Hyoid movement during swallowing in older patients with dysphagia.

OBJECTIVES: To describe the timing, coordination, and extent of hyoid movement in a population of older adults with dysphagia and to evaluate the effect of hyoid movement on upper esophageal sphincter opening. DESIGN: A retrospective review of dynamic swallow studies performed between January 1996 and December 1999 was done. SUBJECTS: Patients included in the study were 65 years or older, without an obvious medical or surgical cause for their dysphagia. Timing and distance measures of hyoid movement from the patient population were compared with those from 60 younger (range, 18-62 years) and 23 older (range 67-83 years) control subjects without dysphagia using 1-way analysis of variance. Analysis of the effect of hyoid movement on upper esophageal sphincter opening was performed using contingency tables. RESULTS: In an older population with dysphagia, the coordination of swallowing gestures and bolus timing was intact, hyoid elevation was slow, and the duration of maximal hyoid elevation was reduced, but appropriate for the age of the patients. The hyoid bone elevated farther than normal for small bolus sizes, but the patients were unable to maintain this strategy in larger bolus swallows. CONCLUSION: An increased extent of hyoid displacement in older patients with dysphagia may represent a necessary compensation designed to minimize the effect of the short duration of hyoid elevation on the upper esophageal sphincter opening.

Pharyngeal constriction in elderly dysphagic patients compared with young and elderly nondysphagic controls.

This article reports the results of our study to determine the incidence of abnormalities in timing and extent of pharyngeal constriction in an elderly population with complaints of dysphagia. We performed a retrospective analysis of videofluoroscopic studies, i.e.. dynamic swallow studies, that were performed between 1996 and 1999. Included in the study were patients over 65 years old without an obvious medical or surgical cause for their dysphagia complaints. The timing of maximum pharyngeal constriction was measured relative to the onset of bolus pharyngeal transit, relative to the arrival of the bolus at the upper esophageal sphincter, and relative to the exit of the tail of the bolus from the upper esophageal sphincter. The extent of maximum pharyngeal constriction was measured from a lateral view. Patient data were compared with data gathered from young (18-62 years old) nondysphagic controls and with data gathered from elderly (67-83 years old) nondysphagic controls. We found that 73% of the patient population demonstrated incomplete pharyngeal constriction relative to controls, although the timing of pharyngeal constriction remained coordinated relative to the position of the bolus in the pharynx. Poor pharyngeal constriction, suggestive of pharyngeal weakness, contributed to 75% of the cases of aspiration.

Accommodation to changes in bolus viscosity in normal deglutition: a videofluoroscopic study.

Videofluoroscopic swallow studies were performed on 60 normal adult volunteers. Swallowing variables were measured during swallows of a 3-cm3 paste bolus and a 3-mL liquid bolus and were compared to identify changes in swallow gesture displacement and timing, as well as changes in bolus movement timing. The study revealed that some differences measured by videofluoroscopy appear to be the result of the inherent bolus characteristics, while others likely represent changes in swallow gestures needed to accommodate variations in bolus viscosity. The overall timing of pharyngeal transit did not vary between bolus types. Oropharyngeal transit trended toward being faster for a liquid bolus with a concurrent early elevation of the aryepiglottic folds. The hyoid bone elevated at the same time, at the same rate, and to the same extent irrespective of bolus viscosity. During a liquid bolus swallow, the hyoid bone trended toward a more prolonged elevation, corresponding to prolonged pharyngoesophageal sphincter opening. The pharyngoesophageal sphincter, however, opened to a greater extent with a paste bolus.

Swallowing in myotonic muscular dystrophy: a videofluoroscopic study.

OBJECTIVES: (1) To determine how swallow function in patients with myotonic muscular dystrophy (MD) differs from that of healthy controls, (2) to identify the contributors to and predictors of improvement, and (3) to evaluate strategies that facilitate swallowing. DESIGN: Observational. SETTING: University medical center. PARTICIPANTS: Eighteen adults with myotonic MD (age range, 24-58 yr) and 60 healthy adult control subjects (age range, 18-73 yr). INTERVENTIONS: Swallow facilitation strategies. MAIN OUTCOME MEASURES: Between-group comparisons of mean bolus transit times, onsets of swallow gestures, and displacement measures obtained by dynamic lateral view videofluoroscopy. RESULTS: The MD patients' bolus transit times were significantly longer, and onsets of some swallow gestures were significantly delayed. Upper esophageal sphincter opening was prolonged (myotonic MD,.61 +/-.13s; control,.5 +/-.11s). Hyoid displacement was significantly less in men with myotonic MD (1.9 +/-.05 cm) than in male controls (2.4 +/-.68 cm); this difference was not observed between control and myotonic women. Of particular importance was the markedly reduced pharyngeal constriction found in the MD group. CONCLUSIONS: Weakness associated with the disease, as opposed to myotonia, was the most significant contributor to impairment. Persons at risk for aspiration may be identified by a measure of pharyngeal area. Selected strategies to facilitate pharyngeal clearing are worthwhile.

Bolus transit and airway protection coordination in older dysphagic patients.

OBJECTIVES/HYPOTHESIS: The intent of this study was to identify and characterize abnormalities of bolus pharyngeal transit and airway protection in a group of elderly patients with dysphagia. STUDY DESIGN: A retrospective analysis of dynamic videofluoroscopic swallowing studies performed in patients over the age of 65 was carried out. The study was limited to individuals with no obvious medical or surgical cause of dysphagia. METHODS: Pharyngeal bolus transit times were determined and compared with those from 60 young normal control subjects and 23 elderly control subjects. The timing of airway closure was analyzed in terms of bolus position in the pharynx. RESULTS: Prolonged bolus transit times were identified in 61% of patients investigated and 65% of elderly control subjects. Overall, the onset of airway closure was appropriate for the position of the bolus in the pharynx but was slow to achieve completion. Elderly control subjects were found to elevate the larynx early in the swallow. Delayed airway closure was identified as a contributor to aspiration in some dysphagic subjects. CONCLUSIONS: Pharyngeal transit of the bolus may be prolonged in elderly individuals. Swallowing coordination mechanisms appear to be intact in the majority of elderly patients with dysphagia, but gestures may be weak and ineffective. Early laryngeal elevation may be an effective strategy to avoid aspiration.

Timing of swallowing events after single-modality treatment of head and neck carcinomas with radiotherapy.

This paper reports the results of a preliminary study designed to evaluate swallowing function in 20 patients 1 year after successful treatment of head and neck carcinomas with radiotherapy. The timing of swallowing events was evaluated by videofluoroscopy. The mean values for each measure were compared to the normative data from 60 control subjects. The radiotherapy patients demonstrated prolonged pharyngeal bolus transit and a delay of laryngeal closure. Hyoid bone elevation began late relative to the onset of bolus movement. A strong trend toward a delay in hyoid elevation relative to bolus movement was demonstrated. The time required for the hyoid bone to reach maximal elevation did not differ from that in normals, but the hyoid was held in an elevated position for a longer period of time. As a result of changes in hyoid movement, the upper esophageal sphincter tended to open early relative to the arrival of the bolus. In conclusion, changes in deglutition occur after radiotherapy, presumably as an adaptation to changes in tissue compliance.

Structural displacements in normal swallowing: a videofluoroscopic study.

Dynamic videofluoroscopic swallow studies were performed on 60 normal adult volunteers to establish normative data for displacement of upper aerodigestive tract structures during deglutition. Variables evaluated included hyoid bone displacement, larynx-to-hyoid bone approximation, pharyngeal constriction, and the extent of pharyngoesophageal sphincter (PES) opening during liquid swallows of 1, 3, and 20 cc. Results showed direct relationships between bolus size and hyoid displacement, between bolus size and PES opening, and between bolus size and pharyngeal constriction. Only hyoid-to-larynx approximation remained unchanged across bolus sizes. Sex differences were noted for all variables except PES opening. Reliability for most measurement variables was excellent. To our knowledge, normative data for pharyngeal constriction and larynx-to-hyoid approximation have not previously been described.

Timing of events in normal swallowing: a videofluoroscopic study.

Dynamic videofluoroscopic swallow studies were performed on 60 normal adult volunteers to establish normative data for clinically useful timing measures. The relation of swallowing gesture timing to the timing of actual bolus transit was of particular interest because it provides insight into the physiology of larger bolus volume accommodation. Parameters evaluated include the timing of bolus pharyngeal transit, soft palate elevation, aryepiglottic fold elevation and supraglottic closure, arrival of the bolus in the vallecula, hyoid bone displacement onset and duration, arrival of the bolus at the pharyngoesophageal sphincter, maximum pharyngeal constriction, and pharyngoesophageal sphincter opening. These parameters represent events required for normal deglutition, can be used to identify abnormalities in dysphagic patients, and provide a basis for comparison of swallowing performance both within and between patients. In addition, our experience has shown them to be reliably obtained. Other investigators have reported some of the measurements. However, to our knowledge, normative data for timing of aryepiglottic fold elevation, soft palate elevation and closure, and maximum pharyngeal constriction have not been described. Other measures included in the present study may provide alternatives when conventional measures cannot be obtained in selected patients. The relevance and clinical utility of new and alternative measures, in particular, are discussed.

Structural mobility in deglutition after single modality treatment of head and neck carcinomas with radiotherapy.

BACKGROUND: The results of a preliminary study designed to evaluate swallowing function in patients 1 year after successful treatment of head and neck carcinomas with radiotherapy are reported. METHODS: Movement of the velum, hyoid, larynx, tongue base, and posterior pharyngeal wall were objectively assessed by dynamic videofluoroscopy. Mean values of each swallowing parameter measured from the study group were compared with normative data from a group of 60 normal control subjects. The radiotherapy patient group was divided based on the location of the primary tumor in an attempt to correlate the effect of tumor location on swallowing. RESULTS: Hyoid displacement was decreased in radiotherapy patients and the hyoid elevated maximally independent of bolus size, unlike control subjects, in whom hyoid displacement increased with increases in bolus size. Patients with tongue base tumors demonstrated decreased pharyngeal constriction compared with patients with larynx and pharynx/nasopharynx tumors. CONCLUSIONS: A generalized decrease in the mobility of pharyngeal structures is demonstrated after radiotherapy.

Treatment of ventricular dysphonia with botulinum toxin.

Ventricular dysphonia, traditionally known as dysphonia plica ventricularis, is a voicing disorder in which the false vocal folds are used as a vibratory source in addition to or instead of the true vocal folds. Traditional treatment of ventricular dysphonia has been voice therapy, which may be slow to produce results if the false fold activity masks an underlying problem of the true folds, is long standing, or has produced hypertrophy of the supraglottic structures. We present seven cases of ventricular dysphonia treated with botulinum toxin injection into the false vocal folds followed by speech therapy. The addition of botulinum toxin to the treatment regimen speeds recovery of normal voicing and allows immediate evaluation of dynamic true vocal fold function by the treating professional.

Recognition of facial expressions of emotion by persons with mental retardation. A matched comparison study.

Children and adults with mental retardation were tested on their ability to recognize facial expressions of emotion. The sample consisted of 80 children and adults with mental retardation and a control group of 80 nonhandicapped children matched on mental age and gender. Ekman and Friesen's normed photographs of the six basic emotions (anger, disgust, fear, happiness, sadness, and surprise) were used in a recognition task of facial expressions. Subjects were individually read two-sentence stories identifying a specific emotion, presented with a randomized array of the six photographs of the basic facial expressions of emotion, and then asked to select the photograph that depicted the emotion identified in the story. This procedure was repeated with 24 different stories, with each of the six basic emotions being represented four times. Results showed that, as a group, individuals with mental retardation were not as proficient as their mental-age-matched nonhandicapped control subjects at recognizing facial expressions of emotion. Although adults with mild mental retardation were more proficient at this task than those with moderate mental retardation, this finding was not true for children. There was a modest difference between the children with moderate mental retardation and their nonhandicapped matched controls in their ability to recognize facial expression of disgust.

Enhancing the ability of adults with mental retardation to recognize facial expressions of emotion.

The ability to recognize accurately and respond appropriately to facial expressions of emotion is essential for interpersonal interaction. Individuals with mental retardation typically are deficient in these skills. The ability of 7 adults, 1 with severe and 6 with moderate mental retardation, to recognize facial expressions of emotion correctly was assessed. Then, they were taught this skill using a combination of a discrimination training procedure for differentiating facial movements, directed rehearsal, and Ekman and Friesen's "flashing photograph" technique. Their average increase in accuracy over baseline was at least 30% during the course of the training and over 50% during the last 5 days of the training phase. Further, these individuals were able to generalize their skills from posed photographs to videotaped role plays and were able to maintain their enhanced skills during the 8 to 9 months following the termination of training. This is the first study to show that individuals with mental retardation can be taught skills that enhance their ability to recognize facial expressions of emotion.

Recognition of facial expressions of emotion by persons with mental retardation.

A sample of 511 children and adults with mental retardation or borderline intelligence (1 SD below the mean IQ) and children of average intelligence were tested on their ability to recognize the six basic facial expressions of emotion as they are exemplified in Ekman and Friesen's (1975) normed photographs. Each subject was shown four sets of six photographs, one of each emotion. Subjects were read 24 short stories; after each one they were asked to point to the photograph that depicted the emotion described. Children and adults with mental retardation or borderline intelligence were less proficient at identifying facial expressions of emotion than were children of average intelligence. Among individuals with mental retardation or borderline intelligence, recognition of accuracy of facial emotion increased with IQ. Among individuals with average intelligence, recognition accuracy increased with age.

Comparative effects of gentle teaching and visual screening on self-injurious behaviour.

Gentle teaching and visual screening procedures have been used to control severe behaviour problems in persons with mental retardation. An alternating treatments design was used to compare gentle teaching, visual screening and a task-training condition in the reduction of high levels of self-injury of an adult with profound mental retardation. Following baseline, a task-training condition using standard behavioural techniques was implemented to establish the effects of training the subject on age-appropriate tasks. Results showed a modest reduction in self-injury. This was followed by an alternating treatments phase in which visual screening, gentle teaching and no-treatment control conditions were compared. Both procedures were superior to the control condition in reducing self-injury, with visual screening being more effective than gentle teaching. When visual screening was implemented across two and then all three daily conditions, self-injury was further reduced to near-zero levels. Bonding occurred at the same low levels under both treatments, contrary to the predictions of gentle teaching's proponents.

Traumatic intratemporal facial nerve injury: management rationale for preservation of function.

A retrospective review of 29 cases of intratemporal facial nerve injuries included 18 temporal bone fractures, 7 gunshot wounds, and 4 iatrogenic complications. Surgical exploration confirmed involvement of the fallopian canal in the perigeniculate region in 14 longitudinal and 3 transverse or mixed fractures of the petrous pyramid. Gunshot and iatrogenic injuries usually occurred within the tympanic and vertical segments of the facial canal and at the stylomastoid foramen. When hearing is salvageable, the middle fossa approach provides the best access to the perigeniculate region of the facial nerve. In the presence of severe sensorineural hearing loss, the transmastoid-translabyrinthine approach is the most appropriate for total facial nerve exploration. Grade I to III results can be anticipated in timely decompression of lesions caused by edema or intraneural hemorrhage. Undetectable at the time of surgery, stretch and compression injuries with disruption of the endoneural tubules often lead to suboptimal results. Moderate-to-severe dysfunction (Grade IV), with slight weakness and synkinesis, is the outcome to be expected from the use of interpositional grafts.