Manometrische und endoskopische Diagnostik oropharyngealer Dysphagien

Abstract

Organic swallowing disorders occur due to peripheric anatomic lesions, neurologic and neuromuscular diseases. There is still a lack of objective diagnostics regarding the oropharygeal phase of swallowing. This study presents an improved combined diagnostic method consisting of oral manometry and simultaneous flexible pharyngoscopy. 24 patients aged 44 to 82 years (20m/4f) from the Department of Maxillofacial Surgery at Gottingen University Hospital were examined. All of them had a tumor in the orofacial region. 30 pre- and postoperative examinations were made. Oral pressure was measured with a modified mouth shield (Silencos, Bredent, Germany) combined with a manometer (Greisinger electronics, Germany) during intraoral bolus application. Pharyngoscopy via nose was conducted simultaneously. All patients gave there informed consent, passed clinical examination and filled in a swallowing questionnaire. Examination consisted of three modalities: (1) active bolus intake, i. e. patient obtains water from suction, passive (2) water bolus and (3) gel bolus application by the examiner. Active bolus intake was repeated ten times, passive bolus applications five times each. Pharyngoscopic position was supravelar for the first five active bolus intakes, subvelar for all following examination. Obtained results were classified regarding the patient's site of lesion caused by the operation: D0 without lesion through operation, D1-D5 with lesion through operation. D1 lesion caused by T1/T2-tumors, D2 by T3/T4-tumors in anterior oral region; D3 lesion caused by T1/T2-tumors, D4 by T3/T4- tumors in posterior oral region. D5 with lesion in any other site. Manometric results showed significant differences comparing D0 with D1-D5 for all parameters, i. e. monophasic and polyphasic swallowing patterns (number of negative (p<0.01) and positive (p=0.02) amplitudes), maximum (p=0.04) and medium (p=0.04) suction pressure in the active bolus intake. D0 showed maximum suction pressure of 83.9 mbar and medium of 62.7 mbar. D1-D5 reached maximum 51.0 mbar and medium 28.8 mbar. In passive water bolus application no significant difference occurred. In passive gel bolus application only positive amplitudes showed a significant difference comparing D0 with D1-D5 (p=0.03). Endoscopic results showed physiologic swallowing in D0 patients. Patients with lesions due to operation revealed impairments in the pharynx. In active bolus intake and passive water bolus application results were significantly different (p=0.02; p<0.01). Passive gel bolus application did not show significant differences. The questionnaire did not produce any meaningful results. From combined manometric and pharyngoscopic examination useful information is obtained to evaluate oral and pharyngeal swallowing in tumor patients. Pressure measurement during water suction allows a graduated identification of patients with and without lesion due to operation. Passive gel bolus application showed almost no difference. Monophasic and polyphasic swallowing patterns provide diagnostics of muscle dyscoordinations and compensation strategies. Dichotomous endoscopic parameters of nasal regurgitation, posterior leakage, residues, penetration and aspiration presented valuable results. Only patients with tumor lesion in the anterior oral region showed results which could be related to manometric results. To conclude, combined use of both methods is recommended.