Effect of Liquid Bolus Consistency and Delivery Method on Aspiration and Pharyngeal Retention in Dysphagia Patients

There is no empirically derived consensus as to what food consistency types and method of food delivery (spoon, cup, straw) should be included in the videofluoroscopic swallowing (VFSS) studies. In the present study, we examine the rates of aspiration and pharyngeal retention in 190 dysphagic patients given thin (apple juice) and thick (apricot nectar) liquids delivered by teaspoon and cup and ultrathick (pudding-like) liquid delivered by teaspoon. Each patient was tested with each of the bolus/delivery method combinations. The fractions of patients exhibiting aspiration for each bolus/method of delivery combination were (1) thick liquids (cup), 13.2%; (2) thick liquids (spoon), 8.9%; (3) thin liquids (cup), 23.7%; (4) thin liquids (spoon), 15.8%, (5) ultrathick liquids (spoon), 5.8%. In each comparison [thick liquid (cup) vs. thick liquid (spoon), thin liquid (cup) vs. thin liquid (spoon), thick liquid (cup) vs. thin liquid (cup), thick liquid (spoon) vs. thin liquid (spoon), and thick liquid (spoon) vs. ultrathick liquid (spoon)], the p value for χ² was <0.001. These results suggest that utilizing thin, thick, and ultrathick liquids and delivery by cup and spoon during a VFSS of a patient with mild or moderate dysphagia can increase the chances of identifying a consistency that the patient can swallow without aspirating and without pharyngeal retention after swallowing. Submitted December 22, 1999; accepted September 6, 2000 with revision     

表面麻醉对球囊扩张治疗鼻咽癌放疗后吞咽障碍疗效的影响

目的探讨表面麻醉对球囊主动扩张治疗鼻咽癌放疗后吞咽障碍疗效的影响。 方法选取54例鼻咽癌放射治疗后出现吞咽障碍的患者,采用随机数字表法将其分为表面麻醉组（表麻组）和无麻醉组（无麻组）,表麻组患者进行球囊主动扩张前给予表面麻醉,无麻组患者进行球囊主动扩张前不给予表面麻醉;2组患者均同时辅以低频电刺激,持续治疗3周。于治疗前、后进行X线吞咽造影及吞咽自觉费力程度评定。 结果治疗后2组患者咽启动延迟时间明显缩短、环咽肌开放程度明显增加（P<0.05）,喉部前移和上抬幅度亦显著改善（P<0.05）,自觉费力吞咽评分和无效吞咽次数均明显减少（P<0.05）,并且无麻组上述指标改善情况均显著优于表麻组（P<0.05）;另外治疗后无麻组患者误吸率（3.6%）较治疗前（57.1%）及对照组水平（38.5%）均显著降低（P<0.05）,经口进食改善率(89.3%)较表麻组(61.5%)明显提高（P<0.05）。 结论球囊主动扩张配合低频电刺激治疗鼻咽癌放疗后吞咽障碍具有协同作用,有利于提高患者吞咽功能,且治疗时不采用表面麻醉的疗效优于使用表面麻醉。     

Endoprosthetics for malignant esophageal disease

Currently used stents for malignant esophageal strictures include self-expanding metal stents (SEMS), self-expanding plastic stents (SEPS), and biodegradable stents. For the palliative treatment of malignant dysphagia, both SEMS and SEPS effectively provide rapid relief of dysphagia. SEMS are preferred over SEPS as randomized controlled trials have shown more technical difficulties and late migration with plastic stents. Despite specific characteristics of recently developed stents, recurrent dysphagia due to food impaction, stent migration, and both tumoral and nontumoral tissue overgrowths are common. Complication rates are probably also affected by stent “behavior” in the esophagus, with radial and axial forces being important determinants. The efficacy of stents with an antireflux valve for patients with distal esophageal cancer has not convincingly been proven. Concurrent treatment with chemotherapy and radiotherapy seems to be safe and effective, although biodegradable stents have shown disappointing results. It can be expected that removable stents will increasingly be used as bridge to surgery to maintain luminal patency during neoadjuvant treatment.     

Oesophageal atresia: The growth gap

Poor growth is an under-recognised yet significant long-term sequelae of oesophageal atresia(OA) repair. Few studies have specifically explored the reasons for growth impairment in this complex cohort. The association between poor growth with younger age and fundoplication appears to have the strongest supportive evidence, highlighting the need for early involvement of a dietitian and speech pathologist, and consideration of optimal medical reflux management prior to referring for anti-reflux surgery. However, it remains difficult to reach conclusions regarding other factors which may negatively influence growth, due to conflicting findings, inconsistent definitions and lack of validated tool utilisation. While swallowing and feeding difficulties are particularly frequent in younger children, their relationship with growth remains unclear. It is possible that these morbidities impact on the diet of children with OA, but detailed analysis of dietary composition and quality, and its relationship with these complications and growth, has not yet been conducted. Another potential area of research in OA is the role of the microbiota in growth and nutrition. While the microbiota has been linked to growth impairment in other paediatric conditions,it is yet to be investigated in OA. Further research is needed to identify the most,important contributory factors to poor growth, the role of the intestinal microbiota, and effective interventions to maximise growth and nutritional outcomes in this cohort.     

低频脉冲电刺激联合吞咽功能训练在脑卒中后吞咽障碍患者中的应用

目的 探讨低频脉冲电刺激联合吞咽功能训练在脑卒中后吞咽障碍患者中的应用。方法 选取2017 年6 月～2019 年2 月我院神经内科治疗的脑卒中后吞咽障碍患者92 例,随机分为联合组和单纯组,每组各46 例。单纯组患者予常规吞咽功能训练,联合组患者在单纯组常规吞咽功能训练的基础上加低频脉冲电刺激治疗,两组干预周期均为6 周。比较干预前后两组患者的吞咽功能评分及血氧饱和度,并评估临床效果。结果 治疗6 周后,两组藤氏评分、饮水试验评分和血氧饱和度均高于治疗前,且联合组均高于单纯组,差异有统计学意义（P＜0.05）;联合组总有效率（95.65%）显著高于单纯组（82.61%）,差异有统计学意义（P＜0.05）。结论 低频脉冲电刺激联合吞咽功能训练用于脑卒中后吞咽障碍患者的效果优于单纯吞咽功能训练,能改善患者的吞咽功能及血氧饱和度水平。     

Swallowing and deep brain stimulation in Parkinson's disease: A systematic review

The purpose of this review is to assess the current state of the literature on the topic of deep brain stimulation (DBS) and its effects on swallowing function in Parkinson's disease (PD). Pubmed, Cochrane review, and web of science searches were completed on all articles addressing DBS that contained a swallowing outcome measure. Outcome measures included the penetration/aspiration scale, pharyngeal transit time, oropharyngeal residue, drooling, aspiration pneumonia, death, hyolaryngeal excursion, epiglottic inversion, UPDRS scores, and presence of coughing/throat clearing during meals. The search identified 13 studies specifically addressing the effects of DBS on swallowing. Critical assessment of the 13 identified peer-reviewed publications revealed nine studies employing an experimental design, (e.g. “on” vs. “off”, pre- vs. post-DBS) and four case reports. None of the nine experimental studies were found to identify clinically significant improvement or decline in swallowing function with DBS. Despite these findings, several common threads were identified across experimental studies and will be examined in this review. Additionally, available data demonstrate that, although subthalamic nucleus (STN) stimulation has been considered to cause more impairment to swallowing function than globus pallidus internus (GPi) stimulation, there are no experimental studies directly comparing swallowing function in STN vs. GPi. Moreover, there has been no comparison of unilateral vs. bilateral DBS surgery and the coincident effects on swallowing function. This review includes a critical analysis of all experimental studies and discusses methodological issues that should be addressed in future studies.     

Temporal trends in the relative prevalence of dysphagia etiologies from 1999-2009

AIM: To examine the relative prevalence and temporal variation of dysphagia etiologies in patients undergoing upper endoscopy (EGD) over the past decade.METHODS: EGDs with the indication of dysphagia at an urban, university medical center in 1999, 2004 and 2009 were retrospectively identified from the electronic medical record. The entire patient chart, including EGD, pathology, manometry, radiographic and clinician reports, was reviewed for demographic and clinical data and to determine the etiology of dysphagia. The number of EGDs in which an esophageal biopsy was performed was also noted. Gastroesophageal reflux disease (GERD) as a cause of dysphagia independent of peptic stricture was defined by symptoms with erosive esophagitis or symptom response to proton pump inhibition (PPI). Cases of eosinophilic esophagitis (EoE) were defined by an appropriate clinical history and histological criteria of ≥ 15 eosinophils per high powered field. PPI-responsive esophageal eosinophilia was not routinely reported prior to 2008. Statistical analysis was performed using one-way analysis of variance to analyze for trends between 1999, 2004 and 2009 and a post-hoc Tukey analysis was performed following a significant main effect.RESULTS: A total of 1371 cases (mean age 54 years, 43% male) met pre-specified inclusion criteria with 191, 504 and 675 cases in 1999, 2004 and 2009, respectively. Patients were older in 2004 compared to 2009 (mean ± SD, 54.0 ± 15.7 years vs 52.3 ± 16.8 years, P = 0.02) and there were more males in 1999 compared to 2004 (57.5% vs 40.8%, P = 0.005). Overall, GERD (27.6%) and EoE (7.7%) were the most common identifiable causes of dysphagia. An unspecified diagnosis accounted for 21% of overall cases. There were no significant differences in the relative prevalence of achalasia or other motility disorders, peptic stricture, Schatzki’s ring, esophageal cancer or unspecified diagnoses over the 10-year time period. There was, however, a decrease in the relative prevalence of GERD (39.3% vs 24.1%, P < 0.001) and increases in the relative prevalence of EoE (1.6% vs 11.2%, P < 0.001) and oropharyngeal disorders (1.6% vs 4.2%, P = 0.02) from 1999 to 2009. Post-hoc analyses determined that the increase in relative prevalence of EoE was significant between 1999 and 2009 as well as 2004 and 2009 (5.4% vs 11.6%, P < 0.001), but not between 1999 and 2004 (1.6% P 5.4%, P = 0.21). On the other hand, the decrease in relative prevalence of GERD was significant between 1999 and 2009 and 1999 and 2004 (39.3% vs 27.7%, P = 0.006), but not between 2004 and 2009 (27.7% vs 24.1%, P = 0.36). There were also significantly more EGDs in which a biopsy was obtained in 1999 compared to 2009 (36.7% vs 68.7%, P < 0.001) as well as between 2004 and 2009 (37.5% vs 68.7%, P < 0.001). While total EGD volume did increase over the 10-year time period, the percentage of EGDs for the indication of dysphagia remained stable making increasing upper endoscopy an unlikely reason for the observed increased prevalence of EoE.CONCLUSION: EoE has emerged as a dominant cause of dysphagia in adults. Whether this was due to a rise in disease incidence or increased recognition is unclear.     

舌面散刺联合金津、玉液点刺出血治疗脑卒中后吞咽困难临床疗效观察

目的 探讨舌面散刺联合金津、玉液点刺出血治疗脑卒中后吞咽困难的临床疗效。方法 将60例脑卒中后吞咽困难患者,采用随机数字表法按患者入院先后顺序随机分为对照组30例,治疗组30例。两组均给予神经内科常规西药治疗及吞咽功能康复训练,对照组采用常规针刺,取廉泉、风府、哑门穴,治疗组在对照组基础上采用舌面散刺联合金津、玉液点刺出血,2周为1个疗程。2周后采用洼田饮水试验量表、改良曼恩吞咽能力评估（Mann assessment of swallowing ability,MASA）量表、改良Barthel指数（modified Barthel index,MBI）量表评价并比较两组的疗效。结果 治疗后两组患者洼田饮水试验量表评级比较,差异有统计学意义（Z=－4.026,P=0.000）;且治疗后治疗组的洼田饮水试验量表评级在Ⅰ级、Ⅱ级分布占比较多;广义估计方程统计结果表明,两组治疗方法产生的疗效不同,治疗组吞咽功能恢复情况优于对照组（P<0.05）,治疗后吞咽功能疗效优于治疗前（P<0.05）。两组患者治疗后MBI量表评分、MASA评分均较治疗前显著升高（P<0.05）,且治疗组MBI量表评分升高程度大于对照组（P<0.05）。结论 舌面散刺联合金津、玉液点刺出血治疗脑卒中后吞咽困难疗效确切,该治疗方法可促进神经功能恢复,减轻患者脑卒中后吞咽困难症状,提高患者生活质量。