Swallowing evaluation with videofluoroscopy in the paediatric population

Paediatric swallowing disorders can have several causes, from prematurity and congenital anomalies to gastro-oesophageal reflux and infective or inflammatory pathologies of the upper digestive tract. In neonates, the swallowing process is reflexive and involuntary. Later in infancy, the oral phase comes under voluntary control, while the pharyngeal phase and oesophageal phases remain involuntary. Swallowing difficulties can severely compromise pulmonary health and nutritional intake of paediatric patients. Videofluoroscopic Swallow Study (VFSS) is a radiographic procedure that provides a dynamic view of the swallowing process and is frequently considered to be definitive evaluation for objective assessment of dysphagia in paediatric patients. This review focuses on the different possible aetiologies of paediatric swallowing disorders and related videofluoroscopic swallowing study procedures and appearances

Breathing, swallowing and voice in laryngeal disorsers

The aim of this work was to examine how breathing, swallowing and voicing are affected in different laryngeal disorders. For this purpose, we examined four different patient groups: patients who had undergone total laryngectomy, anterior cervical decompression (ACD), or injection laryngoplasty with autologous fascia (ILAF), and patients with dyspnea during exercise. We studied the problems and benefits related to the automatic speech valve used for the rehabilitation of speech in laryngectomized patients. The device was given to 14 total laryngectomized patients who used the traditional valve especially well. The usefulness of voice and intelligibility of speech were assessed by speech pathologists. The results demonstrated better performance with the traditional valve in both dimensions. Most of the patients considered the automatic valve a helpful additional device but because of heavier breathing and the greater work needed for speech production, it was not suitable as a sole device in speech rehabilitation. Dysphonia and dysphagia are known complications of ACD. These symptoms are caused due to the stretching of tissue needed during the surgery, but the extent and the recovery from them was not well known before our study. We studied two patient groups, an early group with 50 patients who were examined immediately before and after the surgery and a late group with 64 patients who were examined 3 9 months postoperatively. Altogether, 60% reported dysphonia and 69% dysphagia immediately after the operation. Even though dysphagia and dysphonia often appeared after surgery, permanent problems seldom occurred. Six (12 %) cases of transient and two (3 %) permanent vocal cord paresis were detected. In our third study, the long-term results of ILAF in 43 patients with unilateral vocal cord paralysis were examined. The mean follow-up was 5.8 years (range 3 10). Perceptual evaluation demonstrated improved results for voice quality, and videostroboscopy revealed complete or partial glottal closure in 83% of the patients. Fascia showed to be a stable injection material with good vocal results. In our final study we developed a new diagnostic method for exertional laryngeal dyspnea by combining a cardiovascular exercise test with simultaneous fiberoptic observation of the larynx. With this method, it is possible to visualize paradoxal closure of the vocal cords during inspiration, which is a diagnostic criterion for vocal cord dysfunction (VCD). We examined 30 patients referred to our hospital because of suspicion of exercise-induced vocal cord dysfunction (EIVCD). Twenty seven out of thirty patients were able to perform the test. Dyspnea was induced in 15 patients, and of them five had EIVCD and four high suspicion of EIVCD. With our test it is possible to set an accurate diagnosis for exertional laryngeal dyspnea. Moreover, the often seen unnecessary use of asthma drugs among these patients can be avoided.Hengityksen, äänentuoton ja nielemisen häiriintymättömän toiminnan kannalta kurkunpään merkitys on keskeinen. Tässä kurkunpään sairauksia käsittelevässä väitöskirjatyössä tutkittiin näitä toimintoja neljässä eri potilasryhmässä. Kurkunpään poistoleikkauksessa (laryngektomia) ääntä tuottavat rakenteet poistetaan, ja potilaalle tehdään hengitysavanne. Ääni tuotetaan leikkauksen jälkeen henkitorven ja ruokatorven väliin asetetun ääniproteesin avulla. Perinteinen ääniproteesi vaatii toimiakseen hengitysavanteen sulun sormin. Äänen tuoton apuvälineeksi on kehitetty automaattinen puheläppä, joka mahdollistaa puheen ilman sormisulkua. Laitteen käyttökelpoisuudesta puheen kuntoutuksessa ei ole aiemmin ollut riittävästi tietoa. Tutkimuksessamme automaattinen puheläppä annettiin 14 potilaalle, jotka käyttivät perinteistä puheläppää ongelmitta. Automaattinen puheläppä osoittautui hyödylliseksi puheentuoton apuvälineeksi, mutta jopa näiden valikoitujen potilaiden mukaan hengitys ja puhuminen oli raskaampaa automaattisella puheläpällä kuin perinteisellä puheläpällä. Kaularankaleikkaus on yleinen toimenpide välilevypullistuman ja nikamasiirtymän hoidossa. Recurrens- hermon vaurio on tunnettu kaularankakirurgian komplikaatio, joka aiheuttaa käheyttä ja nielemisvaikeutta. Tarkkoja tietoja sen yleisyydestä, vaurion pysyvyydestä tai potilaalle aiheutuvasta haitasta ei ole aiemmin tunnettu. Lähes 70 %:lla potilaista oli ääni- ja nielemisvaikeuksia heti leikkauksen jälkeen, mutta melkein kaikki potilaat toipuivat 3kk seurannan aikana. Ohimeneviä äänihuulihalvauksia todettiin 12 %:lla ja pysyviä halvauksia 3 %:lla potilaista. Tutkimustulosten perusteella potilaille voidaan kertoa odotettavissa olevista ääni- ja nielemisvaikeuksista sekä niistä toipumisesta aiempaa tarkemmin. Äänihuulihalvaus syntyy recurrens- hermon vaurioituessa esimerkiksi kirurgisen komplikaation seurauksena, ja osa potilaista tarvitsee äänikirurgiaa vaikean käheyden korjaamiseksi. Leikkauksessa halvaantunut äänihuuli yleensä medialisoidaan eli tuodaan keskiviivaan, jolloin liikkuva äänihuuli saa siihen taas kontaktin ja soinnikas ääni palautuu. Faskiainjektiossa reiden fascia latasta irrotettava lihaskalvo (faskia) pilkotaan massaksi, joka ruiskutetaan mikroskooppitarkkailussa halvaantuneeseen äänihuulilihakseen sen medialisoimiseksi. Tutkimuksessamme äänihuulten täydellinen tai osittainen sulku voitiin todeta 83 %:lla potilaista, ja 56 % heistä ilmoitti äänen olevan normaali tai lähes normaali kun faskiainjektiosta oli kulunut 3-10 vuotta. Tulokset osoittivat faskiainjektion turvalliseksi, käyttökelpoiseksi ja pysyväksi lievien ja keskivaikeiden äänihuulihalvausten kirurgiseksi hoitomenetelmäksi. Toiminnallisella äänihuulisalpauksella tarkoitetaan kurkunpään toimintahäiriötä, jossa äänihuulet paradoksaalisesti lähentyvät toisiaan sisäänhengityksen aikana. Tämä aiheuttaa sisäänhengitysvaikeutta ja hengityksen vinkunaa. Rasituksessa oireilevat potilaat voidaan tutkia kehittämämme menetelmän, rasituslaryngoskopian, avulla. Siinä ergometrirasitus yhdistetään taipuisan tähystimen avulla nenän kautta tehtävään kurkunpään tarkkailuun. Hengenahdistus ilmaantui testin aikana viidelletoista (56%) potilaalle ja heistä viidellä (33 %) todettiin toiminnallinen äänihuulihalvaus ja neljällä (27 %) vahva epäilys siitä. Testin avulla rasitushengenahdistusoireita voidaan diagnosoida entistä tarkemmin. Toiminnallinen äänihuulisalpaus sekoitetaan helposti rasitusastmaan, joten parantunut diagnostiikka auttaa välttämään turhaa astmalääkitystä

Oral hypofunction in the older population : Position paper of the Japanese Society of Gerodontology in 2016

Background: There is growing international interest in identifying the effects of ageing on oral health and on appropriate strategies for managing oral disorders. The Japanese Society of Gerodontology (JSG), as the official representative of researchers and clinicians interested in geriatric dentistry in Japan, makes several recommendations on the concept of “oral hypofunction.” Aims: This study proposes diagnostic criteria and management strategies to reduce the risk of oral hypofunction among older people. Conceptual Framework: We define oral hypofunction as a presentation of 7 oral signs or symptoms: oral uncleanness; oral dryness; decline in occlusal force; decline in motor function of tongue and lips; decline in tongue pressure; decline in chewing function; and decline in swallowing function. The criteria of each symptom were determined based on the data of previous studies, and oral hypofunction was diagnosed if the criteria for 3 or more signs or symptoms were met. Conclusions: We recommend that more evidence should be gathered from clinical studies and trials to clarify our diagnostic criteria and management strategies

Recent Advances in Sensing Oropharyngeal Swallowing Function in Japan

Dysphagia (difficulty in swallowing) is an important issue in the elderly because it causes aspiration pneumonia, which is the second largest cause of death in this group. It also causes decline in activities of daily living and quality of life. The oral phase of swallowing has been neglected, despite its importance in the evaluation of dysphagia, because adequate protocols and measuring devices are unavailable. However, recent advances in sensor technology have enabled straightforward, non-invasive measurement of the movement of important swallowing-related organs such as the lips and tongue, as well as the larynx. In this article, we report the present state and possibility of clinical application of such systems developed in Japan

Gastrointestinal Ultrasound in Functional Disorders of the Gastrointestinal Tract - EFSUMB Consensus Statement

Abdominal ultrasonography and intestinal ultrasonography are widely used as first diagnostic tools for investigating patients with abdominal symptoms, mainly for excluding organic diseases. However, gastrointestinal ultrasound (GIUS), as a real-time diagnostic imaging method, can also provide information on motility, flow, perfusion, peristalsis, and organ filling and emptying, with high temporal and spatial resolution. Thanks to its noninvasiveness and high repeatability, GIUS can investigate functional gastrointestinal processes and functional gastrointestinal diseases (FGID) by studying their behavior over time and their response to therapy and providing insight into their pathophysiologic mechanisms. The European Federation of Societies for Ultrasound in Medicine and Biology (EFSUMB) has established a Task Force Group consisting of GIUS experts, which developed clinical recommendations and guidelines on the role of GIUS in several acute and chronic gastrointestinal diseases. This review is dedicated to the role of GIUS in assisting the diagnosis of FGID and particularly in investigating patients with symptoms of functional disorders, such as dysphagia, reflux disorders, dyspepsia, abdominal pain, bloating, and altered bowel habits. The available scientific evidence of GIUS in detecting, assessing, and investigating FGID are reported here, while highlighting sonographic findings and its usefulness in a clinical setting, defining the actual and potential role of GIUS in the management of patients, and providing information regarding future applications and research.publishedVersio

A two-sling mechanism of hyolaryngeal elevation in the pharyngeal phase of swallowing

Thesis (Ph.D.)--Boston UniversityThe pharyngeal phase of swallowing is a complex function that transfers a bolus from the oral cavity through the hypopharynx into the esophagus. A critical event in this process is the elevation of the hyolaryngeal complex, which opens the upper esophageal sphincter and relocates the airway away from an oncoming bolus. The suprahyoid group of muscles (mylohyoid, geniohyoid, digastric, and stylohyoid) and thyrohyoid are thought to underlie this function. The role of a deeper posterior sling of muscles that is comprised of stylopharyngeus, salpingopharyngeus and palatopharyngeus has not been determined. This project aims to investigate a hypothesized two-sling mechanism for hyolaryngeal elevation in the pharyngeal phase of swallowing. The thesis begins with background information of the functional anatomy thought to underlie hyolaryngeal elevation followed by an outline of studies that validate the structure, function, and clinical relevance of the two-sling mechanism. A cadaver model is first used to calculate potential force vectors of the muscular slings. The function of the two-sling apparatus is then investigated in vivo by using muscle functional MRI to evaluate muscles active in swallowing and dynamic MRI to perform kinematic analysis on key anatomical landmarks that represent attachment sites of the two-sling mechanism. Finally, the clinical significance of the two-sling mechanism is demonstrated by comparing spatial and temporal measurements collected from fluoroscopic imaging studies of patients with normal swallowing ability and swallowing difficulty

要介護高齢者における嚥下機能と骨格筋量との関係

昭和大学博士(歯学)2014年

Tongue Movements in Feeding and Speech

The position of the tongue relative to the upper and lower jaws is regulated in part by the position of the hyoid bone, which, with the anterior and posterior suprahyoid muscles, controls the angulation and length of the floor of the mouth on which the tongue body \u27rides\u27. The instantaneous shape of the tongue is controlled by the \u27extrinsic muscles \u27 acting in concert with the \u27intrinsic \u27 muscles. Recent anatomical research in non-human mammals has shown that the intrinsic muscles can best be regarded as a \u27laminated segmental system \u27 with tightly packed layers of the \u27transverse\u27, \u27longitudinal\u27, and \u27vertical\u27 muscle fibers. Each segment receives separate innervation from branches of the hypoglosssal nerve. These new anatomical findings are contributing to the development of functional models of the tongue, many based on increasingly refined finite element modeling techniques. They also begin to explain the observed behavior of the jaw-hyoid-tongue complex, or the hyomandibular \u27kinetic chain\u27, in feeding and consecutive speech. Similarly, major efforts, involving many imaging techniques (cinefluorography, ultrasound, electro-palatography, NMRI, and others), have examined the spatial and temporal relationships of the tongue surface in sound production. The feeding literature shows localized tongue-surface change as the process progresses. The speech literature shows extensive change in tongue shape between classes of vowels and consonants. Although there is a fundamental dichotomy between the referential framework and the methodological approach to studies of the orofacial complex in feeding and speech, it is clear that many of the shapes adopted by the tongue in speaking are seen in feeding. It is suggested that the range of shapes used in feeding is the matrix for both behaviors

Rethinking residue, an investigation of pharyngeal residue on flexible endoscopic evaluation of swallowing: the past, present, and future directions

This dissertation investigated measures of pharyngeal residue as seen on flexible endoscopic evaluation of swallowing (FEES). Research in this area of deglutology has been stalled due to measurement problems. The particular aims of this project were to compare visual analog scale ratings to categorical ratings of residue on FEES, and to investigate various measurement aspects. METHODS: Speech language pathologists were asked to rate residue from 81 swallows on FEES that demonstrated a wide range of residue severity for thin liquid, applesauce, and cracker boluses. A total of 33 clinicians rated the amount of residue at the time point after the first swallow, twice in a randomized fashion: the first time on a visual analog scale (VAS) and the second time categorically on a five point Likert scale. The results were analyzed for (1) inter/intra-rater agreement, (2) correlations between ratings and residue severity for each rating method, and (3) clusters of ratings to better define the scales and their clinical significance. A total of 2,673 VAS ratings and 2,673 categorical ratings were collected. RESULTS: (1) Both inter- and intra-rater reliability met acceptable levels of agreement, although intra-rater reliability on VAS ratings were slightly higher (r=0.8–0.9) than categorical ratings (k=0.7–0.8). Expert ratings were not significantly different from other clinicians’ ratings for any severity of any of the 3 boluses. (2) Residue ratings fit best on a curvilinear model; a quadratic fit of the data significantly improved the r2 values for each bolus type. (3) An increased residue amount, rated on either the VAS or categorical scale, was significantly associated with worse penetration-aspiration scale scores, but no significant relationship was found between the two methods of residue ratings and measures of quality of life or diet. Novel computerized methods are proposed for future measurement pursuits. CONCLUSION: The results of this dissertation suggest that residue is best measured on a scale with unequal intervals, and clinicians can be reliable in rating overall amount of residue on FEES after the first swallow. Novel computerized measurement approaches are useful building blocks for future research. It is hoped that with better measurement will come better understanding of residue, its risks, and consequences

Rethinking residue, an investigation of pharyngeal residue on flexible endoscopic evaluation of swallowing: the past, present, and future directions

This dissertation investigated measures of pharyngeal residue as seen on flexible endoscopic evaluation of swallowing (FEES). Research in this area of deglutology has been stalled due to measurement problems. The particular aims of this project were to compare visual analog scale ratings to categorical ratings of residue on FEES, and to investigate various measurement aspects. METHODS: Speech language pathologists were asked to rate residue from 81 swallows on FEES that demonstrated a wide range of residue severity for thin liquid, applesauce, and cracker boluses. A total of 33 clinicians rated the amount of residue at the time point after the first swallow, twice in a randomized fashion: the first time on a visual analog scale (VAS) and the second time categorically on a five point Likert scale. The results were analyzed for (1) inter/intra-rater agreement, (2) correlations between ratings and residue severity for each rating method, and (3) clusters of ratings to better define the scales and their clinical significance. A total of 2,673 VAS ratings and 2,673 categorical ratings were collected. RESULTS: (1) Both inter- and intra-rater reliability met acceptable levels of agreement, although intra-rater reliability on VAS ratings were slightly higher (r=0.8–0.9) than categorical ratings (k=0.7–0.8). Expert ratings were not significantly different from other clinicians’ ratings for any severity of any of the 3 boluses. (2) Residue ratings fit best on a curvilinear model; a quadratic fit of the data significantly improved the r2 values for each bolus type. (3) An increased residue amount, rated on either the VAS or categorical scale, was significantly associated with worse penetration-aspiration scale scores, but no significant relationship was found between the two methods of residue ratings and measures of quality of life or diet. Novel computerized methods are proposed for future measurement pursuits. CONCLUSION: The results of this dissertation suggest that residue is best measured on a scale with unequal intervals, and clinicians can be reliable in rating overall amount of residue on FEES after the first swallow. Novel computerized measurement approaches are useful building blocks for future research. It is hoped that with better measurement will come better understanding of residue, its risks, and consequences