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.

Peri-Treatment Evaluation of Swallowing in Head and Neck Cancer Patients

Head and neck cancer patients are prone to dysphagia and aspiration, which are usually neglected due to treatment of the cancer itself. However, dysphagia and aspiration could cause malnutrition, dehydration, pneumonia, and moreover, have negative impact on the quality of life, morbidity, and mortality. Due to its multifactorial etiology, thorough clinical and instrumental evaluation are necessary. In managing head and neck cancer patients, it has become very important to identify the possibility of dysphagia and aspiration, and to start management as early as possible.

Screening protocol for dysphagia in adults: comparison with videofluoroscopic findings

OBJECTIVES: To compare the videofluoroscopic findings of patients with suspected oropharyngeal dysphagia with the results of a clinical screening protocol. METHODS: A retrospective observational cohort study was conducted on all consecutive patients with suspected oropharyngeal dysphagia between March 2015 and February 2016 who were assigned to receive a videofluoroscopic assessment of swallowing. All patients were first submitted to videofluoroscopy and then to the clinical assessment of swallowing. The clinical assessment was performed within the first 24 hours after videofluoroscopy. The videofluoroscopy results were analyzed regarding penetration/aspiration using an 8-point multidimensional perceptual scale. The accuracy of the clinical protocol was analyzed using the sensitivity, specificity, likelihood ratios and predictive values. RESULTS: The selected sample consisted of 50 patients. The clinical protocol presented a sensitivity of 50% and specificity of 95%, with an accuracy of 88%. "Cough" and "wet-hoarse" vocal quality after/during swallowing were clinical indicators that appeared to correctly identify the presence of penetration/aspiration risk. CONCLUSION: The clinical protocol used in the present study is a simple, rapid and reliable clinical assessment. Despite the absence of a completely satisfactory result, especially in terms of the sensitivity and positive predictive values, we suggest that lower rates of pneumonia can be achieved using a formal dysphagia screening method.

Value of modified Killian′s method in diagnosis of congenital pyriform sinus fistula / 中华耳鼻咽喉头颈外科杂志

Objective@#To investigate the feasibility and significance of modified Killian(MK) method in the clinical diagnosis of congenital pyriform sinus fistula(CPSF) by electronic laryngoscopy.@*Methods@#The following examinations were performed for 30 suspected cases of CPSF, including the traditional electronic laryngoscopy, MK examination(modified Killian position+ head rotation+ the Valsalva maneuver), barium swallow X-ray(BSX) and CT , and a prospective comparison among them were done. Patients were divided into two groups according to their age: young age group(≤14 years old) and older age group (>14 years old). The results of MK examination from the patients were analyzed and the positive diagnostic rates (PDR) between groups were compared by using χ2 tests.@*Results@#Sinuses in 20 of 30 patients were depicted from pyriform sinus in BSX, and the PDR was 66.7%(20/30). The PRD of CT was 83.3%(25/30). The presence of air bubbles around the upper lobe of the thyroid gland or at the inferomedial edge of cricothyroid joints, morphological changes of thyroid grand as well as pseudo-fistula formation on lower neck were detected clearly on CT. Comparing to the traditional electronic laryngoscopy, the effect of exposing piriform fossa fistula by MK examination is significant(χ2=17.05, P<0.05), with the PDR of 13.3%(4/30) and 76.7%(23/30) respectively. Nevertheless, comparing to BSX and CT, there were no statistically significant differences in the effect to diagnose CPSF (χ2=0.31, χ2=0.10 respectively, P>0.05). The PDR of MK in older group is significantly higher than younger group(χ2=6.68, P<0.05).@*Conclusions@#MK examination can clearly reveal the hypopharyngeal anatomical structure and detect the sinus of CPSF .It could be a safe, feasible, convenient and economical method as an application in preoperative diagnosis and follow-up examination of clinical suspected CPSF.

Dysphagia Lusoria: A Case Report

Aberrant right subclavian artery is a rare cause of dysphagia. This is a congenital anomaly with the right subclavian artery originating from the dorsal part of the aortic arch and coursing through the mediastinum between the esophagus and the vertebral column. We report a case of a patient with chronic dysphagia caused by this condition. We further discuss the case with regards to its clinical features and options of management.

Comparative imaging studies of congenital pyriform sinus fistula / 中华放射学杂志

Objective To investigate the image features of congenital pyriform sinus fistula (CPSF). Methods We retrospectively analyzed the clinical features and preoperative images of 80 patients with confirmed diagnosis of CPSF by surgical and pathological outcome in Guangdong general hospital from January 2007 to December 2014. At least one of the following imaging examinations were performed for all the patients, including Barium swallow X-ray (BSX), CT and MRI. Among them, 63 patients were examined with BSX, while 42 patients underwent plain and enhanced CT scans, wherein 40 of them were exanimated shortly after BSX. Thirty-two patients underwent plain and enhanced MRI scans. Patients were divided into two groups according to their age, young age group (≤14 years old) and older age group (>14 years old). Furthermore, they were also grouped based on inflammatory or quiescent stage clinically. The images of BSX, CT, and MRI from the patients were analyzed and the positive diagnostic rates (PDR) between groups were compared by using χ2 tests. Results For the patients examined with BSX, sinuses in 35 of 63 were depicted from pyriform and fistulas in 9 of 63 were depicted from the pyriform. The overall PDR of BSX was 74.6%(47/63),wherein 46.2%(12/26)in young age group , 94.6%(35/37)in older age group, 52.9%(9/17) in inflammatory stage group ,and 82.6%(38/46)in quiescent stage group. The inter-group differences were statistically significant (χ2 were 18.911 and 5.766,both P0.05).Conclusions BSX could be a screening method for suspected cases of CPSF in quiescent stage. However, the PDR could be affected by many factors (age and inflammation). CT and MRI could provide valuable information for diagnosis. An examination combined BSX and CT is preferred to improve the positive detective rate of CPSF.

Adenocarcinoma of gastro-esophageal junction - Case report.

Adenocarcinoma of the gastro-esophageal junction (GEJ) remains a significant clinical problem that is increasing in incidence and is associated with a poor prognosis. The majority of patients present with advanced disease and less than 50% undergo curative treatment. To diagnose GE junction mass with conventional procedure like Barium swallow where endoscopy cannot be performed, CECT is done to access the potential spread of disease.

Analysis of Dysphagia Patterns Using a Modified Barium Swallowing Test Following Treatment of Head and Neck Cancer

PURPOSE: The purposes of this study were to evaluate specific dysphagia patterns and to identify the factors affecting dysphagia, especially aspiration, following treatment of head and neck cancer. MATERIALS AND METHODS: A retrospective analysis of 57 patients was performed. Dysphagia was evaluated using a modified barium swallow (MBS) test. The MBS results were rated on the 8-point penetration-aspiration scale (PAS) and swallowing performance status (SPS) score. RESULTS: Reduced base of the tongue (BOT) retraction (64.9%), reduced laryngeal elevation (57.9%), and cricopharyngeus (CP) dysfunction (47.4%) were found. Reduced BOT retraction was correlated with clinical stage (p=0.011) and treatment modality (p=0.001). Aspiration in 42.1% and penetration in 33.3% of patients were observed. Twenty-four patients had PAS values over 6, implying aspiration. Forty-one patients had a SPS score of more than 3, 25 patients had a score greater than 5, and 13 patients had a SPS score of more than 7. Aspiration was found more often in patients with penetration (p=0.002) and in older patients (p=0.026). In older patients, abnormal swallowing caused aspiration even in those with a SPS score of more than 3, irrespective of stage or treatment, contrary to younger patients. Tube feeders (n=20) exhibited older age (65.0%), dysphagia/aspiration related structures (DARS) primaries (75.0%), higher stage disease (66.7%), and a history of radiotherapy (68.8%). CONCLUSION: Reduced BOT retraction was the most common dysphagia pattern and was correlated with clinical stage and treatment regimens including radiotherapy. Aspiration was more frequent in patients who had penetration and in older patients. In contrast to younger patients, older patients showed greater risk of aspiration even with a single abnormal swallowing irrespective of stage or treatment.

Clinico-pathological Profile of Oesophageal Dysphagia.

Introduction: Dysphagia can cause significant morbidity and mortality, especially in the elderly and the paediatric population. The study was undertaken to determine the clinico-pathological profile of the patients diagnosed with oesophageal dysphagia in a rural tertiary care hospital of India. Methods: This cross sectional, descriptive study was carried out in the ENT Department of Rural Medical College and Pravara Rural Hospital, Loni, Maharashtra. Patients attending the ENT Out Patient Department during 2009 and later diagnosed as cases of oesophageal dysphagia formed the statistical sample. Results: Out of 61 patients, 37 were male and 24 female. Majority of the patients belonged to age group 41-50 years (24.6%), were farmer by occupation (31.1%) and belonged to middle socioeconomic status (34.4%). Pain (throat, retrosternal or epigastric) was the most common (70.5%) presenting complaint. For 39.3% study subjects, the presenting complaint was 3 to 6 months old. Barium swallow study revealed a positive finding in 74.1% (n=40/54) patients, with carcinoma of oesophagus (27.8%) as the most common aetiology, followed by motility disorders and benign strictures. Oesophagoscopy detected lesions in 49 (90.74%) cases and like barium swallow, it also detected carcinoma oesophagus as the most common cause of oesophageal dysphagia. Reflux oesophagitis was the most common form of the oesophagitis and the microbiological examination and culture of samples of 14 patients diagnosed with any form of oesophagitis showed Candida albicans in 21.4%. Conclusion: Dysphagia is a common presenting complaint in the ENT clinic. There is a male preponderance with incidence of malignancy rising with age. Barium swallow may be used as the first line of investigation; however, oesophagoscopy gives a better diagnosis.

Diet Modification Based on Video Fluoroscopic Swallowing Study/Modified Barium Swallow in Dysphagia (review) / 中国康复理论与实践

@#Diet modification is a common and important approach for dysphagia rehabilitation. Categories of foods/liquids, suitable volumes per swallow, and effective methods of posture adjustment can be selected through Video Fluoroscopic Swallowing Study (VFSS)/Modified Barium Swallow (MBS), to determine a safe and valid strategy of diet modification. Diet modification based on VFSS/MBS will ensure eating ability and promote swallowing function in dysphagia patients to the greatest extent.

Diet Modification Based on Video Fluoroscopic Swallowing Study/Modified Barium Swallow in Dysphagia (review) / 中国康复理论与实践

@#Diet modification is a common and important approach for dysphagia rehabilitation. Categories of foods/liquids, suitable volumes per swallow, and effective methods of posture adjustment can be selected through Video Fluoroscopic Swallowing Study (VFSS)/Modified Barium Swallow (MBS), to determine a safe and valid strategy of diet modification. Diet modification based on VFSS/MBS will ensure eating ability and promote swallowing function in dysphagia patients to the greatest extent.

The Safety of Videofluoroscopic Swallowing Study (VFSS)

OBJECTIVE: The risk of barium aspiration has been reported through animal and clinical studies. Although the barium aspiration occurs frequently during videofluoroscopic barium swallowing study (VFSS) that is used in a standard method for diagnosis of dysphagia, there has been no research about the risk of VFSS. METHOD: One hundred VFSS of sixty nine patients were analyzed prospectively. The patients were diagnosed to dysphagia clinically. VFSS findings were classified into 5 groups according to the severity of aspiration. The incidences of complications, such as fever (>38.3oC), leukocytosis (>10,000), dyspnea and abnormality of chest roentgenogram within 24hours after VFSS were determined in each group. Odds ratios of complications after VFSS for severity of their findings were calculated. RESULTS: The complications of VFSS are as follows; five febrile conditions, three leukocytosis and three dyspnea among 100 VFSS cases. Odds ratios for complications were over 1 except for the abnormality of chest roentgenogram, but which was not statistically significant. CONCLUSION: The incidence of complication after VFSS was 5% in dysphagic patients. But the severity of complication was mild and there was no statistical significance between complication and aspiration on VFSS, so VFSS was a relatively safe procedure.

Evaluation of the Swallowing after Supracricoid Partial Laryngectomy with Modified Barium Swallow / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES: Supracricoid partial laryngectomy is popular due to its satisfactory oncological and functional outcomes in selected laryngeal cancers. Their postoperative management is now well codified, but functional failures still persist. The aims of this study were to analyze the deglutition modification induced by these intervention and to plan a better rehabilitation program of swallowing. MATERIALS AND METHOD: For the evaluation of swallowing function, the swallowing analysis was performed by following the videofluoroscopic evaluation using the modified barium swallow (Logemann, 1983) in 14 laryngeal cancer patients. RESULTS: Asymptomatic aspiration was observed in 4 patients (28.6%), especially in patients with the extended procedures (p=0.032) and delayed decannulation (p=0.035). Aspiration was associated with faulty backward tilting of epiglottis and inadequate movement of the base of tongue (p<0.05). CONCLUSIONS: In planning the swallowing rehabilitation program after supracricoid partial laryngectomy, recuperation of proper epiglottic movement, which is promoted by exercise of backward tongue movement, is the most important concern.

The Functional Dysphagia Scale Using Videofluoroscopic Swallowing Study in Stroke Patients

OBJECTIVE: Early detection and identification of the aspiration in stroke patients are essential for the prevention of respiratory complications. The purpose of this study is to develop a simple, easy-to-use, quantifiable functional dysphagia scale for stroke patients using videofluoroscopic swallowing study findings. METHOD: Oral and pharyngeal videofluoroscopic swallowing study findings of a consecutive series of 103 stroke patients were analysed. Items of the functional dysphagia scale were determined by the polychotomous linear logistic regression analysis between videofluoroscopic findings and aspiration. The sensitivity and specificity of the scale, and correlation between the total score of the scale and aspiration grade were measured. RESULTS: The final scale included the following eleven items; The score of lip closure, bolus formation, residue in oral cavity, oral transit time, triggering of pharyngeal swallow, laryngeal elevation and epiglottic closure, nasal penetration, residue in valleculae, coating of pharyngeal wall after swallow, pharyngeal transit time. The sensitivity and specificity of the scale for detecting supraglottic penetration and subglottic aspiration were 81.0%, 70.7% and 78.1%, 77.9% respectively. The total score of the scale was significantly correlated with the severity of aspiration. (Spermann correlation coefficient r=0.58943, p=0.00001). CONCLUSION: We developed functional dysphagia scale using videofluoroscopic swallowing study in stroke patients, which could be used as a simple, easy-to-use, quantifiable method to evaluate the severity of the dysphagia.

Diagnostic value of serologric test for detection of Helicobacter pylori infection

BACKGROUND: Ever since Helicobacter pylori was discovered in 1983 by Warren and Marshall, many studies were conducted resulting in drastic change of the previous concept of gastrointestinal disorders and its treatment. Most people in developing countries are considered to be exposed to the organism at a very early age, being more susceptible to infection. This study was done to find out the diagnostic value of serology antibody test for Helicobacter pylori infection by comparing differences in those checked positive for H. pylori relative to their symptoms and findings on endoscopy, biopsy, and barium swallow. METHODS: Subjects totaling 1240 who visited the Health Promotion Center of a university hospital were surveyed with questionnaire and were performed serology antibody test for H. pylori. 532 subjects underwent endoscopy and biopsy and in 708 subjects barium swallow was performed. All subjects were compared with respect to gastrointestinal symptoms, findings of pathology from the endoscopic and radiologic procedures with their antibody test results and titration. RESULTS: Among 1240 patients, 804 (64.8%) were positive for Helicobacter pylori antibody. There were 449 males (68%), and 355 females (61%), which was statistically significant (p< 0.05).There was no difference in the positive rates of H. pylori according to smoking, drinking, and exercise. Higher prevalence of family history for gastric cancer was shown among those positive for H. pylori (p< 0.01). There was no difference noted in relation to gastric symptoms or past history of gastrointestinal disorders in the two groups. Relative to the gastric symptoms complained by the patients, the findings on endoscopy, biopsy and radiologic study, most of those checked positive for H. pylori were shown to have antibody titers in the range of 20 to 40 units/mL with 83.1% for symptoms, 83.6% for endoscopy, 84.8% for biopsy, 81.7% for barium swallow. CONCLUSION: There was no significant difference among those positive and negative for serology antibody test with respect to gastrointestinal symptoms, findings on endoscopy, biopsy, and barium swallow in this study. But because H. pylori is associated with most of the gastrointestinal pathology, testing H. pylori with serology antibody method can be beneficial and useful for its accuracy in primary care setting where further investigation is not possible.

A Case of Diffuse Idiopathic Skeletal Hyperostosis with Dysphagia / 대한이비인후과학회지

Diffuse idiopathic skeletal hyperostosis (DISH) is an idiopathic, ossifying diathesis characterized by ossification and thickening at the site of attachment of a ligament or tendon to bone. Although DISH generally affects the lumbar spine, any segment of the spine may be involved. When cervical spine is affected, the extensive cervical spine osteophytes may produce dysphagia and laryngeal symptoms such as hoarseness, dysphonia, and dyspnea etc. We report a DISH patient with dysphagia as a presenting complaint. Plain radiographs and modified barium swallow (MBS) study demonstrated narrowing of esophagus due to severe cervical vertebral osteophytes. Anterior cervical decompression relieved dysphagia and restored esophageal function without major complications.

Prognostic Indicators in Dysphagia Recovery

The purpose of the study was to find prognostic indicators of dysphagia recovery after stroke. 26 dysphagic patients with history of aspiration divided into two groups, oral feeding group and persisting aspirating group(c ontinue tube feeding after acute stage of stroke rehabilitation). We evaluated the neurologic locus of stroke lesion. Functional Independence Measure(FIM) score, parameters of the bedside swallowing test and videofluoroscopic modified barium swallow. The neurologic locus of stroke lesion was not correlate with the recovery of aspiration due to stoke. The low FIM score(less than 50), large amount of pharyngeal residue, decreased clearing ability of residue, and delayed pharyngeal transit time(over 3 sec) were bad prognostic indicators of dysphagia recovery. We may use criteria for recommendation of continuous tube feeding especially, Percutaneous Endoscopic Gastrostomy(PEG) in dysphagic patients after stroke.