Pharyngeal Propulsion Research Articles

Swallowing and dysphagia in the elderly

Disturbances of the swallowing process can occur at any age and might lead to choking. However, the risk of dysphagia increases with advanced age. This is not only due to a higher incidence of diseases that cause dysphagia, but also to age-related changes in the mechanisms of swallowing. Aging affects all of the anatomic structures involved in the swallowing process. Important changes include limitations to mastication, delayed triggering of the swallowing reflex, expansion of pharyngeal structures, prolonged pharyngeal propulsion, loss of pharyngeal sensitivity, increased rigidity of the esophageal wall and reduced esophageal contractility. Changes in swallowing function caused by aging alone are termed presbyphagia. If these changes are so severe that their compensation is no longer possible, presbydysphagia occurs. For diagnostic and therapeutic purposes it is mandatory to evaluate presbyphagic and presbydysphagic changes in the swallowing process, and to distinguish these from other non-age-related causes of dysphagia.

Biomechanical changes in the pharynx and upper esophageal sphincter after modified balloon dilatation in brainstem stroke patients with dysphagia

Few studies have investigated the biomechanical changes in the upper esophageal sphincter (UES) and pharyngeal function after successful dilatation therapy for dysphagia. Using high-resolution manometry (HRM), we examined the biomechanical properties of swallowing in brainstem stroke patients with dysphagia following modified balloon dilation therapy. 30 brainstem stroke patients with dysphagia were included. Patients in the experimental group received 3weeks of modified balloon dilatation treatment and regular dysphagia therapy. Patients in the control group received 3weeks of regular dysphagia therapy only. Efficacy of treatment was evaluated before and following intervention. Functional oral intake was measured using the Functional Oral Intake Scale (FOIS). Pharyngeal maximum pressures and duration, UES residual pressure and duration during swallowing were measured using HRM. In the experimental group, the feeding tube was able to be removed in 12 of 15 patients, vs 2 of 15 patients in the control group. The experimental group had 4-point median improvement, while control groups only had 1-point improvement in FOIS scores. In the experimental group, posttreatment UES relaxation and pharyngeal propulsion were both significantly improved for the three materials (p<0.05) and UES resting pressure approximated normal. In the control group, pharyngeal propulsion was improved for water and thick liquids (p<0.05) but not for paste material; there was no improvement in posttreatment UES relaxation for all three materials (p>0.05). Dysphagia therapy with modified dilatation improved UES relaxation, strengthened pharyngeal propulsion, restored UES resting pressure and improved functional oral intake to a greater extent than regular therapy alone.

New insights into pharyngo‐esophageal bolus transport revealed by pressure‐impedance measurement

Pharyngeal propulsion, strength of peristalsis and esophago-gastric junction (EJG) resistance are determinants of esophageal bolus transport. This study used pressure-impedance methods to correlate pharyngo-esophageal function with the esophageal bolus trajectory pathway and pressures generated during bolus transport. Pharyngo-esophageal pressure-impedance measurements were performed in 20 healthy adult controls. Pharyngeal automated impedance manometry (AIM) analysis was performed to derive pharyngeal swallow function variables. The esophageal time of nadir impedance (TZn) was used to track bolus trajectory pathway. The inflection, or flow stasis point (FSP), of the trajectory curve was determined as were the pressures within the bolus (PZn) above and below the FSP. The size of 20 mmHg isocontour defect (20 mmHg IC defect) measured the integrity of the peristaltic wave. For viscous boluses, weaker pharyngeal bolus propulsion correlated with the FSP being located higher in the esophagus. Pressure within the bolus was observed to increase at the FSP and below the FSP in a manner that correlated with the magnitude of esophageal peak pressures. Larger 20 mmHg IC defects were associated with lower pressures within the bolus at the FSP and below. The FSP of the bolus trajectory pathway appears to represent a switch from bolus propulsion due to pharyngeal mechanisms to bolus propulsion due to esophageal mechanisms. 20 mmHg IC defects significantly reduce bolus driving pressure at or below the FSP.

Development of pharyngo‐esophageal physiology during swallowing in the preterm infant

Poor feeding is a common cause of prolonged hospitalization of preterm infants. Pharyngeal and upper esophageal sphincter (UES) function of preterm infants has been technically difficult to assess and is therefore poorly characterized. The aim of this study was to assess the development of pharyngeal motility, UES function, and their coordination during nutritive swallowing in preterm infants. Development of swallowing was assessed in 18 preterm infants. High resolution manometry was performed at first oral feeding attempt (31-32 week) and then weekly for 4 weeks. Pharyngeal and UES pressure changes were characterized in 980 swallows. During swallowing, we observed an age-related increase in peak pharyngeal pressure at the laryngeal inlet (1 cm above UES) but an age-related decrease in the time required for the UES to fully relax to nadir. Analysis of the timing of proximal pharyngeal contractile peak and UES nadir showed that the UES was not fully relaxed when bolus propulsive forces were at their peak in the youngest infants. Results show developmental changes in infant swallow physiology that can be clearly linked to the effectiveness of nutritive swallowing. Most preterm infants demonstrated poor pharyngeal pressures at the laryngeal inlet coupled with poor coordination of pharyngeal propulsion with UES relaxation. These pressure patterns were less efficient than those demonstrated by older infants who were more adept at feeding. These observations may explain why infants under 34 weeks are physiologically unable to feed effectively and experience frequent choking and fatigue during feeding.

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

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

Oesophageal transport of solid dosage forms depends on body position, swallowing volume and pharyngeal propulsion velocity

Knowledge about transit of solid dosage forms (SDF) in the gastrointestinal tract is incomplete. Detection of magnetically marked capsules (MMC) via superconducting quantum interference device (SQUID) allows monitoring of oesophageal transport of SDF with high tempospatial resolution. The aim of the study was to investigate the influence of body position, volume at swallowing, and oesophageal motility on orogastric transport of SDF. In 360 measurements we determined tempospatial characteristics of orogastric transit of SDFs by a SQUID device in six volunteers. They swallowed MMCs with various amounts of water in upright and supine position with and without simultaneous oesophageal manometry. Orogastric transit time, oesophageal transport velocity and rate of oesophageal retention of SDF depend on swallowing volume and body position at all experimental conditions. At 50 mL water bolus and in upright position, the retention rate depends on the pharyngeal propulsion velocity, and the transport velocity of MMCs in the oesophageal body are faster than the propulsive oesophageal contractions. Body position, swallowing volume and pharyngeal propulsion velocity markedly influence the oesophageal transport of SDF. They should be taken in upright body position with at least 50 mL of water to minimize entrapment in the oesophagus.

Esophageal transit of solid drug forms depends on body position, swallowing volume and pharyngeal propulsion velocity ȁ a magnetic marker monitoring (MMM) study

Esophageal transit of solid drug forms depends on body position, swallowing volume and pharyngeal propulsion velocity ȁ a magnetic marker monitoring (MMM) study

Workshop: Management of adults and children with feeding difficulties secondary to chronic muscle disease, 22nd March 2002, Sheffield, UK

Workshop: Management of adults and children with feeding difficulties secondary to chronic muscle disease, 22nd March 2002, Sheffield, UK

Swallowing disorders in paralysis of the lower cranial nerves: a functional analysis.

Deficits of the lower cranial nerves (nerves IX, X, XI, and XII) occurring after treatment of skull base tumors may cause disabling swallowing disorders. To assess the mechanisms of swallowing disorders involved in such cases, we performed functional examinations: a videoendoscopic swallowing study and simultaneous manometry and videofluoroscopy in 7 patients. This study shows that the main mechanism of the swallowing disorders was a disturbance of the pharyngeal stage, including a decrease of pharyngeal propulsion, reduced laryngeal closure, and cricopharyngeal dysfunction, which led to aspiration. Decreased pharyngeal propulsion was found in 6 patients, with a very high correlation between fiberoscopy and simultaneous manometry-fluoroscopy. The responsibility of the upper esophageal sphincter in swallowing disorders was more difficult to assess. The role of the upper esophageal sphincter and pharyngeal propulsion in the onset of the problem is discussed in regard to the cricopharyngeal myotomy.

Dysphagia in oculopharyngeal muscular dystrophy: a series of 22 French cases

Twenty-two patients (mean age = 67.9 years) with oculopharyngeal muscular dystrophy (OPMD) were referred for dysphagia from 1987 to January 1995. Six patients had suffered aspiration pneumonia, and three had significantly lost weight, while 19 complained of discomfort during swallowing but without weight loss. Swallowing was assessed by fiberscopy during swallowing (last eight patients), videofluoroscopy (12 cases) and manometry (19 cases). Twelve patients underwent a cricopharyngeal (CP) myotomy: 10 showed improvement, one had a partial improvement, and the procedure failed in one (mean follow-up = 29.6 months). In the other cases, CP myotomy was postponed, refused or contraindicated. Of the 22 patients, three died from OPMD consequences. Factors associated with favorable outcome were adequate residual pharyngeal propulsion and no weight loss. In a majority of cases, CP myotomy constitutes an effective treatment of dysphagia with adequate residual propulsion but does not modify the final prognosis and is contraindicated in cases with pharyngeal aperistalsis.

Cricopharyngeal myotomy and arytenoid adduction in the management of combined laryngeal and pharyngeal paralysis.

Aspiration caused by unilateral combined laryngeal and pharyngeal paralysis is a serious clinical problem. This article reviews the abnormal physiology, which includes glottal incompetence, impaired pharyngeal propulsion, and sensory loss, and reports the results of surgical treatment of, 13 patients who had significant dysphagia and aspiration caused by unilateral laryngeal and pharyngeal paralysis. In eight patients the cause was surgical resection or trauma of the tenth cranial nerve, with concomitant twelfth nerve injury in four. Four patients had central lesions. One patient had a surgical tenth cranial nerve injury as well as a stroke. Thyroplasty, alone in two patients, and combined with cricopharyngeal myotomy in a third, improved voice, but not swallowing. In all patients treated by arytenoid adduction plus cricopharyngeal myotomy, aspiration was eliminated, and patients gained weight. Six of these patients had been dependent on enteral tube feedings. The results support the safety and efficacy of simultaneous arytenoid adduction and cricopharyngeal myotomy for dysphagia caused by combined laryngeal and pharyngeal paralysis.

Cricopharyngeal myotomy and arytenoid adduction in the management of combined laryngeal and pharyngeal paralysis

Aspiration caused by unilateral combined laryngeal and pharyngeal paralysis is a serious clinical problem. This article reviews the abnormal physiology, which includes glottal incompetence, impaired pharyngeal propulsion, and sensory loss, and reports the results of surgical treatment of, 13 patients who had significant dysphagia and aspiration caused by unilateral laryngeal and pharyngeal paralysis. In eight patients the cause was surgical resection or trauma of the tenth cranial nerve, with concomitant twelfth nerve injury in four. Four patIents had central lesions. One patient had a surgical tenth cranial nerve injury as well as a stroke. Thyroplasty, alone in two patients, and combined with cricopharyngeal myotomy in a third, improved voice, but not swallowing. In all patients treated by arytenoid adduction plus cricopharyngeal myotomy, aspirationwas eliminated, and patients gained weight. Six of these patients had been dependent on enteral tube feedings. The results support the safety and efficacy of simultaneous arytenoid adduction and cricopharyngeal myotomy for dysphagia caused by combined laryngeal and pharyngeal paralysis. (Otolaryngol Head Neck Surg 1997;116:339-43.)

Role of pharyngeal propulsion as an indicator for upper esophageal sphincter myotomy.

Thirty-eight patients with swallowing disorders underwent cricopharyngeal myotomy. The causes of the disorders were muscular in 12 cases, neurologic in 12, cricopharyngeal achalasia in 7, and unknown in 7. Surgery succeeded in 21 patients, gave a partial improvement in 4, and failed in 13. The quality of residual pharyngeal propulsion on clinical, manometric, and radiologic assessment appeared to be a more important predictor of surgical outcome than upper esophageal sphincter relaxation and the major factor in establishing the indications for cricopharyngeal myotomy. Achalasias in the elderly and oculopharyngeal muscular dystrophies had the most favorable outcome.

The surgical management of motility disorders.

Surgical treatment is either the therapy of choice or a facultative procedure in various types of esophageal motility disorders. In achalasia, cardiomyotomy, frequently combined with fundoplasty, achieves good or excellent results in > 80% of cases, and is, therefore, advised in cases when pneumostatic dilatation fails. Diverticulectomy and myotomy of the upper or lower esophageal sphincter are proven procedures to treat cervical and epiphrenic diverticula, leading to good/excellent results or at least an improvement in more than 95%. If, exceptionally, parabronchial diverticula require therapy, they should be excised transthoracically. Cervical myotomy is indicated in cases of cervical achalasia, when sufficient pharyngeal propulsion is preserved. In systemic diseases like scleroderma reflux induced complications may require surgical intervention in medically intractable cases. In these rather few cases, subtotal gastrectomy with a Roux-en-Y anastomosis is advised. In patients suffering from diffuse esophageal spasm or symptomatic "nutcracker" esophagus, extended esophageal myotomy can relieve symptoms. If a clear diagnosis is provided, about 75% of patients will have an improvement of symptoms.

Normal and disordered swallowing: new insights

Swallowing is a complex sequence of integrated motor events which is programmed entirely within a ‘pattern generator’, the medullary swallow centre. The swallow is not a reflex but rather a programmed response which is only initiated given the right combination of cortical and peripheral sensory cues to the medulla. Interruption of these afferent pathways profoundly influences the ability to initiate a swallow. While the basic sequence of motor events that constitutes a swallow is constant, the temporal relationships among component events are modifiable according to the characteristics of the swallowed bolus. The pathophysiology of dysphagia can be categorized on the basis of dysfunction of one or more of seven broad mechanisms that make up the swallow: bolus preparation, lubrication, oral delivery, palatal closure, airway closure, pharyngeal propulsion and UOS opening. This mechanistic approach originates directly from the videoradiographic observations and provides a rational basis for treatment. Videoradiography is the single most valuable technique in the evaluation of oral pharyngeal dysphagia. Oesophagoscopy and laryngoscopy should be performed in most cases because small tumours in the region can mimic pharyngeal motor disorders and may be easily overlooked. Manometry is providing valuable physiological and pathophysiological information about swallowing but, as an adjunct to videoradiography, only provides additional important information in the minority of patients undergoing investigation.