The effect of bilateral superior laryngeal nerve lesion on swallowing: a novel method to quantitate aspirated volume and pharyngeal threshold in videofluoroscopy.

The purpose was to determine the effect of bilateral superior laryngeal nerve (SLN) lesion on swallowing threshold volume and the occurrence of aspiration, using a novel measurement technique for videofluoroscopic swallowing studies (VFSS) in infant pigs. We used a novel radiographic phantom to assess volume of the milk containing barium from fluoroscopy. The custom made phantom was firstly calibrated by comparing image intensity of the phantom with known cylinder depths. Secondly, known volume pouches of milk in a pig cadaver were compared to volumes calculated with the phantom. Using these standards, we calculated the volume of milk in the valleculae, esophagus and larynx, for 205 feeding sequences from four infant pigs feeding before and after had bilateral SLN lesions. Swallow safety was assessed using the tested and validated IMPAS (Dysphagia 28(2):178-187, 2013). The log-linear correlation between image intensity values from the phantom filled with barium milk and the known phantom cylinder depths was strong (R (2) > 0.95), as was the calculated volumes of the barium milk pouches. The threshold volume of bolus in the valleculae during feeding was significantly larger after bilateral SLN lesion than in control swallows (p < 0.001). The IMPAS score increased in the lesioned swallows relative to the controls, indicating substantially impaired swallowing (p < 0.001). Bilateral SLN lesion dramatically increased the aspiration incidence and the threshold volume of bolus in valleculae. The use of this phantom permits quantification of the aspirated volume of fluid, allowing for more accurate 3D volume estimation from 2D X-ray in VFSS.

Duration of action of bupivacaine hydrochloride used for palatal sensory nerve block in infant pigs.

Bupivacaine hydrochloride is frequently used in veterinary dental procedures to reduce the amount of general anesthesia needed and to reduce post-procedural pain. The aim of this study was to develop a novel method to test local anesthetic duration in mammals. Six infant pigs were placed under deep/surgical anesthesia with 3 % isoflurane and oxygen while 0.5 ml of 0.5% bupivacaine hydrochloride was injected to block the two greater palatine and the nasopalatine nerves. They were then maintained under light anesthesia with 0.5-1.0% isoflurane. Beginning 15-minutes after the injection, 7 sites in the oral cavity were stimulated using a pointed dental waxing instrument, including 3 sites on the hard palate. The response, or lack of response, to the stimulus was recorded on video and in written record The bupivacaine hydrochloride injections lasted 1 to 3-hours before the animals responded to the sensory stimulation with a reflexive movement This study provides evidence that bupivacaine used to anesthetize the hard palate has a relatively short and variable duration of action far below what is expected based on its pharmacokinetic properties.

Variation in the timing and frequency of sucking and swallowing over an entire feeding session in the infant pig Sus scrofa.

Feeding is a rhythmic behavior that consists of several component cycle types. How the timing of these cycles changes over a complete feeding sequence is not well known. To test the hypothesis that cycle frequency/duration changes as a function of time spent feeding, we examined complete feeding sequences in six infant pigs, using EMG of mylohyoid and thyrohyoid as cycle markers. We measured the instantaneous frequency of sucking and of swallowing cycles in 19 sequences. Each sequence contained three qualitatively distinctive phases of sucking frequency. Phase 1 started with cycles at a very high frequency and quickly dropped to a more constant level with low variation, which characterized phase 2. Phase 3 had a steady level of frequency but was interspersed with a number of high- or low-frequency cycles. Each phase differed from the others in patterns of within-phase variation and among-phase variation. Phase 2 had the least variation, and phase 3 had the largest range of frequencies. The number of sucks per swallow also differed among phases. These patterns, which characterize normative feeding, could indicate a physiologic basis in satiation. In human infant clinical studies, where data collection is often limited, these results indicated the utility of collecting data in different phases. Finally, these results can be used as a template or pattern with which to assess clinically compromised infants.

U.S. dental students' attitudes toward research and science: impact of research experience.

This study aimed to provide a first nationwide assessment of dental students' attitudes toward the importance of research and its integration into the dental curriculum. For this purpose, the American Association for Dental Research National Student Research Group developed an online survey that was distributed to 89 percent of U.S. dental students in May 2012. The survey consisted of twenty-one Likert-type items divided into three groups: importance of research in dentistry, barriers to research involvement, and exposure to research in the dental curriculum. There were 733 responses (3.9 percent response rate), including students in all stages of education representing fifty-eight out of sixty-one dental schools. Age and race/ethnic distributions corresponded with U.S. dental school enrollees. Results showed that 63 percent of respondents had conducted research before matriculation, and of the 34 percent that participated in research during dental school, only 27 percent were newcomers. Respondents strongly agreed that scientific research enabled their progress in dentistry. Inadequate time in the curriculum was an obstacle they perceived to research involvement during dental school. Respondents agreed that dental curricula emphasize evidence-based practices but may be inadequately teaching biostatistics and research methodologies. Students with research experience tended to have stronger positive opinions about the importance of research in dental education. Efforts to foster research in schools have been well received by students, but several issues remain for enriching dental education through greater involvement of students in research.

Swallowing kinematics and airway protection after palatal local anesthesia in infant pigs.

OBJECTIVES/HYPOTHESIS: Abnormal kinematics during swallowing can result in aspiration, which may become life threatening. We tested the role of palatal sensation in the motor control of pharyngeal swallow in infants. STUDY DESIGN: In eight infant pigs, we reduced palatal sensation using local anesthesia (PLA) and measured the impact on swallowing kinematics and airway protection. METHODS: The pigs drank milk containing barium while we simultaneously recorded videofluoroscopy and electromyography from fine wire bipolar electrodes in several hyolaryngeal muscles. We compared these results to control feedings and feedings following palatal saline injections. RESULTS: After PLA, four pigs had extreme jaw movements and abnormal tongue movement uncharacteristic of sucking. For this reason, we evaluated differences between these group B pigs and the others that could suck normally after PLA (group A). In the four group A pigs, after PLA there was less hyoid elevation (P < .001) but normal jaw and tongue movements. In group B, in addition to greater jaw movement (P < .001) there was more anterior and superior tongue movement (P < .001) and a larger range of hyoid movement (P < .001). CONCLUSIONS: The airway was protected in all of the pigs, indicating that these changes allowed successful adaptation to the reduction in palatal sensation. However, the oral and pharyngeal phases of the swallow were functionally linked, and trigeminal sensation influenced the motor control of the pharyngeal swallow. LEVEL OF EVIDENCE: N/A.

Sucking and swallowing rates after palatal anesthesia: an electromyographic study in infant pigs.

Infant mammalian feeding consists of rhythmic suck cycles and reflexive pharyngeal swallows. Although we know how oropharyngeal sensation influences the initiation and frequency of suck and swallow cycles, the role of palatal sensation is unknown. We implanted EMG electrodes into the mylohyoid muscle, a muscle active during suckling, and the thyrohyoid muscle, a muscle active during swallowing, in eight infant pigs. Pigs were then bottle-fed while lateral videofluoroscopy was simultaneously recorded from the electrodes. Two treatments were administered prior to feeding and compared with control feedings: 1) palatal anesthesia (0.5% bupivacaine hydrochloride), and 2) palatal saline. Using the timing of mylohyoid muscle and thyrohyoid muscle activity, we tested for differences between treatment and control feedings for swallowing frequency and suck cycle duration. Following palatal anesthesia, four pigs could not suck and exhibited excessive jaw movement. We categorized the four pigs that could suck after palatal anesthesia as group A, and those who could not as group B. Group A had no significant change in suck cycle duration and a higher swallowing frequency after palatal saline (P = 0.021). Group B had significantly longer suck cycles after palatal anesthesia (P < 0.001) and a slower swallowing frequency (P < 0.001). Swallowing frequency may be a way to predict group membership, since it was different in control feedings between groups (P < 0.001). The qualitative and bimodal group response to palatal anesthesia may reflect a developmental difference. This study demonstrates that palatal sensation is involved in the initiation and frequency of suck and swallow cycles in infant feeding.

The effect of unilateral superior laryngeal nerve lesion on swallowing threshold volume.

OBJECTIVES/HYPOTHESIS: The superior laryngeal nerve (SLN) is the major sensory nerve for the upper larynx. Damage to this nerve impacts successful swallowing. The first aim of the study was to assess the effect of unilateral SLN lesion on the threshold volume sufficient to elicit swallowing in an intact pig model; this volume was defined radiographically as the maximum bolus area visible in lateral view. The second aim was to determine if a difference existed between ipsilateral and contralateral function as a result of unilateral sensory loss, measured as the radiologic density of fluid seen in the valleculae. Finally, we determined whether there was a relationship between the threshold volume and the occurrence of aspiration after a unilateral SLN lesion. STUDY DESIGN: Repeated measures animal study. METHODS: Four female infant pigs underwent unilateral SLN lesion surgery. The maximum vallecular bolus area in lateral view and the relative vallecular density on each side in the dorsoventral view were obtained from videofluoroscopic recordings in both the prelesion control and postlesion experimental states. RESULTS: In lateral view, the lesioned group had a larger maximum bolus area than the control group (P < .001). Although occasional left-right asymmetry in the dorsoventral view was observed, the vallecular densities were, on average, equal on both the left (intact) and right (lesioned) sides (P > .05). A bigger maximum bolus area did not predict aspiration in the lesioned group (P > .05). CONCLUSIONS: Unilateral SLN lesions increased the swallowing threshold volume symmetrically in right and left valleculae, but the increased threshold may not be the main mechanism for the occurrence of aspiration.

Unilateral superior laryngeal nerve lesion in an animal model of dysphagia and its effect on sucking and swallowing.

We tested two hypotheses relating to the sensory deficit that follows a unilateral superior laryngeal nerve (SLN) lesion in an infant animal model. We hypothesized that it would result in (1) a higher incidence of aspiration and (2) temporal changes in sucking and swallowing. We ligated the right-side SLN in six 2-3-week-old female pigs. Using videofluoroscopy, we recorded swallows in the same pre- and post-lesion infant pigs. We analyzed the incidence of aspiration and the duration and latency of suck and swallow cycles. After unilateral SLN lesioning, the incidence of silent aspiration during swallowing increased from 0.7 to 41.5%. The durations of the suck containing the swallow, the suck immediately following the swallow, and the swallow itself were significantly longer in the post-lesion swallows, although the suck prior to the swallow was not different. The interval between the start of the suck containing a swallow and the subsequent epiglottal movement was longer in the post-lesion swallows. The number of sucks between swallows was significantly greater in post-lesion swallows compared to pre-lesion swallows. Unilateral SLN lesion increased the incidence of aspiration and changed the temporal relationships between sucking and swallowing. The longer transit time and the temporal coordinative dysfunction between suck and swallow cycles may contribute to aspiration. These results suggest that swallow dysfunction and silent aspiration are common and potentially overlooked sequelae of unilateral SLN injury. This validated animal model of aspiration has the potential for further dysphagia studies.

Development, reliability, and validation of an infant mammalian penetration-aspiration scale.

A penetration-aspiration scale exists for assessing airway protection in adult videofluoroscopy and fiberoptic endoscopic swallowing studies; however, no such scale exists for animal models. The aim of this study was threefold: (1) develop a penetration-aspiration scale (PAS) for infant mammals, (2) test the scale's intra- and interrater reliabilities, and (3) validate the use of the scale for distinguishing between abnormal and normal animals. After discussion and reviewing many videos, the result was a 7-point infant mammal PAS. Reliability was tested by having five judges score 90 swallows recorded with videofluoroscopy across two time points. In these videos, the frame rate was either 30 or 60 frames per second and the animals were either normal, had a unilateral superior laryngeal nerve (SLN) lesion, or had hard palate local anesthesia. The scale was validated by having one judge score videos of both normal and SLN lesioned pigs and testing the difference using a t test. Raters had a high intrarater reliability [average κ = 0.82, intraclass correlation coefficient (ICC) = 0.92] and high interrater reliability (average κ = 0.68, ICC = 0.66). There was a significant difference in reliability for videos captured at 30 and 60 frames per second for scores of 3 and 7 (P < 0.001). The scale was also validated for distinguishing between normal and abnormal pigs (P < 0.001). Given the increasing number of animal studies using videofluoroscopy to study dysphagia, this scale provides a valid and reliable measure of airway protection during swallowing in infant pigs that will give these animal models increased translational significance.

Regional variation in geniohyoid muscle strain during suckling in the infant pig.

The geniohyoid muscle (GH) is a critical suprahyoid muscle in most mammalian oropharyngeal motor activities. We used sonomicrometry to evaluate regional strain (i.e., changes in length) in the muscle origin, belly, and insertion during suckling in infant pigs, and compared the results to existing information on strain heterogeneity in the hyoid musculature. We tested the hypothesis that during rhythmic activity, the GH shows regional variation in muscle strain. We used sonomicrometry transducer pairs to divide the muscle into three regions from anterior to posterior. The results showed differences in strain among the regions within a feeding cycle; however, no region consistently shortened or lengthened over the course of a cycle. Moreover, regional strain patterns were not correlated with timing of the suck cycles, neither (1) relative to a swallow cycle (before or after) nor (2) to the time in feeding sequence (early or late). We also found a tight relationship between muscle activity and muscle strain, however, the relative timing of muscle activity and muscle strain was different in some muscle regions and between individuals. A dissection of the C1 innervations of the geniohyoid showed that there are between one and three branches entering the muscle, possibly explaining the variation seen in regional activity and strain. In combination, our findings suggest that regional heterogeneity in muscle strain during patterned suckling behavior functions to stabilize the hyoid bone, whereas the predictable regional strain differences in reflexive behaviors may be necessary for faster and higher amplitude movements of the hyoid bone.