Dysphagia Symptoms In Patients Research Articles

Efficacy and Safety of Monoclonal Antibodies for the Treatment of Eosinophilic Esophagitis: A Systematic Review and Meta-Analysis of Randomized Controlled Trials.

Monoclonal antibodies (MAbs) have clinical benefits for treating several atopic diseases. However, consensus on its use for eosinophilic esophagitis (EoE) is lacking. The present meta-analysis aimed to compare the efficacy and safety of MAbs versus placebo for treating EoE. We searched PubMed, Embase, and Cochrane Library for randomized controlled trials (RCTs). The primary outcomes were changes in peak esophageal eosinophils count/high power field (HPF) and mean esophageal eosinophils count/HPF. The secondary outcomes were changes in the EoE-Histology Scoring System (EoE-HSS), Endoscopic Reference Score (EREFS), dysphagia score, and adverse events (AEs). We compared binary outcomes using risk ratio (RR) and continuous outcomes using mean difference (MD) or standardized mean difference (SMD), with 95% confidence interval (CI). Considering the diversity of mechanistic properties of MAbs, a pre-specified subgroup analysis by MAb mechanism of action was performed for all outcomes, provided that at least two studies were in each subgroup. Heterogeneity was assessed using Cochran's Q test and I2 statistics. 6 RCTs were included (533 patients). Compared to placebo, MAbs led to a significant reduction in peak esophageal eosinophils count/HPF (MD -0.78; CI 95% -0.87, -0.6801) and mean esophageal eosinophils count/HPF (SMD-0.79; CI 95% -1.5, -0.08). Moreover, MAbs significantly reduced EoE-HSS scores (grade score: SMD-9.31; 95% CI -13.95, -4.6701; stage score: SMD -10.18; 95% CI -15.06, -5.31), EREFS (SMD-5.95; CI 95% -9.19, -2.71) and dysphagia score (SMD -1.79; CI 95% -3.36, -0.23) without increasing AEs compared to placebo. Among those MAbs whose mechanism of action includes the blockage of the receptor for IL-13 (Dupilumab, QAX576, and RPC4046), the scores of EoE-HSS grade, EoE-HSS stage, EREFS, and dysphagia were significantly reduced, and they presented a similar risk of overall and serious AEs compared to placebo. MAbs seem effective and safe in reducing esophageal eosinophil infiltrate, EoE-HSS score, EREFS score, and dysphagia symptoms in patients with EoE. However, further evidence is needed to establish its place in EoE management.

Lateral needling at Lianquan (CV 23) for post-stroke dysphagia: a randomized controlled trial

To observe the effect of lateral needling at Lianquan (CV 23) for post-stroke dysphagia, and explore its mechanism. A total of 64 patients with post-stroke dysphagia were randomly divided into an observation group and a control group, 32 cases in each group. Both groups were treated with conventional basic treatment. The observation group was treated with lateral needling at CV 23, without needle retaining, once a day. The control group was treated with swallowing rehabilitation training, once a day. Both groups were treated for 5 days a week, with 2 days interval, 1 week as one course and 4 courses were required. Before and after treatment, the Kubota water swallowing test grade and standardized swallowing assessment (SSA) score were compared in the two groups. Before and after treatment, the video fluoroscopic swallowing study (VFSS) was used to measure the hyoid bone movement displacement and pharyngeal delivery time in the observation group. Compared before treatment, the Kubota water swallowing test grade after treatment was improved in the two groups (P<0.05), and the observation group was superior to the control group (P<0.05); the SSA scores after treatment were decreased in the two groups (P<0.05), and the observation group was lower than the control group (P<0.05). Compared before treatment, the hyoid bone movement displacement was increased and pharyngeal delivery time was shortened after treatment in the observation group (P<0.05). Lateral needling at CV 23 could improve dysphagia symptoms in patients with post-stroke dysphagia, its mechanism may be related to the increasing of hyoid bone movement displacement and shortening of pharyngeal delivery time.

Relationship between dysphagia, lower esophageal sphincter relaxation, and esophagogastric junction distensibility.

It is debated whether high-resolution manometric (HRM) integrated relaxation pressure (IRP) or functional lumen imaging probe (FLIP) distensibility index (DI) is the superior measure of esophagogastric junction (EGJ) opening. We examined the relationship between the DI and IRP and assessed correlations with dysphagia symptoms in patients with achalasia and EGJ outflow obstruction (EGJOO). Patients with achalasia and those with barium tablet retention at the EGJ were grouped as follows: Group 1:Achalasia (IRP≥15mmHg+complete absence of normal peristalsis); Group 2: Manometric+FLIP EGJOO (IRP≥15mmHg with some intact peristalsis+DI≤2.8mm2 /mmHg); Group 3: Abnormal DI only (DI≤2.8mm2 /mmHg+IRP <15mmHg); and Group 4: Normal IRP and DI (IRP≥15mmHg+DI>2.8mm2 /mmHg). Correlation between the DI, baseline lower esophageal sphincter pressure (BLESP), IRP, and dysphagia (Eckardt score) was assessed. Multivariable analysis was used to assess variables associated with dysphagia score ≥2. A total of 79 patients were included: Group 1 (n=31), Group 2 (n=33), Group 3 (n=14), and Group 4 (n=1). DI did not correlate with BLESP or IRP in the whole sample or subgroups. DI was the only variable associated with dysphagia score ≥2 (p=0.006). DI<1.25mm2 /mmHg had sensitivity of 87% and specificity of 52% (p=0.0003) for dysphagia score ≥2. DI does not correlate with HRM EGJ measurements and is the metric with the strongest effect on dysphagia severity. The various biological elements that may cause restrictive EGJ function should be the subject of future studies.

Reflux, dysphonia, and dysphagia symptoms in patients with diabetes and their association with diabetic complications.

Diabetes mellitus (DM) could influence various organs, especially the eyes, kidneys, nerves, heart, and blood vessels, and finally results in many irreversible disease-related complications. In this paper, the association between reflux, swallowing, and voice symptoms in patients with DM and the possible effect of diabetic complications on these symptoms were investigated. A total of 179 patients with diabetes were included to the study. Three self-reported questionnaires; Reflux Symptom Index (RSI), Eating Assessment Tool-10 (EAT-10), and Voice Handicap Index-10 (VHI-10) were administrated to the patients and, their association with DM-related neuropathy and nephropathy were examined. The scores of each questionnaire were significantly correlated with each other (p < 0.001). There was not any statistically significant association between the score of T-RSI and the diabetic complications (p = 0.077), while a statistically significant association was found between the T-EAT-10 score and neuropathy (p < 0.001). Neither neuropathy nor nephropathy alone had an association with the T-VHI-10 score. However, the presence of nephropathy and neuropathy together was found to be associated with the T-VHI-10 score (p = 0.027). It is possible to conclude that gastrointestinal symptoms such as reflux, dysphonia, and dysphagia are associated with each other and they may possibly be related to the microvascular complications of DM. The clinicians should be aware of the possible reflux, voice, and swallowing complaints and also inquire about the presence of neuropathy and nephropathy in the diabetic population.

AK002, an Anti-Siglec-8 Antibody, Depletes Tissue Eosinophils and Improves Dysphagia Symptoms in Patients with Eosinophilic Esophagitis

AK002, an Anti-Siglec-8 Antibody, Depletes Tissue Eosinophils and Improves Dysphagia Symptoms in Patients with Eosinophilic Esophagitis

The Prevalence of Dysphonia and Dysphagia Symptoms in Patients on Statin Therapy

To investigate the effect of statin therapy on swallowing and phonation. A group of patients on statin therapy and another group not on statins (controls) presenting to the endocrinology clinic between January 2018 and April 2018 were asked to participate. All patients filled Voice Handicap Index (VHI-10), Eating Assessment Tool (EAT-10), and Likert scales for vocal fatigue and hoarseness. Demographic data included age, gender, allergy, and history of smoking. A total of 160 patients were recruited, 75 patients on statin therapy and 85 not on statin therapy. The mean age of the study group was 55.00 years, whereas that of the control group was 45.70 years. The mean duration of statin treatment was 74.92 months. The mean VHI-10 and EAT-10 scores were significantly higher in the statin group compared to the control group (P < 0.05). Although there was no significant difference in the mean Likert scale for vocal fatigue, the mean Likert scale for hoarseness was significantly higher in the statin group compared to the control group (P < 0.05). This investigation revealed a significantly higher prevalence of laryngopharyngeal symptoms in patients on statin therapy versus a control group.

Swallowing in Parkinson’s disease: How is it affected?

ObjectivesThe aim of this study was to evaluate the swallowing in patients with Parkinson’s disease (PD) using comprehensive and multimodal methods. Patients and methodsThe present study was conducted on 120 patients and 60 controls between January 2017 and January 2018. All participants’ demographic data were recorded, and the swallowing of the subjects was evaluated by using several methods, including clinic, electrophysiologic, endoscopic and ultrasonographic procedure.First, the swallowing functions of the patient and control groups were compared. Subsequently, the patients were divided into two groups as patients with (n = 63) or without (n = 57) dysphagia symptoms according to their clinical evaluation. Finally, the data of these three groups were compared. ResultsIn comparison with healthy subjects, the swallowing evaluated by all diagnostic methods were affected in patients with PD. This effect was greater in patients with clinically symptomatic dysphagia. No difference was found between patients without dysphagia symptoms and healthy controls based on clinic, endoscopic and some electrophysiologic methods. Interestingly, thickness of all oral phase muscles in healthy controls were significantly higher than both dysphagic and non-dysphagic PD patients according to ultrasonography. ConclusionAlthough it is widely known that dysphagia symptoms in patients with PD usually occur in advanced stages and cause serious problems for patients, the present study establishes that swallowing functions may have been affected in early stage patients without dysphagia symptoms. Assessment of swallowing functions is important and should be also assessed in patients without dysphagia symptoms. Moreover, ultrasonographic method may be used in the diagnosis and follow-up of patients with PD.

The Role of Botulinum Toxin Injections for Esophageal Motility Disorders.

The advancement of high-resolution esophageal manometry has led to improvement in the diagnosis of esophageal motility disorders. We reviewed the recent medical literature regarding the use of botulinum toxin (BTx) injections in the esophagus and the indications, current outcomes, and reported complications of this therapy. The response rates of BTx injection therapy vary depending on the esophageal motility disorder. Studies have shown that response is transient in achalasia patients and given the more effective therapies available, it is only recommended in patients who are not surgical candidates. In nonachalasia patients, studies of BTx injections have demonstrated improvement in dysphagia symptoms in patients with spastic disorders, though studies are small and largely retrospective. The available literature showed a variable response to BTx in esophagogastric junction outlet obstruction (EGJOO) and non-cardiac chest pain patients. Despite advances in diagnosing esophageal motility disorders, there is a need for further research in patient selection for esophageal BTx, dose and injection location, and disease-specific outcomes. Placebo-controlled trials are crucial to evaluate BTx efficacy and duration of response. Esophageal-directed BTx injections are beneficial in improving dysphagia in spastic motility disorders and in achalasia patients who are elderly or have multiple co-morbidities. There is a lack of evidence to support use in patients with EGJOO and non-cardiac chest pain, or for young or healthy achalasia patients.

Empiric Dilation in Patients With Unexplained Dysphagia

Introduction: Patients with subjective dysphagia with normal findings on both the High Resolution Manometry (HRM) and Esophagogastroduodenoscopy (EGD) represent a challenging cohort to treat. There is a paucity of data on efficacy and safety of the empirical dilation in patients with unexplained dysphagia. The aim of our study is to determine the efficacy and safety of esophageal dilation as empiric therapy for patients with cryptogenic dysphagia.FigureMethods: This is a retrospective cohort study that included patients who met the criteria for unexplained dysphagia, i.e. underlying cause of the dysphagia cannot be determined both on the HRM and EGD between April 2015 and August 2016. Each patient received esophageal dilation with bougie dilators. Post dilation, patients were contacted by telephone and asked about their symptom severity and symptom frequency using the Brief Esophageal Dysphagia Questionnaire* and overall treatment satisfaction (measured on a scale of 1 to 10: 1 being not pleased with current symptoms, 10 being very satisfied. Results: Twenty seven patients (seven male/ twenty female) with dysphagia were dilated with esophageal dilators with a goal of 18mm. Using a questionnaire post dilation, seventeen patients (62.96%%) had improvement of their dysphagia symptoms (i.e. total dysphagia score <3). Seven patients (25.9%) reported symptoms of food stuck in the esophagus for more than 30 minutes; none of the empirically dilated patients had an emergency visit for globus or dysphagia. Conclusion: Empirical esophageal dilation is safe and effective in improving the symptoms of dysphagia in patients without obvious structural lesions or functional disorders. Empirical dilation may improve dysphagia symptoms because subtle structural lesions such as small strictures, webs, rings capable of decreasing the esophageal lumen diameter might go unnoticed on endoscopy. These subtle structural lesions are countered by the empirical esophageal dilation, eventually improve symptoms of dysphagia.

Bethanechol Improves Dysphagia Symptoms in Patients with Ineffective Esophageal Motility Disorder

Bethanechol Improves Dysphagia Symptoms in Patients with Ineffective Esophageal Motility Disorder

Effect of Vocal Fold Medialization on Dysphagia in Patients with Unilateral Vocal Fold Immobility.

The effect of vocal fold medialization (VFM) on vocal improvement in persons with unilateral vocal fold immobility (UVFI) is well established. The effect of VFM on the symptom of dysphagia is uncertain. The purpose of this study is to evaluate dysphagia symptoms in patients with UVFI pre- and post-VFM. Case series with chart review. Academic tertiary care medical center. The charts of 44 persons with UVFI who underwent VFM between June 1, 2013, and December 31, 2014, were abstracted from a prospectively maintained database at the University of California, Davis, Voice and Swallowing Center. Patient demographics, indications, and type of surgical procedure were recorded. Self-reported swallowing impairment was assessed with the validated 10-item Eating Assessment Tool (EAT-10) before and after surgery. A paired samples t test was used to compare pre- and postmedialization EAT-10 scores. Forty-four patients met criteria and underwent either vocal fold injection (73%) or thyroplasty (27%). Etiologies of vocal fold paralysis were iatrogenic (55%), idiopathic (29%), benign or malignant neoplastic (9%), traumatic (5%), or related to the late effects of radiation (2%). EAT-10 (mean ± SD) scores improved from 12.2 ± 11.1 to 7.7 ± 7.2 after medialization (P < .01) with a follow-up of 119 ± 65 days. Patients with UVFI suffer from dysphagia and report significant improvement in swallowing symptoms following VFM. The symptomatic improvement appears to be durable over time.

Dysphagia Following Airway Reconstruction in Adults.

Patients who undergo open airway reconstruction procedures are likely to experience some degree of postoperative dysphagia symptoms and delayed return to oral intake. To review the duration of postoperative dysphagia symptoms and outcomes in a group of adult patients. Retrospective review of the medical records of adult patients undergoing laryngotracheoplasty, posterior cricoid split laryngoplasty, tracheal resection, and cricotracheal resection in a tertiary hospital between July 2009 and September 2014. Laryngotracheoplasty, posterior cricoid split laryngoplasty, tracheal resection, and cricotracheal resection. Demographic characteristics, etiology of airway stenosis, surgical procedure, stent type, and duration of dysphagia symptoms. Thirty-eight patients (14 men, 24 women; mean [SD; range] age, 48 [14.4; 20-80] years) fitting the inclusion criteria were identified. Twenty-four (63%) patients had laryngotracheal stenosis secondary to prolonged intubation, with 3 (8%), 5 (13%), and 6 (16%) cases being due to autoimmune, idiopathic, or other etiology, respectively. Twenty-five (66%) patients underwent tracheal or cricotracheal resection, and 13 (34%) underwent laryngotracheoplasty or posterior cricoid split laryngoplasty. Of the 17 patients with stents placed, 6 (35%) patients had a suprastomal stent sewn at the top with a polypropylene suture using a horizontal mattress technique, 6 (35%) patients had a suprastomal stent capped with an extended Silastic thoracic T-tube segment, and 5 (29%) patients had either a T-tube or hood bronchial stent. Eight of 17 patients used a nasogastric feeding tube while the stent was in place (up to 5 weeks). All patients returned to their preoperative diet. The mean (SD) duration of dysphagia symptoms in all patients (both those without a stent and following stent removal) was 8 (27.2) days (median, 1.5 days). The mean (SD) duration of dysphagia symptoms in patients who did not have a stent placed was 4.8 (5.3) days (median, 4 days). In this study of adults who underwent open airway reconstruction, all returned to their preoperative diet, but those without stents had a shorter duration of dysphagia symptoms than those with stents. Approximately half as many patients with a stent had a prolonged course with dysphagia symptoms compared with those without a stent.

A retrospective study of 512 malignant esophageal strictures treated with covered self-expanding metal stent

Objective To investigate the clinical efficacy of covered self-expanding metal stent in the treatment of malignant esophageal stricture.Methods The clinical data of 512 patients accepted stent were retrospectively analyzed,which included patients' profiles,relief of dysphagia,incidence of complications and survival period.The data were analyzed by t test.Results A total of 596 stents were placed in 512 patients.There was significant difference in mean dysphagia score between before and after stent placement (grade 3.4±0.6 vs grade 1.1±0.8,t=54.09,P＜0.01).After the placement,the overall incidence of complications was 14.5％ (74/512),of which there were 21 cases of severe retrosternal pain (4.1％),16 cases of bleeding (3.1 ％),29 cases of stent displacement (5.7％),six cases of food impaction (1.2％),two cases of fistula without completely blocked (0.4％).The survival period of 238 patients with complete follow-up ranged from 30 to 1445 days,the mean time was 218.9 days.Conclusion Endoscopic covered self-expanding metal stent placement may effectively relieve dysphagia symptoms in patients with malignant esophageal stricture. Key words: Stents; Esophageal neoplasms; Esophageal stenosis; Palliative care; Deglutition disorders

Dysphagia Characteristics in Zenker’s Diverticulum

Objective: To evaluate the presenting signs and symptoms of dysphagia in patients with Zenker’s diverticulum (ZD). Method: All patients surgically treated for ZD over a 6-year period were identified. Charts were reviewed for dysphagia history and findings on fiberoptic endoscopic evaluation of swallowing (FEES). Dysphagia symptoms and swallowing abnormalities were compared across groups based upon diverticulum size (small &lt;1 cm, medium 1-3 cm, and large &gt;3 cm). Results: Forty-one patients were identified. ZD size was available in 39 cases (6 small, 18 medium, 15 large). Regurgitation symptoms were less frequent in patients with small (17%) compared to medium (70%) or large diverticula (73%) ( P &lt; .01). Similarly, esophagopharyngeal reflux (EPR) on FEES was less frequent in patients with small (17%) compared to medium (88%) and large diverticula (92%) ( P &lt; .01). EPR was present in all patients presenting for revision surgery (N = 9). In all cases, EPR resolved after successful treatment. Eighteen percent of all patients had evidence of pharyngeal weakness on FEES which did not change significantly on initial postoperative exam. Conclusion: Dysphagia with EPR is predictive of a ZD larger than 1 cm, and may be useful in preoperative planning. EPR is also helpful in identifying patients with recurrent or residual symptomatic ZD following surgical treatment. Pharyngeal weakness is present in a subset of ZD patients.

A New Therapy for Eosinophilic Esophagitis in Adults

Purpose: Topical steroid therapy such as aerosolized fluticasone has been demonstrated to be an effective treatment of Eosinophilic Esophagitis (EE) but may have oral side effects. We hypothesized that delivery of a budesonide gel specifically formulated to increase the contact time of the gel to the esophageal mucosa will result in a greater reduction in clinical symptoms of dysphagia and less oral side effects. Methods: An oral gel combining budesonide with the mucosal adherent preparation Rincinol (BRG) was compounded. Patients with abnormal Mayo dysphagia questionnaires underwent EGD with biopsies. 16 patients with greater than 15 eos/HPF and solid food dysphagia were enrolled in the study and treated with BRG. Patients were instructed to take BRG 3 mg/10 cc BID. If patients noted marked improvement at one week, they were switched to once daily BRG for 6 weeks; otherwise they were continued on BID BRG for a total of 6 weeks. Dysphagia symptoms and BRG side effects over the last two weeks of treatment were assessed by personal interview. Symptoms were evaluated on a scale of dysphagia resolution: <25%, 25–49%, 50–74%, 75–99% or complete resolution. Those patients, who had previously utilized topical fluticasone for EE, were asked to compare BRG vs topical fluticasone with respect to treatment effect and tolerance. Results: See Table 1 regarding the baseline clinical features of our EE patients. After 6 weeks of BRG therapy, all patients reported at least a 75% improvement in dysphagia symptomatology. 56% (9/16) of patients reported complete dysphagia resolution and 44% (7/16) reported a 75–99% reduction in dysphagia symptoms. Patients who transitioned from BID to once daily BRG noted no increase in dysphagia symptomatology. There was no significant difference in treatment response observed between the dosing regimens (Table 2). With respect to side effects, 13% (2/16) reported hoarseness and 6% (1/16) unpleasant taste. No oral candidiasis was observed with BRG therapy. Of the patients who had previously received fluticasone for treatment of EE, 38% (3/8) felt BRG was more effective, 62% (5/8) had no preference and none preferred fluticasone. When asked about tolerance, 50% (4/8) of patients tolerated both preparations equally, whereas 25% (2/8) favored fluticasone and 25% (2/8) favored budesonide.Table 2: BRG Dosing Regimen and Patient Reported Treatment EffectTable 1: Baseline Clinical Characteristics of Study PatientsConclusion: BRG effectively relieved symptoms of dysphagia in patients with esophageal eosinophilia with minimal side effects in this study. BRG may also be effective in treating EE patients who have previously failed fluticasone. Further studies should be performed to validate these findings.

Concurrent Chemoradiotherapy or Endoscopic Stenting for Advanced Squamous Cell Carcinoma of Esophagus: A Case-Control Study

We evaluated the role of chemoradiotherapy (CRT) for patients with inoperable squamous esophageal cancer. Patients with locally advanced or metastatic squamous esophageal carcinoma who received CRT were recruited. The CRT consists of continuous infusion of 5-fluorouracil at 200 mg/m(2)/day, and cisplatin at 60 mg/m(2) on days 1 and 22, with concurrent radiotherapy for a total of 50 to 60 Gy in 25 to 30 fractions over 6 weeks. Efficacy was assessed by endoscopy and computed tomographic scan before and 8 weeks after completion of the treatment program. Median survival and the need for palliative esophageal stenting were compared with another group of patients who received endoscopic stenting. From 1996 to 2003, a total of 36 consecutive patients (33 male, mean +/- SD age 63.2 +/- 9.5 years) with T4 disease (81%) with or without cervical nodal metastasis (50%) received CRT, while 36 patients treated with endoscopic stenting alone were recruited as controls. Both groups were comparable in demographics, pretreatment dysphagia score, comorbidities, and tumor characteristics. CRT was completed in 32 patients (89%). There was no treatment-related mortality. Tumor volume was greatly reduced after CRT in 19 patients. Four patients (11%) received salvage esophagectomy 9 to 42 months after CRT. Compared with the stenting group, CRT statistically significantly improved 5-year survival (15% vs. 0%, P = .01), median survival (10.8 months vs. 4.0 months, P < .005), and need for stenting (22% vs. 100%, P = .005). Palliative CRT can effectively improve the symptoms of dysphagia in patients with inoperable squamous esophageal carcinoma. It results in better survival compared with endoscopic stenting in these patients.

Critical Evaluation of Esophageal Dilation in Nonobstructive Dysphagia With and Without Esophageal Rings

To evaluate the therapeutic efficacy of esophageal dilation compared with medical treatment in patients with nonobstructive dysphagia (NOD). Clinical studies evaluating the role of esophageal dilation in patients with NOD have reported conflicting results. In addition, studies suggesting beneficial effects of esophageal dilation in this group of patients have not compared it with medical treatment. We conducted a retrospective study in 107 patients with NOD and divided these patients into 2 groups. Group 1 included patients who received esophageal dilation with a polyvinyl bougie along with adjunctive medical treatment, and group 2 included patients who received medical treatment alone. Complete resolution of symptoms occurred in 41 of the 60 patients (68.3%) who received esophageal dilation. In the group that received medical treatment alone (n=47), 28 patients (59.5%) had complete resolution of symptoms. There was no statistically significant difference in symptom resolution between the 2 groups. In addition, among 22 patients with esophageal rings, 17 patients (77%) had complete symptomatic relief with dilation, as compared with 63% patients without esophageal rings. Although there was a trend towards higher frequency of dysphagia resolution with esophageal dilation in patients with NOD and esophageal rings, the difference failed to reach statistical significance. Esophageal dilation and medical therapy are equally efficacious (60% to 70% of cases) in resolving symptoms of dysphagia in patients with NOD. Patients with NOD and esophageal rings may represent the subgroup of patients who are more likely to benefit from esophageal dilation.

Poster 16: Dysphagia Recovery After Initial Diagnosis of Polymyositis: A Case Report

Setting: Rehabilitation hospital. Patient: A 40-year-old man admitted to an acute care hospital with a 1-month history of worsening extremity edema and weakness. Case Description: Workup, including blood chemistries, electromyography, and muscle biopsy, showed findings consistent with polymyositis. The hospital course was significant for severe dysphagia, necessitating gastrostomy-tube placement, and pneumonia. Steroid therapy was initiated. A videofluoroscopic swallow study (VFSS) at the acute care hospital revealed aspiration, and the patient was given nothing by mouth. Assessment/Results: On admission to the rehabilitation hospital, swallowing therapy was initiated including thermal-tactile stimulation, taste stimulation, base of tongue exercises, and laryngeal elevation exercises. Follow-up VFSS 12 days later and after initiation of steroid therapy revealed moderate to severe vallecular residue with solids secondary to reduced pharyngeal constrictor strength and reduced base of tongue retraction; however, there was no evidence of laryngeal penetration or aspiration. Discussion: The patient was advanced to a soft diet with thin liquids. A subsequent VFSS performed 11 days later revealed improved pharyngeal transit with no pharyngeal residue, aspiration, or penetration. The patient was advanced to a regular diet and swallowing therapy was discontinued. Conclusions: Dysphagia secondary to oropharyngeal involvement occurs in about a third of the patients and is a poor prognostic sign. This case report clearly shows the importance of early diagnosis and medical management to restore swallowing ability and improve overall quality of life. Dysphagia symptoms in patients with polymyositis may improve with appropriate medical management and swallowing rehabilitation.

American Gastroenterological Association medical position statement: Clinical use of esophageal manometry

This document presents the official recommendations of the American Gastroenterological Association (AGA) on Clinical Use of Esophageal Manometry. It was approved by the Clinical Practice Committee on October 2, 2004, and by the AGA Governing Board on November 7, 2004. This document presents the official recommendations of the American Gastroenterological Association (AGA) on Clinical Use of Esophageal Manometry. It was approved by the Clinical Practice Committee on October 2, 2004, and by the AGA Governing Board on November 7, 2004. The following recommendations were developed to assist physicians in the appropriate use of esophageal manometry in patient care. These recommendations are an update from previous recommendations published in 1994 and represent the results of meticulous research into areas of controversy from the previous policy statement. In addition, new techniques have evolved that may improve and complement manometric diagnosis. Thus, these recommendations also take into account how these new technologies may alter clinical practice (Table 1).Table 1Summary of the Recommendations for the Clinical Use of Esophageal ManometryManometry indicatedManometry possibly indicatedManometry not indicatedTo establish the diagnosis of dysphagia when obstruction (eg, a stricture) cannot be found. Particularly important if achalasia is suspected.For the preoperative assessment of peristaltic function in patients being considered for antireflux surgery.For making or confirming a suspected diagnosis of gastroesophageal reflux disease.For placement of intraluminal devices (eg, pH probes) when positioning depends on the relationship to functional landmarks, such as the lower esophageal sphincter.For evaluation of dysphagia in patients who have undergone either antireflux surgery or treatment for achalasia.As the initial test for chest pain or other esophageal symptoms because of the low specificity of the findings and the low likelihood of detecting a clinically significant motility disorder.For the preoperative assessment of patients being considered for antireflux surgery if there is any question of an alternative diagnosis, especially achalasia. Open table in a new tab 1Manometry is indicated to establish the diagnosis of dysphagia in instances in which a mechanical obstruction (eg, stricture) cannot be found. This is particularly important if a diagnosis of achalasia is suspected. However, given the low prevalence of achalasia in patients with esophageal symptoms, more common esophageal disorders should be excluded with barium radiographs or endoscopy before manometric evaluation.2Manometric techniques are indicated for placement of intraluminal devices (eg, pH probes) when positioning is dependent on the relationship to functional landmarks, such as the lower esophageal sphincter.3Manometry is indicated for the preoperative assessment of patients being considered for antireflux surgery if there is any question of an alternative diagnosis, especially achalasia. 1Manometry is possibly indicated for the preoperative assessment of peristaltic function in patients being considered for antireflux surgery.2Manometry is possibly indicated to assess symptoms of dysphagia in patients who have undergone either antireflux surgery or treatment for achalasia. 1Manometry is not indicated for making or confirming a suspected diagnosis of gastroesophageal reflux disease.2Manometry should not be routinely used as the initial test for chest pain or other esophageal symptoms because of the low specificity of the findings and the low likelihood of detecting a clinically significant motility disorder.

Dysphagia occurring after polio

Although they are delayed, progressive symptoms occurring after polio have recently received considerable attention, dysphagia in patients who have had polio has not been well-studied. The findings of historical, neurologic, and cineradiographic examinations in 13 patients with dysphagia who had had polio are presented. Historical evidence indicates that progressive dysphagia is among the worsening problems encountered by some patients several decades after their acute polio illness. Thorough evaluation of dysphagia symptoms in patients who have had polio is indicated to determine optimal feeding management and to search for treatable contributing factors.