Pharyngeal Function Research Articles

Kinetic magnetic resonance imaging analysis of swallowing: a new approach to pharyngeal function

Kinetic magnetic resonance imaging analysis of swallowing: a new approach to pharyngeal function

Effects of head rotation on pharyngeal function during normal swallow.

This study quantified the effects of head rotation on pharyngeal swallowing in healthy subjects. Videofluoroscopic and oropharyngeal manometric examinations of pharyngeal swallowing were performed on seven volunteers with the head in neutral and rotated positions. Videofluoroscopic study revealed that head rotation swallow causes the bolus to lateralize away from the direction of head rotation. Pharyngeal manometric study indicated that the pharyngeal peak pressures toward the side of head rotation were significantly increased, whereas the pharyngeal pressures opposite the side of head rotation were not affected. Head rotation swallow produced a significant fall in upper esophageal sphincter (UES) resting pressure and a delay in UES closing. We concluded that the head rotation swallow in normal subjects not only alters the bolus pathway, but also has a useful effect on both pharyngeal clearance and UES dynamics.

Anatomic basis of cleft palate and velopharyngeal surgery: implications from a fresh cadaveric study.

The purpose of this investigation was to apply the findings of an anatomic study of the levator veli palatini, palatopharyngeus, and superior constrictor muscles in 18 fresh cadaveric specimens of normal adults to analyze current controversies in velopharyngeal function and cleft palate surgery. The levator veli palatini was observed to form a muscular sling, suspending the velum from the cranial base. Its fibers occupied the middle 50 percent of the velum, lying in transverse orientation and without significant overlap across the midline. It is well placed to function as the prime mover in the velar component of velopharyngeal closure. The velar component of the palatopharyngeus consisted of two heads clasping the levator and inserting into the latter just short of the midline. Its pharyngeal component inserted into the superior constrictor in the lateral and posterior pharyngeal walls. Together, these two muscles formed a sphincter around the velopharyngeal port, suggesting that both muscles are involved in the pharyngeal component of velopharyngeal closure. Based on the premise that the goal of palatoplasty is to restore normal anatomy, the intravelar veloplasty has a sound basis, and theoretically improves both velar and pharyngeal wall function because it corrects the dysmorphology of both the levator and palatopharyngeus. Although the Furlow palatoplasty also reorients these velar muscles correctly in the transverse position, the resulting overlap of the levator and palatopharyngeus across the midline is morphologically abnormal. In addition, the use of large Z-plasty flaps in wide clefts may cause excessive lateral tension, increasing the risk of fistula formation and causing an impairment of velar stretch capacity. The raising of a vertical pharyngeal flap divides the fibers of the superior constrictor and has the potential to impair pharyngeal wall function. The sphincter pharyngoplasty interferes less with pharyngeal wall anatomy. The potential for an obstructive outcome seems to be related to the use of wide, long flaps and a tight, overlapping type of flap inset. In addition, the level of flap inset is important: an inset at the level of the uvula has the greatest risk of causing obstruction, whereas a higher inset at the level of attempted velopharyngeal closure seems to provide the best opportunity for achieving velopharyngeal competence while avoiding hyponasality and obstruction.

Dysphagia in stroke: a prospective study of quantitative aspects of swallowing in dysphagic patients.

This is a prospective study of 100 consecutive stroke patients. Within 24 h after stroke onset they were asked specifically about swallowing complaints and subjected to a clinical examination including neurologic examination, Mini-Mental test, and Barthel score. Dysphagic patients were examined with the repetitive oral suction swallow test (the ROSS test) for quantitative evaluation of oral and pharyngeal function at 24 h, after 1 week, and after 1 month. At 6 months, the patients were interviewed about persistent dysphagia. Seventy-two patients could respond reliably at 24 h after the stroke onset and 14 of these complained of dysphagia. Non-evaluable patients were either unconscious, aphasic, or demented. The presence of dysphagia was not influenced by age or other risk factors for stroke. Facial paresis, but no other clinical findings, were associated with dysphagia. Dysphagia 24 h after stroke increased the risk of pneumonia but did not influence the length of hospital stay, the manner of discharge from hospital, or the mortality. The initial ROSS test, during which the seated patient ingests water through a straw, was abnormal in all dysphagic stroke patients. One-third of the patients were unable to perform the test completely. Above all, dysfunction was disclosed during forced, repetitive swallow. All phases of the ingestion cycle were prolonged whereas the suction pressures, bolus volumes, and swallowing capacities were low. Abnormalities of quantitative swallowing variables decreased with time whereas the prevalences of swallowing incoordination and abnormal feeding-respiratory pattern became more frequent. After 6 months, 7 patients had persistent dysphagia. Five of these were initially non-evaluable because of unconsciousness, aphasia, or dementia.

Persistent Dysphagia after Laser Uvulopalatoplasty: A Videoradiographic Study of Pharyngeal Function

In a follow-up study of 79 patients two years after laser uvulopalatoplasty 21 (27%) reported persistent postoperative dysphagia, with aspiration symptoms in 22%. None of the patients had suffered from recurrent pneumonia. A total of 4% of the patients regretted the treatment because of their dysphagia problems. The objective of this study was to examine oral and pharyngeal function videoradiographically during swallowing in the patients with persistent dysphagia, to determine whether the subjective symptoms of dysphagia correlated with objective signs of pharyngeal dysfunction. Pharyngeal function during swallowing was deviant in 76% of the dysphagic patients. In 52% of the dysphagic patients premature leakage of bolus down to different levels of the pharynx, from the tongue base to sinus piriformis, was observed before the swallowing reflex was elicited. In the dysphagic patients substantial bolus retention was observed on the epiglottis or in the valleculae after the propagation wave had passed (43%) as well as epiglottal dysmotility (24%). Of the dysphagic patients, 10% could not avoid aspiration during the examination. These findings could explain the symptoms reported by the patients.

Kinetic magnetic resonance imaging analysis of swallowing: a new approach to pharyngeal function.

The emergence of turbo-FLASH MR sequences allows us to acquire five 10-mm sections each second and thus to catch images of the soft tissues during function. One can trace the pathway of a liquid between the tongue, the soft palate, the epiglottis and the pharyngeal apparatus and analysis the role of the anatomic structures during swallowing. Restricted to the sagittal plane for the purpose of this preliminary study, this technique can be extended to the other planes to provide a three-dimensional analysis of oropharyngeal function or dysfunction.

Functional assessment of the pharynx at rest and during swallowing in partially paralyzed humans: simultaneous videomanometry and mechanomyography of awake human volunteers.

Functional characteristics of the pharynx and upper esophagus, including aspiration episodes, were investigated in 14 awake volunteers during various levels of partial neuromuscular block. Pharyngeal function was evaluated using videoradiography and computerized pharyngeal manometry during contrast bolus swallowing. Measurements of pharyngeal constrictor muscle function (contraction amplitude, duration, and slope), upper esophageal sphincter muscle resting tone, muscle coordination, bolus transit time, and aspiration under fluoroscopic control (laryngeal or tracheal penetration) were made before (control measurements) and during a vecuronium-induced partial neuromuscular paralysis, at fixed intervals of mechanical adductor pollicis muscle train-of-four (TOF) fade; that is, at TOF ratios of 0.60, 0.70, 0.80, and after recovery to a TOF ratio > 0.90. Six volunteers aspirated (laryngeal penetration) at a TOF ratio < 0.90. None of them aspirated at a TOF ratio > 0.90 or during control recording. Pharyngeal constrictor muscle function was not affected at any level of paralysis. The upper esophageal sphincter resting tone was significantly reduced at TOF ratios of 0.60, 0.70, and 0.80 (P < 0.05). This was associated with reduced muscle coordination and shortened bolus transit time at a TOF ratio of 0.60. Vecuronium-induced partial paralysis cause pharyngeal dysfunction and increased risk for aspiration at mechanical adductor pollicis TOF ratios < 0.90. Pharyngeal function is not normalized until an adductor pollicis TOF ratio of > 0.90 is reached. The upper esophageal sphincter muscle is more sensitive to vecuronium than is the pharyngeal constrictor muscle.

Influence of altered tongue contour and position on deglutitive pharyngeal and UES function.

The potential influence of altered lingual position and contour during the bolus loading phase of the swallow in mediating the swallowed bolus volume-dependent regulation of upper esophageal sphincter (UES) relaxation and opening was studied in 15 healthy volunteers using simultaneous videoradiography and manometry. A maxillary dental splint modulated tongue deformity during the early oral phase of deglutition. We examined the effect of the splint and swallowed bolus density on bolus volume-dependent changes in the timing of events in the swallow sequence and on hypopharyngeal intrabolus and midpharyngeal pressures. Peak mid-pharyngeal pressure (P = 0.001) and hypopharyngeal intrabolus pressure (P = 0.04) were significantly reduced by the splint. The normal volume-dependent earlier onset of sphincter relaxation and opening was preserved with the splint in situ. The splint significantly delayed the onset of hyoid motion and UES relaxation and opening without influencing transit times or total swallow duration. Alterations in tongue contour and position reduce intrabolus pressure and pharyngeal contraction without influencing normal bolus volume-dependent regulation of timing of UES relaxation and opening.

Rehabilitation Of Lower Cranial Nerve Deficits

Lower cranial nerve deficits following skull base surgery can be accompanied by significant morbidity, especially if the vagus nerve has been sacrificed or injured. Loss of pharyngeal function and glottic closure can result in dysphagia and aspiration. Left untreated, these can result in the major morbidity for the patient following skull base surgery. The authors discuss the management of lower cranial nerve deficits, with emphasis on rehabilitation of swallowing function and prevention of aspiration following vagal injury.

Comments on selected recent dysphagia literature

Hamdy et al. note, ‘‘Oropharyngeal dysphagia occurs in up to a third of patients presenting with a unilateral hemiplegic stroke, yet its neurophysiological basis remains unknown.’’ They continue, ‘‘Animal data indicate that stimulation of either cortical hemisphere can initiate swallowing, which suggests that dysphagia after a stroke is due to damage either to both hemispheres or to the brainstem swallowing centre. However, neuropathological examination of dysphagic stroke patients either at necropsy or with magnetic resonance imaging has shown that, in many cases, the lesion is discrete and unilateral.’’ The authors previously reported on the use of transcranial magneto-electric stimulation (TCMS) to identify the corticofugal projections to the muscles of swallowing [1]. They found ‘‘that oral muscles, such as the mylohyoids are represented symmetrically between the two hemispheres, whereas muscles of the pharynx and oesophagus are represented very asymmetrically, with most individuals having a dominant swallowing hemisphere, independent of handedness.’’ Based on these earlier findings, Hamdy et al. generated ‘‘two hypotheses to explain why a unilateral hemispheric stroke might cause oropharyngeal dysphagia.’’ They state, ‘‘First, innervation of the brainstem by both hemispheric centres might be required to initiate swallowing, so destruction of either would leave inadequate cortical function to evoke normal swallowing. . . . Alternatively, since there is functional asymmetry between the two hemispheres for pharyngeal function, oropharyngeal dysphagia would result from damage to the hemisphere where the dominant pharyngeal centre was located. This second hypothesis would also predict that swallowing should remain normal if the dominant centre for pharyngeal function was present on the unaffected hemisphere.’’ The authors recruited 20 patients with unilateral hemiplegic stroke within the previous 6 weeks. Patients underwent the following evaluations: (1) clinical examination by a speech and language therapist using a standardized bedside assessment, (2) standardized neurological assessment, (3) submental electromyography (EMG) of mylohyoid muscles, (4) pharyngeal EMG via an intraluminal catheter positioned with manometric guidance, (5) EMG of muscles of the thenar eminence (muscles that have contralateral but symmetrical hemispheric representation), and (6) an experimental protocol using TCMS to determine excitability thresholds and motor-evoked response amplitudes and latencies. Eight of the 20 patients had oropharyngeal dysphagia, and the other 12 patients swallowed normally. Computed tomography of the brain revealed that 4 of the dysphagic patients had right hemisphere infarcts and 4 had left hemisphere infarcts. Six of the nondysphagic patients had right hemisphere infarcts, and 6 had left hemisphere infarcts. Hamdy et al. report, ‘‘Our study has shown that patients dysphagic after unilateral hemisphere stroke have smaller pharyngeal responses from the unaffected hemisphere than do non-dysphagic patients, irrespective of the side and level (cortical or subcortical) of the lesion. . . . One possible explanation for this difference is that the smaller responses are a reflection of the asymmetrical motor representation of pharyngeal function on the cerebral cortex. In other words, with damage to the hemisphere containing the predominant pharyngeal centre, swallowing cannot be maintained by the smaller pharyngeal centre in the unaffected hemisphere.’’ The authors continue, ‘‘The similarity in mylohyoid responses between dysphagic and non-dysphagic stroke patients is consistent both with our observation that the dysphagic patients had predominantly pharyngeal swallowing problems, and the fact that the pharyngeal phase of swallowing is the most important clinical determinant of aspiration in stroke populations. Furthermore, . . . our findings suggest that the cortical control of Dysphagia 13:116–120 (1998)

How and why should we stabilize the upper airway?

This review focuses on the evidence for upper airway instability during sleep and on the methods used to correct this instability. Upper airway patency during sleep is determined by the balance between the forces tending to constrict the pharynx (i.e. negative suction force generated by the diaphragm) and those tending to dilate in the pharynx (i.e. force acting on the tongue, soft palate and pharyngeal dilator muscles). The evidence for reduction in genioglossus activity and tensor palatini activity, failure of compensatory mechanisms to maintain these activities, and increase in upper airway resistance during sleep in reviewed. Coupled with abnormal pharyngeal anatomy to start with, the above events lead to abnormal pharyngeal function and cause repetitive episodes of airway occlusion, that is, sleep apnea. It is concluded that abnormal airway function in sleep apnea is a diffuse, rather than a localized process, that may involve the entire airway from the nasopharynx to the larynx. Methods to improve abnormal pharyngeal anatomy and pharyngeal function, such as nasal continuous positive airway pressure (CPAP), oral appliances, posture, weight loss, medications, and surgery are discussed. Given the pathophysiology of sleep apnea, that is, diffuse abnormality of the upper airway, it is reasonable to expect that only those approaches that exert a beneficial effect on the entire upper airway, as opposed to the approaches that modify only a short segment of it, may be expected to be of benefit in treatment of sleep apnea.

Esophageal motor function in patients with myotonic dystrophy.

To investigate pharyngeal and esophageal motor function in myotonic dystrophy (MD), and its relationship to esophageal symptoms, we used low-compliance, high-fidelity esophageal manometry and videofluorography to evaluate 14 consecutive MD patients. Patients exhibited a consistent, typical motor pattern, involving a marked reduction in resting tone of both the upper and lower esophageal sphincters, and a reduction in contraction pressure in the pharynx and throughout the esophagus. Radiology showed hypotonic pharynx with stasis and a hypo- or amotile, often dilated, esophagus. These findings were nonspecific, however, being present in patients both with and without dysphagia, which suggests that MD patients have valid compensatory mechanisms. Dysphagia only correlated to the pharyngeal impairment at manometry. Furthermore, the results of our study suggest that not only the proximal, striated part of the gullet, but also the distal part (in which smooth muscle dominates) is involved in the disease. The latter leads to the impairment of the LES resting tone and competence, highlighting the risk of gastroesophageal reflux disease in these patients.

The Pharyngeal Critical Pressure: The Whys and Hows of Using Nasal Continuous Positive Airway Pressure Diagnostically

The Pharyngeal Critical Pressure: The Whys and Hows of Using Nasal Continuous Positive Airway Pressure Diagnostically

Globus sensation: Value of static radiography combined with videofluoroscopy of the pharynx and oesophagus

Pharyngo-oesophageal abnormalities are found in a high proportion of patients with globus sensation. This study compares the diagnostic value of static single- and double-contrast radiography of the pharynx and oesophagus with videofluoroscopy and with videofluoroscopy combined with static radiography in these patients. Pharyngeal and oesophageal morphology and motor function were studied in 130 consecutive patients with globus sensation (46 males, 84 females; mean age, 47 years) by means of static single and double-contrast radiography and by videofluoroscopy. Videofluoroscopy revealed significantly more functional and structural abnormalities compared to static radiography. Pharyngeal and/or oesophageal disorders were found in 89 vs. 47 patients (chi2 [1] = 19.82, P = 0.0001), pharyngeal abnormalities in 54 vs. 27 patients (chi2 [1] = 13.5, P < 0.0002), and oesophageal abnormalities in 72 vs. 27 patients (chi2 [1] = 28.13, P < 0.0001). Videofluoroscopy combined with static radiography revealed significantly more abnormalities than videofluoroscopy alone (chi2 [1] = 4.23, P < 0.05), and assessed mucosal details more reliably than videofluoroscopy alone. The most frequent abnormalities found were nonspecific oesophageal motor disorders, pharyngo-oesophageal sphincter dysfunction, pharyngeal stasis, achalasia, and laryngeal penetration or aspiration of barium. In most patients with globus sensation, pharyngeal and/or oesophageal abnormalities can be detected radiographically. Videofluoroscopy revealed significantly more functional but not morphological abnormalities than did static radiography. Videofluoroscopic studies combined with static radiography had a higher diagnostic value than videofluoroscopic studies alone.

Modified barium swallow: clinical and radiographic correlation and relation to feeding recommendations

Clinical and videofluoroscopic evaluation of swallowing were correlated to determine their agreement and relationship to feeding recommendations. We reviewed a total of 148 patients with swallowing difficulties, of which 93 (45 women, 48 men; mean age 62 years) were evaluated by both clinical and radiographic examinations. A variety of materials were used for clinical bedside evaluation of oral and pharyngeal function. Radiographic examination was done with variable viscosity materials and videotape recording of the oral cavity and pharynx. The severity of oral and pharyngeal abnormalities was graded and findings of the examinations were compared. The combined results of both evaluations generated an index of swallowing difficulty which was correlated to the type of diet used if oral feeding was recommended or to a nonoral route of nutrition. In the assessment of oral and pharyngeal dysfunction, clinical evaluation and radiographic examination correlated closely in 94% of patients; however, the status of pharyngeal function was not determined in 61 (66%) of the 93 patients by clinical examination alone. The combined swallowing index was calculated in 89 patients and its severity correlated significantly with the type of feeding recommended; 64 patients were placed on one of three types of diets and 25 had enteral feedings. In conclusion, combined clinical and radiographic examinations correlated well, but clinical evaluation alone was limited by failure to evaluate the pharynx in many patients. The swallowing severity correlated well with final feeding recommendations.

Quantitative assessment of swallowing in healthy adults

Swallowing has hitherto been evaluated during physical examination, radiologic barium studies, manometry, and cervical auscultation. Radiography principally demonstrates qualitative aspects of oral and pharyngeal function, whereas quantitative aspects have primarily been documented by manometry. To evaluate swallowing quantitatively, without using invasive methods or radiation, we have applied a combined test of water drinking, i.e., the Repetitive Oral Suction Swallow test (ROSS). The test provides reliable measurements of suction pressure, bolus volume, timing of important events in oral and pharyngeal swallow, and respiration. The test is described and results from 292 healthy, non-dysphagic subjects are presented. We found a mean bolus volume of 25.6 +/- 8.5 ml during single swallow and 21.1 +/- 8.2 ml during stress (forced, repetitive swallow). During forced, repetitive swallow, the bolus volume was more strongly associated with suction time (r2 = 0.55) than with peak suction pressure (r2 = 0.04), indicating that suction time is more important than suction pressure in determining the bolus volume. The oral-pharyngeal transit time decreased: single swallow 0.56 +/- 0.36 sec, forced repetitive swallow 0.23 +/- 0.11 sec, as did the coefficient of variation (48% and 64%, respectively) indicating a more automatic neural process for pharyngeal function in forced, repetitive swallow. The postswallow respiration started with inspiration in 10% of studied individuals, but did not correlate with deviations in other variables in the test. Thus, postswallow inspiration must be considered as normal. The ROSS test offers a rapid and easy quantitative assessment of swallowing.

Swallowing in hereditary sensory ataxia.

The oral, pharyngeal, and esophageal stages of swallowing were evaluated in 8 patients with recessively or dominantly inherited pure sensory ataxia. Six patients had swallowing difficulties: solid bolus obstruction, coughs during eating, and choking episodes. One patient had chronic bronchitis and another had recurrent pneumonia. The patients underwent a biphasic radiological barium swallow, including videofluoroscopy. No patient had a completely normal swallow. All had normal oral function, whereas pharyngeal function was abnormal in 6 patients. Esophageal function was abnormal in 6 patients. The swallowing dysfunction did not correlate with the severity of motor or sensory dysfunction in the limbs, nor with age or duration of ataxia. Our study shows that swallowing dysfunction is common in hereditary sensory ataxia. This dysfunction is likely to be due to involvement of the nucleus of the solitary tract in the brainstem. Despite some of the patients having suffered from choking episodes and others from bronchopulmonary complications, they did not spontaneously admit dysphagia. Swallowing should be evaluated thoroughly in patients with hereditary sensory ataxia since dysphagia in these patients might bring serious and potentially fatal complications.

A comparison of assessment findings using videofluoroscopy and fibreoptic endoscopic evaluation of swallowing safety

ABSTRACT Videofluoroscopic assessment (VF) is the most widely used objective assessment technique for the assessment of dysphagia, but many will acknowledge that the procedure has some limitations. Fibreoptic endoscopic evaluation of swallowing safety (FEESS) was developed in an attempt to provide an adjunct to VF and to meet some of its limitations. It is essentially an extension of the routine fibreoptic examination of the larynx and pharynx used by ENT consultants, in which the patient is given various textures to swallow and observations about swallow events and overall swallowing efficiency can be made. The literature includes several studies comparing results of these two procedures and outlining their relative advantages and disadvantages, but no one has looked at a wide range of swallow events and directly compared results obtained. Before introducing the procedure it was felt that it would be useful to evaluate it with our specific neurogenic population. The questions to be asked in our study were: (1) Do patients tolerate the procedure comfortably enough to make it a valid tool for the assessment of swallowing? Specifically, how many patients tolerate the fibreoptic endoscope in position for the average of 10 minutes which is required? (2) Does the procedure allow us to identify significant swallow events identified with VF?(3) What information, if any, is provided by FEESS that VF does not provide? The study involved 20 neurogenic patients with dysphagia, who were routinely referred to Neuro‐otology for assessment of laryngeal function and who reported swallowing difficulties. All the patients were known to the speech and language therapy department. An extended fibreoptic assessment of palatal, pharyngeal and laryngeal function, and trial swallows of various textures, was carried out within one week of FEESS and involved trial swallows of similar textures to those used in FEESS in lateral and AP views. Facilitators were trialled. Results were collected and recorded in relation to individual swallow events, for example, amount of tongue base retraction, triggering of swallow reflex, and evaluation of facilitators. Analysis of results is incomplete at this stage. Eighteen of the 20 patients tolerated FEESS assessment tasks. However, only eight of the 18 patients tolerated Mailing of facilitators, in particular those involving head positioning. Preliminary results revealed that oral stage events are better evaluated with VF. Nasal regurgitation is identified equally on VF and DEESS. Delay in triggering of the swallow reflex is identified equally with both procedures, but it is possible to obtain objective times with VF. Pharyngeal swallow events are not visualised with FEESS, but residual pharyngeal pooling was clearly visualised and amounts of residue more easily estimated. Aspiration was identified reliably with both procedures. Full results will be presented. Conclusions at this point support those suggested in the literature that FEESS is a useful adjunct to VF and may, in fact, be the assessment technique of choice for some patients, depending on the specific goals of assessment. The procedure was tolerated by most patients but may be limited in allowing evaluation of positioning facilitators.

The action of serotonin and the nematode neuropeptide KSAYMRFamide on the pharyngeal muscle of the parasitic nematode, Ascaris suum.

The pharyngeal component of the enteric nervous system of the parasitic nematode, Ascaris suum exhibits immunoreactivity for serotonin (5-hydroxytryptamine or 5-HT) and for FMRFamide-like peptides. This paper describes the application of an in vitro pharmacological approach to investigate the functional role of 5-HT and FMRFamide-like peptides. The pharyngeal pumping behaviour of Ascaris suum was monitored using a modified pressure transducer system which measures pharyngeal pressure changes and therefore pumping. The pharynx did not contract spontaneously; however, 5-HT (10-1000 microM) stimulated pumping at a frequency of 0.5 Hz. FMRFamide had no apparent effect on pharyngeal pumping. The native nematode FMRFamide-related peptide (FaRP), KSAYMRFamide inhibited the pumping elicited by 5-HT. The duration of inhibition was dose-dependent (0.1-1000 nM) with a threshold of 0.1 nM. In 4 preparations, the inhibition of the pharyngeal muscle was preceded by an initial excitation and increase in the amplitude of pharyngeal pressure changes. The pharynx is involved in various nematode processes, including feeding, regulation of hydrostatic pressure and excretion. The role of 5-HT and KSAYMRFamide in the pharyngeal function of nematodes is discussed.

Positioning improves the oral and pharyngeal swallowing function in children with cerebral palsy.

Many children with cerebral palsy have feeding difficulties. The aim of this study was to investigate if trunk and neck positioning influenced oral and pharyngeal swallow. Five children with feeding problem aged 3-10 years with cerebral palsy were examined using videofluoroscopy. All children had tetraplegia with dystonia, i.e. poor head control and poor trunk stability. All children had gross aspiration and posterior oral leak. The pharyngeal phase was delayed in relation to the oral phase. Two children had pharyngeal retention. The children were positioned with both an extended and flexed neck. The flexed neck position was combined with a 30 degrees reclined sitting position. In both positions they were given purée with barium and liquid barium during video recording. In the reclined position with the neck flexed, aspiration decreased in all five children, oral leak diminished in two children and retention improved in one child.