Bolus Retention Research Articles

Is oropharyngoesophageal scintigraphy the method of choice for assessing dysphagia in systemic sclerosis? A single center experience

ObjectivesTo evaluate the performance of oropharyngoesophageal scintigraphy (OPES) in the assessment of dysphagia in patients with systemic sclerosis (SSc), and to compare OPES results with those of barium esophagogram.MethodsAdult SSc patients who underwent OPES for the assessment of dysphagia were enrolled. OPES was performed with both liquid and semisolid boluses and provided information regarding oropharyngeal transit time, esophageal transit time (ETT), oropharyngeal retention index (OPRI), esophageal retention index (ERI), and site of bolus retention. Barium esophagogram results were also collected.ResultsFifty-seven SSc patients (87.7% female, mean age 57.7 years) with dysphagia were enrolled. OPES identified at least one alteration in each patient and findings were generally worse for the semisolid bolus. Esophageal motility was widely impaired with 89.5% of patients with an increased semisolid ERI, and middle-lower esophagus was the most frequent site of bolus retention. However, oropharyngeal impairment was highlighted by widespread increased OPRI, especially in anti-topoisomerase I positivity. Older patients and with longer disease duration presented slower semisolid ETT (p = 0.029 and p = 0.002, respectively). Eleven patients with dysphagia had a negative barium esophagogram: all of them presented some alterations in OPES parameters.ConclusionOPES revealed a marked SSc esophageal impairment, in terms of both slowed transit time and increased bolus retention, but also shed light on oropharyngeal swallowing alterations. OPES showed high sensitivity, being able to detect swallowing alterations in dysphagic patients with negative barium esophagogram. Therefore, the use of OPES for the assessment of SSc-related dysphagia in clinical practice should be promoted.

Indication for the endoscopic treatment of Zenker’s diverticula

: Zenker’s diverticulum (ZD) is a false pulsion diverticulum located in Killian’s triangle. It accounts for about 70% of all esophageal diverticula. ZD incidence is uncommon, and it is mostly present in the elderly population. Although the pathophysiology has not been completely elucidated, an impaired relaxation of the cricopharyngeal muscle (CPM) has been identified as the leading mechanism. For this reason, the current therapeutic modalities are based on CPM myotomy to eliminate diverticular bolus retention, improve bolus flow, relieve outflow obstruction, and mitigate neuromotor impairment. The conventional open approach through a left cervicotomy has been mostly replaced by transoral techniques using either rigid endoscopy or flexible endoscopes. The minimally invasiveness of these techniques allows for reinterventions in case of recurrence. Endoscopic techniques present several advantages in terms of lower risk of adverse events, can be accomplished without the need for general anesthesia and neck hyperextension, and provide for a rapid patient recovery. The recent introduction of cutting-edge technology Z-POEM allows through a direct septal visualization for a complete myotomy, leading to a lower recurrence rate and higher symptoms resolution than endoscopic septotomy. The potential advantages also account for lower complication rates making it a promising technique.

Chicago Classification update (V4.0): Technical review on diagnostic criteria for ineffective esophageal motility and absent contractility.

Esophageal hypomotility disorders manifest with abnormal esophageal body contraction vigor, breaks in peristaltic integrity, or failure of peristalsis in the context of normal lower esophageal sphincter relaxation on esophageal high-resolution manometry (HRM). The Chicago Classification version 4.0 recognizes two hypomotility disorders, ineffective esophageal motility (IEM) and absent contractility, while fragmented peristalsis has been incorporated into the IEM definition. Updated criteria for ineffective swallows consist of weak esophageal body contraction vigor measured using distal contractile integral (DCI, 100-450mmHg·cm·s), transition zone defects >5cm measured using a 20mmHg isobaric contour, or failure of peristalsis (DCI<100mmHg·cm·s). More than 70% ineffective swallows and/or ≥50% failed swallows are required for a conclusive diagnosis of IEM. When the diagnosis is inconclusive (50%-70% ineffective swallows), supplementary evidence from multiple rapid swallows (absence of contraction reserve), barium radiography (abnormal bolus clearance), or HRM with impedance (abnormal bolus clearance) could support a diagnosis of IEM. Absent contractility requires 100% failed peristalsis, consistent with previous versions of the classification. Consideration needs to be given for the possibility of achalasia in absent contractility with dysphagia despite normal IRP, and alternate complementary tests (including timed upright barium esophagram and functional lumen imaging probe) are recommended to confirm or refute the presence of achalasia. Future research to quantify esophageal bolus retention on stationary HRM with impedance and to understand contraction vigor thresholds that predict bolus clearance will provide further refinement to diagnostic criteria for esophageal hypomotility disorders in future iterations of the Chicago Classification.

Evaluating esophageal motility beyond primary peristalsis: Assessing esophagogastric junction opening mechanics and secondary peristalsis in patients with normal manometry.

Functional luminal imaging probe (FLIP) Panometry assesses the esophageal response to distention and may complement the assessment of primary peristalsis on high-resolution manometry (HRM). We aimed to investigate whether FLIP Panometry provides complementary information in patients with normal esophageal motility on HRM. Adult patients that completed FLIP and had an HRM classification of normal motility were retrospectively identified for inclusion. 16-cm FLIP studies performed during endoscopy were evaluated to assess EGJ distensibility, secondary peristalsis, and identify an abnormal response to distention involving sustained LES contraction (sLESC). Clinical characteristics and esophagram were assessed when available. Of 164 patients included (mean(SD) age 48(16) years, 75% female), 111 (68%) had normal Panometry with EGJ-distensibility index (DI) ≥2.0 mm2 /mmHg, maximum EGJ diameter ≥16mm and antegrade contractions. Abnormal EGJ distensibility was observed in 44/164 (27%), and 38/164 (23%) had an abnormal contractile response to distension. sLESC was observed in 11/164 (7%). Among 68 patients that completed esophagram, abnormal EGJ distensibility was more frequently observed with an abnormal esophagram than normal EGJ opening: 14/23 (61%) vs 10/45 (22%); P=0.003. Epiphrenic diverticula were present in 3/164 patients: 2/3 had sLESC. Symptomatic patients with normal esophageal motility on HRM predominantly have normal FLIP Panometry; however, abnormal FLIP findings can be observed. While abnormal Panometry findings appear clinically relevant via an association with abnormal bolus retention, complementary tests, such as provocative maneuvers with HRM and timed barium esophagram, are useful to determine clinical context.

Are there any differences between the tongue and posterior pharyngeal wall movement patterns during normal and Masako swallow?—An ultrasound analysis

Parkinson's disease (PD) is a neurodegenerative movement disorder affecting volitional movement due to Dopamine-producing neuron death in the substantia nigra. Impaired swallow function is highly prevalent with nearly 100% involvement in PD during the disease course and involves all three phases of swallowing. The oral stage of swallowing is impaired first. Reduced bolus control and reduced interior-to-posterior movement of the bolus transfer lead to delayed swallowing response, premature spillage, decreased base of tongue (BOT) retraction and strength, decreased hyolaryngeal elevation and excursion, and reduced action of pharyngeal constrictors. Together, these result in bolus retention, residue throughout the pharynx, and reduced airway protection leading to significant aspiration. To target these deficits we have designed an exercise regime to teach early to mid-stage PD patients to do the Masako swallow maneuver of saliva (swallow with tongue-tip held between teeth), with high intensity and frequency (i.e., 120 repetitions per day) in one month. The preliminary results are very promising. All participants demonstrated positive changes. To understand the underlying mechanism, we used Ultrasound and recorded 20 normal subjects while they did three normal swallows and 3 Masako swallow maneuvers. The initial observations indicated the tongue and pharyngeal movement patterns differ between the two maneuvers.

Are there any differences between the tongue and posterior pharyngeal wall movement patterns during normal and Masako swallow?—An ultrasound analysis

Parkinson’s disease (PD) is a neurodegenerative movement disorder affecting volitional movement due to Dopamine-producing neuron death in the substantia nigra. Impaired swallow function is highly prevalent with nearly 100% involvement in PD during the disease course and involves all three phases of swallowing. The oral stage of swallowing is impaired first. Reduced bolus control and reduced interior-to-posterior movement of the bolus transfer lead to delayed swallowing response, premature spillage, decreased base of tongue (BOT) retraction and strength, decreased hyolarygneal elevation and excursion, and reduced action of pharyngeal constrictors. Together, these result in bolus retention, residue throughout the pharynx, and reduced airway protection leading to significant aspiration. To target these deficits we have designed an exercise regime to teach early to mid-stage PD patients to do the Masako swallow maneuver of saliva (swallow with tongue-tip held between teeth), with high intensity and frequency (i.e., 120 repetitions per day) in one month. The preliminary results are very promising. All participant demonstrated positive changes. To understand the underlying mechanism, we used Ultrasound and recorded 20 normal subjects while they did three normal swallows and 3 Masako swallow maneuver. The initial observations indicated the tongue and pharyngeal movement patterns differ between the two maneuvers.Parkinson’s disease (PD) is a neurodegenerative movement disorder affecting volitional movement due to Dopamine-producing neuron death in the substantia nigra. Impaired swallow function is highly prevalent with nearly 100% involvement in PD during the disease course and involves all three phases of swallowing. The oral stage of swallowing is impaired first. Reduced bolus control and reduced interior-to-posterior movement of the bolus transfer lead to delayed swallowing response, premature spillage, decreased base of tongue (BOT) retraction and strength, decreased hyolarygneal elevation and excursion, and reduced action of pharyngeal constrictors. Together, these result in bolus retention, residue throughout the pharynx, and reduced airway protection leading to significant aspiration. To target these deficits we have designed an exercise regime to teach early to mid-stage PD patients to do the Masako swallow maneuver of saliva (swallow with tongue-tip held between teeth), with high intensity and frequency ...

Recent advances in dysphagia management.

The literal definition of dysphagia is “disturbed eating”. However, it is more accurately described in clinical practice as a sensation of food or liquid being stuck in the esophagus or chest. If this sensation is associated with pain, it is labeled odynophagia, and if it is associated with persistent obstruction and bolus retention, it is categorized as a food impaction. Through research and technological advances, we continue to expand our understanding of the etiologies and underlying pathophysiology relating to this complaint. However, for now, our clinical algorithms focus on endoscopy and manometry to break down dysphagia into three categories: obstructive dysphagia, esophageal motility disorders, and functional dysphagia. Here, we review some critical pitfalls in our current clinical diagnoses, new proposed underlying mechanisms of esophageal motor disorders, and developing technologies to aid in diagnosis and treatment.

Swallowing Analyses of Neonates and Infants in Breastfeeding and Bottle-feeding: Impact on Videofluoroscopy Swallow Studies.

Introduction Dysphagia, when left untreated, can result in an increase in morbidity and mortality rates, especially among infants with history of life-threatening neonatal diseases. The videofluoroscopy swallowing study (VFSS) is considered the gold standard for the diagnosis of dysphagia. There are few imaging studies of infant swallowing based on videofluoroscopy, none of which were performed during breast-feeding. Objective To analyze the similarities and differences in infant swallowing function –regarding the feeding method – breast or bottle – and the impact on videofluoroscopy findings. Methods A retrospective study of 25 VFSSs of breastfeeding and bottle-feeding infants was performed. The studied variables were: oral capture and control; tongue versus mandible movement coordination; sucking pattern; mandible excursion; liquid flow; bolus retention; laryngeal penetration; tracheal aspiration; clearing of material collected in the pharynx; and gastroesophageal reflux (GER). Results The study showed a statistically significant association between nipple/areole capture; oral control; sucking pattern; mandibular excursion; liquid flow and feeding method. The velar sealing deficit, the place that trigger the pharyngeal swallow, food retention in the pharyngeal recesses, laryngeal penetration and GER were also factors associated with the feeding method. Conclusion The analysis of the swallowing characteristics of both feeding methods revealed significant differences between them, with an impact on the diagnosis in the VFSSs, especially regarding velar function.

Diagnosis of achalasia

The incidence of achalasia is increasing over the recent decade due to the improvement of both the diagnosis methods and management strategies. Clinical investigation focused on symptom and severity evaluation is the fundamental step in the diagnosis algorithm. Upper endoscopy is a necessary examination for achalasia to rule out the malignancy and to determine a differential diagnosis. Barium esophagram shows the typical “bird beak” sign, and the time barium esophagram could provide a quantitative evaluation of esophageal luminal dilation and bolus retention. High resolution manometry (HRM) is the “gold standard” for achalasia, the updated Chicago classification defines the different subtypes of achalasia which are related to the treatment outcomes. The endoscopic functional luminal imaging probe (EndoFLIP) is a new technique which is able to measure the esophagogastric junction (EGJ) distensibility in achalasia patients and also a promising way to detect the contractility of the esophageal body among these patients.

High-resolution impedance manometry parameters in the evaluation of esophageal function of non-obstructive dysphagia patients.

High-resolution impedance manometry (HRIM) allows evaluation of esophageal bolus retention, flow, and pressurization. We explored novel HRIM measures and assessed their temporal relationship to dysphagia symptoms for boluses of different volume and consistency in non-obstructive dysphagia (NOD) patients. Thirty-three NOD patients (n=19 minor or no disorder of peristalsis ("Normal") and n=14 esophagogastric junction outflow obstruction ("EGJOO")) were evaluated with HRIM. Patients were administered 5 and 10mL liquid, semisolid, and 2 and 4cm solid boluses and indicated bolus perception during individual swallows using a 5-point Likert scale. HRIM was analyzed to assess Chicago Classification and pressure flow metrics, esophageal impedance integral (EII) ratio, and bolus flow time (BFT). Overall, bolus perception increased with increasing bolus consistency (P<0.001), but did not differ significantly between EGJOO and Normal patients. EGJOO patients had higher IRP4, higher levels of bolus residual (ie, EII ratio and IR), and restricted esophageal emptying. The results for linking semisolid bolus perception to semisolid-derived measures revealed more biomechanically plausible and consistent patterns when compared to those derived for liquid boluses. In Normal patients, perception of boluses of heavier viscosity was related to higher bolus flow resistance during transport, whilst in EGJOO, perception was related to restriction of esophageal emptying. These novel pressure-impedance measures may aid in the evaluation of NOD patients by revealing abnormal motor patterns, which may explain symptom generation. Future studies are needed to evaluate which of these measures are worthy of calculation and to establish protocol settings that allow for their meaningful interpretation.

Chronic Cough Is Associated With Long Breaks in Esophageal Peristaltic Integrity on High-resolution Manometry.

Background/AimsBreaks in the peristaltic contour on esophageal high-resolution manometry (HRM) may be associated with bolus retention in the esophagus. We evaluated the relationship between peristaltic breaks and esophageal symptoms, reflux exposure, and symptom outcomes in a prospective patient cohort.MethodsTwo hundred and eighteen patients (53.2 ± 0.9 years, 68.3% female) undergoing both pH-impedance testing and HRM over a 5–year period were prospectively evaluated. Demographics, symptom presentation, acid exposure time, symptom association probability, and symptom burden scores were collected. Outcomes were assessed on follow-up using changes in symptom scores. Presence of long breaks (≥ 5 cm) on HRM was assessed by a blinded author. Relationships between breaks, reflux parameters, presenting symptoms, and outcomes were assessed.ResultsPatients with long breaks were more likely to have cough as a presenting symptom than those without (43.4% vs 28.6%, P = 0.024); statistical differences were not demonstrated with other symptoms (P ≥ 0.3). Numbers of swallows with long breaks were higher in patients with cough compared to those without (2.4 ± 0.3 vs 1.6 ± 0.2, P = 0.021); differences were not found with other symptoms (P ≥ 0.4). Long breaks were not associated with age, gender, race, reflux burden, symptom association, or changes in symptom metrics (P ≥ 0.1 for all comparisons). Among patients with cough, the presence of long breaks predicted suboptimal symptom improvement with antireflux therapy (P = 0.018); this difference did not hold true for other symptoms (P ≥ 0.2).ConclusionsLong breaks in esophageal peristaltic integrity are associated with cough. The presence of long breaks is associated with suboptimal benefit from antireflux therapy.

Clinical Application of Flexible Endoscopic Evaluation of Swallowing in Stroke.

This article aims to review the use of laryngoscopy to assess swallowing function in the stroke population. Since its inception in 1988, fiberoptic endoscopic evaluation of swallowing (FEES) has become an established procedure with distinct objective findings and practical applications, enabling many to choose it as the primary instrumental tool in evaluating poststroke dysphagia. In this article, we outline the decision-making process of when to use FEES. We highlight considerations for the acute stroke patient and visual signs that guide decision making during a FEES, such as secretions, swallowing frequency, and pharyngeal squeeze elicitation. The application of the ice chip protocol for stroke patients who have been nil per os is discussed, along with common observable events on FEES performed on stroke patients like a delay, penetration/aspiration, and bolus retention. Finally, we briefly review testing interventions and follow-up readiness with FEES.

Análise do deslocamento do bolo alimentar: comparação entre o esôfago saudável e modelo de megaesôfago chagásico

RESUMO Objetivo: estudar a dinâmica do comportamento do esôfago humano quando afetado por doença de Chagas e propor um controlador orgânico para auxiliar no aperistaltismo do órgão. Métodos: um modelo de massa, mola e amortecedor foi proposto para modelar o deslocamento do bolo alimentar no esôfago durante a ação peristáltica. Foram utilizados parâmetros da literatura para simular o megaesôfago chagásico e o saudável. Resultados: foram analisadas as curvas de velocidade e deslocamento de ambos os modelos e identificou-se as diferenças dinâmicas entre o órgão saudável e um doente. O deslocamento de alimentos em um tipo de Chagas megaesófago II (3 centímetros de dilatação) é apenas 11,84% do deslocamento num esófago saudável. Conclusão: a doença de chagas gera uma velocidade próxima de zero e um alto amortecimento na curva de descida do alimento que devido ao peristaltismo o deslocamento que não pode retornar ao seu estado inicial, o que comprova a retenção do bolo alimentar. Com o sistema de controle orgânico proposto obteve-se uma aproximação das curvas a um comportamento dinâmico próximo do modelo do órgão saudável, minimizando a retenção do alimento.

Collet-Sicard Syndrome With Hypoglossal Nerve Schwannoma: A Case Report.

Collet-Sicard syndrome is a rare syndrome that involves paralysis of 9th to 12th cranial nerves. We report an uncommon case of schwannoma of the hypoglossal nerve in a 39-year-old woman presented with slurred speech, hoarse voice, and swallowing difficulty. Physical examination revealed decreased gag reflex on the right side, decreased laryngeal elevation, tongue deviation to the right side, and weakness of right trapezius muscle. MRI revealed a mass lesion in the right parapharyngeal space below the jugular foramen. The tumor was surgically removed. It was confirmed as hypoglossal nerve schwannoma via pathologic examination. Videofluoroscopic swallowing study revealed aspiration of liquid food and severe bolus retention in the vallecula and piriform sinus. Laryngoscopy revealed right vocal cord palsy. Electrodiagnostic study revealed paralysis of the right 11th cranial nerve. In summary, we report an uncommon case of schwannoma of the hypoglossal nerve with 9th to 12th cranial nerve palsy presenting as Collet-Sicard syndrome.

High-resolution impedance manometry parameters enhance the esophageal motility evaluation in non-obstructive dysphagia patients without a major Chicago Classification motility disorder.

High-resolution impedance manometry (HRIM) allows evaluation of esophageal bolus retention, flow, and pressurization. We aimed to perform a collaborative analysis of HRIM metrics to evaluate patients with non-obstructive dysphagia. Fourteen asymptomatic controls (58% female; ages 20-50) and 41 patients (63% female; ages 24-82), 18 evaluated for dysphagia and 23 for reflux (non-dysphagia patients), with esophageal motility diagnoses of normal motility or ineffective esophageal motility, were evaluated with HRIM and a global dysphagia symptom score (Brief Esophageal Dysphagia Questionnaire). HRIM was analyzed to assess Chicago Classification metrics, automated pressure-flow metrics, the esophageal impedance integral (EII) ratio, and the bolus flow time (BFT). Significant symptom-metric correlations were detected only with basal EGJ pressure, EII ratio, and BFT. The EII ratio, BFT, and impedance ratio differed between controls and dysphagia patients, while the EII ratio in the upright position was the only measure that differentiated dysphagia from non-dysphagia patients. The EII ratio and BFT appear to offer an improved diagnostic evaluation in patients with non-obstructive dysphagia without a major esophageal motility disorder. Bolus retention as measured with the EII ratio appears to carry the strongest association with dysphagia, and thus may aid in the characterization of symptomatic patients with otherwise normal manometry.

Motility characteristics in the transition zone in Gastroesophageal Reflux Disease (GORD) patients.

BackgroundDefects in distal oesophageal peristalsis was thought to be an indication of incomplete bolus transit (BT). However, the role of transition zone (TZ) defects in the BT in gastroesophageal reflux disease (GORD) patients needs clarification. The aim of this study was to assess the TZ defects in GORD patients and to explore the relationship between TZ defects and BT.MethodsOne hundred and two patients with reflux symptoms and 20 healthy adults were included in the study. All subjects underwent upper gastrointestinal endoscopy, high resolution impedance manometry (HRiM) and 24-h ambulatory multichannel impedance-pH (MII-pH) monitoring. Patients were subgrouped into reflux oesophagitis (RE), non-erosive reflux disease (NERD), hypersensitive oesophagus (HO) and functional heartburn (FH) classified following MII-pH monitoring. Oesophageal pressure topography was analysed to define TZ defects by spatial or temporal TZ measurements exceeding 2 cm or 1 s, weak and fragmented swallows were excluded, and the association between TZ and BT was investigated.ResultsFollowing liquid swallows, there were no significant differences in TZ delay time and TZ length between groups (RE: 1.75 s (1.32–2.17) and 2.50 cm (2.40–3.20); NERD: 1.60 s (1.10–2.00) and 2.20 cm (2.10–2.65); HO: 1.60 s (1.30–1.80) and 2.70 cm (2.30–3.00); FH: 1.55 s (1.20–2.17) and 3.10 cm (2.25–5.00); Healthy volunteers: 1.50 s (1.20–1.90) and 2.30 cm (2.10–3.00). However, individuals with TZ defects had lower complete BT rates compared with those without TZ defects (p < 0.001). There were also significantly more incomplete BT in patients with RE, HO and FH than in healthy controls (p < 0.05).ConclusionsIn GORD patients, TZ defects correlated with proximal bolus retention in the corresponding area independent of distal weak peristalsis.Electronic supplementary materialThe online version of this article (doi:10.1186/s12876-016-0525-1) contains supplementary material, which is available to authorized users.

Impaired bolus clearance in asymptomatic older adults during high-resolution impedance manometry.

Dysphagia becomes more common in old age. We performed high-resolution impedance manometry (HRIM) in asymptomatic healthy adults (including an older cohort >80years) to assess HRIM findings in relation to bolus clearance. Esophageal HRIM was performed in a sitting posture in 45 healthy volunteers (n=30 young control, mean age 37±11years and n=15 older subjects aged 85±4years) using a 3.2-mm solid-state catheter (Solar GI system; MMS, Enschede, The Netherlands) with 25 pressure (1-cm spacing) and 12 impedance segments (2-cm intervals). Five swallows each of 5- and 10-mL liquid and viscous bolus were performed and analyzed using esophageal pressure topography metrics and Chicago classification criteria as well as pressure-flow parameters. Bolus transit was determined using standard impedance criteria. A p-value <0.05 was considered significant. Impaired bolus clearance occurred more frequently in asymptomatic older subjects compared with young controls (YC) during liquid (40 vs 18%, χ2 =4.935; p<0.05) and viscous (60 vs 17%; χ2 =39.08; p<0.001) swallowing. Longer peristaltic breaks (p<0.05) and more rapid peristalsis (L: p<0.004, V: p=0.003) occurred in the older cohort, with reduced impedance-based clearance for both bolus consistencies (L: p<0.05, V: p<0.001). Decreased peristaltic vigor (distal contractile integral <450mmHg/s/cm) was associated with reduced liquid clearance in both age groups (p<0.001) and of viscous swallows in the older group (p<0.001). Impedance ratio, a marker of bolus retention, was increased in older subjects during liquid (p=0.002) and viscous (p<0.001) swallowing. Impaired liquid and viscous bolus clearance, esophageal pressure topography, and pressure-flow changes were seen in asymptomatic older subjects.

Correlation of esophageal clearance and dysphagia symptom assessment after treatment for achalasia.

Early relapse after treatment of achalasia occurs in 10-32 % of patients. The best method to follow up these patients is not known. Symptoms often do not correlate with esophageal clearance: some patients are oligosymptomatic despite persistent esophageal stasis/dilatation. The aim was to compare two methods of measurement of esophageal clearance (impedance manometry with barium swallow) in achalasia patients following treatment. Symptom assessment (Eckardt score/detailed dysphagia questions) was correlated with objective measurements of esophageal stasis (barium swallow and impedance manometry) in achalasia patients following treatment. Post-treatment patients were followed up after median 38.4 months (median range 1-144 months). Symptoms were quantified using the Eckardt score and detailed dysphagia questions. Timed barium swallow quantified distal esophageal retention 0.5, 1, 3, and 5 minutes after oral contrast and impedance manometry assessed total and segmental esophageal clearance during water/viscous swallows and free drinking (200 mL). Thirty-two patients (7 women, age 48.3; range 20-74) completed all investigations. Bolus retention in the distal esophagus assessed by impedance correlated well with barium swallow. There were no differences in impedance and timed barium swallow parameters between patients with Eckardt score 0-2 points or ≥3 points. Nine (28%) patients had an Eckardt score ≥3 points and 21 (66%) had ≥1 point in the detailed dysphagia questions. Patients without any dysphagia history had lower barium column height and width at 3 and 5 minutes compared to those with ≥1 positive answer in the detailed dysphagia questions. Correlation between the Eckardt score and detailed dysphagia questions was moderately good (r = 0.546; p = 0.001). A detailed history of esophageal dysphagia rather than the Eckardt score is more sensitive to detect oligosymptomatic patients with disturbed esophageal clearance. Impedance manometry correlates well with the timed-barium swallow examination and represents an alternative objective assessment as it avoids radiation exposure.

Swallow Outcome in Three Female Siblings with Huntingtons Disease and Chorea

The present study focuses on describing characteristics of swallow among Huntingtons Disease (HD) with Chorea before and after dysphagia therapy. 3 female siblings of 21, 22 and 33 years having juvenile type onset of HD with chorea were included. The patients were evaluated comprehensively for swallowing using Manipal Manual for Swallowing Assessment. Each patient was subjected to ingestion of solid, thin liquid and thick liquid of 5ml and 10 ml quantified using a standard measurable cup. Descriptive statistics was administered on the data using statistical package SPSS (Version 17). On observation, all 3 patients presented with sensory and motor issues in addition to posture instability with abrupt body movements, food spillage, piece meal deglutition, intra bolus retention, wet voice and cough. Following which cognitive approach and behavioural approach based intervention was initiated. The symptoms of intra bolus retention and cough decreased post therapy with no change in sensory aspects. The present study evidences three female siblings with severe cognitive deficits and dysphagia secondary to HD. Despite rehabilitation being provided, they could not completely waiver off the symptoms. These evidences highlight the importance of identifying and addressing swallow based treatment outcomes in HD with chorea.

Parameters for quantifying bolus retention with high‐resolution impedance manometry

This study aimed to develop a methodology for quantifying esophageal bolus retention using a high-resolution esophageal impedance topography (EIT) technique. The ability of impedance to quantify bolus retention was validated by comparison with concurrent fluoroscopic imaging (barium bolus) in 10 healthy subjects. High-resolution impedance manometry (HRIM) studies without fluoroscopy were performed in another 15 healthy subjects to define normal values using saline. HRIM data from each subject were analyzed using a MATLAB program customized for calculating the esophageal impedance integral (EII) prior to the contraction wave front as EII1 and after the contraction as EII2, and presented as a ratio of EII2/EII1, which was compared to the percent of barium areas retained in the esophagus on fluoroscopy determined by a blinded reviewer. In 93% (37/40) of barium swallows, the results from the EIT method were in agreement with fluoroscopy results with one of three patterns: (1) 25 normal bolus transit, (2) eight bolus stasis, and (3) four retrograde escape or reflux. Three swallows (8%) had slight retention identified by EIT, but no retention detected by fluoroscopy. The correlation between percent of bolus retained in the esophagus detected by fluoroscopy and percent of bolus retention (EII2/EII1) after swallows with EIT method was r = 0.96 (p < 0.001) in supine and r = 0.69 (p < 0.001) in upright position. The EII ratio (EII2/EII1) is a surrogate for the fraction of retained bolus after a swallow and this metric may be useful in better defining esophageal function.