[Neurologic and neuromuscular functional disorders of the pharynx and esophagus]. / Neurologisch bedingte und neuromuskuläre Funktionsstörungen des Pharynx und Osophagus.

Neurologic swallowing disorders are an increasing diagnostic problem in our overaged population. Undiagnosed chronic aspiration pneumonia is the cause of death in 20-40% of all inhabitants of nursing homes. In neurologic diseases of the pharynx, the physiologic interaction of pharyngeal contraction, closure of the pharynx, and esophageal motility are frequently disturbed. This may be due to cortical, bulbar, or cerebellar brain damage of ischemic or traumatic origin. Furthermore diseases or peripheral nerves, muscles, and synapses cause disturbances. The most life-threatening complication of these disturbances is tracheal aspiration, which requires an iso-osmolar contrast medium for imaging studies that cause no or minimal pulmonary problems. Utilizing fast dynamic documentation we can analyze the swallowing act in 35 images within the passage time of 0.7 s. This requires digital frame sequences from 15-50 images/s, which can be provided by DSI or videofluoroscopy. Neurologic and neuromuscular patterns are demonstrated with and without tracheal aspiration. The differentiation of aspiration in a so-called pre-, intra-, and postdeglutitive form is possible. We distinguish four grades of severity of aspiration, which is also of great clinical impact for the differential rehabilitation therapy. The efficiency of the rehabilitation protocol can be assessed by the dynamic swallowing studies.

[Esophageal motility disorders]. / Motilitätsstörungen des Osophagus.

For the better understanding of esophageal motility, the muscle texture and the distribution of skeletal and smooth muscle fibers in the esophagus are of crucial importance. Esophageal physiology will be shortly mentioned as far as necessary for a comprehensive understanding of peristaltic disturbances. Besides the pure depiction of morphologic criteria, a complete esophageal study has to include an analysis of the motility. New diagnostic tools with reduced radiation for dynamic imaging (digital fluoroscopy, videofluoroscopy) at 4-30 frames/s are available. Radiomanometry is a combination of a functional pressure measurement and a simultaneous dynamic morphologic analysis. Esophageal motility disorders are subdivided by radiologic and manometric criteria into primary, secondary, and nonclassifiable forms. Primary motility disorders of the esophagus are achalasia, diffuse esophageal spasm, nutcracker esophagus, and the hypertonic lower esophageal sphincter. The secondary motility disorders include pseudoachalasia, reflux-associated motility disorders, functionally caused impactions, Boerhaave's syndrome, Chagas'disease, scleroderma, and presbyesophagus. The nonclassificable motility disorders (NEMD) are a very heterogeneous collective.

[Deglutition disorders in neurological patients. A prospective study of diagnosis, pattern of impairment, therapy and outcome]. / Schluckstörungen bei neurologischen Patienten. Eine prospektive Studie zu Diagnostik, Störungsmustern, Therapie und Outcome.

We performed a prospective study on 208 patients with neurogenic dysphagia who were consecutively admitted for swallowing therapy over a 3-year period. The most frequent etiology was stroke (48%). Videofluoroscopic and/or fiber optic endoscopic evaluation of swallowing were performed in 204 patients. Swallowing therapy was comprised of restitution methods, compensation, and adaptation, each of which was applied in more than 80% of the patients. Mean duration of swallowing therapy was 2 months (full oral patients 1 month, patients dependent on tube feeding or tracheostomy 2.5 and 3.5 months, respectively). Fifty-five percent of the patients initially dependent on tube feeding were full oral feeders after swallowing therapy. A target variable reflecting functional feeding status showed significant improvement after swallowing therapy, also in patients with a disease duration of more than half a year, ruling out spontaneous recovery as a sole explanation of amelioration. The following variables were the main contributors to outcome prediction: functional feeding status, Barthel index, duration of disease, and degree of aspiration as shown by endoscopy.

Functional imaging of the pharynx using electron beam tomography.

Due to long scan times it was impossible to make dynamic swallowing imaging using computer tomography (CT) of the third or fourth generation. This study evaluates whether electron beam tomography with scan times of 100 ms enables a more detailed dynamic imaging of swallowing disorders. Examination using electron beam tomography was done in three planes: (1) Passavant's cushion (n = 6), (2) thyrohyoid membrane (n = 9), and (3) upper esophageal sphincter (n = 5). The technique is discussed here in detail and documented with figures of the plane before swallowing as well as the intradeglutitive reachend plane. This study shows that electron beam tomography enables dynamic imaging of pharyngeal deglutition in transverse planes and can give useful additional information to the videofluorographic or kinematographic swallowing examination, which remain the gold standard in the functional evaluation of swallowing disorders.

Topographic evaluation of lateral hypopharyngeal pouches using electron beam tomography.

BACKGROUND: To evaluate the exact topography of lateral hypopharyngeal pouches using electron beam tomography. METHODS: Seventeen patients, nine female, eight male, aged 28-72 years, who showed lateral hypopharyngeal pouches in the videofluorographic swallowing examination were studied using electron beam tomography. Upon swallowing a 20-ml bolus of water, the region of the thyrohyoid membrane was scanned 20 times per level. Scan parameters: single slice cine mode (exposure time 100 ms, slice thickness 3 mm, 620 mA, 130 KV). RESULTS: The lateral hypopharyngeal pouches appeared air-filled in the posterior aspect of the thyrohyoid membrane closely attached to the upper horn of the thyroid cartilage, just below the hyoid bone. CONCLUSIONS: With electron beam tomography it was possible to define the topographic location of the pouches more accurately, compared with the prior assumption of position.

Intramural pseudodiverticulosis of the esophagus: a case series.

Intramural pseudodiverticulosis of the esophagus is a rare benign disease of the esophageal wall, with dilation of the submucosal glands, and the predominant symptom is dysphagia. In the literature, 191 cases have been described so far. Along with a short review of the literature, the present report describes six cases of this disorder, including a patient in whom intramural pseudodiverticulosis of the esophagus was secondary to laser therapy and endoluminal afterloading of an esophageal squamous-cell carcinoma.

[Videocinematography and pre- and postoperative diagnosis of lip-maxillary-palatal clefts]. / Die Videokinematographie in der prä- und postoperativen Diagnostik der Lippen-Kiefer-Gaumen-Spalte.

Videocinematography is a valuable tool in the diagnostic workup and planning of functional surgery in cleft patients. The high resolution and depiction of the finest mucosal structures in motion allow objective and dynamic assessment of the individual velopharyngeal function. A total of 170 cleft patients were examined by videocinematography, and the results were compared to nasoendoscopy and to the clinical examination. The marked superiority of this radiological technique with regard to clearness of depiction and ease of use is shown. It can therefore be recommended without reservation for the pre- and postoperative assessment of cleft patients.

[Analysis and radiologic staging of the type and severity of aspiration]. / Analyse und radiologisches Staging des Typs und Schweregrades einer Aspiration.

The estimated number of the incidence of undiagnosed chronic aspiration pneumonia after cerebral or cerebrovascular injury seems very high. According to American statistics, at least 6% of these patients die from aspiration pneumonia within the first year. The high temporal resolution of cineradiography with frame rates of the complex process of pharyngeal swallowing lasting 0.7 s. The method enables us to differentiate between so-called pre-, intra- and postdeglutitive aspiration, which means aspiration before, during and after the triggering of the swallowing reflex. Together with an established score for the severeness of the aspiration, the method supplies important data for setting up a functional surgical and/or conservative program for rehabilitation and for follow-up-studies.

[The physiology of swallowing]. / Die Physiologie des Schluckakts.

This article reviews the sensory and the motor coordination during the oro-pharyngeal and pharyngo-esophageal stage of deglutition including laryngeal dynamics. The performance of swallowing takes less than one second. In this short period the well-coordinated action of five cranial nerves and 26 muscle-groups has to be accomplished. There is a great number of dysfunctions, that can occur during this rapid and complex motility phenomena.

[Radiological diagnosis of benign dysphagia]. / Radiologische Diagnostik der benignen Dysphagie.

In the diagnostic work-up of the benign dysphagia modern radiology must not only describe morphologic alterations but also has to keep in mind the great importance of motility disorders. Dysfunction of the esophagus can be assessed by fluoroscopy alone. The superior method to analyze the motility disorders of the oropharyngeal and pharyngo-esophageal transport is high-speed cineradiography at a frame-rate of 50 frames/sec on 35-mm film because of the very fast and complex patterns of motion during oropharyngeal deglutition, which occurs within only 0.5 to 0.7 sec. The upper esophageal sphincter turned out to play a very important role in many motility disorders of the pharynx and the esophagus, which often secondarily leads to permanent structural lesions. Examples are given, in which kinds of disorders cineradiography contributes to diagnosis and therapy. In some cases it turned out to be the method of first choice, as for example for aspiration.

Dysphagia of the treated laryngeal cancer--detection of functional and morphological changes by cineradiography.

After treatment of laryngeal cancer 35 patients with dysphagia have been examined by high speed cineradiography. When compared to normal swallowing patterns, the following abnormalities were observed: Excursion of the posterior pharyngeal wall during swallowing is twice as intensive as normal. The function of the base of the tongue becomes more important for pharyngeal emptying--a fact that surgeons should take into consideration when planning laryngeal resection. Timing of pharyngeal constriction and function of the upper esophageal sphincter are definitively altered. In view of these changes we think that cineradiography can help to find better methods for functional surgery of the pharynx and the adjacent structures.

[The feasibility of pretherapeutic diagnosis of malignant pharyngeal processes using high-frequency cineradiography]. / Möglichkeiten der prätherapeutischen Diagnostik maligner Pharynxprozesse durch Einsatz der Hochfrequenzröntgenkinematographie.

The differentiation between stage T3 and stage T4 pharyngeal tumors is of crucial importance for the proper therapeutic approach (surgery, surgery with consecutive radio- or radiochemotherapy, chemotherapy). The clinical relevance of the additional information provided by cineradiography was evaluated in combination with the endoscopic and computed tomographic results. We performed static and dynamic pharyngography with mono- and double-contrast-methods in four planes, including pharyngeal distension (Valsalva's and Müller's maneuver) and phonation. For the dynamic study, high-speed cineradiography (35 mm film, 50 frames/s) was used. Twenty-three patients with histologically proven neoplasms were examined. It was determined that surgery was technically feasible in 4 out of 14 patients who were previously presumed to have inoperable tumors. In 2 cases, an extension of the tumor mass was seen by cineradiography (results proven intraoperatively).

[Cinematography, a new diagnostic procedure in evaluation of the injured painful wrist joint]. / Die Kinematografie, ein neues Diagnoseverfahren in der Beurteilung des verletzten schmerzhaften Handgelenkes.

By the X-ray Cineradiografie we are able to examine and to judge the dynamic of the wrist bones by 50 pictures/sec. in comparison to one another and also depending on their ligaments. We did an investigation of 170 patients with painful wrist. With the method we were able to make up a clear diagnosis and to propose the therapy. I.e.: If consecutive shortening of the radius after distal radius fracture resulting ingruency of the wrist joint is relevant, or a scaphoid pseudarthrosis is fixed elastically, or a scaphoic dissociation is effective. The variations were shown in comparison to normal circumstances.

[Functional and morphological changes in the pharynx in achalasia and diffuse esophageal spasm]. / Funktionelle und morphologische Veränderungen des Pharynx bei der Achalasie und dem diffusen Osophagusspasmus.

Since the pharynx and the esophagus are a functional unit, functional radiodiagnosis has to be directed at pharyngo-esophageal interaction. Among our collective of 73 patients suffering from achalasia or diffuse esophageal spasm, we were able to recognize a substantially increased incidence of morphological or functional pharyngeal disorders by means of cineradiography. The functional alterations in particular were often not revealed by conventional fluoroscopy. High-speed cineradiography, with its high temporal and spatial resolution, turned out to be a valuable tool in analysis of the origin of pharyngeal dysphagia. Manometry correlated very well with the radiologic findings in tubular esophagus, but proved unreliable in the detection of alterations of the upper esophageal sphincter region, because of problems inherent in the method. Furthermore, membranous stenosis (webs), lateral or dorsal diverticula, and asymmetry of the pharynx were observed strikingly often.

[Cinematographic study of the pathologic mechanisms of aspiration pneumonia]. / Kinematographische Untersuchung des Pathomechanismus der Aspirationspneumonie.

6% of all patients suffering from a cerebrovascular injury die from aspiration pneumonia within the first year. The high temporal resolution of high-speed cineradiography (HFK) (50 frames/sec.) allows the recording of the 0.7 sec. process of pharyngeal swallow. Five case-examples are presented (total number of cases: 95) illustrating the possibility of differentiation between three types of aspiration by means of cineradiography. These types are the so-called pre-, intra- and postdeglutitive aspiration, that is aspiration before or after triggering of the swallowing reflex. This differentiation is of great therapeutic importance. The analysis of disturbances of pharyngo-laryngeal motility and the temporal coordination allows setting up individual surgical and/or conservative programme for rehabilitation.