Haruka Tohara

Screening Test for Silent Aspiration at the Bedside

Many screening tests for dysphagia can be given at bedside. However, they cannot accurately screen for silent aspiration (SA). We studied the usefulness of a cough test to screen for SA and combined it with the modified water swallowing test (MWST) to make an accurate screening system. Patients suspected of dysphagia (Nxa0=xa0204) were administered a cough test and underwent videofluorography (VF) or videoendoscopy (VE). Sensitivity of the cough test for detection of SA was 0.87 with specificity of 0.89. Of these 204 patients, 107 were also administered the MWST. Fifty-five were evaluated as normal by the screening system, 49 of whom were evaluated as normal by VF or VE. Sixteen were evaluated as “SA suspected” by the screening system; seven of them were normal, and seven were evaluated as having SA by VF or VE. Nineteen were evaluated as aspirating with cough, 14 of whom had aspiration with cough as shown by VF or VE. Seventeen were evaluated as having SA, 15 of whom had SA shown by VF or VE. The cough test was useful in screening for SA. Moreover, a screening system that included MWST and a cough test could accurately distinguish between the healthy who were safe in swallowing and SA patients who were unsafe.

Jaw-Opening Exercise for Insufficient Opening of Upper Esophageal Sphincter

OBJECTIVEnTo investigate the effects of the jaw-opening exercise on decreased upper esophageal sphincter (UES) opening while swallowing.nnnDESIGNnIntervention study: before-after trial with 4-week follow-up evaluation.nnnSETTINGnA university school of dentistry dental hospital.nnnPARTICIPANTSnPatients with dysphagia (N=8; 7 men, 1 woman; average age ± SD, 70.5±11.3y; age range, 54-86y).nnnINTERVENTIONSnAll patients performed a jaw-opening exercise to strengthen the suprahyoid muscles. The exercise involved opening the jaw to its maximum and maintaining this position for 10 seconds. Each exercise set consisted of 5 repetitions, and 2 sets were carried out daily for 4 weeks. The effectiveness of the exercise was evaluated by a videofluorographic swallowing study (VFSS).nnnMAIN OUTCOME MEASURESnHyoid elevation, UES opening, pharynx passage time, and pharyngeal residue after swallowing at preexercise and postexercise were compared by VFSS.nnnRESULTSnCompared with before starting the exercise, significant improvements were observed in the extent of upward movement of the hyoid bone (P<.05), the amount of UES opening (P<.05), and the time for pharynx passage (P<.05) 4 weeks after initiating the exercise. Pharyngeal residue decreased in some subjects, and no increases were noted in any subjects.nnnCONCLUSIONSnThe jaw-opening exercise is an effective treatment for dysphagia caused by dysfunction of hyoid elevation and UES opening.

Simplified Cough Test for Screening Silent Aspiration

OBJECTIVEnTo simplify the cough test to screen silent aspiration without sacrificing accuracy.nnnDESIGNnCriterion standard.nnnSETTINGnUniversity dental hospital.nnnPARTICIPANTSnConsecutive patients (N=141; 92 men, 49 women; mean age 71±14y, range 23-94y) who had complained of some dysphagic symptoms between June 2008 and February 2010.nnnINTERVENTIONSnAll patients were administrated a simplified cough test and underwent the fiberoptic endoscopic evaluation of swallowing. Citric acid inhalation was terminated when the first cough occurred, and the time between the start of inhalation and the first cough was measured.nnnMAIN OUTCOME MEASURESnThe time when the first cough was observed by the simplified cough test was compared with the results of the fiberoptic endoscopic evaluation of swallowing, which was used as a criterion standard.nnnRESULTSnReceiver operating characteristic curve analysis was performed for 53 patients evaluated as having aspiration by fiberoptic endoscopic evaluation of swallowing. We found that 30 seconds or less was an appropriate cutoff value for detecting patients without silent aspiration, where the sensitivity was .92 and the specificity was .94. From the receiver operating characteristic curve analyses for all patients, 60 seconds or less was determined to be an appropriate cutoff, and the sensitivity and specificity were .81 and .65, respectively.nnnCONCLUSIONnThe simplified cough test is a useful screening tool for silent aspiration in patients with aspiration.

Involvement of ERK phosphorylation in brainstem neurons in modulation of swallowing reflex in rats

In order to evaluate the neuronal mechanisms underlying functional abnormalities of swallowing in orofacial pain patients, this study investigated the effects of noxious orofacial stimulation on the swallowing reflex, phosphorylated extracellular signal‐regulated kinase (pERK) and γ‐aminobutyric acid (GABA) immunohistochemical features in brainstem neurons, and also analysed the effects of brainstem lesioning and of microinjection of GABA receptor agonist or antagonist into the nucleus tractus solitarii (NTS) on the swallowing reflex in anaesthetized rats. The swallowing reflex elicited by topical administration of distilled water to the pharyngolaryngeal region was inhibited after capsaicin injection into the facial (whisker pad) skin or lingual muscle. The capsaicin‐induced inhibitory effect on the swallowing reflex was itself depressed after the intrathecal administration of MAPK kinase (MEK) inhibitor. No change in the capsaicin‐induced inhibitory effect was observed after trigeminal spinal subnucleus caudalis lesioning, but the inhibitory effect was diminished by paratrigeminal nucleus (Pa5) lesioning. Many pERK‐like immunoreactive neurons in the NTS showed GABA immunoreactivity. The local microinjection of the GABAA receptor agonist muscimol into the NTS produced a significant reduction in swallowing reflex, and the capsaicin‐induced depression of the swallowing reflex was abolished by microinjection of the GABAA receptor antagonist bicuculline into the NTS. The present findings suggest that facial skin–NTS, lingual muscle–NTS and lingual muscle–Pa5–NTS pathways are involved in the modulation of swallowing reflex by facial and lingual pain, respectively, and that the activation of GABAergic NTS neurons is involved in the inhibition of the swallowing reflex following noxious stimulation of facial and intraoral structures.

Inter‐ and intra‐rater reliability in fibroptic endoscopic evaluation of swallowing

Fibroptic endoscopic evaluation of swallowing (FEES) is a useful way for dentists to evaluate oropharyngeal dysfunction. However, no study has paid attention to inter- and intra-rater reliability of FEES evaluation about oropharyngeal dysfunction. The purpose of this study is to verify whether dentist who trained and experienced for evaluation of dysphagia could diagnose oropharyngeal function with FEES. Nine dentists independently evaluated FEES images of 10 cases four times each. At first, evaluators performed the first evaluation without consulting the evaluative criteria. Subsequently, evaluators independently re-evaluated at 1-week intervals for three consecutive weeks, consulting the evaluative criteria. And then, inter- and intra-rater reliability was calculated. Cohens Kappa was used to assess reliability. The results found that overall inter-rater reliability was 0·35±0·04 (first evaluation), 0·45±0·05 (s), 0·44±0·05 (third) and 0·46±0·04 (fourth). Most of inter-rater reliability related to aspiration was moderate to high, but lower for categories that evaluated timing of swallowing and mastication. In contrast, intra-rater reliability was moderate to high for overall categories, at 0·53±0·04 (first vs. second evaluation), 0·55±0·04 (first vs. third), 0·53±0·04 (first vs. fourth), 0·55±0·03 (second vs. third), 0·60±0·03 (second vs. fourth) and 0·78±0·03 (third vs. fourth). FEES is reliable for experienced dentists to diagnose oropharyngeal function. Moreover, repeated evaluation with the aids of evaluative criteria is useful to improve the reliability of FEES.

Sequential evaluation of swallowing function in patients with unilateral neck dissection

Neck dissection is the most reliable treatment for cervical lymph node metastases in head and neck cancer. However, it is unknown whether neck dissection can cause dysphagia. The aim of this study was to evaluate swallowing function after neck dissection.

Usefulness of a handheld nebulizer in cough test to screen for silent aspiration

Cough test to screen for silent aspiration (SA) was reported, and the effectiveness was excellent. However, the device was rather large so that the portability was poor. So, the purpose of this study is to investigate the usefulness of a handheld nebulizer for the test and verify the reproducibility of the method. The subjects were 160 patients who were suspected of having dysphagia and underwent videofluorography (VF) or videoendoscopy (VE). They inhaled 1.0xa0% citric acid-physiologic saline orally for 1xa0min using a handheld nebulizer, and the examiner observed the number of coughs: more than five coughs was considered as negative (normal), while less than four coughs was regarded as positive. Among the subjects, 70 patients administered the cough test and VF or VE twice or more at some intervals. The k coefficient was calculated in reproducibility. Using the results of the VF or VE examination as the standards, for SA detection, the sensitivity was 0.86, specificity was 0.71, positive predictive value was 0.53, and negative predictive value was 0.93. The k coefficient was 0.79. In conclusion, the handheld nebulizer was useful in the cough test to screen for SA. Furthermore, satisfactory reproducibility was shown.

Jaw-Opening Force Test to Screen for Dysphagia: Preliminary Results

OBJECTIVEnTo assess the jaw-opening force test (JOFT) for dysphagia screening.nnnDESIGNnCriterion standard.nnnSETTINGnUniversity dental hospital.nnnPARTICIPANTSnPatients complaining of dysphagia (N=95) and with symptoms of dysphagia with chronic underlying causes (mean age ± SD, 79.3±9.61y; range, 50-94y; men: n=49; mean age ± SD, 77.03±9.81y; range, 50-94y; women: n=46; mean age ± SD, 75.42±9.73y; range, 51-93y) admitted for treatment between May 2011 and December 2012 were included.nnnINTERVENTIONSnNone.nnnMAIN OUTCOME MEASURESnAll patients were administered the JOFT and underwent fiberoptic endoscopic evaluation of swallowing (FEES). The mean jaw-opening strength was compared with aspiration (ASP) and pharyngeal residue observations of the FEES, which was used as the criterion standard.nnnRESULTSnA receiver operating characteristic (ROC) curve analysis was performed. Forces of ≤3.2kg for men and ≤4kg for women were appropriate cutoff values for predicting ASP with a sensitivity and specificity of .57 and .79 for men and .93 and .52 for women, respectively. Based on the ROC analyses for predicting pharyngeal residue, forces of ≤5.3kg in men and ≤3.9kg in women were appropriate cutoff values, with a sensitivity and specificity of .80 and .88 for men and .83 and .81 for women, respectively.nnnCONCLUSIONSnThe JOFT could be a useful screening tool for predicting pharyngeal residue and could provide useful information to aid in the referral of patients for further diagnostic imaging testing. However, given its low sensitivity to ASP the JOFT should be paired with other screening tests that predict ASP.

Effects of reclining posture on velopharyngeal closing pressure during swallowing and phonation

Velopharyngeal closure plays an important role in preventing air pressure leakage during swallowing and phonation from oropharynx to nasopharynx. Levator veli palatini muscle activity is influenced by oral and nasal air pressure, volume of the swallow bolus and postural changes. However, it is unclear how velopharyngeal closing pressure is affected by reclining posture. The purpose of this study was to investigate the effects of reclining posture on velopharyngeal closing pressure during swallowing and phonation. Nine healthy male volunteers (age range, 27-34 years) participated in this study. Velopharyngeal closing pressure during a dry swallow, a 5-mL liquid swallow, a 5-mL honey-thick liquid swallow and phonations of /P∧/ and /K∧/ were evaluated in an upright posture and at reclining postures of 60° and 30°. A manometer catheter was inserted transnasally onto the soft palate, and each trial was repeated three times. A solid-state manometer catheter with an intra-luminal transducer was used to evaluate the amplitude and duration of each trial, and data were statistically analysed. Average amplitudes during dry and liquid swallows were significantly lower in reclining postures compared with the upright posture, but the amplitude was not significantly different during the thick liquid swallow. Average durations were not affected by postural changes. The amplitudes during phonations were lower in reclining postures, but the differences were not significant. Velopharyngeal closure is significantly affected by reclining posture. This suggests that velopharyngeal closing pressure may be adjusted according to afferent inputs, such as reclining posture and bolus viscosity.

Changes in Pyriform Sinus Morphology in the Head Rotated Position as Assessed by 320-Row Area Detector CT

In patients with unilateral pharyngeal paresis and dysphagia, the head is rotated to the paretic side to prevent food flow to the rotated side during swallowing. Only a few studies to date have reported on pyriform sinus morphology upon head rotation. The purpose of this study was to measure the volume, depth, and cross-sectional area of the pyriform sinus during head rotation using 320-row area detector computed tomography. We imaged the neck during head rotation at 0° and at 30°, 45°, and 60° to the left or right in nine healthy young adults and determined the volume, depth, and cross-sectional area of the pyriform sinus in each position. On the rotated side, volume and cross-sectional area were significantly decreased at 60°. In contrast, volume, cross-sectional area, and depth were all significantly increased on the opposite side at 60°. These results suggest that head rotation at 60° significantly increases the volume, cross-sectional area, and depth of the opposite side, and significantly decreases the volume and depth of the rotated side of the pyriform sinus.