Can Videofluoroscopic Swallowing Kinematic Analysis Predict Recovery of Oral Intake in Postoperative Oral Cancer Patients Requiring Nasogastric Tube Feeding?

This retrospective study determined the significant predictive factors for the number of days required to remove nasogastric tubes (NGTs) after surgery in patients with oral cancer (OC). In this study, patients underwent a videofluoroscopic swallowing study (VFSS) approximately 2 weeks after surgery. Videofluoroscopic images were analyzed, and variables such as swallowing and swallowing kinematics were measured. Patient characteristics, swallowing kinematics, and swallowing results were assessed using a Cox proportional hazards model. This study assessed 129 participants (66 men, 63 women, mean age: 69.0 ± 14.1 years) with nine types of cancer. The Cox proportional hazard ratio revealed that sex, body mass index before surgery, radiotherapy and/or chemotherapy, dysphagia before surgery, normalized pharyngeal constriction ratio, upper esophageal sphincter (UES) opening, and laryngeal vestibule disclosure (LVC) disorder were predictive factors for the removal of NGTs when adjusted for age. The study identified several predictive factors for the removal of NGTs and oral intake recovery in patients with OC. Regarding swallowing kinematics, UES opening is the most significant predictive factor. After surgery for OC, VFSS should be performed to assess safe eating methods and predict the recovery of oral intake and removal of the NGT.

Functional Changes of the Upper Esophageal Sphincter in Gastroesophageal Reflux

Introduction The upper esophageal sphincter (UES) is a muscular structure located at the transition from the pharynx to the esophagus, with the cricopharyngeal muscle as the most important component. During gastroesophageal reflux, the pressure in the UES elevates, which is apparently a protective mechanism to prevent esophagopharyngeal reflux and airway aspiration. In gastroesophageal reflux disease (GERD), there may be functional changes in the UES. Objective The objective of the present review was to determine UES functional changes in GERD. Data Synthesis In healthy individuals, gastroesophageal reflux causes an increase in the UES pressure. This response of the sphincter is at least partially impaired in patients with GERD. In the disease, the UES has a reduced length and decreased resting pressure. However, other publications found that in chronic gastroesophageal reflux the basal sphincter pressure increase, differences which may be consequent to the measurement method or to disease severity. The UES opening during swallowing has a smaller diameter, and the bolus transit time through the sphincter is longer. Conclusion The UES of patients with GERD does not open as expected and the bolus flow through the sphincter is longer. This behavior may be associated with dysphagia, a frequent complaint in patients with GERD.

The Frequency of Atypical and Extreme Values for Pharyngeal Phase Swallowing Measures in Mild Parkinson Disease Compared to Healthy Aging

Purpose Dysphagia is thought to be prevalent and a leading cause of morbidity and mortality in people with Parkinson disease (PwPD). The aim of this study was to compare the frequencies of atypical and extreme values for measures of swallowing physiology in PwPD and in an age- and sex-matched cohort of healthy adults. Atypical and extreme values were defined, respectively, as values falling in the 25% and 5% tails of the reference distribution for healthy adults under age 60 years. Method A standard videofluoroscopy (VF) protocol was performed in 17 adults with mild PD and 17 age- and sex-matched healthy adults using 20% w/v liquid barium ranging from thin to extremely thick consistency. Blinded VF analysis was performed according to the Analysis of Swallowing Physiology: Events, Kinematics and Timing Method. Frequencies for atypical and extreme values were tabulated by cohort and compared using odds ratios. Results Increased frequencies of atypical values (> 25%) were seen in the PwPD for prolonged swallow reaction time, prolonged time-to-laryngeal-vestibule-closure (LVC), and poor pharyngeal constriction. However, these findings were also observed in the healthy controls. The PwPD showed significantly higher odds of atypical values for narrow upper esophageal sphincter (UES) diameter on thin liquids, a short hyoid-burst-to-UES-opening interval on extremely thick liquids, and prolonged time-to-LVC, LVC duration, and UES opening duration on multiple consistencies. The frequencies of extreme values failed to show any significant cohort differences for any parameter. Conclusions In this study, a group of people with mild PD did not show clear evidence of swallowing impairments distinct from the changes seen in a healthy age-matched control group when odds ratios were used to compare the frequencies of atypical values between PwPD and the control group; only a few parameters showed significant differences. These were findings of significantly higher frequencies in PwPD of prolonged LVC and UES opening duration. Supplemental Material https://doi.org/10.23641/asha.15032241

Which Physiological Swallowing Parameters Change with Healthy Aging?

Research suggests there are age-related changes in swallowing that do not constitute impairment (“presbyphagia”). The goal of this study was to explore the influence of age on quantitative measures of healthy swallowing by controlling for the effects of sex and sip volume in order to determine the specific characteristics of presbyphagia. Videofluoroscopy recordings of thin liquid swallows from 76 healthy adults (38 male), aged 21-82 were analysed. Blinded duplicate ratings of swallowing safety, efficiency, kinematics, and timing were made using the ASPEKT method. Hierarchical regression models were used to determine the effects of age, sex, and sip-volume on swallowing. There were no age-related changes in sip volume, number of swallows per bolus, frequency or severity of penetration-aspiration, duration of the hyoid-burst (HYB)-to-upper-esophageal-sphincter (UES) opening interval, time-to-laryngeal-vestibule-closure (LVC), peak hyoid position, hyoid speed, or pharyngeal residue. Significant changes seen with increasing age included: longer swallow reaction time, UES opening duration and LVC duration; larger pharyngeal area at rest and maximum constriction; and wider UES diameter. Male participants had larger sip volume and pharyngeal area at rest. Larger sip volumes were associated with multiple swallows per bolus and shorter hyoid-burst-to-UES opening intervals. These results help to define presbyphagic changes in swallowing that can be expected in healthy older adults up to 80 years of age, and distinguish them from changes that represent impairment. Certain parameters showed changes that were opposite in direction to changes that are usually considered to reflect impairment: longer UES opening, longer LVC duration and wider UES opening. These changes may reflect possible compensations for slower bolus transit. Further research is needed to determine the points along the age continuum where observed age-related changes in swallowing begin to emerge.

Fluoroscopic Swallowing Abnormalities in Dysphagic Patients Following Anterior Cervical Spine Surgery

Objectives: To evaluate the precise objective fluoroscopic abnormalities in persons with dysphagia following anterior cervical spine surgery (ACSS). Methods: 129 patients with dysphagia after ACSS were age and sex matched to 129 healthy controls. All individuals underwent videofluoroscopic swallow study (VFSS). VFSS parameters abstracted included upper esophageal sphincter (UES) opening, penetration aspiration scale (PAS), and pharyngeal constriction ratio (PCR). Other data collected included patient-reported outcome measures of voice and swallowing, number of levels fused, type of plate, vocal fold immobility, time from surgery to VFSS, and revision surgery status. Results: The mean age of the entire cohort was 63 (SD ± 11) years. The mean number of levels fused was 2.2 (±0.9). 11.6% (15/129) were revision surgeries. The mean time from ACSS to VFSS was 58.3 months (±63.2). The majority of patients (72.9%) had anterior cervical discectomy and fusion (ACDF). For persons with dysphagia after ACSS, 7.8% (10/129) had endoscopic evidence of vocal fold immobility. The mean UES opening was 0.84 (±0.23) cm for patients after ACSS and 0.86 (±0.22) cm for controls ( P > .0125). Mean PCR was 0.12 (±0.12) for persons after ACSS and 0.08 (±0.08) for controls, indicating significant post-surgical pharyngeal weakness ( P < .0125). The median PAS was 1 (IQR 1) for persons after ACSS as well as for controls. For ACSS patients, PCR had a weak correlation with EAT-10 ( P < .0125). Conclusion: Chronic swallowing dysfunction after ACSS appears to be secondary to pharyngeal weakness and not diminished UES opening, the presence of aspiration, vocal fold immobility, or ACSS instrumentation factors. Level of Evidence: 3b

The Importance of Extensional Rheology in Bolus Control during Swallowing

Thickened fluids are commonly used in the medical management of individuals who suffer swallowing difficulty (known as dysphagia). Previous studies have shown that the rheological properties of a liquid affect the flow behavior of the bolus in swallowing, such as pharyngeal transit time. While there is no doubt that shear rheology is a highly important factor for bolus flow, it is suspected that extensional properties of a liquid bolus also plays an important role in swallowing, due to elongation of the bolus as it flows through the oropharynx. Our aim in this work was to observe the effect of extensional viscosity on pharyngeal transit time and elongation of the bolus during swallowing. Eight samples of thickened liquid barium that were shear-controlled, but varied in extensional viscosity and two samples that were extensional-controlled, but varied in shear viscosity were swallowed by eight healthy individuals. Data were collected under lateral view of videofluoroscopy swallow study (VFSS); measures of pharyngeal transit time and the ratio of the length to the width of the bolus on the frame of Upper Esophageal Sphincter (UES) opening were taken from the VFSS recordings. It was observed that the pharyngeal transit time generally increases when the fluids are thickened to higher IDDSI consistency. Additionally, higher extensional viscosity fluids reduced the elongation of the bolus during swallowing, thus potentially reducing the risk of post-swallow residue due to bolus breakage. This study confirmed the relevance of the extensional viscosity of the bolus in swallowing.

Forehead against Resistance (FAR): Preliminary Findings from A Clinical Alternative to Shaker’s Type of Exercise

Background. Reduced UES opening is a well-known risk factor for dysphagia. The Shaker exercise and the CTAR are the widely used intervention strategies to bring about effective UES opening. But there are well-known difficulties with the clinical use of these two exercise regimes. The present study proposes a clinical alternative to Shaker’s exercise and CTAR called the forehead against resistance (FAR) and its variants without altering the central principles of these two regimes. The aim of the present study was to investigate the efficacy of FAR and its variants in bringing about UES opening. Method. The study used a comparative cross-sectional study design, with the nonrandomized convenient sampling that included 27 healthy adults. MBS was carried out in the anterior-posterior and lateral views, while the participants performed FAR and its variants. The UES diameter was measured in the baseline and with the subjects performing FAR maneuver and its variants. Results. The result revealed that the participants had greater UES opening on FAR and its variant than the baseline swallow. Also, mean values of UES opening were greater for FAR with chin tuck when compared to FAR alone, although there was no significant main effect with exercise. Conclusion. FAR and its variant could be one of the options for increasing UES opening in individuals with dysphagia.