Jeri A. Logemann

Upper esophageal sphincter opening and modulation during swallowing

Studies were done on 8 normal subjects with synchronized videofluoroscopy and manometry to facilitate a biomechanical analysis of upper esophageal sphincter opening and volume-dependent modulation during swallowing. Movements of the hyoid and larynx, dimensions of sphincter opening, and intraluminal sphincter pressure were determined at 1/30th-s intervals during swallows of 1, 5, 10, and 20 ml of liquid barium. Our analysis subdivided upper esophageal sphincter activity during swallowing into five phases: (a) relaxation, (b) opening, (c) distention, (d) collapse, and (e) closure. Sphincter relaxation occurred during laryngeal elevation and preceded opening by a mean period of 0.1 s. Opening occurred as the sphincter was pulled apart via muscular attachments to the hyoid such that the hyoid coordinates at which sphincter opening and closing occurred were constant among bolus volumes. Sphincter distention after opening was modulated by intrabolus pressures rather than graded hyoid movement. The generation of intrabolus pressure coincided with the posterior thrust of the tongue that culminated in pharyngeal wall contact and the initiation of pharyngeal peristalsis. Larger volume swallows were associated with greater intrabolus pressure and increased bolus head velocity. The duration of sphincter opening increased in conjunction with a prolongation of the anterior-superior excursion of the hyoid and a delay in the onset of pharyngeal peristalsis (the event that determined the timing of sphincter closure). We conclude that transsphincteric transport of increasing swallow bolus volumes is accomplished by modulating sphincter diameter, opening interval, and flow rate (reflected by bolus head velocity). Furthermore, upper esophageal sphincter opening is an active mechanical event rather than simply a consequence of cricopharyngeal relaxation.

Preliminary observations on the effects of age on oropharyngeal deglutition

Swallows of 4 bolus volumes (1, 5, 10, 20 ml) were examined in three groups of subjects: 6 subjects 20–29 years of age, 12 subjects 30–59 years of age, and 6 subjects 60–79 years of age. A simultaneous manometric and videofluoroscopic data collection protocol permitted measurement of bolus transit, temporal aspects of the oropharyngeal swallow, and pharyngeal peristalsis. Statistically significant effects of increasing bolus volume were oral transit of the bolus head (decreased) and duration of cricopharyngeal opening (increased). Five measures were significantly changed with increasing age: duration of pharyngeal swallow delay (increased), duration of pharyngeal swallow response (decreased), duration of cricopharyngeal opening (decreased), peristaltic amplitude (decreased), and peristaltic velocity (decreased).

Swallowing disorders in head and neck cancer patients treated with radiotherapy and adjuvant chemotherapy

The nature of swallowing problems was examined in nine patients treated primarily with external‐beam radiation and adjuvant chemotherapy for newly diagnosed tumors of the head and neck. All subjects underwent videofluorographic examination of their swallowing. Three analyses were completed, including the following: observations of motility disorders, residue, and aspiration; temporal analyses; and biomechanical analyses. Oropharyngeal swallow efficiency was calculated for the first swallow of each bolus.

Effects of bolus volume, viscosity, and repeated swallows in nonstroke subjects and stroke patients

This study examined the effects of bolus volume and viscosity and the variability of repeated swallows in ten stroke patients and ten age-matched nonstroke subjects. The ten stroke patients demonstrated single unilateral cortical (three subjects), subcortical (six subjects), or brainstem (one subject) infarcts on computed tomography or magnetic resonance imaging scans at three weeks post-ictus. All subjects underwent videofluoroscopic swallow studies in which seven temporal pharyngeal swallow measures were examined. Despite the dissimilarity in lesion locations, the swallow physiology in the stroke patients was relatively homogeneous, ie, no swallowing disorders severe enough to prevent oral intake. As bolus volume increased, pharyngeal delay time diminished in stroke patients, but not in nonstroke subjects. Increasing bolus volume affected three other pharyngeal swallow measures similarly in nonstroke and stroke subjects: laryngeal closure durations and cricopharyngeal (CP) opening durations increased and duration of tongue base contact to posterior pharyngeal wall decreased. On viscosity comparisons (liquid vs paste), both subject groups displayed longer duration of base of tongue contact to posterior pharyngeal wall. On paste swallows, nonstroke subjects had longer CP opening and lower swallow efficiency, whereas stroke patients did not. This study found no statistically significant learning/repetition effect for repeated swallows in either subject group, or both groups combined.

A Screening Procedure for Oropharyngeal Dysphagia

Abstract. The present study was designed to examine the sensitivity and specificity of a 28-item screening test in identifying patients who aspirate, have an oral stage disorder, a pharyngeal delay, or a pharyngeal stage disorder. The screening test includes 28 items divided into 5 categories: (1) 4 medical history variables; (2) 6 behavioral variables; (3) 2 gross motor variables; (4) 9 observations from oromotor testing; and (5) 7 observations during trial swallows. Results identified variables that were able to classify patients correctly as having or not having aspiration 71% of the time, an oral stage disorder 69% of the time, a pharyngeal delay 72% of the time, and a pharyngeal stage swallowing problem 70% of the time. Sensitivity and specificity for each of these judgments and all 28 items on the test are also provided. Results are discussed relative to statistical, clinical, and third-party perspectives on the goals of screening, data from other screening tests, and the role of screening versus diagnostic testing in care of dysphagic patients.

Comparison of 2 Interventions for Liquid Aspiration on Pneumonia Incidence A Randomized Trial

Context Patients with dysphagia are at increased risk for aspiration pneumonia. Contribution This trial involved 515 adults with dementia or Parkinson disease and videofluoroscopically demonstrated aspiration. Participants were randomly assigned to drink thin liquids with a chin-down posture or to drink nectar- or honey-thick liquids in a head-neutral position. At 3 months, the cumulative incidence of pneumonia was about 10%, 8%, and 15% in the thin, nectar-thick, and honey-thick liquid groups. Dehydration was more common with thick than thin liquids. Caution Findings were inconclusive. The incidence of pneumonia was lower than expected, and confidence bounds around differences between groups were wide. The Editors Swallowing disorders are associated with increased morbidity and mortality. An estimated 18 million adults will require care for dysphagia-related malnutrition, dehydration, pneumonia, and reductions in quality of life by 2010 (13). Patients with dysphagia have an increased incidence of aspiration pneumonia because the aspirated material is heavily colonized with bacteria. Pneumonia is the fifth leading cause of infectious death in the United States among persons age 65 years or older and the third leading cause of death for persons age 85 years or older (4). One hospital admission for pneumonia is estimated to cost

Impact of thermal stimulation on the triggering of the swallowing reflex

7166 (5). Rates of hospital discharge for Medicare beneficiaries with pneumonia as a primary diagnosis have increased by 93.5% in the past decade (6), along with length of stay and death rates (4). Liquid aspiration is the most common type of aspiration in elderly persons (1). Relative risk for pneumonia is highest in patients with dementia, followed by those who are institutionalized (7). As many as 50% of patients with parkinsonism are estimated to have dysphagia (8), and one third aspirate silentlythat is, with no external sign (such as coughing) to eject material or alert caregivers (9). Many short- and long-term care facilities use thickened liquid diets to treat aspiration (10). In these diets, thin liquids (for example, water, tea, and coffee) are eliminated, even in the absence of efficacy data, at a substantial cost in financial and quality-of-life terms. It costs approximately

Swallowing disorders in three types of head and neck surgical patients

200 per month for an individual to drink thickened liquids (11, 12). A common alternative to thickened liquids is use of a chin-down posture (1317). Welch and coworkers (13) noted that posterior shift of anterior pharyngeal structures with the chin-down posture improved airway protection. Whereas previous studies have provided a basis for the widespread clinical use of chin-down posture, none has provided long-term health outcome data. Results from a previously reported portion of this study (18) demonstrated that short-term elimination of aspiration during the videofluorographic swallowing evaluation occurred most often with honey-thick liquids, followed by nectar-thick liquids and chin-down position. We sought to compare the effectiveness of chin-down posture and thickened liquids (nectar thick and honey thick) on the incidence of pneumonia in participants with dementia or Parkinson disease during 3 months of treatment. Methods Design The study design and methods are described in detail elsewhere (19). In brief, between enrollment initiation on 9 June 1998 and closure on 16 September 2005, 47 acute-care hospitals and 79 subacute residential facilities combined their patients to enroll 515 participants, a total that was 65 participants short of the recruitment goal. Follow-up was completed on 9 December 2005. The Data and Safety Monitoring Committee recommended discontinuing enrollment, on the basis of a futility analysis suggesting that enrolling additional participants would not change the findings. Participants were enrolled in this 3-month follow-up study if they were observed to aspirate when swallowing 3 mL of thin liquids from a spoon or when drinking from a cup without an intervention during videofluoroscopy of swallowing. Aspiration was defined as barium observed below the vocal folds. Participants who qualified were then given boluses to perform 3 conditions in random order: thin liquid (15 centipoise) swallowed in a chin-down posture, nectar-thick liquid (300 centipoise) swallowed in a head-neutral position, and honey-thick liquid (3000 centipoise) swallowed in a head-neutral position. Participants who did equally well (all conditions eliminated aspiration) or equally poorly (no conditions eliminated aspiration) but wished to continue oral intake, despite being warned about risk for pneumonia, were randomly assigned to 1 of the conditions as an intervention and followed for 3 months. Participants who aspirated during 1 or 2 of the conditions were not randomly assigned. On-site speech-language pathologists, nurses, and direct care and dietary staff who completed rigorous training about facilitation of the chin-down posture and proper techniques to thicken liquids supervised administration of the interventions. The number of participants under supervision by a speech-language pathologist ranged from 1 to 93 (median, 4 participants). Clinicians were instructed to refrain from using concomitant active or compensatory interventions with participants during the study period. Research staff made monthly site visits to monitor protocol adherence. All participants or their representatives provided written informed consent. Each facilitys institutional review board of record, as approved by the Office for Human Research Protections, Department of Health and Human Services, approved the study. Setting and Participants Inclusion criteria were a physician-identified diagnosis of dementia (Alzheimer type, single or multistroke type, or other nonresolving types) or Parkinson disease and patient age (50 to 95 years). Exclusion criteria were tobacco use in the past year, current alcohol abuse, history of head or neck cancer, insulin-dependent diabetes for 20 years or more, nasogastric tube, other progressive or infectious neurologic diseases, or pneumonia within 6 weeks of enrollment. Outpatients and inpatients from participating acute and subacute care facilities who were suspected of aspirating liquids by their physicians and speech-language pathologists during standard clinical care were referred for a videofluoroscopic swallowing study at a participating acute-care facility. The speech-language pathologist or research personnel completed the informed consent process with the patient and care provider before the swallowing study. After the swallowing study, participants returned to their living situation (acute care, subacute care, or home) while the videofluoroscopic images were analyzed. Participants were randomly assigned to an intervention group within 24 hours. Randomization and Interventions The primary interventions were chin-down posture while consuming thin liquids versus consuming thickened liquids (nectar thick or honey thick; Resource ThickenUp, Nestl HealthCare Nutrition [formerly Novartis Medical Nutrition], St. Louis Park, Minnesota) in a head-neutral position. The thin, nectar-thick, and honey-thick barium solutions (Varibar, E-Z-EM, Lake Success, New York) were manufactured in a standardized formulation for this study. Standardized recipes matching the viscosities of the barium products were developed for a wide variety of thickened beverages. Participants were randomly assigned centrally by a telephone system controlled by the Statistical and Data Center at the EMMES Corporation (Rockville, Maryland). A study speech-language pathologist called a central telephone number and entered participant criteria when prompted to, by using the telephone keys. If the patient was eligible, an intervention was assigned and a summary page that included intervention assignment and meal-monitoring was faxed to the speech-language pathologist. Randomization sequences for primary assignment (chin-down posture vs. thickened liquids) were developed by a statistician at the Statistical and Data Center. The sequences were stratified by participant age (50 to 79 years or 80 to 95 years) and diagnosis (Parkinson disease with or without dementia, or dementia only) and included randomly assigned block sizes of 32, 40, or 48 within each of the 4 strata. If a participant was assigned to thickened liquids, a second randomization was done to assign the participant to nectar-thick liquids or honey-thick liquids with equal probability. Neither the participants nor direct caregivers were blinded to intervention assignment, but neither group made outcome judgments. We expected that all liquids, regardless of amount or frequency of administration, would be provided to participants consistent with the intervention to which the participant was randomly assigned. All participants continued nonliquid nutritional intake in the same manner as before enrollment. Eight percent received nutrition by means of a gastrostomy tube. Measurements and Outcomes Primary Outcome The primary outcome for the study was definite pneumonia. Definite pneumonia was defined as evidence of pneumonia on chest radiography or 3 or more of the following: sustained fever (temperature >100F [38C]), rales or rhonchi on chest auscultation, sputum Gram stain showing substantial leukocytes, or sputum culture showing a respiratory pathogen. Suspected pneumonia was defined as at least 2 of the 4 features of definite pneumonia (except evidence of pneumonia on a chest radiograph). The primary care physician determined the need for chest radiography or sputum culture as part of standard clinical care. Chest radiography was done in all 52 patients with pneumonia; 2 of these patients did not have evidence of pneumonia on chest radiography but had 3 or 4 of the features of definite pneumonia. Secondary Outcomes and Comparisons A secondary outcome of interest was definite pneumonia or death. Secondary comparisons of interest were relative effectiveness of the 2 degre

Chin-Down Posture Effect on Aspiration in Dysphagic Patients

This study was designed to quantify the effects of thermal sensitization on the oral and pharyngeal transit times of the swallow following sensitization in a group of 25 neurologically impaired patients exhibiting delayed triggering of the swallowing reflex. Thermal sensitization consists of applying cold (thermal) contact to the base of the anterior faucial arches in order to sensitize the area of the oral cavity where the reflex is triggered. Thermal sensitization improved triggering of the swallowing reflex in 23 of the 25 neurologically impaired patients on swallows of at least one food consistency. Results are discussed in relation to neurologic recovery and carryover of these effects.

Longitudinal assessment of quality of life in laryngeal cancer patients

This study examined swallowing transit times and motility problems in three groups of patients following ablative surgery for oropharyngeal carcinoma and in a control group of 10 normal subjects. A total of 30 patients was studied: 10 after anterior floor of mouth resection, 12 after tonsil/base of tongue resection, and 8 after supraglottic laryngectomy. Videofluoroscopic studies of liquid, thin paste, thick paste, and thick paste plus liquid swallows were completed 1 week post‐initiation of oral feeding following surgery. From the videotapes, oral and pharyngeal transit times were measured, and motility disturbances were defined during each stage of the swallow. All three types of patients in this study showed severe problems with swallowing. The anterior floor of mouth resection patients had problems with preparation for the swallow and oral transit. Tonsil/base of tongue resection patients had slowing in the preparation for the swallow and in the oral and pharyngeal stages. After supraglottic laryngectomy, patients showed only slight slowing in oral transit and pharyngeal transit as compared to other types of surgical patients.