Regulation of interleukin-8 binding and function by heparin and alpha2-macroglobulin

The effect of radiation on speech and swallowing function was assessed for 18 patients surgically treated for oral and oropharyngeal cancer. Nine patients received surgical intervention and postoperative radiation therapy, and nine received surgery only. Patients were matched regarding percentage of oral tongue resected, percentage of tongue base resected, locus of resection, and method of reconstruction. Speech and swallowing function was assessed before and at 1, 3, 6, and 12 months after surgery following a standardized protocol. Speech tasks included an audio recording of a brief conversation and of a standard articulation test; swallowing function was examined with videofluoroscopy. Statistical testing indicated that overall speech function did not differ between the irradiated and nonirradiated patients. Irradiated patients had significantly reduced oral and pharyngeal swallowing performance, specifically, longer oral transit times on paste boluses, lower oropharyngeal swallow efficiency, increased pharyngeal residue, and reduced cricopharyngeal opening duration. Impaired function may be the result of radiation effects such as edema, fibrosis, and reduced salivary flow. Increased use of tongue range-of-motion exercises during and after radiation treatment may reduce the formation of fibrotic tissue in the oral cavity and may improve pharyngeal clearance by maintaining adequate tongue base-to-pharyngeal wall contact.     

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.     

Tongue reconstruction: outcomes with the rectus abdominis flap

Advanced carcinoma of the oral cavity is a devastating disease, with the potential for severe speech and swallowing dysfunction. This is a retrospective review documenting the outcome of 14 patients who underwent resection of at least 75 percent of their tongue with preservation of the larynx and an intact mandible. Reconstruction was accomplished with rectus abdominis free tissue transfer. There were seven male and seven female patients between the ages of 25 and 77 years (mean, 55 years) who underwent total (eight patients) or subtotal (six patients) glossectomy and reconstruction. Decannulation of the tracheostomy tube was performed in 12 patients (86 percent) at an average of 3.5 months postoperatively. One patient required interval laryngectomy for intractable aspiration 1 month postoperatively. Independent evaluation of speech, articulation, and deglutition was performed. Fifty percent of patients achieved oral intake of pureed foods or better. Sixty-four percent had acceptable speech. Reconstruction with rectus abdominis free tissue transfer is a viable method for rehabilitation, improving quality of life after total or subtotal glossectomy with laryngeal preservation.     

Hepatic Kupffer cell blockade reduces mortality of acute hemorrhagic pancreatitis in mice

BACKGROUND: Recovery of upper aerodigestive tract function after reconstruction of segmental oromandiblectomy defects is frequently incomplete. The purpose of this study was to quantitate postreconstruction function and define variables that predict functional outcome in this population. METHODS: A prospective study of 21 patients who underwent microvascular free tissue transfer reconstruction of segmental oromandibular defects was performed. Measures of swallowing, speech, bite, and oral intake were performed preoperatively and at 1, 3, 6, and 12 months postoperatively or until plateau. Preoperative versus maximal postoperative measures were compared and correlated with nine potentially predictive variables. Univariate and multivariate analyses were performed to determine the most significant predictive factors. RESULTS: Baseline function in the study population was abnormal. Postoperative bite force improved, but swallowing, speech, and oral intake were worse than preoperative. Significant (univariate) predictors of outcome included diagnosis of cancer, tongue resection, pharynx resection, and flap skin paddle area. Only tongue resection remained significant in multivariate analysis. CONCLUSIONS: Increasing need for oropharyngeal lining replacement, especially after tongue resection, is the most important predictor of functional outcome in reconstruction of segmental mandible defects.     

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.     

Idiotype vaccination strategies against a murine B-cell lymphoma: dendritic cells loaded with idiotype and bispecific idiotype x anti-class II antibodies can protect against tumor growth

BACKGROUND: Following extensive resections of head and neck tumors, re-establishing speech and masticatory function are of crucial importance for the patient. METHODS: In 23 patients with vascularised jejunal grafts for reconstruction of the intraoral mucosa, tongue and floor of mouth, a speech intelligibility test was performed, tongue and floor of mouth mobility was investigated using a 3.5 MHz ultrasound scanner. In another 18 patients with vascularised bone grafts for reconstruction of the mandible, masticatory function was analysed using a T-scan system and a miniature pressure transducer. RESULTS: Speech results with jejunal grafts in the lateral floor of mouth/tongue region may attain 91.4%, in anterior floor of mouth reconstructions 63.4%. Patients with implant-bone dentures and vascularised bone grafts prefer the non-reconstructed side for chewing. Masticatory force is significantly diminished compared to a control group. DISCUSSION: Lack of neurosensitive feedback mechanisms may be responsible for diminished chewing pressure and also for inferior speech results despite good floor-of-mouth/tongue mobility. CONCLUSIONS: Despite complex microvascular tissue reconstructions, severe functional impairments remain and necessitate further investigations on improvement of postoperative speech, swallowing and chewing function.     

Electromyography in near-total laryngectomy

OBJECTIVE: To investigate the dynamics of speech shunt muscle in patients with Pearson near-total laryngectomy by needle electromyography and correlation of ability to activate shunt muscle with speech production. DESIGN AND SETTINGS: Prospective study of patients with near-total laryngectomy at 2 hospital-based academic tertiary care centers. PARTICIPANTS AND INTERVENTION: Fourteen patients with near-total laryngectomy were subjected to percutaneous needle electromyographic study of the shunt muscle. MAIN OUTCOME MEASURES: Speech ability, electromyographic evidence of viable muscle in shunt wall, and ability to activate shunt muscle were recorded. RESULTS: Twelve of 14 patients had good speech; 11 had evidence of viable shunt muscle; and 9 were able to activate muscle by phonation, swallowing, or deep breathing, indicating preserved innervation. Six of the 12 patients with speech ability and 1 of the 2 patients without speech ability were able to recruit motor units during attempted phonation. CONCLUSIONS: Electromyography demonstrated viable muscle with retained innervation in 64% of the patients with near-total laryngectomy, proving its "dynamic" nature. However, the usefulness of shunt muscle activation in speech and prevention of aspiration needs further confirmation.     

Evaluation of acupuncture and occlusal splint therapy in the treatment of temporomandibular joint disorders

One hundred patients showed signs and symptoms of temporomandibular joint disorder, were participated in a one year follow up study. The patients were randomly divided into four groups: Acuhealth treatment (group A), occlusal splint therapy (group B), Acuhealth and occlusal splint therapy (group C), and control (group D). Each group comprised 25 patients. The patients were examined before and 3, 6, and 12 months after treatment. At the three month evaluation, the patients who were not satisfied with the treatment outcome were offered additional treatment. The result showed that 87% of the patients treated by Acuhealth unit, 77.3% of the patients treated with occlusal splint therapy, and 91.3% of the patients received Acuhealth and occlusal splint therapy were improved subjectively and clinically after 3 months follow-up. The patients who responded well to treatment initially also responded well in the long run. The study showed that the Acuhealth unit proved to be an ideal early therapy for TMD, and complemented later with occlusal splint.     

Effect of muscle relaxation splint therapy on the electromyographic activities of masseter and anterior temporalis muscles

The purpose of this study was to compare the effectiveness of splint therapy on the electromyographic activity of masticatory muscles (anterior temporalis and masseter) before and after the application of a muscle relaxation splint. Electromyography recordings from the masseter and anterior temporalis muscles were analyzed quantitatively during maximal biting in the intercuspal position both before and after treatment without a splint. Fourteen patients whose chief complaint was masticatory muscle pain were selected for the study. After the initial evaluations muscle relaxation splints were applied, and the patients were instructed to use the splints for 6 weeks. Surface electromyographic recordings were taken from each patient before the beginning of clinical therapy and after 6 weeks of wearing the splints. The data obtained were analyzed through paired sample t tests and Wilcoxon's signed rank tests. The results of the study were as follows: (1) the electromyographic activity of the two muscles during maximal biting was not markedly changed after the muscle relaxation splint was used; and (2) the changes observed in electromyographic activity of the involved and noninvolved sides were insignificant as well.     

Swallowing in neurological outpatients: use of a timed test

Swallowing was studied prospectively in a consecutive group of 90 neurology outpatients under 70 years of age. No patient had been referred primarily because of dysphagia. Patients were classified into four groups: those with (1) neurological or (2) non-neurological diagnoses possibly relevant to disordered swallowing, (3) functional disorders, and (4) definite diagnoses not likely to be relevant. They were defined as having abnormal or probably abnormal swallowing if two or more of the following were present: a complaint of swallowing problem, abnormal symptoms or signs, a slow swallowing speed (< 10 ml.s-1). Nineteen patients among the four groups (21%) were found to have abnormal/probably abnormal swallowing. Swallowing speed was significantly slower in patients who perceived a swallowing problem or who had abnormal symptoms or signs compared with those who did not, providing further evidence for the validity of a timed test of swallowing capacity. The study also provides evidence of a significant incidence of disordered swallowing in outpatients who may not have complained spontaneously but who have diagnoses potentially relevant to swallowing.     

Swallowing problems in the nursing home: a novel training response

Various studies suggest that between 50% and 75% of nursing home residents have some difficulty in swallowing. Some of these residents are assessed and treated by speech pathologists, but many are managed by nursing staff without specialist input. A training program called Swallowing ... on a Plate (SOAP) has been developed by the Centre for Education and Research on Ageing and the Inner West Geriatrics and Rehabilitation Service to help address swallowing-related problems in local nursing homes (Inner West of Sydney, Australia). The training program teaches nursing staff how to identify, assess, and manage swallowing problems, including making appropriate referrals. Several new instruments were developed specifically for this program including two assessment checklists, a set of management guidelines, and a swallowing care plan. Evaluation of the program--including 3 months follow-up--showed it to be highly successful. A stand-alone training resource has been produced for wide distribution to help staff implement the program as a permanent aspect of their nursing care. This paper describes the development, content, presentation, resource, and evaluation of the above program.     

Predator-induced nest site preference: safe nests allow courtship in sticklebacks

The sphincter pharyngoplasty is a surgical procedure designed to correct velopharyngeal dysfunction. Its advocates cite the theoretical advantage of its induction of dynamic activity of the neovelopharyngeal port, but this dynamic activity has yet to be quantitatively demonstrated in the literature. The purpose of this study was to quantify postoperative velopharyngeal dynamism and to document the results of intervention outcome on sphincteric excursion measurements from minimal-to-maximal orifice closure. We conducted a 7-year retrospective review of speech videofluoroscopy evaluations in patients who had undergone sphincter pharyngoplasty in our center. Between 1989 and 1994, there were 58 patients so treated for postpalatoplasty velopharyngeal dysfunction by two surgeons using the same operative technique. Patients for whom sphincter pharyngoplasty was recommended fulfilled both of the following criteria: (1) velopharyngeal dysfunction caused by an anatomic, myoneural, or combined deficiency of the velopharyngeal sphincter that would not be expected to be managed by speech therapy alone, and (2) preoperative videonasendoscopy and speech videofluoroscopic studies that demonstrated large-gap coronal, circular, or bow-tie closure patterns or velopharyngeal hypodynamism. Of the original 58 patients, 24 underwent postoperative speech videofluoroscopic evaluations with basal views. Of these, 20 of the evaluations (83 percent) were of adequate quality to be included in a research study. Still images showing maximum and minimum excursion of the sphincter in basal view were obtained. To test for observer reliability, the speech videofluoroscopic studies were randomized and presented for measurement to the same individual on two occasions, each session separated by a 1-month time interval. Topographic imaging software was used to obtain maximum and minimum measurements to within 0.1 mm. Partitioning the variance of the data showed that measurement variability was a very small portion of the total, and that difference between the minimum and maximum values was the largest source of variability. Of the total variability in the data, 64.0 percent originated in the minimum/maximum difference, 34.3 percent came from patient variability, and only 1.7 percent resulted from original or repeat measurements. The patient variability may be exaggerated because of variability in the scale of measurement. Results of this study indicate a quantifiable and statistically significant difference in maximum-to-minimum excursion of sphincteric closure. Sphincter pharyngoplasty appears to be dynamic in the majority of cases.     

Aerodynamic and acoustic characteristics of a speaker with turbulent nasal emission: a case report

Aerodynamic and acoustic characteristics were determined from the speech of an adult female with mild mental retardation and severe velopharyngeal inadequacy. The speaker's productions of /s/ were characterized by consistent nasal grimacing and turbulent air emission. Aerodynamic assessment estimated the size of the velopharyngeal orifice to exceed 200 mm2 during plosive production. Nasal cross-sectional area was estimated to be 35 mm2 during quiet breathing. Nasometric evaluation indicated nasalance of 63% associated with the "Zoo" passage. Acoustic analysis of the separately recorded oral and nasal speech signals indicated spectral energies in the region of approximately 2.5 to 7.0 kHz associated with nasal emission during /s/ production. The occurrence of these frequencies suggested an acoustic/perceptual function of the nasal grimace. Pressure-flow evidence also suggested that the nasal grimace, perhaps with lingual assistance, functioned to enhance speech aerodynamics.     

Treatment research in speech, language and swallowing: lessons from child language disorders

Three major types of treatment research methodologies are described. Studies on child language intervention are reviewed as examples of trends and methodological issues characterizing treatment research in speech, language, and swallowing within the last 2-3 decades. Principles are drawn from that literature and suggestions for future directions are discussed with particular attention to recent efforts to support clinical trials and treatment outcomes research.     

Aesthetic considerations for maxillary obturators retained by implants

Maxillary obturators are prostheses used to replace maxillary tissues, missing congenitally or removed by trauma or tumor ablative surgery. These prostheses are used to restore function (speech, swallowing, and mastication) and aesthetics. A considerable number of edentulous patients have difficulty in retaining this type of prosthesis. Utilization of osseointegrated dental implants is a significant adjunct in treating these cases, but it must be undertaken with careful planning to ensure predictable aesthetic results. The learning objective of this article is to discuss the technique of designing aesthetic maxillary prostheses supported by osseointegrated dental implants. The discussion includes indications and contraindications, and a postcarcinoma surgery case is used to illustrate the clinical procedure.     

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.     

Tendon repair using flexor tendon splints: an experimental study

Mechanical strength of tendon repair using Dacron tendon splints across the laceration site were evaluated in human cadaver profundus tendons; the splints were placed both on the dorsal surface and internally within the tendon substance. Comparison was made to modified Kessler, Becker, and Savage repair techniques. Ultimate tensile strength was 2.55 kgf for the Kessler, 3.00 kgf for the Becker, 8.29 kgf for the Savage, 8.46 kgf for the internal tendon splint, and 8.10 kgf for the dorsal tendon splint; the Savage and both Tendon Splints techniques had significant higher tensile strength than the Kessler and Becker. Gap strength was 1.44 kgf for the Kessler, 2.22 kgf for the Becker, 2.45 kgf for the Savage, 2.05 kgf for internal tendon splint, and 3.15 kgf for the dorsal tendon splint. The dorsal tendon splint technique showed significant greater gap strength than the other four techniques. There was no significant difference in the magnitude of the gap during cyclic testing of these techniques; however, three of seven Kessler repairs failed and one of six Becker repairs failed. The results of these cadaver studies suggest that both tendon splint repair techniques are comparable to the Savage and may have sufficient strength to allow postoperative active motion against minimal resistance. Further in vivo testing is in order.     

College students'' high-risk sexual behavior following alcohol consumption

A new and portable electronic device called the "Digital Phagometer" is described for the time based counting of spontaneous swallowing. This device is composed of a piezoelectric sensor and a digital event counter/ recorder which can be downloaded to any IBM-compatible PC. The sensor of Digital Phagometer is placed and fixed on the coniotomy region between the cricoid and thyroid cartilage. In this way, it is capable of sensing each upward and downward movement of the larynx produced by spontaneous movement as a function of time. Spontaneous swallowing was measured 1-4 h after lunch in 21 normal subjects and 21 patients with Parkinson's disease (PD). The mean frequency of spontaneous swallowing was 0.8 counts/min in PD patients and 1.18 counts/ min in normal subjects (p < 0.05). During the intake of 200 ml water, the mean frequency of voluntary swallowing did not differ significantly between the two groups (24.6 counts/min in normals vs. 22.3 counts/min in PD patients), but the time necessary to swallow the same volume of water was longer in the PD group.     

Biodegradation of indole at high concentration by persolvent fermentation with Pseudomonas sp. ST-200

The value of flexible videoendoscopy as a biofeedback tool in conservative swallowing rehabilitation of patients suffering from aspiration after head and neck surgery was examined. For this purpose, the outcomes of conventional swallowing therapy and of swallowing therapy with support of videoendoscopic biofeedback were compared. In the first 40 days of swallowing therapy, videoendoscopic biofeedback significantly increased the chance of therapeutic success, shortening the period of functional rehabilitation in comparison to conventional swallowing therapy. Limitations of this visual biofeedback procedure are poor cognitive skills of the patient, rejection of the procedure by the patient and local factors that make the positioning of the endoscope difficult.     

The use of splints in the treatment of joint stiffness: biologic rationale and an algorithm for making clinical decisions

The purpose of this article are (1) to discuss the rationale for using splints to increase range of motion (ROM) and (2) to describe an algorithm that can guide therapists' clinical decisions when splints are used to treat patients who have limited ROM. The primary rationale for using splints is to apply relatively long periods of tensile stress to shortened connective tissues to induce tissue lengthening through biologic remodeling. The process of remodeling is contrasted with more temporary mechanical phenomena that occur in biologic tissues. The proposed algorithm guides the use of splints based on measurements of pain and ROM. We describe three variables of splint use that may be adjusted: frequency, duration, and intensity. The relative importance of each of these variables is discussed. The algorithm is not joint or injury specific and requires continual modification of splint use based on a patient's response to treatment. Deciding which patients are appropriate for end-range splinting and deciding when to discontinue splint use are also discussed.