Routine use of ultrasound 24 hours before laparoscopic cholecystectomy can predict the need for intraoperative cholangiogram: results of a 12-month prospective audit

Progressive supranuclear palsy (PSP) is a progressive degenerative extrapyramidal disease that often masquerades as Parkinson's disease (PD). Similar to PD, dysphagia frequently complicates the course of PSP. Because there is only one published report characterizing dysphagia in PSP, we reviewed the neurologic features and dynamic videofluoroscopic swallowing function study results in 10 dysphagic PSP patients. Abnormalities during multiple stages of ingestion were recorded in each patient. Uncoordinated lingual movements, absent velar retraction or elevation, impaired posterior lingual displacement, and copious pharyngeal secretions were noted in all patients. Tongue-assisted mastication, noncohesive lingual transfer, excessive oral bolus lingual leakage to the pharynx prior to active transfer, vallecular bolus retention, abnormal epiglottic positioning, and hiatal hernias were noted in at least half of the cohort. Although ingestion abnormalities in PSP are similar to those previously reported in PD, the number of studied patients and observed differences were too few to clearly differentiate the two diseases.     

Serial fiberoptic endoscopic swallowing evaluations in the management of patients with dysphagia

OBJECTIVE: To determine whether serial fiberoptic endoscopic evaluation of swallowing (FEES) can be used successfully and efficiently in deciding to change a patient's feeding status from nonoral (NPO) to oral (PO) with no adverse health outcome. DESIGN: A prospective, consecutive, cohort study. SETTING: Inpatient population of a tertiary-care university teaching hospital. SUBJECTS: Thirty-two adults were recruited from a cohort of 400 consecutive subjects who participated in a previous dysphagia study. INTERVENTION: Serial FEES was performed 3 to 6 times in each subject to detect objectively pharyngeal phase dysphagia, aspiration, and aspiration risk and to provide information for recommendations regarding oral feeding status and therapeutic intervention. The number of FEES was based on the subject's medical status, evidence of dysphagia, and clinical judgement. MAIN OUTCOME MEASURES: Identification of pharyngeal phase dysphagia, aspiration, and aspiration risk, and recommendations for initial feeding status, when to resume oral feeding, and what bolus consistencies to use for optimal swallowing success. RESULTS: In all subjects, serial FEES detected pharyngeal phase dysphagia, aspiration, and aspiration risk and enabled determination of initial feeding status (NPO or PO), when to resume successful oral feeding, and what bolus consistencies to use for optimal swallowing success. Specifically, 15 of 32 (47%) subjects received FEES 3 to 5 times within only 6 to 22 days. Timely serial FEES allowed 22 of 32 (69%) subjects to resume an oral diet as early and safely as possible. CONCLUSIONS: No subject who resumed an oral diet based on results of FEES developed an aspiration pneumonia. Serial FEES, therefore, enabled feeding status to be successful and efficiently changed from NPO to PO with no adverse health outcome. FEES was an efficient procedure with regard to appointment scheduling, transportation, patient issues, and personnel requirements.     

Clinical and electrophysiological evaluation of dysphagia in myasthenia gravis

OBJECTIVE: To evaluate dysphagia at the oropharyngeal stage of swallowing and to determine the pathophysiological mechanisms of dysphagia in patients with myasthenia gravis. METHODS: Fifteen patients with myasthenia gravis with dysphagia and 10 patients without dysphagia were investigated by a combined electrophysiological and mechanical method described previously. Laryngeal movements were detected by a piezoelectric transducer and the related submental EMG (SM-EMG) and sometimes the EMG of cricopharyngeal muscle of the upper esophageal sphincter (CP-EMG) were recorded during dry or wet swallowing. The results of these electrophysiological variables were compared with those of normal age matched control subjects. RESULTS: In patients with myasthenia gravis with dysphagia, it was found that the time necessary for the larynx to remain in its superior position during swallowing and swallowing variability in successive swallows increased significantly compared with normal subjects and with patients with myasthenia gravis without dysphagia. The total duration of SM-EMG activity was also prolonged in both groups but more severely in the dysphagic patients. Electromyographic activity of the CP sphincter was found to be normal in the dysphagic patients investigated. All the patients with myasthenia gravis with dysphagia had pathological dysphagia limits (<20 ml water) whereas other patients except two, were within normal limits. CONCLUSIONS: Because the electrophysiological variables related to oropharyngeal swallowing were prolonged even in patients with myasthenia gravis without dysphagia, it is concluded that the submental and laryngeal elevators are involved subclinically in myasthenia gravis and, because of compensating mechanisms, the patient may not be dysphagic. As the CP-EMG behaviour was found to be normal, a coordination disorder between normal CP sphincter muscle and the affected striated muscles of the laryngeal elevators may be one of the reasons for dysphagia in myasthenia gravis. This method also made it possible to investigate the myasthenic involvement in the laryngeal elevators that cannot be evaluated by other electrophysiological methods in myasthenia gravis.     

Primary closure of pharyngeal remnant after total laryngectomy and partial pharyngectomy: how much residual mucosa is sufficient?

After total laryngectomy with or without partial pharyngectomy, the remaining pharyngeal defect can be repaired either by primary closure or with additional tissue, depending on the amount of pharyngeal tissue remnant available. The aim of this study was to determine the minimum width of the pharyngeal remnant that could be safely closed primarily without causing difficulty in swallowing. A total of 52 consecutive patients who underwent total laryngectomy were entered into the study. The relaxed and stretched widths of the pharyngeal remnant were measured after removal of the specimen. The widths of the pharyngeal mucosa ranged from 1.5 to 5.0 cm relaxed (mean, 3.24 cm) and from 2.5 to 8.0 cm stretched (mean, 4.83 cm). All neopharynx was reconstructed by closing the pharynx primarily. Seven of the 52 patients developed recurrent tumor with concomitant dysphagia. Two of the 45 patients without recurrence presented with acute dysphagia from food bolus obstruction, and 1 patient developed benign inflammatory stricture following an episode of fish-bone impaction. The narrowest widths of the pharyngeal remnant in this group of 45 were 1.5 cm relaxed and 2.5 cm stretched. As these patients do not have swallowing difficulty, we conclude that in the absence of tumor recurrence, this amount of residual pharyngeal tissue is sufficient both for primary closure of the pharynx and in restoring swallowing function.     

Solid bolus swallowing in the radiologic evaluation of dysphagia

Patients with dysphagia, heartburn and chest pain are regularly referred for radiologic evaluation of swallowing. The liquid barium swallow has been of great value for the biphasic evaluation of the pharynx and esophagus. Though many patients complain of dysphagia specifically for solids, solid bolus swallow is usually not part of the evaluation. For the present study we therefore included the use of a solid bolus with a diameter of 13 mm and interviewed the patients carefully for any symptoms during this tablet swallow. Of 200 patients examined, the tablet passed through the esophagus without delay in 102. In the 98 patients with delayed passage, the solid bolus arrest occurred in the pharynx in 5 and in the esophagus in 93. Arrest in the esophagus was due to esophageal dysmotility in 48 patients. Twenty of these were symptomatic during the tablet swallow. A narrowing was the cause in 45, of whom 9 had symptoms. In 18 patients (9%) the solid bolus added key information to the radiologic evaluation. We therefore recommend that the solid bolus is included in the routine radiologic work-up of patients with dysphagia. Careful attention to symptoms during the tablet swallow is important.     

Microscopic measurement of cellular infiltration in the rheumatoid arthritis synovial membrane: a comparison of semiquantitative and quantitative analysis

BACKGROUND: A significant proportion of burn patients with inhalation injuries incur difficulties with airway protection, dysphagia, and aspiration. In assessing the need for intubation in burn patients, the efficacy of fiberoptic laryngoscopy was compared with clinical findings and the findings of diagnostic tests, such as arterial blood gas analysis, measurement of carboxyhemoglobin levels, pulmonary function tests, and radiography of the lateral aspect of the neck. OBJECTIVE: To determine if these patients were at risk for aspiration or dysphagia, barium-enhanced fluoroscopic swallowing studies were performed. DESIGN: Prospective study. SETTINGS: Burn intensive care unit in an academic tertiary referral center. MAIN OUTCOME MEASURES: Need for endotracheal intubation and potential for aspiration. RESULTS: Six (55%) of 11 patients had clinical findings and symptoms that indicated, under traditional criteria, endotracheal intubation for airway protection. Visualization of the upper airway with fiberoptic laryngoscopy obviated the need for endotracheal intubation in all 11 patients. These patients also failed to evidence an increased risk of aspiration or other swallowing dysfunction. CONCLUSIONS: In comparison with other diagnostic criteria, fiberoptic laryngoscopy allows differentiation of those patients with inhalation injuries who, while at risk for upper airway obstruction, do not require intubation. These patients may be safely observed in a monitored setting with serial fiberoptic examinations, thus avoiding the possible complications associated with intubation of an airway with a compromised mucosalized surface. In these patients, swallowing abnormalities do not manifest.     

Does pulse oximetry reliably detect aspiration in dysphagic stroke patients?

BACKGROUND AND PURPOSE: The aim of the present study was to examine the value of pulse oximetry in the diagnosis of aspiration by comparing it with the gold standard, videofluoroscopy, by use of a prospective, controlled, single-blind study design. METHODS: Pulse oximetry was performed simultaneously with videofluoroscopy in 54 consecutive dysphagic stroke patients. Oxygen saturation measurements were taken before the video-fluoroscopic examination (baseline), on swallowing and continuously for 2 minutes after swallowing, and 10 minutes later. RESULTS: Pulse oximetry reliably predicted aspiration or lack of it in 81.5% of cases. The predictive value of the test was low in patients aged > or = 65 years and possibly those with chronic lung disease. One smoker also had a false-negative pulse oximetry result, ie, normal oxygen saturation despite radiological evidence of aspiration. CONCLUSIONS: Pulse oximetry is a reliable method of diagnosis of aspiration in most dysphagic patients. However, careful interpretation of pulse oximetry data is necessary in older subjects, possibly those with chronic pulmonary disease, and smokers. The method is noninvasive, simple, and quick, and can be used routinely in the clinical assessment of dysphagic patients.     

Videomanometry of the pharynx in dysphagic patients with a posterior cricopharyngeal indentation

RATIONALE AND OBJECTIVES: Patients with a posterior indentation in the pharyngoesophageal segment (PES) are generally considered to have an abnormality of the cricopharyngeal muscle (CPM). In this study we determined the actual width of the PES and the pressure circumstances during swallowing within the pharynx and PES in such patients. METHODS: Simultaneous videofluoroscopy and solid state manometry, radiologic examination of the pharynx, PES, and cervical esophagus were performed in 16 dysphagic patients with a cricopharyngeal (CP) bar. In eight patients the indentation was 25-50%, and in eight it was more than 50% of the adjacent gullet. Sixteen dysphagic patients without a CP bar were used as control subjects. In each patient swallows of 10-ml barium bolus were recorded. RESULTS: Patients with CP bars had a significantly wider PES above (p = .0005) and below (p = .02) the CPM, whereas the diameter at the level of the CPM was smaller only in the patients with more than 50% indentation compared with the patients without a CP bar. The contraction pressure above the CP bar (i.e., at the level of the inferior pharyngeal constrictor) was significantly (p = .002) weaker in patients with a CP bar (131 +/- 16 mm Hg) than in those without a CP bar (222 +/- 20 mm Hg). CONCLUSION: Our findings in patients with a posterior CP bar suggest that the major abnormality is weak constrictors with outpouching of the gullet above and below. Only in patients with more than 50% indentation was there a slight narrowing at the level of the CP bar. The CPM showed no manometric abnormalities in terms of resting pressure, relaxation, and contraction pressure. Therefore, the CPM is likely to relax and distend normally during swallowing in patients with a CP bar.     

Pharyngo-esophageal dysphagia in Parkinson's disease

The radiologic characteristics of pharyngoesophageal (PE) dysfunction in Parkinson's disease (PD) are not well established, partly because most previous studies have examined only small numbers of patients. We administered a dynamic videofluoroscopic swallowing function study to 71 patients with idiopathic PD. Using the Hoehn and Yahr disease severity scale, patients were subdivided into those with mild/moderate disease, subgroup I (n = 38), and advanced PD disease, subgroup II (n = 33). From pharyngeal ingestion to gastric emptying, bolus transport was normal in only 2 patients. The most common abnormalities occurring during pharyngeal ingestion included impaired motility, vallecular and pyriform sinus stasis, supraglottic and glottic aspiration, and deficient epiglottic positioning and range of motion. Esophageal abnormalities were multiple but most commonly included delayed transport, stasis, bolus redirection, and tertiary contractions. Typical aberrations of lower esophageal sphincter (LES) function included an open or delayed opening of the LES and gastro-esophageal reflux. A pathogenesis linking PE with the pathology of PD is proposed.     

Current procedures for diagnosing dysphagia in elderly clients

Intubation no longer remains the only solution to feeding problems of the elderly patient with dysphagia. Dysphagic disorders result from neurogenic, myogenic, psychogenic, or mechanical causes. Thus numerous hospitalized or institutionalized elderly patients may have dysphagic symptoms. The consequences of this disorder are significant, and aspiration pneumonia is often the outcome. Current diagnostic procedures available to identify dysphagia are discussed.     

Amelanotic lentigo maligna melanoma of the face: a case report and review of the literature

Neuroleptic medications may result in extrapyramidal symptoms that can affect swallowing. Both oral and pharyngeal phases of swallowing may be affected. Unlike the more common causes of dysphagia, especially in the elderly, drug-induced dysphagia may be reversible. This report describes a case of neuroleptic-induced dysphagia in an elderly male with Alzheimer's disease. When the loxapine was discontinued, the dysphagia improved significantly.     

Telemedicine in Australia. Recent developments

To assess the frequency and natural history of swallowing problems following an acute stroke, 121 consecutive patients admitted within 24 hours of the onset of their stroke were studied prospectively. The ability to swallow was assessed repeatedly by a physician, a speech and language therapist, and by videofluoroscopy. Clinically 51% (61/121) of patients were assessed as being at risk of aspiration on admission. Many swallowing problems resolved over the first 7 days, through 28/110 (27%) were still considered at risk by the physician. Over a 6-month period, most problems had resolved, but some patients had persistent difficulties (6, 8%), and a few (2, 3% at 6 months) had developed swallowing problems. Ninety-five patients underwent videofluoroscopic examination within a median time of 2 days; 21 (22%) were aspirating. At 1 month a repeat examination showed that 12 (15%) were aspirating. Only 4 of these were persistent; the remaining 8 had not been previously identified. This study has confirmed that swallowing problems following acute stroke are common, and it has been documented that the dysphagia may persist, recur in some patients, or develop in others later in the history of their stroke.     

Shortened PCR cycles in a conventional thermal cycler

Although swallowing difficulties (dysphagia) frequently occur in acute brainstem infarction, physiological studies of dysphagia (videofluoroscopy, manometry) are rarely reported. We present a patient with ipsilateral Horner's syndrome, palatal and laryngeal weakness, aphagia, and ipsilateral face and contralateral extremity pin and temperature loss due to lateral medullary infarction confined to the rostral dorsolateral medulla (RDM). Videofluoroscopy showed that the patient was unable to initiate a swallow. Manometry showed a markedly reduced peak pharyngeal pressure and weak pharyngeal contractions. Within 20 months, the patient's neurological deficits resolved, videofluoroscopy showed a normal swallow, and manometry showed normal peak pharyngeal pressure. Correlation of the clinical, physiological, and imaging evaluations shows that aphagia and severe bilateral pharyngeal paresis can result from unilateral RDM infarction. We suggest that, in man, the bilateral medullary swallowing centers function as one integrated center, and that infarction of a portion of this center is sufficient to cause complete loss of swallowing.     

Severe dysphagia associated with major tranquillizer treatment

A 56 year old patient with psychiatric complications of systemic lupus erythematosus developed severe dysphagia complicated by weight loss and aspiration. Following investigation it was concluded that the addition of haloperidol to her treatment was the major precipitating cause and withdrawal of the drug was followed by an objective improvement in swallowing. Patients taking major transquillizers may be at increased risk of severe dysphagia; regular observation of swallowing is suggested as a useful addition to the clinical examination of these patients.     

Evaluation and treatment of speech and swallowing disorders associated with myopathies

Dysphagia, or disordered swallowing, can be demonstrated at any time over the course of many myopathies. Ability to swallow may be impaired because of weakness, inflammation, or dysfunction of the oropharyngeal, laryngeal, and esophageal musculature. Dysphagia may occur during the progression of disease regardless of whether the patient is properly treated. The presentation of signs of dysphagia can vary among patients because of differing patterns of weakness or incoordination of the facial muscles, lips, tongue, palate, pharyngeal constrictors, or smooth and striated muscles of the esophagus. Although the literature has focused on problems in the esophagus, scant attention has been paid to the oropharynx, which is often equally affected. Studies suggest that surgical myotomy and botulinum toxin injection may provide benefits for some patients with esophageal dysfunction. Although the condition is pervasive, there is little information on the incidence of dysphagia in muscular disorders. Because a major complication of dysphagia is aspiration, any sign of swallowing impairment demands medical attention and treatment.     

Management of vagus nerve injury afer carotid endarterectomy

BACKGROUND: Inadvertent injury to the vagus nerve or its branches during carotid endarterectomy can result in adductor vocal cord paralysis (hoarseness) and cricopharyngeal dysfunction (dysphagia) with aspiration, known as "double trouble." This study describes our experience in the management of this complication in cases where conservative treatment failed. METHODS: All patients were examined by a vascular surgeon, a head and neck surgeon, and a speech therapist. Their examinations included comprehensive speech evaluation, video stroboscopy, video fluoroscopy, and methylene blue testing for aspiration. All patients underwent Teflon injections to medialize the paralyzed vocal cord and a cricopharyngeal myotomy to restore swallowing and alleviate aspiration. RESULTS: Fourteen patients, eight men and six women, were treated. The duration of dysfunction was 24 weeks in two patients, 6 weeks in four patients, 4 weeks in three patients, and 1 week in five patients. Five patients had severe dysfunction (defined as difficulty in swallowing both solid and liquid foods with more than 20% aspiration), seven patients had moderate dysfunction (defined as difficulty swallowing solid food with aspiration of less than 20%), and two patients had mild dysfunction (defined as difficulty in swallowing solids but with no aspirations). After the Teflon injections and myotomy, 13 of 14 patients had satisfactory outcomes, including normal voice and swallowing. CONCLUSIONS: Vagus nerve injury from a carotid endarterectomy can be a debilitating complication. Prevention, early recognition, and prompt correction of these injuries are important in the management of this complication.     

Cricopharyngeal myotomy as a method of treating cricopharyngeal dysphagia secondary to gastroesophageal reflux

Food obstruction at the cricopharyngeal level is a common symptom of gastroesophageal reflux. In selected patients, cricopharyngeal myotomy is effective in relief of symptoms. We have used myotomy in patients whose only symptom was dysphagia, in patients too debilitated for major surgery, and in patients with persistent pharyngoesophageal dysphagia following hiatal hernia repair. All were studied by barium esophagogram, endoscopy, and manometry. Radiologic aspiration of barium was apparent in five of 19 patients. High-speed manometric tracings showed intermittent cricopharyngeal incoordination in the six consecutive patients most recently studied. This finding of incoordination has been shown to be present in 38 patients with reflux and in all with major cricopharyngeal symptoms. Myotomy was effective in relieving symptoms in patients in whom this was the only reflux symptom and in the five patients too debilitated for major surgery. Good symptomatic improvement was obtained in nine of the 12 with persistent dysphagia following hernia repair, but in three relief was partial, with persistent symptoms being secondary to distal esophageal obstruction. Investigation is necessary to exclude other causes of dysphagia. However, withcareful selection, myotomy has proved to be an effective method of treatment.     

Neuropsychological performance and plasma cortisol, arginine vasopressin and oxytocin in patients with major depression

Understanding the nature of swallowing in persons without swallowing problems is a prerequisite to evaluating the nature and extent of dysphagia in persons with compromised swallowing. In order to determine how swallowing varies with age and with liquid bolus volume in women, we assessed 167 normal female swallowers videofluoroscopically and obtained multiple measures of swallowing function. The women in this study demonstrated a change in swallowing function with age, due primarily to an increase in pharyngeal transit and total duration of the motor response. The duration of closure and opening of valves in the upper aerodigestive tract also increased with age, and the duration of laryngeal elevation and hyoid movement peaked in the 60-79-year-old age groups. Bolus volume effects were quite consistent across most measures. As the bolus volume increased from 1 ml to 10 ml, transit times decreased and durations of valve closure and opening increased. The results of this study may be used to specify the relationship of swallowing function to age and liquid bolus volume in women, relationships that heretofore have been observed only in part and in smaller and more heterogeneous populations.     

Analysis and radiologic staging of the type and severity of aspiration

The estimated number of the incidence of undiagnosed chronic aspiration pneumonia after cerebral or cerebrovascular injury seems very high. According to American statistics, at least 6% of these patients die from aspiration pneumonia within the first year. The high temporal resolution of cineradiography with frame rates of the complex process of pharyngeal swallowing lasting 0.7 s. The method enables us to differentiate between so-called pre-, intra- and postdeglutitive aspiration, which means aspiration before, during and after the triggering of the swallowing reflex. Together with an established score for the severeness of the aspiration, the method supplies important data for setting up a functional surgical and/or conservative program for rehabilitation and for follow-up-studies.     

Swallowing changes in cerebrovascular accidents: incidence, natural history, and repercussions on the nutritional status, morbidity, and mortality

OBJECTIVE: To determine the frequency of dysphagia in CVA, its natural history and value as a risk factor of respiratory infection, malnutrition and death. PATIENTS AND METHODS: A prospective study was made of 187 consecutive patients with cerebrovascular accidents (CVA). A standardized test for dysphagia was done during the first two days of the illness and repeated three days a week. The levels of urea, total proteins and albumin were determined on admission and on discharge. The patients were questioned by phone after 6 months. RESULTS: There was dysphagia of liquids in 36.4% of the patients. The incidence of dysphagia for semisolids was of the same frequency but more severe. Coma was the cause of inability to swallow in 25.7% of the patients. During their stay in hospital one third of the patients with dysphagia died, one third became normal and one third still had dysphagia when they were discharged. After one week, one, three and six months respectively, the cure rate for dysphagia was 29.4%, 4.1%, 55.9% and 55.9%, and survival 83.8%, 67.6%, 61.8% and 60.3%. Thus after 6 months only 3 patients (4.4%) were alive and dysphagic. Half of the 'cures' occurred in the first week, and none occurred after more than 77 days. As compared to the non-dysphagic patients, the dysphagic patients had 10 times more risk of respiratory infection, 18 times higher risk of death, greater loss of albumin and less loss of urea. CONCLUSIONS: There is a high prevalence of dysphagia in CVA and although functional prognosis is not unfavorable, respiratory infections, malnutrition and death are frequent.