Dysphagia in patients with Chagas'' disease.
Departamento de Clinica Medica, Faculdade de Medicina de Ribeirao Preto, Universidade de Sao Paulo, Ribeirao Preto, Brazil.
Some patients with Chagas' disease and apparent normal esophageal function complain of dysphagia. With the objective of investigating the esophageal motility of these patients we studied the esophageal contraction amplitude, duration, velocity, and lower esophageal sphincter (LES) pressure of 34 patients with a positive serologic test for Chagas' disease, normal radiologic esophageal examination, peristaltic contractions in the esophageal body, and complete LES relaxation. Fourteen patients complained of dysphagia and 20 had no symptoms. The results were compared with those of 22 healthy controls. We used the manometric method with continuous perfusion. In patients without dysphagia, the LES pressure (17.8 +/- 1.2 mmHg, mean +/- SEM) and distal esophageal amplitude (71.8 +/- 7.9 mmHg) were lower than those of control subjects (24.3 +/- 1.8 mmHg and 100. 4 +/- 10.6 mmHg, respectively). The velocity of peristaltic contractions was higher in patients than in controls, but there was no difference between patients with or without dysphagia. The duration of contraction in the distal esophagus was longer in patients with dysphagia (3.9 +/- 0.2 sec) than in patients without dysphagia (3.1 +/- 0.2 sec) and controls (3.2 +/- 0.2 sec). We conclude that dysphagia in patients with Chagas' disease and a nondilated esophagus with peristaltic contractions and complete LES relaxation is related to a longer duration of contractions in the middle and distal esophageal body.
Cervical osteophytic dysphagia: single and combined mechanisms.
Di Vito J Jr.
Department of Radiology, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, New York 10461, USA.
Cervical osteophytes are common in the aging population. Dysphagia induced by cervical osteophytes, although uncommon, is an important and treatable cause of dysphagia that must be identified during the modified barium swallow. Previous authors have described osteophyte impingement as a cause for dysphagia. This report describes a case of this classic obstructive osteophytic dysphagia and one of combined osteophytic and neurogenic dysphagia. This is the first time that a combined mechanism is described in the literature.
Esophageal manometric abnormalities in Parkinson''s disease.
Bassotti G. Germani U. Pagliaricci S. Plesa A. Giulietti O. Mannarino E. Morelli A.
Laboratorio di Motilita Intestinale, Clinica di Gastroenterologia ed Endoscopia Digestiva, Italy.
The gastrointestinal tract, and especially the esophagus, is frequently involved in neurological diseases; however, objective studies of gut motor function are few. We carried out an esophageal manometric study in 18 patients with various stages of Parkinson's disease (4 stage I, 4 stage II, 7 stage III, and 3 stage IV) to evaluate the function of the viscus in this disease. Clinical assessment showed that 61% complained of esophageal symptoms such as dysphagia, acid regurgitation, pyrosis, and noncardiac chest pain. Manometric abnormalities were documented also in 61% patients, and were represented by repetitive contractions, simultaneous contractions, reduced LES pressure, and high-amplitude contractions. However, only 33.3% of patients had both symptoms and manometric abnormalities. We conclude that esophageal motor abnormalities are frequent in Parkinson's disease, and may appear at an early stage of the disease.
Dysphagia in stroke: a prospective study of quantitative aspects of swallowing in dysphagic patients.
Nilsson H. Ekberg O. Olsson R. Hindfelt B.
Department of Neurology, University of Lund, Malmo University Hospital, Malmo, Sweden.
This is a prospective study of 100 consecutive stroke patients. Within 24 h after stroke onset they were asked specifically about swallowing complaints and subjected to a clinical examination including neurologic examination, Mini-Mental test, and Barthel score. Dysphagic patients were examined with the repetitive oral suction swallow test (the ROSS test) for quantitative evaluation of oral and pharyngeal function at 24 h, after 1 week, and after 1 month. At 6 months, the patients were interviewed about persistent dysphagia. Seventy-two patients could respond reliably at 24 h after the stroke onset and 14 of these complained of dysphagia. Non-evaluable patients were either unconscious, aphasic, or demented. The presence of dysphagia was not influenced by age or other risk factors for stroke. Facial paresis, but no other clinical findings, were associated with dysphagia. Dysphagia 24 h after stroke increased the risk of pneumonia but did not influence the length of hospital stay, the manner of discharge from hospital, or the mortality. The initial ROSS test, during which the seated patient ingests water through a straw, was abnormal in all dysphagic stroke patients. One-third of the patients were unable to perform the test completely. Above all, dysfunction was disclosed during forced, repetitive swallow. All phases of the ingestion cycle were prolonged whereas the suction pressures, bolus volumes, and swallowing capacities were low. Abnormalities of quantitative swallowing variables decreased with time whereas the prevalences of swallowing incoordination and abnormal feeding-respiratory pattern became more frequent. After 6 months, 7 patients had persistent dysphagia. Five of these were initially non-evaluable because of unconsciousness, aphasia, or dementia.
Fiberoptic endoscopic evaluation of dysphagia to identify silent aspiration.
Leder SB. Sasaki CT. Burrell MI.
Department of Surgery, Section of Otolaryngology, Yale University School of Medicine, New Haven, Connecticut 06504, USA.
The traditional bedside dysphagia evaluation has not been able to identify silent aspiration because the pharyngeal phase of swallowing could not be objectively assessed. To date, only videofluoroscopy has been used to detect silent aspiration. This investigation assessed the aspiration status of 400 consecutive, at risk subjects by fiberoptic endoscopic evaluation of swallowing (FEES). Our study demonstrated that 175 of 400 (44%) subjects were without aspiration, 115 of 400 (29%) exhibited aspiration with a cough reflex, and 110 of 400 (28%) aspirated silently. No significant differences were observed for age or gender and aspiration status. The FEES, done at bedside, avoids irradiation exposure, is repeatable as often as necessary, uses regular food, can be videotaped for review, and is a patient-friendly method of identifying silent aspiration.
Do psychogenic dysphagia patients have an eating disorder?
Barofsky I. Fontaine KR.
Department of Psychiatry and Behavioral Sciences, The Johns Hopkins University School of Medicine and The Johns Hopkins Bayview Medical Center, Baltimore, Maryland 21224, USA.
Patients who report dysphagia, but have no detectable physical defect, have often been diagnosed as having an eating disorder. This diagnosis was evaluated by administering the Eating Disorders Inventory-2 (EDI-2) and a measure of distress, the Symptom Checklist-90 (SCL-90R), to a sample of 21 adult psychogenic dysphagia patients (PDPs). Their EDI-2 responses were then compared with samples of anorexics, college men, and college women, and their SCL-90R responses were compared with published data of patients with dysphagia due to a motility disorder, an obstruction, or neither. Relative to the anorexics, the PDPs scored significantly lower on all EDI-2 dimensions except maturity fears. For the SCL-90R, PDPs scored significantly higher on the interpersonal sensitivity, depression, anxiety, and general severity index than did the dysphagia comparison groups. Moreover, PDP scores on the anxiety and interpersonal sensitivity dimensions were indicative of clinically significant distress. These findings suggest that PDPs do not appear to have an eating disorder, but that they report clinically significant levels of psychological distress, particularly anxiety.
Pharmacological treatment of dysphagia in stroke.
Perez I. Smithard DG. Davies H. Kalra L.
Orpington Hospital, Bromley Hospitals NHS Trust, Bromley, UK.
The pharynx is important for a normal swallow and it has been suggested that pharmacological agents may play a role in the management of pharyngeal dysphagia, but none have been formally evaluated. A pilot double-blind, placebo-controlled study was undertaken in 17 hospitalized patients with persistent dysphagia 2 weeks after stroke. Patients were randomized to treatment with slow-release nifedipine 30 mg orally (n = 8) or placebo (n = 9) following specialist swallowing assessment and videofluoroscopy to exclude severe dysphagia. Videofluoroscopy was repeated after 4 weeks of treatment. Fourteen patients (active 6, placebo 8) completed the study. Two patients died (active 1, placebo 1) and 1 patient in the active group had to be withdrawn because of progressive heart failure. Initial assessment showed impairment in the pharyngeal phase with delayed triggering of swallow, poor laryngeal elevation, and prolonged pharyngeal transit times in all patients. Silent aspiration was seen in 4 patients (active 2, placebo 2). Improvement in swallowing was seen in 8 patients (active 5, placebo 3) at the end of 4 weeks. There were significant changes in the pharyngeal transit time (mean -1.34 second; 95% C.I. -2.56, -0.11) and swallow delay (mean -1.91 seconds; 95% C.I. -3.58, -0.24) in the active group suggesting improvement in the initiation of pharyngeal contractions and reduction in the time taken for the bolus to transverse the pharynx. A similar change was not seen in the placebo group. It is suggested that pharmacological agents such as nifedipine may have a role in the management of stroke-related dysphagia and merit further investigation.
Comparing treatment intensities of tactile-thermal application.
Rosenbek JC. Robbins J. Willford WO. Kirk G. Schiltz A. Sowell TW. Deutsch SE. Milanti FJ. Ashford J. Gramigna GD. Fogarty A. Dong K. Rau MT. Prescott TE. Lloyd AM. Sterkel MT. Hansen JE.
William S. Middleton Memorial Veterans Hospital, Department of Neurology, University of Wisconsin School of Medicine, Madison, Wisconsin 53705, USA.
The purpose of this study was to investigate the relationships of four intensities of tactile-thermal application (TTA) to changes in duration of stage transition (DST) and performance on a newly designed scale of penetration and aspiration by groups of patients made dysphagic by stroke. Patients were randomly assigned to receive 150, 300, 450, or 600 trials of TTA during each of 2 weeks. Data on the time required to provide such treatment, the actual number of trials clinicians were able to provide, and on the influence of the four intensities are provided. No single intensity emerged as the most therapeutic. It is suggested that subsequent studies with larger groups include intensities between 300 and 550.
Predictors of aspiration pneumonia: how important is dysphagia?
Langmore SE. Terpenning MS. Schork A. Chen Y. Murray JT. Lopatin D. Loesche WJ.
Audiology & Speech Pathology Department (126), VA Medical Center, Ann Arbor, MI 48105, USA.
Aspiration pneumonia is a major cause of morbidity and mortality among the elderly who are hospitalized or in nursing homes. Multiple risk factors for pneumonia have been identified, but no study has effectively compared the relative risk of factors in several different categories, including dysphagia. In this prospective outcomes study, 189 elderly subjects were recruited from the outpatient clinics, inpatient acute care wards, and the nursing home care center at the VA Medical Center in Ann Arbor, Michigan. They were given a variety of assessments to determine oropharyngeal and esophageal swallowing and feeding status, functional status, medical status, and oral/dental status. The subjects were followed for up to 4 years for an outcome of verified aspiration pneumonia. Bivariate analyses identified several factors as significantly associated with pneumonia. Logistic regression analyses then identified the significant predictors of aspiration pneumonia. The best predictors, in one or more groups of subjects, were dependent for feeding, dependent for oral care, number of decayed teeth, tube feeding, more than one medical diagnosis, number of medications, and smoking. The role that each of the significant predictors might play was described in relation to the pathogenesis of aspiration pneumonia. Dysphagia was concluded to be an important risk for aspiration pneumonia, but generally not sufficient to cause pneumonia unless other risk factors are present as well. A dependency upon others for feeding emerged as the dominant risk factor, with an odds ratio of 19.98 in a logistic regression model that excluded tube-fed patients.
A preliminary comparison of videofluoroscopy of swallow and pulse oximetry in the identification of aspiration in dysphagic patients.
Sellars C. Dunnet C. Carter R.
Department of Speech & Language Therapy, Glasgow Royal Infirmary, UK.
Pulse oximetry has recently received attention in the dysphagia literature because of its possible contribution to the management of neurogenic dysphagia. The present study was devised to examine whether pulse oximetry could be exploited to determine episodes of aspiration in patients with known dysphagia of neurologic origin. To this end, pulse oximetry was undertaken in six patients undergoing videofluoroscopic study of swallow. Normal controls also underwent pulse oximetry during feeding. The results indicate that there is no clear-cut relationship between changes in arterial oxygenation and aspiration. However, some support is found for the association between altered arterial oxygenation and oral feeding in dysphagic individuals. Further research in both normals and compromised individuals is needed.
Fiberoptic endoscopic evaluation of swallowing with sensory testing (FEESST) in healthy controls.
Aviv JE. Kim T. Thomson JE. Sunshine S. Kaplan S. Close LG.
Department of Otolaryngology-Head and Neck Surgery, Columbia-Presbyterian Medical Center, College of Physicians and Surgeons, Columbia University, New York, New York, USA.
The purpose of this study was to introduce a new method of bedside assessment of both the motor and sensory components of swallowing called fiberoptic endoscopic evaluation of swallowing with sensory testing (FEESST). This approach combines the established bedside endoscopic swallowing evaluation with a more recently described technique that allows objective determination of laryngopharyngeal (LP) sensory discrimination thresholds by delivering air pulse stimuli to the mucosa innervated by the superior laryngeal nerve via a flexible endoscope. A prospective study was conducted of FEESST in 20 healthy control subjects, mean age of 34 +/- 11 years. LP sensory thresholds were defined as either normal (< 4.0 mmHg air pulse pressure [APP]), moderate deficit (4.0-6.0 mmHg APP), or severe deficits (> 6.0 mmHg APP). Subsequent to LP sensory testing, food of varying consistencies, mixed with green food coloring, was given and attention was paid to spillage, laryngeal penetration, pharyngeal residue, aspiration, and reflux. Therapeutic maneuvers such as postural changes and airway protection techniques were performed on each subject to determine if the assessed swallowing parameters were affected by maneuvers. All patients completed the study; all had normal LP sensory discrimination thresholds (2.9 +/- 0.7 mmHg APP). There were no instances of spillage, laryngeal penetration, or aspiration. Two of 20 subjects had pharyngeal residue and 2 of 20 had reflux. Institution of therapeutic maneuvers resulted in a predictable change in the endoscopic view of the laryngopharyngeal anatomy. FEESST provides comprehensive, objective sensory and motor information about deglutition in the bedside setting and might have implications for the bedside diagnosis and management of patients with dysphagia.
Videofluorographic study of swallowing in Parkinsons disease.
Nagaya M. Kachi T. Yamada T. Igata A.
Department of Rehabilitation, Chubu National Hospital, Obu, Japan.
We studied 16 patients with Parkinson's disease (PD) with dysphagia and 8 young and 7 elderly normal controls videofluorographically to evaluate the nature of swallowing disorders in PD patients. In 13 patients, abnormal findings in the oral phase were residue on the tongue or residue in the anterior and lateral sulci, repeated pumping tongue motion, uncontrolled bolus or premature loss of liquid, and piecemeal deglutition. Thirteen patients showed abnormal findings in the pharyngeal phase, including vallecular residue after swallow, residue in pyriform sinuses, and delayed onset of laryngeal elevation. Ten of these patients also showed abnormal findings in both the oral and pharyngeal phases. Aspiration was seen in 9 patients. The oral transit duration was significantly longer in the patients with and without aspiration than in the control subjects. The stage transition duration, pharyngeal transit duration, duration of the upper esophageal sphincter (UES) opening, and total swallow duration were significantly longer in the patients with and without aspiration than in the young controls, but were not longer than in the elderly controls. These durational changes in the pharyngeal phase of swallowing were similar to those in the elderly controls. The findings suggest that the disturbed motility in the oral phase of swallowing may be due to bradykinesia. Although PD patients with dysphagia evince a variety of swallowing abnormalities, the duration of pharyngeal swallowing may remain within the age-related range until the symptoms worsen.
Functional imaging of the pharynx using electron beam tomography.
Lindbichler F. Raith J. Uggowitzer M. Wuttge-Hannig A.
University Hospital Graz, Department of Radiology, Austria.
Due to long scan times it was impossible to make dynamic swallowing imaging using computer tomography (CT) of the third or fourth generation. This study evaluates whether electron beam tomography with scan times of 100 ms enables a more detailed dynamic imaging of swallowing disorders. Examination using electron beam tomography was done in three planes: (1) Passavant's cushion (n = 6), (2) thyrohyoid membrane (n = 9), and (3) upper esophageal sphincter (n = 5). The technique is discussed here in detail and documented with figures of the plane before swallowing as well as the intradeglutitive reachend plane. This study shows that electron beam tomography enables dynamic imaging of pharyngeal deglutition in transverse planes and can give useful additional information to the videofluorographic or kinematographic swallowing examination, which remain the gold standard in the functional evaluation of swallowing disorders.
Radiation doses to patients during pharyngeal videofluoroscopy.
Wright RE. Boyd CS. Workman A.
Department of Radiology, Ulster Hospital Dundonald, Belfast, Northern Ireland, UK.
Pharyngeal videofluoroscopy (VTF) is a well-recognized technique for investigating and assessing swallowing disorders. There is, however, a paucity of data available regarding the radiation dose to patients during such procedures, but there is general concern that fluorographic imaging modalities are associated with significant radiation exposure. We have recorded the dose received by 23 patients undergoing VTF in our department using a Dose-Area Product (DAP) Meter and have used the data to calculate the effective dose to the patients. The mean effective dose is 0.4 mSv (range 0.027-1.1) which compares favorably with the effective doses associated with other common radiological procedures. We therefore conclude that the radiation detriment associated with pharyngeal VTF is well within acceptable levels.
Intra- and interrater variation in the evaluation of videofluorographic swallowing studies.
Kuhlemeier KV. Yates P. Palmer JB.
Department of Physical Medicine and Rehabilitation, Johns Hopkins University, Good Samaritan Hospital of Maryland, Baltimore, USA.
The objective of this study was to determine the inter- and intrarater reliability in evaluating videofluoroscopic swallowing studies (VFSS). Participants included 4 physicians (3 physiatrists and 1 internist) and 5 speech-language pathologists with at least 5 years experience in evaluating VFSS. The main outcomes of the study were reliability ratios of positive and negative tests in inter- and intrarater evaluations. Raters independently rated each of 20 VFSS on two separate occasions. Traits evaluated included oral stage impairment, aspiration, pharyngeal retention, and several functional components: timing of swallow onset, adequacy of velopharyngeal apposition, laryngeal elevation, epiglottic tilt, pharyngeal contraction, and pharyngoesophageal (PE) segment opening. Reliability varied widely depending on food type and the trait under evaluation. Inter- and intrarater reliability ratios did not differ widely. Reliability ratios values typically were highest (greater than 90%) for aspiration, especially with solid food, and lowest for the functional components. It was concluded that inter- and intrarater reliability in VFSS are adequate for evaluating oral stage, laryngeal penetration, and aspiration and pharyngeal retention, but questionable for functional components.
Weight loss, dysphagia, and outcome in advanced dementia.
Chouinard J. Lavigne E. Villeneuve C.
Sisters of Charity at Ottawa Hospital, Ontario, Canada.
There has been much debate on the value and risks of long-term enteral feeding in patients with advanced dementia. A retrospective study was carried out on 47 patients with a primary diagnosis of dementia who died over a two-year period. All were inpatients in a nursing home or skilled nursing facility. Marked weight loss and dysphagia occurring in a specific pattern were found to be associated with death from pneumonia. These clinical features probably imply failure of basic homeostatic mechanisms. Patients showing this clinical pattern may be less likely to show benefits from long-term enteral feeding.
Tracheotomy tube occlusion status and aspiration in early postsurgical head and neck cancer patients.
Leder SB. Ross DA. Burrell MI. Sasaki CT.
Department of Surgery, Yale University School of Medicine, New Haven, Connecticut 06504, USA.
The purpose of the present study was to investigate tracheotomy tube occlusion status and prevalence of aspiration utilizing videofluoroscopy. A prospective study was done of 16 consecutive, early, postsurgical head and neck cancer patients with tracheotomy. Selection criteria included the ability to tolerate tracheotomy tube occlusion prior to and during the modified barium swallow procedure, oral and/or pharyngeal surgical resection, no history of neurological disease or stroke, and medical clearance to begin oral feeding. There was 100% agreement among the independent reviewers on ratings of the presence or absence of aspiration. It was found that occlusion status of the tracheotomy tube did not influence the prevalence of aspiration in the immediate postoperative period. No trends were observed when comparing bolus consistency, type of tracheotomy tube, or presence/absence of a nasogastric tube and the ratings of aspiration.
Swallowing problems in the nursing home: a novel training response.
O'Loughlin G. Shanley C.
Speech Pathology Department, Balmain Hospital, Sydney, Australia.
Various studies suggest that between 50% and 75% of nursing home residents have some difficulty in swallowing. Some of these residents are assessed and treated by speech pathologists, but many are managed by nursing staff without specialist input. A training program called Swallowing ... on a Plate (SOAP) has been developed by the Centre for Education and Research on Ageing and the Inner West Geriatrics and Rehabilitation Service to help address swallowing-related problems in local nursing homes (Inner West of Sydney, Australia). The training program teaches nursing staff how to identify, assess, and manage swallowing problems, including making appropriate referrals. Several new instruments were developed specifically for this program including two assessment checklists, a set of management guidelines, and a swallowing care plan. Evaluation of the program--including 3 months follow-up--showed it to be highly successful. A stand-alone training resource has been produced for wide distribution to help staff implement the program as a permanent aspect of their nursing care. This paper describes the development, content, presentation, resource, and evaluation of the above program.