Puree Bolus Research Articles

A Large Cohort Analysis of Epiglottic Phenotypes and Pharyngeal Residue.

To describe the phenotypic characteristics of the epiglottis at rest and their impact on vallecular residue. Videofluoroscopic studies (VFSS) were pooled from 2 Laryngology practices, and Image J was used to measure epiglottic anatomic features at rest. Studies were rated by the MBSImp and presence of vallecular residue following swallow of thin and puree boluses. A conditional inference tree analysis was performed to isolate which epiglottic parameters were risk factors for presence of vallecular reside followed by logistic regression. The majority of patients had a normal shaped epiglottis, followed by omega shape. The mean angle of the epiglottis from the hyoid was approximately 90°. Only abnormal epiglottic movement was associated with increased risk of residue for thin boluses (OR 35.09, CI 10.93-158.66, P < .001). However, in those with normal epiglottic movement, age >70 years old was associated with increased risk of residue (OR 3.98, CI 1.73-9.23, P = .001). For puree boluses, a normal or omega shaped epiglottis was associated with residue (OR 5.19, CI 2.41-11.51, P < .001), and this relationship was further modulated by increased distance of the epiglottic tip from the posterior pharyngeal wall. No other anatomic features of the resting epiglottis were associated with residue. Comorbidities potentially affecting swallow were infrequent in the cohort and were not associated with residue. Abnormal epiglottic movement is associated with aspiration, and in this study we find that abnormal epiglottic movement increases the risk of vallecular residue and that older age is a risk factor for residue. The resting properties of the epiglottis do not appear to be associated with abnormal epiglottic movement or residue.

Airway Protection in Children With Dysphagia: A Preliminary Study

Purpose : The physiology and pathophysiology of pediatric swallowing are challenging due to anatomical differences. There are only a few videofluoroscopic case studies examining the relationship between physiologic events and aspiration in infants, especially, airway protection mechanisms using temporal measurements. This study examined the airway protection mechanisms using two temporal measurements: the initiation and duration of laryngeal closure between two groups of children who were referred for dysphagia evaluation.BRMethods : Twelve children (8 younger and 4 older children) were patriciate in the study. Initiation of laryngeal closure (ILC) and laryngeal closure duration (LCD) were measured using videofluoroscopic swallowing examinations (VFSEs) with a 100-ms timer for bottle-fed or 2mL thin liquids and/or puree boluses. Two-way analysis of variance (ANOVA) was used at a significance level of p.05.BRResults : Younger children showed longer LCD than older children. There was no significant difference in ILC between younger and older children with dysphagia. The puree had longer ILC and shorter LCD than the thin liquid bolus.BRConclusions : The longer duration of laryngeal closure in younger children may indicate that their anatomical structure is more prone to better protect their airways than older children. Longer ILC and shorter LCD were observed in both children groups who presented penetration or aspiration. These pathophysiological phenomena should be observed closely as indicators of the higher risk of dysphagia. Bolus modification such as thickened liquid may help the children to keep from aspiration.

Role of distention in swallow phase transition

The effect of pharyngeal and esophageal distention on swallow phase transition has not been fully elucidated. In quadrupeds we hypothesize pharyngeal to esophageal (P:E) ratio is dependent on distention of the pharynx and/or esophagus to trigger a phase transition. To this effect videofluoroscopy was performed on 8 cats using liquid and puree consistencies laced with 40% barium. Awake cats were given 30 seconds after food/liquid presentation to initiate eating/drinking. Using MicroDicom viewer software (MicroDICOM; Sofia, Bulgaria) diameter was calibrated using an object placed in the viewing field (i.e. dime). The diameter of the pharynx, upper esophageal sphincter opening, and bolus size in the esophagus were measured. There was a significant difference between the tolerated pharyngeal distention between liquid (9.5 ± 1.9 mm) and puree (12.6 ± 2.5 mm) boluses (p=0.01), as well as esophageal distention between liquid (6.5 ± 1.9 mm) and puree (8.3 ± 2.2) boluses (p&lt;0.05). The average distention of the UES was not significantly different (p&gt; 0.05) with a diameter of 7.8 ± 2.0 mm for liquid versus 9.0 ± 2.0 mm for puree. The ratio of pharyngeal to esophageal phase swallows range from 2–6 in liquid boluses and 1–3 in puree boluses. The variable pharyngeal to esophageal phase ratio supports the hypothesis that transition through each phase of swallow is driven by distention of the pharyngeal and esophageal walls and not by a set P:E ratio.Support or Funding InformationSupported by R00‐ HL 111215 and The Kentucky Spinal Cord and Head injury Trust.This abstract is from the Experimental Biology 2018 Meeting. There is no full text article associated with this abstract published in The FASEB Journal.

Developmental changes in pharyngeal swallowing acoustics: a comparison of adults and children

This study examined developmental differences in the acoustics of pharyngeal swallowing. Thirty-one young children (M = 4.5 years) and 29 adults (M = 22.5 years) were recorded swallowing thin liquid and puree boluses. In comparison with adults, children showed longer total swallow sound duration and duration to peak intensity, as well as greater variability in the duration to peak intensity and mean of the averaged spectrum in Hz. Thin and puree boluses differed in measures of duration, intensity and frequency of the averaged sound spectrum, although these effects did not interact with age. The increased variability in swallowing observed in children paralleled that found in acoustic measures of vowel formants, although speech and swallowing acoustic measures were uncorrelated. Using Formant 2 frequency as a proxy measure of vocal tract length, the age differences in swallowing acoustics appear to be independent of physical size, although associations between duration to peak intensity and pharyngeal size warrant further investigation. These findings suggest acoustic measures of swallowing are sensitive to developmental status, possibly reflecting ongoing refinement of the pharyngeal swallow across childhood, and support continued research into the use of digital cervical auscultation as a tool to assess the efficiency and stability of the swallowing neuromuscular control system in children and adults.

Co-occurrence of Dystonic and Dyskinetic Tongue Movements with Oral Apraxia in Post-regression Dysphagia in Classical Rett Syndrome Years of Life 1 Through 5.

We do not know the natural history of dysphagia in classical Rett syndrome (RTT) by stage or age. This study investigated swallowing physiology in 23 females ages 1:7 to 5:8 (years, months) with classical Rett syndrome to determine common and distinguishing features of dysphagia in post-regression early Pseudostationary Stage III. In-depth analysis of videofluoroscopic swallowing studies (VFSS) found dysmotility of oral stage events across subjects implicating oral apraxia. Impaired motility was further compromised by recurrent dystonic and dyskinetic movements that co-occurred with oral apraxia during oral ingestion in 78% (n=18) of the subjects with RTT. Of this group, 44% displayed rocking and/or rolling lingual pattern, 56% had recurrent oral tongue retroflexions, and/or elevated posturing of the tongue tip, and, 72% displayed multi-wave oropharyngeal transfer pattern. The proportion of subjects whose swallowing motility was disrupted by aberrant involuntary tongue movements did not differ significantly between bolus types (liquid, puree, and solid) trialed. Liquid ingestion was significantly more efficient in subjects using bottles with nipples than their counterparts who used spouted or straw cups. Dystonic and dyskinetic tongue movements disrupted liquid ingestion in subjects using cups with spouts or straws significantly more than those using bottles. Analysis of food ingestion revealed that significantly more subjects were able to orally form, transport, and transfer a puree bolus into the pharynx than they were a solid bolus. A significantly larger number of subjects aspirated and penetrated liquid than they did puree or solid. No significant relationship was found between subjects with airway contamination and those with dystonic and dyskinetic tongue movements. Subjects' rocking and rolling lingual patterns were consistent with those evidenced in adults with Parkinson's disease. Subjects' tongue retroflexions were classified as provisionally unique to RTT. VFSS pre-planning, fluoroscopic procedures, and therapeutic strategies specific to this specialty population were derived.

L04 Assessing dysphagia in Huntington's disease using Fiberoptic Endoscopic Evaluation of Swallowing (FEES)

BackgroundDysphagia is a common problem in Huntington's disease (HD) that requires attention and adequate management. Instrumental assessments to visualise the structure and functions of the different stages of swallowing and...

Nil per os except medications order in the dysphagic patient

To demonstrate why the 'nil per os except medications' order is contraindicated prior to dysphagia testing and to recommend ways to prevent aspiration of medications in the dysphagic population. A 71-year-old male deemed at-risk for aspiration due to coughing when drinking thin liquids was made nil per os except medications and referred for dysphagia testing. Swallowing was analyzed objectively with trans-nasal fiberoptic endoscopic evaluation of swallowing. Aspiration on the initial 5 cc puree bolus swallow trial elicited a cough reflex. A 325 mg, 1 cm diameter, enteric coated aspirin pill emerged from the trachea, progressed through the glottis and remained transiently in the laryngeal vestibule before lodging, along with pudding residue, in a mucosal fold of the left vallecula. Neither volitional coughing nor single 5 cc water bolus swallows dislodged the pill. Otolaryngology was called and removed the pill trans-orally under direct visualization with a Kelly clamp. The pill maintained both its enteric coating and integrity for a total of 7.5 h after being aspirated. The nil per os except medications order is contraindicated in the dysphagic population. When aspiration is suspected, nil per os including medications is recommended until dysphagia testing determines what form of medication can be swallowed safely.

A Dilemma in Dysphagia Management: Is Aspiration Pneumonia the Chicken or the Egg?

A Dilemma in Dysphagia Management: Is Aspiration Pneumonia the Chicken or the Egg?

Effect of Nasogastric Tubes on Incidence of Aspiration

Leder SB, Suiter DM. Effect of nasogastric tubes on incidence of aspiration. Objective To determine what effect, if any, a nasogastric (NG) tube has on occurrence of anterograde aspiration during objective evaluation of swallowing using both liquid and puree bolus consistencies. Design Prospective, consecutive. Setting Large, urban, tertiary care, teaching hospital. Participants Referred sample of 1260 consecutively enrolled inpatients. Group 1 (n=630; 346 male, 284 female) had an NG tube and group 2 (n=630; 360 male, 270 female) did not have an NG tube at time of referral for dysphagia evaluation. Intervention Fiberoptic endoscopic evaluation of swallowing (FEES). Main Outcome Measure Aspiration status. Results A Pearson chi-square indicated no significant differences ( P>.05) for aspiration of either liquid or puree food consistencies dependent on presence of an NG tube. Separate binary logistic regression analyses were used to determine if the presence of an NG tube interacted with participants’ age to affect the dependent variables of liquid and puree aspiration. There were no significant effects for liquid aspiration (odds ratio [OR]=1.004, P>.05; 95% confidence interval [CI], 0.987−1.021) or puree aspiration (OR=0.992, P>.05; 95% CI, 0.971−1.014). In addition, no significant interactions ( P>.05) were found between NG tube status and sex, age, or diagnostic category, and presence of an NG tube did not significantly increase the odds of either liquid aspiration (OR=1.092, P>.05; 95% CI, 0.842−1.418) or puree aspiration (OR=0.975, P>.05; 95% CI, 0.713−1.333). Last, subjects between 60 and 90 years of age, regardless of NG tube status, aspirated more frequently than younger subjects. Conclusions No statistically significant differences were found regarding aspiration status for liquid or puree food consistencies between 2 separate but comparable groups, that is, one with and one without an NG tube, regardless of sex, age, or diagnostic category. Because objective swallowing evaluation, for example, FEES, can be performed with an NG tube in place, it is not necessary to remove an NG tube to evaluate dysphagia. Similarly, there is no contraindication to leaving an NG tube in place to supplement oral alimentation.

Incidence of Vocal Fold Immobility in Patients with Dysphagia

This study prospectively investigated the incidence of vocal fold immobility, unilateral and bilateral, and its influence on aspiration status in a referred population of 1452 patients for a dysphagia evaluation from a large, urban, tertiary-care, teaching hospital. Main outcome measures included overall incidence of vocal fold immobility and aspiration status, with specific emphasis on age, etiology, and side of vocal fold immobility, i.e., right, left, or bilateral. Overall incidence of vocal fold immobility was 5.6% (81 of 1452 patients), including 47 males (mean age 55.7 yr) and 34 females (mean age 59.7 yr). In the subgroup of patients with vocal fold immobility, 31% (25 of 81) exhibited unilateral right, 60% (49 of 81) unilateral left, and 9% (7 of 81) bilateral impairment. Overall incidence of aspiration was found to be 29% (426 of 1452) of all patients referred for a swallow evaluation. Aspiration was observed in 44% (36 of 81) of patients presenting with vocal fold immobility, i.e., 44% (11 of 25) unilateral right, 43% (21 of 49) unilateral left, and 57% (4 of 7) bilateral vocal fold immobility. Left vocal fold immobility occurred most frequently due to surgical trauma. A liquid bolus was aspirated more often than a puree bolus. Side of vocal fold immobility and age were not factors that increased incidence of aspiration. In conclusion, vocal fold immobility, with an incidence of 5.6%, is not an uncommon finding in patients referred for a dysphagia evaluation in the acute-care setting, and vocal fold immobility, when present, was associated with a 15% increased incidence of aspiration when compared with a population already being evaluated for dysphagia.

Responding to the Dysphagia Consult: A Report-Writing Primer

Responding to the Dysphagia Consult: A Report-Writing Primer

Swallowing physiology of toddlers with long-term tracheostomies: a preliminary study.

This study investigated the swallowing physiology of toddler-aged patients with long-term tracheostomies. Structural movements and motility of the pharyngeal stage of swallowing were studied in four toddlers ranging in age from 1:2 (years:months) to 2:9 with long-term tracheostomies. A patient aged 1:2 years with no tracheostomy served as a toddler model for comparison. Videofluoroscopic recordings of the patients' liquid and puree bolus swallows were analyzed for a) onset times for pharyngeal stage events, laryngeal vestibule closure, and tracheostomy tube movement; b) timeliness of swallow response initiation; and c) pharyngeal transport function. Results found differences in timing of pharyngeal stage movements between the tracheostomized patients and the patient with no tracheostomy. Laryngeal vestibule closure occurred before or within the same 0.033-s video frame as onset of upper esophageal sphincter (UES) opening in the patient with no tracheostomy, but occurred 0.033-.099 s after onset of UES opening in the tracheostomized patients. The time line required to close the laryngeal vestibule once the arytenoids began their anterior movement was longer in the tracheostomized patients than in the patient with no tracheostomy and was associated with laryngeal penetration. The patient with no tracheostomy displayed superior excursion of the arytenoid and epiglottis during the swallowing; the tracheostomized patients did not. No association was found between onset of tracheostomy tube movement and laryngeal vestibule closure. Delayed swallow response initiation was observed across tracheostomized patients at a mean frequency of 45% with associated penetration. Pharyngeal dysmotility was not observed. Findings supported the concept that long-term tracheostomy in toddler-aged patients affects swallowing physiology.