Pressure topography metrics for high-resolution pharyngeal-esophageal manofluorography-a normative study of younger and older adults.

BACKGROUND: We aimed to define normative values for novel pressure topography metrics for high-resolution pharyngeal-esophageal manofluorography. The effects of age, gender, and bolus properties were examined. METHODS: Concurrent high-resolution manometry (HRM) and videofluoroscopy data were collected from 22 younger (aged 21-40) and 22 older (aged 60-80) healthy subjects. Pressure topography was analyzed by correlating pressure domains with videofluoroscopic events. Nine pressure topography metrics of the pharyngeal and proximal esophageal swallow were extracted; four of these were also compared with previously obtained esophageal HRM studies to assess the effects of catheter diameter. KEY RESULTS: Older individuals exhibited more vigorous contractility in the pharynx than did younger subjects with all bolus types, but the greatest values for both groups were with effortful swallow and on that measure the age groups were similar. Upper esophageal sphincter (UES) intrabolus pressure during sphincter opening was also greater in the older subjects. Some gender differences were observed, particularly related to proximal esophageal contractile vigor. Bolus consistency had no consistent effect. Studies using the larger catheter diameter resulted in significantly greater contractile vigor in the UES and proximal esophagus. CONCLUSIONS & INFERENCES: Older adults exhibited more vigorous pharyngeal contractions than young adults, albeit within a similar range of capacity, perhaps reflecting a compensatory response to other age-related physiological changes. Greater UES intrabolus pressures observed during bolus transit in the older group likely reflect reduced UES compliance with age. Normative data on novel HRM metrics collected in this study can serve as a reference for future clinical studies.

Aging effects on oropharyngeal swallow and the role of dental care in oropharyngeal dysphagia.

Difficulty with oropharyngeal swallow requires careful diagnosis and treatment from a team of professionals including the patients' physicians and the speech-language pathologist specializing in dysphagia. The dentist can be a critical team member in prevention, early identification, and management of oropharyngeal dysphagia. This manuscript reviews the physiology of normal oropharyngeal swallow and the effects of normal aging on this physiology. Typical etiologies for oropharyngeal dysphagia are defined as is the most commonly used physiologic diagnostic procedure, the modified barium swallow (MBS). The critical role of the dentist in identifying risk of oropharyngeal dysphagia, making appropriate referrals, and improving oral hygiene to prevent aspiration pneumonia in the elderly is discussed.

Oropharyngeal dysphagia: pathophysiology and diagnosis for the anniversary issue of Diseases of the Esophagus.

The oropharyngeal swallow involves a rapid, highly coordinated set of neuromuscular actions beginning with lip closure and terminating with opening of the upper esophageal sphincter. Evaluation of the oropharyngeal swallow usually involves the use of a modified barium swallow radiographic study with the goals of (i) defining the patient's swallow anatomy and physiology causing the dysphagia; and (ii) evaluating the immediate effectiveness of treatment procedures including selected postures, sensory enhancement, swallow maneuvers, and diet changes. Exercise programs may be helpful, but their immediate effects cannot be examined during the initial modified barium swallow. Exercise programs can be evaluated on a second radiographic study 3-4 weeks later. The resultant report should include all of this information. The speech-language pathologist is usually the professional most involved in the evaluation and treatment. Medications and surgery have a very limited role in the treatment of oropharyngeal dysphagia.

Swallowing and voice effects of Lee Silverman Voice Treatment (LSVT): a pilot study.

OBJECTIVE: To define the effects of Lee Silverman Voice Treatment (LSVT on swallowing and voice in eight patients with idiopathic Parkinson's disease. METHODS: Each patient received a modified barium swallow (MBS) in addition to voice recording before and after 1 month of LSVT. Swallowing motility disorders were defined and temporal measures of the swallow were completed from the MBS. Voice evaluation included measures of vocal intensity, fundamental frequency, and the patient's perception of speech change. RESULTS: before LSVT, the most prevalent swallowing motility disorders were oral phase problems including reduced tongue control and strength. Reduced tongue base retraction resulting in residue in the vallecula was the most common disorder in the pharyngeal stage of the swallow. Oral transit time (OTT) and pharyngeal transit time (PTT) were prolonged. After LSVT, there was an overall 51% reduction in the number of swallowing motility disorders. Some temporal measures of swallowing were also significantly reduced as was the approximate amount of oral residue after 3 ml and 5 ml liquid swallows. Voice changes after LSVT included a significant increase in vocal intensity during sustained vowel phonation as well as during reading. CONCLUSIONS: LSVT seemingly improved neuromuscular control of the entire upper aerodigestive tract, improving oral tongue and tongue base function during the oral and pharyngeal phases of swallowing as well as improving vocal intensity.

Bulimia and swallowing: cause for concern.

OBJECTIVE: To determine whether there is evidence of a relationship between bulimia and abnormalities in swallowing function. METHOD: Literature review across a variety of professional areas concerning the physiological effects of bulimia on oropharyngeal swallow structures and function. RESULTS: Investigations of bulimic subjects have identified abnormalities in the oral cavity and oropharynx including dental erosion, changes in taste, tissue manifestations, and potential motility disorders that could impact swallowing function. DISCUSSION: While there is cause for concern regarding the effects of repeated self-induced vomiting behavior in bulimic subjects on swallowing function, more research is needed.

Effects of xerostomia on perception and performance of swallow function.

BACKGROUND: Head and neck cancer treatment with high-dose chemoradiation may cause xerostomia and affect the patient's perception of swallowing ability. METHOD: Whole saliva production was measured in 36 patients with advanced-stage cancer of the oropharynx before treatment and 3 months after treatment by weighing a 4 x 4 inch gauze before and after a 2-minute chewing period. Presence of multiple eating difficulties was measured by patient interview. Swallowing was examined videofluorographically (VFG). RESULTS: Saliva weight decreased from a mean (SEM) of 5.1 (0.5) g pretreatment to 1.4 (0.5) g after treatment (p<.0001). At 3 months, significantly more patients perceived difficulty swallowing, dry mouth, needing water while eating, food stuck in the mouth or throat, and change in taste. Saliva weight was not correlated with VFG measures of bolus transit or observations of residue. CONCLUSIONS: Chemoradiation treatment results in xerostomia and a significant increase in patient perception of swallowing difficulties. Saliva weight in patients who perceive swallowing problems was lower. Xerostomia did not affect the physiologic aspects of bolus transport. Xerostomia affected the sensory process and comfort of eating more than bolus transport.

Ultrasonic quantification of geniohyoid cross-sectional area and tissue composition: a preliminary study of age and radiation effects.

BACKGROUND: This study developed and used a new, noninvasive approach to quantify cross-sectional area and tissue composition within the geniohyoid (GH) muscle in normal adults and head and neck cancer patients. METHODS: B-mode ultrasound was used to measure GH cross-sectional area at rest and during four speech gestures and GH tissue composition at rest in normal young adults, patients with SCC head and neck cancer treated with primary radiotherapy, and normal older adults age matched with the patients. RESULTS: Patients exhibited significantly greater GH cross-sectional area than young subjects at rest and in effortful conditions. Significantly greater muscle tissue variability across GH quadrants was observed in patients compared with normal subjects and in older compared with younger subjects. CONCLUSIONS: B-mode ultrasound area analyses and tissue classification techniques can be used to quantify muscle changes, such as those resulting from age, radiotherapy, or rehabilitation for head and neck cancer.

Conducting clinical trials in a constantly changing health care environment.

Continuous change and cost containment characterize the current health care system, making conduct of clinical trials and other clinical research difficult. Identification, accrual, and follow-up of patients who move between health care environments such as hospitals, nursing homes, schools and the home is particularly challenging. This article describes a circuit rider approach to patient identification and follow-up that was established by the Communication Sciences and Disorders Clinical Trials Research Group. It also gives suggestions for design of clinical trials in a constantly changing environment.

Effects of lingual gestures on blood flow into the tongue: a pilot study.

BACKGROUND: Reduced blood flow has been hypothesized to be a major factor in the formation of postradiation fibrosis. This study examined Doppler ultrasonography as a technique to detect changes in blood flow into the tongue during selected lingual gestures, /t/ and /k/. METHODS: Six normal subjects, three young men (mean age, 26 years) and three older men (mean age, 66 years) were examined in an upright position using Doppler ultrasound imaging of the external carotid artery just below the lingual artery. Measurements were made with a standardized segmentation technique before and after three repetitions of four speech production gestures /t/ and /k/, each with natural and maximal force. RESULTS: Blood flow peak systole increased significantly after the speech gestures (p < .001). Pooled before and after gesture values for older subjects were significantly lower than those for younger subjects (p < or = .05). CONCLUSIONS: Ultrasonography is a clinically useful technique for measuring blood flow during a dynamic gesture and may be useful for measuring effects of tumor treatment and in a lingual exercise program.

Assessment of aspiration in patients with tracheostomies: comparison of the bedside colored dye assessment with videofluoroscopic examination.

BACKGROUND: Aspiration is a serious clinical concern in patients with long-term artificial airways. The purpose of this study was to determine the reliability of a bedside colored dye assessment of aspiration in tracheostomized patients and to determine its comparability to a more sophisticated videofluoroscopic study. METHODS: This was a prospective, blinded comparison study conducted in a large, urban, university teaching hospital. We studied 20 consecutive patients who underwent tracheostomy for bronchial hygiene needs and who were referred for videofluorographic evaluation for suspected oropharyngeal dysphagia and possible aspiration. Excluded were patients unable to follow verbal commands and those requiring mechanical ventilatory support. All patients were brought to the videofluorography suite for colored dye assessment for aspiration and videofluorographic assessment of oropharyngeal swallow. A nurse, blinded to the results of videofluorographic swallow study, performed colored dye assessments for aspiration. Speech-language pathologists, blinded to the results of the colored dye assessments, interpreted simultaneous (preliminary) and subsequent complete (final) videofluorographic evaluations of swallow. RESULTS: The colored dye aspiration assessments and the videofluoroscopic studies were compared for the frequency of aspiration detection. Sensitivity and specificity were determined using standard methods. Seven patients showed no aspiration on either the colored dye test or videofluoroscopic examination. Eight patients were judged to aspirate by videofluorography but not by the colored dye test. Five patients were judged to aspirate by both the colored dye test and videofluorography. The data indicate that the colored dye test for aspiration carries a low sensitivity of 38% (95% confidence interval = +/- 7%), but a high specificity of 100%. The videofluoroscopic study detected a significantly greater frequency of aspiration than did the colored dye test (p < 0.01). CONCLUSIONS: The colored dye test for aspiration can provide useful information when positive, but because there is a significant false negative rate, decisions made on the basis of a negative test must be made with caution.

A critical evaluation of the evidence on the association between type of infant feeding and cognitive development.

This paper presents a critical evaluation of 24 studies on the association between type of infant feeding and cognitive development published over the past 20 years. Validity and generalisability of study findings were assessed according to three methodological standards: clearly defined outcome, specification of partial vs. exclusive breast feeding and control of confounding. Only six of the 24 investigations met all three standards. The most frequent study flaw was failure to distinguish between partial and exclusive breast feeding. Studies which made this distinction found larger IQ advantages to breast-fed infants than studies that did not. Four of the six studies meeting all three standards found an advantage in cognitive development to breast-fed infants of the order of two to five IQ points for term infants and eight points for low birthweight infants. We conclude that the question of whether breast feeding and formula feeding have differential effects on cognitive development has not yet been comprehensively answered. Research to date provides only an indication of the effect of relatively brief durations of partial breast feeding and even briefer durations of exclusive breast feeding. Future studies should measure breast feeding as a continuous dose-type variable, examine longer durations of breast feeding and control for a full range of confounders using techniques that deal appropriately with multicollinearity.

Temporal and biomechanical characteristics of oropharyngeal swallow in younger and older men.

As the U.S. population ages, there is increasing need for data on the effects of aging in healthy elderly individuals over age 80. This investigation compared the swallowing ability of 8 healthy younger men between the ages of 21 and 29 and 8 healthy older men between the ages of 80 and 94 during two swallows each of 1 ml and 10 ml liquid. Videofluoroscopic studies of these swallows were analyzed to confirm the absence of swallowing disorders. Biomechanical analysis of each swallow was completed, from which data on temporal, range of motion, and coordination characteristics of the oropharyngeal swallow were taken. Position of the larynx at rest, length of neck, and pattern of hyoid bone movement were also compared between the two groups. None of the younger or older men exhibited any swallowing disorders. The C2 to C4 distance of older men was significantly shorter than that of younger men, and laryngeal position at rest was lower than in younger men but not significantly so. Older men had a significantly longer pharyngeal delay than younger men and significantly faster onset of posterior pharyngeal wall movement in relation to first cricopharyngeal opening. The older men exhibited significantly reduced maximum vertical and anterior hyoid movement as compared to the younger men even when accounting for the difference in C2 to C4 distance in older men. These data support the hypothesis of reduced muscular reserve in the swallows of older men as compared to younger men. Older men also exhibited less width of cricopharyngeal opening than younger men at 10 ml volume, indicating less upper esophageal sphincter flexibility in the swallows of older men. The potential for exercise to improve reserve is discussed. Significant changes in extent of hyoid elevation and duration of cricopharyngeal opening were seen as liquid bolus volume increased.

Effectiveness of four hours of education in interpretation of radiographic studies.

Clinicians working with oropharyngeal swallowing disorders often use videofluoroscopy to define their patients' swallowing abnormalities. This study examined the effect of 4 hours of training in the identification of head and neck anatomy and oropharyngeal swallowing disorders viewed radiographically. Ninety clinicians participated in a 5-hour session which included 30-minute pre- and post-tests requiring identification of head and neck anatomy and oropharyngeal swallowing disorders and a 4-hour training period. Results showed significant improvement in identification of both radiographic anatomy and swallowing disorders. The change in pre- and post-test measures was negatively correlated with extent of prior experience in dysphagia. Similar studies are needed with clinicians or students inexperienced in dysphagia to define the number of hours of education needed in order for students to reach a desired accuracy level in their identifications.

Pretreatment swallowing function in patients with head and neck cancer.

BACKGROUND: Few objective data characterizing the pretreatment swallow function of patients with head and neck cancer are available. METHODS: Pretreatment swallowing function in 352 patients with various lesions was evaluated with videofluoroscopy and compared with control subjects. RESULTS: Patients had significantly longer oral and pharyngeal transit times, greater amounts of oral and pharyngeal residue, shorter cricopharyngeal opening durations, and lower swallow efficiencies. Swallow function worsened significantly with increased tumor stage, and patients with oral or pharyngeal lesions had worse swallow function than patients with laryngeal lesions. Frequency of complaint of swallow difficulty before treatment was 59%. Patients with lower stage tumors had fewer complaints of swallowing, as did patients with oral cavity lesions. CONCLUSIONS: Despite demonstrating significant differences from control subjects, patients had highly functional swallows before treatment. The tendency for patients not to perceive a swallowing problem is consistent with the highly functional nature of their pretreatment swallow.

The SWAL-QOL outcomes tool for oropharyngeal dysphagia in adults: I. Conceptual foundation and item development.

In the past two decades, noteworthy advances have been made in measuring the physiologic outcomes of dysphagia, including measurement of duration of structure and bolus movements, stasis, and penetration-aspiration. However, there is a paucity of data on health outcomes from the patients' perspective, such as quality of life and patient satisfaction. A patient-based, dysphagia-specific outcomes tool is needed to enhance information on treatment variations and treatment effectiveness. We present the conceptual foundation and item generation process for the SWAL-QOL, a quality of life and quality of care outcomes tool under development for dysphagia researchers and clinicians.

Clinical utility of the modified barium swallow.

The purpose of this investigation was to evaluate the immediate and clinically relevant information gained from the modified barium swallow study and to determine the impact of the procedure on patient management. A database containing a nonrandom sample of 608 swallowing studies was reviewed. Results showed that only 10.4% of the studies were classified as normal examinations and aspiration occurred in 32.4%. However, swallowing abnormality without aspiration was recorded in 57.2% of the studies. Five additional outcome variables were assessed: referrals made to other specialties, effectiveness of applied compensatory strategies, treatment recommendations, mode of intake change, and diet grade change. Nearly 83% of the 608 studies showed change in at least one of the variables: needed referral to a specialist was identified on 26.3%; compensatory strategies that improved swallow physiology were identified on 48.4%; swallowing therapy was recommended on 37.2%; changes in mode of intake occurred on 31.4%; and diet texture changes were recommended on 43.8%. The low percentage of normal studies coupled with the high percentage of change in measurable variables indicate high clinical utility for the modified barium swallow study. The misguided tendency to refer to the modified barium study only as a tool for identifying aspiration and the appropriate utilization of the examination for identification of underlying abnormality in swallowing physiology are explained.

Effects of three techniques on maximum posterior movement of the tongue base.

Effects of three techniques designed to improve maximum range of posterior movement of the base of tongue were investigated under videofluoroscopy in 20 subjects. Retraction of the tongue base during 3-ml pudding swallows, tongue pull-back, yawn, and gargle tasks was measured in millimeters, with the second cervical vertebra as a reference point and was judged subjectively as well. The gargle task was the most successful in eliciting most tongue base retraction for the group of subjects, although not in every subject. Gargle also resulted in greater tongue base movement than swallow more often than the other two voluntary tasks. Clinicians' subjective judgment of "most" retracted tongue base position was generally reliable in comparison with actual measurements. The number of repeat swallows on each bolus correlated significantly with the approximate percentage of residue in the valleculae as judged clinically.

Tumor size and pretreatment speech and swallowing in patients with resectable tumors.

The pretreatment relationship of tumor burden to speech and swallowing function in 230 patients with oral or oropharyngeal cancer before surgery was assessed. Reduced articulation, reduced conversational understandability, or self-reported dysphagia were present in at least 34% of patients before treatment. Videofluoroscopy showed at least 9% of patients had reduced swallowing efficiency on liquid, paste, or cookie boluses. By use of regression techniques, the percentages of the oral tongue and of the anterior floor of mouth affected by neoplasm were found to be significantly related to reduced articulation; T stage and the percentage of the oral tongue affected with tumor were mildly related to reduced understandability; tumor volume and having soft palate affected by neoplasm were significantly related to self-reported dysphagia; and percentages of affected oral tongue and of affected tongue base were significantly related to reduced swallowing efficiency. Tumor burden may contribute to functional deficits at diagnosis in patients who have resectable tumors.

Pneumonia in stroke patients: a retrospective study.

This is a retrospective study of 378 consecutive stroke patients who were referred between June 1994 and June 1997 for videofluorographic study of oropharyngeal swallow. Patients who had radiation therapy, brain tumor, brain surgery, head and/or spinal cord trauma, oral-pharyngeal disease or surgery, or other neurologic diseases in addition to the stroke were excluded from the study. Patients were assigned to two groups: one with pneumonia and one without pneumonia. One hundred one patients were included in the pneumonia group, and 277 patients were included in the nonpneumonia group. Within the pneumonia group, patients were assigned to an acute pneumonia group (pneumonia within 6 months poststroke) and a chronic pneumonia group (pneumonia more than 6 months poststroke). Variables examined in the study included patients' medical history and the findings from the videofluorographic studies. Pearson chi-square analysis was used to identify those variables that were significantly different between the pneumonia and nonpneumonia patient groups and between the acute and chronic pneumonia groups. Results showed that stroke patients who developed pneumonia had a significantly higher incidence of multiple-location and unspecified lesion strokes, chronic airway disease in their medical history, and aspiration during the videofluorographic studies when compared with patients who did not develop pneumonia. Within the pneumonia group, the acute pneumonia group was found to have a significantly higher incidence of hypertension and diabetes in their medical history and a significantly higher incidence of aspiration and reduced laryngeal elevation during the videofluorographic studies. Between 48% and 55% of all stroke patients in the study aspirated. Patients who suffered multiple strokes, brainstem stroke, or subcortical stroke had the greatest frequency of aspiration.