Laryngology Seminar
Deglutition Disorder
Dec 10, 2003 R3 施偉勛
Physiology of swallowing
1. oral preparatory phase:
a. lip closure to hold food in the mouth anteriorly
b. tension in the labial and buccal musculature to close the anterior
and lateral sulci
c. rotatory motion of the jaw for chewing
d. lateral rolling motion of the tongue to position food on the teeth
e. bulging forward of the soft palate to seal oral cavity posteriorly
2. oral phase
a. initiate when the tongue begins posterior movement of the bolus
b. move food from the front of the oral cavity to the pharynx
c. pharyngeal swallow triggered by the glossopharyngeal nerve
3. pharyngeal phase
a. velopharyngeal closure to prevent food from refluxing into nose
b. tongue base retraction to propel the bolus through the pharynx
c. laryngeal ( epiglottic, ventricular and true vocal folds) closure to
prevent material from penetrating the larynx
d. pharyngeal peristalsis and contraction to clean pharyngeal residue
e. laryngeal elevation and anterior movement to carry the larynx up
under the tongue and out of the path of the bolus
f. opening of the cricopharyngeal region
4. esophageal phase
a. begin with relaxation of the cricopharyngeus
b. active peristalsis or sequential contraction from top to bottom
Bedside Examination
1. swallowing performance: 5-10 ml water to swallow without drooling,
choking or delay. 3-5 times in the 10-second in normal swallowing
2. gag reflex (CN IX): not use to evaluate the ability of swallowing
3. swallowing frequency: hospitalized elder: normal elder: normal young
= 0.89: 2.82: 2.96 /mins (University of Michigan)
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mean swallowing frequency: 0.088/mins in sleeping, 0.612/mins in
alert → easy aspiration in depressed conscious individual(Lear et al)
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swallowing frequency increased while intubated or employed NG tube
accumulation of oropharyngeal secretions in the laryngeal vestibule
dysphonia, dysarthria, abnormal gag reflex, abnormal volitional cough,
cough after swallow, and voice change after swallow: sensitivity=86%;
specificity= 30%; false negative rate= 14%; false positive rate=70%;
positive predictive value= 50%; negative predictive value= 73%
wet hoarseness, breathy phonation
the most experienced clinicians fail to identify 40% of aspirating
patients during a bedside examination
Diagnosis of the dysphagia
1. Barium Esophagram
Description:
1) A cup of liquid barium under fluoroscopy without speech pathologist
Advantages: widely available
Disadvantages:
1) x-irradiation and dependent on scheduling
2) logistically difficult for gravely ill or bedfast patients
3) imprecise with respect to anatomy and location of pooled residue
4) documented on plain film, dynamic features only described in report
form, and not available on videotape, only focus on esophagus
5) information about effect of food consistency is lacking
6) no therapeutic trials within the test
2. Air Contrast Esophagram
Description
1) addition of effervescent granules to barium
Advantages: provide better anatomic detail, particularly edge contrast
Disadvantages: as barium Esophagram
3. Manometry
Description
1) the strength, timing, and sequencing of pressure events in esophagus
are obtained through multichannel recording
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2) pressure sensors: oropharyngx, larynx, pharyngoesophageal segement
and esophagus
Advantages: actual test of pressure wave physiology
Disadvantages:
1) assess pressure only, can’t diagnose visible lesions (stricture or mass)
2) technically difficult to ensure valid reading due to movement of larynx
4. Manofluorography
Description: simultaneous VFSS and manometry
Advantages: gaining the advantages of each
Disadvantages: not widely available and costly
5. Fiberoptic Endoscopic Evaluation of Swallowing with Sensory
Testing (FEESST)
Description
1) First introduce in 1998 by Aviv et al (Columbia University)
2) add sensory testing to FEES to test laryngeal adductor reflex
3) air pulse stimulation located 2 mm from the surface of AE fold (SLN)
4) air pulse: 50 ms in duration, 0-15 mmHg intensity
5) a masking sound was used to prevent from using auditory cues
Advantages
1) assess in quantitative fashion the progression or regression of sensory
deficit---a predictor of developing aspiration pneumonia
Disadvantages
1) need technical expertise
2) not widespread clinical use
6. Bolus Scinitigraphy
Description
1) short-lived isotope is mixed with a single swallowed bolus
2) gamma camera images the radiation field and count the particles
Advantages
1) only truly quantitative methodology with respect to fraction of bolus
aspirated
2) take later views to assess clearance of retained bolus over time
Disadvantages
1) can’t see anatomy
2) only a single bolus, can’t do multiple swallows with different
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consistency, head positioning change and compensatory maneuvers
7. Ultrasonography
Description
1) image of upper digestive tract structures and mobilities, bolus transit
and vallecular stasis are obtained through submental transducer
2) air surronding the tongue and mouth floor provides contrast for exam
Advantages
1) avoid irradiation, be portable
2) normal food substances are used, not barium
3) good for detection of abnormal tongue movement even in children, ex:
tremor fasciculations, lingual asymmetry or deformity
4) evaluate the oral and oral preparatory phases of swallowing
Disadvantages
1) segmental image, no panoramic anatomic detail
2) not effective for esophageal phase
8. Videofluoroscopic Swallowing Study (VFSS), Modified Barium
Swallow study (MBS) or Videofluoroscopy
Description
1) widely available due to historical ( published by Mosher in 1927)
2) with both radiologist and speech pathologist present
3) administered puree, liquid and solid consistency barium with
fluoroscopic image ( lateral and AP view) recoreded on videotape
Advantages
1) comprehensive test in all phases of swallowing
2) dynamic study of both patient anatomy and actual bolus of food
3) the effect of food consistency, head position, and compensatory
maneuver can be addressed within the test
4) easy to videotape examination
Disadvantages
1) rely on x-irradiation, especially if frequent reassessment is desirable
2) depend on scheduling of a facility and personnel
3) difficult for ill or bedfast patients, such as in ICU or dementia p’t
4) imprecise with respect to anatomy and location of pooled residue
5) can’t use as a real-time biofeedback training tool because of radiation
6) expensive ( twice than FEES)
7) can’t visualize accumulated secretion---a significant factor of
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aspiration pneumonia
8) miss patient fatigue, maximum time of VFSS: 5 mins
9) only visualize the motor component of swallowing, indirectly
demonstrate the sensory component
9. Fiberoptic Endoscopic Evaluation of Swallowing (FEES), or
Videoendoscopic Swallowing Study (VESS)
Description
1) First report by Langmore 1988 in University of Michigan
2) single spray to nasal cavity with 0.5% cocaine and 0.02% bosmin
3) scope in nasopharynx: velopharyngeal competence by dry swallow
4) scope in laryngopharynx: vocal cord movement, pooling or aspiration
of saliva, pharyngeal constrictor competence, and laryngeal elevation
by inspection and palpation
5) hold the pudding (3ml) in mouth for 10 sec to see premature oral
leakage to pharynx or preswallowing aspiration
6) swallow as he usually did (only see pre and post-swallowing)
7) lateralization of food passage, penetration, aspiration, pharyngeal
residue, cough reflex, and spillover
8) try 3 ml of diluted green food color dye for 3 times
9) Sensitivity testing: scope probes the pharyngeal wall, laryngeal
surface of the epiglottis, AE folds, the arytenoids and vocal cords
10) Alternative procedure: at high risk for pneumonia, use water with
blue or green dye (1ml) mixed patient’s saliva as visualized medium
Advantages
1) relatively simple and widely available
2) easily portable, can be taken to any setting, including ICU
3) No radiation, can performed frequently
4) Useful for patient teaching and biofeedback training
5) Better assess neurologic status including sensation and detailed
anatomy, and relatively inexpensive
6) Lower false negative rate of FEES by virtue of its repeatability
7) Can be performed in the patient’s usual feeding environment
Disadvantages
1) The phase of swallowing can’t be seen directly
2) The function of the cricopharyngeus muscle and the esophagus can
not be directly assessed through FEES
3) Not as widely taught as VFSS
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4) quantification of functional deficits is not achievable
Complications
1) Vasovagal Reaction
---stimulation of the nose (nasocardiopulmonary reflex) or
pharynx/larynx (vagal afferents)
---hypotension, bradycardia, dysrhythmia
---prevent by anesthetize the nasal mucosa
---CPR should be readily available
2) Laryngospasm
---reflexive, spastic prolonged closure of the glottic and supraglottic
sphincters, trigger by tactile stimulation of laryngeal mucosa
---self-limited, require positive pressure ventilation with a mask
---poor sensitivity of larynx, low risk of spasm
3) Nasal Hemorrhage
4) Adverse Medication Reaction
5) Aspiration: suction equipment should be available
Swallowing therapy (Facilitation and Compensation, table)
1. After conservation surgery ( hemilaryngectomy, supraglottic
laryngectomy, or supracricoid laryngectomy)
a. consequence of poor airway protection caused by structural changes
b. learn swallowing strategies before surgery
c. supraglottic swallow: reduce risk of aspiration and eliminate residue
from laryngeal vestibule
d. chin down posture: improve airway protection and widen vallecular
space
e. Lying on the side: turn the head towards the operated side
f. Super supraglottic swallow maneuver: add a voluntary Valsalva
maneuver to the supraglottic swallow
g. Thermal-tactile stimulation and temperature or texture variation
2. After total laryngectomy
a. to rule out fistula or stricture, VFSS performed before oral diet
b. food getting stuck due to pseudoepiglottis in vertical than T closure
c. higher rates of dysphagia and stricture in surgery with induction C/T
and R/T than with R/T alone
d. smaller, more frequent meals, soft moist food and liquid chasers
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e. postural changes: head rotation and neck extension to stretch
reconstructed tissue
f. esophageal dilatation, botulinum toxin or myotomy for stricture or
spasm
g. pseudoepiglottis (+), only liquids and purees unless surgical removal
3. After primary radiation therapy
a. short-term effects: erythema, mucositis, candidiasis, xerostomia,
ulceration, and bleeding of mucosa
b. long-term effects: laryngeal edema, fibrosis, stricture, radionecrosis,
trismus, dental caries, xerostomia and reduce sense of smell or taste
c. Mendelsohn maneuver (prolong laryngeal elevation volitionally):
increase laryngeal elevation and cricopharyngeal opening
d. Masako maneuver (tongue protruded and held during swallowing):
improve anterior movement of the posterior pharyngeal wall
e. oral motor exercise and mandibular range of motion exercise
f. Xerostomia affects patient’s perception of comfort but not actually
correlate with physiologic swallowing abnormality (Logemann)
4. After radiotherapy in NPC
a. Time intervals between R/T and deglutition problem: 2 to 20 years
( mean 8.5 years)
b. Initial staging and irradiation dosage to the neck had no relationship
with the development and severity of these deglutition dysfunction
c. Anatomic changes: tongue atrophy (54.8%), vocal palsy (29%)
d. Functional changes: dry mouth (45.2%), nasopharyngeal regurgitation
(58.1%), premature leakage (41.9%), delay or absent of swallow
reflex (87.1%), weakness of pharyngeal constriction (80.6%),
laryngeal penetration or tracheal aspiration (83.9%), pharyngeal
retension (93.5%)
e. Good correlation: vocal cord palsy vs aspiration, poor pharyngeal
constriction and pharyngeal retention vs postswallow aspiration,
velopharyngeal incompetence and poor pharyngeal constriction vs
delayed or absent swallow reflex
f. soft tissue fibrosis, neuropathy and myelopathy, individual differences
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