistencies have different effects on swallowing ability.Videofluoroscopy can evaluate swallowing objectively and provide an objective basis for food preparation.

Correlação entre funcionalidade bulbar e penetração e/ou aspiração laringotraqueal na doença do neurônio motor / Correlation between bulbar functionality and laryngeal penetration and/or laryngotracheal aspiration on motor neuron disease

RESUMO Objetivo Descrever e correlacionar a funcionalidade bulbar com penetração e aspiração laringotraqueal em distintas consistências de alimento na Doença do Neurônio Motor (DNM). Método Participaram do estudo 18 indivíduos diagnosticados com DNM, independentemente do tipo e tempo da doença. Foi aplicada a escala Amyotrophic Lateral Sclerosis Functional Rating Scale-Revised/BR (ALSFRS-R/BR), sendo analisado apenas o parâmetro bulbar que compreende fala, salivação e deglutição, com pontuação de 0 (incapacidade) a 12 (funcionalidade normal). Realizou-se videofluoroscopia da deglutição com aplicação da Penetration-Aspiration Scale (PAS) descrita por Rosenbek et al. (1996). Realizado Teste de Correlação de Pearson. Resultados Considerando a consistência do alimento, o nível da PAS variou de 1 a 5 na consistência pastosa, de 1 a 4 na líquida espessada e de 1 a 3 na líquida rala, e não houve aspiração laringotraqueal. Para todas as consistências de alimentos, houve correlação negativa entre funcionalidade bulbar e penetração laríngea (pastoso: r=-0,487, p=0,041; líquido espessado: r=-0,442, p=0,076; líquido ralo: r=-0,460, p=0,073), porém somente na consistência pastosa houve diferença estatística significante, ou seja, indivíduos com baixa funcionalidade bulbar apresentaram maior nível de penetração laríngea. Conclusão Houve correlação negativa entre funcionalidade bulbar e penetração laríngea na DNM. Os parâmetros bulbares da escala ALSFRS-R/BR mostraram-se significantes para predizer risco de penetração laringotraqueal na consistência pastosa na DNM.

ABSTRACT Objective Describe and correlate bulbar functionality with laryngeal penetration and/or laryngotracheal aspiration for different food consistencies in Motor Neuron Disease (MND). Methods Study participants were 18 individuals diagnosed with MND regardless of the type and time of onset of disease. The Amyotrophic Lateral Sclerosis Functional Rating Scale - Revised/BR (ALSFRS-R/BR) was applied, and only the bulbar parameter, which includes speech, salivation and swallowing, was analyzed, with scores raging from 0 (disability) to 12 (normal functionality). Swallowing videofluoroscopy was performed using the Penetration-Aspiration Scale (PAS) described by Rosenbek et al. (1996). The Pearson correlation test was used for data analysis. Results According to food consistency, the PAS level ranged from 1 to 5 for puree consistency, 1 to 4 for thickened liquid, and 1 to 3 for liquid, and no laryngotracheal aspiration was observed. Negative correlation between bulbar functionality and laryngeal penetration was observed for all food consistencies (pasty: r=-0.487, p=0.041; thickened liquid: r=-0.442, p=0.076; liquid r=0.460, p=0.073), but statistically significant difference was found only for the puree consistency, that is, individuals with poor bulbar functionality presented higher levels of laryngeal penetration. Conclusion Negative correlation was observed between bulbar functionality and laryngeal penetration in MND. The bulbar parameters of the ALSFRS-R/BR are significant for predicting risk of laryngotracheal aspiration for pasty consistency in MND.

Transfer Dysphagia Due to Focal Dystonia

OBJECTIVE: The inability to propel a bolus of food successfully from the posterior part of the oral cavity to the oropharynx is defined as transfer dysphagia. The present case series describes the varied presentation of transfer dysphagia due to focal dystonia and highlights the importance of early detection by following up on strong suspicions. METHODS: We describe seven cases of transfer dysphagia due to focal dystonia. Transfer dysphagia as a form of focal dystonia may appear as the sole presenting complaint or may present with other forms of focal dystonia. RESULTS: Four out of seven patients had pure transfer dysphagia and had previously been treated for functional dysphagia. A high index of suspicion, barium swallow including videofluoroscopy, associated dystonia in other parts of the body and response to drug therapy with trihexyphenidyl/tetrabenazine helped to confirm the diagnosis. CONCLUSION: Awareness of these clinical presentations among neurologists and non-neurologists can facilitate an early diagnosis and prevent unnecessary investigations.

Dysphagia after brain stem infarction : A quantitative analysis of videofluoroscopic observations / 中华物理医学与康复杂志

Objective To evaluate the characteristics of dysphagia after brain stem infarction,and to determine the mechanism of aspiration.Methods The fluoroscopic videos of 12 dysphagia patients who had suffered brain stem infarction and 10 healthy counterparts were analyzed quantitatively using a digital analysis system.Each participant was requested to twice swallow 5ml of thick liquid.The observations included the oral transit time (OTT),the swallow response time (SRT),the hyoid movement time (HMT),the upper esophageal sphincter opening time (UOT) and the laryngeal closure time (LCT).An 8-point penetration-aspiration scale (PAS) was used to evaluate the severity of aspiration,and the results were correlated with the other 5 quantitative observations.Results The average OTT [(3.091±1.803)s],HMT [(1.498±0.550)s] and LCT [(0.651±0.186)s] of the brain stem infarction patients were all significantly longer than those of the healthy controls.However,no significant differences were found between the patients and the healthy volunteers in terms of SRT or UOT.Aspiration severity was significantly correlated with SRT but not with LCT.Conclusion Dysphagia after brain stem infarction involves both the oral and pharyngeal phases.OTT,HMT and LCT can be used to quantify dysphagia after brain stem infarction,while SRT is a predictor of aspiration.

The effectiveness of the head-turn-plus-chin-down maneuver for eliminating vallecular residue

ABSTRACT Purpose When swallowing efficiency is impaired, residue accumulates in the pharynx. Cued or spontaneous swallows in the head neutral position do not always successfully clear residue. We investigated the impact of a novel maneuver on residue clearance by combining a head turn with the chin down posture. Methods Data were collected from 26 participants who demonstrated persistent vallecular residue after an initial head neutral clearance swallow in videofluoroscopy. Participants were cued to perform a head-turn-plus-chin-down swallow, with the direction of head turn randomized. Pixel-based measures of residue in the vallecular space before and after the maneuver were made on still frame lateral images using ImageJ software. Measures of % full and the Normalized Residue Ratio Scale (NRRS) were extracted. Univariate analyses of variance were used to detect significant reductions in residue. Results On average, pre-maneuver measures showed residue filling 56-73% of the valleculae, depending on stimulus consistency (NRRS scores: 0.2-0.4). More than 80% of pre-swallow measures displayed NRRS ratios > 0.06, a threshold previously linked to increased risk of post-swallow aspiration. Conclusion The head-turn-plus-chin-down maneuver achieved significant reductions in residue for thin and nectar-thick fluids, suggesting that this maneuver can be effective in reducing persistent vallecular residue with these consistencies.