Oropharyngeal Phase Research Articles

Clinical Diagnosis of Esophageal Dysphagia Using Transnasal Esophagoscopy: A Case Report.

The aim of the present study was three folds; (i) to correlate clinical case history with objective findings of a client presented with sternal discomfort along with odynophagia; (ii) to evaluate the cause for retrosternal discomfort using Functional Esophagoscopy (FE); and (iii) to reaffirm the Cook's (2008) algorithm for clinical diagnosis of esophageal dysphagia in single sitting using Transnasal Esophagoscopy (TNE). A 72 years old male (named 'G') visited a tertiary health care hospital with a complaint of imbalance for past 2 months. Also, had a complaint of pain while swallowing for the past 15 days along with left arm weakness (for past 2 days) and got admitted for treatment. Pertaining to swallowing, a detailed case history was taken and Fiber-optic endoscopic evaluation of swallowing (FEES) was performed to evaluate swallowing safety functions using digital swallowing workstation (KAYPENTAX, New Jersy, USA). A large growth was noticed in the lower border of esophagous using TNE in this patient. The oral, oro-pharyngeal, and pharyngeal phase of swallowing was intact. Esophageal phase of swallowing revealed reduced peristaltic movement including a mass lesion observed in client 'G' from TNE procedure. Clinical correlation of objective findings in this client corroborated well with history. Visualization studies including TNE can be used safely, comfortably in OPD basis without any anesthesia would be few advantages of TNE procedure. Even lesions at lower end of esophagus can be detected using TNE and it is concluded that the symptom retro-sternal discomfort might be clinically correlated with history and objectively determined by TNE procedure as esophageal dysphagia due to structural lesion. Also, algorithm of Cook's (2008) guides the investigation procedure quickly in a single sitting. Therefore, clinical history about patient is imperative that accurately guides further in terms of patient's care for assessment and treatment.

Exploring the Influence of Dysphagia and Tracheostomy on Pneumonia in Patients with Stroke: A Retrospective Cohort Study.

Pneumonia is common in patients with tracheostomy and dysphagia. However, the influence of dysphagia and tracheostomy on pneumonia in patients with stroke remains unclear. The aim of this study was to explore the risk factors related to pneumonia, and the association between dysphagia, tracheostomy and pneumonia in patients with stroke was investigated. Patients with stroke who experienced tracheostomy and dysphagia were included and divided into two groups based on record of pneumonia at discharge. Clinical manifestations and physical examination were used to diagnose pneumonia, whereas clinical swallowing examination, and videofluoroscopy swallowing studies (VFSS) were used to evaluate swallowing function. There were significant differences between the pneumonia group and the no pneumonia group in total tracheostomy time (6.3 ± 5.9 vs. 4.3 ± 1.7 months, p = 0.003), number of instances of ventilator support (0.41 ± 0.49 vs. 0.18 ± 0.38, p = 0.007), PAS score (5.2 ± 1.92 vs. 4.3 ± 1.79, p = 0.039), impaired or absent cough reflex (76.4 vs. 55.6%, p = 0.035), oropharyngeal phase dysfunction (60.6 vs. 40.8%, p = 0.047), length of hospital stay (36.0 ± 7.2 vs. 30.5 ± 11.7 days, p = 0.025) and direct medical costs (15,702.21 ± 14,244.61 vs. 10,923.99 ± 7250.14 United States dollar [USD], p = 0.042). Multivariate logistic regression showed that the total tracheostomy time (95% confidence interval [CI], 1.966-12.922, p = 0.001), impaired or absent cough reflex (95% CI, 0.084-0.695, p = 0.008), and oropharyngeal phase dysfunction (95% CI, 1.087-8.148, p = 0.034) were risk factors for pneumonia. Spearman's correlation analysis demonstrated that PAS scores were significantly correlated with cough reflex dysfunction (r = 0.277, p = 0.03), oropharyngeal phase dysfunction (r = 0.318, p < 0.01) and total tracheostomy time (r = 0.178, p = 0.045). The oropharyngeal phase dysfunction was significantly correlated with cough reflex (r = 0.549, p < 0.001) and UES opening (r = 0.643, p < 0.01). Tracheostomy and dysphagia increased the risk of pneumonia in patients with stroke. Total tracheostomy time, duration of ventilator support, degree of penetration and aspiration, and oropharyngeal phase dysfunction are risk factors. Given this, we also found that there may be a correlation between tracheostomy and dysphagia.

69-Year Old Man With Dysphagia and Nasal Regurgitation

69-Year Old Man With Dysphagia and Nasal Regurgitation

Esophageal dysphagia in neuromuscular disorder patients with validity and reliability study of the brief esophageal dysphagia questionnaire.

Esophageal dysphagia (ED) is often underestimated in neuromuscular disorders (NMD) and it is important to evaluate the esophageal phase of swallowing with an easy and rapid screening test. We aimed both to assess the prevalence of ED in NMD and to perform validity and reliability study of the brief easophageal dysphagia questionnaire (BEDQ) screening test in NMD patients. This prospective cross-sectional clinical study was performed on NMD patients. Demographic features and disease characteristics were recorded. Endoscopic evaluation for oropharyngeal dysphagia (OD) and high-resolution esophageal manometry for ED were performed. In addition, the BEDQ and the 10-item eating assessment tool (EAT-10) were used to all subjects. Cronbach's α and principle components factor analysis (PFCA) with varimax rotation were used for reliability. The Chicago Classification version 3 (CCv3) level (high-resolution esophageal manometry) and EAT-10 was used for validity. A total of 50 patients were included in the study. Thirty-four (68%) patients were diagnosed with myasthenia gravis and 16 (32%) patients were diagnosed with myopathy. Esophageal dysphagia according to the CCv3 was found in 33 (66%) of patients. While the Cronbach's α was excellent as 0.937 for test overall the T-BEDQ scale. The PCFA included all scale items and resulted in a single factor (eigenvalue = 5.72, 71.5%). The all BEDQ scores were demonstrated good correlation with EAT-10 score and very good correlation with CCv3 level. Evaluation of swallowing in patients with NMD should include not only the oropharyngeal phase of swallowing, but also esophageal phase. For this purpose, the BEDQ can be used as a rapid, valid, and reliable test for the evaluation of ED.

Postural Effects on Normal Oropharyngeal Swallowing: Videofluoroscopic Swallow Study (VFSS)

Background: There is considerable amount of research assessing the effect of posture (supine and upright) on swallowing. However, there are no previous studies that assess the difference between sitting and standing positions and their effect on swallowing.Aim: To assess the physiological difference between standing and sitting positions in oropharyngeal phase of swallowing.Patients and Methods: Dynamic videofluoroscopic swallow studies were performed on 30 healthy adult volunteers (15 males and 15 females) ranging in age from 18 to 45 years. All volunteers were examined in sitting and standing positions with a lateral view using barium sulfate. Oral Transit Time and Pharyngeal Transit Time are measured. In addition, hyoid peak elevation is calculated.Results: During studying fluid bolus, there was significant difference between sitting and standing positions in Pharyngeal Transit Time (P value=0.005). On the other hand, there was no significant difference between sitting & standing positions in Oral Transit Time.Conclusion: Although the PTT was longer in the sitting position with a statistically significant difference with the standing position, it did not affect the hyoid peak elevation. Hence, the body position affected the duration of PTT without affecting the degree of displacement of the hyoid bone.

Risk Factors of Dysphagia Among Community-Dwelling Middle-Aged Women: Focused on Oropharyngeal Phase.

This study aimed to characterize a population of middle-aged South Korean women at risk of developing dysphagia and to identify relevant risk factors. This study describes a cross-sectional survey. Data on the general characteristics of the participants, risk factors for dysphagia, depression, and dental pain were collected and analyzed using descriptive statistics and logistic regression analysis. Among the 247 participants, 80 (32.4%) were assigned to the dysphagia "risk" group. Logistic regression indicated that perceived health status, low body mass index, dental pain, and depression were significant risk factors for developing dysphagia. A greater proportion of individuals were classified as having depression in the dysphagia "risk" group. Depression and dental pain were recognized as dominant risk factors for dysphagia. This work provides a basic reference that can be useful for the development of a general health education program for the prevention of dysphagia in community-dwelling middle-aged women.

Oropharyngeal swallowing functions are impaired in patients with naive-achalasia.

It is generally accepted that achalasia is limited to the pathology of the esophageal body and lower esophageal sphincter. However, patients with achalasia still have symptoms such as aspiration and weight loss after even a succesfull treatment, suggesting that additional oropharyngeal pathologies may be frequent in patients with achalasia. The aim of the study was to assess the oropharyngeal/hypopharyngeal swallowing functions of patients with naive-achalasia. We evaluated the oropharyngeal functions with fiberoptic endoscopic evaluation of swallowing (FEES) and high-resolution manometry (HRM) in 36 patients with naive-achalasia(mean age 47.8 ± 14.7; 20F, 20M) diagnosed with and upper gastrointestinal endoscopy, HRM, radiology compared the results with 40 healthy volunteers (mean age 48.25 ± 12.37; 23F, 17M) as controls. The Beck Depression Inventory (BDI) and the MD Anderson Dysphagia Inventory (MDADI) were used for psychological analysis and to assess quality of life. Mean integrated relaxation pressure (IRP) values were significantly higher (12.7 ± 10.9) for all patients compared to controls (0 ± 4.40). In the presence of pharyngeal residue IRP was 18.6 ± 11.8mmHg compare to patients without pharyngeal residue which was 7.2 ± 6.4mmHg (p < 0.05). Resting pressures were 105.7 ± 60.4mmHg in study group vs 116 ± 55.1mmHg in the control group (NS). In the study group we determined that residues of semisolid and liquid food were significantly higher in the vallecula, retrocricoid region, pharyngeal wall, and piriform sinuses with FEES. The average MDADI score was 58.1 ± 19.8 and 87.6 ± 10.7 in the study and control groups, respectively (p < 0.05). Depression may be significantly higher in achalasia patients based on the BDI. Relaxation of the upper esophageal sphincter is insufficient especially in patient with residue. This finding is supported by the presence of residue during FEES evaluation. In the assessment of patients with achalasia, in the presence of residue symptoms,oropharyngeal phases of swallowing should be examined with FEES. Furthermore, the effect of exercises to improve the pathological findings should be evaluated.

Tongue strengthening exercise is effective in improving the oropharyngeal muscles associated with swallowing in community-dwelling older adults in South Korea

BackgroundTongue strengthening exercise (TSE) is a remedial method for the training of swallowing-related muscles in the oropharyngeal phase. However, clinical evidence of its effectiveness is insufficient.MethodsTo investigate the effect of TSE on the oropharyngeal muscles associated with swallowing in older adults, in this study, 40 elder adults living in the community were recruited and assigned to 2 groups. The experimental group performed a TSE with a 1-repetition maximum resistance level of 70%. The exercise was divided into an isometric and isotonic part. The control group did not perform an exercise. We measured the muscle strength and thickness of the tongue and suprahyoid muscles using an Iowa Oral Performance Instrument and ultrasonography.ResultsThe experimental group showed a statistically significant increase in tongue muscle strength and thickness in the oral phase (P = .001 and <.001, respectively). In the pharyngeal phase, the experimental group showed a statistically significant increase in the mylohyoid and digastric muscles (suprahyoid muscles) (P = .045 and .019, respectively). The control group showed no statistically significant changes.ConclusionTSE is effective in increasing the strength and thickness of the oropharyngeal muscles of elder adults and is recommended for those who are vulnerable to swallowing difficulties.

Association between echo intensity of the tongue and its thickness and function in elderly subjects.

The tongue plays an important role during the oropharyngeal phase of swallowing. Each part of the tongue has a different function during swallowing. Ageing causes changes in muscle quantity and quality. Qualitative changes, such as an increase in intramuscular adipose tissue, can be determined by the echo intensity (EI) of the tongue on ultrasonography (US). To clarify the relationship between EI and thickness and function of the tongue. Ninety-four healthy elderly individuals (30 male, 64 female) aged >65years (mean 71.10±4.13years) were enrolled. Tongue thickness (TT) and EI were determined by US. Tongue function was evaluated by measurement of tongue pressure and oral diadochokinesis (OD). Multiple regression analysis was used to identify the factor with the strongest influence on EI of the tongue. The mean thickness of the middle of the tongue was 40.42±4.24mm and that of the base was 23.35±3.32mm; the respective EI values were 46.54±9.33 and 49.33±9.83. The average OD rates for /ta/ and /ka/ were 5.73±1.09 and 5.40±1.00 times/s, respectively. Multiple regression analysis for EI showed that /ta/ (β=-2.518, P=0.042) and thickness of the middle of the tongue (β=-1.278, P<0.001) were significant independent variables. Similarly, the EI at the base of the tongue showed that /ka/ (β=-4.038, P=0.021) and base of TT (β=-0.913, P=0.004) were significant independent variables. EI may be an indicator of TT and OD in both the middle and base of the tongue. Ultrasound is beneficial for evaluating TT and function.

Phoca vitulina swallowing physiology using videofluoroscopy: Creating a comparative rehabilitation model

BackgroundUp to 150 wild harbor seal pups (Phoca vitulina) are admitted annually to our rescue centre. All require medical management including gavage feeding until weaned to whole fish prior to release back to the wild. The rehabilitation model is personnel intensive requiring animal restraint and force feeding. To the best of our knowledge, no systematic imaging has been conducted on the upper aerodigestive tract of wild seal pups. As a result, the information regarding their swallowing physiology is limited as are ways in which to optimize their feeding and swallowing rehabilitation. Our objectives were to develop a videofluoroscopic swallowing study (VFSS) protocol and to determine the feasibility of conducting a VFSS with a wild seal.MethodsFeasibility parameters included the determination of: contrast delivery methods, image capture and analyses, and the operational and infrastructure requirements. A Siemens mobile c‐arm fluoroscopy unit and retrofitted tub were utilized for imaging. After thawing, we injected whole flash‐frozen herring with liquid barium suspension (105% w/v). Recently weaned seals (N = 2) were imaged at 30 frames per second with loss less capture. Two blinded raters evaluated swallow physiology across 6 metrics with disagreements resolved by consensus. Results were summarized descriptively.ResultsWe conducted a freely‐behaving videofluoroscopic swallowing study on two infant seals (1 male: 8 wks, 3 d; 1 female: 5 wks, 3 d). Personnel included veterinarian, veterinary technicians (2), imaging technician and VFSS raters (2). Five boluses were administered to each seal (67–90 g each) with a total exposure of 2 min, 54 sec. We identified three distinct swallow phases: preparatory (preswallow), oropharyngeal and esophageal. The preparatory phase was characterized by airway closure and base of tongue (BOT) positioning. The oropharyngeal phase included bolus transport via BOT retraction, repeated anterior‐superior hyolaryngeal excursion, and posterior pharyngeal wall contraction. Bolus propulsion to the stomach occurred during the esophageal phase.ConclusionsWe have successfully conducted the first‐ever VFSS on wild seal pups. With this protocol, we will gather the first normative swallowing data, enhance diagnostic capabilities and potentially improve feeding and swallowing rehabilitation for this population. Ultimately, this will inform our development of the first cross‐species conceptual swallowing framework between seals and humans facilitating a synergistic knowledge translation model.Support or Funding InformationDr. Skoretz’ startup funding from the Faculty of Medicine and the School of Audiology and Speech Sciences at UBC provided support for this project.This abstract is from the Experimental Biology 2019 Meeting. There is no full text article associated with this abstract published in The FASEB Journal.

Effect of effortful swallowing training on tongue strength and oropharyngeal swallowing function in stroke patients with dysphagia: a double-blind, randomized controlled trial.

Effortful swallowing training (EST) is a remedial method for the training of swallowing-related muscles in the oropharyngeal phase. However, clinical evidence of its effectiveness is insufficient. To investigate the effects of EST on tongue strength and swallowing function in patients with stroke. Stroke patients with dysphagia were randomly assigned to one of two groups: an experimental group (n = 12) and a control group (n = 12). The experimental group underwent EST, while the control group performed saliva swallowing. Training was conducted 5 days per week for 4 weeks. Both groups underwent conventional dysphagia treatment for 30 min/day, 5 days/week for 4 weeks. Tongue strength was assessed using the Iowa Oral Performance Instrument. The Videofluoroscopic Dysphagia Scale (VDS), based on a videofluoroscopic swallowing study, was used to analyze oropharyngeal swallowing function. The experimental group showed greater improvements in anterior and posterior tongue strength compared with the control group (p = 0.046 and 0.042, respectively), and greater improvement in the oral phases of the VDS (p = 0.017). We recommend EST as a remedial strategy for improving tongue strength and oral swallowing function in patients with stroke.

Gender Differences in Normal Swallow

requires precise coordination between 34 pairs of muscles in just over one second. The rapid sequential and overlapping motions characterizing adult human swallowing behavior were better appreciated with the introduction of radiography, and especially video radiography. There are data suggesting that women swallow liquids at a lower flow rate and ingest smaller volumes in each swallow than men. Aim of the work: To assess the physiological difference between males and females in oropharyngeal and esophageal phases of swallowing in normal middle-aged individuals. Patients and Methods: Cross sectional study, included 30 healthy volunteers (15 males & 15 females) with normal swallowing, whose age ranged from 18-45 yrs. This study was conducted in SohagUniversityHospital, Phoniatric Unit. All volunteers were subjected to Video-Fluroscopic Swallowing Study (VFSS) in sitting position. Oral transit time (OTT), Pharyngeal transient time (PTT), Oropharyngeal transient time, Esophageal transit time (ETT), Total swallow time (TST) were measured. Also, hyoid peak was calculated. Results: There were nosignificant difference between males and females swallowing in both fluid and solid boluses. Conclusion: This study provided insights into normal swallowing physiology and defines measurement alternatives for evaluation of the dysphagic patients

Temporomandibular disorder and comorbid neck pain: facts and hypotheses regarding pain-induced and rehabilitation-induced motor activity changes.

According to the "pain adaptation model", temporomandibular disorder (TMD)-related pain induces a paradoxical activity of masticatory muscles: an agonistic hypoactivity during jaw closing and an antagonistic activity during jaw opening (agonist/antagonist co-activation). However, this model suffers several weaknesses; notably, it does not explain all types of neck muscle activities in neck pain (NP), which is a very prevalent TMD comorbid condition. In NP, neck muscle antagonistic activity is increased, and agonistic activity is decreased as postulated by the pain adaptation model. However, synergistic and compensatory activity may occur and agonistic activity may be unchanged or even increased as postulated within the "vicious cycle theory". Thus, both theories would apply partly as outlined currently in musculoskeletal disorders (MSD). Besides pain, psychological stress may also induce motor dysfunction in TMD and NP. In NP, rehabilitation may increase agonistic activity and decrease compensatory activity and antagonistic activity, thus inducing a switch from agonist/antagonist co-activation towards reciprocal inhibition. Thus, rehabilitation-induced motor activity changes constitute a new research field that should improve MSD therapeutics. Additionally, immature tongue function (so-called infantile swallow) might be connected to TMD where low agonistic activity of masticatory muscles would be compensated by facial muscle hyperactivity during oropharyngeal phase of deglutition.

Dysphagia in myasthenia gravis: the tip of the Iceberg.

We evaluated swallowing function in patients with myasthenia gravis (MG) with or without dysphagia symptoms using different evaluation parameters and compared the results with those of healthy subjects. A total of 36 patients with MG and 25 healthy volunteers were included in the study. The subjects were classified into three groups; patients without dysphagia (group 1), patients with dysphagia (group 2), and healthy participants (group 3). The presence and severity of dysphagia, the oropharyngeal, pharyngeal, pharyngoesophageal, and esophageal phases were assessed using a screening test, manometric test, electrophysiologic studies [electroneuromyography (EMG)], fiberoptic endoscopic evaluation of swallowing (FEES), and barium swallow pharyngeal esophagography (BSPE), respectively. There was a significant difference between group 1 and group 3 in terms of BSPE (p=0.001) and manometry tests (p=0.001). A significant difference was found in all methods between group 2 and group 3 (p=0.001, for all). In the comparison of the patient groups, although the number of patients with dysphagia in group 2 was significantly higher in the clinical tests (p=0.007), FEES (p=0.001), and EMG (p=0.043) than in group 1, no difference was detected for BSPE (p=0.119) and manometry (p=0.644). Swallowing functions in patients with MG may be affected even without symptoms. This condition should be considered in their follow-up.

The Balloon-Based Manometry Evaluation of Swallowing in Patients with Amyotrophic Lateral Sclerosis

The aim of the study was to analyse the disturbances of the oro-pharyngeal swallowing phase of dysphagia in amyotrophic lateral sclerosis (ALS) patients with the use of specific manometric measurements and to evaluate their plausible association with the duration of the disease. Seventeen patients with ALS were evaluated with manometric examinations of the oral and pharyngeal part of the gastrointestinal tract. Tests were carried out by using the oesophageal balloon-based method with four balloon transducers located 5 cm away from each other. The following manometric parameters were analysed: the base of tongue contraction (BTC) and the upper oesophageal sphincter pressure (UESP), and the hypopharyngeal suction pump (HSP) as well as the oro-pharyngeal, pharyngeal and hypopharyngeal transit time and average pharyngeal bolus velocity (oropharyngeal transit time (OTT), pharyngeal transit time (PTT), hypopharyngeal transit time (HTT) and average pharyngeal bolus velocity (APBV), respectively). Manomatric examinations during swallowing in patients with ALS showed significant weakness of BTC, a decrease of HSP and a decrease of the velocity of bolus transit inside the pharynx which were particularly marked between the first and the third examination. Manometric examinations of the oro-pharyngeal part of the gastrointestinal tract are useful and supportive methods in the analysis of swallowing disturbances in ALS patients.

A model experiment to study swallowing of spherical and elongated particles

Swallowing disorders are not uncommon among elderly and people affected by neurological diseases. For these patients the ingestion of solid grains, such as pharmaceutical oral solid formulations, could result in choking. This generally results in a low compliance in taking solid medications. The effect of the solid medication size on the real or perceived ease of swallowing is still to be understood from the mechanistic viewpoint. The interplay of the inclusion shape and the rheology of the liquid being swallowed together with the medication is also not fully understood. In this study, a model experiment was developed to study the oropharyngeal phase of swallowing, replicating the dynamics of the bolus flow induced by the tongue (by means of a roller driven by an applied force). Experiments were performed using a wide set of solid inclusions, dispersed in a thick Newtonian liquid. Predictions for a simple theory are compared with experiments. Results show that an increase in the grain size results in a slower dynamics of the swallowing. Furthermore, the experiments demonstrated the paramount role of shape, as flatter and more streamlined inclusions flow faster than spherical. This approach can support the design of new oral solid formulations that can be ingested more easily and effectively also by people with mild swallowing disorders.

"A Day in the Life of the Fluid Bolus": An Introduction to Fluid Mechanics of the Oropharyngeal Phase of Swallowing with Particular Focus on Dysphagia.

By following the path of a liquid bolus, from the oral preparatory phase to the esophagus, we show that a few fundamental concepts of fluid mechanics can be used to better understand and assess the importance of bolus viscosity during human swallowing, especially when considering dysfunctional swallowing (dysphagia) and how it can be mitigated. In particular, we highlight the important distinction between different flow regimes (i.e. viscosity controlled versus. inertia controlled flow). We also illustrate the difference between understanding bolus movements controlled by a constant force (or pressure) and those controlled by a constant displacement (or velocity). We limit our discussion to simple, Newtonian liquids where the viscosity does not depend on the speed of flow. Consideration of non-Newtonian effects (such as shear thinning or viscoelasticity), which we believe play an important part in human swallowing, requires a sound grasp of the fundamentals discussed here and warrants further consideration in its own right.

Dysphagia in children with repaired oesophageal atresia.

Dysphagia is a common problem in children with repaired oesophageal atresia (OA). Abnormalities in the oropharyngeal and oesophageal phase have hardly been studied. The aims of this study were to assess the prevalence of dysphagia in children with repaired OA and to identify and differentiate oral and pharyngeal dysphagia based on videofluoroscopic swallow study (VFSS) findings in a limited number of children in this cohort. Medical records of 111 patients, born between January 1996 and July 2013 and treated at the Radboudumc Amalia Children’s Hospital, were retrospectively reviewed. The prevalence of dysphagia was determined by the objective and modified Functional Oral Intake Scale (FOIS) in four age groups. The first performed VFSS of 12 children was structurally assessed. The prevalence of dysphagia was 61 of 111 patients (55 %) in age group <1 year. In age group 1–4, 5–11 and 12–18 years, the prevalence of dysphagia decreased from 54 of 106 (51 %) patients to 11 of 64 (17 %) and 5 of 24 (21 %) patients. The 12 VFSS’s reviews revealed oral dysphagia in 36 % and pharyngeal dysphagia in 75 %.Conclusions: This study highlights dysphagia as an important problem in different age groups of children with repaired OA. Furthermore, our study shows the presence of oropharyngeal dysphagia in this population. This study emphasizes the need to standardize the use of objective dysphagia scales, like the modified FOIS, to provide a careful follow-up of children with repaired OA. What is Known: • Prevalence of dysphagia in children with repaired oesophageal atresia varies widely (ranges from 45 to 70 %) in literature. • Oral, pharyngeal and oesophageal dysphagia require different treatment approaches. What is New: • We determined dysphagia based on functional oral intake and provide an overview of change in dysphagia prevalence and severity over time in children with repaired OA. • Our study shows that dysphagia, including oropharyngeal dysphagia, is highly prevalent in young children with repaired OA and improves with time.

Flexible Endoscopic Zenkerʼs Mucomyotomy With the Carr-Locke Cap: Presidential Poster

Flexible endoscopic treatment of Zenker's diverticulum is well-established using different techniques including freehand electrosurgical incision with or without a standard distal endoscope cap. The only purpose-designed accessory is a slotted overtube which is not available in the US. We describe our experience with a novel cap in performing cricopharyngeal mucomyotomy. An 85 year old man with a past medical history of subdural hematoma requiring two craniotomies, asthma and hypothyroidism presented with progressively worsening dysphagia, regurgitation and weight loss over two years. Social history was significant for cigar smoking for over forty years. Evaluations showed normal motility with the oropharyngeal phases of his swallowing mechanism, no cervical lymphadenopathy, and all cranial nerves were intact. Two esophagrams were performed over the course of six months which showed an enlarging 3 centimeter Zenker's diverticulum on the posterior wall of the proximal esophagus. Otolaryngology evaluated the patient for stapler diverticulotomy. However, our patient had a limited ability to open his jaw with an inter-incisor distance of 28 millimeters. Thus, rigid endoscopic repair could not be performed and surgical repair was recommended. Upon patient's request, he was referred to gastroenterology for further evaluation. We performed a flexible endoscopic Zenker's mucomyotomy using the Carr-Locke Cap. The mucomyotomy was performed without complication and the patient had complete recovery and symptom resolution at 1 month follow up. At that time repeat upper endoscopy showed a healed scar at the site of the mucomyotomy. The Carr-Locke Cap is a purpose-designed clear, soft, plastic distal attachment with one long and one short ‘blade' placed on the end of the endoscope to help separate the esophagus from the Zenker's diverticulum. The cap allows isolation of the cricopharyngeal ‘septum' in the slot between the blades, permits advancement of the endoscope and cap as one unit and automatically determines when the incision is complete by passage of the cap into the esophagus with the endoscope. This endotherapy technique was successfully performed in eight patients with 100% clinical success at one month and with no adverse events. No patients reported symptom recurrence and no repeat treatments were required. This technique may become the new standard for endotherapy of Zenker's diverticulum.Figure 1Figure 2Figure 3

Age-related changes in swallowing. Physiology and pathophysiology

The term presbyphagia refers to all changes of swallowing physiology that are manifested with increasing age. Alterations in the pattern of deglutition that are part of healthy aging are called primary presbyphagia. Primary presbyphagia is not an illness in itself but contributes to a more pervasive naturally diminished functional reserve, making older adults more susceptible to dysphagia. If disorders in swallowing occur in the elderly as a comorbidity of a specific disease, for example stroke or neurodegenerative disorders, this is called secondary presbyphagia. Increasing age has an impact on each stage of deglutition. In the oral preparatory phase a diminished input for smell and taste as well as a usually multifactorial cause of dry mouth are the most important influencing factors. Sarcopenia, the degenerative loss of skeletal muscle mass, strength and quality associated with aging, interferes in particular with the oropharyngeal phase. A decreased sensory feedback from the oropharyngeal mucosa leads to a delayed triggering of the swallowing reflex. Finally, a reduction in connective tissue elasticity and changes of the axial skeleton lead to various modifications of the swallowing pattern with advanced age.