Ephraim Eviatar

Surface electromyographic studies of swallowing in normal subjects: a review of 440 adults. Report 2. Quantitative data: amplitude measures.

OBJECTIVES: Surface electromyographic (EMG) studies were performed on 420 normal adults to establish normative database for muscle activitys amplitude during swallowing and drinking clinically useful for ENT department. STUDY DESIGN: Prospective observational study of healthy volunteers. METHODS: Parameters evaluated during swallowing include the EMG activity of the orbicularis oris, masseter, submental, and infrahyoid muscle groups covered by platysma (range, mean, SD). Four tests were examined including voluntary swallow of saliva (“dry” swallow), voluntary single water swallows as normal (variable volume of a bolus), voluntary single swallows of fixed amount of water (20 mL), and continuous drinking of 100 mL of water. Activity of the above-mentioned muscles during swallowing was measured for groups of adults of different age groups. Groups included volunteers and were separated into age groups as follows: ages 18-30, 31-40, 41-50, 51-60, 61-70, and 70+ years of age. RESULTS: Normative data for electric muscle activity (mean ± SD; range, in μV) during single swallowing and continuous drinking are established for healthy adults. The range of submental group activity during swallows showed a significant decrease with the age, whereas the range of masseter activity changed insignificantly (1-dimensional analysis of variance, SPSS, Chi-square criterion, 95% confidence interval). There were no significant changes in mean muscle activity between different age groups. These parameters represent activities required for normal deglutition, and can be used to identify abnormalities in ENT patients, and provide a basis for comparison of swallowing performance both within and between patients. These measurements can be performed in a simple way, cause no discomfort, do not use radiation, and are noninvasive. The relevance and clinical utility of new and alternative measures, in particular, are discussed. CONCLUSIONS: In single swallow tests range of electric activity of involved muscles is more informative than its mean. In the continuous drinking test, the mean electric activity is the only electric variance that can be evaluated. Orbicularis oris muscle activity is not important when reflex phase of a swallow is evaluated. Surface EMG of swallowing is a simple and reliable method for evaluation of swallowing with a low level of discomfort during the examination. The method can be easily used in outpatient ENT departments for quick evaluation of patients. The normative amplitude data can be used for comparison purposes in preoperaive and postoperative stages and in EMG monitoring during ENT treatment.

Evaluation of Normal Deglutition with the Help of Rectified Surface Electromyography Records

Surface electromyographic (sEMG) studies were performed on 300 normal adults to estimate normal values of sEMG records of muscle activity in the detection and evaluation of stages of normal swallowing. Our study was a prospective observational study of healthy volunteers. The parameters evaluated during swallowing include the timing, amplitude (voltage), and graphic patterns of activity of the orbicularis oris, masseter, submental, and laryngeal strap muscles covered by the platysma. Three tests were examined: voluntary single swallows of saliva (“dry” swallow), voluntary single water swallows (“normal”), and voluntary single swallows of excessive amounts of water (20 ml, “stress test”). Duration and amplitude of muscle activity in oral, pharyngeal, and initial esophageal stages of swallowing (mean + standard deviation, range + standard deviation) were measured for groups of adults of different ages (18–40, 41–70, 70+ years). Shapes of graphic records were evaluated relative to timing and voltage. The overall normal mean values for stage-by-stage duration of muscle activity during single swallowing were established for healthy adults. The duration of muscle activity in all tests showed insignificant increases with age except for the elderly group (70+) in which it was statistically significant (SPSS, χ2 criterion, 95% confidence interval, p < 0.05). There were no statistically significant gender-related differences in duration or amplitude of muscle activity during single swallowing for any age group (p ≥ 0.05). We conclude that the rectified and filtered sEMG provides a noninvasive means to assess certain aspects of complex muscle activity in deglutition. Surface EMG of swallowing is a simple and reliable noninvasive screening method for evaluating swallowing with low levels of discomfort. Stage-by-stage evaluation of duration can be very important for diagnosing the etiology of dysphagia. The combined normative timing of events, amplitude, and graphic data can be used for evaluating complaints and symptoms, as well as for comparison purposes in pre- and postoperative stages and in EMG monitoring during otolaryngological or neurological treatment. These parameters represent stages required for normal deglutition and provide a basis for the comparison of swallowing performance both within and between patients.

Review articleSurface electromyographic studies of swallowing in normal subjects: A review of 440 adults. Report 1. Quantitative data: Timing measures

OBJECTIVE: Surface electromyographic studies were performed on 440 normal adults to establish normative database for duration of muscle activity during swallowing and drinking clinically useful for outpatient ENT department. STUDY DESIGN: Prospective observational study of healthy volunteers. METHODS: Parameters evaluated during swallowing include the timing of activity of the orbicularis oris, masseter, submental, and infrahyoid muscle groups covered by platisma. Five tests were examined including voluntary single swallows of saliva (“dry” swallow), voluntary single water swallows as normal, voluntary single swallows of excessive amount of water (20 mL), continuous drinking of 100 mL of water (duration and number of swallows), monitoring of spontaneous swallowing of saliva during 1 hour period. The duration of oral, pharyngeal, and initial esophageal stages of swallowing (mean + SD) were measured for groups of adults of different age (18–30, 31–40, 41–50, 51–60, 61–70, 70+ years old). RESULTS: Normative data for duration of muscle activity during single swallowing and continuous drinking are established for healthy adults. The duration of swallows and drinking in all tests showed insignificant increase with the age except for the geriatric group, in which this tendency is statistically significant (1-dimensional analysis of variance, SPSS, Chi-square criterion, 95% confidence interval). There was no statistically significant difference between male and female adults duration of muscle activity during single swallowing and continuous drinking in all age groups (P ≥ 0.05). The relevance and clinical utility of new and alternative measures, in particular, are discussed. CONCLUSION: Surface EMG of swallowing is a simple and reliable noninvasive method for screening evaluation of swallowing with low level of discomfort during the examination. Stage-by-stage evaluation of duration can be very important for topical diagnosis of etiology of dysphagia. The normative timing of events data can be used for evaluation of complaints and symptoms, as well as for comparison purposes in preoperative and postoperative stages and in EMG monitoring during ENT treatment. These parameters represent stages required for normal deglutition, and can be used to identify abnormalities in ENT patients, and provide a basis for comparison of swallowing performance both within and between patients.

Use of fibrin glue as a hemostatic in endoscopic sinus surgery.

Endoscopic sinus surgery (ESS), especially when combined with turbinectomy and/or with submucous resection of the septum, may involve postoperative bleeding that might end with nasal packing. Nasal packing causes pain, rhinorrhea, and inconvenience and may not stop the postoperative bleeding. The aim of our study was to compare the hemostatic properties of the second-generation surgical sealant Quixil (Crosseal) with those of nasal packing in ESS. We performed a prospective randomized trial in 64 consecutive patients who underwent ESS and presented excessive intraoperative and/or postoperative bleeding. They were allocated by the sealed-envelope method into two groups. A routine ESS procedure was ended with Merocel nasal packing in group 1, and with aerosol application of Quixil sealant at the operative site in group 2. The hemostatic effects were evaluated objectively in the clinic by anterior rhinoscopy and endoscopy and assessed subjectively by the patients at follow-up visits. In group 1, various types of postoperative bleeding occurred in 25% of patients. In group 2 there was no postoperative bleeding, except for 1 case of late hemorrhage (3.12%). Drainage and ventilation of the paranasal sinuses were not impaired. There were no allergic reactions to the glue. We conclude that aerosol application of fibrin glue can be readily performed in ESS, requires no special treatment (antibiotics), and appears to have an adequate hemostatic effect. The use of this second-generation glue in ESS appears to stop nasal bleeding well and to be relatively safe and convenient.

Effectiveness of second-generation fibrin glue in endonasal operations

We evaluated the efficacy and safety of the Quixil fibrin sealant after its application to endonasal operative sites. A total of 153 patients underwent nasal surgery. The rate of hemorrhagic complications was compared in the group with nasal packing and in the group in whom fibrin glue was used to stop postoperative bleeding. Our results indicate that the application of Quixil fibrin glue to the operative sites in various endonasal operations provides effective hemostasis and sealing. This fibrin glue is a more effective hemostatic agent than foam nasal packing and provides no complications, as can occur with packing. Patients with hypertension have no greater risk for postoperative bleeding if Quixil is used.

Tonsillectomy vs. partial tonsillectomy for OSAS in children—10 years post-surgery follow-up

BACKGROUND Today, obstructive hypertrophic tonsils are completely resected to remove the obstruction. Since tonsillar tissue has important protective characteristics, it is more logical to resect only the obstructive tonsillar tissue and leave remnants in the tonsillar beds, thereby presuming to preserve the immunological function of the tonsillar tissue. However, it is as yet unclear whether or not rehypertrophy of this remnant of the tonsils and/or tonsillitis reoccur in the long-term. OBJECTIVES To evaluate the remnants of the tonsils 10-14 years post-tonsillotomy in children who suffered from obstructive sleep apnea syndrome (OSAS) due to obstructive tonsils. METHODS We conducted a retrospective study, telephone survey and selective physical examination of 33 children who had obstructive hypertrophic tonsils (suffered from OSAS due to hypertrophic tonsils), and underwent tonsillotomy (TT) at Assaf Harofeh Medical Center between July 1990 and April 1993, and compared them with a group of 16 children treated by tonsillectomy (TE) for the same diagnosis. RESULTS No statistically significant difference was found between the TT and TE groups in all parameters compared: non-obstructing tonsils recurred (97% vs. 87%); snoring (3% vs. 12.5%); recurrent tonsillitis (6% vs. 6.25%); and recurrent obstruction and unilateral enlargement (3% vs. 12.5%). CONCLUSIONS TT is as effective as TE for the long-term treatment of children suffering from OSAS due to hypertrophic tonsils.

Surface Electromyographic Studies of Swallowing in Normal Subjects: A Review of 440 Adults. Report 3. Qualitative Data

OBJECTIVE: Surface electromyographic studies were performed on 440 normal adults to describe and evaluate different types of normal swallows clinically useful for ENT department. STUDY DESIGN: Prospective observational study of healthy volunteers. METHODS: EMG recordings were made using stick-on surface electrodes. Rectified and filtered EMG signals were evaluated. Parameters evaluated include the graphic configuration of activity of the orbicularis oris, masseter, submental group, and infrahyoid muscles, the last 2 covered by platysma, during single swallowing and continuous drinking. Four tests were examined: voluntary saliva swallows, voluntary separate swallows as normal, voluntary separate swallows of excessive amount of water (20 mL), drinking of 100 mL of water. Graphic recording of activity of the above-mentioned muscles during swallowing and drinking were evaluated for groups of adults of different ages. RESULTS: There are several types of normal swallows as seen at the surface EMG records. There was no difference between EMG recordings of male and female swallows. Only group of elderly patients (age 70+) shows age-induced differences in recorded swallows. There are two main types of normal swallow: single-share and double-share swallows. The oral phase of swallowing, being under conscious control, is very variable and should not be taken into consideration during evaluation of records. Final oral, pharyngeal, and initial esophageal stages of swallowing can be defined and evaluated at the rectified and filtered surface EMG record. CONCLUSION: The normal muscle activity during swallows and drinking has several graphic patterns which can be identified and described similar to EKG records when surface EMG is rectified and filtered. The method of EMG recording is quick and simple, and can be used for screening and evaluation purposes in outpatient and inpatient ENT departments. These parameters represent activities required for normal deglutition, and can be used to identify abnormalities in ENT patients, and provide a basis for comparison of swallowing performance both within and between patients. These normal data form a valuable basis for future comparison with patients in pre- and postoperative stages and in EMG monitoring during ENT treatment.

Surface electromyography as a screening method for evaluation of dysphagia and odynophagia

ObjectivePatients suspected of having swallowing disorders, could highly benefit from simple diagnostic screening before being referred to specialist evaluations. The article analyzes various instrumental methods of dysphagia assessment, introduces surface electromyography (sEMG) to carry out rapid assessment of such patients, and debates proposed suggestions for sEMG screening protocol in order to identify abnormal deglutition.Data sourcesSubject related books and articles from 1813 to 2007 were obtained through library search, MEDLINE (1949–2007) and EMBASE (1975–2007).MethodsSpecifics steps for establishing the protocol for applying the technique for screening purposes (e.g., evaluation of specific muscles), the requirements for diagnostic sEMG equipment, the sEMG technique itself, and defining the tests suitable for assessing deglutition (e.g., saliva, normal, and excessive swallows and uninterrupted drinking of water) are presented in detail. SEMG is compared with other techniques in terms of cost, timing, involvement of radiation, etc.ResultsAccording to the published data, SEMG of swallowing is a simple and reliable method for screening and preliminary differentiation among dysphagia and odynophagia of various origins. This noninvasive radiation-free examination has a low level of discomfort, and is simple, time-saving and inexpensive to perform. The major weakness of the method seems to be inability for precise diagnostic of neurologically induced dysphagia.ConclusionWith standardization of the technique and an established normative database, sEMG might serve as a reliable screening method for optimal patient management but cannot serve for proper investigation of neurogenic dysphagia.

Surface Electromyography of Continuous Drinking in Healthy Adults

Objectives: To give a description of normal surface electromyography (sEMG) aspects of uninterrupted (continuous) drinking and to establish normal sEMG values for swallowing 100 mL of water.

Dimension of Subperiosteal Orbital Abscess as an Indication for Surgical Management in Children

Objective. Eyelid edema in children is one of the signs of orbital complications secondary to acute rhinosinusitis, and identifying abscess formation is crucial for management decision. The objective of this study is to determine whether there are different computed tomography scan abscess dimensions and volumes in children requiring medical versus surgical management for subperiosteal orbital abscess (SPOA). Study Design. Case series with chart review. Setting. The study was conducted at Assaf Harofeh Medical Center. Subjects and Methods. Clinical and radiological parameters of 95 children admitted with eyelid edema between January 2005 and December 2007 were studied. Results. Of 95 cases of orbital cellulitis, a total of 48 children with sinogenic orbital complications with a mean (SD) age of 4.03 (3.46) years were included. No significant difference was found between the surgically and medically treated SPOA groups regarding the use of preadmission antibiotic and clinical presentation. Statistically significant larger abscesses in the surgically treated group were noted (mean volume 1.389 vs 0.486 mL in the conservatively treated group; P = .013) and a longer mean anterior-posterior and medial-lateral dimension (P = .001 and .017, respectively). Conclusion.Children presenting with significant or progressing ocular findings or failure to improve after 48 hours of medical therapy, together with an abscess volume of more than 0.5 mL, a length greater than 17 mm, and a width greater than 4.5 mm, should be strongly considered to have surgical drainage.