老年病人的吞咽功能

吞咽功能由口腔和咽部的协调动作来完成。吞咽时口腔完成下列动作:1)关闭口唇;2)面部紧张以保持咀嚼时迫使唇龈沟和颊龈沟的食物普遍地接近舌;3)当咀嚼期间下颌向侧面进行旋转运动以压碎食物;4)舌向侧面旋转运动以控制口腔内的食物和用唾液混合食物;5)软腭前部突出以防止食物不适当地从口腔进入咽部。吞咽时咽部完成下列动作:1)咽部关闭以防止食物和液体返流到鼻咽部和鼻腔;2)喉和舌骨上升并向前运动;3)喉关闭;4)舌根向后运动至咽后壁以迫使食物和水向下移动;5)蠕动波迫使食物和水继续向下推进;6)咽环肌松弛。口腔和咽部的上述动作需要感觉和运动神经支配及其协调活动才能实现。     

吞咽障碍与神经疾病

0引言由神经疾病引起的吞咽障碍可称为神经性吞咽障碍.此种症状多由于原发的神经疾病累及吞咽的口期和咽期的感觉和运动的功能,影响口、咽部肌肉推送食团自口腔经咽至食管的功能.有些神经疾病亦可同时影响食管.本文主要论述口咽部的神经性吞咽障碍.大多数慢性口咽部吞咽障碍属于神经源性,但也有不少是由气管插管后水肿、咽部肿块、憩室等所致[1].1神经性吞咽障碍的表现1.1患者患有已知的神经疾病有口咽部神经性吞咽障碍症状,如咀嚼困难、吞咽起始困难、鼻腔漏溢、流涎、唾液分泌困难、吞咽时呛咳或噎呛、咽喉梗塞等;并有神经性吞咽障碍的并…     

老年晚期肿瘤误吸与死亡的探讨

误吸指进食或非进食时吞咽过程中有数量不一的液体或固体食物(包括分泌物或血液等)进入到声门以下的气道,而不是象通常一样的全部食团随着吞咽动作顺利地进入到食管[1]。吞咽是一系列复杂的神经肌肉运动过程,受大脑支配,需口、咽、食管共同参与,其中任何一个部位的机能障碍均可导致误吸[2]。我科收治的多数为老年晚期肿瘤患者,老年人由于     

高频、低频rTMS作用健侧半球吞咽皮质代表区对老年脑卒中后吞咽障碍的影响对比

目的 探究与分析高频、低频重复经颅磁刺激(rTMS)作用健侧半球吞咽皮质代表区对老年脑卒中后吞咽障碍的影响。方法 选取2018年1月至2021年2月收治的162例老年急性缺血性脑卒中后吞咽障碍患者，采取随机数字表法分为3组，分别为高频组、低频组及假刺激组，每组各54例，3组均给予常规内科药物治疗及吞咽康复训练，吞咽康复训练30 min/次，1次/d,每周治疗5 d,连续治疗2 w。高频组实施rTMS时在健侧半球舌骨上肌群吞咽皮质代表区给予刺激，每次给予250脉冲，5 Hz, 1次/d, 10 min/次，每周治疗5 d,连续治疗2 w;低频组实施rTMS时在患者健侧半球舌骨上肌群吞咽皮质代表区给予刺激，每次给予250脉冲，1 Hz, 30 min/次，1次/d,每周治疗5 d;假刺激组给予假rTMAS刺激治疗，线圈90°倾斜，采取与高频组同等的刺激频率。对比3组临床疗效、治疗前后基于吞咽造影检查(VFSS)的定量指标、洼田饮水试验评分及经口摄食功能量表(FOIS)评分，同时采用表面肌电(sEMG)测定舌骨上肌群均方根值(RMS)评估控制吞咽功能的肌肉活动功能，观察治疗期间不良反应。结果...     

老年脑梗死患者隐性误吸与吞咽异常模式的相关性研究

目的探讨老年脑梗死患者隐性误吸与吞咽异常模式的相关性。方法选取2011年6月—2012年12月我院神经内科及康复科收治的急性及亚急性老年脑梗死患者80例,入院后24 h内对其进行临床吞咽功能评估,均合并吞咽障碍。患者在入院14 d内完成吞咽X线荧光透视检查(VFSS),记录显性误吸与隐性误吸发生率;分析吞咽异常模式与隐性误吸相关性。结果完成VFSS的80例患者中,误吸者33例,误吸发生率为41.3%(33/80),其中显性误吸20例、隐性误吸13例。隐性误吸患者的临床表现为:舌运动差,软腭运动感觉差,咽反射消失,多次吞咽,重复吞咽,喉上抬差;在临床评估中存在不同程度的自主咳嗽能力下降,吞咽反射减弱或消失,口咽部食物潴留等体征。回归分析显示,与隐性误吸相关的VFSS吞咽异常模式是软腭运动减弱、吞咽启动延迟、舌肌运动减弱、会厌折返不全、声门关闭不全、喉结构上抬不足。结论老年脑梗死患者吞咽异常模式与隐性误吸间存在一定的相关性,且部分吞咽器官功能障碍可表现出一种或多种吞咽异常模式,有助于客观评估隐性误吸风险,对有效防治卒中相关性肺炎,缩短患者住院时间并改善其预后有重要的临床意义。     

口咽部吞咽障碍的治疗

0引言口咽部吞咽障碍的治疗包括恢复代偿功能疗法、口内矫治疗法、感觉运动协调疗法和吞咽动作演练疗法等,是治疗此项病变的主要方法,有效率可达80%以上[1,2].此类治疗方法有其特殊性.设计和指导此项工作的医师必须熟悉口咽部有关吞咽的生理解剖和口咽部动态造影检查的表现;必须在造影检查中观察吞咽失常的情况,选择和试验较为适合的治疗方法并在造影中观察其效果.但患者在实行代偿功能疗法过程中,却可在不了解生理解剖,“知其然而不知其所以然”的情况下,获得良好疗效.1动态造影是治疗的依据口咽部的吞咽动作非常迅速,约在0.75s内完成.口咽…     

吞咽言语诊疗仪治疗脑卒中吞咽障碍的临床观察

脑卒中吞咽障碍是因为与吞咽有关的中枢部位或神经损伤,使吞咽的一个或多个阶段受损而导致的一组临床综合征,可分为咽、食管吞咽障碍两种类型,脑卒中主要表现为口咽吞咽障碍[1].国内外文献报道脑卒中急性期吞咽障碍的发生率为19%～81%[2].脑卒中后吞咽障碍会严重影响患者的生活质量,甚至导致死亡,应该及早开展综合治疗,尽可能使患者吞咽功能得到恢复.我们对吞咽言语诊疗仪治疗脑卒中吞咽障碍的临床疗效进行观察,为其有临床应用提供资料.     

低频脉冲电刺激联合常规康复训练对阿尔茨海默病患者吞咽功能的影响

目的 探究低频脉冲电刺激联合常规康复训练对阿尔茨海默病(AD)患者吞咽功能及营养指标的影响。方法 120例老年AD患者随机分为对照组和观察组各60例。对照组行常规康复训练，观察组在对照组基础上增加低频脉冲电刺激治疗。比较两组临床疗效、进食并发症及治疗前后舌肌活动度及血氧饱和度(SaO₂)下降值、吞咽功能[洼田饮水试验、电视透视吞咽功能检查(VFSS)]、营养指标[血清白蛋白(ALB)、血红蛋白(Hb)]。结果 观察组临床总有效率明显高于对照组(P<0.05)。与对照组相比，观察组治疗后舌前伸、左右运动度明显更高，SaO₂下降值则明显更低(P<0.05);观察组洼田饮水试验评分更低、VFSS评分则更高(P<0.05)。观察组治疗后ALB、Hb水平均明显高于对照组(P<0.05)。观察组咳呛、误吸、肺炎发生率均明显低于对照组(P<0.05)。结论 低频脉冲电刺激联合常规康复训练可有效改善AD伴吞咽障碍患者的吞咽功能及营养状况，降低进食并发症发生率，疗效显著。     

老年鼻咽癌患者放化疗后并发吞咽功能障碍的相关因素

目的 分析老年鼻咽癌(NPC)患者放化疗后吞咽功能障碍及其影响因素。方法 回顾性分析完成放化疗治疗及1 w随访的100例老年NPC患者病历资料,统计其放化疗结束后1 w内吞咽功能障碍发生情况;比较两组基线资料,分析导致老年NPC患者放化疗后并发吞咽功能障碍的相关因素。结果 放化疗结束后1 w内,100例老年NPC患者中37例(37.00%)发生吞咽功能障碍;功能障碍组同步放化疗、有吸烟史、嚼槟榔占比高于无功能障碍组,咽缩肌放疗总剂量高于无功能障碍组,放化疗前营养状况A级占比低于无功能障碍组,差异有统计学意义(P<0.05);经Logistic回归分析显示,咽缩肌放疗总剂量过高、有吸烟史、放化疗前营养状况B及C级均为老年NPC患者放化疗后并发吞咽功能障碍的影响因素(P<0.05)。结论 老年NPC放化疗患者吞咽功能障碍的发生受咽缩肌放疗总剂量、吸烟史、放疗前营养状况的影响。     

导管球囊扩张术结合用力吞咽法治疗老年环咽肌功能障碍的临床研究

目的探讨导管球囊扩张术结合用力吞咽法应用于老年环咽肌功能障碍病人的疗效。方法选择经视频吞咽造影检查(VFSS)明确诊断为环咽肌功能障碍的老年病人32例,按入院顺序分为研究组和对照组,每组各16例。研究组给予导管球囊扩张术结合用力吞咽法治疗,对照组给予常规吞咽康复治疗,2组均辅以神经肌肉电刺激,分别在治疗前和恢复经口进食或治疗满6周后,利用吞咽障碍临床疗效评价标准和VFSS进行评定,分析比较2组病人吞咽功能的变化。结果治疗后,研究组有效率为93.75%,对照组有效率为75.0%,2组差异有统计学意义(P<0.05)。VFSS检查显示,治疗后2组Rosenbek分级较治疗前均有明显改善,且研究组改善更明显,差异均有统计学意义(P<0.05)。结论导管球囊扩张术结合用力吞咽法,在改善老年环咽肌功能障碍方面优于常规吞咽康复治疗。     

Kinematic and Temporal Factors Associated with Penetration–Aspiration in Swallowing Liquids

In this study we undertook careful analysis of 13 quantitative physiological variables related to oropharyngeal swallowing from a sample of 42 subacute patients referred for dysphagia assessment. Each patient underwent a videofluoroscopic swallowing examination in which they swallowed up to five boluses of 22 % w/v ultrathin liquid barium suspension administered by teaspoon. Our goal was to determine whether scores on 13 kinematic or temporal parameters of interest were independently associated with the presence of penetration–aspiration in the final compiled dataset of 178 swallows. Participants were classified as aspirators based on the presence of at least one swallow that demonstrated a Penetration–Aspiration Scale score of ≥3. The parameters of interest included six kinematic parameters for capturing hyoid position, three swallow durations [laryngeal closure duration, hyoid movement duration, and upper esophageal sphincter (UES) opening duration], and four swallow intervals (laryngeal closure to UES opening, bolus dwell time in the pharynx prior to laryngeal closure, stage transition duration, and pharyngeal transit time). Mixed-model repeated-measures ANOVAs were conducted to determine the association between each parameter and aspiration status. Only 1 of the 13 parameters tested distinguished aspirators from nonaspirators: aspirators demonstrated significantly shorter UES opening duration. In addition, a trend toward reduced maximum superior position of the hyoid was seen in aspirators. Limitations and future considerations are discussed.     

Upper esophageal sphincter opening and modulation during swallowing

Studies were done on 8 normal subjects with synchronized videofluoroscopy and manometry to facilitate a biomechanical analysis of upper esophageal sphincter opening and volume-dependent modulation during swallowing. Movements of the hyoid and larynx, dimensions of sphincter opening, and intraluminal sphincter pressure were determined at 1/30th-s intervals during swallows of 1, 5, 10, and 20 ml of liquid barium. Our analysis subdivided upper esophageal sphincter activity during swallowing into five phases: (a) relaxation, (b) opening, (c) distention, (d) collapse, and (e) closure. Sphincter relaxation occurred during laryngeal elevation and preceded opening by a mean period of 0.1 s. Opening occurred as the sphincter was pulled apart via muscular attachments to the hyoid such that the hyoid coordinates at which sphincter opening and closing occurred were constant among bolus volumes. Sphincter distention after opening was modulated by intrabolus pressures rather than graded hyoid movement. The generation of intrabolus pressure coincided with the posterior thrust of the tongue that culminated in pharyngeal wall contact and the initiation of pharyngeal peristalsis. Larger volume swallows were associated with greater intrabolus pressure and increased bolus head velocity. The duration of sphincter opening increased in conjunction with a prolongation of the anterior-superior excursion of the hyoid and a delay in the onset of pharyngeal peristalsis (the event that determined the timing of sphincter closure). We conclude that transsphincteric transport of increasing swallow bolus volumes is accomplished by modulating sphincter diameter, opening interval, and flow rate (reflected by bolus head velocity). Furthermore, upper esophageal sphincter opening is an active mechanical event rather than simply a consequence of cricopharyngeal relaxation.     

Timing Differences Between Cued and Noncued Swallows in Healthy Young Adults

Temporal parameters such as stage transition duration, bolus location at swallow onset, and pharyngeal transit time are often measured during videofluoroscopy, but these parameters may vary depending on assessment instructions. Specifically, “command” (cued) swallows have been observed to alter timing compared to spontaneous (noncued) situations in healthy older adults. The aim of our study was to confirm whether healthy young people show timing differences for thin liquid swallows between cued and noncued conditions. Twenty healthy young adults swallowed 10-cc boluses of ultrathin barium in videofluoroscopy. The cued condition was to hold the bolus in the mouth for 5 s before swallowing. Three noncued swallows were also recorded. In the cued condition, bolus advancement to the pyriform sinuses prior to swallow initiation was seen significantly less frequently. Stage transition durations showed a nonsignificant trend toward being shorter. Pharyngeal transit times and pharyngeal response time (a measure capturing the interval between hyoid movement onset and bolus clearance through the upper esophageal sphincter) were both significantly longer in the cued condition. Our study in healthy young adults confirms findings previously observed in older adults, namely, that swallow onset patterns and timing differ between cued and noncued conditions. In particular, bolus advancement to more distal locations in the pharynx at the time of swallow onset is seen more frequently in noncued conditions. This pattern should not be mistaken for impairment in swallow onset timing during swallowing assessment.     

Variation in Temporal Measures of Swallowing: Sex and Volume Effects

Temporal measures of healthy swallowing appear to be variably sensitive to bolus and participant factors based on a recent meta-analysis of studies in the deglutition literature. In this carefully controlled study of healthy young volunteers, balanced for sex and height, we sought to understand the influence of bolus volume and participant sex on the three durations and three intervals most frequently reported in the deglutition literature. Three boluses per target volume (5, 10, and 20 ml) were repeated for each participant (n = 20, 10 male) using a spontaneous swallow paradigm in lateral view videofluoroscopy. None of the temporal durations or intervals was found to be correlated with participant height above an a priori cutoff point of r ≥ 0.3. Further, none of the temporal durations or intervals varied significantly by participant sex. Bolus volume significantly impacted upper esophageal sphincter (UES) opening duration, laryngeal closure duration, the laryngeal closure-to-UES opening interval, and the pharyngeal transit time interval, but not hyoid movement duration or the stage transition duration interval. When participants are sampled in such a manner as to represent the range of height reported to be typical for both sexes in the population, sex does not significantly influence temporal measures of swallowing.     

Gender Effects on Airway Closure in Head and Neck Cancer Patients

Age, gender, and bolus effects on the duration of laryngeal closure, the onset of laryngeal closure in relation to the first cricopharyngeal opening, and the duration of cricopharyngeal opening in head and neck cancer patients have not been well documented. Thirty-three head and neck cancer patients (middle-aged women and men, and older women and men) were evaluated with videofluoroscopy before and 3?months after their cancer treatment. At 3?months post-treatment, the mean duration of laryngeal closure was longer for women than for men at 1-, 5-, and 10-ml bolus volumes. The duration of laryngeal closure at 3?months post-treatment and the duration of cricopharyngeal opening at both pretreatment and 3?months post-treatment increased as liquid bolus volume increased. Gender effects were observed in the duration of laryngeal closure during swallow. Bolus effects were observed in the duration of laryngeal closure and cricopharyngeal opening.     

Gender Effects on Airway Closure in Normal Subjects

The present study was designed to examine age and gender differences with respect to the duration of laryngeal closure, the onset of laryngeal closure in relation to the first cricopharyngeal opening, and the duration of cricopharyngeal opening for six different groups: normal younger men and women (22–29 years), normal middle-aged men and women (45–53 years), and normal older men and women (81–94 years) (10 subjects in each group for a total of 60 subjects). Data were collected by means of videofluoroscopic studies. During swallows of liquid barium, results indicated that normal older subjects had longer cricopharyngeal opening than younger subjects (P = 0.044). Results also revealed that the mean duration of laryngeal closure was significantly longer in women than in men (P = 0.013). The onset of laryngeal closure was significantly earlier in women than in men (P = 0.006). Also, bolus volume effects were observed for both the duration of laryngeal closure (P < 0.0001) and cricopharyngeal opening (P < 0.0001). During liquid barium swallows there was a linear increase in both the duration of laryngeal closure and cricopharyngeal opening.     

Effects of systematic bolus viscosity and volume changes on hyoid movement kinematics

Using ultrasonography with head and transducer stabilization, this study examined the effects of maximally controlled, systematic changes in bolus viscosity (thin juice-like, 7 cP; nectar-like, 243–260 cP; honey-like, 724–759 cP; spoon-thick, 2760–2819 cP) and volume (5, 10, 20, 30 cc) on hyoid kinematics in 31 healthy subjects (16 male, 15 female) in three age groups (20–39, 40–59, 60–79 years). Frame-by-frame hyoid displacements were tracked from digitized images of 612 swallows. Measures of movement durations, maximal amplitudes, total distances, and peak velocities were subjected to repeated measures multivariate analyses of variance with viscosity, volume, age, and gender as factors. Results showed that (1) spoon-thick swallows had the greatest preswallow gesture and total movement durations; (2) larger-volume swallows had significantly greater maximal amplitudes, forward peak velocity, and total vertical distance; (3) older subjects had longer start-to-max duration (though shorter preswallow gesture and total movement durations), greater maximal vertical amplitude, longer total vertical distance, and greater backward peak velocity than younger subjects; (4) males had greater values for all kinematic parameters except preswallow gesture, hyoid-at-max, and max-to-end durations. The results illustrate the importance of examining the interrelations among kinematic variables to better understand task accommodation and motor control strategies. The evidence also supports the concept of suprahyoid–infrahyoid functional adaptation and compensation in the healthy elderly.     

Effects of Barium Concentration on Oropharyngeal Swallow Timing Measures

Videofluoroscopy is commonly used for evaluating oropharyngeal swallowing but requires radiopaque contrast (typically barium). Prior studies suggest that some aspects of swallowing, including timing measures of oral and pharyngeal bolus transit, vary depending on barium concentration. The aim of our study was to identify timing differences in healthy swallowing between “thin” (40 % w/v concentration) and “ultrathin” (22 % w/v concentration) barium solutions. Twenty healthy adults (Ten women; mean age = 31 years) each performed a series of three noncued 5-ml swallows each of ultrathin and thin liquid barium solutions in videofluoroscopy. Timing measures were compared between barium concentrations using a mixed-model ANOVA. The measures of interest were stage transition duration, pharyngeal transit time, and duration of upper esophageal sphincter opening. Significant differences were observed in the timing measures of swallowing with respect to barium concentration. In all cases, longer durations were seen with the higher barium concentration. Barium concentration influences timing parameters in healthy swallowing, even between ultrathin and thin concentrations. Clinicians need to understand and control for the impact of different barium stimuli on swallowing physiology.     

The Effects of Cervical Bracing Upon Swallowing in Young,Normal, Healthy Volunteers

Abstract The purpose of this study was to evaluate radiographically the effects of cervical bracing upon swallowing thin liquids and solid food in normal adults under three cervical bracing conditions. This was a prospective, repeated measures design study. Seventeen healthy adult volunteers between the ages of 30 and 50 were recruited from hospital staff. All subjects reported no previous history of swallowing difficulty or diseases that might affect swallowing. Subjects were radiographically observed swallowing thin liquids and solid food without cervical bracing and with three common cervical orthoses (Philadelphia collar, SOMI, and halo-vest brace). Order of bracing and type of bolus were randomized. Changes in swallowing function (point of initiation of swallow response, presence of pharyngeal residue, airway penetration, hyoid bone movement, diameter of oropharyngeal airway, and durational measurements) were analyzed by two independent raters. Eighty-two percent (14/17) of the subjects demonstrated radiographic changes under one or more of the bracing conditions. Forty-seven percent (8/17) of subjects demonstrated changes with point of initiation of the swallow response, 59% (10/17) demonstrated increased pharyngeal residue, and 23.5% (4/17) demonstrated changes with bolus flow with laryngeal penetration present. Aspiration did not occur under any of the bracing conditions. Changes noted in durational measurements for oral containment and total pharyngeal transit under the bracing conditions were not considered statistically significant. This study shows that cervical bracing does change swallowing physiology in normal healthy adults.     

Swallowing Physiology of Sequential Straw Drinking

The goal of this study was to examine deglutitive physiology during sequential straw drinking in healthy young adults (n = 15) to learn how sequential swallowing differs from single swallows. The physiology of single swallows has been studied extensively in healthy adults and in adults with a variety of debilitating conditions, but the physiology of sequential swallows has not been studied adequately. Videofluoroscopic analysis revealed three distinct patterns of hyolaryngeal complex (HLC) movement during sequential straw swallows: opening of the laryngeal vestibule after each swallow (Type I, 53%), continued vestibule closure after each swallow (Type II, 27%), and interchangeable vestibule opening and closing during the swallow sequence (Mixed, 20%). Unlike discrete swallowing, the onset of the pharyngeal swallow occurred when the bolus was inferior to the valleculae in the majority of subjects and was significantly associated with HLC movement pattern. The leading bolus edge was inferior to the valleculae at swallow onset for Type II movement patterns. For Type I movement patterns, bolus position at swallow onset was randomly distributed between three anatomical positions: superior to the valleculae, at the level of the valleculae, and inferior to the valleculae. Preswallow pharyngeal bolus accumulation, which is common during mastication, was evident and significantly associated with the HLC pattern of opened laryngeal vestibule after each swallow. These data suggest that in healthy young adults, sequential swallows differ physiologically from discrete swallows and indicate substantial variability in deglutitive biomechanics.