United Kingdom. Purpose: Dysphagia occurs in 50% of acute stroke patients with up to. 20% developing aspiration pneumonia, associated with prolonged.
Dysphagia (2009) 24:461–484 DOI 10.1007/s00455-009-9234-z
ABSTRACTS
Dysphagia Research Society Seventeenth Annual Dysphagia Research Society Meeting March 4–7, 2009 New Orleans, Louisiana
Scientific Poster Sessions Ó Springer Science+Business Media, LLC 2009
A CLUSTER RANDOMISED TRIAL OF DIFFERENT STRATEGIES OF ANTIBIOTIC USE TO REDUCE THE INCIDENCE AND CONSEQUENCE OF CHEST INFECTION IN ACUTE STROKE PATIENTS WITH DYSPHAGIA (STROKE-INF)
A RANDOMIZED CONTROLLED TRIAL OF A WATER PROTOCOL FOR CLIENTS WITH THIN LIQUID DYSPHAGIA Carlaw, Caren1, Finlayson H1, Kathleen B1, Tiffany V1, Caroline M1, Coney D1, Steele C2
Smithard, David1, Kalra L2, Wolfe C2, Patel A3, Rudd A4, Gulliford M2
1
1
2
Purpose: Dysphagia occurs in 50% of acute stroke patients with up to 20% developing aspiration pneumonia, associated with prolonged hospital stay and poor outcomes. Three antibiotic prophylaxis trials are available, showing safety but not effectiveness, possibly because non dysphagic patients were included and mortality was used as the end point. STROKE-INF is a pragmatic cluster randomised trial evaluating the effectiveness and safety of prophylactic antibiotic use (an ‘‘act first’’ approach) compared with monitoring for infection and treatment if necessary (a ‘‘wait and watch’’ approach) in reducing aspiration pneumonia and improving functional outcomes in acute stroke patients with dysphagia. Methods: This is a cluster randomised trial recruiting 800 acute stroke patients from 20 units. Prophylactic treatment will be started with in 24 h of stroke onset and continued for 7 days using antibiotics compliant with local hospital infection control policies. Results: The clinical primary outcome measure will be the incidence of chest infections in the first 14 days after stroke onset. Antibiotic related side effects will monitored (particularly C Difficile infections and MRSA), mortality, participation in rehabilitation, days spent in hospital, level of function and costs associated with care up to 3 months. An intention to treat analysis will be undertaken masked to allocation. Conclusion: The trial is designed as a pragmatic health services study to inform guidelines and is due to start later in 2008.
Purpose: There is a paucity of evidence to support and guide implementation of water protocols. The purpose of this study is to develop and evaluate a process for using a water protocol in a rehabilitation setting. The GF Strong Water Protocol guides decision making for candidacy for the water protocol, type of water protocol (supervised or independent), and appropriate oral hygiene plan of care. Specifically we aim to (1) determine the effect of our water protocol on fluid intake, satisfaction and quality of life for dysphagic clients, (2) assess adverse events, and (3) determine feasibility and provide data for potential design of larger scale studies. Methods: In this prospective single-blind randomized controlled study, 40 subjects age 19 years and older with fluoroscopically confirmed thin liquid dysphagia and who are prescribed thickened liquids, are randomly assigned to their study condition: control or experimental. Using the GF Strong Water Protocol algorithm, subjects are assigned to the appropriate water protocol and oral hygiene plans of care. Pre and post measures in the 14-day study period include 48-h fluid intake, fluid requirements met, SWAL QOL, patient satisfaction questionnaire, and adverse events. Results: The GF Strong Water Protocol algorithm has been successfully instituted to guide clinical decision making. Six subjects have been enrolled to date (control N = 2, experimental N = 4). No adverse events have occurred in either group. Conclusion: The GF Strong Water Protocol is feasible for this study. Preliminary data indicate no adverse events. Further data regarding fluid intake, satisfaction and quality of life will be presented once subject enrolment is complete.
William Harvey Hospital, Ashford, Kent 2 King’s College School of Medicine, London, United Kingdom 3 Centre of Health Economics, Institute of Psychiatry, London, United Kingdom 4 Guy’s and St Thomas’ Hospital Foundation Trust, London, United Kingdom
GF Strong Rehabilitation Centre, Vancouver, Canada Toronto Rehabilitation Institute, Toronto, Canada
123
462 DYSPHAGIA POST BREAST CANCER TREATMENT IN ADULT WOMEN Hind, Jacqueline1, Stewart J1, Schelman W1, Gangnon R1, Robbins J1
Abstracts swallow movement enabled the appropriate bolus transportation from the mouth to the esophagus, suggesting that it is important to comprehensively evaluate both the oral and pharyngeal stages of swallowing.
1
University of Wisconsin—Madison, Madison, WI
Purpose: As the population of breast cancer survivors grows, the healthcare community is developing methods to address issues related to survivorship. The purpose of this pilot study was to evaluate the presence of symptomatic and kinematic evidence of dysphagia in patients with previously-treated breast cancer. Methods: Eighteen women (median age 59 years) completed a questionnaire reporting signs/symptoms of dysphagia. A randomly identified subgroup of nine subjects completed a standardized oropharyngeal esophagram with liquid and semi-solid boluses. Results were compared with normative data for healthy age-matched adults who completed the same tasks. Results: More than 60% of breast cancer survivors reported signs/ symptoms of dysphagia. Instrumentally, 100% of subjects (94% of the boluses) were observed radiographically to have intraesophageal stasis (IES) (P \ 0.01); 80% of which was judged to be severe, defined as retained barium that completely filled the lumen of the esophagus (P \ 0.05). IES occurred most frequently at the midesophagus and more often with semi-solid boluses compared to liquids. Significantly more IES was observed in subjects over 65 years compared with those under 65 years (P \ 0.001). Intraesophageal reflux was observed in 88% (25% of boluses) of these breast cancer survivors. Conclusion: Clinical information generated from this study which documents common complaints of dysphagia while providing kinematic validation, can be useful when counseling patients about potential signs/symptoms of dysphagia and to guide the development of cancer survivorship care plans.
TEMPORAL RELATIONSHIPS BETWEEN TONGUE-PALATE CONTACT AND PHARYNGEAL SWALLOW USING PRESSURE SENSORS AND VIDEOENDOSCOPY Furuya, Junichi1, Suzuki T1, Abe R1, Tamada Y1, Oda N1 1
Iwate Medical University, Morioka, Japan
Purpose: Tongue-palate contact plays a major role in the oral and pharyngeal stages of swallowing. The purpose of this study was to investigate temporal relationships between tongue pressures on the palate and the pharyngeal swallow observed by videoendoscopy (VE). Methods: The subjects were 7 healthy persons (4 males and 3 females; mean age, 28.3 year). Tongue pressure was determined by 4 small pressure sensors placed into the experimental palatal plate. VE was performed nasally and recorded with tongue pressures. The food tested was 10 ml of milk. The time epiglottis returned in resting position on VE was decided as a reference point (0.00 s), and temporal relationships were analyzed (ANOVA, P \ 0.05). Results: Onset of tongue pressures observed in the order corresponding to the anterior (-1.20 s), lateral (-1.03 s), central (-0.92 s), and posterior (-0.84 s) parts of the palate. Bolus transit through fauces was observed at -0.90 s, and the onset of whiteout (-0.77 s) was observed simultaneously with the posterior maximum tongue pressure (-0.76 s). The duration of the anterior tongue pressure was significantly longer (0.97 s) as compared to the other parts. The whiteout persisted for 0.62 s, and ended after the offset of tongue pressures (-0.15 s). Conclusion: Precise temporal relationships between tongue-palate contact in the anterior to posterior direction and the pharyngeal
123
RADIOTHERAPY EFFECTS ON SWALLOWING TO NASOPHARYNGEAL CANCER PATIENTS Chen, Sheng Hwa1, Ting L2, Chang Y3, Ko J4, Lin Y5, Chang C6, Chiang S7 1
Department of Speech and Hearing Disorders and Sciences, Taipei, Taiwan 2 Department of Oncology, National Taiwan University, Taipei, Taiwan 3 Department of Medical Imaging, National Taiwan University, Taipei, Taiwan 4 Department of Otolaryngology, National Taiwan University, Taipei, Taiwan 5 Department of Physical Therapy, Chang Gung University, Taipei, Taiwan 6 Department of Otolaryngology, Mackay Memorial Hospital, Taipei, Taiwan 7 Department of Informatics, Veterans General Hospital, Taipei, Taiwan Purpose: The study investigated (1) tongue function, swallowing function, and life quality before and after radiotherapy for nasopharyngeal cancer patients; and (2) the difference of tongue function, swallowing function, and life quality with and without tongue exercise for nasopharyngeal cancer patients after radiotherapy. Methods: Fifty-one NPC patients were randomized divided into two groups: exercise and nonexercise. The age range was 25–68 years with a mean age of 47.9 years. All exercise group subjects received tongue exercise course for 2 months following the first day of radiotherapy. Nonexercise group subjects received placebo course. The effects of tongue exercise were measured pre and 2 months post radiotherapy with tongue maximum isometric strength, tongue endurance, videofluoroscopy, and swallowing life quality. Two-way ANOVA, Wilcoxon, and Mann–Whitney U test were used to find significant differences. Results: No significant difference was found for tongue strength between exercise and nonexercise groups before and after radiotherapy. Oral residue amount for both groups was significantly increased after radiotherapy. The oral pharyngeal swallow efficiency for nonexercise group was significantly decreased after radiotherapy. The score of swallowing life quality for both groups were significantly decreased after radiotherapy. Conclusion: Radiation effects to tongue function were not found whether the patients received tongue exercise or not. Radiation effects may appear on swallowing function for patients who didn’t do tongue exercise in radiotherapy. The results of swallowing life quality implied that radiotherapy may degrade life quality whether the patients received tongue exercise or not.
EFFORTFUL SWALLOW COMBINED WITH ELECTRICAL STIMULATION IN POST-STROKE DYSPHAGIC PATIENTS Jin-Woo, Park1, Youngsun K2, Jong-Chi O1, Sung-Joon P1 1
Department of Physical Medicine and Rehabilitation, Goyang-si, Korea 2 School of Hearing, Speech and Language Sciences, Athens, OH
Abstracts Purpose: We tested the effect of effortful swallow combined with surface electrical stimulation used as a form of resistance training in post-stroke patients with dysphagia. Methods: Ten post-stoke dysphagic patents were randomly divided into two groups. Electrical stimulation was applied to the skin above the infrahyoid muscle and the stimulation current was adjusted until muscle contraction occurred and the hyoid bone was depressed in one group and just above the sensory threshold in the other group. They were asked to swallow effortfully in order to elevate their hyolaryngeal complex when the stimulation began. Total 12 sessions of 20 min training for 4 weeks were performed. Biomechanical measurements of the extent of hyolaryngeal excursion and the maximal width of upper esophageal sphincter opening before and after training were measured with a blind manner. Results: In motor stimulation group, the maximal vertical displacement of hyoid bone and the maximal anterior displacement of larynx were increased significantly after the intervention (P \ 0.05). There was no increment in sensory stimulation group. Conclusion: Effortful swallow training combined with electrical stimulation increased the extent of hyolaryngeal excursion to help airway protection. This intervention can be used as a new treatment method in post-stroke dysphagic patients.
463 2008, although SAH patients still had the lowest overall rates, average completed screening rates for SAH patients improved from 35% (2007) to 52% (2008). The average screening rates also improved for ICH from 73% (2007) to 84% (2008). Interestingly, average ischemic stroke screening rates slightly declined from 86% (2007) to 83% (2008). Annual nursing competencies were performed in November 2007 and 2008, and in both years, in December, the rates improved after re-education of nursing staff. Although the rates have generally improved since our intervention, there is need for re-education and re-energizing of this important clinical measure among nurses and physicians caring for acute stroke patients. Conclusion: Because of the complexity of dysphagia, assessment and management requires interdisciplinary collaboration. A dysphagia screening tool can reduce hospital costs and length of stay and improve patient satisfaction. Future studies should evaluate if a dysphagia screening tool could be used for neurosurgical patients with head of bed restrictions and for broader patient populations.
SAFETY AND EFFICIENCY OF SWALLOWING IN IPD- IS TIME OF THE ESSENCE? Regan, Julie1, Keane J1
USING AN EVIDENCE-BASED BEDSIDE SWALLOW SCREEN FOR ALL STROKE PATIENTS: HOW HEALTH CARE PROVIDERS CAN IMPROVE STROKE PATIENTS’ OUTCOMES Davis-De Geus, Megan1 1
University of Iowa Hospitals and Clinics, Iowa City, IA
Purpose: Stroke is the third leading cause of death in the US and the leading cause of long-term disability. Stroke produces multiple neurological impairments including lack of postural control, visual, cognitive and communication impairments, upper limb dysfunction, dyspraxia and dysphagia. If dysphagia goes undetected, it can lead to aspiration pneumonia, respiratory distress, malnutrition, dehydration, social isolation and depression. Dysphagia with aspiration is common in stroke patients, and healthcare providers need to utilize a sensitive and specific screening tool to identify dysphagia. The goal of this project was to find and implement a simple, evidence based screening tool to identify dysphagia in all stroke patients (intracranial, subarachnoid, ischemic). Recognizing dysphagia early is important to providing quality care and reducing the risk of complications. Methods: A descriptive, pilot study was performed using the Iowa Model of Evidence-Based Practice. An evidence-based swallow screen tool for stroke patients was selected and piloted on a neuroscience unit. Physicians and nurses were trained to use the tool and document results. New nursing policies were written, documentation systems were updated, and pre-printed stroke orders were created by the multidisciplinary team. Speech pathologists followed up with patients at risk for dysphagia. Results: Percentage of bedside swallow screens completed were assessed each month and divided by SAH, ICH, and ischemic stroke in 2007 and 2008. The wide variability in the percentages may be due to the fact that fewer patients are admitted with SAH and ICH vs. ischemic strokes; therefore the ICH and SAH data has larger variation, due to a smaller sample size. Interestingly, a similar trend was seen in all three populations in 2007 and 2008; there was a decrease in screenings completed in July, when many new residents and nurses are trained. In 2007, screenings for SAH patients were completed [50% of the time in 2 out of 12 months; in 2008, screening [50% of the time increased to 8 out of 12 months. During 2008, six months showed C90% of ICH srceenings completed. In
1
Adelaide and Meath Hospital, Dublin, Ireland
Purpose: Features of dysphagia in Idiopathic Parkinson’s Disease (IPD) include delayed oral and pharyngeal transit times and delayed initiation of the pharyngeal swallow. The purpose of this study is to determine if these temporal measures of swallowing are associated with swallow safety and efficiency in IPD. Methods: Sixty-three videofluoroscopys of individuals with IPD were included for retrospective analysis. First or second fluid swallows were randomised from each videofluoroscopy. Oral transit times (OTT), pharyngeal transit times (PTT) and pharyngeal delay times (PDT) were collated by one researcher. Another researcher, who was blinded to temporal measures obtained, rated the swallows on a safety measure (Penetration-Aspiration Scale) (PAS) and on two efficiency measures (valleculae and pyriform residue rating scales). 10% of data was tested for inter-rater reliability by two independent clinicians. Results: Data collated was acceptable in terms of inter-rater reliability. Pearson’s Correlation tests determined that there was no statistically significant association between oral transit time, pharyngeal transit time or pharyngeal delay time and the measures of swallow safety and efficiency. The only statistically significant association observed was between pyriform residue and safety of swallow (PAS) (r = 0.527; P = 0.000). Conclusion: Oral and pharyngeal transit times and pharyngeal delay times are not associated with safety and efficiency of swallowing in IPD. Rehabilitative attempts to speed up timing of swallow may have limited functional impact and temporal measures should not be used in isolation to determine efficacy of dysphagia intervention. Minimisation of pyriform sinus residue may promote safe swallowing in IPD.
CHANGES IN ARTERIAL OXYGEN SATURATION AND HEART RATE DURING A MEAL IN PATIENTS WITH CHRONIC OBSTRUCTIVE PULMONARY DISEASE Dantas, Roberto1, Cassiani R1, Santos C1, Martinez J1 1
Facudade de Medicina de Ribeira˜o Preto-USP, Sa˜o Paulo, Brazil
Purpose: Patients with chronic obstructive pulmonary disease (COPD) have problems with the coordination between respiration and swallowing. During meals they may have alterations of arterial oxygen saturation because they have limitations of ventilatory function.
123
464 Our objective was to evaluate arterial oxygen saturation (SpO2) and heart rate before, during and after a meal in patients with COPD. Methods: We studied 14 normal volunteers and 16 patients with a clinical and spirometric diagnosis of COPD. All subjects ingested a meal of 1800 calories while SpO2 and heart rate were measured by pulse oximetry. Results: The duration of the meal ingestion was similar in controls (10.9 ± 4.1 min) and COPD patients (9.8 ± 3.5 min), but only 2 (12.5%) of the patients ingested the entire volume whereas 11 (73.3%) of the controls subjects ingested the entire food volume. SpO2 decreased after the meal in the volunteers and patients, and decreased during the meal in the COPD patients when compared with the values before the meal. SpO2 was always lower in COPD patients than in controls. Heart rate was always higher in patients than in controls. In patients and volunteers, heart rate increased from before to during the meal and decreased from during to after the meal. Conclusion: We conclude that COPD patients have a lower SpO2 than controls, which decreases during meals. Heart rate is higher in COPD patients than in controls, a fact that may be a compensation for the lower SpO2.
EFFICACY AND SUCCESS OF ORAL FEEDING WITH SPECIFIC DIET RECOMMENDATIONS BASED SOLELY ON THE 3-OUNCE WATER SWALLOW CHALLENGE Leder, Steven1, Suiter D2 1
Yale University School of Medicine, New Haven, CT The University of Memphis, Memphis, TN
2
Purpose: To investigate the efficacy and success of recommending specific oral feeding diet recommendations based solely on passing the 3-ounce water swallow challenge screen. Methods: Three hundred and seventy-five consecutive adult inpatients participated. Inclusion criteria were referral for dysphagia testing and passing the 3-ounce water swallow challenge. Success of oral feeding was determined in a blinded fashion within a 12–24 h period by recording the volume of thin liquid ingestion and noting if diet recommendations were followed for a representative meal as entered by nursing on each patient’s daily flow sheet. Results: Hundred percent of patients (N = 365) who passed the 3-ounce water swallow challenge successfully drank thin liquids (mean 357 cc, range 90–1160 cc) and received the recommended consistency diet within 12–24 h. Ten patients were medically or surgically unstable for oral alimentation or were discharged prior to follow-up. Conclusion: A long sought goal of all swallow screening techniques has been empirically validated and an important threshold relevant to a specific swallow screen, i.e., the 3-ounce water swallow challenge, has been crossed. Both the clinical utility of using the 3-ounce water swallow challenge and the efficacy of recommending oral feeding with specific diet recommendations when the 3-ounce challenge is passed has been corroborated [1]. Specifically, if the 3-ounce water swallow challenge is passed, diet recommendations, e.g., puree consistency if edentulous and regular consistency if dentate, as well as ingestion of thin liquids, can be made confidently without further objective dysphagia testing. 1. Suiter DM, Leder SB. Clinical utility of the 3-ounce water swallow test. Dysphagia 23:244–250, 2008.
DEVELOPMENT OF HUMANOID ROBOT REPRODUCING A NORMAL SWALLOW Michiwaki, Yukihiro1, Kobayashi, H2 1
Musashino Red Cross Hospital, Tokyo, Japan Tokyo University of Science, Tokyo, Japan
2
123
Abstracts Purpose: The purpose of this study was to produce a humanoid-type swallowing robot for clarifying the mechanism of normal and abnormal swallow. This report demonstrates process of the development and movies how the present robot swallows. Methods: Cine MRI, videofluorography and videoendscopy of healthy volunteers and patients supplied data to analyze movement of swallowing organs. These images were evaluated frame by frame and some were reconstructed for 3-dimensional analysis. Actuators of the robot were McKibben’s type artificial muscles contracted by compressed air and electro-pneumatic regulators with sequential control. The tongue was manufactured by polyurethane with a sheet-type spring on its midline surface. The tongue movement was replicated by continuously pulling the spring from tip to tongue base. ABS resin was used for hyoid bone and thyroid cartilage which moved up-, and forward by actuators arranged for the suprahyoid muscles. The epiglottis made by soft urethane moved at first together with the hyoid, then bent down to close the laryngeal inlet by a actuator matched to ary-epiglottis muscle. The pharynx made by silicon contracted to narrow the space by actuators acting as pharyngeal constrictor muscles. Results: The swallowing robot showed extremely similar movement to the video images. Then an experiment to check the robot could swallow proved successful feeding of thick liquid and elastic food (konjac) until the vallecula, although the food fell down by gravity from valleculla to hypopharynx. Conclusion: The humanoid type swallowing robot can replicate the entire movement, then clarify the mechanism of normal and abnormal swallow to contribute rehabilitation devices for dysphagia patients.
THE RELATIONSHIP BETWEEN QUALITY OF LIFE AND SWALLOWING IN PARKINSON’S DISEASE Plowman-Prine, Emily1, Sapienza C1, Okun M1, Pollock S1, Rosenbek J1 1
University of Florida, Gainesville, FL
Purpose: (1) Evaluate swallow-specific quality of life in Idiopathic Parkinson’s Disease (IPD); (2) Delineate potential relationships between IPD duration and severity with swallow-specific quality of life; (3) Investigate relationships between swallow-specific quality of life and general health-related quality of life and (4) Investigate relationships between swallow-specific quality of life and depression. Methods: Thirty-six patients diagnosed with IPD with and without dysphagia filled out validated self-report assessments of (1) the SwalQOL; (2) the Parkinson’s Disease Questionnaire-39 (PDQ-39) and (3) the Beck Depression Inventory (BDI). A series of Mann Whitney U tests were performed between dysphagic and non-dysphagic groups for the total Swal-QOL score and each of the ten Swal-QOL domains. Spearman’s Rho correlation analyses were performed between the Swal-QOL and (1) PDQ-39, (2) Hoehn and Yahr stage; (3) PD disease duration; (4) UPDRS ‘on’ score; and (5) the BDI. Results: Overall data indicated that swallow-specific quality of life was mild—moderately reduced with scores across Swal-QOL domains ranging from 42–76. The dysphagia swallowing group reported significant reductions compared to the non-dysphagia group for the total Swal-QOL score (P = 0.02), mental health domain score (P = 0.002) and social domain score (P = 0.002). No relationships were revealed between swallow-specific quality of life and disease duration or severity, however significant relationships were observed between swallow-specific quality of life and general health-related quality of life (r = -56, P = 0.000) as well as a relationship to depression (r = -48, P = 0.003).
Abstracts Conclusion: These exploratory data highlight the psychosocial sequelae swallowing impairment can have in a IPD population and suggest a possible association between swallowing function and depression.
RETROSPECTIVE REVIEW OF CHEMORADIATION THERAPY PREFERENCE PATTERNS IN PATIENTS WITH ADVANCED OROPHARYNGEAL CANCER PATIENTS: CETUXIMAB VS CYTOTOXIC CHEMOTHERAPY Goldsmith, Tessa1, Huckabee M2 1
Massachusett General Hospital, Boston, MA University of Canterbury, Christchurch, New Zealand
2
Purpose: The molecular targeted treatment, Cetuximab, has produced promising survival outcomes when combined with radiotherapy in treating advanced oropharyngeal squamous cell carcinoma. Patient selection criteria for prescription of Cetuximab are undefined. This retrospective analysis reviewed patient characteristics in a cohort receiving either Cetuximab or cytotoxic chemotherapy with concurrent radiotherapy to determine whether particular patient factors informed practice patterns in this specialty Head and Neck Cancer Center. Methods: Medical records of 51 newly diagnosed advanced oropharyngeal cancer patients from January 2007 to October 2008 were reviewed for a variety of characteristics including disease features, comorbid factors, chemotherapy and radiation therapy dose, gastrostomy tube placement and formal swallowing intervention. Co-morbid factors were classified according to chronic progressive conditions vs. episodic treatable factors. Results: Result(s): 39 (N = 20) and (N = 22) 43% (N = 22) of patients received Cetuximab vs. cytotoxic drugs respectively. Eight (16%) received an induction chemotherapy approach with a cytotoxic drug because of advanced nodal involvement. No patient with Stage IVb (AJCC) disease received Cetuximab. Chronic multi-organ disease did not stratify patients into a particular drug treatment group. All but two subjects received gastrostomy feeding tubes and (N = 29) 57% (N = 29) were evaluated with videofluoroscopic swallowing studies. All patients received intensity modulated radiation therapy. Conclusion: No practice pattern has emerged differentiating patients regarding stage of disease or comorbidities. At our institution, there does not appear to be an algorithm determining which radiosensitizing drug is prescribed in patients with advanced oropharyngeal cancer. These findings require extension to a larger sample and confirmation in other specialty Head and Neck Cancer centers.
SWALLOWING PHYSIOLOGY AFTER SKULL BASE TUMOR RESECTION Lazarus, Cathy1, Roland J1, Golfinos J1, DeLacure M1, Amin M1, Lalwani A1 1
New York University School of Medicine, New York, NY
Purpose: To examine swallow physiology in patients with skull base tumor resection. Methods: A retrospective review of videofluoroscopic swallow evaluation (VFSE) results for 13 patients with surgically resected skull base tumors sequentially referred for evaluation was completed. Swallow motility disorders were identified, as was presence of cranial nerve deficits with resultant voice, speech and resonance impairment. The etiology and timing of aspiration was identified, as was whether therapeutic strategies, including postures and maneuvers were employed and whether they were effective in improving swallow safety and/or efficiency.
465 Results: Identification of VFSE disorders of dysphagia revealed that 8% demonstrated oral phase impairment and 54% demonstrated pharyngeal phase impairment and 38% demonstrated both oral and pharyngeal phase impairment in swallowing. Sixty-nine percent of patients aspirated, with 7 aspirating after the swallow due to pharyngeal residue, one of whom also aspirated before the swallow due to a pharyngeal motor response delay, and 2 aspirating during the swallow due to incomplete laryngeal vestibule and glottic closure. Swallow motility disorders can be seen in Table 1 below. Although 10/13 patients had a unilateral vocal fold paresis or paralysis following surgery, only 2 of these patients were aspirating during the swallow because of this impairment. Likewise, although 5/13 demonstrated velopharyngeal insufficiency for speech with severe hypernasality, only one patient demonstrated nasal reflux during swallowing. Postures and/or maneuvers eliminated aspiration in 5 patients. Conclusion: Skull base tumor resection can result in oral and pharyngeal phase swallow impairment. Cranial nerve deficits that result in voice, speech or resonance impairment do not necessarily correlate with oropharyngeal swallow impairment. Therapeutic strategies including postures and maneuvers can improve swallow safety and efficiency.
ORAL HEALTH KNOWLEDGE IN LONG-TERM CARE Boczko, Faerella1 1
Jewish Home Lifecare, Bronx, NY
Purpose: This study investigated the oral health care knowledge in certified nursing assistants (CNA) as well an education program provided by speech-language pathologists. Methods: Twenty CNAs were randomly selected. Six residents from each CNA caseload were randomly selected, resulting in a patient pool of 112. The CNAs were blinded to the residents selected. An oral cavity health assessment was conducted 2 weeks before the CNAs participation in the education program for the selected residents assessing six areas of the oral cavity. A 25-item oral health knowledge test (OHKT) was developed for this study and given to all CNA participants before they participated in an oral health education program. The OHKT was readministered to all CNA participants at the completion of the education program. The resident subjects were reassessed using the oral cavity health assessment to determine if the health of the residents’ oral cavities improved following education. Results: Results revealed significant differences from pretest to posttest on the OHKT with a gain of 5.29 points. Cross-tabular analysis was conducted comparing pre-assessment and post-assessment distributions on the 6 oral health criterion. The findings indicated positive change in 5 out of 6 areas assessed. Conclusion: Study results indicate that an education program for CNAs can have immediate results and positive changes and is important for overall patient care and management. By establishing an oral care plan, following standardized oral care protocols, ensuring interdisciplinary collaboration, and promoting better awareness and understanding, we can overcome the barriers to good oral health. Direction for future research is suggested.
QUANTITATIVE EVALUATION OF MUSCLE ACTIVITY OF THE SUPRAHYOID MUSCLE COMPLEX DURING A NEW EXERCISE (CHIN UP/TONGUE PROTRUSION EXERCISE) USING SURFACE EMG Uyama, Risa1, Takahashi K1 1
Showa University, Tokyo, Japan
123
466 Purpose: Mendelsohn maneuver and Shaker exercise were designed to improve laryngeal elevation during swallow. Mendelsohn maneuver without swallow is widely used as an exercise for improving laryngeal elevation. However the isometric training effect of this maneuver is hard to obtain because dysphagic patients stop respiratory movement during the maneuver. The isokinetic training effect of this maneuver is also hard to achieve because of the light load of laryngeal elevation. Shaker exercise is a well-designed exercise. However, the excessive load of this exercise results in low compliance in the aged dysphagic patients. We developed a new exercise to strengthen the suprahyoid muscles to improve laryngeal elevation during swallow. This study was done to quantitatively evaluate the muscle activity of the suprahyoid muscle complex during the new exercise using surface EMG. Methods: Fifteen volunteer medical personnel without any history of swallowing problems and five patients with oropharyngeal dysphagia served as subjects. Results: Peak amplitudes of suprahyoid muscle complex activity during the Mendelsohn maneuver and the new exercise were measured using surface EMG. To perform the new exercise, subjects were instructed as follows: ‘‘Put your chin up as far as you can and protrude your tongue as far forward as you can, and hold it for ten seconds’’. Conclusion: Peak amplitudes of suprahyoid muscle complex activity during the new exercise were significantly greater than the Mendelsohn maneuver (82.8 ± 24.1 vs. 40.0 ± 24.0 lV). This result suggests that the new exercise can be used as an effective training tool for improving laryngeal elevation.
VIDEOENDOSCOPIC EVALUATION OF THE BOLUS PREPARATION FUNCTION Nohara, Kanji1, Sasao Y1, Kotani Y1, Fukatsu H1, Sakai T1 1 Division for Oral and Facial Disorders, Osaka University, Suita-city, Japan
Purpose: It has been reported that most aspirations are not caused by pharyngeal dysfunction but by oral abnormalities, although aspiration indeed occurs during the pharyngeal stage. Thus it is important to evaluate the function of bolus preparation in order to reduce the risk of aspiration. This study investigated a method of evaluating the function of bolus preparation for swallowing using videoendoscopy. Methods: Twenty dentulous healthy adults participated in this study. Rice and cookies were used as examination foods. We prepared foods with two colors in order to evaluate the degree of bolus preparation, that is, white rice and green rice, yellow cookies and green cookies. The subjects were instructed to eat mouthfuls of the same kind of foods with different colors in two different ways: in their usual manner and with proper mastication. From the perspective of grindability, cohesiveness and mixing, we evaluated the function of bolus preparation in the pharynx using videoendoscopy. Results: Rice; The bolus formed in the usual manner showed poor degrees of grindability and cohesiveness. The degrees of grindability and cohesiveness of the bolus formed with proper mastication were significantly higher than those of the bolus made in the usual manner (P \ .01). Cookie; The bolus formed in either way showed high degrees of mixing, graindability and cohesiveness. There was no significant difference between the bolus formed by proper mastication and by the usual manner. Conclusion: These findings indicated that it is possible to evaluate bolus preparation for swallowing using videoendoscopy.
123
Abstracts 3D SUPRA- AND INFRAHYOID MUSCLES MODEL IN SITU DURING DRY SWALLOW Zu, Yihe1, Yang Z2, Perlman A1 1
University of Illinois at Urbana-Champaign, Champaign, IL Florida International University, Miami, FL
2
Purpose: The ability to safely continue with oral intake of food and/ or is an issue for a significant percentage of post-surgery head and neck cancer patients. Successfully overcoming this issue requires ENT surgeons to be able to predict the functional changes in speech, eating, and breathing after reconstructing the head and neck structures that remain after cancer surgery. In this study, a 3D dynamic model of suprahyoid and infrahyoid muscle groups during swallowing was created based on still 3D and dynamic MRI. This model will be further developed to examine the effects of muscle forces on functional changes after head and neck surgery. Methods: 3D MRI of head and neck area were used to reconstruct 3D polygonal meshes of hyoid muscle groups, hyoid bone, mandible, and larynx. Measurement was performed using Amira 4.1. The polygonal meshes were imported in to Alias Maya 8.5. By mapping the dynamic MRI of the swallow, the muscle meshes were reshaped to generate a 3D movie of swallowing. Results: Using MR images, an accurate and realistic computer reconstruction of supra and infra hyoid muscles, in situ, was constructed. A 3D movie was created to demonstrate the anatomy, larynx, and hyoid displacement in all directions. Conclusion: MRI provides high quality soft tissue information. 3D modeling using MRI provide muscle information in situ. The dynamic movie created the opportunity for researchers and physicians to observe anatomical changes in all coordinate planes. These offer a promising future toward increased understanding of head and neck physiology and pathophysiology.
DYNAMIC IMAGING OF SWALLOWING IN A SEATED POSITION USING OPEN-CONFIGURATION MRI Honda, Yasutoshi1, Hata N2, Yanagi Y1, Ishida R3, Arioka K1, Murakami J1, Asaumi J1 1
Okayama University, Okayama-shi, Japan Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 3 Tokyo Dental College, Chiba-shi, Japan 2
Purpose: To assess the feasibility of dynamic MRI of swallowing in a seated position using an open-configuration MRI scanner, and to compare its capacity for motion analysis around the pharyngeal wall with that of videofluorography. Methods: Six healthy individuals (four women and two men, mean age = 31.4 +/-7.5 years) were examined with an open-configuration MRI system using a fast spoiled gradient-recalled echo (SPGR) sequence. Dynamic imaging was performed while the subjects were in a seated position after they swallowed oral contrast medium from a cup. An oral and maxillofacial radiologist measured the motion of six structures: the hyoid bone (HB), larynx (LX), upper oropharynx (UOP), lower oropharynx (LOP), pharyngoesophageal segment (PES) behind the vocal folds, and upper esophagus (ESO). The measured motions were compared with reported values from videofluorography-based observations. Results: Open-configuration MRI depicted the anatomic structures related to swallowing (lip, tongue, soft palate, mandible, pharynx, HB, LX, and PES), and the course of the mylohyoid muscle (MM). The vertical and anteroposterior displacements of these structures did not differ significantly from those measured by videofluorography.
Abstracts Conclusion: Dynamic imaging of swallowing using open-configuration MRI provides image information comparable to that obtained from videofluorography.
TRAINING EFFECT IN SWALLOWING FUNCTIONS FOR STROKE PATIENTS WITH DYSPHAGIA Tsubahara, Akio1, Ishii M2, Metani H1
467 opening followed. Then, maximum displacement of the hyoid, glottal closure, and epiglottic tilt were observed almost simultaneously. Glottal closure occurred in the second half of the hyoid displacement and its duration was approximately 0.2 s. Epiglottic tilt persisted after glottal opening and onset of hyoid bone descent. Conclusion: We were successful in obtaining 4D images (3D dynamic images) of swallowing. Moreover, we could measure the timing of glottal closure and epiglottic tilt distinctively. 320-detector row CT is an innovative tool with great potential for swallowing research and clinical management of dysphagia.
1
Kawasaki Medical School, Kurashiki, Japan Kawasaki University of Medical Welfare, Kurashiki, Japan
2
Purpose: In Japan, the Dysphagia Severity Scale (DSS) has been used to evaluate swallowing functions at the impairment level, whereas the Fujishima’s Dysphagia Grading (FDG) has been used at the disability level. The relationship between swallowing functions using both of these evaluation tools was investigated in analysis of the recovery process of dysphagia in stroke patients. Methods: Eighty stroke patients with dysphagia more than 1 month after the acute onset of stroke participated in the study. Patients who could orally intake sufficient nutrition and water without other supplemental methods at the time the study began were excluded, as were patients who had consciousness disturbance or serious general conditions. The subjects received swallowing training more than four times per week until they reached the plateau in swallowing functions. The swallowing functions in the basement and at the end point were judged by both DSS and FDG based on the findings of videofluoroscopic or videoendoscopic examinations of swallowing. Results: The mean values of DSS were 2.80 +/-1.12 in the basement and 4.55 +/-1.59 at the end point. The mean values of FDG were 2.61 +/-1.39 and 5.98 +/-2.38, respectively. Swallowing training significantly improved swallowing functions. Spearman’s rank-correlation coefficient between DSS and FDG in the basement was 0.522 (P \ 0.01), and that at the end point was 0.859 (P \ 0.01). Some patients with high DSS values showed low FDG values in the basement. Conclusion: The correlation between impairment and disability in swallowing functions was stronger after swallowing training than before the treatment.
KINEMATIC ANALYSIS OF SWALLOWING USING 320-DETECTOR ROW CT Inamoto, Yoko1, Fujii N1, Baba M1, Saitoh E1, Yoshioka S1, Okada S1, Yokoyama M1, Ozaki K1, Ida Y1, Nakai T1, Katada K1 1
Fujita Health University, Toyoake, Japan
Purpose: To determine if 320-detector row computed tomography (CT) can be used to depict oropharyngeal structures, dynamic movement, and timing of kinematic relationships of swallowing. Methods: After informed consent, three healthy subjects received a 320-detector row CT scan from the skull base to the upper esophagus (160-mm range) on Aquilion ONE (Toshiba, Japan) scanner. The scan parameters were 0.5-mm thickness by 320 rows, 0.35 s/rotation, 120 kv and 150 mA. The subjects underwent 3.2 s continuous CT while swallowing 10 ml of contrast medium. Digital images were analyzed using ZIO M900 software (AMIN/ZIO, Japan). We then measured the temporal relationships between hyoid movements, upper esophageal sphincter (UES) opening, glottal closure and epiglottic tilt, at 10 fps. Results: We obtained 4D images of swallowing (3D-dynamic images including multi planar reconstruction images and volume rendering images) and observed the dynamic movement of each structure. Once swallowing was induced, as determined by hyoid elevation, UES
OUTCOMES OF A TONGUE PRESSURE EXERCISE TREATMENT PROTOCOL IN ACQUIRED NEUROGENIC DYSPHAGIA Molfenter, Sonja1, Bailey G1, Buesselberg N2, Cliffe R1, Yeates E1, Steele C1 1
Toronto Rehabilitation Institute, Toronto, Canada SRH Klinikum Karlsbad-Langensteinbach, Karlsbad, Germany
2
Purpose: To report outcomes for a series of 7 patients with neurogenic dysphagia who received a standardized course of treatment involving tongue pressure exercises. Methods: At baseline, all participants demonstrated poor tongue control with thin liquids and vallecular residues (thin or spoon-thick liquids). Treatment was administered over 12–24 sessions, scheduled 2–3 times weekly. Each treatment session comprised 60 tongue pressure tasks, including maximum isometric pressures (MIPs), pressure-accuracy tasks and saliva swallows. Changes in anterior and posterior tongue strength were measured. Associated physiological change was evaluated by standardized videofluoroscopy at treatment baseline, midpoint and endpoint, rated by 3 speech-language pathologists, blinded to patient identity and video timepoint. Ordinal rating scales were used to score bolus location at swallow onset, penetration/aspiration, vallecular residue and pyriform sinus residue. Results: Anterior and posterior tongue strength improved in all participants. Final scores reached the reported normative range. The improvements achieved in one-repetition-maximum pressures achieved were competitive with those reported previously for a more intensive treatment schedule. Changes in videofluoroscopy impairment scores varied across the 7 participants. For each rated feature, one or two participants showed a worse score post-treatment versus baseline. However, the most common patterns of change revealed improved bolus position at swallow onset (thin liquids), unchanged or improved vallecular residues (thin liquids), and improved composite scores (thin and spoon-thick liquids). Conclusion: Improvements in tongue strength can be achieved over a course of 24 treatment sessions delivered on a regular schedule (2– 3 times weekly), when treatment includes distributed practice of different tongue pressure tasks.
DEVELOPMENT OF SWALLOWING ROBOT REPRODUCING HYOID BONE AND EPIGLOTTIS DURING SWALLOWING Kikuchi, Takahiro1, Kobayashi H1, Michiwaki Y2 1
Tokyo University of Science, Chiyoda-ku, Japan Musashino Red Cross Hospital, Musashino City, Japan
2
Purpose: The purpose of this study was to reproduce movements of the hyoid bone and epiglottis during swallowing from the viewpoint of mechanical approach.
123
468 Methods: The movements of the organs were traced frame by frame on videofluorographic images of a normal volunteer. Figures of the hyoid bone and epiglottis were determined based on 3dimensional CT images. The material was ABS resin for the hyoid, and flexible urethane resin for the epiglottis. McKibben artificial muscles were used as actuators. For the hyoid, actuators were arranged at positions matched to suprahyoid muscles. Actuators for the epiglottis substituted ary-epiglottic and thyroepiglottic muscle. Results: The hyoid bone of the robot could be manufactured as it moved similar to images of videofluorography, however, the epiglottis could not. Although the videofluorography demonstrated that the epiglottis reversed downward at the last stage of swallow, such kind of movement was impossible because of smaller space of the pharynx and anatomical connection of epiglottis to hyoid bone and thyroid cartilage. Therefore, the robot’s epiglottis went, at first, up-, and forward together with the hyoid bone and thyroid cartilage, then, bowed down till horizontal level. An experiment to check how the robot fed food demonstrated that the bolus was successfully sent from oral cavity to the hypopharynx without aspiration, although the epiglottis only bowed to horizontal level. Conclusion: Three-dimensional image analysis and reproduction of movement will be necessary to prove the hypothesis for epiglottis. The swallowing robot will be useful to check those hypotheses and to clarify the swallowing mechanism.
DYSPHAGIA IN PEDIATRIC CARDIOPATHY: SPEECH THERAPY INTERVENTION TO IMPROVE ORAL FOOD INTAKE Soria, Franciele1, Duarte S1, Furkim A1, Sacco A2, Jatene I3 1
Universidade Tuiuti do Parana´, Curitiba, Brazil Instituto de Gerenciamento em Fonoaudiologia e Deg, Sao Paulo, Brazil 3 Hospital do Corac¸a˜o da Associac¸a˜o do Sanato´ri, Sao Paulo, Brazil 2
Purpose: To verify outcomes of speech therapy intervention using Functional Oral Intake Scale (FOIS) scale in hospitalized children with dysphagia and cardiopathies. In addition, to analyze the influence of the presence of acyanotic cardiopathies and Down syndrome in the clinical outcome. Methods: Retrospective cohort study with 55 children admitted to Hospital during a period of 23 months, and submitted to speech therapy intervention. It was used Chi-square and T tests to compare the groups, and it was admitted P \ 0.05 as significant. Results: Mean age was 9.83 months (05 day–10 year); 52.7% male; 18.25% had Down Syndrome; 21.8% had cyanotic cardiopathies. Mean duration of speech therapy intervention was 11.85 day, with 6.38 sessions. Patients with longer and more frequent therapy sessions had a better improvement in FOIS (26.17% 9 10.1%). However, there was no statistical significance (P = 0.451). Patients with mechanical ventilation longer than 48 h had less chance to improve in FOIS: 86.8% 9 94.12%, without statistical difference. Significant clinical intercurrences during hospital permanence were predictors of non-improvement of FOIS: 66.7% 9 10.2%, with P = 0.003. Cyanotic cardiopathy and presence of Down Syndrome were not predictors of FOIS worsening. Conclusion: We concluded that speech therapy intervention brought benefits to pediatric patients with cardiopathies and swallowing disorders resulting in a faster and safe oral food intake, with exception for those patients with clinical intercurrences during the therapeutic process.
123
Abstracts THE USE OF SURFACE-EMG AS BIOFEEDBACK IN THE TREATMENT OF STROKE PATIENTS WITH DYSPHAGIA: A SYSTEMATIC REVIEW Bogaardt, Hans1, Kalf H2, Fokkens W1 1
Academic Medical Center, Amsterdam, The Netherlands Radboud University Medical Center, Nijmegen, The Netherlands
2
Purpose: The use of surface EMG (sEMG) biofeedback has proven to be effective in different professions and patient groups, mainly in the rehabilitation of arm or leg function in stroke patients. The first publication on sEMG as biofeedback in swallowing rehabilitation was published as a case study in 1991. A systematic review was conducted to detect and compare all relevant studies to asses the quality of published articles on this topic and to investigate whether the use of sEMG biofeedback is effective in dysphagic stroke patients. Methods: A computer-assisted search was developed using the biomedical databases Pubmed, CINAHL and EMBASE. For assessing the quality of included articles the Physiotherapy Evidence Databasescale or PEDro scale was used. Results: Forty-one articles were identified, of which six met our inclusion criteria. No randomized controlled trials were identified; all studies had a pre-treatment vs. post-treatment design. A total of 55 stroke patients are described in literature. Forty-seven patients were depended on non-oral feeding prior to the treatment. Thirty-three patients returned to an oral diet after treatment. The overall risk reduction ratio of the treatment of biofeedback in dysphagic stroke patients dependent on non-oral feeding was estimated to be 2.65 (95% CI: 1.81–3.86). Conclusion: This review shows that the scarce literature on efficacy of sEMG biofeedback shows a potential benefit in favour of this treatment. Further research on the efficacy of sEMG-biofeedback in the treatment should clearly describe (randomized controlled) trials with clear treatment protocols on treatment intensity and type of exercise(s).
TONGUE BRADYKINESIA IS RELATED TO IMPAIRMENT OF FOOD TRANSPORTATION IN PARKINSON’S DISEASE Umemoto, George1, Tsuboi Y1, Furuya H2, Kitashima A1, Kikuta T1 1
Fukuoka University, Fukuoka, Japan
2
National Omuta Hospital, Omuta, Japan
Purpose: The aim of this study is to demonstrate a relationship between food transportation and deglutitive movement of tongue in patients with Parkinson’s disease (PD). Methods: 26 PD patients ranging in age from 56 to 83 years were studied. These patients were enrolled and divided into 2 groups: a mild/moderate group (n = 13)—Hoehn & Yahr stages II, III, and an advanced group (n = 13)—Hoehn & Yahr stages IV, V. They underwent videofluorography (VF) using barium gelatin jelly as a test food. The speed of the bolus movement and the range of tongue and mandible movement in oral and oropharyngeal transit time were measured with the analysis of VF. Results: In these 26 patients, there were significant positive correlations between the speed of the bolus movement and the range of tongue movement (R = 0.510, P \ 0.01) as well as between the range of tongue movement and mandible movement (R = 0.760, P \ 0.01). But there was no significant correlation between the speed of the bolus movement and mandible movement (R = 0.352, P = 0.077). The range of mandible movement in the mild/moderate group was significantly longer than the advanced group (P \ 0.05),
Abstracts however, there was no significant difference between the speed of the bolus movement or the range of tongue movement and the grade of severity (P = 0.059, P = 0.067). Conclusion: These results indicate that short range of tongue movement, namely tongue bradykinesia in PD patients may affect most impairment of food transportation in oral cavity and oropharynx.
THE RELATIONSHIP BETWEEN IMPAIRMENT AND DISABILITY IN FEEDING FOR PATIENTS WITH DYSPHAGIA AFTER STROKE IN THE SUB-ACUTE PHASE Kajiyama, Naoko1, Metani H1, Matsumoto E1, Ishii M3, Tsubahara A1 1
469 age 72 ± 11) and 43 head and neck tumor patients (24 men and 19 women, average age 62.8 ± 10.7). Results: There were 49 patients (67%) who had a normal cough reflex. Of these, 43 patients (88%) had no problem and left or changed the hospital, 1 patient (2%) suffered from pneumonia, 1 patient (2%) suffered from pleural effusion and 4 patients (8%) died. There were 24 patients (33%) who had a weak or no cough reflex. Of these, 12 patients (50%) had no problem, 9 patients (38%) suffered from pneumonia, 1 patient (4%) suffered from upper airway inflammation and 2 patients (8%) died. Among CVA patients, 12 patients had a weak or no cough reflex and 8 patients (67%) suffered from pneumonia. Conclusion: The state of cough reflex influenced the patients’ progress.
Kawasaki Medical School Hospital,Kurashiki-Shi, Japan Kawasaki University of Medical Welfare, Kurashiki-Shi, Japan
3
Purpose: Videofluorography (VF) is the most common method for evaluating dysphagia. The Dysphagia Severity Scale (DSS) is evaluated by VF and reflects impairment of feeding. Fujishima’s Dysphagia Grading (FDG) is evaluated by findings of physical appearance and reflects disability in feeding. Both methods are important in the evaluation of patients with dysphagia. However, we often experience differences in grade between DSS and FDG clinically. To study the differences feeding between patients with impairment and disability in the early and later sub-acute phases of stroke. Methods: The subjects were 63 patients with dysphagia after stroke admitted to Kawasaki Medical School Hospital. They all underwent VF at least twice and dysphagia rehabilitation. Their feeding function was also evaluated by the DSS and FDG at the same time by VF. We tested the correlation of the DSS with FDG for the first and last evaluations. We also compared changes in the rate of the grade on the DSS with those on FDG. Results: Both the DSS and FDG improved significantly. (DSS; P = 0.001, FG; P \ 0.001) The correlation coefficient between the DSS and FDG was smaller the last time than the first time. (R square: last 0.44, first 0.52) The changing rate in the grade was higher for FDG than for the DSS (P = 0.015). Conclusion: Dysphagia rehabilitation can improve the impairment of feeding in the sub-acute phase of stroke patients. However, disability in feeding can be improved more by changing the food consistency, initial bite size, and environment and situation of eating.
THE PROGRESS OF PATIENTS ADMINISTERED THE COUGH TEST Wakasugi,Yoko1, Tohara H2, Motohashi Y3, Tsushima C1, Uematsu H1 1
EFFECT OF QUALITY IMPROVEMENT OF DYSPHAGIA NURSING BY CERTIFIED NURSES IN JAPAN Fukada, Junko1, Kamakura Y1 1
Aichi Prefectural College of Nursing & Health, Nagoya, Japan
Purpose: The purpose of this study is to clarify whether certified nurses (CNs) who perform the role of CN improve the quality of dysphagia nursing by ward nurses. Methods: The study was approved by the Ethics Committee of the Aichi Prefectural College of Nursing & Health. A questionnaire survey of CNs and their ward nurses was conducted by mail using a quality assessment scale developed for dysphagia nursing (QASDN). The QASDN for ward nurses consisted of 64 items and six factors. The QASDN for CNs consisted of 69 items and seven factor. Both QASDNs were rated on a scale of five, from 0 (no nursing patients corresponding to scale content) to four (always practiced). Results: From the results of multiple regression analysis, the sum score of overall QASDN for ward nurses at 1 year and 7 months after completing the regular course, showed a significantly positive correlation with the length of dysphagia nursing experience, the length of their nursing experience and above-average scores of QASDN for CNs. The sum score showed a significantly negative correlation with belonging to a neurosurgery ward and age. Conclusion: These results suggested that by performing their role CNs would improve the quality of dysphagia nursing of ward nurses.
1st Place Scientific Abstract: Poster Presentation SWALLOWING FREQUENCY IN ELDERLY PEOPLE DURING DAILY LIFE
Tokyo Medical and Dental University, Bunkyo, Japan Nihon University, Chiyoda, Japan 3 Musahimurayama Hospital, Musashimurayama, Japan
Tanaka, Nobukazu1, Nohara K1, Kotani Y1, Sakai T1
Purpose: To investigate the influence of the state of the protect reflex (cough reflex) on patients’ progress, we traced those whose medical records could be found. Methods: We had administered the cough test 2 years earlier. Patients inhaled a mist of citric acid-physiologic saline orally for 1 min with an ultrasonic nebulizer. More than 5 coughs was considered normal, while less than 4 coughs was regarded as weak or no cough reflex. We also performed videofluorography or videoendoscopy at the same time. In this study, 2 years after the test, we reviewed the medical records, and progress pf the patients. We could trace 73 patients, 30 CVA patients (20 men and 10 women, average
Purpose: Disuse atrophy of swallowing-related organs due to an excessive decrease in swallowing frequency is suspected to occur in patients with poor oral intake, especially elderly people. However, swallowing frequency during daily life has not previously been examined in elderly or dysphagic patients. We developed a swallowing frequency meter that is portable and capable of prolonged operation and presented data on the validity of this meter at the last DRS meeting. This study examined swallowing frequency in elderly people using this meter and compared the findings to those in a younger population. Methods: Two groups participated in this study (group E and group Y). Group E consisted of 17 elderly people (average 82.6 ±
2
1
Osaka University, Suita City, Japan
123
470 8.2 years) living in a nursing home and group Y consisted of 10 healthy young people (average 26.2 ± 2.4 years). For one hour each, we examined swallowing frequency during daily life in individuals from these groups and then compared data on swallowing frequency between the two groups. All participants were directed not to eat or drink anything during measurement. Results: The swallowing frequency in group E was 4–24 times/hour and the average was 10.2 ± 5.4 times/hour, and that in group Y was 16–76 times/hour and the average was 41.2 ± 19.7 times/hour. Swallowing frequency in elderly people was significantly lower than that in young healthy people (P = 0.01). Conclusion: These results indicated that during daily life, elderly people tend to swallow less frequently than young people.
EFFECTS OF SOUR TASTE AND COLD TEMPERATURE ON ORAL TRANSIT TIME OF SWALLOWING Gatto, Ana Rita1, Cola P1, Silva R2, Spadotto A1, Schelp A1, Henry M1
Abstracts of dysphagia and feeding methods. Multiple regression analysis was performed using SPSS for Windows. Results: Mean age was 86.3 years (SD = 7.3) and 84.3 years (SD = 7.7) for the dementia and non-dementia groups, respectively. In the dementia group, symptoms of dysphagia were current aspiration pneumonia (3.7%), past aspiration pneumonia (35.8%), coughing while swallowing (69.7%), and fever (14.1%), and feeding methods were fasting (0.1%), tube feeding only (14.2%), both tube and oral feeding (2.9%), assisted oral feeding (68.6%) and non-assisted oral feeding (14.0%). Multiple regression analysis was used to test factors determining feeding methods in subjects for associations with age, symptoms of dysphagia and level of bedridden status. The factor most strongly associated with feeding method was bedridden status (b = .340, P \ .001). Conclusion: This study found that the factor most strongly associated with feeding methods for dysphagic elderly with dementia in LTCFs was not swallowing disorders, but bedridden status. This suggests that some dysphagic elderly with dementia will be able to move from tube to oral feeding to prevent decreases in functions during disuse.
1
Sao Paulo State University, Botucatu, Brazil Sao Paulo State University, Marilia, Brazil
2
Purpose: The neurogenic oropharyngeal dysphagia results of sensory and motor disorders of the oral and pharyngeal phases of swallowing, and it is well-known that stroke is a major cause of this disorder. Some studies report the effect of thermal stimulation and taste about the dynamics of swallowing in this population. The aim of this study was to evaluate the effects of tastes (sour) and thermal (cold) stimulation through time quantitative analysis in the oral phase of swallowing in hemispheric cerebral vascular accident patients. Methods: 30 subjects post cerebral vascular accident with mild to moderate oropharyngeal dysphagia participated in this study, 16 men and 14 women, aged 41–88 years (average 62.3 ± 14.8 years) and median ictus of 6 days. During the videofluoroscopic swallowing, 4 spoons were offered, 5 milliliters each, of thickened substance (natural, cold, sour and sour cold). After examining, the images were digitalized, and using specialized software the time of bolus displacement in the oral phase of swallowing was measured. Results: The results showed that for his hemispheric cerebral vascular accident patients swallowing the bolus with sour/cold stimulus presented significantly lower oral transit time when compared to other stimulus separately. Conclusion: The association of taste and temperature can cause beneficial effects in the oral phase of swallowing in this population and, therefore, it may help the rehabilitation process in these patients.
FACTORS DETERMINING FEEDING METHODS IN DYSPHAGIC ELDERLY WITH DEMENTIA IN JAPAN Yamada, RItsuko1, Chiba Y2, Uchigashima S1 1
Health Sciences University of Hokkaido, Ishikari, Japan Tokyo Medical and Dental University, Bunkyo-ku, Japan
2
Purpose: The purpose of this study was to investigate dysphagic elderly with dementia in long-term care facilities (LTCFs) from all 47 prefectures in Japan and to explore factors determining feeding methods in such patients. This study suggests perspectives of care to prevent the inappropriate use of tube feeding and to maintain oral feeding. Methods: Subjects comprised 12,345 dysphagic elderly in 9,163 LTCFs, divided into dementia (n = 3,841; 3,148 women, 690 men) and non-dementia (n = 8,503; 6,120 women, 2,379 men) groups. Question items consisted of the characteristics of subjects, symptoms
123
PHYSICAL AND ASSOCIATED SENSORY PROPERTIES DETERMINING THE SWALLOWING FUNCTION Loret, Chrystel1, Walter M1, Lenfant F1, Peyron M3, Martin N1, Hartmann C1 1
Nestle´ Research Center, Lausanne, Switzerland INRA, Saint-Gene`s-Champanelle, France
3
Purpose: An important function of human mastication is the formation of a swallowable food bolus with appropriate physical characteristics such as particle size distribution, cohesion and lubrication. Our aim is to investigate whether food bolus should present specific rheological property for swallowing, and if these physical properties are perceived. Methods: The study was performed on food boli obtained from 11 healthy subjects with a good dentition, eating 3 types of breakfast cereals. Mastication behaviour and saliva flow for each subject were characterised. Rheological properties and water content of food boli obtained just before swallowing were measured. The subjects were also trained to evaluate the intensity of sensory properties characterizing this swallowable food bolus. Results: Despite difference in mastication behaviour and saliva floe among subjects, swallowable food bolus from the different cereals showed similar physical properties. The swallowable food bolus showed a visco-elastic property with a storage modulus comprise between 14 and 22 KPa, and a yield stress property varying from 1.3 to 4.3 KPa. The bolus water intake was around 50%. These small differences in physical properties were perceived and the food bolus with a lower visco-elastic and yield stress properties were perceived less sticky and cohesive. Conclusion: Each subject pursues its own oral breakdown strategy from a fixed starting point (food structure) to reach similar physical end-points that subjects can perceive differently. To our knowledge, this study is the first one leading to a rheological and sensory characterization of a food bolus just before swallowing.
FEEDING PERCEPTION OF ELDERLY LIVING AT LONG PERMANENCE INSTITUTION Pazzotti, Andreia1, Cola P2, Freitas J1, de Carvalho Lı´dia R2, Giacheti Celia M1, da Silva R1 1
Sao Paulo State University, Marilia, Brazil
Abstracts 2
Sao Paulo State University, Botucatu, Brazil
Purpose: Changes in the process of feeding during aging deserve special attention, since they are directly related to nutrition and quality of life. The aim of this study was to compare the perception of elderly living in long permanence institution with the caregiver’s perception regarding the feeding. Methods: Thirty-seven long permanence elderly living in long permanence institution, 21 female, 16 male, ages between 60 to 90 years old, variable scholar rating (from illiterate to high school). A checklist was applied to identify the presence or absence of complaints about feeding and afterward the elderly were separated in two groups. Group I (GI) presented complaints about feeding while Group II (GII) did not present complaints. Were excluded from the sample the individuals with cognitive impairments. Afterwards, the checklist was applied on the elderly’s caregivers. Results: The results showed that, from the 37 assessed elderly, 16 (43,24%) presented complaints about feeding (GI) and 21 (56,76%) did not present complaints (GII). From the elderly with complaints about feeding (GI), only 31,25% (5) were classified also by the caregivers as individuals with difficulties on feeding. From the 21 elderly without complaints (GII), 90,48% (19) were also classified by the caregivers as individuals without difficulties on feeding. Conclusion: The agreement between the perception of individuals living in long permanence institution and their caregivers’ perception about the difficulties on feeding is clearer on the group of individuals without feeding complaints. These data suggest the necessity of investing on the qualification of the caregivers of long permanence institutions.
2nd Place Scientific Abstract: Poster Presentation EFFECT OF STRAW DIAMETER ON BOLUS VOLUME AND MUSCLE ACTIVITY Chandler, Caroline1, Hietpas F1, Clark H1, Smead K2 1
Appalachian State University, Boone, NC Speech and Neuro Rehab Inc, Pensacola, FL
471 through strategic straw selection may be used therapeutically to enhance swallowing safety.
QUALITY OF LIFE AND NUTRITIONAL STATUS IN OLDER ADULTS WITH DYSPHAGIA Goldberg, Lyn1 1
Wichita State University, Wichita, KS
Purpose: This study examined the effects of dysphagia on quality of life (QOL) and nutritional health in older adults with and without dysphagia residing in assisted living facilities. Methods: 10 adults over age 65 in each of the two groups (n = 20) completed multiple measures of QOL and perceived nutritional status. Participants also completed a Reflux Symptom Index, a three-day food intake diary, and bioelectric impedance analysis for more objective comparative measures. Results: Adults with dysphagia reported a significantly lower QOL and more difficulty with reflux than older adults without swallowing difficulties. Components affecting QOL were decreased energy (F = 12.08, df = 1, P \ 0.01) and emotional well-being (F = 4.61, df = 1, P \ 0.05), and increased psychological factors (F = 4.87, df = 1, P \ 0.04). There were no significant differences (P \ 0.05) between groups on perceived general health and nutritional status but scores for both groups were lower than expected. Analysis of threeday food intake diaries showed measures of macronutrients, vitamins, and minerals were close to, or at recommended levels with three important exceptions. Measures for fiber, calcium, and potassium were at lower than recommended levels for all participants. These measures were of concern due to older adults’ risks for constipation, osteoporosis, and decreased cognitive function. Conclusion: Findings confirm the importance of (1) incorporating an array of QOL assessment measures in dysphagia management to gain insight into patients’ perspectives of their QOL as it relates to dysphagia and nutritional health, and (2) speech-language pathologists working closely with dietitians to facilitate optimal nutritional intake, particularly for residents in assisted living facilities.
2
Purpose: Straw drinking poses unique physiologic challenges to effective deglutition. Patients who demonstrate a safe swallow with liquids sipped from a cup may be less successful sipping from a standard straw, or vice versa. Moreover, straws of varying diameters may require different levels of muscle activity during sipping. This study sought to determine typical bolus volumes and orofacial muscle activity associated with a single sip from straws varying in internal diameter. Methods: 40 healthy adults sipped water from six straws varying in internal diameter. Bolus volume was determined by measuring the volume of liquid remaining in a graduated cylinder. Volume swallowed during three trials from each straw was recorded. Orofacial muscle activity was recorded from 28 of the participants. Results: Bolus volume correlated strongly with straw diameter (r = .969). ANOVA revealed a significant main effect of straw condition, with follow-up comparisons revealing that each straw yielded bolus volumes that differed significantly from each of the remaining straws. Bolus volume negatively correlated with muscle activity (r = .857) suggesting that smaller straws generally required greater muscular effort. Conclusion: The findings confirm that internal straw diameter is a strong predictor of bolus volume from a single suck by healthy individuals. These data provide norms to which the performance of individuals with dysphagia can be compared. Future studies will examine how physiologic impairments influence the effect of straw diameter on bolus volume as well as how controlling liquid bolus size
3rd Place Scientific Abstract: Poster Presentation RESPIRATORY PATTERNS ASSOCIATED WITH STRAW DRINKING Hietpas, Fletcher1, Chandler C1, Clark H1, Smead K2 1
Appalachian State University, Boone, NC Speech and Neuro Rehab Inc, Pensacola, FL
2
Purpose: Straw drinking poses unique physiologic challenges to effective deglutition. A first step in understanding how dysphagia impacts effectiveness of straw drinking or how straw drinking might be used therapeutically is to document performance of healthy individuals during straw drinking. This study examined respiratory patterns associated with a single sip from straws varying in internal diameter. Methods: Twenty-eight healthy adults sipped water from seven straws varying in internal diameter. Respiratory phase was recorded via nasal cannula and transduced by the Kay Swallowing Signals Lab. The respiratory pattern of the entire sip/swallow sequence was described. Three single-swallow trials from each straw recorded. Results: Mean duration of swallow apnea was .827 s (SD .134). Thirteen percent of all swallows were preceded by complete apnea— that is, the participant did not inhale or exhale during the sip/swallow
123
472 cycle. Fifty-three percent of all swallows were preceded by sips during which participants demonstrated more than one inhalatory/ exhalatory cycle. Straw diameter had no significant effect on any of the respiratory measures. Conclusion: The findings suggest that healthy individuals do not typically suspend respiration during single sucks from straws, regardless of straw diameter. Duration of swallow apnea was not related to straw diameter or bolus volume, which is inconsistent with earlier reports. Additional study of respiratory patterns associated with straw drinking in individuals with oropharyngeal dysphagia is needed.
THE MANN ASSESSMENT OF SWALLOWING ABILITY (MASA) FOR IDENTIFICATION OF PATIENTS AT RISK FOR ASPIRATION IN MIXED-DISEASE POPULATIONS Gonza´lez-Ferna´ndez, Marlı´s1, Sein M2, Palmer J1 1
Johns Hopkins University School of Medicine, Baltimore, MD University of Maryland School of Medicine, Baltimore, MD
2
Purpose: To determine the effectiveness of the Mann Assessment of Swallowing Ability (MASA) in predicting aspiration as determined by videofluorographic swallowing studies (VFSS) in a mixed-disease population. Methods: We selected retrospectively 133 cases clinically evaluated using MASA and VFSS January–June 2007. We abstracted from MASA: (1) the subjective aspiration ordinal risk rating (ORR) and (2) the total numeric score (TNS). We evaluated these values as predictors of aspiration on VFSS. To account for items that were missing or not tested during MASA administration the maximum possible score was determined and a weighted percent score was calculated for each patient. We used receiver operating characteristics (ROC) analysis to compare the sensitivity and specificity of the ORR and TNS for predicting aspiration at different cutoff points in the scale. Results: VFSS identified 51(38.4%) cases as aspirators while the ORR identified 54(40.6%) as probable or definite aspiration and the TNS 19(14.3%) as moderate to severe risk of aspiration. ROC analysis demonstrated an area under the curve of 0.74 (95% CI = 0.66– 0.82) for the ORR and 0.51 (95% CI = 0.41–0.61) for the TNS. These ROC scores mean that the MASA’s ordinal risk rating is better at predicting aspiration on VFSS than the MASA’s numeric score. Conclusion: In this mixed-disease sample the MASA’s subjective ORR had good predictive ability for aspiration on VFSS. The MASA’s numeric score failed to predict aspiration on VFSS. The MASA ORR assessment is more useful for identifying patients at risk for aspiration than the TNS in this mixed disease population.
POST-RADIOTHERAPY NEUROMYOTONIA, BILATERAL HYPOGLOSSAL NERVE PALSIES, AND PROGRESSIVE DYSPHAGIA IN NASOPHARYNX CARCINOMA Jacobson, Marlene1, Balogh J1 1 Sunnybrook Health Sciences Centre—Odette Cancer, Toronto, Canada
Purpose: Literature on the onset of late post-irradiation neurological deterioration and progressive functional impairment in head and neck cancer is sparse. This study reports the history and presentation, progression, and management approaches associated with sudden onset of post-irradiation neuromyotonia, cranial neuropathy, and dysphagia arising after (chemo) radiation for nasopharyngeal carcinoma.
123
Abstracts Methods: Two young, disease-free cases of carcinoma of the nasopharynx treated with (chemo)radiation therapy were evaluated serially by a multidisciplinary team within the setting of a regional cancer centre. Evaluation methods and clinical procedures included videofluoroscopic examination of swallowing and speech, MRI, electrodiagnostic studies, and tracking of frequency, duration, triggers, and timing of episodes of suprahyoid/neck spasm. Results: Sudden onset of neuromyotonic episodes, neurologic and swallowing deterioration occurred several years post-treatment. Onset of oral-pharyngeal dysphagia occurred later in the development of the symptom complex. Interventions included hyperbaric oxygen therapy, pharmacologic agents, and swallowing rehabilitation strategies. Detailed functional investigations revealed an array of component physical impairments of the head and neck and oral-pharyngeal functional mechanisms. Conclusion: Measures of swallowing physiology and performance provide valuable indicators for tracking late onset post-radiotherapy clinical deterioration. Suprahyoid/neck neuromyotonic episodes represent a potential harbinger of hypoglossal nerve palsy and oralpharyngeal dysphagia. The importance of interdisciplinary collaboration in the assessment and management of oncologic cases with progressive late effects involving complex upper aerodigestive tract functions is underscored.
SWALLOWING SOUND ANALYSIS FOR AMYOTROPHIC LATERAL SCLEROSIS PATIENTS Yoshikawa, Mineka1, Nagasaki T1, Okada G2, Yoshida M3, Akagawa Y1 1
Hiroshima University, Hiroshima City, Japan Bihara Hananosato Hospital, Miyoshi City, Japan 3 Hiroshima City Rehabilitation Center, Hiroshima City, Japan 2
Purpose: The purpose is to show some characteristics of swallowing sound in Amyotrophic Lateral Sclerosis (ALS) patients. Methods: Eight ALS patients with predominantly corticospinal tracts involvement (8 male; 41–77 years) and two ALS patients with predominantly corticobulbar tracts involvement (1 male, 1 female; 50 years and 71 years) participated. Their ALS progression level was various, but every patient took ordinary diet by mouth. The swallowing movement and swallowing sound at 3 ml liquid were recorded simultaneously with videofluorography and pediatric auscultator built-in microphone. Swallowing sound during bolus moving through upper esophageal sphincter (UES) was investigated through videofluorographic and acoustic analyses. Results: Three patterns were shown in ALS patients. Pattern-I was that the quality of swallowing sound was similar to the sound in healthy adults, which occurred most frequently when the bolus moved through UES. However, maximum swallowing sound in ALS patients occurred in the situations excluding bolus moving around UES. Also, higher frequency band (444–2640 Hz) of swallowing sound was shown in ALS patients than that (200 Hz band) in healthy adults. Pattern-I was shown in four patients with corticospinal tracts involvement. Pattern-II was that the swallowing sound was shown to be low intensity (9–12 dB) and no frequency band in four ALS patients with corticospinal tracts involvement. Pattern-III was shown in the two patients with corticobulbar tracts involvement. Their swallowing sound was extremely low intensity and no frequency band corresponding with the reduction in tongue movement and pharyngeal contraction. Conclusion: It may be suggested that the quality of swallowing sound differ from the progress of ALS.
Abstracts NATURALLY THICK LIQUIDS: CURRENT PRACTICE VERSUS EVIDENCE Bratlund, Christina1, O’Donoghue C1 1
James Madison University, Harrisonburg, VA
Purpose: This study expands upon a mixed-methods pilot project that reported SLPs examples of natural state liquids when educating patients prescribed to thickened liquids. Sequentially, purposes were (1) do the viscosities of these reported natural state nectar, honey and pudding materials differ significantly from the viscosity of their VaribarÒ counterparts? (2) develop a pilot continuum displaying the viscosities of these naturally thick consistencies (3) report practitioners’ assessment of the proposed continuum. Methods: Pilot findings, coupled with a review of literature on thickened liquids (patient education materials and research studies), drove the questions for the expanded electronic survey. This was completed by 55 SLPs from ASHA SID #13. All naturally thick examples were quantitatively tested at room temperature using a Brookfield rheometer, model RV-DV-III, with small sample adapter. Resulting viscosities were compared to VaribarÒ standards. Spindle and RPMs were adjusted per thickness category (shear rate = 30). Materials were plotted along a continuum, progressing in measured centipose (cP), from nectar to pudding thick viscosities. Subsequent interviews with practitioners were conducted to assess the pilot continuum. Results: From the array of reported naturally thick materials, many were not commensurate with the VaribarÒ ranges. In this study, therapists reported most materials as thicker than viscometry readings confirmed. A pilot continuum is presented. Further, this presentation reports practitioners’ assessments of this continuum. Conclusion: Many influential factors underlie the expansion of this pilot naturally thick continuum. Implementation requires discernment of: statistical versus clinical relevance, temperature effects, and viscosity differences across brands.
A SENSITIVITY ANALYSIS TO DETERMINE WHETHER TEN TEASPOONS OF WATER ARE REALLY NECESSARY Martino, Rosemary1, Streiner D2, Maki E3, Diamant N4 1
University of Toronto, Toronto, Canada Baycrest, Toronto, Canada 3 Analytica Statistical Consulting Inc, Toronto, Canada 4 Toronto Western Research Institute, Toronto, Canada 2
Purpose: Using the bedside dysphagia screening tool (TOR-BSSTÓ) to define the number of swallows necessary to accurately identify dysphagia in stroke patients. The tool utilizes only 4 items identified to be best predictors of dysphagia, and includes the patient swallowing 10 teaspoons of water followed by a sip. This study assessed the incremental value in indentifying dysphagia with each teaspoon of water. Methods: Trained nurses from 2 acute and 2 rehabilitation facilities administered the TOR-BSSTÓ to consecutively admitted eligible stroke inpatients. A positive screen identified patients at high risk for dysphagia. Sensitivity analysis was conducted for the water swallow item to determine an acceptable cutoff point in the number of teaspoons of water required, when 10 teaspoons plus a sip is treated as the standard. Results: One hundred and three acute and 208 rehabilitation were enrolled. The proportion of positive screenings was 59.2% in acute and 38.5% in rehabilitation patients. The water swallow item alone identified dysphagia in 42.7% acute and 29.0% rehabilitation patients. Incremental accuracy for each teaspoon of water demonstrated 8 teaspoons achieved adequate sensitivity of 92% (CI, 85–96) and 10 teaspoons excellent sensitivity of 96% (CI, 90–99), while 5 teaspoons
473 resulted in a sensitivity of only 79% (CI, 70–86). Sensitivity was similar in acute and rehabilitation patients. Conclusion: The TOR-BSSTÓ has proven validity in identifying stroke patients with dysphagia. The water swallow item contributes largely to the total TOR-BSSTÓ screening score. In order to maintain excellent screening accuracy, it is critical that screeners administer the prescribed 10 teaspoons of water.
RECOGNIZING OF SPECIFIC SIGNAL’S BURTS DURING SWALLOWING PHARYNGEAL PHASE AIDED BY VIDEOFLUOROSCOPY Spadotto, Andre´1, Gatto A1, Cola P2, Silva R2, Domenis D3, Schelp A1, Dantas R3, Pereira J4 1
Sao Paulo State University, Botucatu, Brazil UNESP, Marilia, Brazil 3 Facudade de Medicina de Ribeira˜o Preto-USP, Ribeira˜o Preto, Brazil 4 USP, Sa˜o Carlos, Brazil 2
Purpose: Digital cervical auscultation is a new and interesting area that has developed tools for the assessment of swallowing disorders. The potential to diagnose dysphagia in a noninvasive manner by assessing the sounds of swallowing is a highly attractive option for the dysphagia clinician. The objective is verify the duration of the first and second burst and interval between bursts. Methods: We evaluated 13 healthy subjects between 20 and 50 years old (mean 30.5). It was registered the videofluoroscopy simultaneously with swallowing sounds. The analyzed signals (video and sound) were the burst’s duration and interval between bursts during swallowing 10 ml of water and 5 ml of thicked substance. The time was determined analyzing both signals simultaneously, aided by specific software. On software’s screen exhibited the image of each frame and the portion of the signal that represent this frame. The audio signal was obtained by dynamic microphone digitalized with rate of 44100 Hz joined with video signal by a DVD recorder. Results: It was found the mean time of 87.3 ms to water and 78.2 to thick substance in burst one, in burst two 112.9 ms (water) and 85.5 (thick substance). The mean interval between burst one and two was 82.1 and 95.3, between two and three was 339.8 and 322.0, both to water and thick substance respectively. Conclusion: This study gives support for the use duration of the first and second burst and interval between these bursts to help on analysis and management of dysphagic patients.
FINITE ELEMENT (FE) MODEL OF HUMAN LINGUAL DEFORMATION DURING SWALLOWING BASED ON THE MECHANICS OF MESOSCALE MYOFIBER TRACTS OBTAINED BY DIFFUSION TENSOR IMAGING (DTI) WITH TRACTOGRAPHY Gilbert, Richard1, Liang A2, Wang T2, Mijailovich S3 1
Caritas St. Elizabeth’s Medical Center, Boston, MA Massachusetts Institute of Technology, Cambridge, MA 3 Harvard School of Public Health, Boston, MA 2
Purpose: In order to demonstrate the relationship between lingual myoarchitecture and mechanics during the various phases of swallowing, we performed FE simulations of lingual deformation during late accommodation and propulsion employing FE mesh generated from DTI tractography. Methods: DTI tractography (90 gradient directions, b-value 500 s/mm2) was employed to image lingual myoarchitecture in non-swallowing subjects (n = 5) and portrayed as multi-voxel (mesoscale) myofiber tracts whose vector coordinates define FE mesh alignment.
123
474
Abstracts
Material properties were depicted in terms of Hill’s 3-component phenomenological model and activation functions of the imaged myofiber tracts derived from the multi-scale attributes of resting and contracting skeletal myofibers (Smith and Mijailovich, Ann Biomed Eng, 2008). Using early accommodation as a starting condition, we assumed that the FE mesh was composed of anisotropic muscle and isotropic collagen, the mesh was elastically constrained from the superior and inferior directions, and passive bolus effects were negligible. Results: Myofiber tract activation and displacement of the mid-sagittal lingual tissue were simulated over 500 ms in 50 equally spaced steps (10 ms/step) employing a set of programs developed in our laboratory. Synchronous 2D contraction of the mid- genioglossus and verticalis myofiber tracts in the preconfigured tongue generated lingual reconfiguration consistent with the deepening of the bolus containing concavity exhibited during late accommodation and early propulsion. Conclusion: The application of FE techniques based on the mechanics of imaged myofiber tracts obtained by MRI provides a method for simulating complex patterns of human lingual deformation and force generation during normal and pathological swallowing.
FOODS AND CONSISTENCIES THAT ARE MORE LIKELY TO CAUSE ASPIRATION DURING VIDEOFLUOROSCOPIC EXAMINATION OF SWALLOWING 1
1
1
1
1
Ozaki, Kenichiro , Kagaya H , Baba M , Yokoyama M , Okada S , Inamoto Y1, Saitoh E1, Gonzalez-Fernandez M2, Uematsu H3 1
Fujita Health University, Toyoake, Japan 2 Johns Hopkins University School of Medicine, Baltimore, MD 3 Tokyo Medical and Dental University, Bunkyo-ku, Japan Purpose: To assess the rate of aspiration with different liquid and solid consistencies and volumes and determine which are more likely to cause aspiration in patients with dysphagia. Methods: Six hundreds and eleven patients who were suspected to have dysphagia underwent videofluoroscopic examination of swallowing (VF) between January 2006 and September 2008. Our VF clinical protocol includes evaluation of 4 ml thickened liquids (honey thick), 4 ml and 10 ml thin liquid, cup drinking, 8 g corned beef hash and two-phase food (5 ml liquid and 4 g corned beef hash) with and without compensatory maneuvers. We selected the first VF study of 89 patients that received all aforementioned consistencies to determine the aspiration episodes with each consistency and volume. The swallows studied were in upright position without compensatory maneuvers. Results: They were 58 males and 31 females with mean age of 67 years. (Stroke: 32, Neuromuscular diseases: 16, Respiratory diseases: 9, Others: 32) No patients aspirated thickened liquids, 6 aspirated corned beef, 7 aspirated 4 ml thin liquid, 19 aspirated 10 ml thin liquid, 53 aspirated during cup drinking, and 57 aspirated two-phase food. Six patients aspirated only during two-phase food trials and 6 patients aspirated only during cup drinking. Aspiration episodes during cup drinking or two-phase food were significantly higher than other consistencies and volumes. (P \ 0.001, Fisher’s exact test). Conclusion: Cup drinking and two-phase food were more likely to result in aspiration in this population. These findings suggest that cup drinking and two-phase food can be helpful to detect mild dysphagia.
DEVELOPMENT OF ULTRA HANDY VIDEOENDOSCOPE SYSTEM Tohara, Haruka1, Ueda K1 1
Nihon University School of Dentistry, Chiyoda, Japan
123
Purpose: Videoendoscopy is a definitive evaluation of swallowing as well as Videofluorography. Each has an advantage and disadvantage respectively. Videoendoscopy has portability for its advantage, but it needs still big and heavy machinery when bring it to home, nursing home or a narrow ward. We developed an ultra handy videoendoscope system taking it into account, and compared it to an usual videoendoscope. Methods: Ultra handy videoendoscope consisted of videoendoscope, hi-vision handy cam, portable LED light source, and an adapter for the endoscope. Its system weighted under 2 kg. Brightness, sharpness, and shade of its image were compared to the image of usual endoscope. Results: Image of usual videoendoscope was more bright and sharp. Shade of blue of ultra handy videoendoscope was emphasized. However, when looking at aspiration or pharyngeal residue, the image of ultra handy videoendoscope was good enough. Conclusion: Ultra handy videoendoscope was considerably portable. Its image was inferior to usual videoendoscope, but it did not matter when looking at swallowing.
LUNG VOLUME DURING SEQUENTIAL SWALLOWING IN HEALTHY ADULTS Wheeler-Hegland, Karen1, Huber J2, Pitts T1, Sapienza C1 1
University of Florida, Gainesville, FL Purdue University, West Lafayette, IN
2
Purpose: Respiration during swallowing undergoes modification such that the expiratory phase of respiration predominately follows swallows, and the volume of air in the lungs during single thin liquid and paste swallows is slightly above tidal volume (*55% vital capacity). Less is known about respiratory modification during sequential swallowing. The purpose of this project was to identify the lung volume at swallowing initiation for 100 ml boluses administered by cup and by straw. Methods: Twenty healthy adults, 9 male and 11 female, served as study participants. None had a history of dysphagia, voice disorder, chronic respiratory illness, neurologic disease, traumatic brain injury, or stroke. Lung volume and respiratory phase data were recorded as each participant completed 4 trials of a 100 ml bolus, 2 by cup and 2 by straw. Results: Boluses administered by cup exhibited similar lung volumes at initiation to those seen for single bolus swallows administered by cup. However, boluses administered by straw were initiated at significantly higher lung volumes than those given by cup. Conclusion: The coordination of respiration with swallowing, in terms of lung volume at swallow initiation, is markedly different depending on delivery for boluses of the same size and consistency. However, 100 ml boluses requiring multiple swallows were not initiated at lung volumes significantly different than those for small, single bolus swallows administered via the same delivery method. A priori knowledge about delivery method and/or oral/pharyngeal afferent information about delivery method, bolus size or oral-pharyngeal propulsion properties likely play a role in the central integration of these two subsystems.
PULMONARY COMPLICATIONS AFTER VIDEOFLUOROSCOPIC EXAMINATION OF SWALLOWING Yokoyama, Michio1, Kagaya H1, Tanaka T1, Baba M1, Kanamori D1, Ozaki K1, Inamoto Y1, Okada S1, Saitoh E1 1
Fujita Health University, Toyoake, Japan
Purpose: Aspiration is sometimes inevitable during videofluoroscopic examination of swallowing (VF). The purpose of this study
Abstracts is to know whether or not aspiration cause pulmonary complications. Methods: One hundred and ninety-eight patients who were suspected to have dysphagia underwent VF and chest x-rays just after VF between July 2007 and August 2008. Aspiration was diagnosed by the VF findings and the amount of aspirated barium was classified into three levels as follows: small (\0.5 g), medium (0.5–1.0 g) and large amount (1.0 g\). The postural drainage and squeezing technique were used to exhaust barium when the patients aspirated a lot. The residual barium in the trachea and bronchi were identified by the chest X-rays. The relationship between the amount of aspiration and the location of residual barium was examined. Fever (37.5°C\) within 5 days after VF and pneumonia were retrospectively investigated by the medical records. Results: No residual barium were observed in the chest x-rays in 86 cases who did not aspirate during VF. Aspiration had occurred in 112 cases but we could identify residual barium in only 40 cases in the chest x-rays. No significant correlations were observed between the amount of aspiration and the location of residual barium. Ten patients had fever after VF but it was not significantly related to the aspiration or the residual barium. Two patients developed pneumonia after VF but aspiration did not seem to the cause of pneumonia. Conclusion: Aspiration during VF and the residual barium in the chest X-rays did not cause pulmonary complications.
CORTICAL ACTIVITY DURING SWALLOWING IN THE SITTING POSITION Yamawaki, Masanaga1, Okamoto M2, Dan I2 1 Department Neurology, Tokyo Medical & Dental University, Tokyo, Japan 2 National Food Research Institute, Tsukuba, Japan
Purpose: Although MRI, PET and MEG are useful tools for functional brain mapping for dysphagia research, there are limitations on a body position (usually supine) and motion artifacts. To overcome these issues, we used functional near-infrared spectroscopy (fNIRS) for brain mapping during swallowing and swallow-related movements in the sitting position. Methods: Twenty-five healthy subjects were evaluated using fNIRS. Primary sensorimotor cortex (SMI) and frontal cortex, including supplementary motor cortex (SMA), were set as the region of interest (ROI). To determine cerebral localization of swallowing in relation to somatotopy, motor block tasks (tongue, mouth and hand) and sensory block tasks (mouth, tongue and soft palate) were evaluated separately. Cortical activity related to swallowing was measured using event-related design while subjects swallowed continuously-infused water with or without visual command. The flow rate was adjusted for each subject so that subjects swallowed the same bolus volume as non-command swallow (every 20–30 s). Results: Activation areas in each blocked task (motor tasks of tongue and hand, sensory tasks of soft palate) were detected separately in SMI (P \ 0.05 by Student t, one-tailed, FDR controlled). During bolus swallowing, activation was detected in tongue SMI, premotor, and SMA areas (P \ 0.05, one-tailed, FDR controlled). The hemodynamic pattern observed during swallowing appeared different during the command versus non-command tasks spatially and temporally (P \ 0.05, two-tailed, not corrected). Conclusion: By using fNIRS, cerebral activity during swallowing can be measured noninvasively in the sitting position. We can also detect temporal patterns of, and spatial localization of brain activity during swallowing.
475 THE INFLUENCE OF SOUR TASTE AND COLD TEMPERATURE ON PHARYNGEAL SWALLOWING TRANSIT TIME IN MILD TO MODERATE OROPHARYNGEAL DYSPHAGIA Cola, Paula Cristina1, Gatto A1, da Silva R2, Spadotto A1, Schelp A1, Henry M1 1
Sao Paulo State University, Botucatu, Brazil
2
Sao Paulo State University, Marilia, Brazil
Purpose: The influence of taste and temperature on normal and abnormal swallowing has been studied in recent decades. The effect of taste with and without the change of temperature in dysphagic individuals has not been fully elucidated yet. This study aims at verifying the influence of sour taste and cold temperature in oropharyngeal dysphagia. Methods: Forty nine right-handed individuals who had stroke, with mild to moderate oropharyngeal dysphagia participated in this study (Daniel et al. in 1997), 26 males and 23 females, from 45 to 81 years (64-year average). The ictus varied from 1 to 30 days (with a median of 6 days). The videofluoroscopy of swallowing was made and we used specific software to measure the time of the bolus displacement in the pharyngeal phase. Each individual was observed during the swallowing of the bolus in paste consistency. They were submitted to completely different 4 tablespoons: natural, cold, sour, and sour and cold. Results: The results showed that the pharyngeal transit time with sour and cold stimuli in individuals with mild and moderate dysphagia was significantly lower when compared to other stimuli separately (natural and cold). No person presented episode of penetration and / or laringotraqueal aspiration. Conclusion: The stimuli of cold temperature and sour taste together decreases the transit time of the pharyngeal stroke. These findings suggest that these associated stimuli can be used in therapy when it aims to reduce the pharyngeal transit time.
TONGUE STRENGTH AND SWALLOWING IN ORAL CANCER PATIENTS Prasse, Jane1, Sanfilippo N2, DeLacure M1, Falciglia D2, Branski R3, Ho M3, Ganz C3, Kraus D3, Lee N3, Lazarus C2 1
New York University, New York, NY New York University School of Medicine, New York, NY 3 Memorial Sloan-Kettering Cancer Center, New York, NY 2
Purpose: To examine the effects of two swallow exercise programs on tongue function and swallowing in oral and oropharyngeal cancer patients having undergone chemoradiotherapy. Methods: Twenty-two patients who underwent primary chemoradiotherapy for oral/oropharyngeal cancer were included. Patients were randomized into one of two exercise programs: (1) traditional swallow exercise (control group) and; (2) traditional swallow exercise with tongue strength exercises (experimental group). Subjects underwent modified barium swallow (MBS) evaluation, tongue strength (IOPI) and quality of life assessment (Head and Neck Cancer Inventory—HNCI) baseline and 6 weeks post-baseline. RMANOVAs were conducted to compare the mean change across time for the two groups for tongue strength, swallow (OPSE) and QOL measures. Pearson Correlation coefficients were used for tongue strength, swallow and QOL correlations. Results: Results revealed no significant differences within or between groups for the tongue strength measures baseline and post-baseline. Tongue strength did not correlate with OPSE measures at either time-point for both groups, other than a significant positive correlation for tongue strength with OPSE for pudding
123
476 swallows in the control group at baseline. Tongue strength was significantly positively correlated with quality of life at baseline the treatment group. In the speech and social direct disruption domains of the HNCI, the control groups’ attitudinal measures were significantly higher than those of the treatment group. However the treatment group’s attitudinal measures increased significantly more than the control group measures. Conclusion: Neither exercise program resulted in significant change in tongue strength or swallow measures for the two groups. Subsets of the quality-of-life measures increased significantly for the treatment group.
CONTAINMENT OF THICKENED LIQUIDS IN AN EXPERIMENTAL MODEL OF THE ORAL CAVITY Nicosia, Mark1 1
Widener University, Chester, PA
Purpose: Textural modification is a common therapeutic tool for treating individuals who aspirate thin liquids. However, our understanding of how altering fluid properties affects oropharyngeal bolus flow is still incomplete. The purpose of this work was to develop and apply an experimental fluid mechanics model to study the extent to which different thickened liquids were contained in a simulated oral cavity in response to perturbations. Methods: The experimental model consists of a fluid bolus contained in the central groove of a simulated tongue. The tongue model was housed in a transparent plastic casing, allowed visual access to fluid motions during the experiments. The tongue model was perturbed with upward and downward motions of various amplitudes, simulating pre-swallow lingual gestures, and the presence or absence of spillage recorded. In addition to testing water, Resource Thickenup (Nestle Nutrition) powder thickener was added to vary liquid consistency. Nectar, honey, and pudding mixtures were prepared according to the manufacturer directions and tested. Results: For small amplitude perturbations, all liquids were contained with no spillage. For moderate perturbations, un-thickened water spilled, while all thickened liquids were contained in the model. For the largest perturbations studied, only the pudding-thick material did not spill. Conclusion: Our results suggest that the prevention of pre-mature spillage in response to lingual gestures may be a mechanism by which thickened liquids provide protection against aspiration. Furthermore, there was a differential effect across liquids, indicating that there is a graded effect for various consistencies. Further studies are necessary to clarify other possible mechanisms of protection.
THE EFFECTIVENESS OF SWALLOWING EXERCISE FOR THE ELDERLY PERSONS WITH USING DAY CARE SERVICES
Abstracts objective and subjective ingestion and deglutition functions before and after intervention, was answered. The intervention duration was from February 2nd, 2008 to March 4th. Results: The subject of analysis was 73. An average age was 82.6 ± 6.4 and the number of female was 52(71.2%). Comparing before and after intervention, the significant differences were lip projection, tongue roll, voluntary, optional cough, consecutive pronunciation[ta], hoarseness, a repetitive saliva swallowing test and 3 subjective answers; shortening of take in a meal, choking in a meal and fear to drink by Wilcoxon’s rank sumtest (P \ 0.05). The total number of this programmed exercise were significantly effect on tongue roll ability and pronunciation [ka] by Spearman’s rank correlation coefficient (P \ 0.05). Conclusion: The result showed a part of our project. The strengthening closure ability of vocal cord helps to prevent aspiration for the elderly persons in the community. We gradually want to develop this program with other ideas of rehabilitation.
SERIAL SWALLOW STUDIES OVER SEVEN YEARS ON THREE PATIENTS TREATED WITH CHEMORADIATION FOR HEAD AND NECK CANCER Graner, Darlene1, Foote R1, Krein K1 1
Mayo Clinic, Rochester, MN
Purpose: To describe swallowing function in 3 patients followed for 7 years after chemoradiation for advanced head and neck cancer. Methods: Three patients treated with intra-arterial cisplatin chemotherapy with accelerated concomitant boost radiation therapy for advanced head and neck cancer underwent serial videofluoroscopic swallow studies before treatment and up to 7 years following completion of treatment. These case study reports include temporal and biomechanical measurements from the videofluoroscopic swallow studies (VFSS), incidence of aspiration, and overall rating of swallowing severity over time. Results: Patient 1 maintained a functional swallow, but reported increased dysphagia during the 7 year follow-up. Temporal and distance measures were variable between VFSS, but did not reflect any consistent pattern of change. Patient 2 continued to eat a general consistency diet and biomechanical measures from VFSS remained stable over time. The third patient reported increased dysphagia beginning at year 3 post treatment. The 7 year VFSS revealed reduced duration and range of laryngeal movement, severely reduced tongue base retraction, and decreased hyoid displacement compared to previous VFSS. Because the patient was unable to obtain adequate nutrition orally and had recurrent pneumonias, a PEG was placed. Conclusion: Delayed change in swallowing in some patients several years following chemotherapy for head and neck cancer creates the need for continued dysphagia evaluation and management in this patient population.
Chiba,Yumi1, Tohara H2 1
Tokyo Medical and Dental Univers, Bunkyo-ku, Japan Nihon University, Chiyoda, Japan
2
Purpose: The purposes of this research were to develop ‘‘swallowing exercise’’ by nursing and welfare professionals for elderly persons with using day care services and to evaluate the effectiveness of intervention focus on the closure strengthening of vocal cord. Methods: Subjects were 84 elderly persons among all 105 users. They were explained about the purpose of this research and have agreed with participation. The contents of intervention were developed by medical researchers and evidence of literatures. The subjects always participated in a programmed exercise, when they participated in day care. The questionnaire, which structured the contents of
123
ZENKER’S DIVERTICULUM: RESULTS OF ENDOSCOPIC TREATMENT WITH ENDO-GIA 30 STAPLER Jaume Bauza, Gabriel1, Culaciati Tapia Felipe1, Artigas Sapiain Cristian1, Til Perez Guillermo1, Sarria Echegaray Pedro1 1
Hospital Universitario Son Dureta, Palma de Mallorca, Baleares
Purpose: We present our experience in order to demostrate that the endoscopic approach for the treatment of Zenker’s desease if a safe, feasible, and has low morbidity and mortality rates. Methods: We present 27 patients with Zenker’s disease. The clinical presentation was retention of food, secretions and regurgitation 60%, halitosis 75%, cough 80%, dysphonia 10%, recurrent aspiration 20%,
Abstracts bronchitis and pneumonia 10%. Diagnosis was established by the anamnesis, barium swallow test, videofluoroscopy and functional endoscopic swallowing test. All patients were controlled one and then 6 months after the surgery, it was also performed a barium swallow during the first postoperative control. Results: Endoscopic treatment was satisfactory and definitive in 24 cases, and in three cases it was necessary an open approach. The clinical improvement was evident, in only one patient persist with odinodisphagia. The possible complications such as fistulas, mediastinitis, injury of the recurrent laryngeal nerve did not appear in any case. Average hospitalization staying was 0.76 days, eating a diet started on postpoperative day. Conclusion: Endoscopic staple diverticulotomy is a good method to surgically correct Zenker’s diverticulum in many patients. It is a technique with a significantly shorter operative time, hospital stay, time to resumption of oral feeding and lower mortality and fewer morbidity complications.
COMPARATIVE RESEARCH OF THE SWALLOWING PHARYNGEAL PHASE IN PATIENTS WITH AMYOTROPHIC LATERAL SCLEROSIS WITH MOBILITY AND IMMOBILITY OF THE TONGUE Rocha, Camila1, Moura˜o L1, Silva A1
477 Purpose: Dysphagic stroke patients consume inadequate amounts of fluid; however, little is known how this compares to fluid intake of non-dysphagic stroke patients, especially in light of stroke-related sequelae that can alter intake. The purpose of this study was to identify the prevalence of substandard fluid intake, differences in fluids offered and intake between 2 viscosity groups (i.e., thin and thickened liquids), and how well select parameters of functional status post-stroke predict fluid intake. Methods: The amount of fluids offered and fluid intake was monitored for 72 consecutive hours for 39 patients admitted to a large urban hospital with a diagnosis of acute stroke (n = 21 receiving thin liquids and n = 18 receiving thickened liquids). Dysphagia severity and FIM scores for eating, expression, problem solving and memory were retrieved from the medical record to determine how well these clinical variables predict fluid intake. A conservative intake standard of 1500 ml was used. Results: The prevalence of substandard fluid intake was greater than 80% for both viscosity groups. Stroke participants receiving thin liquids drank significantly more than stroke participants receiving thickened liquids (P = 0.003); however, were offered significantly more (P = 0.0002). Both viscosity groups consumed similar proportions of the amount of fluids offered. No one clinical variable predicted fluid intake for either viscosity groups. Conclusion: Dysphagic stroke patients prescribed thickened liquids are not the only subgroup of stroke patients at risk for substandard fluid intake. Factors influencing fluid intake are identified.
1
State University of Campinas, Campinas, Brazil
Purpose: The aim of the study was to compare the swallowing pharyngeal phase in patients with and without mobility of the tongue. Methods: Were evaluated 20 patients with Amyotrophic Lateral Sclerosis ALS, they were divided in two groups, G1—patients with immobility of tongue, and G2—patients with mobility of tongue. The data was collected by realizing in every patients the Videoendoscopy swallowing examination, using liquid (0–50 cp) and honey (351– 1750 cP) consistency (National Dysphagia Diet – ADA), in the quantity of 3 and 5 ml. The consistency was obtained using the thickener Thicken-easyÒ—Resource. The data observed in the examination was registered on a scale of videoendoscopic assessment and subdue to statistic analyzis for Fisher’s Exact Test. The analysis parameters were: presence of escape (anterior and posterior) residue (in valleculae, pyriform sinuses and upper esophageal sphincter), penetration, aspiration and oral transit time, in different quantities. Results: The results of comparison between groups are exposed in table. The G1 presents tendency to increase the oral transit, presence of penetration, residue in pyriform sinuses in liquid consistency and trend of posterior escape to honey consistency, suggesting that the immobility of tongue interferes negatively in swallowing pharyngeal phase (presence of residue in pyriform sinuses, penetration and absence of clearance). The G2 presented increase of the changes with the increase of viscosity and presence of residue in valleculae in higher percentage. Conclusion: both the groups analysed exhibit oropharyngeal dysphagia, the swallowing pharyngeal phase seems more compromised in G2 with the increase of viscosity.
FACTORS INFLUENCING FLUID INTAKE IN DYSPHAGIC AND NON-DYSPHAGIC STROKE PATIENTS McGrail, Anne1, Kelchner L2, Boyce S2, Russell A3, Brehm B4 1
Miami Valley Hospital, Dayton, OH University of Cincinnati, Department of Communication, Cincinnati, OH 3 Wright State University, College of Nursing and Health, Dayton, OH 4 University of Cincinnati, College of Nursing, Cincinnati, OH 2
EFFICACY PROTOCOL IN OROPHARYNGEAL DYSPHAGIA: A PROPOSAL da Silva, Roberta1, Jorge A2, Peres F2, Cola P3, Gatto A3, Spadotto A3 1
Sao Paulo State University, Marilia, Brazil State Hospital Bauru, Bauru, Brazil 3 Sao Paulo State University, Botucatu, Brazil 2
Purpose: Nowadays the studies disagree about criteria more suitable for control of therapeutic efficacy in patients with oropharyngeal dysphagia (Langmore S et al. 1991; Crary et al. 2005; Silva 2007). This study aims to present a proposal for control of effectiveness in neurogenic oropharyngeal dysphagia. Methods: Participated in this study 1 post-stroke individual, with right-hemispheric lesion confirmed by computed tomography, with oropharyngeal dysphagia, male, 66 years, presenting laringotraqueal aspiration and using nasogastric feeding tube before swallowing therapy. To control the therapy effectiveness in pre- and post- swallowing therapy, the following procedures was applied: classification of severity degree of oropharyngeal dysphagia (Silva, 2004 and Daniels et al. 1998), functional oral intake scale (FOIS, Crary et al. 2005), videofluoroscopic evaluation of swallowing with additional swallowing pharyngeal transit time evaluation by specific software (Kendal et al. 2002; Spadotto et al. 2008). Results:Before swallowing therapy, severe oropharyngeal dysphagia, FOIS level 1, presence of laryngotracheal aspiration, and 13 s of pharyngeal transit time was found. After swallowing therapy, moderate oropharyngeal dysphagia, FOIS level 5, absence of laryngotracheal aspiration, and 4 s of pharyngeal transit time was verified. Conclusion: The proposed protocol to assess changes in post-swallowing therapy in neurogenic oropharyngeal dysphagia in stroke was able to measure changes both pathophysiology of swallowing and oral ingestion of the individual. We believed it is still necessary to include nutritional and lung status of the individual in the control of effectiveness in oropharyngeal dysphagia.
123
478 THOROUGH EVALUATION OF CHRONIC COUGH Champagne, Jason1, Burkhead L1, Sostre G1, Chang A1, Postma G1 1
Medical College of Georgia, Augusta, GA
Purpose: Tracheoesophageal (TE) fistula is an uncommon cause of chronic cough and can be overlooked if not among the possibilities in a differential diagnosis. Methods: Case report. Multidisciplinary evaluation including flexible endoscopic evaluation of swallowing (FEES), modified barium swallow study (MBSS), and transnasal esophagoscopy (TNE). Illustrations provided through high-resolution images and 3D reconstruction Computed Tomography (CT). Results: A 46 year-old gentleman presented to us with a one-year history of chronic cough especially with ingestion of liquids. A barium esophagram 9 months prior at an outside facility indicated aspiration by report without further mention of either oropharyngeal or esophageal dysfunction. FEES revealed no aspiration or oropharyngeal dysphagia but ingested material was expelled from the trachea into the larynx with reflexive coughing. Further evaluation by a speech pathologist with a MBSS revealed normal oropharyngeal swallow. No aspiration was noted, however, after several swallows, barium coated the upper tracheal wall from below with coughing. Attention to the distal esophagus revealed findings suggestive of TE fistula. Subsequent high-resolution TNE by an otolaryngologist and 3D CT reconstructions provided excellent visualization of the lesion. Final disposition was consultation with a cardiothoracic surgeon where a calcified hilar lymph node was found to be the source of the fistula. The patient underwent surgical repair and resumed an unrestricted oral diet without complication. Conclusion: The evaluation of chronic cough without an interdisciplinary evaluation of the entire upper alimentary tract can lead to misdiagnosis. Modern technology including the MBSS with a speech pathologist and radiologist with specific attention to the esophagus is of extreme value.
EFFECTS OF OLFACTION AND GUSTATION ON MOTOREVOKED POTENTIAL ASSOCIATED WITH SWALLOWING
Abstracts however, suggest that individuals responded quite differently to stimuli thus negating a significant group effect. Conclusion: From these preliminary data, odour and taste have no significant main effect on MEP amplitude or duration across healthy participants. To better understand the effect of sensory manipulation in dysphagia treatment, further study on a larger sample, and subsequent study on patients with dysphagia is warranted.
TONGUE PRESSURE SENSOR DISTINGUISHES CONSECUTIVE PHARYNGEAL SWALLOW FROM ISOLATED PHARYNGEAL SWALLOW Kanamori, Daisuke1, Kagaya H1, Baba M1, Yokoyama M2, Ozaki K1, Okada S1, Inamoto Y1, Saitoh E1 1
Fujita Health University, Toyokake, Japan Department of Rehabilitation Medicine, Fujita Heal, Toyoake, Japan
2
Purpose: We have shown that pharyngeal swallow consists of the consecutive pharyngeal swallow (CPS) and the isolated pharyngeal swallow (IPS). These 2 swallowing patterns are usually distinguished by the visual inspection of the images of the videofluoroscopic examination of swallowing (VF). The purpose of this study is to distinguish CPS from IPS by using tongue pressure sensor. Methods: The sensor is a 70 mm in length, 13 mm in width and 0.6 mm in depth. It was placed in the hard palate of 5 healthy subjects and the tongue pressure was measured in 16 points between the oral cavity and the pharynx during swallowing. CPS was detected from the command swallow of 5 ml liquid barium and IPS was evaluated by the infusion of liquid barium to the pharynx through a nasal catheter. Lateral projections of VF were recorded simultaneously to know the timing of the elevation of the hyoid bone. Results: In the CPS, the tongue pressure started to increase prior to the elevation of the hyoid bone and the maximum pressure moved sequentially from the tip of the tongue to the pharynx. On the other hand, the tongue pressure increased after the elevation of the hyoid bone and the increase occurred simultaneously between the tip of the tongue and the pharynx in the IPS. Conclusion: CPS and IPS could be distinguished by using the tongue pressure sensor.
Abdul Wahab, Norsila1, Huckabee M1, Jones R2 1 University of Canterbury, Van der Veer Institute, Christchurch, New Zealand 2 Van der Veer Institute, Christchurch, New Zealand
Purpose: These preliminary data report on the excitatory and inhibitory effects of lemon odour and tastant on motor-evoked potentials (MEPs) of the submental muscles evoked by transcranial magnetic stimulation (TMS). This information may provide support to the use of sensory stimulation in dysphagia management. Methods: Eight volunteers (4 males; age 19–34) participated in this study. Twenty-five percent and 100% concentrations of lemon concentrate were presented separately as olfactory and gustatory stimuli. The olfactory stimulus was nebulized and presented via nasal cannula inserted into both nares. Filter paper strips impregnated with the lemon concentrate and placed on the tongue served as the gustatory stimuli. Tap water was used as placebo. 15 trials of TMS-evoked MEPs triggered by volitional contraction of the submental muscles were measured at baseline, with placebo, during stimulus presentation, and immediately, 30-min, 60-min, and 90-min poststimulation. Results: Repeated-measures ANOVA revealed no significant effect of either stimulus or concentration on MEP amplitudes [F(1.88, 11.27) = 1.625, P = 0.240 for odour; F(1.34, 8.02) = 0.270, P = 0.684 for tastant] or durations [F(5, 30) = 0.661, P = 0.656 for odour; F(1.95, 11.71) = 0.590, P = 0.566 for tastant]. Analyses of individual data,
123
DYSPHAGIA FOLLOWING ENDOTRACHEAL INTUBATION: DETERMINING BIAS AND GRADEing THE EVIDENCE Skoretz, Stacey1, Flowers H1, Martino R1 1
University of Toronto, Toronto, Canada
Purpose: Prolonged endotracheal intubation often leads to dysphagia in hospitalized patients. The purpose of this study is to systematically identify and then evaluate the evidence associating duration of intubation with dysphagia in adult patients. Methods: Electronic databases (Medline, Embase, Cinahl, etc) were searched using keywords ‘‘dysphagia’’, ‘‘deglutition disorders’’ and ‘‘intubation’’. Manual searching of relevant journals, selected references, conference proceedings and unpublished sources, including grey literature, was also conducted. Study selection: Two reviewers, blinded to each other, selected and reviewed articles according to the following inclusion criteria: (1) adult participants who received endotracheal intubation, (2) participants were clinically assessed for dysphagia. Excluded were case series (n \ 10) or dysphagia determined by patient report. Critical appraisal utilized the Cochrane Risk of Bias assessment and the GRADE tools.
Abstracts Results: A total of 1,017 citations were identified and reviewed. Of these, 235 articles were accepted for full article review of which 11 articles met inclusion criteria. Dysphagia frequency ranged from 0% to 65% and intubation duration from 0.07 to 14.44 mean days. Patients with the highest dysphagia frequency included those with respiratory illnesses, critical illness, and trauma. Etiologies of patients with lowest dysphagia frequency included those following cardiac surgery and spinal cord injury. Most studies were limited by design and high or unclear risk of bias. Quality of the evidence (GRADE) was low. Conclusion: This review highlights high variation in dysphagia frequency and poor study quality of available evidence, hence the need for high quality prospective trials.
479 Results: All patients were tube fed at the first evaluation postoperatively, and orally fed at the second evaluation postoperatively. In 9 of 10 patients, the extent of PPW at the level of superior and inferior C3 increased after surgery. The average extent of PPW at the level of inferior C3 at the second evaluation postoperatively (0.46 ± 0.04 cm) was greater than that at the first evaluation (0.32 ± 0.07 cm). The average anterior movement of hyoid was reduced after surgery. However, there were no significant differences in movement in the superior direction. Five patients had severe pharyngeal residue scores at the first evaluation postoperatively. Their residue scores were improved at the second evaluation. Conclusion: The extent of PPW at the level of the upper hypopharynx was increased after surgery. This may be caused by compensatory movement of PPW when hyoid and larynx movements are reduced.
SWALLOWING EVALUATION IN UN-ANAESTHETISED AND UN-CONSTRAINEDLY RATS Ouahchi, Yacine1, Verin E1 1
Rouen University Hospital, Rouen, France
Purpose: Post stroke dysphagia increases significantly patient mortality because of respiratory complications. In two third of case, there is a spontaneous improvement in few weeks, but in the last third, oropharyngeal dysphagia persists and could induce laryngeal aspirations or bronchial penetrations. The complexity of swallowing evaluation and rehabilitation explain why oropharyngeal dysphagia evaluation and treatment remain non standardised and the lack of non constrained animal model participates to this non-standardisation. Our aim was therefore to develop an experimental model of swallowing evaluation in un-constrainedly and non anaesthetised animals. Methods: Five Wistar rats (3 months old, 325 ± 25 g) have been studied with a barometric plethysmograph. In box pressure variation corresponding to ventilation acquired with a micro pressure sensor (100 Hz), coupled with a video recording, have been analysed three times during one hour after 24 h diet. Each swallows have been identified by its ventilatory apnea and by video. Results: 972 swallows have been identified. 89% occurred during expiration (EE) and 11% during inspiration (II). Mean duration was 34 ± 18 ms for EE and 18 ± 9 ms for II. During the swallowing period, mean frequency was 1.28 ± 0.4 swallow/s. The reproducibility was excellent for each animal. Conclusion: Our conclusion is that swallowing evaluation is possible in non anaesthetised and un-constrainedly animals and are essentially beginning and ending during expiration.
POSTERIOR PHARYNGEAL WALL AND HYOID MOVEMENT IN PATIENTS WITH TONGUE AND FLOOR OF MOUTH RESECTION Tsushima, Chiaki1, Murata S1, Mikushi S1, Takashima M1, Uematsu H1 1
Tokyo Medical and Dental University, Tokyo, Japan
Purpose: In prior studies, base of tongue and posterior pharyngeal wall (PPW) movement after oral surgery were examined. This study examined hyoid and PPW movements at oropharynx and hypopharynx, and their relationship to swallowing function in postsurgical patients. Methods: Ten patients with tongue and floor of mouth cancers were evaluated. All patients underwent surgical resection and reconstruction. Postoperative changes in hyoid and PPW movement, and pharyngeal residue score were examined using videofluorographic images. Videofluorography was performed preoperatively and twice postoperatively: the first evaluation at a mean of 20 days postoperation, and the second evaluation at a mean of 36 days postoperation.
THE POSSIBILITY OF ORAL FEEDING IN PATIENTS WITH PROLONGED IMPAIRED CONSCIOUSNESS Okada, Sumiko 1, Inayoshi N2, Kagaya H1, Inamoto Y1, Saitoh E1, Baba M1, Yokoyama M1 1
Fujita Health University, Toyoake, Japan Fujita Health University Hospital, Toyoake, Japan
2
Purpose: Many patients with prolonged impaired consciousness are fed by tube without receiving evaluation of swallowing function. The purpose of this study is to know the possibility of oral feeding in those patients. Methods: Sixty-eight patients with prolonged impaired consciousness were referred to our hospital for dorsal column stimulation implant surgery between 2001 and 2005. They were 44 males and 24 females with mean age of 38. They suffered from brain trauma (51%), hypoxic encephalopathy (25%), and brain bleeding (24%). Their swallowing functions were examined by the videofluorography (VF) and dysphagia severity scale (DSS). Level of consciousness (State scale) and eating status were also checked. Results: The average periods from onset to evaluation were 521 days. Half of the patients had spontaneous movements of the oral cavity and pharynx with or without spontaneous extremities movements, not under conscious control. According to the DSS scale, 70% of the patients were classified into food or water aspiration. Sixty-one out of 68 patients had tube feeding only on admission. Eating status weakly correlated with the level of consciousness (r = 0.45) but DSS didn’t correlated significantly (r = 0.19). Forty-six patients had aspirated during VF and 98% of the aspirations were silent. However, 25 patients (41%) who had been fed by tube only could start oral feeding after VF evaluation. Conclusion: It is possible to start oral feeding in many patients with prolonged impaired consciousness. In this patient population, VF is useful to separate patients who are silent aspirators from those who can tolerate oral feeding.
PREVALENCE OF DYSPHAGIA IN PARKINSON’S DISEASE AND CONSEQUENCES FOR TREATMENT Kalf, Johanna1, de Swart B1, Bloem B1, Munneke M1 1 Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
Purpose: Dysphagia in Parkinson’s Disease (PD) is reported to be highly prevalent, but frequencies are various and it is unclear how many PD patients need treatment for their swallowing impairment. The aim of this study was to review the prevalence of dysphagia and to discuss the consequences for treatment. Methods: A systematic literature search was conducted to compare studies reporting on the frequency of dysphagia in PD patients in
123
480 unselected populations. In addition, the data of two hundred consecutive PD patients visiting the Parkinson Centre Nijmegen (ParC) were analyzed considering the outcome of dysphagia assessment and indication for swallowing treatment. Results: In total 9 studies were included. Six studies with patientrated or qualitative outcomes including data from healthy controls had a pooled prevalence estimated weighted for sample size of 47% (95% CI 44.3–50.5) and a pooled relative risk of 4.72 (95% CI 3.44–6.57). Three studies based on clinician-rated or quantitative outcomes had a pooled prevalence estimate of 79% (95% CI 73.2–84.9). In the ParC population (mean age 65 (± 9.6), disease duration 7 years (± 4.9) and median Hoehn & Yahr stage 2.5 range 1–5) 59% demonstrated minimal to moderate severe dysphagia based on the clinician’s judgment, while 62% had normal functional oral intake. Considering treatment, only 34% needed one-time but specific treatment and only 4% was indicated for further swallowing treatment. Conclusion: About half of all community-dwelling PD patients have altered swallowing patterns or dysphagia, but only a small amount needs more than one-time instructions.
CORTICAL REPRESENTATION DURING ORAL AND PHARYNGEAL TRANSPORT IN SOLID AND LIQUID BOLUSES Shibamoto, Isamu1, Fujishima I2, Tanaka T3, Katagiri N3, Uematsu H4, Groher M5
Abstracts Purpose: Research has documented significant influence of taste, particularly sour stimulus, on submental sEMG amplitude. This study sought to probe for a similar effect from olfactory stimuli and compare these findings to taste. Methods: Nineteen healthy participants (10 males) were recruited. Twenty-five percent and 100% concentrations of lemon concentrate were presented first as olfactory and gustatory stimuli separately, then combined as a paired stimulus. The olfactory stimuli were nebulized and presented via nasal cannula inserted into both nares. Filter paper strips (8 cm by 2 cm) impregnated with lemon concentrate and placed on the tongue served as gustatory stimuli. Tap water was used as placebo. Six swallows were completed by each participant for each concentration of each stimulus and the paired stimulus of 100% concentrations. Results: RM ANOVA comparing placebo to low to high concentration revealed no significant effect of odour on amplitude of submental sEMG [F(2, 34) = .916, P = .410]. Evaluation of tastant revealed a significant main effect [F(2, 34) = 5.074, P = .012] with the high concentration producing greater sEMG amplitude than the placebo (P = .014) and the low concentrations (P = .007). When comparing averaged single stimulus data to paired stimulus, no statistically significant main effect was identified [F(2, 34) = .504, P = .609]. No gender effect was identified for any comparison. Conclusion: High concentration of lemon stimuli increased sEMG amplitude, as seen in prior research. Lower concentrations of tastant and presentation of independent or paired odourant produced no similar effects in this small sample.
1
International University of Health and Welfare, Ohtawara, Japan Hamamatsu Rehabilitation Hospital, Hamamatsu, Japan 3 Seirei Hamamatsu General Hospital, Hamamatsu, Japan 4 Tokyo Medical and Dental University, Bunkyou, Japan 5 University of Redlands, Redlands, CA 2
Purpose: Cortical representations of swallow in humans vary by bolus type (Shibamoto, 2007). We investigated the cortical activation areas during oral and pharyngeal transport phase in solid and liquid bolus. Methods: Twenty-one healthy adult volunteers participated in this study. Each subject was asked to swallow the test materials during fMRI recording. Each swallow attempt began with an 18-s rest period followed by a 6-s count down as swallowing preparation, followed by a 6-s window for swallowing (Tanaka, 2006). Correlation statistics and image registration were facilitated by the SPM99 software and implemented in the Matlab v.5.3. A statistical parametric map of the t statistic was generated in each voxel. The activated voxels were analyzed for uncorrected height with the threshold at a p value of 0.001 in each sequence for each subject. In order to complete a group analysis, a one sample t-test of the raw data from the subjects (P = 0.001) was applied for the sequence of the study. Results: The regions of the precentral gyri, temporal gyri, and cingulate gyrus were activated during the oral transport phase in all bolus types (P \ 0.001, uncorrected). No cortical activation was observed for the solid bolus during the pharyngeal transport phase, however, multiple regions of increased brain activity were observed in the liquid bolus (P \ 0.001, uncorrected). Conclusion: The cortical representations for swallow are variable by bolus transport phase and bolus type and may explain the variable responses in swallowing performance seen in patients who evidence oropharyngeal dysphagia.
INFLUENCE OF OLFACTORY AND GUSTATORY STIMULI ON SUBMENTAL SEMG AMPLITUDE Huckabee, Maggie-Lee1 1 University of Canterbury, Van der Veer Institute, Christchurch, New Zealand
123
DYSPHAGIA IN MACHADO-JOSEPH DISEASE: SIGNS AND BEST CONSISTENCY Machado, Deborah1, Mourao L1, Wolf A2, Crespo A2, Tinois E1 1
State University of Campinas, Campinas, Brazil Tuiuti University of Parana, Curitiba, Brazil
2
Purpose: Machado-Joseph disease (MJD) is a neurodegenerative disorder with autossomic dominant inheritance. It starts with muscular modifications, loss of speech and swallowing efficiency. The aim of this study was to compare the results of the fiberoptic endoscopic evaluation of swallowing (FEES) of patients with MJD with the control group, and also analyse the best consistency. Methods: Seventeen patients with MJD, aged between 12 and 67, were assisted at UNICAMP Otolaryngology/Dysphagia Ambulatory of the Clinical Hospital, Brazil, during 2006–2008. Patients were submitted to FEES, in which were tested different consistencies and volumes. The control group was composed of 17 individuals of both genders, aged between 18 and 67 (similar to the patients with MJD), with no swallowing complaints nor functional and neurological alterations. For the statistical analysis was used Fisher’s Exact Test. The parameters used were: residue, posterior escape, penetration, aspiration and clearance. Results: When comparing the control group and the patients with MJD, there was statistical difference for the presence of residue in the pharyngeal region, mainly in vallecula and piriform sinus, in liquid (3 ml), honey (3, 5 and 10 ml), pudding and solid consistencies. The findings revealed difference (P \ 0.005) for volume and consistency increase, with worsening of residue and/or posterior escape, increase of laryngeal penetration and more occurrence of residue in vallecula. Conclusion: Patients with MJD have pharyngeal dysphagia, with presence of residue in vallecula and piriform sinus, different from the control group. The liquid and honey consistencies in small volumes reduce the signs of swallowing alterations.
Abstracts THE ONSET OF PHARYNGEAL SWALLOW IN HEAD AND NECK CANCER PATIENTS de Angelis, Elisabete1, Oliveira A1, Freire J1, Bretas M1, Prodomo L1 1
Hospital ACCamargo, Sa˜o Paulo, Brazil
Purpose: The present study was undertaken to characterize bolus position at the onset of the pharyngeal swallow in head and neck cancer patients and to compare these results with healthy adults. Methods: 40 adult participants divided into two groups. Group 1: 20 head and neck cancer patients; Group 2: 20 healthy subjects without complaint about swallow disorders. Initially, the charts of patients were reviewed. Tapes of videofluoroscopic exams with 5 ml of thick liquids were analyzed by an expert professional to settle the bolus position at the onset of the pharyngeal swallow and to determine PAS and dysphagia severity. Results: Bolus position was positioned in pillar of the fauces in 19% of patients in Group 1 and in 80% of patients in Group 2. Valleculae and pharyngeal recess were the position of the bolus in 20% of Group 1, while 33% of Group 2 had bolus position at the level of superior esophageal sphincter. Penetration was present in 5% of group 1; Group 2 presented 43% of penetration and 14% of aspiration. PAS did not correlate with position of the bolus at the onset of pharyngeal swallow. Conclusion: Patients treated of head and neck cancer present more posterior onset of pharyngeal swallow than healthy individuals but this not implies in worse levels of swallow problems.
SWALLOWING OF PATIENTS WHO DEVELOPED REFRACTORY ESOPHAGUS STENOSIS AFTER TREATMENT FOR LARYNGEAL OR HYPOPHARYNGEAL CANCER
481 Purpose: Demographic data, underlying medical conditions and adherence to guidelines were evaluated as risk factors for (near-)fatal choking episodes. Methods: Data were obtained on patients with a witnessed choking episode using case notes, CSE and FEES, and correlated with multiple parameters, including food consistency, feeding method and guidelines. Results: 5 episodes were fatal while 16 patients survived their asphyxiation. No differences in sex or age were found. Sedatives and neuroleptics increased the incidence of choking. Clinical and endoscopic evaluation showed feeding and swallowing disorders in 65% of patients, both in the oral and pharyngeal phase (insufficient mastication, inappropriate bolus size, severely delayed initiation, nonresponsive to residuals). All fatal cases had neuropsychiatric illnesses with choking attributable to non-adherence to consistency and self-feeding guidelines, with all people choking on bread, 1 patient being family-fed, and 1 patient stealing food. All near-fatal cases were relieved by means of a Heimlich maneuver or manual clearing of the hypopharynx. 3 cases occurred during excursions with insufficient supervision, allowing consumption of unsafe consistencies. 2 newly admitted patients without prior notice of dysphagia showed unexpected choking. Feeding was performed by nursing staff without adherence to prescriptions in half of the cases, with 2 patients cramming food. Conclusion: Choking is relatively common and often fatal in psychogeriatric patients. Non-adherence to prescribed guidelines accounted for half of the incidents. Maladaptive eating strategies and use of psychoactive medication increase the risk of asphyxiation. Multidisciplinary feeding and eating assessment, adherence to guidelines and swift intervention may prevent a fatal outcome.
Claudino, Simone1, Aerosa S1, Pastor M1, Pelosof A1, de Angelis E1 1
Hospital A.C. Camargo, Sa˜o Paulo, Brazil
Purpose: To characterize swallowing of patients submitted to surgery and/or radiotherapy for head and neck cancer which evolved with refractory stenosis pre and post endoscopic dilation. Methods: Prospective study of seven patients who underwent surgery, radiotherapy and/or chemotherapy for laryngeal or hipopharyngeal cancer and evolved with refractory stenosis. The swallowing was assessed by videofluoroscopy and quality of life questionnaire in dysphagia—Swal QOL, in the range of pre-and post-dilatation. We considered variables: age, gender, type of surgery, reconstruction surgery, radiotherapy and chemotherapy. The swallowing was ranked through a four-point scale (Zerbinatti, 2004) and total transit time of the bolus, anatomically demarcated by two points—posterior nasal spine and superior esophageal sphincter (Leonard, Mackenzie, 2008). Results: 100% of patients had dysphagia, and that 72% had moderate degree. Videofluoroscopic analyses showed maintenance of dysphagia severity but better oropharyngeal transit times in 100% of the patients after treatment. There were no significant differences in quality of life questionnaires pre and post dilatations. Conclusion: The refractory stenosis can lead to dysphagia in varying degrees and the expansion as a means of endoscopic treatment may be effective with regard to the transit times.
ANALYSIS OF 21 FATAL AND NEAR-FATAL CHOKING EPISODES DURING EATING IN PSYCHOGERIATRIC AND GERIATRIC PATIENTS Vanderwegen, Jan1, Van Vlasselaer K2 1
Antwerp University Hospital, Edegem, Belgium
2
Psychogeriatric Hospital Damiaan, Tremelo, Belgium
SEQUENTIAL SWALLOWING IN PATIENTS WITH ACUTE STROKE Murguia, Monica1, Corey D2, Daniels S3 1
University of Houston, Houston, TX Tulane University, New Orleans, LA 3 Michael E. DeBakey VA Medical Center, Houston, TX 2
Purpose: The aim of this study was to investigate the effect of stroke on sequential swallowing physiology and safety. Methods: Individuals with right hemisphere damage (n = 12) and left hemisphere damage (n = 14) were selected from a cohort of 34 consecutive acute supratentorial unilateral ischemic stroke patients. For inclusion, single swallows were judged safe to allow for sequential swallowing of thin liquids. Age-matched adults (n = 25) served as controls. Participants sequentially swallowed 100 ml of liquid barium from a cup. Each swallow in the sequence was analyzed for movement of the hyolaryngeal complex (HLC) between swallows (partially elevated, lowered), bolus location at swallow onset (superior to valleculae, inferior to valleculae), and airway invasion (Penetration-Aspiration [P-A] Scale). Results: No significant group differences were observed (P [ .05 for all measures). Most individuals across groups demonstrated a partially elevated HLC movement pattern and bolus location inferior to the valleculae at onset of the pharyngeal swallow. Airway invasion occurred in 63% of participants; average P-A Scale Score was \2 for all three groups indicating limited airway invasion. Neither HLC movement pattern (r = -.146) nor leading edge of the bolus location (r = .178) was significantly correlated with P-A Scale score. Conclusion: Findings suggest that a single supratentorial stroke, regardless of hemisphere lesioned, does not significantly alter sequential swallowing physiology or impact airway invasion. Inherent swallowing patterns do not appear to increase risk of airway invasion. Including
123
482
Abstracts
sequential swallowing as part of the diagnostic protocol may be of limited utility, particularly for individuals with intact discrete swallows.
OROPHARYNGEAL DYSPHAGIA IN MACHADO-JOSEPH DISEASE AND CORRELATION WITH ALTERNATE MOTION RATE: PRELIMINARY RESULTS Moura˜o, Lu´cia 1, Almeida P2, Wolf A1, Silva A1
VOLUNTARY COUGH AND SWALLOW FUNCTION IN NORMAL CONTROL MIDDLE AGE AND OLDER SUBJECTS
1
Universidade Estadual de Campinas, Campinas, Brazil HCFMUSP/UNICAMP, Sa˜o Paulo, Brazil
2
Smith Hammond, Carol1, Scharver C2, Markley L2, Gonzalez-Rothi L3, Horner R4, Goldstein L5, Bolser D6 1
Durham VAMC and Duke University, Durham, NC Durham VAMC, Durham, NC 3 Gainesville VAMC and University of Florida, Gainesville, FL 4 University Cincinnati, Cincinnati, OH 5 Duke University, Durham, NC 6 University of Florida, Gainesville, FL 2
Purpose: Describe objective measures of voluntary cough and airway protection during swallow in men and women without known swallowing deficits, Methods: Forty subjects (24 men, 16 women; mean 66 yo) had clinical, objective and videofluoroscopic evaluations of swallow and cognitive screens. Results: Table 1 gives measures of voluntary cough. Inspiration phase duration peak flow expulsive phase and volume acceleration tended to be higher in men. The highest penetration was entry to the level of the true vocal folds in 10%. None had reflexive cough or throat clearing after water swallow. There were cognitive deficits in 20% with severe memory problem in one subject. Conclusion: These normative data suggest differences in some measures of voluntary cough between men and women. Up to 10% may have unrecognized mild dysphagia.
Cough parameter
All subjects Mean ± SD
Men Women Men vs. Mean ± SD Mean ± SD women (P value)
Purpose: Machado-Joseph disease (MJD) is a hereditary ataxia, characterized by arms and legs weakness, spasticity, difficulty in swallowing and dysarthria, among other manifestations. The purpose of this study was to correlate oropharyngeal dysphagia and alternate motion rates (AMRs) in patients with MJD. Methods: Twelve patients with MJD were submitted to FEES, in which were tested different consistencies and volumes, and the dysphagia was classified using a severity scale. The Motor Speech Profile software was used to analyze the AMRs to the duration measurements in the syllables /pa/, /ta/, /ka/ e /a/. The data obtained through AMRs was compared with the control group (CG): 30 subjects with no neurological symptoms nor speech/voice disorder. For the statistical analysis were used the Mann-Whitney test and the Spearman test. Results: The dysphagia severity was light (4), moderate (4) and severe (1). There was a statistically significant difference between AMRs in the CG and MJD. The correlation between the parameters of dysphagia severity and the AMRs, revealed statistically significant differences, when relating the degree and the measurements of DDKjitt and DDKsdp of the syllable /ta/, and DDKsdp of the syllable /ka/. Conclusion: Patients with MJD present oropharyngeal dysphagia and altered AMRs. They also present correlation between the degree of oropharyngeal dysphagia and the AMRs of the syllables /ta/ e /ka/. It reveals that the motor damage of the tongue interferes negatively both in speech and swallowing.
INTRA- AND INTER-RATER RELIABILITY OF HYOID DISPLACEMENT MEASURED BY ULTRASOUND Macrae, Phoebe1, Huckabee M1, Doeltgen S1, Jones R2
Inspiration phase duration Inspiration phase volume Peak flow inspiration phase Compression phase duration Peak flow expulsive phase Expulsive phase rise time Volume acceleration Sound pressure level
123
1.79 ± 0.43
1.162 ± .485
0.910 ± 0.3
0.07
1189.7 ± 546.2
829.71 ± 590.7
610.2 ± 462.2
0.22
1182.7 ± 830.2
1372.32 ± 842.7
1289.5 ± 835.9
0.76
0.377 ± 0.17
0.271 ± 0.137
0.338 ± .210
0.23
9854.0 ± 5871.4
6874.3 ± 29
0.09
11,164.7 ± 5595.10 0.048 ± 0.001
0.038 ± 0.01
0.039 ± 0.009
0.52
234.22 ± 142.9
267.8 ± 152.1
183.4 ± 114.6
0.06
98.3 ± 6.2
99.34 ± 5.7
96.8 ± 6.9
0.22
1
University of Canterbury, Van der Veer Institute, Christchurch, New Zealand 2 Van der Veer Institute, Christchurch, New Zealand Purpose: Anterior hyoid displacement is essential for effective swallowing, and is most frequently investigated with videofluoroscopy. Ultrasound offers a less expensive and less invasive method of investigation with high reliability of measurement reported in the literature1,2. The present pilot study investigated the intra- and interrater reliability of measuring timing and degree of maximal hyoid displacement. Methods: Three raters reviewed the ultrasound video sweep of 5 swallows, from each of 5 participants and the primary investigator measured each sample on two occasions. Identified from each sweep was a ‘rest’ frame prior to the swallow of interest and a ‘maximal displacement’ frame, at which the hyoid bone was at maximal anterior displacement during each swallow. Electronic callipers were used to measure the distance between the mental spine of the mandible and the intersection of the hyoid shadow and the geniohyoid muscle, for both the rest and maximal displacement frames. Results: Single-measure intraclass correlation (ICC) was high for inter-rater agreement at .861 for rest measures and .899 for maximal displacement. Intra-rater reliability was even higher at .949 for rest hyoid measures and .979 for maximal displacement. ICC also showed high inter-rater agreement on the frame of maximal displacement at .974.
Abstracts Conclusion: These results suggest that raters can achieve high agreement regarding measures of maximal hyoid displacement for both identification of peak hyoid displacement and distance of hyoid from mandibular spine. 1. Chi-Fishman, G., & Sonies, B. C. (2002a). Dysphagia, 17(4), 278–287. 2. Chi-Fishman, G., & Sonies, B. C. (2002b). J Speech Lang Hear Res, 45(3), 457–468.
HYOLARYNGEAL EXCURSION AS THE PHYSIOLOGICAL SOURCE OF DUAL-AXIS ACCELEROMETRY SIGNALS DURING SWALLOWING Zoratto, Dana1, Steele C2, Chau T3 1 Institute of Biomaterials & Biomedical Engineering, Toronto, Canada 2 Toronto Rehabilitation Institute, Toronto, Canada 3 Bloorview Kids Rehab, Toronto, Canada
Purpose: Accelerometry is a non-invasive technique used to measure physiological vibration signals. When placed superficially on a patient’s neck, specifically on the cricoid cartilage, the accelerometer records the epidermal vibration signals of the swallowing mechanism. Previous studies of single-axis swallowing accelerometry have suggested that the signal reflects hyolaryngeal movement. Currently no studies have quantitatively examined the complete temporal trajectory of the hyoid bone movement relative to the evolution of dual-axis accelerometry signals. The main goal of this study was to determine the relationship between hyolaryngeal excursion and the vibration signals produced during swallowing. Methods: During videofluoroscopic examinations, a dual-axis accelerometer was placed on the cricoid cartilage of 40 adult patients with neurogenic dysphagia. The participants swallowed two or three 5 mL teaspoons of thin liquid barium (40% w/v suspension) with their head in a neutral position. A fourth sip from a cup was administered at the clinician’s discretion. Digital signal processing techniques were used to compare the obtained acceleration data to hyoid displacement. Results: From a subset of 10 participants and 27 swallows, qualitative similarities between the trajectory of the hyoid bone and doubleintegration of the accelerometry data can be seen in the number of peaks per bolus, relative magnitudes, and the time between peaks. The average root-mean square error between the two datasets was 0.41 suggesting that the hyoid movement contributes only partially to the acquired signals. Conclusion: These preliminary results suggest that the hyoid movement is only one component of dual-axis accelerometry data. Further investigation is required to determine the other physiological sources contributing to the signal.
A STUDY OF AVERAGE NECK FLEXION ANGLE DURING CHIN-TUCK SWALLOWS Steele, Catriona3, Hung D1, Sejdic´ E2, Chau T2 1 Division of Engineering Science, University of Toronto, Toronto, Canada 2 Bloorview Research Institute, Toronto, Canada 3 Toronto Rehabilitation Institute, Toronto, Canada
Purpose: This study investigated neck flexion angles during chintuck swallows and examined the variability of the average angle across subjects given the same set of instructions to perform a chintuck swallow. The chin-tuck swallow is a common therapeutic process used with dysphagic patients but there is no standard protocol describing the procedure and literature reports on its efficacy have been inconsistent.
483 Methods: Neck angle data were derived from an image processing algorithm applied to videos of healthy participants (age: 18–65, 88 males, 47 females) drinking water in a neutral-head and chin-tuck position. Average neck angle was defined to be the average of the neck angle measured in the duration of each trial and neck angle was defined by markers placed on visors worn by the participants measured with respect to the vertical. Results: Using data from 135 participants, we found the mean neck angle to be 94.9° ± 19.9° (mean ± SD) during the neutral-head swallows and 80° ± 14.6° during the instructed chin-tuck swallows. Student t-test 95% confidence intervals for the mean are (91.5, 98.3) for neutral-heads and (77.6, 82.5) for chin-tucks. Wilcoxon signed rank test 95% confidence intervals for the median are (62.4, 115.2) for neutral-heads and (46.4, 117) for chin-tucks. Conclusion: Our data suggests the average neck angle varies across subjects performing the chin-tuck maneuver given the same set of instructions. This exemplifies the need for a more precise functional or anatomical definition of the chin-tuck maneuver to increase the consistency and efficacy of results for this therapy.
FUNCTIONAL ORAL INTAKE SCALE BEFORE AND AFTER SWALLOW THERAPY IN STROKE Bentim, Claudia1, da Silva R2 1
Sorri Bauru, Bauru, Brazil Sa˜o Paulo State University, Marilia, Brazil
2
Purpose: The efficacy of rehabilitation therapy in oropharingeal dysphagia has been discussed since the 90 s, however few authors proposed measures to control the efficacy of therapy. The aim was to analyze the oral intake as control of efficacy in swallow therapy with post stroke individuals. Methods: Participated from the study 34 post-stroke patients, 24 male gender and 10 female gender, aged between 23 and 80 years old (average 63 years old). From the 34 individuals, 17 had left brain hemisphere injure, 13 had right brain hemisphere injure and 4 had brain stem injure, ictus longer than 3 months. The Functional Oral Intake Scale—FOIS (Crary et al. 2005) was applied before and after swallow therapy. The rehabilitation program lasted an average of 5 months. The program included specific guidelines, cold, tactile and gustatory stimulation, facilitating postures and swallow maneuvers, manipulation of consistencies, volume and speed of intake, adjusting the positioning of the bolus in the oral cavity and nutrition specific evaluation. Results: It was verified before swallow therapy 3 (8,82%) as level 1, 5 (14,71%) as level 4, 26 (76,47%) as level 5. After swallow therapy, 25 (73,53%) became level 7, 6 (17,65%) level 5 and 2 (5,88%) level 2. Conclusion: The functional oral intake scale change after therapy and this suggest that can be one the parameter to measure the efficacy of swallow therapy. Further studies are needed to examine other variables involved in the rehabilitation of this population.
COLLABORATION OF LOW FREQUENCY TREATMENT ON SUPRAHYOID MUSCLES AND BALLOON DILATION METHOD FOR SEVERE CRICOPHARYNGEAL DYSPHASIA Imai, Nobuyuki1, Ohashi Y1, Sato A2, Sato T2, Dobashi C2 1
Niigata University of Health and Welfare, Niigata, Japan Niigata Rehabilitation Hospital, Niigata, Japan
2
Purpose: The availability of therapeutic techniques in the rehabilitation of swallowing disorders is limited in the severe cricopharyngeal
123
484 dysphagia. Using videoendoscope, we examined and verified the potential of low frequency stimulation as a treatment for swallowing disorders. We previously reported that low frequency treatment (LFT) facilitated coordination between lingual muscles and suprahyoid muscles in stroke patients and promoted recovery of swallowing in 16th DRS. This study investigated whether the swallowing muscles of brainstem stroke patients would be influenced by collaboration of LFT and balloon dilation method. Methods: Low frequency electrodes were mounted on the neck skin between the chin and the thyroid cartilage in a brainstem stroke patient with severe dysphasia. These electrodes were mounted in the submandibular position during LFT. A stimulation frequency of 40 Hz was applied, resulting in repetitive contraction of the swallowing muscles. Secondly, balloon dilation method was applied to inadequate opening of UES. Movement of swallowing organs induced by LFT or balloon dilation method was observed by videoendoscope. This technique was collaborated once or twice a week in a few months. After training period swallowing movement were investigated by videoendoscope. Results: Electrodes at the submandibular position during LFT induced slight elevation of the tongue base and inversion of the epiglottis, adduction of the arytenoids cartilage, partial closure of the glottis and opening of pyriform sinuses. Pharyngeal wall movement was observed. A dilated balloon catheter could be pulled out from upper esophagus relative easily after LFT. After training in a few month, pharyngeal wall movement and coordination of swallowing organ were observed. Conclusion: Swallowing muscles repetitively contracted by LFT with electrodes at the submandibular position of electrodes can elicit the initiation of the swallowing reflex. The resulting coordination of the swallowing musculature suggests that the collaboration of LFT and balloon dilation method is effective for severe cricopharyngeal dysphagia.
COMMUNICATION AND SWALLOWING SCREENING IN ONCOLOGICAL HOSPITALIZED PATIENTS Barcelos, Camila1, Goncalves Aline1, Netto I1, Bretas M1, De Angelis E1 1
Hospital AC Camargo, Sa˜o Paulo, Brazil
Purpose: To verify the importance of speech language pathology (SLP) screening in oncological hospitalized patients. Methods: Hospitalized patients and treated by the Department of Clinical Oncology at Hospital AC Camargo, Sa˜o Paulo, Brazil, were submitted to speech language pathology screening. Charts of patients were initially reviewed. Screening consisted of a brief anamnesis and assessment of oral motor system, swallowing and perceptive auditory analysis of voice and speech. When SLP disorders were identified, patients were evaluated. Descriptive analyses of the data were performed. Results: Six hundred and ninety two patients were screened. 129 (18.6%) had voice, speech and/or deglutition disorder. Of these,
123
Abstracts 31.7% were referred by medical staff and 68.2% were not sent because of the clinical status or death. After the doctor referral, 60.9% subjects were evaluated by speech language pathologist. In the assessment was found that 96% of patients had some communication or swallowing disorder, being 95.3% of them diagnosed with dysphagia. Dysphagia was mild in 54.5% patients, moderate in 31.8% and severe in 9%; mechanical ethiology was in 59% and neurogenic in 31.8%. Conclusion: The number of referrals made by medical staff regardless of screening increased by 5 times, from the beginning and the end of the screening program. Screening can help in the short term as an action for the educational speech language pathologist performance in the context of a cancer hospital.
HEAD & NECK CANCER: DOES INTENSITY MODULATED RADIATION THERAPY REDUCE TREATMENT-RELATED DYSPHAGIA? Cohen, Stacy1, Kammer R1, Connor N1, Palazzi-Churas K1, Walker W1, Harari P1 1
University of Wisconsin-Madison, Madison, WI
Purpose: Intensity Modulated Radiation Therapy (IMRT) for head and neck (H&N) cancer promises to reduce treatment morbidity by restricting radiation exposure of critical anatomical structures. This study examined swallowing function in patients who received IMRT compared with those who received conventional 3-beam shrinking field radiotherapy. Methods: A prospective longitudinal study of 20 subjects with H&N cancer receiving IMRT was performed. We compared the results to our previously published study of 10 subjects with H&N cancer who received conventional radiotherapy. We examined perceptual assessments of videofluoroscopic swallow studies (VSS) performed pre-treatment, 1 month post-treatment, and 6 months post-treatment. Two clinicians with greater than 8 years experience each assessed the studies in a blinded fashion by consensus with a third clinician resolving disagreements. Results: Reduction in abnormal swallow findings was found at 6 months post-treatment in the IMRT group as compared to the conventional group in 6 of 10 parameters assessed. With IMRT, fewer abnormalities in the following VSS findings were documented: oral residue, reduced tongue base retraction, reduced laryngeal elevation, reduced epiglottic excursion, reduced pharyngeal constriction, and aspiration. There was greater impairment in the IMRT group in the following areas: penetration, vallecular residue, and delayed pharyngeal swallow. Conclusion: The use of IMRT in the treatment of H&N cancer can result in reduced overall swallow impairment compared with conventional radiotherapy. Furthermore, due to the absence of aspiration noted among all IMRT subjects, morbidity may be greatly reduced with this technique.
