Milton Melciades Barbosa Costa

Esophageal Diverticula: Pathogenesis, Clinical Aspects, and Natural History

It has been gradually accepted that esophageal diverticula result from esophageal motor disorders rather than from primary anatomic abnormalities. Twenty-seven patients with these diverticula were evaluated with respect to pathogenesis, clinical aspects, diagnostic tests, therapy, and natural history for a mean of 27 months of followup. Thirteen diverticula were midesophageal, 11 were situated in the distal third of the esophagus, and 3 were in both regions. Esophageal dysmotility was observed in 85% of patients. Specific esophageal motor disorders were more frequent in association with diverticula of the distal third than in midesophageal diverticula, suggesting that they result from a pulsion mechanism. Traction was the possible mechanism in 27% of midesophageal diverticula. Endoscopic esophagitis was seen in one patient and abnormal acid reflux in 25% of the cases, mainly in patients with distal diverticula. Distal diverticula presented with more severe symptoms than did midesophageal diverticula, and 27% of those required surgical treatment. Patients with midesophageal diverticula seem to have a better prognosis than those with more distal disease.

Coordination of respiration and swallowing: functional pattern and relevance of vocal folds closure

CONTEXT Breathing and swallowing coordination, despite the expressive number of study, remain as theme deserving further research. OBJECTIVE To identify a coordination pattern between swallowing and the natural breathing pause that occur in association with it (swallowing apnea) and also the relevance of the vocal folds closure in this process. METHODS Sixty-six adults, male and female, including normal health people, post-laryngectomy individuals and patients with digestive complaints without dysphagia were analyzed. The respiratory air flux interruptions produced by wet requested swallows and dry, requested and spontaneous swallows, were registered using thermo and piezoelectric receptors coupled to synectics medical manometry equipment, using Polygram upper 4.21 software. The results were analyzed with the Chi-square (3x2) and (2x2) nonparametric independency test with P = 0.05. RESULTS Swallowing apnea is a preventive breathing stop that start just before and stay present during all deglutition pharyngeal phase. It is a well coordinated phenomena that occur as pattern in association with low elastic resistance of the lung, on the expiratory final phase until inspiration initial phase. This breathing stoppage it is usually followed by a short expiration preceding a new breathing cycle. The swallow apnea and vocal folds closure are both independent mechanisms. CONCLUSION It is possible to suppose that in the subconscious condition, swallowing apnea is integrated under coordination of the same control mechanism that also involves the elastic resistance of the lung.

ORAL TASTE RECOGNITION IN HEALTH VOLUNTEERS

CONTEXT Taste food recognition has an important role in the nutritional conditions and also allows protection of the organism integrity against foods potentially dangerous. OBJECTIVE To investigate the presence of the selective taste regions on the tongue and also the palate participation in the oral taste definition. METHODS A standard tongue divided in six regions was exposed with the four basic tastes (sweet, salted, sour and bitter), 10 times each. Thirteen volunteers were studied from both side and 34 only from one side, performing 240 tests with opened mouth and 240 with closing mouth, just after tongue sapid stimulation. A second group, with 12 volunteers, had its taste recognition studied, with and without palate isolation, using silicone prosthesis (n = 120). RESULTS From results, chi-square (3x2) and (2x2), nonparametric independency test with P = 0.05 were obtained. CONCLUSIONS Anterior, medium and posterior regions of the tongue, at both sides, had the same taste discriminative capacity. Nevertheless, closed mouth increased immediate and late recognition capacity by palate participation. It was possible to admit that palate participation increase the sapid perception in the mouth, by recruitment of the palate taste receptors and also by fluid compression and its scattering over tongue surface.

Lateral laryngopharyngeal diverticulum: anatomical and videofluoroscopic study

The aims were to characterize the anatomical region where the lateral laryngopharyngeal protrusion occurs and to define if this protrusion is a normal or a pathological entity. This protrusion was observed on frontal contrasted radiographs as an addition image on the upper portion of the laryngopharynx. We carried out a plane-by-plane qualitative anatomical study through macroscopic and mesoscopic surgical dissection on 12 pieces and analyzed through a videofluoroscopic method on frontal incidence the pharyngeal phase of the swallowing process of 33 patients who had a lateral laryngopharyngeal protrusion. The anatomical study allowed us to identify the morphological characteristics that configure the high portion of the piriform recess as a weak anatomical point. The videofluoroscopic study allowed us to observe the laryngopharyngeal protrusion and its relation to pharyngeal repletion of the contrast medium. All kinds of the observed protrusions could be classified as “lateral laryngopharyngeal diverticula.” The lateral diverticula were more frequent in older people. These lateral protrusions can be found on one or both sides, usually with a small volume, without sex or side prevalence. This formation is probably a sign of a pharyngeal transference difficulty associated with a deficient tissue resistance in the weak anatomical point of the high portion of the piriform recess.

Estudo clínico e videofluoroscópico da disfagia na fase subaguda do acidente vascular encefálico

OBJETIVO: Correlacionar, em pacientes portadores de acidente vascular encefalico (AVE) na fase subaguda, as alteracoes clinicas da degluticao com as observadas na videofluoroscopia. MATERIAIS E METODOS: De 37 portadores de AVE subagudo confirmado por exame de imagem, 26 pacientes de ambos os sexos, com idade media de 59,69 anos, foram avaliados clinica e videofluoroscopicamente. Consideramos como variaveis para pareamento estatistico os parâmetros clinicos indicativos de penetracao/aspiracao e sua confirmacao na videofluoroscopia. RESULTADOS: Identificamos disfagia em 19 (73%) dos 26 pacientes que fizeram videofluoroscopia; dez (38,46%) apresentaram penetracao/aspiracao de liquidos. Os dados resultantes mostraram nao existir correlacao (p < 0,05) entre a presenca de disfagia e/ou disartria e a presenca de penetracao/aspiracao de liquidos na videofluoroscopia. Houve correlacao entre a presenca de penetracao/aspiracao de liquidos observados na videofluoroscopia com os seguintes parâmetros clinicos: estado dos dentes (p = 0,047), mobilidade (p = 0,019) e sensibilidade da face (p = 0,039) e mobilidade da lingua (p = 0,012). CONCLUSAO: Nao foi possivel definir a presenca de penetracao/aspiracao de liquidos nas vias aereas por dados epidemiologicos do AVE. A existencia de mau estado de preservacao dos dentes, alteracoes na mobilidade da face e da lingua e na sensibilidade da face mostrou risco aumentado de penetracao/aspiracao para liquidos. Permanece importante a indicacao da videofluoroscopia para melhor avaliacao dos quadros de disfagia apos AVE.

Videofluoroscopia: método radiológico indispensável para a prática médica

Videofluoroscopy is defined as the recording in magnetic media, of X-ray images of dynamic biological events. Such events, observable at the fluoroscopic screen, are ruled by area of interest, time and exposure regimen. The recording of the images is done in real time (30 frames/second) with appropriate quality for the morphological study of exposed regions. The events can be viewed and reviewed, without new exposures. The visualization frame by frame and/or in slow motion constitute advantages of the video recording resource. The videofluoroscopic method can be utilized for evaluating several organic structures and systems, by utilizing appropriate contrast media. Coronariography can be obtained with similar image quality to that of conventional cinecoronariography, but with much lower radiation dose. Video bronchographic recordings in association with video endoscopy, video arthrography, video colonography in substitution to the traditional opaque enema registered on 35 mm negative film, retrograde video-cystourethrography, or even videophlebography or video-arteriography are exams that can be performed with the support of the videofluoroscopic method. Lower kerma-area product rates and better image quality represent realities available today. It is important that the radiologist knows all the potential of the videofluoroscopic method, particularly the videofluoroscopic swallowing studies. The method is universally accepted as the gold standard for studies of swallowing and its disorders. In the mouth, chewing, organization and ejection can be analyzed. In the pharynx, form, transit, palatal competence and protection of the airways can be viewed and reviewed. In the esophagus, lumen, walls, relations, transit time and sphincteric competence can be analyzed. The Radiologia Brasileira journal has several times covered this theme. However, and very frequently indeed, it comes to our attention that many practitioners and health

Estimulação mecânico-térmica dos pilares palatoglosso

BACKGROUND: The palatoglossus pillars were admitted as the main receptive responsible area by the pharyngeal swallowing reflex produced by food and tongue posterior progression. This concept sustain the mechanical-thermal maneuver used to recovery the committed pharyngeal function. A pharyngeal motor answer by pillar stimulation is common accepted but not unanimously. AIM: To verify the possible pharyngeal motor answers by palatoglossus pillars mechanical thermal stimulation. METHODS: Healthy volunteers are more able to provide effective reflex answers by pillars stimuli than patients. In this way we evaluated 51 healthy adult volunteers from both sexes reproducing the pillars stimuli using metallic probe. The cold condition was obtained by probe immersion in water maintained to 10°C. RESULTS AND CONSIDERATIONS: The study showed that the mechanical thermal stimuli over pillars was not able to produce any active answer linked to the swallowing pharyngeal phase. It is possible that literature observed answers were due to the gag reflex inadequately interpreted or unconscious voluntary contractions effort produced by the opening mouth and tongue externalization during the pillars exposition to execution of the mechanical thermal stimulation maneuvers.

Viscosities reproductive patterns for use in videofluoroscopy and rehabilitation therapy of dysphagic patients

BACKGROUND Usually the suitable consistence identified and indicated as safe by videofluoroscopic method has been empirically obtained by association of barium sulfate solution with meals. However, it has been evidenced to be very difficult to reproduce this consistence in nutritional rehabilitation therapy from subjective information. AIM To build two reproductive similar crescent viscosities series of solutions, with and without barium sulfate, to be used, the first, as radiological contrasted mean and the second, as base to reproduce the defined safer consistence, in the oral diet rehabilitation of dysphagic patients. METHODS Two viscosity solutions series were obtained from starch and distilled water with and without 100% barium sulfate solution. The viscosity levels were defined step by step with digital viscosimeter (Brookfield, model LVTD-II) and with infrared thermometer Icel TD - 960. The fluids viscosity was register in centipoises, with their inferior and superior values followed by complimentary information about spindle kind, rotation speed and temperature. RESULTS The two series of solutions, with and without barium sulfate, could be defined as aqueous (>1-143,5 cP), fine liquid (428 - 551 cP), thick liquid (4.284 -7.346,5 cP)), pasty (7.346,4 - 13.035 cP), pasty thick (19.260 - 34.320 cP) and creamy (163.500 - 255.300 cP). CONCLUSION The study could offer reproductive formulas, with and without contrast mean, to be follow for obtaining the desirable viscosity to be used, each of them, in radiological evaluation and in nutritional diet minimizing the gaps fails between evaluation and therapy.

A New Hypothesis for Fluidification of Vocal-Fold Mucus: Scintigraphic Study

OBJECTIVE Our aim was to establish a new hypothesis for the fluidification of the mucus of the vocal folds, by using a scintigraphic method to analyze the relationship of the saliva from the oral and pharyngeal cavities to the mucosa of the laryngeal vestibule. STUDY DESIGN We theorized that the saliva that is adsorbed on the oral and pharyngeal mucosa enters the larynx and is also adsorbed on its mucosa, as a natural layer, fluidizing the mucus of the vestibule wall. METHOD A saline solution of sodium pertechnetate (Na(99m)TcO(4)) with radioactivity of 1.0 mCi was sprayed in the oral cavity of seven healthy volunteers, who were instructed to chew a piece of apple for as long as possible without swallowing. The migration of the radioactive saliva was recorded by a gamma-chamber apparatus. RESULTS We observed radioactivity in the laryngeal mucosa in six of the seven volunteers, who developed no complaints and no respiratory-defense reactions. The results for frequency were statistically significant (Mann-Whitney test, P=0.05). CONCLUSION The results indicate that an increased volume of saliva enters the larynx and is adsorbed in its mucosa, producing mucus fluidification. This supports our alternative hypothesis to the unlikely concept that hydration by water ingestion is the factor responsible for reduction of the mucus viscosity of the vocal folds.

Cadeira especial para o estudo videofluoroscópico da deglutição e suas disfunções

OBJETIVO: Configurar equipamento que permita avaliacao videofluoroscopica da degluticao e suas desordens sem a necessidade de colaboracao dos individuos na obtencao das posicoes requeridas, com reprodutibilidade das incidencias, posturas e manobras necessarias ao exame, independente das limitacoes impostas pelas doencas associadas. MATERIAIS E METODOS: Utilizamos como base um arco em C Philips BV-22. Implementamos adaptacoes que permitem o registro simultâneo das imagens, em midia analogica e digital. Cadeiras, principal e secundaria, acopladas ao equipamento radiologico foram desenvolvidas. RESULTADOS: Foi possivel acomodar adultos e criancas, obtendo-se todas as incidencias radiologicas necessarias sem que os voluntarios tivessem que se posicionar de modo ativo. Em adicao, desenvolvemos sistema de calibracao que permite a insercao de parâmetros dimensionais, tornando possivel a quantificacao dos fenomenos registrados. CONCLUSAO: Pudemos ampliar o espectro de utilizacao da videofluoroscopia a individuos inquietos e de comportamento semelhante a lesionados neuromotores, com maior efetividade e consequente necessidade de menor tempo de exposicao a radiacao.