Treatment Of Oropharyngeal Dysphagia Research Articles

Oropharyngeal dysphagia: pathophysiology and diagnosis for the anniversary issue of Diseases of the Esophagus

The oropharyngeal swallow involves a rapid, highly coordinated set of neuromuscular actions beginning with lip closure and terminating with opening of the upper esophageal sphincter. Evaluation of the oropharyngeal swallow usually involves the use of a modified barium swallow radiographic study with the goals of (i) defining the patient's swallow anatomy and physiology causing the dysphagia; and (ii) evaluating the immediate effectiveness of treatment procedures including selected postures, sensory enhancement, swallow maneuvers, and diet changes. Exercise programs may be helpful, but their immediate effects cannot be examined during the initial modified barium swallow. Exercise programs can be evaluated on a second radiographic study 3-4 weeks later. The resultant report should include all of this information. The speech-language pathologist is usually the professional most involved in the evaluation and treatment. Medications and surgery have a very limited role in the treatment of oropharyngeal dysphagia.

Esophageal Considerations After Spinal Cord Injury

Speech-Language Pathologists (SLPs) are frequently involved with patients after spinal cord injury due to the frequency of speech and swallowing problems. Any stage of swallowing can be adversely affected, and it is imperative that the SLP be aware that spinal cord injuries at various levels can produce a variety of deficits affecting oropharyngeal, esophageal, and many other functions. The SLP has a role in assessment and treatment of oropharyngeal dysphagia and also in recognizing how and when this injury should lead to screening and referral for disorders in the esophageal stage.

Research Consumerism 101: Evaluating External Evidence of Treatment Effectiveness

Abstract The modern clinician is a research consumer. Rehabilitation of oropharyngeal impairments, and prevention of the adverse outcomes of dysphagia, requires the clinician to select interventions for which evidence of a reasonable likelihood of a successful, important outcome exists. The purpose of this paper is to provide strategies for evaluation of published research regarding treatment of oropharyngeal dysphagia. This article utilizes tutorial and examples to inform and educate practitioners in methods of appraising published research. It provides and encourages the use of methods of efficiently evaluating the validity and clinical importance of published research. Additionally, it discusses the importance of the ethical obligation we, as practitioners, have to use evidence-based treatment selection methods and measurement of patient performance during therapy. The reader is provided with tactics for evaluating treatment studies to establish a study's validity and, thereby, objectively select interventions. The importance of avoiding subjective or unsubstantiated claims and using objective methods of generating empirical clinical evidence is emphasized. The ability to evaluate the quality of research provides clinicians with objective intervention selection as an important, essential component of evidence-based clinical practice. ASHA Code of Ethics (2003): Principle I, Rule F: “Individuals shall fully inform the persons they serve of the nature and possible effects of services rendered and products dispensed…” (p. 2) Principle I, Rule G: “Individuals shall evaluate the effectiveness of services rendered and of products dispensed and shall provide services or dispense products only when benefit can reasonably be expected.” (p. 2) Principle IV, Rule G: “Individuals shall not provide professional services without exercising independent professional judgment, regardless of referral source or prescription.” (p. 4)

Oropharyngeal dysphagia

Oropharyngeal dysphagia is not a single disease but a symptom complex that is recognized by difficulty in transfer of a food bolus from mouth to esophagus or by signs and symptoms of aspiration pneumonia or nasal regurgitation. Its etiologies are legion, with the most common result of underlying neuromuscular disease, including cerebrovascular accidents, Parkinson's disease, multiple sclerosis, and muscular dystrophy. There are two methods of treatment for oropharyngeal dysphagia; one is specific and directed at the underlying disease and the other is general (supportive) and designed to preserve oral intake for nutrition while preventing aspiration pneumonia. Following a general discussion of the etiology and clinical presentation of orophyarngeal dysphagia, a description of the methods for supportive care is presented as well as the approach to the treatment of cricopharyngeal dysfunction and Zenker's diverticulum.

Electromyography of human cricopharyngeal muscle of the upper esophageal sphincter.

The cricopharyngeus (CP) is a striated muscle sphincter situated at the pharyngoesophageal junction. The upper esophageal sphincter is comprised of the striated CP muscle and nonmuscular components at the level of the cricoid cartilage. This review describes the basic anatomy and physiology of the CP muscle, its central and peripheral relationship, methods of investigating it, and electrophysiological properties related to deglutition. The main function of the CP muscle is to control flow between the pharynx and esophagus. The CP sphincter muscle is tonically contracted at rest and relaxes during swallowing, belching, and vomiting. Electromyography (EMG) of the CP sphincter muscle has been undertaken frequently in a variety of subhuman species with the aim of understanding deglutition, whereas it has seldom been reported in healthy human subjects and patients. Increased knowledge of the physiology and anatomy of the human CP sphincter muscle is not only important scientifically but is necessary for advancing the diagnosis and treatment of oropharyngeal dysphagia, for which neurological causes are responsible in 80% of cases.

Videoendoscopic evaluation of supraesophageal dysphagia.

Oropharyngeal dysphagia is a cause of major morbidity and mortality, particularly in the ever-increasing aged population, following stroke, or after extensive head and neck surgery such as for cancer. Videoendoscopy has become a useful tool in the evaluation and treatment of oropharyngeal dysphagia, and it is particularly suited to patients who may be unable to tolerate videofluoroscopy. This paper reviews the current literature regarding the technique of videoendoscopic evaluation and outlines various indications for its use.

Assessment and behavioral management of oropharyngeal dysphagia

This paper reviews the current literature on the screening, diagnosis, and treatment of oropharyngeal dysphagia. Much of the recent literature focuses on the presence or absence of aspiration, with little attention to the “pathobiomechanics” of its cause. Nonetheless, increased attention to sensory swallowing input and its potential therapeutic value is evident. The literature reflects the controversy surrounding the use of clinical/bedside screening procedures in place of instrumental diagnostic assessment. Often a component of diagnostic evaluation, bedside examinations are limited and are of questionable value in providing effective management options. Current health trends have motivated practitioners to further investigate issues including assessment and treatment validity and the resultant effects on quality of life. While some of these studies show refinement and increased validation in available tools, careful consideration of their research design is warranted.

Approaches to management of disordered swallowing

Management of disordered oropharyngeal swallowing begins with careful assessment of the patient's oropharyngeal anatomy and physiology, medical status and cognitive, language and behavioural characteristics. More often, videofluoroscopic studies are performed which enable observation of bolus movement and movements of the oral cavity, pharynx and larynx throughout the swallow. Treatment for oropharyngeal dysphagia may take the form of compensatory strategies, direct therapy or indirect therapy. Compensatory strategies include postural changes and modification of bolus volume and consistency as well as rate of food presentation. These strategies are designed to eliminate the symptoms of the swallowing problem but may not directly change swallow physiology. Direct therapy techniques are designed to change swallow physiology and consist of oral sensory stimulation techniques and swallow manoeuvres, as well as maxillofacial prosthetics, medication and surgical procedures. Indirect therapy procedures are designed to improve the neuromuscular controls necessary for the swallow without actually producing a swallow. Specific swallowing treatment strategies within each category are described. In addition to assessing the patient's swallow physiology, the videofluoroscopic study of the swallow can be used as a treatment efficacy trial in which selected compensatory strategies or direct therapy techniques are used by the patient to improve their swallow safety and efficiency. Factors to be considered in the design of an overall treatment plan for a patient with disordered swallowing are defined.

The Technique of Cricopharyngeal Myotomy

The surgical approach for section of the cricopharyngeus muscle in the treatment of oropharyngeal dysphagia is outlined.