The Mayo Dysphagia Questionnaire-30: Documentation of Reliability and Validity of a Tool for Interventional Trials in Adults with Esophageal Disease

Abstract The aim of this study was to develop the Mayo Dysphagia Questionnaire-30 Day (MDQ-30), a tool to measure esophageal dysphagia, by adapting items from validated instruments for use in clinical trials, and assess its feasibility, reproducibility, and concurrent validity. Outpatients referred to endoscopy for dysphagia or seen in a specialty clinic were recruited. Feasibility testing was done to identify problematic items. Reproducibility was measured by test–retest format. Concurrent validity reflects agreement between information gathered in a structured interview versus the patients’ written responses. The MDQ-30, a 28-item instrument, took 10 min (range = 5–30 min) to complete. Four hundred thirty-one outpatients [210 (49%) men; mean age = 61 years] participated. Overall, most concurrent validity κ values for dysphagia were very good to excellent with a median of 0.78 (min 0.28, max 0.95). The majority of reproducibility κ values for dysphagia were moderate to excellent with a median κ value of 0.66 (min 0.07, max 1.0). Overall, concurrent validity and reproducibility κ values for gastroesophageal reflux disease (GERD) symptoms were 0.81 (95% CI = 0.72, 0.91) and 0.66 (95% CI = 0.55, 0.77), respectively. Individual item percent agreement was generally very good to excellent. Internal consistency was excellent. We conclude that the MDQ-30 is an easy-to-complete tool to evaluate reliably dysphagia symptoms over the last 30 days.

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Sensory Transcutaneous Electrical Stimulation Improves Post-Stroke Dysphagic Patients

Abstract Oropharyngeal dysphagia is frequent in stroke patients and increases mortality, mainly because of pulmonary complications. We hypothesized that sensitive transcutaneous electrical stimulation applied submentally during swallowing could help rehabilitate post-stroke oropharyngeal dysphagia by improving cortical sensory motor circuits. Eleven patients were recruited for the study (5 females, 68 ± 11 years). They all suffered from recent oropharyngeal dysphagia (>eight weeks) induced by a hemispheric (n = 7) or brainstem (n = 4) stroke, with pharyngeal residue and/or laryngeal aspiration diagnosed by videofluoroscopy. Submental electrical stimulations were performed for 1 h every day for 5 days (electrical trains: 5 s every minute, 80 Hz, under motor threshold). During the electrical stimulations, the patients were asked to swallow one teaspoon of paste or liquid. Swallowing was evaluated before and after the week of stimulations using a dysphagia handicap index questionnaire, videofluoroscopy, and cortical mapping of pharyngeal muscles. The results of the questionnaire showed that oropharyngeal dysphagia symptoms had improved (p < 0.05), while the videofluoroscopy measurements showed that laryngeal aspiration (p < 0.05) and pharyngeal residue (p < 0.05) had decreased and that swallowing reaction time (p < 0.05) had improved. In addition, oropharyngeal transit time, pharyngeal transit time, laryngeal closure duration, and cortical pharyngeal muscle mapping after the task had not changed. These results indicated that sensitive submental electrical stimulations during swallowing tasks could help to rehabilitate post-stroke swallowing dysphagia by improving swallowing coordination. Plasticity of the sensory swallowing cortex is suspected.

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Computer-Assisted Assessment of Hyoid Bone Motion from Videofluoroscopic Swallow Studies

Abstract Videofluoroscopic examination of swallowing remains the standard for evaluation of patients with swallowing complaints. Although attempts have been made to objectify aspects of the study, findings from the study are largely subjective and reliant on clinician training and judgment leading to considerable inter-rater variability. We describe a computerized image analysis program designed to objectify one component of the swallow study, the movement of the hyoid bone. Hyoid motion has been shown to be different in dysphagic versus non-dysphagic patients. Reduced hyoid elevation is also considered a risk factor for aspiration; however, there has not been much work done on actually quantifying hyoid motion and associating it with other aspects of the swallow study. The clinician is prompted to define the hyoid bone in a calibration frame, and the system then tracks that region of interest throughout the rest of the study. This system shows strong correlations with manual analysis and can account for head position changes during the study. While the hyoid bone was reported on in this study, other regions of interest within the image field could also be tracked using this technique. A more quantitative analysis such as this has the opportunity to improve the inter-rater reliability of the test and therefore lead to more consistent findings from swallow studies.

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Fluoroscopic Surrogate for Pharyngeal Strength: The Pharyngeal Constriction Ratio (PCR)

Abstract The pharyngeal constriction ratio (PCR), derived directly from videofluoroscopy without the need for manometry, requires validation as a surrogate for pharyngeal strength. A correlation of −0.70 was previously identified between PCR and pharyngeal clearing pressures (PP) on separate fluoroscopic and manometric studies. As PP increases, PCR decreases. The objective of the current study was to evaluate the correlation between PCR and PP in 25 patients undergoing simultaneous fluoroscopy and pharyngeal manometry. The effect of the manometric catheter on PCR was also investigated. The correlation between the PCR and averaged pharyngeal clearing pressures was −0.72 (p 0.25 had a PP < 60 mmHg. PCR did not differ significantly as a consequence of the manometric catheter. Results suggest the utility of an objective fluoroscopic measure in assessing pharyngeal strength when manometry may not be available or possible.

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Severe Dysphagia Secondary to Posterior C1–C3 Instrumentation in a Patient with Atlantoaxial Traumatic Injury: A Case Report and Review of the Literature

Abstract There are only a few reports of dysphagia cases in patients who underwent surgery for posterior cervical fusion, but none provides an explanation for the occurrence of dysphagia. To the best of our knowledge this is the first case report showing evidence of severe neurogenic dysphagia, possibly secondary to vagal nerve praxia, in a patient who underwent posterior fusion. A 61-year-old man presented with severe neck pain after he sustained a fall. Imaging studies in the emergency department showed a C2 fracture associated with anterior subluxation of C2 on C3. Given the instability of the injury, a C1–C3 posterior cervical fusion was performed. The surgery was uneventful. The patient’s postoperative course was complicated by severe dysphagia. Fluoroscopic and endoscopic assessments of the patient’s pharynx and larynx showed significantly decreased epiglottic inversion, hypokinesis of his pharyngeal wall, and decreased hyolaryngeal elevation. There was also mild vocal cord paresis bilaterally, with incomplete approximation of the glottis. He demonstrated intra- and post-deglutitive aspiration. The patient coughed (both immediate and delayed) in response to the aspiration but was not able to clear aspirated material completely from the airway. The patient had a percutaneous endoscopic gastrostomy (PEG) tube placed to provide him with nutrition. He was then discharged home. On postoperative follow-up visit 1 month later, the patient’s swallowing function improved and he could tolerate pureed consistencies and thin liquids with tube feed supplement. The patient could swallow without coughing. Possible causes of dysphagia in this case include traumatized airways from anesthesia, mechanical compromise of the upper gastrointestinal tract, and neurogenic dysphagia. After excluding the other possibilities, we concluded that our patient was suffering from neurogenic dysphagia associated with vagal nerve dysfunction.

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Oropharyngeal Dysphagia in Infants and Children with Infantile Pompe Disease

Pompe disease is a rare genetic progressive neuromuscular disorder. The most severe form, infantile Pompe disease, has historically resulted in early mortality, most commonly due to cardiorespiratory failure. Treatment with enzyme replacement therapy (ERT) using alglucosidase alfa (Myozyme®) has extended the lifespan of individuals with this disease. With the introduction of ERT and the resultant improved survival, dysphagia is being encountered clinically with increasing regularity though systematic data remain unavailable. We retrospectively studied the oropharyngeal swallowing of 13 infants and children with Pompe disease using videofluoroscopy before initiation of ERT, allowing for baseline swallow function to be established in an untreated cohort. Dysphagia was present in all 13 subjects, even in a participant only 15 days old. Oral stage signs were present in 77%, most frequently a weak suck in 69%. Pharyngeal stage signs were present in 100%, including a pharyngeal swallow delay in 92% and pharyngeal residue in 77%. Airway invasion was present in 76.9% of subjects, including penetration in five (38.46%) and silent aspiration in an additional five (38.46%). No relationship in the relative involvement of swallowing, gross motor function, and cardiac disease appeared to be present.

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Age-Related Differences in Laterality of Cortical Activations in Swallowing

The present study examined age differences in neural lateralization patterns during swallowing and three related tasks, using functional magnetic resonance imaging (fMRI). Ten healthy right-handed young adults (mean age = 21.7 years, SD = 2.1 years) and nine healthy elders (mean age = 70.2 years, SD = 3.9 years) were scanned in a 3-T MRI head scanner. Participants were visually cued to “prepare to swallow,” “swallow,” “tap your tongue,” and “clear your throat” in randomized order. Laterality preference for each task was examined within and between groups using region-of-interest (ROI) analyses in seven areas of the left and right primary sensorimotor and premotor cortices. Results of the within-group comparisons verified a more active role of the left premotor cortex in motor-cognitive planning of deglutition in both young and older adults and a more active role of selected areas of the right hemisphere during swallowing in young adults. Greater variability was seen during tongue tapping and throat clearing in both groups. Finally, as people age the cortical hemispheric control of swallowing seems to start becoming more symmetrical/bilateral, which may indicate neural compensatory mechanisms of the aging brain commonly seen for other motor and cognitive functions.

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Long-Term Results of External Upper Esophageal Sphincter Myotomy for Oropharyngeal Dysphagia

The aim of this work was to assess the efficacy of external myotomy of the upper esophageal sphincter (UES) for oropharyngeal dysphagia. In the period 1991–2006, 28 patients with longstanding dysphagia and/or aspiration problems of different etiologies underwent UES myotomy as a single surgical treatment. The main symptoms were difficulties in swallowing of a solid-food bolus, aspiration, and recurrent incidents of solid-food blockages. Pre- and postoperative manometry and videofluoroscopy were used to assess deglutition and aspiration. Outcome was defined as success in the case of complete relief or marked improvement of dysphagia and aspiration and as failure in the case of partial improvement or no improvement. Initial results showed success in 21 and failure in 7 patients. The best outcomes were observed in patients with dysphagia of unknown origin, noncancer-related iatrogenic etiology, and neuromuscular disease. No correlation was found between preoperative constrictor pharyngeal muscle activity and success rate. After follow-up of more than 1 year, 20 patients were marked as success and 3 as failure. All successful patients had full oral intake with a normal bolus consistency without clinically significant aspiration. We conclude that in select cases of oropharyngeal dysphagia success may be achieved by UES myotomy with restoration of oral intake of normal bolus consistency.

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Effects of Therapy in Oropharyngeal Dysphagia by Speech and Language Therapists: A Systematic Review

Medical and paramedical treatments should be evaluated according to current standards of evidence-based medicine. Evaluation of therapy in oropharyngeal dysphagia fits into this growing interest. A systematic review is given of the literature on the effects of therapy in oropharyngeal dysphagia carried out by speech therapists. Thus, the review excludes reports of surgical or pharmacological treatments. The literature search was performed using the electronic databases PubMed and Embase. All available inclusion dates up to November 2008 were used. The search was limited to English, German, French, Spanish, and Dutch publications. MESH terms were supplemented by using free-text words (for the period after January 2005). Fifty-nine studies were included. In general, statistically significant positive therapy effects were found. However, the number of papers was rather small. Moreover, diverse methodological problems were found in many of these studies. For most studies, the conclusions could not be generalized; comparison was hindered by the range of diagnoses, types of therapies, and evaluation techniques. Many questions remain about the effects of therapy in oropharyngeal dysphagia as performed by speech and language therapists. Although some positive significant outcome studies have been published, further research based on randomized controlled trials is needed.

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Initiation and Duration of Laryngeal Closure During the Pharyngeal Swallow in Post-Stroke Patients

As a bolus enters the pharynx during the swallow, the airway is protected by laryngeal closure, a process characterized by approximation of the vocal folds plus approximation of the arytenoid cartilages to the base of the epiglottis. The purpose of this study was to measure initiation of laryngeal closure (ILC) and laryngeal closure duration (LCD) in three groups of subjects: (1) ten stroke patients who aspirated before and during the swallow (aspirators), (2) ten stroke patients who did not aspirate (nonaspirators), and (3) ten normal control subjects. Means and standard deviations of ILC and LCD were analyzed for both 5-ml and 10-ml thin-liquid boluses using a 100-ms timer during subsequent analysis of videofluoroscopic swallowing examinations. There were significant differences between aspirators and control subjects for both ILC and LCD, and significant differences between aspirators and nonaspirators for ILC. There were no significant differences between aspirators and nonaspirators for LCD. Both delayed ILC and reduced LCD were associated with post-stroke aspiration. Delayed ILC is a significant indicator of overall risk of aspiration. Clinical implications for these findings are discussed.

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Supranuclear Control of Swallowing

Swallowing is an act requiring complex sensorimotor integration. Using a variety of methods first used to study limb physiology, initial efforts to study swallowing have yielded information that multiple cortical and subcortical regions are active participants. Not surprisingly, the regions activated appear to overlap those involved in both oral and nonoral motor behaviors. This review offers a perspective that considers the supranuclear control of swallowing in light of these physiological similarities.

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Immediate Effects of Thermal–Tactile Stimulation on Timing of Swallow in Idiopathic Parkinson’s Disease

Abstract Oropharyngeal dysphagia frequently presents in people with idiopathic Parkinson’s disease (IPD). Clinical sequelae of dysphagia in this group include weight loss and aspiration pneumonia, the latter of which is the leading cause of hospital admissions and death in IPD. Thermal–tactile stimulation (TTS) is a sensory technique whereby stimulation is provided to the anterior faucial pillars to speed up the pharyngeal swallow. The effects of TTS on swallowing have not yet been investigated in IPD. The aim of this study was to investigate the immediate effects of TTS on the timing of swallow in a cohort of people with IPD and known oropharyngeal dysphagia. Thirteen participants with IPD and known dysphagia attended for videofluoroscopy during which standardised volumes of liquid barium and barium paste were administered preceding and immediately subsequent to TTS. The immediate effects of TTS on swallowing were examined using oral, pharyngeal, and total transit times and pharyngeal delay times as outcome measures. TTS significantly reduced median pharyngeal transit time on fluids (0.20 s, 95% CI = 0.12–0.28, p = 0.004) and on paste (0.3 s, 95% CI = 0.08–0.66, p = 0.01). Median total transit time was also reduced on fluids (0.48 s, 95% CI = 0.00–1.17, p = 0.049) and on paste (0.52 s, 95% CI = 0.08–1.46, p = 0.033). Median pharyngeal delay time was reduced on fluids (0.20 s, 95% CI = 0.12–0.34, p = 0.002). TTS did not significantly alter median oral transit time on either fluid or paste consistency. TTS significantly reduced temporal measures of the pharyngeal phase of swallowing in the IPD population. Significant results may be attributed to the role of sensory stimulation in improving motor function in IPD, with emphasis on the impaired glossopharyngeal and vagus nerves in this population. It is still unclear whether these findings will translate into a clinically beneficial effect.

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The Effect of Lateral Shift of Cricoid Cartilage on Pharyngeal Swallowing

Abstract Head rotation is widely used as one of the postural techniques for dysphagic patients. However, it cannot be used for patients with severe limitations to the range of motion of the neck. The purpose of this study was to determine the effect of applying pressure to the cricoid while swallowing and to explore the possibility of this maneuver as an alternative to head rotation. The swallowing function of 12 volunteers was examined with videofluorography under nine conditions: neutral, head rotated to the right, head rotated to the left, applying pressure to the cricoid on the right side at 5, 10, and 15 N, and applying pressure to the cricoid on the left side at 5, 10, and 15 N. To examine the effect of this maneuver on pharyngeal swallowing, the laterality of bolus flow was evaluated using 3 ml barium thin liquid from the posterior-anterior (P-A) view. The “pressing-cricoid” maneuver significantly altered the laterality of the bolus flow; the bolus flow was shifted to the side opposite to which the pressure was applied. The results of these changes were similar to those achieved with head rotation. These results demonstrated that the “pressing-cricoid” maneuver changes the bolus flow. This maneuver may have therapeutic value for the treatment of dysphagic patients as an alternative to head rotation.

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Tongue Pressure Patterns During Water Swallowing

Abstract Bolus propulsion during the normal oral phase of swallowing is thought to be characterised by the sequential elevation of the front, middle, and posterior regions of the dorsum of the tongue. However, the coordinated orchestration of lingual movement is still poorly understood. This study examined how pressures generated by the tongue against the hard palate differed between three points along the midline of the tongue. Specifically, we tested three hypotheses: (1) that there are defined individual patterns of pressure change within the mouth during liquid swallowing; (2) that there are significant negative pressures generated at defined moments during normal swallowing; and, (3) that liquid swallowing is governed by the interplay of pressures generated in an anteroposterior direction in the mouth. Using a metal appliance described previously, we measured absolute pressures during water swallows in six healthy volunteers (4 male, 2 female) with an age range of 25–35 years. Participants performed three 10-ml water swallows from a small cup on five separate days, thus providing data for a total of 15 separate water swallows. There was a distinct pattern to the each of the pressure signals, and this pattern was preserved in the mean obtained when the data were pooled. Furthermore, raw signals from the same subjects presented consistent patterns at each of the five testing sessions. In all subjects, pressure at the anterior and hind palate tended to be negative relative to the preswallow value; at mid–palate, however, pressure changes were less consistent between individuals. When the pressure differences between the sites were calculated, we found that during the swallow a net negative pressure difference developed between anterior and mid-palate and a net positive pressure difference developed between mid-palate and hind palate. Large, rapid fluctuations in pressure occurred at all sites and these varied several-fold between subjects. When the brief sharp reduction in pressure that occurred early in each swallow was used to determine the sequence of events, we found that activity occurred first at the anterior of the palate followed by the mid-palate and then the hind palate.

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Anthropometric and Demographic Correlates of Dual-Axis Swallowing Accelerometry Signal Characteristics: A Canonical Correlation Analysis

Abstract Swallowing accelerometry has been proposed as a potential minimally invasive tool for collecting assessment information about swallowing. The first step toward using sounds and signals for dysphagia detection involves characterizing the healthy swallow. The purpose of this article is to explore systematic variations in swallowing accelerometry signals that can be attributed to demographic factors (such as participant gender and age) and anthropometric factors (such as weight and height). Data from 50 healthy participants (25 women and 25 men), ranging in age from 18 to 80 years and with approximately equal distribution across four age groups (18-35, 36-50, 51-65, 66 and older) were analyzed. Anthropometric and demographic variables of interest included participant age, gender, weight, height, body fat percent, neck circumference, and mandibular length. Dual-axis (superior-inferior and anterior-posterior) swallowing accelerometry signals were obtained for five saliva and five water swallows per participant. Several swallowing signal characteristics were derived for each swallowing task, including variance, amplitude distribution skewness, amplitude distribution kurtosis, signal memory, total signal energy, peak energy scale, and peak amplitude. Canonical correlation analysis was performed between the anthropometric/demographic variables and swallowing signal characteristics. No significant linear relationships were identified for saliva swallows or for superior-inferior axis accelerometry signals on water swallows. In the anterior-posterior axis, signal amplitude distribution kurtosis and signal memory were significantly correlated with age (r = 0.52, P = 0.047). These findings suggest that swallowing accelerometry signals may have task-specific associations with demographic (but not anthropometric) factors. Given the limited sample size, our results should be interpreted with caution and replication studies with larger sample sizes are warranted.

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