Positioning improves the oral and pharyngeal swallowing function in children with cerebral palsy

Many children with cerebral palsy have feeding difficulties. The aim of this study was to investigate if trunk and neck positioning influenced oral and pharyngeal swallow. Five children with feeding problem aged 3-10 years with cerebral palsy were examined using videofluoroscopy. All children had tetraplegia with dystonia, i.e. poor head control and poor trunk stability. All children had gross aspiration and posterior oral leak. The pharyngeal phase was delayed in relation to the oral phase. Two children had pharyngeal retention. The children were positioned with both an extended and flexed neck. The flexed neck position was combined with a 30 degrees reclined sitting position. In both positions they were given purée with barium and liquid barium during video recording. In the reclined position with the neck flexed, aspiration decreased in all five children, oral leak diminished in two children and retention improved in one child.     

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.     

Swallow recovery in an oral cancer patient following surgery, radiotherapy, and hyperthermia

BACKGROUND: No study has examined the nature and extent of swallowing impairment in oral cancer patients following treatment with combined hyperthermia and interstitial radiotherapy. Few studies have examined the effects of voluntary swallow maneuvers (supersupraglottic and Mendelsohn) on pharyngeal phase swallowing in the oral cancer patient treated with surgery or radiotherapy. This study examined the effects of combined radiotherapeutic salvage treatments of hyperthermia and interstitial implantation and swallow recovery using swallow maneuvers in a surgically treated and irradiated oral cancer patient. METHODS: The patient under study, a 51-year-old man, underwent radiotherapy, according to Radiation Therapy Oncology Group (RTOG) protocol #8419, consisting of a combination of interstitial irradiation and hyperthermia to the base of tongue, for a recurrent squamous cell cancer. He underwent videofluorographic (VFG) examination of his swallowing, a modified barium swallow at three time points: 2 days following radiotherapy treatment (VFG1), 4 weeks later (VFG2), and 8 months later (VFG3). Temporal and biomechanical analyses of swallows were performed at each time point. RESULTS: Swallow maneuvers and time resulted in improved laryngeal elevation and laryngeal vestibule closure during the swallows on VFG2. Maximum upper esophageal sphincter (UES) opening width and duration were more normal. Fewer swallows were required for bolus clearance through the pharynx. Base of tongue tissue necrosis occurred as a complication of radiotherapy between VFG2 and VFG3, with resultant severe reduction in posterior movement of the tongue base, incomplete tongue base contact to the posterior pharyngeal wall, reduced laryngeal elevation, and incomplete laryngeal vestibule closure during swallowing at VFG3. UES opening became less normal and a greater number of swallows were required for bolus clearance through the pharynx. CONCLUSIONS: Combined interstitial irradiation and hyperthermia can cause oropharyngeal swallowing problems. Time and swallow therapy can improve these swallow disorders. Tongue base tissue necrosis can cause further swallow impairment, emphasizing the importance of the tongue base in normal deglutition. Further studies are needed to examine the impact of combined hyperthermia and interstitial implantation for treatment of tongue base tumors on swallow functioning in a larger group of patients.     

Metabolism of enkephalins in head membranes of the leech Theromyzon tessulatum by peptidases: isolation of an enkephalin-degrading aminopeptidase

This study quantified the effects of the supraglottic maneuver (SGM) and super supraglottic maneuver (SSGM) on laryngeal and pharyngeal movements before and during swallow. Simultaneous videofluoroscopic and videoendoscopic examinations of oropharyngeal swallowing were performed in eight healthy volunteers with and without maneuvers. Data analysis compared 1) temporal relationships of oropharyngeal events, 2) airway conditions at the time of selected oropharyngeal events, and 3) biomechanical computer analysis of swallowing events. Using these maneuvers, normal subjects produced earlier cricopharyngeal opening, prolonged pharyngeal swallow, some degree of laryngeal valving before swallow, and change in extent of vertical laryngeal position before swallow. These changes are more successful and maintained longer with the SSGM than the SGM. We concluded that breath-holding maneuvers alter not only airway conditions before swallow but also both the temporal relationships and biomechanical events during oropharyngeal swallow.     

Respiratory-related pharyngeal constrictor muscle activity in normal human adults

Electromyographic activity of the superior, middle, and inferior pharyngeal constrictor (PC) muscles was examined in 10 normal adult humans during wakefulness and sleep. Wire electrodes were inserted close to the midline of the posterior pharyngeal wall at the level of the soft palate (superior PC), tip of the epiglottis (middle PC), and corniculate tubercle (inferior PC). In general, the three PC muscles exhibited similar patterns of activation. The PCs were activated during swallows, repetitive "pa" sounds, changes in head position, and the last portions of slow inspiratory and expiratory vital capacity maneuvers. Respiratory-related PC activity was infrequent during quiet breathing during wakefulness; variable and inconsistent phasic activation in expiration in one or more of the PCs was present in seven of the 10 subjects, particularly after a swallow. Progressive hyperoxic hypercapnia and progressive isocapnic hypoxia were associated with recruitment of phasic PC activity, which was predominantly expiratory; however, variable discharge patterns were observed within a given muscle and a given subject. When phasic PC activity was present, preactivation during late inspiration was frequently observed. PC activity was absent in NREM sleep and exhibited sporadic, nonrespiratory-related bursts of activity during REM sleep. Passively induced hypocapnic hyperventilation in NREM sleep was not associated with PC activation. The results indicate that the PCs have very similar patterns of activation and exhibit phasic expiratory activity during relatively high ventilatory output states in wakefulness.     

Clinical study of the efficacy of albendazole treatment in human hydatidosis]

Feeding abilities in 20 individuals with Rett syndrome aged 1 1/2 to 33 years were investigated by history and clinical assessment during a meal, followed by videofluoroscopy of feeding. All were shown to have reduced movements of the mid and posterior tongue, with premature spillover of food and liquid from the mouth into the pharynx. They also showed delayed pharyngeal swallow, but otherwise pharyngeal problems were minimal. These findings were noted to be similar to those in Parkinson's disease. Those individuals with the most general neurological impairment tended to have the worst feeding problems and were smaller and malnourished.     

Arthroscopic removal of an osteoid osteoma at the talar neck

PURPOSE: This study used simultaneous videomanometry to measure pressure characteristics in a group of patients with evidence of laryngeal and/or tracheal barium penetration, and to compare the results to those of one group of healthy volunteers and one group of patients with dysphagia but a normal barium swallow. MATERIAL AND METHODS: Videomanometry during barium swallowing was performed in 25 patients who showed penetration of barium into the laryngeal vestibule. Manometric abnormalities were determined by comparing these mean values with those of 25 healthy volunteers, and the frequency of manometric abnormalities was compared to that of 19 patients presenting with oropharyngeal dysphagia with a normal barium swallow. RESULTS: The frequency of abnormalities for four parameters (pharyngo-esophageal segment (PES) resting pressure, PES relaxation duration, pharyngeal peak pressure, pharyngeal contraction duration) differed significantly between the patients with penetration and those with normal barium studies. There was, however, no association between manometric abnormalities and the degree of barium penetration. CONCLUSION: The differences in manometric abnormalities between patients with laryngeal penetration and patients with normal barium swallows may be useful in identifying the mechanisms of laryngeal penetration.     

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.     

Effects of postural change on aspiration in head and neck surgical patients

This study was designed to define the effects of postural change on liquid aspiration during videofluorographic examination of oropharyngeal swallow in head and neck surgical patients. Thirty-two patients were given two swallows of five different amounts of liquid barium as tolerated. When aspiration occurred, the patient's head and/or body position was changed, new posture being determined by the swallowing disorder identified as the cause of the aspiration. Postural techniques were successful in eliminating aspiration on at least one volume of liquid in 81% of these patients. Patients in all surgical groups were able to use postures with equal success. A variety of positions were used in each type of surgical patient, indicating that these patients exhibited a variety of swallowing problems. Results emphasize the importance of introducing postural techniques during the radiographic study of oropharyngeal swallow to facilitate safe oral intake of liquids.     

Endoscope-assisted transscleral suture fixation of intraocular lenses

We describe a new method for placing transscleral sutures when fixating posterior chamber intraocular lenses to the sulcus. An intraocular microendoscope with an 18 gauge probe is used for direct sulcus observation and needle position assessment. The straight needle of a 10-0 polypropylene suture and the tip of the probe are placed in a 16 gauge silicone rubber tube to hold them together. Fixing the needle to the endoscope allows a direct view of its tip and requires only one hand. The other hand is used to grasp the tip of the needle when it comes out under the scleral flap after passing through the sulcus. Assessment of needle position with an endoscope avoids surgically induced iris root or ciliary body damage. Fixing the needle to the endoscope simplifies the surgical technique.     

Staurosporine stimulates phospholipase D activation in human polymorphonuclear leukocytes

Oropharyngeal pressure during swallowing was studied in a total of 40 healthy adult males and females in two age groups (21-27 yr and 62-75 yr). Effects of bolus volume, bolus viscosity, age, and gender were analyzed, and dry and bolus swallows were compared. The duration of the intrabolus pressure, reflecting the pressure exerted by the tongue on the bolus and preceding the generation of the pharyngeal pressure, was significantly affected by bolus volume. The duration of oropharyngeal pressure was affected by age, gender, and bolus type (bolus vs. dry swallow). Peak oropharyngeal pressure was not affected by any of the test factors, although there was a tendency for older subjects to have higher pressures than young subjects.     

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.     

Electromyographic analysis of the ingestion and rejection of sapid stimuli in the rat.

For further clarification of the relation between orofacial movements produced by gustatory stimuli (the buccal phase of ingestion) and the act of swallowing (the pharyngeal phase), electromyogram (EMG) responses to intraoral sapid stimulation were recorded from a subset of orofacial and pharyngeal muscles in 25 male rats. Muscle activity reliably differentiated between ingestive sequences to water (W), sucrose (S), and NaCl (N) and a rejection response elicited by quinine monohydrochloride (Q). Ingestion responses to W, S, and N consisted of rhythmic alternations between genioglossus and styloglossus activity (intraoral licks) accompanied by episodic bursts of pharyngeal constrictor activity (swallowing). Both bout duration and number of swallows increased at higher concentrations of S and N. In contrast, Q stimulation elicited a rejection response characterized by several licks and followed by long duration contractions of the zygomatic and anterior digastric muscles (gapes). During gapes, styloglossus activity rather than genioglossus activity was simultaneous with that of the anterior digastric. At higher concentrations of Q, the latency to gape decreased and the latency to swallow increased. The earliest components of the response to S, N, or Q were indistinguishable from one another, suggesting that tactile (fluid) stimulation initiates the ingestive sequence and that gustatory stimuli modulate this ongoing activity. (49 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

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.     

Streamlined charting for patient education

The swallowing movements of 22 ambulant patients with Parkinson's disease were examined by videofluoroscopy, 15 spouses serving as controls. The relation between bolus volume and movement of the hyoid bone was studied in the lateral view to assess the adaptation of the pharynx musculature. Although movement characteristics of the hyoid varied considerably both intra- and interindividually, mean values followed typical patterns. In controls, the position of the hyoid before the start of the swallow tended to be lower as the bolus volume increased, apparently to create space in the oral cavity by lowering the floor of the mouth. This trend was not seen in the group of Parkinson patients. We suppose that this specific lack of adaptation represents hypokinesia. The amplitude of the hyoid movement did not change with increasing bolus volumes, either in patients or in controls. Moreover, Parkinson patients had many more aborted swallowing movements ("hesitations") than controls, probably representing defective switching from the voluntary phase of swallowing to the involuntary, automatic phase.     

Videofluoroscopic assessment in children with severe cerebral palsy presenting with dysphagia

In this study 16 patients with severe spastic cerebral palsy with an age range between 6 months and 16 years were examined using videofluoroscopy and a modified barium meal. All patients were slow, inefficient eaters. Silent aspiration was demonstrated in five cases. The latter five patients demonstrated a delayed swallow reflex but there was little correlation between aspiration and the oral phase of deglutition. Our data confirms the impression that early diagnostic workup including videofluoroscopy is helpful in managing the feeding difficulties in these children, and may prevent chronic aspiration and malnutrition.     

Electronic three-dimensional imaging of intestinal endoscopy

Endoscopists, especially those investigating the colon, need to know where the tip of the instrument is and whether the tube is kinking. A three-dimensional real-time imaging system consisting of sensors, within or taped to the endoscope, to detect weak electric currents in a wire grid below the mattress yields the information needed and should greatly facilitate performance and teaching of endoscopy.     

Safety of radiating jejunal interposition grafts in head and neck cancer

The safety of high-dose postoperative radiation therapy to a jejunal graft has not been established in the literature. The purpose of the present study is to review the effect of postoperative radiation on swallow function in patients who have received a jejunal interposition graft as part of their reconstruction after cancer resection. Charts of patients undergoing hypopharyngeal resections for cancers with placement of jejunal interposition grafts who received postoperative radiation therapy were reviewed. Swallow function was determined from records of patients' subjective characterization of their swallow function, records of weights at each visit, use of gastrostomy tube, need for jejunal dilatation and review of barium swallows. Seventeen patients were identified who had undergone resection of cancers with jejunal interpositions and postoperative radiation therapy. Four patients never regained adequate swallow function postoperatively to allow G-tube removal. The remaining thirteen patients had their G-tubes removed, generally several months after resection, and were able to obtain adequate nutrition orally to maintain or increase their weights. The present series suggests that a segment of jejunum transferred into the neck after laryngopharyngoesophagectomy can be irradiated to high dose with generally acceptable morbidity.     

Feasibility study of magnetic resonance imaging-guided intranasal flexible microendoscopy

Interventional magnetic resonance imaging (MRI) offers potential advantages over conventional interventional modalities such as X-ray fluoroscopy, ultrasonography, and computed tomography (CT). In particular, it does not use ionizing radiation, can provide high-quality images, and allows acquisition of oblique sections. We have carried out a feasibility study on the use of interventional MRI to track a flexible microendoscope in the paranasal sinuses. In this cadaver study, high-speed MRI was used to track a passive marker attached to the end of the endoscope. Automatic image registration algorithms were used to transfer the coordinates of the endoscope tip into the preoperative MRI and CT images, enabling us to display the position of the endoscope in reformatted orthogonal views or in a rendered view of the preoperative images. The endoscope video images were digitized and could be displayed alongside an approximately aligned, rendered preoperative image. Intraoperative display was provided in the scanner room by means of an liquid crystal display (LCD) projector. We estimate the accuracy of the endoscope tracking to be approximately 2 mm.     

Beneficial effect of proteases on allograft arteriosclerosis in a rat aortic model

PURPOSE: Our goal was to describe the CT findings in patients with an apparent mass at the thoracic inlet on barium swallow and to further explore its etiology by making appropriate measurements on CT. METHOD: Barium swallows and CT scans of five patients with esophageal pseudomass were reviewed and compared with CT scans of 65 controls. Anteroposterior (AP) diameters of the thoracic inlet were measured, and the relationships of the esophagus to the trachea were determined on CT. RESULTS: Absence of a demonstrable mass on CT in patients with an extrinsic impression on barium swallow was associated with narrowed AP diameter of the thoracic inlet (< 5 cm) and the esophagus to the left of the trachea. A significant correlation was observed between the AP diameter of the inlet and the position of the esophagus in relation to the trachea in control subjects (r = 0.52, p < 0.001); with diminished diameter, the esophagus is more frequently located to the left side of the trachea. CONCLUSION: An apparent mass is simulated by lateral deviation of the lower cervical esophagus, due to diminished available space between the trachea and the esophagus in subjects with a narrow (< 5 cm) AP diameter of the thoracic inlet.