Laryngeal Vestibule Research Articles

Establishing a method for quantifying spinal curvature during videofluoroscopic swallow studies: Applying the modified Cobb angle to healthy young and older adults.

The Cobb angle is traditionally used for quantifying the degree of spinal curvature through evaluation of the full spinal cord. When conducting measurements on videofluoroscopy swallowing studies (VFSS), the Cobb angle can measure degree of cervical vertebrae curvature, which may have implications for swallowing. Given that this measure may have utility in dysphagia research, the reliability of this measure taken from C2-C4 and establishing the presence of changes with age were the focus of the current, proof-of-principle study. VFSS from 19 healthy young adults and 39 healthy older adults were retrospectively analyzed. The C2-C4 Cobb angle was measured between cervical vertebrae two and four on frames of laryngeal vestibule closure (LVC) and post-swallow rest. Results revealed excellent levels of inter- and intra-rater reliability for frame of post-swallow rest (ICCs = 0.788 and 0.793), and fair to good levels of agreement for frame of LVC (ICCs = 0.667 and 0.621). Significant differences in the C2-C4 Cobb angle were found between the healthy young and old data (p < 0.01). Healthy younger adults had a mean angle of 5.8±9.0 degrees at LVC and 7.7±4.5 degrees at swallow rest, whereas healthy older adults had a mean angle of 12.5±9.0 degrees at LVC and 12.4±9.7 degrees at rest. Consistent with the existing spine literature, the curvature of cervical vertebrae appears to increase with age. With established reliability, we propose that the C2-C4 Cobb angle may be used to determine the degree of spinal curvature in a variety of patient populations in order to determine impacts on swallowing function.

Objective measurement of acoustic intensity of coughing for clearance of penetration and aspiration on video-fluoroscopy

Purpose This preliminary, exploratory study evaluated the acoustic intensity of effective and ineffective clearance of penetrated and aspirated material from the laryngeal vestibule in patients with dysphagia. Method A lapel microphone was attached anterior to participants’ tragus and recorded coughing in decibels during their videofluoroscopic swallowing studies (VFSS). Result Eighty-eight patients were recruited. Thirteen patients, with visible airway invasion and coughing were included in the final analysis. No coughs were effective at expelling aspirated material from the airway (n = 10). Both effective (4/7) and ineffective (3/7) coughing to penetration were recorded. The mean acoustic intensity of effective coughing to penetration was –44.0 dBFS (decibel level relative to full scale) [SD = 7.3, 95% CI = −51.14, −36.86], and ineffective coughing to penetration was only marginally lower at –42.9 dBFS [SD = 2.0, 95% CI = −45.21, −40.59]. Conclusion No coughs were effective at expelling aspirated material from the airway. Some coughs effectively expelled penetrated material from the airway. However, the relationship between acoustic intensity and cough effectiveness is unclear due to the limited number of observations. Given that perceptual evaluation of coughing is widely used in dysphagia clinical practice to determine cough effectiveness, this is an important area for future research.

Predicting Airway Invasion Using Screening Tools and Laryngeal Kinematics in People with Parkinson’s Disease: A Pilot Study

Background:Dysphagia in Parkinson’s disease (PD) is a common manifestation, particularly in advanced disease stages. However, the pathophysiology and time course of dysphagia progression remains unclear in non-advanced disease stages (e.g., Hoehn & Yahr stages I–III). Conflicting reports from investigations of the perception of dysphagia in people with PD further complicates our understanding of dysphagia in this population.Objective:The objectives of this research were to evaluate the ability of screening tools to detect swallowing impairments and how laryngeal kinematics predict the occurrence of abnormal swallowing events.Methods:14 individuals with non-advanced PD, no previous history of dysphagia diagnosis, and self-reported difficulty swallowing participated. The Swallow Disturbance Questionnaire (SDQ) and 3-oz water swallow test (WSST) were administered, along with a videoflouroscopic swallow study (VFSS). Laryngeal kinematics were represented by laryngeal vestibule closure reaction time (LVrt) and laryngeal vestibule closure duration (LVCd). The Penetration-Aspiration Scale (PAS) was used to quantify airway invasion.Results:A logistic regression indicated a significant model of predicting airway invasion from our predictors (p = 0.003). LVrt and SDQ (p < 0.05) provided the largest impact (OR = 1.11; 1.17). The WSST showed no significance in predicting swallow impairment (p > 0.05).Conclusion:Decreased airway safety related to laryngeal kinematic function in PD may be manifesting at non-advanced disease stages to varied degrees. Our results support expectations of dysphagia manifestation in PD although screening practices may not adequately identify impairment. Future research should target specific laryngeal characteristics within this population to better understand the physiological cause of swallowing impairment and developof targeted interventions.

Oropharyngeal dysphagia increased the risk of pneumonia in patients undergoing nasogastric tube feeding

Aspiration pneumonia is a major cause of death in patients on nasogastric tube (NGT) feeding. This study aimed to evaluate the oropharyngeal dysphagia and stratify risk of pneumonia in patients undergoing NGT feeding. The study included patients on NGT feeding who underwent UGI endoscopy at Tri-Service General Hospital, Taiwan. Endoscopy was performed to examine the pharyngolaryngeal region. The severity of oropharyngeal dysphagia was evaluated according to the visualized amount and location of pooling of secretions in the pharyngolaryngeal region; 60 patients showed absent or minimal amount of secretions (control group), 14 patients showed moderate-to-large amounts of secretions filling the pyriform sinus (pharyngeal group), and 27 patients showed secretions entering the laryngeal vestibule (laryngeal group). Demographic data and occurrence of pneumonia were analyzed. The incidence of pneumonia was highest in the pharyngeal group (4.2±3.6 episodes/person-years), followed by the laryngeal (2.6±2.2 episodes/ person-years) and control groups (1.7±3.8 episodes/person-years) (p=0.042). Multivariable regression showed significantly higher risk of pneumonia in the pharyngeal (adjusted odds ratio=2.7, 95% CI, 2.4-2.8, p<0.001) and laryngeal (adjusted odds ratio=2.0, 95% CI, 1.7-2.4, p<0.001) groups. The cumulative incidence rate of pneumonia was significantly higher in the laryngeal and pharyngeal groups than in the control group (log rank test, p<0.001). Endoscopic pharyngolaryngeal observation can evaluate the oropharyngeal dysphagia. Visual evidence of oropharyngeal dysphagia increase the risk of pneumonia in patients on NGT feeding.

Dysphagia in Myositis: A Study of the Structural and Physiologic Changes Resulting in Disordered Swallowing.

Dysphagia in patients with myositis is associated with an increased risk of aspiration pneumonia. However, the pathophysiology of dysphagia is poorly understood. The aim of this study was to understand how myositis affects swallowing physiology on videofluoroscopic swallow study. This is a retrospective review of video fluoroscopic swallowing studies on 23 myositis patients with dysphagia from 2011 to 2016. Swallow studies were analyzed by timing of swallowing events and duration of swallowing events, diameter of upper esophageal sphincter opening, Modified Barium Swallow Impairment Profile, and Penetration-Aspiration Scale. The outcome measures for patients were compared with an archived videofluoroscopic swallow study from healthy, age-matched participants by Wilcoxon rank-sum tests. Patients with myositis had a shorter duration of upper esophageal sphincter opening (P < 0.0001) and laryngeal vestibule closure (P < 0.0001) than healthy subjects. The diameter of upper esophageal sphincter opening did not differ between groups. Patients with myositis presented with higher scores on the MBSIMP than healthy subjects, indicating great impairment particularly during the pharyngeal phase of swallowing, and a higher frequency of penetration and aspiration. Dysphagia in patients with myositis may be attributed to reduced endurance of swallowing musculature rather than mechanical obstruction of the upper esophageal sphincter.

A Cross-Sectional, Quantitative Videofluoroscopic Analysis of Swallowing Physiology and Function in Individuals With Amyotrophic Lateral Sclerosis.

PurposeTo date, research characterizing swallowing changes in individuals with amyotrophic lateral sclerosis (ALS) has primarily relied on subjective descriptions. Thus, the degree to which swallowing physiology is altered in ALS, and relationships between such alterations and swallow safety and/or efficiency are not well characterized. This study provides a quantitative representation of swallow physiology, safety, and efficiency in a sample of individuals with ALS, to estimate the degree of difference in comparison to published healthy reference data and identify parameters that pose risk to swallow safety and efficiency. Secondary analyses explored the therapeutic effect of thickened liquids on swallowing safety and efficiency.MethodNineteen adults with a diagnosis of probable-definite ALS (El-Escorial Criteria–Revised) underwent a videofluoroscopic swallowing study, involving up to 15 sips of barium liquid (20% w/v), ranging in thickness from thin to extremely thick. Blinded frame-by-frame videofluoroscopy analysis yielded the following measures: Penetration–Aspiration Scale, number of swallows per bolus, amount of pharyngeal residue, degree of laryngeal vestibule closure (LVC), time-to-LVC, duration of LVC (LVCdur), pharyngeal area at maximum constriction, diameter of upper esophageal sphincter opening, and duration of UES opening (UESOdur). Measures of swallow physiology obtained from thin liquid trials were compared against published healthy reference data using unpaired t tests, chi-squared tests, and Cohen’s d effect sizes (adjusted p < .008). Preliminary relationships between parameters of swallowing physiology, safety, and efficiency were explored using nonparametric Cochrane’s Q, Friedman’s test, and generalized estimating equations (p < .05).ResultsCompared to healthy reference data, this sample of individuals with ALS displayed a higher proportion of swallows with partial or incomplete LVC (24% vs. < 1%), increased time-to-LVC (d = 1.09), reduced UESwidth (d = 0.59), enlarged pharyngeal area at maximum constriction, prolonged LVCdur (d = 0.64), and prolonged UESOdur (d = 1.34). Unsafe swallowing (i.e., PAS ≥ 3) occurred more frequently when LVC was partial/incomplete or time-to-LVC was prolonged. Pharyngeal residue was associated with larger pharyngeal areas at maximum constriction. Unsafe swallowing occurred less frequently with extremely thick liquids, compared to thin liquids. No significant differences in pharyngeal residue were observed based on liquid thickness.ConclusionsQuantitative videofluoroscopic measurements revealed moderate-to-large differences in swallow physiology between this sample of individuals with ALS and healthy reference data. Increased time-to-LVC, noncomplete LVC, and enlarged pharyngeal area at maximum constriction were associated with impaired swallow safety or efficiency. Thickened liquids may mitigate the risk of acute episodes of aspiration in individuals with ALS. Further work is needed to corroborate these preliminary findings and explore how swallowing profiles evolve throughout disease progression.

The Superior Laryngeal Nerve and its Vulnerability in Surgeries of the Neck

Knowledge of anatomical considerations of the superior laryngeal nerve, a branch of the vagus, provides information to prevent intraoperative injuries and associated dysfunctions. The superior laryngeal nerve has external and internal branches providing motor innervation to the cricothyroid muscle and sensory innervation to the supraglottic mucosa of the larynx, respectively. The external laryngeal branch travels for a relatively greater distance together with the superior thyroid artery and the internal laryngeal branch accompanies, for a shorter distance, the superior laryngeal artery, though their relationship with their respective artery varies. Isolation and identification of the superior pole and superior laryngeal vessels, which are intimately related to the external and internal laryngeal branches, respectively, is clinically important. Both branches can potentially be severed, compressed, or stretched during surgical procedures of the neck such as thyroidectomy and anterior cervical discectomy. Injury to the external laryngeal nerve results in a reduction in the highest attainable frequency of the voice, while injury to the internal laryngeal nerve results in a loss of sensation in the laryngeal vestibule, increasing the risk of aspiration pneumonia. The consequences of superior laryngeal nerve injury are variable in growing literature and are commonly disregarded compared to the recurrent laryngeal nerve. The present study aims to assess the anatomical considerations of the superior laryngeal nerve pertaining to its course and relationship to the superior thyroid and superior laryngeal arteries. The study was done on 35 formalin‐fixed cadavers at Oakland University William Beaumont School of Medicine in 2018–2020. Following critical observation and careful dissection, photographs were taken and the data was analyzed quantitatively and in a descriptive manner. In our investigation, we found that out of twenty‐one cadavers, 52.4% of the external laryngeal branches are related posteromedial to the superior thyroid artery, while 47.6% are related anteromedial to it. On the other hand, our findings indicate that out of fourteen cadavers, 64.3% of the internal laryngeal branches are related superoposterior to the superior laryngeal artery, while 35.7% are inferoposterior to it. In addition, in most cases, the superior laryngeal artery crosses above the external laryngeal branch while traveling to pierce the thyrohyoid membrane to reach the larynx. The data portrays that both the external and internal laryngeal branches display a variation in their relationship with the superior thyroid artery and the superior laryngeal artery. The findings show a clinically important variation in the course and relationship of the superior laryngeal nerve and its related vessels, especially the posteromedial and superoposterior relationships, which exposes the nerves during ligation of the respective vessels. Awareness of these variable relationships is critical for identification and isolation of the neurovascular structures in order to preserve the nerve, prevent a reduction in the highest attainable frequency of the voice, and minimize the risk of aspiration pneumonia during surgical procedures of the neck.

A randomized clinical trial on the acute therapeutic effect of TRPA1 and TRPM8 agonists in patients with oropharyngeal dysphagia.

Oropharyngeal dysphagia (OD) treatment is moving away from compensatory strategies toward active treatments that improve swallowing function. The aim of this study was to assess the acute therapeutic effect of TRPA1/M8 agonists in improving swallowing function in OD patients. Fifty-eight patients with OD caused by aging, stroke, or neurodegenerative disease were included in a three-arm, quadruple-blind, randomized clinical trial (NCT02193438). Swallowing safety and efficacy and the kinematics of the swallow response were assessed by videofluoroscopy (VFS) during the swallow of 182±2mPa·s viscosity (nectar) boluses of a xanthan gum thickener supplemented with (a) 756.6μmol/L cinnamaldehyde and 70μmol/L zinc (CIN-Zn) (TRPA1 agonists), (b) 1.6mmol/L citral (CIT) (TRPA1 agonist), or (c) 1.6mmol/L citral and 1.3mmol/L isopulegol (CIT-ISO) (TRPA1 and TRPM8 agonists). The effects on pharyngeal event-related potentials (ERP) were assessed by electroencephalography. TRPA1 stimulation with either CIN-Zn or CIT reduced time to laryngeal vestibule closure (CIN-Zn P=.002, CIT P=.023) and upper esophageal sphincter opening (CIN-Zn P=.007, CIT P=.035). In addition, CIN-Zn reduced the penetration-aspiration scale score (P=.009), increased the prevalence of safe swallows (P=.041), and reduced the latency of the P2 peak of the ERP. CIT-ISO had no positive effect on biomechanics or neurophysiology. No significant adverse events were observed. TRPA1 stimulation with CIN-Zn or CIT improves the swallow response which, in the case of CIN-Zn, is associated with a significant improvement in cortical activation and safety of swallow. These results provide the basis for the development of new active treatments for OD using TRPA1 agonists.

Laryngeal and soft palate valving in the harbour seal (Phoca vitulina).

Effective 'valving' in the upper aerodigestive tract (UAT) is essential to temporarily separate the digestive and respiratory pathways. Marine mammals are largely dedicated to feeding underwater, and in many cases swallowing prey whole. In seals, little work has been done to explore the anatomy and function of the UAT in the context of valving mechanisms that function to separate food and air pathways. Here we use videofluoroscopy, gross dissection, histology and computed tomography (CT) renderings to explore the anatomy of the larynx and soft palate in the harbour seal (Phoca vitulina), and generate models for how valving mechanisms in the head and neck may function during breathing, phonating, diving and swallowing. Harbour seals have an elevated larynx and the epiglottis may rise above the level of the soft palate, particularly in pups when sucking. In addition, the corniculate and arytenoid cartilages with associated muscles form most of the lateral margins of the laryngeal inlet and vestibule, and move independently to facilitate airway closure. The corniculate cartilages flex over the laryngeal inlet beneath the epiglottis to completely close the laryngeal vestibule and inlet. The vocal folds are thick and muscular and the medial margin of the folds contains a small vocal ligament. The soft palate has well-defined levator veli palatini muscles that probably function to elevate the palate and close the pharyngeal isthmus during feeding. Our results support the conclusion that harbour seals have evolved UAT valving mechanisms as adaptations to a marine environment that are not seen in terrestrial carnivores.

Physiological Compensation for Advanced Bolus Location at Swallow Onset: A Retrospective Analysis in Healthy Seniors.

Purpose Previous work has established that advanced bolus location at swallow onset (BLSO) alone is not correlated with an increased swallowing safety risk in healthy seniors. The primary goal of this retrospective study was to examine whether healthy seniors systematically alter their laryngeal vestibule closure reaction time (LVCrt) to maintain a safe swallow in the context of advanced BLSO. The secondary goal was to determine if longer LVCrt distinguished Penetration-Aspiration Scale (PAS; Rosenbek, Robbins, Roecker, Coyle, & Wood, 1996) scores of 1 versus 2. Method Videofluoroscopy studies from 43 healthy seniors (21 men, 22 women; M age = 76.7 years, SD = 7.2) were analyzed. LVCrt was calculated for 3 × 5 ml and 3 × 20 ml thin liquid barium boluses per participant. PAS and BLSO (Modified Barium Swallow Impairment Profile Component 6) were scored for all swallows. Reliability (intraclass correlation coefficient > .75) was established on all measures. A linear mixed-effects regression was run to examine the effect of PAS and BLSO on LVCrt while controlling for bolus volume and repeated swallow trial. Results There was a main effect of BLSO (F = 4.6, p = .004) and PAS (F = 29.3, p < .001) on LVCrt. Post hoc pairwise comparisons revealed that LVCrt was significantly faster in BLSO scores of 3 (pyriforms) compared to scores of both 0 (posterior angle of the ramus) and 1 (valleculae). Significantly prolonged LVCrt was observed in PAS scores of 2 in comparison to 1. No significant main effects of bolus volume or trial, or interactions, were observed. Conclusions Our findings suggest that healthy seniors compensate for advanced BLSO by increasing their LVCrt. Furthermore, faster LVCrt was shown to distinguish PAS scores of 1 versus 2. Additional work should explore the relationship between LVCrt, BLSO, and PAS scores in dysphagic populations, specifically those with known sensory impairments.

Dysphagia in Progressive Supranuclear Palsy.

Progressive supranuclear palsy (PSP) is the most common Parkinson-Plus syndrome and is associated with early onset of dysphagia relative to Parkinson Disease. The current study contributes to the growing understanding of swallowing dysfunction in PSP by describing oropharyngeal swallowing characteristics in a large prospective cohort of participants with PSP employing a nationally standardized videofluoroscopy protocol and a disease severity scale developed expressly for PSP. Participants were 51 adults diagnosed with PSP. Each participant underwent a clinical interview and standardized videofluorographic assessment. Swallowing function was characterized with the Modified Barium Swallow Impairment Scale (MBSImP) and Penetration-Aspiration Scale (PAS). Variables of interest were participant-reported difficulties with liquids and/or solids; overall impression score for each of the 17 individual MBSImP components, as well as Oral Total Sum and Pharyngeal Total Sum; and PAS. Data were described with median interquartile range, counts, and proportions. Spearman's rank correlations were calculated between MBSImP scores and participant-reported indices, FOIS, and PSP Rating Scale. Approximately two-thirds of participants reported difficulties with liquids, solids, or both, although fewer than 15% reported modifying consistencies. Videofluorographic findings included predominant oral phase impairments, including back and forth rocking motion of the tongue, delayed initiation of the pharyngeal swallow, and oral residue. Pharyngeal phase impairments were relatively infrequent and comparatively mild, with the exception of reduced tongue base retraction contributing to pharyngeal residue, and mildly disrupted laryngeal vestibule closure. Disease severity correlated significantly with oral (r = .0.42, p = .0.002) and pharyngeal (r = 0.41, p = .0.003) total sum scores as well as with the oral phase components of oral transport (r = .0.33, p = .0.02) and initiation of the pharyngeal swallow (r = .0.38, p = .0.007), and PAS for thin liquids (r = .0.44, p = .0.001). The PSP Rating Scale was not more strongly correlated with swallowing impairment than has been reported for other disease severity rating scales. Dysphagia is a common complaint of patients with PSP. The current findings corroborate and expand upon those reported in the literature, detailing relatively more frequent and more severe oral phase impairments and relatively spared hyolaryngeal excursion. Further research is needed to characterize the progression of dysphagia in PSP and to determine whether dysphagia varies in character or in rate of progression across variants of PSP.

Impaired Movement Scaling and Reduced Synchrony with Vestibule Closure Characterize Swallowing in Severe Dysphagia.

The contribution of hyoid and laryngeal movement deficits to penetration or aspiration in dysphagia is unclear, partly due to large variations in normal hyolaryngeal kinematics for swallowing. In healthy volunteers, laryngeal and hyoid kinematics relate to the requirements for laryngeal vestibule closure suggesting a central schematic control of movement magnitude and patterning for airway protection. Our first aim was to determine if patients with severe dysphagia showed evidence of an impaired swallowing schema, by examining if their kinematic measures were related to their hyolaryngeal space before swallow onset, and if hyolaryngeal movement synchrony for vestibule closure was disrupted. Our second aim was to determine the kinematic measures that predicted bolus penetration and aspiration in dysphagia. The methods included two-dimensional measures of the hyoid and laryngeal anterior and superior displacement and velocity, and the change in laryngeal vestibule area made from videofluoroscopic swallow recordings of 21 healthy volunteers and 21 patients with dysphagia on tube feeding secondary to the stroke or head and neck cancer. The results demonstrated that the patients did not adapt their hyolaryngeal movements during swallowing to their initial hyolaryngeal space. Further, none of the patients' measures of hyoid or laryngeal peak velocity timing were synchronized with vestibule closure, demonstrating a disorganized movement patterning. Laryngeal elevation peak velocity independently predicted penetration and aspiration. In conclusion, the central schema for swallowing patterning was disturbed, impairing the integration of kinematic actions for airway protection in severe dysphagia, while laryngeal peak elevation velocity predicted penetration and aspiration on patient swallows.

Validation of the Normalized Laryngeal Constriction Ratio in Normal and Disordered Swallowing.

The timing of laryngeal vestibule closure (LVC) is important for airway protection during swallowing. However, it is unknown whether the extent of LVC contributes to airway protection. The goal of this study is to validate the extent of LVC via a measure called laryngeal constriction ratio (LCR). A retrospective analysis of videofluoroscopic swallows was conducted on 38 stroke participants and 40 healthy controls. The LCR was calculated by deriving a size-normalized area of airspace from a 1) maximum closed laryngeal vestibule and a 2) maximum open laryngeal airspace (at rest). Airway invasion severity was derived via the Penetration-Aspiration Scale score. Six hundred forty-nine videofluoroscopic swallows were analyzed. A mixed model analysis revealed a statistically significant mean difference between the normalized laryngeal constriction ratios of healthy individuals (mean (m) = 0.003) versus older dysphagic patients (m = .026) (P = 0.001), quantifying less closure in older patients with dysphagia. Additionally, swallows with airway compromise had a statistically worse LCR when compared to swallows without airway compromise (P = 0.001). The normalized LCR might be a valid fluoroscopic surrogate measure for LVC and, furthermore, airway compromise during swallowing. By investigating spatial measurements in the laryngeal vestibule during safe and unsafe swallows, the LCR provides a direction for further research to allow for critical examination of the physiology relating to closure degree in order to precisely detect and treat abnormalities during swallowing. 4 Laryngoscope, 130:E190-E198, 2020.

Evaluation of swallowing function in patients with oropharyngeal secretions.

BackgroundSeveral studies have reported a strong association between the presence of oropharyngeal secretions in the laryngeal vestibule and the likelihood of aspiration of food or liquid. However, no previous studies have evaluated the accumulation of saliva and swallowing dynamics.ObjectiveThe objective of this study was to examine the factors related to decreased function that result in saliva accumulation based on images from videofluoroscopic examination of swallowing (VF) performed on the same day as videoendoscopic examination of swallowing (VE).MethodsThis retrospective study investigated 47 patients with dysphagia who underwent VF and VE on the same day. Saliva accumulation in the pharynx was assessed on VE and classified by the Murray secretion scale. Pharyngeal residue was assessed on VF. In addition, displacement of the hyoid bone and larynx on swallowing and the opening size of the esophageal orifice were measured, and contact between the base of the tongue and the posterior pharyngeal wall was examined on VF.ResultsModerate correlations were found between saliva accumulation and perpendicular displacement of the larynx and upper esophageal sphincter opening. The percentage of patients showing contact between the base of the tongue and the posterior pharyngeal wall was significantly greater in those with a saliva accumulation score of 0 or 1.ConclusionLess laryngeal elevation and upper esophageal sphincter opening and absence of contact between the base of the tongue and the posterior pharyngeal wall when swallowing tended to result in accumulation of saliva in the pharynx.

Glottal Closure in Women with No Voice Complaints or Laryngeal Disorders.

Introduction The understanding of normal vocal production is essential to guide any voice professional as it is fundamental to understand the effects of the posterior glottal gap on the vocal quality. Objective The aim of the present study was to verify the association between glottic closure, acoustic parameters, and some characteristics of the videolaryngostroboscopy of young women without vocal complaints nor laryngeal disorders. Methods This is a cross-sectional study with 56 women between 20 and 30 years old who underwent videolaryngostroboscopy. The acoustic parameters of the vowel /a:/ were analyzed using the Praat software, Release 4.6.10 (Paul Boersman and David Weenik, Amsterdam, Netherlands). Statistical Analysis The chi-squared, Fischer, and Kruskall-Wallis tests were applied, with 5% significance. Results Significant occurrence of posterior glottal gap (85.71%, p < 0.001), of normal vocal folds vibration amplitude (82.14%, p < 0.001), and of absence of significant constriction of the laryngeal vestibule (98.21%, p < 0.001); no significant association of the glottic closure with the vocal acoustic parameters; no significant association of glottic closure, vocal folds vibration amplitude, and constriction of the laryngeal vestibule. Conclusion There was a predominance of posterior glottal gap, normal vocal folds vibration amplitude, and absence of laryngeal vestibule constriction, and no relation with the acoustic parameters, suggesting that the posterior glottal gap did not generate impact on the vocal production of the young adult women studied.

Reference Values for Healthy Swallowing Across the Range From Thin to Extremely Thick Liquids.

PurposeThickened liquids are frequently used as an intervention for dysphagia, but gaps persist in our understanding of variations in swallowing behavior based on incremental thickening of liquids. The goal of this study was to establish reference values for measures of bolus flow and swallowing physiology in healthy adults across the continuum from thin to extremely thick liquids.MethodA sex-balanced sample of 38 healthy adults underwent videofluoroscopy and swallowed 20% weight-to-volume concentration barium prepared in thin and slightly, mildly, moderately, and extremely thick consistencies using a xanthan gum thickener. Participants took comfortable sips and swallowed without a cue; sip volume was measured based on presip and postsip cup weights. A standard operating procedure (the ASPEKT method: Analysis of Swallowing Physiology: Events, Kinematics and Timing) was used to analyze videofluoroscopy recordings.ResultsThe results clarify that, for thin liquid sips (10–14 ml), a single swallow without clearing swallows is typical and is characterized by complete laryngeal vestibule closure, complete pharyngeal constriction, and minimal postswallow residue. Aspiration was not seen, and penetration was extremely rare. Bolus position at swallow onset was variable, extending as low as the pyriform sinuses in 37% of cases. With thicker liquids, no changes in event sequencing, laryngeal vestibule closure, pharyngeal constriction, or postswallow residue were seen. The odds of penetration were significantly reduced. A longer timing interval until onset of the hyoid burst movement was seen, with an associated higher bolus position at swallow onset. Other timing measures remained unaffected by changes in bolus consistency.ConclusionThe results include new reference data for swallowing in healthy adults across the range from thin to extremely thick liquids.

Evaluation of Oropharyngeal Dysphagia in Patients Who Underwent Percutaneous Endoscopic Gastrostomy: Stratification Risk of Pneumonia.

Aspiration pneumonia is the most common cause of death in patients who undergo percutaneous endoscopic gastrostomy (PEG). This study aims to evaluate the severity of oropharyngeal dysphagia and predict the risk of pneumonia in such patients, using upper gastrointestinal endoscopy. Endoscope examined the pharyngolaryngeal region in patients who underwent PEG. The severity of oropharyngeal dysphagia was evaluated according to the amount and location of pooling of secretions in the pharyngolaryngeal region. Overall, 55 patients showed absent or minimal amount of secretions (control group), 10 patients showed moderate-to-large amounts of secretions filling the pyriform sinus (pharyngeal group), and 23 patients showed secretions entering the laryngeal vestibule (laryngeal group). Demographic data, swallowing level scale, and occurrence of pneumonia were recorded. The incidence of pneumonia was the highest in the pharyngeal group (70.0%), followed by that in the laryngeal (60.9%) and control groups (30.9%; P=0.010). Multivariable regression showed that risk of pneumonia was significantly higher in the pharyngeal and laryngeal groups. Cumulative incidence rate of pneumonia was significantly higher in the laryngeal and pharyngeal groups than in the control group (log-rank test, P=0.001). Mortality rate was significantly higher in patients with suboptimal protective cough reflex than in others (50.0% vs 5.9%, P=0.034). Accumulation of abnormal amounts of secretions in the pyriform sinus or in the laryngeal vestibule increased the risk of the hospital admission following pneumonia in patients who underwent PEG. The mortality rate was higher in patients with suboptimal protective cough reflex.

Neurophysiological and Biomechanical Evaluation of the Mechanisms Which Impair Safety of Swallow in Chronic Post-stroke Patients.

Oropharyngeal dysphagia (OD) is a common post-stroke complication and is associated with respiratory infections. The aim was to assess the biomechanical impairments in swallow function and the afferent and efferent swallowing pathways impairing swallow safety in chronic post-stroke patients. We studied 30 patients with unilateral stroke and chronic OD (> 3months from stroke onset) with impaired safety of swallow (Penetration-Aspiration Scale [PAS] ≥ 2). We evaluated the efficacy, safety, and kinematics of the swallow response (residue, PAS, laryngeal vestibule closure time [LVCT]) with videofluoroscopy, sensory evoked potentials to pharyngeal electrical stimulation (pSEP), and pharyngeal motor evoked potentials (pMEP) to transcranial magnetic stimulation of both hemispheres. Mean age of patients was 70.1 ± 10.9years (7 women). Stroke severity at onset was moderate (NIHSS median 10 [IQ range 3-11.5]), and modified Rankin Scale 2.8 ± 1.3. Mean PAS was 5.1 ± 1.9; prevalence of delayed LVCT was 86.7% and 30% presented aspirations. Pharyngeal hypoesthesia was present in 46.7% of patients and 92.3% showed abnormally asymmetrical pSEPs when comparing the ipsilesional with the contralesional hemisphere. Increased duration of swallow was associated with lower pSEP amplitude (P1-N2) in the contralesional hemisphere (p= 0.033). Patients with right hemispheric strokes showed greater reduction of pSEPs amplitude (N1-P1, p = 0.049). In contrast, pharyngeal resting motor threshold and pMEPs were symmetric in 73.3% patients without the physiologic hemispheric dominance. Mild-to-moderate disabled chronic post-stroke patients with OD presented severe impaired biomechanics of swallow response and high prevalence of aspirations. Initial results from the neurophysiological evaluation demonstrated prevalent impairments with disrupted integration of pharyngeal sensory inputs and reduced cortical excitability of efferent pathways. Patients with right hemispheric strokes showed poorer neurophysiological responses.

Swallow Screen Associated With Airway Protection and Dysphagia After Acute Stroke

ObjectiveThe goal was to examine the outcomes of an existing swallow screen protocol in comparison to results from a formal videofluoroscopic protocol. DesignProspective cohort study. SettingAcute hospital. ParticipantsPatients after acute stroke (N=48). InterventionsNot applicable. Main Outcome MeasuresThe Johns Hopkins Hospital Brain Rescue Unit 3 oz Swallow Screen was implemented by nursing staff upon admission. Videofluoroscopy was conducted within 72 hours of diagnostic neuroimaging and initial swallow screen. Predictive values of the bedside swallow screen (pass/fail) for clinical judgment of dysphagia on videofluoroscopy (presence/absence) were calculated. Overall impairment scores from the Modified Barium Swallowing Impairment Profile were analyzed with respect to swallow screen results. ResultsThirteen participants failed the swallow screen, and 35 passed. Of the 35 patients who passed the swallow screen, 15 were clinically diagnosed with dysphagia on videofluoroscopy. Although pass/fail of the swallow screen was not a significant predictor of presence/absence of dysphagia, a logistic regression model including components of Laryngeal Elevation, Laryngeal Vestibule Closure, and Anterior Hyoid Excursion, and sex was statistically significant for swallow screen outcome. ConclusionThe results of this study suggest that a swallow screen of aspiration risk can identify patients with the most need for videofluoroscopic evaluation and dysphagia management. Additionally, patients who fail a swallow screen are more likely to present with physiologic impairments related to airway protection on videofluoroscopy.

Acute and subacute effects of oropharyngeal sensory stimulation with TRPV1 agonists in older patients with oropharyngeal dysphagia: a biomechanical and neurophysiological randomized pilot study.

Background:Older people with oropharyngeal dysphagia (OD) present a decline in pharyngeal sensory function. The aim of this proof-of-concept study was to assess the biomechanical and neurophysiological effects of acute and subacute oropharyngeal sensory stimulation with transient receptor potential vanilloid 1 (TRPV1) agonists (capsaicinoids) in older patients with OD.Methods:We studied the effect of a single dose versus multiple doses (2 weeks) of oral capsaicin treatment (10–5 M) or placebo in 28 older patients with OD (81.2 ± 4.6 years) using videofluoroscopy (penetration-aspiration scale [PAS], timing of swallow response) and electroencephalography (EEG) (latency and amplitude of pharyngeal event-related potential [ERP]).Results:Acute stimulation by capsaicinoids 10–5 M did not improve swallow function and did not produce significant changes in pharyngeal ERP. In contrast, after 10 days of treatment, patients presented a clinically relevant and statistically significant reduction in the laryngeal vestibule closure (LVC) time (22.5%, p = 0.042), and in the PAS (24.2%, p = 0.038), compared with the placebo group. EEG results showed a reduction in the latency of the N1 peak (28.6%, p = 0.007) and an increase of the amplitude of the P1-N2 (59.4%, p = 0.038) and the N2-P2 (43.6%, p = 0.050) peaks. We observed a strong and significant correlation between the reduction in the latency of the N1 peak and change in LVC time after subacute treatment (r = 0.750, p = 0.003).Conclusions:After 2 weeks of treatment, oropharyngeal sensory stimulation with capsaicinoids induced cortical changes that were correlated with improvements in swallowing biomechanics in older patients with OD. These results further show that sensory stimulation by TRPV1 agonists can become a useful pharmacological treatment for older patients with OD.