Jonathan E. Aviv

Laryngopharyngeal reflux: Position statement of the committee on speech, voice, and swallowing disorders of the American Academy of Otolaryngology-Head and Neck Surgery

The termreflux (derived from the Latin wordsre [“back”] andfluere [“to flow”]) literally meansbackflow. The termgastroesophageal reflux (GER) refers to the backflow of stomach contents into the esophagus. GER may be physiologic, and indeed up to 50 GER episodes a day, occurring mostly after meals, is accepted as being within the normal range. 1-3 Gastroesophageal reflux disease (GERD) is a clinical term that refers to GER that is excessive and that causes tissue damage (eg, esophagitis) and/or clinical symptoms (eg, heartburn). 1

Prospective, randomized outcome study of endoscopy versus modified barium swallow in patients with dysphagia.

Objective Aspiration pneumonia is a significant cause of morbidity and mortality in both acute and long‐term care settings. While there are many reasons for patients to develop aspiration pneumonia, there exists a strong association between difficulty swallowing, or dysphagia, and the development of aspiration pneumonia. The modified barium swallow test (MBS) and endoscopic evaluations of swallowing are considered to be the most comprehensive tests used to evaluate and manage patients with dysphagia in an effort to reduce the incidence of pneumonia. The purpose of this study was to provide an initial investigation of whether flexible endoscopic evaluation of swallowing with sensory testing (FEESST) or MBS is superior as the diagnostic test for evaluating and guiding the behavioral and dietary management of outpatients with dysphagia. FEESST combines the standard endoscopic evaluation of swallowing with a technique that determines laryngopharyngeal sensory discrimination thresholds by endoscopically delivering air pulse stimuli to the mucosa innervated by the superior laryngeal nerve.

Supraglottic and Pharyngeal Sensory Abnormalities in Stroke Patients with Dysphagia

Dysphagia and aspiration are two devastating sequelae of stroke, accounting for nearly 40,000 deaths from aspiration pneumonia each year in the United States. While motor deficits in the larynx and pharynx are thought responsible for dysphagia and aspiration in stroke patients, no prior study has evaluated whether these patients also have sensory deficits. The aim of this study was to evaluate the sensory capacity of the laryngopharynx (LP) in supratentorial or brain stem stroke patients who presented with dysphagia. Fifteen stroke patients (mean age, 66.7 ± 13.8 [SD] years) were prospectively evaluated by means of our previously described method whereby air pulse stimuli were delivered via a flexible fiberoptic telescope to the mucosa innervated by the superior laryngeal nerve. There were 15 age-matched controls. No LP sensory deficits were found in any of the age-matched controls. In all stroke patients studied, either unilateral (n = 9) or bilateral (n=6) sensory deficits were identified. Deficits were defined as either a moderate impairment in sensory discrimination thresholds (3.5 to 6.0 mm Hg) or a severe sensory impairment (>6.0 mm Hg). These sensory discrimination thresholds were significantly greater than in age-matched controls (7.05 ± 0.17 mm Hg for the supratentorial group and 6.05 ± 1.22 mm Hg for the infratentorial group versus 2.61 ± 0.69 mm Hg for the controls). Among patients with unilateral deficits, sensory thresholds were moderately to severely elevated in all 9 cases on the affected side compared with the unaffected side (p < .01, Fishers exact test). Moreover, the sensory thresholds of the unaffected side were not significantly different from those of age-matched controls (2.51 ± 0.25 mm Hg versus 2.61 ± 0.69 mm Hg, respectively). All 6 patients with bilateral deficits had severe impairments. The results of an outcome assessment in 13 of 15 patients revealed that 2 out of 5 patients with moderate LP sensory impairment and 5 out of 8 with severe impairment developed aspiration. Our results show for the first time that stroke patients with dysphagia have significant sensory deficits in the LP and that these impairments are likely to contribute to the development of aspiration.

Botulinum toxin A for hyperkinetic facial lines : results of a double-blind, placebo-controlled study

Previous work on patients with muscular dystonia has shown that small intramuscular doses of botulinum toxin A eliminated hyperkinetic facial lines for approximately 6 months. The purpose of this study was to determine the efficacy of botulinum toxin A injections in eliminating facial wrinkles in aesthetic surgery patients who do not have muscular dystonia. Eleven healthy subjects were studied in a double-blind fashion. On both sides of the face, 0.2 cc of either normal saline or botulinum toxin A was injected into the forehead or into the periorbital wrinkles (crows feet). Documentation of results was made by photographs taken of the patients during repose and during facial animation before and after injection. Assessment of facial wrinkles was done from a grading system in which the patient and the facial plastic surgeon were asked to judge the severity of the wrinkles on a scale from 0 to 3, with 0 reflecting no facial wrinkles and 3 reflecting severe facial wrinkling. Nine of 11 subjects injected with botulinum toxin A noted a significant improvement in the severity of their facial wrinkles in comparison with the side of the face injected with saline, with a rating improvement of 2 points. Two of 11 subjects noted a moderate improvement, with a rating improvement of 1 point. No patient injected with saline reported an improvement in the severity of the facial wrinkles on the control side. There were no serious complications. Botulinum toxin A is an efficacious method of nonsurgically eliminating facial wrinkles and may play a role in the cosmetic enhancement of the aging face.

Age-Related Changes in Pharyngeal and Supraglottic Sensation

As one ages, sensory discrimination in the oral cavity progressively diminishes, and dysphagia and aspiration are more likely to occur. Whether similar age-related laryngeal and pharyngeal sensory abnormalities exist and contribute to dysphagia and aspiration is unknown. The purpose of this study was to determine if sensory discrimination in the area innervated by the superior laryngeal nerve diminishes with increasing age. By applying a previously described new device and technique that utilizes brief air pulse stimulation of the anterior wall of the pyriform sinus, sensory discrimination can be reliably determined. We carried out 672 trials in 56 healthy adults divided into three age groups: 20 to 40, 41 to 60, and 61 to 90 years of age. Overall, the average sensory discrimination was 2.30 ± 0.50 mm Hg. In subjects 20 to 40 years of age, sensory discrimination was 2.07 ± 0.20 mm Hg, while in subjects 61 to 90 years of age, sensory discrimination was 2.68 ± 0.63 mm Hg (p < .05). There also was a statistically significant difference between the 41- to 60-year and 61- to 90-year age groups (p < .05). Progressive diminution in pharyngeal and supraglottic sensitivity with increasing age might be a contributing factor in the development of dysphagia and aspiration in the elderly.

FEESST: A New Bedside Endoscopic Test of the Motor and Sensory Components of Swallowing

We here introduce an office or bedside method of evaluating both the motor and sensory components of swallowing, called fiberoptic endoscopic evaluation of swallowing with sensory testing (FEESST). FEESST combines the established endoscopic evaluation of swallowing with a technique that determines laryngopharyngeal (LP) sensory discrimination thresholds by endoscopically delivering air pulse stimuli to the mucosa innervated by the superior laryngeal nerve. Endoscopic assessment of LP sensory capacity followed by endoscopic visualization of deglutition was prospectively performed 148 times on 133 patients with dysphagia over an 8-month period. The patients had a variety of underlying diagnoses, with stroke and chronic neurologic disease predominating (n = 94). Subsequent to LP sensory testing, a complete dysphagia evaluation was conducted. Various food and liquid consistencies were dyed green, and attention was paid to their management throughout the pharyngeal stage of swallowing. Evidence of latent swallow initiation, pharyngeal pooling and/or residue, laryngeal penetration, laryngeal aspiration, and/or reflux was noted. Recommendations for therapeutic intervention were based on information obtained during the FEESST and often involved the employment of compensatory swallowing strategies, modification of the diet or its presentation, placement on non-oral feeding status, and/or referral to other related specialists. All patients successfully completed the examination. In 111 of the evaluations (75%), severe (>6.0 mm Hg air pulse pressure [APP]) unilateral or bilateral LP sensory deficits were found. With puree consistencies, 31% of evaluations with severe deficits, compared to 5% of evaluations with either normal sensitivity or moderate (4.0 to 6.0 mm Hg APP) LP sensory deficits, displayed aspiration (p <.001, χ2 test). With puree consistencies, 69% of evaluations with severe deficits, compared to 24% with normal or moderate deficits, displayed laryngeal penetration (p <.001, χ2 test). FEESST allows the clinician to obtain a comprehensive bedside assessment of swallowing that is performed as the initial swallowing evaluation for the patient with dysphagia.

Air pulse quantification of supraglottic and pharyngeal sensation : a new technique

There are no published studies evaluating the sensory capacity of the region innervated by the superior laryngeal nerve. A normal sensory capacity is important in this area, since hypesthesia or anesthesia of the pharynx and supraglottic larynx may result in dysphagia and aspiration. This often occurs after stroke or after ablative surgery of the pharynx and larynx. Evaluating the efficacy of restorative procedures for supraglottic and pharyngeal sensation is dependent on defining and quantifying the sensory deficit. We have developed a new, noninvasive method to measure sensation in the pharynx and supraglottic larynx. A puff of air—of precisely controlled duration and pressure—was delivered via a flexible telescope to the anterior wall of the pyriform sinus. Surface sensibility was determined according to the psychophysical method of limits by varying air pressure while holding puff duration constant. We conducted 204 trials in 20 healthy adults. The average sensory discrimination threshold was 2.09 ± 0.15 mm Hg. An intraclass correlation revealed excellent consistency (R̂ = .80). There was no statistically significant difference between the right and left sides. Brief air pulse stimulation is an easy, relatively safe, and reliable method of determining supraglottic and pharyngeal sensory discrimination thresholds.

Effects of aging on sensitivity of the pharyngeal and supraglottic areas

As one ages, sensory discrimination in the oral cavity progressively diminishes, and dysphagia and aspiration are more likely to occur. Whether similar age-related laryngopharyngeal (LP) sensory abnormalities exist and contribute to dysphagia and aspiration is unknown. The purpose of this study was to determine if sensory discrimination in the area of the laryngopharynx innervated by the superior laryngeal nerve diminishes with increasing age. By applying a previously described device and technique that utilized endoscopically delivered air pulse stimulation of the anterior wall of the pyriform sinus, sensory discrimination can be reliably determined. LP sensory discrimination testing was performed in 80 healthy adults 23-87 years of age, with a mean age of 47 +/- 20 years. There were 60 men and 20 women. The test subjects were divided into 3 age groups, 20-40, 41-60, and > or =61. For the entire population studied, average LP sensory discrimination thresholds were 2.60 +/- 0.56 mm Hg air pulse pressure (APP). In general, there was a progressive increase in sensory discrimination threshold with each decade of life. A correlation analysis revealed that there were significant increases in pressure thresholds with advancing age (r = 0.62, P <0.0001). For subjects 20-40 years, average threshold was 2.06 +/- 0.20 mm Hg APP, for the 41-60 age group, 2.45 +/- 0.34 mm Hg APP, and for subjects > or =61, 2.97 +/- 0.78 mm Hg APP. Thresholds for the > or =61 group were significantly different from those for the 20-40 and the 41-60 groups (P <0.05). Progressive diminution in LP sensitivity with increasing age might be a contributing factor in the development of dysphagia and aspiration in the elderly.

The Safety of Flexible Endoscopic Evaluation of Swallowing with Sensory Testing (FEESST): An Analysis of 500 Consecutive Evaluations

We assessed the safety of a new office or bedside method of evaluating both the motor and sensory components of swallowing called flexible endoscopic evaluation of swallowing with sensory testing (FEESST). FEESST combines the established endoscopic evaluation of swallowing with a technique that determines laryngopharyngeal sensory discrimination thresholds by endoscopically delivering air-pulse stimuli to the mucosa innervated by the superior laryngeal nerve. Endoscopic assessment of laryngopharyngeal sensory capacity followed by endoscopic visualization of deglutition was prospectively performed 500 times in 253 patients with dysphagia over a 2.5-year period in a tertiary care center. The patients had a variety of underlying diagnoses, with stroke and chronic neurological disease predominating (n= 155). To determine the safety of FEESST, the presence of epistaxis, airway compromise, and significant changes in heart rate before and after the evaluation were assessed. Patients were also asked to rate the level of discomfort of the examination; 498 evaluations were completed. There were three instances of epistaxis that were self-limited. There were no cases of airway compromise. There were no significant differences in heart rate between pre- and posttest measurements (p > 0.05). Eighty-one percent of patients noted either no discomfort or mild discomfort as a result of the examination. In conclusion, FEESST is a safe method of evaluating dysphagia in the tertiary care setting and may also have application for the chronic care setting.

Laryngeal Adductor Reflex and Pharyngeal Squeeze as Predictors of Laryngeal Penetration and Aspiration

Objectives The contribution of laryngopharyngeal (LP) sensory deficits to the outcome of swallowing and the relationship between sensory and motor deficits in the laryngopharynx is unclear. The study purpose is to determine if patients with LP sensory and motor deficits are at increased risk for laryngeal penetration and aspiration during swallowing, and to determine the relationship between pharyngeal motor weakness and LP sensory deficits.