Weight and Muscle Mass Loss Associated with Acute Disease Can be Reversed with Appropriate Nutrition Therapy and Exercise in a Patient with Amyotrophic Lateral Sclerosisa: A Case Report.

Introduction Nutritional interventions targeting weight loss are useful for the treatment of amyotrophic lateral sclerosis (ALS). However, the changes in body composition after nutritional intervention remain unclear. We herein present a patient with ALS who experienced an increased weight and muscle mass owing to nutritional therapy and physical exercise. Case Presentation An 86-year-old man presented with dysphagia and dysarthria. The patient was diagnosed with bulbar-type ALS. As weight loss progressed, a gastrostomy was performed. After 21 months of disease onset, gastrointestinal bleeding due to a bumper ulcer led to further weight loss (from 40.2 kg to 36.8 kg). The patient experienced difficulty walking and ingesting food orally. Although the total daily energy expenditure (TDEE) was estimated to be 1,122 kcal/day, an intake of 1,500 kcal/day beyond the calculated TDEE was administered. The patient continued to perform daily voluntary exercises in addition to his usual rehabilitation. After 5 months, his weight increased from 36.8 kg to 40.4 kg. Muscle mass increased from 25.1 kg to 30.1 kg, as measured using a multifrequency bioelectrical impedance device. Muscle strength improved from 8.5/10.0 kg to 15.0/18.0 kg in grip strength and from 15.2 kPa to 20.4 kPa in tongue pressure. The patient's physical and swallowing functions also improved. Conclusion In patients with ALS, a decreased body weight and muscle mass due to acute disease may be improved by appropriate nutritional therapy and physical exercise.

Cutoff value of the geniohyoid muscle mass to identify sarcopenic dysphagia by ultrasonography.

PURPOSE: Determining the strength and area of the swallowing muscles is important in patients with sarcopenic dysphagia. Although the normative data on the strength of the swallowing muscles have been reported, those of the area of the geniohyoid muscle are poorly investigated. We investigated the cross-sectional area of the geniohyoid muscle in Japanese subjects without dysphagia using ultrasonography to determine the normative and cut-off values. METHODS: 142 subjects without dysphagia were included. The older group (age ≥ 65 years) included 36 (women 27/men 9) subjects, and the younger group (age ≤ 39 years) included 106 (women 54/men 52) subjects. The cross-sectional area of the geniohyoid muscle was measured by ultrasound. The mean of the younger group-2 standard deviation (SD) was calculated and used as a cut-off value for low swallowing muscle mass. RESULTS: The mean (SD) of the area of the geniohyoid muscle of each group was as follows: older women group 167.2 (32.6) mm2, older men group 193.2 (49.5) mm2, younger women group 247.3 (37.4) mm2, younger men group 313.1 (59.2) mm2. The mean 2SD of the geniohyoid muscle area in the younger women group was 172.5 mm2 and in the younger men group 194.7 mm2. CONCLUSION: We found that the cut-off value of the ultrasonographic cross-sectional area of the geniohyoid muscle was 172.5 mm2 for women and 194.7 mm2 for men. These values could be used as cut-off values for the mass of the geniohyoid muscle to identify patients with sarcopenic dysphagia.

Use of Pinching Nose Maneuver in a Patient With Severe Dysphagia Caused by Pseudobulbar Palsy.

Swallowing disorders resulting from pseudobulbar palsy are characterized by deficiencies in the oral preparatory and oral stages of the swallowing process. In certain cases, obstruction can occur when the tongue base comes into contact with the palate, impeding the intraoral bolus flow into the pharyngeal cavity. In this report, we discuss a case of severe pseudobulbar palsy, in which an intraoral bolus flowed into the pharyngeal cavity with pinching the nose. A 78-year-old man with a history of recurrent cerebral infarction was evaluated. The patient had severe dysphagia and cognitive impairment due to pseudobulbar palsy. A videofluoroscopic examination of swallowing (VF) was conducted while the patient was in a reclined position. In the oral cavity, when the bolus reached the posterior tongue section, the flow was hindered by the functional obstruction caused by the tongue base pressing against the palate. Despite the clinician's instructions to swallow, the patient was unable to comply due to the severity of his cognitive impairment. To alleviate this obstruction, the clinician pinched the patient's nose. This action opened the fauces, facilitating breathing and relieving the functional obstruction. Subsequently, the bolus flowed into the pharyngeal cavity and successfully flowed into the esophagus while swallowing. This maneuver was named the "pinching nose maneuver" (PNM). The PNM, as described here, can serve as a technique to improve the movement of an intraoral bolus into the pharyngeal cavity in patients with cognitive dysfunction.

Sliced Jelly Whole Swallowing Reduces Deglutition Risk: A Novel Feeding Method for Patients with Dysphagia.

Texture modification in the form of gels or jellies is used for patients with dysphagia. For over 20 years, our group has been using gelatin jellies, a type of gel, as a starting diet for patients with dysphagia. Gelatin jellies are served in a small-sliced form and swallowed whole. In sliced jelly whole swallowing (SJWS), sliced gelatin jelly (SGJ) passes through the pharynx in one lump without collapsing. This study aimed to examine the usefulness of SJWS. We analyzed the images of videofluoroscopic swallowing studies performed using the normalized residue ratio scale (NRRSv: vallecula, NRRSp: pyriform sinus), the penetration-aspiration scale (PAS), and pharyngeal transit time (PTT) in 50 patients with dysphagia and compared the results in a prospective study. SJWS had significantly less residue in both NRRSv and NRRSp than in moderately thickened liquid swallowing. No significant differences in PAS scores were found between SGJ and moderately thickened liquid. Additionally, no significant differences in PTT scores were noted between the two. This study demonstrated the usefulness of SJWS in improving swallowing safety in patients with dysphagia. Further studies are needed to evaluate the reproducibility of the test, the comparison of SGJ with other thickened liquids, and the safety of SJWS for different diseases.

Speech-Swallow Dissociation of Velopharyngeal Incompetence with Pseudobulbar Palsy: Evaluation by High-Resolution Manometry.

Patients with pseudobulbar palsy often present with velopharyngeal incompetence. Velopharyngeal incompetence is usually observed during expiratory activities such as speech and/or blowing during laryngoscopy. These patients typically exhibit good velopharyngeal closure during swallowing, which is dissociated from expiratory activities. We named this phenomenon "speech-swallow dissociation" (SSD). SSD on endoscopic findings can help in diagnosing the underlying disease causing dysphagia. This endoscopic finding is qualitative, and the quantitative characteristics of SSD are still unclear. Accordingly, the current study aimed to quantitatively evaluate SSD in patients with pseudobulbar palsy. We evaluated velopharyngeal pressure during swallowing and expiratory activity in 10 healthy subjects and 10 patients with pseudobulbar palsy using high-resolution manometry, and compared the results between the two groups. No significant differences in maximal velopharyngeal contraction pressure (V-Pmax) were observed during dry swallowing between the pseudobulbar palsy group and healthy subjects (190.5 mmHg vs. 173.6 mmHg; P = 0.583). V-Pmax during speech was significantly decreased in the pseudobulbar palsy group (85.4 mmHg vs. 34.5 mmHg; P < 0.001). The degree of dissociation of speech to swallowing in V-Pmax, when compared across groups, exhibited a larger difference in the pseudobulbar palsy group, at 52% versus 80% (P = 0.001). Velopharyngeal pressure during blowing was similar to that during speech. Velopharyngeal closure in patients with pseudobulbar palsy exhibited weaker pressure during speech and blowing compared with swallowing, quantitatively confirming the presence of SSD. Pseudobulbar palsy often presents with SSD, and this finding may be helpful in differentiating the etiology of dysphagia.

A Novel Exercise to Improve Suprahyoid Muscle Area and Intensity as Evaluated by Ultrasonography.

Insufficient suprahyoid muscle strength with poor opening of the upper esophageal sphincter can cause dysphagia. This study investigated whether an exercise of the suprahyoid muscle, named forehead exercise for suprahyoid muscles (FESM, "Enge-Odeko-Taiso" in Japanese), improves the geniohyoid muscle area and intensity using ultrasonography. Sixty-four participants (15 men and 49 women, 82.8 ± 6.0 years) living independently with no symptoms of swallowing difficulties were enrolled. The participants were divided into the FESM and the control group. The FESM is an isometric exercise involving repetitions of looking into the navel as if the chin is pulled back with little neck motion using a hand pushed against the forehead for resistance. This exercise is performed five times in 10 courses a day (total 50 times) for 8 weeks. Participants in the control group did not conduct any exercises. Body mass index, hand grip strength, gait speed, calf circumference, Mini Nutritional Assessment short-form, eating assessment tool, repetitive saliva swallowing test (RSST), and Food Intake LEVEL Scale scores were examined. The ultrasonographic geniohyoid muscle area, intensity, and RSST were investigated before and after the program. In the FESM group, the geniohyoid muscle area increased from 2.24 to 2.52 cm2 (P < 0.05), intensity decreased from 34.6 to 32.0 (P < 0.05), and the median RSST increased from 5 to 6 (P < 0.05) significantly. Conversely, no significant differences were observed in the control group. The FESM was effective to increase the area and decrease the intensity of the geniohyoid muscle and may improve swallowing function.

A Case of a Patient With Spinal Muscular Atrophy With Dysphagia Who Acquired Vacuum Swallowing.

We present a case of acquired vacuum swallowing in a patient with spinal muscular atrophy associated with dysphagia. A 67-year-old male presented with spinal muscular atrophy. Even though he was able to eat orally, he required a long time to eat and faced difficulty while swallowing saliva, resulting in frequent spitting. Instructions regarding vacuum swallowing to eliminate pharyngeal residue were provided, and a reduction in meal duration and improved saliva swallowing were observed. High-resolution manometry revealed a significant increase in pharyngeal contractile integral and a significant decrease in esophageal pressure with vacuum swallowing, which enabled the passage of a bolus through the pharynx compared with non-vacuum swallowing. Furthermore, an increase in the lower esophageal sphincter pressure, reflecting diaphragmatic contraction, was also observed. Therefore, this case report elucidates that a patient with neuromuscular disorders could acquire vacuum swallowing with proper instructions.

Neural substrates of cough control during coughing.

Cough is known as a protective reflex to keep the airway free from harmful substances. Although brain activity during cough was previously examined mainly by functional magnetic resonance imaging (fMRI) with model analysis, this method does not capture real brain activity during cough. To obtain accurate measurements of brain activity during cough, we conducted whole-brain scans during different coughing tasks while correcting for head motion using a restraint-free positron emission tomography (PET) system. Twenty-four healthy right-handed males underwent multiple PET scans with [15O]H2O. Four tasks were performed during scans: "resting"; "voluntary cough (VC)", which simply repeated spontaneous coughing; "induced cough (IC)", where participants coughed in response to an acid stimulus in the cough-inducing method with tartaric acid (CiTA); and "suppressed cough (SC)", where coughing was suppressed against CiTA. The whole brain analyses of motion-corrected data revealed that VC chiefly activated the cerebellum extending to pons. In contrast, CiTA-related tasks (IC and SC) activated the higher sensory regions of the cerebral cortex and associated brain regions. The present results suggest that brain activity during simple cough is controlled chiefly by infratentorial areas, whereas manipulating cough predominantly requires the higher sensory brain regions to allow top-down control of information from the periphery.

Combined laryngeal framework surgery and cricopharyngeal muscle-origin transection: a novel effective surgery for dysphagia with pharyngolaryngeal palsy and cricopharyngeal dysfunction under local anesthesia.

BACKGROUND: Cricopharyngeal myotomy and laryngeal framework surgery can improve swallowing function in patients with severe dysphagia. We developed a novel surgical technique for severe dysphagia associated with pharyngolaryngeal paralysis and cricopharyngeal dysfunction, performed under local anesthesia, and investigated its effectiveness. METHODS: We included nine patients who underwent cricopharyngeal muscle-origin transection with laryngeal framework surgery through a horizontal skin incision under local anesthesia. CONCLUSIONS: All patients demonstrated significant improvement in the Food Intake LEVEL Scale without complications. Thus, this surgical technique may serve as a useful and less invasive treatment option for patients with severe dysphagia.

Neuroanatomy of reduced distortion of body-centred spatial coding during body tilt in stroke patients.

Awareness of the direction of the body's (longitudinal) axis is fundamental for action and perception. The perceived body axis orientation is strongly biased during body tilt; however, the neural substrates underlying this phenomenon remain largely unknown. Here, we tackled this issue using a neuropsychological approach in patients with hemispheric stroke. Thirty-seven stroke patients and 20 age-matched healthy controls adjusted a visual line with the perceived body longitudinal axis when the body was upright or laterally tilted by 10 degrees. The bias of the perceived body axis caused by body tilt, termed tilt-dependent error (TDE), was compared between the groups. The TDE was significantly smaller (i.e., less affected performance by body tilt) in the stroke group (15.9 ± 15.9°) than in the control group (25.7 ± 17.1°). Lesion subtraction analysis and Bayesian lesion-symptom inference revealed that the abnormally reduced TDEs were associated with lesions in the right occipitotemporal cortex, such as the superior and middle temporal gyri. Our findings contribute to a better understanding of the neuroanatomy of body-centred spatial coding during whole-body tilt.

Pre-existing sarcopenia and swallowing outcomes in acute stroke patients.

BACKGROUND & AIMS: This study aimed to investigate the associations of pre-existing sarcopenia with swallowing function, oral intake level, and aspiration pneumonia in patients with acute stroke. METHODS: This observational study included patients (≥60 years of age) with acute ischemic stroke or intracerebral hemorrhage within 7 days of onset who were screened for sarcopenia, malnutrition, and swallowing difficulties in a stroke-care unit within 48 h of admission. Sarcopenia was defined by the Asian Working Group on Sarcopenia 2019 as having a low calf circumference, handgrip strength, and appendicular muscle mass index. The primary outcome was impaired oral intake (functional oral intake scale <5 points) at 3, 7, and 14 days after admission, and the secondary outcome was aspiration pneumonia during hospitalization. RESULTS: We enrolled 350 patients (median age of 77 years; 63% males) who underwent the aforementioned screening. Sarcopenia was diagnosed in 34% of patients, and malnutrition was found in 66% of patients with sarcopenia. When compared with the comparison group (defined as patients with either or both normal calf circumference and handgrip strength), the sarcopenia group had significantly lower tongue pressure and a higher prevalence of dysphagia. Sarcopenia was associated with functional oral intake scale <5 at 7 days (adjusted odds ratio [OR], 4.72; 95% confidence interval [CI], 1.91-11.71); p = 0.002) and 14 days (adjusted OR, 3.93; 95% CI, 1.47-10.53; p = 0.006) and with aspiration pneumonia during hospitalization (adjusted OR, 6.12; 95% CI, 1.63-22.94; p = 0.007). CONCLUSION: Acute stroke patients with sarcopenia may have weakness of the swallowing-related muscles which may lead to impaired oral intake and aspiration pneumonia.

Effect of a restrictive orthosis on the paralyzed hand in combination with constraint-induced movement therapy in a patient with chronic stroke: a case report.

PURPOSE: Many studies have reported the effects of constraint-induced movement therapy (CIMT) with an orthosis on the residual function of the impaired side of post-stroke patients. We encountered a case with left hemiparesis whose functioning of the impaired hand improved by CIMT with an orthosis not to assist as in the past but to restrict the residual function of the paralyzed fingers. METHODS: The patient was a 46-year-old woman with left hemiparesis due to cerebral infarction 18 months ago. The patient had resumed work but would easily tire while typing the keyboard. We found that the extrinsic hand muscles were more engaged in compensatory movements than the intrinsic muscles. Therefore, we designed an orthosis that would extend and fixation the distal interphalangeal joint and proximal interphalangeal joint muscles to promote the engagement of the intrinsic muscles and restrict the compensatory movements of the extrinsic muscles. RESULTS: The orthosis was used for 8 h/day for 2 weeks; CIMT were performed. Left hemiplegia improved from CIMT and the patient was able to handle the same amount of work as that before onset. CONCLUSION: Restrictive orthosis on the paralyzed hand in combination with CIMT was found to be a beneficial rehabilitation approach.IMPLICATIONS FOR REHABILITATIONThis case suggests that not assistive but suppressive orthosis with constraint-induced movement therapy can be effective in strengthening the intrinsic muscles of the hand and restricting compensatory movements by the extrinsic muscles in hemiplegic patients.Treating the paralyzed side with a suppressive orthosis may be an effective novel approach for improving the physical function of the paralyzed hand in post-stroke patients.

A revised version of the Seirei Swallowing Questionnaire for people with cognitive decline (Swallow-10).

The Seirei dysphagia screening questionnaire (namely, Seirei dsq) has been used to screen for oropharyngeal dysphagia (OD). Some of the questions in the questionnaire are difficult for people with cognitive decline to answer. We selected 10 items from the Seirei dsq that could be assessed by others, such as care workers (named Swallow-10). This study aims to verify the validity of the scoring method used in Swallow-10. The dataset used in this study was the one used in the development of Seirei dsq : 50 patients with cerebrovascular disease who were diagnosed with OD, 145 patients with cerebrovascular disease who did not have OD, and 170 healthy subjects. Among the answer choices, "A" for severe symptom, "B" for mild symptom and "C" for no symptom were scored with 4, 1 and 0 points respectively. Factor analysis extracted two factors : one related to pharyngeal function and another related to oral function. In addition, the Cronbach's alpha coefficient was 0.84. ROC analysis indicated that optimal cutoff value was 5 points, with a sensitivity of 90.0% and a specificity of 88.5%. These results suggest that Swallow-10 may be useful as an OD screening tool for subjects with cognitive decline J. Med. Invest. 70 : 231-235, February, 2023.

The Evaluation of Benzodiazepine-induced Dysphagia Using High-resolution Manometry.

We evaluated the pathophysiology of dysphagia considered to be induced by benzodiazepine using high-resolution manometry (HRM). A 53-year-old man with Parkinson disease had had dysphagia for over 3 months. He had been taking several benzodiazepines for more than four years. Two weeks after discontinuation of the benzodiazepines, HRM revealed increased pharyngeal contractility and residual pressure at the upper esophageal sphincter. A video-fluoroscopic swallowing study showed improved pharyngeal bolus passage. Benzodiazepine-induced dysphagia may be due to the muscle relaxant effects on the swallowing muscles and attenuation of the barrier function which prevents reflux from the esophagus into the pharynx.

A Case of Dysphagia and Dysarthria Improved by Flexible-palatal Lift/augmentation Combination Prosthesis.

Background: Palatal augmentation prosthesis (PAP) and palatal lift prosthesis (PLP) have been used to improve dysphagia and dysarthria. However, to date, there are few reports on their combined use. We report a quantitative evaluation of the effectiveness of a flexible-palatal lift/augmentation combination prosthesis (fPL/ACP) based on videofluoroscopic swallowing study (VFSS) and speech intelligibility testing. Case: An 83-year-old woman was admitted to our hospital with a hip fracture. She developed aspiration pneumonia at 1 month after partial hip replacement. Oral motor function tests revealed a motor deficit of the tongue and soft palate. VFSS showed delayed oral transit, nasopharyngeal reflux, and excessive pharyngeal residue. The cause of her dysphagia was assumed to be pre-existing diffuse large B-cell lymphoma and sarcopenia. To improve the dysphagia, an fPL/ACP was fabricated and applied. It improved the patient's oral and pharyngeal swallowing and speech intelligibility. In addition to prosthetic treatment, rehabilitation and nutritional support allowed her to be discharged. Discussion: The effects of fPL/ACP in the present case were similar to those of flexible-PLP and PAP. f-PLP assists in elevation of the soft palate and improved the nasopharyngeal reflux and hypernasal speech. PAP promotes tongue movement and results in improved oral transit and speech intelligibility. Therefore, fPL/ACP may be effective in patients with motor deficits in both the tongue and soft palate. To maximize the effect of the intraoral prosthesis, a transdisciplinary approach with concurrent swallowing rehabilitation, nutritional support, and physical and occupational therapy is necessary.

Association of poor oral health status and faecal incontinence in patients with dysphagia: A cross-sectional analysis from the Sarcopenic Dysphagia Database.

BACKGROUND: Poor oral health status may alter oral and gut microbiota. Previous studies have shown that poor oral health can exacerbate gut inflammation. Therefore, poor oral health status may be related to faecal incontinence via changes in the gut. OBJECTIVE: To investigate the association between poor oral health status and faecal incontinence in inpatients with dysphagia. METHODS: This multicentre cross-sectional study included 423 patients (mean age 79.8 ± 11.5 years, 48.2% female) with dysphagia. Oral health status was assessed at each facility using the Oral Health Assessment Tool (OHAT) or the Revised Oral Assessment Guide (ROAG). Poor oral health status was defined as an OHAT score of ≥3 or a ROAG score of ≥13. A multivariate logistic model was used to analyse the association between poor oral health status and faecal incontinence. RESULTS: A total of 351 (83.0%) patients had poor oral health and 97 (22.7%) had faecal incontinence. Patients with poor oral health status had a higher proportion of faecal incontinence than those with normal oral health status (25.4% vs. 11.1%, p = .009). A multivariate logistic model revealed an association between faecal incontinence and poor oral health status (adjusted odds ratio = 2.501, 95% confidence interval = 1.065-5.873, p = .035). CONCLUSIONS: Poor oral health status assessed by OHAT or ROAG in inpatients with dysphagia may adversely affect faecal incontinence. Further studies are needed to determine the causal relationship between poor oral health status and faecal incontinence.

Cricopharyngeal muscle origin transection for oropharyngeal dysphagia, a novel surgical technique.

BACKGROUND: Cricopharyngeal myotomy improves pharyngeal dysphagia by resecting the cricopharyngeal muscle. METHODS: Our procedure, cricopharyngeal muscle origin transection (CPM-OT) is performed through a midline skin incision at the cricoid cartilage level under local anesthesia. CONCLUSIONS: Sixteen patients demonstrated preservation of vocal fold movement without laryngeal nerve injury immediately after CPM-OT in the awake state during aspiration prevention surgery using the glottic closure technique. Postoperative videofluoroscopic examination of swallowing revealed the cricopharyngeal bar was absent and pharyngeal passage of the bolus and Food Intake LEVEL Scale was improved in all patients. CPM-OT is a feasible and less invasive treatment option.

Association of medial gastrocnemius adiposity with poststroke severe malnutrition and functional performance of activities of daily living in older patients: A prospective analysis.

BACKGROUND: Relationships among medial gastrocnemius intramuscular adipose tissue, nutrition status, and functional outcomes of patients after a stroke are unknown. This study was conducted to determine the relationship between nutrition status and gastrocnemius intramuscular adipose tissue and whether medial gastrocnemius intramuscular adipose tissue affects functional outcomes of older patients after a stroke. METHODS: This prospective cohort study included 217 patients with stroke. Nutrition status was evaluated by the Global Leadership Initiative on Malnutrition. The medial gastrocnemius intramuscular adipose tissue was assessed using ultrasound echographic intensity. Multivariate linear regression analysis was used to determine the relationship between nutrition status at admission and medial gastrocnemius intramuscular adipose tissue. Furthermore, we examined the influence of medial gastrocnemius intramuscular adipose tissue on the Functional Independence Measure (FIM)-motor score at discharge and FIM-motor efficiency, which indicates FIM-motor changes during the hospital stay. RESULTS: Severe malnutrition had a positive influence on medial gastrocnemius intramuscular adipose tissue on the nonparalyzed side (ß = 0.175; P = 0.044). Additionally, the medial gastrocnemius intramuscular adipose tissue on the nonparalyzed side was negatively correlated with the FIM-motor score at discharge (ß = -0.102; P = 0.005) and FIM-motor efficiency (ß = -0.273; P = 0.005). CONCLUSIONS: This study clarified the factors that contribute to a higher medial gastrocnemius intramuscular adipose tissue content on the nonparalyzed side and the effect of the higher adipose tissue content on functional outcomes.

Impact of Poor Oral Health Status on Swallowing Function Improvement in Older Dysphagic Patients.

Background This study aimed to explore the relationship between poor oral health status and improvement in swallowing function in older patients with dysphagia across various clinical settings, including acute and post-acute care environments. Methods This retrospective cohort study encompassed patients aged 65 years and older with dysphagia. Oral health status was assessed using the oral health assessment tool (OHAT) or the revised oral assessment guide (ROAG). In this study, an OHAT score of ≥3 or an ROAG score of ≥13 indicated poor oral health status. The primary outcome measured was the change in the food intake level scale (FILS) score, which reflects swallowing function, during the observation period. The association between changes in FILS score and poor oral health status was analyzed using a multivariable linear regression model. Results The study included 361 older patients with dysphagia (mean age 82.7 ± 7.7 years; 47.3% male), of whom 82.5% had poor oral health. A negative association was found between poor oral health status and improvement in FILS score at the endpoint (partial regression coefficient: -0.523, 95% confidence interval: -0.99 to -0.06, P=0.026). Conclusions Our findings underscore the negative impact of poor oral health status on the improvement of swallowing function and emphasize the importance of oral health interventions for older patients. Further study on oral health interventions' effects on improving swallowing function in older patients with dysphagia is warranted.

Use of the "ee" Maneuver in a Patient With Dysphagia Due to Severe Pseudobulbar Palsy.

Dysphagia in pseudobulbar palsy is characterized by impairment of the oral stage of swallowing. The flow of the bolus from the oral cavity into the pharynx at the fauces may be blocked in some patients, which prevents the bolus flow by contact of the tongue with the palate. Herein, we demonstrated a case with pseudobulbar palsy who could deliver bolus from the oral cavity to the pharynx by vocalizing "ee." An 81-year-old man presented with a recurrent cerebral infarction due to cardiogenic embolism. He presented with pseudobulbar palsy and had severe dysphagia due to bilateral cerebral hemisphere lesions. On day 84, a videofluoroscopic examination of swallowing was performed in a 30° reclining posture. When the bolus reached the posterior part of the tongue in the oral cavity, the clinician asked the patient to say "ee." The base of the tongue moved forward and downward, and the anterior to the middle part of the tongue was elevated in the mouth. As a result, the fauces opened, the functional blockage was released, and the bolus flowed into the pharyngeal cavity. Shortly after the swallowing reflex, the bolus passed through the pharynx. We have named this swallowing maneuver the "ee" maneuver. The "ee" maneuver can be one of the swallowing methods to improve bolus transport from the oral cavity to the pharynx in patients with dysphagia and cognitive impairment due to pseudobulbar palsy.