Cricopharyngeal Opening Research Articles

How Well Can a Person with Parkinson’s Swallow?

documented in literature. They can be summed up depending upon the phases of swallowing oropharyngeal bradykinesia and rigidity, incomplete cricopharyngeal relaxation, reduced cricopharyngeal opening, and delayed initiation of swallowing [2]. Other components comprise of limited excursion of mandible, tongue pumping, drooling, and incomplete laryngeal closure [3,4]. These are further complicated by additional cognitive impairment, upper extremity impairment, and impulsive feeding behavior observed in these individuals. At times, esophageal phase may reveal incomplete upper esophgeal sphincter relaxation, impaired performance of supra hyoid muscles and hypertonic sphincter [5].

The Effect of Radiation Dose on Swallowing: Evaluation of Aspiration and Kinematics.

Radiation oncologists have focused on the pharyngeal constrictors as the primary muscles of concern for dysphagia. However, our prior investigations have demonstrated that radiation dose to the geniohyoid rather than the constrictor muscles was more closely related to penetration aspiration scores (PAS). We examined the relationship between (1) radiation dose and swallowing temporal kinematics, and (2) between PAS and swallowing kinematics in these patients. Videofluoroscopic swallowing studies of 41 patients following radiation therapy for oropharyngeal cancer were analyzed for thin liquid boluses. Timing measures included duration of laryngeal vestibule closure (DLVC), duration to maximum hyoid elevation (DTMHE), duration to cricopharyngeal opening (DTCPO), and pharyngeal transit time (PTT). PAS was extracted for each swallow and considered normal if ≤ 2. As minimum and mean dose to the geniohyoid increased, DTMHE, DTCPO, and PTT increased. Worse PA scores were most strongly correlated with radiation dose received by geniohyoid (r = 0.445, p < 0.0001). Mean DLVC varied according to PAS group (normal PAS mean = 0.67 s, abnormal PAS mean = 0.13 s; p < 0.001). Similarly, DTCPO was significantly different based upon PAS (normal PAS mean = 0.22 s, abnormal PAS mean = 0.37 s, p = 0.016). As PAS increased, DTPCO and PTT increased (r = 0.208, p = 0.04; r = 0.204, p = 0.043). A negative correlation was noted between PAS and DLVC (r = -0.375, p = 0.001). Higher doses of radiation to the geniohyoid muscles are associated with increased severity of dysphagia as measured through both kinematics and PAS. Consideration of dose to the geniohyoid should be considered when planning radiation.

Swallowing outcomes in patients with oropharyngeal cancer undergoing organ‐ preservation treatment

The purpose of this study was to assess swallowing outcomes in a cohort of patients with oropharyngeal squamous cell carcinoma (SCC) undergoing nonoperative treatment. We conducted a retrospective study of patients who completed videofluoroscopic swallowing studies (VFSS) after nonoperative treatment of oropharyngeal SCC. All patients received intensity-modulated radiation therapy (IMRT) ± chemotherapy. Swallowing abnormalities were recorded and the Penetration Aspiration Scale (PAS) quantified airway infiltration. Posttreatment VFSS (n = 71) occurred at an average of 4.69 months posttreatment. Abnormal PAS was noted in 45% of swallow studies. Swallowing decompensations included reduced pharyngeal constriction (75%), epiglottic tilt (70%), cricopharyngeal opening (42%), and hyoid excursion (42%). The only variable independently associated with abnormal PAS was pretreatment swallowing difficulty (odds ratio [OR] = 4.02; p = .009). This study demonstrates that patients undergoing nonsurgical treatment for oropharyngeal SCC are at risk for posttreatment dysphagia. This suggests a need for dysphagia evaluation/management and refinement of interventions to minimize dysphagia.

Pharyngeal Stimulation in Head and Neck Cancer Patients with Dysphagia: Functional Outcomes and Transcranial Magnetic Stimulation Motor Evoked Potentials

Purpose: Head and neck cancer patients often experience swallowing disorders, impacting health and quality of life. This study examined effects of electrical stimulation to the pharynx on swallowing outcomes in post-surgical head and neck cancer patients. Methods: Swallowing was assessed using video fluoroscopy before, and 30 minutes after, a ten-minute application of electrical stimulation to the pharynx in five patients experiencing moderate-severe dysphagia. Corticopharyngeal motor projections were measured before and after stimulation of the pharynx using transcranial magnetic stimulation of motor cortex and measurements of motor evoked potentials (MEPs) in the striated muscle of the posterior pharyngeal wall. Results: Short-term changes in swallowing function were observed post-stimulation in: pharyngeal transit time, cricopharyngeal opening duration, total number of swallows, penetration/aspiration score, and duration of contact between the base of tongue and posterior pharyngeal wall. MEPs could not be measured in two participants. In the remaining participants, the MEP measures were not strongly associated with changes in observed swallowing function as has been found for neurogenic dysphagia. Conclusions: These findings indicated that somatosensory input, generated by electrical stimulation of the pharynx, changes swallowing function in head and neck cancer patients. These changes are not strongly correlated with alterations of corticopharyngeal excitability as previously observed in acutely dysphagic stroke patients.

The evaluation of swallowing in patients with spinocerebellar ataxia and oropharyngeal dysphagia: A comparison study of videofluoroscopic and sonar doppler.

Sumarry Introduction: Spinocerebellar ataxia (SCA) is a degenerative disease that can cause loss of coordination of voluntary muscle movement such as that required for swallowing. Aims: The purposes of this cross-sectional and comparative case study were: (1) to assess the severity of dysphagia through a videofluoroscopic swallow study, and (2) to compare differences in frequency, intensity, and duration of sound waves produced during swallowing in normal and SCA patients by using sonar Doppler. Method: During swallow evaluation using videofluoroscopy, a sonar Doppler transducer was placed on the right side of the neck, at the lateral edge of the trachea, just below the cricoid cartilage to capture the sounds of swallowing in 30 SCA patients and 30 controls. Result: The prevalence in the dynamic evaluation of swallowing videofluoroscopy was by changes in the oral phase of swallowing. The analysis of variance of the averages found in each variable - frequency, intensity and duration of swallowing - shows there was a significant correlation when compared to the healthy individual curve. Conclusion: The study demonstrates the prevalence of oral dysphagia observed in dynamic videofluoroscopic swallow evaluation. In patients with SCA, the mean initial frequency (IF), initial intensity (II), and final intensity (FI) were higher and the time (T) and peak frequency (PF) were lower, demonstrating a pattern of cricopharyngeal opening very close to that found in normal populations.

Comparison between swallowing-related and limb muscle involvement in dermatomyositis patients

Objective: To determine the relationship between the movement of the hyolaryngeal complex and the motor power of limb muscles and the differences in the hyolaryngeal movement according to the creatine kinase (CK) levels in dermatomyositis patients.Method: We retrospectively selected 13 patients who had undergone a videofluoroscopic swallowing study (VFSS) for swallowing difficulty from patients diagnosed with dermatomyositis. The maximal anterior and superior displacements of the hyoid and larynx and the cricopharyngeal opening were acquired by frame-by-frame analysis using the VFSS. We investigated the motor power of the bilateral shoulder abductor, elbow flexor, hip flexor, and knee extensor muscles to determine the limb muscle involvement and used the American Speech-Language-Hearing Association (ASHA) National Outcomes Measurement System (NOMS) swallowing level (ASHA level) to assess dysphagia severity. Spearman's correlation test was used to identify the relationship between the kinematic data of the laryngeal structures, ASHA levels, and the total motor scores in dermatomyositis patients.Results: There was no significant correlation between the kinematic data of the laryngeal structures, ASHA levels, and total motor scores. Only the anterior movements of the hyoid and larynx had a significant relationship to the upper oesophageal sphincter opening.Conclusion: Dysphagia evaluation should be considered separately in dermatomyositis patients irrespective of limb involvement or dysphagia severity because the swallowing-related muscle involvement had no relationship to the limb muscle involvement or the severity of dysphagia in dermatomyositis. It is hoped that our results can be used to evaluate the therapeutic effects of dysphagia management in dermatomyositis patients.

Gender Effects on Airway Closure in Head and Neck Cancer Patients

Age, gender, and bolus effects on the duration of laryngeal closure, the onset of laryngeal closure in relation to the first cricopharyngeal opening, and the duration of cricopharyngeal opening in head and neck cancer patients have not been well documented. Thirty-three head and neck cancer patients (middle-aged women and men, and older women and men) were evaluated with videofluoroscopy before and 3 months after their cancer treatment. At 3 months post-treatment, the mean duration of laryngeal closure was longer for women than for men at 1-, 5-, and 10-ml bolus volumes. The duration of laryngeal closure at 3 months post-treatment and the duration of cricopharyngeal opening at both pretreatment and 3 months post-treatment increased as liquid bolus volume increased. Gender effects were observed in the duration of laryngeal closure during swallow. Bolus effects were observed in the duration of laryngeal closure and cricopharyngeal opening.

Gender Effects on Airway Closure in Normal Subjects

The present study was designed to examine age and gender differences with respect to the duration of laryngeal closure, the onset of laryngeal closure in relation to the first cricopharyngeal opening, and the duration of cricopharyngeal opening for six different groups: normal younger men and women (22-29years), normal middle-aged men and women (45-53years), and normal older men and women (81-94years) (10 subjects in each group for a total of 60 subjects). Data were collected by means of videofluoroscopic studies. During swallows of liquid barium, results indicated that normal older subjects had longer cricopharyngeal opening than younger subjects (P=0.044). Results also revealed that the mean duration of laryngeal closure was significantly longer in women than in men (P=0.013). The onset of laryngeal closure was significantly earlier in women than in men (P=0.006). Also, bolus volume effects were observed for both the duration of laryngeal closure (P<0.0001) and cricopharyngeal opening (P<0.0001). During liquid barium swallows there was a linear increase in both the duration of laryngeal closure and cricopharyngeal opening.

Phase 2 trial of leuprorelin in patients with spinal and bulbar muscular atrophy

Spinal and bulbar muscular atrophy (SBMA) is a hereditary motor neuron disease caused by the expansion of a polyglutamine tract in the androgen receptor (AR). Animal studies have shown that the pathogenesis of SBMA is dependent on serum testosterone level. This study is aimed at evaluating the efficacy and safety of androgen deprivation by leuprorelin acetate in patients with SBMA. Fifty SBMA patients underwent subcutaneous injections of leuprorelin acetate or placebo in a randomized, placebo-controlled trial for 48 weeks, followed by an open-label trial for an additional 96 weeks, in which 19 patients of the leuprorelin group and 15 of the placebo group received leuprorelin acetate. The patients who did not participate in the open-label trial were also followed up for the 96-week period (UMIN000000474). Leuprorelin acetate significantly extended the duration of cricopharyngeal opening in videofluorography and decreased mutant AR accumulation in scrotal skin biopsy. The patients treated with leuprorelin acetate for 144 weeks exhibited significantly greater functional scores and better swallowing parameters than those who received placebo. Autopsy of one patient who received leuprorelin acetate for 118 weeks suggested that androgen deprivation inhibits the nuclear accumulation or stabilization, or both, of mutant AR in the motor neurons of the spinal cord and brainstem. These observations suggest that administration of leuprorelin acetate suppresses the deterioration of neuromuscular impairment in SBMA by inhibiting the toxic accumulation of mutant AR. The results of this phase 2 trial support the start of large-scale clinical trials of androgen deprivation for SBMA.

Anti‐androgen treatment for spinal and bulbar muscular atrophy

Anti‐androgen treatment for spinal and bulbar muscular atrophy

Pretreatment Swallowing Exercises Improve Swallow Function After Chemoradiation

Swallowing dysfunction is a devastating complication of chemoradiation therapy (CRT) for head and neck squamous cell carcinoma. We have previously demonstrated that pretreatment swallowing exercises improve posttreatment swallowing-related quality of life. This study evaluates the effect of pretreatment swallowing exercises on posttreatment swallow function as measured by videofluoroscopy. Retrospective case control. Eighteen patients with advanced squamous cell carcinoma of the oropharynx, hypopharynx, and larynx treated at University of Alabama at Birmingham with CRT were included in the study. Nine patients received pretreatment swallowing exercises prior to CRT, and nine patients received swallowing exercises during routine posttreatment management. Approximately 3 months after completing treatment, standard videofluoroscopy examinations were conducted. Outcomes measured by the videofluoroscopy examinations included hyoid elevation, epiglottis inversion, tongue base movement, cricopharyngeal opening, and Rosenbeck aspiration score. Percutaneous endoscopic gastrostomy (PEG) tube use was assessed at 12 months after treatment. Epiglottis inversion was better maintained (P = .05) in patients receiving pretreatment swallowing therapy. The position of the tongue base during swallowing was also significantly closer to the posterior pharyngeal wall (P = .025) for patients receiving pretreatment exercises. PEG tube removal rates did not significantly differ between groups. Performing pretreatment swallowing exercises produces measurable improvements in posttreatment swallowing function in patients who undergo organ-preservation CRT for head and neck cancer. This study provides an initial foundation for the development of noninvasive, cost-effective, evidence-based interventions in this group of vulnerable patients.

Videomanometric Evaluation of Pharyngo‐oesophageal Dysmotility in Children With Velocardiofacial Syndrome

Videomanometric Evaluation of Pharyngo‐oesophageal Dysmotility in Children With Velocardiofacial Syndrome

Relationship between swallow motility disorders on videofluorography and oral intake in patients treated for head and neck cancer with radiotherapy with or without chemotherapy

Current research demonstrates that swallow function is impaired after treatment with organ-sparing chemoradiotherapy. Few studies, however, have related observed swallowing disorders with the patient's oral intake and diet in a large cohort of patients. Swallowing function was examined using the modified barium swallow (MBS) procedure in 170 patients treated with radiotherapy with or without chemotherapy for cancer of the head and neck at 5 evaluation points: pretreatment and at 1, 3, 6, and 12 months posttreatment. Fisher's exact test was used to examine the relationship between swallow motility disorders and oral intake or diet consistencies. Limitations in oral intake and diet during the first year after cancer treatment were significantly related to reduced laryngeal elevation, reduced cricopharyngeal opening, and rating of nonfunctional swallow on at least 1 swallow of any bolus type. Swallow motility disorders had a significant impact on the eating ability of patients after treatment for head and neck cancer with radiotherapy with or without chemotherapy.

Effects of bilateral lingual and inferior alveolar nerve anesthesia effects on masticatory function and early swallowing.

To determine whether bilateral lingual and inferior alveolar nerve anesthesia affects the onset of swallowing including masticatory function. Twenty young male volunteers were asked to chew and swallow corned beef and then a mixture of corned beef and liquid in their usual manner before and after local anesthesia. The oral and pharyngeal swallowing was investigated using videofluoroscopic examination in a lateral plane. Eight objective indicators including oral containment time, swallowing threshold, and pharynx-to-swallow interval were measured. Oral containment time and total sequence duration, total number of chews, and total number of swallows for the 2 test foods varied significantly between those before and after anesthesia. Individual pharynx-to-swallow intervals varied with both foods without remarkable increases or decreases in the swallow duration and cricopharyngeal opening time. Bilateral lingual and inferior alveolar nerve anesthesia may affect early swallowing; changes in the onset of swallowing varied among the participants.

Effects of bilateral lingual and inferior alveolar nerve anesthesia effects on masticatory function and early swallowing

Objective To determine whether bilateral lingual and inferior alveolar nerve anesthesia affects the onset of swallowing including masticatory function. Study design Twenty young male volunteers were asked to chew and swallow corned beef and then a mixture of corned beef and liquid in their usual manner before and after local anesthesia. The oral and pharyngeal swallowing was investigated using videofluoroscopic examination in a lateral plane. Eight objective indicators including oral containment time, swallowing threshold, and pharynx-to-swallow interval were measured. Results Oral containment time and total sequence duration, total number of chews, and total number of swallows for the 2 test foods varied significantly between those before and after anesthesia. Individual pharynx-to-swallow intervals varied with both foods without remarkable increases or decreases in the swallow duration and cricopharyngeal opening time. Conclusion Bilateral lingual and inferior alveolar nerve anesthesia may affect early swallowing; changes in the onset of swallowing varied among the participants.

Oropharyngeal Deglutition in Stable COPD

The aim of this study was to examine deglutition in stable patients with COPD and lung hyperinflation. Twenty consecutive, eligible COPD patients with an FEV(1) < or = 65% of predicted and a total lung capacity > or = 120% of predicted were enrolled prospectively. Patients received a detailed videofluoroscopic evaluation of oropharyngeal swallowing and were compared to 20 age-matched and sex-matched historical control subjects. An outpatient pulmonary clinic at a Veterans Affairs Medical Center. The mean total lung capacity, functional residual capacity, and residual volume for the patients were 128% of predicted, 168% of predicted, and 218% of predicted, respectively. The mean FEV(1) was 39% of predicted. There was no evidence of tracheal aspiration in either group. The laryngeal position at rest measured relative to the cervical vertebrae was not different between groups. The maximal laryngeal elevation during swallowing was significantly lower in patients with COPD (p < 0.001). Patients with COPD exhibited more frequent use of spontaneous protective swallowing maneuvers such as longer duration of airway closure and earlier laryngeal closure relative to the cricopharyngeal opening than did control subjects (p < 0.05). We conclude that hyperinflated patients with COPD have an altered swallowing physiology. We suspect that the protective alterations in swallowing physiology (swallow maneuvers) may reduce the risk of aspiration. However, these swallowing maneuvers may not be useful during an exacerbation and may require further research.

Temporal and Biomechanical Characteristics of Oropharyngeal Swallow in Younger and Older Men

As the U.S. population ages, there is increasing need for data on the effects of aging in healthy elderly individuals over age 80. This investigation compared the swallowing ability of 8 healthy younger men between the ages of 21 and 29 and 8 healthy older men between the ages of 80 and 94 during two swallows each of 1 ml and 10 ml liquid. Videofluoroscopic studies of these swallows were analyzed to confirm the absence of swallowing disorders. Biomechanical analysis of each swallow was completed, from which data on temporal, range of motion, and coordination characteristics of the oropharyngeal swallow were taken. Position of the larynx at rest, length of neck, and pattern of hyoid bone movement were also compared between the two groups. None of the younger or older men exhibited any swallowing disorders. The C2 to C4 distance of older men was significantly shorter than that of younger men, and laryngeal position at rest was lower than in younger men but not significantly so. Older men had a significantly longer pharyngeal delay than younger men and significantly faster onset of posterior pharyngeal wall movement in relation to first cricopharyngeal opening. The older men exhibited significantly reduced maximum vertical and anterior hyoid movement as compared to the younger men even when accounting for the difference in C2 to C4 distance in older men. These data support the hypothesis of reduced muscular reserve in the swallows of older men as compared to younger men. Older men also exhibited less width of cricopharyngeal opening than younger men at 10 ml volume, indicating less upper esophageal sphincter flexibility in the swallows of older men. The potential for exercise to improve reserve is discussed. Significant changes in extent of hyoid elevation and duration of cricopharyngeal opening were seen as liquid bolus volume increased.

Speech and swallowing in irradiated and nonirradiated postsurgical oral cancer patients

The effect of radiation on speech and swallowing function was assessed for 18 patients surgically treated for oral and oropharyngeal cancer. Nine patients received surgical intervention and postoperative radiation therapy, and nine received surgery only. Patients were matched regarding percentage of oral tongue resected, percentage of tongue base resected, locus of resection, and method of reconstruction. Speech and swallowing function was assessed before and at 1, 3, 6, and 12 months after surgery following a standardized protocol. Speech tasks included an audio recording of a brief conversation and of a standard articulation test; swallowing function was examined with videofluoroscopy. Statistical testing indicated that overall speech function did not differ between the irradiated and nonirradiated patients. Irradiated patients had significantly reduced oral and pharyngeal swallowing performance, specifically, longer oral transit times on paste boluses, lower oropharyngeal swallow efficiency, increased pharyngeal residue, and reduced cricopharyngeal opening duration. Impaired function may be the result of radiation effects such as edema, fibrosis, and reduced salivary flow. Increased use of tongue range-of-motion exercises during and after radiation treatment may reduce the formation of fibrotic tissue in the oral cavity and may improve pharyngeal clearance by maintaining adequate tongue base-to–pharyngeal wall contact. (Otolaryngol Head Neck Surg 1998;118:616-24.)

Speech and swallowing in irradiated and nonirradiated postsurgical oral cancer patients.

The effect of radiation on speech and swallowing function was assessed for 18 patients surgically treated for oral and oropharyngeal cancer. Nine patients received surgical intervention and postoperative radiation therapy, and nine received surgery only. Patients were matched regarding percentage of oral tongue resected, percentage of tongue base resected, locus of resection, and method of reconstruction. Speech and swallowing function was assessed before and at 1, 3, 6, and 12 months after surgery following a standardized protocol. Speech tasks included an audio recording of a brief conversation and of a standard articulation test; swallowing function was examined with videofluoroscopy. Statistical testing indicated that overall speech function did not differ between the irradiated and nonirradiated patients. Irradiated patients had significantly reduced oral and pharyngeal swallowing performance, specifically, longer oral transit times on paste boluses, lower oropharyngeal swallow efficiency, increased pharyngeal residue, and reduced cricopharyngeal opening duration. Impaired function may be the result of radiation effects such as edema, fibrosis, and reduced salivary flow. Increased use of tongue range-of-motion exercises during and after radiation treatment may reduce the formation of fibrotic tissue in the oral cavity and may improve pharyngeal clearance by maintaining adequate tongue base-to-pharyngeal wall contact.

Light digital occlusion of the tracheostomy tube: A pilot study of effects on aspiration and biomechanics of the swallow

Background This study examined the effects of digital occlusion of the tracheostomy tube versus no occlusion on oropharyngeal swallowing in head and neck cancer patients. Methods Eight treated head and neck cancer patients were studied, six of whom had undergone surgical treatment for oral or laryngeal cancer and two who had undergone high-dose chemotherapy and radiotherapy for laryngeal cancer. Videofluorographic studies of oropharyngeal swallowing were accomplished on 3-mL boluses of liquid in seven patients and 3-mL boluses of paste in three patients, first with the tracheostomy not occluded and then with it lightly digitally occluded by the patient. Videofluorographic studies of swallow were examined for observations of aspiration and residue. Biomechanical analysis of each liquid swallow was also completed. Results Four of the seven patients aspirated on thin liquids with the tube unoccluded. Aspiration was eliminated with the tracheostomy digitally occluded in two of these four patients. One of the patients also aspirated on paste with the tube unoccluded, and the aspiration was eliminated with the tube occluded. A third patient who aspirated on thin liquid had no change when the tube was occluded, and one patient's swallow worsened with the tube occluded on liquid. There were significant changes in five measures of swallow biomechanics on liquids with the tube occluded: (1) duration of base of tongue contact to the posterior pharyngeal wall was reduced, (2) maximal laryngeal elevation increased, (3) and (4) laryngeal and hyoid elevation at the time of initial cricopharyngeal opening increased, and (5) onset of anterior movement of the posterior pharyngeal wall relative to the onset of cricopharyngeal opening began later. Conclusions Light digital occlusion of the tracheostomy tube appears to be a safe procedure, because most biomechanics of swallow are positively affected, perhaps because of the increased resistance provided by the closed trachea. However, not all patients received benefit from tube occlusion, indicating that each patient must be evaluated individually to determine whether or not tube occlusion improves their swallow. © 1998 John Wiley & Sons, Inc. Head Neck 20: 52–57, 1998.