Laryngeal Vestibule Closure Research Articles

Mechanisms of Airway Protection During Chin-Down Swallowing

This study examined the effects of chin-down swallowing on laryngeal vestibule closure. It also investigated the technique's rehabilitative impact, by assessing the stability of effects across multiple trials and aftereffects in neutral swallows on cessation of the technique. Duration of laryngeal vestibule closure (dLVC) was measured with videofluoroscopy in 16 healthy participants (mean = 33.2 years, 9 men). Participants swallowed 40 times: 5 head-neutral swallows (N1), then 30 chin-down swallows, followed by 5 head-neutral swallows (N2). The first 5 chin-down swallows were categorized as early posture swallows (P1) and the last 5 as late posture swallows (P2). Within-participant comparisons determined the effects of the maneuver on dLVC during and after execution. The study found that dLVC increased during chin-down swallows (N1 to P1, p = .018). This increase remained stable throughout 30 repetitions (P1 to P2, p = .994). On return to neutral, dLVC returned to baseline (N1 to N2, p = .875). This study demonstrated increased dLVC during chin-down swallowing, offering a possible mechanism responsible for previously reported reduced aspiration during the technique. As aftereffects were not evident after multiple chin-down swallows, the maneuver appears to offer more compensatory benefit than rehabilitative value for patients with dysphagia.

The Effect of Bolus Volume on Hyoid Kinematics in Healthy Swallowing

Hyoid movement in swallowing is biomechanically linked to closure of the laryngeal vestibule for airway protection and to opening of the upper esophageal sphincter. Studies suggest that the range of hyoid movement is highly variable in the healthy population. However, other aspects of hyoid movement such as velocity remain relatively unexplored. In this study, we analyze data from a sample of 20 healthy young participants (10 male) to determine whether hyoid movement distance, duration, velocity, and peak velocity vary systematically with increases in thin liquid bolus volume from 5 to 20 mL. The temporal correspondence between peak hyoid velocity and laryngeal vestibule closure was also examined. The results show that maximum hyoid position and peak velocity increase significantly for 20 mL bolus volumes compared to smaller volumes, and that the timing of peak velocity is closely linked to achieving laryngeal vestibule closure. This suggests that generating hyoid movements with increased power is a strategy for handling larger volumes.

Effect of oral piperine on the swallow response of patients with oropharyngeal dysphagia

Oropharyngeal dysphagia (OD) is a major gastrointestinal motility disorder that causes severe nutritional and respiratory complications in elderly and neurological patients. In an earlier study, we found that stimulation of pharyngeal sensory neurons by capsaicinoids acting on transient receptor potential vanilloid 1 (TRPV1) improved the swallow response of dysphagic patients. The aim of this study was to explore the effect of piperine, a dual TRPV1/TRPA1 agonist, on the swallow response of dysphagic patients. A videofluoroscopic study was performed to assess the signs of impaired safety and efficacy of swallow and the swallow response of 40 dysphagic patients while swallowing one series of nectar control boluses and two series of nectar boluses supplemented with piperine. Patients were randomized into two groups: one group received 150 μM piperine and the other group received 1 mM. Piperine improved the safety of swallow by: (a) reducing the prevalence of unsafe swallows by -34.48% (P = 0.004) at 150 μM and -57.19% (P < 0.001) at 1 mM, and the severity score of the penetration-aspiration scale from 3.25 ± 0.51 to 1.85 ± 0.27 (P = 0.003, 1 mM); and (b) shortening the time to laryngeal vestibule closure from 0.366 ± 0.024 to 0.270 ± 0.022 s with 150 μM piperine (P < 0.001) and from 0.380 ± 0.032 to 0.306 ± 0.028 s with 1 mM piperine (P < 0.05). Supplementing the alimentary bolus with piperine speeds swallow response and strongly improves safety of swallow in patients with OD, with a maximal therapeutic effect at 1 mM. Our results suggest that activation of TRPV1/A1 in oropharyngeal sensory neurons is a very promising neurostimulation strategy for dysphagic patients.

Comparison of timing abnormalities leading to penetration versus aspiration during the oropharyngeal swallow

Objectives/HypothesisPenetration and aspiration during the oropharyngeal swallow have different clinical implications. This study examined temporal measures made from modified barium swallow examinations that might differentiate the two events.Study DesignRetrospective cohort study.MethodsTemporal measures of swallows of male patients with penetration only on the modified barium swallow study, those who showed aspiration (during the swallow), and normal control subjects were compared.ResultsSignificantly longer durations of temporal measures (glossopalatal junction opening until laryngeal vestibule closure and laryngeal lifting onset until laryngeal vestibule closure) were found for the penetration and aspiration groups compared to the normal group. No significant differences were found between the penetration and aspiration groups for any temporal measure.ConclusionsBoth aspiration and penetration cases showed abnormal timing measures compared to normal. However, aspiration during the swallow was not associated with a more extreme abnormality of temporal measures than penetration. Therefore, in the aspiration cases, there may be an additional neuromuscular disorder at the vocal fold level, allowing for deeper invasion of material into the airway. In addition, findings point to slow laryngeal elevation, and not a delayed onset of laryngeal elevation, as the dominant cause for the prolonged intervals seen with aspiration during the swallow.Level of Evidence3b. Laryngoscope, 124:935–941, 2014

Effect of surface sensory and motor electrical stimulation on chronic poststroke oropharyngeal dysfunction

Chronic poststroke oropharyngeal dysfunction (OD) is a common condition, leading to severe complications, including death. Treatments for chronic poststroke OD are scarce. The aim of our study was to assess and compare the efficacy and safety of treatment with surface electrical stimulation (e-stim) at sensory and motor intensities in patients with chronic poststroke OD. Twenty chronic poststroke patients with OD were randomly assigned to (i) sensory e-stim (treatment intensity: 75% of motor threshold) or (ii) motor e-stim (treatment intensity: motor threshold). Patients were treated during 10days, 1h/day. Videofluoroscopy was performed at the beginning and end of the study to assess signs of impaired efficacy and safety of swallow and timing of swallow response. Patients presented advanced age (74.95±2.18), 75% were men. The mean days poststroke was 336.26±89.6. After sensory stimulation, the number of unsafe swallows was reduced by 66.7% (p<0.001), the laryngeal vestibule closure time by 22.94% (p=0.027) and maximal vertical hyoid extension time by 18.6% (p=0.036). After motor stimulation, the number of unsafe swallows was reduced by 62.5% (p=0.002), the laryngeal vestibule closure time by 38.26% (p=0.009) and maximal vertical hyoid extension time by 24.8% (p=0.008). Moreover, the motor stimulus reduced the pharyngeal residue by 66.7% (p=0.002), the upper esophageal sphincter opening time by 39.39% (p=0.009), and increased bolus propulsion force by 211.1% (p=0.008). No serious adverse events were detected during the treatment. Surface e-stim is a safe and effective treatment for chronic poststroke dysphagic patients.

Natural capsaicinoids improve swallow response in older patients with oropharyngeal dysphagia

ObjectiveThere is no pharmacological treatment for oropharyngeal dysphagia (OD). The aim of this study was to compare the therapeutic effect of stimulation of oropharyngeal transient receptor potential vanilloid type 1...

Pathophysiology of oropharyngeal dysphagia in the frail elderly

Oropharyngeal dysphagia is a major complaint among the elderly. Our aim was to assess the pathophysiology of oropharyngeal dysphagia in frail elderly patients (FEP). A total of 45 FEP (81.5 +/- 1.1 years) with oropharyngeal dysphagia and 12 healthy volunteers (HV, 40 +/- 2.4 years) were studied using videofluoroscopy. Each subject's clinical records, signs of safety and efficacy of swallow, timing of swallow response, hyoid motion and tongue bolus propulsion forces were assessed. Healthy volunteers presented a safe and efficacious swallow, faster laryngeal closure (0.157 +/- 0.013 s) upper esophageal sphincter opening (0.200 +/- 0.011 s), and maximal vertical hyoid motion (0.310 +/- 0.048 s), and stronger tongue propulsion forces (22.16 +/- 2.54 mN) than FEP. By contrast, 63.63% of FEP presented oropharyngeal residue, 57.10%, laryngeal penetration and 17.14%, tracheobronchial aspiration. Frail elderly patients with impaired swallow safety showed delayed laryngeal vestibule (LV) closure (0.476 +/- 0.047 s), similar bolus propulsion forces, poor functional capacity and higher 1-year mortality rates (51.7%vs 13.3%, P = 0.021) than FEP with safe swallow. Frail elderly patients with oropharyngeal residue showed impaired tongue propulsion (9.00 +/- 0.10 mN), delayed maximal vertical hyoid motion (0.612 +/- 0.071 s) and higher (56.0%vs 15.8%, P = 0.012) 1-year mortality rates than those with efficient swallow. Frail elderly patients with oropharyngeal dysphagia presented poor outcome and high mortality rates. Impaired safety of deglutition and aspirations are mainly caused by delayed LV closure. Impaired efficacy and residue are mainly related to weak tongue bolus propulsion forces and slow hyoid motion. Treatment of dysphagia in FEP should be targeted to improve these critical events.

Preliminary Temporal Measurement Analysis of Normal Oropharyngeal Swallowing in Infants and Young Children

Temporal measures of normal pediatric oropharyngeal deglutition have not been studied. Knowledge of range and variation of normative temporal measures could define abnormal deglutition and assist in design of appropriate compensatory and rehabilitative treatment techniques. The purpose of this retrospective study was to determine temporal measurements for oral filling, oral transit, onset of laryngeal closure, time of bolus arrival at the valleculae, pharyngeal delay, pharyngeal transit, and UES opening. Videofluoroscopic swallow studies of 15 normally swallowing pediatric subjects were divided into three age groups and method of liquid delivery. Mean, standard deviation, percentages, and extension of the median were utilized to determine relationships of temporal measures. Mean temporal duration increased with age for oral filling, oral transit time, time of laryngeal closure, UES opening, and pharyngeal delay time. However, no significant differences were found between age groups indicating a deglutitive biomechanical adaptation to growth of the oral and pharyngeal cavity. Feeding method for bottle versus cup mean duration increased for oral transit time, laryngeal closure time, UES opening, and pharyngeal delay time. Bolus head location relative to onset of laryngeal vestibule closure changed with increased age and method of feeding. Temporal measures were not significantly different for age groups or feeding methods. Bolus location was at or fully contained in the valleculae at the onset of laryngeal closure and appeared to be a normal finding in functional pediatric swallows and is not indicative of a delay or disorder.

Swallowing disorders in the first year after radiation and chemoradiation

Radiation alone or concurrent chemoradiation can result in severe swallowing disorders. This manuscript defines the swallowing disorders occurring at pretreatment and 3 and 12 months after completion of radiation or chemoradiation. Forty-eight patients (10 women and 38 men) participated in this study involving videofluorographic evaluation of oropharyngeal swallow at the 3 time points. At baseline, patients had some swallow disorders, probably related to presence of their tumor. At 3 months posttreatment, frequency of reduced tongue base retraction, slow or delayed laryngeal vestibule closure, and reduced laryngeal elevation increased from baseline. Some disorders continued at 12 months posttreatment. Functional swallow decreased over time in patients treated with chemoradiation, but not those treated with radiation alone. Chemoradiation results in fewer functional swallowers than radiation alone at 12 months posttreatment completion.

Site of disease and treatment protocol as correlates of swallowing function in patients with head and neck cancer treated with chemoradiation

The relationship between type of chemoradiation treatment, site of disease, and swallowing function has not been sufficiently examined in patients with head and neck cancer treated primarily with chemoradiation. Fifty-three patients with advanced-stage head and neck cancer were evaluated before and 3 months after chemoradiation treatment to define their swallowing disorders and characterize their swallowing physiology by site of lesion and chemoradiation protocol. One hundred forty normal subjects were also studied. The most common disorders at baseline and 3 months after treatment were reduced tongue base retraction, reduced tongue strength, and slowed or delayed laryngeal vestibule closure. Frequency of functional swallow did not differ significantly across disease sites after treatment, although frequency of disorders was different at various sites of lesion. The effects of the chemotherapy protocols were small. The site of the lesion affects the frequency of occurrence of specific swallow disorders, whereas chemoradiation protocols have minimal effect on oropharyngeal swallow function.

Swallowing dysfunction after chemoradiation for advanced squamous cell carcinoma of the head and neck.

Swallowing dysfunction is a common side effect of chemoradiation. Twelve patients with stage III or IV squamous cell carcinoma of the head and neck were enrolled. Videofluorographic swallowing studies were performed before initiation of chemoradiation to provide baseline swallowing function data. Postchemoradiation videofluorographic swallowing studies were performed from 1 to 14 weeks after the completion of treatment (mean, 8 weeks). Changes in swallowing physiology after treatment included decreased base of tongue to posterior pharyngeal wall contact (p =.0010) and reduced pharyngeal contraction (p =.0313), resulting in impaired bolus transport through the pharynx. In addition, decreased laryngeal elevation (p =.0039), decreased laryngeal vestibule closure (p =.0078), and laryngeal penetration (p =.0078) were present. Bolus volume did not have a significant effect on swallowing ability. Aspiration was observed in four patients. Organ preservation treatment impairs movement of structures essential for normal swallowing. Prophylactic swallowing exercises may benefit these patients.

Babies With Tracheostomies

Babies With Tracheostomies

Comparison of effortful and noneffortful swallows in healthy middle-aged and older adults

Hind JA, Nicosia MA, Roecker EB, Carnes ML, Robbins J. Comparison of effortful and noneffortful swallows in healthy middle-aged and older adults. Arch Phys Med Rehabil 2001;82:1661-5. Objective: To assess the effects of effortful swallowing, a common compensatory strategy for dysphagia, on the bolus and swallowing mechanism of middle-aged and older men and women. Design: Case-controlled design in which subjects completed both the intervention technique and the control behavior. Setting: A university hospital. Participants: Sixty-four healthy men and women between 45 and 93 years of age from the community. Interventions: Participants swallowed 3-mL thin liquid boluses both normally and using the effortful swallow strategy. Main Outcomes Measures: The biomechanics and bolus flow patterns of swallows were analyzed from videofluoroscopic and simultaneous oral pressure data. Results: Subjects at all ages generated significantly increased oral pressures at each sensor location using the effortful swallow (p = .0001), with the pressure increase greater for the middle-aged subjects compared with older subjects. Several durational measures were significantly longer with the effortful swallow including: hyoid maximum anterior excursion (p < .04), laryngeal vestibule closure (p < .0001), and duration of the upper esophageal sphincter opening (p = .0001). The hyoid bone moved further in the superior direction with the effortful swallow (p = .002). There was a trend of decreased oral residue with the effortful swallow (p = .06). Conclusion: Biomechanical and bolus flow aspects of swallowing changed when healthy individuals performed effortful swallows with 3-mL boluses. © 2001 by the American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation

Swallowing physiology of toddlers with long-term tracheostomies: a preliminary study.

This study investigated the swallowing physiology of toddler-aged patients with long-term tracheostomies. Structural movements and motility of the pharyngeal stage of swallowing were studied in four toddlers ranging in age from 1:2 (years:months) to 2:9 with long-term tracheostomies. A patient aged 1:2 years with no tracheostomy served as a toddler model for comparison. Videofluoroscopic recordings of the patients' liquid and puree bolus swallows were analyzed for a) onset times for pharyngeal stage events, laryngeal vestibule closure, and tracheostomy tube movement; b) timeliness of swallow response initiation; and c) pharyngeal transport function. Results found differences in timing of pharyngeal stage movements between the tracheostomized patients and the patient with no tracheostomy. Laryngeal vestibule closure occurred before or within the same 0.033-s video frame as onset of upper esophageal sphincter (UES) opening in the patient with no tracheostomy, but occurred 0.033-.099 s after onset of UES opening in the tracheostomized patients. The time line required to close the laryngeal vestibule once the arytenoids began their anterior movement was longer in the tracheostomized patients than in the patient with no tracheostomy and was associated with laryngeal penetration. The patient with no tracheostomy displayed superior excursion of the arytenoid and epiglottis during the swallowing; the tracheostomized patients did not. No association was found between onset of tracheostomy tube movement and laryngeal vestibule closure. Delayed swallow response initiation was observed across tracheostomized patients at a mean frequency of 45% with associated penetration. Pharyngeal dysmotility was not observed. Findings supported the concept that long-term tracheostomy in toddler-aged patients affects swallowing physiology.

Impaired deglutitive airway protection: A videofluoroscopic analysis of severity and mechanism

BACKGROUND & AIMS: Laryngeal vestibule penetration is a prerequisite for deglutitive aspiration. This study aimed to analyze the mechanism and model the risk of laryngeal penetration before or during the pharyngeal swallow.METHODS: Videofluoroscopic swallowing studies of 29 patients with neurogenic dysphagia with penetration before or during the pharyngeal swallow were compared with 12 controls. A stepwise regression analysis was used to define the coordinative defects leading to bolus penetration into the laryngeal vestibule. The mechanism was biomechanically analyzed.RESULTS: The stepwise regression modeled a laryngeal penetration index from the coordination between laryngeal vestibule closure and bolus release at the glossopalatal junction and the timing of upper esophageal sphincter opening relative to glossopalatal junction opening. The model accounted for 86% of the observed variance in severity of laryngeal penetration among the dysphagics. The observed incoordination resulted from both delayed initiation and slowed enactment of deglutitive laryngeal elevation.CONCLUSIONS: A dysphagic individual's risk of incurring laryngeal penetration before or during 1-, 3-, or 5-mL swallows is proportional to two temporal measures of coordination made from 1-mL swallows. The severity of the relevant defects (delayed and slowed laryngeal elevation) is proportional to the severity of swallow dysfunction.(Gastroenterology 1997 Nov;113(5):1457-64)