Pharyngeal Pressure Variability During Volitional Swallowing Maneuvers

Purpose: Within-individual pharyngeal swallowing pressure variability differs among pharyngeal regions in healthy individuals and increases with age. It remains unknown if pharyngeal pressure variability is impacted by volitional swallowing tasks. We hypothesized that pressure variability would increase during volitional swallowing maneuvers and differ among pharyngeal regions depending on the type of swallowing task being performed. Method: Pharyngeal high-resolution manometry was used to record swallowing pressure data from 156 healthy participants during liquid (5 cc) or saliva swallows, and during volitional swallowing tasks including effortful swallow, Mendelsohn maneuver, Masako maneuver, or during postural adjustments. The coefficient of variation was used to determine pressure variability of velopharynx, tongue base, hypopharynx, and upper esophageal sphincter regions. Repeated-measures analysis of variance was used on log-transformed data to examine effects of pharyngeal region and swallowing tasks on swallow-to-swallow variability. Results: There was a significant main effect of task with greater pressure variability for the effortful swallow ( p = .002), Mendelsohn maneuver ( p < .001), Masako maneuver ( p = .002), and the head turn ( p = .006) compared with normal effort swallowing. There was also a significant main effect of region ( p < .01). In general, swallowing pressure variability was lower for the tongue base and upper esophageal sphincter regions than the hypopharynx. There was no significant interaction of task and region (effortful, p = .182; Mendelsohn, p = .365; Masako, p = .885; chin tuck, p = .840; head turn, p = .059; and inverted, p = .773). Conclusions: Pharyngeal swallowing pressure variability increases in healthy individuals during volitional swallowing tasks. Less stable swallow patterns may result when tasks are less automatic and greater in complexity. These findings may have relevance to swallowing motor control integrity in healthy aging and individuals with neurogenic dysphagia.

Successful treatment of dysphagia in a COVID-19 survivor

<p class="abstract">This study was aimed<strong> </strong>document a successful case of dysphagia management after coronavirus disease 2019 (COVID-19) infection. COVID-19 is highly infectious disease and causes 75 million infection and 1.66 million deaths worldwide. Clinical features of COVID-19 including respiratory compromise, microvascular thrombosis and neurologic dysfunction as well as well as prolonged intensive care unit (ICU) care in severe cases yield patients particularly susceptible to mild to severe swallowing impairment which can persist for months or years after ICU discharge. A 52 years old female was diagnosed with severe pharyngo-oesophageal dysphagia after COVID-19 infection and was advised for swallowing therapy. The swallowing therapy was given thrice a week for 45 minutes including Masako, Shaker’s and modified Shaker’s exercise along with effortful swallow, Mendelsohn maneuvers and super-supraglottic swallow. After 2 weeks of swallowing therapy patient started taking semisolid food orally and maintain normal SpO₂level during feeding. This study concluded early intervention is the key to boost faster recovery and helped to improve patient’s quality of life.<strong> </strong>Swallowing manuvers and exercises were very effective for the management of dysphagia secondary to COVID-19 infection. This can be generalized and efficacy can be determined with large group of patients having swallowing difficulty after COVID-19 infection.</p>

Prehabilitation in head and neck cancer patients: a literature review

Background Dysphagia is one consequence of head and neck cancer that has a significant impact on quality of life for head and neck cancer survivors. While survival rates continue to improve, focus has shifted to maximizing long-term function, with prevention or prehabilitation programs becoming more common. Prehabilitation programs typically include an exercise regime that specifies the exercise type, the number of repetitions to complete per set, the number of sets of each exercise to complete per day, as well as the length of the treatment block. Ideally, exercise programs are designed with principles of neuromuscular plasticity in mind. Methods Twenty-nine original research articles published between 2006 and 2020 were included in this state-of-the-art review and examined for program timing and details. Results Two definitions for prehabilitation were noted: one third of the studies defined prehabilitation as preventative exercises prior to the start of acute cancer treatment; the remaining two thirds defined prehabilitation as treatment concurrent prehabilitation. Exercises prescribed ranged from general stretching and range of motion exercises, to trismus and swallowing specific exercises. The most common swallowing specific exercise was the Mendelsohn’s maneuver, followed by the effortful swallow, Shaker, and Masako maneuver. The most common dose was 10 repetitions of an exercise, three times per day for the duration of radiation therapy. The most common measures were questionnaires, followed by g-tube dependence, mouth opening, and MBS reports. Conclusion This review of the literature has shed light on the variability of prehabilitation timing, exercise type, dose, duration of treatment, and outcomes associated with prehabilitation, making the selection of an optimal prehabilitation program difficult at this time.

The Influence of Surface Electromyography Visual and Clinician Verbal Feedback on Swallow Effort Ratio at Different Bolus Volumes in a Healthy Population

<b><i>Background/Aims:</i></b> The effortful swallow is a common treatment intervention requiring increased intensity to facilitate adaptations and modify swallow kinematics. The type of feedback and bolus volume provided may influence the intensity of the effortful swallow. To determine the increased effortful swallow intensity, a clinician can collect the peak amplitude of an effortful swallow and a typical swallow and compute a “swallow effort ratio” (SER). Dividing the effortful swallow surface electromyography (sEMG) peak amplitude by the typical swallow sEMG peak amplitude derives the SER. A higher SER suggests increased intensity. An increase in the SER may have clinical relevance in swallowing therapy as a threshold of intensity is required to elicit neuroplastic change. The purpose of this investigation was to determine whether sEMG visual and clinician verbal feedback increases the SER. Additionally, the investigation examined whether the SER is influenced by different liquid bolus volumes. <b><i>Methods:</i></b> Eighty-two nondysphagic, healthy adults were assigned at random to 2 groups. One group received no feedback, and the other received verbal and visual feedback while performing typical and effortful swallows at 3 liquid volumes. <b><i>Results:</i></b> An analysis of covariance compared the typical and effortful peak swallow amplitudes among 3 volumes in the 2 feedback groups. There was a significant effect on the peak amplitude values by feedback group <i>F</i>(2, 79) = 22.82, <i>p</i> &#x3c; 0.001. There were no differences in peak amplitude by volume regardless of feedback <i>F</i>(2, 78) = 0.413, <i>p</i> = 0.663. <b><i>Conclusion:</i></b> It appears that sEMG visual and clinician verbal feedback increases the SER, which may be a surrogate for intensity. An increased SER may have a positive effect on swallow intervention as intensity is known to influence outcomes of exercise and elicit neuroplastic change.

A Systematic Review of the Physiological Effects of the Effortful Swallow Maneuver in Adults With Normal and Disordered Swallowing

Purpose This systematic review summarizes the biomechanical and functional effects of the effortful swallow in adults with and without dysphagia, highlighting clinical implications and future research needs. Specifically, the effects of the effortful swallow on swallowing physiology, safety, and efficiency were identified, as well as the strengths and limitations of current research. Method Recommendations specified by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses were followed. A literature search of three databases and relevant articles cited in the searched studies was performed. Two evaluators independently analyzed the studies for eligibility criteria, and final inclusion of studies was decided by consensus. Evaluators also assessed each study for quality of evidence. Results Twenty-three studies were included in this systematic review. Main findings indicated that the effortful swallow generated greater pressures in the tongue-to-palate, pharynx, upper esophageal sphincter, and esophageal regions. Inconsistent results for hyolaryngeal excursion were reported, as well as for swallowing function. Instructions of the effortful swallow varied greatly across studies. Two of the 23 studies were judged to be of high quality, and the remaining studies were of medium quality based on the quality indicators of this review. Conclusions Biomechanical effects of the effortful swallow included increased pressures in the oral, pharyngeal, and esophageal regions. Future investigations should address the effects of the effortful swallow in individuals with dysphagia and its potential role as a rehabilitative maneuver. Moreover, standardization of the effortful swallow instructions based on its physiological and functional effects is essential.

Assessment and Management of Dysphagia in Acute Stroke: An Initial Service Review of International Practice

The international approach to the assessment and management of dysphagia in the acute phase post stroke is little studied. A questionnaire was sent to clinicians in stroke services that explored the current practice in dysphagia screening, assessment, and management within the acute phase post stroke. The findings from four (the UK, the US, Canada, and Australia) of the 22 countries returning data are analysed. Consistent approaches to dysphagia screening and the modification of food and liquid were identified across all four countries. The timing of videofluoroscopy (VFS) assessment was significantly different, with the US utilising this assessment earlier post stroke. Compensatory and Postural techniques were employed significantly more by Canada and the US than the UK and Australia. Only food and fluid modification, tongue exercises, effortful swallow and chin down/tuck were employed by more than fifty percent of all respondents. The techniques used for assessment and management tended to be similar within, but not between, countries. Relationships were found between the use of instrumental assessment and the compensatory management techniques that were employed. The variation in practice that was found, may reflect the lack of an available robust evidence base to develop care pathways and identify the best practice. Further investigation and identification of the impact on dysphagia outcome is needed.

Dysphagia following total laryngectomy: a myth or a reality? How can we help

<p class="Default">Total laryngectomy leads to drastic anatomical changes in the swallowing and breathing mechanism. Reduced tongue base retraction, poor pharyngeal clearance, stricture and prominence in the posterior pharyngeal wall have been reported to cause swallowing difficulties in individuals with total laryngectomy. The present case study describes the swallowing characteristics in an individual with total laryngectomy and discusses efficacy of swallowing maneuvers in total laryngectomy. A 55 yr/male, operated case of total laryngectomy using TEP reported with complaint of food getting stuck in the throat and vomiting sensation. He was fed orally and could tolerate only thick liquids. Swallowing assessment was carried out by clinical and instrumental tools (modified barium swallow) which revealed cricopharyngeal prominence, poor pharyngeal clearance and significant post swallow residue. Effortful swallow was attempted to explore the change in swallowing mechanism. Relaxation of pharyngeal wall with better pharyngeal clearance was seen with the maneuver. Clinically, the case reported of ability to swallow semisolids and solids well with the maneuver. At 3 month follow up, the case reported no difficulty in swallowing semisolids and solids orally. The above case study highlights on radiological evidence of swallowing abnormalities following total laryngectomy and further on the efficacy of maneuver on mechanism of swallowing. Hence, it can be noted that swallowing intervention has strong implications in patients with total laryngectomy. </p>