Jung Hoi Koo

Inter-rater Reliability of Videofluoroscopic Dysphagia Scale

Objective To investigate the inter-rater agreement using the Videofluoroscopic Dysphagia Scale (VDS). Method The present study was designed as a multicenter, single-blind trial. A Videofluoroscopic Swallowing Study (VFSS) was performed using the protocol described by J.A Logemann. Thick-fluid, pureed food, mechanically altered food, regularly textured food, and thin-fluid boluses were sequentially swallowed. Each participant received a 3 ml bolus followed by a 5 ml bolus of each food material, in the order mentioned above. All study procedures were video recorded. Discs containing these video recordings in random order were distributed to interpreters who were blinded to the participant information. The video recordings were evaluated using a standardized VDS sheet and the inter-rater reliability was calculated. Results In total, 100 patients participated in this study and 10 interpreters analyzed the findings. Inter-rater reliability was fair in terms of lip closure (κ: 0.325), oral transit time (0.253), delayed triggering of pharyngeal swallowing (0.300), vallecular residue (0.275), laryngeal elevation (0.345), pyriform sinus residue (0.310), coating of the pharyngeal wall (0.310), and aspiration (0.393). However, other parameters of the oral phase were lower than those of the pharyngeal phase (0.06-0.153). Moreover, the summation of VDS reliability (intraclass correlation coefficient: 0.556) showed moderate agreement. Conclusion VDS shows a moderate rate of agreement for evaluating the swallowing function. However, many of the parameters demonstrated a lower rate of agreement, particularly the oral phase parameters.

Central cholinergic dysfunction could be associated with oropharyngeal dysphagia in early Parkinson’s disease

Dysphagia is an important issue in the prognosis of Parkinson’s disease (PD). Although several studies have reported that oropharyngeal dysphagia may be associated with cognitive dysfunction, the exact relationship between cortical function and swallowing function in PD patients is unclear. Therefore, we investigated the association between an electrophysiological marker of central cholinergic function, which reflected cognitive function, and swallowing function, as measured by videofluoroscopic studies (VFSS). We enrolled 29 early PD patients. Using the Swallowing Disturbance Questionnaire (SDQ), we divided the enrolled patients into two groups: PD with dysphagia and PD without dysphagia. The videofluoroscopic dysphagia scale (VDS) was applied to explore the nature of the dysphagia. To assess central cholinergic dysfunction, short latency afferent inhibition (SAI) was evaluated. We analyzed the relationship between central cholinergic dysfunction and oropharyngeal dysphagia and investigated the characteristics of the dysphagia. The SAI values were significantly different between the two groups. The comparison of each VFSS component between the PD with dysphagia group and the PD without dysphagia group showed statistical significance for most of the oral phase components and for a single pharyngeal phase component. The total score on the VDS was higher in the PD with dysphagia group than in the PD without dysphagia group. The Mini-Mental State Examination and SAI values showed significant correlations with the total score of the oral phase components. According to binary logistic regression analysis, SAI value independently contributed to the presence of dysphagia in PD patients. Our findings suggest that cholinergic dysfunction is associated with dysphagia in early PD and that an abnormal SAI value is a good biomarker for predicting the risk of dysphagia in PD patients.

Gastrocolic Fistula as a Cause of Persistent Diarrhea in a Patient With a Gastrostomy Tube

A 60-year-old man with a history of recurrent strokes secondary to moyamoya disease underwent insertion of a percutaneous radiologic gastrostomy tube because of severe dysphagia. Feeding was continued for 5 months after the procedure without complications. Persistent diarrhea began 2 weeks after admission for comprehensive rehabilitation. Conservative treatment was not effective. Sigmoidoscopy showed a U-shaped tube suggestive of a gastrocolic fistula in the transverse colon. This was confirmed by means of a tubogram obtained through a gastrostomy tube. The diarrhea resolved after changing the gastrostomy tube. This case report highlights the importance of considering other uncommon conditions, such as a gastrocolic fistula, in the differential diagnosis of persistent diarrhea in a patient with a gastrostomy tube.

Effects of Head Rotation and Head Tilt on Pharyngeal Pressure Events Using High Resolution Manometry

Objective To observe changes in pharyngeal pressure during the swallowing process according to postures in normal individuals using high-resolution manometry (HRM). Methods Ten healthy volunteers drank 5 mL of water twice while sitting in a neutral posture. Thereafter, they drank the same amount of water twice in the head rotation and head tilting postures. The pressure and time during the deglutition process for each posture were measured with HRM. The data obtained for these two postures were compared with those obtained from the neutral posture. Results The maximum pressure, area, rise time, and duration in velopharynx (VP) and tongue base (TB) were not affected by changes in posture. In comparison, the maximum pressure and the pre-upper esophageal sphincter (UES) maximum pressure of the lower pharynx in the counter-catheter head rotation posture were lower than those in the neutral posture. The lower pharynx pressure in the catheter head tilting posture was higher than that in the counter-catheter head tilting. The changes in the VP peak and epiglottis, VP and TB peaks, and the VP onset and post-UES time intervals were significant in head tilting and head rotation toward the catheter postures, as compared with neutral posture. Conclusion The pharyngeal pressure and time parameter analysis using HRM determined the availability of head rotation as a compensatory technique for safe swallowing. Tilting the head smoothes the progress of food by increasing the pressure in the pharynx.

Myelopathy Caused by Spinal Dural Arterio-Venous Fistula after First Lumbar Vertebral Body Fracture - A Case Report -

Spinal dural arteriovenous fistula is a rare vascular lesion of the spinal cord associated with progressive myelopathy. Symptoms include progressive gait dysfunction, weakness, sensory loss, and bowel and bladder dysfunction. Because these symptoms overlap with other common causes of myelopathy and the disease is rare, spinal dural arteriovenous fistula is often not suspected and the time to diagnosis is long. We report the case of a 60-year-old woman who presented with progressive lower limb weakness and gait disturbance diagnosed as spinal dural arteriovenous fistula involving a fractured L1 vertebral body.

Median Nerve Injury Caused by Brachial Plexus Block for Carpal Tunnel Release Surgery

Carpal tunnel release is required to treat patients with severe carpal tunnel syndrome. The regional anesthesia of the upper limb by brachial plexus block (BPB) may be a good alternative to general anesthesia for carpal tunnel release surgery, because it results in less complications. However, the regional anesthesia still has various side effects, such as hematoma, infection, and peripheral neuropathy. We hereby report a rare case of median nerve injury caused by BPB for carpal tunnel release.

Association of Post-extubation Dysphagia With Tongue Weakness and Somatosensory Disturbance in Non-neurologic Critically Ill Patients

Objective To prospectively assess the association between impoverished sensorimotor integration of the tongue and lips and post-extubation dysphagia (PED). Methods This cross-sectional study included non-neurologic critically ill adult patients who required endotracheal intubation and underwent videofluoroscopic swallowing study (VFSS) between October and December 2016. Participants underwent evaluation for tongue and lip performance, and oral somatosensory function. Demographic and clinical data were retrieved from medical records. Results Nineteen patients without a definite cause of dysphagia were divided into the non-dysphagia (n=6) and the PED (n=13) groups based on VFSS findings. Patients with PED exhibited greater mean duration of intubation (11.85±3.72 days) and length of stay in the intensive care unit (LOS-ICU; 13.69±3.40 days) than those without PED (6.83±5.12 days and 9.50±5.96 days; p=0.02 and p=0.04, respectively). The PED group exhibited greater incidence of pneumonia, higher videofluoroscopy swallow study dysphagia scale score, higher oral transit time, and lower tongue power and endurance and lip strength than the non-dysphagia groups. The differences in two-point discrimination and sensations of light touch and taste among the two groups were insignificant. Patients intubated for more than 7 days exhibited lower maximal tongue power and tongue endurance than those intubated for less than a week. Conclusion Duration of endotracheal intubation, LOS-ICU, and oromotor degradation were associated with PED development. Oromotor degradation was associated with the severity of dysphagia. Bedside oral performance evaluation might help identify patients who might experience post-extubation swallowing difficulty.

Proposed Use of Thickener According to Fluid Intake on Videofluoroscopic Swallowing Studies: Preliminary Study in Normal Healthy Persons

Objective To examine the characteristics and changes in the pharyngeal phase of swallowing according to fluid viscosity in normal healthy persons, to help determine fluid intake methods in more detail than the use of standardized fluid. Methods This was a prospective observational study involving 10 normal healthy adults. While the participants sequentially took in fluids with 10 different viscosities changes in the pharyngeal phase of the swallowing process were monitored using videofluoroscopic swallowing studies (VFSS). Twenty parameters of the pharyngeal phase, including epiglottis contact, laryngeal elevation, pharyngeal constriction, and upper esophageal sphincter opening, were determined and compared. Results No significant viscosity-based changes in epiglottis contact, laryngeal elevation, or upper esophageal sphincter-opening duration of the pharyngeal phase were observed. However, pharyngeal transit time and time from the start of the pharyngeal phase to peak pharyngeal constriction were significantly delayed upon intake of fluid with viscosities of 150.0 centipoise (cP) and 200.0 cP. Conclusion VFSS analysis of fluid intake may require the use of fluids of various concentrations to determine a suitable viscosity of thickener mixture for each subject.

Deep vein thrombosis associated with may-thurner syndrome in an amyotrophic lateral sclerosis patient -a case report-.

There have been a few reports on deep vein thrombosis (DVT) associated with compression of the left common iliac vein by the right common iliac artery, referred to as May-Thurner syndrome (MTS). However, there have been no reports on DVT associated with MTS in amyotrophic lateral sclerosis (ALS) patients exhibiting similar clinical features to paraplegic spinal cord injury patients. We hereby report a case of DVT associated with MTS in an ALS patient, who was treated successfully.