An electrophysiological study of the sequential water swallowing.

BACKGROUND: Sequential water swallowing (SWS) was mostly investigated by the videofluoroscopic and endoscopic methods. However some physiological features of SWS was rarely evaluated by neurophysiological techniques. Our aim was to investigate some neural and muscular changes on sequences of SWS using electromyography (EMG) methods. METHODS: Fifty-eight normal adults were investigated. SWS was initiated voluntarily with 50ml and 100ml water volumes from a cup. Submental EMG, respiratory signals, heart rate, and sympathetic skin responses (SSR) were measured during SWS. KEY RESULTS: All parameters were increased significantly during the 100ml SWS. During swallowing apnea period, compensatory respiration cycles occurred in 24% and 48% of participants in the 50ml and 100ml SWS, respectively. Heart rate increased during swallowing apnea. SSR were evoked just before and just after the SWS in more than halves of participants. A foreburst EMG in SM muscles at the initiation of SWS was recorded in 86% of normal participants. Older age was associated with a prolonged duration of the apnea period. CONCLUSIONS: All parameters of the SWS could be recorded numerically and objectively using electrphysiological methods. These are similar to those obtained by videofluoroscopic and similar methods. The foreburst activity of the initiation of SWS may represents preparatory activity from the activation of the fast cortical descending motor pathway. Increasing heart rate and the prolonged apnea urged that older people and patients could be carefully tested for respiratory and cardiac rhythm disorders.

Sympathetic skin responses in adult humans during sequential swallowing.

STUDY AIMS: Autonomic changes, especially those of sympathetic skin responses (SSR), during sequential water swallowing (SWS) have not been systematically investigated. This study aims to electrophysiologically examine these autonomic changes (SSR and heart rate) that occur during 50 ml sequential water swallowing from a cup. MATERIALS AND METHODS: Fifty-eight normal healthy adults were included in the study. Their submental muscle activity, respiratory activity, heart rate changes, and sympathetic skin responses were recorded during 50 ml water swallowing. In addition, we requested subjects to imagine drinking water as they did just before. The same recordings were performed during this imagination period. RESULTS: SSR appeared at the beginning and at the end of SWS in 52% of subjects. A first sympathetic skin response was evoked at the onset of SWS, and a second one appeared 8.6±1.7 seconds after the first one and at the end of swallowing. Similar double SSRs were also obtained during imagination in most investigated subjects (33 out of 35 of selected subjects in a total group of 58 subjects). Swallowing tachycardia was observed during the SWS-associated apnea period, but not during the imagination period. Heart rate significantly increased during the SWS-associated apnea period. CONCLUSION: The first SSR that appeared at the onset of swallowing is likely related to arousal. The appearance of a second response is a novel finding, which is probably related to the activity of subtil corticosubcortical networks. While discrete/single swallows can be used to evoke SSRs, SWS is unlikely to be clinically useful in its current form. In contrast, swallowing tachycardia could be a useful tool to examine dysphagic patients.

Oculopharyngodistal myopathy is a distinct entity: clinical and genetic features of 47 patients.

BACKGROUND: Oculopharyngodistal myopathy (OPDM) has been reported as a rare, adult-onset hereditary muscle disease with putative autosomal dominant and autosomal recessive inheritance. Patients with OPDM present with progressive ocular, pharyngeal, and distal limb muscle involvement. The genetic defect causing OPDM has not been elucidated. METHODS: Clinical and genetic findings of 47 patients from 9 unrelated Turkish families diagnosed with OPDM at the Department of Neurology, Istanbul Faculty of Medicine, between 1982 and 2009 were evaluated. RESULTS: The mean age at onset was around 22 years. Both autosomal dominant and autosomal recessive traits were observed, without any clear difference in clinical phenotype or severity. The most common initial symptom was ptosis, followed by oropharyngeal symptoms and distal weakness, which started after the fifth disease year. Intrafamilial variability of disease phenotype and severity was notable in the largest autosomal dominant family. Atypical presentations, such as absence of limb weakness in long-term follow-up in 9, proximal predominant weakness in 4, and asymmetric ptosis in 3 patients, were observed. Swallowing difficulty was due to oropharyngeal dysphagia with myopathic origin. Serum creatine kinase levels were slightly increased and EMG revealed myopathic pattern with occasional myotonic discharges. Myopathologic findings included rimmed and autophagic vacuoles and chronic myopathic changes. Importantly, a considerable proportion of patients developed respiratory muscle weakness while still ambulant. Linkage to the genetic loci for all known muscular dystrophies, and for distal and myofibrillar myopathies, was excluded in the largest autosomal dominant and autosomal recessive OPDM families. CONCLUSIONS: We suggest that OPDM is a clinically and genetically distinct myopathy.

Selective conservative management of penetrating hollow viscus injuries: a report of three cases.

In this manuscript, we report three cases of penetrating abdominal injury: one with pellet injury, one with pellet injury after a bomb explosion and one with gunshot injury. All three patients were successfully managed nonoperatively. A 30-year-old male was admitted to our trauma and emergency service with a pellet injury. His physical examination revealed multiple pellet injuries in the left upper abdominal quadrant, left hemithorax, left axilla, dorsal side of the abdomen, left upper extremity, and left gluteus. The second case was a 16-year-old male admitted with a shrapnel injury after a bomb explosion. His physical examination revealed multiple shrapnel injuries in the thoracal and abdominal regions, extremities and left eye. The third case was a 30-year-old male admitted with gunshot and stab wound injury. He had multiple stab wound injuries in both lower extremities and a gunshot wound in the left posterosuperior hemithorax, left upper abdomen and left dorsolumbar region. All these cases were treated non-operatively. We advocate a policy of selective conservatism based on careful initial and subsequent serial clinical examinations and imaging techniques as needed.

Identification of distinct swallowing patterns for different bolus volumes.

OBJECTIVE: To investigate the time interval between glottic closure and the opening of upper esophageal sphincter during swallowing, by means of the coupling of electromyographical (EMG) recordings on the thyroarytenoid (TA) and the cricopharyngeus (CP) muscles. METHODS: TA-EMG and CP-EMG pause were recorded by concentric needle electrodes using time-locked delay-line circuitry of the EMG apparatus. EMG data obtained from a total of 273 swallows of saliva, 3, 5, 10 and 15 ml volumes of water, were compared. RESULTS: The relation between the onsets of TA-EMG activity and the CP-EMG pause demonstrated three different patterns of swallows. Pattern A was the delay of the onset of TA-EMG between 50-500 ms, and pattern B was the overlap of its activity with the CP-EMG pause. Pattern C was the earlier occurrence of the TA-EMG 50-550 ms before the CP-EMG pause. Pattern A was the most frequent type of swallows whereas the pattern C appeared during swallowing of larger volumes. CONCLUSIONS: Physiologically, there is a delay of the TA activation after the onset of CP-EMG pause during swallowing of small amounts in healthy subjects. SIGNIFICANCE: This physiological phenomenon could be a potential risk of aspiration in patients with neurogenic dysphagia.

Facial motor cortex plasticity in patients with unilateral peripheral facial paralysis.

Hand motor representation area expands towards the area of the perioral facial motor cortex in patients with peripheral facial paralysis (PFP) and in hemifacial spasm cases treated with botulinum toxin. In this current study, we aimed to investigate the changes both in the ipsilateral and contralateral facial motor cortex areas in patients with PFP with transcranial magnetic stimulation (TMS). Thirty healthy individuals and 41 patients with unilateral PFP with partial or total axonal degeneration participated in this study. Motor evoked potentials (MEPs) of perioral muscles elicited by TMS of the intracranial portion of the facial nerve and motor cortex, were recorded. TMS was delivered through a figure-of-eight coil. Mapping of the cortical representation of perioral muscles were also studied in 13 of 41 patients and in 10 of control subjects. Mean amplitude of the intact perioral MEPs elicited by the ipsilateral hemisphere TMS, was significantly higher in patients than the control subjects. There was also a mild enlargement of the mean cortical representation area of intact perioral muscles on both hemispheres though it was not significant. We have concluded that there was a cortical reorganization in the hemisphere contralateral to the paralytic side resulting in an increase at corticofugal output related to intact perioral muscles.

An EMG screening method (dysphagia limit) for evaluation of neurogenic dysphagia in childhood above 5 years old.

Oropharyngeal dysphagia is not rare in older children before the adult age, especially the patients with cerebral palsy. Non-invasive simple tests are needed for the evaluation of children with neurogenic dysphagia including the patients with cerebral palsy. So we aimed to evaluate non-invasive ways to screen for dysphagia in children and the usefulness of this almost new electrophysiologic method for the detection of dysphagia in children with cerebral palsy. Twenty-eight healthy children and 12 patients with cerebral palsy were investigated for the applicability of this method. The movement of the larynx was monitored using a simple piezoelectric wafer sensor and submental surface EMG activity was recorded by bipolar silver-chloride electrodes taped under the chin over the submental muscle complex. The onset and duration of pharyngeal swallowing was recorded from submental-suprahyoid muscles such as the mylohyoid-genitohyoid-anterior digastric complex. By this method, the maximal water volume capacity was measured in single swallows with progressively increasing water volumes, this was called 'dysphagia limit'. The healthy control children revealed to swallow the bolus at once maximally 11.2+/-0.4 and 2.5 ml in average. Dysphagia limit varied from 7 to above 20 ml water volume from age 5-16 years old. Patients with cerebral palsy had the dysphagia limit of 7.7+/-1.8 and 6.4 ml in average. The dysphagia limit was significantly reduced in patients with cerebral palsy (p<0.05). Dysphagia limit seemed to be less sensitive in demonstrating the oropharyngeal swallowing disorders in childhood period (90% in the adult dysphagic patients). But the majority of patients with cerebral palsy (58%) showed abnormality. This electrophysiologic method is completely non-invasive, devoid from any hazard and applicable to children above 5 years. It may be candidate as a screening test before selection of dysphagic children.

Percutaneous transcatheter embolization in arterial injuries of the lower limbs.

PURPOSE: To evaluate the efficacy and safety of percutaneous transcatheter arterial embolization (PTE) in lower extremity arterial injuries. MATERIAL AND METHODS: From January 2000 to June 2004, patients who presented with a penetrating trauma of the lower limbs, along with bleeding and with no sign of ischemia or hemodynamic instability, were included in the study. The injuries were embolized by coils and Gelfoam. The efficacy of PTE was defined as its ability to stop bleeding both radiographically and clinically, and its safety was determined by the complication rate. RESULTS: There were 10 embolizations, which consisted of 5 profundal femoral, 3 superior gluteal, and 2 inferior gluteal artery embolizations. PTE was effective in all patients. There were two inguinal hematomas, which did not require any intervention, and there was a temporary renal function alteration. The mean hospital stay of these patients was 2.67 +/- 0.91 days. CONCLUSION: PTE may be an effective and safe method of treatment in certain cases with lower limb arterial injuries. However, patients should be selected meticulously by both the vascular surgeon and the interventional radiologist, and PTE should be undertaken only in experienced hands.

Unnecessary laparotomy by using physical examination and different diagnostic modalities for penetrating abdominal stab wounds.

BACKGROUND: The modern management of penetrating abdominal trauma has decreased the incidence of unnecessary laparotomy by using selective non-operative management protocols. However, the real benefits of physical examination and different diagnostic methods are still unclear. METHODS: From January 2000 to April 2003, we prospectively collected data on 117 patients with penetrating stab wounds to the thoracoabdominal, anterior abdominal, and back regions who had non-operative management. Clinical examination was the primary tool to differentiate those patients requiring operation. Findings of physical examination, ultrasound, computed tomography, endoscopy, echocardiography, diagnostic peritoneal lavage, and diagnostic laparoscopy were reviewed. The number of therapeutic, non-therapeutic, and negative laparotomies were recorded. RESULTS: Non-operative management was successful in 79% of patients. There were 11 early (within 8 hours of admission) and 14 delayed (more than 8 hours after admission) laparotomies performed, depending on the results of various diagnostic procedures. Non-operative management failed in 21% of patients, and the rate of non-therapeutic laparotomy in early and delayed laparatomy groups was 9% and 14% respectively. There was no negative laparatomy. CONCLUSIONS: The use of physical examination alone and/or together with different diagnostic methods allows reduction of non-therapeutic laparotomies and elimination of negative laparatomies.

Central and peripheral motor conduction to cremasteric muscle.

The few electrophysiologic studies of the cremasteric muscle (CM) have mainly been restricted to the cremaster reflex with no reference to central and peripheral nerve conduction to the muscle, probably for technical reasons.Twenty-six normal adult male volunteers were studied by transcranial magnetic cortical stimulation (TMS) and stimulation of thoracolumbar roots. The genitofemoral nerve (GFN) was stimulated electrically at the anterior superior iliac spine and a needle electrode was inserted into the CM for conduction studies. The motor latency to the CM from the cortical TMS ranged from 20 to 33 ms among the subjects (25.8 +/- 2.9 ms, mean +/- SD). Magnetic stimulation of the lumbar roots produced a motor response of the CM within 9.6 +/- 1.9 ms (range, 6-15). The central motor conduction time to the CM was 16.5 +/- 2.8 ms (range, 10-21). Stimulation of the GFN produced a compound muscle action potential with a mean value of 6.4 +/- 1.8 (range, 4-10) ms in 23 of the 26 cases. Thus, central motor nerve fibers to the CM motor neurons exist, and there may be a representation area for the CM in the cerebral cortex. The GFN motor conduction time to the CM may have clinical utility, such as in the evaluation of the groin pain due to surgical procedures in the lower abdomen.

Changes in the perioral muscle responses to cortical TMS induced by decrease of sensory input and electrical stimulation to lower facial region.

OBJECTIVE: To determine the changes in the motor cortex due to repetitive electrical stimulation and cutaneous anesthesia in lower facial region. METHODS: A total of 11 subjects participated in the study of repetitive electrical stimulation, and 10 other subjects in the study of lower facial anesthesia. Facial nerve root and face associated cortical MEPs by transcranial magnetic stimulation (eight-shaped coil) were recorded from perioral muscles pre- and post- electrical stimulation and lower facial anesthesia. Cheek near to the corner of the mouth was transcutaneously stimulated by bipolar surface electrode giving repetitive electrical shocks at 5 Hz. Five percent lidocain/prilocain local anesthetic cream was applied to left or right lip-cheek region. RESULTS: There was no significant change in perioral MEP responses after 10-30 min of 5 Hz electrical stimulation. We found a significant increase of amplitude in cortical MEP recordings during lower facial anesthesia especially in cases of cortical magnetic stimulations ipsilateral and contralateral to the anaesthetized side and in perioral recordings contralateral to the anaesthetized side. CONCLUSIONS: The present study demonstrates that topical anesthesia to the lower facial region leads to cortical modulation and fast plastic changes in both hemispheres that are directed to the normal side.

The case of acute appendicitis and appendiceal duplication.

BACKGROUND: Appendiceal anomalies are extremely rare malformations that are usually found in the adult population as an incidental finding during laparotomy performed for other reasons. Abnormal development of the appendix usually takes the form of a double appendix. Accompanying intestinal, genito-urinary or vertebral malformations may be present when appendiceal duplications are detected in childhood. CASE REPORT: Presented herein is a case of perforated double appendix, which causes acute abdomen in a child, without any co-existing pathology. CONCLUSION: Appendiceal anomalies are of great practical importance and a surgeon must bear them in mind during an operation. If he overlooks them, the patient undergoing surgery may experience grave consequences. They also may be a forensic issue in cases when a second explorative laparotomy reveals 'previously removed' vermiform appendix.

Oropharyngeal swallowing in craniocervical dystonia.

OBJECTIVE: To clarify the pathophysiology of dysphagia by electrophysiological methods. METHOD: Electrophysiological methods related to oropharyngeal swallowing were used to investigate 25 patients with cervical dystonia and 25 age matched normal volunteers. RESULTS: Dysphagia was suspected in 36% of patients with cervical dystonia on the basis of clinical assessment. The incidence of dysphagia increased to 72% on electrophysiological evaluation of pharyngeal swallowing. Submental muscle electromyographic (EMG) and laryngeal relocation times were significantly prolonged and the triggering time to swallowing reflex was significantly delayed. Some abnormalities seen in cricopharyngeal sphincter muscle EMG indicated that the striated sphincter muscle is hyperreflexive in some patients. CONCLUSION: Neurogenic dysphagia was more prominent and longer lasting than mechanical dysphagia, which was transient and varied from patient to patient. Although these electrophysiological methods were not suitable for detecting anatomical changes during swallowing, as in videofluoroscopic studies, observations supported the neurogenic cause of dysphagia in patients with any kind of cervical dystonia.

Dieulafoy's lesion of esophagus.

Dieulafoy's lesion is a rare arterial malformation that can cause massive gastrointestinal hemorrhage. The lesion occurs most commonly in the proximal stomach. The esophagus is not a common location for this lesion. We present the case of a 25-year-old woman who was admitted to our emergency unit with the findings of hematemesis and melena. Early upper gastrointestinal endoscopic examination revealed a Dieulafoy's lesion, which was located in the distal esophagus. Endoscopic band ligation stopped the bleeding successfully. The patient was discharged 3 days after the band ligation without any complications. Dieulafoy's lesion may cause severe, life-threatening bleeding. Endoscopic diagnosis can be difficult because of the small size and obscure location of the lesion. An abnormally dilated artery that penetrates through the mucosa constitutes the etiology. Endoscopy plays an important role in the diagnosis and treatment of this pathology. Despite widespread awareness of this entity, it may present a real challenge for the endoscopist due to the small size and hidden location of the lesion. The endoscopic approach to occult gastrointestinal bleeding for the diagnosis of vascular malformations is accepted as a quick and safe diagnostic method.

Diagnostic value of electrical stimulation of lumbosacral roots in lumbar spinal stenosis.

OBJECTIVES: This paper compares the diagnostic sensitivity of two tests in lumbar spinal stenosis (LSS): lumbosacral root stimulation with needle electrodes and needle electromyograph (EMG). MATERIAL AND METHODS: Twenty patients with LSS were assigned to two groups: Patients with 'neurogenic intermittent claudication' (NIC) only (n=11), and patients with 'neurological signs' (n=9). Ten normal subjects were also examined. The effects of direct stimulation of the lumbosacral roots and conventional EMG recorded from important muscles [rectus femoris (RF): L4, tibialis anterior (TA): L5, soleus muscle (SOL): S1], were compared with each other and correlated with their respective clinical findings and radiological images. RESULTS: Needle EMG and nerve conduction study revealed pathology in 15/20 patients, and electrical stimulation of the roots in 17/20 patients. Agreement in radiological findings with electrical stimulation of the roots and EMG was found in 12 patients. The other patients were harmonic with radiological findings either in EMG or in electrical stimulation of the roots. CONCLUSIONS: Electrical root stimulation revealed more abnormalities in patients with LSS in comparison with needle EMG. However, both methods seemed to complement each other to show additional pathology in a given patient.

Peripheral facial palsy and dysfunction of the oropharynx.

The facial nerve contributes to the oropharyngeal phase of deglutition via the buccinator, perioral, digastricus posterior, and stylohyoid muscles. The gustatory and salivatory functions of the facial nerve are also known to contribute to swallowing. The relation between peripheral facial nerve palsy (PFP) and swallowing dysfunction has never been studied systematically. Forty four patients with unilateral Bell's palsy (acute or chronic stages) and 20 normal control subjects were investigated. In 66% of patients with PFP, oropharyngeal swallowing was disturbed as demonstrated electrophysiologically by the patients' dysphagia limit at or below 20 ml of water. In patients with PFP investigated within the first 2 weeks of the palsy, the dysphagia limit normalised during the period of recovery. Normalisation of the dysphagia limit is highly correlated with the recovery of PFP. Thus, subclinical deglutition is very frequent in patients with PFP. The severity of abnormal deglutition increased with the severity of the PFP, especially with the involvement of the perioral and buccinator muscles.

Endoscopic ligation for patients with active bleeding Mallory-Weiss tears.

BACKGROUND: Only a few patients with active nonesophageal variceal upper gastrointestinal bleeding have been treated with endoscopic ligation. To further address this issue, four patients with active bleeding Mallory-Weiss tears who underwent endoscopic band ligation are presented. PATIENTS AND METHODS: Endoscopic ligation was performed in four patients with a median age of 52 years (range, 40-93 years) after a diagnosis of active bleeding Mallory-Weiss tears (MWTs). A 45-year-old man with massive persistent upper gastrointestinal bleeding as a cause of a MWT underwent therapeutical endoscopic band ligation after an unsuccessful endoscopic injection trial. On the contrary, injection therapy should have been performed on a 93-year-old woman with multiple myeloma because of an actively bleeding MWT caused by the fibrotic tissue after an unsuccessful endoscopic ligation trial, although her other actively bleeding MWT lesion had been ligated successfully. RESULTS: After endoscopic ligation, all patients achieved complete hemostasis, and rebleeding did not occur. They were discharged without complications after a control endoscopy. CONCLUSIONS: Endoscopic ligation can be performed easily and without any complications such as perforation or delayed hemorrhage in patients with actively bleeding nonfibrotic MWTs.

[Results of conservative treatment for solid abdominal organ trauma]. / Solid organ yaralanmalarinda konservatif tedavi sonuçlarimiz.

We analyzed 59 cases of intraabdominal solid organ injury treated at the Surgical Emergency Service of Istanbul Medical School between January 1996 and January 2001. Fifty-six of these cases suffered blunt and 3 penetrating trauma. Twenty-three cases had injuries involving the liver, 14 spleen, 5 kidney, 6 liver and spleen, 6 liver and kidney, 6 spleen and kidney and four liver and kidney. In 4 of splenic and 5 of hepatic injuries Grade IV injuries were detected. Among the cases, 21% were Grade I, 45% were Grade II, 19% were Grade III, and 15% were Grade IV. Associated injuries were: head trauma in 34 cases (57.6%--Glasgow Coma Score under 7 in 6 cases), thoracic trauma in 19 cases (32%), pelvic fracture in 6 cases (10%), vertebral compression fracture in 3 cases (5%). One patient with splenic (Grade III) and hepatic (Grade II) injury, and one patient with Grade IV splenic injury required surgery during close follow-up due to hemodynamic instability. Our failure rate for conservative treatment of solid organ injuries is 3.3%. Three patients with polytrauma in the ICU died (5% mortality rate). Conservative management in solid organ injuries is gaining more popularity every day. Our work, and current studies accept physiologic parameters in the follow-up of solid organ injuries. Conservative treatment guided with hemodynamic stability, accounts almost a 98% success rate.