Severe Oropharyngeal Dysphagia Research Articles

An Unusual Case of Contralateral Hypoglossal and Recurrent Laryngeal Nerve Palsies Following Endotracheal Intubation.

We present an unusual case of a 62-year-old male presenting with contralateral hypoglossal and recurrent laryngeal nerve palsies following endotracheal intubation for emergency cardiac surgery. Postoperative, the patient was referred to Speech and Language Therapy due to concerns regarding the safety of his swallow. Oromotor assessment revealed left-sided tongue weakness and aphonia. Flexible endoscopic evaluation of swallowing (FEES) revealed a right vocal cord palsy and severe oropharyngeal dysphagia. There were no other focal neurological signs. An MRI head did not demonstrate a medial medullary stroke or other intracranial lesion. CT neck showed no abnormality identified in relation to the course of the right vagus nerve or recurrent laryngeal nerve at the skull base or through the neck respectively. The patient required a gastrostomy for nutrition and hydration. He continued to be assessed at several month intervals over the course of a year using FEES to obtain a range of voice, secretion and swallowing outcome measures. The patient commenced intensive dysphagia therapy targeting pharyngeal drive, hyolaryngeal excursion and laryngeal sensation. Swallow manoeuvres were trialled during FEES and a head-turn to the side of the vocal cord palsy during deglutition reduced aspiration risk which expedited return to oral intake. The patient had partial recovery over twelve months. Hypoglossal nerve palsy completely resolved. The right vocal cord remained paralysed however the left vocal cord compensated enabling the patient to produce a normal voice. The patient was able to take thin fluids and regular diet and the gastrostomy was removed.

Successful treatment of post COVID-19 neurogenic dysphagia with botulinum toxin

Introduction: Dysphagia in post COVID-19 patients could be caused by several factors, including reduced pharyngolaryngeal coordination due to SARS-CoV-2 tropism to the central and/or peripheral nervous system. To our knowledge, this is the first reported case of COVID-19-related dysphagia successfully treated with botulinum toxin type A injection. Case description: We report the case of a patient with severe oropharyngeal dysphagia due to COVID-19 confirmed by fibre endoscopy. As a result, the patient required an enteral feeding tube. After two months of traditional swallowing therapies, there was only limited improvement. An electrophysiologic evaluation of the cricopharyngeal muscle was performed and showed a normal inhibition of the cricopharyngeal muscle, followed by a hypertonic rebound. Based on this result, we decided to perform a unilateral laryngeal injection of botulinum toxin type A. After the injection, the patient’s swallowing function improved significantly, allowing him to return to oral feeding. Discussion: Newly diagnosed oropharyngeal dysphagia was found in 35.3% of hospitalised patients with COVID-19. There are several possible causes of COVID-19-associated dysphagia, including stroke, encephalitis, critical illness neuropathy, Guillain-Barré syndrome and skeletal muscle injury. In our case, since stroke was excluded by brain MRI, cranial nerve injury was a possible explanation for the difficult recovery of swallowing despite daily swallowing therapy. Conclusion: We suggest that electrophysiology is a valid tool for the diagnosis and follow-up of patients with oropharyngeal dysphagia.

Shear-Viscosity-Dependent Effect of a Gum-Based Thickening Product on the Safety of Swallowing in Older Patients with Severe Oropharyngeal Dysphagia.

Fluid thickening is a valid therapeutic strategy for patients with oropharyngeal dysphagia (OD). The main aim of this study was to determine the therapeutic effect of the xanthan-gum-based thickener Tsururinko Quickly (TQ, Morinaga Milk Co., Tokyo, Japan) in older patients with severe OD. A total of 85 patients (83.32 ± 6.75 y) with OD and a penetration-aspiration score (PAS) of n ≥ 3 were studied by videofluoroscopy while swallowing duplicate 10 mL boluses at <50 mPa·s, 100, 200, 400, 800, and 1600 mPa·s, to assess the safety and efficacy of swallowing and the biomechanics of a swallowing response at each viscosity level. At <50 mPa·s, only 16.25% patients swallowed safely, 45% had penetrations (PAS 3-5), and 38.75% had aspirations (PAS 6-8). Fluid thickening with TQ greatly increased the prevalence of patients with safe swallowing from 62.90% at 100 mPa·s to 95.24% at 1600 mPa·s in a shear-viscosity-dependent manner. The penetrations and aspirations were significantly reduced to 3.60% and 1.19%, respectively, at 1600 mPa·s. The threshold viscosity was 100 mPa·s and the increasing viscosity above 800 mPa·s did not further improve the therapeutic effect significantly. Increasing the shear viscosity significantly reduced the time to laryngeal vestibule closure (-16.70%), increased the time to upper oesophageal sphincter opening (+26.88%), and reduced the pharyngeal bolus velocity (-31.62%) without affecting the pharyngeal residue. TQ has a strong shear-viscosity-dependent effect on the safety of swallowing in older patients with severe OD without increasing the pharyngeal residue. The therapeutic range for TQ is 100-800 mPa·s, with 200 and 800 mPa·s being the optimal doses to cover the needs of older patients with OD.

Cancer-associated Regional Ischemic Myopathy: A Rare Immune Myopathy (P9-8.008)

<h3>Objective:</h3> To describe clinical and pathological features of a rare immune myopathy featured by regional ischemia in the setting of cancer. <h3>Background:</h3> Regional ischemic immune myopathy (RIIM) is a rare disorder attributed to myovasculopathy and considered paraneoplastic. It has a high mortality rate. Contrary to dermatomyositis, where microvasculopathy leads to perifascicular pathology and sometimes muscle ischemia, RIIM is characterized by regional necrosis in border zones between perimysial vessels. <h3>Design/Methods:</h3> Review of patient’s clinical and laboratory findings. <h3>Results:</h3> An 81-year-old man manifested subacute proximal limb weakness, dysphagia, and 25-pound weight loss. He had stage IV prostate cancer, diagnosed 3 months prior to weakness-onset. Examination revealed mild facial weakness, flaccid dysarthria, moderate-to-severe neck and limb girdle weakness and atrophy. Videofluoroscopic swallow study showed severe oropharyngeal dysphagia with aspiration. CK was 689 U/L (normal 39–108 U/L) at presentation but 6,145 U/L six weeks earlier. Myositis-associated and HMGCR antibodies were negative. EMG showed proximal-predominant myopathic changes with fibrillation potentials. Muscle biopsy revealed several well-demarcated areas of ischemia involving adjacent fascicles. Necrotic fibers were in a similar early stage of necrosis with no macrophagic infiltration and diffuse sarcoplasmic C5b-9 deposition. A few small collections of perimysial perivascular inflammatory cells were present in the areas of the specimen not affected by ischemia. There was patchy capillary depletion and dilation; some capillaries in areas not affected by ischemia showed complement deposition. Myxovirus resistance protein A (MxA) expression occurred diffusely, especially in necrotic fibers, but without perifascicular predominance. Patient received IVIG 2g/Kg and prednisone 40 mg daily. The limb weakness stabilized while the dysphagia progressed. He expired 3 weeks later. <h3>Conclusions:</h3> RIIM is a rare myovasculopathy leading to muscle weakness in the setting of cancer. In keeping with published data, it has a poor prognosis. The identification of RIIM myopathological changes should trigger the search for underlying malignancy in patients without known cancer. <b>Disclosure:</b> Dr. Granger has nothing to disclose. Dr. Soontrapa has nothing to disclose. Dr. Klein has a non-compensated relationship as a Klein with Neurology Journal that is relevant to AAN interests or activities. Dr. Milone has received personal compensation in the range of $500-$4,999 for serving on a Scientific Advisory or Data Safety Monitoring board for Argenx. Dr. Milone has received personal compensation in the range of $500-$4,999 for serving as an Editor, Associate Editor, or Editorial Advisory Board Member for Neurology Genetics, AAN. The institution of Dr. Milone has received research support from Mayo Clinic, CCaTS-CBD. The institution of Dr. Milone has received research support from Mayo Clinic, SGP Award. The institution of Dr. Milone has received research support from MDA for Care Center grant. The institution of Dr. Milone has received research support from Regenerative medicine Minnesota.

Dietary and Nutritional Support in Gastrointestinal Diseases of the Upper Gastrointestinal Tract (I): Esophagus.

The esophagus is the centerpiece of the digestive system of individuals and plays an essential role in transporting swallowed nutrients to the stomach. Diseases of the esophagus can alter this mechanism either by causing anatomical damage that obstructs the lumen of the organ (e.g., peptic, or eosinophilic stricture) or by generating severe motility disorders that impair the progression of the alimentary bolus (e.g., severe dysphagia of neurological origin or achalasia). In all cases, nutrient assimilation may be compromised. In some cases (e.g., ingestion of corrosive agents), a hypercatabolic state is generated, which increases resting energy expenditure. This manuscript reviews current clinical guidelines on the dietary and nutritional management of esophageal disorders such as severe oropharyngeal dysphagia, achalasia, eosinophilic esophagitis, lesions by caustics, and gastroesophageal reflux disease and its complications (Barrett's esophagus and adenocarcinoma). The importance of nutritional support in improving outcomes is also highlighted.

ODP475 Developing suppurative thyroiditis

Abstract Suppurative thyroiditis is rare and associated with significant mortality. A high level of suspicion and aggressive management is needed to reduce the risk of serious outcomes. A 67-year-old male with a medical history including diabetes type 2, cognitive impairment, and ESRD presented with decreased appetite and lethargy for a few days. He presented with fever, tachycardia, and hypertension. There was a non-tender fullness around the anterior neck region. Initial laboratory tests revealed leukocytosis to 24K/uL, lactic acid of 5. 0 mmol/L, ESR 100 mm/hr, CRP 419 ng/dl, and blood culture was positive for gram-positive cocci in clusters for which he was started on iv vancomycin and piperacillin/tazobactam. CT scan on admission showed a probable inflammatory process in the neck originating from the thyroid bed, concerning acute thyroiditis and developing abscess/abscesses vs. very atypical presentation of thyroid cancer. Thyroid ultrasound showed diffuse thyroid enlargement with heterogeneous echogenicity. Repeat CT obtained due to apparent thyroid enlargement with erythema and tenderness on examination and fever on day 7 showed extensive heterogeneous thyroid enlargement with ill-defined margins to the adjacent soft tissue structures. A modified barium swallow revealed severe oropharyngeal dysphagia leading to thyroid fine-needle aspiration of both thyroid lobes by interventional radiology and subsequent urgent incision and drainage (I&amp;D) of the right neck and thyroid biopsy under general anesthesia by ENT. I&amp;D showed purulent drainage from the thyroid. Cultures were positive for MRSA. Surgical pathology reported a necrotic muscle and abscess and fragment of thyroid tissue. Thyroid function tests (TFTs) on admission revealed a TSH 0.31 mcIU/ml (reference: 0.30 - 5. 0 mcIU/ml) and a free T4 of 2.21 ng/dl (reference: 0.76- 1.46 ng/dl) and repeat TFTs with a TSH of 0.30 mcIU/mL, free T4 of 1.87 ng/dL, free T3 of 2.15 pg/ml (reference: 2.18- 3.98 pg/ml), consistent with sick euthyroid syndrome. TPO and TSI were negative. Subsequently, the patient's fever resolved, and the neck swelling improved. He continued IV vancomycin for a month. TFTs six weeks later showed an elevated TSH of 13.10 mcIU/ml and normal free T4 of 1. 03 ng/dl. Conclusion MRSA suppurative thyroiditis is rare, and its diagnosis may be delayed due to its indolent course, especially in immunocompromised patients. Therefore, a high index of clinical suspicion is needed for this endocrine emergency in a patient presenting with fever and neck swelling. While an early FNA of the thyroid is likely to aid in diagnosing thyroid infection, TFTs may be variable and not helpful. Presentation: No date and time listed

S2355 Although Rare, a Hardware Fracture and Migration of Anterior Cervical Spine Plating Can Present With Upper Gastrointestinal Bleeding and Associated With High Mortality

Introduction: Anterior cervical spine plating (ACSP) is a common surgical intervention indicated for many cervical osteopathologies. Esophageal perforation is a rare complication of ACSP that can occur shortly following surgery, due to over prominent screws or friction between the esophagus and the plate. Screw fracture and migration following the surgery is very rare but is a potentially life-threatening complication that can result in perforation of the adjacent organs like the esophagus and mediastinum, and increase the risk of infections in this area. (1-4) Case Description/Methods: An 84-year-old man with cervical disc disease (C6-C7) status post ACSP (Anterior cervical spine plating ) with resultant need for a PEG tube placement secondary to newly developed severe oropharyngeal dysphagia after aforementioned spinal surgery with persistent aspiration, who presented with dark color liquid output coming out from the PEG tube.Esophagogastroduodenoscopy (EGD) showed a foreign metal hardware (looks like cervical plate) seen embedded in the wall of the hypopharynx and eroding out, but no ulceration or blood was seen around the PEG insertion site. CT cervical spine showed a fracture of the right C6 anterior fusion screw with evidence of anterior displacement of the fusion plate with 4 to 5 mm gap between the plate and the anterior margin of C6. Disc spacer material appears to extend beyond the anterior margin of the C6-7 disc space ( Figure). Discussion: Comprehensive surgical history is important for any patient presenting with evidence of upper gastrointestinal bleeding. Patients with a history of Anterior cervical spine plating (ACSP) need urgent cervical spine imaging to assess the status of the hardware, and if there are any radiologic features of infection. Cervical spine imaging will help to triage the urgency and type of intervention, whether conservative or urgent surgical intervention.Figure 1.: CT scan on the cervical spine showing the hardware and screw migration to the esophagus.

S1940 Acute Pancreatitis: Caused by Dislodged PEG Tube?

Introduction: Percutaneous endoscopic gastrostomy (PEG) is a common endoscopic procedure and a preferred route for long-term enteral nutrition for patients incapable of oral intake or for whom oral intake is insufficient. The insertion of PEG tubes is a relatively safe procedure with complications which include bleeding, aspiration, perforation, periostomal leaks, tube dislodgement and occlusion, gastric outlet obstruction due to tube migration and accidental removal. Acute pancreatitis secondary to PEG migration is rare. We present a patient with acute pancreatitis secondary to PEG tube migration. Case Description/Methods: A 57-year-old woman known to have severe developmental delays, seizure disorder, bipolar 1 disorder presented with nausea, vomiting and abdominal pain. She is bedridden and nonverbal at baseline. She gets nutrition through a PEG tube for severe oropharyngeal dysphagia. Abdominal examination revealed significant biliary drainage from the gastrostomy site and tenderness present without rigidity or guarding. Labs showed WBC of 17.7 and lipase levels greater than 4,000 U/L. AST, ALT, alkaline phosphatase and total bilirubin were within normal range (31, 6, 94 and 0.9 respectively). CT abdomen without IV contrast revealed peripancreatic soft tissue stranding and pancreatic edema, the tip of the PEG tube in the second part of the duodenum (Figure). Her home medications are verified and are not known to cause acute pancreatitis (AP). So she was suspected to have AP from PEG tube migration. The tube was repositioned and she was treated with Ringer lactate. Four days later, her symptoms resolved and lipase level was within normal range (282 U/L). Discussion: In comparison to other methods, enteral feeding has the benefit of maintaining gut mucosal integrity and decreasing the possibility for bacterial translocation. Migration of the PEG tube has been associated with gastric outlet obstruction and biliary obstruction. In rare cases, this can present as AP either through ampullary obstruction at the second part of the duodenum or through compression of the pancreatic head itself. This case highlights the inclusion of PEG tube induced pancreatitis as a differential for AP in patients receiving enteral feeding. Proper placement of the tube, regular examination of the site and marking the PEG position can help avoid migration and complications. The treatment for acute pancreatitis secondary to PEG tube migration is PEG tube removal followed by placement of a new PEG tube or repositioning.Figure 1.: Peripancreatic soft tissue stranding and pancreatic edema, the tip of the PEG tube in the second part of the duodenum.

DENTISTRY INVOLVEMENT IN THE AMYLOIDOSIS DIAGNOSIS: CASE REPORT

A 79-year-old female patient was monitored under hospital care by the multidisciplinary team because of severe oropharyngeal dysphagia with a 3-year evolution. Clinical examination revealed a medical history of systemic arterial hypertension, left ventricle diastolic dysfunction, hypothyroidism, and bilateral carpal tunnel syndrome. In view of the clinical picture presented, amyloidosis was the main diagnostic hypothesis. During intraoral examination the hospital dental team's evaluation revealed macroglossia, crenated tongue and lingual varicosities, saliva accumulation in the oral cavity, and vestibularized anteroinferior teeth. Therefore, an incisional biopsy was performed in the tongue dorsum region and in the intraoral lower lip mucosa (minor salivary gland). After the anatomopathologic examination with a special Congo red stain, amyloidosis was diagnosed. With the diagnostic definition, the patient proceeded with specific medical treatment and speech therapy.

Desfechos de deglutição e alimentação associados à intubação orotraqueal e à traqueostomia em pediatria

ABSTRACT Purpose To verify the swallowing and feeding outcomes of pediatric patients undergoing prolonged OTI, considering those who progressed to tracheostomy afterward. Methods Retrospective cohort study, carried out by analyzing the medical records of patients admitted to the Pediatric ICU and followed up until hospital discharge, between 03/2017 and 12/2018. Results Of the 51 patients included, 64.7% were male and the median age 6.7 months. Patients undergoing OTI for a median of 7 days had mild dysphagia and when submitted for more than 14 days had moderate/severe dysphagia and PFD with characteristics of food refusal, with contraindication to oral feeding at hospital discharge. 74.5% of the patients underwent OTI only and 25.5% progressed to tracheostomy afterward. Tracheostomized patients had a higher occurrence of hospital discharge with moderate/ severe oropharyngeal dysphagia, pediatric feeding disorder (PFD) with characteristics of food refusal and alternative method of feeding compared to patients without tracheostomy (p=0.001). Non-tracheostomized patients had a final diagnosis with milder degrees of dysphagia when compared to the initial diagnosis (p&lt;0.001). Conclusion The time of OTI and the presence of tracheostomy are factors associated with the speech-language pathology diagnosis of moderate/severe oropharyngeal dysphagia, presence of signs of PFD with characteristics of food refusal and the need for an alternative method of feeding that persists until hospital discharge, being frequent findings among the swallowing/feeding outcomes in pediatrics.

69-Year Old Man With Dysphagia and Nasal Regurgitation

69-Year Old Man With Dysphagia and Nasal Regurgitation

S2022 Rare Cause of Acute Onset Dysphagia and Treatment With Z-Peroral Endoscopic Myotomy (Z-POEM)

INTRODUCTION: Zenker's Diverticulum (ZD) is a rare disease with a prevalence of 0.01 to 0.11% in the general population.It is commonly associated with symptoms of progressive and chronic symptoms of dysphagia and weight loss. We describe a rare case of acute onset of dysphagia related to ZD and its management with a novel endoscopic technique. CASE DESCRIPTION/METHODS: An 82-year-old female with multiple co-morbidities presented to the hospital with acute onset dysphagia to solids and liquids since last 2 weeks. She lost 10 lbs and started coughing incessantly with any solids or liquid intake. Vital signs and routine laboratory values were within normal limits. On examination by speech and language pathologist, she was noted to have severe oropharyngeal dysphagia and frank aspiration with all consistencies. A modified barium swallow showed a large ZD and aspiration. Neurology consultation was sought given acuity of dysphagia, however there were no local neurological deficits on imaging and physical exam. Subsequently an Esophagogastroduodenoscopy (EGD) was performed which showed a 4-5 cm ZD and the septum separating the diverticulum from the pinpoint esophageal lumen. The case was discussed at a multidisciplinary conference involving gastroenterology, ENT and radiology and decision was made to proceed with endoscopic septotomy. A Z-peroral endoscopic myotomy (POEM) was performed with septotomy. It was technically challenging to expose the anterior aspect of the septum secondary to significant fibrosis and difficulty with dissection. Therefore a partial septotomy was performed extending to about 2 cm distally at the posterior aspect of the septum. The scope was withdrawn and reintroduced into the true esophageal lumen more easily despite the anterior aspect of the septum not being completely dissected. Patient was started on clear liquid diet after 48 hours with gradual advancement and tolerated it well. On a 4-week follow up visit, patient continued to tolerate diet well with weight gain and no signs of aspiration. DISCUSSION: Treatment of ZD can be accomplished with open surgery, a rigid endoscope, flexible endoscope or more recently, the novel Z-POEM procedure. Z-POEM utilizes the concept of submucosal tunneling endoscopic septum division (STESD) technique and has permitted complete muscular septum dissection while maintaining the mucosal integrity. It is associated with fewer rates of complications and symptom recurrence as compared to septotomy with standard flexible endoscopy.Figure 1.: Z-Per oral endoscopic myotomy.

Advanced Stage Stuck Gland Adenocarcinoma: Case Report

Parotid gland adenocarcinoma is commonly a tumor of low malignancy and low incidence worldwide. The reported case shows the rapid progression of this tumor in an elderly patient and infrequent effects, such as a presentation of facial edema not commonly described in the medical literature. Patient was admitted to hospital in November 2019 with secretion and partial hearing loss in the right ear and infiltrative and stone lesion with initial skin ulceration in the right cervical region. After 42 days, he returned and was admitted to the intensive care unit with significant swelling of the face, hardened and hyperemic neck, difficulty in speech and inability to open the eye. He presented changes in the mobility of the speech and hearing organs, reduced laryngeal mobility, vocal changes, speech with altered articulation and severe oropharyngeal dysphagia with risk of bronchoaspiration. The patient was diagnosed in September 2019 with a parotid tumor (salivary gland adenocarcinoma T4). The medical team requested computed tomography, computed tomography angiography of the chest and cervical vessels and computed tomography of the neck, in addition to evaluation by the head and neck surgery service and general surgery. After analyzing the results, the medical team suggested a hypothesis of tumor invasion that could result in obstruction of local lymphatic drainage, something unusual in the evolution of this type of tumor. In addition, it was not possible to adhere to radiotherapy treatment due to the extent of the lesion and there was also no confirmation of metastases. The reported case shows us that parotid gland adenocarcinoma, when diagnosed in an advanced stage, can limit the approach to treatment. It was chosen in agreement with the family to proceed with palliative care without invasive measures. Palliative care may be the best option for cases like this, bringing some comfort to the patient and his family.

Tomada de decisão: papel do fonoaudiólogo em cuidados paliativos

Introdução: A tomada de decisão compartilhada é uma estratégia centrada na pessoa, procurando alinhar a comunicação entre profissionais da saúde e pacientes, conjuntamente com as preferências, valores e objetivos dos indivíduos Objetivo: Correlacionar os achados clínicos da disartria, disfagia e cognição com o processo de tomada de decisão em saúde em um paciente com diagnóstico molecular confirmado de Ataxia Telangiectasia em cuidados paliativos em fase terminal. Método: Foi realizada avaliação clínica fonoaudiológica da disartria, disfagia e cognição. À partir dos resultados apresentados na avaliação, foram abordados princípios e diretrizes do processo de tomada de decisão em saúde, a fim de auxiliar na definição do processo terapêutico em pacientes em cuidados paliativos. Resultados: Paciente apresentou disartria atáxica e disfagia orofaríngea moderada a grave, porém apesar do risco significativo de aspiração laríngea para todas as consistências alimentares, demonstrou forte desejo em manter alimentação via oral exclusiva. Com relação à cognição paciente apresentou funções cognitivas de acordo com a normalidade para idade e escolaridade. Por meio de um processo de escolha informada, discussão multidisciplinar e baseando-se em princípios da tomada de decisão compartilhada em saúde, optou-se por priorizar o desejo do paciente e indicou-se alimentação via oral. Conclusão: Partindo do processo de tomada de decisão compartilhada e buscando minimizar o sofrimento de pacientes em cuidados paliativos, o fonoaudiólogo deve assumir uma nova perspectiva às decisões terapêuticas a fim de favorecer e envolver o paciente e seus familiares desde o início do diagnóstico até as decisões de fim de vida.

Effectiveness of Therapy on Post-Extubation Dysphagia: Clinical and Electromyographic Findings.

Introduction:Patients who require prolonged endotracheal intubation (>48 hours) are at risk of dysphagia. Speech-language pathologists should perform swallowing exercises after extubation due to the high probability of developing aspiration pneumonia. There are no studies describing the use of swallowing techniques employed in post-extubation therapy aided by surface electromyography.Objectives:To evaluate the effects of swallowing function therapy in extubated patients after prolonged orotracheal intubation by means of clinical and electromyographic evaluation.Methods:A total of 15 patients were enrolled in this study (average age 48.6 ± 16.5 years). The study was carried out in three phases: (1) Clinical and electromyographic evaluation using the Dysphagia Risk Assessment Protocol following dysphagia scores criteria, and the measurement of the suprahyoid muscles amplitude (μV) expressed by root mean square (RMS), respectively; (2) swallowing rehabilitation program; and (3) reevaluation of patients after therapy. The Wilcoxon paired test assuming a significance level of 5% was used for statistical analysis.Results:By means of the swallowing scale, it was verified that patients suffered from severe oropharyngeal dysphagia at the first evaluation (80%), but the rehabilitation therapy reduced clinical signs, persistent only in one patient (6.7%) post-therapy, thus, improving swallowing. Significant differences, pre- and post-therapy, for suprahyoid muscles during maximal voluntary isometric contractions of right (P = .0067) and left (P = .0215), saliva swallowing by right (P = .0413) and left (P = .0151), and liquid swallowing by right (P = .0479) and left (P = .0215) sides, were found, as shown by electromyography.Conclusions:Swallowing exercises carried out by extubated patients after prolonged orotracheal intubation increased neuromuscular recruitment of suprahyoid muscles involved with swallowing and reduced dysphagia levels.

Management of feeding decisions in hospitalised adults with severe oropharyngeal dysphagia.

For patients with dysphagia, decisions must be made for provision of nutrition and hydration. This retrospective audit explored feeding decisions for patients with severe oropharyngeal dysphagia. Fifty adult inpatients were identified across a 15-month period as requiring a feeding decision due to severe persisting oropharyngeal dysphagia. For each patient, all admissions (previous and subsequent admissions up to and including six months postrecruitment) where dysphagia or dysphagia-related complications were reported in the discharge summary were audited. A total of 103 admissions were identified with palliation in 22%. Enteral tube feeding (ETF) was initiated in 19% of admissions; and 63% of enteral tube placements failed. Nil-by-mouth with ETF was the final feeding decision in only 8% of admissions, while 43% of admissions led to documented oral feeding despite risk. Dysphagia was documented in only 44% of discharge summaries, with a feeding decision documented in only 34%. Variation in management and poor documentation in this cohort suggest the need for a Risk Feeding Clinical Guideline.

Vagus nerve magnetic modulation facilitates dysphagia recovery in patients with stroke involving the brainstem - A proof of concept study

Background & aimsStroke involving the brainstem (SBS) causes severe oropharyngeal dysphagia (OD). Research on the therapeutic efficacy of vagus nerve modulation (VNM) by using repetitive transcranial magnetic stimulation (rTMS) in SBS patients with OD has been limited thus far. We aimed to assess the effect of VNM by using rTMS in improving swallowing function after SBS. MethodWe conducted a sham-controlled, double-blinded, parallel pilot study in 28 SBS patients with OD randomly allocated to a real rTMS group (n = 13; TMSreal) or a sham group (n = 15; TMSsham). For VNM, 5-Hz rTMS was applied to the left mastoid in 10 sessions. We evaluated all patients for swallowing function before and after rTMS conditioning, assessed on the 8-point Penetration–Aspiration Scale (PAS) through videofluoroscopy and the Australian Therapy Outcome Measures–Swallowing scale (AusTOMs). We measured the amplitude and latency of cricopharyngeal motor evoked potentials (CP-MEPs) as the neurophysiological parameters. ResultsTMSreal exhibited significant improvement in all swallowing outcomes—neurophysiological, radiological, and functional—compared with TMSsham: We noted higher CP-MEP amplitude (p = 0.004), shorter CP-MEP latency (p = 0.004), a lower PAS score (p = 0.001), and a higher AusTOMs score (p < 0.001) following rTMS in TMSreal. Moreover, the neurophysiological improvements were significantly correlated with the functional outcomes (p < 0.05). ConclusionsOur results encourage the application of VNM by using rTMS for improving swallowing function after SBS. The immediate therapeutic effects suggest that this novel intervention can be an effective complementary therapy to traditional oropharyngeal rehabilitation. Clinical trial registrationURL: https://www.clinicaltrials.gov. Unique identifier: NCT02893033.

Association between neurological injury and the severity of oropharyngeal dysphagia after stroke.

To associate the degree of biomechanical impairment in the swallowing process with the severity (National Institute of Health Stroke Scale - NIHSS) and type of neurological injury in patients post stroke. A cross-sectional, descriptive study conducted with 42 patients (22 females), aged 65.7 years on average diagnosed with stroke. All patients underwent clinical neurological evaluation and application of the NIHSS in the first 48 hours after stroke. The swallowing function was evaluated using the Functional Oral Intake Scale (FOIS) and the Protocol for the Investigation of Oropharyngeal Dysphagia in Adults. The Fisher's Exact Probability Test was used to assess the correlation between the degree of swallowing impairment and the severity (NIHSS score) and type of stroke. The study results were statistically analyzed at 5% significance level (p≤0.05). 92.9% of the patients presented ischemic stroke; 59.5% presented impairment of the anterior cerebral circulation. Statistically significant correlation was found between the neurological scale (NIHSS) scores and the swallowing impairment scale (p=0.016). An association between stroke severity and oropharyngeal dysphagia severity was observed. A high proportion of patients with ischemic stroke with circulation affected in the anterior cerebral region presented severe oropharyngeal dysphagia. No statistically significant correlation was observed between the FOIS scale and stroke severity.

Comments on Selected Recent Dysphagia Literature

The overall goal of this study was to determine whether manual control over the opening of the upper esophageal sphincter (UES) was possible. Specific objectives included (1) evaluation of the UES opening under videofluoroscopy by anterior traction with a transcutaneous suture placed around the anterior rim of the cricoid cartilage in gastrostomy tube-dependent patients due to severe oropharyngeal dysphagia; (2) design and fabrication of a swallow expansion device (SED) to allow for mechanical opening of the UES; (3) investigation of the ability of the SED to open the UES in fresh cadavers; and (4) evaluation of the safety and efficacy of the SED in an ovine model. Effectiveness of the cricoid suture in six feeding tube-dependent adult participants (mean age = 67 years; 4 with head and neck cancer and 2 with stroke) revealed UES opening improved from 0.16 cm (±0.14 cm) without traction to 0.52 cm (±0.07 cm) with traction on the suture. Anterior traction on the suture eliminated aspiration in three of four participants who requested to go home with the suture in place in order to facilitate oral alimentation. However, the suture caused local skin irritation in all participants and was removed (range = 2–9 days) without complication. The SED was designed with an internal (titanium-coated ferrous implant secured to the cricoid cartilage via a small skin incision) and external component (housing a magnet for attraction to the implant across the skin barrier). The SED was fixed to the cricoid cartilage of ten fresh cadavers. A total of 50,000 anterior pulls were completed (mean UES opening of 11.6 ± 2.18 mm) with no gross damage to the cricoid cartilage or overlying skin noted at explantation. Lastly, the SED was implanted on the cricoid cartilage of eight sheep and 5000 pulls were performed on each animal weekly for 4 weeks. At explantation there was a thick, fibrous capsule around the implant and gross remodeling of the cricoid cartilage to the shape of the implant, but no gross damage to skin or strap muscles. All animals aspirated without anterior traction and aspiration was eliminated 100% of the time with traction (UES opened from a mean baseline of 0.15 cm ± 0.07 cm to a mean maximum opening of 1.42 cm ± 0.41 cm). Manual control of the UES was shown to be possible by placement of an anterior traction suture around the anterior aspect of the cricoid cartilage in a human model and by an internal implant fixed to the cricoid cartilage with an external magnet to open the UES in cadaver and living sheep models.

Corticosteroid-resistant bulbar neurosarcoidosis responsive to intravenous immunoglobulin

We report an intriguing case of corticosteroid-resistant bulbar neurosarcoidosis responding to intravenous immunoglobulin. A 37-year-old man presented with dysphagia to solids and liquids, dysphonia, fatigue and 50 lb weight loss...